Jumping's Knee

							The Eccentric Exercise Protocol
for Chronic Patellar
Tendinitis / Tendonitis
I suffered from severely painful patellar tendinopathy for 5 years. Now I can complete 100-
mile bike rides pain-free. I credit my success to "eccentric exercise." Through trial and error,
after reviewing the medical literature, I found a regimen that helped me eliminate knee pain.
Do not do these exercises if you have inflammation and until you consult with medical
professionals to determine whether these exercises are appropriate for you.

What is Eccentric Exercise? See the YouTube video
Sunday, September 13, 2009
Will "Eccentric Exercise" Cure You?

Will "eccentric exercise" cure your chronic patellar tendinitis?

-- Even using the ideal protocol for eccentric exercise, one may not be completely cured.
However, there are many success stories where people who have had years of patellar
tendinitis have outstanding success after a program of eccentric exercise. It is fast becoming
the most accepted form of treatment for chronic patellar tendinitis.

-- These exercises put a lot of force on the patellar tendon, so they must be done very
carefully over many months. If done improperly, they can lead to a worsening of symptoms.
They should be used only for chronic cases, should not be used for inflammatory tendinitis,
and should be done only under the recommendation of an appropriate physician.

-- Even if you are not completely cured, however, your pain might be reduced substantially
and you may be much happier. Your pain may be reduced to such a low extent that it does not
bother you much. And, there may be more times of the day when you have no pain, or much
less pain. In my case, the exercises have helped me to reduce pain a substantial amount. Now,
I rarely have pain. The times I do have some pain, it is substantially more tolerable -- and I
am much, much happier.

-- The exercises may help you to have no pain or substantially less pain while you do certain
activities, such as walking down stairs; driving a car; walking for long distances; bicycling,
etc...

-- Even if you find you are not completely cured, eccentric exercise may still be a
substantially better alternative than most other kinds of treatment, including surgery, other
kinds of physical therapy, certain chiropractic techniques, extracorporeal shock wave therapy,
prolotherapy, sclerosing treatments, etc...

-- In my opinion after reviewing the medical literature and trying a number of different kinds
of treatments myself, I believe eccentric exercise is far better than other alternatives. The
success rate is generally much better. Furthermore, other kinds of treatments, such as surgery,
may lead to irreversible adverse effects.



Posted by Sigfús Víkþörðson at Sunday, September 13, 2009 43 comments

Healthy & injured patellar tendons: microscopic images

The microscopic images below show healthy and injured patellar tendons. (If the images
don't show below, try clicking within the image boxes.)

Image #1 -- Normal patellar tendon: collagen fibers oriented in an organized linear fashion.
(Collagen is the principal protein of tendons, ligaments, and bones and in the normal state has
great tensile strength.)




Image #2 -- Injured patellar tendon: disrupted collagen fibers with wavy orientation,
fragmentation, and interspersed blood vessels. There is no inflammation present.
It is not known how eccentric exercise heals patellar tendinosis or reduces knee pain.
Theoretical mechanisms include the possible remodeling of tendon, strengthening of tendon,
and the elimination of the small blood vessels that occur in tendons affected by tendinosis.

(Images and commentary courtesy of Gréta Pathology. Slides prepared with hematoxylin &
eosin stain.)


Posted by Sigfús Víkþörðson at Sunday, September 13, 2009 1 comments

Questions and Comments I've Received

Additional questions and answers can be found in the "comment" section beneath
postings on this and other pages of this website.

Q: You say on this website that you have shown improvement from doing your
eccentric exercise protocol. What are your symptoms and level of pain now?

A: After 5 years, my pain has mostly disappeared. While I used to have constant, unbearable
and terrible knee pain every day, now on some days I have minor knee "sensations," but no
pain. The sensations feel like slight pressure on the tendon, but usually nothing significant.
Also, the duration of these sensations accounts for a very small percentage of a day. Maybe a
couple of days every few months, I will have knee pain, although the level of pain is typically
very low. It is difficult to figure out the cause of the pain and it may be related to something I
did in prior days, rather than that day. The biggest improvement in my pain is that it doesn't
completely occupy my thoughts. I can concentrate on other things without being aware of
constant pain. The eccentric exercises have also been very helpful to reduce or eliminate
symptoms while doing symptom-provoking activities like walking down stairs, walking long
distances, driving, and standing in one place. Furthermore, I typically have no (or little) pain
bicycling. During and after a 102 mile bike ride today I had no pain. It took 3 years until I
consistently had no or little pain bicycling.
Positively, each year my symptoms have improved over the prior year. The eccentric
exercises helped accelerate this improvement. I continue to stretch on a daily basis. I no
longer feel the need to do eccentric exercise on a daily basis, but continue do eccentric sets on
every few weeks.

Q: I have improved my knees by doing eccentric exercise somewhat differently than you
demonstrate on the video. I lower with one leg (the affected) and raise with both. In
your video, you don't raise with both legs.
A: Your way is fine, too. You can do it either way. The key thing, however, is to take more
time on the down squat, and come up relatively faster. It's on the down squat that you are
doing the eccentric work. It doesn't matter if you come up with one or both legs. One benefit
of your approach, however, is that you will be less tired and be able to do more reps or add
more weights over time.


Q: What is the purpose of using a slant board?

A: The slant board reduces help from the calf muscles, thereby making the patellar tendon do
more eccentric work.

Q: I would like to begin an eccentric exercise protocol. Would it be alright to begin a
program of rowing (on an indoor rowing machine) at the same time? If not, what type
of aerobic type exercise would be best while beginning an eccentric protocol?

A: Eccentric exercise protocols generally require you to do no exercise involving the knee for
the first 2 months of the protocol. With my protocol I recommend waiting at least 3 months.
After that, start with aerobic exercise that is easy on your knee. Ramp up slowly -- start with
only 5 minutes the first day you resume exercise and build slowly from there, so long as there
is no significant pain. I do not recommend rowing as the first exercise you do following an
eccentric protocol. Exercises I might consider include:

-- Bicycling using very easy gears on flat terrain.
-- Swimming, particularly the front crawl stroke. Avoid the breaststroke.
-- Short-distance jogging on flat terrain.
-- Cross-country skiing (classic style) on generally flat terrain.

I would avoid sports that involve jumping, such as basketball and volleyball.

Q: My sports medicine doctor believes that I fall into a small, but definitely observed,
portion of sufferers that are "super-sensitive" in that any little increase in activity will
cause tendinopathy flare-ups. I tried only 4 eccentric squats on the decline board and
got a flare-up right away!

A: Before giving up you can try 1) doing the eccentric squats without a decline board; 2)
doing the eccentric squats with both legs at the same time; and 3) doing only a partial, rather
than a fuller squat. These items will reduce force on the tendon. In addition, you can do the
downwards motion more quickly. Instead of 2-3 seconds on the downward phase, take 1
second. You may want to start with only one squat per day and add an additional squat every
4 days if you feel fine. I also recommend doing the eccentric exercise at night before going to
bed, so the tendon can rest overnight. Your doctor and/or physical therapist may have other
suggestions.

Q: Medical journal articles on patellar tendinopathy refer to a diagnostic questionnaire
called the Victorian Institute of Sport Assessment (VISA). What is it? Where can I find
it?

A: The VISA (sometimes called VISA-P for patellar tendinopathy) is an 8-question form that
asks questions about one's level of pain, duration of pain, etc... Sample questions are "For
how many minutes can you sit pain-free?" and "Do you have pain walking downstairs with a
normal gait cycle?" It quantifies one's answers. The maximum score for all 8 questions
combined is 100. The lower the score the worse the overall symptoms and level of
dysfunction. Some physicians and researchers use the questionnaire to assess a patient's
progress over time.

An article that includes VISA questionnaires in English and Swedish can be found in: Frohm
A, Saartok T, G Edman, et al. Psychometric properties of a Swedish translation of the
VISA-P outcome score for patellar tendinopathy. BMC Musculoskeletal Disorders.
2004;5:49.

Links are: http://www.biomedcentral.com/content/supplementary/1471-2474-5-49-s1.doc

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15606923


Q: Can you develop tendinosis without having first developed tendinitis?

A: This is not clear. Some researchers believe that what most patients have is tendinosis,
rather than tendinitis. Some believe there may be a period of only a few weeks right after the
initial overuse injury when there may be inflammation -- the period of tendinitis. But, soon
the inflammation goes away and you are left with tendinosis. In my case, I had symptoms
suggestive of inflammation for a period of months after the initial injury -- I had a knee that
was much warmer than normal along with some signs of minor swelling. Unless you actually
do a biopsy of the tendon to see whether there is inflammation, you don't really know for sure
if you have tendinitis or tendinosis. And, very rarely is a biopsy performed on the tendon
shortly after an overuse injury.



Q: If you don't want to buy a slant board, you can build one out of plywood and super-
gluing some 80 grit sandpaper to the board with a piece of 2X4 in between this wedge-
shaped contraption for extra strength. This is what I have been making and it is at 25
degrees.

A: I'd consider this only if one has good carpentry and engineering skills. You will be putting
a lot of force on the slant board while doing the exercises and won't want it to collapse on
your bad knee. While a slant board may cost $60+, buying one will be preferable for most
people.

Q: I have chronic tendinitis in my hands. Apart from patellar tendinopathy, are there
eccentric exercises for other kinds of tendinopathy such as in the hand, elbow, shoulder,
achilles, etc... ?

A: I know there are eccentric exercises for at least some of these conditions. Clearly, the
exercises will be different than those used for patellar tendinopathy, but the science behind
why eccentric exercise is beneficial will be the same. Given that much of the research on
using ecentric exercise for tendinopathy has been done in very recent years, exercises and
proper protocols may be in their early stages of development. It would not surprise me that
many medical specialists and physical therapists would not be familiar with such exercises at
this point in time , so one may need to check around for expertise in this area.

Q: Can eccentric exercises be used to treat other knee problems apart from patellar
tendinosis?
A: For the knee, eccentric exercises are primarily indicated for patellar tendinosis. Unless this
is your diagnosis from a medical professional, I would not recommend these exercises. It's
possible there may be situations where such exercises may be of help for other knee
conditions, but consult your doctor.

Q: When doing the eccentric squat, how deep are you squatting?

A: A "medium" to "almost full" squat. It's certainly not a completely full squat, i.e. as low as
you can go. However, it approaches a full squat. Please see the video demonstration on this
site.

Q: Are leg cramps associated with chronic patellar tendinitis? I developed cramps in
my thigh and calf after a period of running and playing a lot of squash. I then developed
patellar tendinitis which I have had for the past two years.

A: I do not recall ever reading about an association between leg cramps and patellar
tendinitis. However, patellar tendinitis can co-exist and develop at the same time as other
knee-related problems, such as patellofemoral pain syndrome, Iliotibial band syndrome, and
in your case leg cramps. You should consult a medical physician about your situation.

Q: I have had tendinitis/tendinosis for about 18 months in my right knee. The knee is
red hot while my other knee is normal temperature. Why is my injured knee red hot?
Should I be put ice on it to cool it down?

A: For the first 1 to 2 years of my own patellar tendinopathy my bad knee was also much
warmer than usual at times. After that, other knee symptoms continued, but the temperature
differential went away. Doctors most likely would say you have symptoms consistent with
chronic inflammation. (Whether or not you actually have inflammation cells present is not
clear. Research suggests that there actually may not be be inflammation in longstanding
tendinopathy.) Hopefully, you have seen a doctor, given your knee a generous period of rest,
and are not continually re-injuring it. Applying ice for 5 to 10 minutes every few hours may
help reduce your symptoms, although this is unlikely to make the underlying condition go
away. Be careful because icing for too many minutes at a time can be harmful to the skin.

Q: I developed patellar tendinosis in both knees after a period of time playing soccer. In
2007 I underwent surgical debridement to remove degenerative tissue in both knees. I
have found strengthening to be helpful, but I am concerned that the strain could cause
new degeneration. Is there need to be worried?

A: Clearly, you need to be careful how you go about doing your exercise. "Overuse" likely
got you into your problem to begin with. In addition, given your surgery, your knee tendons
may have less capacity to withstand problems compared to before you developed tendinosis. I
think the answer to your question is not "if" you can strengthen your knees, but how you go
about it. You should speak with your doctor and a good physical therapist about a
strengthening and stretching program. As for eccentric exercise programs, these are generally
focused on people who have not had surgery. However, perhaps, your physical therapist can
help design a protocol for you focused on very gradual increases in repetitions and weights.

Q: Can eccentric exercise promote "scar tissue," thereby making it more difficult to
heal patellar tendinosis?

A: Based on my understanding of the medical literature, eccentric exercise when done
correctly won't worsen the tendon tissue. Instead, some theories suggest the exercise may
improve the tendon tissue. However, if you do the exercises improperly -- such as ramping up
too quickly, doing too many repetitions, using too much weight -- you potentially could
worsen your tendon tissue.

Q: My physician recently diagnosed me with patellar tendinopathy and recommended
"nitrate patches." What are your thoughts?

A: I am not a medical doctor, but have some thoughts. I surveyed the medical literature on
PubMed. There have been experiments in recent years involving topical glyceryl trinitrate
and/or nitric oxide to treat several kinds of tendinopathy, including that of the Achilles,
elbow, and shoulder. I saw no reports of experiments (yet) involving the patellar tendon.
While there are some experiments with favorable conclusions for the use of patches infused
with nitrogen compounds for other kinds of tendinopathy, the conclusions are not unanimous.
For example, the conclusion of one article in the American Journal of Sports Medicine from
June, 2008 states "This study failed to support the clinical benefit of GTN [glyceryl trinitrate]
patches previously described in the literature." But, another article's conclusion (from the
October 2007 Foot and Ankle International) states "topical glyceryl trinitrate treatment has
demonstrated efficacy in treating chronic noninsertional Achilles tendinopathy, and the
treatment benefits continue at 3 years." Given mixed reviews for uses on other kinds of
tendinopathy and no data from experiments on patellar tendinopathy, it is unclear whether
such treatment will help you. However, under your doctor's supervision, it may be worth
trying.

Q: What were your knee symptoms?

A: Below describes the pain I had during the first 3 to 4 years since the problem began. Now,
at the 4 1/2 year mark, I am happy to say I no longer have most of these symptoms. Today, I
occasionally have low-grade "sensations" that don't rise to the level of pain.

Pain during the first 3 to 4 years:
-- Mostly horrible nagging achy tendon pain everyday. Also, gnawing, tearing, and pulling
pain. All of these symptoms have either disappeared or become much minor versions what
they had been.
-- Frequent unrelenting burning pain. This eventually went away completely. (I don't believe
this neuropathic symptom is typical for most people with chronic tendinitis. But, others have
reported having it, too. It may be related to temporary nerve damage that was created at the
same time as the initial knee injury. As the underlying knee injury heals, so hopefully will the
nerve injury. You may want to consult a neurologist if you have burning symptoms. They
may prescribe drugs such as Neurontin (Gabapentin) or Lidoderm patches that may help
somewhat.)
-- Occasional feelings of knee stiffness. This eventually went away.
-- Rarely, I had some "bone-on-bone" type sensations. This went away.
-- Very rarely, some "pins & needle" sensations. This went away.
-- On very rare occasions, the feeling the knee was unstable and could twist or buckle off.
This went away.
-- On rare occasions, the tendon felt tender when touched. This went away.

Pain was most pronounced:
-- During and after walking. (Today, I sometimes still have some sensations after walking
longer distances.)
-- While standing in one place.
-- With prolonged sitting.
-- When driving, especially when pressing the accelerator. (I had the tendinitis in my right
knee.) Today, I still have some sensations when driving.

In addition, my pain generally increased as the day went on. So, during the mornings I had
less or little pain. In the late afternoon, I had much more pain.

I sometimes had pain walking downstairs. Less so, walking upstairs.

I typically had less or no pain when laying down completely flat.

Some days the pain was worse than others with no clear reason why.

The pain itself was throughout the length of the tendon, not just at the insertion points.


Q: I was recently diagnosed NOT with patellar tendinopathy, but a tendinopathy of a
different tendon in my leg. Might the exercises work for me?

A: The specific protocol described in this website is focused solely on patellar tendinopathy. I
cannot endorse it for any other kind of tendinopathy. Roughly similar protocols to mine have
been described in medical journals, but only for the treatment of patellar tendinopathy.

However, the larger concept of "eccentric exercise" has been shown to be helpful for other
kinds of tendinopathy throughout the body. You would need a protocol suited to the specific
kind of tendinopathy you have. For example, eccentric exercise is used for Achilles
tendinopathy.



Q: What do you think about 1) therapeutic ultrasound and 2) prolotherapy for chronic
patellar tendinopathy?
A: As for ultrasound, I don't believe it is helpful based on medical journal articles I have read.
It also did not benefit me, personally. As for prolotherapy, it may be helpful for some
ailments, but there is little to no documented research on using it to treat chronic patellar
tendinopathy. Again, I would stick with eccentric exercise.

Q: I do NOT have patellar tendinosis, but I am interested in doing these eccentric
exercises as a way to build up strength. What do you think?

A: If you do not have patellar tendinosis and have no knee or other ailments, then instead of
doing these exercises, I think you should find an excellent weightlifting coach and have them
design and supervise a well-rounded strengthening program for you. If you don't have
patellar tendinosis, but have some other knee ailment, then you should consult with a doctor
and physical therapist to provide you exercises that are appropriate for your condition. The
eccentric exercise described here is meant for those with longstanding patellar tendinitis.

Q: At what point did you begin doing eccentric exercise? Did you still have pain when
you began?

A: I began doing eccentric exercise 2 years and 2 months after developing patellar tendinitis.
I still had significant pain everyday when I decided to start the exercise program. However,
during the several minutes each day when I performed the exercise, I did not have any
increase in pain. I do not recommend doing the exercise if it increases one's pain.

Q: Will the pain of my chronic tendinopathy go away if I simply rest for a long enough
time and not do the exercises?

A: Some period of rest is reasonable. However, complete rest for too many weeks may lead
to muscle atrophy, which could worsen your problems. While complete rest may reduce your
pain during the period of rest, once you resume your sport, walk for a prolonged period, or go
down stairs, the pain will likely return.



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Click on "comments" just below for additional questions and answers. Also, many other
questions and answers can be found on other pages of this website.