Podcast #58: Patellar Tendon Rehab with Enda King


“The diagnosis of Patellar tendinopathy should be very easy… a lot of the difficulty comes as a combination diagnosis.”

Differential diagnosis: “For the most part, it really shouldn’t matter… a lot of the times, you’re looking for the same strength gains, change in motor control and coordination.”

“The principles of why the anterior knee becomes overloaded are very similar regardless of patellofemoral pain or patellar tendon.”

“When you have someone who is presenting to you with a 6-12 month history of ongoing chronic patellar tendon pain, the partial tear component is probably less relevant than someone who did a landing yesterday and had an episode.”

Tendon overload injuries: “It’s always a triangle of anatomy, function, and load.”

  • “You might have a very degenerative tendon but if you’re a sedentary person, that might never cause you any trouble.”
  • “If you’re an elite athlete… you may have a very degenerative tendon but of excellent function and excellent mechanics and a well-balanced training load and live happily ever after.”

“Chronic injuries are acute injuries where the window of opportunity to turn them and keep them as acute injuries was lost.”

BPS model in tendon pain: “They have mechanical pain. The psycho-social element isn’t causing the pain, it’s just turning the volume up and down. they still have mechanical pain. They’re a very functional presentation.”

PFP: “Certainly, the nervous system can start to drift towards non mechanical presentations.”

“The psycho-social elements turn the pain up or down but they’re not necessarily the cause of pain.”

“If they believe they have a tear and it needs to be fixed, unless you’re a magician, you’re not going to be able to turn them around.”

“The #1 thing is, what’s your quadriceps strength… #2 is what’s the strength of that limb… #3 is how do you express that strength during double- and single-leg squat…”

“The best way to know how your tendon is feeling is when you get out of bed in the morning.”

“Pain is not good or bad, pain is just informative.”

Morning tendon pain: “It’s the most reliable thing to use… getting out of the bed is getting out of the bed.”

“Pain during the session is important but it’s not as important as how you feel getting out of bed the next morning… because getting out of bed the next morning is a true reflection of how yesterday went.”

“Every time I’ve allowed a bit of discomfort, I’ve never really made as much profit on the rehab session as when I’ve allowed no discomfort.”

“If I had some anterior knee discomfort… maybe I’m loading my anterior knee more than I’m loading my quadriceps.”

“If I have pain doing the exercise, that probably tells me I’m annoying the area more than I am addressing the functional deficit that I’m trying to target.”

“Anterior knee pain after an ACL, that’s a rehab problem, that’s not a surgical problem.”

“It’s not that knee dominance is bad, it just has a consequence… the greater the shear and the greater the forces will be through the patellar tendon and patellofemoral joint.”

“You don’t get patellar tendinopathy without load. There’s a reason they call it jumper’s knee and not sitting down knee.”

“Injury prediction is a waste of time… because there is always more than one factor… we can never properly measure all the load and quantify the anatomy and quantify the biomechanics.”

Calf/Achilles complex… it’s probably the biggest factor that influences anterior tibial translation.”

Bending the knee during single-leg pogos: “They don’t have ankle stiffness so they’re going to tap in to the next available resource along the kinetic chain which invariably is their patellar tendon.”

Failed rehab: “They tend to just not have developed enough quadriceps strength.”

“80% of them will get better almost no matter what we do, give them enough time, offload them enough and they’ll settle down and get better.”

“If I want to optimize quadricep load, then for the most part, a front squat is the best way to do it because it will keep me more upright.”

“Far more people get better than don’t get better… not everyone who has ever had anterior knee pain is walking around with it for 3 or 4 years.”

“The reality is, the body wants to heal.”

People getting better: “If it’s not happening, very often we go to blame the anatomy rather than looking who is poking the bear here?”

“The hardest part in any rehab is trying to find the entry point… where based on their irritability and function, you can find a way of getting an adaptation that’s going to start bringing them up the ladder.”

“Every chronic injury is possibly an acute injury that was an opportunity missed.”

“If I can’t do a modified through range exercise without getting pain then an isometric will be the way in to that.”

Decline/Sissy squat: “Because of the knee angle, they’ll have a bigger knee extension moment and a greater quad activation, but at what cost?”

“Any exercise that gets a massive quad hit while not irritating the area is a winner for me.”

“A big anterior [tibial] translation… is not necessarily your friend for patellar tendon graft or when you’re trying to regulate the load through the ACL during jumping, landing, changing direction activities… I don’t generally see the functional benefit of it.”

“If I can smash the quads well in a pain-free manner and progress it through, that will look after the vast majority of injuries.”

“If I can do one exercise, it will be a quads exercise. If I can do two exercises, it will be two quads exercises.”

The tendon healing process: “If we are addressing our function, focusing on good mechanics, symptoms during training, and getting out of bed the next morning, the biological process will do what it’s doing and we’ll kind of be paddling out canoe alongside it.”

“The broader my assessment is, the less I’ll miss.”

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Tendinopathy Course: https://study.physiotutors.com/course/the-big-3-advanced-rehabilitation-of-hamstring-quadriceps-and-calf-muscle-and-tendon-injuries/