Wednesday, December 26, 2007

MY ECCENTRIC EXERCISE PROTOCOL

I describe my eccentric exercise protocol below. I developed it through trial-and-error over the past 1-2 years. It is what has worked for me to eliminate knee pain related to longstanding patellar tendinopathy.

Unlike prior eccentric exercise protocols I experimented with, this protocol has not led to relapses in my knee pain. Through trial-and-error, I discovered that if too much weight is added too soon, eccentric exercises can lead to flare-ups in symptoms, particularly increased pain. So, I caution anyone who embarks on eccentric exercises to use a proper protocol. Furthermore, I highly recommend that prior to starting eccentric exercises that you consult an appropriate medical specialist and a good physical therapist.

The exercises should not be done in the early stages when one still has inflammation. They are recommended once the inflammation of tendinitis has gone away, but the pain remains.

I developed my protocol after reviewing the medical literature on using eccentric exercise to treat patellar tendinopathy. However, the articles in most cases were not very precise on the exact protocols used and left out some important details. I had to fill in the details through my own trial-and-error over the past couple of years. In late 2005 I started on my first self-designed program of eccentric exercises. However, after a number of weeks of doing the exercises, my pain increased and I stopped doing the exercises. Then, in mid-2006, I started my second program of eccentric exercise, but my pain started to increase again after a month and I again temporarily stopped the exercises. During the first few weeks of the two programs, the exercises seemed to somewhat reduce my daily knee pain. However, as I continued to add weights in each case, I eventually ran into problems. While I did not have more-than-usual knee pain doing the exercises, my pain began to increase significantly during the day in the following 1-3 days just before stopping the programs. I was determined to come up with a protocol that would not lead to a relapse.

As I look back on my data from the first two programs, I firmly believe the problem was that I added weight to the backpack too quickly. So, the protocol I now use corrects this problem.

These are key aspects to the protocol that has worked for me:

-- I do the exercises ONCE a day and AT NIGHT before going to bed. I discovered that when I did the exercises in the morning, I had greater, annoying knee pain during the day. However, when I did the exercises before going to bed, the tendon and surrounding muscles had time to rest over night. I do not endorse protocols that call for doing the exercise in the morning. I also do not believe the exercise needs to be done twice a day to be effective.

-- For the first 2 months, I did the eccentrics on the slant board without using any weights in a backpack.

-- For the first two weeks, I used BOTH legs together to do the eccentric squats. I ramped up from 1 set of 10 repetitions to 3 sets of 15 repetitions over that period. By squating with both legs at the same time, you will be putting much less force on the bad knee compared to doing a single-leg squat.

-- After that, I stopped the two-leg squats and began performing one-leg squats (i.e., performing squats with the bad-knee leg.) I began with 10 repetitions and added only 1 or 2 repetitions per day. When I built up to 45 repetitions over four weeks, I stayed at 45 repetitions for another couple of weeks. Again, all of this was without any weights in a backpack. (Every 15 repetitions I considered a set. I usually took a 5-20 second break between each set.)

-- When doing the one-legged squats, I'd recommend the following, which is not shown in the video, and which was not part of my original protocol.  It will help you to focus more of your bad leg's energy on the eccentric portion of the movement, and less on the concentric part:  Once You Are At The Bottom Of The One-Legged Squat (In Other Words, The Point Of Maximum Squat, Just When You Are About To Return Up To Standing) Come Up To Standing With BOTH Legs.

-- During month 3, I introduced weights into a backpack that I wore while doing the eccentric exercises on the slant board. I started with 1/2 pound. Then, every 4 days I would add another 1/2 pound into the backpack. (1/2 pounds weights can be obtained from ankle weights that use 1/2-pound inserts.) THIS STEP IS VERY IMPORTANT. IT IS WHAT CAN MAKE THE DIFFERENCE BETWEEN HAVING SUCCESS OR FAILURE WITH ECCENTRIC EXERCISE. Weight must be added S-L-O-W-L-Y over time.

-- There will be the temptation to add weights more quickly. DON'T DO IT. You may find that in the early weeks of doing the eccentric exercises they are helping to reduce pain. You may believe that you can add weights at a faster pace because of this improvement. Through trial-and-error, I learned the hard way not to add weights any faster than 1/2 pound every 4 days. After a period of time, after adding weights, if you find your pain rising in the four days after increasing the weight increment, I would not increase weight further. You may need to stop altogether or for a few days or a week or more. You may need to reduce weight in the backpack. When you resume, you may need to stay on the same weight for more than 4 days.

-- Even if your pain is not rising in the days after adding weight to the backpack, you may still decide to hold off adding weight for more than 4 days if you are not absolutely comfortable with adding additional weight. For example, when I got to 15 pounds, I stayed at that level for 8 days before I went to 15 1/2 pounds. I wanted to be able to do the 45th repetition at 15 pounds fairly easily before proceeding to 15 1/2 pounds.

Please double click the forward button to start video:

video

-- Weights should continue to be added over time at the same rate described. It is not clear what the upper limit of weights should be, however. A number of research protocols seem to suggest 20-25 pounds as a possible upper limit. However, the upper limit will likely be different for each person depending on a variety of factors -- age, general health, one's own weight, general physical abilities, etc... I believe one will be able to see improvement well before getting to 20 pounds, however, and I cannot say I endorse going all the way to 20 pounds. It is very possible that for some people 10 pounds (or less) may be as far as you should go. It is also not clear when to stop the exercises altogether. A number of research protocols suggest that after a period of months of doing the exercises every day that the exercises be continued for another year, but not necessarily each day. This is one part of my protocol that is not yet nailed down.

-- The slant board I use has roughly a 25-degree angle. (If you have a slant board with less angulation, you can increase it with a thin piece of wood. But you would need to review some trigonometry so you don't raise the angle too much!)

-- I DO NOT subscribe to those protocols that say you should experience higher-than-typical pain while doing the eccentric exercise. If you have significantly more pain while doing the exercise, you should stop. You may have ramped up your weights or reps too fast in prior days. You should take off a couple of days from the eccentrics and consult with your physical therapist and/or doctor.

-- I attempted to do the eccentric exercises every day. However, there were times when I had a bad cold, or my pain was temporarily elevated, or I was away from home. On average, I took off 1 day out of every 18 days.

-- IT IS VERY IMPORTANT TO KEEP A DAILY LOG BOOK. The log book should include the number of repetitions and the amount of weight being used that day. Additional information, such as your pain score on a scale from 0 to 10 and other notes can be added.

-- I generally tried to limit other kinds of exercise when doing the eccentric protocol. On occasion, I did go bicycling. However, when bicycling I used very easy gears, a higher cadence, and avoided hills. For the first 2-4 months, I'd limit significant exercise. (If you swim, I'd avoid the breaststroke.)

-- I stretch on a daily basis. After doing the eccentric exercise each day, I also roll my IT-band and quadriceps on a "foam roller."

-- I do not apply ice after doing the eccentric exercises. (In my first two programs of eccentric exercise I religiously iced, but did not do so for the protocol described here after I determined that icing may not have been providing any benefit.)

-- I set up my slant board with chairs or other large objects to the left and right of the slant board. This is so I could lightly brush my hands against these objects to maintain balance while doing the eccentric exercises. It is important to maintain balance while doing the exercises. However, I did not want to hold firmly to any object given that it could have negated the effects of the weight in the backpack. So, I maintained my balance by lightly brushing my hands against objects on either side of the slant board.

-- Once on the slant board, I squat down to a count of 2 to 3, and then rise up from the squat more quickly. It is the downward part of the exercise that is the eccentric phase. The move back up should be steady and smooth, not explosive.

-- A number of medical journals use a 12-week protocol. However, my protocol is at least twice as long. Through trial-and-error I found that doing too much too soon can lead to relapses, which will ultimately lead to needing to take time off before starting again. If there is a relapse, then the total time required may be substantially longer.

-- To remind oneself to do the exercises, place a note by your bed.

48 comments:

Anonymous said...

Hi - Very interesting blog. How deep are you squatting? thanks/ Brian

Sigfus said...

I would say 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.

I would like to add a video demonstration to the site, and hopefully, one can see the extent of the squat.

Anonymous said...

what is the purpose of using a slant board? thanks.
DP

Sigfus said...

The purpose of the slant board is to reduce help from the calf muscles, thereby making the patellar tendon do more eccentric work.

KickingWorld.com said...

these exercises are great for soccer-style football kickers and soccer players. I coach kickers & punters and many have overused patellar tendons from the hard plant foot movement toward the ground and therefore get patellar tendinitis. It is important to strengthen this tendon. Check out our website if you are a kicker or punter- www.kickingworld.com

Anonymous said...

I came down with this injury a few months ago after a 40 km bike ride on a cold leg and not warming up properly and not listening to the sharp stabbing pain in my knee, then running the Vancouver Sun Run a week later -- well I paid for it. I was out for 2 months!!!! This injury is no joke and it'll be with me the rest of my life. Luckily I don't have it as bad as you and after 2 months the pain has almost totally gone (I'm still babying my knee though), and now the strengthening begins. A couple days ago I started the eccentric exercises and even though I can feel the tendon while I'm doing it I don't feel pain afterwards, I think I actually have become a bit stronger in 2 days. I am very glad about this, it suggests that I am fully healable providing I rehab properly and keep up with exercises and ALWAYS remember to warm up properly before pushing my legs. I'm sorry, body!

KnäTomas said...

Thanks for your excellent website with all interesting information!
Im not alone.............

I have had problems with "jumpers knee" since october 2007.
I injured my knee when i was jumping from a 2 meters height. (a split second decision)
I was also training for MMA competition and had to keep my weight. Therefor i was walking every day, running intervalls, bicycle etc. (overuse)
There was a burning sensation that i ignored and later tried to forgett. (STUPID of course!) After a while i had to rest, or i thought i had to rest for maybe one week....
The first 4 months i was limping. I could not walk far before pain and stiffness. I have tried the most: Voltaren, Diklofenak, Ipren, Naprapat with massage, 3 different doctors, rehab practitioners, shock wave therapy etc.
The only thing that work is.

In first stage= Rest, rest, rest. Until inflammatory is over.
Then some light workout and stretching.
I tried to hard in the begining and overused the knee lot of times

Later= Eccentric exercise as one leg squat with a decline board. I have a machine (benspark in swedish) I pull up weight by hand and slowly lower with bad leg. Both excercises works for me.
I also do my excercise in the evening because i feel better if i heal and rest to next day.
I have one good aerobic exercise, Rollerblades with sticks (stavar). Here i can work with my whole body and do not have to make consentric movement with knee (I have big problems to straighten my leg if it is bent= consentric movement of tendon and quadriceps.) I have problems when I bicycle and walking to far.

Now it is better but it is still very easy to overuse the knee and have to take som days of extra pain.


If you make 1 leg decline board squat it is important that you make it correct. Conclusion from an article regarding angles:

"What this study adds

This biomechanical analysis provides validation for the use of the single-leg decline squat.

Decline angles between 15° and 30° can be used to increase the patellar tendon force.

Knee flexion >60° should be avoided to prevent excessive patellofemoral load."

It is better to add weight than increasing Knee flexion angle!

Anonymous said...

I am July 17 anonymous.

Well it's back. I took one step forward and two steps back. After my exercises I did too much activity and boy do I feel it. Lesson learned.

You HAVE TO take these exercises slowly. Just because it doesn't hurt doesn't mean you aren't going too far. I have lapsed back a month and it will be a huge test of my discipline to NOT push myself too hard, even if my leg feels OK. I have finally accepted that I will be out for the rest of the season. An entire summer wasted because of 1 hour of stupidity.

Anonymous said...

Thank you for this website.

After suffering for 4 years, I have understood that this problem does not go away so easily.

1. Yoga helps a little bit only. 2. Regular squats are useless. 3. Taping seems helpful but does not heal the real problem

I have never done the slant board before, I will try and post my results.

Joseph said...

I am a 42 y/o md (anesthesiologist) I have daily access to multiple orthopeadic surgeons. They no very little about how to treat this.I was an avid basketball player, runner weight lifter. I have had a rough 2 years with this pain.
I had a PRP(platelet rich protein ) injection, it made me worse.
I just found this site now I have a good new years resolution.

good luck to all

Joe

Anto said...

Hi, thanks for an excellent site! One question though: Do you do any warmup before your exercises?

Sigfús Víkþörðson said...

Anto,

No need to do warm-up exercises before doing the eccentric exercises. You can stretch before and/or after, however.

ario said...

Hi Sigfús, what's your advice for performing the protocol at night if you've already done some form of leg exercise during the day?

I already feel a bit of knee tenderness after a long bike ride, yoga, or weight workout... so I'm not sure if I should do the eccentrics on the days where I've already worked my legs.

thanks!
--ario

Sigfús Víkþörðson said...

Ario,

To properly do the protocol, you should refrain from doing much other exercise for a period of 2-4 months. If you must do other exercise, hopefully it is light exercise that is not putting strain on your knee. I would avoid doing the eccentrics the same day as other exercise. If you feel tenderness, you may also want to skip an additional day before doing the eccentrics.

Good Luck!

ario said...

Hi Sigfus, here's an update on my knee pain:

http://interimlover.livejournal.com/554029.html

short version: I'm running again and the eccentrics really helped!

Billy said...

You mention starting out with 10 repetitions and slowly increasing up to 45 however I can't find any mentioning of how many sets of this you would recommend. I read that you consider every 15 reps to be a set but I'd like to know how many total per day this would mean.

Sigfús Víkþörðson said...

Billy,

You do the exercises 1 time per day, at night. So, in other words, you will get to 45 repetitions once per day. That's all. (You will do them in 3 sets of 15.)

Kit Kline said...

Hi Sigfús,

Having just done 3 months of rest (vey little improvement at all and some wasting of the quad muscles - exactly as you state in your blog - but I wanted to be sure it was not inflammatory and make sure I had given 'rest' a chance) I'm going to start in v-e-r-y gradually on your protocol.

I did have a couple of questions. Along with pat tendinosis I also have quad tendinosis as well. Do you think:

(a) It might have any benefit for the quad tendon as well? It's still going through eccentric phase in that down motion after all

(b) Or, do you think there could be a risk of making the qaud problem worse by this protocol?

(c) Did you, or have you heard anyone else describe symptoms like a 'cold wet feeling' all around the affected tendons. I get that a lot - more than the pain and it's really weird and uncomfy

(d) If I fully extend the leg, keep the load on and then flex it - I get a nasty grindy sound from the tendon/patella join (i'm guessing scar tissue) . Do you think it is best to avoid making that noise (I do get it if I come right up to full extension and then start down on a sqaut) or should I 'work into it' in the hope of improving that area of tendon?

I really appreciate your excellent blog and advice

Many thanks

Kit

Sigfús Víkþörðson said...

Kit,

I believe eccentric exercise may also help with your quadriceps tendinosis. When I had patellar tendinosis, I also had -- at times -- symptoms of quadriceps tendinosis.

The "cold-wet" feeling you also have could be neuropathic pain, which can accompany the underlying tendinosis. I also had neuropathic pain, although my symptoms were more typically that of burning pain. These neuropathic symptoms typically go away over time and when the underlying tendinosis improves. If it is very bothersome, you may decide to consult a neurologist.

The noise, likely crepitus, may not be a problem, but if you can avoid it, that might be better. You should consult a physician, particularly if you have pain that accompanies the noise.

If you haven't already, I would consult with a medical doctor and/or physical therapist, as well, as you go about your treatment.

Anonymous said...

I've just started eccentric treatment. My question is about the other activities and exercises we undertake during the day. How minimal should they be? Should we avoid long days at work, moving furniture, long walks, riding bicycles to the local shop. Each day I do a different amount of activity and logically it must impact on my tendon. Does regularity help? Any ideas? thanks

Sigfús Víkþörðson said...

During the weeks/months you are working on the eccentric protocol, I would certainly limit other exercise that can impact the tendon. Hence, no long walks; no lifting/moving heavy furniture; avoid bicycling, etc... Avoiding all of this may be the toughest part of the protocol.

NC said...

Hi Sigfus

With your protocol, can you describe your rate of progress (pain relief, etc)? I imagine the improvement was progressive? Looking back at your log, was there one day/session that was memorable in terms of an "aha!" moment?

Thanks

Sigfús Víkþörðson said...

NC,

Today I looked back at my diary of daily pain scores. The improvement was progressive, but within a couple of weeks of starting the eccentric exercise I noticed improvement.

Let's start with a baseline of my average daily pain scores for the three weeks prior to my commencing eccentric exercise. Let's then compare this to my pain scores for the weekly averages three, six, nine, and 12 weeks after starting the eccentrics.

For the third week after starting the eccentrics, my pain was 12% less compared to the baseline.

For the sixth week, my pain was 18%less than the baseline.

For the ninth week, my pain was 15%less than the baseline.

For the twelfth week, my pain was also 15% less than the baseline.

Some comments -- You can see that there was improvement within a few weeks of starting. However, the improvement plateaued in the weeks after that. Further improvement took more time, but the pain eventually went away.

On the surface a 15% improvement may not sound like a lot. However, when you are in a lot of pain, a 15% reduction is very satisfying. It also showed that I was on the right track, and my pain reduced further over time.

NC said...

Hi Sigfus

Can you comment more on how you determined when to increase reps/weight resistance during your progression? You mention 4 days between increases and monitoring increases in pain (I assume from your log) to determine your progression. Can you comment more on how you determined you went too quickly and your "setbacks"?

I'm progressing slowly along with declines, but naturally over the course of my workday (although largely seated, I attend and must walk to several meetings per day), I feel rather sore by the afternoon/evening. This makes it difficult to tell if I've progressed too quickly/slowly as I can't really determine a sense of "feedback" as to increases in pain, or if I'm just feeling ache/soreness from just everyday use.

Sigfús Víkþörðson said...

NC --

Every four days after adding weights in the backpack, the main choices are 1) Add an additional weight OR 2) Don't add additional weight; OR 3) Stop altogether for a period of time.

The key question to decide this is: Has your average pain increased during the past few days RELATIVE to what it was the last time you had to make the same choice, that is the several days before you last decided whether or not to increase the weight.

If the pain did not increase, then add weight. If the pain increased a little, then don't add weight (or even reduce weight). If the pain increased a lot, then stop altogether for a period of time.

The nature of my patellar tendinitis was that every day I had some level of pain. Hence, I had to focus on whether the pain increased or decreased, not simply whether pain existed or not. The only way to do this is to take daily pain scores.

Separately, I'm not sure how far you need to walk to your meetings. Lots of walking per day (say more than a half mile or 0.8 km) may interfere with the effectiveness of the protocol. In the worst phases of my tendinitis, I took taxicabs instead of walking the few city blocks I'd normally walk.

I encourage you to record careful daily pain scores and try to use that as your guide. Unfortunately, you may have to do some experimenting as I did with a trial-and-error approach.

Good Luck!

Pamela said...

Sigfus,

Thank you for your informative web site. I have had chronic patellar tendinitis for 8 years. I was doing a lot of hill running when I injured my knee and have had chronic symptoms that are minimal at times and then worsen related to my activities.

This winter I took up nordic skate skiing and the symptoms worsened. I consulted a pt and an orthopedic md; both recommended the eccentric exercise protocol you recommend. Though I was instructed to do the exercise protocol 3 times per day 12 repetitions per leg.

I run, swim and rollerski 5-6 days per week and have cross trained for years to cope with the knee injury. Neither the pt nor the orthopedic md recommended that I discontinue aerobic exercise while I use the eccentric exercise. Do you think it is necessary to discontinue my aerobic exercise completely?

Do you think the skate skiing could worsen the symptoms of patellar tendonitis?

Thanks for your help.
Pam

Sigfús Víkþörðson said...

Pam,

I believe skate skiing can worsen the symptoms of patellar tendinitis. And, in your case it easily could have been the trigger. I've tried skate skiing and know it is very strenuous exercise. I could easily imagine it worsening your underlying symptoms.

Ideally, you won't do heavy amounts of other exercise when engaging in the protocol. I might suggest taking off a couple of weeks of aerobic exercise and then only do a low-to-moderate amount while doing the protocol. You do a lot of exercise that could interfere with the protocol. You may need to experiment and re-start the protocol with less outside exercise if it doesn't work the first time.

Good Luck!

Don Brasco said...

Helllo,

First just wanted to say thanks for the website and sharing your experiences, it is very encouraging. I was wondering if I should start using the slant board right away or is this something to build up to? If I don't use it right away am I basically just doing squats with out weights in a slow fashion? Any help would be appreciated. Thank you.

Sigfús Víkþörðson said...

Hello,

The Protocol is designed to be started on a slant board. However, if you prefer, you can start slowly without the slant board at first -- say for the first couple of weeks or so.

To build up slowly you could also do the eccentric squats with both legs for several days or weeks before you move to just one leg.

An integral part of the protocol is the tempo of descending slowly (the eccentric phase) into the squat. So, it's not exactly the same as doing regular squats.

Anonymous said...

My story - 12 months with both knees. I have daily pain with simply walking. Seems like straight legged lifts cause pain. I've tried doing the squats = 1 rep every other day and have increased pain on day 8. Should i stretch out the days rest between my 1 rep or is this so severe I should go back to the ortho and have him cut me?

Sigfús Víkþörðson said...

Given that you are doing only one rep every other day -- and I assume with zero added weight -- it is likely that your increased pain on day 8 is unrelated to the eccentric squats. I don't think that adding more rest days will have any effect.

Perhaps there are other reasons for your increased pain. For example, are you doing a lot of walking or other activity in the days prior to day 8?

Surgery is irreversible and it may not help. I had considered surgery and glad that i didn't pursue it, although I suffered with patellar tendinopathy for several years until I found something that worked.

I would suggest you consult with your orthopedist and a good physical therapist about trying non-surgical methods. Perhaps, a physical therapist might work with you and design an eccentric protocol that works best for you. They may even try to increase your starting reps, rather than start at one.

Good luck!

Sam said...

Thanks for the website.

I have been doing the protocol for about 6months now! I am up to 26pounds but can't really go higher as my quads are not that strong.

The squats have taken away the pain, but what should I do before I start playing sports again? I have slowly been increasing the resistance of my bike machine and can ride for 30minutes on quite a high setting without pain, although the tendon does feel slightly tender afterwards. Shall I start jogging soon, or aim to cycle for longer periods on a lower setting? And shall I continue with the squats? I was thinking maybe doing cycling every other day, and squats in between.

Thanks so much,

Sam

Sigfús Víkþörðson said...

Sam,

Great work on following the protocol. Congratulations!
As for cycling, I always advocate less resistance and higher rpms, rather than heavy resistance and lower rpms. Assuming there is no medical issue in returning to sports, you probably could start jogging and continue cycling. However, you really must ramp up slowly with jogging. Literally, jog only a couple of minutes the first time out and wait a day. Add time slowly until it is clear there's no problem. Also, your approach of doing cycling every other day with the squats in between seems reasonable. I would not add any further weight to the squats. In fact, you may want to reduce the weight.

Make sure to document your daily sports and squat actvities including reps, time, mileage, resistance level, etc... as well as how your knee feels. This daily log will be very useful to help you determine whether you can progress further.

Good Luck!

Anonymous said...

Thanks for your site. It's extremely helpful and valuable. I had a question about the angle of the slant board. This protocol calls for a 45 degree slant: http://www.sportsinjurybulletin.com/archive/patellar-tendon.html. But you say it should be around 25 degrees. Do you think there's any advantage to increasing the angle to 45 degrees?

Also, I've read that transverse friction massage of the patella tendon can help. Did you do this or do you do it now that you've recovered?

Thanks.

Sigfús Víkþörðson said...

Hello and thank you for your questions.

As a reminder, the purpose of the slant board is to reduce help from the calf muscles, thereby making the patella tendon do more eccentric work.

It's correct that my protocol calls for around a 25-degree slant board. I'm not sure whether or not there would be an advantage to using 45-degrees. It's possible there could be disadvantages, instead, because of the greater stress on the tendon. In any case, if you were to experiment with a 45-degree slant board, I would certainly work up to that level slowly over time rather than starting on 45 degrees immediately!

If you were interested in experimenting, there are "multi adjustable slant boards" on the market in which you can adjust the level of the slant up to approximately 45 degrees. You can find these on the internet. You will find several by searching in Amazon.com.

As always, I recommend you consult with a physician or physical therapist, particularly if you begin experimenting with anything that will put more stress on the tendon.

On your second question... I had also had read that transverse friction massage of the patella tendon could help. And, I sought out massage therapists to do this. Unfortunately, for me, it did not help, even temporarily. However, I did find benefit in massage of the muscles around the knee, rather than massage of the tendon itself.

If you do test out a 45-degree slant board, please let us know of your progress!

Best of luck!

JM Maldonado said...

Dear Sigfus:

It's really great to have this information on te web. Many, many thanks!
My question: About the angle of squatting... is it related to the pain during the exercise? I Mean: is there a pain sign (even little) to stop, or I should allow a little bit?

many thanks again!

Sigfús Víkþörðson said...

JM,

You should avoid pain during the exercise.

The lower you squat, the more likely you will get pain.

If you squat too low, you may develop too much pain you that will take days or more than a week to go away. You will then have to stop the Protocol and rest for days or longer. So, it is best to to avoid pain.

Tony Radford said...

Hello Sigfus,
Thanks so much for having this blog site. I have made a incline and started doing this two days ago. I have some questions.

I am working out with weights and have stopped all lower body workouts until I get my knee better. I have had this problem for two years and woke up one morning with it after a long run on a treadmill. I need to do some kind of cardio, because I need to exercise my heart and get my metabolism going to lose weight. What can I do if I need to not walk and bike? I do like to do the elliptical, is that a option? What do you suggest?

Also, do you suggest always doing this exercise the rest of my life? It was something I was planning on doing, even after my knee gets better.

Thanks,
Tony

Sigfús Víkþörðson said...

Tony,

I would refrain from the elliptical for a couple of weeks and then try to limit it. I would keep the resistance very low and don't use much of an incline.

You can continue to do the eccentric exercise even when the knee improves.

Make sure you consult with a proper physician to make sure these exercises are right for you.

Remember to ramp up very slowly.

Let us know of your progress. Good luck!

Matt A said...

Hi Sigfus thank you for creating this excellent blog. You strongly stress avoiding a pain increase/relapse. I was wondering if you continued to perform eccentric exercises even though the pain was slightly worse the next day, could the improvement of tendon tissue still be possible over time? Would the benefits of eccentric exercises eventually come into effect after the apparent relapse?

Sigfús Víkþörðson said...

Hello Matt,

If the pain was just slightly worse the next day, I would still do the eccentrics, but might reduce the number of repetitions or weight. Anything more than a slight increase of pain may require taking at least a day off the protocol.

Good Luck!

coastaltrio said...

Sigfus, I've been dealing with patellae tendonitis and patellae femoral syndrome for about two years now. This is most likely because of my history of running and biking (I'm a full time bike commuter).

Been through the same hoopla with doctors as you. However, your website has given me a bit of hope.

I purchased a 22 degree slant board and have been doing the two legged squats for about a week and a half - switching to one legged for the past couple days.

After doing the eccentric exercises for the past couple weeks, my knees feel slightly inflamed immediately after squats, but felt MUCH better than they have in the past after waking up in the morning.

I've continued to commute to work as well on the bike (which doesn't help), but my knees aren't nearly as aggravated as they were before. I think this is working, as the irritation is much more focused than in the past - and the pain is nearly gone (just minor inflammation at this point).

I also got a bike fitting and clipless shoes/cleats.

Anyhow, thanks for your site. I'm hoping that after a few months of doing this, the knees will be in better shape. A couple weeks has proven beneficial and I'm really looking forward to the next few months.

Luis said...

Hi,

Thanks a lot for all the info you posted. I kind of reached the same conclusions as you over time - that eccentric exercises are the one that will really help (with results proven in scientific literature).

However I have a questions I cannot find answered and maybe you have an idea: do you know if the eccentric exercises will work on a 35º slant board (instead of a 25º board)?

Luis said...

Hi,

Thanks a lot for all the info you posted. I kind of reached the same conclusions as you over time - that eccentric exercises are the one that will really help (with results proven in scientific literature).

However I have a questions I cannot find answered and maybe you have an idea: do you know if the eccentric exercises will work on a 35º slant board (instead of a 25º board)?

Sigfús Víkþörðson said...

Luis,
It will likely work, but the angle of decline may put too much force on the patella. It may intensify the eccentrics to an unhealthy level.
Sigfus

Luis said...

Thanks for the fast answer. That's what I though about. However I've also wondered if reducing the squat angle may also reduce the force in the patella to a level close to the one used in the 25º board.

I tried a 25º board on PT; but decided to make one to use at home. However, not sure why (as the calculations were right; maybe the cuts werent!) it came out at a 30-35º angle.

Rob said...

Hi Sigfus,

Thanks for your careful description of your recovery on this site. I've visited often since developing this problem over a year ago. I've been seeing a therapist regularly, and she has included eccentric squats as part of my treatment, but both she and my orthopaedic doctor have told me to continue cycling, etc. (I developed the injury with running.)

I have gradually come to the conclusion that their advice is, in my particular case, not conservative enough. So, I've stopped all activity and am going to follow your protocol from scratch.

In that regard, you suggest that the eccentric exercises "are recommended once the inflammation of tendinitis has gone away, but the pain remains."

How does one tell if the inflammation has gone away? I ask because I always have a spot on one side of the bottom ridge of my kneecap that is somewhat sore when it is palpated while I am seated. Should I be waiting until this palpation-pain is gone before starting the protocol?

Thank you!

Sigfús Víkþörðson said...

Hi Rob,

Yes, I would refrain from cycling. (I developed my patellar tendinopathy from cycling!) Once you start cycling again, use easy gears and avoid hills for a period of time.

Being conservative with the Protocol is what I endorse, as you know. So, I am glad to hear that you will try this.

Inflammation typically lasts only days to a few weeks. It sounds like you are well past that point. So, you can assume you have entered the "tendinosis" phase and no longer have "tendinitis" in the true sense of the word.

The sore tender spot can be consistent with tendinosis. You ask if you should wait until the pain is gone before starting the protocol. The pain upon palpation may not go away until your tendinosis goes away. So, you can start the protocol. However, since you have been cycling, I would wait at least 2 weeks before you begin the Protocol. I also recommend stretching and using a foam roller as mentioned on this site.

Good Luck!
Sigfus