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 (also spelled tendonitis or called tendinopathy) 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.

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.)

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:

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.

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.