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:



-- 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.