Conquering Knee Tendonpathy in Athletes - Avoiding being the S&C woodpecker

What can be a royal pain which effects around a third of athletes? Good old knee tendonopathy – whether patella or quadricep, it’s a regular challenge for any S&C coach. This can be in youth’s or adults, distance runners or footballers, world champion or weekend warrior.

I have no doubt you’re well read on the topic, have case studies under your belt and attain a good degree of confidence in this area. However, I also suspect you have current or past experiences of when this pain issue, has indeed presented you with your own pain in trying to resolve it when it seems at times like you’re banging your head against the proverbial brick wall?

Tendon pain can often linger even once it appears to be gone, it can be unpredictable in what can trigger it, and the best ways to often help can easily sound irrational to those that you coach.? All in all, this throws various curve balls to your well planned out reconditioning strategy.

That’s what motivated me today away from my coffee (and if I’m honest listening to my wife while trying to work), to share the deeper, important and easily overlooked aspects to a successful outcome with knee tendonopathy, back to full sporting performance.

To focus in and make this bitesized, I’m going to avoid some of the common chit-chat around this, which while commonly valid and totally fair, is ground already well covered. Instead focusing one main area…

Post Mortem - To get answers, we’ve got to strip it back to it’s bones.

We know tendonpathy in the patella and quadriceps comes from mechanical loading beyond the tolerance of the tendon, leading it to become reactive or more chronically degenerative. Additionally, by increasing strength of the muscles locally and peripherally, this can reduce the mechanical loading on the tendon, which is key to the solution. But we can easily forget another crucial variable in this equation and where we will focus today – recovery (disclaimer – by this I am not about to refer to ice baths, supplements and all that jazz).

With this type of injury, it’s not due to a one off acute problem. But instead, chronic loading, and the recovery the tendon is provided will influence its future ability to tolerate mechanical loading from a sport. In true, authentic Performance Peek style, I’ve sketched this below, kind of how you might on the back of a beer mat. This slightly sloppy but fundamentally accurate piece of art shows the following key points:

• You can expose someone to similar loading (e.g. training) but insufficient recovery can make a similar stimulus go from not triggering tendon pain, to now triggering pain.
• If this happens more chronically it means the tendon is spending more and more time above the threshold that evokes negative adaptations either neurologically or structurally.

While increasing strength to heighten the ability to tolerate more mechanical loading is 100% spot on and logical (as shown in the second picture below, where the threshold is heightened and the same training doesn’t surpass this). The other side of this is how you can manipulate recovery from training - the repetitive ground contacts, acceleration and deceleration performed out on the pitch or road.

While I fully believe, as science supports, that strength training to heighten this threshold is powerful. In cases which are more problematic in knee tendonopathy, this second variable of recovery almost always has to be managed without fail. Dare I say it, if it’s not, no amount of iso’s, knee extensions, wall sits or anything will allow the athlete to return to successful performance long term.

Hammering tendon strength like a woodpecker

Do you remember the old lecture at uni which showed that, to create an adaptation physically, you needed recovery? Look at this now through the lens of strength training, rather than running - there is high risk that in the pursuit of optimal strength development and our own enthusiasm to nail it, that we don’t give sufficient recovery to optimise strength development to reduce tendon loading – because you can over do the strength stimulus. How?

With good evidence to show strength training causes acute and chronic benefits favourable to a tendon, this can lead to an almost daily bout of strength work targeting the key muscles, to achieve short and long term wins. Two main strength sessions in the week, separate isometric exercises most days before field training, physio led training, on top of sport training – bang, bang, bang. Would we train a hamstring strain like this?

This concept of allowing sufficient recovery is so simple, yet through thought and reflection, is a common area positive tweaks can be made (and equally errors made). Even when overall training volume is out of our hands when an athlete returns to performance, we can still manage these other training variables noted if as common, technical coaches are reluctant to listen. Avoiding pecking away with a constant training stimulus aimed at the tendon, to limit excess workload and give a suitable recovery window can be easily missed in pursuit of the perfect programmee

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A Case Study – Back to what he loves

As an example, at CP recently, we supported a youth academy level footballer back from major knee injury (bipartite patella with patella tendonopathy). This was so significant that jogging cased high levels of pain, as did even walking up a staircase, which ultimately made him wonder if he would play football again. ?The surgeon didn’t want to operate, other forms of treatment had failed, so it was kind of last chance saloon.

His reconditioning plan was three-fold:

• Strength training to develop local and peripheral muscles to greater stabilise the knee and reduce tendon loading
• Start, from scratch, a progressive return to running programme based on the training demands he needs to return to.
• Considering how to manipulate recovery alongside this, over each week, to keep below the threshold which evokes issues.

This was a tightrope, as this ‘threshold’ isn’t a fixed number, or something you can see. It’s a logical point you acknowledge from feedback, experience, knowledge and intuition. And each week you’re doing your best to use all of this to progress to the next point. ?

The objective was to get him back into full club training, so he could then progress back into match-play – something the club were very accommodating of and gave us free will to manage everything before he returned. To achieve this, the overall plan started with:

• Linear running, no significant decelerations, at ~50% of max velocity only, for a volume of 20% of what he would in a match (this was a short session to test the water).
• Performed twice in week 1 with 4 days between them and no strength on these days. Strength training was twice a week (stripped right back).

Over the weeks the following progressed:

• Running distances went from 50 to 100% of max velocity in match. Decelerations went from none, up to including hard decelerations.
• Both of these went up to totalling ~60% volume of what he would in a match. This was a point I felt would be enough to cover the demands of football training upon his return, with a good surplus in reserve.
• We did not worry about running speeds below 50% of max velocity, as these were not a priority, as they were not the main culprit in tendon loading and would easily be attained in training later on without concern.
• He had two full recovery days each week, even at the backend of this before returning to full training. And this was recovery – no isometrics, no ‘movement prep’, just rest.

I could go into further detail, but don’t want to stray from the main theme on this article. The point is that his successful return to football was underpinned hugely by addressing the absolute basics and not forgetting them, in particular recovery and pursing quality not quantity. If I had not been able to control the return to run progression and overall training plan over these weeks, I’m convinced the outcome would have been the complete opposite.

And in closing, the irony of all of this, is that it required stripping things back and doing the bare basics with laser focus. Even the strength exercises and drills used for this were very simple, no fancy rehab drills like you see on your insta reel. It’s often easier to try and go with everything, rather than have to back yourself to strip things back and trust what from the outset can look simple.

Thanks for reading and just one simple ask. I spend a good chunk of time each week writing these off my own back. The simple gesture of sharing, liking or commenting on this is a 1 second action, which would be massively appreciated.

Have a great weekend.

Dave