Patellar tendinopathy. Load it, don’t rest it.

A five-stage loading template for the athlete with anterior knee pain at the bottom of the kneecap. Built from the plans I run with professional athletes, stripped back so you can use the structure yourself. There are no fixed timelines here. The criteria at the end of each stage decide when you move on.

A tendon that has lost its capacity — not an inflamed one.

Repeated lunging, decelerating and jumping loads the patellar tendon where it attaches to the bottom of the kneecap. Over time the fibres take on microinjury and the tissue degenerates. It is a degenerative process, not an inflammatory one, which is why anti-inflammatories and rest alone don't fix it.

The longer symptoms have been there, the worse the outcome tends to be, whatever the treatment. Start early, start with load.

You probably have it if

• Pain points to one spot at the lower edge of the kneecap
• It warms up during activity, then bites harder the next morning
• Jumping, decelerating, stairs and decline squats provoke it
• Sitting still for a while makes it stiff and sore to stand up

Get it confirmed first

Anterior knee pain has several possible sources. This template assumes a confirmed patellar tendinopathy. If you haven't had it assessed, get that done before you start loading to a plan.

The one rule that governs everything

Judge the session by tomorrow morning.

Score your knee out of ten during the session, then again in the first steps the next morning. Tendons tolerate load; they don't tolerate spikes. Use the check below after every session.

Next-morning pain score

Rate the knee in your first steps out of bed, the morning after a session.

0–2 · Green

Settles within 24 hours. Repeat the session, then progress on plan.

3–5 · Amber

Hold the current level. No new exercises, no added volume, until it drops.

6+ · Red

Step back a stage. Return to isometrics and rebuild. Get it reviewed.

The template

Five stages. Isometric, isotonic, then energy storage.

Each stage has an aim, a restriction and an exit criterion. You leave a stage when you meet the criterion, not when the week ends.

Recovery

Off-loading · diagnosis

Aims

• Settle the irritation and get the diagnosis confirmed
• Cut the aggravating load: jumping, deceleration, deep knee bend
• Keep the rest of the body working — upper body strength, low-impact cardio

Restrictions

Limit walking volume and stairs. Nothing that takes the knee above 2/10 during or after.

Move on when

Pain is trending down and daily tasks — stairs, standing from a chair — feel easier.

Where a clinician earns their keep

This is where most self-managed cases go wrong in both directions: total rest, or carrying on regardless. An assessment tells you which end of that you are on.

Regain

Isometric loading

Aims

• Long isometric holds to reduce pain and rebuild tolerance
• Restart structured strength work above the knee and upper body
• Build cardio through bike or pool where the tendon is unloaded

Restrictions

No running, no jumping. Keep every session at or below 2/10.

Move on when

You can complete the full isometric prescription at high effort with pain no higher than 2/10, and morning stiffness is short-lived.

Where a clinician earns their keep

Isometric dose is easy to get wrong — too short, too light, too few. A quick check of effort level and hold quality usually doubles the effect.

Reload

Isotonic strength

Aims

• Heavy slow resistance through full range: squat, leg press, leg extension
• Eccentric-focused decline squat work on a 25° board
• Rebuild walking then running mechanics, single leg control

Restrictions

Controlled tissue load only. No plyometrics or change of direction yet. Progress one variable at a time.

Move on when

Full-range loading at meaningful weight sits at 2/10 or below, and the injured leg is within roughly 10–15% of the other side.

Where a clinician earns their keep

Strength symmetry is the thing people guess at and get wrong. Objective testing here is what stops you carrying a deficit into jumping.

Recondition

Energy storage · plyometric

Aims

• Introduce plyometrics in order: both legs in place, one leg in place, then for height and distance
• Add sport movement patterns — lunging, lateral shuffles, deceleration
• Keep the isometric and isotonic work going underneath it

Restrictions

Plyometrics on alternate days only, low volume, quality over quantity. Stop the set when landing quality drops.

Move on when

You clear a hop and jump battery with symmetry, and complete one full block of sport drills at 0/10.

Where a clinician earns their keep

The jump from strength to energy storage is the highest-risk transition in the whole plan. Getting the volume and the order right is worth a conversation.

Return to play

Integration · competition

Aims

• Graded exposure: session duration first, then intensity, then competition
• Track load every session — time, volume, and how hard it felt out of 10
• Keep two loading sessions a week in place permanently

Restrictions

Nothing new in a competition week. Build up to games and matches rather than starting there.

Move on when

Unrestricted. Full training and competition with the morning score staying green.

Where a clinician earns their keep

Load planning around a real fixture list is the part a template cannot do for you — it needs your calendar in front of it.

Loading progressions

What to actually do, in order.

Progress the speed of the lowering phase first, then add resistance. Never both in the same week.

Isometric

Stage 2 onward

• Wall sit or Spanish squat hold
• Single leg extension hold at 60° knee bend
• Leg press hold, both legs then one
• Hold position at the angle that feels strongest

Dose

5 holds × 45 seconds at hard-but-controlled effort. Up to twice daily. Rest 2 minutes between holds.

Isotonic

Stage 3 onward

• Decline squat on a 25° board, slow lowering
• Leg press and leg extension for graded load
• Split squat and step-down for single leg control
• Full range, both directions, no rushing the bottom

Dose

3–4 sets × 6–8 reps, 3 seconds lowering. Progress lowering speed first, then add weight. 3 sessions a week.

Energy storage

Stage 4 onward

• Pogos and small bilateral hops in place
• Unilateral hops in place, then for height and distance
• Bounding and continuous hopping
• Deceleration and change of direction drills

Dose

Alternate days. Start around 3 sets × 10 contacts and build slowly. Stop when landing quality drops.

Print and fill in

Adjuncts help at the edges. Loading is the treatment.

Worth it

Shockwave therapy

A reasonable addition when loading alone has stalled. Around half of cases report symptom improvement. An addition, never a replacement.

Worth it

Platelet-rich plasma

Multiple injections may give better long-term results than eccentric exercise alone and can speed up the early phase. Still needs the loading programme behind it.

Situational

Taping and straps

Useful to take the edge off the tendon during sport. Treat it as symptom management while the plan does the work.

Situational

Anti-inflammatories

May help short-term pain control. They do nothing to the underlying tendon change, so they buy comfort, not progress.

Avoid

Corticosteroid injection

The evidence shows no benefit for patellar tendinopathy. Don’t have one for this.

Avoid

Complete rest

Tendons need graded load to remodel. Rest lowers capacity, symptoms return the moment you play, and you have lost weeks.

The evidence in one line

A phased progressive tendon-loading programme beat eccentric-only exercise in a randomised trial: 28 versus 18 points of VISA-P improvement at 24 weeks. Eccentric work still helps — it just isn't the whole plan.

If nothing changes

Around one in ten athletes eventually needs surgery, and only after at least six months of genuine conservative treatment. Most of the time the plan wasn't loaded hard enough or long enough.

Make it yours

A template gets you moving. A plan gets you back.

This is the generic version. The athletes I work with get the same structure built around their calendar, their competition dates and their objective testing — with the load reviewed every week rather than every stage. If you want that, get in touch.

This guide is general education, not individual medical advice. Anterior knee pain has several possible causes and every tendon tolerates load differently. Have your knee assessed and your programme supervised by a qualified clinician before following it.

References

• Arner JW, Kaeding CC, Bradley JP. Management of Patellar Tendinopathy. Arthroscopy, 2024.
• Everhart JS, Cole D, Sojka JH, et al. Treatment Options for Patellar Tendinopathy: A Systematic Review. Arthroscopy, 2017.
• Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of Progressive Tendon-Loading Exercise Therapy in Patients With Patellar Tendinopathy: A Randomised Clinical Trial. British Journal of Sports Medicine, 2021.
• Lopes AD, Rizzo RR, Hespanhol L, Costa LO, Kamper SJ. Exercise for Patellar Tendinopathy. Cochrane Database of Systematic Reviews, 2025.
• Marigi EM, Buckley P, Razi F, et al. Patellar Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments. JBJS Reviews, 2022.
• Andriolo L, Altamura SA, Reale D, et al. Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option. American Journal of Sports Medicine, 2019.
• Dan M, Phillips A, Johnston RV, Harris IA. Surgery for Patellar Tendinopathy (Jumper’s Knee). Cochrane Database of Systematic Reviews, 2019.