In this blog, I am going to teach you everything you need to know about Quadriceps Tendinopathy rehab!
Be sure to also check out our Knee Resilience Program!
Knee Extensor Mechanism
The quadriceps consists of 4 different muscles – the vastus medialis (green), the vastus lateralis (blue), the vastus intermedius (not visible), and the rectus femoris (red). All four muscles come together to form the quadriceps tendon (pink) that attaches to the patella, or kneecap. They’ll then insert on the tibial tuberosity via the patellar tendon (yellow) and act to extend, or straighten, the knee.
“Together, the quadriceps muscle and tendon, patella, and patellar tendon are referred to as the knee extensor mechanism.” Therefore, any time your quads are working, such as when squatting, jumping, running, and climbing stairs, your quadriceps tendon is also working.
Quadriceps Tendinopathy (Not Tendinitis, Tendinosis, or Jumper’s Knee)
Quadriceps tendinopathy should not be confused with patellar tendinopathy or jumper’s knee, which refers to pain localized to the inferior pole of the patella.
Although similar, quadriceps tendinopathy, the less common of the two diagnoses, refers to pain localized to the superior pole of the patella that has a dose-dependent relationship with the magnitude and rate of loading.
For example, I’d expect a single leg squat to hurt more than a double leg squat. I’d also expect a double leg jump to hurt more than a double leg squat based on the load experienced by the quadriceps tendon.
The term “tendinopathy” just means that there is persistent tendon pain and loss of function related to this mechanical loading.
Tendinitis, used to indicate an inflammatory process, is not the preferred diagnosis because, similar to other tendon-related issues, inflammation is NOT believed to be the primary driver of the condition and may reflect the normal response to tendon loading and adaptation. Plus, people often associate inflammation with the need for ice and complete rest, which are not the primary treatment strategies recommended.
Tendinosis, used to indicate a degenerative process, is also not the appropriate terminology as abnormalities on imaging can be found in people without symptoms and are not predictive of future issues.
Therefore, instead of unnecessarily focusing on inflammation or what the tendon looks like on imaging, the goal of rehab is two-fold:
- Improve your tolerance to various forms of loading
- Restore function of the knee extensor mechanism, the rest of the kinetic chain, and you, the person, in general.
Understanding and Monitoring Pain
A fundamental component of rehab is understanding and monitoring pain. Do you have to avoid pain during exercise or is it safe to push into a little pain?
Well, the majority of researched exercise programs use pain-based criteria for progressing exercises. In fact, some papers actually increase the difficulty of an exercise if participants have a decrease in pain.
Silbernagel et al in 2007 helped popularize the model that’s most often used today, which involves exercising to a tolerable level of pain. This is unique to you. One person reading this blog might only be comfortable exercising with slight pain while someone else might be comfortable exercising with moderate pain. There’s not necessarily a right or wrong way to go about it, but there are some strategies that you can use to help find what works best for you.
You’re not only going to monitor symptoms during exercise, but immediately after and the following day.
Ask yourself 3 questions:
1. Is my pain tolerable during exercise? If it’s helpful for you, you can rate your pain on a scale from 0-10 and determine the highest acceptable number for you. Some physical therapists might recommend staying at a 3/10 pain or less while others might suggest 5/10 pain or less. You get to decide.
2. Is my pain better, worse, or the same after exercise? Quadriceps tendinopathy may exhibit a warm-up phenomenon where symptoms actually improve with physical activity, so it’s possible that you feel better after exercising for a short period.
3. Is my pain better, worse, or the same the day after exercise? This is the most important question because it gives us an understanding of how you’re responding to the current dosage of exercise. If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that’s an indication that you’re doing too much and need to back off a bit.
You can assess your next-day symptoms with your normal functional activities or use a specific assessment, such as the single leg decline squat.
For example, you rate your pain on day 1 with the single leg decline squat as a 3/10 pain. You then perform your exercise routine within tolerance, go about your day, and go to bed without any major issues. The next morning you perform the single leg decline squat again, but this time you rate your pain as a 6/10. This means that even though your symptoms were tolerable during exercise, you might have done more than what you can currently recover from. You didn’t do any harm, but decreasing the volume or intensity would be recommended.
So, do you have to avoid pain during exercise? Not necessarily.
Is it safe to push into a little pain? Yes. However, you’re going to have to find what works best for you.
Load Management and Activity Modifications
Before outlining the exercises, it’s important to discuss load management and activity modifications.
Quadriceps tendinopathy is thought to occur when the intensity, frequency, and volume of quadriceps tendon loading exceeds your capacity to recover and adapt appropriately. It often comes down to doing too much, too soon although that’ll look slightly different for more active individuals vs less active individuals.
Let’s tie the goals of rehab, pain monitoring, and load management together by reviewing the boom-bust cycle. Tell me if this sounds familiar.
You have a spike in activity over the course of a day, week, or month that contributes to symptoms of your knee. You decide to rest completely and your symptoms go away. Excellent! You recognize that you overdid it last time, so you don’t do quite as much this time around. However, you have a flare-up despite doing less of the same activity! You rest again until your pain goes away and repeat this process until your activity level is severely diminished.
This is not an uncommon cycle. It’s often driven by the belief that pain is bad and rest is good, while also using a reduction in pain as the primary metric for success.
But that’s not the way to approach quadriceps tendinopathy because rehab can take 3 months, 6 months, or even a year or longer. Symptoms will fluctuate on a day-to-day and week-to-week basis, which is why your focus should be on function while monitoring pain to guide the appropriate amount of physical activity.
An increase in function will not always correlate with a linear decrease in pain. If you go from running 1 mile with a 3/10 pain to running 3 miles with a 3/10 pain over the course of 3 months, that’s actually significant progress. The pain may seem like it’s staying the same, but technically it’s getting better because it requires more activity to reach the same level of pain that you initially experienced.
Remember, one of the primary goals of rehab is to restore function. You’ll monitor your symptoms during and after exercise to ensure that you’re not exceeding your current capacity, while keeping track of your progress with the various exercises.
At the same time, you’ll reduce the frequency, intensity, or volume of activities, such as basketball or volleyball, that are aggravating your symptoms and limiting your functional progress. If needed, you can replace the reduction in that specific activity with a different activity that doesn’t exacerbate symptoms to maintain your fitness.
Exercise Overview
I’m going to present 4 overlapping stages of rehab. There’s no criteria that you have to meet to progress from one stage to the next. Rather, your exercise selection and progressions should be dictated by your symptoms, tolerance, and function. The intention is for you to slowly and gradually improve your quadriceps tendon’s ability to handle increasing loads.
A study by Song et al in 2023 established a loading index for exercises related to the quadriceps tendon. As you can see below, there’s a fairly predictable increase in loading of the quadriceps tendon with exercises performed on one leg compared to exercises performed on two legs, including jumping and hopping type exercises. Running and cutting and a single leg decline squat were the only activities that crossed their threshold for tier 3 loading.
Two things to note:
1. I’m not going to follow their hierarchy exactly, but it can be helpful to keep this general framework in mind throughout the rehab process.
2. The loading profiles of these movements are also influenced by other factors, such as the weight being used and the effort you exert. Similarly, exercises that require greater degrees of knee flexion, like a deep squat, cause higher loading of the quadriceps tendon, so that may be another variable you choose to modify.
Okay, let’s get into it.
Stage 0: Isometrics
Most tendinopathy protocols actually have isometrics listed as stage 1, but they’re listed here as stage 0 because I don’t think there’s an isometric milestone that you need to pass before performing the next group of exercises. However, they do have the potential to provide an analgesic effect and are typically quite tolerable since little to no movement is occurring.
I am going to provide you with five examples so you can choose what works best for you based on your preference, equipment availability, tolerance, function, etc.
1. Double Leg Wall Sit
2. Single Leg Wall Sit
3. Heel Elevated Wall Sit
The single leg and heel elevated variations are both progressions of the double leg wall sit.
4. Spanish Squat. With a strap or band anchored around your legs and a squat rack, you’ll sit back until your hips and knees are at roughly 90 degree angles.
5. Single Leg Seated Knee Extension. You can perform this exercise with a machine, band, or some other setup with your knee between 90 and 60 degrees of flexion.
How would you incorporate these into your routine? You can perform them as a warmup prior to your workouts or they can be used as an independent stimulus, completed 1-3 times per day.
You’d pick one option to complete for 3-5 sets of 30-45 second holds with a 2 minute rest between sets.
Make it hard, but keep it tolerable.
Stage 1: Heavy Slow Resistance
You can pick any exercise in this stage as long as it is tolerable and sufficiently loads the quadriceps tendon. I’ll provide 4 options.
1. Squat – Progressions can be made by increasing the resistance over time or choosing a variation that emphasizes the knee extensors more, such as a heel elevated squat.
2. Split Squat – Similarly, progress the resistance, range of motion, or amount of forward knee travel over time.
3. Step Down – Progress by elevating the height of the step or your heel, or increase the amount of forward knee travel.
4. Single Leg Seated Knee Extension
You can perform 1-2 exercises for 3-4 sets of 6-15 repetitions, 2 to 3 days per week. I’d recommend picking at least one single leg variation.
The speed of each repetition should be slow. For example, if you’re performing a squat, descend over the course of 3 seconds, pause for 1 second at the bottom, and ascend for 3 seconds. That’s a 7 second repetition! If you want to ensure consistency with your tempo, you can download a metronome app on your phone.
Remember to manipulate the range of motion, intensity, etc. as needed, and focus on consistency, gradual progressions, and strategies that align with your goals.
Stage 2: Energy Storage and Release
Along with the isometrics and resistance training, stage 2 includes jumping, landing, plyometrics, and exercises that prioritize a faster rate of loading. These exercises should be performed 2-3 times per week with an emphasis on execution. This isn’t meant to be cardio.
There’s an infinite number of possibilities and loading schemes here, so I’m just going to provide 2 options. You don’t have to follow the exact order of either option.
1. Countermovement jump to a box, countermovement jump, bilateral depth drop, bilateral depth jump, single leg depth drop, and single leg depth jump.
2. Forward lunge, forward lunge with step back, step and land, step and land with a step back, and running with a step back.
For exercises in this stage, it’s important to intentionally load the knee extensor mechanism as much as tolerable because individuals with quadriceps tendinopathy may actually unknowingly offload their affected knee.
Stage 3: Return To Sport
There are no distinct exercises that need to be performed in this stage. Instead, this stage is about gradually returning to your preferred sport or activity.
For example, if you’re a marathon runner, you’d train for that marathon over the course of several months as you build up your volume. If you’re a recreational basketball player, the same thought process applies. You can’t expect to just jump back into hours of full court games after doing 3 months of exercises in the gym. You have to build back up to it.
Putting It All Together
Let me help make sense of all this information by providing you with 3 tips:
1. As I mentioned earlier, these are overlapping stages that should be considered as a continuum as opposed to completely separate categories.
You might be doing isometrics 5 days per week, isometrics and heavy slow resistance 3 times per week, or a combination of all 4 stages 6 days per week.
Some of it is trial and error, but taking small steps in your progressions will reduce your risk of flare-ups. For example, if you can’t perform one repetition of a single leg squat, it doesn’t make sense to try a single leg drop landing.
2. Not everyone will need to work through all of the stages. If your only goal is to lift weights in the gym, stages 2 and 3 might not be applicable to you.
3. You don’t have to follow this exact protocol or only perform these specific exercises. I didn’t mention the leg press, reverse nordics, and a host of other exercises, including movements that focus on your calves, hamstrings, trunk, etc. Instead, I wanted to create a guideline, so you better understand the fundamental components of rehab for quadriceps tendinopathy.
If you take away anything from this blog, just remember to keep the goal of rehab simple – gradually improve tolerance and restore function!
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before? Check out our Knee Resilience Program!
Want to learn more? Check out some of our other similar blogs:
Exercises for Knee Pain, Return To Sport Rehab, Reverse Nordics
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