Patellar Tendinopathy in
Team Sports: Preventive
Exercises
Javier Peña, PhD, CSCS,1 Daniel Moreno-Doutres, PhD, CSCS,2 Xantal Borràs, PhD,1 Albert Altarriba, PhD,1
Ernest Baiget, PhD,1 Antoni Caparrós, PhD,1 and Bernat Buscà, PhD3
1
Sport Performance Analysis Research Group, University of Vic—Central University of Catalonia, Barcelona, Spain;
2
Club Joventut Badalona, Barcelona, Spain; and 3FPCEE Blanquerna, Ramon Llull University, Barcelona, Spain
ABSTRACT
PATELLAR TENDINOPATHY IS AN
OVERUSE INJURY COMMONLY
KNOWN AS “JUMPER’S KNEE”
THAT CAUSES PAIN IN THE INFE-
RIOR REGION OF THE PATELLA.
THIS PATHOLOGY IS RECURRENT
IN TEAM SPORTS AND HAS MORE
IMPACT ON MALE ATHLETES.
SOME ANATOMICAL INTRINSIC
FACTORS AND SEVERAL EXTRIN-
SIC FACTORS SEEM TO BE KEY IN
TRIGGERING THIS CONDITION
THAT IS ALSO INCREASINGLY AP-
PEARING IN CHILDREN AND ADO-
LESCENTS. THE AIM OF THIS
ARTICLE IS TO PROVIDE COACHES
AND PRACTITIONERS WITH
SOME USEFUL PRACTICE-BASED
EXERCISES THAT CAN BE HELP-
FUL IN PREVENTING THESE
DISABLING TENDON INJURIES IN
SPORTS SUCH AS VOLLEYBALL,
BASKETBALL, SOCCER, AMERI-
CAN FOOTBALL, AND TEAM
HANDBALL.
INTRODUCTION
atellar tendinopathy is a knee
P pathology affecting the patellar
tendon connecting the kneecap
(patella) to the tibia. Commonly
known as “jumper’s knee” (4), it is
widely accepted that one of its main
Address correspondence to Javier Peña, javier.
pena@uvic.cat.
20 VOLUME 39 | NUMBER 3 | JUNE 2017
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causes is a functional stress overload
caused by high-demanding jumping
activities (14,68). Numerous articles
have attempted to define this condi-
tion and to classify the different
stages of its development (61), as
well as to introduce methods to pre-
vent and treat the condition in sports
practice (3,7). One of the main chal-
lenges for appropriate tendinopathy
diagnosis is that it presents similar
symptoms to other knee injuries,
such as bursitis, meniscal injuries,
chondromalacia, or patellofemoral
syndrome (15), therefore confound-
ing proper prevention and therapeu-
tic approaches.
Patellar tendinopathy is an injury with
an increased frequency of appearance
in male athletes (11,34,68). The odds of
suffering from patellar tendinopathy in
adult men who participate in volleyball
and basketball are 2-fold when com-
pared with women (14,34). Sport-
specific loading characteristics of the
knee extensor apparatus, greater body
weight, and greater height are addi-
tional intrinsic and extrinsic factors of
this rise in risk (69). This increased ten-
dency in men can also be observed at
high-school ages (65) with overuse or
repetitive trauma injuries representing
approximately 50% of all pediatric
sport-related injuries (58).
Knowing the proper mechanisms for
injury prevention is as important as
understanding the causes. Several
injury prevention strategies related to
Copyright Ó National Strength and Conditioning Association
the use of different exercises have been
described in past literature. Thus, con-
centric (5), eccentric (23,33,45), fly-
wheel resistance (44,53), whole-body
vibration (WBV) (39,54), and electrical
muscle stimulation (EMS) training
(37,40) have shown benefits improving
tendon structure and raising lower limb
strength levels. Moreover, combining
these exercises in a single training pro-
gram might have a potentially benefi-
cial effect on positive tendon training
adaptations while preventing overuse
knee injuries. This article will focus
on providing coaches and practitioners
with a specific and practical set of use-
ful exercises, designed to prevent this
pathology that gives rise to a consider-
able functional deficit and disability in
recreational and professional athletes.
INCIDENCE IN TEAM SPORTS
Several studies have been published on
the frequency of sport- and exercise-
related tendinopathies (17,20,36,69).
However, comparison and interpreta-
tion of results are difficult because of
a lack of consistent case definitions and
inappropriate time loss–based injury
registration methods. Most studies are
conducted in select populations such as
elite athletes or in participants of 1
specific sport (55). The number and the
incidence of tendon injuries, in general,
KEY WORDS:
injury prevention; male athlete; team
sports; technology

Figure 1. Full range of motion squat: left (A) and right (B). Feet should be placed flat
on the floor or on a decline board in athletes with less ankle mobility.
Three seconds per movement phase are recommended.
have increased substantially during the
last few decades. It is estimated that
tendon injuries, caused by overloading,
account for 30–50% of all injuries that
are related to sports (22,32,38).
Hägglund et al. (17) followed 51
European elite soccer clubs (2,229
players) between 2001 and 2009,
observing an incidence of 0.12 patellar
tendinopathies per 1,000 hours of
exposure. In another injury study of
the Union of European Football Asso-
ciations (UEFA), Ekstrand et al. (12)
found similar incidence between the
2001–2002 and 2008–2009 seasons.
Patellar tendinopathy can have
a major effect on the career of many
athletes, and for some, it is the rea-
son that their careers end prema-
turely (25). Overuse injuries of the
Figure 2. Eccentric hamstring curl: initial (A), middle (B), and final (C) positions. Two-legged flexion followed by alternative 1-legged
slow extensions.
Copyright ª National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
patellar tendon are often associated
with athletes involved in some type
of repetitive activity, such as jumping
(volleyball, basketball, and team
handball), kicking (soccer and Amer-
ican football), quick stops and starts
with a sudden change of direction
(COD), running, and weightlifting
(4,14,26,41,43,52,67). Specifically, in
soccer and American football, a pro-
longed repetitive stress of the knee
extensor apparatus occurs when the
ball is kicked, leading to this overuse
injury of the patellar tendon (24,34).
The prevalence of jumper’s knee in
different team sports is mostly
unknown. However, there are several
studies published among volleyball
players at the elite level in which
the prevalence is between 40 and
Strength and Conditioning Journal | www.nsca-scj.com
50% (14,34), and 32% in elite basket-
ball players (34). Martens et al. (41)
found that volleyball and soccer were
the sports in which two-thirds of all
their patients with patellar tendinop-
athy were involved. In another study,
of the 2,800 athletes in the Turku
Outpatient Sports Clinic, approxi-
mately 700 male and 190 female pa-
tients had suffered a knee disorder,
with patellar tendinopathy being
the most prevalent tendinopathy,
registering 20.8% of all registered
cases (30). The highest incidences
among team sports were recorded
in soccer (21%), volleyball (12%),
and ice hockey (7%).
Other studies have analyzed run-
ning, which is one of the most pop-
ular leisure sports activities, and is
integral to the training of almost
every sport. The overall yearly inci-
dence rate for running injuries varies
between 24 and 65% (18,30,60).
Approximately 50–75% of all run-
ning injuries are overuse injuries
because of the repetition of the same
movement, with most injuries occur-
ring in the tendons around the knee
or in the Achilles tendon (31).
As we can recognize in the cited stud-
ies, the incidence of patellar tendinop-
athy in team sports is certainly
important, and for that reason, a cor-
rect preventive approach through the
use of exercise becomes necessary in
this family of sports.
DEFINITION AND ROLE OF
EXERCISE IN PREVENTION
Patellar tendinopathy is a patellar ten-
don injury, causing anterior knee pain
21
 Patellar Tendinopathy: Preventive Exercises

related to the activity (59). Recent his-

topathological and biochemical evi-
dence indicates that the underlying
pathology of tendinopathy is not an
inflammatory tendinitis, but a degener-
ative tendinosis (2). Nevertheless, its
origin still remains unclear being con-
sidered as a syndrome (48,49). Today,
it is treated as a chronic injury caused
by the overuse of the knee extensor
mechanism and frequently with a pro-
tracted, repetitive, and bilateral natural
course (21,61). Overuse in chronic ten-
don pathologies occurs when tendon
Figure 3. Eccentric pistol squat using a suspension trainer: left (A) and right (B). The fascicles and fibrils have been strained
action ends when a 90-degree knee bend is achieved. repeatedly to 4–8% strain. In such
conditions, the tendon is unable to
endure further tension, and the injury
appears (24).
During the past 10 years, much more
information has become available on
the causative factors of patellar ten-
dinopathy. According to literature,
several intrinsic factors such as liga-
mentous hyperlaxity, lack of muscle
flexibility, Q-angle, patellar height
(high), tenderness, pattern of force
development, and extrinsic disposi-
tions such as frequency of training,
level of performance, hardness of
ground, and weekly number of
jumps have been identified as influ-
ential in developing this pathology
Figure 4. Parallel squat on an unstable surface: left (A) and right (B). Feet should be
maintained flat over the surface at all times, and 3 seconds per movement (57,66). Some studies have pointed
phase are recommended. The downward movement stops when a 90- out a manifest susceptibility to patel-
degree knee angle is achieved. lar tendinopathy when body weight,
weight training, jumping perfor-
mance, and overall load are increased
(34,68). In studies conducted with
young volleyball athletes aged 16–
18 years, a sudden increase in the
volume of training, when they are
approaching the senior level, is
hypothesized as an important risk
factor of jumper’s knee (62). What
is so far clear is that some predispos-
ing factors play an important role
developing this injury when exposed
to training loads (34,50).
Sex is also a relevant factor in patellar
tendinopathy occurrence. Despite no
clear evidence to explain why men
Figure 5. Ankle extension using a stability ball: left (A) and right (B). A maximum are at a greater risk, some possible
extension of the calves should be provided with a time of 3 seconds per explanations can be higher body mass,
phase recommended. larger muscle mass, greater ankle

22 VOLUME 39 | NUMBER 3 | JUNE 2017

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Figure 6. Barbell Bulgarian squat: left (A) and right (B). The distance between the front
and the back leg should be adjusted to provide a correct back positioning
and to ensure proper lowering of the posterior leg.
dorsiflexion, trunk torque velocities at
landing, and the ability to jump higher
(in what some authors have called the
“jumper’s knee paradox”), resulting in
greater tendon load (21,34,59,63). Epi-
demiological studies have found 3–4
times higher risk of developing tendin-
opathy in men who play volleyball
than in women in the same discipline
Figure 7. Flywheel parallel squat: left (A) and right (B). Feet should be maintained flat
over the platform at all times. The downward movement stops when a 90-
degree knee angle is achieved.
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(62). By contrast, other knee-related
pathologies, such as anterior cruciate
ligament injuries, occur more fre-
quently in the female population (9).
The role of exercise to prevent jump-
er’s knee has been widely demon-
strated in previous research. Human
tendons have shown several adapta-
tions to exercise, such as increased
Strength and Conditioning Journal | www.nsca-scj.com
metabolic activity (6), increased colla-
gen synthesis (46), tendon hypertrophy
(10,56), increased compliance or stiff-
ness (2), and increased tendon
mechanical properties (5,56). Recent
research has shown increases in colla-
gen synthesis in human tendons close
to 100% with just 1 bout of 60 minutes
of acute exercise, and this synthesis is
still stimulated 3 days after exercise
(42). Some other authors propose a sin-
gle bout of 10 minutes of exercise (time
limit for tendon adaptation) with a 6-
hour recovery period to promote
collagen synthesis (47). An increase
in collagen synthesis in engineered
ligaments can also be observed when
optimizing an intermittent stretch
paradigm using extracellular signal–
regulated kinase 1/2 phosphorylation
(47). This fact confirms that human
tendons are mechanoresponsive,
therefore demonstrating their ability to
improve adaptive patterns by exercise.
In this direction, an increase in insulin-
like growth factor (IGF-I), one of the
most important peptide hormones
involved in net collagen synthesis, cel-
lular proliferation, and matrix remodel-
ing, is involved in the upregulation
process induced by a load, in both in-
vitro and in vivo processes (64). Me-
chanotransduction is also an important
process in tendon adaptation. It con-
sists of 3 steps: (a) mechanocoupling:
the direct or indirect physical pertur-
bation of the cell due to shear or
compression forces; (b) cell-cell com-
munication: refers to the leading of one
stimulus from one cell to another that
did not receive a mechanical stimulus;
and (c) effector cell response: is the
stimulus of the protein synthesis gen-
erated by a mechanical loading at the
cellular level due to the activity of the
integrin proteins that bridge the intra-
cellular and extracellular regions
involving the cytoskeleton, maintain-
ing cell integrity, and distributing
mechanical load (27). External loads
induce autocrine and paracrine up-
regulation, raising the levels of local
IGF-I and binding proteins leading to
a cellular proliferation and matrix re-
modeling both, which are key pro-
cesses in tendon healing (1,13,28).
23
 Patellar Tendinopathy: Preventive Exercises

tendinopathies (3,23,27,35,45). The rea-

Figure 8. Leg extension using electrical muscle stimulation. The electrodes should be
placed on the rectus femoris, vastus medialis, and vastus lateralis portions
of the quadriceps muscle.
Besides, morphologically, tendons with
a larger cross-sectional area (CSA) are
less likely to suffer from mechanic
stress for any given load and are less
prone to develop patellar tendinopathy
(8). However, tendons appear to react
differently to heavy load resistance
training increasing in their proximal
and distal regions while presenting no
changes in their midregion (29,49).
Exercise of different natures has been
tested in the past to prevent or to heal
tendon injuries. Eccentric training is
a promising training regime to prevent
sons are less oxygen consumption in
the eccentric phase of the movement
than during the concentric regime,
due to a reduced need of this molecule
by tendons and ligaments when com-
pared with skeletal muscle (35),
increased synthesis of type I collagen,
and changes in the thickness of the ten-
don associated with an improvement in
the arrangement of the tendon internal
fibers (2,33,45). Nevertheless, recent
research has demonstrated that ten-
dons are responsive to diverse loading
regimes, diverse contraction types, and
different rates of movement. When per-
formed at low speeds, these varied
training regimes are able to increase
tendon compliance and break tendon
fiber crosslinks (2,5). The use of high
loads seems to be only effective in long-
time programs over 12 weeks (5). A
combination of high-load training with
a low speed can be one important
countermeasure to the occurrence of
this condition. Flywheel resistance
training has also been tested in the past
to prevent and heal tendon injuries
showing good results, with studies pre-
senting increased leg strength and
decreased pain perception of patients
using this technology in the treatment
of patellar tendinopathy (16,53). It has
also been demonstrated that flywheel
resistance training can cause greater ef-
fects in muscle activation than tradi-
tional resistance training (44). This
improved effect is attributed to the iso-
inertial loading features arising from the
use of this technology (maintaining
a constant resistance and maximal mus-
cle demand in every angle), resulting in

Figure 9. Eccentric alternative leg press: initial (A), middle (B), and final (C) positions. Slow single-leg 90-degree flexion on eccentric
contraction. Alternate between legs. Three seconds per movement phase are recommended.

24 VOLUME 39 | NUMBER 3 | JUNE 2017

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 better muscle hypertrophy. WBV has
also shown promising results prevent-
ing tendon injuries. According to recent
research, vibration training can result in
increases at the proximal and mean ten-
don CSA, eliciting tendon hypertrophy
in humans (51), even in patients with
insertional pain who did not respond to
eccentric training (19). Researchers also
have found alteration in the trunk, knee,
and ankle angular velocity during flex-
ion when landing in volleyball players
presenting with patellar pain (21). Thus,
technical factors in sports involving
a great number of jumps or COD, both
Figure 10. One-legged alternative 908 squats on a vibration plate: left (A) and right (B). actions that mainly increase the effect
Foot should be maintained flat over the platform at all times. The down- of gravity and tension to joints and ten-
ward movement stops when a 90-degree knee angle is achieved. Three dons, may demand a greater landing
seconds per phase are recommended. and stop technique performance.

Table 1
Exercises to prevent patellar tendinopathy in team sports
Number Exercise Description

1 Full range of motion squat
2 Eccentric hamstring curl
3 Eccentric pistol squat using
a suspension trainer
4 Parallel squat on an unstable
surface
5 Ankle extension using a stability
ball
6 Barbell Bulgarian squat
7 Flywheel parallel squat
8 Leg extension using electrical
muscle stimulation
9 Eccentric alternative leg press
10 One-legged alternative 90º squats Slow unilateral alternative downward movement using a whole-body vibration
on a vibration plate
Full range of motion deep squat. The use of weightlifting shoes, plates, or decline
boards is optional to increase movement depth. Three seconds per movement
phase are recommended.
Two-legged full flexion followed by a slow 1-legged extension. Alternate between
legs.
Slow down motion with 1 leg to achieve a 90-degree bend. Return to the initial
position using both arms help and alternating between legs.
Two-legged weighted parallel (908) squat on BOSU. Three seconds per movement
phase are recommended.
Two-legged calf raise using a stability ball against a wall to increase the
stabilization demands of the abdominal wall. Three seconds per movement
phase are recommended.
One-legged alternative rear foot elevated squat using a barbell. The movement
ends before the thigh is parallel to the floor. Three seconds per movement phase
are recommended.
Two-legged parallel squat using a flywheel resistance training device applying
inertia to create resistance.
Unilateral voluntary quadriceps flexion and extension on the stimulation impulse.
The warm-up and stretch phases must be off, and the rest between stimulus
should be reduced at minimum intensity. Alternate between hypertrophy and
maximal strength programs. Place the electrodes on the rectus femoris, vastus
medialis, and vastus lateralis portions of the quadriceps muscle.
Two-legged concentric slow extension from 908 flexion to nearly full extension and
slow single-leg return on eccentric. Alternate between legs. Three seconds per
movement phase are recommended.
device set to 35 Hz and low amplitude. Alternate between legs, and 3 seconds
per movement phase are recommended.

25
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26 VOLUME 39 | NUMBER 3 | JUNE 2017

Patellar Tendinopathy: Preventive Exercises

Table 2
Sample periodization by season period and suggested load
Period

Off-season Preseason In-season

Exercise Load Frequency, Exercise Load Frequency, Exercise Load Frequency,

(number) d$wk21 (number) d$wk21 (number) d$wk21

2 Reps: 8–12 per leg 2 1 Reps: 10–15 2 1 Reps: 10 2

Sets: 3 Sets: 3 Sets: 2–3
Rest time: 2–3 min Rest time: 1–2 min Rest time: 1–2 min
Intensity: high load at Intensity: light to medium Intensity: light to medium
eccentric contraction load, low speed load, low speed
with slow speed
5 Reps: 10–15 2 2 Reps: 8–12 1 2 Reps: 8 per leg 1
Sets: 3 Sets: 3 Sets: 3
Rest time: 1 min Rest time: 2–3 min Rest time: 2–3 min
Intensity: body weight, low Intensity: high load at Intensity: high load at
speed eccentric contraction eccentric contraction
with low speed with low speed
6 Reps: 10–15 4 3 Reps: 10–15 2 3 Reps: 10 1
Sets: 3 Sets: 3–4 Sets: 3
Rest time: 1–2 min Rest time: 1 min Rest time: 1 min
Intensity: body weight, low Intensity: body weight, Intensity: body weight,
speed low speed low speed
7 Reps: 8 1 4 Reps: 10–15 1 4 Reps: 10 1
Sets: 3 Sets: 3–4 Sets: 3
Rest time: 2–3 min Rest time: 2–3 min Rest time: 2–3 min
Intensity: moderate to Intensity: light load, low Intensity: light load, low
high load, low to speed speed
moderate speed
9 Reps: 6–8 per leg 1 5 Reps: 10–15 2 5 Reps: 10–15 1
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Table 2
(continued )
Sets: 4 Sets: 3 Sets: 3
Rest time: 2–3 min Rest time: 1 min Rest time: 1 min
Intensity: moderate to Intensity: body weight, Intensity: body weight,
high load, low to low speed low speed
moderate speed
7 Reps: 6 1
Sets: 3
Rest time: 2–3 min
Intensity: moderate to
high load, low to
moderate speed
8 Reps: 6–8 per leg 1
Sets: 3
Rest time: 2–3 min
Intensity: moderate to
high load, low to
moderate speed
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10 Time of set: 30 s 2
Sets: 3
Rest time: 2 min
Intensity: 35 Hz, body
weight with low speed
27
 Patellar Tendinopathy: Preventive Exercises

SELECTED PREVENTIVE therapeutic approach because of a high Xantal Borràs

EXERCISES recurrence rate and an extended period is a member of
As mentioned earlier in this article, pre- of time to be resolved once it appears. the Sport Per-
venting an injury such as patellar tendin- For that reason, preventing the onset of
formance Anal-
opathy through exercise is a complex this condition seems critical in main-
ysis Research
aspect. Because the use of different taining athletes’ health, and different
Group at the
types of contractions, loads, equipment, nature exercises have demonstrated
University of
and training regimens have shown sat- a great influence in this prevention man-
Vic—Central
isfactory and promising results in the agement. Because reducing training and
University of
past, the combination of several of these competition volume in high-standard
Catalonia and
methods might result in a more success- sport is something controversial, the ex-
a Biomechanist.
ful and complete preventive approach. If ercises presented here offer a good
the production of an injury is somewhat option for healthy athletes who present
multifactorial, it makes sense that its internal risk factors, or for those
prevention uses the maximum number involved in disciplines frequently devel- Albert
of resources available to the athlete. oping this condition and wanting to Altarriba is
avoid it. Although the field of injury a member of the
Here, a battery of exercises that meet
recovery and rehabilitation is not the Sport Perfor-
these requirements and may be useful
main subject of this article, many of mance Analysis
for coaches and practitioners trying to
the proposed exercises may also be Research Group
avoid this medical condition is pre-
helpful in recovering athletes from at the University
sented. In it, exercises using weighted
patellar tendinopathies, provided that of Vic—Central
concentric and eccentric movements,
the described loads and intensities are University of
suspension trainers, 30-degree slant
modulated appropriately for each case. Catalonia.
boards, flywheel resistance devices,
WBV platforms, and EMS have been Conflicts of Interest and Source of Funding:
included (Figures 1–10). The authors report no conflicts of interest
Ernest Baiget
Coaches and practitioners can better and no source of funding.
is the leader of
understand the proposal by observing
the Sport Per-
the provided description for each exer-
formance Anal-
cise (Table 1).
Javier Peña is ysis Research
An example of exercise periodization is a member of the Group at the
also provided in Table 2. Listed exercises Sport Perfor- University of
can be useful at all stages of the training mance Analysis Vic—Central
season but with different levels of rele- Research Group University of
vance depending on the season period. at the University Catalonia and a strength & condi-
The periodization sample includes 5 dif- of Vic—Central tioning coach for professional tennis
ferent exercises for the off-season and University of players.
preseason periods. Within the competi- Catalonia and
tion period, the number of exercises in- a strength & conditioning consultant for
creases to 8. The main reason for this professional teams.
increment is the athletes’ tendency to Antoni
refer more discomfort in the tendon area Caparrós is
during congested competition periods, Daniel a member of the
the moment when more attention to Moreno- Sport Perfor-
injury prevention processes should be Doutres is the mance Analysis
paid. To avoid pain while competing Head of the Research Group
seems a key aspect of sports performance. Strength & at the University
Conditioning of Vic—Central
CONCLUSIONS Department at University of
Previous research has suggested that Club Joventut Catalonia and a strength & conditioning
patellar tendinopathy is a common Badalona coach for the Spanish men’s basketball
injury in team sports, having a difficult (ACB). national team.

28 VOLUME 39 | NUMBER 3 | JUNE 2017

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Bernat Buscà is
a professor at
FPCEE Blan-
querna, Ramon
Llull University
and a strength &
conditioning
coach of the skel-
eton athlete
and Olympian,
Ander Mirambell.
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