Articles  >  Mobility, Prep, Recovery & Injury
Knee Pain: Patellar Tendonitis and Coming Back to Weightlifting
Greg Everett
March 1 2012

Andrew Asks: Been reading your site and came across your Q&A section and figured I'd give it a shot. I am a 25yr old male, 6'3" 230. Here is my dilemma: been training (see crossfit, crossfit football, etc) for about three years now with a recent emphasis on strength gaining starting back in october of last year to prepare for a powerlifting (unassisted) comp this past march. The work mainly consisted of 3x5 squats, bench, press, and deadlift(only ever two weeks) plus conditioning on the side for GPP(4 times/week). Made it to the comp (18 Mar '11) and ended up squatting 440lb, bench 308, deadlift 508. Gave it a weeks rest and mobility afterwards and started to try and train again. Thats when the problem started. Began with pain above my left patella(i am right handed, if that matters) and now ( 16 May '11) has eased up a bit, but the pain will radiate through my patella in almost a linear fashion along to my patellar tendon during a squat when on the way back up just above parallel. The pain will intensify with things such as agility movements (tennis, etc) however running provides no pain. I have rested the knee, in the only way an athlete can haha, by not squatting/lunging/etc and doing everything else the same, and iced everyday 15-20 min. The pain has decreased in total magnitude, however the pain above the patella, right where the quadricep tendon attaches, is still present. If you can provide any help whatsoever to my situation, or any words of wisdom regarding this issue, I would be most grateful.

Greg Says: I’m not a medical professional, but this sounds like patellar tendonitis. My guess would be that following that period of rest, you came back to training a bit too aggressively and the connective tissue wasn’t adequately prepared (it was likely on the verge of tendonitis before the time off).

My recommendation would involve a few different things. If it still hasn’t cleared up, I would take a week off of squatting or anything involving loading of the knees, especially ballistic. When you come back to training, spend a couple weeks with some high-rep, high-volume work at fairly light weights, e.g. squats at 50-60% for 8-10 reps and 3-5 sets. This should help prepare the connective tissue a bit. Make sure you’re getting a balanced dose of quad, hamstring, adductor and glute strengthening. I would keep it all bilateral during this first couple weeks to avoid stressing the aggravated knee excessively. Perform your squats with a controlled speed down and no bounce—focus on maintaining tension all the way down and through the bottom as you change directions.

Prior to training, spend a lot of time foam rolling the quads, especially down the mid-line trying to get into the rectus femoris and the lateral quad where it connects with the ITB. Stretch the quads and hip flexors after you warm up and roll, and do a few passes on the roller and stretch in between squat sets. When you warm up, make sure you are getting the knees really warm—don’t be in a hurry. If you normally train in shorts, try training in pants to get and keep the legs warmer. Basically the idea is to really try to make sure everything is moving fluidly to help prevent any aggravation of the patellar tendon and ligament.

After each workout, you can get into the quad with a lacrosse ball—get into the area just above the knee cap where you have that convergence of quads and quad tendons. If the ball is hard to do, you can just sit on a bench or box and lean over to grind your elbow into the area. I would warm it up a bit moving longitudinally with the tendon, then progress to some cross-tissue work. You can do this with the knee straight and slightly bent. After this, get ice on it. If you have time again later in the day, ice again.

Aside from that direct work, do a good investigation of everything above and below the knee: make sure your ankles are moving properly and your calves are strong but flexible, and even do some anterior tibialis work. Likewise, make sure your hip mobility is up to par and that everything is functioning as it should, in particular the glutes. Stretch, activate and strengthen as needed. Get into the ITB with a foam roller and lacrosse ball. Often the mistake people make is focusing only on the local area where the pain is present, forgetting that it may very well be originating from a seemingly unrelated problem.

After that first couple weeks of the lighter, high-volume work, transition gradually into your heavier squatting. If you’re aiming to get back to 5s, maybe spend 2 weeks at 8s, 2 weeks at 6s, making each week a bit heavier as tolerated, then a somewhat lighter, lower volume week prior to your first heavy week of 5s. During this transition time, start adding in some unilateral leg work as tolerated without pain or dysfunction. Unweighted lunges are a good starting place, and will remain a good supplemental exercise. I would keep these at relatively high reps, e.g. 8-12, focusing on tension and control at the hip.

I would stay away from running, even if there is no pain at the time, and activities with cutting, rapid changes of direction, etc. until you’re transitioning into the heavier squatting, and make sure you come back to it conservatively rather than switching it on right away to full volume and intensity.

Good luck!
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Joe H
March 5 2012
Hi Greg,

I've got a knee Problem I'm 5"11. It happened gradually, I started getting pain in the front of my right knee and thought nothing of it, but its getting really bad now and I don't know what to do. I don't know whether its because my back squat is weak or I clean my 1rm front squat, and now when I'm lifting my left side is becoming more dominant.

Any help would be great.
March 10 2012
I've been having a similar problem, thanks Greg.
Greg Everett
March 13 2012
Joe -

My advice would be the same as in the article.
March 20 2012
As the Doc knows, I collect iiuernjs. I am dealing with some patellar tendinitis right now. (Despite a very modest run/walking program which I've been doing for over 2 years. With proper orthotics and all that. As I have written here before, iiuernjs just happen to many of us.)Anyway, if you have patellar tendinitis you will have sharp pain whenever you contract your quadriceps. Even a little bit. Which makes most activities very painful, although nothing is painful to the touch. For the first few days of this, simple things like getting into the car and getting out of bed were almost impossible.In my experience, it takes 6-8 weeks for this to heal to the point where running is safe again. After about a week, I'm almost back to walking correctly, no longer dragging my leg along and losing my balance occasionally because it hurts too much to use the quad muscle. Very frustrating. Ice, ibuprofen and total rest until the pain dies down, and (non-running) exercise for the next couple of months. The main mode of treatment for these kinds of iiuernjs (patellar tendinitis, achilles tendinitis, etc.) really is rest. And common sense exercise as you are able.Perhaps you have been resuming your running too soon. You feel better and you want to get back out there. Try some extra down time and other forms of exercise for a while. And definitely check with a foot specialist to see if orthotics will help you.
June 8 2014
Hi Greg
Thanks for this article, I've been having a similar problem and plan to do what you suggest. Was just wondering how you think olympic lifts might fit in to the higher rep/volume weeks if at all?
Greg Everett
June 9 2014
Sam -

Similar structure, but don't exceed 3 reps for the actual competition lifts, and keep them light. Generally the power variations will actually feel worse due to the need to stop in a partial squat position with maximal tension on the quads/quad tendon.
June 12 2014
Cheers Greg, another thing I thought about the article that was touched on but maybe not emphasised enough was a focus on the eccentric portion of the movements. Having recently spoken to my coach about this he was advising squats at a pace of 8,1,1 as this increases blood flow to areas that generally heal slowly due to lack of blood flow.
Thanks again though.
January 21 2015
Excellent reference, Greg. Just heard you on the Weightlifting Scoop podcast and thought that you must have an article about tendonitis - i was not disappointed.

Thanks for putting this together. Love what you are doing.
Rich S
February 18 2015
Almost a year, countless rehab and 1 minimally invasive surgery and I'm still down and out from Patellae Tendonitis. I'm going nuts and have gained considerable weight from lack of exercise. I used to CFit 4 times a week with 3 days of Snatch & C+J mixed in (5-3-1 as well) . Headed for my second MRI, as the doc doesn't like m progress after surgery. Possibly PRP shots to come. I really want to get back to it and have followed the PT's advice religiously. Gregg, can you be a little less technical and a little more layman and explain which exercises would help. I do foam roll, and now I will try the lacrosse ball on my ITB and above the knee cap. Moral is, this seemingly minimal injury has turned into a nightmare for me. Just looking for any help I get. Thanks in advance.
Greg Everett
February 20 2015
Rich -

More stretching of the quads and hip flexors; more foam-rolling, massage of the quads; fewer total training reps of squat movements until better; hot/cold water contrast frequently.
John B
May 8 2015
Regarding the Olympic lifts, do you mean 3 reps per set or 3 reps tots at a reduced "working" weight? Thanks.
Greg Everett
May 9 2015
John B -
3 reps per set.
April 18 2016
No mention of eccentric rehab exercises, which is the current recommended treatment for Tendonopathy?
Andrew Ridley
April 20 2016
The experts in tendon rehab are currently prescribing high volume isometric holds in mid range (staying well away from deep range which is too much tension). 10 minutes of total volume daily (10x1 minute holds etc) slowly increasing the weight each week etc. should be slightly painful during but can actually feel better following the exercises. Eventually this progresses to slow concentric eccentric and very controlled plyometric. I've been using this protocol at my clinic works well in most cases. Some stubborn tendons require a PRP injection. (Platelet rich plasma). Rest wont really heal a tendon it will just settle it down but the tendon structure wont return back to a dense strong structure without some controlled loading.

Gabriel C
April 27 2017
Hi Greg, I'm suffering of tendonitis in my hands due to catching the bar in my hands and not on my shoulders. I'm correcting it, but it's extremely painful to even hold an empty bar in the rack position. The doctor gave me 3 weeks of complete rest, no weightlifting at all. Do you have advice on how to catch the bar on the soulders instead f in the hands? thanks
July 7 2017
Patellar tendonitis and some other knee problems may be a result of squatting incorrectly when the femur and tibia are not aligned properly. This results in patella not running down and up its ideal "track" but rather coming outside of it and rubbing the femur, which is the cause of inflammation and the rest damage. A great explanation is here

Just as it was explained here

Your feet are flat on the floor.
Your hips are comfortable, i.e. no pinching or pressure—find a position in which the hips move the most freely.
Each thigh is approximately parallel with the corresponding foot—if you look straight down from above one thigh, your foot is in line with it.

My own experience is that in the OH squat/snatches I am much more prone to squatting incorrectly with riding on the inside of my feet and with my knees moving inward. This doesn't happen during front/back squats.

As mentioned in the comments above, isometric holds are great for healing joints. Also, as suggested by Greg, high volume/low intensity exercising. I would only suggest in a bad case the intensity needs to be even lower, and the volume even higher that 8-10 rep sets. Multiple air squats or light-weighted leg press machine with perfect form, or bike - stationary or real, are all great. The idea here is to supply extra blood to the knees and affected muscles that will help healing faster.
Marko Schiefelbein
July 7 2019
For Everyone who is dealing with Patella issues. I highly recommend to do Heavy Slow Squats 3sec down, 1sec pause and 3 secs up. There is a good rehab plan on how to recover and come back to your sport (University of Delaware Rehab Practice Guidelines):