T Nation

Quad Tendinopathy

Hi @j4gga2 !

Thanks for this message. I’m an Olympic weightlifter and have been suffering from quad tendinopathy for more than 2 years now.

I found your rehab plan interesting because it reminds me of Jake Tuura’s approach (which I’ve used with some success but not 100% success) but differ on some points (rep ranges and the reactive loading part).

If I may, I would like to ask some questions:

  1. for iso exercice, I’m surprised by the 1-3 sets: usually, I see 3-5 sets suggested. Is there any reason for this recommandation of yours?

  2. for quad tendons, can the heavy loading to strain the tendon be heavy squats/front squats in the 3-5 rep range?

  3. what do you base you reactive/elastic recommandation for tendon stiffening on? studies, personal experience? I’m especially interested as this is something I haven’t yet tested, and might be especially applicable to oly lifting!

  4. what would be appropriate reactive/elastic exercises for quad tendons? I find hopping or rope skipping not « deep » enough for triggering any quad tendon pain, so what would you recommend? Light snatchs? Drop snatches? With which loading and rep range?

  5. Finally, what are your thoughts on PRP and BPC-157 for quad tendinopathy?

Thanks again for this message, and for any answer your might give!

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For context since this was split from the original thread, this is referring to @j4gga2 ’s very informative and comprehensive post on this thread.

Hey mate, I very flattered by this post and hope I can help :slight_smile:

Yeah both Jake’s approach and that approach were heavily influenced by Keith Baar. However, I’ve learnt some more about tendinopathy rehab since then, so my approach has changed

Short answer: because I was recommending completing isos 2-4x daily, so daily volume was still high.

Realistically, the volume itself doesn’t matter too much, as long as there is sufficient volume to have an analgesic effect and promote strength adaptations

It definitely could be, however the difference between quad tendinopathy and patellar tendinopathy (as I have learnt since that original post) is that quad tendinopathy is aggravated by deep knee flexion/bending. Quad tendinopathy has a load component (as for patellar tendinopathy), but another contributing factor is compression of the bottom of the femur against the underside of the tendon in deep knee bending. That compression also results in quad symptoms.

As such, it’s usually recommended to avoid deep knee flexion whilst the quad tendon is irritable. As such, a good option for heavy loading would be maximally-loaded 10-30s Jefferson split Squat isos.

Work of Dr Keith Baar:

He frequently features in podcasts for athletic performance coaches. However, it is worth noting that in the physiotherapy/rehab world, Dr Jill Cook is generally considered the world-leading expert in anterior knee pain.

I would suggest that reactive loading may not be necessary for weightlifting. See how far you get with heavy loading only.

That said, if heavy loading isn’t enough to get you to full resolution, you could use some jumping that requires you to hit ~90° of knee bend such as:

Seated jump:

Don’t know enough about it. Ask a sports physician or experienced sports physiotherapist in your area.

Usually, individuals are able to make very good recovery without such interventions

Consideration for O-Lifting

Finally, since quad tendinopathy is aggravated by deep knee bending and hard bouncing, I think it’s a good idea to avoid or limit exposure to the full catch position for at least 2-3ish weeks. I also recommend using half squats for the first phase of the below protocol, then 3/4 squats for Phase 2, then bury it in Phase 3. If you feel the tendon become irritable after a session, reduce ROM next time.

The triphasic progression often works very well I people with tendinopathy. This progress model works for your heavy primary strength training (e.g. heavy back squatting). Usually, 3-5 x 3-8 reps ~2-3 times per week. You might choose to do a heavy (5x3) / light (3x8) / medium (3x5) rotation across the training week.

  • Phase 1: Weeks 1-3: 7s eccentrics
  • Phase 2: Weeks 4-6: 5s pauses
  • Phase 3+: Weeks 7+ normal tempo
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Thanks for your answer, I really appreciate your taking the time to help me!

[…] another contributing factor is compression of the bottom of the femur against the underside of the tendon in deep knee bending. That compression also results in quad symptoms.

Really interesting as it might explain why I did not recover after all this time (2 years and a half) despite all my efforts. I’ve totally stopped oly lifts for some lengthy periods (up to 6 months) while keeping the squat/front squat loading in the 3-5 rep range in conjunction with iso, but with limited results. (As soon as I get back to oly lifting, even with light weights, the pain comes back with a vengeance.)

Also, when the quad pain flares up, it is often associated with a different feeling that I can only describe as “rusty knees”. MRI ruled out any problem other than tendinopathy, other tissues are fine, so maybe this is something related with this compression issue.

Is the risk of tendon tear higher with compression than with load? (I guess one way of looking at this is: are there more quad tendon tears that patellar tendon tears?) Also, what specifically is triggering it: the bounce at bottom depth? Or overall deep squatting volume? (Before this injury I really used to squat deep and often, as all oly lifters I guess…)

[…] a good option for heavy loading would be maximally-loaded 10-30s Jefferson split Squat isos.

I guess front rack split squats could be a good option as well as long as I don’t go too deep? (I’ve done those extensively at some point, they do seem to help.) Also, why isos and not full fledged Jeff split squats? Would the motion itself be especially aggravating for compression? And should I even avoid isos in deep flexion?

I would suggest that reactive loading may not be necessary for weightlifting. See how far you get with heavy loading only.

Interesting. Why sho? Because this is more applicable to patellar tendinopathy?

Finally, since quad tendinopathy is aggravated by deep knee bending and hard bouncing, I think it’s a good idea to avoid or limit exposure to the full catch position for at least 2-3ish weeks. I also recommend using half squats for the first phase of the below protocol, then 3/4 squats for Phase 2, then bury it in Phase 3. If you feel the tendon become irritable after a session, reduce ROM next time.

Awesome, I think this was the missing component: I trained through full ROM in squats and front squats, thinking that as long as I did them slowly and without bounce the pain didn’t matter during the exercise, only in the next 24-48h window. But because of the compression factor, this apparently does not work for quad tendons, so I should increase the ROM gradually.

One question on this plan: should I use pain during the first two sets dictate how deep I can go (after that the pain is usually gone)? Or should I stick to an arbitrary ROM increase like the one you outlined?

The triphasic progression often works very well I people with tendinopathy.

I actually more or less did the same king of tempo/pause manipulation on squats and front squats, only less organized: I simply did slow eccentric with a pause at the bottom. It did help somewhat, but I guess I was missing the ROM increase component.
How would you advise I structure this triphasic progression with the ROM increase progression? As long as ROM is not back to full depth, remain in the eccentric phase? And as soon as I can reach bottom without triggering pain in the next 24h, add pauses?

Again, thanks a lot for your answers, I have to admit that quad tendinopathy rellay screw with your head! Your help really is invaluable to me!

Eh it is what it is. Sensations are a weird thing and are rarely diagnostic of any issues. I wouldn’t be too concerned about it.

No. There is no difference. Also, please keep in mind that complete tendon ruptures are very very rare, and I wouldn’t be too concerned about it happening to you.

Compressive tendonopathies have the same aetiology as “normal” tendinopathies, just with an added anatomical factor (compression of bone against tendon). The compression only affects management, not onset. Onset is still highly related to training history.

Yeah that is fine, just staying above 90 or so degrees of knee bend at the start. Personally, I like that Jefferson set-up because it prevents you from dropping lower than 90, and the limiting factor for it is rarely the trunk

The issue at the start is just the degree of flexion you’re in

Exactly. All your usual tendon principles apply, but you also need to include a ROM progression

I’d start with an arbitrary limit (90 degrees) for the first 2 weeks to set your baseline, then try playing around with it a little. If you find playing around doesn’t help, go back to a strict ROM progression (90 deg for two to four weeks, 3/4 squat for two to four weeks, full ROM)

To be honest, I don’t know. I’d probably do:

  • phase 1 and 2 at 90 degrees, 1wk deload
  • phase 1 and 2 at 3/4 depth, 1 wk deload
  • phase 1 and 2 at full ROM, deload then return to normal training

Happy to help mate

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Ok then, I’ll apply these principles and see how it goes! I’ll be sure to report on the progress. Two last questions if I may:

If compressive load is a factor for quad tendon, would knee wraps or even neoprene knee sleeves be ill-advised? What about quad stretches?

What is your take on the whole muscle imbalance theory for tendinopathy? I’ve done a fair amount of hamstring training in the past two years (RDL and leg curls, mostly) and it never seemed to change anything… In the case of leg curls, could they be an aggravating factor because of compression at the end of ROM? Or on the contrary, could they help alleviate compression through some muscle rebalancing magic?

Thanks again!

Don’t stretch tendons across the board (compressive or non-compressive).

Knee sleeves should be fine, not too sure about knee wraps. I would start with naked knees, introduce sleeves after a few weeks when symptoms are improve, then consider progressing to wraps.

In this context, I doubt it’s an issue

Maybe. Maybe not.

Having strong hamstrings is almost never a bad thing, so if they aren’t worsening your symptoms, I wouldn’t remove them