Ranking the Top Patellar Tendon Exercises by Tendon Load - #AMR384

We all have our favorite "go-to" exercises for patellar tendinopathy. For years, the single-leg decline squat has been the gold standard, often introduced early in rehabilitation to target the tendon. But what if I told you that this specific exercise actually places more load on the patellar tendon than running or double-leg jumping?

A massive new study just analyzed 35 common rehabilitation exercises—from step-ups to plyometrics—and ranked them based on actual biomechanical load. The results turn traditional progression models upside down and might explain why some of your patients flare up during "standard" rehab protocols. In this week's episode, we break down the 3 distinct tiers of tendon loading and give you a data-backed roadmap to build the perfect progression.

To see full show notes and more, head to: https://mikereinold.com/ranking-the-top-patellar-tendon-exercises-by-tendon-load/

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Transcript

Welcome And Free Course

SPEAKER_02 0:53

On this episode of the Ask Mike Rhinel Show, we have a journal article review on patellar tendon loading progressions. The Ask Mike Rhinel Show. Helping people feel better, move better, perform better. Before we get to the podcast, I wanted to make sure you knew about my free online course on the introduction to performance therapy and training. If you want to learn how to get started optimizing and enhancing performance, this is the course for you. Head to MikeRynold.com/slash performance to sign up today. Welcome back, everybody, the latest episode of the Ask Mike Reynolds Show. We are here today, not answering your questions. We're going to do journal article review today. So we're going to kind of keep mixing up the formats a little bit. We've got some great feedback on that. So I think we're going to keep going with it. I think we're enjoying it, right, guys? Like we're we actually have had fun kind of going through some of these articles and talking about them. But I'm here today with Anthony Vedetto, Brendan Gates, Dewesh Bodell, Dave Tilley, Kevin Coughlin, Dan Pope, Lenny McCrina, so many people. We are here today. And what what do we have for an article today? So, Kevin, you're going to review, but I'm going to do a better job introducing it. And I'll put a link in the show notes. But we're going over an article today called Patellar Tendon Load Progressions During Rehabilitation Exercises, Implications for the Treatment of Patellar Tendon Injuries. And this is in medicine, science, and sports and exercise from 2025. Kevin, what do you think of this article?

Exercise Tiers And Key Findings

Progress Without Pulling Sport Away

SPEAKER_05 2:27

Yeah, uh, this was a good one. I think this really complemented um a 2021 paper by Baxter and colleagues about uh progressive loads on the Achilles tendon. So I think that was the inspiration for the authors for this paper, is they were trying to figure out uh through a series of exercises what's the lowest to highest amount of load going through the patellar tendon. So I thought it was a really good paper. Um, getting into it a little bit. So what they did, as I said, they evaluated the patellar tendon loading profiles uh during 35 common exercises. And in the rehab of uh patellar tendinopathy was the goal. They ended up making uh what they were calling a loading index, and they used a biomechanics lab to determine uh the loads through the tendon. So a little bit just about the loading index, uh, this was a sum, weighted, a weighted sum of the loading peak, the loading impulse and the loading rate of these different exercises. So they were kind of taking all those things into consideration. Uh, the loading peak for each exercise was the maximal force seen by the tendon in each rep. Uh, the loading impulse was the area under the force time curve. So kind of like how much load was the tendon exposed to throughout the whole entire rep. And then the loading rate was the speed at which the force changed over time. Uh, so those were the things they were considering. And when they ranked the exercises, which I'll get into a little bit, uh, they weighted each one a certain percentage. And the cool thing about this was they they included a spreadsheet where you could go in and change the weights for each of those different types of loads if you wanted to, you know, bias an exercise for loading rate versus loading peak, uh, if that's something you were considering looking at. So why they did it again, uh they were inspired by that paper by Baxter in 2021 looking at progressive loads to the Achilles tendon. And they they were just in their research, obviously noticing how many people are affected by patellar tendinopathy and how many people, especially after ACL reconstruction with a uh bone patellar tendon, bone uh autographed, are affected by patellar tendinopathy. So they wanted to get kind of a good idea of how we should probably progress our exercises over time. Uh their methods, they included 20 adults. Uh, and I think the important thing to note here is these were healthy adults, so they were not dealing with patellar tendinopathy at the time of the study because they wanted baselines on how to healthy folks move, and that was their priority. The average age was 25 years old, uh, plus or minus five years, and they included 10 females and 10 males uh as well. So again, the inclusion criteria they had to be between the ages of 18 and 40. Uh, they had to have no history of lower limb or spine pain in the last six months. So, again, using people without pain currently. Uh, they decided to use the patients with alpertellar tendinopathy to categorize the loading index during pain-free movement. Uh, with the implementation of the exercises, they standardized them. Uh, they had each patient wear the same shoes, the same pair of shorts, uh, the same amount of rest between exercises. So they really kind of were pretty systematic about that. They also had the same physical therapist demonstrate all the exercises to make sure that they were all taught the same way, which again, I think is important. And then uh they used the biomechanics lab to collect kinetic and kinematic data on the 35 different movements that they did. And they just noted this was a validated way of analyzing movement um, according to prior research. And then, as I said, for this study, they were looking at loading peak, loading impulse, and loading loading rate. The way they decided to weight it was loading peak uh was weighted 50% in their final equation. Loading impulse was weighted 30%, and loading rate was weighted 20%. But again, they were kind of nice enough to provide a spreadsheet where you could go in and tweak those, you know, say you're really interested in focusing on getting a really high loading rate, um, maybe towards the end of rehab, you could weight that 100% and look at what exercises are doing that uh most effectively. Um and then just getting into the results. So what they decided to do was break these 35 exercises up into low uh medium or low, moderate, and high loading index, where low is below 0.33, moderate is 0.33 to 0.66, and high is over 0.66. And in that model, one is like the most load you could possibly put in the patellar tendon, and zero was the lowest amount of load. So um they provided some nice graphics and figures in the study where they just made it really organized, like this is low, this is moderate, this is high. Um, I'm I'm not gonna go through every single exercise because that would definitely take a long time. But I think just a summarizing some of what they found. Uh, and the reason why I think this was really interesting is because they noted that a lot of times when you look at research on rehabbing patellar tendon pain, uh, you'd see very commonly uh dominated by eccentrics, but especially like an eccentric decline single-leg squat. That's something that we have all seen in research studies looking at patellar tendon pain. Uh, but what they thought was interesting about that is that's the highest load exercise on the patellar tendon. So, you know, if you're trying to load that and and you're watching videos online and you see kind of like knees over toes guy on his decline board, well, that's the highest possible load. So we we have to understand that, and maybe that's something we build the patient up to, but it can't be an entry point into our exercise program. So they definitely made a note about that. Um, and then just to kind of, you know, some other high-tier exercises. And again, you can all look at the paper for specifics, but like a single leg forward hop was really high, single leg counter movement jump, running and cutting, kind of down in that moderate tier. We were at uh Spanish squat or uh just just running, counter movement jumping, uh and so on and so forth. And tier one was like little step-ups and step downs from a small box, uh, and then like a double leg squat as well. So I think those provided, they provided really nice images to look at for that. And the other interesting thing they noted in the discussion was just that I think a lot of times people are afraid of single-leg exercises, but there's not a uh hundred percent increase in the load of the patellar tendon going from two to one. It's actually a very minor increase. It's more increased by depth. So that's something you could play around with as well. Like going from two to one is okay if you're in a fairly shallow range of motion. Uh, it's really going lower that's putting more load through the patellar tendon. So uh I thought it was a good paper. And again, I think it's worth um actually what I've done since the Baxter paper, and I have a few people with Achilles tendon pain, is just having on my desktop like a screenshot of those exercises to reference. And I did the same thing for this. So it kind of just lives on my desktop uh as something I can quickly open and reference if I'm thinking like, all right, well, I know this exercise has been pretty painful for this person. What are a few options I have at hand to uh try something a little a little lighter and see if they tolerate that a little bit better? Um, so I really like the paper and curious what everyone else's thoughts were on it as well.

SPEAKER_02 10:00

Thanks, Kev. Yeah, that was great. I mean, uh the papers like this make us better, right? Like we think we know these exercises really well, but we can get a little bit more precise, like little things, you know, manipulate the depth versus the you know, double versus single right away, those little things. But when when you can categorize exercises based on load, we're getting more and more precise. And when you see, like probably some of the more common exercises on Instagram are some of the highest, like the single-line leg decline, like that was the one where you know you read the article, you're like, oh man, like that's that's gonna mess with people because everybody wants to do that on Instagram. It's such a popular exercise now, but that should be what you're doing last, right? Like, and everyone wants to do that first when they have that. So uh what do you guys think? What are some thoughts on the article? Uh Dave, you want to start?

SPEAKER_03 10:43

Yeah, this is uh uh ironic because that the year that paper came out for the Baxter paper was the same year we published a huge review paper on Achilles' tears and gymnastics. And I remember uh the research group and the people I work with being so grateful to Baxter's group that they put that up because we had a bunch of risk factors come out on what might contribute to somebody saying, I tore my Achilles. And then they were like, Okay, well, like, well, now what? Like, what do I do about it? Like, I don't want to tear my Achilles, but I want to do sports. Like, how do I not help this? And we know that exercise is such a huge part of, you know, if someone's got attendonopathy, like Kevin said, rebuilding someone's um tolerance to pain-free exercise, and then what we do more is like workload-based. Um, but that paper, uh, that paper series of like that exercise and some other things has like made a massive difference in my clinical practice the last three years to the point where on Monday I had a level 10 gymnast going to college with Achilles tendon issues, and I pretty much just fully, you know, kind of worked my way through our vowel, whatever, but I was referencing that paper for how to help her in their next three to five years. And I feel like when you have a paper like this, patellar tenant-wise, we all see so many patellar tendon issues, whether it's tendonitis, tendinopathy, um, you think about someone who's post-ACLR with like a BTB, like we're trying to figure out what is the best way to help somebody. And we also were just talking at Champion last week, Duesh gave a great in-service on power. And a lot of our conversations are okay, if we have someone who's kind of floating between PT and fitness and we're trying to help them maintain as much workload as possible, the suggestions that we make as PTs are oftentimes a modification to the load of a tendon or the load of a bone or something like that. But we don't want to pull somebody fully away from fitness and from sports because we know the more we reduce their workload, the harder it is to get back to full activity. So I, you know, regularly talk with Kaz and Duesh and everybody about like, okay, can we switch a few things out? And this paper is great. Like, can we just take these plyos and maybe move someone down to a tier one type quad exercise or patellotendon exercise if someone's having a flare-up? So maybe we reduce their volume by 20 to 50% based on a small exercise choice, not like, okay, let's just sit you out for two weeks and not do anything at all because that's gonna be problematic. Um, and I think that when somebody has a uh suggestion of exercises from the strength side, it's easy for us, like Kev said, to reference this paper and be like, okay, over the next two weeks, here are the next three steps in this progression that you might want to work somebody up for. So it's very easy to get around the social media, the what I think is the best exercise for this, and instead not really go on this very systematic evidence-based progression. Um, but the more studies that we have like this that categorize certain things we see all the time, Achilles, Patel or tenant, whatever, um, it's really helpful to give somebody a guide.

SPEAKER_02 13:16

Yeah, for sure. I completely agree. Uh Dawesh, from your perspective, strength coach-wise in the gym, when you look at these tears and you look at those spectrums of exercises. Anything surprise you? Anything that made you kind of like rethink some of our progressions, or were we on pace? I mean, I think the that one we we keep talking about, the single leg decline squat being the highest, I think kind of surprised us a little bit. But anything else jump out at you?

Pain, Impulse, And Loading Rate

SPEAKER_01 13:40

Yeah, there actually was a couple that um that I thought was gonna elicit a lot more um and be higher tier. Like um when working with a lot of these peter tenanopti athletes, like we get a lot of complaints about um like a Bulgarian split squat, an RFE split squat. Um, and that was kind of in tier one. Um, we we tended to be a little bit more cautious in introducing something like that because that back leg, especially being on a massive stretch for the Pizarro tendon, tends to be pretty irritable. Um, so I did find that one to be a little bit surprising. Um, and then the other one was um the the repeated lateral jumps. Um we we definitely like assume that the jumping and hopping is gonna be a little bit more painful um and a little bit less tolerable. Um, but I was definitely a little surprised to see the the two-legged repeated lateral jumps, and apprentices says fast. Um I I thought that was interesting that it was uh a tier one and uh you know kind of in line with like a step up, which you know, even me personally, I've been dealing with a kid a bit of pitar xenophty, and I definitely don't think I tolerate the lateral jumping as much as I tolerate a step up. So that one was a little interesting, but the others seem like they they fall in line pretty well, actually.

SPEAKER_02 14:55

Awesome. Dan, what do you think?

SPEAKER_04 14:57

Yeah, I th I think it was a little bit misleading in terms of the exercises where they were. I think a really good example is a Spanish squat, which is pretty close to the advanced section. I think it's still in tier two, but it's three seconds on the way down, three seconds on the way back up again, right? And I think there are actually some jumping and landing drills that were uh less stressful than the Spanish squat. And I think from rehab perspective, you're like, that doesn't make any sense whatsoever. Uh, one of my thoughts is that just the way they loaded, or excuse me, they um ended up um calculating this. So loading peak was one of the most important things, right? At 50%, and then loading impulse. So the three-second up, three-second down Spanish squat is gonna have a huge loading impulse, right? But then it's not gonna have as much of a loading peak or a loading rate, right? And one of my thoughts too, and I'm not sure, it'd be kind of interesting to see this in people actually have patellotinopathy, but I wonder if that loading rate influences people's pain. So if we uh overweight the loading rate, right, maybe that's 50%, then maybe we find that these shuffle around a lot and give us a more accurate measurement of how someone might behave with pain, just because for a lot of things, patellotinopathy being one of them, when we're dosing exercises, one of the biggest considerations is how much pain the patient is experiencing, which is probably not gonna match this perfectly. So I think a lot of it's take it with a grain of salt. Um, if you wanted to mess around, it's it looks like you could with this study to change some of those parameters and see if it changes kind of what it gives you. But I think at the end of the day, it's not a perfect science. And once you have a patient that has patellotinopathy, you probably want to go in the gym, try these out, see what feels good, see what doesn't. Uh, just like you, uh Dewey, what's interesting to me, and this is what I found over the course of time, if someone has like, let's say, patellotenopathy or excuse me, um, patello femoral pain, usually that back leg on a lunge doesn't hurt very much. But for patellotenopathy, it does for some reason. I don't exactly know why, just because like when you're using your quad, you strain the patelephemoral joint. Obviously, when you're you know doing a lunge with patellotinopathy, you're straining the quad, should strain the patellar tendon, but it just pain behaves a little bit differently for different pathologies and different people, right? So I think a lot of it is you have these numbers, these are obviously awesome. I think it's great for progressing the non-op patient as well as a post-op patient. So let's say A cell reconstruction, quad or patellar tendon, uh, as well as some with patellotinopathy, but you got to probably go out in the gym and try it out and see what feels good for the patient, and then basically use both of those inputs to figure out what's best for the person in front of you.

Open Chain Gap And Coaching Effects

SPEAKER_02 17:21

Yeah, that makes sense. I I I agree with the concept there too. And yeah, I will say, like, I've started looking at load differently, right? We in PT in these articles, we tend to always look at like peak, right? But impulse over time is important, you know. We show that with our weighted ball studies, right? Like heavier weighted balls when you throw them have a lower peak load, but a higher impulse, which we think might have, you know, the consequence of you know the neurophysiological change that we see. So I think there's a lot behind this, but it's a dance point. If you have an acute raging patellar tendon pain, right, like load probably matters more than impulse, for example, just like throwing that out there. So uh what else? Anthony, what do you think?

SPEAKER_00 18:03

Yeah, again, I thought along with you guys, I thought this would be great for clinical practice. But one thing I noticed was that uh the majority of these exercises, I believe all of them, were all closed chain exercises. And I don't think there was an open chain exercise included on there, like in like a knee extension or even like an isometric uh knee extension at 90, which I know could be a good introduction for people with more severe type patellar tendon pain that they can't tolerate loading through a range of motion. So, Kev, I thought I'd propose this to you. I was wondering if you thought maybe this was a miss in the article, because you know, if we're trying to load the patellar tendon or the quads, one of the most direct ways we can do that is with an open kinetic chain knee extension. So I thought, I don't know, do you think that that could be applicable? Where do you see those falling into line with these other exercises? And where where do you see those being kind of fit in your clinical practice?

Practical Takeaways And Wrap

SPEAKER_05 18:56

Nice, Anthony. Good question. Um, I think that what popped in my head as you were asking that is that maybe for each person, like if you're doing a isometric open chain knee extension, it would be hard to for each person quantify like what percentage of their maximum they're doing it at. So I I wonder if that would require just more work from the researchers where you know they had to fake kind of figure out like if this is a certain percentage, you know, say it's a hundred pounds and I can only lift you know 105 pounds, but you can lift 300 pounds that might elicit a different response in the tendon. So maybe, maybe it had something to do with that. Um, but I'm with you on that. I mean, I think that's a way we all load the tendon uh at Champion and we we know the value of open chain uh strengthening for people. Uh and then something that I was just you know speaking with uh Meredith about last night, our student, is that I think for all of these, like the thing is there's a way to coach them to bias load toward the rod and the patellar tendon or bias load toward the hip. Um so I think all of these could be coached to be, you know, you could make a certain exercise very, very heavy on the patellar tendon, or you could make it very little. And that that could even relate to um like a single leg counter movement jump. How you however you coach it could change the output. So I think that is a consideration as well. And they did they did put videos in. I I didn't uh watch them yet with all the demonstrations of how they coach these different things, but I I'm sure that could play a role as well. So um I think that could be another another shortcoming, but I agree with you, Anthony. I think uh it would be nice to see that as well and see where we could fit that into the rehab progression.

SPEAKER_02 20:44

Awesome. Thanks, Kev. I'd say two big take-homes from me, kind of wrapping it up here. One is I think it's more than just peak force. I think we have to keep that in mind. And if you actually look at the graph, which again is a great graph, I like how you can visually see peak force, impulse, and rate, like all visually, because they different exercises have maybe a more bias towards impulse versus rate, for example, like just little things like that. I think it I think it matters, and it matters for the person in front of you, so that's good. But the other thing too is I love seeing some of the overlap here with some like plyos and running in earlier phases. Sometimes I think young clinicians they get wrapped up and it's like it's like strength, agility, plyo, run, and it's like, you know, linear sequential, right? You have to achieve one. But you can see there's there's plenty of running and plyo drills that were less aggressive, you know, and have less loading than some of the exercises that you're probably trying to have them do, right? So again, I think this is to us, this is how we build programs of champions. This is how we even do everything, ACLs, everything is there's that blend going on. So I think that's a big take-home for me is you get to see that visually as a young clinician. Like maybe you'll feel a little bit less, you know, scared to do like, I'm just gonna look real quick, like, you know, drop lands, you know, repeated forward jumps, like stuff like that, that is a little bit lower on the scale than you know, running, for example, like or jogging or a decline squat. So, you know, you use that as a linear scale to try to help you pick your exercise selection. So awesome. Great article. Thanks, Kevin. I really appreciate it. We're gonna keep doing these, so check them out. Please subscribe to the podcast so you get these episodes, and we'll see you on the next one.