Patellar Tendinopathy Template for Weightlifters
User Manual
Thank you for implementing our rehab template. This template provides a framework for
weightlifters dealing with patellar tendinopathy and guiding the process back to their desired
level of performance.
Template Phases - General Overview
The template is layered through 4 phases:
Phase 1 - Analgesia (pain control) with Isometrics
Phase 2 - Tempo-Strength Training
Phase 3 - Dynamic Loading (integrating back to weightlifting)
Phase 4 - Return to Sport (normal weightlifting training)
Phase 1 (Week 1 exclusively - then layered through Week 16):
The goal of this initial phase is pain control with isometric exercise.
Phase 2 (Weeks 2-5 exclusively - then layered through Week 16):
Isotonics (tempo strength training) will re-introduce the lifter back to squatting and developing
lower body strength and load tolerance. Volume of Phase 2 will be decreased as the athlete
progresses into dynamic loading (Phase 3) and RTS (Phase 4).
Phase 3 (Week 6 - 16):
Dynamic loading will begin after 4 weeks of isotonics-only. This phase will focus on re-introduction
of the snatch and clean & jerk through various progressions. Volume, frequency, and intensity of
the lifts will be increased from week to week.
Phase 4 (17-20 *post-rehab):
This is a 4-week block of weightlifting training, in which the lifter has moved beyond the ‘rehab’
stage and is now preparing for future competition.
Before beginning Phase 1, please read through the next section,
“Patient Education”, to set expectations appropriately.
Patient Education
The following expectations should be set with the athlete prior to beginning this template:
● The rehab process may increase symptoms during exercise.
● Symptom increase should not last more than 24 hours and should not lead to a decrease in
function.
○ Examples of loss of function:
■ athlete experiences loss of range of motion, loss of ability to complete
activities of daily living such as getting in and out of car, going up or down
stairs, getting in and out of a chair.
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Outcome Testing
1. Written Assessment (for clinicians):
a. Victorian Institute of Sport Assessment (VISA) Questionnaire, Patellar Tendon.
b. https://www.ncbi.nlm.nih.gov/pubmed/23012320
c. Have the athlete complete this form (1) before beginning template, (2) at the 8week mark, and (3) after completion of template.
d. Minimal clinically important difference (MCID):
i.
Assessment score needs to change by 13 points
2. Provocation test/biofeedback:
AT INITIAL CONSULTATION AND PRIOR TO EACH REHAB SESSION:
a. Athlete performs single leg decline squat (see picture below).
i.
Athlete must be able to complete 3 repetitions to knee flexion of 90 degrees,
with a tempo of 3-1-3 (3 seconds down, 1 seconds pause, 3 seconds up)
1. If athlete is able to perform these repetitions without an increase in
pain after testing, then select “pass” for Biofeedback Testing 1, and
proceed to training.
2. If athlete is unable to perform these repetitions due to pain OR there
is an increase in pain after testing, then select “fail” for Biofeedback
Testing 1, wait 3 minutes, and test again.
a. If athlete passes Biofeedback Testing #2, proceed to
scheduled training.
b. If athlete fails Biofeedback Testing #2, athlete is to perform
isometrics for the day.
ii.
Assess both depth (knee flexion) and pain level (Verbal Rating Scale 0 - 10;
where 0 = no pain, 5 = moderate intensity, and 10 = worst possible pain).
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1. The athlete should attempt to reach 90 degrees of knee flexion or
max allowable range of motion based on symptoms.
2. As long as symptoms have returned to baseline levels within 24
hours of rehab session, then load has been well tolerated. If pain has
worsened then tolerance for load has been exceeded (see below for
how to proceed in Phase 1).
Single leg decline squat with heel elevation – with board
Note: the incline board can be substituted with a plate or other sturdy object under the athlete’s
heel, shown here:
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Sport Participation Restriction Recommendations:
For many team and individual sport athletes, patellar tendinopathies usually involve symptomatic
movements dynamically loading the tendon; such as jumping, running, sprinting, cutting,
accelerating, and decelerating. For the weightlifter, this likely means the full movements for snatch,
clean, and jerk.
● Athletes can still complete normal training sessions involving upper body movements not
loading the knee; and even non-trigger lower body movements. However, if the athlete is
not tolerating the workload of the template, the non-trigger lower body training may need
to be modified to accommodate the template.
● Athletes should avoid competition at this time.
● Phase 3, Dynamic Loading, will discuss in detail how to grade exercise exposure specific to
practice and competition for the snatch and clean & jerk.
Template Metrics
Metrics are being tracked in order to manage fatigue levels of the athlete while ensuring
appropriate progressions.
Throughout the template the following metrics will be tracked:
1) Daily Metrics:
a) Exercise Tonnage = sets x reps x load
b) Average Intensity = total weight utilized for an exercise / total sets
c) Absolute Intensity = highest weight utilized for an exercise
d) sRPE = session rate of perceived exertion
e) Duration = amount of time spent training for a session
f) Session Score (AU) = (sRPE x Duration)
2) Weekly Metrics:
a) Exercise Tonnage = sum of daily exercise tonnage
b) Average Intensity = sum of daily average intensity / total weekly sessions
c) Absolute Intensity = sum of daily absolute intensity / totally weekly sessions
d) Total Session Score (AU) = sum of daily session score
e) % Weekly Differences = week to week changes between tonnage, average intensity,
and absolute intensity. NOTE: Ideally, these differences are less than 10% per week.
If they exceed 10%, then the template box will change to a red color.
3) Data Analysis: graphs will be available on the template’s “data analysis” tab.
a) The following graphs will be created tracking week to week changes in tonnage,
average intensity, absolute intensity, AU, and A:C ratio.
b) A:C Ratios: Weekly Session Score / Average of prior 4 Weeks Session Scores. Ideally,
the A:C Ratios will be maintained between .8 and 1.3, termed the “Sweet Spot”.
(NOTE: This information is extrapolated from team based sports’, and even then, the
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data is not terribly strong. We do not have data currently on strength-based
athletes.). You will need to be mindful of trends over time.
**Videos will be available further explaining the importance of metrics and tracking.**
Template Phases - Detailed Overview
Phase 1 - Analgesia with Isometrics (Week 1):
REMEMBER TO BEGIN EACH REHAB SESSION WITH:
Provocation Test / Biofeedback: if athlete is unable to tolerate/perform 90 degrees of knee flexion
(see photo above) for 3 repetitions at tempo (3 second decent, 1 second pause at depth, and 3
second accent) then proceed with isometrics.
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Isometrics
Exercises
(select one bilateral exercise and
one unilateral)
Frequency
Sets and
Repetitions
Rest
Intensity
Wall-Sit
Spanish Squat
Counterbalance Squat
Split Squat
Knee Extension (60 degrees of flexion)
2 times per day (usually morning and afternoon/evening), 5-7
days per week.
5 sets of :30 - :45 second holds are ideal, however, the time
and/or sets may need to be reduced based on symptoms.
Athlete should rest 90 - 120 seconds, between sets, based on
fatigue levels.
Isometrics should be held to volitional tolerance without
increase in symptoms within 24 hours after session.
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When is it appropriate to progress to Phase 2?
Isometrics do NOT create the same load, demand, or training adaptation as eccentrics and/or Heavy
Slow Resistance (HSR). It is advantageous to progress to Phase 2 as soon as possible. Isometrics are
typically used for pain modulation only.
If athlete tolerates Phase 1 for one week, without an increase in baseline level symptoms, progress
to Phase 2.
When should isometrics be added back into the regimen?
If the athlete has an exacerbation of symptoms, then it is appropriate to briefly return to isometrics
until tolerance to biofeedback test is improved.
“Exacerbation” includes:
○ Symptoms lasting longer than 24 hours after rehab session
○ Symptoms more intense than previously experienced that decrease daily function
(previously explained), or create apprehension to movement that has not been
previously reported by the athlete.
**Disclaimer**: when dealing with tendinopathic issues, exercise may cause
symptomatic increase during the session, however symptoms should not last
longer than 24 hours. If an exacerbation of symptoms occurs longer than 24
hours, return to phase 1 with isometric movements for analgesia. Progression
back to phase 2 is outlined above.
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Phase 2 - Tempo-Strength Training (Weeks 2-16)
BEFORE EACH REHAB SESSION, ASSESS LOAD TOLERANCE USING DECLINE SQUAT BIOFEEDBACK
TEST.
Tempo-Strength Training
Bilateral
Exercises
(select 2 double leg and 1 single
leg)
Frequency
Sets and Repetitions
Rest
Tempo
Counterbalance Squat
Belt Squat
Bilateral Leg Press
Hack Squat
Safety Bar Squat
High Bar Back Squat
Front Squat
Overhead Squat
Lift-Offs
Clean-Grip Deadlift
Snatch-Grip Deadlift
Single Leg Squat (Pistol)
Split Squat
Front-Foot Elevated Split Squat
Bulgarian Split Squat
Unilateral Leg Press
Leg Extension
Step-Ups (Hip at 90 degrees of flexion)
Isotonic exercises are to be completed every 2 days with a day of recovery between
each session.
● Monday/Wednesday/Friday OR Tuesday/Thursday/Saturday
● Isometric exercises can be completed on the days off from isotonics for
analgesic purposes, if needed.
Phase 2 should begin by setting a 15 repetition maximum for each movement.
Exercises are then progressed based on intensity while decreasing volume from week
to week until achieving a 6RM.
Rest between sets: 2-3 minutes should be utilized between each set.
3-0-3
Three second concentric phase, no pause, 3 second eccentric phase - for a total of 6
seconds each repetition.
●
●
Range of Motion
Unilateral
●
●
●
In beginning stages, athlete may need to limit anterior tibial translation
during hip/knee flexion movements.
Effort should be made to return athlete to full range of motion mechanics as
quickly as possible to maintain relevance to functional activities.
In general, the athlete should be cued to go to self-selected, tolerable depth.
An attempt should be made to achieve maximal effort (weight-utilized and
RPE) during prescribed number of “working” sets.
Warm-up sets at lower intensity are appropriate but should not be fatiguing.
After warm-up sets, complete the prescribed working sets for that particular
session.
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●
Intensity
Rate of Perceived Exertion (RPE scale below) can be utilized to assess
progressive overload for each set and session. RPEs approaching 9-10 is the
goal for the prescribed number of “working sets”.
#
Level of Exertion
0
No Exertion at all
1
Very Light
2
Light
3
4
Moderate
5
6
7
Vigorous
8
9
Very Hard
10
Max Effort
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Example:
Day 1 of Phase 2: progressively overload to 15RM of high bar back squat:
● 2 warm-up sets, based on athlete preference or coach/clinician discretion.
○ Example warm up:
■ #1 x 5-10: Barbell only (45 pounds) - RPE: 1-2
■ #2 x 5-10: 65 pounds - RPE: 2-3
● 3 Working sets, building towards maximal effort on final set.
○ #3: 95 pounds x 15 (RPE: 4-6)
○ #4: 115 pounds x 15 (RPE: 6-8)
○ #5: 135 pounds x 15 (RPE: 9-10)
● Total of 5 sets are allotted to reach max effort on final set programmed for the day.
● Caveat: If person reaches 5th set and has not reached an RPE of 9-10/10, then an effort should
be made to increase load accordingly to reach a true 15RM. No more than 2 additional sets to
minimize chances of intolerable overload and to leave room for improvement in the next two
subsequent week 1 sessions.
○ If two extra sets are completed, then record the last five sets as “working” sets to
determine future session loads.
○ Efficiency of choosing warm up sets and accurately predicting required load will improve
over time.
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When is it appropriate to progress to Phase 3 (Dynamic Loading)?
It is recommended the athlete completes four weeks of phase 2 before introducing Phase 3 (dynamic
loading) to ensure the following:
1. Strength has reached a minimum of 80% total volume symmetry (explained below) from side to
side
2. Symptoms are maintained at minimal levels (approximate VAS 3/10), and not exceeding 24 hour
window.
80% Rule explanation:
We are recommending that the athlete develops a minimum ability to perform and tolerate 80% of the
work done on on the “weaker”/less capable side, compared to the “stronger”/more capable side.
● Example: athlete performs split squats on the “stronger”/more capable side, for 4x10 with 50lbs
total load. The overall “tonnage” in this example is 4x10x50 = 2,000lbs. On the “weaker”/less
capable side, it is recommended that this athlete should be able to perform a minimum of
1,600lbs of total tonnage, in order to move to Phase 3. The athlete could achieve this by
performing 4x10 with 40lbs total load, or 4x8 with 50lbs total load.
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Phase 3 - Dynamic Loading
●
●
●
Dynamic Loading for the weightlifter includes variations of the snatch and clean & jerk.
Tolerance to these exercises will need to be assessed from session to session.
Begin each session with biofeedback single leg decline squat, as described in above phases.
○ Before progressing to a new sub-phase, assess the athlete’s tolerance 24 hours after the
previous dynamic loading session. If the previous session was tolerated (symptoms have
returned to baseline after 24 hours), then proceed to the next progression of dynamic
loading.
**We deliberately have not given reps and sets during the snatch and clean & jerk specific movements
of Phase 3. This is because the athlete may need the freedom to work back into those movements as
lightly as they need. As in, that could mean several sets with the empty bar or much lighter loads then
they have previously been using for squatting; and we do not want the athlete constrained by a
controlled set and rep count at this stage. Be sure that the sets, reps, and weight used for these
exercises are recorded, however; in order to guide future workouts.
Progressions for this phase may appear as such for weightlifting:
Layered Approach:
●
●
●
Week 6: When the athlete has completed and tolerated 4 weeks of phase two (isotonics),
introduce dynamic loading at the beginning of Day 1 of Week 6.
○ An example week:
■ Monday - Dynamic + Isotonics
■ Wednesday - Isotonics Only
■ Friday - Dynamic (optional) + Isotonics Only
Week 7: If athlete tolerates week 6, then week 7 should include two days of dynamic loading
(beginning of session 1 and beginning of session 3).
○ An example week:
■ Monday - Dynamic + Isotonics
■ Wednesday - Isotonics Only
■ Friday - Dynamic + Isotonics
Week 8 - 10: If athlete tolerates week 7, then weeks 8 - 10 should include 2 days of dynamic
loading (beginning of session 1 and an entire session on day 3) and 3 days of isotonic loading.
○ An example week:
■ Monday - Dynamic + Isotonics
■ Wednesday - Isotonics Only
■ Thursday - Dynamic Loading Only
■ Friday - Isotonics Only
■ Saturday and Sunday - Rest
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●
●
Week 11-12: If athlete tolerates weeks 8 - 10, then weeks 11 - 12 should include 3 days of
dynamic loading (beginning of session 1, an entire session on day 3, and an entire session on day
5) and 3 days of isotonic loading.
○ An example week:
■ Monday - Dynamic + Isotonics
■ Wednesday - Isotonics Only
■ Thursday - Dynamic Loading Only
■ Friday - Isotonics Only
■ Saturday - Dynamic Only
■ Sunday - Rest
Week 13 - 16: If athlete tolerates weeks 11 - 12, then weeks 12 - 16 should include 4 days of
dynamic loading (beginning of session 1, an entire session on day 2, beginning session of day
5,and an entire session on day 6) and 3 days of isotonic loading.
○ An example week:
■ Monday - Dynamic Loading + Isotonics
■ Tuesday - Dynamic Loading
■ Wednesday - Isotonics
■ Thursday - off
■ Friday - Dynamic Loading + Isotonics
■ Saturday - Dynamic Loading
■ Sunday - off
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Clusters:
Dynamic loading progressions are based on clusters of movement (see below).
● Clusters are divided based on demands of tendon loading and not necessarily on coaching
progressions.
● Each cluster could be an entire session or further divided across multiple sessions dependent on
athlete’s tolerance to loading.
Snatch Clusters
Clean Clusters
Jerk Progressions
Cluster 1
● Lift off to knee
● Lift off to hip
● Pull/extension
Cluster 1
● Lift off to knee
● Lift off to hip
● Pull/extension
Cluster 1
● Push Press with Tempo
dip and pause
● Push press with Tempo
dip
● Push press
Cluster 2
Cluster 2
● Muscle Snatch (no hook
● Muscle Clean (no hook
and no feet)
and no feet)
● snatch grip push press
● Power Clean no feet with
with tempo dip and
pause in catch
pause
● Power clean no feet +
tempo front squat
Cluster 2
● Push jerk with tempo
dip and pause
● Push jerk with tempo
dip
● Push jerk
Cluster 3
● Snatch grip push press
to tempo overhead
squat
● Power Snatch no feet
with pause in catch
Cluster 3
● Power jerk with tempo
dip and pause
● Power jerk with tempo
dip
● Power jerk
Cluster 3
● Power Clean with feet
and pause in catch
● Power clean with feet +
tempo front squat
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Cluster 4
● Behind the Neck snatch
progression
● No feet snatch balance
with tempo dip and
pause
● No feet snatch balance
tempo dip
● No feet snatch balance
● No feet drop snatch
Cluster 4
● Tall clean no feet
● Dip clean no feet
● No Feet Full Clean
● Tall clean
● Dip clean
● Full Clean
Cluster 5
● Power Snatch no feet +
tempo overhead squat
● Power Snatch with feet
and pause in catch
● Power Snatch with feet
+ tempo overhead
squat
Cluster 4
● Press in split
● Jerk balance with pause
in split
● Tall jerk with pause in
split
Cluster 5
● Jerk with pause in split
● Jerk
Cluster 6
● Snatch balance
● No Feet Full Snatch
● Drop Snatch
Cluster 7
● Tall snatch
● Dip snatch
● Full Snatch
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●
Here is an example for how programming can look for weeks 6 and 7:
■ Week 6:
● Monday - Snatch Cluster 1 + Isotonics
● Wednesday - Isotonics
● Friday - If Monday was well tolerated then complete Cluster 1 for Clean.
■ Week 7:
● Monday - Jerk Cluster 1 + isotonics
● Wednesday - Isotonics
● Friday - Snatch Cluster 2 + Isotonics
Phase 4 - Return to Sport
●
●
●
Return to previous programming for weightlifting, or
Follow our weightlifting template provided at the end of rehab phases (Weeks 17-20).
Next, sign-up for a competition.
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References
1. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology:
what is its merit in clinical practice and research? British journal of sports medicine. 2016;
50(19):1187-91.
2. Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load
Management, and Advice for Challenging Case Presentations. The Journal of orthopaedic and
sports physical therapy. 2015; 45(11):887-98.
3. Hernandez-Sanchez S, Hidalgo MD, Gomez A. Responsiveness of the VISA-P scale for patellar
tendinopathy in athletes. British journal of sports medicine. 2014; 48(6):453-7.
4. Kongsgaard M, Qvortrup K, Larsen J. Fibril morphology and tendon mechanical properties in
patellar tendinopathy: effects of heavy slow resistance training. The American journal of sports
medicine. 2010; 38(4):749-56.
5. Rio E, Kidgell D, Purdam C. Isometric exercise induces analgesia and reduces inhibition in patellar
tendinopathy. British journal of sports medicine. 2015; 49(19):1277-83.
6. Rio E, Purdam C, Girdwood M, Cook J. Isometric Exercise to Reduce Pain in Patellar
Tendinopathy In-Season; Is It Effective "on the Road?" Clinical journal of sport medicine : official
journal of the Canadian Academy of Sport Medicine. 2017;
7. Rio E, van Ark M, Docking S. Isometric Contractions Are More Analgesic Than Isotonic
Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial. Clinical journal of
sport medicine : official journal of the Canadian Academy of Sport Medicine. 2017; 27(3):253259.
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