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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!