Patellar Tendon Load Progression During Rehabilitation Exercises

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Published ahead of Print
Patellar Tendon Load Progression during Rehabilitation Exercises:
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Implications for the Treatment of Patellar Tendon Injuries
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Rodrigo Scattone Silva1,2, Ke Song3, Todd J. Hullfish3, Andrew Sprague4, Karin Grävare
Silbernagel2, and Josh R. Baxter3
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Postgraduate Program in Rehabilitation Sciences, Postgraduate Program in Physical Therapy,
Federal University of Rio Grande do Norte, Santa Cruz, BRAZIL; 2Department of Physical
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Therapy, University of Delaware, Newark, DE; 3Department of Orthopaedic Surgery, University
of Pennsylvania School of Medicine, Philadelphia, PA; 4Department of Physical Therapy,
University of Pittsburgh, Pittsburgh, PA
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Accepted for Publication: 5 October 2023

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Copyright © 2023 American College of Sports Medicine

Medicine & Science in Sports & Exercise, Publish Ahead of Print
DOI: 10.1249/MSS.0000000000003323
Patellar Tendon Load Progression during Rehabilitation Exercises:
Implications for the Treatment of Patellar Tendon Injuries
Rodrigo Scattone Silva1,2, Ke Song3, Todd J. Hullfish3, Andrew Sprague4, Karin Grävare
Silbernagel2, and Josh R. Baxter3
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1
Postgraduate Program in Rehabilitation Sciences, Postgraduate Program in Physical Therapy,
Federal University of Rio Grande do Norte, Santa Cruz, BRAZIL; 2Department of Physical
Therapy, University of Delaware, Newark, DE; 3Department of Orthopaedic Surgery, University

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of Pennsylvania School of Medicine, Philadelphia, PA; 4Department of Physical Therapy,
University of Pittsburgh, Pittsburgh, PA

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Address for Correspondence: Rodrigo Scattone Silva, PT, MSc, PhD, Postgraduate Program in
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Rehabilitation Sciences, Federal University of Rio Grande do Norte. Rua Vila Trairi, S/N,
Centro, Santa Cruz, RN, Brazil, CEP: 59200-000; E-mail: [email protected]; Telephone:
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+55 84 3291-2411
Conflict of Interest and Funding Source: The authors acknowledge the National Institutes of
Health (NIAMS R01AR078898, R01AR072034, and NICHD R37HD037985) for the financial
support to this study. The authors have no conflicts of interest to declare.
Copyright © 2023 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
ABSTRACT
Purpose: To evaluate patellar tendon loading profiles (loading index, based on loading peak,
loading impulse, and loading rate) of rehabilitation exercises to develop clinical guidelines to
incrementally increase the rate and magnitude of patellar tendon loading during rehabilitation.
Methods: Twenty healthy adults (10 females/10 males, 25.9 ± 5.7 years) performed 35
rehabilitation exercises, including different variations of squats, lunge, jumps, hops, landings,
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running, and sports specific tasks. Kinematic and kinetic data were collected and a patellar
tendon loading index was determined for each exercise using a weighted sum of loading peak,
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loading rate, and cumulative loading impulse. Then, the exercises were ranked, according to the
loading index, into tier 1 (loading index≤0.33), tier 2 (0.33<loading index<0.66), and tier 3
(loading index≥0.66). Results: The single-leg decline squat showed the highest loading index
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(0.747). Other tier 3 exercises included single-leg forward hop (0.666), single-leg
countermovement jump (0.711), and running cut (0.725). The Spanish squat was categorized as a
tier 2 exercise (0.563), as was running (0.612), double-leg countermovement jump (0.610),
single-leg drop vertical jump (0.599), single-leg full squat (0.580), double-leg drop vertical jump
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(0.563), lunge (0.471), double-leg full squat (0.428), single-leg 60° squat (0.411), and the
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Bulgarian squat (0.406). Tier 1 exercises included 20cm step up (0.187), 20cm step down
(0.288), 30cm step up (0.321), and double-leg 60° squat (0.224). Conclusions: Three patellar
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tendon loading tiers were established based on a combination of loading peak, loading impulse,
and loading rate. Clinicians may use these loading tiers as a guide to progressively increase
patellar tendon loading during the rehabilitation of patients with patellar tendon disorders and
after anterior cruciate ligament reconstruction using the bone patellar tendon bone graft.
Key Words: PATELLAR TENDINOPATHY, JUMPER’S KNEE, PHYSICAL THERAPY,
BIOMECHANICS, ANTERIOR CRUCIATE LIGAMENT, MOTION
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INTRODUCTION
Patellar tendinopathy is one of the most common causes of knee pain in young active
individuals (1,2). The prevalence of patellar tendinopathy has been reported to be 33% among
young athletes (2,3). Among elite volleyball athletes, the prevalence can be as high as 45% (1).
Because patellar tendinopathy is a common reason for young individuals to stop being physically
active and abandon sports participation (4), if not properly managed, this condition has long-term
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detrimental health effects. Patellar tendon pain is also a common complication after anterior
cruciate ligament (ACL) reconstruction using the bone-patellar tendon-bone graft (5,6). It is
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possible that this patellar tendon morbidity is related to overly conservative or excessively
aggressive rehabilitation programs that fail to gradually progress the quadriceps muscle/patellar
tendon load tolerance after surgery. In this context, a more comprehensive knowledge of how
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much load the patellar tendon undergoes during common rehabilitation exercises is crucial for
progressively increasing load in the patellar tendon during the rehabilitation of patellar
tendinopathy and after ACL reconstruction.

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Exercise is the main intervention for the treatment of patients with patellar tendon injury.
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The single-leg decline squat is the most commonly prescribed exercise for the rehabilitation of
patellar tendinopathy (7), probably due to the fact that the large majority of studies involving
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patellar tendinopathy patients have used the eccentric single-leg decline squat as the main
exercise intervention (8–14). However, there is no convincing clinical evidence to demonstrate
that isolated eccentric exercise improves clinical outcomes more than other loading therapies
(15–17). In fact, similar improvements in pain and function in patellar tendinopathy patients
occur with progressive loading protocols regardless of contraction type (11,14,15,18,19). The
patellar tendon force has been quantified during the single-leg decline squat (20–22). A few
studies have also evaluated the patellar tendon force during activities such as the drop jump
(23,24) and the stop-jump (25–27). However, little is known about how much load the patellar
tendon undergoes during other rehabilitation exercises, such as the lunge, variations of the squat,
running, different jumps and landings.
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Recently, Baxter et al (28) developed a loading index system to characterize loading
progression in the Achilles tendon during 25 rehabilitation exercises. A loading index for each
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exercise was established based on a comprehensive dataset that factored not only loading peak,
but also loading rate and the cumulative loading impulse (28). To our knowledge, such a
complete loading dataset is still missing for exercises typically used for the rehabilitation of
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patellar tendon injury. In addition, no studies have reported how patellar tendon loading during
rehabilitation exercises compares to activities such as walking and running in the same
individuals. Patients with an ACL reconstruction using the bone-patellar tendon-bone autograft
have been suggested to have a surgically induced tendinopathy at the graft harvest site that
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should be treated with a progressive loading program (29). However, in the absence of objective
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data, clinicians need to rely solely on their experience and on theoretical premises when
developing rehabilitation exercise protocols for patients, which highlights the importance of
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quantitative evidence to refine patellar tendon disorders rehabilitation.
In this context, in both treatment of patellar tendinopathy and prevention of patellar
tendon pain after ACL reconstruction using the bone-patellar tendon-bone graft, clinicians would
benefit from a greater understanding of the loads that act on the tendon during exercises. The
purpose of this study was to determine a loading index to quantify, compare, rank, and categorize
overall loading levels in the patellar tendon across 35 exercises typically used in the clinical
rehabilitation of patients with knee disorders. This loading rank will provide clinicians with
meaningful guidelines to progressively load the patellar tendon and improve tissue healing and
functional recovery of young active individuals.
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METHODS
Participants
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Twenty healthy adults were recruited (10 females, 25.9 ± 5.7 years, 71.2 ± 14.0 kg, 1.71
± 0.09 m, and 24.1 ± 2.6 kg/m2) from the University campus and local community between
January and June 2022. To be included, participants had to be between 18 and 40 years of age
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and have no history of injury in the lower limbs or spine in the last 6 months. An experienced
physical therapist (XXX) confirmed that each subject had no current ongoing musculoskeletal
injuries or history of patellar tendon pain. We decided to study individuals without patellar
tendon pain to characterize the loading biomechanics during pain-free movement. Participants
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provided written informed consent before initiating the procedures and the study was approved
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by the Institutional Review Board at XXXXX.

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Initial Procedures
Before data collections, participants changed into standard exercise clothing (running
shorts and tank tops) and were provided with a pair of the same running shoes (Air Pegasus;
Nike, Beaverton, OR). Thirty-one retro-reflective markers were placed over anatomic landmarks
of the pelvis, thighs, shanks, feet (on the shoes), and torso (30). On the lower extremity, single
markers were placed bilaterally on the anterior thighs, lateral shanks, and medial and lateral
femoral epicondyles and malleoli. Markers were also placed over the shoes over the first and
fifth metatarsal heads, the distal phalanx of the hallux, and behind the calcaneus.
A static trial was recorded with the participants in the anatomical position to align them
with the global coordinates and identify joint axes. Then, the medial knee and ankle markers
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were removed so they would not interfere with each participant’s natural movement during the
evaluated exercises. A 5-minute walk on a treadmill at a self-selected pace was used as warm-up.
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Data Collection
For the biomechanical data collection, a 12-camera motion capture system was used at
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sampling frequency of 100 Hz (Raptor Series, Motion Analysis Corp., Rohnert Park, CA).
Ground reaction forces were simultaneously collected using 3 force platforms embedded under
the floor at a frequency of 1,000 Hz (BP600900, AMTI, Watertown, MA).

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Participants performed 35 exercises that are typically used in the rehabilitation of patellar
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tendinopathy and after ACL reconstruction (8,11,14,29,31–36). The exercises included different
variations of squats (half squat, full squat, sumo squat, Bulgarian squat, Spanish squat, single-leg
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decline squat), step up and step down, lunge, countermovement jumps and hops (double and
single-legged), drop landings, drop vertical jumps and hops, forward jumps and hops, repetitive
forward and lateral jumps and hops, running, run-and-cut, running deceleration (run-and-stop),
split jumps, and sports specific jumps. A detailed description of the exercises is presented in
Supplemental Table 1 (Supplemental Digital Content 1, Demonstration of the 35 exercises
assessed in the study, http://links.lww.com/MSS/C926). The exercises were divided into 4
modules, in an order that was determined during pilot testing to minimize the effects of physical
exhaustion. Participants rested at least 1 minute between each exercise while the set up for the
next exercise was prepared and while a physical therapist demonstrated the next exercise.
Between modules, participants were provided 3-5 minutes of rest periods (37). Participants were
provided visual demonstrations and verbal guidance throughout each exercise by the same
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physical therapist with more than 10 years of clinical experience. All participants performed the
exercises in the same order. At least 3 successful repetitions of each exercise were collected,
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including 3 back-and-forth repetitions during exercises such as the split jumps. Repetitions were
considered successful if the exercise was completed at the force plate without losing balance.
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Data Analysis
Marker trajectories were labeled, and the data was imported into a biomechanical model
(Visual3D, C-Motion, Germantown, MD). A constrained link-segment model was used for best
estimates of segment positions (30). This model constrains the knee joint to sagittal plane motion
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only, while allowing the hip and ankle joints to have all 3 degrees of freedom. Slater et al (30)
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have showed that this model can accurately track segment positions with the simple marker set
that was used. The individual exercise repetitions within each trial were extracted using the
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ground reaction forces or manually defined start and stop events for the subsequent
biomechanical analysis. Each exercise was considered in its entirety for data analysis, i.e., both
the eccentric and concentric phases of squats and both the weight acceptance and propulsion
phases of jumps. For all but one exercise, ground reaction forces represented all external forces
applied onto the participants. The only exception was the Spanish squat, which uses a belt placed
behind the proximal shank to support the subjects while they squat with their center of body
mass behind the heels. Because the Spanish squat is quasi-static, the belt forces applied to the
proximal shanks were estimated by assuming that the force through either belt strap is of equal
magnitude and opposite direction to the horizontal ground reaction force under the corresponding
foot. These belt forces were assigned at 20% of the shank length from the knee joint towards the
ankle joint in the model to match the experimental setup.
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To quantify patellar tendon loading during each exercise, the knee joint flexion angles
and extension moments from the link-segment model were calculated using inverse kinematics
and inverse dynamics algorithms (Visual3D, C-Motion, Germantown, MD) (38). The right lower
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limb was chosen as the side of interest for each participant to standardize testing. It was also the
dominant lower limb of all participants. The data was filtered using a 4th order Butterworth low-
pass filter with a 6Hz cutoff frequency (38).

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For determining patellar tendon force, first, a knee angle-dependent cubic polynomial
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function for patellar tendon moment arms (Equation 1) was derived from a recent imaging study
database, which reported data from 0 (neutral) to 120 degrees of knee flexion (39). This
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polynomial was extrapolated for patellar tendon moment arms during hyperextension up to 10
degrees and set moments arms in extreme knee flexion to equal of 120 degrees when it
approached a plateau (39,40). Next, the patellar tendon (PT) force was estimated by dividing the
knee moment by the patellar tendon moment arm at the specific knee angle during each time
instance of motion (Equation 2).
[Equation 1] 𝑀𝐴𝑃𝑇 (𝜃𝑡 ) = 4.66𝑒 −5 𝜃𝑡 3 − 9.43𝑒 −3 𝜃𝑡 2 + 0.397𝜃𝑡 + 46.7 (𝑢𝑛𝑖𝑡: 𝑚𝑚)
[Equation 2] 𝐹𝑃𝑇 (𝜃𝑡 ) = 𝑀𝑘𝑛𝑒𝑒 (𝜃𝑡 )⁄𝑀𝐴𝑃𝑇 (𝜃𝑡 ) (𝑢𝑛𝑖𝑡: 𝑁)
MA, moment arm; F, force; θ, knee flexion angle; t, time.
Patellar tendon force was normalized by the participant’s bodyweight, and loading peak,
loading impulse, and loading rate were determined following procedures adapted from Baxter et
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al (28). Briefly, loading peak was calculated as the maximum force in each repetition; loading
impulse was determined as the area under the force-time curve over each repetition; and loading
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rate was calculated as the maximum instantaneous change of force overtime (Figure 1) (28).
Average values of each exercise repetition were used for analysis, including pairs of alternating
motions where the right leg was in a leading/trailing or abducted/adducted positions.

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For the group analysis, inter-subject averages and standard deviations were calculated for
each metric of the patellar tendon force (peak, impulse, rate) during all 35 exercises. To quantify
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the overall patellar tendon load during each exercise, the group-average of the loading metrics
were used to compute a weighted loading index (28). For this, the loading peak, impulse, and
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rate of the patellar tendon force were normalized by its maximum among the 35 exercises. Then,
a weighted sum was computed with 50% of weight on loading peak, 30% on impulse, and 20%
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on rate, resulting in a single loading index for each exercise (28). The loading index ranges from
0 to 1 theoretically, with 0 representing no load and 1 representing an exercise that would have
loading peak, impulse, and rate all reaching maximum. For comparison of the overall loading
levels among exercises, the loading index of all 35 exercises was ranked in an ascending order
(from 0 to 1), and the index was categorized into 3 tiers: Tier 1 (low, ≤ 0.33), Tier 2 (moderate,
0.33 – 0.66), and Tier 3 (high, ≥ 0.66).
Data Sharing
The biomechanical data and musculoskeletal models that were used are available on a
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public repository (XXX). A modifiable worksheet that embeds the group-average loading
metrics is also presented as Supplemental Digital Content (see Supplemental Digital Content 2,
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http://links.lww.com/MSS/C927), so anyone can re-rank and re-categorize the loading index
based on user-selected loading metric weights.

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RESULTS
The patellar tendon loading index ranged from 0.106 during walking to 0.747 during the
single-leg decline squat (Figure 2). Tier 1 exercises (loading index ≤ 0.33) included walking, low
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step up, 60º double-leg squat, low step down and high step up. These exercises involved peak
loads ranging from 0.8 to 2.7 bodyweights (Table 1). Tier 2 exercises (0.33 < loading index <
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0.66) included high step down, lunge, running, running deceleration, and most squats and
jump/landing exercises. The peak loads of the Tier 2 exercises ranged from 2.8 to 5.0
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bodyweights. Tier 3 exercises (loading index ≥ 0.66) included the single-leg decline squat, run-
and-cut, single-leg countermovement hop, single-leg repeated forward hops, and single-leg
maximal forward hop. Peak loading in Tier 3 exercises ranged from 4.6 to 5.5 bodyweights
(Table 1).
The single-leg decline squat was the exercise with the highest loading index. The squat
exercises loaded the patellar tendon differently based on the movement variation and whether
one or two legs were used to complete the exercise. Figure 3 presents the patellar tendon loading
during different variations of squats as well as during walking and running. The single-leg
decline squat was the only squat variation that generated more peak patellar tendon loading than
running. Single-leg squats did not double peak loading compared to double-leg squats. However,
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60º squats resulted in approximately half the peak loading when compared to full squats (Figure
3).
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DISCUSSION
In this study, through the biomechanical analysis of 35 rehabilitation exercises, an

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exercise order that gradually increases patellar tendon loading was established. To the best of our
knowledge, this is the first study to establish a comprehensive biomechanical set of patellar
tendon loading data based on a battery of exercises commonly prescribed by clinicians. By
defining a patellar tendon loading index that incorporates three components of patellar tendon
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loading, this study allows clinicians to rank exercises based on loading peak, loading impulse,
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and loading rate. These loading guidelines will be especially useful for clinicians to better
prescribe progressive therapeutic loading for patients with knee disorders like patellar
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tendinopathy and ACL reconstruction using bone-patellar tendon-bone grafts. A modifiable
worksheet (Supplemental Digital Content 2) is also provided so that the clinician can use it to
automatically re-rank and re-categorize exercises according to the relative importance assigned
to loading peak, impulse, and rate for their specific patient. In the beginning stages of
rehabilitation, the clinician might want to rank the exercises based on loading peak and loading
impulse, aiming to progressively increase the tendon’s load tolerance. In the advanced stages,
however, to adequately prepare the patient for return to sport, the clinician might want to re-rank
the exercises based on how fast the load is applied to the tendon, in which case the loading rate
would have a greater importance.
The single-leg decline squat is the most common exercise used at the beginning of
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rehabilitation to treat patellar tendinopathy patients (8–14). Some authors even consider the
eccentric training, using the single-leg decline squat, the gold standard first-line management
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approach for patellar tendinopathy, mostly due to this exercise having the largest body of
evidence supporting its effects (41,42). However, several authors have shown that improvements
in pain and function in tendinopathy patients occur with progressive loading protocols regardless
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of contraction type (11,15,18,19), and there is no convincing evidence that isolated eccentric
exercises are superior to other loading therapies (15–17). Interestingly, in the present study the
single-leg decline squat showed the highest loading index, with very high loading peak (5.2
bodyweights) and impulse (6.8 bodyweights * second). This indicates that using the single-leg
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decline squat at the beginning of patellar tendinopathy rehabilitation is not the best approach,
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considering that the treatment premise is building a progressive load tolerance to the tendon.
This may be one of the reasons why interventions based exclusively on the eccentric single-leg
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decline squat exercise have lower patient satisfaction in comparison to other exercise
interventions (11,15) and less than optimal results in the long-term, with 45% of patients not
being able to return to sport (10). Also, the use of the single-leg decline squat as a prevention
exercise during season had the opposite effect, with asymptomatic athletes developing patellar
tendinopathy after the intervention (43). Given the results of the current study, it is possible that
this is because the single-leg decline squat generates a large amount of force in the patellar
tendon, which, in addition to the in-season loads generated in sports participation could cause
overuse, instead of a therapeutic load.
In the present study, the Spanish squat exercise had a moderate loading index (0.563)
with this value mostly explained by loading impulse (cumulative load in the tendon). Recently,
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the Spanish squat has emerged as an exercise of choice for the treatment of patellar tendinopathy
patients (32,34,36,44). The Spanish squat is being recommended in the initial stages of
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rehabilitation and is considered a particularly useful exercise for the treatment of athletes on-the-
road, when they have no access to gym equipment (44). However, in the present study, several
other exercises, including other variations of the squat (i.e., Bulgarian squat, sumo squat, double
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and single-leg 60° squats) showed lower loading indexes than the Spanish squat. In this context,
starting the rehabilitation with these exercises, later progressing to the Spanish squat at an
intermediate stage, might be a better approach for the treatment of patellar tendinopathy patients.
After ACL reconstruction using bone-patellar tendon-bone grafts, the clinician should keep in
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mind that the Spanish squat not only produces a substantial amount of load in the healing patellar
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tendon but also generates a significant anterior tibial translation force, which is contraindicated
in the initial stages of graft healing.

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The results of patellar tendon loading in the present study are similar to those of previous
studies (21,45). The analysis of the different variations of the squat exercise in the present study
showed that single-leg squats did not double peak loading compared to double-leg squats.
However, 60º squats resulted in approximately half the peak loading when compared to full
squats. This finding is in accordance with the results of a recent study that found that deeper
squats (>60°) generate significantly more muscle activation of the rectus femoris, vastus
medialis, and vastus lateralis (46). In this context, in order to progressively load the patellar
tendon in rehabilitation, the clinician should consider progressing from double-leg squats to
single-leg squats before progressing from 60º squats to full squats. The same rationale might be
useful in the early stages after ACL reconstruction using bone-patellar tendon-bone grafts, when
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graft site healing is still occurring, and excessive load could cause overuse in the patellar tendon.
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Recently, jump-landing trainings have been included in the rehabilitation protocols of
patellar tendinopathy patients (14,33). This approach comes from the observation that athletes
with patellar tendinopathy have stiffer landing mechanics, with smaller range of motion in the
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lower limb joints after foot contact (47). More recent reviews have also highlighted that athletes
with patellar tendinopathy and those with ACL reconstruction have an abnormal landing
mechanics (48–50). The inclusion of commonly prescribed jumps and jump-landing exercises in
this study was based on the need to understand how much load the patellar tendon undergoes
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during these exercises in relation to other rehabilitation exercises. The results showed that most
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jumping and landing exercises generated moderate loads in the patellar tendon, being categorized
as Tier 2 exercises. The only exceptions were the single-leg maximal forward hop, single-leg
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countermovement jump, and single-leg repeated forward hops, which generated higher loads,
being categorized as Tier 3 exercises. This indicates that jumping and landing exercises could
potentially be introduced at an intermediate stage in the rehabilitation of patellar tendinopathy
patients, with the exception of the higher loading index exercises.
The clinician should also keep in mind that the patellar tendon force during landing is
influenced by trunk position (24). Verbal instructions to encourage patients to increase trunk
flexion and land softly have been shown to improve the load transmission between the three
major lower limb joints in patellar tendinopathy patients, also resulting in significant
improvements in terms of pain and function (14,33). In this context, trunk position during
landing exercises is a variable that can be modulated to decrease patellar tendon load in the
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initial stages of rehabilitation and to increase the load in the advanced stages. Jumping and
landing exercises are also frequently prescribed in the rehabilitation after ACL reconstruction
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(51,52), also with the use of verbal instructions to improve jump landing mechanics (53,54). The
findings of the current study may help clinicians establish an order of progression in the jump
and landing training. The tiering system also provides clinicians with more freedom to tailor
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rehabilitation protocols based on patient’s specific needs and preferences while meeting tendon
loading goals in a clear, well-established progression (14).
This study has limitations that need to be acknowledged. Only young healthy males and
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females participated in this study, therefore the generalization of these results to other
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populations, such as patellar tendinopathy patients, should be done with caution. Another
limitation is the fact that by defining a constrained knee with flexion-extension only, the model
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did not consider the effects of frontal or transverse plane movements on patellar tendon loading.
This decision was made based on the fact that past studies reported that patellar tendon forces
primarily act in the sagittal plane (21,22). However, since frontal and transverse movements may
affect patellar tendon forces, especially during single-limb exercises (55), future research should
include those aspects in the model. A third limitation is the fact that the model used net knee
moment to estimate the quadriceps loading required for knee extension, which neglects the
potential effects of co-activation and force production by the hamstrings. Further studies should
examine the activation of the quadriceps and hamstring muscles to verify whether patellar tendon
loading is influenced by muscle co-activations during these exercises. The order of the exercises
was not random, so fatigue may have influenced the movement patterns and consequently the
tendon forces of the last exercises of each module. Lastly, the loading index was calculated as a
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weighted summation of peak load, loading impulse, and loading rate (28) based on the fact that
the tendon is a viscoelastic tissue (56). Although the authors’ intuition was used to scale these 3
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loading parameters, changing the scaling factors of each of these parameters may affect the
exercise ranking. To minimize this limitation, a spreadsheet is provided so that clinicians can
recalculate the exercise rankings based on their interpretation about the importance of each
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loading parameter. Future studies should investigate the effects of interventions using the loading
tiers exercise progression in the rehabilitation of patients with knee disorders such as patellar
tendinopathy and after ACL reconstruction.

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CONCLUSIONS
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An exercise ranking that progressively increases patellar tendon loading across a diverse
set of exercises routinely used in the treatment of patients with knee disorders was established.
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Three loading tiers were established based not only on loading peak, but also on loading impulse
and loading rate. This knowledge may help clinicians better understand the loads that act on the
tendon during different exercises and may help with the tailoring of interventions for the
rehabilitation of patients with patellar tendon disorders and after ACL reconstruction with a
bone-patellar tendon-bone autograft.
Acknowledgments
The authors acknowledge the National Institutes of Health (NIAMS R01AR078898,
R01AR072034, and NICHD R37HD037985) for the financial support to this study. The authors
would also like to thank Audrey Lehneis and Liliann Zou for their help with data collection and
processing. The authors have no conflicts of interest to declare. The results of the study are
presented clearly, honestly, and without fabrication, falsification, or inappropriate data
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manipulation. The results of the present study do not constitute endorsement by the American
College of Sports Medicine.
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FIGURE LEGENDS
Figure 1. Loading peak (maximum force), loading rate (maximum instantaneous change of force
overtime), and loading impulse (area under the force-time curve) during a rehabilitation exercise.
Figure 2. Patellar tendon loading index across 35 rehabilitation exercises, categorized as low
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(Tier 1), moderate (Tier 2), and high (Tier 3). Each loading index was determined with a 50%
weight on loading peak (bodyweight), 30% weight on loading impulse (bodyweight * second),
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and 20% on loading rate (bodyweight / second).
Figure 3. Patellar tendon loading during different variations of the squat exercise. Group
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averages are represented as solid or dashed lines and the standard deviation is represented as
shades. Patellar tendon loading during self-selected pace walking and running are graphed in
light gray solid and dashed lines, respectively. X-axis indicates normalized exercise time and y-
axis indicates patellar tendon load normalized against body weight. BW, bodyweight; 1-Leg,
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single-leg; 2-Leg, double-leg.

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SUPPLEMENTAL DIGITAL CONTENT
SDC 1: Supplementary Material.docx.
SDC 2: PT_Loading_Index_Modifiable_Worksheet.xls
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Figure 1
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Figure 2
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Figure 3
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TABLE 1. Patellar tendon loading index, loading peak, loading impulse, and loading rate across
35 rehabilitation exercises (n=20).
Loading Loading Loading Loading Rate

Exercise Index* Peak (BW) Impulse (BWs) (BW/s)
Walking 0.106 0.8 ± 0.4 0.2 ± 0.1 13.4 ± 4.9
Low Step Up 0.187 1.6 ± 0.3 0.4 ± 0.1 12.6 ± 2.9
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Tier 1 2-Leg Squat (60°) 0.224 1.8 ± 0.5 1.5 ± 0.5 4.7 ± 1.8
Low Step Down 0.288 2.5 ± 0.5 0.9 ± 0.4 10.5 ± 2.5
High Step Up 0.321 2.7 ± 0.4 0.7 ± 0.2 21.4 ± 3.5
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2-Leg Repeated
0.403 3.3 ± 1.0 0.4 ± 0.2 44.0 ± 12.1
Lateral Jumps (Fast)
Bulgarian Squat 0.406 3.0 ± 0.5 2.9 ± 0.7 10.1 ± 2.2
Sumo Squat 0.406 3.1 ± 0.5 2.9 ± 0.7 9.1 ± 1.7

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1-Leg Squat (60°) 0.411 3.2 ± 0.7 2.9 ± 0.7 8.1 ± 2.6
2-Leg Squat (Full) 0.428 3.4 ± 0.7 2.7 ± 0.5 9.2 ± 2.7
High Step Down 0.441 3.8 ± 0.5 1.8 ± 0.8 12.9 ± 3.1
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2-Leg Repeated
0.452 3.7 ± 0.9 0.7 ± 0.2 42.2 ± 7.5
Lateral Jumps (Regular)
Tier 2
Lunge 0.471 3.3 ± 0.6 3.6 ± 0.9 16.8 ± 4.7
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2-Leg Repeated
0.494 3.8 ± 1.3 0.4 ± 0.2 64.4 ± 20.3
Forward Jumps (Fast)
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Sport Movement Jump 0.498 3.5 ± 0.7 1.4 ± 0.6 60.3 ± 15.4
1-Leg Drop Landing 0.509 3.7 ± 0.8 1.7 ± 0.7 51.4 ± 9.3
2-Leg Drop Landing 0.517 3.9 ± 0.8 1.7 ± 0.7 48.1 ± 9.5
Alternating Split Jumps 0.554 4.5 ± 0.9 1.5 ± 0.4 40.1 ± 9.5
2-Leg Maximal
0.560 4.1 ± 0.5 1.4 ± 0.5 64.4 ± 10.4
Forward Jump
2-Leg Drop Vertical Jump 0.563 4.4 ± 0.9 1.8 ± 0.5 46.1 ± 9.0
3-Second Spanish Squat 0.563 2.8 ± 1.1 8.2 ± 3.0 1.6 ± 1.3
Run-and-Stop 0.569 4.0 ± 0.9 1.0 ± 0.4 79.6 ± 20.7
1-Leg Repeated
0.571 4.2 ± 1.4 0.5 ± 0.2 80.3 ± 17.8
Forward Hops (Fast)
1-Leg Repeated Lateral

Hops (Regular)
0.573 4.6 ± 1.4 0.6 ± 0.2 63.2 ± 14.8
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1-Leg Squat (Full) 0.580 4.3 ± 0.7 4.4 ± 0.9 11.3 ± 2.4
2-Leg Repeated
0.597 4.7 ± 0.8 0.8 ± 0.2 65.1 ± 13.9
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Forward Jumps (Regular)
1-Leg Drop Vertical Hop 0.599 4.7 ± 1.1 1.6 ± 0.4 55.8 ± 10.9
1-Leg Repeated
0.605 5.0 ± 1.1 1.0 ± 0.3 56.0 ± 9.5
Lateral Hops (Regular)
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2-Leg Countermovement
Jump
0.610 4.3 ± 0.7 3.1 ± 1.0 50.7 ± 10.5
Running 0.612 4.8 ± 0.8 0.5 ± 0.1 75.7 ± 11.4
1-Leg Maximal
0.666 4.6 ± 0.8 1.9 ± 0.9 83.9 ± 16.2
Forward Hop
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1-Leg Repeated
0.673 5.3 ± 1.2 0.7 ± 0.2 77.0 ± 11.2
Forward Hops (Regular)
Tier 3 1-Leg Countermovement

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Hop
0.711 4.7 ± 1.0 4.5 ± 1.3 57.4 ± 15.3
Run-and-Cut 0.725 5.5 ± 1.2 0.7 ± 0.2 96.2 ± 18.3

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1-Leg Decline
0.747 5.2 ± 0.6 6.8 ± 2.0 12.3 ± 2.4
Squat
*
Loading index is the weighted sum of scaled and normalized peak loading, loading impulse, and
loading rate. BW, bodyweight; s, second; 1-Leg, single-leg; 2-Leg, double-leg; Full, complete
range of motion; Regular, self-selected speed; Fast, faster speed.
SUPPLEMENTARY TABLE. Demonstration of the 35 exercises assessed in the study.
Module Exercise Instructions to Participants Illustration
Walking Walk at your self-selected speed
Step up with your right leg,

Low step up (10-cm)
followed by the left leg
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Step down with your left leg,
Low step down (10-cm)
followed by the right leg
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Step up with your right leg,
High step up (20-cm)
followed by the left leg
Module
1
Step down with your left leg,

High step down (20-cm)
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followed by the right leg

C
Lunge forward with the right leg,

Lunge keeping the right shank as vertical as
possible, then return to the initial position
A
Stand on both legs,

2-leg countermovement
perform a countermovement jump,
jump
aiming to reach as high as possible
Drop from the step and

2-leg drop landing
land on both legs
Drop from the step, land on both legs,
2-leg drop vertical jump then immediately perform a vertical jump as
high as possible
2-leg maximal forward Jump forward as far as possible and land on

jump both legs, without losing balance
3-5 minutes of rest
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Running Run at your self-selected speed
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Keep your feet shoulder-width apart and
perform a half squat. Touch the chair behind
2-leg squat (60-degree)
you (60° knee flexion) then return to the
initial position
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Keep your feet shoulder-width apart and
2-leg squat (full depth) perform a full squat. Squat down as far as
possible then return to the initial position
Module
C
Stand on the decline surface in just one leg

and keep your trunk as upright as possible.
1-leg decline squat
C
Perform a full single-leg squat then return to

the initial position
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Keep your feet a bit further apart than your

shoulder width with your toes pointing out
Sumo squat in a 45° angle.
Perform a full squat, then return to the
initial position
Position the rigid strap around your shank as

high as possible. With the trunk as upright
as possible, squat and hold a 90° knee
3-second Spanish squat flexion position for 5 seconds* then return to
the initial position.
*
3 seconds were used for analysis
Run forward as fast as possible and, when
Run-and-cut you step with your right leg, change
direction at a 45° angle to your left
Stand on your right leg then hop forward as

1-leg maximal forward hop far as possible, landing on your right leg,
without losing balance
Run forward as fast as possible and stop

Run-and-stop suddenly with the right leg, without losing
balance
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Start running and jump forward, landing
with both legs together. Immediately
Sports movement jump
perform a vertical jump as high as possible
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and land on both legs
3-5 minutes of rest
Stand on your right leg and perform a

single-leg half squat. Touch the chair behind
1-leg squat (60-degree)
you (60° knee flexion) then return to the
initial position
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Stand on your right leg and perform a full
1-leg squat (full depth) single-leg squat. Squat down as far as
possible then return to the initial position
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Module
3 Position your right foot forward and your
left foot back, on the step. Perform a full
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Bulgarian squat split squat until you almost touch the ground
with your left knee, then return to the initial
position
A
Stand on your right leg and

1-leg countermovement
perform a countermovement jump,
hop
aiming to reach as high as possible
2-leg repetitive forward Perform small, repeated jumps forward with

jumps (regular speed) both knees slightly bent at each landing
Perform small, repeated jumps forward with
2-leg repetitive forward
both knees slightly bent at each landing,
jumps (fast speed)
now at a faster speed
Perform a side jump, landing with both feet,
2-leg repetitive lateral
then jump back to initial position. Repeat
jumps (regular speed)
the process back and forth
Perform a side jump, landing with both feet,
2-leg repetitive lateral then jump back to initial position. Repeat
jumps (fast speed) the process back and forth,
now at a faster speed
3-5 minutes of rest
D
Drop from the step and
1-leg drop landing land on your right leg without
losing balance
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Drop from the step, land on your right leg,
1-leg drop vertical hop then immediately perform a vertical hop as
high as possible
Perform small, repeated hops forward

1-leg repetitive forward
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with your right leg, keeping the knee
hops (regular speed)
slightly bent when landing
Module Perform small, repeated hops forward with
4 1-leg repetitive forward
your right leg, keeping the knee slightly
hops (fast speed)
bent, now at a faster speed
Perform a side hop to the right with your
1-leg repetitive lateral right leg, landing with the right leg without
hops, 40cm distance touching the lines on the ground, then hop
(regular speed) back to initial position. Repeat back and
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forth
Perform a side hop with your right leg,
1-leg repetitive lateral landing with the right leg without touching
hops, 40cm distance (fast the lines on the ground, then hop back to
speed) initial position. Repeat back and forth, now
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at a faster speed
Start in a lunge position with right leg in

front, jump up switching the leading and
Alternating split jumps
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trailing legs and repeat the process back and

forth
Patellar Tendon Loading
Peak_Mean Peak_SD Impulse_Mean Impulse_SD Rate_Mean Rate_SD
Exercise Loading Index
(×BW) (×BW) (×BW*s) (×BW*s) (×BW/s) (×BW/s)
Walking 0.106 0.8 0.4 0.2 0.1 13.4 4.9
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Low step up (10-cm) 0.187 1.6 0.3 0.4 0.1 12.6 2.9
2-leg squat (60-degree) 0.224 1.8 0.5 1.5 0.5 4.7 1.8
Low step down (10-cm) 0.288 2.5 0.5 0.9 0.4 10.5 2.5
High step up (20-cm) 0.321 2.7 0.4 0.7 0.2 21.4 3.5
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2-leg repetitive lateral jumps (Fast) 0.403 3.3 1.0 0.4 0.2 44.0 12.1
Bulgarian squat 0.406 3.0 0.5 2.9 0.7 10.1 2.2
Sumo squat 0.406 3.1 0.5 2.9 0.7 9.1 1.7
1-leg squat (60-degree) 0.411 3.2 0.7 2.9 0.7 8.1 2.6
2-leg squat (Full depth) 0.428 3.4 0.7 2.7 0.5 9.2 2.7
High step down (20-cm) 0.441 3.8 0.5 1.8 0.8 12.9 3.1
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2-leg repetitive lateral jumps (Regular) 0.452 3.7 0.9 0.7 0.2 42.2 7.5
Lunge 0.471 3.3 0.6 3.6 0.9 16.8 4.7
2-leg repetitive forward jumps (Fast) 0.494 3.8 1.3 0.4 0.2 64.4 20.3
Sports movement jump 0.498 3.5 0.7 1.4 0.6 60.3 15.4
1-leg drop landing 0.509 3.7 0.8 1.7 0.7 51.4 9.3
2-leg drop landing 0.517 3.9 0.8 1.7 0.7 48.1 9.5
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Alternating split jumps 0.554 4.5 0.9 1.5 0.4 40.1 9.5
2-leg maximal forward jump 0.560 4.1 0.5 1.4 0.5 64.4 10.4
2-leg drop vertical jump 0.563 4.4 0.9 1.8 0.5 46.1 9.0
C
3-second Spanish squat 0.563 2.8 1.1 8.2 3.0 1.6 1.3
Run-and-stop 0.569 4.0 0.9 1.0 0.4 79.6 20.7
1-leg repetitive forward hops (Fast) 0.571 4.2 1.4 0.5 0.2 80.3 17.8
1-leg repetitive lateral hops (Fast) 0.573 4.6 1.4 0.6 0.2 63.2 14.8
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1-leg squat (Full depth) 0.580 4.3 0.7 4.4 0.9 11.3 2.4
2-leg repetitive forward jumps (Regular) 0.597 4.7 0.8 0.8 0.2 65.1 13.9
1-leg drop vertical hop 0.599 4.7 1.1 1.6 0.4 55.8 10.9
1-leg repetitive lateral hops (Regular) 0.605 5.0 1.1 1.0 0.3 56.0 9.5
2-leg countermovement jump 0.610 4.3 0.7 3.1 1.0 50.7 10.5
Running 0.612 4.8 0.8 0.5 0.1 75.7 11.4
1-leg maximal forward hop 0.666 4.6 0.8 1.9 0.9 83.9 16.2
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1-leg repetitive forward hops (Regular) 0.673 5.3 1.2 0.7 0.2 77.0 11.2
1-leg countermovement hop 0.711 4.7 1.0 4.5 1.3 57.4 15.3
Run-and-cut 0.725 5.5 1.2 0.7 0.2 96.2 18.3
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1-leg decline squat 0.747 5.2 0.6 6.8 2.0 12.3 2.4
3-second
MAX Exercise Run-and-cut Run-and-cut
Spanish squat
WEIGHT 5.5 0.5 8.2 0.3 96.2 0.2
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Patellar Tendon Load Progression During Rehabilitation Exercises

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Patellar Tendon Load Progression during Rehabilitation Exercises:

Accepted for Publication: 5 October 2023

Copyright © 2023 American College of Sports Medicine

Patellar Tendon Load Progression during Rehabilitation Exercises:

Implications for the Treatment of Patellar Tendon Injuries

Silbernagel2, and Josh R. Baxter3

Therapy, University of Delaware, Newark, DE; 3Department of Orthopaedic Surgery, University

University of Pittsburgh, Pittsburgh, PA

support to this study. The authors have no conflicts of interest to declare.

BIOMECHANICS, ANTERIOR CRUCIATE LIGAMENT, MOTION

tendinopathy and after ACL reconstruction.

exercise intervention (8–14). However, there is no convincing clinical evidence to demonstrate

running, different jumps and landings.

quantitative evidence to refine patellar tendon disorders rehabilitation.

In this context, in both treatment of patellar tendinopathy and prevention of patellar

functional recovery of young active individuals.

by the Institutional Review Board at XXXXX.

the floor at a frequency of 1,000 Hz (BP600900, AMTI, Watertown, MA).

Supplemental Table 1 (Supplemental Digital Content 1, Demonstration of the 35 exercises

ankle joint in the model to match the experimental setup.

pass filter with a 6Hz cutoff frequency (38).

instance of motion (Equation 2).

[Equation 2] 𝐹𝑃𝑇 (𝜃𝑡 ) = 𝑀𝑘𝑛𝑒𝑒 (𝜃𝑡 )⁄𝑀𝐴𝑃𝑇 (𝜃𝑡 ) (𝑢𝑛𝑖𝑡: 𝑁)

MA, moment arm; F, force; θ, knee flexion angle; t, time.

motions where the right leg was in a leading/trailing or abducted/adducted positions.

0.33 – 0.66), and Tier 3 (high, ≥ 0.66).

based on user-selected loading metric weights.

In this study, through the biomechanical analysis of 35 rehabilitation exercises, an

tendon loading data based on a battery of exercises commonly prescribed by clinicians. By

tendinopathy and ACL reconstruction using bone-patellar tendon-bone grafts. A modifiable

would have a greater importance.

overuse, instead of a therapeutic load.

in the initial stages of graft healing.

potentially be introduced at an intermediate stage in the rehabilitation of patellar tendinopathy

patients, with the exception of the higher loading index exercises.

loading goals in a clear, well-established progression (14).

tendinopathy and after ACL reconstruction.

bone-patellar tendon-bone autograft.

The authors acknowledge the National Institutes of Health (NIAMS R01AR078898,

presented clearly, honestly, and without fabrication, falsification, or inappropriate data

College of Sports Medicine.

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