Cortisone, Eccentric vs Heavy Slow Resistance for Patellar Tendinopathy

Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Scand J Med Sci Sports. 2009 Dec;19(6):790-802. Epub 2009 May 28.


A randomized-controlled single-blind trial was conducted to investigate the clinical, structural and functional effects of peritendinous corticosteroid injections (CORT), eccentric decline squat training (ECC) and heavy slow resistance training (HSR) in patellar tendinopathy. Thirty-nine male patients were randomized to CORT, ECC or HSR for 12 weeks. We assessed function and symptoms (VISA-p questionnaire), tendon pain during activity (VAS), treatment satisfaction, tendon swelling, tendon vascularization, tendon mechanical properties and collagen crosslink properties. Assessments were made at 0 weeks, 12 weeks and at follow-up (half-year). All groups improved in VISA-p and VAS from 0 to 12 weeks (P<0.05). VISA-p and VAS improvements were maintained at follow-up in ECC and HSR but deteriorated in CORT (P<0.05). In CORT and HSR, tendon swelling decreased (-13+/-9% and -12+/-13%, P<0.05) and so did vascularization (-52+/-49% and -45+/-23%, P<0.01) at 12 weeks. Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. HSR yielded an elevated collagen network turnover. At the half-year follow-up, treatment satisfaction differed between groups, with HSR being most satisfied. Conclusively, CORT has good short-term but poor long-term clinical effects, in patellar tendinopathy. HSR has good short- and long-term clinical effects accompanied by pathology improvement and increased collagen turnover.

Diagnosis: Patellar Tendinitis

Outcome: VAS during sports and VISA-P Cortisone group VISA-P increased from 64 to 82 at 12 weeks but returned to 64 at 6 months, VAS during preferred sporting activity decreased from 58 to 18 at 12 weeks, but back up to 31 at 6 months. The eccentric group VISA-P increased from 53 to 75 at 12 weeks and 76 at 6 months, VAS during preferred sporting activity decreased from 59 to 31 at 12 weeks, and 22 at 6 months. The concentric group VISA-P increased from 56 to 78 at 12 weeks and 86 at 6 months, VAS during preferred sporting activity decreased from 61 to 19 at 12 weeks, and 13 at 6 months.

When Assessed: 12 weeks and 6 months

Subjects: 52 male recreational athletes, age 18-50, average 31-34 years, 12 in CORT group, 12 in ECC group, 13 in HSR group.

Protocol: Cortisone group had 2 shots in patellar tendon, one at week zero and one at 4 weeks. The Eccentric group did eccentric decline squats 3×15 twice per day 7 days per week for 12 weeks. The concentric group did 15 RM worked down to 6 RM by week 12, 4 sets per exercise on squats, leg press and hack squats 3 times per week. 3 second concentric and 3 second eccentric phases on each. Pain was OK during both eccentric and concentric exercises so long as pain was not increased following the exercise.

Other Activity: Sporting activities were allowed in all groups so long as pain did not rise above 30 on VAS. They noted other studies had gone as high as 50 on VAS in recreational activities and still been successful.

Chad’s Comments:  Most interesting new study to me, found combined concentric/eccentric training better than eccentric training, with benefits being greater as time went on. “HSR proved to be more effective than ECC with regard to tendon tissue normalization and collagen turnover/production, and tended to improve clinical outcomes more than ECC.” The cortisone group started off best in the short term (12 weeks) but finished up worst in the long term (26 weeks) as usual.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.


4 responses to “Cortisone, Eccentric vs Heavy Slow Resistance for Patellar Tendinopathy”

  1. Does the hst training work for proximal biceps tendinosis also?

    I’ve always heard that you should stop every activation that aggravates the pain so should i train through it?

    Best regards

    1. Chad Reilly

      Hi Stefan,

      Generally for tendinopathy I recommend people continue to train through the pain (within reason). It’s counter intuitive, but resting tendinopathy/tendinosis does not seem to be evidence based, and in my experience the right duration and intensity of exercise immediately lessens pain. That’s not a universal rehab prescription as, for example, back and neck pain I would advise the opposite.

      Since you mention proximal biceps tendinosis, I would encourage you to read my coracoidopathy blog, which in my experience is probably the source of pain 9/10 times in people with a diagnosis of biceps tendinosis. It’s a bit technical but I have a video at the bottom. In short I don’t think it’s not often the long head of the biceps causing pain, but rather the short head of the biceps and coracobrachialis muscles/tendons. I give my entire rationale for diagnosis and treatment in that blog so I would love to hear if it sounds right to you and if it helps. Feel free to follow up with any additional questions or comments.

  2. Hi Chad,

    Unfortunately i’m suffering from patella tendonitis for 4 years now. Till today no doctor or physiotherapist could really help me.

    While searching for treatment options i bumped into your blog which lead to some questions. On your blog you mentioned a study which basically showed that there is no need to rest while doing your rehab. What is your experience with that? Is it possible to get pain free while doing a jumping/running sport 5-6 times per week?

    How are you treating patella tendonitis specifically? Are you following the “normal” heavy-slow-resistance protocol as mentioned in this study? Or do you have a specific plan you are following? Which exercises are you suggesting for treating patella tendonitis?

    I really hope you can help me out.

    Kind regards form Germany,

    1. Chad Reilly

      Hi Jan,

      Patellar tendinitis is a tough one. I had bilateral patellar tendinitis for years myself when I was doing Olympic weightlifting in college. I was in physical therapy school part of that time, and that’s how I got my initial interest in tendinitis/tendinopathy. It’s worth pointing out that what we once thought was tedin”itis” is generally now referred to as tendin”opathy” because of a lack of inflammatory cells found in the tendon which “itis” would imply should be there. That’s somewhat of an academic distinction, but it does help to explain while anti-inflammatory treatments like rest, ice, compression and elevation don’t work, nor do anti-inflammatory drugs.

      So on to your questions:

      About rest, I generally tell people not to rest. Besides the above paper, this one specifically looked at rest during the rehabilitation process and found it didn’t help. Taking a break if pain becomes “debilitating” has been successfully done, and the linked paper had people stop if pain increased above 5/10.

      Knowing what I know now I generally tell my patients not to rest and to start adding the rehab exercises. I’ve noticed they still get better and they really know where they are at. If you take time off from training, and start the exercises, often the pain comes back, making you want to rest again. So continual training lets you avoid all that. That said, if you’re onset of tendinopathy were new, and secondary to having really overdone it, and you were having severe pain, I would advocate “relative rest,” still doing the activity but cutting down one intensity or duration for a while and slowly ramping back up, all while continuing with your rehabilitation exercises. Unfortunately, with rehab things are rarely absolute, but usually a little iffy, so take everything with a grain of salt.

      Pain free on a jumping sport is the goal I would have if I were you, but it might depend a bit on your training schedule, how bad the tendinopathy is, and how optimal your sport and rehab program is. For example I think plyometric depth jumps might be particularly risky, and not delivering that much of a training effect anyway. Aside from depth jumps I would think you should be able to fully resolve pain, and I have done so with recreational basketball players, however I haven’t been able to test out my program on any in season volleyball players, which I think is probably the ultimate test.

      I don’t do heavy slow resistance (HSR). While I’m sure it works, and the research indicates HSR is a little better than eccentric exercise, I already had my training program working just fine with just relatively heavy resistance (leaving out the slow part). My reps are maybe a half second up and a half second down. I think what HSR accomplishes is keeping the weight down somewhat and the time under tension up. I think I’m accomplishing the exact same goals by using higher reps so my rehab program for tendinopathy is generally three sets of 15 reps (easy-medium-hard) performed once daily to the involved tendons. So the goal for positive tendon adaptations per some combination of amount of resistance, and time under tension, and nobody knows what’s optimal. Three sets of 15 reps (easy-medium-hard) done once per day is my best guess as to what’s optimal. So with patellar tendinitis, if you have gym access, let extension would be my exercise of choice performed daily. But if someone has patellar tendinitis I would think that they might be quad dominant (indicating weaker glutes and hamstrings). So while I would be trying to increase tendon adaptation with daily training, I wouldn’t want to further worsen a muscle imbalance that I expect is already there. While hamstring flex the knee they also extend the hips, and glutes extend the hips also and in doing, in a closed kinetic chain help to extend the knee, unloading the quads. Increase calf strength in theory should do the same by pulling the tibial bones back as you come up from a bent knee position. A weak low back limits, hamstring strength in my favorite exercise So I it would be wise to work really hard (though not daily) on your posterior chain, calves, hamstrings, glutes and low back.

      All that’s a long story that I may not have explained well enough to make sense, so to answer your question, this is the program I used on my last patellar tendinopathy patient.

      Stationary bike: 5 min
      Barbell squats: 3 sets of 15 reps, working to 4 sets of 10 reps over a few weeks
      RDLs: 3 x 15, working to 4 sets of 10 reps over a few weeks
      Leg Extensions: 3 x 15 (separated right and left leg, but bilateral is fine if tendinopathy symptoms and strength are equal, otherwise I continue to work one leg at a time until they are)
      Hip out machine: 3 x 15
      Hip in machine: 3 x 15
      Standing calf raises 3 x 15
      EMS to the hamstrings with the legs braced on a seated leg curl machine just to prevent knee motion.

      In the above program I had him do all the strength work 2-3 times per week, with the exception of the leg extensions being done daily. The last set of each exercise is generally done to failure or close, with weights increased the next time if you can get all the reps on the last set with good technique. I’ve written the most about my overall tendinopathy approach in my shooter’s elbow and coracoidopathy blog and I apply the same principles across the board for tendinopathy of almost any tendon. So far it works great for me.

      The EMS (electric muscle stimulation) to the hamstrings probably isn’t crucial, but I did that with the expectation that it would help catch up hamstrings to that patient’s quad strength. The same could be done with glutes if you have access to a good EMS machine, but just training RDLs hard would hopefully eventually serve the same purpose.

      The above is what I had one of my patients with patellar tendinopathy do, and would do again for an otherwise athletic individual with weight training experience. Since I haven’t personally evaluated you it’s not something I would necessarily tell you to do. Caveat emptor.

      That said, I would love to hear what you decide to do and how well it works for you. I like talking about this stuff, so feel free to ask questions as you have them.

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