Experience recovering from patellofemoral pain syndrome and/or patellar tendonitis?

[knee_slider]

Short version: 22 yo novice lifter wondering how long it will take me to get back to athletic activities

I haven't seen a doctor and all of this is self-diagnosed. All I know is that there is knee pain and a tender bump slightly below the knee cap

For my training background and goals, I have been quite a program hopper. I enjoyed SS as it got me my best lifts ever (for some reason no knee pain when I ran it previously with heavier weights) and my squat doesn't feel as strong on programs where I squat less frequently. However, inconsistency and layoffs mean that I have regressed back to being a novice. I also have experience playing various sports, some at a high school/college varsity level, and have little injury history from sports or previous lifting programs. I don't play organized sports anymore but I have loved seeing the benefits of strength training when just playing basketball with my friends. My main goal right now is just to get generally stronger and healthier as I am not training for a particular event or sport.

During my SSNLP, I was getting slight left knee pain (started around 185 lbs) during and for a couple hours after my sessions. But it wasn't affecting me when I ran or played basketball on other days, so I kind of ignored it. I started at 135, and I eventually got to 225. During this session, I experienced a sharp pain in both of my knees and it was almost debilitating for a couple of days. Just walking the stairs and sitting down/getting up from a chair was extremely painful. After this I knew that the issue was likely my form since I am relatively young and healthy, with no prior knee issues.

I read from SS and SS-related websites (barbell logic) that a big issue could be that I was too upright on the squat (which I am pretty sure I was) and another major issue was knee slide (still have some slight knee slide even after working on it). Another thing I read was that rest would not solve this issue. I have added knee sleeves (they seem to be helping) and am working on correcting my form. I am now able to squat 200 for 3 sets of 5 with a little knee soreness, and mild to no pain which does not affect me when walking or sitting/standing up.

However, today I was shooting a basketball around in my driveway and my knees felt weak. It was taking a lot more effort to jump, and I knew it would cause pain if I jumped as hard as I normally do. My biggest question is if I am approaching this knee pain correctly, and what is the best way to getting back to running and jumping again?

Edit: Also one potential problem I have found in my squat is squatting too deep. I think this has been causing most of the knee slide. Since I started leaning forward more, my squat feels extremely shallow even when I hit depth. I was also wondering if there was a way to better tell when I am at depth, because I get a stretch reflex if I go a bit too low as well and it is hard for me to tell the difference.

[Austin Baraki]

Hi there,

Welcome to the forum. Based on your description, it does indeed sound like you're dealing with a tendinopathy situation. In fact, in your original description where you wrote: "During my SSNLP, I was getting slight left knee pain (started around 185 lbs) during and for a couple hours after my sessions." -- this was already likely a manifestation of evolving tendinopathy.

Unfortunately, the information and ideas you have received from those other sources about the cause and management of this condition is incorrect. This is not a "form" issue, nor is it due to squatting too deep. Lots of people can squat very deep, very upright, or with so-called "knee slide" -- and if it is loaded and progressed appropriately, can adapt to these positions just like any other.

We have lots of relevant content, starting here: https://www.barbellmedicine.com/blog...-tendinopathy/

As well as a more general article on our approach to managing pain in training, here: https://www.barbellmedicine.com/blog...ining-what-do/

The bottom line is that tendinopathy is an issue where the affected areas are being loaded beyond their tolerance/recovery capacity at any given time. This is a typical experience, particularly on SS programming, since it forces load increases every session, no matter what. For reasons we've discussed in a lot of our content elsewhere, we are not fans of this approach, and end up consulting with lots of people from that world to guide them through the rehab process.

In order to mitigate this issue we will need to alter your programming (using the strategies outlined in the articles above) in order to get below the threshold where you feel an increase in pain and aching during/after your session, and plan on a more gradual progression back towards your normal loads. The specifics of this process are outlined for free in the articles above; if you are interested in more structured programming we have a knee rehab template, or 1-on-1 consultation and coaching with our rehab professionals through the website.

[knee_slider]

Thank you for your response Austin!

I have read those articles in the past and when posting I actually forgot that "knee slide does not directly cause tendinopathy" was mentioned in the first article. I did try to fix my form, and with the addition of knee sleeves, I have been feeling little to no pain during and after squatting (was able to work back up to 205 with no pain). However, so many factors in my squat have changed recently, so I cannot really tell what has caused the decrease in pain. These articles should help me manage my programming better when recovering from this issue.

I also wanted to ask a few general questions about BBM programming and progression

1. The thing that most attracted me to Starting Strength were the rapid gains (weight and strength for a skinny weak guy like me). This mentality of adding more to the bar every session has become addicting to me, and I always feel like I am training sub-optimally if I am not using this type of progression. The one time when I used RPE (press/bench plug in for LP), I felt like I was not making progress because I wasn't directly improving (increasing weight) from my previous workout. What would your advice/philosophy be for someone who wants to progress as fast as they can, but also has to deal with a tendinopathy issue? I feel like this mentality could cause me to re-injure myself or make my issue worse.


2. My plan right now is to start beginner prescription/template and modify intensity if the squats become too painful. I would prefer not to modify exercise selection if I do not have to (since I am still learning proper low bar squat form and how to push through tough reps), and modifying volume seems a bit complex to me. Do you think this sounds like a fine plan or would you recommend some more slight changes to the program?

3. I know that Jordan specifically has talked a bunch about how form is overrated (its impact on injuries specifically). But I feel like you guys are just saying this because your form is so good and efficient. I definitely agree that smart loading and progression plays a bigger role in injuries than form, or else I would have broke my back my first couple times squatting, but what is the point where form becomes unacceptable? Is your approach to address form issues more when it becomes related to the sticking point of the lift?

[RVR]

knee_slider: I can't answer all your questions in detail, but a few points.

1. Rapid gains is a newbie phenomenon, and a fun one, but it doesn't last forever; don't get married to it. No one has ever stayed on the path of linear progress. Full stop. BBM did a widescale survey (iirc) of SS linear program users and found that after (I think) 1 year, adherence to the program was 0. Essentially no one pulling 550lb off the floor or squatting 400 is making linear gains, and this is one of the only surefire ways that most can say you're likely to be injured (too much too soon). As someone 10 years ahead of you and with a history of annoying injuries (like many others), if you try to outpace pain issues, you'll regret it. Fortunately, working around injuries is very doable and doesn't mean you have to stop, like some would advocate. Play the long game, not the short-term ego game -- you want to be lifting solid numbers and be in good health in 20 years.

2. Can't comment specifically here, but don't be afraid of variations. There are many and you can learn to love them. In all likelihood they will only serve you well in the longterm.

3. The diagram of "form" in one of their articles is probably one of the better explanations (can't find it now) -- essentially, in beginner phases, assuming you're not loading too ambitiously, a fairly wide range of form is fine (and possibly beneficial), within reason, and only as weights get heavier and your exposure time to an exercise has greatly increased (during which your brain generally improves efficiency) does your form need to get more specific. As I've found venturing into backsquatting after years of exclusively front-squatting: your form develops over time, as does the load tolerance of the tissues used. The TL;DR is that "injury" has more to do with load relative to load tolerance than it does perfection in "form" (since there is no such thing). Of course, if you're a world champion powerlifter trying to squat 1000lb but suddenly decide to comically vary your form in that moment, you'll likely fail the lift and may get injured, but that's not really a relevant example, only pointing out boundaries.

[knee_slider]

Thanks RVR , these are are all helpful pieces of advice.

I just need a clarification on how to progress with pain. How do I play the long game, while still pushing myself to progress? Is the goal more to lift the same weight (maybe more reps) with less pain, or to be able to lift more weight while not going above a certain pain threshold? Both seem like progression to me.

I have squatted 225+ with no pain in the past, so I am pretty confident that within 1-2 months I could get back to this even with the tendinopathy issue. I am also wondering how aggressively I can push, without risking a worsening of the condition.

[RVR]

Thanks RVR , these are are all helpful pieces of advice.

I just need a clarification on how to progress with pain. How do I play the long game, while still pushing myself to progress? Is the goal more to lift the same weight (maybe more reps) with less pain, or to be able to lift more weight while not going above a certain pain threshold? Both seem like progression to me.

I have squatted 225+ with no pain in the past, so I am pretty confident that within 1-2 months I could get back to this even with the tendinopathy issue. I am also wondering how aggressively I can push, without risking a worsening of the condition.

I don't want to give you rehab/medical advice as it's not my field, but simply regurgitating what some of the docs have told me here:
Generally, pain is simply part of the process, but if the issue is markedly worse a few hours to 24h after the workout, you likely exceeded capacity. I'm not sure there's harm in using kneewraps if it helps. Again, variations can also help. Form can play a role here, even if it isn't causal per se -- for instance, if I don't sit back enough in the squat, I tend to load my knees and get sharp pains, but developing form over time means I can go lower and push my knees further forward than I was able to previously (meaning I can get lower).

There are also strategies some of the docs would know more about for specific injuries. If I recall correctly, higher rep ranges utilizing somewhat lower RIR (reps in reserve) are a good approach for tendonopathy, but some forum searching could confirm this.

[Austin Baraki]

1. The thing that most attracted me to Starting Strength were the rapid gains (weight and strength for a skinny weak guy like me). This mentality of adding more to the bar every session has become addicting to me, and I always feel like I am training sub-optimally if I am not using this type of progression. The one time when I used RPE (press/bench plug in for LP), I felt like I was not making progress because I wasn't directly improving (increasing weight) from my previous workout. What would your advice/philosophy be for someone who wants to progress as fast as they can, but also has to deal with a tendinopathy issue? I feel like this mentality could cause me to re-injure myself or make my issue worse.

This "addicting" nature of extremely rapid load increases is a common mentality coming from that world. However, training is a very long-term process, and this mentality you describe engrains many habits and beliefs that fail to support -- or outwardly harm -- long-term progress. For example, people begin to believe that any session where weight is not increased represents a "waste of time", or that any training that does not involve maximal effort is a "waste of time". It holds that absolute weight on the bar is the only possible metric of performance and improvement. None of these things are true, and learning them earlier in your training career rather than the hard way -- during a lengthy rehab bout from injury -- is preferable, especially if someone will be training for many years or decades.

It is very likely that with a different programming strategy that involved slower progression, more movement variation, and less training at/near-failure, your knee tendinopathy would not have occurred, and you would still be training productively to this day, rather than having to take an extended period of time away from doing what you want in order to recover. This supposed "wasted time" not aggressively adding weight to the bar every single session would have led to much less "wasted time" dealing with tendinopathy down the road.

My advice is honestly to ditch the idea of "progressing as fast as you can". I understand this may not be what you want to hear, although you will end up learning this lesson either way in the long run. I've been lifting extremely consistently for well over a decade, and I attribute my overall progress to that -- not to how quickly I got strong in the first 12-16 weeks of my lifting career.

2. My plan right now is to start beginner prescription/template and modify intensity if the squats become too painful. I would prefer not to modify exercise selection if I do not have to (since I am still learning proper low bar squat form and how to push through tough reps), and modifying volume seems a bit complex to me. Do you think this sounds like a fine plan or would you recommend some more slight changes to the program?

I cannot say whether that program is appropriate for you at this time without more information, the kind that we gather in our rehab consultation with clients. If you are intending to rehab this yourself, my best advice for management and programming is contained in the articles I linked. There is an example squat approach in the "Pain in Training" article, if needed.

3. I know that Jordan specifically has talked a bunch about how form is overrated (its impact on injuries specifically). But I feel like you guys are just saying this because your form is so good and efficient. I definitely agree that smart loading and progression plays a bigger role in injuries than form, or else I would have broke my back my first couple times squatting, but what is the point where form becomes unacceptable? Is your approach to address form issues more when it becomes related to the sticking point of the lift?

This has been discussed numerous times on the forum/site in the past.
https://forum.barbellmedicine.com/fo...y-relationship
https://forum.barbellmedicine.com/fo...risk-of-injury
https://forum.barbellmedicine.com/fo...risk-reduction
https://forum.barbellmedicine.com/fo...s-about-method
https://www.barbellmedicine.com/blog...ect-technique/