Exercise For Patellar Tendinopathy: What the Latest Evidence Says

By Grant Frost · Physiotherapist • Last clinically reviewed: 25 June 2026

If you are an athlete or active person with patellar tendinopathy - often called 'jumper's knee' - you have probably been given a list of exercises to do to try and help it go away. Maybe eccentric decline squats. Maybe heavy slow resistance. Maybe isometrics. And you may (or may not) have wondered: which one is actually best?

A new systematic review and network meta-analysis published in BMC Sports Science, Medicine and Rehabilitation (Liu et al., 2026) set out to answer this question. The researchers analysed data from 17 randomised controlled trials to compare the effectiveness of different exercise interventions for patellar tendinopathy.

The headline finding? No single exercise intervention was clearly superior to heavy slow resistance training (HSR) for improving VISA-P scores (the primary outcome measure for patellar tendinopathy function).

This is both reassuring and, perhaps, a little frustrating. It suggests that many load-based approaches can work, but it also highlights significant gaps in the evidence. And it raises an important clinical question that I see every day in practice: why do some people get better and others don't, even when they are doing the 'right' exercises?

What the study found

The researchers conducted a network meta-analysis - a method that allows comparison of multiple treatments simultaneously, even if they haven't been directly compared in head-to-head trials. The primary outcome was the VISA-P score, a validated questionnaire that measures pain, function, and ability to participate in sport.

The revised primary analysis included 10 studies with 313 participants and 11 different treatments. The key finding was that no intervention demonstrated statistical superiority over heavy slow resistance training (HSR).

This analysis suggests that eccentric overload, blood flow restriction training, and moderate slow resistance training performed comparably to HSR. However, flywheel training, eccentric step training, and concentric exercise were estimated to perform less favourably.

Comparing the key interventions

Understanding what each intervention actually involves is important for making sense of the findings.

Heavy Slow Resistance (HSR): This typically involves exercises like deep squats, leg presses, and hack squats performed with heavy loads (up to 90% of 1RM) at a slow, controlled tempo. The focus is on both the concentric and eccentric phases. HSR has been shown to induce tendon hypertrophy and improve mechanical properties.

Eccentric Overload: This emphasises the lengthening phase of a muscle contraction. The classic example is the single-leg decline squat, where the athlete lowers down on the affected leg and uses the other leg to return back up to the start position. This approach became popular after early studies showed promising results.

Blood Flow Restriction (BFR) Training: This involves performing low-load exercise (often around 30% of 1RM) while a cuff or tourniquet partially restricts blood flow to the working muscle. It aims to stimulate muscle and tendon adaptations with lower joint and tissue loads. One recent trial found BFR and HSR produced comparable improvements at 12 and 52 weeks.

Eccentric Step Training: A specific form of eccentric loading, often performed on a step or decline board. The study estimated this performed less favourably than HSR, though the confidence interval was wide.

Quality of the evidence

It is important to interpret these findings with appropriate caution. The authors themselves acknowledge several limitations:

• Sparse network: The revised primary network included only 10 studies with 313 participants. Several comparisons were informed by limited evidence.
• Risk of bias: Most trials were judged as having 'some concerns' for overall risk of bias, particularly related to adherence and the difficulty of blinding in exercise trials.
• Short-term follow-up: The analysis focused on short-term VISA-P changes. Long-term outcomes remain less clear.
• Population heterogeneity: Participants varied in terms of symptom duration, activity level, and baseline severity.

This caution is appropriate. As one previous review noted, 'no convincing evidence' exists that any adjuncts administered alongside exercise are more effective than exercise alone.

A clinical perspective: why the lower back matters

With the results of the study in mind, I'd like to add the important context that I've learned over the last 20 years of clinical practice that isn't captured in this meta-analysis.

When I assess someone with patellar tendinopathy, I almost always find underlying dysfunction in their lower back. And when I address that, the knee tends to improve more readily.

This makes sense biomechanically. The patellar tendon doesn't exist in isolation. It is part of a kinetic chain that starts at the foot and runs up through the knee, hip, pelvis, and spine. If the lower back is stiff the knee has to compensate in a number of different ways. The quadriceps may become overactive or tight, the patellar tendon may be more overloaded at rest, gluteal muscles can become inhibited, and you may end up with a tendinopathy that just won't settle - not necessarily because it's a bad tendon, or the strength program of choice isn't appropriate, but because we aren't also treating the thing that may have asked it to be there (and stay there) in the first place.

It happens alot. An athlete comes in with 'jumper's knee'. They have been doing their eccentric strength program religiously. But the pain persists. When I check their lower back, I find restricted lumbar extension, stiffer facet joints, restricted soft-tissue, or trunk. muscle function. We address this - even with just basic manual therapy, or trunk strength exercises - and suddenly the knee starts to respond beyond what it has to that point.

If we just focus on the knee, we might be missing the bigger picture that give knee tendinopathy context. The lower back might be the reason your patellar tendinopathy isn't improving, even when you are doing all the 'right' exercises.

We also know that even with the best loading-based rehabilitation, clinical symptoms can persist for years. One study found that at 3 to 4 years follow-up, VISA-P scores averaged 84 out of 100 (not fully recovered), and only 25% of athletes had returned to their pre-injury level of sport. This suggests that while loading helps, it may still be an incomplete approach.

Practical implications for rehabilitation

So, what does this mean for someone with patellar tendinopathy?

1. HSR is a reasonable starting point. The evidence suggests it works, it is broadly comparable to other approaches, and it has a strong evidence base. If you can access a leg press or perform heavy squats with good form, this is a solid option.

2. Don't get hung up on the 'best' exercise. The data suggest that many progressive loading strategies are broadly comparable. What matters more is whether you can tolerate the load, whether you can progress it appropriately, and whether it fits your life and goals.

3. Look beyond the knee. In my clinical experience, addressing lower back is often a missing piece. If your knee isn't improving, it is worth having your whole kinetic chain assessed.

4. Be realistic about recovery. Patellar tendinopathy can be stubborn. Even with good rehabilitation, you may not return to your pre-injury level of sport. This is not a failure - it is a reality of the condition. The goal is to get you functioning as well as possible, managing your load, and staying active. Aim high but be prepared for a bit of a potential slog.

5. Consider blood flow restriction training. BFR training is an emerging option that appears to be comparable to HSR in effectiveness. It may be particularly useful if you cannot tolerate heavy loads.

6. Think about the whole person. The mechanisms of improvement are not fully understood. It may not be about changes in the tendon itself. It may be about changes in the nervous system, pain processing, or movement patterns. A holistic approach is likely to be more effective than a narrow focus on the knee.

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