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Exercise Guide: Heavy Slow Resistance Training for Patellar Tendinopathy

hack squat machine

The patella tendon is at risk for injury in sports like soccer, volleyball and basketball. During these activities small injuries may occur. As the body heals the tendon to make it stronger, it sometimes heals abnormally which weakens the tendon and makes it susceptible to even more damage later on. Abnormal healing causes the tendon to become degenerative with damage. This is called tendinopathy.

Treating tendinopathy should start with special exercises that target the cause for the tendinopathy and disrupt the abnormal healing. One of these exercises is heavy slow resistance training. The heavy weight and slow repetitions load the tendon, signaling it to make new tendon. These exercises are different than the rapid loading, ballistic activities that caused the problem to develop.

As always, please consult with your physician before starting an exercise program.

How to do Heavy Slow Resistance Training

The exercises are done during three sessions per week. Each session should consist of three bilateral exercises:

  1. Squat
  2. Leg press
  3. Hack squat (see picture for hack squat machine)

You complete four sets in each exercise with a 2–3-minute rest between sets.

The repetitions/loads change each week with you doing the most weight you can to complete the number of repetitions noted for the week.

A repetition maximum (RM) is the most weight you can lift for a defined number of exercise movements. For example, a 10RM would be the heaviest weight you could lift for 10 consecutive exercise repetitions.


  • Week 1: 15 RM (usually 60% of 1 rep max)
  • Weeks 2-3: 12RM (usually 65% of 1 rep max)
  • Weeks 4-5: 10RM (usually 70% of 1 rep max)
  • Weeks 6-8: 8RM (usually 75% of 1 rep max)
  • Weeks 9-12: 6RM (usually 85% of 1 rep max)

All exercises should be performed from complete extension to 90 degrees of knee flexion and back again. Spend three seconds completing each of the eccentric (lowering) and concentric (raising) phases, respectively (i.e. 6 seconds per repetition).

Pain during exercises is acceptable (about a 4 out of 10) but pain and discomfort should not increase after stopping the exercises.

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

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