Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial
Stephan J Breda, Edwin H G Oei, Johannes Zwerver, Edwin Visser, Erwin Waarsing, Gabriel P Krestin, Robert-Jan de Vos, Stephan J Breda, Edwin H G Oei, Johannes Zwerver, Edwin Visser, Erwin Waarsing, Gabriel P Krestin, Robert-Jan de Vos
Abstract
Objective: To compare the effectiveness of progressive tendon-loading exercises (PTLE) with eccentric exercise therapy (EET) in patients with patellar tendinopathy (PT).
Methods: In a stratified, investigator-blinded, block-randomised trial, 76 patients with clinically diagnosed and ultrasound-confirmed PT were randomly assigned in a 1:1 ratio to receive either PTLE or EET. The primary end point was clinical outcome after 24 weeks following an intention-to-treat analysis, as assessed with the validated Victorian Institute of Sports Assessment for patellar tendons (VISA-P) questionnaire measuring pain, function and ability to play sports. Secondary outcomes included the return to sports rate, subjective patient satisfaction and exercise adherence.
Results: Patients were randomised between January 2017 and July 2019. The intention-to-treat population (mean age, 24 years, SD 4); 58 (76%) male) consisted of patients with mostly chronic PT (median symptom duration 2 years). Most patients (82%) underwent prior treatment for PT but failed to recover fully. 38 patients were randomised to the PTLE group and 38 patients to the EET group. The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 vs 18 points, adjusted mean between-group difference, 9 (95% CI 1 to 16); p=0.023). There was a trend towards a higher return to sports rate in the PTLE group (43% vs 27%, p=0.13). No significant between-group difference was found for subjective patient satisfaction (81% vs 83%, p=0.54) and exercise adherence between the PTLE group and EET group after 24 weeks (40% vs 49%, p=0.33).
Conclusions: In patients with PT, PTLE resulted in a significantly better clinical outcome after 24 weeks than EET. PTLE are superior to EET and are therefore recommended as initial conservative treatment for PT.
Keywords: exercise rehabilitation; overuse injury; randomised controlled trial; sports rehabilitation programs; tendinopathy.
Conflict of interest statement
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: EHGO and R-JdV had financial support from the National Basketball Association (NBA) and GE Healthcare Orthopaedics and Sports Medicine Collaboration for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.
© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Figures
References
- Scott A, Squier K, Alfredson H, et al. . Icon 2019: international scientific tendinopathy symposium consensus: clinical terminology. Br J Sports Med 2020;54:260–2. 10.1136/bjsports-2019-100885
- Lian OB, Engebretsen L, Bahr R. Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med 2005;33:561–7. 10.1177/0363546504270454
- Malliaras P, Cook J, Purdam C, et al. . Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther 2015;45:887–98. 10.2519/jospt.2015.5987
- De Vries AJ, Koolhaas W, Zwerver J, et al. . The impact of Patellar tendinopathy on sports and work performance in active athletes. Res Sports Med 2017;25:253–65. 10.1080/15438627.2017.1314292
- Morgan S, Coetzee FF. Proposing a Patellar tendinopathy screening tool following a systematic review. S Afr J Physiother 2018;74:74. 10.4102/sajp.v74i1.454
- Samiric T, Parkinson J, Ilic MZ, et al. . Changes in the composition of the extracellular matrix in Patellar tendinopathy. Matrix Biol 2009;28:230–6. 10.1016/j.matbio.2009.04.001
- Khan KM, Cook JL, Kannus P, et al. . Time to abandon the "tendinitis" myth. BMJ 2002;324:626–7. 10.1136/bmj.324.7338.626
- Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010;376:1751–67. 10.1016/S0140-6736(10)61160-9
- Bourke D, Patel S, Flint D. The best physiotherapy exercises for management of patella tendinopathy. National Institute for health and care excellence. Available:
- Everhart JS, Cole D, Sojka JH, et al. . Treatment Options for Patellar Tendinopathy: A Systematic Review. Arthroscopy J Arthroscopic Related Surg 2017;33:861–72. 10.1016/j.arthro.2016.11.007
- Visnes H, Hoksrud A, Cook J, et al. . No effect of eccentric training on jumper's knee in volleyball players during the competitive season: a randomized clinical trial. Clin J Sport Med 2005;15:227–34. 10.1097/01.jsm.0000168073.82121.20
- Zwerver J, Kramer T, van den Akker-Scheek I. Validity and reliability of the Dutch translation of the VISA-P questionnaire for Patellar tendinopathy. BMC Musculoskelet Disord 2009;10:102. 10.1186/1471-2474-10-102
- Zwerver J, Hartgens F, Verhagen E, et al. . No effect of extracorporeal shockwave therapy on Patellar tendinopathy in jumping athletes during the competitive season: a randomized clinical trial. Am J Sports Med 2011;39:1191–9. 10.1177/0363546510395492
- van der Worp H, van Ark M, Zwerver J, et al. . Risk factors for Patellar tendinopathy in basketball and volleyball players: a cross-sectional study. Scand J Med Sci Sports 2012;22:783–90. 10.1111/j.1600-0838.2011.01308.x
- Barber-Westin SD, Noyes FR. Assessment of sports participation levels following knee injuries. Sports Med 1999;28:1–10. 10.2165/00007256-199928010-00001
- Crossley KM, Stefanik JJ, Selfe J, et al. . 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral pain research retreat, Manchester. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. Br J Sports Med 2016;50:839–43. 10.1136/bjsports-2016-096384
- Kulig K, Landel R, Chang Y-J, et al. . Patellar tendon morphology in volleyball athletes with and without patellar tendinopathy. Scand J Med Sci Sports 2013;23:e81–8. 10.1111/sms.12021
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43:409–16. 10.1136/bjsm.2008.051193
- Young MA, Cook JL, Purdam CR, et al. . Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for Patellar tendinopathy in volleyball players. Br J Sports Med 2005;39:102–5. 10.1136/bjsm.2003.010587
- Crossley KM, Thancanamootoo K, Metcalf BR, et al. . Clinical features of Patellar tendinopathy and their implications for rehabilitation. J Orthop Res 2007;25:1164–75. 10.1002/jor.20415
- Malliaras P, Cook JL, Kent P. Reduced ankle dorsiflexion range may increase the risk of Patellar tendon injury among volleyball players. J Sci Med Sport 2006;9:304–9. 10.1016/j.jsams.2006.03.015
- Silbernagel KG, Thomeé R, Eriksson BI, et al. . Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med 2007;35:897–906. 10.1177/0363546506298279
- de Vos RJ, Weir A, van Schie HTM, et al. . Platelet-Rich plasma injection for chronic Achilles tendinopathy. JAMA 2010;303:144. 10.1001/jama.2009.1986
- Hernandez-Sanchez S, Hidalgo MD, Gomez A. Responsiveness of the VISA-P scale for Patellar tendinopathy in athletes. Br J Sports Med 2014;48:453–7. 10.1136/bjsports-2012-091163
- Hughes RA, Heron J, Sterne JAC, et al. . Accounting for missing data in statistical analyses: multiple imputation is not always the answer. Int J Epidemiol 2019;48:1294–304. 10.1093/ije/dyz032
- Rio E, van Ark M, Docking S, et al. . Isometric contractions are more analgesic than isotonic contractions for Patellar tendon pain: an In-Season randomized clinical trial. Clin J Sport Med 2017;27:253–9. 10.1097/JSM.0000000000000364
- Holden S, Lyng K, Graven-Nielsen T, et al. . Isometric exercise and pain in Patellar tendinopathy: a randomized crossover trial. J Sci Med Sport 2020;23:208–14. 10.1016/j.jsams.2019.09.015
- Breda SJ, van der Vlist A, de Vos R-J, et al. . The association between Patellar tendon stiffness measured with shear-wave elastography and Patellar tendinopathy-a case-control study. Eur Radiol 2020;30:5942–51. 10.1007/s00330-020-06952-0
- Breda SJ, Poot DHJ, Papp D, et al. . Tissue‐Specific T2* Biomarkers in Patellar Tendinopathy by Subregional Quantification Using 3D Ultrashort Echo Time MRI. J Magn Reson Imaging 2020;52:420–30. 10.1002/jmri.27108
Source: PubMed