Progressive tendon loading exercise is superior to traditional eccentric strengthening for patient with patellar tendinopathy

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There are a range of rehabilitation programmes that can be used to treat players with patellar tendinopathy (PT), most of which involve some form of strengthening exercises. This week’s FastFact compares a progressive tendon-loading programme with a more traditional eccentric strengthening programme.1

This randomised, assessor-blinded trial involved a total of 76 patients with clinically diagnosed and ultrasound-confirmed PT. Patients were randomly assigned to receive either progressive tendon-loading exercise (PTLE) or eccentric exercise therapy (EET). The primary end point was clinical outcome after 24 weeks, as assessed using the Victorian Institute of Sports Assessment for patellar tendons (VISA-P) questionnaire. Secondary outcomes included the return to sport rate, patient satisfaction and exercise adherence. Patients had a mean age of 24 years, were predominantly male (n=58, 76%) and had a medium symptom duration of two years. The majority of patients had also received prior treatment, but had failed to recover.

The PTLE programme contained four stages. Patients in the intervention group performed either daily isometric (static), isotonic (dynamic), energy-storage (explosive) or sport-specific exercises depending on their treatment stage. Progressive load was administered based on the individual pain response (the Visual Analogue Scale score needed to be ≤3 points). The full treatment protocol is well described in the open-source article (see below). The control group performed eccentric squatting exercises, using a decline board, for twelve weeks. Patients in both groups were also asked to perform additional exercises targeting risk factors for PT.

While players in both groups improved during the treatment period, the improvement in VISA-P score was significantly better for players who had been allocated to the PTLE group at 24 weeks follow-up (a 28 vs 18 point improvement). An interesting finding was that the major between-group difference was found in the latter half of the exercise programme. The study’s authors propose that the energy-storage (explosive) exercises included during these phases may therefore be important before starting the sport-specific exercises. There was also a trend towards a higher return to sports rate in the PTLE group (43% vs 27%) however the relative success of the programme should be tempered by the fact that less than half of the patients in each group were able to return to sport. There was no significant difference in other outcomes, including patient satisfaction and exercise adherence.

While the results of this study suggest that the PTLE programme may be better than other rehabilitation programmes, less than 50% of participants in each group were able to return to play. The need for further research is further demonstrated by the fact that this is the largest clinical trial evaluating physiotherapy treatment for PT, with sample size of only 76 participants.

To learn more about the treatment of tendinopathy complete the “Tendinopathy” module in the FIFA Diploma in Football medicine.

1. Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British Journal of Sports Medicine. 2021;55:501-509.

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15 May 2021 11:01

Good article with great patient information material and programming in the supplementary section.