Eccentric exercise in the treatment of Patella Tendinopathy
Date First Published:
June 25, 2010
Last Updated:
June 25, 2010
Report by:
Aldo Russell de Boer, , Senior Musculoskeletal Physiotherapist (Imperial College Healthcare NHS Trust )
Search checked by:
Suzanne Pearson , Imperial College Healthcare NHS Trust
Three-Part Question:
In [adults with Patella tendinopathy] is [eccentric exercise more beneficial than other non invasive treatments] at [decreasing pain and improving function]
Clinical Scenario:
A 28 year old male is referred to physiotherapy with a 18 month history of right patella tendinopathy. You plan to use a eccentric exercise programme and wish to know what the efficiency of this treatment is against other non-invasive treatments is.
Search Strategy:
Medline 1966-09 using the PubMed Clinical queries database was searched using the following terms (patellar tendinitis[All Fields] OR patellar tendinopathies[All Fields] OR patellar tendinopathy[All Fields] OR patellar tendinosis[All Fields]) AND Therapy/broad[filter]. In addition the BestBETS database, PEDrO database and Cochrane library (April 2010) was searched using similar terms.
Pub Med: http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Best BETS http://www.bestbets.org
PEDrO (Physiotherapy best evidence database): http://www.pedro.org.au/
Pub Med: http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Best BETS http://www.bestbets.org
PEDrO (Physiotherapy best evidence database): http://www.pedro.org.au/
Outcome:
After duplicates had been removed, 55 abstracts were identified as being possibly relevant from the combined searches. 14 papers were identified that potentially answered the three part search question and the full articles were retrieved. One paper was a critical review that covered searches up until 2006.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes Visnes H, Bahr R 2007 Norway | 7 studies (5 RCTs, 1 PRS, 1 CCT) | Critical Review | Pain – VAS (4 studies) | No attempt to pool data due to heterogenous nature of studies | Unable to pool data to perform meta-analysis due to hetergenous nature of studies. Poor quality studies included |
| VISA (4 studies) | |||||
| Return to sport (2 studies) | |||||
| Patient satisfaction (1 study) | |||||
| Extracorporeal Shockwave for Chronic Patellar Tendinopathy Wang C-J, Ko J-Y, Chan Y-S, Weng L-H and Hsu S-L 2007 Taiwan | N=50, 2 groups Group 1 – received extracorporeal shockwave. Group 2 – received NSAIDs, physiotherapy (including eccentric stretching and strengthening), exercise programmes and knee straps |
RCT | Pain score | Group 1 – Significantly improved, Group 2 – no significant change | No description or record of physiotherapy exercise programme or method. No description of the method or use of the knee strap. Un-validated method of analysing the VISA results. |
| Victorian Institute of Sports Assessment score | Group 1 - significantly improved Group 2 – no significant change | ||||
| Ultrasonographic examination at 1, 3, 6, and 12 months and then once a year | No significant change in either group | ||||
| Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols Frohm A, Saartok T, Halvorsen K, Renstrom P 2007 Sweden | N=20, 2 Groups Group 1 - bilateral eccentric overload strength training using the Bromsman device twice a week. Group 2 - unilateral eccentric body load training using a decline board twice a week, supplemented with daily home exercises. |
Prospective RCT | Swedish Victorian Institute of Sport Assessment for Patella (VISA-P) score. | Both groups significantly improved. | Small sample size. No Blinding |
| Low-intensity pulsed ultrasound for chronic patellar tendinopathy:a randomized, double-blind, placebo-controlled trial Warden SJ, Metcalf BR, Kiss ZS, Cook JL, Purdam CR, Bennell KL, Crossley KM 2008 Australia | N=37, 2 groups Group 1 – Eccentric decline squats exs programme with low intensity pulsed ultrasound. Group 2 – Eccentric decline squats exs programme without low intensity pulsed ultrasound. |
RCT | Visual analogue scales for both usual (VAS-U) and worst (VAS-W) tendon pain. | VAS-U and VAS-W for the entire cohort decreased by 1.6-1.9 cm (P<0.01) and 2.5-2.4 cm (P<0.01), respectively. | No Control group. |
| Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, S. P. Magnusson 2009 Denmark | N=39 Group 1 (N=13) – received peritendinous corticosteroid injections (CORT) Group 2 (N=13) – Eccentric decline Squat (ECC) Group 3 (N=13) – Heavy slow resistence training (HSR) |
RCT | VISA-p questionnaire | All groups significantly improved at 12 weeks. ECC & HSR results maintained at 6 months. CORT scores decreased at 6 months. (P<0.05) | Small sample size. Self selected patients may lead to biasing. |
| Tendon pain during activity (VAS) | All groups significantly improved at 12 weeks. ECC & HSR results maintained at 6 months. CORT scores decreased at 6 months. (P<0.05) | ||||
| Treatment satisfaction | Four CORT (36% of responders), two ECC (22% of responders) and eight HSR subjects (73% of responders) were satisfied at the half-year follow-up. | ||||
| Tendon swelling | Decreased in CORT and HSR (-13±9%, P<0.01) | ||||
| Tendon vascularization | Decreased in CORT and HSR (-52±49% and -43%±23%, P<0.01) | ||||
| Tendon mechanical properties | Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. | ||||
| Collagen crosslink properties | HSR yielded an elevated collagen network turnover. |
Author Commentary:
The sole critical review was unable to pool any data for meta-analysis. It did suggest that although many of the studies have small sample sizes that most indicated that eccentric exercise may be beneficial. Two studies with small sample sizes indicated that heavy resistance training was beneficial.
Bottom Line:
There is only weak evidence to support the use of eccentric strengthening exercises in patella tendinopathy.
References:
- Visnes H, Bahr R . The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes
- Wang C-J, Ko J-Y, Chan Y-S, Weng L-H and Hsu S-L. Extracorporeal Shockwave for Chronic Patellar Tendinopathy
- Frohm A, Saartok T, Halvorsen K, Renstrom P . Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols
- Warden SJ, Metcalf BR, Kiss ZS, Cook JL, Purdam CR, Bennell KL, Crossley KM . Low-intensity pulsed ultrasound for chronic patellar tendinopathy:a randomized, double-blind, placebo-controlled trial
- Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, S. P. Magnusson . Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy