Management of Patellar Tendinopathy Through Monitoring, Load Control, and Therapeutic Exercise: A Systematic Review

in Journal of Sport Rehabilitation

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Pablo Núñez-Martínez
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David Hernández-Guillen
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DOI:
https://doi.org/10.1123/jsr.2021-0117
Keywords:
patellar tendinopathy; exercise therapy; education; therapy; treatment
First Published Online:
23 Dec 2021
In Print:
Volume 31: Issue 3
Page Range:
337–350
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Context: Patellar tendinopathy presents with persistent tendon pain located in the lower pole of the patella and loss of function related to mechanical load. Although its pathogenesis is not completely clear, conservative treatment including exercise is the main intervention of patellar tendinopathy treatment. Objective: To describe the efficacy of patellar tendinopathy management through therapeutic exercise, and control and monitoring of loads. Evidence Acquisition: MEDLINE, WoS, Cochrane Plus, PEDro, and the gray literature were searched from inception to July 2021. Based on the PICO strategy, the inclusion criteria were clinical trials published in English or Spanish; outcomes of function, pain, and strength; patients with patellar tendinopathy with no age or gender limitations; using an active intervention; and at least a methodological quality equal to or greater than 3 points on the Jadad scale. All data were analyzed by 2 independent reviewers (P.N.-M. and D.H.-G.). Studies were qualitatively synthesized using a descriptive synthesis. The methodological quality and risk of bias assessment were performed with the PEDro and Jadad scale, respectively. Evidence Synthesis: A total of 136 articles were identified, of which 12 met the eligibility criteria. All of them were regarded as presenting a moderate risk of bias and their methodological quality was considered acceptable to good. Recovering patellar tendinopathy with therapeutic exercise seems to significantly improve function, pain, and strength after intervention and even lasted over time. Conclusion: A treatment based on load monitoring and physical exercise has proven to be effective in rehabilitating patellar tendinopathy, with positive results in the short and medium term.

Núñez-Martínez is with the University of Valencia, Valencia, Spain. Hernández-Guillen is with the Department of Physiotherapy, University of Valencia, Valencia, Spain.

Hernández-Guillen (david.hernandez@uv.es) is corresponding author.

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  • 1.

    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(6):409–416. PubMed ID: 18812414 doi:10.1136/bjsm.2008.051193

    • Search Google Scholar
    • Export Citation
  • 2.

    Cook JL, Rio E, Purdam CR, Girdwood M, Ortega-Cebrian S, Docking SI. El continuum de la patología de tendón: concepto actual e implicaciones clínicas. Apunts Sports Med. 2017;52(194):61–69.

    • Search Google Scholar
    • Export Citation
  • 3.

    van der Worp H, Zwerver J, Kuijer PPFM, Frings-Dresen MHW, van den Akker-Scheek I. The impact of physically demanding work of basketball and volleyball players on the risk for patellar tendinopathy and on work limitations. J Back Musculoskelet Rehabil. 2011;24(1):49–55. PubMed ID: 21248400 doi:10.3233/BMR-2011-0274

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Scott A, Squier K, Alfredson H, et al. ICON 2019: international scientific tendinopathy symposium consensus: clinical terminology. Br J Sports Med. 2020;54(5):260–262. PubMed ID: 31399426 doi:10.1136/bjsports-2019-100885

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther. 2015;45(11):887–898. PubMed ID: 26390269 doi:10.2519/jospt.2015.5987

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019;33(1):122–140. PubMed ID: 31431267 doi:10.1016/j.berh.2019.02.001

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Abate M, Gravare-Silbernagel K, Siljeholm C, et al. Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Res Ther. 2009;11(3):235. PubMed ID: 19591655 doi:10.1186/ar2723

    • Search Google Scholar
    • Export Citation
  • 8.

    Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). J Physiother. 2014;60(3):122–129. PubMed ID: 25092419 doi:10.1016/j.jphys.2014.06.022

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Joyce D, Lewinton D. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions. London and New York: Routledge, Taylor & Francis Group; 2016.

    • Search Google Scholar
    • Export Citation
  • 10.

    Docking SI, Cook J. How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: a narrative review. J Musculoskelet Neuronal Interact. 2019;19(3):300–310. PubMed ID: 31475937

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Heinemeier KM, Schjerling P, Heinemeier J, Magnusson SP, Kjaer M. Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb 14C. FASEB J Off Publ Fed Am Soc Exp Biol. 2013;27(5):2074–2079. doi:10.1096/fj.12-225599

    • Search Google Scholar
    • Export Citation
  • 12.

    Cook JL, Khan KM, Harcourt PR, Grant M, Young DA, Bonar SF. A cross sectional study of 100 athletes with jumper’s knee managed conservatively and surgically. The Victorian institute of sport tendon study group. Br J Sports Med. 1997;31(4):332–336. PubMed ID: 9429013 doi:10.1136/bjsm.31.4.332

    • Search Google Scholar
    • Export Citation
  • 13.

    Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46(3):163–168. PubMed ID: 22113234 doi:10.1136/bjsports-2011-090414

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Khan KM, Bonar F, Desmond PM, et al. Patellar tendinosis (jumper’s knee): findings at histopathologic examination, US, and MR imaging. Victorian institute of sport tendon study group. Radiology. 1996;200(3):821–827. PubMed ID: 8756939 doi:10.1148/radiology.200.3.8756939

    • Search Google Scholar
    • Export Citation
  • 15.

    Cook JL, Khan KM, Harcourt PR, et al. Patellar tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian institute of sport tendon study group. Clin J Sport Med Off J Can Acad Sport Med. 1998;8(2):73–77. doi:10.1097/00042752-199804000-00001

    • Search Google Scholar
    • Export Citation
  • 16.

    Rio E, Moseley L, Purdam C, et al. The pain of tendinopathy: physiological or pathophysiological? Sports Med Auckl NZ. 2014;44(1):9–23. doi:10.1007/s40279-013-0096-z

    • Search Google Scholar
    • Export Citation
  • 17.

    Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016;50(19):1187–1191. PubMed ID: 27127294 doi:10.1136/bjsports-2015-095422

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Docking SI, Cook J. Pathological tendons maintain sufficient aligned fibrillar structure on ultrasound tissue characterization (UTC). Scand J Med Sci Sports. 2016;26(6):675–683. PubMed ID: 26059532 doi:10.1111/sms.12491

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016;50(4):209–215. PubMed ID: 26407586 doi:10.1136/bjsports-2015-095215

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Malliaras P. Understanding mechanisms to improve exercise interventions in tendinopathy. Phys Ther Sport Off J Assoc Chart Physiother Sports Med. 2017;27:50–51. doi:10.1016/j.ptsp.2016.12.006

    • Search Google Scholar
    • Export Citation
  • 21.

    Littlewood C, Malliaras P, Bateman M, Stace R, May S, Walters S. The central nervous system—an additional consideration in “rotator cuff tendinopathy” and a potential basis for understanding response to loaded therapeutic exercise. Man Ther. 2013;18(6):468–472. PubMed ID: 23932100 doi:10.1016/j.math.2013.07.005

    • Search Google Scholar
    • Export Citation
  • 22.

    Cook JL. Ten treatments to avoid in patients with lower limb tendon pain. Br J Sports Med. 2018;52(14):882. PubMed ID: 29475840 doi:10.1136/bjsports-2018-099045

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Rio E, Docking SI. Adaptation of the pathological tendon: you cannot trade in for a new one, but perhaps you don’t need to? Br J Sports Med. 2018;52(10):622–623. PubMed ID: 28724715 doi:10.1136/bjsports-2016-097325

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Mascaró A, Cos MÀ, Morral A, Roig A, Purdam C, Cook J. Load management in tendinopathy: clinical progression for Achilles and patellar tendinopathy. Apunts Med Esport. 2018;53(197):19–27. doi:10.1016/j.apunts.2017.11.005

    • Search Google Scholar
    • Export Citation
  • 25.

    Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790–802. PubMed ID: 19793213 doi:10.1111/j.1600-0838.2009.00949.x

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper’s knee in volleyball players during the competitive season: a randomized clinical trial. Clin J Sport Med Off J Can Acad Sport Med. 2005;15(4):227–234. doi:10.1097/01.jsm.0000168073.82121.20

    • Search Google Scholar
    • Export Citation
  • 27.

    Hutton B, Catalá-López F, Moher D. La extensión de la declaración PRISMA para revisiones sistemáticas que incorporan metaanálisis en red: PRISMA-NMA. Med Clínica. 2016;147(6):262–266. doi:10.1016/j.medcli.2016.02.025

    • Search Google Scholar
    • Export Citation
  • 28.

    Higgins J, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions. Published 2020. www.training.cochrane.org/handbook. Accessed October 1, 2020.

    • Search Google Scholar
    • Export Citation
  • 29.

    Halpern SH, Douglas MJ. Appendix: Jadad scale for reporting randomized controlled trials. In: Evidence-Based Obstetric Anesthesia. Blackwell Publishing Ltd; 2005:237–238. doi:10.1002/9780470988343.app1

    • Search Google Scholar
    • Export Citation
  • 30.

    Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(7):1000097. doi:10.1371/journal.pmed.1000097

    • Search Google Scholar
    • Export Citation
  • 31.

    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(3):208–214. PubMed ID: 31735531 doi:10.1016/j.jsams.2019.09.015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277–1283. PubMed ID: 25979840 doi:10.1136/bjsports-2014-094386

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    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 Off J Can Acad Sport Med. 2017;27(3):253–259. doi:10.1097/JSM.0000000000000364

    • Search Google Scholar
    • Export Citation
  • 34.

    van Ark M, Cook JL, Docking SI, et al. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. J Sci Med Sport. 2016;19(9):702–706. PubMed ID: 26707957 doi:10.1016/j.jsams.2015.11.006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med. 2020;55(9):501–509. PubMed ID: 33219115 doi:10.1136/bjsports-2020-103403

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Agergaard A-S, Svensson RB, Malmgaard-Clausen NM, et al. Clinical outcomes, structure, and function improve with both heavy and moderate loads in the treatment of patellar tendinopathy: a randomized clinical trial. Am J Sports Med. 2021;49(4):982–993. PubMed ID: 33616456 doi:10.1177/0363546520988741

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Pietrosimone LS, Blackburn JT, Wikstrom EA, et al. Landing biomechanics are not immediately altered by a single-dose patellar tendon isometric exercise protocol in male athletes with patellar tendinopathy: a single-blinded randomized cross-over trial. Phys Ther Sport. 2020;46:177–185. PubMed ID: 32957034 doi:10.1016/j.ptsp.2020.09.003

    • Search Google Scholar
    • Export Citation
  • 38.

    Bahr R, Fossan B, Løken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s Knee). A randomized, controlled trial. J Bone Joint Surg Am. 2006;88(8):1689–1698. PubMed ID: 16882889 doi:10.2106/JBJS.E.01181

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Clin Rehabil. 2004;18(4):347–352. PubMed ID: 15180116 doi:10.1191/0269215504cr757oa

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Frohm A, Saartok T, Halvorsen K, Renström P. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols. Br J Sports Med. 2007;41(7):e7. PubMed ID: 17289855 doi:10.1136/bjsm.2006.032599

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014;48(7):506–509. PubMed ID: 23666020 doi:10.1136/bjsports-2012-092078

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Lim HY, Wong SH. Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: a systematic review. Physiother Res Int J Res Clin Phys Ther. 2018;23(4):e1721. doi:10.1002/pri.1721

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Gravare Silbernagel K, Vicenzino BT, Rathleff MS, Thorborg K. Isometric exercise for acute pain relief: is it relevant in tendinopathy management? Br J Sports Med. 2019;53(21):1330–1331. PubMed ID: 31076398 doi:10.1136/bjsports-2019-100591

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):966–972. PubMed ID: 23118117 doi:10.1136/bjsports-2012-091285

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010;6(5):262–268. PubMed ID: 20308995 doi:10.1038/nrrheum.2010.43

    • PubMed
    • Search Google Scholar
    • Export Citation
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