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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/

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Visnes & Bahr 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)
Wang et al 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
Frome et al 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
Warden et al 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.
Kongsgaard et al 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.

Comment(s)

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.

Clinical Bottom Line

There is only weak evidence to support the use of eccentric strengthening exercises in patella tendinopathy.

References

1. Visnes H, Bahr R The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes British Journal of Sports Medicine 2007; 41: 217-223
2. Wang C-J, Ko J-Y, Chan Y-S, Weng L-H and Hsu S-L Extracorporeal Shockwave for Chronic Patellar Tendinopathy The American Journal of Sports Medicine 2007; 35: 972-978
3. Frohm A, Saartok T, Halvorsen K, Renstrom P Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols British Journal of Sports Medicine 2007; 41: e7
4. 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 Rheumatology 2008; 47: 467–471
5. 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 Scandinavian Journal of Medcine & Science in Sport 2009; 19: 790–802