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Three Part Question

In patients with [patella tendinopathy] are [eccentric decline squats or high load exercise] more beneficial compared to [Isometric or Concentric high load exercises] in [improving pain and function].

Clinical Scenario

A 35 year old, male, recreational basketball player, attends the physiotherapy department with a diagnosis of right sided patella tendinopathy. He wants to know what the best exercise regime is to allow him to return to pain free basketball

Search Strategy

PubMed Clinical queries database was searched in addition the BestBETS, Cochrane and PEDrO (Physiotherapy best evidence) databases were searched and no further articles were found
Therapy/Broad[filter] AND (("patella"[MeSH Terms] OR "patella"[All Fields] OR "patellar"[All Fields]) AND ("tendinopathy"[MeSH Terms] OR "tendinopathy"[All Fields]) AND ("exercise"[MeSH Terms] OR "exercise"[All Fields]))
systematic[sb] AND (("patella"[MeSH Terms] OR "patella"[All Fields] OR "patellar"[All Fields]) AND ("tendinopathy"[MeSH Terms] OR "tendinopathy"[All Fields]) AND ("exercise"[MeSH Terms] OR "exercise"[All Fields]))
58 results in clinical study categories of which 9 were relevant, 8 were retrieved as one article was written in German

Search Outcome

11 papers were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Young MA, Cook JL, Purdam CR, Kiss ZS and Alfredson H 2005 Australia	17 elite volleyball players (13 men, 4 women)	eccentric decline squat off 25 degree board versus traditional decline squat on 10cm step. Decline group trained into tendon pain – step group were avoiding tendon pain	VISA score and VAS	Improvements in VAS and VISA scores at 12 weeks post intervention and 12 months post for both groups – but nil significant difference between the groups	Small sample size No evidence of sample size calculation/estimates Step group exercised into minimal tendon pain whilst the decline group worked into moderate tendon pain Both exercises performed differently i.e as above and with different speeds/ loads – difficult to differentiate what the main cause for change in function/symptoms was Nil control group to compare against both eccentric programs Predominantly male cohort – only one female out of 8 in the step group Study was performed out of season – during pre-season rather than whilst competitive sport being played
Visnes H and Bahr R 2007 Norway	7 studies (5 RCTs, 1 PRS, 1 CCT)	Eccentric training for patellar tendinopathy	VAS, return to sport, VISA score, patient satisfaction	3 studies found a difference between the groups, 4 did not	Unable to pool data to perform meta-analysis due to heterogeneous nature of studies. Some studies were not randomised Quality of the studies were variable Pilot studies had small numbers Poor quality studies included 50-70% improvement in knee function and pain could be estimated, but it is not possible to determine which exact protocol component is responsible for the observed effects
Jonsson P and Alfredson H 2005 Sweden	19 patella tendons from 15 patients.13 men, 2 women. Age 24.9 (mean. Symptom duration 17.2(mean)	Prospective, RCT	VAS, VISA and satisfaction	12/52 follow up: VAS sig. lower (22vs68 p<0.01) & VISA score sig. higher (83 v 37 p<0.001) in the ecc. compared to conc. training group.	Not adequately powered – needed 20 in each group There is a short period of eccentric activity in the concentric exercise group Drop outs from concentric group – 4 tendons from concentric group due to pain (VAS 75) at 6/52 Only 5 tendons remained in concentric group at 12/52 follow up compared to 10 in eccentric group. Decided not ethical to recruit more to study because of poor outcomes with concentric group.
Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M and Magnuss 2009 Denmark	39 recreational male (18-50yrs) with chronic patellar tendinopathy (>3/12) (Proximal 85% and distal 15%)	Prospective Randomised single blind clinical trial with 12 week intervention and 6 month follow up	VAS and VISA-P	Decline squat and HSR more effective than steroid injection (P <0.05)
Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ and Cook J 2015 Australia	Six male volleyball athletes between 18-40 years old Unilateral or bilateral patella tendon pain All athletes were playing once a week and training twice a week	Single blinded randomised cross over study	VAS, Quadriceps torque on a single leg declined squat , Measures of corticospinal excitability and inhibition	Isometric exercise immediately reduced patella tendon pain with the effect sustained for at least 45minutes	Small study Specific to athletic patients who train on a 1-2 week basis Didn’t mention a power calculation Didn’t discuss the validity or reliability of the outcome measures Measurement of the corticospinal excitability and inhibition is not reproducible in clinical setting Specific in its testing: sessions completed on the same day at the same time of the day Results not applicable to anterior knee pain and may be specific to patella tendinopathy Study only included men No control group
Larsson ME, Käll I and Nilsson-Helander K 2012 Sweden	Patella tendinopathy	Systematic review 13 articles reviewed ( 9 to be of high methodological quality)	VAS, VISA-P, patient satisfaction, isokinetic strength test	5/7 high quality papers reported significant improvement among participants compared with baseline	Study designs varied therefore difficult to draw conclusions Small number of participants in some studies Short duration of the intervention period therefore only looking at short term effect Incomplete reporting in studies affecting quality (lack of noting dosage and frequency of taking medication during the study) Use of assessment tool used to measure and rate quality of articles Lack of detail in some studies ( randomisation of patients) The assessment tool does not include a question about power analysis
Frohm A, Saartok T, Halvorsen K and Renstrom P 2007 Sweden	20 athletes (16 men, 4 women)- all had clinical diagnosis of patellar tendinopathy- verified by ultrasound or MRI	Randomised clinical trial	VISA-P, 8 questions assessing pain, function, ability to participate in sports- completed weekly , Isokinetic strength tests, Functional tests:Five repetition counter movement jumps, and One- leg triple hop test	VISA-P- both groups significantly improved during treatment period of 12 weeks.	Small study with only athletes Validity and reliability and reproducibility not accounted for Not clear if patients blinded or if investigators blinded Poor presentation of P values. Lack of use of SD and mean. Looked at short term effects only (3 months)
Malliaras P, Barton CJ, Reeves ND and Langberg H 2013 UK	Achilles and patellar tendinopathy	Systematic review 10 studies comparing loading programmes and 28 studies investigating mechanisms	VAS, VISA-pP , return to sport	Eccentric loading;Moderate evidence for 2 high quality studies which showed improved clinical outcomes are associated with (i) increased extensor torque, (ii) increased leg press 1 rep max (iii) increased quadriceps muscle cross sectional area (CSA), Conflicting evidence that eccentric loading is superior to other loading programmes. There is limited evidence that VISA improvement is greater following eccentric loading compared with concentric loading and Stanish and Curwin loading. Eccentric loading is equivalent on VISA outcomes and inferior on patient satisfaction compared to Heavy strength resistance loading.	No true data analysis of studies, therefore difficult to draw accurate conclusions. Most of the article is beyond scope of Best bets question. Limited homogeneity of studies. Limited and conflicting evidence that clinical outcomes are superior with eccentric loading compared with other loading programme. There is need for further good quality studies comparing loading programmes

Comment(s)

The systematic reviews in this review were limited by their inability to perform meta-analysis due to study heterogeneity.

Clinical Bottom Line

There is currently strong evidence to support eccentric training on a decline board in the treatment of patellar tendinopathy, with consistent favourable changes in VAS and VISA-P. There is one study to support heavy slow resistance training as having similar outcomes to eccentric training in the treatment of patellar tendinopathy. A new area of interesting research from Rio et al., (2015) is high MVC isometric exercises to bring about immediate pain relief (45 minutes) and modulation of corticospinal changes in athletes with patellar tendon pain who are already perfoming a lot of heavy load. However this study is limited by sample size and may be difficult to transfer to the clinical setting fully.

References

1. Young MA, Cook JL, Purdam CR, Kiss ZS and Alfredson H Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol from patellar tendinopathy in volleyball players British Journal of sports medicine 2005; 102-105
2. Visnes H and 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; 217-223
3. Jonsson P and Alfredson H Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomised study British Journal of Sports Medicine 2005; 847-850
4. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M and Magnuss Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy Scandanavian journal of medicine and science in sports 2009; 790-802
5. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ and Cook J Isometric exercises induces analgesia and reduces inhibition in patella tendinopathy British Journal of Sports Medicine 2015; 1277-1283
6. Larsson ME, Käll I and Nilsson-Helander K Treatment of patella tendinopathy- a systematic review of randomized controlled trials Knee Surgery Sports Traumatol Arthroscopy journal 2012;1632-1646
7. Frohm A, Saartok T, Halvorsen K and Renstrom P Eccentric treatment for patellar tendinoapthy: a prospective randomised short-term pilot study of two rehabilitation protocols British Journal of Sports medicine 2007;
8. Malliaras P, Barton CJ, Reeves ND and Langberg H Achilles and Patellar Tendinopathy Loading Programmes Sport medicine journal 2013