Exercise for patellar tendinopathy – should we be withdrawing athletes from sport? ~ Dr. Alex Scott RPT, PhD Department of Physical Therapy, UBC

Scott-A-post130226Treating athletes with an overuse injury who continue to compete is challenging, particularly for athletes with resistant injuries like patellar tendinopathy.

A recommended first-line treatment for patellar tendinopathy involves a period of relative rest, biomechanical assessment and intervention, and prescription of therapeutic exercise (such as slow, controlled, heavy resistance training or eccentric training) to stimulate tissue healing.  Attention to detail by the physiotherapist is key – the function of the entire kinetic chain including the spine and core stabilizers should be assessed and treated as necessary. The type and amount of exercise must be tailored to the individual presentation, including location and severity of pathology.

Should the athlete continue to play while this treatment is initiated? This question is likely to be at the tip of the patient’s (and coach’s or parents’) tongue. Let’s have a look at the clinical research evidence – there are several possible approaches which have RCT support.

1) Allow the patient to continue to compete at whatever level they can tolerate, while prescribing additional therapeutic exercise like decline squats, which are performed in between games and training sessions (Young et al).

2) Allow the patient to continue to compete and train as long as their symptoms during and after activity don’t exceed a certain threshold (a visual analogue scale of 3/10), while prescribing additional therapeutic exercise such as heavy concentric-eccentric resistance training (Kongsgaard et al).

3) Require the patient to desist from competition and regular training for a certain period of time, (e.g. 4 weeks), while receiving a generalized stretch and strength program plus adjunct medical treatments (Vetrano et al ).

Recently, the question of whether or not athletes should be withdrawn from sport was subjected to a “systematic review” (Saithna et al 2012). I use quotation marks, because upon closer reading the review does not actually use a recognizable systematic review methodology – for a discussion of levels of evidence, see B&K chapter 3. This blogger is going out on a distal limb to voice his view that a systematic review should not be conducted if there is no evidence capable of answering the question posed.

However, the authors of this recent review do make an important point – withdrawing an athlete from sport can have negative psychological and physiological consequences, so the question deserves careful consideration.

There another type of evidence – clinical observation – which would suggest that some tendons do respond well to a period of relative unloading, particularly if acute pain and swelling has developed in response to a sudden increase in loading. B&K has a good discussion of the “continuum model” for tendinopathy management, which presents the concept that relevant rest is sometimes the treatment of choice, and that the volume of loading on the tendon, including competition, training, and additional therapeutic exercises, must be carefully balanced and individualized. This is a finer level of detail which is not typically captured in RCTs or meta analyses, but which is vital to achieving good clinical results.

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Saithna AGogna RBaraza N, et al. Eccentric Exercise Protocols for Patella Tendinopathy: Should we Really be Withdrawing Athletes from Sport? A Systematic Review. Open Orthop J. 2012;6:553-7. doi: 10.2174/1874325001206010553. Epub 2012 Nov 30.

Young MACook JLPurdam CRKiss ZSAlfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med. 2005 Feb;39(2):102-5.

Kongsgaard MKovanen VAagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009 Dec;19(6):790-802. doi: 10.1111/j.1600-0838.2009.00949.x. Epub 2009 May 28.

Vetrano M, Castorina A, Vulpiani MC, et al. Platelet-Rich Plasma Versus Focused Shock Waves in the Treatment of Jumper’s Knee in Athletes. Am J Sports Med. 2013 Feb 13. [Epub ahead of print]



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