Read on Twitter
*Results of a randomised clinical trial*:
Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy
#openaccess
https://bjsm.bmj.com/content/early/2020/11/19/bjsports-2020-103403.long
Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy
#openaccess
https://bjsm.bmj.com/content/early/2020/11/19/bjsports-2020-103403.long
@bmj_latest @BJSM_BMJ @rj_devos @HansZwerver @Oei_Edwin @ErasmusMC @SGK_RDAM @Sportzorg @Basketball_NED @3x3NL @Nevobo @VolleybalNL
Sponsered by: @NBA @GEHealthcare
Sponsered by: @NBA @GEHealthcare
Thread*
1/
Patellar tendinopathy is a common chronic tendon injury that affects as many as 45% of elite athletes in jumping sports like basketball and volleyball.
https://pubmed.ncbi.nlm.nih.gov/15722279/
1/
Patellar tendinopathy is a common chronic tendon injury that affects as many as 45% of elite athletes in jumping sports like basketball and volleyball.
https://pubmed.ncbi.nlm.nih.gov/15722279/
2/
Eccentric exercise therapy has strong evidence of effectiveness for patellar tendinopathy and is also supported in guidelines by the National Institute for Health and Care Excellence (NICE), London, UK.
https://bestbets.org/bets/bet.php?id=2873/
Eccentric exercise therapy has strong evidence of effectiveness for patellar tendinopathy and is also supported in guidelines by the National Institute for Health and Care Excellence (NICE), London, UK.
https://bestbets.org/bets/bet.php?id=2873/
3/
However, eccentric exercises are pain-provoking and the therapeutic effects on pain and functional outcome are debated when applied during the competitive season.
https://pubmed.ncbi.nlm.nih.gov/16003036/
However, eccentric exercises are pain-provoking and the therapeutic effects on pain and functional outcome are debated when applied during the competitive season.
https://pubmed.ncbi.nlm.nih.gov/16003036/
4/
Progressive tendon-loading exercises (PTLE) have been proposed as alternative exercise therapy for patellar tendinopathy, which are typically performed within the limits of acceptable pain.
https://pubmed.ncbi.nlm.nih.gov/26390269/
Progressive tendon-loading exercises (PTLE) have been proposed as alternative exercise therapy for patellar tendinopathy, which are typically performed within the limits of acceptable pain.
https://pubmed.ncbi.nlm.nih.gov/26390269/
5/
Progressive tendon-loading exercises consist of 4 consecutive stages: isometric (static), isotonic (dynamic), energy-storage (explosive) and sport-specific exercises. Progressive load is administered based on the individual pain response.
Progressive tendon-loading exercises consist of 4 consecutive stages: isometric (static), isotonic (dynamic), energy-storage (explosive) and sport-specific exercises. Progressive load is administered based on the individual pain response.
6/
To date, it is unknown how the effectiveness of progressive tendon-loading exercises (PTLE) compares to eccentric exercise therapy (EET).
To date, it is unknown how the effectiveness of progressive tendon-loading exercises (PTLE) compares to eccentric exercise therapy (EET).
7/
In this study, we compared effectiveness of progressive tendon-loading exercises (PTLE) to eccentric exercise therapy (EET) in 76 athletes aged 18-35 years with clinically diagnosed and ultrasound-confirmed patellar tendinopathy.
In this study, we compared effectiveness of progressive tendon-loading exercises (PTLE) to eccentric exercise therapy (EET) in 76 athletes aged 18-35 years with clinically diagnosed and ultrasound-confirmed patellar tendinopathy.
8/
The study population consisted of patients with chronic patellar tendinopathy (median symptom duration 2 years) and 42% had bilateral symptoms. Most patients (82%) underwent prior treatment for PT but failed to recover fully.
The study population consisted of patients with chronic patellar tendinopathy (median symptom duration 2 years) and 42% had bilateral symptoms. Most patients (82%) underwent prior treatment for PT but failed to recover fully.
9/
Patients were randomly assigned to progressive tendon-loading exercises (PTLE) within the limits of acceptable pain or pain-provoking eccentric exercise therapy (EET) during 24 weeks.
Patients were randomly assigned to progressive tendon-loading exercises (PTLE) within the limits of acceptable pain or pain-provoking eccentric exercise therapy (EET) during 24 weeks.
10/
The primary outcome was evaluated using the validated VISA-P questionnaire at baseline, 12 and 24 weeks follow up. A VISA-P score of 100 indicates no pain, maximum function and unrestricted ability to play sports.
https://pubmed.ncbi.nlm.nih.gov/19671174/
The primary outcome was evaluated using the validated VISA-P questionnaire at baseline, 12 and 24 weeks follow up. A VISA-P score of 100 indicates no pain, maximum function and unrestricted ability to play sports.
https://pubmed.ncbi.nlm.nih.gov/19671174/
11/
The VISA-P score improved significantly in both exercise groups. However, the improvement in the progressive tendon-loading exercise group (interventional treatment) was significantly better after 24 weeks.
The VISA-P score improved significantly in both exercise groups. However, the improvement in the progressive tendon-loading exercise group (interventional treatment) was significantly better after 24 weeks.
12/
The adherence to the exercise programmes (49% in EET group vs 40% in PTLE group) was not statistically different between both groups.
The adherence to the exercise programmes (49% in EET group vs 40% in PTLE group) was not statistically different between both groups.
13/
There was a similar patient satisfaction between both groups (83% in EET group vs 81% in PTLE group). There was a trend towards a higher return to sports rate in the PTLE-group compared with EET (43% vs 27%).
There was a similar patient satisfaction between both groups (83% in EET group vs 81% in PTLE group). There was a trend towards a higher return to sports rate in the PTLE-group compared with EET (43% vs 27%).
14/
Additionally, the pain as a result of the therapeutic exercises was significantly lower in the group performing progressive tendon-loading exercises (mean 0-10 VAS score 4 in the EET group vs 2 in the PTLE group).
Additionally, the pain as a result of the therapeutic exercises was significantly lower in the group performing progressive tendon-loading exercises (mean 0-10 VAS score 4 in the EET group vs 2 in the PTLE group).
15/
The improved performance of PTLE is important and clinically relevant as EET is commonly used in clinical practice and currently the recommended therapy in some guidelines (eg, NICE guidelines).
The improved performance of PTLE is important and clinically relevant as EET is commonly used in clinical practice and currently the recommended therapy in some guidelines (eg, NICE guidelines).
16/
This study emphasises the importance of exercise therapy for the conservative treatment of patients with patellar tendinopathy, even in patients with chronic symptoms and failure of conservative treatment.
This study emphasises the importance of exercise therapy for the conservative treatment of patients with patellar tendinopathy, even in patients with chronic symptoms and failure of conservative treatment.
17/
Main study caveats:
Still less than half of these recreational/competitive athletes returned to sports at preinjury level after performing PTLE for 24 weeks. There was no difference in patients achieving the predefined MCID of the VISA-P score.
Main study caveats:
Still less than half of these recreational/competitive athletes returned to sports at preinjury level after performing PTLE for 24 weeks. There was no difference in patients achieving the predefined MCID of the VISA-P score.
This implicates that there is room for improvement of the current unsupervised PTLE programme, for example, with guidance from a sports physiotherapist.
18/
In this largest clinical trial in patients with patellar tendinopathy to date, progressive tendon-loading exercises (PTLE) resulted in a clinically relevant benefit compared with pain-provoking eccentric exercise therapy (EET) after 24 weeks follow-up.
In this largest clinical trial in patients with patellar tendinopathy to date, progressive tendon-loading exercises (PTLE) resulted in a clinically relevant benefit compared with pain-provoking eccentric exercise therapy (EET) after 24 weeks follow-up.
Therefore, PTLE should be regarded as standard initial care for the treatment of patients with PT.
See this website for movies of the basic exercises:
https://www.erasmusmc.nl/en/research/projects/jumper-project
See this website for movies of the basic exercises:
https://www.erasmusmc.nl/en/research/projects/jumper-project
Please see the Supplementary Appendix in the BJSM publication for the full exercise program and patient brochures.
https://bjsm.bmj.com/content/bjsports/early/2020/12/23/bjsports-2020-103403.full.pdf
https://bjsm.bmj.com/content/bjsports/early/2020/12/23/bjsports-2020-103403.full.pdf
