Part of the BJSM’s Young Clinician Blog Series – to contribute please email bjsmblog@bmj.com

Patella tendinopathy (PT) is one of the most debilitating/long term pathologies in running and jumping sports. (1, 2) Despite much controversy about the optimal treatment of tendinopathy, in my 3 years of practice I have finally got to the conclusion that it is possible to make tendons pain free and able to transmit load appropriately. Three strategies in particular have completely transformed my approach, and some of the outcomes for my patients:

• listening to my patient’s pain and feelings (before and after my sessions)
• appropriate load management
• isometric exercise

It is reassuring that in the majority of cases we can make such a difficult pathology fairly simple to treat.

For many years I have heard of practitioners treating patella tendinopathy with eccentric contractions. This straight-forward approach has excessively limited my critical thinking, to the point that I was focusing too much on the type of contraction rather than making appropriate considerations on load progression and management.

A recently published paper has finally clarified this controversial debate by proving the importance of load management in patella tendinopathies. (2)

This paper was an RCT (randomised control trial) comparing eccentric exercise therapy with progressive tendon loading exercises. Results were based on the clinical outcome after 24 weeks in patients with patella tendinopathy. The primary outcome was the VISA-P injury specific questionnaire, which  incorporates pain measures, function and return to sport ability. The secondary outcomes were return to sport rate, patient satisfaction and exercise adherence. (2)

What were the findings?

• Progressive loading (pain less than 3/10) results in higher satisfaction and superior clinical outcomes for return-to-sport than eccentric loading at 24weeks follow up
• Isometrics help to reduce tendon pain (Is this the reason why progressive loading works better than eccentric exercise therapy?) (1, 6, 7)
• Pain-provoking eccentrics, are effective and supported by NICE and NHI. However, they are a high load for the tendon therefore they need to be appropriately introduced
• Energy storing exercises, including plyometrics and sport specific movements are fundamental before going back to sport.

How did this research relate to my patients and clinical practice?

• Very easy to apply with clear load progression example
• It is important to have compliant patients to apply this piece of evidence
• I did notice that keeping the pain level as close as possible to zero was a successful strategy in avoiding any flare up the following day
• I have found it fundamentally important to use the VAS pain scale the day after my session – IF THE PAIN WAS INCREASED THE DAY AFTER THE SESSION, THIS MEANT THE LOAD WAS TOO HIGH
• Supervising patients while they perform the exercises leads to a superior effect; when unsupervised, the exercises are usually done with reduced quality
• The programme needs to be suited for the patient’s case and eventually it needs to be modified depending on the pain level

In conclusion, based on recent evidence and my clinical experiences, this is  my clinical reasoning when treating a patellar tendinopathy patient

• Load management is essential. Starting the rehabilitation with a very heavy eccentric programme could be aggravating for the tendon
• Isometric type of loading is key to reduce the pain. Its efficacy creates a window of opportunity to proceed with a pain free rehabilitation programme (6, 7)
• Muscle tightness often leads to an incapacity of the muscle itself to produce its maximal force; thus, the tendon will be limited in transferring force from the muscle to the bone. This might increase the stress through the tendon if we also try to stretch the muscle in order to release it. We do need to remember that tendons hate compression! In fact, foam rolling instead is a great solution in order to obtain muscle relaxation while avoiding tendon compression (5)
• Most of my patients with patella tendinopathy present with weak glutes! In most of the cases, they display a knee dominant pattern characterised by high load going through the knee joint and patella tendon; it is in fact important to involve glutes strengthening in the rehabilitation plan (3)
• Always ask for the pain response the day after your session, you do not want them to have more pain than before
• It takes time to make a tendon better! Be patient and listen to your patients
• If the load is increased and the tendon becomes suddenly painful, it is suggested to step back a little in order to reintroduce isometrics prior to reloading the tendon again.

Author & Affiliation

Marin Vittoria

Physiotherapist at Isokinetic Medical Centre, London

Twitter: @vittoriamarin

Linkedin: Vittoria Marin

References

1. Ark M, Cook J, Docking I, 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 2015
2. Breda S, Oei E, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. BJSM 2021;55:501–509.
3. Buckthorpe M, Stride M, Della Villa F, ASSESSING AND TREATING GLUTEUS MAXIMUS WEAKNESS – A CLINICAL COMMENTARY The International Journal of Sports Physical Therapy 2019;14(4):655-669.
4. Cook J, Purdam C R, Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy BJSM 2009;43:409–416.
5. Cook J, Purdam C, Is compressive load a factor in the development of tendinopathy? BJSM 2012;46:163–168.
6. Rio E, Kidgell D, Purdam C, et al Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy BJSM 2015;49:1277–1283.
7. Cook J, Rio E, Purdam C R, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? BJSM 2016;50:1187–1191.