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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2021 Patellar Tendinopathy: Eccentrics May Not Be The Way to Go! by Karen Napierala MS, AT, PT, CAFS CURRENT EVIDENCE “Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomized clinical trial. Breda SJ, et al. Br J Sports Med 2021; 55:501–509. “ (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Eccentric exercise has been the key form of exercise prescribed by physicians/surgeons and used by therapists and trainers during rehab for tendinopathy conditions. Breda et al in BJSM present important data that contradicts this reliance and focus on eccentrics. Instead their study demonstrated that a HEP based program of progressive loading/strengthening outperformed an eccentric based program in a RCT of patellar tendinopathy patients, 82% of which had failed prior care, in self report pain/function/sport questionnaire after 24 weeks and also showed a trend toward higher return to sport (43% vs 27%) . Despite concerns about generally low compliance with this HEP based treatment of independent exercise progression (40-49% compliance) and low overall return to sport rates after 6 months the study does still demonstrate that eccentric focused rehab approaches are not superior to progressive loading based approaches. The low compliance also suggests more formal care from a therapist is warranted since reliance on patients following a HEP progression without regular follow ups produced mediocre outcomes, however, this group was a mostly “failed care” group to begin with. Our experiences and successes with tendinopathy also suggest that kinetic chain biomechanics must be well understood and evaluated/addressed, that in-depth appreciation of subtle exercise adjustments for proper loading combined with control of symptoms, and the use of other treatment modalities such as Class IV laser all play an important role in effectively treating patellar tendinopathy. Meticulous appreciation for and attention to optimal ranges for training the extensor mechanism, for optimizing Quad recruitment while avoiding sx typical of traditional rehab exercises, and limiting recruitment of compensatory muscle groups during attempted strengthening are all key factors we see in failed PT/conservative care cases referred for advanced rehab. Background: Studies note that 45% of elite jumping athletes and up to 58% of those with physically demanding work/sports activities at some time experience patellar tendinopathy. The term tendinopathy has replaced the commonly referred “tendinitis” based on numerous studies showing histopathologic tissue changes and only minimal inflammatory cells in these cases. Anti inflammatories alone are thought to be not recommended. Research has demonstrated the effectiveness of eccentric overload to enhance tendon strength and recovery, however, is pain-provoking and especially a concern for in-season athletes. This study compared progressive tendon loading exercises (PTLE) with the eccentric exercise therapy (EET) over 24 wks on clinical outcome measures. Methods: Seventy-six patients (18-35 years old) who participated in sports at least 3/wk with diagnosed patellar tendinopathy based on local tenderness, structural changes on Doppler, and <80 score on the Victorian Institute of Sports Assessment for Patellar Tendons (VISA-P) were randomly assigned into the EET or the PTLE group for 24 weeks of an independent exercise program. Median symptom length prior to the study was 2 years. 82% had failed prior PT. The EET group was instructed to perform pain provoking single leg decline squat (eccentric only) on a 24 0slant board with body weight at 2/day x 12 weeks with a maximum pain level of 5/10 (VAS, visual analog scale). They progressed to loaded single leg squat and then to sports specific exercises over the next 12 weeks as able. The PTLE group started with isometric leg press at 60 0 or a body weight wall squat with 70% max voluntary contraction 45 seconds x 5 reps. They moved to isometrics plus isotonic leg press 4 x 6 reps the following day. Their maximum pain allowed was 3/10 on the VAS scale. Step ups or lunges were added on the isotonic day when able. They progressed to day three jumping, split squat jumps, box jumps with the isometric and isotonic exercise on day one and two, respectively. Finally, sports specific activities such as running, cutting, and their actual sports were slowly resumed. They maintained a < 3/10 pain level using the VAS and progressed as tolerated through this sequence over 24 weeks. Both groups were also assessed for open chain hamstring, gastrocnemius and quadriceps flexibility. They noted their WB squat dorsiflexion soleus length and had isometric hip abductors and quad strength measured. The program and the targeted flexibility / strength exercises were given to each of the participants via a pamphlet. Videos were included and the participants met at baseline, 12 weeks and 24 weeks for retesting. All exercise groups performed their programs independently of each other and of tester feedback. Findings: The primary outcome was the VISA-P questionnaire (100 point maximum as no pain, maximal function and unrestricted return to play). It was self -administered at baseline, 12 and 24 weeks. Secondary outcomes were the return to sports rate, exercise adherence (% of sessions registered) , and patient satisfaction. VISA-P score improved significantly from 56 to 84 at 24 wks in PTLE. And from 57 to 75 in the EET group. After 24 weeks 87% in the PTLE group (32 patients) and 77% in the EET group (23 patients) achieved the 13 point MCID or better. In the PTLE group 21% returned to the desired sports at preinjury level after 12 weeks and 43% after 24 weeks. In the EET group, only 7% after 12 weeks and 27% after 24 weeks returned to pre-injury levels. Percent of patients with an excellent satisfaction rating was 38% in PTLE and10% in EET. After 24 weeks and 23 patients in the EET group achieved the MCID (Visa score increased 13 points minimally. In the PTLE group, 21% (n=7) returned to the desired sports at preinjury level after 12 weeks and 43% (n=16) after 24 weeks. In the EET group, 7% (n=2) returned to the desired sports at preinjury level after 12 weeks and 27% (n=8) after 24 weeks. The VAS for pain related to tendon-specific exercises at 24 weeks was significantly lower in the PTLE group than in the EET group with an estimated mean of 2 vs 4 (adjusted mean between- group difference: 2 (95% CI 1 to 3); p=0.0 Author's Conclusion: In the largest clinical trial in patients with patellar tendinopathy (PT) 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. THE PEAK PERFORMANCE PERSPECTIVE The use of eccentric based strengthening exercises for tendinopathy has for some time now been accepted “best practices” in prescribing conservative care for these cases. Numerous prior studies had shown the efficacy of eccentrics,which usually includes an intentional pain-provoking aspect, especially with achilles tendinopathy. The challenge does remain, however, that most athletes who develop tendinopathy symptoms do so gradually and with a period of ‘working through symptoms” that eventually did not result in resolution but likely, in part, contributed to their “overuse” stresses. It can be difficult for providers and patients alike to have certainty over those levels of intentionally produced symptoms that are actually therapeutic. This study reminds us how common failed tendinopathy cases can be. Failed cases present a unique task for referring physicians who are charged with determining possibly why prior PT failed or what more thorough or advanced conservative care may be called for since surgical procedures here are the very last resort and rarely necessary. The participant’s limited/poor compliance and the low return to play rates do suggest that “keeping it simple” with easy-to-do home program recommendations is inadequate. ... The question must always be asked “What exactly was the actual cause of their tendinopathy?” While referring physicians generally are and should be less concerned with this question it is incumbent on therapists and athletic trainers to be not only concerned about this but equipped to test and assess in ways that give athletes confidence the right changes have been induced that will prevent recurrence upon return. Athletes often are confused that the entire team is jumping or cutting, yet only they or a few ever developed tendon symptoms. Very frequently both lower extremities are experiencing essentially the same bilateral or reciprocating stresses with a sport, making identification of the “overuse” more challenging and oftentimes uncertain or illogical, since the opposite knee tolerated the very same “overuse” without trouble. In other cases there are clear asymmetric loading patterns that occur such as in soccer kicking (plant leg and kick leg each) or basketball (layups) or high/long jumping. In all cases it is critical to discern any biomechanical factors such as leg length discrepancy that produce asymmetric loading. Other issues such as asymmetric anteversion, overpronation, loss of ankle dorsiflexion, hip extensor weakness all are examples of commonly seen contributing factors consistent with potential overloading of the patellar tendon/extensor mechanism. Oftentimes “protocol” driven mindsets or “one-size fits all” approaches may address gradual tissue loading and training but never end up in having addressed what may be the real underlying mechanism - leaving patients “treated” but never really rehabilitated. This study by Breda et al had 82% of the cases happened to be failed prior PT situations. This itself is cause for concern regarding traditional PT approaches. . The direct correlation according to this author is not known. Whether internal biomechanics, or external overload, the tendon needs to be restored to its full strength to handle the loads of the activity. Breda et al’s randomised controlled clinical trial showed the PTLE approach provided superior clinical outcomes compared with EET after 24 weeks follow-up. Additionally PTLE showed a trend towards a higher return to sports rate compared with EET (43% vs 27%) and that the exercises were significantly less painful to perform (VAS 2/10 vs 4/10). While this study itself is not enough to completely disregard all the prior evidence supporting eccentrics it does present some compelling evidence that even with an unsupervised independent home routine approach that progressive loading approaches do not require “eccentric only/emphasized” design to reduce symptoms and improve function. Since only 27 - 43% of the patients in either group returned to sport over the 6 month period, the overall perspective should not be that the treatment approach used was a success. Based on our experience with similar cases we would suggest that the treatment approach itself was inadequate, the limited compliance contributed to mediocre outcomes, and/or the protocol did not address predisposing factors adequately - although they did attempt to address this with the additional testing and exercises provided. We find regularly that alternative rehab methods that include triplanar strengthening, using emphasized eccentrics at a lower pain scale, and progressive loading similar to Breda et al’s approach and also Class IV laser use are important aspects of effective tendinopathy care. The lack of regular professional supervision in this study left patients in a decision making position regarding technique, general program advancement, and load progression that is normally done by or in conjunction with the rehab professional. Training was designed to be 3/week for PTLE and 2 / week for EET, but the groups left to their own showed a low rate of compliance with 7-8 of the people not completing the testing, and all participants averaging .9 mean sessions of training over the 24 weeks. All exercises were performed without the benefit of skilled and knowledgeable feedback. The exercise program especially for the PTLE group was quite specific and extensive. Clinically, to foster progressions of this nature to be not only within the pain scale limitations and also to be mechanically correct with no substitutions, professional guidance is necessary. A HEP only approach risks a patient choosing to progress too quickly out of impatience and yet for others too slowly out of fear. A limited number of secondary contributing factors were assessed, but more extensive biomechanical examination was lacking. Thus while several stretches and non-functional strengthening exercises were included, they were not given based on individual test findings for need, and were very limited in scope. Another shortcoming was the singular resistance band for exercise loading. It would not likely provide either customized loading for each participant nor proper loading over a span of 24 weeks to be considered proper training stimulus. The participants were pre and post tested on their flexibility and vertical jump height. From baseline to 24 weeks there was literally no change in strength or jumping ability. There was some significant pain with single leg squat test where PTLE went from pain of 4.8/10 to 1.5 after 24 weeks, and EET group reduced from 4.9/10 pain to 2.7. THE PEAK PERFORMANCE EXPERIENCE: John said: “ I am back to skating in practice with no pain the next day. I'm looking forward to really playing hard in games soon!” History: John was a hockey player who had R > L patellar tendinopathy. He had pain for > 6 months that limited play until he finally had to discontinue athletics. Symptoms limited walking, sitting, and stairs. Objective: See below. Objective: (*=pain) Initial Eval Re-Eval STJn WB Dorsiflexion 13 R/ 15 L 17 R / 20 L Single leg squat R 10 * / L 22 * R 55 / L 70 Step ups 8" Unable * 15 # low reach R/25 L 32 3" quad dom step down( eccentric ) Unable * 10 # front racked R/ 22 L / 35 B squat proper form Pronates, heel rise R, lumbar flexion** 25# front racked 16 reps Lateral lunge Unable * 15# low reach R 17 L 21 Single leg bal rotation hands on hips 15 sec Unable R 5 L 7 Forefoot varus R 10deg L 7deg Corrected with superfeet and wedge posting 4-6 deg forefoot 2-3 degrees rearfoot Key Findings: Limited ankle dorsiflexion combined with forefoot varus producing compensatory overpronation and tibial IR producing abnormal loading at knee/patellar tendons with squatting activity. Treatment: John began stretching soleus in STJ neutral for late stance gait mechanics authenticity along w functional strengthening combination using opposite foot anterior foot reaches. Gradually he was able to begin squats at 50 % BW and progress to single leg quad dominant step downs. He also obtained SuperFeet OTC orthotics which were posted in the clinic accordingly to produce improved function on WB testing. Eccentric slow lowering was incorporated here with 2-3/10 max pain during this phase. By dominating the hip and transverse plane to accomplish strengthening he was able to overload his muscles, and also load his patellar tendon in two planes for added strength while avoiding tendon pain. While the tendon is primarily a sagittal plane worker, by loading in transverse and frontal planes, the strengthening could be progressed faster - with increasing tensile loading capacity while remaining still pain-free. At the same time, the hip ER’s were facilitated using tubing in the transverse plane upright. Hip flexion was increased during the ER for more authentic skating stimulus. He then began speed training to stimulate fast twitch fibers and start impact loading needed for running in gym class and life. After 6 weeks: He was able to begin skating 15 minutes at a time painfree. Outcome: He continues to improve his strength and stability. He uses the posted OTC Superfeet in his shoes and skates. He is now practicing 30-45 minutes at near maximum and is ready to progress to game status. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com