Hindawi Publishing Corporation

International Journal of Photoenergy

Volume 2014, Article ID 785386, 6 pages
http://dx.doi.org/10.1155/2014/785386

Research Article
Effects of Low-Level Laser Therapy and Eccentric Exercises in
the Treatment of Patellar Tendinopathy

Xiao-Guang Liu,1 Lin Cheng,1,2 and Ji-Mei Song1

1
Laboratory of Laser Sports Medicine, South China Normal University, Guangzhou 510006, China
2
Sichuan University for Nationalities, Sichuan 626001, China

Correspondence should be addressed to Xiao-Guang Liu; tygx@jnu.edu.cn

Received 18 April 2014; Revised 4 July 2014; Accepted 7 July 2014; Published 16 July 2014

Academic Editor: Timon Cheng-Yi Liu

Copyright © 2014 Xiao-Guang Liu et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The study aims to investigate if low-level laser therapy (LLLT) combined with eccentric exercises could more effectively treat patellar
tendinopathy than LLLT alone and eccentric exercises alone. Twenty-one patients with patellar tendinopathy were randomized to
three groups: laser alone, exercise alone, or laser plus exercise, with seven in each group. Laser irradiations were administered at the
inferior pole of the patella and the two acupoints of Extra 36 (Xiyan) with the intensity of 1592 mW/cm2 . Eccentric training program
consisted of three sets of 15 repetitions of unilateral squat on level ground. All patients received six treatments per week for four
weeks. Knee pain and function and quadriceps muscle strength and endurance were evaluated at baseline and the end of treatment.
After the 4-week intervention, all groups showed significant improvements in all the outcomes (𝑃 < 0.01). The laser + exercise group
had significantly greater improvements in all the outcomes than the other two groups (𝑃 < 0.05), except nonsignificant difference
in pain relief between the laser + exercise group and the laser group. In conclusion, LLLT combined with eccentric exercises is
superior to LLLT alone and eccentric exercises alone to reduce pain and improve function in patients with patellar tendinopathy.

1. Introduction tendinopathy [4, 7]. However, eccentric training intervention

needs a fairly long period and often induces some transient
Patellar tendinopathy is an overuse injury of the patellar discomfort and pain. To increase efficacy and reduce exercise-
tendon and most prevalent in sports involving some form induced pain, some adjunctive interventions have been added
of jumping, such as volleyball, basketball, soccer, and ath- to eccentric training for treating patellar tendinopathy. Dim-
letics. Patients with patellar tendinopathy clinically man- itrios et al. [8] have shown that eccentric training and static
ifested activity-related, anterior knee pain associated with stretching exercises produced a larger effect than eccentric
focal patellar-tendon tenderness [1, 2]. Histopathological and training alone in the treatment of patellar tendinopathy. In
biochemical evidences indicate that patellar tendinopathy is a clinical trial to treat patellar tendinopathy by Cannell et
mainly due to collagen fiber degeneration and inflammation al. [9], cryotherapy was used to reduce pain of the patellar
plays a minor role in its pathophysiology [3]. There are many tendon after eccentric drop squats.
treatment methods for patellar tendinopathy, including anti- Low-level laser therapy (LLLT) has been widely applied in
inflammatory drugs, massage, eccentric training, low-level the field of sports medicine. LLLT can exert effects of reducing
laser, ultrasound, surgery, and other modalities [3, 4]. How- inflammation and pain and promoting tissues regeneration in
ever, no ideal treatment has emerged for the management of the treatment of soft tissue injuries [10–12]. Bjordal et al. [13]
patellar tendinopathy. and Tumilty et al. [14] have reviewed LLLT for tendinopathy
Eccentric training has proven to be a useful treatment and have founded that LLLT can potentially be effective in
for patellar tendinopathy in a number of randomized con- treating tendinopathy when recommended dosages are used.
trolled trials [5, 6]. Researchers have recommended eccentric Stergioulas et al. [15] have shown that LLLT can accelerate
training as an important conservative treatment for patellar clinical recovery from Achilles tendinopathy when added to
2 International Journal of Photoenergy

an eccentric training regimen. However, it remains unclear 2.3. Eccentric Exercise Program. The eccentric training was
whether LLLT can bring about additional benefits to eccentric the same for the exercise group and the laser + exercise
training in the treatment of patellar tendinopathy. group. As eccentric exercises, participants carried out three
In the current study, we conducted a randomized con- sets of 15 repetitions of unilateral squat on a flat floor.
trolled trial to investigate if LLLT combined with eccentric The squat was performed at a slow speed of 30 counts
exercises could more effectively treat patients with patellar in 10 seconds at every treatment session [8], following an
tendinopathy than LLLT alone and eccentric exercises alone. audio file. As they moved from the standing to the squat
position, the quadriceps muscle and patellar tendon by
inference were loaded eccentrically; no following concentric
2. Materials and Methods loading was done, as the noninjured leg was used to get
The study protocol was approved by the Ethics Committee of back to the start position. At the beginning the load con-
the Faculty of South China Normal University, Guangzhou, sisted of the body weight and participants were standing
China. Written informed consent was obtained from each with all their body weight on the injured leg. The load
participant prior to the start of treatment. was increased by 5 kg per week in a backpack. Between
each set there was a one-minute rest. After the eccentric
training, double lean-back quadriceps stretch was performed
2.1. Subjects and Groups. Twenty-one patients with patellar as described by Walker [16]. Each stretch lasted one minute.
tendinopathy aged 18–23 years were enrolled in this study. Each training session was to be completed once daily, six
All patients were male undergraduate students studying at times per week, for four weeks. The subjects in the laser +
School of Physical Education and Sports Science of South exercise group received the laser treatment after each training
China Normal University. The study was conducted at the session.
Laboratory of Laser Sports Medicine of South China Normal
University in Guangzhou in April and May 2013.
The selection criteria for the study were the following 2.4. Outcome Measures. Perceived pain, functional capacity
[1–3]: of knee, and strength and endurance of the quadriceps muscle
were evaluated at baseline and the end of treatment.
(i) unilateral painful activity-related symptoms from the Pain intensity was quantified on a 100 mm visual ana-
patellar tendon region for at least three months; logue scale (VAS). A modified Victorian Institute of Sport
(ii) tenderness with palpation over the inferior pole of the Assessment (VISA) questionnaire was used to evaluate
patella; the functional capacity of knee in patients with patellar
tendinopathy, which consisted of ten items to cover walk-
(iii) no history of trauma to the knee; ing, squatting, standing, running, jumping, weight-bearing
(iv) unsuccessful conservative treatment before entering movement, training, and sports performance [17]. The range
the study, but not in the preceding one month; of scores was from 0 to 100 and the highest score represented
the maximum of functional capacity.
(v) no other current knee or lower extremity problems
Maximal isometric strength of the quadriceps muscle was
including chondromalacia, muscle strains, and hip or
ankle injuries; measured in a sitting position with both hip and knee at 90∘
with a leg extension ergometer (Model NH-3000W, Seoul,
(vi) positive decline squat test. This is a clinical diagnostic Korea). Relative muscle strength was calculated as maximal
test. isometric strength divided by body weight. Quadriceps mus-
cle endurance was evaluated using a single-leg wall squat test.
All patients were randomly divided into three groups: The test was conducted as described by Beck and Norling
(1) laser group receiving low-level laser treatment alone; [18]. During the test, subjects stood comfortably on both feet
(2) exercise group receiving eccentric exercise treatment with their back against av smooth wall. They then slid their
alone; (3) laser + exercise group receiving low-level laser and back down the wall until a 90∘ angle at the hip and knee was
eccentric exercise treatment, seven in each group.
achieved. One foot was lifted off the ground, at which time the
stop watch was started. The watch was stopped when subjects
2.2. Laser Irradiation Procedure. A GaAlAs laser (Model LD- had to return the raised foot to the ground. Measures were
1, Guangzhou, China) with a continuous output power of 0– taken in seconds.
500 mW and wavelength of 810 nm was used. The subjects
in the laser group and the laser + exercise group received
laser irradiations with the intensity of 1592 mW/cm2 (power: 2.5. Statistical Analysis. Data were expressed as mean ±
200 mW, beam diameter: 0.4 cm) at the inferior pole of the standard deviation. Differences between before and after
patella for 10 minutes and the two acupoints of Extra 36 treatment in each group were analyzed by paired 𝑡-tests.
(Xiyan) medial and lateral to the patellar tendon for 5 minutes Differences between group means were analyzed using one-
each acupoint, once daily, six times per week, for four weeks. way ANOVA with post hoc test. The statistical level of
The laser irradiations were applied directly to the skin of the significance was set at 𝑃 < 0.05. SPSS 17.0 statistical software
points with a perpendicular beam. was used for the statistical analysis.
International Journal of Photoenergy 3

Table 1: Changes in VAS score before and after treatment in all therapy groups.

Group Before treatment After treatment Change over time

Laser 67.86 ± 13.18 15.00 ± 13.54∗∗ 52.86 ± 12.20
Exercise 65.71 ± 15.39 19.29 ± 12.93∗∗ 46.43 ± 10.69
Laser + exercise 67.86 ± 12.20 5.00 ± 4.08∗∗ 62.86 ± 10.35#
Asterisks indicate significant differences from pretreatment (∗∗ 𝑃 < 0.01). Crosses indicate significant differences from the exercise group (# 𝑃 < 0.05).

Table 2: Changes in modified-VISA score before and after treatment in all therapy groups.

Group Before treatment After treatment Change over time

Laser 63.14 ± 9.75 88.14 ± 7.22∗∗ 25.00 ± 6.40
Exercise 67.00 ± 10.05 90.71 ± 7.85∗∗ 23.71 ± 5.83
Laser + exercise 58.86 ± 12.62 96.57 ± 2.07∗∗ 37.71 ± 11.77△#
Asterisks indicate significant differences from pretreatment (∗∗ 𝑃 < 0.01). Triangles indicate significant differences from the laser group (△ 𝑃 < 0.05). Crosses
indicate significant differences from the exercise group (# 𝑃 < 0.05).

3. Results significantly greater increment in quadriceps muscle strength

than the other two groups (𝑃 < 0.05). There was no
3.1. Pain. There were no significant differences for VAS score significant difference in quadriceps muscle strength after
at baseline between any groups (Table 1). After 4 weeks treatment between the laser group and the exercise group.
of intervention, all the groups exhibited significant pain
reductions (𝑃 < 0.01). The mean VAS scores in the laser
3.4. Quadriceps Muscle Endurance. There was no difference
group, the exercise group, and the laser + exercise group were
in quadriceps muscle endurance represented by the wall
reduced by 52.86, 46.43, and 62.86 points (percent reductions:
squat test time at baseline between any groups (Table 4).
77.9%, 70.1%, and 92.6%), respectively. The proportion of
After 4 weeks of intervention, all groups exhibited significant
patients who became pain free was 2/7 (28.6%) in the laser +
improvements in quadriceps muscle endurance (𝑃 < 0.01).
exercise group and 1/7 (14.3%) in the laser group within four
The mean times of wall squat test in the laser group, the
weeks. No patient became pain free in the exercise group.
exercise group, and the laser + exercise group were increased
The drop of VAS score in the laser + exercise group was
by 22.54, 23.14, and 40.97 seconds (percentage increment:
significantly greater than in the exercise group. There was no
85.0%, 84.7%, and 149.0%), respectively. The laser + exercise
significant difference for VAS score after treatment between
group had a significantly greater improvement in quadriceps
the laser group and the exercise group.
muscle endurance than the other two groups (𝑃 < 0.05).
There was no significant difference in quadriceps muscle
3.2. Functional Capacity. There was no difference for mod- endurance after treatment between the laser group and the
ified-VISA score of knee function at baseline between any exercise group.
groups (Table 2). After 4 weeks of intervention, all groups
exhibited significant improvements in functional capacity of
knee (𝑃 < 0.01). The mean modified-VISA scores in the
4. Discussion
laser group, the exercise group, and the laser + exercise group This randomized controlled study demonstrates that LLLT
were increased by 25.00, 23.71, and 37.71 points (percentage combined with eccentric training can produce greater
increment: 39.6%, 35.4%, and 64.1%), respectively. The laser + improvements in knee pain and function and quadriceps
exercise group showed a significantly greater improvement muscle strength and endurance for patients with patellar
in functional capacity of knee than the other two groups tendinopathy than LLLT alone and eccentric training alone.
(𝑃 < 0.05). There was no significant difference in functional VAS score and VISA-P score have been widely used in
capacity of knee after treatment between the laser group and orthopedic and sports injury investigations [17, 19, 20]. In this
the exercise group. study, pain and function in patients with patellar tendinopa-
thy were evaluated using VAS and modified VISA-P question-
3.3. Quadriceps Muscle Strength. There was no difference for naire, respectively. LLLT and eccentric exercises reduced pain
relative quadriceps muscle strength at baseline between any by 77.9% and 70.1% and increased the questionnaire score by
groups (Table 3). After 4 weeks of intervention, all groups 39.6% and 35.4%, respectively, over the 4-week intervention.
exhibited significant improvements in quadriceps muscle Although there was no significant difference, LLLT was
strength (𝑃 < 0.01). The mean relative quadriceps muscle more effective for pain relief than eccentric exercises in the
strengths in the laser group, the exercise group, and the treatment of patellar tendinopathy. The combination of LLLT
laser + exercise group were increased by 0.16, 0.19, and and eccentric exercises provided a pain reduction by 92.6%
0.31 kg/kg body weight (percentage increment: 42.1%, 50.0%, and a function score increment by 64.1% over the treatment
and 70.5%), respectively. The laser + exercise group had a period. The results indicated that LLLT can increase effects of
4 International Journal of Photoenergy

Table 3: Changes in relative quadriceps muscle strength before and after treatment in all therapy groups.

Group Before treatment After treatment Change over time

Laser 0.38 ± 0.04 0.54 ± 0.06∗∗ 0.16 ± 0.08
Exercise 0.38 ± 0.10 0.57 ± 0.12∗∗ 0.19 ± 0.09
Laser + exercise 0.44 ± 0.14 0.75 ± 0.10∗∗ 0.31 ± 0.10△#
Values are expressed in kg/kg body weight. Asterisks indicate significant differences from pretreatment (∗∗ 𝑃 < 0.01). Triangles indicate significant differences
from the laser group (△ 𝑃 < 0.05). Crosses indicate significant differences from the exercise group (# 𝑃 < 0.05).

Table 4: Changes in wall squat test time before and after treatment in all therapy groups.

Group Before treatment After treatment Change over time

Laser 26.53 ± 6.79 49.07 ± 13.19∗∗ 22.54 ± 14.74
Exercise 27.33 ± 7.06 50.47 ± 10.98∗∗ 23.14 ± 12.67
Laser + exercise 27.44 ± 12.65 68.41 ± 23.92∗∗ 40.97 ± 12.63△#
Values are expressed in seconds. Asterisks indicate significant differences from pretreatment (∗∗ 𝑃 < 0.01). Triangles indicate significant differences from the
laser group (△ 𝑃 < 0.05). Crosses indicate significant differences from the exercise group (# 𝑃 < 0.05).

eccentric exercises on pain relief and functional improvement can reduce peritendinous prostaglandin E2 (PGE2) concen-
of knee in the treatment of patellar tendinopathy. trations in activated Achilles tendinitis. Therefore, LLLT may
Single-leg wall squat test is a simple isometric strength reduce pain in patients with tendinopathy through modu-
test to assess quadriceps muscle endurance and has been lating inflammation. On the other hand, the biostimulatory
shown to be reliable and valid in physical fitness assess- effects of LLLT on collagen fibers synthesis may be respon-
ment [18, 21]. In this study, quadriceps muscle endurance sible for the muscle strength improvement of patients with
in patients with patellar tendinopathy was measured using tendinopathy, because Reddy et al. [30] have shown that LLLT
the functional test, while quadriceps muscle strength was can increase collagen production in healing rabbit Achilles
measured using the leg extension ergometer. With respect tendon. It is well known that the therapeutic effect of LLLT is
to quadriceps muscle endurance, LLLT and eccentric exer- dose-dependent [13, 31]. Bjordal et al. [13] have recommended
cises increased the squat test time after treatment by 85.0% that power densities of LLLT for Achilles, patellar, and elbow
and 84.7%, respectively. With respect to quadriceps muscle tendinopathies be between 2 and 100 mW/cm2 . The results
strength, LLLT and eccentric exercises increased the rela- of LLLT trials for tendinopathies with the recommended
tive strength after treatment by 42.1% and 50.0%, respec- power densities seem to be consistently positive [15, 27,
tively. Therefore, eccentric exercises seem more effective 32]. Nonsignificant effects of LLLT have been observed in
for strength improvement than LLLT in the treatment of clinical trials for treating elbow tendinopathy with power
patellar tendinopathy. After the four weeks of treatment, densities between 100 and 500 mW/cm2 [33, 34]. However,
LLLT combined with eccentric exercises increased the squat LLLT with power densities above 1 W/cm2 has shown pos-
test time by 149.0% and the relative quadriceps muscle itive effects on reducing exercise-induced muscle damage
strength by 70.5%, with greater efficacies than LLLT alone and and fatigue in some randomized controlled studies [35–
exercise alone. The results indicated that LLLT can increase 37]. Our results showed that LLLT with an 810 nm GaAlAs
effects of eccentric exercises on strength and endurance of the laser at 1592 mW/cm2 was significantly effective in patients
quadriceps muscle in the treatment of patellar tendinopathy. with patellar tendinopathy. Of course, further researches are
There are some factors influencing efficacy of eccen- needed to identify the optimal intensity and dose of LLLT in
tric exercise for tendinopathy, including eccentric exercise the treatment of patellar tendinopathy.
protocol, sports training during the treatment period, and
subject’s compliance. Some authors advocated that eccentric
exercises be performed at a slow speed with mild pain [8, 5. Conclusion
22, 23]. In contrast, other authors have found exercising
Low-level laser therapy combined with eccentric exercises
without induced pain to be beneficial to healing [24, 25]. This
is superior to low-level laser therapy alone and eccentric
study has adopted the eccentric exercise program at a slow
exercises alone to reduce pain and improve function in
speed without pain and has obtained good results. To avoid
patients with patellar tendinopathy. It is suggested that low-
painful sports activities is crucial for tendinopathy treatment,
level laser therapy can be used as an important adjunct to
because it has been reported that eccentric training is not
eccentric exercises in the treatment of tendinopathies.
effective for patellar tendinopathy in volleyball players during
the competitive season [26].
In accordance with our results, previous studies have Conflict of Interests
shown that LLLT could exert effects on pain relief and
function improvement in the treatment of tendinopathies The authors declare that there is no conflict of interests
[15, 27–29]. Bjordal et al. [27] have demonstrated that LLLT regarding the publication of this paper.
International Journal of Photoenergy 5

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