COMPARATIVE STUDY OF TWO PROTOCOLS OF LOCOMOTOR APPARATUS IN

EXERCISE AND SPORTS

ECCENTRIC EXERCISE ON KNEE PAIN AND FUNCTION

IN ATHLETES WITH PATELLAR TENDINOPATHY:
RANDOMIZED CONTROLLED STUDY Original Article

Ronaldo Alves da Cunha1 ABSTRACT

Andreia Natacha Dias1
Marcelo Bannwart Santos1 Introduction: The eccentric squat on a slope has been proved effective in conservative treatment
Alexandre Dias Lopes2 of patellar tendinopathy, especially in the athletic population. However, several aspects such as
intensity and pain during therapy still differ among authors. Objectives: To compare the effective-
1. Center of Sports Traumato- ness of two protocols of eccentric exercise (performed with and without pain), in the improvement
Orthopedics (CETE) of the Federal of knee function and pain intensity in athletes with patellar tendinopathy. Methods: 7 athletes
University of São Paulo (Unifesp),
of both genders with diagnosis of patellar tendinopathy were selected and randomly assigned
São Paulo, SP, Brazil.
2. Master’s Program in Physiotherapy
to two treatment groups. The first group of volunteers performed eccentric squat exercises on a
of the University São Paulo City slope with pain in the patellar tendon. The second group of volunteers was instructed to perform
(UNICID), São Paulo, SP, Brazil. the same exercise, but without presenting pain in the patellar tendon during performance. The
treatment lasted 12 weeks and the evaluation of pain and function was performed by the VISA-P
Mailing address: and VAS before starting treatment, at eight weeks of intervention, and at treatment completion.
Rua Santa Clara, 215
Results: There was improvement in both groups when results of evaluations carried out after eight
12900-470 – Centro
Bragança Paulista, SP, Brasil
and 12 weeks of beginning of the treatment were compared with the initial evaluation; however,
E-mail: ronaldoalvesdacunha@ no significant difference between the group that performed exercise with pain and the group
yahoo.com.br that performed exercises without pain was found. Analysis of the probability of obtaining clinical
improvement for VISA and VAS scores at eight and 12 weeks, there was no difference between
the two groups. Conclusion: A program of eccentric exercise on an inclined plane using squat,
performed with or without the presence of pain, was effective in improving pain and function in
athletes with patellar tendinopathy.

Keywords: patellar tendon, rehabilitation, sports.

INTRODUCTION esis that there is an inflammatory process originating pain11. The

The patellar tendinopathy (PT) is an overload injury, common alterations observed in the region close to the tendon were sug-
in elite athletes1, being much more frequent and recurrent in gested as a biomechanical adaptation hypothesis to the com-
sports involving jumps2. The prevalence of unilateral and bilateral pression forces where the peripheral tissues would be respon-
PT is different between genders; bilateral tendinopathy is twice sible for pain, since they are not adapted and would stimulate
commonly men than in women; however, unilateral tendinopa- nociceptors12. There is also a biochemical model which considers
thy presents equivalent prevalence3. the alterations of chemical substances asthe cause for pain10.
Firstly described by Blazina et al.in 19734, it still presents an ob- The difficulty in the PT treatment has been described by some
scure etiology. In the literature, there is are two hypotheses about authors2,9, and there is not a gold standard for its treatment2,13.
the tendon injury: a mechanical and a vascular theory, but the Many interventions have been used, such as rest, alteration in
two are not mutually exclusive5. In the mechanical theory, great the lifestyle, weight reduction, medication, surgery and specific
part of injuries on the tendon is related to the microtrauma of skills, such as physiotherapy and physical exercises14. Therapeu-
repetition, frequently described as overuse disease6. Many tendon tic exercises recommended as a way of decreasing pain and
injuries are also associated with the reduced vascular perfusion improving function have proved their efficiency through sys-
on the tendons7. Many theories on the circulation decrease have tematic reviews15.
been described; however, in contradiction to this theory, chronic Performance of eccentric exercises (EE) is accepted as an
tendon´s injury many times present increase in vascularization8. important part of the conservative treatment2,16, and the squat
Studies with ultrasound have shown increase in vascularization exercise performed on a slope is one of the most recommended
in the areas with structural alteration1,7,9. Nevertheless, the same exercises for PT17,18. The efficiency of the EE has been demon-
alterations are seen in asymptomatic individuals8. strated19; however, different explanations are proposed to eluci-
The pain origin in PT is obscure10. Microdialysis studies ob- date these good results10,20.
served the absence of inflammatory cells discarding the hypoth- The concept of eccentric training in the tendon rehabilitation

Rev Bras Med Esporte – Vol. 18, No 3 – Mai/Jun, 2012 167

was firstly proposed by Stanish et al.21, and has become popu- did not cause alteration in the exercise performance standard.
lar afterwards9. Nevertheless, there is divergence among these The WP subjects performed the exercise without causing any
authors: while some recommend that the patients perform ec- discomfort or pain. When the subjects from the WP group, even
centric squat exercise without pain, others suggest that it should without load addition, presented pain during the exercise, they
be performed even in the presence of moderate or intense pain16. were told to rest the upper limbs on a bar with the purpose to
The lack of consensus about which would be the best way to decrease overload on the patellar tendon.
perform the EE protocol (exercise performance with or without
pain), justifies the performance of controlled and randomized Evaluations
studies comparing these two kinds of intervention. The subjects of the two groups were evaluated in three mo-
The present study had as main aim to compare the efficiency ments: an initial evaluation (pre-treatment), which consisted in
of two EE protocols, one performed without pain and the other the application of specific questionnaire to evaluate the knee
with pain, in the improvement of the knee function and pain function with athletes with PT; VISA-P (Victorian Institute of Sport
intensity in athletes with PT. Assessment – Patellar)22; and the visual analog scale (VAS), with the
aim to measure the pain intensity caused by the PT on the knee
METHOD 23
. Two other evaluations were done after eight and 12 weeks
This research is a random controlled and prospective study, from the beginning of the treatment. The application of the VISA-
in which subjects were selected by medical recommendation P questionnaire and the VAS for pain was filled out with not any
provided to the Physiotherapy Sector of the Center of Sports intervention from the evaluator. It is worth mentioning that in the
Traumato-Orthopedics (CETE) of the Federal University of São evaluations through the VISA-P questionnaire, higher final values
Paulo (Unifesp), with PT diagnosis. represent better therapeutic result, while in the VAS evaluations
Individuals of both genders, aged over 18 years, who prac- higher final values represent worse therapeutic results.
ticed any sport activity, with medical PT diagnosis guided by
ultrasound exam (US) and/or nuclear magnetic resonance (NMR) STATISTICAL ANALYSIS
were included. The participants who underwent through a sur- A mean comparison test was used to evaluate the differences
gery on the knee in the last 12 months, made use of corticoste- between groups before the beginning of the intervention. The
roid injections on the patellar tendon, performed physiotherapy values obtained from the VISA-P and the VAS were compared
in the last month for knee problems or used medication such as between groups with analysis of variance with two repeated
hormonal or non-hormonal anti-inflammatory, were not included measures, for group and time interaction. The data analysis of
in the study 18. the two groups was performed with descriptive statistics with
All volunteers received clarification on the performed proce- one measure of central tendency (mean) and one measure of
dures and signed a Free and Clarified Consent Form carried out dispersion (standard deviation). The significance adopted was
according to the National Health Board, resolution 196/96. This α = 0.05. The statistical program used was the SPSS (Statistical
study was approved by the Ethics in Research Committee of the Package for Social Sciences), version 17.0 for data analysis.
Federal University of São Paulo. In order to determine the probability to obtain clinically useful
After inclusion of the athletes in the study, they were divided in two results, a specific analysis was performed to detect the lowest
groups. Pain Group (PG), which performed the EE with maximal toler- clinically important alteration in the VISA-P and VAS18.An altera-
ated pain, and the group named Without Pain (WP), which performed tion above 20 points in both scales was considered a clinically
the exercises without causing any discomfort or pain. All athletes were important alteration, probably reflecting a significant alteration
treated by treatment intention. The subjects were distributed in these in the clinical functional capacity 23. When alterations between
two groups through a random draw, with a sealed matte bag which 20 and 10 points occurred, they were considered moderate
had two pieces of paper inside it with the names of the two groups clinical alterations, and when alterations with values lower than
(PG or WP). The patients were blind since they were not informed there 10 points occurred inthe scales, they were considered without
were two groups in the study. clinical significance.

Intervention RESULTS
The PG and the WP groups were submitted to three physio- All the 17 participants (14 men and three women) completed
therapy sessions per week, during 12 weeks, with a total of 36 the eight-week evaluation and 14 (11 men and three women),
sessions. The patients of both groups performed squat exercises completed the 12-week follow-up evaluation (three individuals
up to 60° of knee flexionon a slope of 25°, in which the eccentric were excluded from the study due to lack of periodicity in the
part of the exercise was performed with the injured limb and treatment), as can be observed in figure 1. There was not statisti-
the concentric part with the contralateral limb. Three sets of 15 cally significant difference for any of the variables of the results
repetitions with a one-minute interval between each set were in the initial evaluations before the intervention. Table1 illustrates
performed. A squat instrument with a guided bar was used for the general characteristics of the population.
load increment in the exercise, which allowed the addition of Improvement in both groups was observed when the results
plates from five to five kilos. The load used in the EE varied for of the evaluations performed after eight and 12 weeks from the
each patient concerning the tolerance to pain group and the beginning of the treatment and the initial evaluation were com-
group he was in. The PG subjects were told to perform the ex- pared; however, there was no significant difference between the
ercise with the most pain as possible on the tendon, but which group which performed exercise with pain (PG) and the one
168 Rev Bras Med Esporte – Vol. 18, No 3 – Mai/Jun, 2012
which performed the exercises without pain (WP) (figure 2). In
the probability analysis of clinical improvement for the VISA and
VAS scores in eight and 12 weeks, there was not any difference 100
WP
between the two groups (figure 3). 90 PG

80

VISA-P score
70
Recruitment
(n=17) 60

50

Randomization 40

30
Baseline Evaluation 8th week 12th week
Pain Group Without Pain – WP
PG (n=10) (n-7) 60
WP
50 PG

Evaluation 8 weeks 40
Evaluation 8 weeks
(n=10)

VAS score
(n = 7) 30

20
2 excluded 1 excluded
10
Evaluation 12 Evaluation 12
weeks (n=8) weeks (n=6) 0

Baseline Evaluation 8th week 12th week

Figure 2. Variations of the mean (SDP) in (A) results of the VISA-P and (B) VAS in 12 weeks.
Figure 1. Chart illustrating the volunteers’ participation in the study.

Table 1. General characteristics of the participants.

DISCUSSION
Without Pain Group The results of this controlled and randomized clinical essay
Pain Group (n = 10)
(n = 7) conducted with athletes with PT diagnosis, demonstrated that a
Gender (men/women) 8/2 6/1 12-week intervention with eccentric squat exercises on a slope can
Age (years) 24.1 (8.3) 26 (5.9) be performed with and without pain, since both groups presented
Weight (kg) 76.7 (9.4) 75.5 (10.8)
pain decrease and function improvement.
In order to verify improvement in the knee function a question-
Height (cm) 176 (10) 175 (8)
naire specific to PT was used (VISA-P). Other studies evaluated the
Injured knee efficiency of the EE in the PT, and great part of these studies also
Right 3 4 used the VISA-P for evaluation of the knee function18,24. The results of
Left 7 3 our study could not be compared with other research since it is the
Type of diagnosis (exam)
first investigation concerning with the comparison of the efficiency
of the EE performance with or without pain in individuals with PT.
NMR + US 7 3
Decrease in pain was observed in both groups of athletes of
US 3 3 this investigation. The VAS was used here such as in many other
NMR 1 studies. The pain improvement was evaluated after performance
Time of sports practice (years) 8.2 (5.8) 7.8 (6) of EE for PT16-18. The same way it was not possible to compare the
knee function due to existence of investigations which enabled
Sports modality
us perform any kind of comparative analysis, the discussion on
Track and Field 3 1
the pain aspect was also limited by the lack of reference which
Basketball 1 approached similar issues
Capoeira 1 The use of eccentric exercises for the treatment of PT has
increased over the last years and it is based on few studies
Soccer 2
which demonstrated positive results in the pain and function
Handball 1 improvement in athletes. Although the pain indication during
Fights 2 exercise and high intensity of performance seem to be crucial
pre-requisites for the good therapeutic result for some authors
Skateboarding 1 16,18,25
, our study demonstrated that both groups benefited from
Triátlon 1 the EE practice.
Volleyball 3 1 The results of the present study also questioned about the
The variables age, weight, height and time of practice are presented as mean and standard deviation. need for EE performance in an aggressive manner and in the

Rev Bras Med Esporte – Vol. 18, No 3 – Mai/Jun, 2012 169

 presence of painon the knee extensor mechanism. As observed,
regardless of the application choice (with or without pain), im-
Negative Trivial Positive provement in the severity of symptoms was reached, although
8 weeks it is not known for sure which mechanism would lead to the PT
PG improvement after EE performance. From the practical point of
view, it shows us that it is not necessary to submit the patient
WP to a painful and uncomfortableintervention since even when
12 weeks performed in a less aggressive and painless manner, the EE pres-
PG ent positive results.
This study presented some limitations which should be avoided
WP
in future studies which involve PT in athletes. We believe that the
low number of participants and the short follow-up period (12
Change in VISA-P scores
weeks) may have influenced on the results of this study, as some
other researchers have reported. Perhaps the difficulty in getting a
Negative Trivial Positive population with a medical diagnosis and at least a complementary
8 weeks exam (US orNMR) may make it difficult to increase the number of
participants in future investigations. A longer follow-up period is
PG
another difficulty factor with this kind of study, since the evolution
WP of the clinical status of the athletes with PT is very fast, being hence
12 weeks very difficult to keep them under treatment for a longer period.
PG
CONCLUSION
WP The results of this study corroborate that an EE program using
squatting on a slope performed with or without pain was efficient
in improving the pain and function scenario in athletes with PT.
Change in VAS scores

All authors have declared there is not any potential conflict of

Figure 3. Probability of clinical results for (A) results of VISA-P and (B) VAS, in eight and
12 weeks (mean variation).
interests concerning this article.

REFEReNCeS
1. Cook JL, Kiss ZS, Khan KM, Purdam CR, Webster KE. Anthropometry, physical performance, and 14. Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med 2009;37:1855-67.
ultrasound patellar tendon abnormality in elite junior basketball players: a cross-sectional study. Br 15. Wasielewski NJ, Kotsko KM. Does eccentric exercise reduce pain and improve strength in physically active
J Sports Med 2004;38:206-9. adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train 2007;42:409-21.
2. Cook JL, Khan KM. What is the most appropriate treatment for patellar tendinopathy? Br J Sports 16. Purdam CR, Jonsson P, Alfredson H, Lorentzon R, Cook JL, Khan KM. A pilot study of the eccentric decline
Med 2001;35:291-4. squat in the management of painful chronic patellar tendinopathy. Br J Sports Med 2004;38:395-7.
3. Cook JL, Khan KM, Harcourt PR, Kiss ZS, Fehrmann MW, Griffiths L, et al. Patellar tendon ultrasonography 17. Cannell LJ, Taunton JE, Clement DB, Smith C, Khan KM. A randomised clinical trial of the efficacy of
in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian Institute drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes:
of Sport Tendon Study Group. Clin J Sport Med 1998;8:73-7. pilot study. Br J Sports Med 2001;35:60-4.
4. Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carlson GJ. Jumper’s knee. Orthop Clin North Am 1973;4:665-78. 18. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Eccentric decline squat protocol offers superior
5. Riley G. The pathogenesis of tendinopathy. A molecular perspective. Rheumatology (Oxford) results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in vol-
2004;43:131-42. leyball players. Br J Sports Med 2005;39:102-5.
6. Kjaer M. The treatment of overuse injuries in sports. Scand J Med Sci Sports 2001;11:195-6. 19. Alfredson H, Ohberg L. Sclerosing injections to areas of neo-vascularisation reduce pain in chronic
7. Gisslen K, Alfredson H. Neovascularisation and pain in jumper’s knee: a prospective clinical and Achilles tendinopathy: a double-blind randomised controlled trial. Knee Surg Sports Traumatol Ar-
sonographic study in elite junior volleyball players. Br J Sports Med 2005;39:423-8; discussion -8. throsc 2005;13:338-44.
8. Cook JL, Malliaras P, De Luca J, Ptasznik R, Morris M. Vascularity and pain in the patellar tendon of 20. Rees JD, Wolman RL, Wilson A. Eccentric exercises; why do they work, what are the problems and
adult jumping athletes: a 5 month longitudinal study. Br J Sports Med 2005;39:458-61; discussion -61. how can we improve them? Br J Sports Med 2009;43:242-6.
9. Alfredson H. The chronic painful Achilles and patellar tendon: research on basic biology and treatment. 21. Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat
Scand J Med Sci Sports 2005;15:252-9. Res 1986;65-8.
10. Khan KM, Cook JL, Maffulli N, Kannus P. Where is the pain coming from in tendinopathy? It may be 22. Visentini PJ, Khan KM, Cook JL, Kiss ZS, Harcourt PR, Wark JD. The VISA score: an index of severity of
biochemical, not only structural, in origin. Br J Sports Med 2000;34:81-3. symptoms in patients with jumper’s knee (patellar tendinosis). Victorian Institute of Sport Tendon
11. Alfredson H, Forsgren S, Thorsen K, Lorentzon R. In vivo microdialysis and immunohistochemical Study Group. J Sci Med Sport 1998;1:22-8.
analyses of tendon tissue demonstrated high amounts of free glutamate and glutamate NMDAR1 23. Flandry F, Hunt JP, Terry GC, Hughston JC. Analysis of subjective knee complaints using visual analog
receptors, but no signs of inflammation, in Jumper’s knee. J Orthop Res 2001;19:881-6. scales. Am J Sports Med 1991;19:112-8.
12. Hamilton B, Purdam C. Patellar tendinosis as an adaptive process: a new hypothesis. Br J Sports Med 24. Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper’s knee in volleyball
2004;38:758-61. players during the competitive season: a randomized clinical trial. Clin J Sport Med 2005;15:227-34.
13. Khan KM, Maffulli N, Coleman BD, Cook JL, Taunton JE. Patellar tendinopathy: some aspects of basic 25. Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, pulsed ultrasound
science and clinical management. Br J Sports Med 1998;32:346-55. and transverse friction in the treatment of chronic patellar tendinopathy. Clin Rehabil 2004;18:347-52.

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