Accepted Manuscript

Effects of a strength protocol combined with electrical stimulation on patellar

tendinopathy: 42 months retrospective follow-up on 6 high-level jumping athletes

Ángel Basas, Jill Cook, Miguel A. Gómez, Manuel A. Rafael, Christophe Ramirez,
Brendan Medeiros, Alberto Lorenzo

PII: S1466-853X(18)30137-8
DOI: 10.1016/j.ptsp.2018.09.005
Reference: YPTSP 948

To appear in: Physical Therapy in Sport

Received Date: 17 June 2018

Revised Date: 11 September 2018
Accepted Date: 11 September 2018

Please cite this article as: Basas, Á., Cook, J., Gómez, M.A., Rafael, M.A., Ramirez, C., Medeiros, B.,
Lorenzo, A., Effects of a strength protocol combined with electrical stimulation on patellar tendinopathy:
42 months retrospective follow-up on 6 high-level jumping athletes, Physical Therapy in Sports (2018),
doi: https://doi.org/10.1016/j.ptsp.2018.09.005.

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 ACCEPTED MANUSCRIPT

Effects of a strength protocol combined with electrical stimulation on patellar

tendinopathy: 42 months retrospective follow-up on 6 high-level jumping athletes

Royal Spanish Athletics Federation. Faculty of Physical Activity and Sport Science,
Polytechnic University of Madrid, Spain

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ÁNGEL BASAS; JILL COOK; MIGUEL A. GÓMEZ; MANUEL A RAFAEL;
CHRISTOPHE RAMIREZ; BRENDAN MEDEIROS; ALBERTO LORENZO

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Angel Basas: Head of Physical Therapist Department. Royal Spanish Athletics

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Federation, Madrid, Spain. [email protected]
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Jill Cook: Professor. La Trobe Sport and Exercise Research Centre, La Trobe
university, Melbourne, Australia [email protected]
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Miguel A Gómez: Professor. Faculty of Physical Activity and Sport Science,

Polytechnic University of Madrid, Spain
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Manuel A Rafael: Physiotherapist. Royal Spanish Athletics Federation.

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Christophe Ramirez: Head of the Royal Spanish Athletics Federation’s Medical

Department.
Brendan Medeiros: MsC Neuroscience. Complutense University of Madrid, Spain.
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Alberto Lorenzo: Professor. Faculty of Physical Activity and Sport Science,

Polytechnic University of Madrid, Spain.
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Corresponding author: Ángel Basas. +34 627404389 [email protected]

 ACCEPTED MANUSCRIPT

Effects of a strength protocol combined with electrical stimulation on patellar

tendinopathy: 42 months retrospective follow-up on 6 high-level jumping athletes

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RI
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AN
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C EP
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This manuscript is original and not previously published, nor is it being considered elsewhere

until a decision is made as to its acceptability by Physical Therapy in Sport. The authors declare
 ACCEPTED MANUSCRIPT

that they have no conflict of interest and the paper was not prior submitted or published to

another journal. This study received no financial support.

ABSTRACT (Short-form):

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Objectives
To analyze the development of a protocol using eccentric, isometric, concentric

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exercises, and electrostimulation to treat elite athletes suffering from Patellar
tendinopathy (PT) or jumper's knee (JK) in elite athletes

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Design
Experimental, retrospective follow-up

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Setting
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High Performance Olympic Development Center.
Participants
Six high-level jumping athletes with chronic painful JK
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Outcome measure
Pain during patellar tendon loading activity on a visual analogue pain scale (VAS)
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Results
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There was a significant (p<0.01) decrease in the VAS from start to the 18, 24 and 48
months follow-ups.
Conclusions
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The established protocol of eccentric exercises combined with electrical stimulation

showed the promising clinical results with significant pain reduction during tendon
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loading activity.
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Keywords: patellar tendinopathy, jumper’s knee, eccentric, electrostimulation.

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ABSTRACT (Long-form)

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Study design: a retrospective study.

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Introduction: Patellar tendinopathy (PT) or jumper's knee (JK) in elite athletes is a

challenging condition for sports medicine professionals. This study analyzes the

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development of a protocol using eccentric, isometric, concentric exercises, and

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electrostimulation to treat elite athletes suffering from JK. The semiannual strength
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protocol was completed during a total of 36 months by six high-level jumping athletes

with chronic painful JK. Pain during patellar tendon loading activity was evaluated on a
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visual analogue pain scale (VAS). Upon protocol completion, promising clinical results

were evidenced by significant pain reduction during tendon loading activity.

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Material and methods: Six high level jumping athletes with chronic painful JK

completed a semiannual strength program using eccentric, isometric, concentric and

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electrical stimulation exercises. The protocol was done 12 weeks in the winter pre-

season and 10 weeks in the summer pre-season, for altogether 36 months, with an
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interruption of the protocol at 24 months for 6 months. Pain during patellar tendon
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loading activity was evaluated on a visual analogue pain scale (VAS), before the first

session and then every 6 months, coinciding with the competitive phase, the time of

maximum pain.

Results: There was a significant (p<0.01) decrease in the VAS from start to the 18, 24

and 48 months follow-ups.

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Conclusions: in a small group of high level jumping athletes with chronic painful JK,

eccentric exercises combined with electrical stimulation showed promising clinical

results with significant pain reduction during tendon loading activity.

Key words: jumper’s knee (JK), patellar tendinopathy (PT), eccentric, electrical

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stimulation.

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INTRODUCTION.

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Patellar tendinopathy (PT) is characterized by pain in the frontal surface of the knee; it is

normally localized at the proximal insertion of the patellar tendon in the lower pole of the

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patella, although it may also present at the distal insertion in the tibia, and even at the insertion
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of the tendon of the quadriceps in the upper pole of the patella. Its association with jumping

sports led it to be called jumper’s knee (Blazina et al., 1973, Ferreti, 1968, Kannus, 1997a), as
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it fundamentally occurs in sports characterized by high demands for speed and strength

in the extensor apparatus of the knee, such as volleyball, basketball or athletics, with a
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prevalence of up to 45% at the elite level (Lian et al., 2005) and 14.4% in recreational
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sports (Zwerver et al., 2011). It is the tendon pathology that most often causes an
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interruption in training and competition (Kannus, 1997b). Clinical decision-making is

hindered by lack of knowledge about over-use tendinopathy, so that athletes may

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experience long, frustrating periods of rehabilitation with unpredictable results (Cook et

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al., 1997).

Although different treatments have been described with promising results, a more

effective protocol has yet to be found (Cook et al., 2001, Rutland et al., 2010, Cook and

Khan, 2001), especially in athletes with high load demands on the patellar tendon.

Studies suggest that protocols should be designed on the basis of eccentric muscle

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strengthening exercises which show positive results in terms of the subjective

perception of pain (Biernat et al., 2014) as well as improved functionality (Purdam et

al., 2004a, Jonsson and Alfredson, 2005, Peers and Lysens, 2005, Kongsgaard et al.,

2006, Frohm et al., 2007, Woodley et al., 2007, Reinking, 2012, Romero-Rodriguez et

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al., 2011, Kaux et al., 2011) and strength (Cook et al., 2013). Nevertheless, it is still not

possible to strongly recommend a specific protocol (Visnes and Bahr, 2007), especially

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in elite sports, where the demands for tendon loading are far greater.

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In cases of athletes with prior history of pain, if possible, protocols should be initiated

before the start of the competition season, since it has been found that no positive

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results have been found if treatment commences during the competition season (Visnes
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et al., 2005).
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Upon designing a protocol, care should be taken in establishing the optimal load by
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using exercises with progressively increasing tension. Optimal-load exercises have

been shown to be more effective due to an improved isolation effect of the extensor
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apparatus of the knee by subjecting it to a more localized load on the tendon (Purdam et

al., 2004a, Kongsgaard et al., 2006). This has led to a search for exercises involving
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direct loading, such as those that can be achieved using specific eccentric exercises or
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isometric electrical stimulation when stretching. Neuromuscular electrical stimulation

technique has shown benefits in physiological adaptation by acting on the muscular

metabolism (Requena Sanchez et al., 2005, Gondin et al., 2005, Jubeau et al., 2008,

Malone et al., 2014, Martinez-Lopez et al., 2012, Holcomb, 2006). Although they are

not directly associated with tendon metabolism, the tendons have been shown to

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respond to progressive stress and the gradual and controlled increase of their loading

force, leading to an increase in collagen and thereby participating in remodeling

(Stanish et al., 1986). In the same way, mechanical loading is known to be beneficial for

tendon health, influencing their structure, chemical composition and mechanical

PT
properties (Magnusson et al., 2010, Kongsgaard et al., 2010). If electrical stimulation is

applied to bring about isometric contraction in the muscle at a certain degree of

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stretching, the tendon will be subjected to this stress and longitudinal loading; this could

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be taken into account as an extra exercise when designing protocols for elite sportsmen.

Nevertheless, the specialized literature contains no electrical stimulation protocols for

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this pathology. Therefore, the aim of this study was to analyze the effects of a program
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of tendon training using a combination of eccentric, isometric, concentric exercises, and

electrical stimulation on pain reduction, both in positions of direct tendon loading, in

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the treatment of elite athletes with patellar tendinopathy when other treatments have
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failed, interrupting their normal sports activity.

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This work is the continuation of a previous study that showed promising results in a

follow-up study of 24 months (Basas et al., 2014) during which pain progressively
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decreased to the point of its near disappearance. However, in the subsequent 6 months,

during which the protocol was discontinued, the level of pain increased again to the
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point in which it was necessary to resume the protocol. The results of the protocol’s
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consequent implementation are shown in this present study, which adds the effects of

protocol discontinuation and its reapplication.

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METHODS

Experimental Approach to the problem.

This study was designed to determine the beneficial effects of a strength protocol

combined with electrical stimulation on patellar tendinopathy. A retrospective

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longitudinal study of cases was performed, using a design of repeated measurements

over a period of intervention of 12 weeks in the winter pre-season and 10 weeks in the

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summer pre-season during a period of 36 months, with an interruption of the protocol at

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24 months for 6 months. The protocol was interrupted at 24 months after the end of the

summer season with the almost complete relief of symptoms. Due to this relief, it was

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thought to be no longer necessary to continue the program, but the protocol was
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resumed at 30 months after relapse occurred after a competitive season without prior

protocol. Pain was evaluated every 6 months including the interruption and subsequent
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resumption, up to 42 months. The independent variables were time (6,12,18,24,30,36

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and 42 months) and the strength protocol. Values obtained for the different pain tests

(VAS) were used as a dependent variables.

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In order to understand the study’s methodology, it is important to understand the

athlete's season. For a full season, there are two competitive periods, winter and
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summer, distributed approximately as follows and changing slightly depending on the

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dates of major competitions such as World Championships or Olympic Games. The

preseason phase is understood to be the phase of general training and preparation and

the competitive phase includes all competitions with the most important one taking

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place during the last month of this phase.

Pre-season (Winter): October, November and December.

Competitive Season (Winter): January, February and March.

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Pre-season (Summer): April, May and mid-June. This season is shorter than the winter

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season and the tendon should be better prepared due to prior completion of the protocol

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(because of this, the summer protocol is also shorter).

Competitive Season (Summer): mid-June, July and August.

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Subjects
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The described protocol in this study was applied to thirty elite athletes with patellar
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tendinopathy. To obtain the sample for this study, rigorous criteria for inclusion and

exclusion were set, as shown in table 1. Six athletes fulfilled these criteria. The entire
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protocol and study were designed, directed and supervised directly by the same
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physiotherapist in the sports facilities of the high performance center in Madrid. Three

of the athletes were high jumpers and three were triple jumpers. All six of them were
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male and started the protocol at an age of (± DT) 22.18 ±2.14 years old, and all were
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competitors at international level with the Spanish national athletics team. Their training

during the protocol was similar to that in previous years as directed by their respective

coaches.

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All participants signed an informed consent form to participate in the study and to allow

the use and publication of the results and the images.

The protocol was approved by an Ethics Committee.

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***Table 1 near here***

Procedures

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For the exercises to strengthen the muscle and tendon using electrical stimulation,

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MEGASONIC 313- ELECTROMEDICARIN S.A. (Barcelona, Spain) electrotherapy

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equipment was used. This made it possible to vary all current parameters.
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Asymmetrical two-phase low frequency excitomotor current was used, according to the

nomenclature of the equipment used (figure 1). Being a biphasic current, the pulse
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width marked in table 2, makes reference to each of the phases of the current.
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***Figure 1 near here***

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Electrode placement: 10 x 5 cm and 5 x 5 cm Electromedicarin reusable adhesive

electrodes were employed in the following positions to stimulate the entire quadriceps
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muscle (figure. 2):

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a) Two proximal 10 x 5 cm electrodes, which stimulate the output of the femoral nerve.
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b) Three 5 x 5 cm electrodes on the motor points of the vastus medialis, rectus femoris

and vastus lateralis.

***Figure 2 near here***

To close the circuits two channels were formed in the following way:

a) Channel 1: the lower proximal electrode connected to the vastus medialis.

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b) Channel 2: the upper proximal electrode connected to the rectus femoris and the

vastus lateralis, both connected to the same output of channel 2 by means of a split

cable.

Training

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The protocol consisted of the combination of strengthening exercises that subject the

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tendon to gradual and controlled loadings up to situations involving maximum tendon

loading. The first employed isometric electrical stimulation when stretching, and the

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second used eccentric, isometric and concentric muscular contractions, carried out in

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this order.
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The total duration of the protocol was twelve weeks in the winter pre-season and 10
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weeks in the summer pre-season. The participants completed the protocol three times a

week on alternating days, except for weeks 3, 6, 9 and 12, when they completed it twice
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a week in order to avoid overstimulation of the tendon. This specific schedule coincides

with the training micro-cycles of the athletes. The first week of each microcycle is high
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intensity training, the second is of even higher intensity, and the third is of low intensity
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to promote regeneration and training supercompensation.

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Description of the exercises

The progression of the exercises and the current parameters are shown in table 2..

***Table 2 near here***

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Exercise 1 (E1): isometric electrical stimulation of the stretched quadriceps muscle

(Figure 3). The athlete sat with the knee blocked at 90º. Immediately before the

electrical stimulus, the athlete was asked to make a voluntary contraction of the

quadriceps according to the intensity shown in table 2. The intensity of the current was

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increased until it overcame the previous voluntary contraction. The athlete should notice

that the electrical stimulation contraction is more intense than the previous voluntary

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one. This increase in contraction should also be visible and palpable due to the increase

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of muscle tone. The voluntary contraction was maintained during the time the current

acts to conserve the neuromuscular connection. The intensities of current set by the

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protocol gradually increase from low to high, and they must be increased week by
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week, up to the level set as maximum, which will be the intensity that overcomes the

maximum voluntary contraction by the athletes.

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***Figure 3 near here***

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Exercise 2 (E2): isometric electrical stimulation of the quadriceps muscle in a position

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of a higher tension (Figure 3). The athlete lies down to stretch the rectus femoris further,
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keeping his knee blocked at 90º. This position will increase the loading on the patellar

tendon. The other leg is kept flexed over the table to protect the lumbar area.
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Exercise 3, 4, 5: Eccentric + isometric + concentric exercises: Inelastic belts or bands

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were used for the exercises, making it possible to hold the athlete in a semi-sitting

position (a semi-squat) with his center of gravity moved to the rear, as is shown in the

exercises in Figure 4.

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***Figure 4 near here***

Exercise 3 (E3): Eccentric + isometric + concentric bipedal exercise of the quadriceps

with the knee – hip at 90º (Figure 4). This exercise consists of 3 phases: a) a first

eccentric phase, from standing to a sitting position, from 0º to 90º hip-knee, going down

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slowly for 3 seconds; b) a second isometric phase, keeping the knees –hips bent at 90º

for an additional 3 seconds; and c) a third concentric phase, in which the athlete returns

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to the initial standing position in 1 second. To advance within the protocol, loads are

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gradually added, starting with 15% body weight, using waistcoats or weights added to

the chest. This will be denominated “3+.” (Each “+” signifies a 15% increase in body

weight).
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Exercise 4 (E4): Eccentric + isometric + concentric bipedal with the knee at 90º and the
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hip at 0º (Figure 4). The same as the previous exercise, but keeping the hip at 0º. The
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loading on the tendon will be increased by the lever arm created and the loading exerted
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by stretching of the

rectus femoris. Weights are gradually added, denominated “4+.”

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Exercise 5 (E5): Eccentric + isometric + concentric single leg with the knee at 75º
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(Figure 4). Weights are gradually added, denominated “5+”.

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Testing

The initial assessment and results of the treatment protocol were evaluated using a

visual analogue scale of pain (VAS) (9) from 0 to 10, which has been shown to be

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effective and reproducible, and which has been widely used in medical research

(Romero-Rodriguez et al., 2011, Young et al., 2005a, Purdam et al., 2004a, Frohm et

al., 2007). The athletes themselves set the pain level during patellar tendon loading

activity in a 10cm VAS marked in millimeters., where 0 was no pain and 10 meant

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maximum pain that didn’t allow the athlete to train or compete. Pain data were recorded

before starting the protocol and three months after finishing each (at 6, 12, 18, 24, 30,

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36 and 42 months), coinciding with the end of competition seasons, thereby evaluating

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pain following a time of maximum demand. Evaluation also took place following the

half-yearly period during which the protocol was discontinued (at 30 months), and

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following restarting (at 36 months) and finishing the last protocol (at 42 months).
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(Figure 5)

***Figure 5 near here***

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Statistical Analyses.
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Data were analyzed using the PASW data statistics editor program 18.0 (SPSS inc.

Chicago, Il, USA). Friedman’s test was used for pre-post comparisons. This test is the
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non-parametric alternative to single factor fixed effect repeated measurements ANOVA,

as the sample contains fewer than 30 subjects. Differences in ranges were compared by
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means of Tukey’s post-hoc test. The level of significance was set at p<0.05.
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RESULTS

The results show that the training protocol had a positive effect (reduction) on the pain level,

while there were significant differences between the measurements by the subjects (χ2

(7)=30.68; p<0.001).

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More specifically, the results of Tukey’s post-hoc test showed that pain scores at 18, 24 and 42

months fell significantly in comparison with the initial measurement (p<0.01).

However, no statistically significant differences were found in the comparisons of the

other measurements (Table 3; Figure 6).

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***Table 3 near here***

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***Figure 6 near here***

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When all of the measurements are compared (see Table 3), the results show that the

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average pain level clearly fell following the complete undertaking of the first protocol
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(VAS 2). However, no statistically significant differences (p>0.05) were found for a
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sample of 6 subjects. After the application of the second protocol (VAS 3), pain

continued to fall although no significant differences were detected (p>0.05).

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Nevertheless, significant differences were detected after the third protocol (VAS 4), in
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the 18th month (p<0.05) compared with the initial score for pain, and this situation
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occurred again after the fourth protocol (VAS 5). After this fifth assessment the
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protocol corresponding to this half-year was interrupted, and the average pain levels
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rose (VAS 6) although differences were not significant (p>0.05), and then lowered

again (p>0.05) after reapplication of the protocol (VAS 7). Significant differences

(p<0.05) were found after the final application (VAS 8).

It is important to point out that during the first weeks of the protocol’s application, the

athletes experienced delayed onsent muscle soreness (DOMS) and a slight discomfort in

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the tendon itself, not being able to affirm if the cause was the dynamic exercises, the

electrostimulation, or both, because they were carried out in the same session. This

soreness began disappearing from the fourth week of the protocol and unfortunately it is

a data point that was only recorded in observations without a quantitative data

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collection.

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DISCUSSION.

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Electrical stimulation with an excitomotor effect was used in this study as a means of
AN
strengthening the muscle and tendon. This is a new approach to the treatment of patellar

tendinopathy. No references have been found to protocols combined with electrical

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stimulation such as that described in this study, which means that it cannot be compared
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with other previous similar studies of the training of patellar tendinopathy.

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Although electrical stimulation is not included in the designs of previous studies

(preventing comparisons), its proposed usage is justified by the beneficial effect of the
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gradual and controlled loading of the tendon, as its tensile strength increases along with
C

the amount of collagen within (Stanish et al., 1986). It is also the case that isometric
AC

tension leads to direct mechanical loading on the tendon, which has a positive influence

on the structure, chemical composition and mechanical properties of the same

(Kongsgaard et al., 2010). It would be of interest to study mechanical properties of

patellar tendon in response to an isometric electrical stimulation, compared with

voluntary isometric contraction. It would increase the understanding of advantageous

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adaptation training and optimal intervention as was done with the Achilles tendon with

a maximum voluntary isometric contraction in a recent study (Joseph et al., 2014).

The efficacy of our proposal agrees with the scientific literature, showing satisfactory

clinical results in the reduction of pain in response to strengthening exercises involving

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eccentric overloading in athletes with chronic patellar tendinopathy (Bahr et al., 2006,

Visnes and Bahr, 2007, Frohm et al., 2007, Jonsson and Alfredson, 2005, Purdam et al.,

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2004b, Romero-Rodriguez et al., 2011, Rutland et al., 2010, Young et al., 2005a).

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However, it is still not possible to strongly recommend a specific protocol (Visnes and

Bahr, 2007, Lorenzen et al., 2010, Rees et al., 2009, Wasielewski and Kotsko, 2007).

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One of the reasons why exercises may be less effective is when they involve
AN
biomechanics that restrict the loading on the tendon (Purdam et al., 2004a, Kongsgaard

et al., 2006). For this study exercises were selected that give rise to maximum direct
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loading of the patellar tendon, getting as close as possible to the stress that is necessary
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to adapt the tendon to the aggressive demands of sport.

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It must be pointed out that application of the protocol gave rise to benefits after the end
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of the first protocol, although these were not statistically significant due to the small

sample. This improvement increased gradually with the subsequent protocols. It is also
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of interest that, following interruption of a two-year long protocol, pain levels went up
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again within six months without any protocol being applied, although they went down

again once the protocol was applied once more. This suggests that elite athletes with

chronic patellar tendinopathy should include training protocols in each training cycle.

However, the fact that this worsening in the pain level after a 6 month interruption in

the protocol contrasts with studies in which 12 months after the application of protocol

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the improvement continued and even increased (Young et al., 2005b), or with others in

which follow-up after 32.6 months showed that patient satisfaction had remained

constant following the application of a protocol (Jonsson and Alfredson, 2005). The

protocol used in this study would therefore not be a long-term solution after a single

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application. This may be due to the specific sports and level of the athletes involved, as

their sports demand explosive maximum performance from tendons. Therefore, in the

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case of elite athletes of this type, it would be of interest to keep the protocol as a part of

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training during their sporting life.

Given the results of this study, we have to await the application of three protocols at six-

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monthly intervals to obtain statistically significant differences. The benefits obtained
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after the first two protocols, while they were positive in terms of the perception of pain,

are insufficient to show such differences in a sample of 6 subjects.

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One aspect of this study that should be underlined is that it was applied and followed up
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for 42 months with athletes who had been training with restrictions and subjected to
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different treatments for at least two years. This situation was corrected by the first
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application of the combined protocol of isometric, concentric, eccentric exercises and

electrical stimulation, and they continued to improve with each new application and
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worsened when the protocol was interrupted. Planned surgical treatment for three of
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them was cancelled, and all six were able to continue their elite sports activity normally.

Although the results cannot be compared, as no research studies have been found

involving the application and follow-up of a continuous protocol over such a long time,

the evolution of our research shows hopeful results for elite jumpers. Nevertheless,

these should be contrasted with new research studies.

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The change in pain levels over 42 months suggests that the favorable results most likely

are the direct result of the protocol, while the unfavorable results coincide with the

suppression of the same. The protocol is the only controllable variable that changes in

the group of athletes over It is important to underline the following limitations of this

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study: there was no control group and the sample was small due to the difficulty of

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finding world standard jumpers. Given that the results obtained are not significant for

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applications before 18 months, they should be contrasted with a greater number of

participants. To achieve conclusive results, randomized studies comparing different

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types of exercises are necessary: groups with electrical stimulation combined with
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isometric, concentric and eccentric exercises, groups using a single technique, as well as
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a control group.
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In future studies, pain levels would ideally be evaluated weekly in order to observe the
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evolution of pain throughout the entire adaptive process of the protocol, using the

validated Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy

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(VISA-P) in conjunction with VAS.

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PRACTICAL APPLICATIONS.
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The result of this study suggests that the use of a protocol that combines eccentric,

isometric, concentric exercises with electrical stimulation of maximum loading may

have a positive effect on the reduction of pain in elite athletes with patellar tendinopathy

or jumper’s knee. The evolution of the pain following the application and interruption

of the protocol indicates that these athletes, whose sports specialties directly involve the

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patellar tendon at extreme loadings, would need to apply the protocol twice a year to

obtain and increase its benefits, including it in their training programs while they remain

involved in elite sports. However, given the small number of subjects included, data

should be interpreted cautiously.

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This proposal is designed for elite athletes. Its level of demand and the need for

equipment such as inelastic bands for the eccentric exercises and electrical stimulation

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equipment make it unsuitable for the general population and those who do recreational

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sport.

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References
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BAHR, R., FOSSAN, B., LOKEN, S. & ENGEBRETSEN, L. 2006. Surgical treatment
compared with eccentric training for patellar tendinopathy (Jumper's Knee). A
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randomized, controlled trial. J Bone Joint Surg Am, 88, 1689-98.

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BASAS, A., LORENZO, A., GÓMEZ, M., MORENO, C. & RAMIREZ, C. 2014.
Exercise Protocol and Electrical Muscle Stimulation in the Prevention,
Treatment and Readaptation of Jumper’s Knee. New Studies in Athletics., 29,
41-51.

BIERNAT, R., TRZASKOMA, Z., TRZASKOMA, L. & CZAPROWSKI, D. 2014.

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Appendices.
Tables and figures.
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Table 1.
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Table 1.
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Inclusion and exclusion criteria.

Inclusion criteria ● International jumpers.

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● Diagnosed chronic patellar tendinopathy or jumper’s knee

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by a specialist doctor in sports medicine, by means of

ultrasound assessment and magnetic nuclear resonance.

● Evolution of the condition over at least two years.

● Failure during these two years of other medical and

physiotherapeutic treatments, including surgery.

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● Athletes who have carried out the protocol for 36

months with an interruption at the 24th month and
restarting the protocol after the 30th month.

Exclusion criteria ● Other associated pathologies of the knee.

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Table 2
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Table 3.
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Table 3. Subjective pain by visual

analogue scale of pain (VAS). Mean± SD.

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VAS1. baseline test 7,67 ±1,96

VAS 2. Month 6 3,67 ±2,34
VAS 3. Month 12 2,50 ±1,52
VAS 4.Month 18 1,00 ±1,67*
VAS 5.Month 24 0,33 ±0,52*

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The protocol is interrupted.
VAS 6.Month 30. 2,83 ±2,79
Reapplication of the

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protocol.

VAS 7.Month 36 1,67 ±1,97

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VAS 8. Month 48 0,67 ±0,82*

* p<0.01

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Figure 1.

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Fig. 1. Graphic representation of the asymmetric rectangular current.
Nomenclature used by the company ELECTROMEDICARIN S.A.

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Figure 2.
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Fig.2. Electrode placement.

Figure 3.

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Fig.
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Isom
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electr
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stimu
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of the
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quadr
iceps

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muscle.
Exercise 1(E1): sitting 90º knees-hips; Exercise 2 (E2): lying knees 90º-hips 0º .
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Figure 4.
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Fig. 4. Eccentric exercises.

Exercise 3 (E3): bipedal position. Sitting 90º knees-hips.
Exercise 4 (E4): bipedal position. Lying knees 90º-hips 0º.
Exercise 5 (E5): single leg 75º knee-hip.

Figure 5.

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Figure 6.

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Fig.6. Subjective pain by visual analogue scale of pain (VAS).

Mean ±SD .*Significant differences at 18, 24 and 42 months (p<0.01)
IP: The protocol is interrupted following the assessment at 24 months.
RP: Reapplication of the protocol following the assessment at 30 months.

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Highlights:

Effects of a strength protocol combined with electrical stimulation on patellar

tendinopathy (jumper's knee) in elite athletes: A retrospective follow-up study on 6
high-level jumping athletes during 42 months.

! Different treatments have been described with promising results, but nevertheless, a

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more effective protocol has yet to be found, especially in athletes with high load
demands on the patellar tendon.

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! The tendon requires different stimuli with the goal of increasing tension and resistance.
The rehabilitation program should include the different types of contractions and
exercises, each adapted to the athlete’s needs.

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! The protocol combines eccentric, concentric, and isometric exercises with isometric
electrostimulation in position of maximum tendon tension and has demonstrated
promising results in an elite athlete population.

!
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The present protocol has been designed for high-level athletes. For sports with lower
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patellar tendon tension loads, the protocol should be adapted accordingly.

! The readaptation protocol should be continued during the pre-season and even when
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the athlete returns to competition-level capacity.

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