Brazilian Journal of Physical Therapy 2020;24(1):46---53

Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy

ORIGINAL RESEARCH

Interventions used for Rehabilitation and Prevention

of Patellar Tendinopathy in athletes: a survey of
Brazilian Sports Physical Therapists
Luciana De Michelis Mendonça a,b,∗ , Natália Franco Netto Bittencourt c ,
Laís Emanuelle Meira Alves a , Renan Alves Resende b,d , Fábio Viadanna Serrão e,f

a
Physical Therapy Department, School of Biological and Health Sciences (FCBS), Universidade Federal dos Vales do Jequitinhonha
e do Mucuri (UFVJM), Diamantina, MG, Brazil
b
Postgraduate Program of Rehabilitation and Functional Performance (PPGReab), Universidade Federal dos Vales do
Jequitinhonha e do Mucuri (UFVJM), Diamantina, MG, Brazil
c
Centro Universitário UNI-BH e Minas Tenis Clube, Belo Horizonte, MG, Brazil
d
Physical Therapy Department, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal
de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
e
Physical Therapy Department, Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil
f
Postgraduate Program of Physical Therapy, Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil

Received 23 March 2018; accepted 6 December 2018

Available online 19 December 2018

KEYWORDS Abstract
Prevention; Objectives: (1) To identify the type and frequency of interventions used by Brazilian physi-
Rehabilitation; cal therapists to treat and prevent the occurrence of patellar tendinopathy in athletes and
Sports; the criteria used to return to sport; (2) to compare the interventions used to the grade of
Tendon injury recommendation of current evidence.
Methods: Design: cross-sectional study. Setting: online survey throughout sports physical ther-
apy association. Participants: Physical therapists who were invited to complete a structured
questionnaire. Main Outcome Measures: Interventions more frequently used for treating and
preventing PT in athletes and the criteria used to define return to sport.
Results: One-hundred and twenty-one physical therapists participated in this study. Quadriceps
eccentric strengthening (75.2%), education (61.2%) and lower limb joint/lumbo-pelvic stabiliza-
tion/hamstrings stretching (59.5%) were more frequently cited for prevention purposes, while
lower limb joint stabilization (81.8%), education (80.2%) and myofascial release (78.5%) were
more frequently reported for treatment. The majority of the physical therapists based their
decision of athlete discharge on a combination of pain intensity, function and functional test
results (44.6%).

∗ Corresponding author at: Physical Therapy Department, School of Biological and Health Sciences (FCBS), Universidade Federal dos Vales

do Jequitinhonha e do Mucuri, Rodovia MGT 367 --- Km 583, No. 5000, Alto da Jacuba, CEP: 39100-000, Diamantina, MG, Brazil.
E-mail: [email protected] (L.D. Mendonça).
https://doi.org/10.1016/j.bjpt.2018.12.001
1413-3555/© 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.

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Interventions for PT in athletes 47

Conclusion: There was inconsistency between interventions used in clinical practice and inter-
ventions recommended by the best available evidence.
© 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier
Editora Ltda. All rights reserved.

Introduction in epidemiology (STROBE) statement’’.16 This study was

approved by the Ethics Committee of the Universidade Fed-
Patellar tendinopathy (PT) is a chronic condition that causes eral dos Vales do Jequitinhonha e Mucuri (Diamantina, Minas
prolonged disability for athletes and that may be challeng- Gerais, Brazil) (55498416.1.0000.5108).
ing to treat and prevent.1 Athletes with PT usually complain
about pain and tenderness to palpation in the patellar ten- Participants
don during sports-related activities, such as sprinting and
jumping.1,2 The prevalence of PT in elite volleyball and bas-
Physical therapists were invited to participate in this study
ketball athletes is approximately 40%,2 in athletics is 22%2
through the Brazilian National Society of Sport Physical Ther-
and in soccer is 13%.2
apy (SONAFE-Brazil) database (electronic address and social
The management of PT frequently involves a wide range
media). SONAFE-Brazil had 444 associates. These associates
of interventions, such as knee extensors eccentric strength-
were invited to participate in this study, as well as other pro-
ening, heavy-slow resistance training, extracorporeal shock
fessionals without membership, throughout SONAFE’s social
wave therapy (ESWT) and low-intensity pulsed ultrasound.3,4
media. They were invited through cover letter sent by email
However, interventions commonly implemented in athletes
by SONAFE’s secretary, which had: (i) a short explanation of
with PT might not be supported by scientific evidence.5---7
the study purposes, clinical relevance and inclusion crite-
For example, Gaida and Cook3 found that ESWT and low-
ria, ii) the consent form and iii) the structured questionnaire
intensity pulsed ultrasound have only short-term effects and
(assessed by clicking on a link or opening a PDF file). When a
consequently may not be a good option for long-term treat-
participant answered the entire questionnaire using the link,
ment of PT. On the other hand, scientific evidence supports
an automatic electronic message was sent to the examiner
the use of quadriceps eccentric-concentric loading for long-
(L.D.M.), who was responsible for organizing the data sheet
term treatment of PT.8 In addition to local interventions,
and analyzing it. On the other hand, the participants that
physical therapists should also identify and treat possible
fulfilled the PDF file sent that file back to the same exam-
non-local causes of PT based on clinical reasoning and on
iner (L.D.M.). After sending the cover letters, we waited
scientific evidence, such as hip muscles weakness and ankle
for three months to get the responses back from the poten-
dorsiflexion ROM.1,7,9,10 Finally, proper criteria to return to
tial participants. In addition, for those potential participants
sport should be considered at the end of rehabilitation to
who did not answer back after one month, reminders were
promote a safe sport practice.1,7,11,12
resent twice during the following two months. The inclusion
Most of the clinical trials regarding the effects of
criteria were as follows: (i) be a registered physical thera-
different interventions on athletes with PT lack proper
pist at the Brazilian federal council of Physical Therapy and
follow-up data.13 Moreover, a systematic review14 showed
Occupational Therapy and (ii) have previous experience with
that physical therapists reported lack of time and inability
rehabilitation of athletes (professional or amateurs) with PT
to interpreted statistical results and a surveillance in Brazil15
(a minimum time of experience was not established). All
demonstrated that 80% of the PTs have difficulty in obtaining
participants read and signed the consent form and had their
full-text paper. Based on this data, it would be not surprising
confidentiality protected.
that the physical therapist may not use high quality clinical
research routinely to treat and prevent PT. The purpose of
this study were (1) to identify the type and frequency of Data collection
interventions used by Brazilian physical therapists to treat
and prevent the occurrence of PT in athletes and the criteria The questionnaire had ten questions: (i) four questions
used to return to sport and (2) to compare the interventions related to clinical practice and the characteristics of the
used to the grade of recommendation of current evidence. treated athletes, (ii) two multiple choice questions about
Our hypothesis is that physical therapists do not discharge interventions more frequently used for athletes with PT,
athletes from treatment and do not implement their inter- (iii) two questions about the frequency of the implemented
ventions for rehabilitation and prevention according to the interventions and the duration of the treatment, (iv) one
best scientific evidence. multiple choice question about the time loss from practice
and (v) one question about the criteria used to define return
to sport. The majority of the questions were answered by
Methods checking boxes.
The answer options regarding the questions about inter-
This cross-sectional study was reported in accordance with ventions most frequently used were: eccentric protocol,17---19
‘‘the strengthening the reporting of observational studies eccentric/isometric/concentric strengthening,20---23

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48 L.D. Mendonça et al.

Figure 1 Flow diagram.

stretching,10,20,24 joint mobilization,20,25 foot orthotics,20,26 C, weak evidence, D, conflicting evidence, E, theoreti-
electrotherapy,27---30 lumbo-pelvic stabilization,1,3,9 mio- cal/foundational evidence and F, expert opinion. Grades E or
fascial release,31 functional training,1,7,13 lower limb F were provided for the groups of interventions that we did
stabilization,1,7,13,32 taping,33,34 transverse friction,3,9,35 find scientific evidence from systematic reviews and meta-
plyometric,1,3,9 load control,1,3,8,9 education,1,3,9 analysis.
1,3,9,36
cryotherapy and others. The physical therapist
could select multiple interventions. The definition of the Results
intervention options to include in the questionnaire was
based in the literature,1,7,8,21,37 common sense, and in the
Sample characteristics
clinical experience of the authors.
The answer options regarding the question about the cri-
One hundred and twenty-one Brazilian physical therapists
teria used to return to sport were: pain,1,3,4,9 function,1,3,9
participated in this study (95 males and 26 females).
the Victorian Institute of Sport Assessment --- Patella (VISA-
Questionnaires with one-third or more of the questions
P) score,1,3,9,11 performance in a functional test and others.
unanswered were excluded from analysis (n = 1). Fig. 1
Finally, we asked about the athletes’ amount of time loss
shows the flow diagram of the study and Table 1 indicates
from sport due to PT.
descriptive data and clinical practice characteristics of the
participants.
Data analysis
Frequency of selected interventions
Descriptive analysis was performed to define the char-
acteristics of the participants, the absolute and relative Table 2 shows the frequency of interventions used by the
frequency of responses related to used interventions, time participants for rehabilitation and prevention purposes.
to return to play and discharge from treatment crite- Information about grade of recommendation was extracted
ria. The different interventions were clustered in the on October 21st through consecutives simple search of sys-
following groups of interventions: Electrothermal Pho- tematic reviews and meta-analysis.
totherapy, Strengthening exercises, Stretching exercises and Most of the participants reported that the frequency of
Others. rehabilitation sessions was one to three times per week
Considering that there is no guideline38 for PT treatment, (48.8%), followed by four to six times per week (37.20%). In
the authors searched for the best available evidence for addition, the duration of the rehabilitation treatment was
each group of interventions. This simple search was per- five to eight weeks (43.8%), followed by two to four weeks
formed in PUBMED using the term ‘‘patellar tendinopathy’’ (24%) and nine to twelve weeks (19%). The mean time loss
combined by the Boolean operator ‘‘AND’’ with the name from training was more than fifteen days for 50.4% and only
of the group of intervention (e.g. patellar tendinopathy 6.6% allow athletes to keep training during the treatment
AND strengthening exercises) to identify systematic reviews period. The frequency of prevention sessions was mainly one
and/or meta-analysis that assessed the efficacy of the inter- to three times per week (66.1%), followed by no specific
ventions cited by the participants of this study. We have frequency (23.1%).
also indicated the grade of recommendation, when avail- Only twenty physical therapists (16.5%) indicated the
able, for each group of interventions. Therefore, grade A use of the single-leg decline squat as an eccentric protocol
indicates strong evidence, B indicates moderate evidence, and only fifteen (12.4%) indicated the heavy-slow resistance

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Interventions for PT in athletes 49

Table 1 Descriptive data and clinical practice characteristics of the participants.

Descriptive data Mean (SD) Minimum Maximum
Sample (n = 121)
Age (years) 35.2 (6.7) 23 63
Time of graduation (years) 11.4 (5.7) 0 34
Time of specialty (years) 7.3 (4.7) 0 18
With specialty (n = 98)
Age (years) 35.2 (6.7) 25 63
Time of graduation (years) 11.4 (5.7) 1 34
Without specialty (n = 23)
Age (years) 32.2 (1.5) 23 45
Time of graduation (years) 7.1 (3.7) 0 20

Clinical practice characteristics Frequency (n(%))

Sample (n = 121)
Sports modality attended
Soccer 40 (19.3%)
Running 27 (13.0%)
Volleyball 24 (11.6%)
Martial Arts 19 (9.1%)
Swimming 17 (8.2%)
Tennis 15 (7.2%)
Basketball 13 (6.2%)
Athletics 10 (4.8%)
Others 42 (20.3%)
Clinical practice experience
Private practice 65 (38.0%)
Sports event 41 (23.9%)
Sports team 27 (15.8%)
All 26 (15.2%)
Others 12 (7.0%)
SD, standard deviation.

training. Twenty-four (19.8%) participants used the muscle education, stabilization and stretching were used for PT
strengthening in specific lengths (e.g. elongated or short- prevention. It was possible to indicate that the physical ther-
ened). apist’s choices weren’t in accordance to current evidence.

Return to play criteria Rehabilitation

The participants reported that the most cited criteria to The participants based their rehabilitation program on
define return to sport was the combination of pain intensity, education, myofascial release, lower limb joint stabiliza-
function and performance in a functional test (Table 3). The tion/proprioception/balance, and quadriceps stretching and
top three functional tests indicated by the participants were eccentric exercises. Education improves athlete’s adher-
hop test (n = 28; 23.2%), single-leg decline squat/single-leg ence during rehabilitation and eighty percent of the physical
squat (n = 13; 10.8%) and step-down test (n = 8; 6.6%). therapists reported using this intervention.9,43,44 Myofascial
release is a manual technique with recent studies demon-
strating that it increases range of motion and reduces
Discussion delayed onset of muscle soreness of recreational to highly
active individuals.31 Although there is no evidence of the
This study showed the profile of Brazilian physical therapists benefits for athletes with PT, future studies are neces-
that work with athletes with PT, capturing interventions sary to validate (or refute) the benefits of this intervention
related to rehabilitation, prevention and criteria to decide for this population. Interestingly, lower limb stabilization
about return to play. The Brazilian physical therapists that was selected by 81.8% of the physical therapists, even
participated in this study were mainly sport specialists work- though previous studies have not demonstrated the ben-
ing in private practices with more than ten years of clinical efits of this intervention to tendinopathy.32 A systematic
experience. Education, myofascial release and stabiliza- review published in 201120 indicated that quadriceps flexi-
tion were used for PT rehabilitation and strengthening, bility is a risk factor for PT, which could explain why most of

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50 L.D. Mendonça et al.

Table 2 Frequency (n (%)) of interventions targeting rehabilitation and prevention and grade of recommendation.
Electrothermal phototherapy Grade of recommendation39,40,41 : D to F

Intervention Rehabilitation Prevention Is it recommended?

Cryotherapy 56 (46.2%) 9 (7.4%) N
Laser 38 (31.4%) 8 (6.6%) N
Ultrasound 20 (16.5%) 5 (4.1%) N
TENS 14 (11.5%) 0 (0%) N/A
None (electrotherapy) 28 (23.1%) 108 (89.2%)

Stretching exercises Grade of recommendation40,41 : C to F

Intervention Rehabilitation Prevention Is it recommended?
Quadriceps 91 (75.2%) 59 (48.7%) Y
Hamstrings 75 (61.9%) 72 (59.5%) Y
Iliotibial band 70 (57.8%) 55 (45.4%) N/A
Plantar flexors 51 (42.1%) 51 (42.1%) N/A
None (stretching) 18 (14.8%) 39 (32.2%)

Strengthening exercises Grade of recommendation40,41,42 : A to F

Intervention Rehabilitation Prevention Is it recommended?

Quadriceps concentric 38 (31.4%) 43 (35.5%) Y
Hamstrings concentric 56 (46.2%) 44 (36.3%) N/A
Abdominal concentric 15 (12.4%) 18 (14.8%) N/A
Plantar flexors concentric 47 (38.8%) 25 (20.6%) N/A
Hip abductors concentric 63 (52.0%) 63 (52.0%) N/A
Hip ER concentric 66 (54.5%) 52 (42.9%) N/A
Hip extensors concentric 62 (51.2%) 55 (45.4%) Y
None (concentric) 20 (16.5%) 29 (23.9%)
Quadriceps isometric 61 (50.4%) 22 (18.1%) Y
Hamstrings isometric 17 (14.0%) 7 (5.7%) N/A
Abdominal isometric 27 (22.3%) 17 (14.0%) N/A
Plantar flexors isometric 8 (6.6%) 5 (4.1%) N/A
Hip abductors isometric 25 (20.6%) 24 (19.8%) N/A
Hip ER isometric 26 (21.4%) 17 (14.0%) N/A
Hip extensors isometric 25 (20.6%) 18 (14.8%) N/A
None (isometric) 39 (32.2%) 63 (52.0%)
Quadriceps eccentric 88 (72.7%) 91 (75.2%) Y
Hamstrings eccentric 35 (28.9%) 43 (35.5%) N/A
Abdominal eccentric 11 (9.1%) 11 (9.1%) N/A
Plantar flexors eccentric 27 (22.3%) 29 (23.9%) N/A
Hip abductors eccentric 40 (33.0%) 47 (38.8%) N/A
Hip ER eccentric 37 (30.5%) 41 (33.8%) N/A
Hip extensors eccentric 36 (29.7%) 45 (37.2%) Y
None (eccentric) 6 (4.9%) 17 (14.0%)
Plyometric 53 (43.8%) 42 (40.5%) Y
Single-Leg decline squat 59 (48.7%) 42 (34.7%) Y
Others Grade of recommendation39,40,41 : D to F

Intervention Rehabilitation Prevention Is it recommended?

Taping 75 (61.9%) 12 (9.9%) N
Foot orthotics 35 (28.9%) 21 (17.3%) N
Education 97 (80.1%) 74 (61.1%) Y
Load control 66 (54.5%) 33 (27.2%) Y
Transverse friction 54 (44.6%) 1 (0.8%) N
Myofascial Release 95 (78.5%) 45 (37.2%) N
Lower limb joint stabiliza- 99 (81.8%) 72 (59.5%) Y
tion/proprioception/balance
Functional training 64 (52.9%) 59 (48.7%) Y
Lumbo-pelvic stabilization 76 (62.8%) 72 (59.5%) Y
Ankle dorsiflexion mobilization 68 (56.2%) 48 (39.6%) N/A
Y, yes; N, no; N/A, not investigated. Grade of recommendation (based on the references indicated) was A in case of strong evidence,
B if moderate evidence, C if weak evidence, D if conflicting evidence, E if theoretical/foundational evidence and F in case of expert
opinion. The interventions recommended for athletes with PT based on systematic reviews and meta-analysis are marked as ‘‘yes’’ and
for those interventions not recommended or not investigated in the cited references, we indicated as ‘‘no’’ and ‘‘N/A’’, respectively.

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Interventions for PT in athletes 51

participants (hop test, single-leg decline squat/single-leg

Table 3 Return to sport criteria (n = 121).
squat and step-down test) are standardized and indicated
Criteria Frequency (n(%)) to PT management.1,44
Pain 4 (3.3%)
Our study was capable to capture the viewpoints of dif-
Function 6 (4.9%)
ferent competences to know how physical therapists act
Functional test 4 (3.3%)
when dealing with athletes in rehabilitation, prevention
Pain + function 26 (21.5%)
and return to play. This information could help physical
Pain + functional test 6 (4.9%)
therapists to identify their state of evidence-based prac-
Function + functional test 18 (14.8%)
tice when dealing with patients with PT. Moreover, we
All 54 (44.6%)
could recommend strategies to enhance the implementa-
Cited VISA-Pa 9 (7.4%)
tion of scientific evidence on physical therapists’ clinical
No answer 3 (2.4%)
practice, such as organize study groups to discuss new
evidence and scientific events to share experiences and
a Frequency extracted from a specific question. knowledge with each other. Future studies could investi-
gate the relationship between the interventions used to
the participants mentioned the use of quadriceps stretch- treat or prevent PT and the barriers to access scientific
ing. Seventy-two percent of the physical therapists chose literature.
quadriceps eccentric strengthening exercise, which agrees This study had some limitations. Although all of the
with scientific evidence.21 For example, Kongsgaard et al.21 participants had experience with PT, it is not clear that
demonstrated that eccentric training decreased tendon pain their main expertise was athletes with PT. We instructed
and improved collagen remodeling short and after a 12 the physical therapists to consider their clinical experi-
months follow-up. Moreover, Yu et al.27 found that almost ence with professional and amateur athletes. Therefore,
half of the randomized controlled trials that investigated the athletes’ training level and dedication may have
the effectiveness of physical agents for the management of influenced the results. Moreover, the questionnaire was
lower-limb soft tissue injuries, such as PT, had a high risk of self-administered and filled by Brazilians physical thera-
bias. Moreover, the authors didn’t find randomized clinical pists. Thus, we were not able to solve possible doubts
trials investigating the effects of laser therapy in patients of the participants to answer the questionnaire and our
with PT.27 results may not be applied to physical therapists from other
countries.
Prevention
Conclusion
The participants of the present study reported that they fre-
quently use quadriceps eccentric strengthening, education, The most frequently interventions used by Brazilians phys-
lower limb joint/lumbo-pelvic stabilization and hamstrings ical therapists to treat PT were education, myofascial
stretching. Quadriceps eccentrics strengthening was indi- release and lower limb joint stabilization. Considering pre-
cated as a usual preventive intervention by the participants vention of PT, the most used interventions were quadriceps
of the present study.8,17,18 Eccentric is a proper interven- strengthening, education, lower limb joint and lumbo-pelvic
tion to enhance tissue energy absorption.45 The adherence stabilization and hamstring stretching. In relation to return
of preventive programs is directly related to their effec- to sport, combined criteria (pain, function and functional
tiveness and education influences this process.9,43,44 Lower tests) were used. Finally, there was inconsistency between
limb joint stabilization and lumbo-pelvic stabilization exer- interventions used in clinical practice and interventions rec-
cises are usually included in general preventive programs ommended by the literature.
in sports, since it aims to improve functional capability of
the athlete.46---48 However, this type of general preventive
program has no evidence specifically related to PT.49 Ham- Funding
string stretching is adopted based on a systematic review
published in 2011 about risk factors for PT.20 This research did not receive any specific grant from fund-
ing agencies in the public, commercial, or not-for-profit
sectors.
Return to sport

Return to sport for athletes with PT can be slow and Conflicts of interest
is often dependent on severity of the tendon pain, dys-
function and the quality of the rehabilitation. Our results The authors declare no conflicts of interest.
indicated that the physical therapists chosen a combination
of pain, function and functional tests to decide about return
to sport. The presence of pain and dysfunction could be Acknowledgments
assessed through VISA-P, since it is largely used to assess
PT severity in athletes and its responsiveness in athletes The authors would like to thank the Brazilian National
has been reported.12,19,27,50 Despite this, approximately 10% Society of Sport Physical Therapy (SONAFE-Brazil) for their
of the participants cited VISA-P as a criterion to define support and all physical therapists that participated in this
return to sport. The main functional tests used by the study.

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52 L.D. Mendonça et al.

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