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Interventions for Prevention and In-season Management of Patellar

Tendinopathy in Athletes: A scoping review

Preprint · January 2022

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Replication in Kinesiology (STORK)

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Interventions for Prevention and In-season

Management of Patellar Tendinopathy in Athletes: A
scoping review

Ian Burton MSc, CSCS

Specialist Musculoskeletal Physiotherapist, MSK Service, Fraserburgh

Physiotherapy Department, Fraserburgh Hospital, NHS Grampian, Aberdeen.

For correspondence: [email protected]

Aisling McCormack, Aberdeen City Council

Please cite as: Burton I & McCormack A. (2022). Interventions for

Prevention and In-season Management of Patellar Tendinopathy in
Athletes: A scoping review

All authors have read and approved this version of the manuscript.
This article was last modified on January 26th 2022.
ABSTRACT

Introduction: Patellar tendinopathy has a significant prevalence in athletes and

presents a tremendous burden on athletes and clinicians due to its long-lasting
duration, persistent symptoms, and lack of available effective treatments. This
scoping review aimed to summarise current evidence on prevention and in-season
management interventions for patellar tendinopathy in athletes, evaluating
intervention parameters and outcomes.

Methods and analysis: The recommended methodological framework described

by the Joanna Briggs Institute was used to structure this review, with reporting in
accordance with the PRISMA-ScR. Databases searched included MEDLINE,
CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library (Controlled trials,
Systematic reviews). All primary study designs investigating prevention or in-
season management interventions for patellar tendinopathy, while maintaining
athletes in sport were considered for inclusion.
Findings: 5987 articles were identified with 29 included in the review. Despite a
dearth of studies to date on preventative interventions for athletes with patellar
tendinopathy, evidence suggests that resistance training is an effective
prophylactic method. There is a significant body of evidence suggesting that
resistance training is effective for managing patellar tendinopathy in-season, with
evidence greater for eccentric training, followed by heavy slow resistance training
and isometric training. Inertial flywheel and blood-flow restricted resistance
training may also be effective in-season management strategies. There is
currently no evidence to suggest that ESWT offers any additional benefit over
resistance training in competing athletes. Patellar strapping and taping may offer
short-term pain relief during training and competition. High risk athletes,
particularly those participating in jumping sports, should be required to undergo
progressive resistance training as a preventative method for patellar
tendinopathy. Similarly, athletes diagnosed with patellar tendinopathy should
undergo a progressive resistance training intervention while maintaining sports
participation, prior to considering sport withdrawal.

Keywords: Prevention; Tendinopathy; Resistance training; Patellar;

Physiotherapy; Tendon

2
INTRODUCTION

Tendinopathy is a chronic degenerative condition, associated with changes to the

structural tendon collagen matrix, presence of various inflammatory cells and
clinical symptoms of pain and impaired performance (Millar et al. 2021). Patellar
tendinopathy is common in athletes with high training demands and is caused by
repetitive patellar tendon microtrauma (Malliaras et al. 2015). Patellar
tendinopathy is most common in jumping athletes competing in sports such as
basketball and volleyball which require repetitive patellar tendon loading, leading
to the condition being labelled as ‘jumper’s knee’ (Janssen et al. 2018). Prevalence
data suggest up to 22% of elite athletes will report patellar tendon pain at least
once during their sporting careers, with up to 50% of elite volleyball and basketball
players being diagnosed with the condition during their careers (Lian et al. 2005,
Saithna et al. 2012, Zwerver et al. 2011). Symptoms of patellar tendinopathy
include persistent pain and physical dysfunction, particularly with patellar tendon
loading, leading to impairments in athletic performance (Rosen et al. 2021, Scott
et al. 2019). Diagnosis is typically based on the presence of pain at the insertion
of the patellar tendon under the apex of the patella, provoked by palpation or
loading tests such as the loaded decline squat test (Sanchez-Gomez et al. 2022).
A plethora of risk factors specific to jumping athletes have been identified,
highlighting their vulnerability and predisposition for developing patellar
tendinopathy (Fendri et al. 2021, Harris et al. 2020, Sprague et al. 2018, Van der
Worp et al. 2012, 2011, Witvrouw et al. 2001). In the initial stages of patellar
tendinopathy, athletes can often continue with sports participation, however with
progressive tendon degeneration symptoms can worsen, with the average
duration of the condition lasting up to 32 months (Doelen and Jelley 2020).

There are a range of available treatment modalities available for patellar

tendinopathy, with often conflicting findings on their efficacy in the literature such
as extracorporeal shockwave therapy (ESWT), corticosteroid injections, platelet-
rich-plasma injections, topical glyceryl trinitrate, laser therapy, and anti-
inflammatory medications (Challoumas et al. 2021, van Rijn et al. 2019). More
invasive approaches such as percutaneous electrolysis and surgery may be

3
required if conservative treatment fails (Mendonca et al. 2020). Eccentric
resistance training using decline squat exercises to load the patellar tendon has
been the gold standard first-line management approach for patellar tendinopathy
in recent years, due to its documented beneficial clinical effects for improving pain
and function (Irby et al. 2020). Despite the best evidence existing for eccentric
training, recently heavy slow resistance training (HSRT), which does not eliminate
concentric actions, and isometric training have been shown to have comparable
beneficial effects (Breda et al. 2021, Sprague et al. 2021, Kongsgaard et al. 2009;
Lim et al. 2018). Despite resistance training having the best evidence of
effectiveness out of all available treatments for patellar tendinopathy, estimates
suggest they may be only up to 50% effective for improving clinical symptoms at
three to six months, suggesting other strategies should be investigated (Gaida
and Cook 2011, Challoumas et al. 2021). Withdrawing athletes from sport and the
decision to undergo rehabilitation in isolation should not be taken lightly and the
decision should involve consideration of the evidence for intervention options to
maintain athletes in sport with a risk/benefit ratio analysis of the consequences
required (Saithna et al. 2012). Withdrawing competitive athletes from sport is
associated with negative psychological consequences such as depression, anxiety,
low mood, and self-esteem (Scully et al. 1998; Ford et al. 2017). Physiological
consequences can include de-training and loss of fitness and sport specific skills,
potentially affecting an athlete’s employment and career prospects, leading to
financial losses (Arvinen-barrow et al. 2017, Wiese-Bjornstal 2010, Secrist et al.
2016).

Given the burden of patellar tendinopathy in athletic populations, its often-long-

lasting duration, and inconsistencies in the effects of treatment modalities, efforts
should be made to ascertain the availability of methods for preventing and
manging the condition during the competitive season, to prevent the deleterious
consequences of withdrawing athletes from sport (Saithna et al. 2012). Despite
the importance of identifying such methods, there have been a paucity of studies
investigating interventions for prevention and in-season management of patellar
tendinopathy in competing athletes, with a lack of recommendations currently
available (Peters et al. 2016). Therefore, the objective of this scoping review is to
evaluate current research on the use of prevention and in-season management

4
interventions for patellar tendinopathy in athletes. The scoping review will be
guided by addressing the following review questions on specific aspects of
prevention and in-season management interventions for patellar tendinopathy:1.
What interventions have been reported for prevention and in-season management
for patellar tendinopathy in athletes? 2. What intervention parameters and
outcome measures have been used in published studies? 3. What outcomes have
been reported for prevention and in-season management interventions for patellar
tendinopathy in athletes?

METHODS

Due to the exploratory nature of the research questions of this review, a scoping
review was conducted as they are recommended for mapping key concepts,
evidence gaps and types of evidence within a particular field and can help guide
future research and the possibility of conducting systematic reviews on the topic
(Tricco et al. 2018). The scoping review is reported in accordance with the
Preferred Reporting Items for Systematic reviews and Meta-analysis extension for
Scoping reviews (PRISMA-ScR) (Tricco et al. 2018).

Inclusion criteria

The inclusion criteria for the scoping review were guided by a modified PICO, which
includes population, concept, and context (PCoCo) as recommended for scoping
reviews (Peters et al. 2020). The review considered athletes of any age with a
diagnosis of patellar tendinopathy for any time duration or athletes with healthy
patellar tendons at risk for patellar tendinopathy. Included participants must be
athletes competing in any sport at any level such as recreational, amateur, elite,
or professional. Any patellar tendon condition characterised by common
tendinopathy symptoms, in the absence of a full thickness tendon rupture was
considered for inclusion. A clinician’s diagnosis based on symptoms including pain
location and a symptom altering response to palpation or tendon loading with
specific tendinopathy tests such as the loaded decline squat test were accepted
for inclusion. Studies including participants with other concurrent injuries or
medical conditions were excluded. Studies that have provided an intervention

5
while withdrawing athletes from sports participation were excluded. The concept
of interest is prevention and in-season management interventions for patellar
tendinopathy in athletes, including any type or format of intervention using active
or passive modalities, in a supervised or unsupervised manner. The intervention
may be delivered in isolation or combined with other interventions. Rehabilitation
interventions such as resistance training protocols, injections or ESWT were
considered as in-season management interventions if athletes continued sports
participation while receiving them. The context considered for inclusion included
any health or exercise setting in which prevention and in-season management
interventions for patellar tendinopathy in athletes have been provided. This
scoping review considered both experimental and quasi-experimental study
designs including randomized controlled trials and non-randomized controlled. In
addition, prospective and retrospective cohort studies, case series and case
reports were considered for inclusion. Unpublished studies, reviews or reports
were not considered for inclusion.

Search strategy

A 3-step search strategy was implemented in this scoping review. It incorporated

the following: 1) a limited search of MEDLINE and CINAHL using initial keywords,
followed by analysis of the text words in the title/abstract and those used to
describe articles to develop a full search strategy; 2) The full search strategy was
adapted to each database and applied to MEDLINE, CINAHL, AMED, EMBase,
SPORTDiscus, Cochrane library (Controlled trials, Systematic reviews), JBI
Evidence Synthesis, and PEDro. The following trial registries were searched:
ClinicalTrials.gov, ISRCTN, The Research Registry, EU-CTR (European Union
Clinical Trials Registry), ANZCTR (Australia and New Zealand Clinical trials
Registry). Databases were searched from inception to January 20th, 2022. The
search for grey literature included Open Grey, MedNar, Cochrane central register
of controlled trials (CENTRAL), EThOS, CORE, and Google Scholar. 3) For each
article located in steps 1 and 2, a search of cited and citing articles using Scopus
and hand-searching where necessary, was conducted. Studies published in a
language other than English were only considered if a translation was available as
translation services were not available to the authors.

6
Study selection

Following the search, all identified citations were collated and uploaded
into RefWorks and duplicates removed. Titles and abstracts were screened by two
independent reviewers (IB and AM) and assessed against the review inclusion
criteria. Potentially relevant studies were retrieved in full, with their details
imported into Covidence software (Veritas Health Innovation, Melbourne,
Australia). Two independent reviewers (IB and AM) assessed the full text of
selected articles in detail against the review inclusion criteria. Any disagreements
that arose at any stage of the study selection process were resolved through
discussion. The results of the search are reported in accordance with the PRISMA-
ScR (Figure 1). In accordance with guidance on conducting scoping reviews,
critical appraisal was not conducted (Peters et al. 2020).

Data extraction and analysis

Data were extracted from sources included in the scoping review by one reviewer
(IB), with independent data extraction by a second reviewer (AM) for 10% of
studies. The data extracted included dimensions such as study type, purpose,
population & sample size, methods, details of intervention, outcome measures
used and clinical outcomes. Interventions details included type, dosage,
intervention parameters, and any methods used for progression and monitoring
compliance. Data were also extracted on any physiological mechanisms such as
effects on tendon morphological and mechanical properties, which have been
investigated to explain the effects of the interventions on patellar tendinopathy or
healthy patellar tendons. The extracted data are presented in Tables 1 and 2 with
a narrative synthesis accompanying the tabulated results. The extracted data were
analysed using descriptive statistics, with findings presented in tabular form as
tables and figures, along with a narrative synthesis.

7
FIGURE 1: PRISMA study flow diagram

Number of records identified Number of additional records

through a systematic search identified through other sources
(N=5978) (N=0)
Identification

Number of records after duplicates

removed (N=5629)
Screening

Number of records
screened (title and Number of records
abstract) (N=5629) excluded (N=5565)

Number of full-text Number of articles

articles assessed for excluded for: withdrawing
eligibility (N=64) athletes from sport during
Eligibility

intervention (N=22) or
non-athlete population
(N=13)
Included

Number of articles included

(N=29)

8
RESULTS

Included study characteristics

The literature search yielded 5978 articles, reduced to 5629 after removing
duplicates, of which 29 met the inclusion criteria and were included in the review.
The search results are summarised in the PRISMA flow chart (Figure 1). An
overview of the characteristics, intervention parameters and outcomes of the
included studies are provided in Tables 1 and 2. Five studies investigated the
effects of exercise-based prevention interventions on athletes at risk for patellar
tendinopathy, including two randomized controlled trials (RCTs), two cohort
studies and one case-control study. 24 studies investigated the effects of in-
season management or rehabilitation in athletes with patellar tendinopathy,
including 18 RCTs, three case reports, one cohort study, one case series, one
retrospective review. Of these 24 studies, 22 used an exercise-based intervention,
one used ESWT and one used patellar strapping and taping. The types of exercise
interventions included eccentric training, HSRT, isometric training, inertial
flywheel training, blood-flow restriction training (BFRT), and general isotonic
training. The most common type of training was eccentric training, used in 9
studies, with eccentric single leg decline squats the most common exercise used
in 7 studies. The sample sizes of included studies ranged from 1-209 and
intervention duration ranged from a single session to three years, with 12 weeks
being the most common intervention duration, used in 13 studies. All studies
included competitive athletes as their population and did not withdraw athletes
from competitive sport during the intervention period. Various categories of
athletes were described, including recreational (9), elite (8), collegiate (2),
professional, or the type of sport played, mainly basketball, volleyball, handball,
and soccer (5).

Outcome measures

9
Of the 29 included studies, 24 assessed pain and or function as a main outcome
measure of the intervention, using measures such as the visual analogue scale
(VAS) (11), Victorian Institute of Sport Assessment – Patellar (VISA-P) (20), and
the pain numeric rating scale (NRS-P) (5). Other outcome measures included
tendon properties assessed by ultrasound (6), MRI (1) or electromyography (1),
patellar tendinopathy incidence (6), measures of strength (6), measures of power
(3), quality of life (1) and biomechanics (1).

Outcomes

Four of the five studies investigating the effects of preventative exercise

interventions in athletes with patellar tendinopathy found a reduction in
tendinopathy incidence following the intervention (Kramer et al. 2008, Gual et al.
2016, Bittencourt et al. 2022, Mersmann et al. 2021). One study did not find
reduced incidence despite finding reduced risk for developing patellar tendon
abnormalities on ultrasound (Fredberg et al. 2008). The four studies finding
reduced incidence all included progressively loaded isotonic exercises, whereas
the study finding no reduction used stretching and unloaded eccentric exercises,
which may have been underdosed to derive significant tendon adaptations. The
RCT using ESWT in isolation in in-season athletes did not find any clinical benefit
of the intervention over placebo (Zwerver et al. 2011). Two RCTs combined ESWT
with eccentric training in competing athletes, with both finding no additional effect
of ESWT over eccentric training alone (Thijs et al. 2017, Lee et al. 2020). These
findings suggest ESWT is not an effective management option for in-season
athletes who continue to compete in sport. One RCT found that the use of a
patellar strap or sports tape provided short-term pain relief in competing athletes
with patellar tendinopathy, suggesting it may be a useful adjunctive management
option to reduce pain in the short-term (De Vries et al. 2016). Significantly, all the
22 studies investigating an exercise-based intervention for in-season
management of patellar tendinopathy found positive clinical outcomes in terms of
pain and function improvement. Eccentric training (Cannell et al. 2001, Visnes et
al. 2005, Young et al. 2005, Biernat et al. 2014, Lee et al. 2020, Thijs et al. 2017,
Basas et al. 2018), HSRT (Ruffino et al. 2021, Kongsgaard et al. 2009, Sprague

10
et al. 2021, Agergaard et al. 2021), isometric training (Van Ark et al. 2016, Rio et
al. 2015, Rio et al. 2017, Pietrosimone et al. 2020, Holden et al. 2020), isotonic
training (vander Doelen et al. 2020, Bianco et al. 2019, Silva et al. 2015), inertial
flywheel training (Romero-Rodriguez et al. 2011, Ruffino et al. 2020), and BFRT
(Cuddeford et al. 2020, Sata et al. 2005), were all feasible and effective
intervention methods for managing patellar tendinopathy in competing athletes.
Although determining which of these exercise training methods is the most
effective option is beyond the scope of this review, the quantity of evidence from
RCTs is currently greater for eccentric training, followed by HSRT and isometric
training. Preliminary evidence suggests inertial flywheel training and BFRT may be
comparable in terms of in-season effectiveness, but further large-scale RCTs are
required to determine their true effectiveness due to a paucity of current research.

Training parameters

Of the 29 included studies in this scoping review, 27 used an exercise-based

intervention. As various types of exercise were used, there was significant
heterogeneity in the exercise training parameters and prescription across studies
(Tables 1 & 2). Exercise types included, eccentric (10), isotonic (9), isometric (7),
HSRT (5), BFRT (2), and inertial flywheel (2). Specific exercises used more than
once throughout studies included, single leg decline squats (7), squats (10), leg
press (8), knee extension (4) and heel raises (2). The number of exercise sets
ranged from 1-6, repetitions ranged from 4-30, and frequency ranged from a
single session to 7 days a week, twice a day. In studies that reported exercise
progression methods, the most common method was to progressively increase
training resistance based on pain response, typically with small increments in
external weight. The most common rest time reported between training sets was
2-3 minutes, with many studies not reporting rest times. Adherence to exercise
was poorly reported across studies, with 16 studies not reporting exercise
adherence level, and seven studies supervised all exercise so did not report
adherence. Only five studies fully reported exercise adherence, which ranged from
67-100% per intervention, with all five studies reporting an overall high level of

11
exercise adherence of more than 70% (Ruffino et al. 2021, Young et al. 2005,
Kongsgaard et al. 2009, Sprague et al. 2021, Agergaard et al. 2021).

DISCUSSION

This scoping review aimed to assess what interventions have been used for
prevention and in-season management of patellar tendinopathy in athletes and
what outcomes have been reported. Despite a paucity of literature on prevention
programs for patellar tendinopathy, four studies have found positive effects of
exercise-based interventions for reducing the incidence of patellar tendinopathy
in athletes (Kramer et al. 2008, Gual et al. 2016, Bittencourt et al. 2022,
Mersmann et al. 2021). Despite these encouraging findings, further high-quality
large scale RCTs are required to confirm the prophylactic effect of exercise in
reducing patellar tendinopathy incidence, as only one of these studies was a RCT,
which found benefit of inertial flywheel training in preventing patellar tendinopathy
in athletes (Gual et al. 2016). Despite the common practice of withdrawing
athletes from sports training and competition during patellar tendinopathy,
findings from this review suggest that practice may be unwarranted and perhaps
even counterproductive for competing athletes, given the consequences of sport
withdrawal. Of the 24 studies using an in-season management intervention while
maintaining athletes in sports participation, 22 used an exercise-based approach.
Whilst it may not be surprising that most interventions were exercise-based given
that exercise is the most recommended treatment intervention for patellar
tendinopathy, the lack of other interventions employed could be considered
surprising, given the plethora of methods used in treating patellar tendinopathy.
An advantage of exercise over other common treatments such as injection-based
therapies is that a period of sport withdrawal is not necessary while undergoing
treatment. In comparison, common treatments such as percutaneous electrolysis
and injection-based therapies such as corticosteroid, blood-derived, and
hyaluronic acid, typically stipulate a period of rest is required after treatment
(Mendonca et al. 2020). Despite conflicting evidence of its effectiveness for
patellar tendinopathy compared to other lower limb tendinopathies, ESWT is a
commonly used treatment option, particularly in competing athletes (Zwerver et

12
al. 2011). However, findings from this review suggest ESWT offers no benefit over
eccentric resistance training during in-season management for athletes,
suggesting it should not be recommended and should only be considered as
adjunct to exercise (Lee et al. 2020, Thijs et al. 2017). Recently, it has also been
suggested that ESWT offers little benefit in any population with patellar
tendinopathy, not just competing athletes subjected to high training loads
(Challoumas et al. 2021). Patellar strapping and taping were found to offer short-
term pain reduction in competing athletes, suggesting it may be an appropriate
adjunctive treatment to resistance exercise, particularly for short-term pain
management during training and competition (De Vries et al. 2016).

A significant finding from this review, was that despite a range of exercise types
and prescription parameters being used across studies, all exercise interventions
found clinical improvement in patellar tendinopathy in athletes while maintaining
sports participation. All exercise interventions were progressive resistance training
in varying formats, suggesting the type of resistance training is less important,
provided it is appropriately loaded and progressed to stimulate positive tendon
adaptations. The four out of the five prevention studies using adequately loaded
resistance exercise found it had a prophylactic effect, whereas the study using an
unloaded exercise intervention found no benefit. Resistance exercise types such
as eccentric, isotonic, isometric, HSRT, BFRT, and inertial flywheel training all
showed clinical benefit in athletes when used during the competitive season.
However, despite all these options being potentially feasible and effective for
patellar tendinopathy in-season, there is a clear hierarchy in terms of the strength
of evidence behind each method at present, due to the overall body of evidence
and number of adequately powered RCTs that have been conducted. As also found
in recent systematic reviews, it appears the strength of evidence from RCTs is
currently greater for eccentric training, followed by HSRT and isometric training
(Challoumas et al. 2021, Mendonca et al. 2020, Irby et al. 2020, Girgis et al.
2021). Preliminary evidence suggests inertial flywheel training and BFRT may be
comparable in terms of in-season effectiveness, but further large-scale RCTs are
required to determine their true effectiveness due to a paucity of current research.

13
Although local strengthening of knee musculature is a proven method for treating
patellar tendinopathy, it is important that clinicians also consider non-local factors,
such as kinetic chain strength, hip muscle weakness and ankle range of motion
(Cook and Purdam 2013, Silva et al. 2016, Mendonca et al. 2016, Mendonca et al.
2018). Only one study in this review had an intervention focused on hip muscle
strengthening, which was found to be an effective management strategy despite
not including recommended eccentric knee focused exercise (Silva et al. 2015).
None of the included studies had a primary or secondary focus on education within
their intervention, which is concerning as education within tendinopathy
rehabilitation is normally a significant clinical intervention component, which is
known to also affect exercise adherence (Vicenzino 2015, Nunez-Martinez et al.
2021, Sancho et al. 2019, Mellor et al. 2018, Alghamdi et al. 2021). For example,
a recent survey found that 80% of physical therapists routinely implement
education within their patellar tendinopathy rehabilitation interventions
(Mendonca et al. 2020). Return to sport criteria is a rehabilitation component that
appears to be overlooked within patellar tendinopathy rehabilitation research,
despite its importance for guiding clinicians in safely returning athletes to sport
(Rudavsky and Cook 2014). Although studies in this review did not withdraw
athletes from sport, doing so is still common practice in patellar tendinopathy
(Kulig et al. 2005). In clinical practice, physical therapists typical rely on measures
of pain and function such as the VISA-P, and functional tests, such as hopping and
single-leg decline squats to make decisions on return to play (Hernandez-Sanchez
et al. 2012, Larsson et al. 2012). While these methods may be helpful, better
guidelines and consensus criteria are required to guide clinicians in returning
athletes with patellar tendinopathy to sport, if the decision is made to undergo a
period of sport withdrawal.

This scoping review is not without limitations. The review has included a range of
study designs from RCTs to individual case reports, so there is therefore vast
heterogeneity in interventions and findings across all the studies. Therefore, the
findings should be interpreted with caution. However, determining effectiveness
of interventions through meta-analysis techniques was not the objective of the
review, with the aims focused on understanding what interventions and outcomes
have been found for prevention and in-season management of patellar

14
tendinopathy in athletes. Only studies available in English language were included,
which may introduce language bias. Although all primary research designs were
considered for inclusion, this review did not consider review papers or clinical
practice guidelines, which may have included detailed information on prevention
and in-season management interventions.

CONCLUSION

Despite a dearth of studies to date on preventative interventions for athletes with

patellar tendinopathy, preliminary evidence suggests that progressive resistance
training is an effective prophylactic method, which should be recommended to all
athletes at risk such as those in jumping sports. There is a significant body of
evidence suggesting that resistance training interventions are effective for
managing patellar tendinopathy during the competitive season, without the need
to withdraw athletes from sport, negating the associated deleterious
consequences. The strength of evidence from RCTs is currently greater for
eccentric training, followed by HSRT and isometric training, with preliminary
evidence suggesting inertial flywheel training and BFRT may also be effective in-
season management strategies. There is currently no evidence to suggest that
ESWT offers any additional benefit over resistance training, in competing athletes,
so it should only be considered as a possible adjunct to resistance training,
alongside patellar strapping and taping, which may offer short-term pain relief
during training and competition. The main recommendations from this review, is
that high risk athletes, particularly those participating in jumping sports, should
be required to undergo progressive resistance training as a preventative method
for patellar tendinopathy. Similarly, athletes already diagnosed with clinical
patellar tendinopathy should undergo a progressive resistance training
intervention while maintaining sports participation, prior to considering sport
withdrawal.

15
Acknowledgements: None declared

Authorship contributions: IB conceptualised the work and developed the

methods, search strategy and framework for the review. IB and AM contributed
to the development of the research questions and the study design. All authors
developed the first and subsequent drafts of the manuscript and reviewed and
approved the manuscript.

Funding: No sources of funding were used to assist in the preparation of this

article.

Conflicts of interest/Competing interests: None declared.

Patient consent: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: All data relevant to the study are included in the
article or uploaded as supplementary information.

16
Appendix 1: Search strategy

- Information sources and search strategy.

Databases: MEDLINE (PubMed), CINAHL, AMED, EMBase, SPORTDiscus CENTRAL
of Cochrane Library
Search fields: Title, abstract, key words
Search terms (database subject headings)
1. - “prevention” OR “preventative” OR “in-season” OR “management” OR
“rehabilitation” OR “treatment” 2 - “patellar tendon” OR “patellar tendinopathy”
OR “patellar tendinitis” OR “patella tendon” OR “knee tendon”
3. 1 AND 2

17
Table 1: Prevention studies in athletes at risk for patellar tendinopathy

Author, Study Intervention, exercises, Training parameters Outcome measures Outcomes, results
design, population duration

Fredberg et al. 1. ECCT (heel raises, step- Sets: 1, Reps: 25, Freq: 7 x PT incidence, tendon ECCT and stretching program reduced
2008, RCT, n=209, ups), stretching (calf & WK, Prog: NR, Int: 25-RM. changes (US) the risk of developing ultrasonographic
professional male quadriceps). 12 months Adherence: NR abnormalities in the patellar tendons
soccer players but had no positive effects on the risk
of PT.
Kraemer et al. 2009 1. Soccer specific balance Sets: 1, Reps: 15-30 seconds, PT incidence Soccer-specific balance training can
Cohort, n=24, elite training: (sitting, standing, Freq: NR, Prog: increase significantly reduce the incidence of PT.
female soccer and jumping based balance difficultly, Int: 25-RM. A dose-effect relationship between
players exercises). 3 years Adherence: 100% duration of balance training and injury
incidence is evident.
Gual et al. 2016, 1. Normal sports training + Sets: 4, Reps: 10, Freq: 1 x Pain & function (VISA- Countermovement jump scores
RCT, n=81, athletes inertial flywheel training, WK, Prog: NR, Int: 8-RM, reps P), Vertical counter (power) and concentric and eccentric
at risk for PT YoYo-squat 2, normal sports 1–2 were used for increasing movement jump, and strength improved more in flywheel
training.24 weeks inertial resistance, and reps 3– squat power, both group, with no cases of PT recorded.
10 were executed with maximal concentric and eccentric
effort. Rest: 2 MIN between strength, PT incidence
sets. Session time: 20 MIN.
Adherence: supervised, %NR
Bittencourt et al. 1. Individually tailored Sets: NR, Reps: NR, Freq: 2 x PT incidence Intervention showed 51% less risk of
2022, Cohort, exercise program: warm-up WK, Prog: NR, Int: NR, Time; developing PT. 26 athletes developed
n=271, elite youth drills, ankle stretches, hip 15-20 MIN per session. PT in the observation year, whereas 13
jumping athletes bridge, squats, lateral and Adherence: NR developed PT in the intervention year.
(basketball and frontal planks, SL balance, A tailored preventive program may be
volleyball) trunk mobility, landing able to reduce the incidence of PT in
pattern training. 1 year male youth volleyball athletes.
Mersmann et al. 1. Functional high-load Sets: 5, Reps: 4, Freq: 2 x WK, PT incidence, muscle, 30% of control athletes reported a
2021, Case control, exercise: single & double leg Prog: increase resistance, Int: and tendon mechanical clinically significant aggravation of
n=34, elite squats 2. Control: regular 4-RM, Rest; 2-3 MIN between properties (US), symptoms, all players in the
adolescent handball training: explosive strength & sets, Time; 20 MIN per session. quadriceps strength experimental group remained or
players Adherence: NR (dynamometer) became pain-free until the end of the

18
 muscular endurance training. season. There was a similar increase of
1 year. strength and VL thickness in both
groups, but no significant changes of
tendon stiffness or tendon strain. High-
load exercises reduced the prevalence
of patellar tendon pain.

Table 2: In-season management studies in athletes with patellar tendinopathy

Author, Study Intervention, Training parameters Outcome measures Outcomes, results

design, population exercises, duration

Ruffino et al. 2021, 1. HSRT (squat, hack Sets: 4, Reps: 12(10 max effort), Freq: Pain & function (VISA-P, Both groups improved clinical
RCT, n=42, squat, leg press). 2. 1 x WK, Prog: NR, Int: 8-RM, reps 1–2 SLDS, PSFS), health outcomes, with no significant
recreational athletes Inertial Flywheel were used for increasing the inertial status (EuroQol-5D), difference between groups in
(Volleyball, training (squat, leg resistance, and reps 3–12 were executed physical tests (strength & clinical outcomes, physical tests
basketball, soccer, press, knee extension). with maximal effort. Rest: 2-3 MIN power), tendon (strength & power), or tendon
Running) 12 weeks between sets. Session time: 20 MIN. properties (US) thickness & neovascularization.
Adherence: 88-90%
Cannell et al. 2001, 1. ECCT: Progressive Sets: 6, Reps: 15, Freq: 7 x WK, 2 x Pain (VAS), return to Progressive drop squats
RCT, n=19 athletes drop squats and leg day, Prog: increase resistance, Int: 15- sport and leg extension/curl exercises
extension/curl exercises RM, pain response. Adherence: NR both reduced pain and enable
2. Isotonic Ex. 12 return to sport.
weeks
Visnes et al. 2005, 1. ECCT (SLDS) 2. Sets: 6, Reps: 15, Freq: 7 x WK, 2 x Pain & Function (VISA-P) No effect of ECCT compared with
RCT, n=29, elite Normal volleyball day, Prog: increase resistance in 5kg those who continued volleyball
volleyball athletes training. 12 weeks increments, Int: 15-RM, pain response. training.
Adherence: NR
Young et al. 2005, 1. ECCT step 2. ECCT Sets: 6, Reps: 15, Freq: 7 x WK, 2 x Pain (VAS), function Both groups improved pain and
RCT, n=17, athletes decline (SLDS). 12 day, Prog: increase speed & resistance in (VISA-P) sporting function at 12 months.
weeks 5kg increments, Int: 15-RM, pain Decline squat more effective.
response. Adherence: 72%
Kongsgaard et al. 1. CSI 2. HSRT (squat, Sets: 3-4, Reps: 6-15, Freq: 3 x WK, Pain (VAS), Function All groups improved, with only
2009, RCT, n=39 leg press, hack squat) Prog: increase resistance, Int: 6-15-RM, (VISA-P), tendon exercise groups maintaining
recreational athletes 3. ECCT (SLDS). 12 pain response. Adherence: 89-91% properties (US) improvements at 6 months. HSRT
weeks

19
 has good short and long-term
clinical effects.
Cuddeford et al. 1. Low-load BFRT: SL Sets:4, Reps:15-30; Freq 2 x WK: Prog: Pain (VAS), Function Patients improved clinical
2020, Case report, leg press, SLDS. 12 increase resistance (10lbs Inc), Int: 15- (VISA-P), Tendon size outcomes and returned to sports
n=2, 2 male college weeks 30RM (1RM load). Occlusion pressure: (US), Hip & knee activity. Improvements in tendon
decathletes 80% restriction of arterial inflow. 30 strength (handheld thickness and resolution of
second rest between sets (cuff not dynamometry, SL leg hypoechoic region. Increased
removed). Adherence: supervised, NR. press 1RM) lower limb strength.
Sata et al. 2005, 1. Low-load BFRT: Sets: 3, Reps; 15, Freq: 5-6 x WK, Prog: MRI (signal intensity). Patient improved clinical outcomes
Case report, n=1, straight leg raises, hip Int:15rm (30% of 1RM). Occlusion Thigh circumference and returned to playing basketball
male basketball abduction & adduction, pressure range: 160-180 mmHg.
player calf raise, toe raise, Adherence: NR
squat, crunch, back
extension, basketball
shooting. 3 weeks
Romero-rodriguez et 1. Isoinertial flywheel Sets: 4, Reps: 10, Freq: 1 x WK, Prog: Pain (VAS), function Intervention was effective for
al. 2011, case ECCT, maximal effort, NR, Int: 8-RM, reps 1–2 were used for (VISA-P), lower limb improving clinical outcomes.
series, n=10, leg press. 6 weeks increasing the inertial resistance, and maximal strength and Eccentric strength increased but
national level reps 3–10 were executed with maximal vertical counter- power (CMJ) did not.
athletes (soccer, effort. Rest: 2 MIN between sets. movement-jump (CMJ)
basketball, running) Session time: 20 MIN. Adherence: NR height, SEMG

Biernat et al. 2014, 1. ECCT (SLDS) 2. Sets: 6, Repetitions: 15, Freq: 7 x WK, Pain & Function (VISA-P), ECCT group superior for pain and
RCT, n=28 male Normal training, 12 Prog: increase difficulty (unstable PT incidence function improvement
volleyball players weeks surface), Int: 15RM, pain response. Patellar tendinopathy
Adherence: NR was observed in 18% of the tested
young volleyball players.
De Vries et al. 2016, 1. Patellar strap 2. Adherence: NR Pain (VAS) & Function VAS reduced significantly in the
RCT, n=97, athletes Sports tape 3. Placebo (VISA-P), SLDS, vertical patellar strap and the sports tape
4. Control. 2 weeks jump test, triple hop test condition, compared with control,
but not placebo. Orthosis during
sports can reduce pain in the short
term.
Vander Doelen et al. 1. Multimodal Sets: 3-4, Reps: 6-15, Freq: 3 x WK, Pain (NRS-P), Function Patients improved clinical
2020, retrospective, rehabilitation (isometric Prog: increase resistance, Int: 6-15-RM, (VISA-P) outcomes and returned to sports
n=9 basketball knee extension, isotonic pain response, 70% MVIC for isometric. activity.
players HSRT leg press, squat, Adherence: NR
hack squat), DN, ESWT,
MT. 32 weeks

20
Lee et al. 2020, 1. ECCT (SLDS) 2. Sets: 6, Reps: 15, Freq: 7 x WK, 2 x Pain (VAS), Function Combining exercise and ESWT
RCT, n=34, ECCT + ESWT. 12 day, Prog: increase speed & resistance in (VISA-P), tendon could not been shown to be more
recreational athletes weeks 5kg increments, Int: 15-RM, pain properties (US) effective than exercise alone
response. Adherence: NR
Van Ark et al. 2016, 1. isotonic (leg Sets: 4-5, Reps: 5-8, Freq: 4 x WK, Pain (NRS), function Both isometric and isotonic
RCT, n=29, extension) Ex 2. Prog: increase resistance in 2.5% weekly (SLDS) exercise programs improved pain
recreational athletes Isometric Ex (leg increments, Int: 5-8-RM, 80% MVIC for and function
extension). 4 weeks isometric, pain response. Adherence: NR
Thijs et al. 2017, 1. ECCT (SLDS) + Sets: 6, Reps: 15, Freq: 7 x WK, 2 x Pain & function (VISA-P) No additional effect of ESWT to
RCT, n=52, ESWT 2. ECCT. 12 day, Prog: increase resistance, Int: 15- ECCT for pain and function
recreational athletes weeks RM, pain response. Adherence: NR improvement.
Zwerver et al. 2011, 1. Focused ESWT. 3 3 sessions at 1-week, 2000 impulses at Pain (VAS), Function ESWT during the competitive
RCT, n=62, weeks a frequency of 4 Hz were administered. (VISA-P), season had no benefit over
basketball, volleyball The energy flux density was titrated placebo treatment in competing
& handball athletes according to individual pain tolerance up jumping athletes with PT
to a possible maximum of 0.58 mJ/mm2
(level 20). Adherence: supervised
Rio et al. 2015, RCT, 1. Isometric EX (biodex Sets:4 Reps: 8 Freq: single session, Int: Pain & function (SLDS, A single session of isometric EX
n=6, elite athletes leg extension) 2. 8-RM. Adherence: supervised VISA-P), MVIC significantly reduced pain &
Isotonic EX (leg increased MVIC compared to
extension machine). isotonic EX.
Single session
Rio et al. 2017, RCT, 1. Isometric EX (leg Sets: 4, Reps: 8, Freq: 4 x WK, 2 x day, Pain & function (SLDS, Both groups reduced pain,
n=20, elite athletes extension) 2. Isotonic Prog: increase resistance by 2.5% VISA-P) Isometric EX had significantly
EX (leg extension). 4 weekly, Int: 8-RM, pain response. greater immediate analgesic
weeks Adherence: supervised effects
Sprague et al. 2021, 1. HSRT (squat, knee Sets: 4, Reps: 6-15, Freq: 3 x WK, Prog: Trial measures, Pain & A fully powered RCT would be
pilot RCT, n=15, extension, leg press) + increase resistance, Int: 6-15-RM, pain function (VISA-P) feasible, both groups improved
recreational athletes PGA 2. HSRT + PFA. 12 response. Adherence: 67-86% clinical outcomes.
weeks
Agergaard et al. 1. HSRT (leg press, Sets: 3-5, Reps: 4-15, Freq: 3 x WK, Pain (NRS-P), Function Both groups improved clinical
2021, RCT. N=44, knee extension) 2. Prog: increase resistance (% of 1-RM), (VISA-P) outcomes, with no significant
recreational athletes Moderate HSRT. 12 Int: 6-15-RM, 55-90% of 1-RM, pain difference between groups.
weeks response. Adherence: 78-86%
Pietrosimone et al. 1. Isometric EX 2. Sets: 5, Reps: 1 x 45 seconds, Freq: Pain & function (VISA-P), Single session isometric EX did not
2020, RCT, n=28, Sham TENS. Single single session, Prog: increase resistance, biomechanics have acute effects on pain or
recreational athletes session Int: 70% MVIC. Adherence: supervised landing biomechanics.
Holden et al. 2020, 1. Isometric EX Sets: 3, Reps: 8, Freq: single session, Pain (NRS, PPT) Both groups immediately
RCT, n=21, (biodex) 2. Dynamic EX Prog: increase resistance, Int: 8-RM. decreased pain but not after 45
recreational athletes Adherence: supervised

21
 (leg extension). Single mins, no difference between
session groups.
Basas et al. 2018, 1. ECCT + isometric Sets: NR, Reps: NR, Freq: 3 x WK, Prog: Pain (VAS) Intervention was effective for
cohort, n=6, elite quadriceps exercises + increase resistance, Int: NR, pain improving clinical outcomes.
jumping athletes Electro stimulation. 12 response. Adherence: NR
weeks
Bianco et al. 2019, 1. MT + Exercise (Wall Sets: 2-3, Reps: 10-15, Freq: NR, Prog: Pain (VAS), Function Patients improved clinical
case series, n=3, decline squat, SL mini increase speed, Int: 10-15-RM, pain (VISA-P) outcomes and returned to sports
college male squat, squat, DSLS, response. Adherence: NR activity
basketball athletes drop squat, SL squat,
jump downs). 12 weeks
Silva et al. 2015, 1. Hip strength exercise Sets: 3, Reps: 15, Freq: 3 x WK, Prog: Pain (VAS), Function Patient improved clinical outcomes
case report, n=1, (Prone hip extension, increase resistance in 2kg increments, (VISA-P) and returned to sports activity
elite male volleyball birddog, SL deadlift, Int: 15-RM, 50% of 1-RM, pain
athlete drop jumps). 8 weeks response. Adherence: NR

Abbreviations: Abbreviations: PT: Patellar tendinopathy, ECCT: eccentric training, ESWT: extracorporeal shockwave therapy, DN: dry needling; MT:
manual therapy, EX: exercise; VAS: visual analogue scale, NRS-P: pain numeric rating scale, VISA-P: Victorian Institute of Sport Assessment – Patellar,
WKS: weeks, US: ultrasound, HSRT: heavy slow resistance training: CONCT: concentric training, E-STIM: electrical stimulation, CSI: corticosteroid
injection: LLLT: low-level laser therapy, BFRT: blood flow restriction training, MRI: magnetic resonance imaging, PPI: pain pressure intensity, SLDS:
single leg decline squat, SL: single leg, Reps: repetitions, Freq: frequency, Prog: progression, Int: intensity, RM: repetition maximum, NR: not reported,
TENS: transcutaneous electrical nerve stimulation, n: number, RCT: randomized controlled trial, VL: vastus lateralis, SEMG: Surface electromyography,
CMJ: countermovement jump, PGA: pain-guided activity, PFA: pain-free activity.

22
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