Journal of Science and Medicine in Sport 23 (2020) 118–124

Contents lists available at ScienceDirect

Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Review

Non-surgical treatment of patellar tendinopathy: A systematic review

of randomized controlled trials
Trevor Vander Doelen a,∗ , Wilma Jelley b
a
DC University of British Columbia Faculty of Medicine, Department of Rehabilitation Sciences, Canada
b
University of British Columbia Faculty of Medicine, Department of Occupational Sciences & Occupational Therapy, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Study design: Systematic review of randomized controlled trials.

Received 21 April 2018 Objectives: To determine the most effective non-surgical treatment interventions for reducing pain and
Received in revised form 20 July 2019 improving function for patients with patellar tendinopathy.
Accepted 5 September 2019
Methods: Studies considered for this systematic review were from peer-reviewed journals published
Available online 13 September 2019
between January 2012 and September 2017. All included studies used a visual analogue scale (VAS) to
evaluate the participant’s pain. The majority of the included studies also used the Victorian Institute of
Keywords:
Sport Assessment Patellar Tendinopathy (VISA-P questionnaire) to assess participant’s symptoms and
Patellar tendinopathy
Isometric exercise
function.
Platelet rich plasma injections Results: Nine randomized controlled trials fit the inclusion criteria and were analyzed. The results of
Shockwave therapy three studies supported the use of isometric exercise to reduce pain immediately. One study found patel-
Patellar strapping lar strapping and sports taping to be effective for reduction in pain during sport and immediately after.
Dry needling Eccentric exercise, Dry Needling (DN) (2 studies), injections with Platelet Rich Plasma (PRP), Autolo-
gous Blood Injection (ABI), and saline were found to have a more sustained effect on reducing pain and
improving knee function.
Conclusion: Isometric exercise, patellar strapping, sports taping, eccentric exercise, injections with PRP,
ABI, and saline and DN demonstrated a short-term pain relieving and functional improvement effect in
subjects with patellar tendinopathy. Longer term follow up on interventions involving eccentric exercise,
DN, and injections with PRP, ABI and saline showed sustained pain reduction and improvement in knee
function.
Level of evidence: Level 1.
© 2019 Published by Elsevier Ltd on behalf of Sports Medicine Australia.

1. Introduction difficult to manage and can result in chronic impairment with an

average duration of 32 months.9
Patellar tendinopathy is diagnosed clinically by pain in the patel- This pain may be transient and is closely linked to lower body
lar tendon. This tendinopathy typically presents in adolescent-aged loading, as excessive energy storage in the tendon often precedes
athletes that are involved in jumping sports such as basketball and pain.13 The pain associated with patellar tendinopathy is also rarely
volleyball but may persist into adulthood. Patellar tendinopathy felt at rest or under minimal loading situations, and often improves
is present in approximately 14% of all elite athletes at any given as the tendon warms up during exercise.
time and 22% of elite athletes will have patellar tendon pain at Several models have been proposed to explain the pathoetiology
some point during their athletic career.9 The prevalence varies of patellar tendinopathy. The failed healing model of tendinopathy
amongst sports and is much more common in sports that involve described by Leadbetter8 suggests that the involved tendon is in a
high-impact ballistic loading of the knee extensors, as approxi- healing phase where numerous changes are occurring. The contin-
mately 31.9% of basketball players and 44.6% of volleyball players uum model2 hypothesizes that a normal tendon is able to withstand
are affected. The pain associated with patellar tendinopathy is often optimal loading until intrinsic factors are applied, and then the
tendon becomes reactive. Intrinsic factors include genetics, age,
circulating and local cytokine production, gender, biomechanics,
and body composition. Scott et al.15 found that when tendons are
∗ Corresponding author. chronically exposed to volumes of loading such as tension, com-
E-mail address: [email protected] (T. Vander Doelen).

https://doi.org/10.1016/j.jsams.2019.09.008
1440-2440/© 2019 Published by Elsevier Ltd on behalf of Sports Medicine Australia.

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 T. Vander Doelen and W. Jelley / Journal of Science and Medicine in Sport 23 (2020) 118–124 119

pression, and friction that are beyond their physiological capacity,

there is a cycle of injury and repair that is cumulative.
Currently health care professionals employ surgical and non-
surgical treatment strategies to deal with patellar tendinopathy.
Non-surgical interventions include eccentric, isometric and/or iso-
tonic exercises, PRP injections, DN, extracorporeal shockwave
therapy (ESWT), manual therapy, and corticosteroid injections. The
purpose of this systematic review was to determine the most effec-
tive non-surgical treatments currently available.

2. Methods

The systematic review was performed following the PRISMA

(Preferred Reporting Items for Systematic Reviews and Meta-
analyses) statement. One reviewer (T.V.) completed the literature
search, assessed the literature and removed duplicates. Two
reviewers (T.V. and W.J.) were involved in the extraction of the
data.
Medline, CINAHL, Embase, Sportdiscus, and Cochrane databases
were searched using the terms “patellar tendon” or “patellar liga-
ment”. The key terms were generally exploded and combined with
“tendinopathy”, which was also exploded. A grey literature search
was also performed in the Web of Science and PEDro databases.
These grey literature databases were included to ensure all qualify-
ing studies were included in this review. The search terms required
modification for these databases and were simply set at “patellar
tendinopathy”.
The initial search was not limited by year, language, or study
design to include as many results as possible. Initial results included
biomechanical, histological, and animal studies as well as sur-
gical and non-surgical treatment studies. After duplicates were
removed, the inclusion and exclusion criteria were applied to the
remaining results. Studies were included if they were random-
ized controlled trials investigating treatment for patients with
a diagnosis of patellar tendinopathy published between January
2012 and September 2017. The search was limited to studies Fig. 1. PRISMA flow diagram.
conducted over the last 5-year period to remain current. The
abstracts for all remaining results from peer-reviewed journals
were reviewed. Full-text versions were obtained to determine con-
clusively whether to include or exclude the studies. Studies not
available in English or in full-text were excluded (Fig. 1). sion criteria. Among the 29 non-surgical treatment articles found,
Inclusion criteria required the use of a visual analogue scale articles were removed that did not involve a control group, ran-
(VAS) for pain. As well the use of the outcome measure, the Victo- domization, were retrospective and were published prior to 2012.
rian Institute of Sport Assessment - Patellar Tendinopathy (VISA-P) Nine articles remained. These included studies investigating the
to evaluate participants’ knee symptoms and function was pre- efficacy of eccentric exercise, isotonic exercise, isometric exercise,
ferred, but was not required. Preference was made for the use PRP injections, saline injections, ABI injections, ESWT, DN, patellar
of the VISA-P, as it is the most commonly used questionnaire of strapping, and sports taping. These studies included a total of 336
pain free function in patients with patellar tendon pain. The VISA-P subjects. Eccentric exercise programs were used in combination
was shown by Visentini et al.20 to have excellent short term test- with the interventions mentioned above for 138 subjects. In total
retest, inter-rater reliability, and good short-term stability over a 27 had isotonic exercises, 24 had isometric exercises, 33 had PRP
one-week period. injections, 11 had saline injections, 11 had ABI injections, 97 had
Descriptive data collected included type of intervention, sam- ESWT, 43 had DN, 34 had sports taping and 21 patellar strapping.
ple size, duration of the intervention, age of subjects, outcome No studies involving corticosteroid injection or manual therapy fit
measures used, and follow-up duration. Outcome data extracted the inclusion criteria.
included VAS scores, VISA-P scores (if available), and conclusions The VAS for pain was measured in each study while each subject
of the study. Effect size was not reported in all studies. Evaluation performed a single leg decline squat. The VAS is an 11-point scale of
of the quality of studies included was not performed to include as pain severity where 0 is no pain and 10 is the most severe pain. The
many studies as possible in the review. The data is presented narra- VAS has been shown to have a minimal clinically important differ-
tively in a systematic review. It was not possible to summarize the ence (MCID) of 3.0–3.5 mm out of 10. The majority of the studies
extracted data statistically in a meta-analysis as the studies were also incorporated the VISA-P. The VISA-P is a questionnaire with a
too diverse. scale from 0 to 100 that describes the pain-free functional status of
a patient with patellar tendinopathy. With a score of 100 indicating
3. Results maximal pain-free function. The VISA-P has been shown to have an
MCID of 13 points according to Kvien et al.7 or a relative change of
The literature search yielded 1427 results. 1056 were removed 15.4–27% according to Hernandez-Sanchez et al.5 The results from
due to duplication and 362 were excluded for not meeting the inclu- each study are presented in Table 1.

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Table 1
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Summary of results of randomized controlled trials.

Author (Year) Intervention (Duration) n (Age) Follow-up Relevant Results Conclusions of the Study

De Vries et al.3 Patellar strapping 97 (19–35) None VISA-P (Baseline) Patellar strapping and sports taping reduced
Sports taping Mean age 27.0 The objective of this study 58.5 pain on application and during and
Placebo sports tape 61% male was to look at short term VAS immediate immediately after participation in sport (up to
Control effects only. Patellar Strap: 14 mm reduction 2 h).
(1 week) Sports Tape: 13 mm reduction
VAS During Sport
Patellar Tape: 7 mm less than control
Placebo Sports Tape: 6 mm less than control

T. Vander Doelen and W. Jelley / Journal of Science and Medicine in Sport 23 (2020) 118–124
VAS two hours after exercise
Patellar strap: 8 mm less than control
Sports Tape: 10 mm less than control
Placebo Sports Tape: 7 mm less than control

Dragoo et al.4 Standardized eccentric 23 12 weeks VISA-P VISA-P: At 12 weeks the eccentric ex. + DN
exercise + PRP injection (22–48) 26 weeks Eccentric ex + PRP + DN group improved only modestly but at 26 weeks
Standardized eccentric Mean age 35.0 Baseline: 41 12 weeks: 66.4 26 weeks: 67.8 they had greater improvement.
exercise + Dry needling 100% male Eccentric ex + DN The eccentric ex. + PRP + DN group had
(DN) Baseline: 47.4 12 weeks: 52 improved more than the other group at 12
(1 injection & structured 26 weeks: 83.9 weeks. At week 26 both groups showed
eccentric exercise & home VAS clinically significant improvement and the
exercise program for 26 Eccentric ex. + PRP + DN difference between groups was not significant.
weeks) Baseline: 4.1 12 weeks: 1.7 VAS: There was no significant difference
26 weeks: 1.7 between groups at 12 and 26 weeks.
Eccentric ex. + DN
Baseline: 3 12 weeks: 2.3
26 weeks: 0.3

Resteghini et al.11 ABI 22 1 month VISA-P VISA-P and VAS scores improved significantly
injection + DN + eccentric (22–61) 3 months ABI in both groups. When the results were
ex. ABI group 8 males & 3 1 year Initial: 34.1 1 month 50.7 compared there was no significant difference
Saline females. 3 months 57.71 year: 62.5 between the two groups.
injection +DN + eccentric Saline group 10 males & 1 Saline
ex. female. Initial: 19.6 1 month 39.2
(1 injection) 3 months 39.2 1 year: 48.6
VAS
ABI
Initial: 7.5 1 month 4.5
3 months 3.5 1 Year: 3.1
Saline
Initial: 7.9 1 month 4.5
3 months 4.0 1 year: 3.3

Rio et al.12 Isometric Exercise 6 None VISA-P Baseline 52.8 Isometric exercise results in significantly
Isotonic Exercise 100% male VAS reduced tendon pain immediately and the
(Single bout of exercise) Median age 26.9 Isometric reduction in pain was sustained when tested at
(18–40) Initial: 7.00 Post: 0.17 45 minutes post exercise.
45 min post exercise: Reduction in pain Isotonic exercise did not result in the same
sustained degree of pain reduction and the pain
Isotonic reduction was not sustained when tested at 45
Initial: 6.33 Post: 3.75 post exercise.
45 min post exercise: Reduction in pain not
sustained
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Rio et al.14 Isometric Exercise 20 None VISA-P Isometric exercise demonstrated significantly
Isotonic Exercise (not set) Isometric greater immediate analgesia than isotonic
(4 weeks) Baseline: 72.5 4 weeks: 84 exercise.
Isotonic
Baseline: 69.5 4 weeks: 80
VAS
Baseline: 5/10
Isometric
After: 3.2/10
Isotonic
After: 4.1/10

Thijs et al.16 ESWT + Eccentric Exercise 52 24 weeks VISA-P There was no additional effect of ESWT over

T. Vander Doelen and W. Jelley / Journal of Science and Medicine in Sport 23 (2020) 118–124
Sham ESWT (18–45) ESWT + Eccentric exercise placebo (sham shockwave) in participants with
(placebo) + Eccentric Male & female Baseline: 54.5 24 weeks: 70.9 chronic patellar tendinopathy who were
Exercise Median age 28.6 Sham ESWT + Eccentric exercise following a daily eccentric exercise program.
(ESWT or placebo 1x/week Baseline: 58.9 24 weeks: 78.2
for 3 weeks) VAS (10 × SLDS)
Both groups performed an ESWT + eccentric
eccentric exercise program Baseline: 4.1 24 weeks: 1.8
2x/ day for 24 weeks. Sham ESWT
Baseline: 4.7 24 weeks: 2.2

van Ark et al.17 Isometric Exercise 29 4 weeks VISA-P Both isometric and isotonic exercise programs
Isotonic Exercise (16–32) Isometric reduced pain and improved knee function
(4 weeks) Median age 23.9 Baseline: 66.5 4 weeks: 75
2 females & 27 males. Isotonic
Baseline: 69.5 4 weeks: 79
VAS
Isometric
Baseline: 6.3 4 weeks: 4.0
Isotonic
Baseline: 5.5 4 weeks: 2.0

Van der worp et al.18 Focused ESWT + Eccentric 43 14 Weeks VISA-P The study found no differences in effectiveness
Exercise (21–41) FESWT between FESWT and RESWT. The authors also
Radial ESWT + Eccentric Baseline: 48.6 14 weeks: 63.6 put forward that it was also questionable
Exercise RESWT whether the slight improvement achieved
(Focused or radial ESWT Baseline: 48.8 14 weeks: 58.4 after 14 weeks was clinically relevant.
1x/week for 3 weeks) VAS
Eccentric exercise for 14 FESWT
weeks) Baseline: 3.3 14 weeks: 2.5
RESWT
Baseline: 3.5 14 weeks: 2.4

Vetrano et al.19 PRP Injections 46 2 months VISA-P At 2 months, both PRP injections and ESWT
ESWT (17–35) 6 months PRP were effective in reducing pain and improving
(PRP injections 1x/week for Median age 26. 85 1 year Baseline: 55.3 1 year: 91.3 function.
2 weeks, ESWT 3 sessions ESWT At 6 and 12-month follow-up the PRP injection
separated by 48–72 h) Baseline: 56.1 1 year: 77.6 group showed significantly better
VAS improvement.
PRP
Baseline: 6.6 1 year: 1.5
ESWT
Baseline: 6.3 1 year: 3.2

Victorian Institute of Sport Assessment – Patellar Tendon (VISA-P), Visual Analogue Scale (VAS), Dry needling (DN), Extracorporeal Shockwave Therapy (ESWT), Focused Extracorporeal Shockwave Therapy (FESWT), Radial
Extracorporeal Shockwave Therapy (RESWT), Autologous Blood Injection (ABI), Platelet Rich Plasma (PRP).

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3.1. Isometric and isotonic exercise larger sample size of 46 subjects. Dragoo et al.3 had a shorter follow-
up period of 26 weeks while Resteghini et al.11 and Vetrano et al.19
Eccentric exercise was used in combination with other treat- had follow-ups of one year. All three studies found clinically signifi-
ment interventions for over one third of the subjects in this review. cant improvement in function as measured by the VISA-P following
No studies looked exclusively at eccentric exercise. Three of the PRP, ABI and saline injections. In the Dragoo et al. study the addi-
nine studies evaluated the benefits of isotonic versus isometric tion of PRP apparently improved function initially but the benefits
exercise. Rio et al.12 found that isometric exercise resulted in sig- dissipated after 26 weeks. The finding of Resteghini et al. that there
nificantly reduced tendon pain immediately and that the reduction was no statistical difference between the saline and ABI injection
in pain was sustained when retested after 45 min. Isotonic exercise groups may support the hypothesis of Vetrano et al. Vetrano et al.
did not result in the same degree of pain reduction and the pain proposed that needling itself on tendinopathic tissue may have a
reduction was not sustained. In this study, the isometric group per- positive effect on tissue healing.
formed five 45-s isometric holds at 70% of one repetition maximum
(RM) and the isotonic group performed four sets of eight repetitions 3.3. Extracorporeal shockwave therapy (ESWT)
involving a 4-s eccentric phase and 3-s concentric phase at 100% of
eight RM. Three of the nine studies assessed the effectiveness of ESWT.
Van Ark et al.17 used a similar protocol involving an isomet- Van der Worp et al.18 demonstrated that after three sessions, par-
ric group performing five 45 s holds at 60◦ of knee flexion at 80% ticipants receiving either focused (electromagnetic or peizoelectric
maximal voluntary isometric contraction and an isotonic group mechanism) or radial (pneumatic mechanism) ESWT treatment
performing four sets of eight repetitions at 80% of eight RM with a showed only slight improvement after 14 weeks. The improvement
4-s eccentric phase and a 3-s concentric phase. These authors found was not clinically relevant.
a clinically important decrease in pain and improvement in func- As mentioned above in the PRP injection results section, Vetrano
tion during a 4-week trial of both isotonic and isometric exercise et al.19 found that either three sessions of ESWT or two PRP injec-
with athletes during in-season training. tions were effective at 2 month, 6 month, and 12 month follow up.
In 2017, Rio et al.14 used the same isometric protocol as Van ark However, at 6 and 12-month follow-up the PRP injection group had
et al.17 but with a 4-s eccentric and 3-s concentric phase for the iso- better results.
tonic protocol. This study demonstrated that isometric contractions Thijs et al.16 compared ESWT to sham shockwave (placebo). All
provided significantly greater immediate analgesia as compared to subjects were also following a daily eccentric exercise program.
isotonic contractions throughout a 4-week in-season trial. This study found no additional effect of ESWT over placebo.
These three studies were performed with similar exercise pro- The three ESWT studies had follow-up between 14 weeks and
tocols but with different timing of follow-ups. Isometric exercise 1 year. Only one study, Vetrano et al., demonstrated positive results
consistently resulted in immediately reducing knee pain with this with the use of ESWT. Even then, the positive results were with
reduction in pain sustained for a short period afterward in all three functional improvement only and were not as significant as those
studies. Isotonic was found to be effective in one of the three stud- achieved with PRP injections.
ies.
3.4. Dry needling (DN)
3.2. Platelet rich plasma (PRP) injections and autologous blood
injection (ABI)
One study compared the use of DN and eccentric exercise to PRP
injection, DN and eccentric exercise. DN was also used in combina-
Three studies look at the use of injections as an intervention for
tion with saline injection or ABI injection in another study. DN was
patellar tendinopathy. One study evaluated the use of ABI injections
never carried out as an intervention on its own. In the two studies
and compared it to saline injections. Two studies evaluated the use
that incorporated DN there was significant improvement in knee
of PRP injections. It should be noted that DN was included with all
function at follow-up.
injections.
Resteghini et al.11 used a single injection of either ABI or saline,
in two groups of patients previously not responding to three 3.5. Patellar strapping and patellar taping
months of eccentric exercise. Patients were advised to continue
their eccentric exercise programs post-injection as well. Follow- One of the nine studies evaluated sports taping and patellar
up was done at 1-month, 3-months, and 6-months. Both groups strapping. De Vries et al.2 established that a patellar strap, non-
had significantly decreased knee pain and improved knee function. stretch tape, and placebo tape used during sport for two weeks
When the results were compared there was no statistical difference could reduce pain during and immediately after exercise for up
between the saline and ABI injections groups. to two hours. Placebo taping was done using a non-specific appli-
Vetrano et al.19 used two PRP injections one each week for two cation of a stretch tape over the patellar tendon. The authors
weeks. This was found to be effective in reducing pain and improv- put forward a possible explanation for the placebo tape results.
ing knee function at the follow-up at 2-months, 6-months and They hypothesized that by applying any orthosis, including placebo
12-months. This treatment intervention was compared to a group sports tape, to the knee, pain will be reduced due to the cutaneous
that received 3 sessions of ESWT, the results for this group were structures being stimulated. There was no long term follow up car-
not significant. ried out in this study.
Dragoo et al.3 compared PRP injection to DN both interventions
were combined with standardized eccentric exercise. In terms of 4. Discussion
function at 12 weeks the DN group had only modest improvement
but had greater improvement at 26 weeks. The PRP group was sig- The results of this review found a number of non-surgical treat-
nificantly better at 12 weeks but at 26 weeks the difference between ment interventions may help to reduce pain and improve knee
the groups was not significant. With regards to pain there was a function in patients with patellar tendinopathy. Certain interven-
slight reduction in pain for both groups at 12 and 26 weeks. tions in this review were proven to be more effective in the
Resteghini et al.11 and Dragoo et al.3 had similar smaller sample short-term including isometric exercise, sports taping and patel-
sizes of 22 and 21 subjects respectively and Vetrano et al.19 had a lar strapping, while others PRP injections and DN proved to have

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sustained results and therefore are beneficial for longer term pain included in the review. It is possible that relevant studies published
reduction and functional improvement. in other languages may have been excluded.
In a clinical commentary published in 2015, Malliaras et al.10
emphasized an exercise focused approach to the treatment of patel- 5. Conclusion
lar tendinopathy with passive interventions used only as an adjunct
alongside exercise interventions. They described a four-stage reha- This review of the highest level of evidence found that isomet-
bilitation progression with a focus on developing kinetic chain ric and eccentric exercise, patellar strapping and taping, DN, and
muscle and patellar tendon load tolerance. Stage one is the iso- certain injections have a short-term pain reducing and knee func-
metric loading exercise phase, Stage two is the isotonic exercise tional improvement effect in patients with patellar tendinopathy.
phase, Stage three is the energy storage exercise phase, and stage PRP injections, DN, and eccentric exercise were also shown to be
four is the progressive return to sport phase. significantly effective for long-term pain relief and improvement
The results of this systematic review support incorporating in knee function for patients with patellar tendinopathy. There is
short-term pain relief interventions such as patellar strapping and no current evidence to suggest how to use these potential options
sports taping into all stages of rehabilitation progression. The inter- together for maximum benefit. This review will help clinicians
ventions that showed longer term effect such as PRP injections and select the best non-surgical intervention(s) indicated for patients
DN could be incorporated into Stage two of rehabilitation progres- with patellar tendinopathy based on the current available evidence.
sion.

Key points
4.1. Findings regarding short-term effect

Findings
Isometric and isotonic exercises, patellar strapping, and patellar
taping were shown to result in significant short-term pain reduc-
Numerous non-surgical interventions showed significant
tion in patients with patellar tendinopathy. Isometric contractions
changes in patellar tendon pain and improvement in knee func-
as an exercise intervention were not included in the most recent
tion. Isometric exercise and sports taping and patellar strapping
systematic review by Everhart et al.4 The three studies included in
provided short-term pain relief. Eccentric exercise, DN, PRP, ABI
this review by Rio et al.,12 Van Ark et al.,17 and Rio et al.14 found
and saline injections demonstrated long-term pain relief and
that similar isometric exercise protocols could be very effective for
functional improvement.
immediate pain relief and up to 45 min after exercise. These iso-
metric protocols were shown to be more effective than isotonic
exercise protocols similar to heavy slow resistance (HSR) protocols Implications
demonstrated to be effective in previous research by Konsgaard
et al.6 Konsgaard et al.6 demonstrated that three specific HSR exer- A multimodal approach to patellar tendinopathy management
cises, squat, leg press, and hack squat had good short and long-term should be implemented alongside specific exercise prescription.
clinical and histological tendon effects. The exercise intervention
studies presented in this review used isotonic protocols using 3–4 s Acknowledgements
eccentric and concentric phases, similar to the timing used in the
HSR protocols by Konsgaard et al.6 Unfortunately, the studies did We thank Helen Brown, Reference Librarian at Woodward Sci-
not completely replicate the HSR protocols used by Konsgaard ences Library at the University of British Columbia for her guidance
et al.6 so the results of these studies need to be critically evaluated on literature search strategy and optimization.
for their applicability for patients with patellar tendinopathy. Patel- We thank Patricia Mortensen, Rehabilitation Sciences Program
lar strapping and sports taping were shown by De Vries et al.2 also Manager, for her coordination and creation of the working relation-
had a beneficial short-term effect on pain during and after sport. ship between both authors.

4.2. Findings regarding long-term effect References

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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.