Physical Therapy in Sport 34 (2018) 105e112

Contents lists available at ScienceDirect

Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original Research

Effects of a strength protocol combined with electrical stimulation on

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

Angel Basas a, *, Jill Cook b, Miguel A. Go mez c, Manuel A. Rafael a, Christophe Ramirez a,
d c
Brendan Medeiros , Alberto Lorenzo
a
Royal Spanish Athletics Federation's Medical Department, Madrid, Spain
b
La Trobe Sport and Exercise Research Centre, La Trobe University, Melbourne, Australia
c
Faculty of Physical Activity and Sport Science, Polytechnic University of Madrid, Spain
d
Complutense University of Madrid, Spain

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

Article history: Study design: A retrospective study.

Received 17 June 2018 Introduction: Patellar tendinopathy (PT) or jumper's knee (JK) in elite athletes is a challenging condition
Received in revised form for sports medicine professionals. This study analyzes the development of a protocol using eccentric,
11 September 2018
isometric, concentric exercises, and electrostimulation to treat elite athletes suffering from JK. The
Accepted 11 September 2018
semiannual strength protocol was completed during a total of 36 months by six high-level jumping
athletes with chronic painful JK. Pain during patellar tendon loading activity was evaluated on a visual
Keywords:
analogue pain scale (VAS). Upon protocol completion, promising clinical results were evidenced by
Jumper's knee (JK)
Patellar tendinopathy (PT)
significant pain reduction during tendon loading activity.
Eccentric Material and methods: Six high level jumping athletes with chronic painful JK completed a semiannual
Electrical stimulation strength program using eccentric, isometric, concentric and electrical stimulation exercises. The protocol
was done 12 weeks in the winter pre-season and 10 weeks in the summer pre-season, for altogether 36
months, with an interruption of the protocol at 24 months for 6 months. Pain during patellar tendon
loading activity was evaluated on a visual analogue pain scale (VAS), before the first session and then
every 6 months, coinciding with the competitive phase, the time of maximum pain.
Results: There was a significant (p < 0.01) decrease in the VAS from start to the 18, 24 and 48 months
follow-ups.
Conclusions: In a small group of high level jumping athletes with chronic painful JK, a strength protocol
combined with electrical stimulation showed promising clinical results with significant pain reduction
during tendon loading activity.
© 2018 Elsevier Ltd. All rights reserved.

1. Introduction insertion of the patellar tendon in the lower pole of the patella,
although it may also present at the distal insertion in the tibia, and
Patellar tendinopathy (PT) is characterized by pain in the frontal even at the insertion of the tendon of the quadriceps in the upper
surface of the knee; it is normally localized at the proximal pole of the patella. Its association with jumping sports led it to be
called jumper's knee (Blazina, Kerlan, Jobe, Carter, & Carlson, 1973;
Ferreti, 1968; Kannus, 1997a), as it fundamentally occurs in sports
characterized by high demands for speed and strength in the
*
This manuscript is original and not previously published, nor is it being extensor apparatus of the knee, such as volleyball, basketball or
considered elsewhere until a decision is made as to its acceptability by Physical
athletics, with a prevalence of up to 45% at the elite level (Lian,
Therapy in Sport. The authors declare that they have no conflict of interest and the
paper was not prior submitted or published to another journal. This study received Engebretsen, & Bahr, 2005) and 14.4% in recreational sports
no financial support. (Zwerver, Bredeweg, & Van Den Akker-Scheek, 2011). It is the
* Corresponding author. tendon pathology that most often causes an interruption in training
 Basas), [email protected] (J. Cook).
E-mail addresses: fi[email protected] (A.

https://doi.org/10.1016/j.ptsp.2018.09.005
1466-853X/© 2018 Elsevier Ltd. All rights reserved.
106  Basas et al. / Physical Therapy in Sport 34 (2018) 105e112
A.

and competition (Kannus, 1997b). Clinical decision-making is hin- However, in the subsequent 6 months, during which the protocol
dered by lack of knowledge about over-use tendinopathy, so that was discontinued, the level of pain increased again to the point in
athletes may experience long, frustrating periods of rehabilitation which it was necessary to resume the protocol. The results of the
with unpredictable results (Cook et al., 1997). protocol's consequent implementation are shown in this present
Although different treatments have been described with study, which adds the effects of protocol discontinuation and its
promising results, a more effective protocol has yet to be found reapplication.
(Cook, Khan & Purdam, 2001; Rutland et al., 2010, Cook & Khan,
2001), especially in athletes with high load demands on the 2. Methods
patellar tendon. Studies suggest that protocols should be designed
on the basis of eccentric muscle strengthening exercises which 2.1. Experimental approach to the problem
show positive results in terms of the subjective perception of pain
(Biernat, Trzaskoma, Trzaskoma, & Czaprowski, 2014) as well as This study was designed to determine the beneficial effects of a
improved functionality (Frohm, Saartok, Halvorsen, & Renstrom, strength protocol combined with electrical stimulation on patellar
2007; Jonsson & Alfredson, 2005; Kaux, Forthomme, Goff, tendinopathy. A retrospective longitudinal study of cases was per-
Crielaard, & Croisier, 2011; Kongsgaard et al., 2006; Peers & formed, using a design of repeated measurements over a period of
Lysens, 2005; Purdam et al., 2004a; Reinking, 2012; Romero- intervention of 12 weeks in the winter pre-season and 10 weeks in
Rodriguez, Gual, & Tesch, 2011; Woodley, Newsham-West, & the summer pre-season during a period of 36 months, with an
Baxter, 2007) and strength (Cook, Beaven, & Kilduff, 2013). Never- interruption of the protocol at 24 months for 6 months. The pro-
theless, it is still not possible to strongly recommend a specific tocol was interrupted at 24 months after the end of the summer
protocol (Visnes & Bahr, 2007), especially in elite sports, where the season with the almost complete relief of symptoms. Due to this
demands for tendon loading are far greater. relief, it was thought to be no longer necessary to continue the
In cases of athletes with prior history of pain, if possible, pro- program, but the protocol was resumed at 30 months after relapse
tocols should be initiated before the start of the competition sea- occurred after a competitive season without prior protocol. Pain
son, since it has been found that no positive results have been was evaluated every 6 months including the interruption and
found if treatment commences during the competition season subsequent resumption, up to 42 months. The independent vari-
(Visnes, Hoksrud, Cook, & Bahr, 2005). ables were time (6,12,18,24,30,36 and 42 months) and the strength
Upon designing a protocol, care should be taken in establishing protocol. Values obtained for the different pain tests (VAS) were
the optimal load by using exercises with progressively increasing used as a dependent variables.
tension. Optimal-load exercises have been shown to be more In order to understand the study's methodology, it is important
effective due to an improved isolation effect of the extensor to understand the athlete's season. For a full season, there are two
apparatus of the knee by subjecting it to a more localized load on competitive periods, winter and summer, distributed approxi-
the tendon (Kongsgaard et al., 2006; Purdam et al., 2004a). This has mately as follows and changing slightly depending on the dates of
led to a search for exercises involving direct loading, such as those major competitions such as World Championships or Olympic
that can be achieved using specific eccentric exercises or isometric Games. The preseason phase is understood to be the phase of
electrical stimulation when stretching. Neuromuscular electrical general training and preparation and the competitive phase in-
stimulation technique has shown benefits in physiological adap- cludes all competitions with the most important one taking place
tation by acting on the muscular metabolism (Gondin, Guette, during the last month of this phase.
Ballay, & Martin, 2005; Holcomb, 2006; Jubeau et al., 2008;
Malone, Blake, & Caulfield, 2014; Martinez-Lopez, Benito-Martinez, 2.1.1. Pre-season (winter)
Hita-Contreras, Lara-Sanchez, & Martinez-Amat, 2012; Requena October, November and December.
Sanchez, PadialPuche, & Gonzalez-Badillo, 2005). Although they
are not directly associated with tendon metabolism, the tendons 2.1.2. Competitive season (winter)
have been shown to respond to progressive stress and the gradual January, February and March.
and controlled increase of their loading force, leading to an increase
in collagen and thereby participating in remodeling (Stanish, 2.1.3. Pre-season (summer)
Rubinovich, & Curwin, 1986). In the same way, mechanical April, May and mid-June. This season is shorter than the winter
loading is known to be beneficial for tendon health, influencing season and the tendon should be better prepared due to prior
their structure, chemical composition and mechanical properties completion of the protocol (because of this, the summer protocol is
(Kongsgaard et al., 2010; Magnusson, Langberg, & Kjaer, 2010). If also shorter).
electrical stimulation is applied to bring about isometric contrac-
tion in the muscle at a certain degree of stretching, the tendon will 2.1.4. Competitive season (summer)
be subjected to this stress and longitudinal loading; this could be Mid-June, July and August.
taken into account as an extra exercise when designing protocols
for elite sportsmen. Nevertheless, the specialized literature con- 2.2. Subjects
tains no electrical stimulation protocols for this pathology. There-
fore, the aim of this study was to analyze the effects of a program of The described protocol in this study was applied to thirty elite
tendon training using a combination of eccentric, isometric, athletes with patellar tendinopathy. To obtain the sample for this
concentric exercises, and electrical stimulation on pain reduction, study, rigorous criteria for inclusion and exclusion were set, as
both in positions of direct tendon loading, in the treatment of elite shown in Table 1. Six athletes fulfilled these criteria. The entire
athletes with patellar tendinopathy when other treatments have protocol and study were designed, directed and supervised directly
failed, interrupting their normal sports activity. by the same physiotherapist in the sports facilities of the high
This work is the continuation of a previous study that showed performance center in Madrid. Three of the athletes were high
promising results in a follow-up study of 24 months (Basas, jumpers and three were triple jumpers. All six of them were male
Lorenzo, Go mez, Moreno, & Ramirez, 2014) during which pain and started the protocol at an age of (±DT) 22.18 ± 2.14 years old,
progressively decreased to the point of its near disappearance. and all were competitors at international level with the Spanish
  Basas et al. / Physical Therapy in Sport 34 (2018) 105e112
A. 107

Table 1
Inclusion and exclusion criteria.

Inclusion C International jumpers.

criteria C Diagnosed chronic patellar tendinopathy or jumper's knee by a specialist doctor in sports medicine, by means of ultrasound assessment and magnetic
nuclear resonance.
C Evolution of the condition over at least two years.
C Failure during these two years of other medical and physiotherapeutic treatments, including surgery.
C Athletes who have carried out the protocol for 36 months with an interruption at the 24th month and restarting the protocol after the 30th month.
Exclusion C Other associated pathologies of the knee.
criteria

national athletics team. Their training during the protocol was 2.4. Training
similar to that in previous years as directed by their respective
coaches. The protocol consisted of the combination of strengthening
All participants signed an informed consent form to participate exercises that subject the tendon to gradual and controlled loadings
in the study and to allow the use and publication of the results and up to situations involving maximum tendon loading. The first
the images. employed isometric electrical stimulation when stretching, and the
The protocol was approved by an Ethics Committee. second used eccentric, isometric and concentric muscular con-
tractions, carried out in this order.
The total duration of the protocol was twelve weeks in the
2.3. Procedures winter pre-season and 10 weeks in the summer pre-season. The
participants completed the protocol three times a week on
For the exercises to strengthen the muscle and tendon using alternating days, except for weeks 3, 6, 9 and 12, when they
electrical stimulation, MEGASONIC 313- ELECTROMEDICARIN S.A. completed it twice a week in order to avoid overstimulation of
(Barcelona, Spain) electrotherapy equipment was used. This made the tendon. This specific schedule coincides with the training
it possible to vary all current parameters. micro-cycles of the athletes. The first week of each microcycle is
Asymmetrical two-phase low frequency excitomotor current high intensity training, the second is of even higher intensity,
was used, according to the nomenclature of the equipment used and the third is of low intensity to promote regeneration and
(Fig. 1). Being a biphasic current, the pulse width marked in Table 2, training supercompensation.
makes reference to each of the phases of the current.
Electrode placement: 10
5 cm and 5
5 cm Electromedicarin 2.5. Description of the exercises
reusable adhesive electrodes were employed in the following po-
sitions to stimulate the entire quadriceps muscle (Fig. 2): The progression of the exercises and the current parameters are
shown in Table 2.
a) Two proximal 10
5 cm electrodes, which stimulate the output Exercise 1 (E1): isometric electrical stimulation of the
of the femoral nerve. stretched quadriceps muscle (Fig. 3). The athlete sat with the knee
b) Three 5
5 cm electrodes on the motor points of the vastus blocked at 90 . Immediately before the electrical stimulus, the
medialis, rectus femoris and vastus lateralis. athlete was asked to make a voluntary contraction of the quad-
riceps according to the intensity shown in Table 2. The intensity of
To close the circuits two channels were formed in the following the current was increased until it overcame the previous volun-
way: tary contraction. The athlete should notice that the electrical
stimulation contraction is more intense than the previous
a) Channel 1: the lower proximal electrode connected to the vastus voluntary one. This increase in contraction should also be visible
medialis. and palpable due to the increase of muscle tone. The voluntary
b) Channel 2: the upper proximal electrode connected to the rectus contraction was maintained during the time the current acts to
femoris and the vastus lateralis, both connected to the same conserve the neuromuscular connection. The intensities of cur-
output of channel 2 by means of a split cable. rent set by the protocol gradually increase from low to high, and
they must be increased week by week, up to the level set as
maximum, which will be the intensity that overcomes the
maximum voluntary contraction by the athletes.
Exercise 2 (E2): isometric electrical stimulation of the quadri-
ceps muscle in a position of a higher tension (Fig. 3). The athlete lies
down to stretch the rectus femoris further, keeping his knee
blocked at 90 . This position will increase the loading on the
patellar tendon. The other leg is kept flexed over the table to protect
the lumbar area.
Exercise 3, 4, 5: Eccentric þ isometric þ concentric exercises:
Inelastic belts or bands were used for the exercises, making it
possible to hold the athlete in a semi-sitting position (a semi-squat)
with his center of gravity moved to the rear, as is shown in the
exercises in Fig. 4.
Exercise 3 (E3): Eccentric þ isometric þ concentric bipedal ex-
ercise of the quadriceps with the knee e hip at 90 (Fig. 4). This
Fig. 1. Graphic representation of the asymmetric rectangular current. Nomenclature exercise consists of 3 phases: a) a first eccentric phase, from
used by the company ELECTROMEDICARIN S.A. standing to a sitting position, from 0 to 90 hip-knee, going down
108  Basas et al. / Physical Therapy in Sport 34 (2018) 105e112
A.

Table 2
Protocol. Exercise, electrical stimulation parameters and progression.

slowly for 3 s; b) a second isometric phase, keeping the knees ehips the knee at 90 and the hip at 0 (Fig. 4). The same as the previous
bent at 90 for an additional 3 s; and c) a third concentric phase, in exercise, but keeping the hip at 0 . The loading on the tendon will
which the athlete returns to the initial standing position in 1 s. To be increased by the lever arm created and the loading exerted by
advance within the protocol, loads are gradually added, starting stretching of the rectus femoris. Weights are gradually added,
with 15% body weight, using waistcoats or weights added to the denominated “4þ.”
chest. This will be denominated “3þ.” (Each “þ” signifies a 15% Exercise 5 (E5): Eccentric þ isometric þ concentric single leg
increase in body weight). with the knee at 75 (Fig. 4). Weights are gradually added,
Exercise 4 (E4): Eccentric þ isometric þ concentric bipedal with denominated “5þ”.
  Basas et al. / Physical Therapy in Sport 34 (2018) 105e112
A. 109

coinciding with the end of competition seasons, thereby evaluating

pain following a time of maximum demand. Evaluation also took
place following the half-yearly period during which the protocol
was discontinued (at 30 months), and following restarting (at 36
months) and finishing the last protocol (at 42 months). (Fig. 5).

2.7. Statistical analyses

Data were analyzed using the PASW data statistics editor pro-
gram 18.0 (SPSS inc. Chicago, Il, USA). Friedman's test was used for
pre-post comparisons. This test is the non-parametric alternative to
single factor fixed effect repeated measurements ANOVA, as the
sample contains fewer than 30 subjects. Differences in ranges were
compared by means of Tukey's post-hoc test. The level of signifi-
cance was set at p < 0.05.

3. Results

The results show that the training protocol had a positive effect
(reduction) on the pain level, while there were significant differ-
ences between the measurements by the subjects (c2 (7) ¼ 30.68;
p < 0.001).
More specifically, the results of Tukey's post-hoc test showed
that pain scores at 18, 24 and 42 months fell significantly in com-
parison with the initial measurement (p < 0.01). However, no sta-
Fig. 2. Electrode placement. tistically significant differences were found in the comparisons of

Fig. 3. Isometric electrical stimulation of the stretched quadriceps muscle. Exercise 1 (E1): sitting 90 knees-hips; Exercise 2 (E2): lying knees 90º-hips 0 .

2.6. Testing the other measurements (Table 3; Fig. 6).

When all of the measurements are compared (see Table 3), the
The initial assessment and results of the treatment protocol results show that the average pain level clearly fell following the
were evaluated using a visual analogue scale of pain (VAS) (9) from complete undertaking of the first protocol (VAS 2). However, no
0 to 10, which has been shown to be effective and reproducible, and statistically significant differences (p > 0.05) were found for a
which has been widely used in medical research (Frohm et al., sample of 6 subjects. After the application of the second protocol
2007; Purdam et al., 2004a; Romero-Rodriguez et al., 2011; (VAS 3), pain continued to fall although no significant differences
Young, Cook, & Purdam, 2005a). The athletes themselves set the were detected (p > 0.05). Nevertheless, significant differences were
pain level during patellar tendon loading activity in a 10 cm VAS detected after the third protocol (VAS 4), in the 18th month
marked in millimeters., where 0 was no pain and 10 meant (p < 0.05) compared with the initial score for pain, and this situa-
maximum pain that didn't allow the athlete to train or compete. tion occurred again after the fourth protocol (VAS 5). After this fifth
Pain data were recorded before starting the protocol and three assessment the protocol corresponding to this half-year was
months after finishing each (at 6, 12, 18, 24, 30, 36 and 42 months), interrupted, and the average pain levels rose (VAS 6) although
110  Basas et al. / Physical Therapy in Sport 34 (2018) 105e112
A.

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

Fig. 5. Timeline of interventions. Date collection by visual analogue scale of pain (VAS) and appllication protocols.

Table 3 justified by the beneficial effect of the gradual and controlled

Subjective pain by visual analogue scale of pain (VAS). Mean ± SD. loading of the tendon, as its tensile strength increases along with
VAS1. baseline test 7,67 ± 1,96 the amount of collagen within (Stanish et al., 1986). It is also the
VAS 2. Month 6 3,67 ± 2,34 case that isometric tension leads to direct mechanical loading on
VAS 3. Month 12 2,50 ± 1,52 the tendon, which has a positive influence on the structure,
VAS 4.Month 18 1,00 ± 1,67*
chemical composition and mechanical properties of the same
VAS 5.Month 24 The protocol is interrupted. 0,33 ± 0,52*
VAS 6.Month 30. Reapplication of the protocol. 2,83 ± 2,79 (Kongsgaard et al., 2010). It would be of interest to study me-
VAS 7.Month 36 1,67 ± 1,97 chanical properties of patellar tendon in response to an isometric
VAS 8. Month 48 0,67 ± 0,82* electrical stimulation, compared with voluntary isometric
*p < 0.01. contraction. It would increase the understanding of advantageous
adaptation training and optimal intervention as was done with the
Achilles tendon with a maximum voluntary isometric contraction
differences were not significant (p > 0.05), and then lowered again in a recent study (Joseph et al., 2014).
(p > 0.05) after reapplication of the protocol (VAS 7). Significant The efficacy of our proposal agrees with the scientific literature,
differences (p < 0.05) were found after the final application (VAS 8). showing satisfactory clinical results in the reduction of pain in
It is important to point out that during the first weeks of the response to strengthening exercises involving eccentric over-
protocol's application, the athletes experienced delayed onsent loading in athletes with chronic patellar tendinopathy (Bahr,
muscle soreness (DOMS) and a slight discomfort in the tendon it- Fossan, Loken, & Engebretsen, 2006; Frohm et al., 2007; Jonsson
self, not being able to affirm if the cause was the dynamic exercises, & Alfredson, 2005; Purdam et al., 2004b; Romero-Rodriguez
the electrostimulation, or both, because they were carried out in et al., 2011; Rutland et al., 2010; Visnes & Bahr, 2007; Young
the same session. This soreness began disappearing from the fourth et al., 2005a). However, it is still not possible to strongly recom-
week of the protocol and unfortunately it is a data point that was mend a specific protocol (Lorenzen, Kramer, Vogt, & Knobloch,
only recorded in observations without a quantitative data 2010; Rees, Wolman, & Wilson, 2009; Visnes & Bahr, 2007;
collection. Wasielewski & Kotsko, 2007). One of the reasons why exercises
may be less effective is when they involve biomechanics that
4. Discussion restrict the loading on the tendon (Kongsgaard et al., 2006; Purdam
et al., 2004a). For this study exercises were selected that give rise to
Electrical stimulation with an excitomotor effect was used in maximum direct loading of the patellar tendon, getting as close as
this study as a means of strengthening the muscle and tendon. This possible to the stress that is necessary to adapt the tendon to the
is a new approach to the treatment of patellar tendinopathy. No aggressive demands of sport.
references have been found to protocols combined with electrical It must be pointed out that application of the protocol gave rise
stimulation such as that described in this study, which means that to benefits after the end of the first protocol, although these were
it cannot be compared with other previous similar studies of the not statistically significant due to the small sample. This improve-
training of patellar tendinopathy. ment increased gradually with the subsequent protocols. It is also
Although electrical stimulation is not included in the designs of of interest that, following interruption of a two-year long protocol,
previous studies (preventing comparisons), its proposed usage is pain levels went up again within six months without any protocol
  Basas et al. / Physical Therapy in Sport 34 (2018) 105e112
A. 111

Fig. 6. Subjective pain by visual analogue scale of pain (VAS). Mean ± SD.*Significant differences at 18, 24 and 42 months (p < 0.01). IP: The protocol is interrupted following the
assessment at 24 months. RP: Reapplication of the protocol following the assessment at 30 months.

being applied, although they went down again once the protocol exercises and electrical stimulation, and they continued to improve
was applied once more. This suggests that elite athletes with with each new application and worsened when the protocol was
chronic patellar tendinopathy should include training protocols in interrupted. Planned surgical treatment for three of them was
each training cycle. However, the fact that this worsening in the cancelled, and all six were able to continue their elite sports activity
pain level after a 6 month interruption in the protocol contrasts normally. Although the results cannot be compared, as no research
with studies in which 12 months after the application of protocol studies have been found involving the application and follow-up of
the improvement continued and even increased (Young, Cook, a continuous protocol over such a long time, the evolution of our
Purdam, Kiss, & Alfredson, 2005b), or with others in which research shows hopeful results for elite jumpers. Nevertheless,
follow-up after 32.6 months showed that patient satisfaction had these should be contrasted with new research studies.
remained constant following the application of a protocol (Jonsson The change in pain levels over 42 months suggests that the
& Alfredson, 2005). The protocol used in this study would therefore favorable results most likely are the direct result of the protocol,
not be a long-term solution after a single application. This may be while the unfavorable results coincide with the suppression of the
due to the specific sports and level of the athletes involved, as their same. The protocol is the only controllable variable that changes in
sports demand explosive maximum performance from tendons. the group of athletes over It is important to underline the following
Therefore, in the case of elite athletes of this type, it would be of limitations of this study: there was no control group and the
interest to keep the protocol as a part of training during their sample was small due to the difficulty of finding world standard
sporting life. jumpers. Given that the results obtained are not significant for
Given the results of this study, we have to await the application applications before 18 months, they should be contrasted with a
of three protocols at six-monthly intervals to obtain statistically greater number of participants. To achieve conclusive results, ran-
significant differences. The benefits obtained after the first two domized studies comparing different types of exercises are neces-
protocols, while they were positive in terms of the perception of sary: groups with electrical stimulation combined with isometric,
pain, are insufficient to show such differences in a sample of 6 concentric and eccentric exercises, groups using a single technique,
subjects. as well as a control group.
One aspect of this study that should be underlined is that it was In future studies, pain levels would ideally be evaluated weekly
applied and followed up for 42 months with athletes who had been in order to observe the evolution of pain throughout the entire
training with restrictions and subjected to different treatments for adaptive process of the protocol, using the validated Victorian
at least two years. This situation was corrected by the first appli- Institute of Sport Assessment Scale for Patellar Tendinopathy (VISA-
cation of the combined protocol of isometric, concentric, eccentric P) in conjunction with VAS.
112  Basas et al. / Physical Therapy in Sport 34 (2018) 105e112
A.

4.1. Practical applications Kaux, J. F., Forthomme, B., Goff, C. L., Crielaard, J. M., & Croisier, J. L. (2011). Current
opinions on tendinopathy. Journal of Sports Science and Medicine, 10, 238e253.
Kongsgaard, M., Aagaard, P., Roikjaer, S., Olsen, D., Jensen, M., Langberg, H., et al.
The result of this study suggests that the use of a protocol that (2006). Decline eccentric squats increases patellar tendon loading compared to
combines eccentric, isometric, concentric exercises with electrical standard eccentric squats. Clinical Biomechanics, 21, 748e754.
stimulation of maximum loading may have a positive effect on the Kongsgaard, M., Qvortrup, K., Larsen, J., Aagaard, P., Doessing, S., Hansen, P., et al.
(2010). Fibril morphology and tendon mechanical properties in patellar ten-
reduction of pain in elite athletes with patellar tendinopathy or dinopathy: Effects of heavy slow resistance training. The American Journal of
jumper's knee. The evolution of the pain following the application Sports Medicine, 38, 749e756.
and interruption of the protocol indicates that these athletes, Lian, O. B., Engebretsen, L., & Bahr, R. (2005). Prevalence of jumper's knee among
elite athletes from different sports: A cross-sectional study. The American
whose sports specialties directly involve the patellar tendon at Journal of Sports Medicine, 33, 561e567.
extreme loadings, would need to apply the protocol twice a year to Lorenzen, J., Kramer, R., Vogt, P. M., & Knobloch, K. (2010). [Systematic review about
obtain and increase its benefits, including it in their training pro- eccentric training in chronic patella tendinopathy]. Sportverletzung - Sports-
chaden, 24, 198e203.
grams while they remain involved in elite sports. However, given Magnusson, S. P., Langberg, H., & Kjaer, M. (2010). The pathogenesis of tendinop-
the small number of subjects included, data should be interpreted athy: Balancing the response to loading. Nature Reviews Rheumatology, 6,
cautiously. 262e268.
Malone, J. K., Blake, C., & Caulfield, B. M. (2014). Neuromuscular electrical stimu-
This proposal is designed for elite athletes. Its level of demand lation during recovery from exercise: A systematic review. The Journal of
and the need for equipment such as inelastic bands for the eccen- Strength & Conditioning Research, 28, 2478e2506.
tric exercises and electrical stimulation equipment make it un- Martinez-Lopez, E. J., Benito-Martinez, E., Hita-Contreras, F., Lara-Sanchez, A., &
Martinez-Amat, A. (2012). Effects of electrostimulation and plyometric training
suitable for the general population and those who do recreational
program combination on jump height in teenage athletes. Journal of Sports
sport. Science and Medicine, 11, 727e735.
Peers, K. H., & Lysens, R. J. (2005). Patellar tendinopathy in athletes: Current diag-
References nostic and therapeutic recommendations. Sports Medicine, 35, 71e87.
Purdam, C. R., Johnsson, P., Alfredson, H., Lorentzon, R., Cook, J. L., & Khan, K. M.
(2004a). A pilot study of the eccentric decline squat in the management of
Bahr, R., Fossan, B., Loken, S., & Engebretsen, L. (2006). Surgical treatment compared painful chronic patellar tendinopathy. British Journal of Sports Medicine, 38,
with eccentric training for patellar tendinopathy (Jumper's Knee). A random- 395e397.
ized, controlled trial. J Bone Joint Surg Am, 88, 1689e1698. Purdam, C. R., Jonsson, P., Alfredson, H., Lorentzon, R., Cook, J. L., & Khan, K. M.
Basas, A., Lorenzo, A., Go mez, M., Moreno, C., & Ramirez, C. (2014). Exercise protocol
(2004b). A pilot study of the eccentric decline squat in the management of
and electrical muscle stimulation in the prevention, treatment and readapt- painful chronic patellar tendinopathy. British Journal of Sports Medicine, 38,
ation of jumper's knee. New Studies in Athletics, 29, 41e51. 395e397.
Biernat, R., Trzaskoma, Z., Trzaskoma, L., & Czaprowski, D. (2014). Rehabilitation Rees, J. D., Wolman, R. L., & Wilson, A. (2009). Eccentric exercises; why do they
protocol for patellar tendinopathy applied among 16- to 19-year old volleyball work, what are the problems and how can we improve them? British Journal of
players. The Journal of Strength & Conditioning Research, 28, 43e52. Sports Medicine, 43, 242e246.
Blazina, M. E., Kerlan, R. K., Jobe, F. W., Carter, V. S., & Carlson, G. J. (1973). Jumper's Reinking, M. (2012). Tendinopathy in athletes. Physical Therapy in Sport, 13, 3e10.
knee. Orthopedic Clinics of North America, 4, 665e678. Requena Sanchez, B., Padial Puche, P., & Gonzalez-Badillo, J. J. (2005). Percutaneous
Cook, J., Beaven, C. M., & Kilduff, L. P. (2013). Three weeks of eccentric training electrical stimulation in strength training: An update. The Journal of Strength &
combined with overspeed exercises enhances power and running speed per- Conditioning Research, 19, 438e448.
formance gains in trained athletes. The Journal of Strength & Conditioning Romero-Rodriguez, D., Gual, G., & Tesch, P. A. (2011). Efficacy of an inertial resis-
Research, 27, 1280e1286. tance training paradigm in the treatment of patellar tendinopathy in athletes: A
Cook, J., & Khan, K. M. (2001). What is the most appropriate treatment for patellar case-series study. Physical Therapy in Sport, 12, 43e48.
tendinopathy? British Journal of Sports Medicine, 35, 291e294. Rutland, M., O'connell, D., Brismee, J. M., Sizer, P., Apte, G., & O'connell, J. (2010).
Cook, J., Khan, K. M., Harcourt, P. R., Grant, M., Young, D. A., & Bonar, S. F. (1997). Evidence-supported rehabilitation of patellar tendinopathy. N Am J Sports Phys
A cross sectional study of 100 athletes with jumper's knee managed conser- Ther, 5, 166e178.
vatively and surgically. The Victorian Institute of Sport Tendon Study Group. Stanish, W. D., Rubinovich, R. M., & Curwin, S. (1986). Eccentric exercise in chronic
British Journal of Sports Medicine, 31, 332e336. tendinitis. Clinical Orthopaedics and Related Research, 65e68.
Cook, J., Khan, K. M., & Purdam, C. R. (2001). Conservative treatment of patellar Visnes, H., & Bahr, R. (2007). The evolution of eccentric training as treatment for
tendinopathy. Physical Therapy in Sport, 2, 54e65. patellar tendinopathy (jumper's knee): A critical review of exercise pro-
Ferreti, A. (1968). Epidemiology of jumper's knee. Sports Medicine, 3, 289e295. grammes. British Journal of Sports Medicine, 41, 217e223.
Frohm, A., Saartok, T., Halvorsen, K., & Renstrom, P. (2007). Eccentric treatment for Visnes, H., Hoksrud, A., Cook, J., & Bahr, R. (2005). No effect of eccentric training on
patellar tendinopathy: A prospective randomised short-term pilot study of two jumper's knee in volleyball players during the competitive season: A ran-
rehabilitation protocols. British Journal of Sports Medicine, 41, e7. domized clinical trial. Clinical Journal of Sport Medicine, 15, 227e234.
Gondin, J., Guette, M., Ballay, Y., & Martin, A. (2005). Electromyostimulation training Wasielewski, N. J., & Kotsko, K. M. (2007). Does eccentric exercise reduce pain and
effects on neural drive and muscle architecture. Medicine & Science in Sports & improve strength in physically active adults with symptomatic lower extremity
Exercise, 37, 1291e1299. tendinosis? A systematic review. Journal of Athletic Training, 42, 409e421.
Holcomb, W. R. (2006). Effect of training with neuromuscular electrical stimulation Woodley, B. L., Newsham-West, R. J., & Baxter, G. D. (2007). Chronic tendinopathy:
on elbow flexion strength. Journal of Sports Science and Medicine, 5, 276e281. Effectiveness of eccentric exercise. British Journal of Sports Medicine, 41,
Jonsson, P., & Alfredson, H. (2005). Superior results with eccentric compared to 188e198. discussion 199.
concentric quadriceps training in patients with jumper's knee: A prospective Young, M. A., Cook, J. L., & Purdam, C. R. (2005a). Eccentric decline squat protocol
randomised study. British Journal of Sports Medicine, 39, 847e850. offers superior results at 12 months compared with traditional eccentric pro-
Joseph, M. F., Lillie, K. R., Bergeron, D. J., Cota, K. C., Yoon, J. S., Kraemer, W. J., et al. tocol for patellar tendinopathy in volleyball players (vol 39, pg 102, 2005).
(2014). Achilles tendon biomechanics in response to acute intense exercise. The British Journal of Sports Medicine, 39, 246-246.
Journal of Strength & Conditioning Research, 28, 1181e1186. Young, M. A., Cook, J. L., Purdam, C. R., Kiss, Z. S., & Alfredson, H. (2005b). Eccentric
Jubeau, M., Sartorio, A., Marinone, P. G., Agosti, F., Van Hoecke, J., Nosaka, K., et al. decline squat protocol offers superior results at 12 months compared with
(2008). Comparison between voluntary and stimulated contractions of the traditional eccentric protocol for patellar tendinopathy in volleyball players.
quadriceps femoris for growth hormone response and muscle damage. Journal British Journal of Sports Medicine, 39, 102e105.
of Applied Physiology, 104, 75e81. Zwerver, J., Bredeweg, S. W., & Van Den Akker-Scheek, I. (2011). Prevalence of
Kannus, P. (1997a). Etiology and pathophysiology of chronic tendon disorders in jumper's knee among nonelite athletes from different sports: A cross-sectional
sports. Scandinavian Journal of Medicine & Science in Sports, 7, 78e85. survey. The American Journal of Sports Medicine, 39, 1984e1988.
Kannus, P. (1997b). Tendons–a source of major concern in competitive and recre-
ational athletes. Scandinavian Journal of Medicine & Science in Sports, 7, 53e54.