Accepted Manuscript

Title: Do isometric and isotonic exercise programs reduce pain

in athletes with patellar tendinopathy in-season? A
randomised clinical trial

Author: Mathijs van Ark Jill Cook Sean I. Docking Johannes

Zwerver James E. Gaida Inge van den Akker-Scheek Ebonie
Rio

PII: S1440-2440(15)00231-5
DOI: http://dx.doi.org/doi:10.1016/j.jsams.2015.11.006
Reference: JSAMS 1246

To appear in: Journal of Science and Medicine in Sport

Received date: 30-1-2015

Revised date: 14-11-2015
Accepted date: 27-11-2015

Please cite this article as: van Ark M, Cook J, Docking SI, Zwerver J, Gaida JE, van
den Akker-Scheek I, Rio E, Do isometric and isotonic exercise programs reduce pain
in athletes with patellar tendinopathy in-season? A randomised clinical trial, Journal of
Science and Medicine in Sport (2015), http://dx.doi.org/10.1016/j.jsams.2015.11.006

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 1 Do isometric and isotonic exercise programs reduce pain in athletes with patellar

2 tendinopathy in-season? A randomised clinical trial

4 Mathijs van Arka,b, Jill Cookb, Sean I. Dockingb, Johannes Zwervera, James E. Gaidab,c, Inge

5 van den Akker-Scheeka, Ebonie Riob

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6

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7

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8 University of Groningen, University Medical Center Groningen, Center for Sports Medicinea

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9 PO Box 30.001

10 9700 RB Groningen, The Netherlands

11 an
12 Monash University, School of Physiotherapy b
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13 PO Box 527

14 Frankston VIC 3199, Australia

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15
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16 University of Canberra, Discipline of Physiotherapy c

17 University Drive,
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18 Bruce ACT 2617, Australia

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19

20 Corresponding author: Mathijs van Ark, [email protected]

21 Word count: 2114

22 Abstract word count: 243
23 Number of Tables: 2
24 Number of Figures: 1
25

26

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Page 1 of 18
26 Do isometric and isotonic exercise programs reduce pain in athletes with patellar

27 tendinopathy in-season? A randomised clinical trial

28 Abstract

29 Objectives: Many athletes with patellar tendinopathy participate in sports with symptoms

30 during or after activities. Current treatments do not decrease pain in-season; eccentric

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31 exercises in-season result in an increase in pain. This study examined if isometric and

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32 isotonic exercises relieved pain in competing athletes with patellar tendinopathy.

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33 Design: Randomised clinical trial

34 Methods: Jumping athletes with patellar tendinopathy playing at least three times per week

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35 participated in this study. Athletes were randomised into an isometric or isotonic exercise

36 group. The exercise programs consisted of four isometric or isotonic exercise sessions per

37
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week for 4 weeks. Pain during a single leg decline squat (SLDS) on a Numeric Rating Scale

38 (NRS; 0-10) was used as the main outcome measure; measurements were completed at
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39 baseline and at 4-week follow-up.

40 Results: Twenty-nine athletes were included in this study. Median pain scores improved
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41 significantly over the 4-week intervention period in both the isometric group (Z=-2.527.

42 p=0.012, r = -0.63) and isotonic group (Z=-2.952, p=0.003, r= -0.63). There was no
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43 significant difference in NRS pain score change (U = 29.0 p=0.208 r=0.29) between the
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44 isometric group (median (IQR), 2.5 (1-4.5)) and isotonic group (median (IQR), 3.0 (2-6)).

45 Conclusions: This is the first study to show a decrease in patellar tendon pain without a
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46 modification of training and competition load and the first study to investigate isometric

47 exercises in a clinical setting. Both isometric and isotonic exercise programs are easy-to-use

48 exercises that can reduce pain from patellar tendinopathy for athletes in-season.

49

50 Keywords: tendinopathy, physical therapy modalities, exercise therapy, patellar ligament,

51 tendons, jumper’s knee

52
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52 Introduction

53 Patellar tendinopathy, also known as jumper’s knee, is an overuse injury of the patellar

54 tendon that causes pain and dysfunction. It is a common injury in sports that involve

55 explosive movements that load the extensor mechanism of the knee.1 High prevalence rates

56 are reported in jumping sports such as volleyball and basketball (45% and 32% in elite

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57 athletes respectively).1

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58 Many different modalities are used for the treatment of patellar tendinopathy, however

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59 treatments like injections, shockwave and surgery require athletes to cease sporting

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60 activities.2-4 Exercise may be the best treatment for tendinopathies as histopathological

61 changes and clinical improvements in pain and function have been demonstrated.5 Most

62

63
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studies have been conducted using eccentric exercise protocols6-8 and early studies showed

positive results. However, eccentric exercises may not be effective when used in-season and
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64 might even make symptoms worse in athletes with patellar tendon pathology.7,9,10 Moreover,

65 when eccentric exercise was used prophylactically in-season in asymptomatic soccer players
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66 with pathology on imaging, there was a higher risk of developing a jumper’s knee.11

67 Many athletes play with jumper’s knee symptoms and pain negatively affects capacity to train
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68 and perform in matches. They cope with their injury because pain often decreases after
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69 warm-up but returns and is worse the day after activity. Isometric and isotonic exercises have

70 the potential to decrease pain while continuing sport activities.12,13 Isotonic muscle
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71 contractions (heavy slow resistance training 3-5 times per week) resulted in a significant

72 reduction in pain after a 12-week program.14,15 Isometric exercises have been found to

73 decrease tendon pain in athletes with patellar tendinopathy in the short-term (45 minutes).16

74 It is unknown if isometric exercises can decrease tendon pain over a longer period of time

75 and if repeated isometric exercises are beneficial.

76 The aim of this study was to examine whether isometric and isotonic exercises relieve pain in

77 competing athletes with patellar tendinopathy. It was hypothesised that both isometric and

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 78 isotonic exercises would decrease pain in athletes with patellar tendinopathy in-season and

79 that isometric exercises would decrease patellar tendon pain more than isotonic exercises.

80

81 Methods

82

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This study was a randomised trial of two interventions – participants were randomly assigned

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83 to one of two exercise intervention groups. The study was approved by the Monash

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84 University Human Research Ethics Committee (MUHREC), Australia (CF12/0230 –

85 2012000067). All participants provided written informed consent. This trial was registered in

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86 the Australian New Zealand Clinical Trial Registry (ACTRN12613000871741).

87

88
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Participants were volleyball and basketball players (16-32 years) playing or training at least

89 three times per week, presenting with patellar tendinopathy diagnosed by an experienced
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90 physiotherapist. Inclusion criteria consisted of focal tendon pain at the inferior or superior

91 pole of the patella and a history of exercise associated knee pain at the same spot. Exclusion
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92 criteria were existence of other knee pathology, previous patellar tendon rupture, previous

93 patellar tendon surgery, inflammatory disorders, metabolic bone diseases, type II diabetes,
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94 use of fluroquinolones or corticosteroids in the last 12 months, known familial

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95 hypercholesterolemia and chronic pain conditions.

96
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97 Players from Victorian volleyball leagues and basketball leagues who played or trained at

98 least three times per week were approached at their game or training venue. After baseline

99 measurements were performed, participants were given an exercise program. Participants

100 were randomised to an exercise program by the draw of a sealed opaque envelope from 40

101 identical envelopes that were randomised using a randomisation table created by computer

102 software (20 in each group). The program was demonstrated (including repetition maximum

103 testing) at the gym where they were going to perform their exercises. Every week

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104 participants were followed-up in person or by phone, asking participants if they encountered

105 any problems with the exercise program. After the 4-week exercise program baseline

106 measurements were repeated.

107

108 Both groups performed a 4-week exercise program with exercises performed four times per

109 week. The isometric and isotonic exercise program were matched for time under tension and

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110 rest. Pilot testing was used to ensure that the protocols were matched for rate of perceived

111 exertion. The isometric exercise consisted of 5 x 45 second single leg isometric contractions

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112 of each leg on a leg extension machine. Isometric contractions were performed at 80% of

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113 maximal voluntary contraction with a knee joint angle of 60 degrees.

114 Isotonic exercise consisted of four sets of eight repetitions of single leg isotonic contractions

115
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of each leg on a leg extension machine. Isotonic contractions consisted of a three second

116 concentric phase immediately followed by a four second eccentric phase and were
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117 performed on 80% of 8 repetitions maximum. After performing the exercises for each leg,

118 participants rested for 15 seconds before continuing with the first leg again.
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119 Weight was increased by 2.5% every week if possible. If pain was experienced during an

120 exercise or if participants were not able to complete their repetitions with proper execution
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121 (e.g. shaking during the contraction), they were instructed to lower the weight for the

122 following repetitions and complete the entire session (equal time under tension). Audio files
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123 that counted the timing of the exercises were provided for use during their exercises to

124
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standardise the speed of repetition and rest and therefore time under tension for all

125 participants.

126

127 The primary outcome measure was pain during a single leg decline squat (SLDS) scored on

128 a numeric rating scale (NRS) (0 -10), which is a provocative clinical test to monitor tendon

129 pain.17,18 A 2-point difference on the NRS was considered to be a minimal clinical important

130 difference (MCID).19 The VISA-P, a questionnaire on pain and function of the knee,20 was

131 also completed. The score on the VISA-P ranges from 0-100, 100 being a completely

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132 asymptomatic and fully functioning athlete. The MCID of the VISA-P was considered to be 13

133 points.21 Participants were asked about their average tendon pain compared to the

134 beginning of the exercise program on a global rating of change scale from very much worse

135 (-4) to very much better (+4). A diary was also provided to the participants, in which they

136 reported completed exercise sessions. These data were used to calculate adherence to the

137 exercise program.

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138 All outcome measures were administered at baseline and four weeks later at the end of the

139 program. Only the worst knee was used in the analysis of the data in athletes with bilateral

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140 patellar tendinopathy.

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141 NRS pain scores on the SLDS had a non-normal distribution, and non-parametric tests were

142 used to test for differences. A Wilcoxon signed rank test was conducted to test for

143
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differences between baseline and follow-up measurements for NRS pain score during SLDS

144 within each group. A Mann-Whitney U test was used to test for differences between the
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145 isometric and isotonic intervention group. As secondary analyses, the same tests were

146 performed for the VISA-P score. Analyses were conducted using IBM SPSS Statistics 20
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147 software and an alpha of 0.05 was considered significant.

148
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149 Results
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150 Participants were included in the trial between August 2013 and July 2014 (Figure 1).
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151 Thirteen participants were randomised to the isometric group and 16 to the isotonic group.

152 Group characteristics did not differ at baseline (Table 1) and mean adherence to the exercise

153 program was 81%. Median pain scores improved significantly over the 4-week intervention

154 period within the isometric group (Z=-2.527. p=0.012, r = -0.63) and within the isotonic group

155 (Z=-2.952, p=0.003, r= -0.63) (Table 2).There was no significant difference in NRS pain

156 score change (U = 29.0 p=0.208 r=0.29) between the isometric group (median (IQR), 2.5 (1-

157 4.5)) and isotonic group (median (IQR), 3.0 (2-6)) (Table 2). Median VISA-P scores also

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158 improved significantly over the 4 week intervention period within the isometric group (Z= -

159 2.201, p=0.028, r=-0.55) and within the isotonic group (Z=-2.952, p=0.003, r=-0.66). The

160 median change in VISA-P was 9 points (3-25). There was no significant difference in VISA-P

161 score change (U = 39.5 p=0.965 r=-0.01) between the isometric group and isotonic group

162 (Table 2). The median perceived global rating of change (-4 to +4) for tendon pain at follow-

163 up compared to pre-intervention was +2.3 (2.0-3.0).

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164

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165 Discussion

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166 This study showed a clinically important decrease in pain in athletes with patellar

167 tendinopathy during a season with both isometric and isotonic exercises. The VISA-P also

168

169
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showed a significant improvement over time (close to MCID), which indicates that not only

pain but also function of the knee improved in this population. No significant difference
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170 between the isometric and isotonic exercise group was found.

171 In the field of tendinopathy, where exercise is the primary and most effective treatment
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172 available,22,23 relatively few studies have been conducted on exercise programs for patellar

173 tendinopathy.24 Improvements in pain have been reported when resistance exercise/training
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174 is used as rehabilitation. Kongsgaard et al14 showed a similar improvement in pain after 12

175 weeks of heavy slow resistance training as our study. After 6 weeks of a heavy slow isotonic
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176 exercise rehabilitation program, Cannell et al15 also found a decrease in pain. Other studies

177 have focussed on eccentric exercises as rehabilitation, and these exercise protocols also
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178 relieved pain in non-competing athletes.7,25,26 Eccentric exercise in-season may have no

179 effect or even worsens patellar tendinopathy symptoms.7,9,10 The findings of our study using

180 isotonic and isometric exercise are in contrast with eccentric exercises in-season.

181

182 An important difference between the exercise programs in our study compared to previous

183 studies investigating eccentric exercises on a decline board,7,9,14 is that eccentric exercises

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184 on a decline board were designed to provoke pain in the tendon.7,18 Since participants in this

185 study were still participating in basketball or volleyball matches and training sessions

186 (exposing their tendons to a high tendon load), provocative loads for the patellar tendon

187 should be avoided. An essential part of the exercises performed in our study is that the

188 exercises are a high load for the muscle, however not in a way that that is provocative to the

189 tendon and may increase pain.27

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190 The dosage (e.g. number of repetitions, days per week and duration of a contraction) and

191 type of exercise are important characteristics of an exercise program. A high percentage of

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192 repetition maximum (RM) has been used in our study for the isometric (80% 1RM) as well as

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193 the isotonic exercises (80% 8RM). Beneficial effects from rehabilitation for tendons require

194 high load per repetition.28 Furthermore, a high percentage of RM in leg extension exercises

195
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has been shown to improve muscle strength and neural activation.29 The leg extension

196 machine was used to isolate the load through the quadriceps muscle and patellar tendon as
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197 much as possible. Despite the positive effect of exercise for tendinopathy, both in research

198 labs and in the clinic, the precise mechanism of effect, optimal dosage and loading strategy
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199 has not yet been determined and further research is required.

200 Previous studies investigating short-term effects of isometric and isotonic exercises on
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201 (tendon) pain12,16 have found a decrease in pain post exercise. Isometric exercises resulted
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202 in a significant decrease in tendon pain and cortical inhibition (present at elevated levels in

203 patellar tendinopathy); pain relief lasted for at least 45 minutes after isometric exercises,
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204 while a much smaller decrease in pain and no change in cortical inhibition was found after

205 isotonic exercises.16 In contrast to these studies on the acute effects of isometric and isotonic

206 exercise, our study found no difference between isotonic and isometric exercise after 4

207 weeks. Previous studies suggest it may be that isometric exercises have a greater effect in

208 reducing acute pain, while isotonic exercise may cause a more gradual decrease in pain.15,16

209 How exercises affect pain is still unclear. An ongoing debate about pain in (patellar)

210 tendinopathy exists; it is still unclear if pain is physiological or pathophysiological or a

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211 combination in patellar tendinopathy.30

212

213 Our study has an important contribution to the conservative management of patellar

214 tendinopathy, in particular for in-season athletes with patellar tendinopathy. It also confirms

215 the recent shift in the literature away from isolated eccentrics for the rehabilitation of patellar

216 tendinopathy.Woodley, 2007; Scott, 2013 The shift away from isolated eccentric exercises does not

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217 seem to be exclusive for patellar tendinopathy, a similar shift in the literature seems to take

218 place in other tendinopathies as well. Habets et al 2015;Kulig et al 2009; Silbernagel et al 2007 More high quality

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219 research in this field is needed to find the best treatment strategy for every phase of

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220 tendinopathy.Cook et al,2009

221

222
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The current study had relatively small numbers in the intervention groups. Despite small

223 group sizes, we found significant improvements in pain scores in both groups. There were no
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224 data on which to base an a priori sample size calculation, as this was the first study to

225 compare these exercise programs. The group sizes in this study are similar to other studies
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226 investigating exercise programs for patellar tendinopathy.24 The 4-week follow-up was

227 relatively short as the study was designed to investigate if an (initial) decrease in patellar
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228 tendon pain could be achieved in competing athletes. Another limitation was that sessions

229 were not supervised and no random checks for compliance in the gym were performed. This
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230 was a real-life study, supervision of all patients was therefore not feasible and it reflects what

231
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is done in clinical practice. The chance to successfully implement the exercise programs in

232 practice with a high adherence of the patient might also be greater than in studies with a

233 more controlled environment.

234 Conclusion

235 This study was, to our knowledge, the first to find positive results for athletes with patellar

236 tendinopathy without modification of the training and competition load and it was the first

237 study to investigate isometric exercises in a clinical setting. Both isometric and isotonic

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238 exercise programs can reduce pain and improve function in athletes with patellar

239 tendinopathy in-season.

240

241 Practical implications

242  This study shows that isometric and isotonic exercises can decrease pain in athletes

243

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with patellar tendinopathy in-season.

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244  The exercises are easy to perform and also have the advantage over conventional

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245 eccentric training that they are less time-consuming for the athlete.

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246  The programs should be applied in a situation in which an athlete has pain in-season

247 or in the first weeks after a patient comes to a sports medicine/physiotherapy clinic

248 with patellar tendinopathy symptoms.

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249  Pain decrease in the relatively short term possibly increases the adherence of
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250 patients with a program and reduces the chance of transition to invasive and more

251 expensive treatments.

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252 Acknowledgements

253 The first author has been supported by Foundation “De Drie Lichten”,

254 “Wetenschappelijk College Fysiotherapie” and “Anna Foundation | NOREF” in The

255 Netherlands for this project. This study has also been supported by the Australian

256 Institute of Sport. Prof Cook was supported by the Australian centre for research into

257 sports injury and its prevention (ACRISP), which is one of the International Research

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258 Centres for the Prevention of Injury and Protection of Athlete Health supported by the

259 International Olympic Committee (IOC). Prof Cook is a NHMRC practitioner fellow

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260 (ID 1058493).

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261

262 an
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262 References

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264 different sports - A cross-sectional study. Am J.Sports Med 2005; 33(4):561-567.

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(3) Van Ark M, Van den Akker-Scheek I, Meijer L et al. An exercise-based physical therapy
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274 (5) Kjaer M, Langberg H, Heinemeier K et al. From mechanical loading to collagen synthesis,
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279 (7) Purdam CR, Jonsson P, Alfredson H et al. A pilot study of the eccentric decline squat in
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282 (8) Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin
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319 (23) Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy—a

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322 (24) Malliaras P, Barton CJ, Reeves ND et al. Achilles and patellar tendinopathy loading
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324 (25) Jonsson P, Alfredson H. Superior results with eccentric compared to concentric
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326 Sports Med. 2005; 39(11):847-850.

327 (26) Young MA, Cook JL, Purdam CR et al. Eccentric decline squat protocol offers superior
328 results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in
329 volleyball players. Br J Sports Med. 2005; 39(2):102-105.

330 (27) Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes.
331 Br J Sports Med. 2014 Apr;48(7):506-509.

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333 mechanical and morphological properties in response to cyclic strain. J Biomech
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335 (29) Kubo K, Ikebukuro T, Yata H et al. Effects of training on muscle and tendon in knee
336 extensors and plantar flexors in vivo. J Appl Biomech 2010;26(3):316-323.

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338 pathophysiological? Sports med 2014;44(1):9-23.

339

340

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340 Table 1. Characteristics of the population

Characteristics Isometric group Isotonic group Total

n=13 n=16 n=29

Age, yr 22.9 ± 4.9 (16-30) 23.1 ± 4.7 (17-32) 23.0 ± 4.7 (16-32)

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mean ± SD (range)

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Sex (male/female) 12/1 15/1 27/2

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Duration of symptoms, 30.8 ± 26.1 (1-84) 39.6 ± 39.1 (1-120) 35.8 ± 33.8 (1-120)

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months

mean ± SD (range)

BMI, kg/m2
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23.7 ± 2.0 (19.8-26.5) 24.2 ± 3.7 (18.9-34.7) 24.0 ± 3.0 (18.9-34.7)

mean ± SD (range)
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Unilateral/bilateral symptoms 6/7 7/9 13/16
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342 Table 2. Main outcome measures at baseline and follow-up for the intervention groups and

343 total population.

measurements Isometric group Isotonic group Total

NRS pain SLDS – 6.3 (5.3-7.0) 5.5 (4.0-6.0) 6.0 (4.0-7.0)

baseline n=8 n=11 n= 19

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median (IQR)

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NRS pain SLDS – 4.0 (2.0-5.0) ^* 2.0 (1.0-3.0) ^* 2.0 (2.0-3.8) ^*

4wk n=8 n=11 n=19

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median (IQR)

VISA-P – baseline

median (IQR)
66.5 (59.5-75.8)

n=8
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69.5 (55.0-75.8)

n=10
69.5 (58.3-75.3)

n=18
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VISA-P – 4wk 75.0 (72.5-87)* 79.0 (67.0-86.0)* 77.5 (70.8-86.5)*

median (IQR) n=8 n=10 n=18

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Number of exercise 3.0 (2.5-3.9) 3 (2.75-3.75) 3.1 (2.8-3.8)

performed per week, n=9 n=11 n=20

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median (IQR)
ce

Tendon pain change +2.5 (.5-3.0) +2 (2-3) +2.3 (2.0-3.0)

compared to pre- n=9 n=11 n=20

Ac

intervention on GRC

(-4 - +4), median

(IQR)

344 * Significant difference from baseline (p<0.05) ^Minimal clinical important difference from

345 baseline

346 IQR = Inter quartile range, GRC = global rating of change scale

347
16
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347 Figure legends

348 Figure 1. Flow chart of participants included in the trial

349

350

t
ip
cr
us
an
M
ed
pt
ce
Ac

17
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 Included (randomised)
n = 29

t
Drop-out before start
program (not responding

ip
after inclusion and initial
measurements) n = 5

cr
Drop-out during exercise

us
program (researchers
unable to contact)
n=2

an
M
Completed exercise
program
n = 22
d

Excluded
Did not play volleyball /
te

basketball for 2 weeks

n=2
(1 other injury, 1 personal reasons)
p

Included in analysis
n = 20
ce
Ac

Missing NRS SLDS Missing VISA

(excluded in analysis for NRS pain) (excluded in analysis for VISA)
n=1 n= 2

Page 18 of 18