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The Best Current Research on Patellar Tendinopathy: A Review of Published Meta-Analyses

Llombart, R., Mariscal, G., Barrios, C. and Llombart-Ais, R., 2024. The Best Current Research on Patellar Tendinopathy: A Review of Published Meta-Analyses. Sports, 12(2), p.46.

In today’s letter

• A summary of the most recent review of meta-analysis of patellar tendinopathy

• Rapid Results =

  Eccentric exercise helps with discomfort in short term

  Risk factors include reduced flexibility in hip and ankle joints as well as muscles such as quads and hamstrings. However, its not fully proven by all meta-analyses (it makes sense though as less flexibility = more load on tendons)

• 3 Reads to check out to further you knowledge about To further you knowledge about patellar tendinopathy

• Meme of the week: Name a book that made you cry 🥲 

Aim of study

• The primary aim of this review was to assess existing meta-analyses looking at the management of patellar tendinopathy & to summarise recommendations based on the best current evidence

• Additionally, the authors aimed to examine the characteristics and results of the included clinical trials, comparing the effectiveness between therapeutic modalities and identifying areas that require further high-quality research

Did you Know?

• Patellar tendinopathy, increasingly relevant in recent times particularly in sports, is the second most common knee injury among athletes after medial collateral ligament injury

• Prevalence in collegiate basketball (USA) players exceeds 20%, with 12% showing signs with ultrasound

• Dubbed "jumper’s knee," it is prevalent in sports involving repetitive quad loading such as basketball, volleyball, and track and field.

• Athletes with symptoms often experience pain, swelling, and stiffness during and after activity.

• These symptoms can impair performance, reducing training and competition time.

Results

Study characteristics

• A total of 21 studies met the inclusion criteria.

• Originating countries of the meta-analyses included:

  United States (3), Italy (2), New Zealand (1), United Kingdom (3), Australia (3), China (1), Ireland (1), Canada (1), Netherlands (1), Brazil (1), Spain (1), Finland (1), and Belgium (1).

• Publication types varied: 15 meta-analyses were in sports medicine journals, 2 in rehabilitation and physical therapy fields, and the rest in journals covering various topics.

• Anatomical focus varied: 6 studies solely addressed patellar tendinopathy, 3 included both Achilles and patellar tendinopathy, and the rest covered lower-limb or knee tendinopathy broadly.

• Few meta-analyses specifically analysed patellar tendinopathy.

• Concerningly, only 6 out of 21 meta-analyses had a previously registered protocol in PROSPERO, a database promoting review protocol transparency.

• Regarding quality:

  10 out of 21 studies presented critically low-quality findings

  6 had low-quality results

  5 had moderate-quality results

Risk factors

1. Ankle dorsiflexion range of motion

2. Hamstring and quadricep flexibility

3. Jump training volume

4. Countermovement jump (CMJ) height

5. Activity volume

• Most studies showed the above as risk factors for developing patellar tendinopathy.

• Conversely, other studies have not established a significant association between these factors and patellar tendinopathy.

• Discrepancies in findings may come from variations in studied populations, measurement techniques, and other variables.

• Enhancing ankle dorsiflexion-plantarflexion range of motion is proposed to mitigate the risk of patellar tendinopathy.

• Improved ankle flexibility and range of motion can lessen load and tension on the patellar tendon during physical exertion.

• Some research indicates a positive correlation between greater jump training volume and an increased risk of patellar tendinopathy.

• However, other studies have not identified a significant relationship, possibly due to variations in training methods, activity intensity, and individual athlete characteristics.

• CMJ height and physical activity volume have also been assessed as risk factors for patellar tendinopathy, with conflicting findings.

• Higher CMJ height and increased physical activity volume may raise the risk of developing this condition in some studies, while others have not found a significant association, potentially due to measurement standardisation and individual participant differences

• It is important to consider that these risk factors may interact with each other and with other individual factors such as genetics, age, and general fitness level

Platalet-Rich Plasma (PRP)

• Platelet-rich plasma (PRP) injection therapy has become increasingly favoured as a treatment for patellar tendinopathy.

• Studies consistently show good overall outcome for treating patellar tendinopathy with PRP injections.

• A common theme with this analysis, but, the existing evidence is limited, and outcomes can vary among studies.

• Some studies have shown no significant difference in pain or function between PRP-treated groups and control groups in patellar tendinopathy.

• These findings suggest that PRP may not offer additional benefits in terms of pain relief or functional improvement compared to standard treatments in control groups.

• Moreover, PRP isn't the sole treatment option for patellar tendinopathy.

• Conservative approaches like eccentric exercises, physiotherapy, anti-inflammatory medication, and activity modifications are also commonly used.

• Selecting the most suitable treatment should involve an evaluation of the patient's condition, considering symptom severity, response to previous treatments, and goals

Rehabilitation

• The effectiveness of eccentric exercise therapy in treating common tendinopathies is still a subject of ongoing discussion, primarily because of a lack of definitive, high-quality research.

• Eccentric exercises involve deliberately lengthening a muscle while under tension, with the aim of strengthening affected tendons and promoting healing. Despite significant research for this type of exercise, there's yet to be a unanimous agreement on its effectiveness compared to other tendinopathy treatments

Shockwave

• Extracorporeal shockwave therapy (ESWT) has shown promise in decreasing pain and improving functionality compared to placebo or other non-surgical treatments like NSAIDs, physical therapy, and injections.

• It is theorised that the positive effects of ESWT could be due to increased angiogenesis, enhanced vascularization, and the repair of damaged tendon tissue

  *** Other reviews (in 2021) showed no benefit of shockwave compare to placebo *** LINK

Ultrasound

• Longitudinal studies have provided evidence suggesting that ultrasounds can detect initial structural abnormalities in tendons, potentially aiding in predicting the development of clinical symptoms and dysfunction.

• However, the diagnostic use of ultrasound is affected by methodological constraints, making it challenging to compare studies and establish standardised diagnostic criteria.

• Due to the lack of agreement on a protocol for ultrasound-based assessments of tendinopathies, additional research is necessary to overcome these limitations and enhance diagnostic precision

Reliability

• The VISA-P questionnaire, designed to assess the severity of patellar tendinopathy, is a promising tool. However, its reliability requires further validation through larger, methodologically robust studies to determine its test–retest reliability, internal consistency, construct validity, and ability to detect clinical changes

Central sensitisation

• Presently, there's incomplete evidence to fully confirm how tendinopathy affects the mechanical characteristics of the patellar tendon.

• Additionally, individuals with tendinopathies frequently display sensory and motor impairments in their unaffected limbs, hinting at broader central nervous system involvement.

Nitroglycine

• Nitroglycerin (NTG), typically employed to alleviate angina by widening blood vessels and enhancing blood circulation, has been investigated as a prospective remedy for Achilles and patellar tendinopathies.

• Yet, existing literature fails to furnish evidence substantiating NTG's effectiveness in mitigating pain linked with these ailments

Top 3 Reads

To further you knowledge about patellar tendinopathy

1. Treating athletes in season
   https://www.sportsmith.co/articles/managing-patellar-tendinopathy-in-season/

2. In depth article about assessing Patella tendinopathy

   https://sportsmedu.com/2023/12/30/jumpers-knee-symptoms-risk-factors-healing-timeframe/

3. In depth article about Treating Patella tendinopathy

   https://sportsmedu.com/2023/12/30/diagnose-treat-jumpers-knee-effectively/

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