Isometric Exercise To Reduce Pain in Patellar Tendinopathy In-Season Is It Effective "On The Road?"
Isometric Exercise To Reduce Pain in Patellar Tendinopathy In-Season Is It Effective "On The Road?"
Abstract
Objective: To investigate the effectiveness of an isometric squat exercise using a portable belt, on patellar tendon pain and
function, in athletes during their competitive season. Design: Case series with no requirements to change any aspect of games or
training. The object of this pragmatic study was to investigate this intervention in addition to “usual management.” A control or sham
intervention was considered unacceptable to teams. Setting: In-season. Participants: A total of 25 male and female elite and
subelite athletes from 5 sports. Intervention: 5 3 30-second isometric quadriceps squat exercise using a rigid belt completed
over a 4-week period. Main Outcome Measures: (1) single-leg decline squat (SLDS)—a pain provocation test for the patellar
tendon (numerical rating score of pain between 0 and 10), (2) VISA-P questionnaire assessing patellar tendon pain and function, and
(3) self-reported adherence with completing the exercise over a 4-week period. Results: Baseline SLDS pain was high for these in-
season athletes, median 7.5/10 (range 3.5-9) and was significantly reduced over the 4-week intervention (P , 0.001, ES r 5 0.580,
median change 3.5). VISA-P scores improved after intervention (P , 0.001, ES r 5 0.568, mean change 12.2 6 8.9, percentage
mean change 18.8%, where minimum clinical important difference of relative change for VISA-P is 15.4%-27%). Adherence was
high; athletes reported completing the exercise 5 times per week. Conclusions: This pragmatic study suggests that a portable
isometric squat reduced pain in-season for athletes with PT. This form of treatment may be effective, but clinical trials with a control
group are needed to confirm the results.
Key Words: patellar tendinopathy, in-season, pain, tendon, isometric
(Clin J Sport Med 2017;0:1–5)
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E. Rio et al. (2017) Clin J Sport Med
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The instructions were to position the belt around a sturdy per week in those that returned adherence data (n 5 23,
pillar. The belt was long, so any size pillar/pole could be used. range 4-7).
Athletes were told to wrap the belt as many times around pillar For SLDS data, 2 athletes did not provide baseline or 4-
as needed so that when they stepped 1 leg inside each loop; the week follow-up; thus, 23 athletes were included in analysis
belt was around upper calf (not popliteal fossa) and toes for SLDS. Missing 4-week SLDS (n 5 3) where baseline
against pillar as shown. Participants were instructed to place SLDS data were provided were given a change score of zero
their legs inside each loop, with toes positioned against a pillar (these athletes had baseline SLDS pain of 6, 7, and 8/10). All
to stop any sliding. They were asked to make sure that the participants provided baseline VISA-P, and 4 athletes did
loops were even. Athletes were instructed to squat back as not return 4-week VISA-P data, thus were given a change
deep as possible, keeping their spine upright, and not to lean score of zero for VISA-P (baseline VISA-P were 63, 64, 66,
forward. It should be noted that the belt used was a continuous and 48). All athletes except 2, returned either SLDS or
loop because a seatbelt with buckle was considered to be VISA-P data, or both, at 4-week follow-up, thus only 2
a safety risk. Two pictures are provided, demonstrating athletes were lost to follow up. Both participants who
different depths but a straight spine with green ticks to indicate dropped out of the study (defined as no 4-week data at all)
acceptable positions. An additional picture demonstrating the were women.
athlete leaning forward (thus unloading their quadriceps) is
provided with a red cross indicating ineffective position.
Single-Leg Decline Squat
Tendon pain measured on the SLDS was significantly reduced
Statistical Analysis
during the 4-week intervention (P , 0.001, effect size [ES] r 5
Where athletes reported bilateral symptoms, a coin toss was 0.580, median change 3.5, Figure 2). This represents an
used to select the side that was included for analysis. De- average reduction in pain of 49% of their baseline pain and
identified data were entered in Microsoft Excel, and a clinically important change.
participant data order randomized so that SLDS and VISA-P
data were independently analyzed, blinded to the other
VISA-P Questionnaire
outcome measure. Data were presented as median and range
inter-quartile range (IQR). Single-leg decline squat and VISA- VISA-P scores improved at the end of the intervention [P ,
P scores were analyzed using repeated-samples Wilcoxon 0.001, ES r 5 0.568, mean change 12.2 6 8.9, percentage
Signed-Rank tests, with the alpha level set at 0.05, and effect mean change 18.8% (MCID of relative change for VISA-P is
sizes calculated post hoc. All participant data were included, 15.4%-27% from baseline score)].
and missing 4-week data were analyzed using the baseline
score of SLDS or VISA-P carried forward. Reasons for drop
outs were also explored. DISCUSSION
This study demonstrates that a simple, double-leg isometric
squat exercise using a portable rigid belt reduced patellar
RESULTS
tendon pain in a real world sporting environment across
A total of 25 participants (mean height 1.82 6 0.11 m and different sports. These results have immediate clinical
body mass index 23.04, 6 women) returned signed consent applicability for athletes’ in-season, where there is a dearth
forms during the recruitment period from 2014 to 2017 of loading protocols to reduce patellar tendinopathy [PT] pain
from 5 sports (national Australian football, national level and enable continued sports performance.
squash, dance and volleyball, and world ranked tennis). Nineteen of the 25 participants recruited were men
Athletes reported completing the exercise median 5 times supporting previous literature that PT is predominantly
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E. Rio et al. (2017) Clin J Sport Med
a condition of male athletes1 and in fact more common in The intervention consisted of 5 3 30-second isometric
those with better jumping ability.12 Furthermore, 2 female double-leg squat holds, and this protocol represents less
athletes were lost to follow up; 1 athlete retired but reported time under tension than other published isometrics studies
“pain in the whole front of the knee”; and 1 athlete cited “knee demonstrating an effect.6,7 This is because the current study
swelling.” The patellar tendon is extra-articular; thus, one was commenced before the pilot testing by Rio et al.6 It is
may question whether the patellofemoral joint was in- possible that the results from this current study protocol
volved in these pain presentations rather than tendinopathy could be improved by increasing the time under tension to 5
because tendinopathy is not associated with joint swelling 3 45 seconds or alternatively the shorter duration was more
or diffuse anterior knee pain. As imaging was not acceptable to athletes and demonstrated effectiveness.
performed for clinical diagnosis, it is plausible that other Further studies should aim to identify the optimal exercise
knee pathologies were included especially in this instance protocol; however, it is likely to be highly individual, and
where participants provided reasons for drop out. How- based on clinical decision-making around the athletes
ever, as imaging does not correlate with tendon pain,13 capabilities including muscle strength. One advantage of
imaging may not have been helpful. As there were only 2 the bilateral isometric squat exercise is the ability to modify
drop outs, it is difficult to infer clinical implications; depth based on individual capabilities.
however, it is possible that the isometric squat exercise
may provoke symptoms in those people with vague pain or
Clinical Perspective
knee swelling. Other conditions of the anterior knee, such
as patellofemoral joint pain may be aggravated by the This study demonstrates that an isometric squat exercise
position, given the retro-patellar forces in closed kinetic offered in-season in athletes with localized inferior pole
chain squatting.14 Furthermore, the SLDS will actually pain, has good adherence and reduced pain across different
provoke different types of anterior knee pain, given the sports and schedules. Although it would not replace
patellofemoral forces.15 Future studies aiming to investi- a comprehensive rehabilitation that includes progressive
gate responders and nonresponders should consider pro- strength, energy storage, and release activities then sports-
viding clinicians with a short video demonstration of specific function (reserved for the off-season), 17 it does
assessment to ensure uniformity (and identify features of provide clinicians with a practical in-season option, given
these subgroups). the challenges around time, pain, equipment, and the
There were limitations in this study. It was not possible to inability to complete thorough rehabilitation during the
recruit a control group within the athlete population competitive season. Further given that the exercise is easy to
approached because all athletes chose to receive the perform and requires minimal equipment, it may be useful
intervention. However, the natural history of PT is that it to clinicians and patients who do not have access to
does not seem to improve in-season even with cointerven- specialized equipment. This isometric squat exercise may be
tions such as anti-inflammatory medication.4 Given the especially beneficial for sports in which travel schedules
complexities of performing research in an elite environment limit access to more conventional means of knee extensor
(eg, international tennis athletes with various support staff resistance exercise.
and their full-time occupation), the study design was very
much dictated by the clinicians and staff managing these References
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