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Meta-Analysis
. 2025 May 27;5(5):CD013078.
doi: 10.1002/14651858.CD013078.pub2.

Exercise for patellar tendinopathy

Alexandre D Lopes  1 , Rodrigo Rn Rizzo  2   3 , Luiz Hespanhol  4 , Leonardo Op Costa  5   6 , Steven J Kamper  7   8
Affiliations
Meta-Analysis

Exercise for patellar tendinopathy

Alexandre D Lopes et al. Cochrane Database Syst Rev. .

Abstract

Background: Patellar tendinopathy is a prevalent condition that commonly affects the tendon's origin, causing pain at the front of the knee. The main treatment for patellar tendinopathy involves different types of exercise (e.g. strengthening and stretching). The most common method of strengthening exercise is eccentric (lengthening) muscle loading. Strengthening exercises can be land-based or water-based, weight-bearing or non-weight-bearing, or both. Other treatments include surgery and glucocorticoid injections.

Objectives: To evaluate the benefits and harms of exercise for the treatment of patellar tendinopathy.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trials registers to 5 September 2023, with no restrictions by language.

Selection criteria: We included randomized controlled trials of strengthening exercise interventions compared to placebo or sham intervention; no treatment, usual care, or minimal intervention; or other active intervention. Strengthening exercises include concentric, eccentric, eccentric-concentric, and isometric exercises designed to enhance the strength and power of muscles.

Data collection and analysis: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. Major outcomes included pain, function, participant-reported global assessment of treatment success, quality of life, return to sport, proportion of participants with adverse events, and proportion of participant withdrawals.

Main results: We included seven trials (211 participants with chronic patellar tendinopathy) comparing strengthening exercises with no treatment (3 trials, 93 participants), glucocorticoid injection (1 trial, 38 participants), surgery (1 trial, 40 participants), stretching exercise (1 trial, 15 participants), or pulsed ultrasound and transverse friction (1 trial, 30 participants). All trials included athletes (88% males, mean age 26 years) with a mean duration of symptoms of 41.6 months. Most trials were susceptible to bias, particularly selection bias/random sequence (57.1%), selection bias/allocation concealment (42.8%), detection bias (28.5%), attrition bias (71.4%), and selective reporting biases (28.5%). Given the nature of the intervention, neither participants nor investigators were blinded to group allocation in any trials (performance bias). We did not find any studies that compared exercise with placebo or sham intervention. Strengthening exercise versus no treatment We are very uncertain whether strengthening exercise reduces pain compared to no treatment. Mean pain with no treatment was 62.00 points on a 0 to 100 scale (0 = no pain) compared to 27.06 points with exercise (mean difference (MD) 34.94 points better, 95% confidence interval (CI) 20.94 better to 48.94 better; 1 study, 39 participants; very low-certainty evidence (downgraded twice for imprecision and once for bias)). Strengthening exercise may make little or no difference to function compared to no treatment at the end of treatment. Mean function with no treatment was 65.00 points on a 0 to 100 scale (100 = best function) compared to 72.04 points with exercise (MD 7.04 points better, 95% CI 6.94 points worse to 21.02 points better; 2 studies, 95 participants; low-certainty evidence (downgraded once for imprecision and once for bias)). The studies reported none of the other outcomes. Strengthening exercise versus glucocorticoid injection Strengthening exercise may make little or no difference to pain compared to glucocorticoid injection at the end of treatment. Mean pain with glucocorticoid injection was 18.00 points on a 0 to 100 scale (0 = no pain) compared to 24.04 points with exercise (MD 6.04 points worse, 95% CI 8.19 better to 20.26 better; 1 trial, 38 participants; low-certainty evidence (downgraded twice for imprecision)). Strengthening exercise may make little or no difference to function compared to glucocorticoid injection at the end of treatment. Mean function with no treatment was 82.00 points on a 0 to 100 scale (100 = best function) compared to 76.25 points with exercise (MD 5.75 points worse, 95% CI 17.41 worse to 5.93 better; 1 trial, 38 participants; low-certainty evidence (downgraded twice for imprecision)). The trial reported none of the other outcomes. Strengthening exercise versus surgery We are very uncertain whether strengthening exercise reduces pain compared to surgery at 12-month follow-up. Mean pain with surgery was 13.00 points on a 0 to 100 scale (0 = no pain) compared to 17.00 points with exercise (MD 4.00 points worse, 95% CI 4.06 better to 12.06 worse; 1 trial, 40 participants; very low-certainty evidence). We are very uncertain whether strengthening exercise improves function compared to surgery. Mean function in the surgery group at the end of treatment was 45.10 points on a 0 to 100 scale (100 = best function) compared to 52.4 points in the exercise group (MD 7.30 points better, 95% CI 5.02 worse to 19.62 better; 1 trial, 40 participants; very low-certainty evidence (downgraded once for bias and twice for serious imprecision)). Strengthening exercise may make little or no difference to treatment success compared to surgery at the end of treatment. The mean global assessment of treatment success with surgery was 0.2 points on a -5 to +5 scale (+5 maximum was improvement) compared to 1.76 points with exercise (MD 1.56 points better, 95% CI 0.52 worse to 3.64 better; 1 trial, 40 participants; low-certainty evidence (downgraded once for bias and once for imprecision)). Strengthening exercise may make little or no difference to the rate of participants who returned fully or partially to sport when compared to surgery at 12-month follow-up. The return to sport rate with surgery was 86% compared to 85% with exercise (risk ratio 1.02, 95% CI 0.78 to 1.34; 1 trial, 40 participants; low-certainty evidence (downgraded once for bias and once for imprecision)). The trial reported none of the other outcomes.

Authors' conclusions: We are very uncertain whether strengthening exercise reduces pain compared to no treatment. Strengthening exercise may make little or no difference to function compared to no treatment and to function or pain compared to glucocorticoid injection. Compared to surgery, we are very uncertain whether strengthening exercise reduces pain or improves function, and it may make little or no difference to treatment success and the proportion of athletes returning to sport. No trials measured adverse events. All trials analyzed in this review included participants who were athletes, limiting the findings to athletes rather than the general public.

Trial registration: ClinicalTrials.gov NCT02597660.

PubMed Disclaimer

Conflict of interest statement

ADL: none.

RRR: none.

LCH: none.

LOC: none.

SJK: none.

Update of

  • doi: 10.1002/14651858.CD013078

References

References to studies included in this review

Bahr 2006 {published and unpublished data}
    1. Bahr R, Fossan B, Løken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendinopathy (jumper's knee). Journal of Bone and Joint Surgery 2006;88(8):1689-98. - PubMed
Biernat 2014 {published data only}
    1. Biernat R, Trzaskoma Z, Trzaskoma L, Czaprowski D. Rehabilitation protocol for patellar tendinopathy applied among 16- to 19-year old volleyball players. Journal of Strength & Conditioning Research 2014;28(1):43-52. - PubMed
Jensen 1989 {published data only}
    1. Jensen K, Di Fabio RP. Evaluation of eccentric exercise in treatment of patellar tendinitis. Physical Therapy 1989;69(3):211-6. - PubMed
Kongsgaard 2009 {published data only}
    1. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine & Science in Sports 2009;19(6):790-802. - PubMed
Rieder 2022 {published and unpublished data}
    1. Rieder F, Wiesinger H-P, Herfert J, Lampl K, Hecht S, Niebauer J, et al. Whole body vibration for chronic patellar tendinopathy: a randomized equivalence trial. Frontiers in Physiology 2022;13:1-14. [PMID: ] - PMC - PubMed
Stasinopoulos 2004 {published data only}
    1. Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Clinical Rehabilitation 2004;18(4):347-52. - PubMed
Visnes 2005 {published data only}
    1. Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper's knee in volleyball players during the competitive season: a randomized clinical trial. Clinical Journal of Sport Medicine 2005;15(4):227-34. - PubMed

References to studies excluded from this review

Abián‐Vicén 2021 {published data only}
    1. Abián-Vicén J, Martínez F, Jiménez F, Abián P. Effects of eccentric single-leg decline squat training performed with different execution times on maximal strength and muscle contraction properties of the knee extensor muscles. Journal of Strength and Conditioning Research 2022;36(11):3040-7. - PubMed
Agergaard 2021 {published data only}
    1. Agergaard A, Svensson RB, Malmgaard-Clausen NM, Couppé C, Hjortshoej MH, Doessing S, et al. Clinical outcomes, structure, and function improve with both heavy and moderate loads in the treatment of patellar tendinopathy. American Journal of Sports Medicine 2021;49(4):982-93. - PubMed
Breda 2021 {published and unpublished data}
    1. Breda SJ, Oei EH, Zwerver J, Visser E, Waarsing E, Krestin GP, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British Journal of Sports Medicine 2021;55:501-9. - PMC - PubMed
Cannell 2001 {published data only}
    1. Cannell LJ, Taunton JE, Clement DB, Smith C, Khan KM. A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper's knee in athletes: pilot study. British Journal of Sports Medicine 2001;35(1):60-4. - PMC - PubMed
Cunha 2012 {published data only}
    1. Cunha RA, Dias AN, Santos MB, Lopes AD. Comparative study of two protocols of eccentric exercise on knee pain and function in athletes with patellar tendinopathy: randomized controlled study. Revista Brasileira de Medicina do Esporte 2012;18(3):167-70.
Dimitrios 2012 {published and unpublished data}
    1. Dimitrios S, Pantelis M, Kalliopi S. Comparing the effects of eccentric training with eccentric training and static stretching exercises in the treatment of patellar tendinopathy. A controlled clinical trial. Clinical Rehabilitation 2012;26(5):423-30. - PubMed
Dragoo 2014 {published data only}
    1. Dragoo JL, Amy S, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar tendinopathy. American Journal of Sports Medicine 2014;42(3):610-8. - PubMed
Frohm 2007 {published data only}
    1. Frohm A, Saartok T, Halvorsen K, Renstrom P. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols. British Journal of Sports Medicine 2007;41(7):e7. - PMC - PubMed
Furia 2013 {published and unpublished data}
    1. Furia JP, Rompe JD, Cacchio A, Del Buono A, Maffulli N. A single application of low-energy radial extracorporeal shock wave therapy is effective for the management of chronic patellar tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy 2013;21(2):346-50. - PubMed
Gual 2016 {published and unpublished data}
    1. Gual G, Fort-Vanmeerhaegue A, Romero-Rodríguez D, Tesch PA. Effects of in-season inertial resistance training with eccentric overload in a sports population at risk for patellar tendinopathy. Journal of Strength and Conditioning Research 2016;30(7):1834-42. - PubMed
Jonsson 2005 {published data only}
    1. Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study. British Journal of Sports Medicine 2005;39(11):847-50. - PMC - PubMed
Kumar 2020 {published data only}
    1. Kumar MP, Hari Hara Subramanyan PV, Balamurugan N, Rajavel R, Sargunum B. Comparison between the effectiveness of decline squat exercise and forward lunges in athletes with patellar tendinopathy. Drug Invention Today 2020;14(3):228-31.
MacDonald 2019 {published data only}
    1. MacDonald K, Day J, Dionne C. Effect of eccentric exercises at the knee with hip muscle strengthening to treat patellar tendinopathy in active duty military personnel: a randomized pilot. Orthopaedic Physical Therapy Practice 2019;31(1):8-16.
Pearson 2020 {published and unpublished data}
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Purdam 2004 {published data only}
    1. Purdam CR, Jonsson P, Alfredson H, Lorentzon R, Cook JL, Khan KM. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. British Journal of Sports Medicine 2004;38(4):395-7. - PMC - PubMed
Resteghini 2016 {published data only}
    1. Resteghini P, Khanbhai TA, Mughal S, Sivardeen Z. Double-blind randomized controlled trial: injection of autologous blood in the treatment of chronic patella tendinopathy – a pilot study. Clinical Journal of Sport Medicine 2016;26(1):17-23. - PubMed
Rio 2015 {published and unpublished data}
    1. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine 2015;49(19):1277-83. - PubMed
Rio 2017 {published data only}
    1. Rio E, Ark M, Docking S, Moseley GL, Kidgell D, Gaida JE, et al. Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clinical Journal of Sport Medicine 2017;27(3):253-59. - PubMed
Rosety‐Rodríguez 2006 {published data only}
    1. Rosety-Rodríguez M, Ordóñez-Muñoz FJ, Huesa-Jiménez F, Rosety Rodriguez J, Gómez-Rodríguez F, Rosety-Plaza M. Eccentric training programs for infrapatellar tendinopathy: new strategies for an old problem [Actualización del trabajo excéntricode cuádriceps en pacientes en edadlaboral con tendinopatía rotuliana]. Patología del Aparato Locomotor 2006;4(2):105-7.
Scott 2019 {published data only}
    1. Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Villa SD, et al. Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline. American Journal of Sports Medicine 2019;47(7):1654-61. [PMID: ] - PubMed
Sprague 2021 {published data only}
    1. Sprague AL, Couppé C, Pohlig RT, Snyder-Mackler L, Silbernagel KG. Pain-guided activity modification during treatment for patellar tendinopathy: a feasibility and pilot randomized clinical trial. Pilot and Feasibility Studies 2021;7(58):1-17. - PMC - PubMed
Steunebrink 2013 {published and unpublished data}
    1. Steunebrink M, Zwerver J, Brandsema R, Groenenboom P, Akker-Scheek I, Weir A. Topical glyceryl trinitrate treatment of chronic patellar tendinopathy: a randomised, double-blind, placebo-controlled clinical trial. British Journal of Sports Medicine 2013;47(1):34-9. - PMC - PubMed
Thijs 2017 {published data only}
    1. Thijs KM, Zwerver J, Backx FJ, Steeneken V, Rayer S, Groenenboom P, et al. Effectiveness of shockwave treatment combined with eccentric training for patellar tendinopathy: a double-blinded randomized study. Clinical Journal of Sport Medicine 2017;27(2):89-96. - PubMed
van Ark 2016 {published data only}
    1. Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, den Akker-Scheek I, et al. 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 2016;19(9):702-6. - PubMed
Young 2005 {published data only}
    1. Young M, Cook J, Purdam C, Kiss Z, Alfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. British Journal of Sports Medicine 2005;39(2):102-5. - PMC - PubMed
Zihao 2023 {published and unpublished data}
    1. Zihao J, Guanglan W, Peng C, Xianghong S, Ting W, Shaohui J, et al. Eccentric training combined with different frequencies of whole-body vibration training for the treatment of terminal patellar tendon disease. Chinese Journal of Tissue Engineering Research 2023;28(4):493-501. [DOI: 10.12307/2024.211] - DOI

References to ongoing studies

CTRI/2019/08/020643 {unpublished data only}2019/08/020643
    1. CTRI/2019/08/020643. To compare the difference between fascial manipulation and eccentric training in patellar tendinopathy patients. https://trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2019/08/020643 (first received 9 August 2019). [WHO ICTRP: https://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=34063]
NCT02597660 {unpublished data only}
    1. NCT02597660. A study to evaluate the efficacy of somatropin in the treatment of patellar tendinopathy. https://clinicaltrials.gov/study/NCT02597660 (first received 3 November 2015).
PACTR202304561563965 {unpublished data only}202304561563965
    1. PACTR202304561563965. The effect of eccentric training on postural balance in athletes with patellar tendinopathy. https://trialsearch.who.int/Trial2.aspx?TrialID=PACTR202304561563965 (first received 19 March 2023). [PACTR: 202304561563965]

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