Eccentric training as effective as surgery for patellar tendinopathy

Training group had the same chance of returning to sport a the surgical group in a randomized trial.

INNSBRUCK, Austria — Although many orthopedists recommend surgery for patients with severe patellar tendinopathy, eccentric training may, in fact, be as effective, according to a top Scandinavian sports medicine specialist.

Roald Bahr, MD, PhD, of Oslo, Norway, performed a randomized controlled trial comparing open patellar tenotomy and eccentric training outcomes. Patients were selected between March 2001 and December 2004. Inclusion criteria included: a history of "jumper's knee," local tenderness at the patellar fold and MRI changes in the patellar tendon.

Bahr was a finalist for the Theo van Rens Award for his paper at the European Society of Sports, Traumatology and Knee Arthroscopy (ESSKA) 12th Congress, here.

The study group included 35 patients (40 knees). Patients were randomized into two groups: primary surgery or eccentric training, Bahr said. Five patients who failed eccentric training and did not improve after 3 to 6 months were assigned to a third group. All patients were followed for 12 months after the start of their treatment.

The home exercise regimen, adapted from a program designed for Achilles tendinopathy, comprised exercises twice daily on a 25° decline board. Loads were increased as patients' pain decreased, so the exercises were always painful, Bahr said.

Outcomes

The patients completed the Victorian Institute of Sport Assessment (VISA) score, an assessment tool developed for patellar tendinopathy, and were followed up at 3, 6 and 12 months. Patients in both the eccentric training and primary surgery groups showed improvement during treatment. However, VISA scores showed no outcome differences between the two groups.

The five patients who failed eccentric training also improved after secondary surgery, but their results were "not very impressive" compared with the other groups, Bahr said.

"If you look at ... return to sport ... you can see that in the eccentric training group, about half the patients were able to return to full training, some of them without symptoms," Bahr said. Researchers saw comparable results in the primary surgery group.

Still, no patients from the secondary surgery group were able to resume full training. One patient returned to full training, but with symptoms, Bahr said.

Overall, 55% of patients from the eccentric training group and 45% of those from the primary surgery group were able to resume full training, Bahr said.

"The conclusion for this study is that no advantage was demonstrated with surgical treatment compared to eccentric training alone, and eccentric training should be tried for at least 12 weeks before open tenotomy is considered," Bahr said.

A note on methodology

Bahr cited a 2000 study in which Karim Khan, PhD, FACSP, and Beth Coleman, MD, reviewed studies on outcomes after patellar tendinopathy surgery. Khan and Coleman developed a 100-point methodology score.

"The results of that paper are very interesting in two ways," Bahr said. "First of all, they showed that the results of patellar tendinopathy surgery are variable across studies. ... But interestingly, the [return to sport] results were inversely related to the methodology scores. In other words, the worse the study was, the better the results, and the better the study was, the worse the results.

"However, they also showed clearly that there were not very many good studies on this," he added. "In fact, there were no randomized controlled trials. Most of the papers were retrospective case reviews."

For more information:
Bahr R. Surgical treatment vs. eccentric training for patellar tendinopathy: a randomized controlled trial. Theo van Rens Award Star Paper #1. Presented at the 12th ESSKA Congress and 5th World Congress on Sports Trauma. May 24-27, 2006. Innsbruck, Austria.
Bahr R, Fossan B, Loken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper's knee). J Bone Joint Surg Am. 2006;88-A:1689-1698.