Article

Clinical Rehabilitation
26(5) 423–430
Comparing the effects of eccentric ! The Author(s) 2011
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DOI: 10.1177/0269215511411114
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and static stretching exercises
in the treatment of patellar
tendinopathy. A controlled
clinical trial

Stasinopoulos Dimitrios1,2,3,, Manias Pantelis4 and

Stasinopoulou Kalliopi1

Abstract
Objective:The aim of the present study was to investigate the effectiveness of eccentric training and
eccentric training with static stretching exercises in the management of patellar tendinopathy.
Design:Controlled clinical trial.
Setting:Rheumatology and rehabilitation centre.
Subjects: Forty-three patients who had patellar tendinopathy for at least three months. They were
allocated to two groups by alternative allocation.
Interventions: Group A (n ¼ 22) was treated with eccentric training of patellar tendon and static
stretching exercises of quadriceps and hamstrings and Group B (n ¼ 21) received eccentric training of
patellar tendon. All patients received five treatments per week for four weeks.
Outcomes:Pain and function were evaluated using the VISA-P score at baseline, at the end of treatment
(week 4), and six months (week 24) after the end of treatment.
Results:At the end of treatment, there was a rise in VISA-P score in both groups compared with baseline
(P<0.0005, paired t test). There were significant differences in the VISA-P score between the groups at
the end of treatment (+14; 10 to 18) and at the six-month follow-up (+19; 13 to 24); eccentric training
and static stretching exercises produced the largest effect (P<0.0005, one-way ANOVA).
Conclusions:Eccentric training and static stretching exercises is superior to eccentric training alone to
reduce pain and improve function in patients with patellar tendinopathy at the end of the treatment and at
follow-up.
Received: 6 November 2010; accepted: 1 May 2011

4
Private Clinic, Ithaki, Greece
1
Private Clinic, Patissia, Athens, Greece Corresponding author:
2
School of Health and Human Sciences, Leeds Metropolitan Stasinopoulos Dimitrios, 16 Orfanidou street, A. Patissia,
University, Leeds, UK Athens 11141, Greece.
3
European University of Cyprus, Nicosia, Cyprus Email: d_stasinopoulos@yahoo.gr
424
Introduction
The term patellar tendinopathy refers to painful
overuse tendon without implying pathology; it
is ideal for clinical diagnosis.1 Patellar tendino-
pathy was first referred to as ‘jumper’s knee’.
This term is not appropriate for clinical diagno-
sis because the condition can occur in athletes
who do not perform jumping in their sports as
well as in people who are not athletes.2 The term
patellar tendonitis is also incorrect for clinical
diagnosis because the condition is degenerative
rather than inflammatory. This condition is
characterized by the increased presence of fibro-
blasts, vascular hyperplasia, increased amounts
of proteoglycans and glycosaminoglycans, disor-
ganized collagen, absence of inflammatory cells
and prostaglandin.3 The term patellar tendinosis
refers to pathology of the patellar tendon and
is the best diagnostic term.
The principal factors that lead to its develop-
ment are hard playing surfaces, increased
frequency of training sessions with repetitive
eccentric movement and finally tight hamstring
and quadriceps.4,5 It is most commonly charac-
terized by pain at the inferior pole of the patella,
although pain can also be at the tibial attach-
ment, in the attachment of the tendon to the
superior pole of the patella as well as midsub-
stance pain has been reported.6–8 The pain can
be caused by performing a functional activity
such as squat or hop.8
However, no ideal treatment has emerged for
the management of patellar tendinopathy. Many
clinicians advocate a conservative approach9 and
physiotherapy is usually recommended.2 A wide
array of physiotherapy treatments has been rec-
ommended for the management of patellar tendi-
nopathy such as electrotherapeutic modalities,
exercise programmes, soft tissue manipulation,
and manual techniques.1 These treatments have
different theoretical mechanisms of action, but all
have the same aim, to reduce pain and improve
function. Such a variety of treatment options sug-
gests that the optimal treatment strategy is not
known, and more research is needed to discover
Clinical Rehabilitation 26(5)
the most effective treatment in patients with patel-
lar tendinopathy.
One of the most common physiotherapy treat-
ments for patellar tendinopathy is an exercise pro-
gramme. One consisting of eccentric exercises has
shown good clinical results in patellar10–13 and
Achilles tendinopathy.14–19 On the other hand,
eccentric and static stretching exercises seems to
be an effective treatment for lateral elbow tendi-
nopathy, commonly referred to as tennis elbow or
lateral epicondylitis.20–22 Such an exercise pro-
gramme is used as the first treatment option for
patients with lateral elbow tendinopathy.23
To our knowledge, there have been no studies
to investigate the effectiveness of eccentric and
static stretching exercises in patients with patel-
lar tendinopathy. Tightness of hamstring and
quadriceps has been found in patients with
patellar tendinopathy as an aetiological factor.
It is possible to combine eccentric training with
static stretching exercises to see if the combina-
tion of these two therapeutic approaches offers
superior results to eccentric training alone in
patellar tendinopathy patients. Therefore, the
aim of the present article was to make a com-
parison of the effects of an exercise programme
consisting of eccentric training and an exercise
programme consisting of eccentric training and
static stretching exercises for the treatment of
patellar tendinopathy.
Methods
A controlled, monocentre trial was conducted in
a clinical setting to assess the effectiveness of an
eccentric training programme and once involv-
ing eccentric training with static stretching exer-
cises. A parallel group design was used because
crossover designs are limited in situations where
patients are cured by the intervention and do not
have the opportunity to receive the other treat-
ments after crossover.24 Three investigators were
involved in the study: (1) the primary investiga-
tor who administered the treatments (DS); (2) a
medical doctor (KS) who evaluated the patients
to confirm the patellar tendinopathy diagnosis;
Stasinopoulos et al.
and (3) a physiotherapist (PM) who performed
all baseline and follow-up assessments, and
gained informed consent. All assessments were
conducted by PM who was blind to the patients’
therapy group. PM interviewed each patient to
ascertain baseline demographic and clinical
characteristics, including patient name, sex,
age, duration of symptoms, previous treatment,
occupation, affected leg and dominant leg.
Patients between 18 and 30 years old who
were experiencing anterior knee pain were
examined and evaluated in a private outpatient
physiotherapy clinic located in Athens, Greece,
between September 2003 and September 2007.
All patients lived in Athens, were native speak-
ers of Greek and were either self-referred or
referred by their physician or physiotherapist.
The selection criteria for the study were1,3,9:
. tenderness with palpation over the inferior
pole of the patella;
. no history of trauma to the knee;
. minimum duration of symptoms three months;
. unsuccessful conservative treatment before
entering the study, but not in the preceding
one month;
. no other current knee or lower extremity prob-
lems including anterior knee pain, muscle
strains and hip or ankle injuries;
. positive decline squat test.1,3,20 This is a clin-
ical diagnostic test.
All patients received a written explanation of
the trial before entry into the study and then
gave signed consent to participate. They were
allocated to two groups by sequential, alternate
allocation: the first patient was assigned to the
eccentric training and static stretching exercises
group, the second to the eccentric training
group, and so on.
All patients were instructed to use their knee
during the course of the study but to avoid activ-
ities that irritated the joint such as jumping, hop-
ping and running. They were also told to refrain
from taking anti-inflammatory drugs throughout
the course of study. Patient compliance with
425
this request was monitored using a treatment
diary.
Communication and interaction (verbal and
non-verbal) between the therapist and patient
was kept to a minimum, and behaviours some-
times used by therapists to facilitate positive treat-
ment outcomes were purposefully avoided. For
example, patients were given no indication of
the potentially beneficial effects of the treatments
or any feedback on their performance in the pre-
application and post-application measurements.25
The eccentric training was the same for both
groups. As eccentric exercises, participants car-
ried out three sets of 15 repetitions of unilateral
squat on a 25o decline board. The squat was per-
formed at a slow speed at every treatment session.
The patients counted to 30 during the squat.20 As
they moved from the standing to the squat posi-
tion, the quadriceps muscle and patellar tendon
by inference were loaded eccentrically; no follow-
ing concentric loading was done, as the nonin-
jured leg was used to get back to the start
position. At the beginning the load consisted of
the body weight and participants were standing
with all their body weight on the injured leg.
Subjects were told to go ahead with the exercise
even if they experienced mild pain. However, they
were told to stop the exercise if the pain became
disabling. When the squat was pain-free the load
was increased by holding weights in their hands.
Between each set there was a two-minute rest. In
the eccentric training and static stretching exer-
cises group, static stretching exercises were per-
formed as described by Jensen and Di Fabio28
before and after the eccentric training.10 Each
stretch lasted 30 seconds and there was a one-
minute rest between each stretch. Each training
session was to be completed once daily, five times
per week, for four weeks and was individualized
on the basis of the patient’s description of pain
experienced during the procedure.28
Pain, function and dropout rate were
measured in the present study. Each patient was
evaluated at baseline (week 0), at the end of treat-
ment (week 4) and at six months (week 24) after
the end of treatment.
426
The VISA-P questionnaire was used to
monitor the pain and function of patients. The
instrument is a simple questionnaire, consisted
of eight questions that takes less than five minutes
to complete and once patients are familiar with it
they will be able to complete most of it themselves.
It is a valid and reliable outcome measure for
patients with patellar tendinopathy.26
A dropout rate was also used as an indicator
of treatment outcome. Reasons for patient drop-
out were categorized as follows: (1) withdrawal
without reason, (2) not returned for follow-up,
and (3) request for an alternative treatment.
The change from baseline was calculated for
each follow-up. Differences in this change was
calculated between the groups and was deter-
mined using a one-way analysis of variance
(one-way ANOVA). Bonferroni post-hoc com-
parisons were conducted when the results from
the one-way ANOVA were significant to deter-
mine how the two groups differed. A 5% level of
probability was adopted as the level of statistical
significance. SPSS 11.5 statistical software was
used for the statistical analysis (SPSS Inc.,
Chicago, IL, USA).
Results
Sixty-three patients eligible for inclusion visited
the clinic within the trial period. Twelve were
unwilling to participate in the study, and eight
did not meet the inclusion criteria described
above. The other 43 patients were sequentially
allocated to one of the two possible groups:
(a) eccentric training and static stretching exer-
cises (n ¼ 22; 16 men, 6 women; mean (SD) age
26.38 (4.32) years; the duration of patellar ten-
dinopathy was 5.985 months); (b) eccentric
training (n ¼ 21; 15 men, 6 women; mean (SD)
age 27.04 (5.11) years; the duration of patellar
tendinopathy was 6.126 months). Patient flow
through the trial is summarized in a CONSORT
flowchart (Figure 1).
At baseline, there were more men in the
groups (19 more in total). Patellar tendinopathy
was in the dominant leg in 93% of patients.
There were no significant differences in mean
Clinical Rehabilitation 26(5)
age (P<0.0005, one-way ANOVA) or the mean
duration of symptoms (P<0.0005, one-way
ANOVA) between the groups. Patients had
received a wide range of previous treatments
(Table 1). Drug therapy had been tried by
65%. All patients were non-athletes.
Mean VISA-P score was 45 (95% confidence
interval 32 to 59) for the whole sample at base-
line (n ¼ 43; Table 2). There were no significant
differences between the groups for baseline
VISA-P score (P>0.05 one-way ANOVA;
Table 2). At week 4, there was a rise in VISA
score of 42 units in the eccentric training and
static stretching exercises group and 28 units in
the eccentric training group with the baseline
(P<0.0005, paired t test; Table 3). There was a
significant difference in the magnitude of
improvement between the groups (P<0.0005,
one-way ANOVA, Table 3), so post-hoc tests
were performed.
The magnitude of improvement was signifi-
cantly larger for the eccentric training and
static stretching exercises group when compared
with eccentric training group (+14 VISA-P
units, Bonferroni, Table 3). Similarly, at week
24 there were comparable magnitudes of
improvement with larger improvements for the
eccentric training and static stretching exercises
group than for eccentric training group (P<0.05,
Bonferroni, Table 3).
There were no dropouts, no adverse effects
were referred and all patients successfully com-
pleted the study.
Discussion
The eccentric training with static stretching
exercises produced the largest effect at the end
of the treatment and six months after the end of
the treatment. The results obtained from this
controlled clinical trial are novel; to date, there
have been no data comparing the effectiveness
of eccentric training on a 25" decline board
with static stretching exercises and eccentric
training alone for the reduction of pain and
improvement of function in patellar tendinopa-
thy in non-athletes between 18 and 30 years old.
Stasinopoulos et al. 427

All patellar tendinopathy patients presenting to the clinic

(n=63)

Unwillingness
(n=12)

Potential participants
(n=51)

Inclusion criteria

Not meeting inclusion

criteria
(n=8)

Eligible patients
(n=43)

Sequential allocation
(n=43)

Eccentric training and Eccentric training

static stretching exercises (n=21)
(n=22)

Completed trial Completed trial

(n=22) (n=21)

Figure 1. Study flowchart.

Standard eccentric exercises offer adequate
rehabilitation for tendon disorders, but many
patients with tendinopathies do not respond to
this prescription alone.27 The load of eccentric
exercises was increased according to the
patients’ symptoms because the opposite has
shown poor results.28 Eccentric exercises were
performed at a low speed in every treatment ses-
sion because this allows tissue healing.14,29 The
avoidance of painful activities is crucial for
428 Clinical Rehabilitation 26(5)

tendon healing, because training during the
treatment period increases patients’ symptoms
and delays tendon healing.30
Eccentric training and static stretching exer-
cises appear to reduce the pain and improve
function, reversing the pathology of tendinopa-
thy2,31–33 as supported by experimental studies
on animals.34 The way that eccentric training
and static stretching exercises achieves the
goals remains uncertain as there is a lack of
good quality evidence to confirm that physiolog-
ical effects translate into clinically meaningful
outcomes and vice versa.
Eccentric training with or without static
stretching exercises is called an exercise
Table 1. Previous treatments of participants
Eccentric training
and static stretching
exercises n (%)
Drugs 14 (63.6)
Physiotherapy 3 (13.63)
Injection 5 (22.72)
programme. There are two types of exercise pro-
gramme: home exercise programmes and exer-
cise programmes carried out in a clinical
setting. The former is commonly advocated for
patients with tendinopathies, such as patellar
tendinopathy, because it can be performed any
time during the day without requiring supervi-
sion by a physiotherapist. Our clinical experience,
however, has shown that patients fail to comply
with this regimen.23 This problem can be solved
by exercise programmes performed in a clinical
setting under the supervision of a physiotherapist.
For the purposes of this report, ‘supervised exer-
cise programme’ will refer to such programmes.
Therefore, such a supervised exercise programme
was used in the present trial.
Previous trials have found that a home exercise
programme reduced the pain in patellar,10–13
lateral elbow35 and Achilles14–19 tendinopathy.
Eccentric
However, it was performed for about three
training n (%) months in all previous studies. In contrast, in
the present controlled clinical trial and the studies
14 (66.6) of Stasinopoulos and colleagues,20–22 a super-
1 (4.76) vised exercise programme was administered for
6 (28.57) one month. Thus it seems that the supervised

Table 2. VISA-P score before each evaluation

Week 0 Week 4 Week 24

Eccentric training 44 (95%CI 31 to 58) 86 (95%CI 70 to 94) 94 (95%CI 75 to 100)

and static stretching
exercises
Eccentric training 46 (95%CI 33 to 60) 74 (95%CI 58 to 82) 77 (95%CI 68 to 84)
Values are means (95% confidence interval).

Table 3. Change in VISA-P score

Eccentric training
Eccentric training One-way ANOVA and static stretching
and static stretching Eccentric on change in VISA-P exercises versus
exercises training from baseline Eccentric training

Week 4 +42 (33.3 to 48.6) +28 (24.4 to 33.5) P<0.0005 +14 (*) (10 to 18)
Week 24 +50 (38.9 to 54.5) +31 (26.8 to 36.1) P<0.0005 +19 (*) (13 to 24)
(*) The mean difference is significant at the 0.05 level.
Values are means (95% confidence interval).
Stasinopoulos et al.
exercise programme may give good long-term
clinical results in a shorter period of time than a
home exercise programme. The most likely expla-
nation for this difference is that a supervised exer-
cise programme achieves a higher degree of
patient compliance. Studies to compare the effects
of these two types of exercise programmes are
required to confirm the findings of the present
controlled clinical trial.
However, this trial does have some shortcom-
ings. First, a power analysis was not performed.
Second, although this study was not a random-
ized controlled trial because a genuine randomi-
zation procedure was not followed, the use of
sequential allocation to allocate patients to treat-
ment groups allowed a true cause and effect rela-
tion to be demonstrated. Third, no placebo
(sham) or no treatment group was included in
the present trial. The placebo (sham)/no treat-
ment group is important when the absolute effec-
tiveness of a treatment is determined. However,
the absolute effectiveness of technique-based
interventions is difficult to investigate because a
good and trustworthy placebo (sham)/no treat-
ment control for exercise programmes appears
to be difficult or impossible to devise, due in
part to difficulties in defining the active element
of these treatments. Absolute effectiveness also
does not provide the therapists with information
as to which is the most appropriate treatment for
the management of a condition, in this case LET.
Finally, the blinding of patients and therapists
would be problematic in that case, if not impossi-
ble, because patients know if they are receiving
the exercise programme treatment and therapists
need to be aware of the treatment to administer it
appropriately.
In summary, eccentric training of patellar
tendon and static stretching exercises of quadri-
ceps and hamstrings had reduced the pain and
improved the function in non-athletes between
18 and 30 years old with patellar tendinopathy
at the end of the treatment and at follow-up.
Controlled studies are needed to establish the
effects and the mechanism of action of such a
treatment approach in patellar tendinopathy. A
cost-effectiveness analysis should be incorporated
429
into the analysis of the effectiveness of such a
treatment approach in future trials.
Clinical messages
. Eccentric training of patellar tendon and
static stretching exercises of quadriceps
and hamstrings is superior to eccentric
training alone in non-athletes with patellar
tendinopathy aged between 18 and 30 years
in terms of reducing pain and improving
function.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
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