Research Article

Comparison between the effectiveness of decline squat

exercise and forward lunges in athletes with patellar
tendinopathy
P. G. Mahesh Kumar1*, P. V. Hari hara Subramanyan1, N. Balamurugan1, R. Rajavel1, Baby Sargunum2

ABSTRACT

Background and Objective: Jumper’s knee or patellar tendinopathy is one of the common overuse or repeated stress injury
in sports. It implies functional stress overload while jumping, most commonly affecting the inferior pole of patella. The
prevalence of jumper’s knee is about 40–50% among the elite basketball players. In basketball players, the patellar tendon is
exposed to landing forces of 8 kN (equaling 6–8 times the body weight), compared with 0.5 kN during walking. Aim: The aim
of the study was to evaluate the comparative effectiveness in patellar tendinopathy athletes who were receiving decline squat
and forward lunges in the rehabilitation program. Materials and Methodology: It is a randomized clinical trial consisting
of 30 basketball players with clinically diagnosed and imaging confirmed with patellar tendinopathy. They were randomly
assigned into two groups consisting of 15 in each group. Group A received single-leg decline squat exercise at a decline
board of 25° and progressing with load along with conventional physiotherapy and Group B received forward lunges on the
flat floor and progressing with load along with conventional physiotherapy for three sets of 15 repetitions daily for 4 weeks.
The outcome measurement tools used in this study is Victorian Institute of Sport Assessment (VISA) score and visual analog
scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period of 4 weeks. Results: The
result suggests that both the groups had a significant higher score at VISA and reduction in VAS score, but there will be more
significant improvement seen in Group A. Conclusion: Both exercise protocols were alleviate pain and sporting functions in
basketball players over 4 weeks. This study shows that the decline squat exercise protocol shows higher clinical gains during
the rehabilitation of patellar tendinopathy in athletes.

KEY WORDS: Athletes, Decline squat exercise, Elite basketball players, Forward lunges, Patellar tendinopathy

INTRODUCTION especially when jumping. This is often a recurrent

Jumper’s knee is also known as patellar
tendinopathy,[1-3] is one of the most common overuse
or repeated stress injury in sports. The term jumper’s
knee was first coined in the year 1973 to describe
insertional tendinopathy. It implies functional stress
overload due to jumping in which it most commonly
affecting the inferior pole of patella and it is not an
inflammatory condition. The patellar tendon is also
known as patellar ligament because it connects the
patella to the shin bone. The large quadriceps muscles
at the anterior aspect of the thigh pull the kneecap
producing greater forces through the patella tendon,
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condition that can severely limit an athlete career.[4]
The increased level of stress through the patellar
tendon is during jumping and landing activities.
During jumping, the quadriceps muscles provide
a maximal contraction, which extends the knee and
pushes you into the air. While landing, the quadriceps
muscle will absorb the forces by allowing a small
amount of controlled knee flexion.[5]
Excessive forces while jumping or landing strains the
patella tendon. If the tendon is repeatedly strained, the
lesions which are occurring in the tendon can exceed
the rate of repair. The damage will progressively
worse and cause pain and dysfunction which is termed
as patellar tendinopathy.[2,6] Many different types of
sports activity have an increased risk for overuse of the

1
Department of Physiotherapy, Faculty of Physiotherapy, Meenakshi Academy of Higher Education and Research, Chennai,
Tamil Nadu, India, 2Clinical Physiotherapist, PG Physiotherapy and Rehabilitation Centre, Chennai, Tamil Nadu, India

*Corresponding author: P. G. Mahesh Kumar, Department of Cardiorespiratory, Faculty of Physiotherapy,

Meenakshi Academy of Higher Education and Research, Chennai, Tamil Nadu, India. Phone: +91-9841767329.
E-mail: pgmaheshkumar@gmail.com

Received on: 14-01-2020; Revised on: 21-02-2020; Accepted on: 27-03-2020

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 P. G. Mahesh Kumar, et al.

patellar tendon (e.g., baseball, basketball, volleyball, Procedure

tennis, and ballet). The prevalence of jumper’s knee is
40–50% among the elite basketball players.
The etiology and pathogenesis are unknown, but
an association with overuse of the knee extensor
mechanism is suggested as the main causative factor.
In basketball players, the patellar tendon is exposed to
landing forces of 8kN (equaling 6–8 times the body
weight), compared with 0.5 kN during walking.[1,3]
Treatment for jumper’s knee includes ice massage over
the areas of tenderness after activity. Closed kinematic
exercises such as lunges, leg press, and squats are used
for strengthening. Exercises combined with specified
loading conditions will make the tendon more resistant
to injury. The concept of using eccentric exercise in
tendinopathy was introduced in 1984 and it is been
superior to concentric exercise. Eccentric exercises
that are commonly recommended for the treatment of
patellar tendon are squatting and lunge.[7-9] The initial
method of treatment in the jumper’s knee typically
includes rest, ice, electrotherapeutic modalities,
massage, taping, anti-inflammatory medication, or
corticosteroid injections.[10] The purpose of this study
was to investigate the short- and long-term efficacy
of two exercise programs, one based on a traditional
eccentric protocol (forward lunges), and one based on
more contemporary treatment protocol (decline squat),
for the treatment of patellar tendinopathy.
The study was done with 30 subjects both male
and female athletes who had patellar tendinopathy
and satisfying inclusion criteria that limit their
sports activities. The subjects were divided into two
groups Group A (decline squat) Figure 1 Group B
(forward lunges) Figure 2 with 15 subjects in each
group. The single-leg decline squat was done on a 25°
decline board Figure 3 and forward lunge was done on
a flat floor surface.
The primary outcome measure used in this study was
VISA score, designed specifically to quantify knee
function in athletes with patellar tendinopathy.[2] The
VAS was used as a secondary outcome measure.
Both measures have been shown to be valid and
reliable.[3,14]
All the subjects in both groups were completed
with three sets of 15 repetitions daily for 12 weeks,
progressing with a load. The participants were
instructed to perform the exercise with their trunk
upright.

MATERIALS AND
METHODOLOGY
This study was done from June 2019 to December
2019 in Meenakshi College of Engineering. This
study was approved by the Institution Ethics
Committee. The sampling technique used in this
study was nonprobability sampling, totally 30 athletes
were selected for this study, and they were assigned Figure 1: Decline squat exercise -The participants were
into Group A and Group B, consisting of 15 subjects instructed to squat up to 60° knee flexion
in each group. Inclusion criteria: Subjects diagnosed
as patellar tendinopathy, symptoms presenting for
more than 3 months, age group between 19 and 30,
symptoms reproducing on jumping and squatting,
moderate tenderness on palpation, absence of referred
pain outside the patellar tendon, only basketball
players, Victorian Institute of Sport Assessment
(VISA) score below 80 was taken into the study,[11,12]
and Medical Research Council grading of quadriceps
will be of 4 and visual analog scale (VAS) score of
moderate pain with the range of 4–5.[13] Exclusion
criteria: Patellar tendon surgery, knee surgery in the
preceding 6 months, corticosteroid injection into
the patellar tendon, patellofemoral pain, anterior
cruciate ligament injury, Osgood-Schlatter disease,
Diabetes and chronic inflammatory, or rheumatic
joint disease. Figure 2: The athlete’s starting position for forward lunges

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 P. G. Mahesh Kumar, et al.

DISCUSSION
Both the decline squat and forward lunges protocols
were effective in the treatment of patellar tendinopathy
and improving sporting function in athletes. Clinicians
can confidently use both of these conservative
protocols investigated in this study to alleviate pain
and, more importantly, the ability to play a sport in
jumping athletes. However, over a 4 weeks period,
the decline protocol gave a considerably greater
improvement in VISA score.

A major strength of this study is that we enlist the athletes

Figure 3: Decline Board for performing decline squat
The subjects in both groups were instructed to exercise
despite minimal tendon pain of VAS score 4–5 during
exercise, but to stop if the pain becomes disabling.
The pre-test and post-test scores were assessed using
outcome measures.[15]
RESULTS
Comparison Between Pre-test and Post-test VISA
Scores Between Group A and Group B
Table 1 showed that the comparison between pre-
test and post-test VISA scores between experimental
groups. From my study, I have arrived that there was
no significant difference between the pre-test mean. In
VISA outcome measure, there is a highly significant
(P < 0.001) difference in the post-test mean between
the Groups A and B.
Comparison Between Pre-test and Post-test VAS
Scores Between Group A and Group B
Table 2 indicated that the comparison between pre-test
and post-test VAS scores between experimental groups.
In VAS measure, there is significant in a post-test mean
between Group A and Group B. In VAS outcome measure,
there is a highly significant (P < 0.001) difference in the
post-test mean between the Groups A and B.
who were all continued to compete with continuing
patellar tendon pain at an elite level during the previous
season. When eccentric contractions are used in weight
training normally called “negatives.” Exercise featuring
a heavy eccentric load supports a greater weight (muscles
are approximately 10% stronger during an eccentric
contraction than during concentric contractions).[9]
Specifically, tendons become stronger as fibroblast
(tenoblast) activity increases and an appropriate
collagen reaction accelerates; adaptations are
characterized by a thickening of the collagen fibers
and fibrils and an increase in tropocollagen cross-
links. The tendon fibers align themselves optimally to
manage the high-stress levels transmitted from muscle
to tendon.
Exercise increases the production of insulin-like
growth factor-1 in the tendon which stimulates
collagen synthesis and cell replication and marks
modeling activity.
The forward lunges achieve a maximal patellar
tendon force Zwerver et al., a point of concern is
that patellofemoral contact force should not become
excessive as this lead to the patellofemoral pain
syndrome.[5]
In the decline squat group, the participants were
instructed to squat up to 60° knee flexion as flexion

Table 1: Comparison between pre-test and post-test VISA scores between Group A and Group B
VISA Group A Group B t-test Significance
Mean S.D Mean S.D
Pre-test 59.75 5.675 58.27 3.535 0.850 0.403
Post-test 86.20 3.427 82.20 1.935 3.937 0.000
S.D: Standard deviation, VISA: Victorian Institute of Sport Assessment

Table 2: Comparison between pre-test and post-test VAS scores between Group A and Group B
VAS Group A Group B t-test Significance
Mean S.D Mean S.D
Pre-test 4.27 0.704 0.743 0.743 1.514 0.141
Post-test 0.93 0.704 1.53 0.834 2.130 0.000
S.D: Standard deviation, VAS: Visual analog scale

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 P. G. Mahesh Kumar, et al.
of knee beyond 60° increases the patellofemoral force
sleeper than the tendon force.
At 60°, the patellofemoral contact force is 9 times the
body weight, a further increase seems undesirable.
Eccentric exercise in forward lunges appeared to be a
less effective form of rehabilitation in reducing pain
and returning subjects to previous levels of activity
(CR Purdam 2004).[10]
Biomechanical studies compared the patellar tendon
force between forward lunges on a flat floor and single
leg decline squat on a decline board and upshots in
40% higher knee moment in decline squat.[5]
With greater decline angles, the ground reaction force
moves further from the knee joint, thus increasing the
knee extensor moment.
The effectiveness of the decline squat is due to the
result of the decline board reducing calf muscle
tension, allowing better isolation of the knee extensor.
CONCLUSION
In active jumping athletes with patellar tendinopathy,
decline squat exercise shows greater improvement
and in that decline squat exercise on 25° decline board
shows much effect in improving functional ability and
pain. Hence, it can be included in the rehabilitation
program for patellar tendinopathy.
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Source of support: Nil; Conflicts of interest: None Declared
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