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A Comparative Study of Treatment Interventions for Patellar Tendinopathy: A Randomized Controlled Trial

Published:February 05, 2021DOI:https://doi.org/10.1016/j.apmr.2021.01.073

      Abstract

      Objectives

      To determine the additional effect of dry needling (DN) or percutaneous needle electrolysis (PNE) combined with eccentric exercise (EE) and determine which is the most effective for patients with patellar tendinopathy (PT).

      Design

      Blinded, randomized controlled trial, with follow-up at 10 and 22 weeks.

      Settings

      Recruitment was performed in sport clubs. Diagnosis and intervention were conducted at San Jorge University.

      Participants

      Patients (N=48) with PT with pain for at least 3 months between the ages of 18 and 45 years.

      Interventions

      Three interventions were carried out: DN and EE, PNE and EE, and EE with sham needle as the control group.

      Main Outcome Measures

      Disability was measured using the Victorian Institute of Sports Assessment Questionnaire, patellar tendon. Visual analog scale was used to measure pain over time, the Short Form-36 was used to measure quality of life, and ultrasound was used to measure structural abnormalities.

      Results

      A total of 48 participants (42 men, 6 women; average age, 32.46y; SD, 7.14y) were enrolled. The improvement in disability and pain in each group between baseline and post-treatment and baseline and follow-up was significant (P≤.05), without differences among groups.

      Conclusion

      DN or PNE combined with an EE program has not shown to be more effective than a program of only EE to improve disability and pain in patients with PT in the short (10wk) and medium (22wk) terms. Clinical improvements were not associated with structural changes in the tendon.

      Keywords

      List of abbreviations:

      CD-US (color Doppler ultrasound), CONSORT (Consolidated Standards of Reporting Trials), DN (dry needling), EE (eccentric exercise), ICON (International Consensus), PNE (percutaneous needle electrolysis), PRP (plasm-rich platelet), PT (patellar tendinopathy), QOL (quality of life), RCT (randomized controlled trial), SF-36 (Short Form-36 Health Survey), US (ultrasound), VAS (visual analog scale), VISA-p (Victorian Institute of Sports Assessment Questionnaire, patellar tendon)
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      References

        • Scott A.
        • Squier K.
        • Alfredson H.
        • Bahr R.
        • Cook J.L.
        • Coombes B.
        • et al.
        ICON 2019: International Scientific Tendinopathy Symposium Consensus: clinical terminology.
        Br J Sports Med. 2020; 54: 260-262
        • Zwerver J.
        • Bredeweg S.W.
        • van den Akker-Scheek I.
        Prevalence of jumper's knee among nonelite athletes from different sports: a cross-sectional survey.
        Am J Sports Med. 2011; 39: 1984-1988
        • Lian O.B.
        • Engebretsen L.
        • Bahr R.
        Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study.
        Am J Sports Med. 2005; 33: 561-567
        • Weber C.D.
        • Horst K.
        • Nguyen A.R.
        • et al.
        Return to sports after multiple trauma: which factors are responsible? Results from a 17-year follow-up.
        Clin J Sport Med. 2017; 27: 481-486
        • Vicenzino B.
        • de Vos R.J.
        • Alfredson H.
        • et al.
        ICON 2019-International Scientific Tendinopathy Symposium Consensus: there are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients.
        Br J Sports Med. 2020; 54: 444-451
        • Rios-Diaz J.
        • Martinez-Paya J.J.
        • del Bano-Aledo M.E.
        • de Groot-Ferrando A.
        • Botia-Castillo P.
        • Fernandez-Rodriguez D.
        Sonoelastography of plantar fascia: reproducibility and pattern description in healthy subjects and symptomatic subjects.
        Ultrasound Med Biol. 2015; 41: 2605-2613
        • Martinez-Paya J.J.
        • Del Bano-Aledo M.E.
        • Rios-Diaz J.
        • Tembl-Ferrairo J.I.
        • Vazquez-Costa J.F.
        • Medina-Mirapeix F.
        Muscular echovariation: a new biomarker in amyotrophic lateral sclerosis.
        Ultrasound Med Biol. 2017; : 431153-431162
        • Ishigaki T.
        • Kouno M.
        • Ikebukuro T.
        • Kubo K.
        Quantification of collagen fiber orientation in human tendons with the coefficient of variation of echogenicity.
        J Biomech. 2016; 49: 3923-3927
        • Larsson M.E.H.
        • Kall I.
        • Nilsson-Helander K.
        Treatment of patellar tendinopathy-a systematic review of randomized controlled trials.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1632-1646
        • Chen Z.
        • Baker N.A.
        Effectiveness of eccentric strengthening in the treatment of lateral elbow tendinopathy: a systematic review with meta-analysis.
        J Hand Ther. 2020 Apr 10; ([Epub ahead of print])
        • Murphy M.C.
        • Travers M.J.
        • Chivers P.
        • et al.
        Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis.
        Br J Sports Med. 2019; 53: 1070-1077
        • Knapik J.J.
        • Pope R.
        Achilles tendinopathy: pathophysiology, epidemiology, diagnosis, treatment, prevention, and screening.
        J Spec Oper Med. 2020; 20: 125-140
        • Young M.A.
        • Cook J.L.
        • Purdam C.R.
        • Kiss Z.S.
        • Alfredson H.
        Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players.
        Br J Sports Med. 2005; 39: 102-105
        • Kongsgaard M.
        • Kovanen V.
        • Aagaard P.
        • et al.
        Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy.
        Scand J Med Sci Sports. 2009; 19: 790-802
        • Rio E.
        • Kidgell D.
        • Purdam C.
        • et al.
        Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.
        Br J Sports Med. 2015; 49: 1277-1283
        • Ortega-Castillo M.
        • Medina-Porqueres I.
        Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: a systematic review.
        J Sci Med Sport. 2016; 19: 438-453
        • Mendonca L.M.
        • Leite H.R.
        • Zwerver J.
        • Henschke N.
        • Branco G.
        • Oliveira V.C.
        How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations.
        Br J Sports Med. 2020; 54: 87-93
        • James S.L.J.
        • Ali K.
        • Pocock C.
        • et al.
        Ultrasound guided dry needling and autologous blood injection for patellar tendinosis.
        Br J Sports Med. 2007; 41: 518-521
        • Dragoo J.L.
        • Wasterlain A.S.
        • Braun H.J.
        • Nead K.T.
        Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial.
        Am J Sports Med. 2014; 42: 610-618
        • Abat F.
        • Gelber P.E.
        • Polidori F.
        • Monllau J.C.
        • Sanchez-Ibanez J.M.
        Clinical results after ultrasound-guided intratissue percutaneous electrolysis (EPIA®) and eccentric exercise in the treatment of patellar tendinopathy.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 1046-1052
        • Abat F.D.W.
        • Gelber P.E.
        • Polidori F.
        • Monllau J.C.
        • Sanchez-Ibañez J.M.
        Effectiveness of the Intratissue Percutaneous Electrolysis (EPI®) technique and isoinertial eccentric exercise in the treatment of patellar tendinopathy at two years follow-up.
        Muscles Ligaments Tendons J. 2014; 14: 188-193
        • Valera Garrido F.
        • Minaya Muñoz F.
        • JM S.I.
        Effectiveness of electrolysis percutaneous intratisular (EPI®) in chronic insertional patellar tendinopathy.
        Trauma Fund MAPFRE. 2010; 21: 227-236
        • Sánchez-Ibáñez J.
        • Alves R.
        • Polidori F.
        • et al.
        Effectiveness of ultrasound-guided percutaneous electrolysis intratendon (EPI) in the treatment of insertional patellar tendinopathy in soccer players.
        Br J Sports Med. 2013; 47: e2
        • Chiavaras M.M.
        • Jacobson J.A.
        Ultrasound-guided tendon fenestration.
        Semin Musculoskelet Radiol. 2013; 17: 85-90
        • Krey D.
        • Borchers J.
        • McCamey K.
        Tendon needling for treatment of tendinopathy: a systematic review.
        Phys Sportsmed. 2015; 43: 80-86
        • Lopez-Royo M.P.
        • Gomez-Trullen E.M.
        • Ortiz-Lucas M.
        • et al.
        Comparative study of treatment interventions for patellar tendinopathy: a protocol for a randomised controlled trial.
        BMJ Open. 2020; 10e034304
        • Silbernagel K.G.
        • Crossley K.M.
        A proposed return-to-sport program for patients with midportion achilles tendinopathy: rationale and implementation.
        J Orthop Sports Phys Ther. 2015; 45: 876-886
        • Braithwaite F.A.
        • Walters J.L.
        • Li L.S.K.
        • Moseley G.L.
        • Williams M.T.
        • McEvoy M.P.
        Effectiveness and adequacy of blinding in the moderation of pain outcomes: systematic review and meta-analyses of dry needling trials.
        PeerJ. 2018; 6: e5318
        • Hernandez-Sanchez S.
        • Hidalgo M.D.
        • Gomez A.
        Cross-cultural adaptation of VISA-P score for patellar tendinopathy in Spanish population.
        J Orthop Sports Phys Ther. 2011; 41: 581-591
        • Visentini P.J.
        • Khan K.M.
        • Cook J.L.
        • Kiss Z.S.
        • Harcourt P.R.
        • Wark J.D.
        The VISA score: an index of severity of symptoms in patients with jumper's knee (patellar tendinosis). Victorian Institute of Sport Tendon Study Group.
        J Sci Med Sport. 1998; 1: 22-28
        • Boonstra A.M.
        • Schiphorst Preuper H.R.
        • Reneman M.F.
        • Posthumus J.B.
        • Stewart R.E.
        Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain.
        Int J Rehabil Res. 2008; 31: 165-169
        • Alonso J.
        • Prieto L.
        • Anto J.M.
        The spanish version of the SF-36 health survey- A measure of clinical outcomes.
        Medicina Clinica. 1995; 104: 771-776
        • Martinoli C.
        Musculoskeletal ultrasound: technical guidelines.
        Insights Imaging. 2010; 1: 99-141
        • Rios-Diaz J.
        • de Groot Ferrando A.
        • Martinez-Paya J.J.
        • del Bano Aledo M.E.
        [Reliability and reproducibility of a morpho-textural image analysis method over a patellar ligament ultrasonography] [Spanish].
        Reumatol Clin. 2010; 6: 278-284
        • Scott A.
        • LaPrade R.F.
        • Harmon K.G.
        • et al.
        Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline.
        Am J Sports Med. 2019; 47: 1654-1661
        • Yeo A.
        • Kendall N.
        • Jayaraman S.
        Ultrasound-guided dry needling with percutaneous paratenon decompression for chronic Achilles tendinopathy.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2112-2118
        • Martin B.R.
        Multimodal care in the management of a patient with chronic tendinopathy of the biceps femoris: a case report.
        J Chiropr Med. 2017; 16: 156-162
        • Rha D.W.
        • Park G.Y.
        • Kim Y.K.
        • Kim M.T.
        • Lee S.C.
        Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial.
        Clin Rehabil. 2013; 27: 113-122
        • Dunning J.
        • Butts R.
        • Henry N.
        • et al.
        Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: a multi-center randomized clinical trial.
        PLoS One. 2018; 13e0205405
        • Moreno C.
        • Mattiussi G.
        • Núñez F.J.
        Therapeutic results after ultrasound-guided intratissue percutaneous electrolysis (EPI®) in the treatment of rectus abdominis-related groin pain in professional footballers: a pilot study.
        J Sports Med Phys Fitness. 2016; 56: 1171-1178
        • Iborra-Marcos Á
        • Ramos-Álvarez J.J.
        • Rodriguez-Fabián G.
        • et al.
        Intratissue percutaneous electrolysis vs corticosteroid infiltration for the treatment of plantar fasciosis.
        Foot Ankle Int. 2018; 39: 704-711
        • Mattiussi G.
        • Moreno C.
        Treatment of proximal hamstring tendinopathy-related sciatic nerve entrapment: presentation of an ultrasound-guided "intratissue percutaneous electrolysis" application.
        Muscles Ligaments Tendons J. 2016; 6: 248-252
        • Moreno C.
        • Mattiussi G.
        • Nunez F.J.
        • Messina G.
        • Rejc E.
        Intratissue percutaneous electolysis combined with active physical therapy for the treatment of adductor longus enthesopathy-related groin pain: a randomized trial.
        J Sports Med Phys Fitness. 2017; 57: 1318-1329
        • Resteghini P.
        • Khanbhai T.A.
        • Mughal S.
        • Sivardeen Z.
        Double-blind randomized controlled trial: injection of autologous blood in the treatment of chronic patella tendinopathy-a pilot study.
        Clin J Sport Med. 2016; 26: 17-23
        • Khan K.M.
        • Cook J.L.
        • Kiss Z.S.
        • et al.
        Patellar tendon ultrasonography and jumper's knee in female basketball players: a longitudinal study.
        Clin J Sport Med. 1997; 7: 199-206
        • Khan K.M.
        • Maffulli N.
        • Coleman B.D.
        • Cook J.L.
        • Taunton J.E.
        Patellar tendinopathy: some aspects of basic science and clinical management.
        Br J Sports Med. 1998; 32: 346-355
        • Lian O.
        • Holen K.J.
        • Engebretsen L.
        • Bahr R.
        Relationship between symptoms of jumper's knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players.
        Scand J Med Sci Sports. 1996; 6: 291-296
        • Drew B.T.
        • Smith T.O.
        • Littlewood C.
        • Sturrock B.
        Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review.
        Br J Sports Med. 2014; 48: 966-972
        • Scott A.
        • Docking S.
        • Vicenzino B.
        • et al.
        Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012.
        Br J Sports Med. 2013; 47: 536-544
        • de Vos R.J.
        • Heijboer M.P.
        • Weinans H.
        • Verhaar J.A.
        • van Schie J.T.
        Tendon structure's lack of relation to clinical outcome after eccentric exercises in chronic midportion Achilles tendinopathy.
        J Sport Rehabil. 2012; 21: 34-43
        • De Jonge S.
        • Warnaars J.L.
        • De Vos R.J.
        • et al.
        Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements.
        Scand J Med Sci Sports. 2014; 24: 773-778
        • Lieberthal K.
        • Paterson K.L.
        • Cook J.
        • Kiss Z.
        • Girdwood M.
        • Bradshaw E.J.
        Prevalence and factors associated with asymptomatic Achilles tendon pathology in male distance runners.
        Phys Ther Sport. 2019; 39: 64-68
        • Ohberg L.
        • Alfredson H.
        Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?.
        Knee Surg Sports Traumatol Arthrosc. 2004; 12: 465-470
        • Ohberg L.
        • Lorentzon R.
        • Alfredson H.
        Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation.
        Knee Surg Sports Traumatol Arthrosc. 2001; 9: 233-238
        • Ohberg L.
        • Alfredson H.
        Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment.
        Br J Sports Med. 2002; 36 (discussion 6-7): 173-175
        • Hrobjartsson A.
        • Emanuelsson F.
        • Skou Thomsen A.S.
        • Hilden J.
        • Brorson S.
        Bias due to lack of patient blinding in clinical trials. A systematic review of trials randomizing patients to blind and nonblind sub-studies.
        Int J Epidemiol. 2014; 43: 1272-1283
        • Savovic J.
        • Jones H.E.
        • Altman D.G.
        • et al.
        Influence of reported study design characteristics on intervention effect estimates from randomized, controlled trials.
        Ann Intern Med. 2012; 157: 429-438
        • Braithwaite F.A.
        • Walters J.L.
        • Moseley G.L.
        • Williams M.T.
        • McEvoy M.P.
        Towards more homogenous and rigorous methods in sham-controlled dry needling trials: two Delphi surveys.
        Physiotherapy. 2020; 106: 12-23