Surgical Treatment vs. Eccentric Training for Jumper’s Knee

Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s Knee). A randomized, controlled trial. Bahr R, Fossan B, Løken S, Engebretsen L. J Bone Joint Surg Am. 2006 Aug;88(8):1689-98.

Abstract
BACKGROUND: Although the surgical treatment of patellar tendinopathy (jumper’s knee) is a common procedure, there have been no randomized, controlled trials comparing this treatment with forms of nonoperative treatment. The purpose of the present study was to compare the outcome of open patellar tenotomy with that of eccentric strength training in patients with patellar tendinopathy.

METHODS: Thirty-five patients (forty knees) who had been referred for the treatment of grade-IIIB patellar tendinopathy were randomized to surgical treatment (twenty knees) or eccentric strength training (twenty knees). The eccentric training group performed squats on a 25 degrees decline board as a home exercise program (with three sets of fifteen repetitions being performed twice daily) for a twelve-week intervention period. In the surgical treatment group, the abnormal tissue was removed by means of a wedge-shaped full-thickness excision, followed by a structured rehabilitation program with gradual progression to eccentric training. The primary outcome measure was the VISA (Victorian Institute of Sport Assessment) score (possible range, 0 to 100), which was calculated on the basis of answers to a symptom-based questionnaire that was developed specifically for patellar tendinopathy. The patients were evaluated after three, six, and twelve months of follow-up.

RESULTS: There was no difference between the groups with regard to the VISA score during the twelve-month follow-up period, but both groups had improvement (p < 0.001). The mean combined VISA score for the two groups increased from 30 (95% confidence interval, 25 to 35) before the start of treatment to 49 (95% confidence interval, 42 to 55) at three months, 58 (95% confidence interval, 51 to 65) at six months, and 70 (95% confidence interval, 62 to 78) at twelve months. In the surgical treatment group, five knees had no symptoms, twelve had improvement but were still symptomatic, two were unchanged, and one was worse after twelve months (p = 0.49 compared with the eccentric training group). In the eccentric training group, five knees did not respond to treatment and underwent secondary surgery after three to six months. Of the remaining fifteen knees in the eccentric training group, seven had no symptoms and eight had improvement but were still symptomatic after twelve months.

CONCLUSIONS: No advantage was demonstrated for surgical treatment compared with eccentric strength training. Eccentric training should be tried for twelve weeks before open tenotomy is considered for the treatment of patellar tendinopathy.

Diagnosis: Patellar Tendinopathy

Outcome: VISA-P scores improved similarly in both groups from 30 at baseline to 49 at 3 months, to 58 at 6 months, and 70 at one year. Leg press strength improved statistically at 6 months and more at 12 months. Standing jump and countermovement jump height did not change significantly in either groups, but decreased slightly in the surgery group. 55% of eccentric group returned to prior level of sports with no pain or mild to moderate pain while only 45% of the surgery group did so.

When Assessed: 3, 6, and 12 months

Subjects: Average age 30-31 years. Only 14% female. Majority of patients were recreational or sub-elite athletes.

Protocol: 3 sets of 15 reps of eccentric squats on a 25 degree decline board performed 2x per day for 12 weeks. Pain kept between 3-5/10 VAS, with resistance (5 kg) added when pain dropped below 3/10. Surgery group performed similar exercises protocol, though delayed 6 weeks after procedure, and they were instructed not to train with pain. 66% compliance with exercise in eccentric group and 72% in surgery group.

Other Activity: “During the first 8 weeks of treatment, the patients were not allowed to take part in sports-specific training. After four weeks, they were allowed to cycle, to jog on a flat surface, or to exercise in water if these activities could be done without pain. After 8 weeks, the patients were allowed to gradually return to their sport if there was no or minimal pain.”

Chad’s Comments:  If anything the exercise group outperformed the surgery group.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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