Case Report
The Effectiveness of Isometric Contractions Combined with Eccentric – Concentric Training and Simple Lumbo-Pelvic Control Exercises on Pain and Disability in Chronic Patellar Tendinopathy: A Case Report
Stasinopoulos Dimitrios*
Department of Health Sciences, School of Sciences European University of Cyprus, Cyprus
*Corresponding author: Stasinopoulos Dimitrios, Physiotherapy Program, Department of Health Sciences, School of Sciences European University of Cyprus, 6, Diogenes Str. Engomi
Published: 22 Sep, 2016
Cite this article as: Dimitrios S. The Effectiveness of
Isometric Contractions Combined with
Eccentric – Concentric Training and
Simple Lumbo-Pelvic Control Exercises
on Pain and Disability in Chronic
Patellar Tendinopathy: A Case Report.
Ann Clin Case Rep. 2016; 1: 1144.
Abstract
Eccentric exercises are not effective for all patients with chronic patellar tendinopathy (CPT). The aim of the present case report is to present the effect of eccentric - concentric training combined with isometric contraction and simple lumbo-pelvic control exercises on pain and disability in a patient experiencing CPT. A patient with unilateral CPT for 4 months was included in the present report. The patient followed a supervised exercise five times per week for 6 weeks consisting of, isometric quadriceps exercise, and slow progressive eccentric - concentric training of quadriceps and simple lumbo-pelvic control exercises. The programmer was individualized on the basis of the patient’s description of pain experienced during the procedure. The patient was evaluated using the VISA – P questionnaire at baseline, at the end of treatment (week 6), and 1 month (week 10) after the end of treatment. At the end of the treatment and at the follow – up there was a decline in pain and a rise in function. The results of the present trial suggest that the combination of isometric quadriceps exercise, slow progressive eccentric - concentric training of quadriceps and simple lumbo-pelvic control exercises can produce significant improvements in terms of pain and disability in CPT.
Introduction
Chronic Patellar Tendinopathy (CPT) is a common clinical condition that is managed by
physical therapists and is common among athletes and non-athletes alike. CPT is characterized by
the absence of inflammatory cells and prostaglandins and an increased presence of fibroblasts and
disorganized collagen [1]. Therefore, this condition is not inflammatory as originally thought but is a degenerative condition. The ideal term for clinical diagnosis is patellar tendinopathy because
this term refers to the painful tendon without implying the pathology [2]. Jumper’s knee was the
first diagnostic term used for this condition. However, this condition can occur in people who are
not athletes and athletes who do not perform jumping in their sports. Thus, jumper’s knee is not an
appropriate term for clinical diagnosis [3]. Patellar tendonitis is also an incorrect term for clinical
diagnosis because the condition is not inflammatory but is degenerative as mentioned. The best
diagnostic term may be the term patellar tendinosis because this term refers to the pathology of the
tendon [4].
Extrinsic factors such as inappropriate footwear, sport technique, training errors, and intrinsic
factors such as muscle weakness and/or inflexibility, and misalignment are the main factors that lead
to CPT [1]. It is most commonly characterized by pain at the inferior pole of the patella; although
pain can also be at the tibial attachment, in the attachment of the tendon to the superior pole of the
patella as well as midsubstance pain has been reported [3]. The pain can be caused by performing a functional activity such as squat or hop [5].
However, no ideal treatment has emerged for the management of CPT. Many clinicians
advocate a conservative approach [5] and physiotherapy is usually recommended [4]. A wide
array of physiotherapy treatments has been recommended for the management of CPT such as
electrotherapeutic/physical 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 suggests that
the optimal treatment strategy is not known, and more research is needed to discover the most
effective treatment in patients with CPT.
One of the most common physiotherapy treatments for CPT is
exercise. Eccentric exercise has shown good clinical results in CPT
[6] as well as in conditions similar to CPT in clinical behaviour and
histopathological appearance, such as lateral elbow [7], rotator cuff
[8] and Achilles tendinopathy [6].
Eccentric training is not enough for all patients with CPT [9].
Malliaras and his colleagues [3] concluded that clinicians should
consider eccentric-concentric loading alongside or instead of eccentric
loading in lower limb tendinopathy. Recently, isometric exercises
are indicated to reduce and manage tendon pain [10,11]. Moreover,
a component lacking from evidence-based programs is adequate
consideration of the kinetic chain and therefore poor lumbopelvic
control has the potential to alter load distribution on the lower limb
kinetic chain and increase the risk of lower limb tendinopathy [5].
Perhaps if the eccentric-concentric training combines to isometric
contractions and simple lumbo-pelvic control exercises the success
rate in the management of tendinopathy will be higher.
To our knowledge, there have been no studies to investigate the
effectiveness of these kinds of contractions (concentric, eccentric
and isometric) and simple lumbo-pelvic control exercises for the
management of CPT. Therefore, the aim of the present case report is
to present the effect of eccentric- concentric training combined with
isometric contraction and simple lumbo-pelvic control exercises on
pain and disability in a patient experiencing CPT.
Case Presentation
History
The subject was a 20-year-old female volleyball player with a
four- month history of anterior knee pain, in her right knee. She was
diagnosed by a specialist (orthopaedic) as having CPT. She has played
volleyball for about six years. The site of pain was over the inferior
pole of the patella without spreading down and she complained of
pain after her training only. The pain subsided within one or two
hours after her training. She did not complain of pain after prolonged
sitting or while walking downstairs. She did not have any problems
with the other joints. She did not complain of other symptoms such
as stiffness, swelling, locking, crepitus or giving away. She took no
drugs at the time of assessment; she had no history of trauma in the
knee before, only two ankle sprains in the same leg. She had followed
a physiotherapy rehabilitation program following the ankle sprains.
She had no prior physiotherapy treatment for the problem in her
knee. She did not have a history of diabetes, epilepsy or cancer and
none in her family did. She did not have any operation or illness in
the past.
Examination findings
Although the condition was diagnosed by a specialist, the
physiotherapist D. S. assessed her knee to rule out other conditions
and confirm the diagnosis.
No pain was mentioned during gait and posture. Body deformity,
colour changes, muscle wasting or swelling were not noted. In
palpation, signs of inflammatory activity like heat, swelling and
synovial thickening were not found.
On physical examination, the movements of the low back, hip
and ankle were pain free, with full range of motion and full power.
All ligamentous stress tests were normal, meniscal stress tests were
normal, muscle strength tests were normal and no capsular pattern
was found. Isotonic resisted extension reproduced mild pain on the
inferior pole of the patella; what is more, after ten fast squats (decline
test) [3], she experienced a mild pain. The squats were carried out,
because the researcher wanted to reproduce the pain. Knee extension
by gliding the patella medially was negative, without reproducing the
pain; furthermore the position of the patella was normal [12]. These
two latter procedures ruled out the patellofemoral joint dysfunction.
Tenderness with palpation over the inferior pole of the patella was
found, confirming the diagnosis.
Procedure
The patient followed a supervised exercise programmer consisting
of, isometric quadriceps exercise, slow progressive eccentricconcentric
training of quadriceps and simple lumbo-pelvic control
exercises. Firstly, the patient performed the Spanish squat as an
isometric quadriceps exercise. The Spanish squat is a double leg squat
to be performed at an angle of approximately 70-90° of knee flexion
with the assistance of a rigid strap fixating the lower legs. The patient
performed 3 sets of five repetitions of Spanish squat with 1-min rest
interval between each set. Each repetition was painless and lasted
45 seconds. Later, the patient carried out the eccentric–concentric
training. As eccentric – concentric training, the participant carried out
three sets of 15 repetitions of unilateral squat on a 25o decline board
with 1-min rest interval between each set. The squat was performed
at a slow speed at every treatment session. The patient counted to 6
during the squat. As the subject moved from the standing to the squat
position, the quadriceps muscle and patellar tendon by inference were
loaded eccentrically; followed by concentric loading, as the injured leg
was used to get back to the start position. At the beginning the load
consisted of the body weight and the participant was standing with all
her body weight on the injured leg. The subject was told to go ahead
with the exercise even if she experienced mild pain. However, she
was told to stop the exercise if the pain became disabling. When the
squat was pain-free the load was increased by holding hand weights.
Finally, the patient performed two simple lumbo-pelvic control
exercises such as single leg bridging in supine and four-point prone
bridging exercises. The patient performed 3 sets of five repetitions
of each of the above lumbo-pelvic control exercises with 1-min rest
interval between each set. Each repetition was painless and lasted 45
seconds. Static stretching exercises of quadriceps and hamstrings
were performed as described by Stasinopoulos and his colleagues [2]
before and after the eccentric training. Each stretch lasted 30 seconds
and there was a one minute rest between each stretch.
Supervised exercise programme was given five times a week for 6
weeks and was individualized on the basis of the patient’s description
of pain experienced during the procedure. The patient was instructed
to use her knee during the course of the study but to avoid activities
that irritated pain such as jumping, hopping and running [2,9,11].
She was also told to refrain from taking anti-inflammatory drugs
throughout the course of the study. Patient compliance 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
sometimes used by therapists to facilitate positive treatment 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 postapplication
measurements [13].
Pain and function were measured in the present study. The
patient was evaluated at the baseline (week 0), at the end of treatment
(week 6) and at 1 month (week 10) after the end of treatment.
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 [14].
Results
VISA-P score was 42 at the initial evaluation. At the end of the treatment (week 6), there was a rise in VISA - P score of 39 units. At week 10, the VISA – P score was 86 (Table 1).
Discussion
The present study examined the effect of isometric quadriceps
exercise, slow progressive eccentric - concentric training of quadriceps
and simple lumbo-pelvic control exercises in a patient experiencing
CPT and its findings have demonstrated significant improvements in
terms of pain and disability. The results obtained from this case report
are novel; as to date, similar studies have not been conducted.
Alfredson et al. [1] first proposed the eccentric training of the
injured tendon. It is the most commonly used conservative approach
in the treatment of tendinopathy. Malliaras and his colleagues [3]
concluded that clinicians should consider eccentric-concentric
loading alongside or instead of eccentric loading in Achilles and
patellar tendinopathy. A Heavy Slow Resistance (HSR) program
is recommended in the management of lower limb tendinopathy
[16,17]. The HSR program was produced equivalent pain and
function improvement (VISA) than the Alfredson eccentric program,
but significantly better patient satisfaction at six month follow–up. In
the Achilles tendon, eccentric and HSR have recently been shown to
yield similar clinical outcomes (VISA and patient satisfaction) at 1
year follow up. Based on the above findings, the HSR program can be
recommended as an alternative to the Alfredson eccentric program
lower limb tendinopathy rehabilitation.
Recently, isometric exercises have been recommended to reduce
and manage tendon pain increasing the strength at the angle of
contraction without producing inflammatory signs [3,10]. Five
repetitions of 45-second isometric mid-range quadriceps exercise
at 70% of maximal voluntary contraction have been shown to
reduce patellar tendon pain for 45 minutes post exercise and this
was also associated with a reduction in motor cortex inhibition of
the quadriceps that was associated with patellar tendinopathy [10].
The dosage of isometric contractions in the present was based on
clinical experience [3,10,11] and their effect on pain in patients with
CPT requires further study. The ‘Spanish squat was used as isometric
contraction in the present study and is useful when there is limited
or no access to gym equipment as in the present situation. Therefore,
it was hypothesized that the simultaneous use of these two kinds
of contractions (isotonic and isometric) will further enhance the
analgesic effect of contractions in the treatment of CPT, increasing
the lower limb function.
A component lacking from evidence-based programs is adequate
consideration of the kinetic chain. Poor lumbopelvic control has the
potential to alter load distribution on the lower limb kinetic chain
and increase the risk of lower limb tendinopathy [5,18]. It is our
belief that the improvement of lumbo-pelvic control can be achieved
by performing simple exercises such as single leg bridging in supine
and four point prone bridging exercises. Future research is needed to
confirm this suggestion.
In addition, hip extensors weakness has been associated with
patellar tendinopathy [19]. Exercises to strengthen these muscle
groups should be considered in exercise protocols and patellar
tendinopathy. However, hip extensors were not strengthened in
the present case trial because the strength of hip muscles in the
assessment was normal. Functional activities such as jumping, cutting
and sprinting should also be included in lower limb tendinopoathy
rehabilitation programs among athletes, but have so far not been
included in popular programs in the literature [19]. These activities
were included in the present study. The athlete carried out these
activities in the court under the supervision of the gymnast.
The load of exercises was increased according to the patients
symptoms otherwise the results are poor [20]. Furthermore, eccentric
exercises were performed at a low speed in every treatment session
because this allows tissue healing [21]. Ice was not recommended
at the end of the treatment because research has shown that ice as
a supplement to an eccentric exercise programme offers no benefit
to patients with tendinopathy [22]. Finally, the avoidance of painful
activities is crucial for tendon healing, because training during the
treatment period increases patients’ symptoms and delays tendon
healing [23].
Eccentric exercises appear to reduce the pain and improve
function. The mechanism by which eccentric training achieves
these outcomes remains uncertain, as there is a lack of good quality
evidence relating to physiological effects. The clinical improvement of
the HSR group was accompanied by increased collagen turnover. It is
unknown if the isometric contractions can reverse the pathology of
the tendinopathy and in this case the pathology of CPT.
Although a home exercise programme can be performed any time
during the day without requiring supervision from a therapist, our
clinical experience has shown that patients fail to comply with the
regimen of home exercise programmes [22]. Although many ways
can be recommended to improve the compliance of patients with the
home exercise programme such as phone calls, exercise monitors and
better self-management education, it is believed that this problem
can be solved by the supervised exercise programmes performed in
a clinical setting under the supervision of a therapist. It is believed
because our experience has shown that many patients stopped the
home exercise programme without giving an explanation, whereas
patients completed the supervised programme. One possible reason
why they continue the supervised exercise programme could be the
cost. In the supervised exercise programme, the patients visit the
therapist more times than the home exercise programme, and this
is more expensive. A future study will combine the both types of
exercise programmes in order to maximize the compliance of the
patients.
Even though the positive effects of such an exercise programme
in CPT have been reported in the present report, its study design
limits the generalization of these findings. Future well-designed clinical trials are needed to confirm the positive results of this case
study establishing the effectiveness of such an exercise program in the
management of CPT. In addition, structural changes in the tendons
related to the treatment interventions and the long-term effects (6
months or more after the end of treatment) of these treatments are
needed to investigate. Further research is needed to establish the
possible mechanism of action of this treatment approach, and the cost
effectiveness of such treatment, because reduced cost is an important
issue for the recommendation of any given treatment.
Conclusions
The exercise programme, consisting of isometric quadriceps exercise, slow progressive eccentric - concentric training of quadriceps and simple lumbo-pelvic control exercises, had reduced the pain and improved the function in a patient with CPT at the end of the treatment and at one month follow-up. Further well-designed trials are needed to confirm the results of the present case report.
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