Bittencourt et al. 2022

Preventive effect of tailored exercises on patellar tendinopathy in elite youth athletes

A tailored exercise program can reduce the incidence of patellar tendinopathy in an elite youth cohort

The program was performed during 15-20 minutes each training session

A RCT should be conducted in order to study the cause-effect relationship

Introduction

Sports such as volleyball and basketball involve frequent jumping and landing and are characterized by high prevalences of patellar tendinopathy. The prevalence was reported to range between 32-45% in elite athletes. It has been shown that often, talented youth athletes withdraw from these sports when they encounter problems like patellar tendinopathy as these are often tough to treat. These observations led to the growing interest in preventive programs designed to target commonly known risk factors such as deficits in ankle dorsiflexion, decreased strength of the hip extensors, abductors and external rotators, and stiff landing mechanics. However, these preventive programs are scarce, especially in the youth elite population and therefore, this study’s aim was to investigate the effectiveness of a tailored exercise program on the incidence of patellar tendinopathy in youth athletes.

 

Methods

In this prospective crossover cohort study which was conducted in 2016 and 2017, youth elite volleyball and basketball players were followed for two consecutive years. The first year served as the observation year in which players’ injury incidence was registered. During the second year, alongside the tracking of the athletes, tailored exercises were performed based on the athletes’ needs as defined by the preseason assessment. Each program session lasted for 15-20 minutes and was done twice a week for the whole season (10 months) during the warm-up.

Outcomes of interest were the incidence of patellar tendinopathy per 1000h of exposure to sporting activities. A Cox survival analysis was conducted to verify the effects of the intervention on the incidence of patellar tendinopathy.

preventive exercises for patellar tendinopathy
From: Bittencourt et al., Physical Therapy in Sport (2022)

 

Results

Athletes who developed patellar tendinopathy were older than those who didn’t and males were 3.3 times more likely than females, but these variables are not influenceable. When looking at the effect of the preventive program, a significant reduction in the incidence of patellar tendinopathy was observed. During the observation year, the incidence of patellar tendinopathy was 5.9 per 1000h of exposure while an incidence of 2.8 per 1000h of exposure was seen in the intervention year. In the first year, 26 athletes developed patellar tendinopathy and only 13 did in the intervention year. The calculated hazard ratio was 0.493 which means that there was 51% less risk of developing patellar tendinopathy in the intervention year.

preventive exercises for patellar tendinopathy
From: Bittencourt et al., Physical Therapy in Sport (2022)

 

preventive exercises for patellar tendinopathy
From: Bittencourt et al., Physical Therapy in Sport (2022)

 

 

preventive exercises for patellar tendinopathy
From: Bittencourt et al., Physical Therapy in Sport (2022)

 

Questions and thoughts

The cohort design as was used in this study is a form of a nonexperimental design where a group of people at risk for a certain outcome is followed over a period of time. The groups are compared on the occurrence of a disease or condition (incidence of patellar tendinopathy) in two cohorts of people that differ on a certain characteristic, risk factor, or exposure (tailored exercise program). As this was a crossover cohort, people from one cohort (the observation year) crossed over to the other cohort (the intervention year). Cohort studies are preferred over experimental studies when experiments are not feasible for practical or ethical reasons. However, it is unclear and not explained why an experimental design like a RCT was not conducted as it seems feasible and ethical to design such a study.

No info on the rehabilitation status of the athletes who developed patellar tendinopathy was presented, so it is unclear whether they continued and relapsed, or whether the 13 cases who developed patellar tendinopathy in the second year were new cases. This study used a cohort design which means that it is not clear if the effects are truly attributable to the intervention program that was followed in the second year. To determine that, a randomized controlled trial should be held. Nonetheless, the provided information gives interesting insights which can be further explored in more detail.

In the intervention year, the risk of developing patellar tendinopathy was reduced, but this came from the effect that was observed in male volleyball athletes since little change in risk reduction was observed in female volleyball athletes. However, for basketball only male athletes were followed so here it remains unclear if this effect is also observed in this sport

 

Talk nerdy to me

This study prescribed a tailored program based on the preseason assessment of each individual athlete. What’s really interesting is that they made use of tests easily applicable in real life (like the weight-bearing lunge test, hamstring bridge test, passive hip internal rotation ROM and single-leg squat). So there is no requirement of having specific or costly equipment. The choice of these tests was based on knowledge of risk factors associated with patellar tendinopathy such as dorsiflexion ROM restriction and weakness of the hip musculature.

Results of the preseason assessment were discussed by the team sports physiotherapist and the coaches, but unfortunately the athlete was not involved in the decision making process. Shared decision making is an important aspect and a proper explanation of the importance of the tailored program can be crucial in the compliance and adherence to the prescribed exercises. However, the team physio was present during the warm-up sessions, so therefore we can assume that the instructions were followed properly.

A reduction in the incidence of patellar tendinopathy was seen in the intervention year, which is interesting since more sporting hours were recorded (5,884h during the observation year and of 6,104h during the intervention year). The authors attribute this effect to the prevention program, although this must be tested in a more rigorous RCT setting. It is possible that the reduced incidence of patellar tendinopathy in the intervention year was influenced by the Hawthorne effect in which the individual may report differently as a result of being observed.

 

Take home messages

A tailored program can reduce the incidence of patellar tendinopathy in elite youth athletes who play volleyball and basketball. The program was designed to target specific impairments that were observed in the preseason assessment of each individual athlete. When the exercise program was implemented in the intervention year, the athletes participated in the program every training session for 15-20 minutes during the warming up.

 

Reference

Bittencourt NFN, Oliveira RR, Vaz RPM, Silva RS, Mendonça LM. Preventive effect of tailored exercises on patellar tendinopathy in elite youth athletes: A cohort study. Phys Ther Sport. 2022 Jan;53:60-66. doi: 10.1016/j.ptsp.2021.11.006. 

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