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Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial
  1. Stephan J Breda1,2,
  2. Edwin H G Oei1,
  3. Johannes Zwerver3,4,
  4. Edwin Visser5,
  5. Erwin Waarsing2,
  6. Gabriel P Krestin1,
  7. Robert-Jan de Vos2
  1. 1Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
  2. 2Department of Orthopaedics and Sports Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
  3. 3Centre for Human Movement Sciences, University Medical Centre Groningen, Groningen, The Netherlands
  4. 4Sports Valley, High Performance Medical Centre, Gelderse Vallei Hospital, Ede, Gelderland, The Netherlands
  5. 5Department of Physical Therapy, Sportgeneeskunde Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
  1. Correspondence to Stephan J Breda, Department of Radiology & Nuclear Medicine, Erasmus MC, 3015 GD Rotterdam, Netherlands; s.breda{at}


Objective To compare the effectiveness of progressive tendon-loading exercises (PTLE) with eccentric exercise therapy (EET) in patients with patellar tendinopathy (PT).

Methods In a stratified, investigator-blinded, block-randomised trial, 76 patients with clinically diagnosed and ultrasound-confirmed PT were randomly assigned in a 1:1 ratio to receive either PTLE or EET. The primary end point was clinical outcome after 24 weeks following an intention-to-treat analysis, as assessed with the validated Victorian Institute of Sports Assessment for patellar tendons (VISA-P) questionnaire measuring pain, function and ability to play sports. Secondary outcomes included the return to sports rate, subjective patient satisfaction and exercise adherence.

Results Patients were randomised between January 2017 and July 2019. The intention-to-treat population (mean age, 24 years, SD 4); 58 (76%) male) consisted of patients with mostly chronic PT (median symptom duration 2 years). Most patients (82%) underwent prior treatment for PT but failed to recover fully. 38 patients were randomised to the PTLE group and 38 patients to the EET group. The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 vs 18 points, adjusted mean between-group difference, 9 (95% CI 1 to 16); p=0.023). There was a trend towards a higher return to sports rate in the PTLE group (43% vs 27%, p=0.13). No significant between-group difference was found for subjective patient satisfaction (81% vs 83%, p=0.54) and exercise adherence between the PTLE group and EET group after 24 weeks (40% vs 49%, p=0.33).

Conclusions In patients with PT, PTLE resulted in a significantly better clinical outcome after 24 weeks than EET. PTLE are superior to EET and are therefore recommended as initial conservative treatment for PT.

  • overuse injury
  • exercise rehabilitation
  • randomised controlled trial
  • sports rehabilitation programs
  • tendinopathy

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  • Contributors R-JdV is the guarantor for this study. R-JdV, EHGO, SJB and EV were involved in designing the trial. SJB was the main investigator and responsible for data collection, analyses and writing of the manuscript, while the remaining coauthors revised the manuscript for important intellectual content. R-JdV was responsible for the clinical eligibility assessment in this trial and final randomisation with treatment allocation. SJB and EHGO were responsible for the radiological eligibility assessment in this trial. EV was responsible for the exercise therapy performed in the trial. JZ was the dedicated contact person for participants in the trial after randomisation. JZ was responsible for the statistical analyses performed in this trial. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding Research grant from the National Basketball Association (NBA) and GE Healthcare Orthopaedics and Sports Medicine Collaboration. Ultrasound equipment for this study provided by GE Healthcare.

  • Disclaimer We plan to disseminate the results to study patients and or patient organisations.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at and declare: EHGO and R-JdV had financial support from the National Basketball Association (NBA) and GE Healthcare Orthopaedics and Sports Medicine Collaboration for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Patient consent for publication Not required.

  • Ethics approval The study protocol for the JUMPER study was approved by the local ethics committee: The Medical Ethics Review Committee of the Erasmus MC University Medical Centre Rotterdam, The Netherlands (NL58512.078.016).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.