The Use of Eccentric Overloading Robyn B. Goldman, DPT1 Trevor A. Lentz, PT, CSCS2 Exercise for the Treatment of Patellar Tendinosis in an Olympic-style Weightlifter: A Case Report

1This manuscript was completed while enrolled in the University of Florida Doctor of Program, Gainesville, FL 2Physical Therapist, UF & Shands Orthopaedics and Sports Medicine Institute, Gainesville, FL

ABSTRACT “tendinosis” refers to a chronic degeneration Study Design: Case report. Background Key Words: patellar tendinosis, of a due to failed healing without and Purpose: The purpose of this case weightlifter, eccentric overload an inflammatory process present.4 While report is to describe the conservative man- imaging and histologic studies are the gold agement of patellar tendinosis in a college- INTRODUCTION standard in the diagnosis of these two con- aged Olympic-style weightlifter using a re- Patellar , also known as ditions, a clinical history and examination habilitation protocol focusing on eccentric “Jumper’s Knee,” is a common pathology may be helpful in determining one diagno- overloading of the affected patellar tendon. affecting athletes at all levels across many sis over the other.6 Tendinitis is considered Case Description: An 18-year-old male, sports.1 Those participating in jumping a rare, acute condition and is likely to be competitive Olympic-style weightlifter sports such as volleyball and basketball are reported by the patient as responding to presented to the clinic with complaints of most often affected.1-3 Patellar tendinopa- anti-inflammatory treatments.2,7 Tendino- aching at the proximal insertion of thy, however, has also been known to affect sis, however, is a much more common and the right patellar tendon into the inferior nonjumping athletes in which high leg ex- chronic condition. The patient suffering patella limiting his ability to perform knee- tensor speed, power, and eccentric demands from tendinosis is likely to report this as a flexing activities and his ability to perform are placed on the knee extensor mechanism, long-term issue that has not responded well his sport for the previous 2.5 months. A such as those participating in Olympic-style to anti-inflammatory interventions.2,7 It is diagnosis of patellar tendinosis was sup- weightlifting.1-3 this confusion in terminology and difficulty ported by the physical examination and Olympic-style weightlifting requires the with diagnosis that may interfere with op- subjective history. The patient’s quadriceps athlete to perform controlled, high force timal treatment since the focus in treating strength, knee range of motion (ROM), movements at the knee. It has been esti- tendinitis would be on decreasing inflam- and reported pain were monitored over mated that forces 17 times the weightlifter’s mation while the treatment of tendinosis time. The patient’s functional progress was body weight are acting through the patel- would be on promoting collagen synthesis monitored throughout the patient’s rehab lar tendon during heavy-weighted lifts such and strengthening.7 using 4 reliable and validated self-report as the “snatch” and “clean and jerk.”4 Dur- Once a tendinosis diagnosis has been questionnaires. Intervention: Treatment ing these lifts, the athlete’s knees quickly established, the treatment focus becomes consisted of independent stretching of the and repeatedly go through the full range stimulation of collagen synthesis in order quadriceps, resistive strengthening of the of motion (ROM) at high speeds, and the to reverse the degeneration of the tendon. gluteus medius and quadriceps, eccentric patellar tendon must control the motion While many conservative management overloading of the quadriceps and patellar concentrically and eccentrically. During a options exist for patellar tendinosis, many tendon, and proprioceptive/balance activi- 6-year study performed at the US Olympic lack the evidence to support their use, es- ties for the knee complex. As the primary Training Centers at Colorado Springs and pecially in collagen synthesis.2,6 Exercise in focus for strengthening, a progressive ec- Lake Placid, the knee was the second most general has been shown to increase collagen centric overload exercise program was used commonly injured site (n= 107) of the 560 synthesis in peritendinous connective tis- in order to promote collagen synthesis and training related injuries occurring in Olym- sue.8 Recent literature has demonstrated regeneration of the degenerative tendon. pic-style weightlifters. Of those 107 knee promising results in the treatment of ten- Outcomes: The patient had improvements injuries, 85.1% of them were designated as dinopathy using eccentric exercise.2-4,7,9-11 in reported pain, knee flexion ROM, and knee tendinitis.5 A 2007 study by Langberg et al11 demon- quadriceps strength of the affected knee. There is much confusion in the litera- strated that a 12-week program of eccentric Improvements were also seen in all func- ture and within the clinical setting regard- exercise may be associated with increased tional questionnaires from initial evalua- ing the terminology of tendon conditions. rates of collagen synthesis in subjects with tion to discharge. Discussion: Currently, “Tendinopathy” is a broad term referring to Achilles tendinosis. Recent studies have there is no preferred treatment for patellar a tendon injury without specifying a par- been able to demonstrate the advantages of tendinosis. Eccentric exercise training has ticular pathology. Tendinopathy can then eccentric exercises in treating patellar ten- been described with successful results in be subdivided into tendinitis and tendino- dinosis versus surgical treatment and other the treatment of this condition both in the sis with the difference being the underlying types of conservative management. Bahr et literature and with this patient, but no op- pathology. “Tendinitis” implies an acute al3 supported the use of eccentric training timal protocol has been described. inflammatory process is taking place while as a “low-risk and low-cost” alternative to

76 Orthopaedic Practice Vol. 22;2:10 open tenotomy surgery in the treatment of that the radiographs taken were negative. on the right and 4+/5 on the left; quadri- patellar tendinosis since no advantage was The patient denied any prior physical thera- ceps strength was 4+/5 on the right with demonstrated in surgical subjects over the py for the current condition. pain during manual loading, and 5/5 on the eccentric training subjects participating in At the time of initial evaluation, the left. Florence et al found that MMT is reli- the study. Additionally, Alfredson and col- patient’s subjective report revealed that his able in measuring knee strength (r = .93).17 leagues9,10 published 2 articles supporting condition was aggravated by ascending/ Lower extremity flexibility was measured the use of eccentric exercises in the treat- descending stairs, squatting/kneeling, and using positions outlined by Dutton13 for ment of patellar tendinosis. While there is performing weightlifting maneuvers, and , iliotibial band, quad, hip flexor, literature to support the use of eccentric was temporarily eased by rest. A visual an- and soleus length. Using a prone knee flex- exercises in treating patellar tendinosis, the alog scale (VAS) was used to measure the ion test,13 only a minimal limitation was underlying mechanisms for its benefits are patient’s reported levels of patellar tendon found in the flexibility of the right quadri- debated. Several theories have been pro- pain at the initial evaluation and the start ceps as exhibited by the patient’s inability to posed to explain these benefits including: and completion of each treatment session. touch his right heel to his buttocks. (1) eccentric exercises generate a loading-in- The VAS is a reliable (r = 0.97) 11-point Upon observation of the bilateral knees, duced hypertrophy that produces collagen Likert Scale ranging from 0 to 10 in which there was no visible redness, increased heat, and increases tensile strength of the tendon, 0 is no pain and 10 is the patient’s worst or swelling. Palpation of the right knee (2) eccentric exercises produce a stretching pain imaginable.12 At best and at the time revealed tenderness at the proximal inser- effect lengthening the muscle-tendon unit of evaluation, the patient’s patellar tendon tion of the patellar tendon. Cook and col- and reducing strain on the tendon, and (3) pain was a 3/10, and at worst, an 8/10. The leagues18 has found moderate to severe ten- eccentric exercises damage the neovascu- patient also reported that his pain had in- derness during palpation of the proximal larization found in degenerative creased in intensity and frequency since the third of the patellar tendon and its inser- that may be responsible for the patient’s time of his initial injury. tion into the patella to be a predictor of pa- pain.4,6,11 The patient reported a past medical tellar tendinopathy in young athletes. The With encouraging results found in the history of bilateral knee pain secondary to patient’s patellar tendon pain was further literature, the use of eccentric training has abnormal lateral tracking of the patella. exacerbated in performing a quad set. Ad- gained support in the treatment of patellar He stated that this occurred 2.5 years ago ditional testing included unsupported bilat- tendinosis. Despite the lack of evidence for and that he was prescribed patella tracking eral and single leg squat tests.13 During both an optimal protocol in the prescription of braces and physical therapy but chose to squat tests, the patient experienced painful eccentric exercise interventions, research- forgo physical therapy since the braces were popping and clicking in the right knee with ers continue to suggest varying treatment relieving his pain. The patient reported he deep knee flexion and during the ascending programs producing positive results. The was wearing both braces at the time of his portion of the squat. purpose of this case report is to describe current injury. In addition to the tests performed dur- the conservative management of patellar ing the examination that would be used tendinosis in a college-aged Olympic-style Patient Examination to monitor the patient’s impairment out- weightlifter using a rehabilitation protocol Upon examination, the patient ambu- comes, the patient was asked to fill out a focusing on eccentric overloading of the af- lated independently without significant number of surveys that would be used to fected patellar tendon. gait abnormalities. A standing postural monitor his self-reported functional prog- screen revealed no significant findings and ress throughout treatment. The following CASE DESCRIPTION leg length screenings were unremarkable. functional outcome surveys were used: The History Physical examination of the knee indicated Lower Extremity Functional Scale (LEFS), The patient was an 18-year-old male, patellar crepitus, bilaterally, right greater The Cincinnati Knee Rating System (Cin- competitive, Olympic-style weightlifter than left, with normal tracking of the pa- cinnati), The International Knee Docu- who presented to our outpatient physical tella during active knee extension from 90° mentation Committee Subjective Knee therapy clinic with complaints of aching to 0° of flexion. However, a patellofemoral Form (IKDC), and the Victorian Institute pain at the proximal insertion of the right compression test, also known as the McCo- of Sport Assessment (VISA). The LEFS patellar tendon into the inferior patella. nnell Test,13 was negative, bilaterally. Patel- was used to evaluate general lower extrem- The patient was experiencing these symp- lofemoral mobility testing in all planes ity physical function. Both the Cincinnati toms for the previous 2.5 months following did not reveal any limitations, bilaterally. and IKDC more specifically focused on the a sudden onset of excruciating knee pain Range of motion measurements of the knee, with the Cincinnati monitoring knee while performing a jerk during competi- knee were 10°/0°/140° and 10°/0°/145° for impairments and function, and the IKDC tion. During those 2.5 months, the patient the right and left, respectively using stan- monitoring function in sport in addition abstained from weightlifting activities that dard landmarks as outlined by Norkin and to function during activities of daily living. required motion at the knee and began tak- White.14 The literature indicates that gonio- The VISA, specifically designed to monitor ing nonsteroidal anti-inflammatory drugs metric measurements of the knee joint are patellar tendinopathy, tested similar con- (NSAIDs) and using cryotherapy for pain both reliable (r = .98) and valid (r = .97- structs to those found in the other ques- and inflammation. The patient decided to .98).15 Manual muscle testing (MMT) of tionnaires but was used in this case because see his physician and was then referred to the , gluteus medius, and quad- it contains items focusing on the amount physical therapy when his symptoms failed riceps were tested in standard positions.16 of time the patient is able to participate in to improve despite rest and anti-inflamma- The strength of the hamstrings were a 5/5 sporting activities based on 3 categories. tory interventions. The patient reported bilaterally; gluteus medius strength was 5/5 These 3 categories ranged in severity from

Orthopaedic Practice Vol. 22;2:10 77 “pain that stops you from completing sport activities,” to “pain while undertaking sport activities but it does not stop you,” and, fi- nally “no pain while undertaking sport ac- tivities.” The patient would be questioned on the amount of time he was able to par- ticipate in sports based on the category he fell into at that point in his rehabilitation and his score would be weighted according to the level of function reported. All of the stated tests were found to be reliable, valid, and responsive to change in evaluating their given patient population as seen in Table 1.

Patient Evaluation Examination revealed ROM, strength, and flexibility impairments in the right knee compared to the left knee and tender- ness to palpation of the patellar tendon at its attachment into the patella. In evaluat- established that the patient presented with Both of these motions increase torque forc- ing these findings, the following differential signs and symptoms consistent with patel- es and rotary stresses acting on the knee and diagnoses were considered: patellofemoral lar tendinosis. Intervention was directed increase the likelihood of injury.23,24 The pain syndrome (PFPS), patellar tendinitis, toward treatment of the pathology and im- knee extension machine was used in a more and patellar tendinosis. Patellofemoral pain pairments associated with this diagnosis. focused effort to strengthen the right quad- syndrome was the first consideration as the riceps. During all leg presses, mini-squats, patient complained of many of the symp- Intervention and knee extension exercises, the patient toms consistent with this diagnosis includ- The patient was seen for 11 visits (in- was instructed to perform the eccentric ing aching anterior knee pain, retropatellar cluding the initial evaluation) over a span quadriceps phase with his right lower ex- pain, and pain with knee-flexing activities of 6 weeks. During that time, treatment tremity only and to use both lower extremi- such as squatting and stair ascending/de- was focused on addressing those functional ties during the concentric quadriceps phase. scending. The patient also had reported a deficits and impairments found during In all resistance exercises completed by the history of lateral tracking of the patella in the initial evaluation. Treatment addressed patient, the weight initially lifted by the each limb, which is another finding consis- ROM, strength, flexibility, and functional patient was 70% of a one repetition maxi- tent with PFPS. Although the examination limitations through a progressive program mum for his right lower extremity and was revealed normal tracking of the patella and of independent stretching of the quadri- then progressed over time to 100% of a one a negative patellofemoral compression test, ceps, resistive strengthening of the gluteus repetition maximum. PFPS could not be ruled out as a diagnosis medius and quadriceps, eccentric overload- As the patient was able to competently based on the patient’s reported symptoms. ing of the quadriceps and patellar tendon, perform the exercises with proper biome- Regardless of this finding, this does not and proprioceptive/balance activities for the chanical technique and reduced pain, the address the patient’s primary complaint of knee complex. The specific interventions focus of the squat exercises changed to point tenderness directly over the patellar used each visit are outlined in Table 2. increasing strength of the quadriceps and tendon, which is a common symptom of a The primary focus of the strength train- increasing the load through the patellar patellar tendinopathy.2 In instituting a plan ing component of the patient’s treatment tendon in order to improve tensile strength of care for this patient, it would be helpful was eccentric overloading of the quadriceps and encourage collagen synthesis. At visit 5, to establish the underlying pathology of this and patellar tendon. The supine shuttle, the patient began performing squats on a tendinopathy. Based on the patient’s history step downs, heel taps, leg press, and mini- 25° decline. The purpose of the 25° decline of a poor response to anti-inflammatory squats were prescribed with emphasis on was to increase the demands on the knee interventions such as NSAIDs and ice, the overloading the eccentric phase of the ex- extensor mechanism by relaxing the gas- patient’s 2.5 month time from injury, and ercise in order to improve tensile strength trocsoleus muscle complex.9,10 Initially the the lack of localized swelling and erythema and promote tendon regeneration. These patient performed the decline squat with- evident during examination, it was hypoth- exercises were initially prescribed in order out additional weight and facing a wall in esized that the patient was likely suffering to improve the patient’s mechanics and ec- order to use the wall for balance as neces- from a necrotic, rather than inflammatory, centric control at the knee. The patient was sary. During the squat, the patient stood on condition. Patellar tendinitis is defined as asked to focus on keeping his right knee the decline board with his full weight on the an acute inflammation of the patellar ten- pointing in the same direction as his toes right lower extremity. He was instructed to don;4 therefore, this diagnosis was eliminat- during all exercises in order to reduce the keep the trunk as vertical as possible in or- ed from consideration. Patellar tendinosis, rotary forces on the knee. He was also told der to minimize activity of the gluteal mus- however, is a chronic degeneration of the to not allow his knee to extend beyond his cles9 and slowly flex the right knee to 70° in patellar tendon without a present inflam- toes during shuttle and squats in order to order to guarantee that his knee was beyond matory process, and consequently, it was reduce torque forces acting on the knee. the 60° position, the joint angle considered

78 Orthopaedic Practice Vol. 22;2:10 at which the maximum load is placed on the riceps MMT were recorded for each of the ally, changes from visit 6 to visit 11 in the patellar tendon.3 At this point, the patient 11 visits. In addition, the patient completed LEFS, IKDC, and VISA may also be im- was told to place his left foot on the decline the LEFS, Cincinnati, IKDC, and VISA at provements beyond error. While there was board and use both lower extremities to initial evaluation, on visit 6 and on visit 11. a 10-point improvement in the Cincinnati complete the ascending portion of the squat These measurements and scores are shown from visit 6 to visit 11, this may or may not in order to return to the starting position. in Table 3 and Table 4. By the third visit, the be a change due to error. Scoring improve- The patient was told to work through what patient’s right knee ROM had improved to ments noted in the LEFS, IKDC, VISA, he considered to be “moderate” pain, and that of the left knee and by visit 6, the patient and Cincinnati were across many constructs the exercise was progressed when there was was considered to have normal right quadri- of function. The largest increases in scores no pain felt in the patellar tendon during ceps strength; while both improvements can for all questionnaires were seen from initial the exercise.9,10 As the patient was able to be considered marginal, the patient’s initial evaluation to visit 6. Because many of the progress, the exercise was performed using deficits were minimal. More importantly, constructs measured by these questionnaires the Smith machine in order to safely mimic the patient was reporting no patellar tendon considered pain’s effects on function, there some of the techniques used in Olympic- pain by visit 4. Improvements were also seen may be an association between the patient’s style weightlifting. Figure 1 depicts the from initial evaluation to visit 6 and visit 6 score improvements and the fact that he was decline squat being performed using the to visit 11 in the LEFS, Cincinnati, IKDC no longer reporting patellar tendon pain by Smith machine. and VISA. As stated earlier in the text, the visit 6. The patient’s largest score increases In addition to the interventions listed in Standard Error of Measure (SEM) for the across the LEFS, Cincinnati, and IKDC Table 2, the patient performed a twice daily LEFS, Cincinnati, IKDC, and VISA are questionnaires were seen in items pertain- home exercise program consisting of quad- +3.9, 10, 9 and 3 points, respectively.19-22 ing to those activities the patient reported riceps stretches (2x30 sec) and ice as needed. In considering the SEM for each of these as his most painful at initial evaluation. functional scales, it is likely that changes in These painful activities included squatting OUTCOMES all 4 measures from initial evaluation to visit and stair ascending/descending. In addition Over the course of the patient’s 6-week 6, as well as overall from initial evaluation the patient cited inability to perform higher rehabilitation program, reported pain on a to visit 11 can be considered improvements functioning tasks such as, sport-related ac- VAS, knee ROM measurements, and quad- beyond measurement error. Addition- tivities, and endurance activities secondary

Orthopaedic Practice Vol. 22;2:10 79 to pain and weakness. Furthermore, over time as the patient’s pain improved and no longer affected his ability to perform sport- related activities, the VISA voided the larg- est score improvements in heavily weighted scoring items pertaining to pain and time spent on sports training. The patient was discharged following visit 11 because of his decreased pain symp- toms, increased flexibility and strength, im- provement in function, and independence in performing the exercises comprising his rehab program. Furthermore, he success- fully met his rehabilitation goals set out in his initial evaluation. He was provided with verbal and written instruction in a home exercise program (HEP) comprised of knee stretching and strengthening exercises. Be- cause the patient had access to a gym, many of the exercises in his HEP were those he had performed during his rehab program.

DISCUSSION This case report describes the specific protocol used in the treatment of a com- petitive Olympic-style weightlifter present- ‡ ing with signs and symptoms of patellar Overall score change from initial evaluation to discharge tendinosis. While the literature currently *Change larger than SEM does not allude to a preferred treatment for patellar tendinosis, surgical treatment has not been demonstrated to be more effective than conservative treatment.3 The patient in ing a progressive eccentric overload to the had equally successful results. Considering this case report was able to demonstrate im- patellar tendon and closely monitoring the these points, there needs to be more ran- provements in right knee ROM, right quad- patient’s symptom and functional improve- domized controlled trials with larger sam- riceps strength, reported patellar tendon ments, we feel our initial hypothesis of deg- ples and more diverse subject populations, pain, and overall knee function following a radation versus inflammation of the patellar specifically studying the optimal frequency, conservative rehabilitation program consist- tendon were supported by the successful duration, and time for an eccentric exercise ing of stretching and strengthening of the outcomes. training protocol in the treatment of patel- right quadriceps and a progressive eccentric Despite the promising results seen in lar tendinosis. Additionally, there is very exercise program that was aimed at over- this case and those reported in the literature little quality research that has been pub- loading the affected patellar tendon in order in using eccentric training as a conservative lished comparing outcomes following surgi- to encourage collagen synthesis and improve treatment for patellar tendinosis, the vari- cal versus conservative treatment for patellar tensile strength of the tendon. While there ability in treatment protocols in the litera- tendinopathy. Open patellar tenotomy is are few studies evaluating eccentric training ture reflects the need for studies outlining the surgical treatment of choice as it is the as a treatment for patellar tendinosis, the ec- an optimal protocol. Additionally, many of most widely described. Other surgical op- centric training program used during this the referenced articles study young athletic tions include: curettage of the patella at the patient’s rehab reflected the positive results populations and report the use of 12-week tendon-bone junction, percutaneous longi- found in studies by Alfredson et al.9,10 They programs in which exercises are performed tudinal tenotomy, arthroscopic tenotomy found that eccentric training was superior 7 days per week, twice daily.3,9,10 These pro- and drilling of the inferior patellar pole.3 to concentric training in patients with pa- grams require an extreme amount of dedi- Further research comparing surgical to non- tellar tendinosis. Furthermore the addition cation and time commitment that is not surgical treatment approaches are warranted of a decline in performing eccentric squats necessarily a plausible option for all patients in order to determine long-term outcomes. showed superior results when compared suffering from this condition. The patient To our knowledge, no studies describing with patients performing flat-step squats. in this case report performed a 6-week pro- the use of eccentric overload strengthen- While diagnosis in cases such as these gram with eccentric training one time per ing for the treatment of patellar tendinosis can be difficult to establish without imaging day, 3 days per week with a stretching main- provide a detailed comprehensive inter- studies, we feel that this patient’s diagnosis tenance program to be performed at home vention protocol. The literature supports of patellar tendinosis was confirmed retro- daily. Even with the differences in frequency the use of the eccentric decline squat as a spectively. In treating the patient’s impair- and duration of this patient’s program ver- single intervention for patellar tendinosis, ments and primary complaints by follow- sus those found in the literature, this patient but does not specifically describe any ad-

80 Orthopaedic Practice Vol. 22;2:10 Starting position Squat descent on right Placement of left lower lower extremity extremity in preparation for bilateral lower extremity ascent

Figure 1. Eccentric Decline Squat Performed on the Smith Machine ditional eccentric overload exercises as part patient’s functional outcome measures. We elite athletes from different sports: a of their treatment programs; therefore, it is are therefore unable to make any judgments cross-sectional study. Am J Sports Med. likely our approach is novel. Our approach regarding the clinical significance of the 2005;33:561-567. is more comprehensive than those we found changes in self-reported function follow- 2. Tan SC, Chan O. Achilles and patellar in the literature since this patient was suc- ing treatment based on MCID measures. tendinopathy: Current understanding cessfully treated with 3 eccentric overload We believe that, despite having no objective of pathophysiology and management. exercises in addition to the eccentric decline proof of a clinically important difference, Disabil Rehabil. 2008;30:1608-1615. squat. A strength of this case report is the this patient experienced clinically significant 3. Bahr R, Fossan B, Loken S, Engebret- detailed description of the prescribed in- improvements due to his subjective reports sen L. Surgical treatment compared terventions. We feel that this will lend well that he was “back to normal.” with eccentric training for patellar ten- to reproducibility in undertaking such ec- This case report describes the use of a dinopathy (Jumper’s knee). A random- centric exercise protocols in the future. comprehensive eccentric overload training ized, controlled trial. J Bone Joint Surg. Furthermore, as patellar are protocol in the treatment of an Olympic- 2006;88:1689-1698. often associated with jumping sports, few style weightlifter with signs and symptoms 4. Rees JD, Wilson AM, Wolman RL. studies have examined this pathology in of patellar tendinosis. The patient was able Current concepts in the management weightlifters. This study provides evidence to report successful improvement in symp- of tendon disorders. Rheumatology. of the use of eccentric overload exercise in toms and function by using a similar, yet 2006;45:508-521. the successful treatment of tendinopathy in more comprehensive eccentric overload 5. Calhoon G, Fry AC. Injury rates and an individual of an understudied popula- program than those found in the literature. profiles of elite competitive weightlifters. tion. Additional strengths of this case study While the interpretations able to be drawn J Athl Train. 1999;34:232-238. are the use of knee specific questionnaires from this case are limited, we believe it pres- 6. Alfredson H. The chronic painful Achil- such as the IKDC and Cincinnati to moni- ents another potential option for the use of les and patellar tendon: research on ba- tor the patient’s functional progress and a eccentric overload training in the treatment sic biology and treatment. Scand J Med questionnaire specifically designed to moni- of patellar tendinosis and warrants consider- Sci Sports. 2005;15:252-259. tor the severity of patellar tendinopathy as ation for further study. 7. Khan KM, Cook JL, Taunton JE, Bonar it relates to function, the VISA. There are a F. Overuse tendinosis, not tendinitis. few limitations to consider when interpret- ACKNOWLEDGEMENTS Phys Sports Med. 2000;28:38-48. ing the results of this study. As with any case The authors would like to acknowledge 8. Langberg H, Rosendal L, Kjaer M. study, the authors are limited in their ability Steven Z. George, PT, PhD for his guidance Training-induced changes in periten- to establish a cause and effect relationship in the data collection process and develop- dinous type I collagen turnover deter- between our interventions and outcomes of ment of this case study. mined by microdialysis in humans. J interest. Another limitation to note is that Physiol. 2001;534:297-302. no minimal clinically important differences REFERENCES 9. Alfredson H, Jonsson P. Superior results (MCID) were reported for the question- 1. Lian OB, Engebretesen L, Bahr R. with eccentric compared to concentric naires that were used in monitoring the Prevalence of jumper’s knee among quadriceps training in patients with

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