Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial

Key points

1. 01PTLE improved VISA-P score by 28 points vs 18 points for EET over 24 weeks, a statistically significant difference (p=0.023)
2. 02Exercise-related pain during the programme was significantly lower with PTLE (VAS 2 vs 4, p=0.006)
3. 03A higher proportion of PTLE patients rated their outcome as excellent (38% vs 10%, p=0.009)
4. 04Return to pre-injury sports level trended higher with PTLE (43% vs 27%) but did not reach significance (p=0.16)
5. 05Overall satisfaction at 24 weeks was similar between groups (81% vs 83%, p=0.54) despite the functional advantage of PTLE

How it was conducted

Design

Stratified, investigator-blinded, block-randomised controlled trial (JUMPER study)

Participants

76 athletes aged 18-35 with clinically and ultrasound-confirmed patellar tendinopathy; median symptom duration 2 years; 82% had failed prior treatment

Groups

PTLE (n=38): 4-stage progressive programme within acceptable pain limits (VAS ≤3); EET (n=38): pain-provoking decline-board eccentric squats (VAS ≥5)

Duration

24 weeks of unsupervised home exercise with web-based support

Primary outcome

VISA-P questionnaire (0-100 scale) measuring pain, function and sports ability at 24 weeks

Analysis

Intention-to-treat using generalised estimating equations, adjusted for age, sex, BMI, symptom duration and activity level

What they found

• VISA-P improved from 56 (95% CI 52-61) at baseline to 84 (95% CI 79-89) in the PTLE group (p<0.001) and from 57 (95% CI 53-62) to 75 (95% CI 69-82) in the EET group (p<0.001)
• Adjusted mean between-group difference in VISA-P at 24 weeks: 9 points (95% CI 1 to 16; p=0.023) in favour of PTLE
• At 24 weeks, 87% of PTLE patients vs 77% of EET patients achieved the minimum clinically important difference of 13 points (between-group difference not significant, p=0.24)
• Return to desired sports at pre-injury level at 24 weeks: 43% (n=16) PTLE vs 27% (n=8) EET (p=0.16)
• Exercise-related VAS pain at 24 weeks: estimated mean 2 (PTLE) vs 4 (EET); adjusted between-group difference 2 (95% CI 1 to 3; p=0.006)
• Excellent satisfaction at 24 weeks: 38% PTLE vs 10% EET (p=0.009)
• Exercise adherence to tendon-specific exercises at 24 weeks: 40% PTLE vs 49% EET (p=0.33)
• 9 patients lost to follow-up: 1 in PTLE group, 8 in EET group

Limitations

• Blinding of patients to treatment allocation was not possible due to the nature of the interventions
• Under the worst-case sensitivity analysis for missing data, the PTLE advantage over EET was no longer maintained
• The study population was a mix of recreational and competitive athletes, which may limit generalisability to either group specifically
• Exercises were unsupervised, and results may have been better with physiotherapist-guided programmes

Why it matters

For patients

Athletes with chronic jumper's knee who have not responded to previous treatment can expect meaningful pain and function improvement with a progressive loading programme that stays within tolerable pain limits.

For clinicians

PTLE should replace pain-provoking eccentric exercise as first-line conservative therapy for patellar tendinopathy, given superior VISA-P outcomes and lower exercise-related pain at 24 weeks.

For readers

This is the largest RCT in patellar tendinopathy to date and directly challenges NICE guideline support for eccentric-only therapy, providing evidence to update clinical recommendations.