systematic Review About Eccentric Training in Chronic Patella Tendinopathy

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Furnishings of Concrete Training on Physical and Psychological Parameters in Individuals with Patella Tendinopathy: A Systematic Review and Meta-Analysis

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Department of Health and Social Affairs, FHM Hannover—University of Applied Sciences, 30163 Hannover, Federal republic of germany

²

Division of Movement and Training Sciences/Biomechanics of Sport, University of Duisburg-Essen, 45141 Essen, Deutschland

^*

Author to whom correspondence should exist addressed.

Received: 18 November 2020 / Revised: eleven January 2021 / Accepted: 14 January 2021 / Published: xix January 2021

Abstruse

The effectiveness of physical preparation on physical and psychological parameters in individuals with patella tendinopathy has not been investigated in a systematic review and meta-analysis. The aim of the present study was to determine the effects of physical exercise interventions for measures of physical and psychological functioning in subjects with patella tendinopathy. A computerised systematic literature search was conducted in the electronic databases PubMed, Medline, and Spider web of Science from January 1960 to July 2020. Initially, 506 manufactures were identified for review of which 11 manufactures met the inclusion criteria. Our results revealed a pocket-sized effect (weighted mean standardized mean difference (SMD) = 0.12; nine studies) of concrete training on the psychological measure Victorian Institute of Sport Cess–Patellar tendon scale and a medium effect (weighted hateful SMD = 0.61; five studies) on the psychological measure visual analogue scale—both in favour of the intervention group. In contrast, a small outcome (weighted hateful SMD = −0.05; ii studies) in favour of the control grouping was detected for the physical measure muscle ability. Compared to the control condition, physical training seems to exist an effective means to improve psychological just not physical parameters in individuals with patella tendinopathy; although conclusions on the latter could accept been biased by the small amount of eligible studies (due north = 2). In addition, the predetermined cut-off value of ≥vi for the Physiotherapy Testify Database scale score (i.due east., assessment of methodological quality) was only accomplished past half-dozen out of eleven studies. Thus, further research of high methodological quality is needed to verify whether in that location is or is not an effect of physical grooming on physical parameters in persons with patella tendinopathy.

1. Introduction

Overuse injuries affect boyish athletes with incidence rates up to 50% [1]. Patella tendinopathy, also known every bit jumper's knee joint (JK), is a mutual overload injury that is ofttimes observed in young athletes performing loftier-impact jumping sports, such as soccer, volleyball, or basketball [2,3,4]. Compared to other mutual injuries (e.yard., anterior cruciate ligament lesions), the prevalence of patella tendinopathy is relatively loftier affecting approximately 31.ix% of basketball players and 44.6% in volleyball players [v], which underlines the relevance of this injury amid common sports. Peculiarly within a competitive season, during which athletes are under constant pressure to perform on a high level, treatment of patella tendinopathy can be challenging [vi]. Male athletes are afflicted twice as oft equally females [seven]. Age does non play a significant office with regard to the presentation of symptoms [3].

A variety of extrinsic (e.g., loftier tendon loads due to exercise or short recovery periods afterwards mechanical overload) and intrinsic factors (e.k., malalignment, muscular tightness, imbalance) have been shown to cause patella tendinopathy [eight]. Direct medical expenses of patients with tendinopathy are effectually £20,000 to £30,000 (currency in 2015) and are comparable to the medical expenses of osteoarthritis and osteoporosis (currency in 2005 and 2004, respectively) [9]. Contempo literature reports a loss of work ability by 16%, equally well equally a 36% decrease in productivity in patients with patellar tendinopathy [x], both calculation to the indirect medical costs.

Several treatment options aim to reduce pain related to patella tendinopathy. Apart from surgical interventions, dry needling, extracorporeal shockwave therapy, and a broad range of physical exercise interventions, which take proven useful in the reduction of hurting and symptoms, are available. Pain relief interventions using physical preparation present many benefits for patients. Exercises that ameliorate symptoms of patella tendinopathy and preclude consequential trauma can be practiced with lower pain intensity, therefore improving execution of these practise [11]. More specifically, eccentric muscle strengthening has proven to exist particularly effective when performed on a declined surface [12,13]. Also, a heavy boring resistance training program showed a meaning reduction of tendon stiffness and similar effects in treating patella tendinopathy [14]. The main effects of the aforementioned do therapies are a reduction in hurting with and without stress on the tendon, besides as improved athletic ability, in particular leap height. Even so, the current literature is sparse with regard to psychological parameters, although pain relief after a long flow of injury-related downtime often correlates with higher motivation in sports and everyday activities. The aim of this systematic review and meta-analysis was to determine the effects of physical training on concrete and psychological parameters in individuals with patella tendinopathy. Due to the loftier prevalence of patella tendinopathy in adolescent athletes in particular [4], it is of utmost importance to measure the effectiveness of physical practice on both event categories. More than precisely, in that location is evidence that better values in concrete and psychological parameters have an impact on athletes' operation during practise and competition [xv,16].

ii. Methods

In the present written report, we followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines (see Supplementary Tabular array S1) [17].

2.one. Literature Search

The authors performed a systematic computerised literature search in PubMed, Medline, and Web of Science using the following Boolean search strategy: "(patellar OR patella) AND (tendinopathy OR tendinosis OR "tendon pain" OR tendinitis OR "jumpers genu" OR "jumper´south knee") AND (treatment OR therapy OR exercise OR training)". In addition, the search was limited to the post-obit: full-text availability, publication dates: i Jan 1960 to 31 July 2020, language: English, article blazon: no review. Moreover, the reference lists of the included articles were screened to identify other suitable studies for inclusion in our assay.

ii.ii. Selection Criteria

We considered studies to be eligible for inclusion in our review if they provided enough relevant data with regard to the PICOS (Population, Interventions, Comparators, Outcomes, Study design) approach. For eligibility, we used the following criteria: (a) Population: participants with a diagnosed (by imaging or palpation technique) patellar overuse injury; (b) Intervention: physical training protocols comprising eccentric, concentric, or isometric strength grooming; (c) Comparator: active or passive control grouping (i.eastward., different physical intervention, no training at all); (d) Outcome: at to the lowest degree one measure of physical or psychological performance; (e) Written report pattern: controlled trials with pre- and mail-measures. The exclusion criteria were as follows: (a) participants were non diagnosed by a health professional; (b) intervention was not exercise-based (i.e., ultrasound, injection, dry out needling, shockwave); (c) reported data did non let for calculation (i.eastward., no fundamental tendency and dispersion measure in the results section or upon request); (d) effects were examined without control condition; (e) assessments did non include a concrete or psychological consequence measure; (f) cantankerous-sectional report blueprint. Two independent reviewers (MN, TM) assessed the eligibility of the relevant papers past analysing titles, abstracts, and full texts of the respective articles.

2.three. Written report Coding

The included studies were coded for the variables listed in Tabular array 1. In our analyses, we focused on different categories of outcome measures. If an eligible article reported multiple variables inside i of these categories, nosotros prioritized the near unremarkably reported outcome for each category in gild to reduce heterogeneity between studies. In the case that a report included only similar, but not identical, tests, we selected the test that seemed most relevant with regard to physical or psychological functioning outcomes. Leap and attain tests as well as countermovement jumps (with/without use of artillery) were considered to exist the most important variables of muscle power. Validity and reliability have been shown for both tests [xviii,19]. Pain at rest was evaluated using the Victorian Institute of Sport Assessment—Patellar tendon (VISA-P) scale or the Visual Analogue Scale (VAS) scale score, whereas pain during exercise was measured using pain during single leg decline squat (SLDS). Validity and reliability have previously been shown for the VISA-P [20], the VAS [21], and the SLDS [22]. Further, nosotros considered the use of training equipment, dissimilar types of exercises, the use of closed or open kinetic chain, and the type of underground used. Treatment modality was coded according to the following parameters: preparation weeks/sessions, number of sets, number of repetitions, exercise elapsing, and training intensity. If the considered studies did not disembalm relevant results, the authors were contacted via e-mail [23,24,25,26,27]. When authors failed to respond to our request, or the requested information was no longer available [24,25], we excluded the respective outcome measure out.

2.4. Assessment of Methodological Study Quality

The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of all eligible studies, also as to quantify the take chances of potential bias. The PEDro scale rates internal written report validity and the presence of statistical replicable data on a scale from 0 to 10, with ≥6 representing a cut-off score for studies of high quality [28]. Two contained reviewers (MN, TM) assessed the quality of the included studies.

2.5. Statistical Analyses

To make up one's mind the effectiveness of physical grooming on physical and psychological parameters in individuals with patella tendinopathy, we calculated the weighted standardized mean difference (SMD = (mean post-exam value for the intervention [INT] group minus mean post-test value of the control [CON] group)/pooled variance) using a random-effects meta-analysis model provided past the Review Manager v.3 software (version 5.three.5, The Nordic Cochrane Centre, Copenhagen, Kingdom of denmark). From nine studies [14,25,26,27,29,30,31,32,33] that only reported the median and range, we calculated the hateful and the standard deviation, in understanding with Hozo et al. [34]. For another report [35] that only stated confidence intervals, we used the formula provided in the Cochrane Handbook of Systematic Reviews of Interventions [36] to summate the standard deviations. The weighting of the included studies was also performed with the help of Review Manager v.iii software. In accordance to Cohen, effect size values of 0 ≤ 0.49 indicate small, of 0.50 ≤ 0.79 indicate medium, and of ≥0.eighty indicate large effects. In add-on, I ^two statistics was used to assess heterogeneity between studies. In understanding with Deeks et al. [37], heterogeneity can be classified as being either trivial (0% ≤ I ² ≤ 40%), moderate (30% ≤ I ² ≤ 60%), substantial (50% ≤ I ^two ≤ ninety%), or considerable (75% ≤ I ² ≤ 100%).

3. Results

Figure 1 summarizes the process of the systematic literature search, which identified a total of 506 studies. Afterward removing duplicates, screening titles, and excluding ineligible articles, eleven studies remained and were included in our meta-analysis.

3.one. Characteristics of the Included Studies

Table one displays the characteristics of the eleven included studies. Ii studies [23,xxx] reported data for both physical and psychological variables, viii studies [fourteen,26,27,29,31,32,33,35] reported data for just psychological variables. A total of 277 subjects participated in the 11 trials; 155 of them received eccentric force training, 42 concentric strength training, 23 isometric strength training, thirteen dynamic heavy slow resistance grooming, 29 sports grooming, and 20 tendons were surgically treated. The sample size of the included studies ranged from 15 to 43 subjects, and participants had a mean age of sixteen–32 years. Training periods ranged from four to 24 weeks, with the respective grooming frequencies ranging from 0.five to 14 sessions per week. Training protocols comprised unilateral/bilateral squats on a decline lath/flat surface/unstable surface, leg extensions, leg curls, leg press, too equally static stretching. All eleven studies analysed outcomes of pain cess (1 × VISA-P, ii × VAS, 3 × VISA-P/VAS, 1 × VISA-P/SLDS) [14,23,25,26,27,29,xxx,31,32,33,35]. Three studies reporting physical information examining strength variables (2 × CMJ, iv × leg strength) [23,25,30].

3.2. Methodological Study Quality

The median PEDro score of the included studies was half dozen, which equals the predetermined cutting-off value of ≥half-dozen and was achieved past half dozen out of eleven studies (Table 1).

3.three. Effects of Physical Training on Physical Parameters in Individuals with Patella Tendinopathy

Effigy 2 shows the effectiveness of physical training on measures of musculus power in individuals with patella tendinopathy. The weighted hateful SMD amounted to −0.05 (2 studies; I² = 0%, Chi ² = 0.22, df = 1, p = 0.85), which is indicative of a small-scale-sized effect in favour of the CON grouping.

three.4. Effects of Physical Training on Psychological Parameters in Individuals with Patella Tendinopathy

Effigy three illustrates the bear on of concrete grooming on the psychological measure VISA-P in individuals with patella tendinopathy. The weighted mean SMD yielded 0.12 (ix studies; I² = 64%, Chi ² = 22.17, df = viii, p = 0.005), indicating a modest-sized result and favouring the INT group.

The effect of physical grooming on the psychological measure VAS in individuals with patella tendinopathy is displayed in Figure 4. The weighted mean SMD amounted to 0.61 (five studies; I² = lxxx%, Chi ² = 20.07, df = 4, p = 0.22), which indicates a medium-sized outcome in favour of the INT group.

four. Discussion

To the best of our knowledge, the present systematic review with meta-assay is the start to examine and quantify the effects of physical preparation on proxies of physical and psychological parameters in individuals with patella tendinopathy. The analyses of the information of 11 studies revealed mixed results with (i) small-sized merely meliorate effects on musculus ability for the CON grouping, (ii) small-scale-sized but better effects on VISA-P for the INT group; and (3) medium-sized effects on VAS in favour of the INT group.

4.1. Effects of Physical Training on Concrete Parameters in Individuals with Patella Tendinopathy

Physical training displayed only minimal positive effects on variables of muscle power. Eccentric preparation intervention, in item, which had been considered useful in previous reviews [38,39], showed only pocket-size furnishings on musculus power compared to team preparation. Notwithstanding, information technology is important to bear in mind that Biernat et al. [thirty] and Visnes et al. [23] both implemented a very high grooming volume (two sessions daily) in comparison to other studies. The eccentric training protocol was performed on a turn down board, a method which had shown positive results in previous studies. While both studies examined volleyball players, Visnes et al. [13] included both adult males and females and Biernat et al. [thirty] included boyish male athletes only. The subjects in the above-mentioned studies also took part in all squad practices and matches regardless of pain intensity, therefore resulting in a much college training load than the CON group, which just took function in team practice. Furthermore, on days with intensive squad practice, the subjects were permitted to make up one's mind whether or not to take part in the training intervention on their own, which may take led to inconsistent preparation. Both studies but included subjects with a high burden of symptoms, which may have farther affected the impact of the intervention and the volleyball practice. It can exist assumed that the high grooming intensity resulted in an immense burden on the articulatio genus joint and the patella, especially as a result of the frequent jumps in volleyball, therefore causing farther strain inhibiting the positive effects of grooming on muscle power.

Overall, a complex, high-intensity physical training intervention should not be combined with intensive team practice and competitive matches. In this regard, further enquiry is required in order to prove the unlike furnishings of combined versus single-mode physical exercise interventions on muscle power. Moreover, the investigation of different strength grooming methods (isometric, eccentric, concentric) in combination with team training may be able to provide insights into the efficacy of therapy.

4.2. Effects of Physical Grooming on Psychological Parameters in Individuals with Patella Tendinopathy

We were able to discover a small-sized upshot apropos pain reduction, which was verified by the VISA-P test. Previous reviews [38,39,40] revealed a pregnant relief of pain and symptoms using eccentric and isometric training in comparison to other handling methods. In Bahr's et al. [25] randomized report, it must exist considered that the CON group received surgical treatment and, post-functioning, the aforementioned eccentric intervention as the INT group. It is therefore not possible to ascribe their results to either surgical or conservative intervention. The results of da Cunha et al. [26] must also be interpreted carefully, since both groups received an eccentric training intervention; while the INT grouping performed the exercises at maximum pain level, the CON group trained without any pain. No pregnant group differences could exist determined, but both groups reported an improvement in the pain and symptoms. Of the studies examined, Jonsson and Alfredson [31] showed the clearest advantages of eccentric preparation in contrast to concentric training. However, this study was lacking in terms of sample size and study quality, so these outcomes need to be interpreted appropriately. More than specifically, this study but included 15 patients and showed a rather low methodological quality because no data was provided for some criteria of the PEDro calibration (i.e., curtained allotment; blinding of subjects, therapists, and assessors; acceptable follow-up or intention-to-care for analysis). While our systematic review with meta-analysis reported only a medium-sized outcome of VAS favouring the INT group, Jonsson and Alfredson [31] showed the most pregnant improvement of the INT grouping in comparison to the CON group. Similarly to da Cunha et al. [26], Purdam et al. [32] compared two eccentric exercises with one another; while the CON group performed the exercises on a flat surface, the INT grouping used a decline board. Therefore, this report cannot make claims pertaining to the effectiveness of eccentric preparation per se, merely but to a variation of eccentric preparation, which relaxes the calf muscles and in doing so exerts a greater load on the knee extensor muscles. Regarding the time frame of hurting reduction, Purdam et al. [32] also as Jonsson and Alfredson [31] reported a significant pain reduction after twelve weeks in the eccentric group. Further, Bahr et al. [25] did not examine or describe whatsoever modify in pain reduction earlier the first testing after twelve weeks. Lastly, da Cunha et al. [26] described an comeback in pain reduction afterward simply 8 weeks in both handling groups—results which are similar to those of Rio et al. [27] and van Ark et al. [29], who establish a pregnant comeback in both treatment groups later four weeks.

In sum, there are slight advantages of eccentric and isometric training compared to other treatment methods in terms of pain management, and these exercises tin besides be performed using simple equipment. Since all the investigated studies implemented similar intensities and extents of eccentric/isometric training, only none of them combined both methods, it is not possible to draw an adequate conclusion every bit to what an effective conventional therapy entails. Furthermore, the question whether withdrawing from sports and activities is beneficial for pain and symptom management remains unanswered. The studies presented in this systematic review but vaguely comment on this without describing in item the intensity/duration of action, so it is impossible to determine the effect of this variable on the study outcomes.

4.3. Limitations

The heterogeneity among the included studies with regards to the implemented preparation modalities (i.e., eccentric, concentric, or isometric training) is a stiff limitation of this systematic review and meta-analysis. Thus, it remains unclear which type of forcefulness training produces the greatest effect on concrete and psychological parameters in individuals with patella tendinopathy. Past using equal load dimensions (i.e., preparation duration, frequency, volume), futurity studies should directly compare the effects of different physical training programs (i.eastward., eccentric vs. concentric vs. isometric strength exercises) on physical and psychological parameters in individuals with patella tendinopathy. Some other limitation is that only active CON groups (i.due east., a unlike type of physical training) were used in the included studies. This circumstance most likely led to the fact that the furnishings in the INT groups were only small (muscle ability and VISA-P) to medium (VAS) compared to the CON groups.

five. Conclusions

Unlike previous reviews, the present systematic review and meta-analysis detected only pocket-size (muscle power and VISA-P) to medium (VAS) effects amongst both physical and psychological parameters when comparing eccentric and isometric training protocols to other treatment methods. We therefore conclude that further enquiry is needed to establish the optimal handling modality in social club to reduce pain and symptoms in athletes with patella tendinopathy. Although eccentric and isometric training seem to be useful in pain management, nosotros did non detect whatever written report that combined dissimilar methods in gild to notice benefits when used synergistically. Moreover, nosotros were unable to find a study that examined the postal service-interventional effects on performance in training and contest. The studies included in this review mainly used isolated exercises, such as eccentric leg extension, that were non combined with other treatment methods as training intervention. In addition, only agile CON groups were used and compared with the treatment groups. This likely contributed to the fact that only small (muscle power and VISA-P) to medium (VAS) furnishings were found.

Supplementary Materials

The following are bachelor online at https://www.mdpi.com/2075-4663/9/1/12/s1, Table S1: PRISMA Checklist: transparent reporting of systematic reviews and meta-analyses.

Author Contributions

Conceptualization: Chiliad.N.; methodology: M.North.; formal analysis: M.N. and T.M.; writing—original draft grooming: M.N.; writing—review and editing: M.N. and T.Grand. All authors accept read and agreed to the published version of the manuscript.

Funding

We acknowledge support by the Open Admission Publication Fund of the Academy of Duisburg-Essen. Neither the Open up Access Publication Fund of the University of Duisburg-Essen nor whatsoever of its employees were involved in the design of the study, the drove, analysis, and estimation of data, or in writing the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and canonical by the Ethics Commission of the Faculty of Educational Sciences at the University of Duisburg-Essen, Germany (date of approval: TM_29.eleven.2018).

Informed Consent Statement

Not applicable.

Data Availability Statement

The data presented in this study are available on request from the corresponding writer.

Conflicts of Interest

The authors declare no disharmonize of interest.

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Figure 1. Flowchart illustrating the different phases of the literature search and study selection.

Figure 1. Flowchart illustrating the unlike phases of the literature search and report pick.

Effigy 2. Effects of physical training on physical parameters (i.east., muscle ability) in individuals with patella tendinopathy. CI: conviction interval; CON: control group; df: degrees of liberty; INT: intervention grouping; IV: inverse variance; SE: standard error; Std.: standard.

Effigy 2. Furnishings of concrete training on physical parameters (i.due east., muscle power) in individuals with patella tendinopathy. CI: confidence interval; CON: control group; df: degrees of liberty; INT: intervention group; IV: changed variance; SE: standard error; Std.: standard.

Figure iii. Effects of physical training on psychological parameters (i.e., VISA-P) in individuals with patella tendinopathy. CI: confidence interval; CON: control group; df: degrees of freedom; INT: intervention group; 4: inverse variance; SE: standard error; Std.: standard.

Effigy 3. Effects of physical training on psychological parameters (i.eastward., VISA-P) in individuals with patella tendinopathy. CI: confidence interval; CON: control group; df: degrees of freedom; INT: intervention group; Four: inverse variance; SE: standard mistake; Std.: standard.

Effigy 4. Effects of concrete preparation on psychological parameters (i.e., VAS) in individuals with patella tendinopathy. CI: confidence interval; CON: control group; df: degrees of liberty; INT: intervention group; 4: inverse variance; SE: standard mistake; Std.: standard.

Effigy 4. Effects of physical training on psychological parameters (i.e., VAS) in individuals with patella tendinopathy. CI: confidence interval; CON: command group; df: degrees of freedom; INT: intervention group; IV: inverse variance; SE: standard error; Std.: standard.

Tabular array 1. Included studies examining the effects of physical preparation on physical and psychological parameters in individuals with patella tendinopathy.

Table 1. Included studies examining the effects of concrete grooming on physical and psychological parameters in individuals with patella tendinopathy.

References	No. of Subjects (Tendons); Sex activity; Age (Hateful ± SD, or Range); Preparation Condition; Sport	Diagnosis	Groups (Subjects/Tendons); Treatment Blazon	Treatment Modality: No. of Preparation Weeks/Sessions; No. of Sets/Reps/Duration Per Exercise; Grooming Intensity	Test Modality, Upshot Measures	PEDro
van Ark et al. [29]	29 (45); 2 F, 27 M; 23.0 ± 4.seven yrs; sub-elite; volleyball, basketball	Palpation	INT (north = 13/20); forcefulness training (isometric quadriceps training, leg extension machine) CON (n = 16/25); force training (concentric quadriceps grooming, leg extension machine)	iv wk/12 sessions; v sets of 45 s concord at 60° flexion at 80% MVIC iv wk/12 sessions; iv sets of 8 reps (4 s eccentric, 3 due south concentric) at 80% eight RM	Concrete: NT Psychological: VISA-P (score), SLDS (Numeric Rating Scale 0–0) at pre-/post-intervention	5
Rio et al. [27]	xx (28); 2 F, eighteen K; ≥16 yrs; elite and sub-elite; volleyball, basketball	Imaging, SLDS test	INT (n = 10/15); force preparation (isometric quadriceps training, leg extension automobile) CON (n = 10/xiii); forcefulness preparation (concentric quadriceps grooming, leg extension motorcar)	iv wk/12 sessions; five sets of 45 s agree at threescore° flexion at eighty% MVIC four wk/12 sessions; iv sets of 8 reps (4 s eccentric, 3 s concentric) at fourscore% 8 RM	Concrete: NT Psychological: VISA-P (score) at pre-/postal service-intervention	half-dozen
Biernat et al. [thirty]	28 (NR); 1000; 17.0 ± 0.i yrs; recreational; volleyball	Imaging	INT (northward = 15/NR); volleyball training + strength exercises (eccentric) CON (n = xiii/NR); volleyball training just	four wk/daily; iii sets of 15 reps on decline board followed by 20 wk/daily; 3 sets of xv reps on unstable decline board 24 wk/12 sessions; 5 sets of 45 s hold at 60° flexion at fourscore% MVIC	Physical: Isokinetic leg strength; CMJ (cm, W) Psychological: VISA-P (score) at pre-/mid-/post-intervention	5
Dimitrios et al. [35]	43 (NR); 12 F, 31 One thousand; 27 ± five yrs; recreational; NR	Palpation, SLDS test	INT (n = 22/NR); forcefulness (eccentric) and stretching (static) exercises CON (north = 21/NR); strength (eccentric) exercises	iv wk/20 sessions; three sets of 15 reps on decline board, weight increased when hurting-free, static quadriceps/hamstrings stretching before and later the eccentric training, 4 exercises of 30 due south 4 wk/xx sessions, 3 sets of 15 reps on decline board, weight increased when pain-complimentary	Physical: NT Psychological: VISA-P (score) at pre-/post-intervention	5
da Cunha et al. [26]	17 (fourteen); 3 F, 14 M; 25 ± eight yrs; recreational; volleyball, soccer, athletics, basketball game, handball, capoeira, jiu jitsu, triathlon, skating	Imaging	INT (northward = x/8); forcefulness (eccentric) grooming, maximum pain CON (n = seven/vi); strength (eccentric) training, pain-free	12 wk/36 sessions; 3 sets of 15 reps, weight increased when reps possible, pain mandatory 12 wk/36 sessions; iii sets of fifteen reps, weight increased when pain-complimentary	Physical: NT Psychological: VISA-P (score), VAS (0–10) at pre-/mid-/mail-intervention	seven
Kongsgaard et al. [fourteen]	25 (25); 25 M; 32 ± eight yrs; recreational; running, soccer, basketball, floorball, handball	Palpation, imaging	INT (n = 12/12); force (eccentric) training CON I (n = 13/13); strength (dynamic) trainingCON II (n = 12/12); peritendinous corticosteroid injections	12 wk/168 sessions; 3 sets of 15 reps on 25° decline lath, pain-acceptable, weight increased when pain diminished 12 wk/36 sessions; 4 sets of half dozen–15 reps, pain-acceptable ultrasound-guided injections of 1 mL of 40 mg/mL methylprednisolon	Physical: MVIC Psychological: VISA-P (score), VAS (0–100) at pre-/post-intervention and six months post-intervention	half-dozen
Bahr et al. [25]	35 (xl); 5 F, thirty Thousand; xxx ± 8 yrs; recreational; running, soccer, handball, martial arts	Palpation, imaging	INT (n = NR/20); eccentric refuse squat, sports from wk 8+ CON (north = NR/xx); surgical treatment, sports from wk 8+	12 wk; 9.3 ± 4.one sessions per wk; 3 sets of 15 reps on 25° turn down board to ninety° knee flexion, moderate hurting mandatory (VAS = four/five), weight increased when VAS < 3 12 wk post-operative training; sessions increased weekly; x.one ± iv.3 sessions per wk; wk 1: isometric quadriceps exercises, wk ii: adding walking, wk 3: adding cycling and high squats, wk four: calculation step-ups to a low (five–6 cm) stride, wk 5: step-downs from a depression (five–half dozen cm) step, wk half dozen: adding eccentric squat preparation similar to INT grouping only without whatever hurting	Physical: Leg press force (kg); CMJ (cm) at pre-intervention only Psychological: VISA-P (score) at pre-/post-intervention and vi and 12 months post-intervention	7
Jonsson and Alfredson [31]	fifteen (xix); 2 F, xiii M; 25 ± ix yrs; recreational; running, soccer, basketball game, floorball, handball	Palpation, imaging	INT (due north = viii/10); strength (eccentric) grooming CON (northward = seven/9); strength (concentric) training	12 wk/168 sessions; iii sets of fifteen reps on 25° decline lath, pain mandatory, weight increased when reps non painful 12 wk/168 sessions; 3 sets of 15 reps concentric knee extension from seventy° genu flexion on 25° decline board, pain mandatory	Physical: NT Psychological: VISA-P (score), VAS (0–100) at pre-/mail service-intervention	4
Visnes et al. [23]	29 (29); ten F, 19 Yard; 27 ± 4 yrs; elite; volleyball	Palpation	INT (n = xiii/13); forcefulness (eccentric) training CON (northward = 16/16); volleyball grooming but	12 wk/168 sessions; 3 sets of 15 reps on 25° decline board to ninety° knee flexion, ii s eccentric phase, weight increased when VAS < 5 volleyball grooming as usual without information on training load	Physical: CMJ (cm), SJ (cm) Psychological: VISA-P (score) at pre-/mail-intervention and 6 and 24 wk post-intervention	7
Purdam et al. [32]	17 (22); four F, 13 M; 25 yrs; recreational; floorball, soccer, volleyball, running, ice hockey, loftier jump, skiing	Palpation, imaging	INT (due north = 8/12); strength (eccentric) training, decline squat CON (n = 9/10); strength (eccentric) training, flat-surface squat	12 wk/168 sessions; iii sets of fifteen reps on 25° decline board to 90° knee flexion, some pain mandatory, weight increased when reps not painful 12 wk/168 sessions; iii sets of fifteen reps on flat surface to 90° knee flexion, some pain mandatory, weight increased when reps not painful	Physical: NT Psychological: VAS (0–100) at pre-/post-intervention	5
Cannell et al. [33]	19 (NR); 6 F, 13 M; 26 ± 7 yrs; recreational; basketball, soccer, running, volleyball, tennis, squash, rowing, American football, gymnastics	Palpation	INT (n = ten/NR); progressive strength (eccentric) training, drop squats CON (n = 9/NR); progressive forcefulness (concentric) training, leg extension/roll	12 wk/sixty sessions; 3 sets of 20 reps, pain mandatory, weight increased when reps not painful; activity (running) added when reps not painful 12 wk/60 sessions; 3 sets of 10 reps with 5 kg each leg extension/leg curl exercise, weight increased when reps not painful; action (running) added when reps non painful	Physical: Isokinetic leg strength Psychological: VAS (0–10) at pre-/mid-/post-intervention	vii

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