Patellar tendinopathy (PT) is an overuse injury of the knee. The mechanism of injury is associated with repetitive stress on the patellar tendon of the knee as a result of explosive movement. Patellar tendinopathy is prevalent in all populations and is associated with intrinsic and extrinsic risk factors.
Primarily, the objective was to report on the intrinsic and extrinsic risk factors for PT, entailing a systematic review of the literature; the secondary objective was to use these risk factors to compile a proposed PT screening tool from the review and standard outcome measures.
A systematic review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Elimination criteria of the articles included duplicates, titles, abstracts and methodological quality. The evidence was collected, characterised with regard to the intrinsic and extrinsic risk factors and summarised descriptively.
The search yielded 157 feasible articles prior to commencement of article elimination. Six articles were included with a mean methodological quality score of 69%. Eight intrinsic and five extrinsic risk factors were identified. These identified risk factors are all relevant to the pathology and formed the basis for a proposed PT screening tool. The Victorian Institute of Sports Assessment for Patellar Tendinopathy Questionnaire, Visual Analog Scale and the Pain Provocation Test are also included in the proposed test.
Intrinsic and extrinsic risk factors for PT were identified, and consequently, the proposed PT screening tool was formulated for possible future testing in appropriate studies.
Prevention of PT through intrinsic and extrinsic risk factor identification, and implementation in the clinical setup as a possible outcome measurement tool with which to verify functional improvement in PT rehabilitation.
Patellar tendinopathy (PT), an overuse injury (Reinking
The physical diagnosis of PT is based on clinical and predominantly ultrasound examination, although findings may not necessarily be associated with the severity of the symptoms (Celebi et al.
Even though PT is a familiar pathology amongst elite and recreational athlete populations (Reinking
Prior systematic reviews have identified a list of risk factors for PT, but there is a paucity of information on PT screening tools for practical implementation in the clinical setup. Therefore, a need was identified for an in-depth systematic literature review to form the basis of a draft screening tool for PT as well as updating current data in this field. Such a PT screening tool may facilitate PT research, once it has been appropriately developed. Clinically, it may then assist in prevention of PT by early identification of risk factors and serve as an outcome measure in rehabilitation. Thus, the primary objective of this study was to systematically identify and appraise studies reporting on the intrinsic and extrinsic risk factors for PT, with the secondary aim of using the identified risk factors in a proposed PT screening tool, in combination with appropriate outcome measures.
Systematic reviews are a cornerstone in research for complete, accurate and reliable recapitulating of evidence, and consequently provide several benefits to clinicians (Liberati et al.
Inclusion and exclusion criteria.
The authors conducted two independent systematic review searches, first in October 2017 and in January 2018, for articles published between January 2010 and September 2017, with an allotted time period (approximately three months apart) between the searches by the authors. This ensured that results cross-referenced and that all eligible articles were included in the review. This interval was chosen to be a supplementary addition to a previously published systematic review on the causative risk factors and rehabilitation for PT in which articles were selected only up to October 2015 (Morgan, Janse van Vuuren & Coetzee
EBSCO host electronic databases were searched and included the following: Africa-Wide Information, ERIC, Academic Search Complete, AHFS Consumer Medication Information, CINAHL with Full Text, MEDLINE with Full Text, Health Source: Nursing/Academic Edition, Health Source – Consumer Edition, PsycARTICLES, Humanities Source, PsycEXTRA, SocINDEX with Full Text, PsycINFO, PsycTESTS, and SPORTDiscus with Full Text.
The following keywords were applied in the search strategy for the identification of applicable articles for the review:
(‘patella* tendinopath*’ or [patella* and tendinit*])(‘intrinsic factor*’ or age or gender or ‘body composition*’ or ‘fat mass’ or ‘body weight’ or ‘body mass index’ or injur* or ‘joint instability*’ or ‘musc* strength’ or ‘musc* power’ or ‘range of motion’ or ‘range of movement’ or ‘anatomic* alignment*’ or ‘postural stability*’ or ‘sport* specific technique*’ or ‘level of skill*’ or ‘skill* level*’ or ‘extrinsic factor*’ or strapping or bracing or ‘foot wear’ or footwear* or shoe* or ‘training surface*’ or ‘eccentric decline squat*’ or ‘skill* acquisition’ or proprioception* or flexib* or ‘muscle activat*’ or etiolog* or aetiolog*) AND (rehab* or ‘return to sport’ or ‘return to play’ or ‘motor re-educat*’) and (exercise* or train* or sport*)
Each author undertook the study selection process according to the inclusion and exclusion criteria in
Flow diagram of search strategy to determine the final sample of articles for the systematic review.
The eligibility and quality of the articles were appraised by the authors using two checklists (
Methodological assessment of included articles.
Study design | Methodological checklist | Range of quality scoring | Quality scoring average | Article exclusion reason |
---|---|---|---|---|
Systematic reviews | AMSTAR checklist | 8/11 ( |
73% ( |
Methodology scoring of 50% or less |
Quantitative research | National Institute for Health and Excellence checklist | 15/27 – 22/27 ( |
67% ( |
Methodology scoring of 50% or less |
The methodological quality scoring was performed on 13 articles that met the inclusion criteria, with 6 articles remaining for the systematic review.
The data contained in the eligible articles were extracted and incorporated into a customised Microsoft Excel data spread- sheet developed by the authors (
Characteristics of the included articles.
Authors and year of publication | Aim of the study | Study design | Study population | Level of participation |
---|---|---|---|---|
De Vries et al. ( |
Investigating if the identified risk factors in a previous study in 2008 can prospectively be identified as risk factors of PT in 2011 | Survey-based prospective cohort study | Male and female | Not applicable |
Mendonça et al. ( |
Determine the connotation of lower limb muscle strength and lower limb alignment, range of motion or flexibility in male athletes with PT | Cross-sectional study | Male | Elite athletes |
Van Der Worp et al. ( |
Identification of the risk factors for PT | Systematic review | Male and female | Elite and recreational athletes |
Toppi et al. ( |
Determining the prevalence of magnetic resonance imaging–diagnosed PT in middle-age community-based women and the factors associated | Prospective cohort study | Female | General population |
Van der Worp et al. ( |
Work-related etiological factor identification for PT and the connection amongst work limitations and PT | Online survey: descriptive | Male and female | Elite and recreational athletes |
Van der Worp et al. ( |
Identification of risk factors of PT in volleyball and basketball players | Cross-sectional study | Male and female | Elite and recreational athletes |
PT, Patellar tendinopathy.
Intrinsic and extrinsic risk factors for patellar tendinopathy.
Author cited the risk factor | Intrinsic risk factor | Extrinsic risk factor | Risk factor ratio or prevalence | |
---|---|---|---|---|
De Vries et al. ( |
Male > female | Hard physical work in combination with jumping sports | Not applicable | Not applicable |
Mendonça et al. ( |
Decreased ITB flexibility |
Not applicable | Not applicable | Decreased ITB flexibility |
Toppi et al. ( |
Increased Vastus Medialis size or muscle strength | Physical activity | Prevalence of MRI defined patellar tendinopathy for increased Vastus Medialis size or strength and physical activity was 30.1% | MRI defined patellar tendinopathy Cross-sectional area of Vastus Medialis (cm2) |
Van der Worp et al. ( |
Male > female | Heavy physical demanding work in volleyball and basketball players | Twice as high in men in relation to women (24.8% vs. 11.9%) | Not applicable |
Van Der Worp et al. ( |
Weight, body mass index, waist-to-hip ratio, leg length variance, arch height of the foot |
Not applicable | Not applicable | Not applicable |
Van der Worp et al. ( |
Male > female |
Level of sports participation (elite vs recreational) |
Prevalence male > female (25.3% vs 13.1%) | Male > female ( |
ITB, Iliotibial band; MRI, magnetic resonance imaging.
Combining of the data for the formulation of a meta-analysis was not the intention of this systematic review because of the differences of the results in terms of the variety of articles with different study populations. All the empirical evidence was collected, characterised with regard to the intrinsic and extrinsic risk factors for PT and summarised descriptively.
Ethics approval was obtained from the Ethics Committee of the Faculty of Health Sciences, University of the Free State (approval no. 181/2015).
The collective results of both independent searches yielded 157 feasible articles for inclusion prior to the commencement of article elimination (
The demographic information obtained from the systematic review shows that all six of the included articles described the study population. Two articles consisted of exclusively either male or female participants, whilst the other four articles described both male and female participants. Eighty-three per cent (
Eight intrinsic risk factors associated with PT were identified in the articles that described their intrinsic risk factors. Categorisation of these risk factors included three main intrinsic risk factors, namely gender (male > female), impaired lower limb muscle flexibility and muscle strength. The other identified intrinsic risk factors were body composition, leg length variances, anatomy of the foot, lower patellar pole and age of the study participants.
Five extrinsic risk factors for PT were identified with the main extrinsic risk factor being the common prevalence of PT in sports that involve jumping (50%). The additional four extrinsic risk factors were heavy physical work in combination with jumping sports, level of sport participation (elite vs recreational level), physical activity and type of sport.
PT is a well-recognised pathology with an inclusive aetiology of intrinsic non-modifiable and intrinsic and extrinsic modifiable risk factors that are directly linked to overloading of the patellar tendon (Hägglund et al.
The second non-modifiable intrinsic risk factor was increased age, granted that there was no conclusion regarding a specific age group in the results. The evidence shows that age may be associated with altered cellular activity in the patellar tendon, muscular function and mechanical properties (Malliaras & O’Neill
In general, the anatomy and biomechanics of each individual athlete or person have an influence on the risk of developing PT (Malliaras & O’Neill
There are a further eight modifiable risk factors for PT which can be either intrinsic or extrinsic. Impaired quadriceps, hamstring and iliotibial band muscle flexibility is an intrinsic risk factor for PT (Malliaras & O’Neill
Impaired muscle strength of the quadriceps femoris increases the likelihood of developing PT (Rudvasky & Cook 2015). The rationale behind this is that lower leg muscle strength, especially weakness surrounding the knee joint, contributes to patellar tendon strain by the abnormal distribution of load and malalignment of patellar tracking (Torres et al.
Body weight and body mass index are modifiable intrinsic risk factors for PT. The connection between body composition and the risk for PT is multifaceted and not simply related to loading of the tendon, thus outlining a complexity of confounding interconnected factors (Malliaras & O’Neill
Irrespective of the type of sport or activity that athletes or the general population participate in, musculoskeletal injuries are a reality (Saragiotto, Di Pierro & Lopes
Jumping sports participation is an important risk factor (De Vries et al.
The prevalence of PT fluctuates according to the specific jumping sport and between elite and recreational athletes (Rudavsky & Cook
Unfortunately, PT is also prevalent in the general ageing population because of changes in the patellar tendon anatomical structure (Longo et al.
The secondary aim of the study was to initiate the development of a tool to screen for risk factors, as well as to potentially serve as an outcome measure in the rehabilitation of PT. This may contribute to the refining of PT management in terms of risk factor identification and determining and monitoring pain and function over time. A further possibility of the proposed screening tool in PT (
Proposed Patellar Tendinopathy Screening tool.
The identified non-modifiable and modifiable intrinsic and extrinsic risk factors in this systematic review (despite the small sample size of the included articles) are all potentially relevant to the pathology and were used as the basis for the proposed PT screening tool (
Inclusion of a pain provocation test (Malliaras et al.
According to the authors’ knowledge, there are no other PT screening tools. The proposed PT screening tool may possibly be useful in rehabilitation, as it includes a dual function of outlining likely intrinsic and extrinsic risk factors for the development of PT, the estimation of pain and functional impairments and is not indicated for any specific population. The value of the proposed PT screening tool will only be verified if properly tested in appropriate studies (Bishop
The strength of this systematic review is that the intrinsic and extrinsic risk factors for PT have been identified. Risk factor identification promotes the development and implementation of prevention strategies in the management of this condition. The evidence on the risk factors was used to suggest a proposed PT screening tool which will need to be tested in appropriate studies. A limitation of this systematic review was the limited number of included articles and a probable reason might be the explicit exclusion of youth populations. Another limitation was the lack of randomised clinical trials to validate the results.
Intrinsic and extrinsic risk factors for PT were identified in this systematic review. This evidence, as well as appropriate literature, formed the basis for the formulation of a proposed PT screening tool which will require testing to determine its usefulness.
The authors declare that they have no financial or personal relations that may have inappropriately influenced them in writing the article.
S.M. and F.F.C. compiled the systematic review, discussed the construction of the article, screened the literature according to the eligibility criteria and analysed the data in order to formulate the checklist described in the article. S.M. wrote the article with the advice and editing of the co-author.
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Author | AMSTAR Checklist Scoring |
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Van Der Worp et al. ( |
8/11 |
Author | National Institute for Health and Excellence Checklist Scoring |
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De Vries et al. ( |
21/27 |
Mendonça et al. (2016) | 18/27 |
Toppi et al. ( |
16/27 |
Van der Worp et al. ( |
16/27 |
Van der Worp et al. (2012) | 15/27 |