











































MANUSCRIPT TYPE


CLINCAL OUTCOMES RESEARCH  

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

 
 

An Exploratory Analysis of a Treatment Based Classification 
Algorithm to Treat Patellar Tendinopathy 
Monica Matocha, DAT, LAT, ATC*; Patti Syvertson, DAT, ATC†; Janet McMurray, DAT, LAT, ATC‡; Emily R. 
Dietz, DAT, LAT, ATC, CEIS**, Russell T. Baker, PhD, DAT, AT, CMP, PRT-c© §; Alan Nasypany, EdD, LAT, 
ATC§; Don Reordan, PT, MS, OCS, MCTA, CIDN€; Darcy Downey EdD, LAT, ATC¥ 
*Texas Lutheran University, Seguin, TX; †Crystal Springs Upland Schools, Uplands, CA; ‡ McMurry University, Abilene, TX; 
**Elizabethtown College, Elizabethtown, PA; § University of Idaho, Moscow, ID; €Jacksonville Physical Therapy, Jacksonville, FL; 
¥Texas State Universtiy, San Marcos, TX 
  

 

ABSTRACT 
The general and athletic populations commonly experience 
patellar tendon pain, which is frequently treated with a gold 
standard 12-week eccentric exercise protocol. The present 
research study was designed to determine the effects of a 
treatment based classification (TBC) algorithm utilizing 
indirect treatment techniques in patellar tendinopathy 
participants. Ten participants (seven females, three males, 
mean age = 19.6 ± 1.07, mean symptom duration = 2.14 
years with a range of one week to six years) with patellar 
tendinopathy were evaluated and included in this study. 
Each participant underwent a thorough evaluation process 
to aid in determining inclusion: participant medical history, 
range of motion measurements, orthopedic tests, a scan for 
soft tissue tender points, neurodynamic tests, and a local 
Mulligan Concept technique to determine diagnosis, study 
inclusion, and treatment classification. The following outcome 
measures were collected to establish baseline scores and 
assess participant improvement: the Disablement in the 
Physically Active Scale (DPA Scale), Numerical Rating Scale 
(NRS), Victorian Institute of Sports Assessment for the 
Patellar Tendon (VISA-P), Global Rating of Change (GRC), 
Nirschl Phase Rating Scale, and Blazina Knee Scale. Paired 
t-tests with 95% confidence intervals, were analyzed on 
NRS, DPA Scale, and VISA-P to determine the effectiveness 
of all treatment from initial exam to discharge. Cohen’s d 
was also computed to determine the effect size of each of 
the aforementioned outcome measures. Descriptive statistics 
were computed for the GRC at discharge. The mean change 
for the NRS (M = 4.7, 95% CI[3.57 to 5.82], p < .001), DPA 
Scale (M = 21.8, 95% CI[12.43 to 31.16], p = .001), and 
VISA-P (M = 22.70, 95% CI[33.71 to 11.68], p < .001) 
were statistically significant. The mean for the GRC (M = 
5.3) was clinically meaningful. All of the participants 
(100%) met discharge criteria. The results of this case series 
demonstrated an increase in function and decrease in pain 
for participants with patellar tendinopathy within three 
office visits when utilizing a TBC algorithm.  
 
Key Phrases 
Patellar tendinopathy, manual therapies, treatment-
based classification, patient-reported outcomes 
 
Correspondence 
Dr. Monica Matocha, Texas Lutheran 
University, 1000 W Court St, Seguin, TX 
78155 
E-mail: mamatocha@tlu.edu.  

 
 
 
 

Full Citation 
Matocha M, Syvertson P, McMurray J, Dietz ER, Baker 
RT, Nasypany A, Reordan D, Downey D. An 
exploratory analysis of a treatment based 
classification algorithm to treat patellar tendinopathy. 
Clin Pract Athl Train. 2021;4(2): 6-20. 
https://doi.org/10.31622/2021/0004.2.2.   
 
Submitted: April 3, 2019, 2020 Accepted: February 1, 2021. 

 
INTRODUCTION 
 

Tendon related pathologies comprise 30 to 

45% of sport related injuries,1 and frequently 
cause impairment in the general population.2 
Patellar tendinopathy accounts for 7 to 40% of 
tendon related pathologies in sport3 and is 
characterized clinically by tendon pain, tendon 
dysfunction,4,5 decreased performance in 
association with tendon swelling, morning 
stiffness,4,6,7 palpable crepitus,3,6,7 and localized 
swelling.4 Pain over a tendon is the key clinical 
diagnostic criteria used by clinicians to diagnose 
tendinopathy.8 The use of advanced diagnostic 
imaging/testing (e.g., diagnostic ultrasound) is not 
common clinically, but is necessary to determine 
the exact physical state of the tendon.5 

Though the clinical exam is the accepted standard 
for tendinopathy diagnosis, varying patient 
presentations and injury states make it difficult to 
identify the origin of tendon pain.9 Previously, 
tendon pain was thought to be a mechanical 
overuse injury, which caused inflammation in the 
tendon, and was classified as a tendinitis.10 Due to 
a lack of inflammatory markers being present  

mailto:mamatocha@tlu.edu
https://doi.org/10.31622/2021/0004.2.2


An Exploratory Analysis of a Treatment Based Classification Algorithm to Treat Patellar Tendinopathy 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

during histological tests, the term tendinopathy has 
generally become the preferred diagnostic term 
for tendon pain,2,11 while tendinosis is utilized for 
a degenerative tendon diagnosed using 
diagnostic imaging.2 As tendon pathology 
research has elucidated other causative factors 
for the presentation of tendon pain (e.g., 
mechanical, neural, vascular),10 other researchers 
have proposed the use of the terms reactive 
tendinopathy and tendinalgia when classifying a 
patient with tendon pain. 12, 13 The use of the term 
tendinalgia would allow clinicians to acknowledge 
the patient complaint of pain at the site of a 
tendon without predetermining a state of tissue 
pathology.13 

The risk of using terminology focused on a specific 
causative factor is that it may lead to treatments 
that are not optimal for a specific patient or 
situation.9 Due to the previous acceptance of an 
inflammatory condition being present when 
diagnosed as tendinitis, most interventions have 
been aimed at treating the inflammatory process. 
Most of these strategies do not produce effective 
long-term results (i.e., improvement past six 
weeks).14-16 Commonly used conservative 
treatments for patellar tendinalgia include: rest, 
nonsteroidal anti-inflammatory drugs (NSAIDs), 
stretching, eccentric exercises, and corticosteroid 
injections.2,7,17 The current treatment gold 
standard is the use of eccentric exercises. The 
Alfredson et al. protocol has become the 
foundation of most eccentric exercise protocols 
with participants performing the exercises two 
times a day, seven days a week, for 12 weeks. 18-

24 For many patients, however, compliance is 
difficult due to the length of the treatment, muscle 
soreness, and/or the pain experienced with 
treatment.18,23,25 Other concerns with the protocol, 
such as tendon rupture rates, are not well 
understood as researchers do not always report 
treatment complications. Upon return to activity, 
participants who complete the protocol also 
report a high recurrence rate.15,26  

Another treatment option is to utilize manual 
therapies theorized to address the different 

causative factors of tendon pain; however, few 
research studies have been conducted to assess 
the effectiveness of manual therapy for the 
treatment of patellar tendinalgia. While there are 
a variety of manual therapy options that have 
been proposed to treat this disorder, clinicians 
could theoretically address the causative factors 
by applying the Mulligan Concept (MC), Positional 
Release Therapy (PRT), and/or neurodynamics in 
these cases. The MC techniques for knee 
dysfunction are based on applying a pain free 
glide (mobilization) to the joint while the patient 
actively moves into a position that was painful 
prior to the glide being applied.27 Positional 
Release Therapy (PRT) is theorized to restore the 
muscle or tendon to normal function by increasing 
oxygen and decreasing inflammatory 
metabolites.28 To determine if a peripheral neural 
sliding or tension dysfunction is present, 
neurodynamics is performed. Neurodynamics is 
the movement of the nervous system on other body 
structures.29 The use of these techniques in 
isolation, or combination, might better target the 
individual differences in patient presentation.  

The use of manual therapies and tendon 
classification have been proposed as a means to 
improve the treatment of tendon pain12,13 due to 
the high rate of tendon pathology recurrence15,26 

and patient non-compliance.23,25 Researchers 
have proposed that many patients classified with 
tendinalgia may not actually have a true tissue 
pathology that must be addressed with tissue 
remodeling13 and that classifying patients based 
on their response to sub-therapeutic doses of 
intervention techniques may improve patient 
outcomes.9,13 Thus, it is important for clinicians to 
consider alternative examination and treatment 
strategies to better identify and treat these 
patients. The purpose of this study was to 
determine if a novel treatment based 
classification (TBC) algorithm could be used to 
classify tendon pain, participants, and what the 
effects of using the algorithm would be in 
participants diagnosed with patellar tendinalgia.  

PARTICIPANTS 



An Exploratory Analysis of a Treatment Based Classification Algorithm to Treat Patellar Tendinopathy 
 

 

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Case Description   

A convenience sample of participants diagnosed 
by athletic trainers with patellar tendinalgia at 
four clinical sites across the United States of 
America participated in the study. The Texas 
Lutheran University Institutional Review Board 
approved the research project. All participants 
signed an informed consent form; if the 
participant was under the age of 18 years old, 
the legal guardian signed the informed consent 
and assent was provided by the minor. During the 
evaluation period, a total of 10 participants 
(seven females, three males, mean age = 19.6 ± 
1.07, mean symptom duration = 2.14 years with 
a range of one week to six years) presented for 
possible inclusion in the study. All of the potential 
participants were diagnosed with patellar 
tendinalgia according to the inclusion criteria 
(Table 1), agreed to participate in the study, and 
completed the study through discharge. All 
participants reported with patellar tendon pain, 
increased pain and stiffness in the morning and 
after sitting for long periods of time with a 
decrease in symptoms after warm up for physical 
activity.35  

Examination  

Each participant was examined using a pre-
determined clinical evaluation to ensure 
consistency in patellar tendinalgia diagnosis and 
classification with the TBC Algorithm. Inclusion 
criteria included: tendon pain before, during, or 
after patella loading activities; point tenderness 
over the patellar tendon upon palpation; pain 
near patella origin; impaired function; and tendon 
focal or generalized swelling. Exclusion criteria 
included: cortisone injection (<six weeks), 
fluoroquinolones ciprofloxacin use (<12 months), 
post-operative participants unable to perform the 
treatment (<eight weeks), wore orthotics, currently 
healing or suspected fractures, or receiving 
physical therapy for the tendon of concern. 
Participants who met the inclusion criteria then 
completed a thorough history, range of motion 
(ROM), and special test examination. Special tests 

performed included: Clark’s sign, patellar grind, 
patellar compression, prone knee bend, slump, a 
quarter screen for tender points (TP),28 and the 
application of the MC technique for the knee (an 
internal rotation glide followed by an external 
rotation glide if pain was not resolved during 
application). 27 Clark’s sign, patellar grind, and 
patellar compression tests were performed to rule 
out patellar dysfunction as the source of pain. The 
prone knee bend and slump tests were performed 
to rule in neurological tension and sliding 
dysfunctions. 29 The quarter screen was performed 
to determine the presence of TPs; while the MC 
Technique was performed last to determine 
classification into the MC treatment.  

Treatment-Based Classification Algorithm 

The TBC algorithm consisted of a MC technique, 
PRT, neurodynamics, and eccentric exercise. If the 
participant reported a resolution of his or her 
symptoms when the MC technique was applied 
during the exam, then the participant was 
classified as being a responder to the MC 
treatment. If the application of the MC did not 
resolve symptoms during the exam and the 
participant presented with TPs in the lower 
extremity, which could be reduced by moving the 
participant into a position of comfort (POC), then 
the participant was classified as being a 
responder to the PRT treatment. If the application 
of the MC did not resolve symptoms and a POC 
could not be identified with PRT, the participant 
would be classified into the neurodynamic 
treatment if a positive neurodynamic test was 
found during the initial exam. In the case where 
the participant could not be classified into the MC, 
PRT, or neurodynamic group, the participant was 
classified into the eccentric exercise treatment 
protocol (Figure 1). 

Once the clinician determined the appropriate 
treatment classification, the participant underwent 
three bouts of treatment within 10 days. The 
participant was re-assessed to determine if 
discharge criteria had been met at the conclusion 
of the third visit. Discharge criteria included: phase  



CLINCAL OUTCOMES RESEARCH  

 

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Table 1. Participant Presentation and Treatment 
Participant # Symptoms Symptom Duration Positive Special Tests 

Participant 1  Pain mid-patellar tendon; unable to sit for more than 30 minutes without 
pain; pain interferes with competition; intermittent pain at rest; increase 

pain with stairs and squats; worst pain in the morning 
1 Week TP: patellar tendon, tibialis anterior 

MWM: lateral rotation – lunge 

Participant 2 Pain mid-patellar tendon; pain interferes with competition; intermittent 
pain at rest; increase pain with stairs, cutting, and squats; worst pain in 

the morning 
2 Weeks 

TP: Flexor digitorum longus 
MWM: medial rotation – squat 

 
Participant 3 Pain slightly inferior to patella; increase pain when sitting with knees 

bent, squatting, lunging, going up stairs; pain at start of activity; worst 
pain in the morning 

2 Months 
TP: patella and ACL 

MWM: lateral rotation – lunge 
 

Participant 4  Pain slightly inferior to patella; increased pain when sitting with knees 
bent longer than 30 minutes, squatting, lunging, and going upstairs; pain 

at start of activity; worst pain in the morning 
2 Months 

TP: patellar tendon 
MWM: lateral rotation – lunge 

 
Participant 5 Pain mid-patellar tendon; pain during ADLs, lunging, stairs, single leg 

hops; pain at onset of activity but able to perform; difficulty maintaining 
same position for extended period of time; pain at start of activity; worst 

pain in the morning 

6 Months 
TP: ACL and patellar tendon 

MWM: lateral rotation – squat 
 

Participant 6 Pain mid-patellar tendon; pain during ADLs, lunging, stairs, single leg 
hops; pain at onset of activity but able to perform; difficulty maintaining 

same position for extended period of time; worst pain in the morning 
6 Months 

TP: patellar tendon 
MWM: lateral rotation – single leg 

squat 
Participant 7  Pain inferior to patella; unable to sit longer than 10 minutes without pain; 

unable to perform squats due to pain; difficulty with running and 
jumping; pain with ADLs and competition; worst pain in the morning 

4 Years 

ND: prone knee bend 
TP: medial hamstring 

MWM: medial rotation – squat 
 

Participant 8 Pain slightly superior to tibial tuberosity; unable to sit longer than 10 
minutes without pain; unable to perform squats due to pain; difficulty with 

running and jumping; pain with ADLs and competition; worst pain in the 
morning 

4 Years 

ND: prone knee bend 
TP: patellar tendon 

MWM: medial rotation – squat 
 

Participant 9 Pain mid-patellar tendon; unable to perform single leg hops due to pain; 
difficulty with running and jumping; unable to compete due to pain; worst 

pain in the morning 
6 Years TP: patella, patellar tendon, ACL, and 

medial hamstring 

Participant 10  Pain slightly superior to tibial tuberosity; intermittent pain at rest; unable 
to compete due to pain; worst pain in the morning 6 Years TP: patella and patellar tendon 

MWM: lateral rotation - squat 
ND: neurodynamics, TP: tender point, Positive MWM: achieved PILL effect; ADLs: activities of daily living 



CLINCAL OUTCOMES RESEARCH  

 

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1 on the Nirschl Phase Rating Scale, phase 1 on 
the Blazina Knee Scale, and met minimal clinical 
important difference (MCID) for Global Rating of 
Change (GRC), and acute MCID for the 
Disablement of the Physically Active Scale (DPA 
Scale). Additionally, participants had to report a 
worst pain score equal to or less than two out of 
ten on the Numerical Rating Scale (NRS) during 
the discharge evaluation. If the participant was 
not discharged, a re-evaluation using the TBC 
algorithm was conducted to determine the 
participant’s treatment classification for the next 
three visits. The participant was only able to be 
re-classified into the initial treatment classification 
if the participant demonstrated enough 
improvement to meet 50% of each discharge 
outcome criteria; if not, the participant was 
classified into the eccentric exercise treatment. 
Following discharge, each participant was sent a 
one-month follow up survey to collect follow-up 
scores on the NRS post-discharge. 

OUTCOME MEASURES 

Disablement and global participant outcome 
measures were utilized in this study to determine 
participant perceptions of their condition and 
recovery. The six outcome measures utilized in this 
study were the: NRS, GRC, DPA Scale, VISA-P, 
Nirschl Phase Rating Scale, and the Blazina Knee 
Scale.  

The NRS is a rating scale a clinician can utilize to 
determine a participant’s perception of his or her 
pain from zero, no pain, to ten, worst pain 
imaginable.30 Each participant of this case series 
was asked to rate his or her pain at best, worst, 
and rest before and after each treatment. The 
recorded NRS scores represent the participant’s 
reported worst pain. The participant was also 
asked to rate his or her pain while the clinician 
performed a quarter screen for TPs. The GRC was 
utilized to determine participant’s perception of 
his or her improvement or deterioration over 
time.31 The GRC was reported at every third visit 
for each participant. The (MCID) has been 

established at two points for both the NRS32 and 
GRC.31  

The DPA Scale was developed to determine the 
participant’s perception of how his or her injury 
has effected disablement.33 A participant 
reported his or her perception on a scale of one, 
no problem, to five, severe, on 16 questions across 
multiple domains: pain, motion, muscular function, 
stability, changing directions, daily actions, 
maintaining positions, skill performance, overall 
fitness, participation in activities, and well-being. 
The rating for each item on the scale is summed 
and 16 points are subtracted to produce a final 
score that ranges from zero to 64 points. The DPA 
Scale was administered upon the first visit, third 
visit, and every third visit after until discharged. 
The MCID has been established for the DPA Scale 
as nine points for acute injuries and six points for 
chronic injuries.33 The range of scores for healthy 
patients on the DPA Scale has been reported to 
be between zero and 34 points.33 

The VISA-P was created to determine functional 
impairment in a participant with patellar tendon 
pain.34 The participant recorded responses to 
questions regarding his or her function on a 
numerical scale from zero, unable to perform, to 
ten, fully functional. All responses were then 
summed and recorded on a scale from zero, no 
function, to 100, fully functional. Each participant 
recorded VISA-P score upon the first visit, third 
visit, and discharge visit. Currently, a MCID has not 
been established for VISA-P. 

The Nirschl Phase Rating Scale and Blazina Knee 
Scale were both developed to help classify 
participant symptoms. The Nirschl Phase Rating 
Scale was created for all tendon pain 
participants,2,35 whereas the Blazina Knee Scale 
was created to determine dysfunction specifically 
for participants with patellar tendon pain.36 All 
participants reported his or her symptoms in 
accordance with both scales upon the first visit, 
third visit, and discharge visit. Currently, the 
Nirschl Phase Rating Scale, and Blazina Knee 



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  

All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

 

Figure 1. Treatment Based Classification Algorithm for Patellar Tendinopathy 

  Does 
Internal/External 
Rotation MWM 

resolve symptoms? 

Yes 

Perform MWM 

No 
Are TPs & 

POCs present?  No 
Positive knee 
bend test?   Yes 

Perform 
neurodynmaics 
for treatment 

Yes No 

Perform PRT 
Eccentric 
exercise 
protocol 

Meets 
Discharge 
Criteria 

Yes 

Discharge and 
send follow-up 

survey at 1 month 

No 
Re-evaluate 
the patient 



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

 
 

Scale do not have an established method for 
evaluating patient improvement on the scales. 

INTERVENTION  

If the participant was classified into the MC 
treatment subgroup, the participant was treated 
with the Mobilization with Movement (MWM) 
(internal or external rotation glide) to resolve the 
participant’s pain complaint.27 The internal or 
external rotation glide was applied by having the 
participant perform a movement that 
exacerbated the chief complaint. Once the painful 
movement was established, the clinician gently 
placed her hands just below the tibiofemoral joint 
line, around the tibia and fibula and applied the 
appropriate glide to the tibia in association to the 
femur (Figure 2). Simultaneously, the participant 
performed the previously established painful 
movement. The MWM was performed through 
three sets of 10 repetitions of pain-free 
movement.27  

If the participant was classified into the PRT 
treatment subgroup, the dominant TP was 
monitored while the participant was passively 
moved into a POC.28 The clinician would begin 
with the participant in a supine position on a plinth 
with a bolster under their ankle to allow full knee 
extension. The clinician would then apply tibial 
rotation with the hand not palpating the TP. The 
POC was defined as a position resulting in the 
resolution of pain (zero out of 10 on the NRS) 
during palpation of the TP. If a POC was 
achieved, the participant received PRT for the 
dominant TP only. The dominant TP was treated 
while the clinician maintained the POC (Figure 3). 
The POC was held for a minimum of 30 seconds, 
and a maximum of 90 seconds.28 The participant 
was then returned to the normal anatomical 
position while the clinician continued monitoring 
the TP. The TP was reassessed by determining 
pain to palpation (using the NRS) in the normal 
anatomical position. If the participant still 

reported tenderness to palpation of the TP after 
one set of treatment, the clinician repeated the 
treatment; if the patient reported resolution of 
pain to palpation, the treatment was concluded 
for that session. A patient could receive a 
maximum of three treatment sets per visit.  

If the participant was classified into the 
neurodynamic treatment subgroup, the participant 
was instructed on the proper technique to perform 
a general neural slider in the prone knee bend 
position (Figure 4).29 As the participant released 
tension at the head (head moved from cervical 
extension to neutral), tension was increased at the 
knee (knee moved from extension to flexion).29 
Each participant completed three sets of 10 
repetitions, through a slow and controlled 
movement.  

If the participant was classified into Eccentric 
Exercise (EE) treatment subgroup, the participant 
completed a monitored EE protocol two times a 
day, seven days a week for 12 weeks.37 
Participants completed one set of 15 repetitions 
of a single leg squat on a 25-degree decline 
board for each session.37 The participant was 
instructed to keep the trunk in the upright position, 
slowly flexing the knee to 90 degrees and 
returning to the starting position with the uninjured 
leg.37 The participant was then instructed to squat 
into pain without exceeding seven out of ten on 
the NRS during the eccentric portion (knee 
flexion). If the participant’s pain decreased to less 
than or equal to two out of ten on the NRS while 
performing EE, an external load by use of a 
dumbbell was added to increase the difficulty of 
the exercise. 



An Exploratory Analysis of a Treatment Based Classification Algorithm to Treat Patellar Tendinopathy 
 

 

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Figure 2. Example of the Mobilization with 
Movement 

Statistical Analysis  
All data was analyzed using SPSS version 23.0 
(SPSS Inc., Chicago, IL, USA). Paired t-tests were 
performed on the NRS, DPA Scale, and VISA-P to 
determine the effects of classifying and treating 
participants with this novel TBC algorithm for 
patellar tendinalgia. Mean differences from the 
initial visit scores and 95% confidence intervals 
(CIs) were calculated for the NRS, DPA Scale, and 
VISA-P for discharge. Cohen’s d was also 
computed to determine the effect size, or 
maximum likelihood, of each of the 
aforementioned outcome measures. For Cohen's d 
an effect size of 0.2 to 0.3 was considered a 
"small" effect, around 0.5 a "medium" effect and 
0.8 to infinity, a "large" effect.38 Descriptive 
statistics were performed on the GRC scores 
reported at discharge. 

 

Figure 3. Example of Positional Release Therapy 
Position of Comfort  

 

Figure 4. Example of Neurodynamic Slider 
Technique 

RESULTS 

During the initial examination, all participants 
were classified into a manual therapy treatment 
sub-group (MC = 9, PRT = 1). All participants 
were successfully treated through discharge with 
the initial treatment classification and no 
participants met the criteria for classification into 
the EE subgroup at any point of time during 
treatment. The number of treatments each 
participant received was three over a mean of 
4.8 ±1.4 days to discharge.  

Numerical Rating Scale  

The use of the TBC algorithm resulted in a 
significant mean change in pain from initial visit to 
discharge, M = 4.7 ± 1.64 (95% CI [3.57 to 
5.82], p < .001) with a large effect size (Cohen’s 
d = 2.41) (Table 2). The mean difference in pain 



An Exploratory Analysis of a Treatment Based Classification Algorithm to Treat Patellar Tendinopathy 
 

 

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scores from initial visit to discharge, as well as the 
lower boundary CI, exceeded the MCID of “much 
better” for the NRS.26 The mean change was 
accomplished in just three visits that took place 
within 4.8 ± 1.4 days. At discharge, 60% of 
participants (6/10) reported a complete 
resolution of their pain. The remaining 40% of 
participants (4/10) reported their “worst” pain as 
a one (20%, 2/10) or two (20%, 2/10) on the 
NRS. One-month post discharge data 
demonstrated that all participants who completed 
the follow-up survey (n = 2) continued to 
experience a resolution of pain with full return to 
activity.  

Disablement in the Physically Active Scale   

Statistically significant changes on the DPA Scale 
from initial evaluation to discharge were recorded 
M = 21.8 ± 12.3130, (95% CI [12.43 to 31.16], 
p = .001), with a large effect size (Cohen’s d = 
1.98) when using the TBC algorithm (Table 2). The 
mean change from initial visit to discharge, as well 
as the lower boundary of the CI, exceeded the 
MCID for acute conditions, a reduction of nine 
points or greater, which is greater than the MCID 
for chronic conditions (six points).33 All of the 
participants (100%) met MCID for both acute and 
chronic conditions prior to discharge, as well as 
being discharged within the healthy range (zero 
to 34 points).33 Published data for DPA Scale 
scores for return to activity for chronic conditions 
does not exist; however, the reported mean for 
participants who returned from acute injury is M = 
8.82 ± 6.71 (R = 0 – 23 points). All of the 
participants (100%) in this case series were 
discharged below the reported mean score for 
returning to activity after an acute injury (M = 8.5 
± 9.11; R = 0 - 22). Consequently, participants in 
this case series perceived less disablement than 
has been reported in the previous literature on the 
DPA Scale.33  

Victorian Institute Sport Assessment - Patella   

The use of the TBC algorithm resulted in a 
significant increase in scores on the Victorian 

Institute of Sport Assessment-Patella outcome 
measure from initial exam to discharge (M = 
22.70 ± 16.07, 95% CI [33.71 to 11.68], p < 
.001), with a large effect size (Cohen’s d = 1.37) 
(Table 2). Of greater clinical importance, 80% 
(8/10) of the participants reported a VISA-P 
score for “completely recovered” within three 
days of initiating treatment.  

Global Rating of Change    

A clinically meaningful increase on GRC scores 
from initial visit to discharge was reported (M= 
5.7 ± 2.11) (Table 2). The GRC scale ranges from 
-7 (a very great deal worse) to +7 (a very great 
deal better).31 All (100%) of the participants 
exceeded a MCID for the GRC scale (≥ 2) upon 
discharge.31 More clinically relevant, 50% (5/10) 
of participants reported a +7 (a very great deal 
better), 10% (1/10) reported a +6 (a great deal 
better), and 40% (4/10) reported a +4 
(moderately better) at discharge.31  

Nirschl Phase Rating Scale 

During initial evaluations, 30% (3/10) of 
participants reported a phase three on the Nirschl 
Phase Rating Scale meaning “pain that is present 
during activity without causing activity 
modification”,35 40% (4/10) reported a phase 
five “pain that is present during all activities and 
occurs with activities of daily living”,35 and 30% 
(3/10) reported a phase six “intermittent rest 
pain that does not disturb sleep”.35 All 
participants (100%, 10/10) reported a phase 
one (“mild stiffness or soreness after activity with 
resolution of symptoms within 24 hours”) on the 
Nirschl Phase Rating Scale prior to discharge. 
More clinically relevant, 60% (6/10) of the 
participants did not feel a phase one rating on the 
Nirschl Phase Rating Scale was applicable due to 
their experience of full resolution of symptoms.  

 

 



CLINCAL OUTCOMES RESEARCH  

 

15 
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All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

 
 

Table 2. Outcome Results  
Outcome 
Measure 

Intake Score Discharge 
Score 

Mean Change 95% CIs P-value Effect Size 
(Cohen’s d) 

NPRS 5.30±1.94 0.60±0.84 4.78±1.64 3.52, 6.04 0.000 2.41 
DPA Scale   30.3±11.02 8.50±9.12 19.89±12.31 10.42, 29.35 0.001 1.98 
VISA-P 53.60±16.58 76.30±18.36 -23.56±16.71 -35.91, 11.20 0.002 1.37 
NPRS: Numeric Pain Rating Scale; DPA Scale: Disablement of the Physically Active Scale; VISA-P: 
Victorian Institute of Sport Assessment for Patellar Tendon; CIs: Confidence Intervals  

Blazina Knee Scale 

During the initial evaluation, 50% (5/10) of 
participants reported a phase two on the Blazina 
Knee Scale “pain/discomfort during and after 
activity with the subject still able to perform at a 
satisfactory level (does not interfere with 
participation)”;36 while the other 50% (5/10) of 
participants reported a phase three “pain during 
and after activity with more prolonged, with 
subject having progressively increasing difficulty 
in performing at a satisfactory level (interferes 
with competition)”.36 All of the participants 
(100%) reported a phase one on the Blazina 
Knee Scale prior to discharge (“pain after activity 
only”).36 More clinically relevant, 60% (6/10) of 
participants did not feel a phase one rating on the 
Blazina Knee Scale was applicable due to their 
experience of full resolution of symptoms. 

DISCUSSION 

Currently, eccentric exercise is the gold standard 
treatment for patellar tendinalgia. Several 
researchers have demonstrated positive results 
with the use of a 12-week protocol.18-21,23-25,38,39 
Jonsson and Alfredson40 compared an eccentric 
exercise group to a concentric exercise group for 
the treatment of “jumper’s knee” and reported 
nine out of 10 participants who completed the 
study were “satisfied” and discharged with a 
mean Visual Analogue Scale (VAS) of 23 out of 
100 and a VISA-P score of 83 points with the use 
of a 12-week eccentric exercise protocol. 
Similarly, Purdam, et al.24 reported a mean VAS 
score of 28.5 points at discharge for participants 
who performed eccentric exercises on a decline 

board, compared to a mean VAS score of 72 
points at discharge for participants who 
performed traditional squat eccentric exercises 
for 12 weeks. In these studies, however, not all 
participants reported being “satisfied” at 
discharge (10%,40 25%24). The participants, who 
did report being “satisfied” did not, on average, 
experience a full resolution of pain at discharge 
after 12 weeks of therapy.24,40 Although NRS and 
VAS are measured on different scales, the values 
of the numbers are similar. The clinicians of the 
present study were able to discharge participants 
with mean NRS scores of .05 out of 10 (0/10=6, 
1/10=2, 2/10=2), which is lower than the 
aforementioned studies. Although the mean VAS 
of the present study was lower, the mean VISA-P 
(M = 78.11) of this study is also lower than the 
aforementioned study, which is potentially 
indicative of participant perception of more 
function from the EE protocol. 

Although EE has been found to produce beneficial 
results when the protocol is completed, there are 
still concerns over the effectiveness of the 
protocols for all patients and a lack of a clear 
understanding of the mechanism of action. Thus, 
there is a need to determine if tendinalgia 
participants should be screened prior to using an 
EE protocol in a one-size fits all model.8,9 The lack 
of a screening process for identifying patients 
likely to respond to EE and the extended time 
required for patients to become symptom free has 
created a need for improved assessment 
methods.8,9 One potential solution to improve 
tendinalgia outcomes is the use of a TBC system or 
more novel manual therapy techniques. Lewis9 has 
suggested a series of four mechanical techniques, 



An Exploratory Analysis of a Treatment Based Classification Algorithm to Treat Patellar Tendinopathy 
 

 

16 
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All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

or a combination of interventions, to be used as a 
TBC system to produce improved patient 
classification and treatment outcomes for patients 
with rotator cuff tendinalgia. The manual 
therapies used in the TBC algorithm in this study 
also have evidence of effectiveness on 
tendinalgia patients in other research studies.13,42-

44 

Researchers have found promising results with the 
use of the MC when treating lateral 
epicondylalgia.41-43 Bisset, et al.43 observed 
favorable outcomes for the use of MC 
mobilizations in combination with exercises over 
corticosteroids and a “wait and see” method. 
Although corticosteroid injections were more 
statistically significant   

While the preliminary results of this case series 
are important, the limitations of this study must 
also be noted. Although many attempts were 
made to decrease the risk of bias, there could 
have been a bias created because the clinician 
and participants were not blinded to the 
treatment or collection of outcome measures. 
Additionally, a control or placebo group was not 
used in the study. The lack of control group and 
long term follow-up made it difficult to definitively 
determine if the outcomes were the result of 
treatment or the natural course of healing; 
however, a number of participants presented with 
chronic symptoms (mean symptom duration = 2.14 
years with a range of one week to six years) 
unlikely to have spontaneously healed over the 
treatment period. The lack of comparison group 
made it difficult to determine if one treatment 
intervention was superior to another within the TBC 
algorithm, but the purpose of the study was not to 
identify the “best” intervention. Instead, the focus 
was on determining the effectiveness of classifying 
patients using sub-therapeutic doses on indirect 
manual therapies. Additionally, it could be 
argued the treatments provided as part of the 
TBC algorithm were provided at sub-therapeutic 
doses (e.g., not treating multiple TPs with PRT, etc.) 
and the interventions could be more effective if 
treatment dose was maximized. Furthermore, the 

specific techniques utilized (e.g., internal rotation 
and external rotation MWM, etc.) for this TBC 
algorithm were limited to increase usability of the 
algorithm; however, other techniques within the 
different intervention paradigms have the 
potential to maximize the effectiveness of each 
paradigm (e.g., MC taping technique, other 
glides, etc.). The full examination of the original 
TBC was not fully assessed due to the lack of 
diverse treatment subgroups. There were nine 
participants classified in the MC subgroup, one in 
the PRT subgroup, and zero in the ND and EE 
subgroups. The final limitation is that the 
participants may not have fully represented 
patellar tendinalgia patients and those who 
volunteered may have been motivated to 
improve.   

As this study is an initial examination of a TBC 
algorithm for patellar tendon pain, it is possible 
that altering the order or adding other treatment 
paradigms may be appropriate to maximize the 
effectiveness of the TBC algorithm. The results of 
this study do provide support for the utilization of 
a TBC algorithm for patellar tendinalgia patients 
because all 10 participants experienced 
statistically and clinically significant improvements 
in pain and function in three visits. Future research 
should compare this TBC algorithm with a control 
or placebo group and utilize long-term follow-up 
with the participants. Forthcoming research should 
also include diagnostic imaging or histological 
exams, which would benefit the understanding of 
the physiological changes in the tendon following 
treatment utilizing the TBC algorithm.  

CLINICAL APPLICATION  

The TBC algorithm used in this study was designed 
because the clinicians could observe participant 
response to potential interventions while in a 
painful state and to utilize manual therapy 
techniques that could potentially produce rapid 
changes. Patient response enabled the clinician to 
classify the participant to an intervention that was 
designed to be matched to their dysfunction. In 
theory, matching tendinalgia patients to therapies 



An Exploratory Analysis of a Treatment Based Classification Algorithm to Treat Patellar Tendinopathy 
 

 

17 
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All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

through classification could improve outcomes. In 
this study, all of the participants were classified as 
being a responder to either the MC or PRT and 
were able to meet the pre-established discharge 
criteria without a single participant needing to be 
classified into the EE protocol sub-group at any 
time. Thus, a TBC algorithm may be more effective 
at matching participants to appropriate 
treatments that do not require extended therapy 
or a painful experience to produce effective 
outcomes. Additionally, the use of a TBC algorithm 
may allow clinicians to identify which participants 
actually need to participate in an EE protocol or 
when to add this protocol as an adjunct therapy 
to provide complete resolution of participant 
complaints.  

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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and see for tennis elbow: randomised trial. 
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https://doi.org/10.1123/jsr.2016-0033

	ABSTRACT

