MANUSCRIPT TYPE CLINCAL OUTCOMES RESEARCH 6 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 7 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 8 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 4 – Issue 2 – September 2021 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 (