healthcare

Systematic Review
The Effects of Soft-Tissue Techniques and Exercise in the
Treatment of Patellar Tendinopathy—Systematic Review
and Meta-Analysis
Federico Ragone 1 , Silvia Pérez-Guillén 1, *, Andoni Carrasco-Uribarren 1 , Sara Cabanillas-Barea 1 ,
Luis Ceballos-Laita 2 , Pere Ramón Rodríguez-Rubio 1 and Rosa Cabanas-Valdés 1

1 Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallés,
Spain; f.ragone99@uic.es (F.R.); acarrasco@uic.es (A.C.-U.); scabanillas@uic.es (S.C.-B.);
prodriguez@uic.es (P.R.R.-R.); rosacabanas@uic.es (R.C.-V.)
2 Department of Surgery, Ophthalmology, Otorhinolaryngology and Physiotherapy, University of Valladolid,
42004 Soria, Spain; luis.ceballos@uva.es
* Correspondence: sperezgu@uic.es

Abstract: Background: Patellar tendinopathy is a degenerative clinical disorder that causes load-
related pain in the lower pole of the patella or patellar tendon. It predominantly affects young
male athletes engaged in sports involving repetitive tendon loading, particularly explosive jumping.
The combination of manual techniques with therapeutic exercise is hypothesized to provide greater
benefits than exercise alone. Objective: The aim of this study is to analyze the scientific evidence
regarding the effects of soft-tissue techniques combined with therapeutic exercise versus therapeutic
exercise alone on pain intensity and function in individuals with patellar tendinopathy. Methods: A
systematic review with meta-analysis was conducted following the PRISMA guidelines. PubMed,
Lilacs, IBECS, CENTRAL, WOS, SciELO, Academic Search, CINAHL, SportDiscus, PEDro, and
Google Scholar databases were consulted. Randomized controlled trials and quasi-randomized trials
Citation: Ragone, F.; Pérez-Guillén, S.; focusing on the effects of soft-tissue techniques combined with therapeutic exercise (experimental
Carrasco-Uribarren, A.; group) versus therapeutic exercise alone (control group) on pain and function in individuals aged
Cabanillas-Barea, S.; Ceballos-Laita, 16 years and older with patellar tendinopathy were selected. The Cochrane tool for risk-of-bias
L.; Rodríguez-Rubio, P.R.; assessment and the PEDro scale for methodological quality were used. Results and Discussion: A
Cabanas-Valdés, R. The Effects of
total of six studies (n = 309; age range = 16–40 years), considered to have a low risk of bias and
Soft-Tissue Techniques and Exercise in
moderate-to-high methodological quality, were included. The results showed improvements in
the Treatment of Patellar
function in the experimental group (mean of 60% on the Visa-P scale) and pain in the experimental
Tendinopathy—Systematic Review
and Meta-Analysis. Healthcare 2024,
group (mean decrease of 2 points in the VAS scale). There were improvements in 50% of the
12, 427. https://doi.org/10.3390/ studies when comparing variables between the experimental and control groups. Conclusions: The
healthcare12040427 combination of manual techniques, such as dry needling, percutaneous electrolysis, transverse friction
massage, and stretching, along with a squat on a 25◦ inclined plane, appears to be effective in the
Academic Editor: Gilbert Ramirez
treatment of patellar tendinopathy. Static stretching of the quadriceps before and after the squat
Received: 6 November 2023 five times per week, along with dry needling or percutaneous electrolysis sessions twice a week for
Revised: 29 January 2024 8 weeks, is recommended. However, future studies analyzing groups with passive techniques versus
Accepted: 5 February 2024 therapeutic exercise are needed to standardize the treatment and establish the optimal dose.
Published: 7 February 2024

Keywords: soft-tissue therapy; patellar tendinopathy; exercise therapy

Copyright: © 2024 by the authors.

Licensee MDPI, Basel, Switzerland.
1. Introduction
This article is an open access article
distributed under the terms and Patellar tendinopathy (PT) is a clinical degenerative condition that causes load-related
conditions of the Creative Commons pain in the inferior pole of the patella or patellar tendon [1,2]. It predominantly affects
Attribution (CC BY) license (https:// young male athletes practicing sports that involve repetitive loading of the tendon, partic-
creativecommons.org/licenses/by/ ularly explosive jumping [3]. The prevalence varies according to the sport played, being
4.0/). more common in elite and recreational volleyball and basketball. It is estimated that as

Healthcare 2024, 12, 427. https://doi.org/10.3390/healthcare12040427 https://www.mdpi.com/journal/healthcare

Healthcare 2024, 12, 427 2 of 12

many as 45% and 32% of these athletes, respectively, suffer from PT [3–6]. The recovery
rates for PT are not satisfactory, causing significant time off sports and high recurrence
rates [7–9].
The term “tendinitis” has been replaced by “tendinopathy”, since the minimal pres-
ence of inflammatory cells has been demonstrated, and histopathological studies con-
firm structural degenerative changes in the tendon tissue as the key feature of tendon
dysfunction [1,10]. Thus, tendon pathology is described as a continuum of three tissue
states: reactive tendinopathy, unstructured tendon, and degenerative tendinopathy. The
most widely accepted etiological factors are mechanical overload and repetitive micro-
trauma, although other intrinsic and extrinsic factors may also be predisposing factors for
pathology [9,11]. Some risk factors include hamstring and quadriceps muscle tightness,
reduced ankle dorsiflexion, foot hyperpronation, poor joint coordination, overweight, leg
length discrepancy, an increased volume and intensity of jump training, and activity on
hard courts and synthetic turf [12]. Many of these risk factors are thus modifiable and
preventable through appropriate physiotherapy programs [12–14]. A diagnosis of PT is
typically based on the clinical history and symptomatic findings, with color-Doppler ultra-
sound (CD-US) and magnetic resonance imaging (MRI) being the most used methods to
confirm tendon pathology [15].
The management of PT can be active or passive. Active strategies involve tendon-
loading regimes, and eccentric training is the most widely adopted approach. It has been
shown that there is a 50–70% likelihood of improvement at 3–6-month follow-up with this
method [14,16]. In fact, many authors have advocated for eccentric training as the gold
standard in the treatment of tendinopathies [17–19]. Passive treatments for PT include
different minimally invasive techniques (MITs), such as corticosteroid and platelet-rich
plasma (PRP) injections, extracorporeal shockwave therapy (ESWT), low-energy laser
therapy, dry needling (DN), and percutaneous needle electrolysis (PNE) [20–22].
The conclusion of the systematic review of Everhart JS et al. in 2017 was that the initial
treatment of PT may consist of eccentric exercise, shockwave, or PRP as monotherapy or
an adjunct to accelerate recovery. Surgery or ESWT should be considered if the conser-
vative treatment fails after 6 months [23]. A recent meta-analysis determined that MIT,
when combined with exercise, was effective post-treatment and at follow-up [21]. Several
authors have also studied the effects of manual non-invasive soft-tissue techniques, such
as stretching, massage, and muscle tissue mobilization, showing a reduction in pain and
an improvement in the function of patients with PT. It seems that these techniques have
different theoretical mechanisms of action but the same aim of restoring the normal healing
of the affected tissues and muscle imbalances [24–26].
To the best of our knowledge, within MIT, there are some procedures that are outside
the scope of competence of physiotherapy, such as PRP or corticosteroid injection. However,
DN and PRP are two MITs that, together with manual non-invasive soft-tissue techniques,
constitute therapeutic strategies to address PT. We also believe that the use of standardized
symptom scores, such as the Victorian Institute of Sports Assessment Patellar Tendinopa-
thy Questionnaire (VISA-P), in the current PT literature allows for a more quantitative
assessment of treatment outcomes using statistical techniques to gain new insight into the
efficacy of these treatments [26,27]. Consequently, the aim of this systematic review and
meta-analysis is to evaluate the effectiveness of incorporating soft-tissue techniques into
exercise therapy in improving pain and function in patients with PT. It is hypothesized
that the combination of any of the previously mentioned muscle techniques with exercise
therapy may provide better results in pain and function than exercise therapy alone in
patients with PT.

2. Materials and Methods

2.1. Study Design
A systematic review and meta-analysis were conducted following the Preferred Report-
ing Items for Systematic Review (PRISMA) [28] guidelines to investigate the effectiveness
Healthcare 2024, 12, 427 3 of 12

of soft-tissue techniques in patients with patellar tendinopathy. The review was registered
in the international prospective register for systematic reviews (PROSPERO) database
(CRD42022501825).

2.2. Data Sources and Search

The following computerized databases were consulted by two independent reviewers
(FR and SP) to carry out the present review: Pubmed, Lilacs, IBECS, CENTRAL, WOS
Core Collection, SciELO, Academic Search, CINAHL, SportDiscus, PEDro, and Google
Scholar. The search strategy involved a combination of MeSH terms and free terms, such as
“Patellar Ligament”, “Exercise Therapy”, “Musculoskeletal Manipulations”, “Acupuncture
Therapy”, “Muscle Stretching Exercises”, and “Electrolysis”, with the truncation term
“Random*” to locate randomized clinical trials. The search was completed on the 10th of
April 2023. The adapted search strategies for each database are included in Supplementary
Material S1.

2.3. Study Selection Process and Eligibility Criteria

The article selection process, identified through the literature search and the re-
moval of duplicate findings in databases, was carried out using the RayyanQCRI software
(1 Broadway Street, 14th Floor, Cambridge, MA 02142, USA). The selection process was
performed by two independent reviewers (FR and SP) in two stages. After identifying all
the studies, a first screening was carried out by reading the titles and abstracts. From the
selected articles, a full-text reading was conducted to verify whether they met the inclusion
or exclusion criteria. Any discrepancies were solved by a third reviewer (RC) if necessary.
Only studies that met the following inclusion criteria were included: (P: population)
participants of all sexes and ages =/> 16 years diagnosed with patellar tendinopathy
in any stage of the disease; (I: intervention) studies that evaluated the effectiveness of
soft-tissue techniques combined with therapeutic exercises in the affected knee region,
(C: comparison) compared to the application of therapeutic exercise alone; (O: outcomes)
studies that evaluated one of the following variables: pain intensity and tendon function;
(S: studies) Randomized and quasi-randomized controlled trials published in national and
international journals.
As part of the selection criteria, the included articles were rated using the Phys-
iotherapy Evidence Database (PEDro) scale. Studies with scores between 6 and 8 are
classified as having good methodological quality, scores between 4 and 5 indicate reg-
ular quality, and scores below 4 points are considered to have poor methodological
quality [29].

2.4. Data Extraction

Data extraction was performed in pairs according to the P.I.C.O. strategy. Data were
extracted on participant characteristics (sample size, age, sex, disease severity), interven-
tion and control group characteristics (type of intervention, type of soft tissue addressed,
intensity, frequency, duration of session and program), outcome variables on Victorian
Institute of Sport Assessment-Patella (Visa-P) and Visual Analog Scores (VAS), and the type of
study design.

2.5. Risk-of-Bias and Methodological Quality Assessment

The methodological quality was assessed using the PEDro scale [30] by two blinded
evaluators (FR and SP), and discrepancies were solved by a third reviewer (RC). This tool
consists of a total of 11 items that assess external validity, internal validity, and statistical
analysis. The first item of the PEDro scale was not considered in this review. Thus, the
maximum score for an article did not exceed 10 points, with the minimum score being
0 points.
Healthcare 2024, 12, 427 4 of 12

The same blinded evaluator (FR and SP) performed the assessment of the risk of bias.
The Cochrane Collaboration tool was used for this aim [31]. This tool evaluates six domains,
including sequence generation (selection bias), allocation concealment (selection bias),
the blinding of participants and personnel (performance bias), the blinding of outcome
assessment (detection bias), incomplete outcome data (attrition bias), selective reporting
(reporting bias), and other biases. Each item is scored as “high risk”, “low risk”, or
“unclear risk”.

2.6. Strength of Evidence

The quality of the evidence was assessed through the Grading of Recommendations,
Assessment, Development, and Evaluation system (GRADE) [32]. The GRADE system
evaluates the quality of evidence based on the extent to which users can be confident that
the reported effect reflects the element being evaluated.
The assessment of the quality of evidence includes the risk of bias in the studies,
inconsistency, imprecision, publication bias, indirect results, and other factors that may
influence the quality of evidence. To summarize this information, summary tables of the
findings were developed.

2.7. Statistical Analysis

A random-effects meta-analysis was performed using the RevMan version 5.4
software (The Cochrane Collaboration, Copenhagen, Denmark). The mean difference
(MD) was used if all studies used the same tool to measure an outcome, and a standard
mean difference (SMD) was used if the tool varied between studies. The generic inverse
variance method was used for adjusted effect estimates and its standard error. Each
study estimate of the relative treatment was given a weight that is equal to the inverse
of the variance of the effect estimate. We used a p-value of less than 0.05 to determine
statistical significance. The effect size was categorized as 0.2, 0.5, 0.8, and 1.3, which
were considered small, medium, large, and very large, respectively. All effect size
measures were expressed with a 95% confidence interval. Heterogeneity was expressed
and visually assessed by forest plots and using the I2 statistic. The I2 statistic describes
the percentage of total variation across studies that is attributable to heterogeneity rather
than chance. A value greater than 25% is considered to reflect low heterogeneity, 50%
moderate, and 75% high heterogeneity.
A narrative review and tables were used when there was insufficient data for quanti-
tative analysis. Missing data from studies was requested by email from the correspond-
ing author.

3. Results
3.1. Study Selection
The PRISMA diagram (Figure 1) summarizes the results of the scientific literature
search. Out of the total number of databases consulted, a total of 71 studies were
obtained. After removing duplicates, the titles and abstracts of 50 studies were reviewed,
and a total of 6 trials met the inclusion criteria. After reading the full text of these
studies, no other articles were excluded. Finally, a total of 6 trials were included in this
systematic review.
They were randomized and quasi-randomized controlled clinical trials (n = 6) pub-
lished from 2012 to 2023. The studies were conducted in Greece [25], USA [33], India [24],
Spain [21,34] and Pakistan [35].
Healthcare 2024, 12, x FOR PEER REVIEW 5 of 13
Healthcare 2024, 12, 427 5 of 12

Figure
Figure 1. PRISMA
1. PRISMA diagram.
diagram.

3.2.
TheyQuality
wereand Risk of Biasand quasi-randomized controlled clinical trials (n = 6) pub-
randomized
Two2012
lished from independent reviewers
to 2023. The studiesanalyzed and measured
were conducted in Greece the[25],
methodological
USA [33], Indiaquality
[24],and
risk of bias of the included
Spain [21,34] and Pakistan [35]. studies using the PEDro scale [30] and The Cochrane Collabora-
tion scale [32]. The methodological quality of the included studies ranged from 6 to 8 points,
3.2.with an average
Quality and Riskofof6.83
Biaspoints [6–11]. The homogeneity between the studies was quite good.
All studies were assigned
Two independent reviewers a “No” for notand
analyzed blinding
measuredthe physiotherapists
the methodological whoquality
administered
and
the therapy, as well as the subjects included. Only Dragoo et al.
risk of bias of the included studies using the PEDro scale [30] and The Cochrane Collabo-[33] blinded both the
therapists
ration andThe
scale [32]. the participants.
methodological Only Dimitrios
quality et included
of the al. [25] obtained
studiesaranged
negative score
from for8not
6 to
points, with an average of 6.83 points [6–11]. The homogeneity between the studies was in
randomizing the participants correctly. The remaining authors obtained a positive score
thegood.
quite randomization
All studies of were
the participants,
assigned a but“No”Jadhav
for notet al. [24] andthe
blinding Abat et al. [34] did not
physiotherapists whomen-
tion whether the assignment was concealed. There was a positive homogeneity between all
administered the therapy, as well as the subjects included. Only Dragoo et al. [33] blinded
studies in items 8, 9, 10, and 11, except for Abat et al. [34] and López-Royo et al. [21].
both the therapists and the participants. Only Dimitrios et al. [25] obtained a negative
In the “generation of sequence” and “allocation concealment”, only Dimitrios et al. [25]
score for not randomizing the participants correctly. The remaining authors obtained a
obtained a high risk of bias in these two items. The highest risk of bias was found in
positive score in the randomization of the participants, but Jadhav et al. [24] and Abat et
“blinding of participants and personnel”, in which almost all studies had a high risk of
al. [34] did not mention whether the assignment was concealed. There was a positive ho-
bias. Only Dragoo et al.’s study [33] was assigned a low risk of bias because both the
mogeneity between all studies in items 8, 9, 10, and 11, except for Abat et al. [34] and
orthopedic surgeon and the patients remained blinded with respect to the treatment group.
López-Royo et al. [21].
The majority of the studies had a low risk of bias in “incomplete outcome data” and “other
In the “generation of sequence” and “allocation concealment”, only Dimitrios et al.
biases”. In the “blinding of evaluators”, Dragoo et al. [33] and Jadhav et al. [24] had a high
[25] obtained a high risk of bias in these two items. The highest risk of bias was found in
risk of bias, while Jadhav et al. [24] and López-Royo et al. [21] had a high risk of bias in
“blinding of participants and personnel”, in which almost all studies had a high risk of
“selective reporting” because the authors did not report all results according to the study
bias. Only Dragoo
protocol. Finally,etaal.
lows study [33]assigned
risk was was assigned
to the aother
low studies.
risk of bias because both the or-
thopedic surgeon and the patients remained blinded with respect to the treatment group.
 Healthcare 2024, 12, 427 6 of 12

3.3. Participants
This systematic review included a total of 309 participants, with an average of 51.5
(±25.05) patients per study. The age range of the participants was 16–36 years old. The
sample had a higher percentage of male participants (77%, n = 235) than female participants
(23%, n = 70), except for two studies that only included male participants [24,33]. Notably,
Dragoo et al. [33] had the smallest sample size with 22 participants, while Sharif et al. [35]
had the largest sample size with 96 participants. All participants were diagnosed with
patellar tendinopathy, with a Visa-p scale score ranging from 37 to 69.1 points, which
quantifies the severity of the pathology. The authors agreed on the eligibility criteria
for patients: being over 16 years old, feeling pain on palpation of the lower pole of the
patella, having a clinical diagnosis of patellar tendinopathy, experiencing symptoms that
persist for more than three months, and practicing sports [21,24,25,33–35]. There was
also considerable homogeneity in the exclusion criteria, with previous surgery and local
injections of corticosteroids or other drugs being the most commonly used [21,24,33–35].
Only Dimitrios et al. [25] did not mention the exclusion criteria.
Healthcare 2024, 12, x FOR PEER REVIEW 7 of 14
3.4. Quality of Evidence
The findings on the quality of evidence are summarized in Figure 2. Overall, the
studies reviewed have a moderate level of quality, which implies that there is a possibility
that the actual effect is far from the estimated effect.

Figure 2. RoB
Figure 2. RoB[21,24,25,33–35]
[21,24,25,33–35]. .

For the six RCTs, “risk of bias” and “inconsistency” were assessed as “not serious”,
3.5. Characteristics of the Intervention
because in most domains, the risk of bias is low, in addition to the fact that there is quite a
3.5.1.
highTherapeutic
homogeneity Exercise
among all results for the variables Visa-p and VAS. “Indirect evidence”
was assessed
The authorsas reviewed
“not serious”
the and “imprecision”
therapeutic as “very
exercise serious”, because
interventions used in the
the included
experimental
and control groups across multiple studies and found that there was a high level of simi-
larity among them. A protocol of exercises based on a single-leg or double-leg squat on a
25°-inclined board was applied, with a focus on the eccentric phase, meaning a greater
duration of this phase. In addition, static stretching of the quadriceps and hamstrings was
Healthcare 2024, 12, 427 7 of 12

studies had a small sample size. The quality of evidence was downgraded by one point, in
that the available evidence was based on few studies with positive results and, in some
cases, was subject to funding. Conversely, it went up by one point because studies with
higher doses/frequency of treatment were observed to show a greater response.

3.5. Characteristics of the Intervention

3.5.1. Therapeutic Exercise
The authors reviewed the therapeutic exercise interventions used in the experimental
and control groups across multiple studies and found that there was a high level of simi-
larity among them. A protocol of exercises based on a single-leg or double-leg squat on
a 25◦ -inclined board was applied, with a focus on the eccentric phase, meaning a greater
duration of this phase. In addition, static stretching of the quadriceps and hamstrings
was applied in one study [24], and conventional physiotherapy protocols were used in
another study [35], which included stretching, strengthening exercises, ultrasound applica-
tion, and transverse friction massage. The authors agreed on three sets of 15 repetitions
with a rest period between 2 and 3 min. Patients were instructed to train at a perceived
intensity of no pain, little pain, or a pain score of 5 out of 10 during eccentric exercises.
However, Dragoo et al. [33] only mentioned that a three-phase eccentric exercise program
(concentric–isometric–eccentric) would be applied to both groups without specifying the
sets, repetitions, rest periods, intensity, or types of exercises provided (Supplementary
Material S2).

3.5.2. Soft-Tissue Techniques

Regarding the soft-tissue techniques and structures involved, all authors focused
their interventions on the quadriceps, especially on the patellar tendon, which was the
most treated structure. Three studies used instrumental techniques. Dragoo et al. [33]
and Sharif et al. [35] used ultrasound-guided DN, while Abat et al. [34] used ultrasound-
guided intratissue percutaneous electrolysis (EPI), and López-Royo et al. [21] used
both techniques. However, despite differences in the intensity and dosage, there was a
consensus on the location of the portion of the patellar tendon to be needled. Dimitrios
et al. [25] administered static stretches of 30 s with a 1 min rest between each stretch
before and after completing eccentric exercise. However, they did not describe the types
of stretches or the number of sets of each one. Meanwhile, Jadhav et al. [24] applied
10 min of transverse massage to the intervention group and 10 min of cryotherapy to the
control group.

3.5.3. Frequency and Duration of Intervention

The frequency and duration of interventions varied among studies. Most studies pre-
scribed eccentric exercises and stretching 2–5 times a week for 4–12 weeks, with one study
prescribing twice daily exercises [21]. Studies using DN and EPI interventions included
sessions every 2 weeks for 8 weeks.

3.6. Effectiveness of the Intervention

3.6.1. Severity of Symptoms
The Visa-p scale was used to assess the symptoms of individuals.
A meta-analysis was performed for DN (Figure 3). A pooled mean difference of 25.03
(95% CI from 5.53 to 44.53, p = 0.01) was observed, and no heterogeneity was shown.
Dragoo et al.’s [33] measurements were taken at 26 weeks and Lopez-Royo et al.’s [21] at
10 weeks.
 Healthcare 2024, 12, x FOR PEER REVIEW 8 of 13

Healthcare 2024, 12, 427 Dragoo et al. s [33] measurements were taken at 26 weeks and Lopez-Royo et al. s [21]
8 of 12at
10 weeks.
Figure 3. Forest plot of the Visa-p scale [21,33].

The results showed significant improvements in all experimental groups, with a

range of 29% to 95% improvement in the first evaluations [21,25,34]. Only two studies did
not show significant changes in the early evaluations [24,33]. However, by the later eval-
uations, there was an average improvement of 67% [21,24,25,33]. The study by Dimitrios
et al. [25] reported a remarkable 113% improvement in the Visa-p score in week 24. In the
Sharif
Figureet3.al. [35]plot
Forest study,
of the theVisa-p
median scaleand IQR were used instead of the mean and standard
[21,33].
Figure 3. Forest plot of the Visa-p scale [21,33].
deviation, and significant improvements were observed in the Visa-p score in all evalua-
tions in The theresults
DN group, showed but significant
only in the first two evaluations
improvements inexperimental
the control group.
The results showed significant improvements ininall allexperimental groups,with
groups, withaa
range The of control
29% to groups
95% in all
improvement studies in also
the showed
first improvements
evaluations
range of 29% to 95% improvement in the first evaluations [21,25,34]. Only two stud- [21,25,34].in function,
Only two with an
studies av-
did
erage
not improvement
show significant of 43%
changes in the
in thefirst
earlyevaluations,
evaluations
ies did not show significant changes in the early evaluations [24,33]. However, by the similar
[24,33]. to the
However,experimental
by the groups.
later eval-
However,
uations,
later in was
there
evaluations, thetherelater
an evaluations,
average
was averagethe
animprovement average improvement
of 67% [21,24,25,33].
improvement The dropped
of 67% [21,24,25,33]. study by The to study
42%
Dimitrios
[21,24,25,33,34]
byet Dimitrios
al. [25] reported compared
et al. [25] to 67%a113%
a remarkable
reported in theimprovement
remarkable experimental ingroups.
113% improvementthe Visa-p Two instudies
score added
theinVisa-p
week 24. addi-
scoreIn the
in
tional
Sharif interventions
et al. [35] to
study, thethecontrol
median groups,
and IQR but there
were was
used
week 24. In the Sharif et al. [35] study, the median and IQR were used instead of the mean not
insteadmuch of difference
the mean in
and the aver-
standard
age
and improvement
deviation,
standard and compared
significant
deviation, to the experimental
andimprovements
significant groups
were observed
improvements werethat received
inobserved
the Visa-p DN
in orVisa-p
score
the percutaneous
in allscore
evalua-
in
electrolysis.
tions in the DN group, but only in the first two evaluations
all evaluations in the DN group, but only in the first two evaluations in the control group. in the control group.
Regarding
Thecontrol
The control intergroup
groupsininall
groups comparisons
allstudies
studiesalso alsoof the Visa-p
showed
showed scale, significant
improvements
improvements in in changes
function,
function, with were
withanan re-
av-
aver-
ported
erage
age in 50% of the
improvement
improvement of studies,
of 43%
43% with
in the infirsttheevaluations,
the most
first significant
evaluations,
similar improvement
similar
to the to the observed
experimental
experimental in thegroups.
groups. study
How-
by
ever,Dimitrios
However,
in the later et al.
in the[25]later
and Jadhav
evaluations, evaluations, et al. [24].
the average the Sharif et al. improvement
average
improvement [35] reported
dropped to 42%significant
dropped changes
to 42%
[21,24,25,33,34]
in all evaluations,
[21,24,25,33,34] while
compared Dragoo
to 67% et al.
in [33]
the showed
experimental
compared to 67% in the experimental groups. Two studies added additional interventionsa negative
groups. change
Two of 21%
studies in
addedfavor of
addi-
the control
totional
the control group.
interventions
groups, tobutthe there
control wasgroups,
not much but there was not
difference inmuch difference
the average in the aver-
improvement
age improvement
compared compared togroups
to the experimental the experimental
that received groups
DN or that received DNelectrolysis.
percutaneous or percutaneous
3.6.2. Pain Intensity
electrolysis.
Regarding intergroup comparisons of the Visa-p scale, significant changes were re-
ported Regarding
Painin 50%
intensity intergroup
of the wasstudies,
assessedcomparisons
withby the
the mostVAS. ofsignificant
themeta-analysis
A Visa-p scale, was
improvement significant
observed
performed changes in the
for DN were
study
(Fig-re-
byported
Dimitriosin 50% et of
al. the
[25] studies,
and with
Jadhav the
et most
al. [24]. significant
Sharif et
ure 4). A pooled MD of −3.53 (95% CI from −7.12 to 0.07, p = 0.05) was obtained, and no improvement
al. [35] reported observed
significant in the study
changes
inbyallDimitrios
evaluations,
heterogeneity et
wasal.while
[25]
shown. Dragoo
and Jadhav
For et al.et
the [33] showed
al. [24].
meta-analysis, a the
Sharif negative
et al.data[35]change
reported
from of 21%
Drago etinal.favor
significant of
atthe
[33]changes26
control
in all and
weeks group.
evaluations,
by López-Royowhile Dragooet al. [21] et al.
at 10 [33] showed
weeks werea used.
negative change of 21% in favor of
the control
According group.
to Sharif et al. [35] in the comparison between DN and the control group,
3.6.2. Pain Intensity
significant differences were observed in reducing pain in 2 and 4 weeks, suggesting that
DN3.6.2.Pain
was Pain intensity
more Intensity
effective wasthan assessed by the VAS.
conventional A meta-analysis
therapy. Jadhav et al. [24] wasreported
performed onlyfor DN
a 13%
(Figure
significant 4). A pooled
change inwas
Pain intensity MD
week of − 3.53
12, andbynothe
assessed (95% CI
significant from − 7.12
differences were
VAS. A meta-analysis to 0.07, p
wasfound= 0.05)
performed was
in thefor obtained,
other
DNarti-
(Fig-
and
cles no
4).heterogeneity
ure[21,33]. A pooled MDwas shown.
of −3.53 (95% ForCIthe meta-analysis,
from −7.12 to 0.07, thepdata from
= 0.05) was Drago et al. [33]
obtained, and at no
26 weeks and bywas
heterogeneity López-Royo
shown. For et al.the[21] at 10 weeks were
meta-analysis, the data used.from Drago et al. [33] at 26
weeks and by López-Royo et al. [21] at 10 weeks were used.
According to Sharif et al. [35] in the comparison between DN and the control group,
significant differences were observed in reducing pain in 2 and 4 weeks, suggesting that
DN was more effective than conventional therapy. Jadhav et al. [24] reported only a 13%
significant change in week 12, and no significant differences were found in the other arti-
cles [21,33].

Figure 4.
Figure 4. Forest plot of
Forest plot of the
the pain
pain intensity
intensity [21,33].
[21,33].

According to Sharif et al. [35] in the comparison between DN and the control group,
significant differences were observed in reducing pain in 2 and 4 weeks, suggesting that
DN was more effective than conventional therapy. Jadhav et al. [24] reported only a 13%
significant change in week 12, and no significant differences were found in the other
articles [21,33].
Figure 4. Forest plot of the pain intensity [21,33].
3.6.3. Quality of Life
Quality of life was assessed by SF-36 and SF-12. A meta-analysis was performed for
DN (Figure 5). A pooled MD of 0.01 (95% CI from −0.22 to 0.25, p = 0.92) was obtained, and
no heterogeneity was shown. No differences were revealed. Dragoo et al.’s [33] assessment
was conducted at 26 weeks and Lopez-Royo et al.’s [21] at 10 weeks.
 3.6.3. Quality of Life
Quality of life was assessed by SF-36 and SF-12. A meta-analysis was performed for
DN (Figure 5). A pooled MD of 0.01 (95% CI from −0.22 to 0.25, p = 0.92) was obtained, and
Healthcare 2024, 12, 427 9 of 12
no heterogeneity was shown. No differences were revealed. Dragoo et al. s [33] assess-
ment was conducted at 26 weeks and Lopez-Royo et al. s [21] at 10 weeks.

Figure 5. Forest plot of the quality of life [21,33].

4. Discussion
This systematic review and meta-analysis assessed the effects effects of of several
several muscle
muscle tech-
tech-
niques when combined with exercise therapy on pain intensity and function in patients
suffering from PT. Six RTCs were identified, and the results show a tendency toward a
suffering
greater improvement in these two outcomes when exercise therapy was combined with
muscle techniques
techniquesversus versuswhenwhen it was applied
it was appliedin isolation.
in isolation. A meta-analysis
A meta-analysis was conducted
was con-
with
ductedtwo RCTs
with two that included
RCTs DN.
that included DN.
Manual therapy
Manual therapy embraces
embraces aa widewide variety
variety of of muscle techniques for
muscle techniques for the
the treatment
treatment of of
tendinopathies, including manual and instrumental approaches. These techniques are are
tendinopathies, including manual and instrumental approaches. These techniques di-
directed
rected to to either
either thethe tendon,
tendon, muscle
muscle belly,
belly, or fascial
or fascial tissue.
tissue. In thisIn systematic
this systematic
review, review,
a locala
local approach directly addressing the patellar tendon structure
approach directly addressing the patellar tendon structure prevailed. A broad body of prevailed. A broad body of
literature has
literature shown the
has shown the correlation
correlation between
between quadriceps
quadriceps shortening
shortening and and anan increased
increased riskrisk
of developing long-lasting PT [12,14,15], suggesting that the normalization
of developing long-lasting PT [12,14,15], suggesting that the normalization of quadriceps of quadriceps
length may
length may lead
lead to to better recovery from
better recovery from this
this condition.
condition. In In this
this line,
line, Zhang
Zhang ZJ ZJ et
et al. showed
al. showed
an increase in passive muscle tension in the vastus lateralis that is
an increase in passive muscle tension in the vastus lateralis that is associated with proxi- associated with proximal
patellar tendon
mal patellar stiffness
tendon in athletes,
stiffness suggesting
in athletes, that a muscle-specific
suggesting that a muscle-specific approach is needed
approach is
in the prevention and rehabilitation of PT [36]. According to
needed in the prevention and rehabilitation of PT [36]. According to fascial manipulationfascial manipulation theory,
patellar tendon pain
theory, patellar tendonis often
paindue to andue
is often uncoordinated contractioncontraction
to an uncoordinated of the quadriceps caused
of the quadri-
by abnormal fascial tension in the thigh. Therefore, the coordination deficit should be
ceps caused by abnormal fascial tension in the thigh. Therefore, the coordination deficit
identified instead of directing attention solely to the patellar tendinopathy [37]. A broader
should be identified instead of directing attention solely to the patellar tendinopathy [37].
approach addressing not only the patellar tendon but also other muscle structures, such as
A broader approach addressing not only the patellar tendon but also other muscle struc-
the quadriceps muscle and fascial tissue, may be useful for treating PT. This type of fascial
tures, such as the quadriceps muscle and fascial tissue, may be useful for treating PT. This
approach has been shown to be effective in the treatment of lateral elbow tendinopathies
type of fascial approach has been shown to be effective in the treatment of lateral elbow
when an instrumental technique by means of a hook is applied to muscle septa in the
tendinopathies when an instrumental technique by means of a hook is applied to muscle
forearm [38].
septa in the forearm [38].
The results of the meta-analysis seem to suggest that improvements in both pain and
The results of the meta-analysis seem to suggest that improvements in both pain and
function are maintained at mid-term and 10 and 22 weeks after the first treatment with DN.
function are maintained at mid-term and 10 and 22 weeks after the first treatment with
This is a crucial fact for PT, as recovery rates for these patients are not satisfactory, with
DN. This is a crucial fact for PT, as recovery rates for these patients are not satisfactory,
49% of patients experiencing recurrent symptoms [39] and more than 50% of them retiring
with
from 49%
sports ofparticipation
patients experiencing recurrent
due to persistent painsymptoms
[7]. Authors [39]have
and not more than 50%
reached of them
a consensus
retiring from sports participation due to persistent pain [7].
on the underlying DN mechanisms, but they may be related to the release of cellular and Authors have not reached a
consensus on the underlying DN mechanisms,
humoral mediators, which promote the healing of tendon tissues [40].but they may be related to the release of
cellular and humoral
Percutaneous mediators,
needle which
electrolysis promote
(PNE) [41,42]thehas healing
shownofexcellent
tendon tissues
results in[40].
the short
Percutaneous needle electrolysis (PNE) [41,42] has shown
term, with a rapid return to the previous level of activity [43]. However, no structural excellent results in the
short term, with a rapid return to the previous level of activity
changes in the tendon have been shown to be derived from DN or PNE [21]. This is an [43]. However, no structural
changes
important infact
the to tendon
considerhave beenperforming
when shown to be thederived
follow-up from of DN or PNE
patients with[21].
PT, This is an
as clinical
important fact to consider when performing the follow-up
findings may improve, but this is not necessarily accompanied by an improvement in theof patients with PT, as clinical
findings
ultrasound may improve,
image. Thus,butreturn-to-play
this is not necessarily
decisions accompanied
for players by withan PT
improvement
should be made in the
ultrasound image. Thus,
based on functional return-to-play
outcomes, such as VISA-pdecisions for players
scores, with PTinformation
which include should be about made
symptoms, functional tests, and subjects’ ability to perform sports activities and have
been shown to be highly reproducible for both test–retest and inter-evaluator scoring
(r > 0.95) [44].
Other less conservative treatments have proven their effectiveness in the treatment
of PT. Injectable techniques, such as platelet-rich-plasma (PRP) infiltrations, manage to
have long-term positive effects on PT. However, other treatments are more effective than
Healthcare 2024, 12, 427 10 of 12

PRP [33]. One such treatment is skin-derived tenocyte-like cells, which have been shown to
be effective for recovery from other tendinopathies, such as lateral epicondylitis [45].
The methodological quality and risk of bias revealed a lack of blinding for subjects,
therapists, and assessors. Only one trial documented blinding for either therapists or sub-
jects. Blinding participants proves to be challenging, particularly in non-needle interven-
tions, as conducting a reliable placebo-controlled experiment is often difficult. Additionally,
blinding the therapist is unattainable in most muscle techniques, given that a portion of the
treatment efficacy relies on the intensity and force applied by the physiotherapist.
To the best of our knowledge, this is the first systematic review and meta-analysis
covering non-injectable muscle techniques. This is particularly relevant for the fields of
physiotherapy and manual therapy, as injectable interventions are not within the scope
of competency of the profession. These results may shed some light on conservative
techniques that are very frequently used clinically when treating patients with PT. However,
it has several limitations due to the inherent biases of the included studies. Thus, caution
should be taken when interpreting the findings. First, there is a scarcity of RCTs concerning
muscle techniques that do not rely on the infiltration of substances. This hinders the
possibility of performing a meta-analysis with all the muscle techniques applied in the
studies included in the systematic review. Second, the standardization of treatment may be
necessary. Whereas exercise therapy applied in the studies was quite homogeneous in terms
of the type of exercise and dosage, muscle techniques showed greater heterogeneity. Only
six randomized controlled trials were included, and only two were meta-analyzed, which
complicates the interpretation of the results, which should be interpreted with caution.
Finally, only subjects over 16 years of age were included. We considered that subjects under
that age could have confounding factors and that patellar tendinopathy may be related to
growth factors. For this reason, the results of this meta-analysis cannot be extrapolated to
that age group.

5. Conclusions
This systematic review and meta-analysis showed that the combination of manual
techniques, such as DN, percutaneous electrolysis, transverse friction massage, and stretch-
ing, along with a squat on a 25◦ -inclined plane, appears to be effective in the treatment
of patellar tendinopathy. Static stretching of the quadriceps before and after the squat
five times per week, along with DN or percutaneous electrolysis sessions twice a week
for 8 weeks, is recommended. But the results should be interpreted with caution, as only
a few studies were meta-analyzed. Future studies analyzing groups with passive tech-
niques versus eccentric exercises are needed to standardize the treatment and establish the
optimal dose.

Supplementary Materials: The following supporting information can be downloaded at https://

www.mdpi.com/article/10.3390/healthcare12040427/s1. Supplementary Material S1: Search strategy.
Supplementary Material S2: Characteristics of the intervention.
Author Contributions: Conceptualization, A.C.-U., S.C.-B. and S.P.-G.; methodology, P.R.R.-R.,
L.C.-L., F.R. and R.C.-V.; software, F.R.; validation, R.C.-V., A.C.-U., S.P.-G. and L.C.-L.; formal
analysis, R.C.-V. and F.R.; investigation, A.C.-U. and F.R.; resources, S.C.-B., P.R.R.-R. and S.P.-G.;
data curation, R.C.-V. and S.P.-G.; writing—original draft preparation, F.R., R.C.-V. and S.P.-G.;
writing—review and editing, A.C.-U. and R.C.-V.; visualization, S.P.-G.; supervision, A.C.-U. and
S.C.-B.; project administration, R.C.-V. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The raw data supporting the conclusions of this article will be made
available by the authors on request.
Healthcare 2024, 12, 427 11 of 12

Conflicts of Interest: The authors declare no conflicts of interest.

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