33 Removing high-load drills from training, reducing frequency of training (twice a week is tolerable for many tendons) and decreasing volume (reducing time of training) are all useful means of reducing load on the tendon without resorting to complete rest. Sustained isometric contractions have been shown to

be analgesic.37 In painful patellar tendinopathy (usually a reactive or reactive on degenerative pathology), pain relief can be obtained for 2 to 8 hours with heavy sustained isometric contractions. Voluntary contractions at 70% of maximum, held for 45 to 60 seconds and repeated four times is one Afatinib in vivo loading strategy that has been shown to have a large hypoalgesic effect. This loading can be done before a game or training, and can be done several times a day.38 If the tendon is highly irritable, bilateral

exercise, shorter holding time and fewer repetitions are recommended.38 Additionally, medication may help to augment pain reduction and/or pathological change in a reactive tendon,39 so consultation with a physician is advised. Eccentric, heavy slow resistance, isotonic and isometric exercises have all been investigated in patellar tendinopathy. Eccentric exercises have generally been shown to have good short-term and long-term effects on symptoms and VISA-P scores. There are several different types of eccentric RG7204 nmr patellar tendon loading exercises; however, there is no difference in the results of a 12-week eccentric training program between the bilateral weighted squat (Bromsman device) twice a week and the unilateral decline squat daily.40 Several interventions have used the 25 deg single-leg Parvulin decline squat, which has been shown to have better outcomes than a single-leg flat squat.41 Two investigations have shown that angles above 15 deg are equivocal,42 and 43 and that the decline board is effective by increasing the moment arm of the knee.44 Two studies have investigated the effect of eccentric exercise in the competitive season. Visnes et al reported no overall

effect and a short-term worsening with decline squat training on function in symptomatic athletes continuing a regular training program, compared to a regular training program only.45 Fredberg et al showed an increased risk of injury for asymptomatic athletes with pathology on ultrasound who completed a prophylactic eccentric decline squat training program.46 This suggests that the addition of eccentric exercise while an athlete is in a high-load environment is detrimental to the tendon. When comparing an eccentric decline squat protocol to a patellar tenotomy, there was no difference in the outcomes and both showed improvement.47 Surgical intervention is not recommended over an exercise rehabilitation program in the first instance.