Association Between Clinical and Imaging Outcomes After Therapeutic Loading Exercise in Patients Diagnosed With Achilles or Patellar Tendinopathy at Short- and Long-Term Follow-up: A Systematic Review

Clin J Sport Med. 2020 Jul;30(4):390-403. doi: 10.1097/JSM.0000000000000624.


Objective: To determine the association between clinical and imaging outcomes after therapeutic loading exercise in Achilles tendinopathy (AT) and patellar tendinopathy (PT) populations at both short- and long-term follow-up.

Data sources: The PUBMED and EMBASE databases were searched (up to June 2017) to identify articles that meet the inclusion criteria: (1) patients diagnosed with AT (insertional or midportion) or PT; (2) rehabilitation based on therapeutic loading exercise; and (3) assessment of clinical outcomes and tendon structure using an imaging modality.

Main results: Two independent reviewers screened 2894 search results, identifying 21 suitable studies. According to the studies included in this review, clinical results showed significant improvements for patients with AT and PT after eccentric exercise (ECC) and heavy slow resistance (HSR) at short- and long-term follow-up. Imaging outcomes were not consistent. Moderate-to-strong evidence for patients with AT suggested an association between clinical outcomes and imaging outcomes (tendon thickness and tendon neovascularization) after ECC at long-term follow-up. For patients with PT, there was moderate evidence supporting an association between clinical outcomes (questionnaire score and pain) and imaging (tendon thickness and tendon neovascularization) after ECC at short-term follow-up. For both the AT and PT groups, there was moderate evidence for an association between clinical outcomes and tendon thickness and neovascularization after HSR exercise. Results related to the HSR exercise should be interpreted with caution because of the small number of studies.

Conclusions: Based on the findings of the present review, the use of imaging outcomes as a complementary examination to the clinical assessment was confirmed. Overall, an improvement in clinical outcomes seems to be associated with a reduction in tendon thickness and tendon neovascularization. Clinicians should be aware that during the interpretation of the imaging outcomes, factors such as tendinopathy location, exercise modality performed, and a follow-up period should be considered.

Publication types

  • Systematic Review

MeSH terms

  • Achilles Tendon / blood supply
  • Achilles Tendon / diagnostic imaging*
  • Achilles Tendon / pathology
  • Exercise Therapy / methods*
  • Humans
  • Neovascularization, Physiologic
  • Patellar Ligament / blood supply
  • Patellar Ligament / diagnostic imaging*
  • Patellar Ligament / pathology
  • Resistance Training
  • Tendinopathy / diagnostic imaging*
  • Tendinopathy / pathology
  • Tendinopathy / therapy*
  • Treatment Outcome