Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes

Achilles (AT) and patellar tendons (PT) are commonly affected by tendinopathy in adult athletes but prevalence of symptoms and morphological changes in adolescents is unclear. The study aimed to determine prevalence of tendinopathy and intratendinous changes in ATs and PTs of adolescent athletes. A total of 760 adolescent athletes (13.0 ± 1.9 years; 160 ± 13 cm; 50 ± 14 kg) were examined. History, local clinical examination, and longitudinal Doppler ultrasound analysis for both ATs and PTs were performed including identification of intratendinous echoic changes and vascularization. Diagnosis of tendinopathy was complied clinically in case of positive history of tendon pain and tendon pain on palpation. Achilles tendinopathy was diagnosed in 1.8% and patellar tendinopathy in 5.8%. Vascularizations were visible in 3.0% of ATs and 11.4% of PTs, hypoechogenicities in 0.7% and 3.2% as well as hyperechogenicities in 0% and 0.3%, respectively. Vascularizations and hypoechogenicities were statistically significantly more often in males than in females (P ≤ 0.02). Subjects with patellar tendinopathy had higher prevalence of structural intratendinous changes than those without PT symptoms (P ≤ 0.001). In adolescent athletes, patellar tendinopathy is three times more frequent compared with Achilles tendinopathy. Longitudinal studies are necessary to investigate physiological or pathological origin of vascularizations and its predictive value in development of tendinopathy.     

Achilles tendon pain intensity and level of neovascularization in athletes as determined by color Doppler ultrasound

The cause of pain in Achilles tendinopathy is thought to be related to the presence of neovascularization in the tendon as seen on color Doppler ultrasound. Asymptomatic pathology has been observed in patellar tendons of elite athletes. The purpose of this study was to examine the prevalence of Achilles tendon pain and the characteristics of Achilles tendons in a young athletic population. Sixty-four varsity athletes underwent color Doppler ultrasound imaging to determine tendon thickness, presence of degeneration and neovascularization. The presence of swelling and tenderness was determined, and Achilles tendon pain was rated on three visual analogue scales (VAS) (pain during exercise, pain at rest, pain during daily activities) as well as on the VISA-A scale. Tendon symptoms were not related to the presence of neovascularization. There was a low prevalence of Achilles tendinopathy, tenderness, and neovascularization in this population. Neovascularization was seen in both a painful and a non-painful tendon.     

Proximal patellar tendon pathology can develop during adolescence in young ballet dancers—A 2‐year longitudinal study

Patellar tendinopathy (tendon pain and dysfunction), or jumper's knee, is prevalent in adult jumping athletes. Pathology in the proximal patellar tendon is a key risk factor for developing patellar tendinopathy. When pathology develops in the proximal patellar tendon is not known, although it is reported to exist in adolescent athletes. The aim of this study was to follow young jumping athletes (ballet dancers) through adolescence to identify whether pathology develops and its relation to the adolescent growth spurt. Fifty‐seven elite ballet students between ages 11 and 18 were monitored for 2 years. Data were collected every 6 months, including an ultrasound scan on their left tendons using ultrasound tissue characterization (UTC ) to quantify intratendinous changes, anthropometric data to calculate peak height velocity (adolescent growth spurt), participant reports of any injuries or dance modifications, and a VISA ‐P and single leg decline squat for patellar tendon pain. Nine percentage of adolescent dancers developed pathology during this study, and development was not associated with growth spurt. Peak height velocity and dance participation/volume both at the start and throughout the study were similar in those who did develop pathology and those who did not. Only 2 of 5 participants who developed pathology reported pain associated with their tendon. Pathology in the proximal patellar tendon can develop during adolescence.     

Low prevalence of patellar tendon abnormality and low incidence of patellar tendinopathy in female collegiate volleyball players

ABSTRACT

The prevalence of patellar tendinopathy has been reported to be as high as 50% in elite male volleyball (VB) players; however, the rate of injury in female collegiate VB athletes is unknown. The purpose of this study was to 1) identify the prevalence of ultrasonographic evidence of patellar tendon abnormality at the start of the preseason in female collegiate VB players; 2) report the incidence of tendinopathy during the season; and 3) determine if the preseason presence of tendon abnormality is associated with onset of disease. One hundred and six female collegiate VB players had both patellar tendons imaged. Incidence of patellar tendinopathy was tracked during the course of the 4-month season. Twenty-two athletes presented with ultrasonographic evidence of patellar tendon abnormality in at least one knee at the start of the preseason. The incidence of time-loss patellar tendinopathy was 0.26 (95% CI: 0.04, 0.85) per 1000 athletic exposures. This study was unable to determine if preseason presence of tendon abnormality was associated with a greater risk of tendinopathy due to power. The prevalence of tendon abnormality in the preseason and the incidence of patellar tendinopathy in female collegiate VB players are lower than that observed in other populations.     

Self-reported jumpers’ knee is common in elite basketball athletes – But is it all patellar tendinopathy?

ObjectivesTo describe the prevalence and pain location of self-reported patellar tendinopathy and patellar tendon abnormality in a male elite basketball population.DesignCross-sectional.SettingPre-season tournament.ParticipantsSixty male athletes from the Australian National Basketball League.Main outcome measuresSelf-reported patellar tendinopathy (PT) using the Oslo Sports Trauma Research Centre Overuse Questionnaire (OSTRC). Pain location using pain mapping (dichotomised: focal/diffuse) and severity during the single leg decline squat. Ultrasound tissue characterisation scans of both patellar tendons.ResultsThirteen participants (22.7%) self-reported PT. Only 3 who reported PT had localised inferior pole pain. Thirty athletes reported pain during the decline squat, 15 described focal pain; 10 diffuse pain (5 missing data). Those with diffuse pain had greater years played [Md = 21 (13–24), n = 10 than focal pain (Md = 12 (7–26), n = 15), p = 0.042, r = 0.3]. Bilateral tendon abnormality was found in 45% of athletes and 15% had unilateral tendon abnormality.ConclusionElite male basketball athletes self-reporting PT had heterogeneity in pain location. When focal pain with loading was used as a primary definition of PT, ‘jumpers’ knee’ was not common in this cohort. This study found that abnormality of the patellar tendon was common and did not correlate with symptoms.     

Feasibility and reliability of pain pressure threshold measurements in patellar tendinopathy

Patellar tendinopathy is a common and often difficult to treat overuse injury which is characterized by activity-related anterior knee and focal palpation tenderness of the patellar tendon. The clinical diagnosis is mainly based on clinical examination, in which the yardstick is a non-standardized manual palpation. To standardize this palpation procedure the use of an algometer seems applicable. The purpose of this study was to investigate the feasibility and reliability of the algometer in patellar tendinopathy. A cross sectional study was carried out.The algometer was applied to the patellar tendon in 20 asymptomatic volleyball players to measure the ‘normal’ pressure pain threshold. The inter-rater reliability was analyzed in 54 athletes with symptomatic patellar tendinopathy, the intra-rater reliability was analyzed in 48 athletes with symptomatic patellar tendinopathy. During the procedure difficulties were described, the SEM, intra class correlations and limits of agreement were determined using the Bland and Altman method. The feasibility of the algometer is adequate. The PPT of asymptomatic athletes differs significantly (p < .001) from athletes with a diagnosis of patellar tendinopathy. The inter-rater (ICC 0.93) and intra-rater (ICC 0.60) reliability of the pain pressure threshold are adequate to moderate. Although further research is warranted PPT algometry seems to be a feasible, reliable and useful tool in the diagnosis and treatment evaluation of athletes with patellar tendinopathy.     

Previously identified patellar tendinopathy risk factors differ between elite and sub‐elite volleyball players

Patellar tendinopathy is the most common knee injury incurred in volleyball, with its prevalence in elite athletes more than three times that of their sub‐elite counterparts. The purpose of this study was to determine whether patellar tendinopathy risk factors differed between elite and sub‐elite male volleyball players. Nine elite and nine sub‐elite male volleyball players performed a lateral stop–jump block movement. Maximum vertical jump, training history, muscle extensibility and strength, three‐dimensional landing kinematics (250 Hz), along with lower limb neuromuscular activation patterns (1500 Hz), and patellar tendon loading were collected during each trial. Multivariate analyses of variance (P < 0.05) assessed for between‐group differences in risk factors or patellar tendon loading. Significant interaction effects were further evaluated using post‐hoc univariate analysis of variance tests. Landing kinematics, neuromuscular activation patterns, patellar tendon loading, and most of the previously identified risk factors did not differ between the elite and sub‐elite players. However, elite players participated in a higher training volume and had less quadriceps extensibility than sub‐elite players. Therefore, high training volume is likely the primary contributor to the injury discrepancy between elite and sub‐elite volleyball players. Interventions designed to reduce landing frequency and improve quadriceps extensibility are recommended to reduce patellar tendinopathy prevalence in volleyball players.     

The prevalence of Achilles and patellar tendon injuries in Australian football players beyond a time‐loss definition

Little is known about the prevalence and associated of morbidity of tendon problems. With only severe cases of tendon problems missing games, players that have their training and performance impacted are not captured by traditional injury surveillance. The aim of this study was to report the prevalence of Achilles and patellar tendon problems in elite male Australian football players using the Oslo Sports Trauma Research Centre (OSTRC ) overuse questionnaire, compared to a time‐loss definition. Male athletes from 12 professional Australian football teams were invited to complete a monthly questionnaire over a 9‐month period in the 2016 pre‐ and competitive season. The OSTRC overuse injury questionnaire was used to measure the prevalence and severity of Achilles and patellar tendon symptoms and was compared to traditional match‐loss statistics. A total of 441 participants were included. Of all participants, 21.5% (95% CI : 17.9‐25.6) and 25.2% (95% CI 21.3‐29.4) reported Achilles or patellar tendon problems during the season, respectively. Based on the traditional match‐loss definition, a combined 4.1% of participants missed games due to either Achilles or patellar tendon injury. A greater average monthly prevalence was observed during the pre‐season compared to the competitive season. Achilles and patellar tendon problems are prevalent in elite male Australian football players. These injuries are not adequately captured using a traditional match‐loss definition. Prevention of these injuries may be best targeted during the off‐ and pre‐season due to higher prevalence of symptoms during the pre‐season compared to during the competitive season.     

Leg stiffness changes in athletes with Achilles tendinopathy

Overuse injuries of the Achilles tendon cause impairment in lower leg muscle-tendon function. The purpose of this study was to evaluate leg stiffness in patients suffering unilateral Achilles tendinopathy. 51 athletes with unilateral Achilles tendinopathy underwent leg stiffness testing by modeling the vertical ground reaction force in a contact mat, measuring flight and contact time during hopping. Clinical status was estimated with a pain VAS and a validated questionnaire (VISA-A). The 'leg stiffness ratio' (LSR=stiffness of injured leg/stiffness of healthy leg) was calculated to determine the relative patient affectation and for intra-group comparison. 84 percent of subjects showed lower leg stiffness in the affected side during hopping. Leg stiffness was significantly lower in the limb affected by Achilles tendinopathy than in the healthy side (14.07±3.74 kN/m vs. 15.61±4.01 kN/m, p=0.047); overall LSR was 0.90±0.09. Intra-group comparison did not show significant differences related to patients' age, gender, sport level, and site of tendon injury (midportion or insertional). Leg stiffness was significantly reduced in patients with unilateral Achilles tendinopathy probably related to increasing ankle compliance. Regular leg stiffness assessment would be beneficial for athletes suffering Achilles tendon problems in terms of quantifying performance capabilities and providing objective data for a safer return to sport activity.     

Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players.

Patellar tendon injury, a chronic overuse injury characterised by pain during tendon loading, is common in volleyball players and may profoundly restrict their ability to compete. This cross-sectional study investigated the association between performance factors and the presence of patellar tendon injury. These performance factors (sit and reach flexibility, ankle dorsiflexion range, jump height, ankle plantarflexor strength, years of volleyball competition and activity level) were measured in 113 male and female volleyball players. Patellar tendon health was determined by measures of pain and ultrasound imaging. The association between these performance factors and patellar tendon health (normal tendon, abnormal imaging without pain, abnormal imaging with pain) was investigated using analysis of variance. Only reduced ankle dorsiflexion range was associated with patellar tendinopathy (p<0.05). As coupling between ankle dorsiflexion and eccentric contraction of the calf muscle is important in absorbing lower limb force when landing from a jump, reduced ankle dorsiflexion range may increase the risk of patellar tendinopathy.     

Variations in jump height explain the between‐sex difference in patellar tendon loading during landing

Patellar tendinopathy is the most common overuse knee injury in volleyball, with men reporting more than twice the injury prevalence than women. Although high patellar tendon loading is thought to be a causative factor of patellar tendinopathy, it is unknown whether between‐sex variations in landing technique account for differences in patellar tendon loading. It was hypothesized that male volleyball players would display differences in landing technique and would generate higher patellar tendon loading than their female counterparts. The landing technique and patellar tendon loading of 20 male and 20 female volleyball players performing a lateral stop‐jump block movement were collected. Independent t‐tests were used to identify any between‐sex differences in landing technique with the data grouped to account for differences in jump height and in anthropometry. Male volleyball players were taller and heavier, landed from a higher height, displayed differences in landing kinematics, generated a significantly greater knee extensor moment, and experienced higher patellar tendon loading than female players when all 40 participants were compared. However, when participants were matched on jump height, they generated similar patellar tendon loading, irrespective of their sex. These results imply that jump height is a more important determinant of patellar tendon loading than sex.     

Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes

BACKGROUND: Neovascularisation can be detected qualitatively by Power Doppler in Achilles tendinopathy. Quantitative data regarding tendon microcirculation have not been established and may be substantial. PURPOSE: To assess the microcirculation of the Achilles tendon and the paratendon in healthy volunteers as well as in athletes with either midportion or insertional tendinopathy. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In 66 physically active volunteers, parameters of Achilles tendon and paratendon microcirculation, such as tissue oxygen saturation, relative postcapillary venous filling pressures, and microcirculatory blood flow, were determined at rest at 2-mm and 8-mm tissue depths. Forty-one patients never had Achilles pain (25 men, 27 +/- 8 years), 14 patients had insertional pain (7 men, 29 +/- 8 years), and 11 patients had midportion tendinopathy (7 men, 38 +/- 13 years, not significant). RESULTS: Achilles tendon diameter 2 cm and 6 cm proximal to the insertion was increased in symptomatic tendons. Compared with the uninvolved opposite tendon, deep microcirculatory blood flow was significantly elevated at insertional (160 +/- 79 vs 132 +/- 42, P < .05) as well as in midportion tendinopathy (150 +/- 74 vs 119 +/- 34, P < .05). The microcirculation in the uninvolved opposite tendon and the normal athlete controls were not significantly different from each other (132 +/- 42 insertional asymptomatic vs 119 +/- 34 mid-portion vs 120 +/- 48 healthy tendon). Insertional paratendon deep microcirculatory flow was elevated in all groups, whereas tissue oxygen saturation and relative postcapillary venous filling pressures were not significantly different. CONCLUSION: Microcirculatory blood flow is significantly elevated at the point of pain in insertional and midportion tendinopathy. Postcapillary venous filling pressures are increased at both the midportion Achilles tendon and the midportion paratendon, whereas tissue oxygen saturation is not different among the studied groups. We found no evidence of an abnormal microcirculation of the asymptomatic limb in Achilles tendinopathy.     

Standardized pain mapping for diagnosing Achilles tendinopathy

ObjectivesTo assess the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy.DesignCross-sectional study.MethodsEligible patients were adults visiting a sports physician for symptoms in the Achilles tendon region. Patients completed a digital questionnaire and indicated one location on a pain map where they experienced their pain. The primary outcome measure was level of agreement (% and Kappa coefficient) between patient-reported pain on the pain map and the physician-determined clinical diagnosis (defined as localized pain associated with tendon-loading activities and pain on palpation with or without tendon thickening). The secondary outcome measure was the agreement between the location on the pain map (midportion/insertional region) with the clinical diagnosis of midportion/insertional Achilles tendinopathy.Results110 patients (mean (SD) age 48 (13), 61% men) with pain in the Achilles region were included. In 102 (93%, Kappa = 0.86, CI 0.78–0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54–0.79).ConclusionsThere is almost perfect agreement between patient-reported pain on a pain map and a physician-established clinical diagnosis of Achilles tendinopathy. There was substantial agreement between the localization of the pain that was selected by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. This tool could potentially aid in adequate triage for specialized care and for researchers performing large epidemiological studies.     

Imaging the infrapatellar tendon in the elite athlete

Extensor mechanism injuries constitute a major cause of anterior knee pain in the elite athlete. Sonography and magnetic resonance imaging (MRI) are the imaging methods of choice when assessing the infrapatellar tendon. A comprehensive imaging review of infrapatellar tendon normal anatomy, tendinopathy, and partial/full-thickness tendon tears is provided. The value of imaging the infrapatellar tendon in clinical practice, including whether sonography can predict symptoms in asymptomatic athletes, is discussed. Acute avulsion fractures, including periosteal sleeve avulsion, and chronic avulsion injuries, including Sinding-Larsen-Johansson and Osgood-Schlatter syndromes, are shown. Mimics of infrapatellar tendon pathology, including infrapatellar plica injury, patellar tendon-lateral femoral condyle friction syndrome, and Hoffa's syndrome, are illustrated.     

Achilles tendinopathy in club runners

Ultrasound (US) changes within the Achilles tendon are present in asymptomatic Achilles individuals. We assessed the association of US signs with symptoms of Achilles tendinopathy in a study group of club level running athletes and in a control group of athletes training at least 2 times per week. The Achilles tendon was assessed in its entirety on longitudinal US scans, at the musculotendinous junction (MTJ), the calcaneal insertion site, and at a midtendon point. 25 middle distance runners, 19 males and 6 females, aged from 18 to 58, were enrolled in each group. When compared to control athletes, club level runners presented significantly increased tendon thickness (p=0.046) at the musculo-tendinous junction, and increased tendon thickness, with no statistical significance, at the other landmarks points. Although club level runners were significantly more symptomatic and predisposed to develop signs of tendinopathy than control athletes (p=<0.001), ultrasound abnormalities were not significantly associated with local symptoms complained at the US investigation time. Prospective studies on asymptomatic athletes are needed to define the predictive value of US signs of Achilles tendinopathy in the development of symptoms in the long-term.     

Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations

Formerly known as 'jumper's knee', patellar tendinopathy gives rise to considerable functional deficit and disability in recreational as well as professional athletes. It can interfere with their performance, often perseveres throughout the sporting career and may be the primary cause to end it. The diagnosis of patellar tendinopathy is primarily a clinical one but new imaging techniques, such as Doppler ultrasonography, may provide additional diagnostic value. Current therapeutic protocols are characterised by wide variability ensuing from anecdotal experience rather than evidence. Moreover, numerous reports in recent years have shattered previous doctrines and dogmatic belief on tendon overuse. Histopathological and biochemical evidence has indicated that the underlying pathology of tendinopathy is not an inflammatory tendinitis but a degenerative tendinosis. Consequently, pain in chronic patellar tendinopathy is not inflammatory in nature, but its exact origin remains unexplained. In pursuit of pathology- and evidence-based management, conservative therapy should be shifted from anti-inflammatory strategies towards a complete rehabilitation with eccentric tendon strengthening as a key element. If conservative management fails, surgery is opted for. However, considering the heterogeneity of surgical procedures and the absence of randomised studies, no conclusive evidence can be drawn from the literature regarding the effectiveness of surgical treatment for patellar tendinopathy. Parallel with the improved knowledge on the pathophysiology and pain mechanisms in patellar tendinopathy, new treatment strategies are expected to emerge in the near future.     

Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Victorian Institute of Sport tendon study group

BACKGROUND: Palpation is an important clinical test for jumper's knee. OBJECTIVES: To (a) test the reproducibility of palpation tenderness, (b) evaluate the sensitivity and specificity of palpation in subjects with clinical symptoms of jumper's knee, and (c) determine whether tenderness to palpation may serve as a useful screening test for patellar tendinopathy. The yardstick for diagnosis of patellar tendinopathy was ultrasonographic abnormality. METHODS: In 326 junior symptomatic and asymptomatic athletes' tendons, palpation was performed by a single examiner before ultrasonographic examination by a certified ultrasound radiologist. In 58 tendons, palpation was performed twice to test reliability. Tenderness to palpation was scored on a scale from 0 to 3 where 0 represented no pain, and 1, 2, and 3 represented mild, moderate, and severe tenderness respectively. RESULTS: Patellar tendon palpation was a reliable examination for a single examiner (Pearson r = 0.82). In symptomatic tendons, the positive predictive value of palpation was 68%. As a screening examination in asymptomatic subjects, the positive predictive value of tendon palpation was 36-38%. Moderate and severe palpation tenderness were better predictors of ultrasonographic tendon pathology than absent or mild tenderness (p<0.001). Tender and symptomatic tendons were more likely to have ultrasound abnormality than tenderness alone (p<0.01). CONCLUSIONS: In this age group, palpation is a reliable test but it is not cost effective in detecting patellar tendinopathy in a preparticipation examination. In symptomatic tendons, palpation is a moderately sensitive but not specific test. Mild tenderness in the patellar tendons in asymptomatic jumping athletes should be considered normal.     

Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study

Objectiveto examine psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy as well as the association between psychological factors and tendinopathy severity, sport participation, and satisfaction with activity level and tendon function.Designcross-sectional study. Setting: online survey platform.Participants119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy.Main outcome measuresA range of patient-reported psychological and outcome measures were recorded. Multivariate regression analyses were performed to establish the association between each psychological factor and outcome measures, adjusted for relevant confounders.ResultsPsychological readiness and confidence to return to sports (I-PRRS) and pain catastrophizing (PCS) were significantly associated with tendinopathy severity (modified VISA), sport participation(OSTRC-O), and satisfaction. Kinesiophobia (TSK) and the importance to patients of returning to pre-injury activity level were significantly associated with sports participation and satisfaction.ConclusionThe current study provides evidence of impairments in psychological factors during rehabilitation of patients with Achilles and patellar tendinopathy. Most investigated psychological factors were associated with tendinopathy severity, function, participation, and satisfaction. Physical therapists should recognize patients with lack of psychological readiness to return to sports and also patients with kinesiophobia or catastrophizing thoughts when experiencing pain.     

Noninsertional Achilles tendinopathy: Pathology and management

Many patients present to their physician's office with the chief complaint of pain at the Achilles tendon. This review discusses the pathology, diagnosis, and treatment of Achilles tendinopathy. Achilles tendinopathy is generally caused by chronic stress to the tendon, leading to a defective arrangement of collagen fibers in the Achilles tendon. This then results in pain and limited function. Ultrasound imaging can help identify the abnormal portion of the tendon. Various treatments are available for Achilles tendinopathy, the most current of which are discussed in this article. Appropriate treatment can potentially lead to a full recovery.     

Patellar tendinopathy in athletes. Outcome of nonoperative and operative management

We report the results of nonoperative and operative management of patellar tendinopathy in 42 athletes with Blazina stage 2 (26 patients) or stage 3 (16 patients) patellar tendinopathy. All patients were initially managed nonoperatively with nonsteroidal antiinflammatory drugs, physical therapy, and a progressive rehabilitation program based on isometric exercises, stretching, and eccentric exercises. After 6 months, 33 patients showed symptomatic improvement and were able to resume their sports. In nine patients with Blazina stage 3 tendinopathy, nonoperative measures failed, and surgery was performed. Operative treatment consisted of removal of the degenerated areas of the tendon, multiple longitudinal tenotomies, and drilling of the lower pole of the patella at the site of tendon attachment. Histologic examination of the excised tendon tissue showed areas of necrosis and mucoid degeneration, and alterations of the bone-tendon junction. After a mean follow-up of 4.8 years, clinical results were excellent or good in all patients. In the group treated nonoperatively, results were better in the patients who had stage 2 tendinopathy than in those with stage 3.