Treatment of patellar tendinopathy in sportsmen through In Percutaneous Intratendon Electrolysis (PIE)

Jose Manuel Sánchez PhsD,PsyD,PT
Professor of the Master High Performance of the F.C.Barcelona
International Center Sports Rehabilitation of Barcelona (Spain)
C/ Comte d’Urgell nº 182,etlo 5ª.Barcelona,Spain
Telephone: 0034934523510

PURPOSE:

Patellar tendinopathy or “jumper’s knee”is considered more a degenerative process than an“inflamed tendinitis”proper . Histopatológical studies do not show the presence of the inflamationary cells, rather disruption of the collagen fibres,degeneration (deterioration) of the mixoide anoxic signs of tenocitos.The Intratendon Electrolysis Percutaneous (PIE) consists in the application of high intensity current through cathodic needles provoking an electro-chemical reaction in the region of the degenerated tendon.The disassociation of the water and salt molecules into their constitutional elements will cause, through ionic instability . The reaction organic produced under the active electrode or cathode needle will provoke very localised inflammation, only and exclusively, in the region we are treating, allowing fagocitosis and the healing of the tendon.

MATERIALS AND METHODS:

A survival analysis is done, using the Kaplan-Meier method according to the Victorian Institute of Sport Assessment (VISA) classification, on 34 sportsmen with patellar tendinopathy who have been treated with PIE .

Fig1: patellar tendon anesthesia

Fig. 3: Sportsman with patellar tendonitis of a year of evolution, A) treatment with PIE in inferior border patellar.B)PIE in medial face of the patellarp tendon (SànchezJM, 2002).

The number of knees treated was 39 with an age range of 16 to 53 years (average 25.4 years). Of the 34 patients , 33 were diagnosed with entesopathy of the inferior pole of the patella and only one case presented entesopathy quadricipital associated with entesopathy patellar.The range of clinical evolution was between 4 and 288 weeks (an average of 19,7 months) and the time of absence from sporting activity as a consequence of the tendinopathy covered a range of between 0 and 240 weeks (an average of 12.6 months). For their first observation they were passed (assessed) through the VISA scale and depending on the result obtained by each one of the 34 patients they were categorized into two groups: GROUP 1:(17 patients who during the primary observation had a VISA <50 = Patients with the worst prognosis) and GROUP 2 (17 patients who in the primary observation had a VISA >50 = Patients with the better prognosis) The patients were placed in supine decubitus with the knee in slight flexion (+ / - 20º) placing a pad in the popliteus area.They were carried out a shave,and disinfection of the region to try with polividona yodada (Betadine). The investigator used disposable sterile gloves in each intervention.To all the patients they were applied in each session EPI during a period of fifteen seconds three or four phases respectively, using an electroestimulador of two channels (Galvanic).

RESULTS:

of the 17 patients in GROUP 1, or the worse prognosis, 7 abandoned the treatment. By the 6th. week of treatment 50.2% of the remaining patients had been cured and by eight weeks the cure rate was 77%. 27% of the patients hadn't been cured by the 10th. week of treatment.The average time spent in treatment of those who were cured in group 1 was 6.8 weeks and the average number of sessions required was 17.4. Of the 17 patients in GROUP 2, 15 were cured and 1 abandoned the treatment. The percentage of patients cured was 88% and uncured 11.7% .The average timespan of the treatment was 2.45 weeks and the average number of sessions was 8.7.In the survival function with respect to the time in weeks from the first observation to the last for the group with the worse prognosis (VISA<50) and the group with the better prognosis(VISA<50) there are differences which are statistically significant (p=0,001).Likewise in the survival function with regard to the number of sessions of treatment undergone for group1 and group 2 there are statistically significant differences (p = 0,0006).

Graph A. Function survival regarding the number of sessions for the group of worse pronostic (VISA <50) and of the group of better pronostic (VISA> 50) being the statistical significance of p = 0,0006.Graph B.. Function survival regarding the time from the first observation to the last observation for the group of worse pronostic (VISA <50) and of the group of better pronostic (VISA> 50) with differences statistically significant being the value p = 0,0001

CONCLUSION : It can be seen that the PIE technique is highly effective in the treatment of patellar tendinopathy, independently of the duration of its clinical evolution and Blazina classification, 28 patients were in stage III (82.3%) and 6 were in stage II (17.6%).The patients with the better prognosis are the ones that in the first observation had a result of VISA >50, 100% of them being cured after 15 sessions of treatment and in an average of 2.45 weeks. The patients with the worse prognosis are those who have a result of the primary observation <50.Even then, 50% were cured in 17 sessions of treatment and in a period of 6 weeks.The VISA scale is an effective instrument for the prognosis of patients with patellar tendinopathy to whom PIE is applied independently of the duration of clinical evolution.

Author references:

Sánchez,JM : Fisiopatología de la regeneración de los tejidos blandos.En Fisioterapia del aparato locomotor.Ed Mc Graw Hill.2005.
Sánchez,JM.Regeneración acelerada de las lesiones musculares en el futbolista profesional.Publicación digital en www.efisioterapia.net,2004.
Sánchez,JM .Tratamiento de la entesopatía rotuliana en deportistas mediante  Microregeneración Endógena Guiada (MEG)Análisis de supervivencia dependiendo de la clasificación Victorian Institute of Sport Assessment (VISA). Memoria de Tesis Doctoral por la  Universitat Internacional Cataluña ,2003.
Sánchez,JM. ¿Fascitis o Fasciosis plantar?.Bases biológicas de su tratamiento mediante electrólisis percutánea intratisular (EPI).Podologia Clinica 5(1)pags.22-29,2004.
Sánchez,JM.Análisis isocinético de los eversores e inversores en la estabilidad dinámica de la zona de inversión del tobillo.Revista de Fisioterapia ,vol.20,monogràfico,p.65-80.Madrid 1998.
Sánchez,JM,Badal L .Complicaciones en la reconstrucción del ligamento cruzado anterior de la rodilla,Divulgación Científica de los Laboratorios Carín,nº5,p.4-6.Barcelona,1997.
Sánchez,JM ,Oregui O,Gonzalez I .Terapia de Neuromodulación Percutánea (TNP) en la evolución del hombro doloroso hiperagudo.En el Third European Congress of Sports Medicine and Science in Tennis.Barcelona,2001.
Sánchez,JM .Dinamometría muscular isocinética.  Revista de Fisioterapia,nº2,1993.
Sánchez,JM.Síndrome de fricción de la bandeleta iliotibial.Tratamiento mediante Electrólisis Percutánea Intratisular (EPI) asociado a microregeneración percutánea. Publicación digital en www.efisioterapia.net,2004
Sánchez ,JM.Modelos teóricos del dolor en la tendinopatía rotuliana del deportista.Publicación digital en www.efisioterapia.net;2003
Sánchez, JM.Terapia acelerada de la tendinopatía rotuliana del deportista mediante la técnica de Eectrólisis Percutánea Transtendinosa (EPI).Publicación digital en www.efisioterapia.net,2003
Sánchez JM .Bases científicas de la fisioterapia acelerada en la reconstrucción del LCA mediante la técnica de H-T-H.Publicación digital en www.efisioterapia.net,2003.

1.Almekinders, LC.,Temple, JD.:Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 30, 1183,1998.
2.Almekinders LC., Vellema JH., Weinhold PS.:Strain patterns in the patellar tendon and the implications for patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc.Jan;10(1):2-5. Epub 2001 Aug 16,2002.
3.Blazina, ME., Kerlan, RK., Jobe, FW., Carter, VS.,Carlson, JG.:Jumper's knee. Orthop Clin North Am 4, 665,1973.
4.Bodne D., Quinn SF., Murray WT., Bolton T, Rudd S., Lewis K., Daines P, Bishop J., Cochran C.:Magnetic resonance images of chronic patellar tendinitis. Skeletal Radiol. 17(1):24-8,1988.
5.Bolga, LA., Keskula, DR.:Reliability of lower extremity functional performance tests. J Orthop Sports Phys Ther 26, 138,1997.
6.Bose, K., Kanagasuntheram, R.,Osman, MBH.:Vastus medialis oblique: an anatomical and physiologic study. Orthopedics 3, 880,1980.
7.Carr JC., Hanly S., Griffin J., Gibney R.:Sonography of the patellar tendon and adjacent structures in pediatric and adult patients. AJR Am J Roentgenol.  Jun;176(6):1535-9,2001.
8.Clancy, WG. Leadbetter, WB., Buckwalter, JA., Gordon, SL.: Sports-Induced Inflammation. (American Academy of Orthopaedic Surgeons, Park Ridge, IL),1990.
9.Coleman BD., Khan KM., Kiss ZS, Bartlett J., Young DA., Wark JD.:Open and arthroscopic patellar tenotomy for chronic patellar tendinopathy. A retrospective outcome study. Victorian Institute of Sport Tendon Study Group. Am J Sports Med. Mar-Apr;28(2):183-90,2000.
10.Coleman BD., Khan KM., Maffulli N., Cook JL., Wark JD.:Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports.Feb;10(1):2-11,2000.
11.Colosimo, AJ., Bassett, FH.:Jumper's knee: diagnosis and treatment .Orthop Rev 19, 139,1990.
12.Cook JL., Khan KM., Kiss ZS., Purdam CR., Griffiths L.:Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J Ultrasound Med.Jul;19(7):473-9,2000.
13.Cook, JL., Khan, KM., Harcourt, PR., Grant, M., Young, DA., Bonar, SF.:A cross sectional study of 100 athletes with jumper's knee managed conservatively and surgically .Br J Sports Med 31, 332,1997.
14.Cook JL., Khan KM., Harcourt PR., Kiss ZS., Fehrmann MW., Griffiths L., Wark JD.:Patellar tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian Institute of Sport Tendon Study Group. Clin J Sport Med. Apr;8(2):73-7,1998.
15.Cook JL., Khan KM., Harcourt PR., Grant M., Young DA., Bonar SF.:A cross sectional study of 100 athletes with jumper's knee managed conservatively and surgically. The Victorian Institute of Sport Tendon Study Group. Br J Sports Med. Dec;31(4):332-6,1997.
16.Cook JL., Khan KM.:What is the most appropriate treatment for patellar tendinopathy?. Br J Sports Med.Oct;35(5):291-4,2001.
17.Danova NA., Muir P.:Extracorporeal shock wave therapy for supraspinatus calcifying tendinopathy in two dogs. Vet Rec.Feb 15;152(7):208-9,2003.
18.Dye SF., Campagna-Pinto D., Dye CC., Shifflett S., Eiman T.:Soft-tissue anatomy anterior to the human patella. Bone Joint Surg Am. Jun;85-A(6):1012-7, 2003.
19.Dye SF.:Functional morphologic features of the human knee: an evolutionary perspective. Clin Orthop.May;(410):19-24,2003.
20.Dye SF., Vaupel GL., Dye CC.:Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med.Nov-Dec;26(6):773-7,1998.
21.Eifert-Mangine, M., Brewster, C., Wong, M., et al.:Patellar tendinitis in the recreational athlete. Orthopedics 15, 1359,1992.
22.Ferretti, A.:Epidemiology of jumper's knee. Sports Med 3, 289,1986.
23.Ferretti, A., Puddu, G., Mariani, PP.,Neri, M.:The natural history of jumper's knee: patellar or quadriceps tendonitis. Int Orthop 8, 239,1985.
24.Ferretti, A., Ippolito, E., Mariani, P., Puddu, G.:Jumper's knee .Am J Sports Med 11, 58,1983.
25.Fyfe I., Stanish WD.: The use of eccentric training and stretching in the treatment and prevention of tendon injuries. Clin Sports Med. Jul;11(3):601-24,1992.
26.Fornage BD., Rifkin MD., Touche DH., Segal PM.: Sonography of the patellar tendon: preliminary observations. AJR Am J Roentgenol.Jul;143(1):179-82,1984.
27.Gerster JC., Landry M, Rappoport G., Rivier G., Duvoisin B., Schnyder P.: Enthesopathy and tendinopathy in gout: computed tomographic assessment. Ann Rheum Dis.Dec;55(12):921-3,1996.
28.Gothelf A., Mir LM., Gehl J.: Electrochemotherapy: results of cancer treatment using enhanced delivery of bleomycin by electroporation. Cancer Treat Rev.  Oct;29(5):371-87,2003.
29.Greene BL.: Physical therapist management of fluoroquinolone-induced Achilles tendinopathy. Phys Ther. Dec;82(12):1224-31,2002.
30.Haake M., Wirth T., Schmitt J.:Focussing of extracorporal shock wave therapy (ESWT) in the treatment of calcifying tendinitis. Joint Bone Spine. May;69 (3) : 344-5,2002.
31.Hayes DW J.r, Gilbertson EK., Mandracchia VJ., Dolphin TF.:Tendon pathology in the foot. The use of corticosteroid injection therapy. Clin Podiatr Med Surg.Oct;17(4):723-35,2000.
32.Hanten, WP., Schulthies, SS.:Exercise effect on electromyographic activity of the vastus medialis oblique and vastus lateralis muscles. Phys Ther 70, 561,1990.
33.Haspl M., Dubravcic-Simunjak S., Bojanic I., Pecina M.:Anterior knee pain associated with sports and work. Arh Hig Rada Toksikol. Dec;52(4):441-9,2001.
34.Haupt G.:Use of extracorporeal shock waves in the treatment of pseudarthrosis tendinopathy and other orthopedic diseases. Urol. Jul;158(1):4-11,1997.
35.Heller R., Coppola D., Pottinger C., Gilbert R., Jaroszeski MJ.: Effect of electrochemotherapy on muscle and skin. Technol Cancer Res Treat. Oct;1(5):385-92,2002.
36.Hess GP., Cappiello W.L, Poole RM., Hunter SC.: Prevention and treatment of overuse tendon injuries. Sports Med.Dec;8(6):371-84,1989.
37.Hodges, PW.,Richardson, CA.:The influence of isometric hip adduction on quadriceps femoris activity. Scand J Rehabil Med 25, 57,1993.
38.Horvath G.: Therapy of injuried Achilles tendon in athletes with balneotherapy in Piestany. Acta Chir Orthop Traumatol Cech. Feb;35(1):86-8,1968.
39.Jakob RP., Segesser B.: Extension training of the quadriceps-a new concept in the therapy of tendinoses of the knee extensor apparatus (jumper's knee). Orthopade. Jun;9(3):201-6,1980.
40.Jaroszeski MJ., Coppola D., Pottinger C., Gilbert RA, Heller R.: Electrochemotherapy for the treatment of human sarcoma in athymic rats. Technol Cancer Res Treat.Oct;1(5):393-9,2002.
41.Jozsa, L.,Kannus, P.:Human Tendons: Anatomy, Physiology, and Pathology. (Human Kinetics, Champaign, IL),1997.
42.Karst, GM., Jewett, PD. :Electromyographic analysis of exercises proposed for differential activation of medial and lateral quadriceps femoris muscle components. Phys Ther 73: 286,1993.
43.Khan, KM., Cook, JL., Bonar, F., Harcourt, P.,Astrom, M.:Histopathology of common tendinopathies: update and implications for clinical management .Sports Med 27, 393,1999.
44.Khan KM., Visentini PJ., Kiss ZS., Desmond PM., Coleman BD., Cook JL., Tress BM., Wark JD., Forster BB.:Correlation of ultrasound and magnetic resonance imaging with clinical outcome after patellar tenotomy: prospective and retrospective studies. Victorian Institute of Sport Tendon Study Group. Clin J Sport Med.Jul;9(3):129-37,1999.
45.Khan KM., Cook JL., Kiss ZS., Visentini PJ., Fehrmann MW., Harcourt PR., Tress BW., Wark JD.: Patellar tendon ultrasonography and jumper's knee in female basketball players: a longitudinal study. Clin J Sport Med. Jul;7(3):199-206,1997.
46.Khan KM., Bonar F., Desmond PM., Cook JL., Young DA., Visentini PJ., Fehrmann MW., Kiss ZS., O'Brien PA., Harcourt PR., Dowling RJ., .O'Sullivan RM., Crichton KJ., Tress BM., Wark JD. :Patellar tendinosis (jumper's knee): findings at histopathologic examination, US, and MR imaging. Victorian Institute of Sport Tendon Study Group. Radiology. Sep;200(3):821-7,1996.
47. Khan K; Cook J.:The painful nonruptured tendon: clinical aspects. Clin Sports Med. Oct;22(4):711-25,2003.
48.Kelly, DW., Carter, VS., Jobe, FW.,Kerlan, RK.:Patellar and quadriceps tendon ruptures: jumper's knee. Am J Sports Med 12, 3,1984.
49.Kettunen JA., Kvist M., Alanen E., Kujala UM.: Long-term prognosis for jumper's knee in male athletes. A prospective follow-up study. Am J Sports Med. Sep-Oct;30(5):689-92,2002.
50.Kitamura A.: Bleomycin-mediated electrochemotherapy in mouse NR-S1 carcinoma. Cancer Chemother Pharmacol. Apr;51(4):359-62. Epub 2003 Mar 21,2003.
51.Krahl H.:Jumper's knee"-etiology, differential diagnosis, and therapy. Orthopade.Jun;9(3):193-7,1980.
52.Kujala, UM., Jaakkola, LH., Koskinen, SK., Taimela, S., Hurme, M., Nelimarkka, O.:Scoring of patellofemoral disorders.Arthroscopy 9, 159,1993.
53.Kujala, UM., Osterman, K., Kvist, M., Aalto, T.,Friberg, O.:Factors predisposing to patellar chondroplasty and patellar apicitis in athletes .Int Orthop 10, 195,1986.
54.Kujala UM., Kvist M, Osterman K.:Knee injuries in athletes. Review of exertion injuries and retrospective study of outpatient sports clinic material. Sports Med.  Nov-Dec;3(6):447-60,1986.
55.Kvist M., Jarvinen M.:Clinical, histochemical and biomechanical features in repair of muscle and tendon injuries. Int J Sports Med.Feb;3 Suppl 1:12-4,1982.
56.Laine HR., Harjula A., Peltokallio P.:Ultrasound in the evaluation of the knee and patellar regions. J Ultrasound Med.Jan;6(1):33-6,1987.
57.Laprade, J., Culham, E., Brouwer, B.: Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 27:197,1998.
58.Leadbetter, WB.:Cell-matrix response in tendon injury .Clin Sports Med 11, 533,1992.
59.Lian O., Holen KJ., Engebretsen L., Bahr R.: Relationship between symptoms of jumper's knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Sci Sports. Oct;6(5):291-6,1996.
60.Luo QD., Xing ZM., Xiao W., Dai N., Shan YH., Huang GY., Luo SL.: Clinical observations in 185 cases of ligament and tendon injuries treated by the method of dissipating blood stasis and promoting the meridian.Tradit Chin Med. Mar;9(1):15-7,1989.
61.Maddox PA., Garth WP Jr.: Tendinitis of the patellar ligament and quadriceps (jumper's knee) as an initial presentation of hyperparathyroidism. A case report. Bone Joint Surg Am. Feb;68(2):288-92,1986.
62.Magalini, SI.,Magalini, SC.:Dictionary of Medical Syndromes 4th ed .(Lippincott-Raven Publishers, Philadelphia, PA,1997.
63.Marsolais D., Cote CH., Frenette J.: Nonsteroidal anti-inflammatory drug reduces neutrophil and macrophage accumulation but does not improve tendon regeneration. Lab Invest.Jul;83(7):991-9,2003.
64.Martin DF., Carlson CS., Berry J., Reboussin BA., Gordon ES., Smith BP.: Effect of injected versus iontophoretic corticosteroid on the rabbit tendon. South Med J. Jun;92(6):600-8,1999.
65.Min BH., Han MS., Woo JI, Park HJ., Park SR.: The origin of cells that repopulate patellar tendons used for reconstructing anterior cruciate ligaments in man. J Bone Joint Surg Br. Jul;85(5):753-7,2003.
66.Mohtadi, N.: Development and validation of the quality of life outcome measure (questionnaire) for chronic anterior cruciate ligament deficiency .Am J Sports Med 26, 350,1998.
67.Miyazaki S., Gunji Y., Matsubara H., Shimada H., Uesato M., Suzuki T., Kouzu T., Ochiai T.: Possible involvement of antitumor immunity in the eradication of colon 26 induced by low-voltage electrochemotherapy with bleomycin. Surg Today.33(1):39-44,2003.
68.Noyes, FR., McGinniss, GH., Mooar, LA.:Functional disability in the anterior cruciate insufficient knee syndrome: knee rating systems and projected risk factors in determining treatment.Sports Med 1, 278,1984.
69.Orava S., Osterback L., Hurme M.:Surgical treatment of patellar tendon pain in athletes. Br J Sports Med.Dec;20(4):167-9,1986.
70.Orava S., Rantanen J., Kujala UM.: Fasciotomy of the posterior femoral muscle compartment in athletes. Int J Sports Med.Jan;19(1):71-5,1998.
  71.Orava S., Kujala UM.: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med.Nov-Dec;23(6):702-5,1995. 
  72.Paavola M., Kannus P., Jarvinen TA., Jarvinen TL., Jozsa L., Jarvinen M.: Treatment of tendon disorders. Is there a role for corticosteroid injection?. Foot Ankle Clin.Sep;7(3):501-13,2002.
73.Paavola M., Kannus P., Jarvinen TA., Khan K., Jozsa L., Jarvinen M.: Achilles tendinopathy. J Bone Joint Surg Am.Nov;84-A(11):2062-76,2002.
  74.Peers KH., Lysens RJ., Brys P., Bellemans.:Cross-sectional outcome analysis of athletes with chronic patellar tendinopathy treated surgically and by extracorporeal shock wave therapy. Clin J Sport Med. Mar;13(2):79-83,2003.
75.Perlick L., Korth O., Wallny T., Wagner U., Hesse A., Schmitt O.: The mechanical effects of shock waves in extracorporeal shock wave treatment of calcific tendinitis--an in vitro model. Z Orthop Ihre Grenzgeb.Jan-Feb;137(1):10-6,1999.
76.Petschnig, R., Baron, R.,Albrecht, M.: The relationship between isokinetic quadriceps strength test and hop tests for distance and one-legged vertical jump test following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 28, 23,1998.
77.Pierets K., Verdonk R., De Muynck M., Lagast J.:Jumper's knee: postoperative assessment. A retrospective clinical study. Knee Surg Sports Traumatol. Arthrosc. 7(4):239-42,1999.
78.Popp, JE., Yu, JS.,Kaeding, CC. :Recalcitrant patellar tendinitis: magnetic resonance imaging, histologic evaluation, and surgical treatment .Am J Sports Med 25, 218,1.
79.Puddu G. The effect of volleyball playing on the knee extensor mechanism. Am J Sports Med. 1990 Jan-Feb;18(1):112.
80.Richards DP., Ajemian SV., Wiley JP., Brunet JA., Zernicke RF.: Relation between ankle joint dynamics and patellar tendinopathy in elite volleyball players. Clin J Sport Med.Sep;12(5):266-72,2002.
81.Richards DP., Ajemian SV., Wiley JP., Zernicke RF.: Knee joint dynamics predict patellar tendinitis in elite volleyball players. Am J Sports Med. Sep-Oct;24(5):676-83,1996.
82.Robinson JM., Cook JL., Purdam C., Visentini PJ., Ross J., Maffulli N., Taunton JE., Khan KM.: The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achillestendinopathy. Br J Sports Med. Oct;35(5):335-41,2001.
83.Roels, J., Martens, M., Mulier, JC., Burssens, A.: Patellar tendinitis (jumper's knee). Am J Sports Med 6, 362,1978.
84.Salomskaite-Davalgiene S., Venslauskas MS., Pauziene N.:Histological analysis of electrochemotherapy influence in Lewis lung carcinoma. Medicina (Kaunas).38(5):540-4,2002.
85.Sandmeier R., Renstrom PA.:Diagnosis and treatment of chronic tendon disorders in sports. Scand J Med Sci Sports. Apr;7(2):96-106,1997.
86.Sanchis-Alfonso V., Rosello-Sastre E., Subias-Lopez A.:Neuroanatomic basis for pain in patellar tendinosis ("jumper's knee"): a neuroimmunohistochemical study. Am J Knee Surg. Summer;14(3):174-7,2001.
87.Sanchis-Alfonso V., Rosello-Sastre E.:Immunohistochemical analysis for neural markers of the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A neuroanatomic basis for anterior knee pain in the active young patient. Am J Sports Med.Sep-Oct;28(5):725-31,2000.
 88.Sanchis-Alfonso V., Rosello-Sastre E., Monteagudo-Castro C., Esquerdo J.:Quantitative analysis of nerve changes in the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A preliminary study. Am J Sports Med. Sep-Oct;26(5):703-9,1998.
 89.Sanchis-Alfonso V., Subias-Lopez A., Monteagudo-Castro C., Rosello-Sastre E.:Healing of the patellar tendon donor defect created after central-third patellar tendon autograft harvest. A long-term histological evaluation in the lamb model. Knee Surg Sports Traumatol Arthrosc.7(6):340-8,1997.
90.Scranton, PE.,Farrar, EL.:Mucoid degeneration of the patellar ligament in athletes .J Bone Joint Surg Am 74, 435,1992.
91.Seil R., Rupp S., Hammer DS., Ensslin S., Gebhardt T., Kohn D.: Extracorporeal shockwave therapy in tendionosis calcarea of the rotator cuff: comparison of different treatment protocols. Orthop Ihre Grenzgeb.Jul-Aug;137(4):310-5,1999.
92.Schmid MR., Hodler J., Cathrein P., Duewell S., Jacob HA., Romero J.:Is impingement the cause of jumper's knee? Dynamic and static magnetic resonance imaging of patellar tendinitis in an open-configuration system. Am J Sports Med.May-Jun;30(3):388-95,2002.
93.Shimizu T., Nikaido T., Gomyo H., Yoshimura Y., Horiuchi A., Isobe K., Ebara S., Takaoka K.:Electrochemotherapy for digital chondrosarcoma. J Orthop Sci. ;8(2):248-51,2003.
94.Stanish, WD., Rubinovich, RM.,Curwin, S.: Eccentric exercise in chronic tendinitis. Clin Orthop 208, 65,1986.
95.Stanish WD., Curwin S., Rubinovich M.:Tendinitis: the analysis and treatment for running. Clin Sports Med.Oct;4(4):593-609,1985.
96.Tarsney FF.:Catastrophic jumper's knee. A case report. Am J Sports Med. Jan-Feb;9(1):60-1,1981.
97.Wang LQ., Wang AM., Zhang SD.: Clinical analysis and experimental observation on acupuncture and moxibustion treatment of patellar tendon terminal disease in athletes. J Tradit Chin Med.Sep;5(3):162-6,1985.
98.Wojtys EM., Beaman DN., Glover RA., Janda D.:Innervation of the human knee joint by substance-P fibers. Arthroscopy. 6(4):254-63,1990.
99.Zakaria, D., Harburn, KL., Kramer, JF.:Preferential activation of the vastus medialis oblique, vastus lateralis, and hip adductor muscles during isometric exercises in females. J Orthop Sports Phys Ther 26, 23,1997.
100.Zarins B., Ciullo JV.: Acute muscle and tendon injuries in athletes. Clin Sports Med.Mar;2(1):167-82,1983.