Can the addition of transverse frictionmassage to an exercise programme intreatment of infrapatellar tendinopathyreduce pain and improve function?A pilot studyJoanne Blackwood1, Fery Ghazi2

1Nuffield Physiotherapy Department, Nuffield Health Ipswich Hospital, Ipswich, Suffolk, UK, 2MiddlesexUniversity, Archway Campus, London, UK

Aim: To undertake a pilot study looking at the addition of transverse friction massage (TFM) to an exerciseprogramme in treatment of infrapatellar tendinopathy to test design feasibility and assess if it can improveoutcomes of pain and function.Design: Comparative clinical trial approach with convenient sampling.Setting: A private physiotherapy clinic.Participants: Fourteen participants were allocated to group A (exercise, n= 6, mean age 38 years) or group B(TFM and exercise, n= 8, mean age 43 years).Outcome measures: A blinded assessor measured the visual analogue score (VAS) for pain and the VictorianInstitute of Sport Assessment Patellar score (VISA-P) for function before the first treatment and after the last.Intervention: Both groups attended twice a week for 3 weeks completing an exercise programme of eccentricexercise on a decline board and proprioceptive exercises. Group B received TFM prior to exercise. Exerciseswere also completed at home.Results: An independent t-test demonstrated that the pre/post change in scores were significantly betterin group B for pain (t(12)= 2.388, P= 0.034) and function (t(12)= 2.469, P= 0.030) with medium effect(r= 0.57). In group A, a dependent t-test demonstrated a significant difference for outcomes after treatmentwhen compared with before treatment for pain (t(5)= 3.181, P= 0.025) and function (t(5)= 5.209,P= 0.003) with high effect (r= 0.82 (VAS) and 0.92 (VISA-P)). In group B, a dependent t-test demonstrateda significant difference for outcomes after treatment when compared with before for pain (t(7)= 7.342,P= 0.0001) and function (t(7)=−6.527, P= 0.0001) with high effect (r= 0.94 (VAS) and 0.93 (VISA-P)).Conclusion: This study demonstrated that the design was feasible with both groups significantly improvingpain/function but with significantly greater change in group B who received TFM prior to exercise. Futurestudies should use a larger sample size with a wider sampling population and long-term outcomemeasures to further test the efficacy of TFM in this setting.

Keywords: Infrapatellar tendinopathy, Tendinopathy, Jumper’s knee, Transverse friction massage, Friction massage

IntroductionInfrapatellar tendinopathy is a common conditionwith incidence as high as 40% in sports that involverepetitive high-impact jumping activities.1 It occursat the patellar enthesis in 97% of cases, is characterizedby pain over the inferior pole of the patella, and willoften affect function.2 Diagnosis of infrapatellar

tendinopathy can be made using imaging techniques;however, false-positive findings and accessibility totherapists have meant that functional testing andpalpation have continued to be used and have beendemonstrated as being moderately sensitive.2–4

Tendinopathies can affect many different areas inthe body and are thought to occur when cell matrixadaptation to trauma causes an imbalance betweendegeneration and synthesis. They are characterizedby an absence of inflammatory cells with the presence

Correspondence to: Joanne Blackwood, Nuffield PhysiotherapyDepartment, Nuffield Health Ipswich Hospital, Foxhall Road, Ipswich IP45SW, Suffolk, UK. Email: Joanne.Blackwood@nuffieldhealth.com

© W.S. Maney & Son Ltd. and the British Institute of Musculoskeletal Medicine 2012DOI 10.1179/1753615412Y.0000000005 International Musculoskeletal Medicine 2012 VOL. 34 NO. 3108

of collagen fibre disorientation/thinning, hypercellu-larity, and vascular ingrowth.5

Pain generation within tendons is not well under-stood; therefore, treatment regimes can vary betweentherapists.6 Treatment options include exercise, softtissue techniques, electrotherapy, ultrasound, andsurgery. Eccentric exercise has been the focus ofmuch of the research into tendinopathies althoughthe quality of these studies has been questioned bysome systematic reviews.6,7

As exercise has been a popular treatment modalityfor treatment of infrapatellar tendinopathies, severalstudies have used a between-subject design tocompare different types of exercise.7 One study com-pared concentric and eccentric exercise and demon-strated that eccentric exercise significantly improvedoutcome measures when compared with concentricexercise;8 however, the small sample size would affectthe generalization of this result. Another study com-pared eccentric exercise on a flat surface versus adecline board.9 Outcome measures were taken over a12-week period and again a small sample size as wellas non-random allocation was evident. It was demon-strated that eccentric exercise on a decline board wassignificantly more effective than on a flat surface butagain limitations would affect generalization of results.Two studies have subsequently investigated the

stress placed on the infrapatellar tendon in differentpositions and using electromyography (EMG) mea-surements demonstrated that activity was significantlyhigher when completing an eccentric exercise on adecline board with increased work within the kneeextensors.10,11 This was thought in part to be due toan altered centre of gravity and altered stop/startangles for the movements.Proprioceptive exercise has also been demonstrated

as being beneficial as part of an exercise programmefor treatment of lower-limb tendinopathies. In onestudy, a prospective crossover design was used toassess tendinopathies in soccer players at differentphases of the season. It was demonstrated that theaddition of balance exercises to a training programmecould significantly reduce the incidence of tendinopa-thies including infrapatellar tendinopathy.12

Transverse friction massage (TFM) is an orthopae-dic medicine technique advocated for the treatment ofinfrapatellar tendinopathy.13 The mechanism of actionof TFM is not fully understood. A reduction in painis thought to be achieved though stimulation of sensi-tized neurones and A beta fibres. Alterations in motorneurone excitability can also cause altered painpressure thresholds.13,14 A traumatic hyperaemia isalso created which is thought to remove irritants andexcite local nociceptors.13 The therapeutic movementbetween collagen fibres may also prevent the excessiveformation of cross links between collagen fibres and

allow the collagen to regain or retain its viscoelasticproperties and therefore prevent excessive strain.15

Two literature reviews have concluded that evidenceto support the use of TFM for treatment of infrapatel-lar tendinopathy is limited.16,17 One of these reviewscited methodological issues for this conclusion includ-ing small sample sizes and lack of control groupmeaning that only two studies were eligible forinclusion within the review.16 These studies comparedthe use of TFM versus no TFM in treatment of theextensor carpi radialis tendon and the addition ofTFM to normal physiotherapy in treatment of ilioti-bial band friction syndrome.18,19 Both studies con-cluded that TFM gave no additional benefit whenadded to the normal treatment option. However,despite inclusion within this review both of thesetrials were still criticized in terms of methodologicalquality due to several aspects including use of com-bined interventions and lack of double blinding.Two studies since this systematic review have

assessed the effects of TFM using a between-subjectdesign and also concluded that the addition of TFMdid not give any additional benefit to treatment.20,21

One study compared subjects receiving treatment inan exercise group to those in a TFM group to thosein an ultrasound group. Outcome measures weretaken over a total of 16 weeks; however, thesemeasures were validated only by the authors andwere therefore conceded by them as a limitation. Itwas demonstrated that the exercise group had signifi-cantly less pain than the other treatment groups.20 Asecond study compared TFM/Mills manipulationversus exercise versus polarized polychromatic non-coherent light therapy,21 and demonstrated thatTFM did not give any additional benefit althoughmethodological issues identified in systematic reviewswere still evident including small sample sizes andlack of control group.16,21

However, there have been some studies, albeit withsimilar methodological issues, which have foundTFM to be beneficial when compared with other treat-ment modalities.14,22–25 One study compared TFMand the Mills manipulation to phonophoresis withexercises in treatment of tennis elbow and demon-strated that the TFM/Mills manipulation groupsignificantly improved outcomes over 8 weeks.22

Another study compared the effect of TFM and exer-cise versus TFM, exercise and ultrasound on supraspi-natus tendinopathy, and using a purposive sample in amulti-centre location demonstrated that the additionof ultrasound did not significantly improve outcomessuggesting that TFM and exercise were valid treatmentoptions.23 The benefits of TFM were also demon-strated by another study that assessed ischaemictrigger point release with TFM in the treatment ofmyofascial trigger points. While short-term outcome

Blackwood and Ghazi TFM in treatment of infrapatellar tendinopathy

International Musculoskeletal Medicine 2012 VOL. 34 NO. 3 109

measures were used, it was demonstrated that TFMsignificantly reduced pain pressure threshold andpain scores.25

Due to the prevalence of infrapatellar tendinopathy1

and lack of consensus with regard to most effectivetreatment, this area was deemed an important topicto study. As some studies have demonstrated eccentricexercise as being an effective treatment technique,8,9

the aim of this study was therefore to establish if theaddition of TFM to an exercise programme may givebetter outcomes measures in the treatment of infrapa-tellar tendinopathy.

MethodsThis study collected quantitative data using a com-parative clinical trial approach. Ethical approval wasapplied for and granted by the School of Health andSocial Sciences Ethics committee at MiddlesexUniversity.

SampleA convenience sample was used in which referralsreceived to the department (from consultant, generalpractitioner or self-referral) who met the inclusion cri-teria (see Table 1) were invited to participate in thestudy. Subjects who gave informed consent to partici-pate were given an appointment the following weekwhere the data collection and intervention couldbegin.

RandomizationTo ensure subjects had an equal chance of being allo-cated to either treatment group and equalize anydifferences in confounding variables, they were ran-domly allocated using a random numbers table.26,27

The initial number was selected on the table witheyes closed and then numbers were selected byreading horizontally from left to right from theinitial number. Even numbers allowed for allocation

to group A (exercise) and odd numbers to group B(TFM and exercise).

InterventionsAll treatments were implemented by the researcher.Both groups completed an exercise programme con-sisting of eccentric and proprioceptive exercises.Eccentric exercises were carried out on a 25° declineboard as this has been demonstrated as being moreeffective than a flat surface.9 Three sets of 15 rep-etitions were completed and progressed with weightadded in a back pack when the exercise was deemedby the subject to be pain free. Subjects were instructedto stand up tall and try to slowly flex the knee to 90° sothat the infrapatellar tendon was maximally loaded,returning to neutral using the contralateral leg.Subjects were also informed that they might experi-ence some pain after the exercise. Proprioceptive exer-cises were included as they have been found to beeffective12 and consisted of a one-leg stand that wasprogressed to one-leg stand with cervical spine rotationand then using a wobble cushion, when 10 repetitionsof 20 seconds could be completed.

Group B received TFM to the teno-osseous junctionof the infrapatellar tendon using the technique andduration (based on acute or chronic presentation)as recommended by the Society of OrthopaedicMedicine.13 This was applied prior to the exercises.

All subjects received treatment twice a week for3 weeks. This interval was chosen due to suggestionsthat the reparative influence that TFM can have maybe present for up to 6 days.24 Subjects were alsoasked to complete the exercises at home twice a dayand to refrain from any sporting activity for the3-week duration of the study.

Data collection and analysisThe VAS was used to measure pain and VISA-P ques-tionnaire used to measure function. These outcomemeasures have been tested and deemed as reliableand valid.28–30 The outcome measures were collectedby a blinded assessor prior to the first treatment andafter the last treatment. The Kolmogrov–Smirnovtest was used to demonstrate that the VAS scores(D(6)= 0.196, P= 0.20) and VISA-P scores (D(6)=0.245, P= 0.20) were distributed normally. Thisallowed the baseline scores to be compared using anindependent t-test. To compare the two treatmentgroups and test the null hypothesis the pre to postchange in score for each outcome measure wasrecorded and then the independent t-test used to estab-lish any differences. A within-group comparison wasalso made to compare mean scores before and aftertreatment with a dependent t-test used to establishany differences. The Pearson r value was calculatedfor both between-group and within-group’s

Table 1 Inclusion and exclusion criteria

Inclusion Exclusion

Pain on palpation of the teno-osseous junction of theinfrapatellar tendon

Other structural kneepathologies

Unilateral pain Knee OAPain on resisted knee

extensionInfection

Onset of symptoms greaterthan 6 weeks

Inflammatory or traumaticarthritis

Age >18 years Cutaneous malignancyActive skin diseaseDeep vein thrombosisCardiac/respiratory problems

so unable to exerciseOther lower-limb joint

problems

Blackwood and Ghazi TFM in treatment of infrapatellar tendinopathy

International Musculoskeletal Medicine 2012 VOL. 34 NO. 3110

comparisons to assess effect size.31 Data were analysedusing SPSS version 17 (Chicago, Illinois, USA).

ResultsFourteen subjects with infrapatellar tendinopathy gaveinformed consent to participate in the study: noinvited subjects declined to participate. All subjectscompleted the study and attended all treatment ses-sions with no withdrawals. Demographic and baselineVAS and VISA-P scores are shown in Table 2 alongwith the P value for the baseline independent t-test.This test demonstrated that there was no significantdifference between the two treatment groups prior tothe interventions commencing (P> 0.05).

Pre/post change scores: between-groupcomparisonThe mean change in pre/post change scores for eachoutcome measure was compared using an independentt-test. Table 3 illustrates the mean changes in VAS andVISA-P score for each treatment group. The t-testdemonstrated that on average the changes in function(VISA-P) scores from pre- to post-test in group B(M= 25.75, SE= 3.945) was greater than group A(M= 13.50, SE= 2.172) and that this difference wassignificant t(12)= 2.469, P< 0.05. The t-test alsodemonstrated that on average the change in pain (VAS)scores from pre- to post-test in group B (M= 23.75,

SE= 3.167) was greater than group A (M= 12.17,SE 3.291) and that this difference was also significantt(12)= 2.388, P< 0.05. The Pearson r value for bothoutcome measures was 0.57 suggesting a mediumeffect size. The independent t-test has therefore suggestedthat group B had significantly greater changes in painand function when compared with group A. Fig. 1 illus-trates these results graphically.

Scores before and after treatment: within-groupcomparisonTable 4 illustrates the mean scores before and aftereach treatment for each outcome measure in groupA. The dependent t-test demonstrated that partici-pants had a significantly reduced pain (VAS) scoreafter treatment (M= 34.67, SD= 20.91) than beforetreatment (M= 46.83, SD= 19.813), t(5)= 3.698,P< 0.05. It also demonstrated that participants hada significantly higher function (VISA-P) scoreafter treatment (M= 47.83, SD= 16.85) than before(M= 34.33, SD= 12.738), t(5)=−6.216, P< 0.05.The Pearson r values were 0.82 for VAS and 0.92 forVISA-P score suggesting a large effect. The dependentt-test has therefore suggested that there was a signifi-cant difference in both outcome measures after treat-ment when compared with before in group A. Fig. 2illustrates these results graphically.Table 5 illustrates the mean scores before and after

treatment in group B. The dependent t-test demon-strated that the pain (VAS) score was significantlyless after treatment (M= 22.25, SD= 14.646) than

Table 2 Demographic data and baseline VAS and VISA-Pscores

TFM/exercisegroup Exercise group

Number of participants 8 6Male:female ratio 5:3 3:3Mean age 43 38VAS score

Mean 45.50 46.83Standard deviation 19.183 19.813Standard error mean 6.782 8.089

VISA-P scoreMean 31.50 34.33Standard deviation 18.532 12.738Standard error mean 6.552 5.20

P value 0.901 0.754

Table 3 Mean change in score for VAS and VISA-P scores

TFM/exercisegroup

Exercisegroup

VASMean −23.25 −12.17Standard deviation 8.956 8.060Standard error mean 3.167 3.291

VISA-PMean 25.75 13.50Standard deviation 11.158 5.320Standard error mean 3.945 2.172

P value 0.034 0.030Pearson’s r value 0.57 0.57

Figure 1 Mean change in scores for each treatmentoutcomes.

Table 4 Mean scores before and after treatment group A

Score beforetreatment

Score aftertreatment

VASMean 46.83 34.67Standard deviation 19.813 20.91

VISA-PMean 34.33 47.83Standard deviation 12.738 16.85

P value 0.01 0.002Pearson’s r value 0.86 0.94

Blackwood and Ghazi TFM in treatment of infrapatellar tendinopathy

International Musculoskeletal Medicine 2012 VOL. 34 NO. 3 111

before treatment (M= 45.50, SD= 14.646), t(7)=7.342, P< 0.05. It also demonstrated that function(VISA-P) scores were significantly higher after treat-ment (M= 57.25, SD= 10.647) than before treatment(M= 31.50, SD= 18.532), t(7) =− 6.527, P< 0.05.The Pearson r value was 0.92 for VAS and 0.93 forVISA-P score again suggesting a large effect. Thedependent t-test has therefore suggested that therewas a significant difference in both outcome measuresafter treatment when compared with before in groupB. Fig. 3 illustrates these results graphically.

DiscussionAlthough this was a pilot study and therefore aimed totest design feasibility, the results suggest that theaddition of TFM to an exercise programme may

significantly reduce pain and improve function in com-parison with exercise alone in the treatment of infrapa-tellar tendinopathy. This result supports several otherstudies which found that TFM produced a beneficialeffect.22–25 These studies also used a between-subjectdesign although the body sites and thereforeoutcome measures varied.22,23,25 Some studies werealso able to provide some physiological explanationsfor these beneficial results14,24 through demonstratingthe presence of a reparative process in histologicalanalysis of rabbit tendons24 and also reduced motorneurone excitability14 in those receiving TFM.

While group B was found to make significantlymore improvements in pain and function, the within-group comparison demonstrated that both treatmentgroups did significantly improve when comparingoutcome measures from before to after treatment.The use of exercise as an effective treatment modalityfor infrapatellar tendinopathy has also been demon-strated by previous studies.8,9,32,33 The findings ofthis study also support those who have demonstratedthat proprioceptive exercises can be an effective exer-cise in treatment of tendinopathies.12 However in thisstudy, due to the use of both eccentric and propriocep-tive exercises, it is not possible to distinguish whetherone exercise contributed to the reduction in pain/improvement in function more so than the other.

While the source of pain generation within tendons isstill not fully understood there have been several studiesthat have suggested mechanisms behind tendon behav-iour under stress and pain generation. One study hasdemonstrated that infrapatellar tendon collagen fibrilssignificantly elongate under stress.15 It has beensuggested that should a tendon be stressed beyond 4%then mechanical failure may occur causing failure tomediate cytokines, a loss of tenocytes and thereforelimited ability to repair.34,35 The benefits of exerciseand TFM within this study may therefore have helpedto improve pain and function through affecting thestructural aspects of healing pathology. However,studies have demonstrated that it is possible to havealtered structure within an asymptomatic tendon onimaging therefore whether structural changes causepain could still be disputed.3,4

Biochemical influences have also been demonstratedas being a potential pain source within tendons.36,37

One study found a significant increase in substance Pand calcitonin with correlations to double stance gaitin rat infrapatellar tendons.36 It has also been demon-strated that should a tendon be stressed less than 4%a significant increase in inflammatory mediatorsresulted: however, a stress of more than 4% producedan decrease in inflammatory mediators.37 It may there-fore be suggested that the influence of TFM and exer-cise may affect these mechanisms to bring about areduction in pain and increase in function.

Table 5 Mean scores before and after treatment group B

Before treatment After treatment

VASMean 45.50 22.25Standard deviation 19.183 14.646

VISA-PMean 31.50 57.25Standard deviation 18.532 10.647

P value 0.0001 0.0001Pearson’s r value 0.94 0.93

Figure 2 Mean scores for treatment outcomes before/aftertreatment group A.

Figure 3 Mean scores for treatment outcomes before/aftertreatment group B.

Blackwood and Ghazi TFM in treatment of infrapatellar tendinopathy

International Musculoskeletal Medicine 2012 VOL. 34 NO. 3112

LimitationsThis study proceeded with minimal disruptionsuggesting that the design was feasible: however,there were some limitations to this study whichshould be considered when considering the clinicalimplications of the results and in planning of futurestudies. Due to the time constraints of this study, itwas only possible to assess outcome measures over 3weeks, which would limit the applicability of theresults in the long term. As previously discussed,other studies have demonstrated that exercise can beeffective when assessed over a 12-week period;8,9,20,32

therefore, it may be appropriate for future studies toconsider at least this time frame in order to ensurethat the groups can be compared. However, the con-clusion of this study – although only applicable whenconsidering short-term outcomes – may suggest thatthe addition of TFM will be able to reduce pain andimprove function for those with infrapatellar tendino-pathy over a potentially shorter time frame than if justexercise alone was used.While the study proceeded with minimal disruption,

this could be attributed to the small sample size. Thedata collected were normally distributed whichallowed for parametric statistical analysis; however,results could be questioned due to the size of thesample. Using a sample size calculation, where adifference of 20 points was deemed to be clinically sig-nificant,38,39 the sample size for future larger-scalestudies should consist of at least 70 subjects. Futurestudies may therefore try to recruit a larger sample,which would in turn make the sample more represen-tative and give the results more clinical applicability.40

The sampling method selected for this study was oneof convenience due to the setting within the clinic. Thismay be deemed a limitation as it limits the ability togeneralize results. Future studies may therefore wishto consider a multi-centre approach which can allowfor a more representative sample, although care mustbe taken to ensure internal validity is maintained.The compliance with exercises within both groups

was neither measured nor assessed. Should compli-ance have been significantly higher in one of the treat-ment groups then this could have influenced theoutcome measure scores.There was no control group used in this study which

could be depicted as a limitation. However, it was feltthat the presence of a control group in this instancemight have brought about ethical difficulties with thestudy in terms of withholding treatment, althoughsham massage could have been considered. By ensur-ing that both groups completed the exercises andthat outcome measures were comparable at the startof the study, it was felt that the independent variableTFM was still tested effectively.

ConclusionThis study suggests that the addition of TFM to anexercise programme may significantly reduce painand improve function. However, in light of some ofthe study limitations the clinical applicability islimited. This study has therefore created a platformfrom which future studies may develop a more defini-tive trial.

AcknowledgementsThe authors would like to thank the Society ofOrthopaedic Medicine especially Elaine Atkins (pro-gramme leader) and Mr Ramesh Vaswani (clinicalsupervisor). They would also like to thank those atthe University of Middlesex for their supportthrough the M.Sc. programme. The authors wouldalso like to thank Nuffield Health for their fundingtowards completing the M.Sc. programme.

References1 Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s kneeamong elite athletes from different sports: a cross-sectionalstudy. Am J Sports Med 2005;33(4):561–7.

2 Ramos LA, Carvalho RT, Garms E, Navarro MS, Abdalla RJ,Cohen M. Prevalence of pain on palpation of the inferior pole ofthe patella among patients with complaints of knee pain. Clinics(Sao Paulo) 2009;64(3):199–202.

3 Cook JL, Khan KM, Purdam CR. Conservative treatment ofpatellar tendinopathy. Phys Ther Sport 2001;2:54–65.

4 Wilson JJ, Best TM. Common overuse tendon problems: areview and recommendations for treatment. Am Fam Physician2005;72(5):811–8.

5 Sharma P, Maffulli N. Tendon injury and tendinopathy: healingand repair. J Bone Joint Surg Am 2005;87:187–202.

6 Visnes H, Bahr R. The evolution of eccentric training as a treat-ment for patellar tendinopathy ( jumper’s knee): a critical reviewof exercise programmes. Br J Sports Med 2007;41:217–23.

7 Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendino-pathy: effectiveness of eccentric exercise. Br J Sports Med 2007;41:188–98.

8 Jonsson P, Alfredson H. Superior results with eccentric com-pared to concentric quadriceps training in patients withjumper’s knee: a prospective randomised study. Br J SportsMed 2005;39:847–50.

9 Purdam CR, Jonsson P, Alfredson H, Lorentzon R, Cook JL,Khan KM. A pilot study of the eccentric decline squat in themanagement of painful chronic patellar tendinopathy. Br JSports Med 2004;38:395–7.

10 Kongsgaard M, Aagaard P, Roikjaer S, Olsen D, Jensen M,Langberg H, et al. Decline eccentric squats increases patellartendon loading compared to standard eccentric squats. ClinBiomech 2006;21:748–54.

11 Frohm A, Halvorsen K, Thorstensson A. Patellar tendon loadin different types of eccentric squats. Clin Biomech 2007;22(6):704–11.

12 Kraemer R, Knobloch K. A soccer specific balance training pro-gramme for hamstring muscle and patellar and Achilles tendoninjuries – an intervention study in premier league femalesoccer. Am J Sports Med 2009;37:1384–93.

13 Atkins E, Kerr J, Goodlad E. Orthopaedic medicine – a practicalapproach. 3rd ed. Oxford: Butterworth Heinemann; 2010.

14 Lee H-M, Wu S-K, You J-Y. Quantitative application of trans-verse friction massage and its neurological effects on flexorcarpi radialis. Man Ther 2009;14(5):501–7.

15 Clemmer J, Liao J, Davis D, Horstemeyer MF, Williams LN.A mechanistic study for strain rate sensitivity of rabbit patellartendon. J Biomech 2010;43(14):2785–91.

16 Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P,et al. Deep transverse friction massage for treating tendinitis.

Blackwood and Ghazi TFM in treatment of infrapatellar tendinopathy

International Musculoskeletal Medicine 2012 VOL. 34 NO. 3 113

Cochrane Database of Syst Rev, 2002;Issue 4. Art. No.:CD003528. DOI: 10.1002/14651858.CD003528.

17 Pfefer MT, Cooper SR, Uhl NL. Chiropractic management oftendinopathy: a literature synthesis. J Manipulative PhysiolTher 2009;32:41–52.

18 Schwellnus MP, Mackintosh L, Mee J. Deep transverse frictionsin the treatment of iliotibial band friction syndrome in athletes:A clinic trial. Physiotherapy 1992;78(8):564–8.

19 Stratford PW, Levy DR, Gauldie S, Miseferi D, Levy K. Theevaluation of phonophoresis and friction massage as treatmentsfor extensor carpi radialis tendonitis: a randomised controlledtrial. Physiother Canada 1989;41:93–9.

20 Stasinopoulos D, Stasinopoulos I. Comparison of effects of exer-cise programme, pulsed ultrasound and transverse friction in thetreatment of chronic patellar tendinopathy. Clin Rehabil 2004;18:347–52.

21 Stasinopoulos D, Stasinopoulos I. Comparison of effects ofCyriax physiotherapy, a supervised exercise programme andpolarized polychromatic non-coherent light (Bioptron light) forthe treatment of lateral epicondylitis. Clin Rehabil 2006;20(1):12–23.

22 Nagrale AV, Herd CR, Ganvir S, Ramteke G. Cyriax physiother-apy versus phonophoresis with supervised exercise in subjectswith lateral epicondylalgia: A randomised clinical trial. J ManManipulative Ther 2009;17(3):171–8.

23 Cooil R, Ghazi F. A pilot study to compare the out-come measures in patients with supraspinatus when treatedwith either transverse frictions or transverse frictions com-bined with ultrasound. Int Musculoskel Med 2010;32(3):124–8.

24 Gregory MA, Deane MN, Mars M. Ultrastructural changes inuntraumatised rabbit skeletal muscle treated with transversefriction massage. Physiotherapy 2003;89:408–16.

25 Fernandez-de-las Penas C, Alonso-Blanco C, Fernandez-Carnero J, Carlos Miangolarra-Page J. The immediate effectsof ischaemic compression technique and transverse frictionmassage on tenderness of active and latent myofascial triggerpoints: a pilot study. J Bodyw Mov Ther 2006;10:3–9.

26 Bulpitt CJ. Randomised controlled clinical trials. 2nd ed.,Boston: Kluwer Academic; 1996.

27 Sculz KF, Grimes DA. General allocation of sequences in ran-domised trials: chance, not choice. The Lancet 2002;359:515–9.

28 Visentini PJ, Khan KM, Cook JL. The VISA score: an indexof severity of symptoms in patients with jumper’s knee (patellartendinosis). J Sci Med Sport 1998;1:22–8.

29 Zwerver J, Kramer T, van der Akker-Scheek I. Validity andreliability of the Dutch translation of the VISA-P questionnairefor patellar tendinopathy. BMC Musculoskeletal Disord 2009;10:102.

30 Jensen M, Karoly P. Handbook of pain assessment. 3rd ed.,New York: The Guildford Press; 2010.

31 Field A. Discovering statistics using SPSS. 3rd ed., London:SAGE Publications Limited; 2009.

32 Frohm A, Saartok T, Halvorsen K, Renstrom P. Eccentric treat-ment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols. Br J Sports Med2007;41:e7. doi:10.1136/bjsm2006.032599.

33 Cannell LJ, Taunton JE, Clement DB, Smith C, Khan KM. Arandomised clinical trial on the efficacy of drop squats or legextensions/leg curl exercises to treat clinically diagnosed jumper’sknee in athletes: pilot study. Br J Sports Med 2001;35:60–4.

34 Campbell RS, Grainger AJ. Current concepts in imaging oftendinopathy. Clin Radiol 2001;56(4):253–67.

35 Rees JD, Maffulli N, Cook J. Management of tendinopathy. AmJ Sports Med 2009;37(9):1855–67.

36 Lui PP, Chan L, Fu S, Chan K. Expression of sensory neuropep-tides in tendon is associated with failed healing and activity-related tendon pain in collagenase-induced tendon injury. AmJ Sports Med 2010;38(4):757–64.

37 Yang G, Im H, Wang J. Repetitive mechanical stretching modu-lates IL-1B induced COX-2, MMP-1 expression and PGE2 pro-duction in human patellar tendon fibroblasts. Gene 2005;363:166–72.

38 Kelly AM. The minimum clinical significant difference in visualanalogue scale pain score does not differ with severity of pain.Emerg Med J 2001;18(3):205–7.

39 Myles PA, Christelis N. Measuring pain and analgesic response.Eur J Anaesthesiol 2011;28(6):399–400.

40 Hicks C. Research methods for clinical therapists – appliedproject design and analysis. 4th ed., China: Elsevier; 2005.

Blackwood and Ghazi TFM in treatment of infrapatellar tendinopathy

International Musculoskeletal Medicine 2012 VOL. 34 NO. 3114