Article

Effects of In-Season Inertial Resistance Training With Eccentric Overload in a Sports Population at Risk for Patellar Tendinopathy

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Volley- and basketball players can be considered as a population at risk for patellar tendinopathy. Given the paradox that eccentric training elicits therapeutic benefits yet might provoke such injury, we investigated the influence of a weekly bout of inertial squat resistance exercise offering eccentric overload on lower limb muscle power and patellar tendon complaints. Players of eight (4 basket- and 4 volleyball) teams (38 women and 43 men) were randomly assigned to either the intervention (IG) or control (CG) group. While IG and CG maintained scheduled in-season training routines over 24 weeks, IG in addition performed one weekly session of eccentric overload by 4 sets of 8 repetitions of the squat employing flywheel inertial resistance. Patellar tendinopathy questionnaire (VISA-p), vertical countermovement jump (CMJ) and squat-power, both concentric (Squat-Con) and eccentric (Squat-Ecc), tests were performed before (T1), during (T2) and after (T3) the 24 weeks of intervention. Neither group suffered from patellar tendinopathy during the study period. VISA-p displayed no differences across groups at any measurement period. CMJ scores significantly (p<0.05) differed between groups in favour of the IG. Both Squat-Con and Squat-Ecc mean scores from the IG were significantly (p<0.01) higher than the CG. Adding a weekly eccentric overload squat training bout to a regular basket- and volleyball exercise routine, enhances lower limb muscle power without triggering patellar tendon complaints. Future studies, using the current exercise paradigm, aim to explore its efficacy to prevent or combat patellar tendinopathy in sports calling for frequent explosive jumps.
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... The full text of the remaining 20 studies was examined in more detail, with 13 studies being excluded because they did not meet the inclusion criteria. After the final screening, seven studies were included in the review (as reported in Figure 1) (Fernandez-Gonzalo et al., 2014;Gual et al., 2016;Lundberg et al., 2019;Onambélé et al., 2008;Sañudo et al., 2019;Seynnes et al., 2007;Tesch et al., 2004). ...
... m 2 ), which also improved 1RM by 20% (g = 2.49, very large). Similarly, Gual et al. (Gual et al., 2016) implemented a 24-week protocol involving weekly flywheel half-squat training with a mixed group of male and female basketball and volleyball players. However, a lower improvement was reported in jumping performance such as CMJ (3%; g = 0.19, trivial) in comparison to the investigation by Fernández-Gonzalo et al. (Fernandez-Gonzalo et al., 2014). ...
... Firstly, the differences in inertial load and training frequency per week (1 vs. 3 times a week) could have impacted outcomes. Secondly, differences between physical level of the two samples enrolled: volleyball and basketball athletes (Gual et al., 2016) vs. physically active subjects (Fernandez-Gonzalo et al., 2014) may have affected response to the protocol. Differences in response to flywheel training can be attributable to differences in participant physical level and this should be taken into consideration when applying flywheel technology. ...
Article
This study aimed to evaluate the effect of flywheel training on female populations, report practical recommendations for practitioners based on the currently available evidence, underline the limitations of current literature, and establish future research directions. Studies were searched through the electronic databases (PubMed, SPORTDiscus, and Web of Science) following the preferred reporting items for systematic reviews and meta-analysis statement guidelines. The methodological quality of the seven studies included in this review ranged from 10 to 19 points (good to excellent), with an average score of 14-points (good). These studies were carried out between 2004 and 2019 and comprised a total of 100 female participants. The training duration ranged from 5 weeks to 24 weeks, with volume ranging from 1 to 4 sets and 7 to 12 repetitions, and frequency ranged from 1 to 3 times a week. The contemporary literature suggests that flywheel training is a safe and time-effective strategy to enhance physical outcomes with young and elderly females. With this information, practitioners may be inclined to prescribe flywheel training as an effective countermeasure for injuries or falls and as potent stimulus for physical enhancement.
... Four of the five studies investigating the effects of preventative exercise interventions in athletes with patellar tendinopathy found a reduction in tendinopathy incidence following the intervention (Kramer et al. 2008, Gual et al. 2016, Bittencourt et al. 2022, Mersmann et al. 2021). One study did not find reduced incidence despite finding reduced risk for developing patellar tendon abnormalities on ultrasound (Fredberg et al. 2008). ...
... Only five studies fully reported exercise adherence, which ranged from 67-100% per intervention, with all five studies reporting an overall high level of exercise adherence of more than 70% (Ruffino et al. 2021, Young et al. 2005, Kongsgaard et al. 2009, Sprague et al. 2021, Agergaard et al. 2021. reducing patellar tendinopathy incidence, as only one of these studies was a RCT, which found benefit of inertial flywheel training in preventing patellar tendinopathy in athletes (Gual et al. 2016). Despite the common practice of withdrawing athletes from sports training and competition during patellar tendinopathy, findings from this review suggest that practice may be unwarranted and perhaps even counterproductive for competing athletes, given the consequences of sport withdrawal. ...
... This scoping review aimed to assess what interventions have been used for prevention and in-season management of patellar tendinopathy in athletes and what outcomes have been reported. Despite a paucity of literature on prevention programs for patellar tendinopathy, four studies have found positive effects of exercise-based interventions for reducing the incidence of patellar tendinopathy in athletes(Kramer et al. 2008, Gual et al. 2016, Bittencourt et al. 2022, Mersmann et al. 2021. Despite these encouraging findings, further high-quality large scale RCTs are required to confirm the prophylactic effect of exercise in ...
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Introduction: Patellar tendinopathy has a significant prevalence in athletes and presents a tremendous burden on athletes and clinicians due to its long-lasting duration, persistent symptoms, and lack of available effective treatments. This scoping review aimed to summarise current evidence on prevention and in-season management interventions for patellar tendinopathy in athletes, evaluating intervention parameters and outcomes. Methods and analysis: The recommended methodological framework described by the Joanna Briggs Institute was used to structure this review, with reporting in accordance with the PRISMA-ScR. Databases searched included MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library (Controlled trials, Systematic reviews). All primary study designs investigating prevention or in-season management interventions for patellar tendinopathy, while maintaining athletes in sport were considered for inclusion. Findings: 5987 articles were identified with 29 included in the review. Despite a dearth of studies to date on preventative interventions for athletes with patellar tendinopathy, evidence suggests that resistance training is an effective prophylactic method. There is a significant body of evidence suggesting that resistance training is effective for managing patellar tendinopathy in-season, with evidence greater for eccentric training, followed by heavy slow resistance training and isometric training. Inertial flywheel and blood-flow restricted resistance training may also be effective in-season management strategies. There is currently no evidence to suggest that ESWT offers any additional benefit over resistance training in competing athletes. Patellar strapping and taping may offer short-term pain relief during training and competition. High risk athletes, particularly those participating in jumping sports, should be required to undergo progressive resistance training as a preventative method for patellar tendinopathy. Similarly, athletes diagnosed with patellar tendinopathy should undergo a progressive resistance training intervention while maintaining sports participation, prior to considering sport withdrawal.
... In contrast to the strength recommendations above, recent studies have suggested that lower inertial resistances should be used to enhance power output [30,44]. Several studies have reported improvements in power output or explosive performance (e.g., countermovement jump (CMJ), squat jump, running speed, etc.) [31][32][33][34]36,37,44,[47][48][49][50][51][52]. While many of these studies used protocols similar to those discussed above (i.e., four sets of 7-8 repetitions), other studies reported positive results using three sets of 15-20 s [48,50,51]. ...
... It should be noted that the authors defined "well-trained" as "sport-participating individuals, elite athletes, and individuals with self-reported high activity level." Within their analysis, several improvements in power output stood out including increases of 32.6% in five weeks [48], 30.0% in six weeks [37], 38.2% in seven weeks [44], and 59.2% in 24 weeks [49]. These are very large increases in power output over short periods of time and should be interpreted with caution. ...
... These are very large increases in power output over short periods of time and should be interpreted with caution. In addition, it should be noted that all of the highlighted studies measured power output during the FIT training protocol [37,44,48,49]. Thus, it is possible that the novel training stimulus led to greater performance improvements within the task they were performing. ...
Article
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The purpose of this review is to provide strength and conditioning practitioners with recommendations on how best to implement tempo eccentric training (TEMPO), flywheel inertial training (FIT), accentuated eccentric loading (AEL), and plyometric training (PT) into resistance training programs that seek to improve an athlete’s hypertrophy, strength, and power output. Based on the existing literature, TEMPO may be best implemented with weaker athletes to benefit positional strength and hypertrophy due to the time under tension. FIT may provide an effective hypertrophy, strength, and power stimulus for untrained and weaker individuals; however, stronger individuals may not receive the same eccentric (ECC) overload stimulus. Although AEL may be implemented throughout the training year to benefit hypertrophy, strength, and power output, this strategy is better suited for stronger individuals. When weaker and stronger individuals are exposed to PT, they are exposed to an ECC overload stimulus as a result of increases in the ECC force and ECC rate of force development. In conclusion, when choosing to utilize ECC training methods, the practitioner must integrate these methods into a holistic training program that is designed to improve the athlete’s performance capacity.
... Although a large portion of practitioners (n = 47) agreed that familiarisation is necessary to optimise training, the literature suggests it remains difficult to quantify how many sessions are necessary to achieve reliable outcomes with flywheel devices [9,22]. Previous studies have reported using either no sessions [23], one [14,17,18,21,[24][25][26], two [27][28][29][30], three [10,19], or 4-6 sessions [15], and participant dependent familiarisation [31]. ...
... Apart from athlete, coach, and environmental factors (e.g., team timetables), considerations for exercise choice, intensity, and volume are important for determining optimal training frequency [9,11,12]. The application of low volume flywheel protocols [17,19,23,24,27,38] may be particularly important during the initial stages of the inseason period if athletes are not accustomed to flywheel training. ...
... Practitioners (n = 31) mostly agree that jumping, an important capacity in team sports [31], can be enhanced by flywheel training. Although flywheel training has improved jumping performance in highly-trained youth [27,31,[36][37][38], semi-professional, and professional male team sport players [23,24,26,28], some practitioners (n = 19) stated they neither agreed nor disagreed, while one practitioner disagreed with such statement (Figure 2). Some of the practitioners (n = 16) prescribing weekly training sessions during the in-season period may also be encouraged by the literature showing how such exposure can specifically enhance unilateral vertical and horizontal jumping ability after 7-10 weeks of training with youth soccer players [24,38]. ...
Article
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Growing evidence supports use of eccentric methods for strength development and injury prevention within elite soccer, yet uncertainty remains regarding practitioners’ application of flywheel (isoinertial) methods. The aims of this study were to investigate how the flywheel training literature is perceived and applied by elite soccer practitioners, highlight gaps in knowledge and develop industry-relevant research questions. Fifty-one practitioners completed an electronic questionnaire. Fourteen Likert scale statements were grouped into topics: strength and performance; post-activation performance enhancement and methodological considerations; chronic strength; chronic performance; injury prevention. Three general questions followed, allowing more detail about flywheel training application. A Majority of the participants reported ≥ 2 years’ experience of programming flywheel training. Nearly all participants agreed that familiarisation is needed. Practitioners agree that flywheel training can improve sport performance, strength and likelihood of non-contact injury outcomes. Most practitioners prescribe 2 weekly sessions during pre- and in-season periods. Flywheel sessions mostly consist of squats but a variety of exercises (lunge, hip hinge, and open kinetic chain) are also frequently included. Practitioners are mostly unsure about differences between flywheel and traditional resistance training equipment and outcomes, practicality of flywheel equipment, and evidence-based guidelines. The investigation provides valuable insight into the perspectives and application of flywheel training within elite soccer, highlighting its perceived efficacy for strength and injury prevention.
... After the review by Peters et al. (Peters et al., 2016), to our knowledge, only one study (Gual et al., 2016) investigated the effects of a preventive intervention on the incidence of patellar tendinopathy. Gual et al.(Gual et al., 2016) investigated the effects of a weekly bout of inertial squat resistance exercises on lower limb muscle power and patellar tendon complaints in a small group of volleyball and basketball athletes. ...
... After the review by Peters et al. (Peters et al., 2016), to our knowledge, only one study (Gual et al., 2016) investigated the effects of a preventive intervention on the incidence of patellar tendinopathy. Gual et al.(Gual et al., 2016) investigated the effects of a weekly bout of inertial squat resistance exercises on lower limb muscle power and patellar tendon complaints in a small group of volleyball and basketball athletes. After the intervention, the athletes of the intervention group had significant improvements in countermovement jump performance in comparison to the control group (Gual et al., 2016). ...
... Gual et al.(Gual et al., 2016) investigated the effects of a weekly bout of inertial squat resistance exercises on lower limb muscle power and patellar tendon complaints in a small group of volleyball and basketball athletes. After the intervention, the athletes of the intervention group had significant improvements in countermovement jump performance in comparison to the control group (Gual et al., 2016). However, the athletes of both the intervention and control groups remained completely asymptomatic during the study, with no athlete being diagnosed with patellar tendinopathy. ...
Article
Objective To investigate the effects of an intervention with tailored exercises on the incidence of patellar tendinopathy (PT) in elite youth jumping athletes. Design Prospective crossover cohort. Setting One sport club facility. Participants 271 elite youth basketball and volleyball player were followed in the first year of the study (Observation year) and 270 athletes were followed in the second year (intervention year). Main outcome measure Incidence rates of PT per 1,000h of exposure. Cox survival analysis was used to verify the effects of the intervention (exercises implemented according to the findings of a preseason assessment) on PT incidence. Results The exercise prevention program significantly reduced the number of cases of PT, with athletes submitted to the intervention showing 51% less risk of developing PT. The overall PT incidence in the Observation year (5.9 per 1,000h of exposure) was significantly higher than that in the intervention year (2.8 per 1,000h of exposure) (P = .037). Twenty-six athletes developed PT in the observation year, whereas 13 athletes developed PT in the intervention year. Conclusions A tailored preventive program may be able to reduce the incidence of patellar tendinopathy, especially in male youth volleyball athletes. Randomized controlled trials are encouraged to confirm these findings.
... The training load for this technology can be regulated by increasing the speed of movement or by adding flywheel weights. Several studies confirmed the efficacy of flywheel exercise for improving hypertrophy [13,20,21], power [13,22,23] countermovement jump (CMJ) performance [2,7,23], 10-m sprint time [2,7,24] and changes of direction [2,7,24]. ...
... The training load for this technology can be regulated by increasing the speed of movement or by adding flywheel weights. Several studies confirmed the efficacy of flywheel exercise for improving hypertrophy [13,20,21], power [13,22,23] countermovement jump (CMJ) performance [2,7,23], 10-m sprint time [2,7,24] and changes of direction [2,7,24]. ...
... However, no studies compared the effect of halfsquat training with free weights and flywheel device training on knee extensor and flexor muscle strength. Improving lower limbs eccentric strength contributes not only to improving the performance of athletes on the field [2,7,13,[22][23][24], but, constitutes an important parameter that can help prevent injuries to the lower extremities [8]. The increased eccentric loads claimed to exist when using flywheel(s) equipment would give a potential advantage in improving lower limbs strength of athletes compared to free weight training. ...
Article
Backround: New training methods are constantly used to improve the ability of skeletal muscles to develop strength. Objective: The aim of the present study was to investigate the effect of half-squat training with free weights and flywheel device on isokinetic knee muscle strength for well-trained amateur soccer players. Methods: Forty eight players were randomly divided into three groups (n= 16 each): Desmotech Training group (DT), Free Weight Training group (WT) and one Control Group (CON). DT and WT performed an eight-week half-squat training program, with two sessions per week. The DT group performed training with a flywheel device. Isokinetic concentric-eccentric strength assessments of the knee extensors-flexors muscle groups were performed at different angular velocities (60, 180 and 240∘/s). Results: The eight-week training program improved all the isokinetic joint moment indicators examined in the DT and WT groups (p< 0.01). The DT group achieved higher performances at all the isokinetic parameters examined, however, without statistically significant differences to the WT group. Conclusions: Flywheel-based exercise is an effective training method and is suggested to be used to strengthen the lower limbs of soccer players.
... The positive effects of flywheel training in fitness and training are well documented and multiple reviews have been written. 4,5,6,7,8,9 However, flywheel training has received scant attention in the rehabilitation and sports physical therapy literature. This clinical commentary will address the value of flywheel training in musculoskeletal rehabilitation. ...
... Flywheel training makes use of the stretch-shortening cycle, leading to, compared with weight resistance training, greater efficiency in the stretch-shortening cycle, higher specificity and enhanced adaptation during rehabilitation. 8,9 Another noteworthy physiological change that has been documented after flywheel training is the hypertrophy of type II muscle fibers. 9 Importantly, the described effects occur without triggering pain in patients with a musculoskeletal injury. ...
... 9 Importantly, the described effects occur without triggering pain in patients with a musculoskeletal injury. 8 Skeletal muscle shows increased peak torque during eccentric movement compared with concentric movement. 9,10 The explanation for the increased peak torque during eccentric movement can be found in the two-state cross bridge model. ...
Article
Full-text available
Flywheel training is a relatively new method used to train the human body with continuous resistance and eccentric overload. The performed exercises result in improvements of strength and power, hypertrophy, muscle activation, muscle length, and tendon stiffness. Other positive effects of flywheel training are athletically relevant improvements in things such as speed, jump height and change of direction. The positive results can be explained by the eccentric and power characteristics of the training, making flywheel training ideal for use in musculoskeletal rehabilitation. Flywheel training can be used for injury prevention, training after a period of unloading, tendon and muscle rehabilitation, as part of post-operative rehabilitation, during late stage sport specific rehabilitation as well as for fall prevention and treatment of sarcopenia among elderly. The purpose of this commentary is to inform physical therapists about the use of flywheel training in musculoskeletal rehabilitation. Level of evidence: 5.
... 43,44 One RCT investigated IFRT in an athletic population at risk for patellar tendinopathy. 45 No studies investigating the effects of IFRT on other tendinopathies were found in the literature search. The sample sizes of included studies ranged from ten to 81, with only 125 participants with patellar tendinopathy out of a total of 206 participants. ...
... The sample sizes of included studies ranged from ten to 81, with only 125 participants with patellar tendinopathy out of a total of 206 participants. All included studies investigated the effects of a IFRT intervention, one in isolation, 42 one compared with HSRT, 41 one combined with normal sports training, 45 and two combined with intratissue percutaneous electrolysis. 43,44 The duration of IFRT interventions ranged from six to 24 weeks. ...
... Three studies prescribed 4 sets of 10 repetitions, once per week, with the first two repetitions used for increasing the inertial resistance, and repetitions 3-10 were always executed with maximal effort. 41,42,45 The studies following this same protocol allowed for two minutes of rest between sets. The other two studies prescribed 3 sets of 10 repetitions, twice per week, all repetitions were performed with maximum intensity for 10 repetition maximum (RM). ...
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Objective: To identify current evidence on inertial flywheel resistance training (IFRT) in the treatment of tendinopathy, evaluating intervention parameters and outcomes. Methods: This scoping review was reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Databases searched included MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, Cochrane library (Controlled trials, Systematic reviews), and five trial registries. Two independent reviewers screened studies at title, abstract and full text. Following screening, data was extracted and charted, and presented as figures and tables alongside a narrative synthesis. Any study design conducted on adults, investigating the effects of IFRT for tendinopathy were included. Data were extracted on intervention parameters and outcomes of IFRT interventions. Results: Five studies were included, four on patellar tendinopathy and one in a population at risk of patellar tendinopathy. A variety of outcomes were assessed, including pain, function, strength, power, and tendon morphological and mechanical properties, particularly changes in tendon thickness. IFRT intervention parameters were largely homogenously prescribed, with slight variances. Conclusion: Despite a dearth of studies to date on the effects of IFRT for treating tendinopathy, preliminary evidence for beneficial effects of IFRT on clinical outcomes in patellar tendinopathy is encouraging. As IFRT is a relatively new and unexplored method in tendinopathy rehabilitation, definitive conclusions, and recommendations cannot be made at present, which should be addressed in future research, due to the potential therapeutic benefits highlighted in this review.
... In the last years, new procedures to improve strength have been developed under the concept of eccentric overload. Several studies have observed the efficiency of the use of apparatus such as flywheel devices or versa pulleysin the improvement of sport performance (Tous-Fajardo et al, 2016;Sabido et al, 2017) and in injury prevention (De Hoyo et al, 2015;Gual et al, 2016). These procedures are designed to produce high forces during both concentric and eccentric phases of movement, but with a special emphasis on the eccentric phase. ...
... These values are similar to studies in which EOT was employed. For example, Gual et al (2016) showed gains of 3.22% after a season with a one-week EOT session in basketball and volleyball players. In soccer players, several studies (Tous Fajardo et al, 2016;De Hoyo et al, 2015;Raya-González et al, 2018) obtained increases between 4.4% and 7.6% for CMJ, similar values to our study. ...
... However, different results were obtained when the test was performed with one leg: improvements were similar for the dominant leg, but very different for the non-dominant leg. While increases in the BG are similar to previous studies (Gual et al 2016;Raya-González et al, 2018), gains after treatment in the UG are lower for two-leg and non-dominant tests. As was previously noted, the difficulty to maintain balance during one leg training (especially with the non-dominant leg) resulted in a poor power production during training. ...
Article
Full-text available
Basketball is a team sport in which strength and power in the lower limb are key variables. The use of eccentric overload devices has augmented in the past years, and several studies have shown the benefits of this methodology to improve physical parameters. The aim of the present study is to compare the effects of bilateral and unilateral squat during eccentric overload training. Ten players from a same team participated in a six weeks of two session per week eccentric overload training. Participants were divided in two groups according to their performance in pretest. Test measured in pre and postest situation were a power test in flywheel, CMJ, triple hop test and T-Test. Training consisted in 4 sets of 8 repetitions of bilateral or unilateral squat. After treatment both groups improve their performance in T-Test and power test in flywheel device. Trends of improve were observed for triple hop test, with a greater ES for unilateral group. Results shown as eccentric overload training of bilateral or unilateral squat can be a good choice to improve physical performance, with different benefits according to the type of execution.
... The full text of the remaining 20 studies was examined in more detail, with 13 studies being excluded because they did not meet the inclusion criteria. After the final screening, seven studies were included in the review (as reported in Figure 1) (Fernandez-Gonzalo et al., 2014;Gual et al., 2016;Lundberg et al., 2019;Onambélé et al., 2008;Sañudo et al., 2019;Seynnes et al., 2007;Tesch et al., 2004). ...
... m 2 ), which also improved 1RM by 20% (g = 2.49, very large). Similarly, Gual et al. (Gual et al., 2016) implemented a 24-week protocol involving weekly flywheel half-squat training with a mixed group of male and female basketball and volleyball players. However, a lower improvement was reported in jumping performance such as CMJ (3%; g = 0.19, trivial) in comparison to the investigation by Fernández-Gonzalo et al. (Fernandez-Gonzalo et al., 2014). ...
... Firstly, the differences in inertial load and training frequency per week (1 vs. 3 times a week) could have impacted outcomes. Secondly, differences between physical level of the two samples enrolled: volleyball and basketball athletes (Gual et al., 2016) vs. physically active subjects (Fernandez-Gonzalo et al., 2014) may have affected response to the protocol. Differences in response to flywheel training can be attributable to differences in participant physical level and this should be taken into consideration when applying flywheel technology. ...
Preprint
Background: This study aimed to evaluate the effect of flywheel training on female populations, report practical recommendations for practitioners based on the current available evidence, underline the limitations of current literature, and establish future research directions.Methods: Studies were searched through the electronic databases (PubMed, SPORTDiscus, and Web of Science) following the preferred reporting items for systematic reviews and meta-analysis statement guidelines.Results: The methodological quality of the 7 studies included in this review ranged from 10 to 19 points (good to excellent), with an average score of 14-points (good). These studies were carried out between 2004 and 2019 and comprised a total of 100 female participants. The training duration ranged from 5 weeks to 24 weeks, with volume ranging from 1 to 4 sets and 7 to 12 repetitions, and frequency ranged from 1 to 3 times a week. Discussion: The literature suggests that flywheel training is a safe and time effective strategy to obtain lower limb performance enhancements and positive muscle morphological adaptations with elderly and young females. The present literature, although limited, supports the use flywheel training for the prevention of falls and the enhancement of physical capabilities in young and elderly female populations. Nonetheless, a lack of clarity still exists regarding appropriate flywheel training volume, frequency, and intensity. Further high-quality investigation into this topic is warranted to establish clear guidelines about the use of flywheel training methodologies with female populations.
... Four studies included a non-training passive control group [6,15,26,34]. Three studies performed flywheel training in-season [30,35,36], two of which performed additional training for the experimental group in addition to the standard training performed by both groups [29,37]. One of the studies included a control group performing conventional resistance training, including free weight strength training [14]. ...
... The selection process is outlined in Fig. 2. The initial search identified 426 studies of potential relevance. However, after applying and screening for the inclusion and exclusion criteria specified above, 20 studies met the inclusion criteria and were thus included in the meta-analysis [2,6,12,15,16,26,27,29,34,36,37,[40][41][42][43][44][45][46][47][48]. ...
... The rest times between sets varied between 1 and 5 min (1 study had 1 min, 1 study had 1.5 min, 11 studies had 2 min, 5 studies had 3 min, and 2 studies had 5 min). In four of the studies [37,44,52], the intervention period coincided with the competition season and the other 16 studies were performed during pre-season or when there was no other physical activity at the time of the study period. ...
Article
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Background Strength and power development are abilities important for athletic performance in many sports. Generally, resistance training based on gravity is used to improve these qualities. Flywheel training instead utilizes kinetic energy transferred to a flywheel. This allows for eccentric overload and variable resistance throughout the movement. The aim of this review was to identify the effects of flywheel training on multiple strength-related variables affecting athletic performance. The meta-analysis investigates the effects on (1) muscle growth (cross-sectional area (CSA) and volume/mass), (2) maximum dynamic strength, (3) development of power, (4) development of horizontal movement, and (5) development of vertical movement. Methods The meta-analysis includes 20 experimental studies that met the inclusion criteria. The quality of included studies was ranked according to the PEDro scale. Possible bias was identified in Funnel plot analyses. To enable the compilation of all results analyses, the random effect model was carried out using the software Review Manager Version 5.3 and presented with Forest plots. Results Flywheel training for a period of 4–24 weeks shows statistically significant increases in all strength aspects. Effect sizes were for hypertrophy, CSA 0.59; volume/mass 0.59; maximum strength 1.33; power 1.19; horizontal 1.01 and vertical movement 0.85. The evidence is particularly strong for beneficial effects from flywheel training in the development of maximal strength and power in trained younger individuals, and utilization of this training modality in shorter more intensive blocks. Conclusions Flywheel training is an effective method for improving several aspects of strength and power with importance for sports performance. Electronic supplementary material The online version of this article (10.1186/s40798-018-0169-5) contains supplementary material, which is available to authorized users.
... Because of the relevance of power outputs in sport performance (e.g., team sports), a large number of studies have analyzed the effects of flywheel training programs on this variable (14,19,21,23,24,(29)(30)(31)(32)36,38), which has been measured usually as peak power or mean power. Regarding the upper limbs (i.e., elbow joint), only 3 studies investigated the effectiveness of flywheel training programs (24,29,30). ...
... The majority of the studies have focused on developing power in the lower limbs and report improvements of 8.3-37.9% after flywheel training programs (14,19,20,23,31,32,36,38). The main configuration used in these studies was 4 sets of 7 repetitions over 5-6 weeks. ...
... These studies reported a weekly frequency ranging between 2 and 3 sessions per week. Interestingly, Gual et al. (14) observed enhancements in power after a flywheel training program applying only a weekly training session but over a longer (24 weeks) period with team-sport athletes. The moments of inertia that were effectively used in these studies ranged between 0.050 and 0.110 kg$m 2 . ...
... Although FW training can result in equal (29) or superior (18) improvements in CON and ECC force, muscle strength, power, and muscle hypertrophy in healthy and trained subjects compared with traditional resistance training, studies comparing FW training with other more traditional training modalities such as free weights are currently scarce, especially in elite athletes. However, based on the physiological demands of ice hockey and the positive results noted with FW training in, e.g., soccer, handball, and basketball players (5,9,12,18,26,28), it is plausible that FW could be an effective alternative training modality to enhance fitness performance in ice hockey players during off-season and pre-season training. Considering the high loading, high neural activation, and maximal nature of FW training, it could also be used as a time-saving method to maintain or even increase neuromuscular fitness during the season. ...
... Moreover, FW squat causes higher metabolic and perceptual demands than barbell squat training, which may explain different training responses (23). Flywheel training has been shown to be efficient in enhancing individual performance enhancement of team sport athletes, where players are often required to perform repeated high-intensity actions (5,9,12,16,19,28). Because muscle strength, power, and anaerobic capacity are key fitness attributes for ice hockey players, an appropriate strategy to maximize on-ice performance is important (25). ...
Article
Puustinen, J, Venojärvi, M, Haverinen, M, and Lundberg, TR. Effects of flywheel versus traditional resistance training on neuromuscular performance of elite ice hockey players. J Strength Cond Res XX(X): 000–000, 2021—This study aimed to examine the effects of 8 weeks of flywheel (FW) vs. traditional resistance training on neuromuscular performance of elite ice hockey players during the off-season. Eighteen male players (U-18 to U-21) were assigned to a flywheel group (FG) or traditional training group (TG). The FG (n = 9) performed FW training with 4 different exercises (3–4 sets × 6–7 repetitions). The TG (n = 9) used barbells and free weights (4 sets × 4–12 repetitions). Outcome measures included loaded and unloaded countermovement jumps (CMJs) and a 200 m sprint test that included split times and direction changes. There were no group effects (analysis of covariance with adjustments for pretest values, all p > 0.05, all effect sizes <0.8), suggesting comparable performance improvements between groups. Within-group changes for the unloaded CMJ were 5.7% in FG vs. 4.8% in TG. Similar or slightly greater improvements were seen for the loaded CMJs. For sprint times, there were improvements in both groups for the split time of the first 20 m (FG: −3.2 vs. TG: −2.6%) and also for the 200 m total sprint time (FG −1.8% and TG −1.5%). In conclusion, although FW resistance training improves neuromuscular performance in elite ice hockey players, it does not elicit superior improvements compared with traditional resistance training in players with no prior experience with this training method.
... Intervenções baseadas em exercícios focadas em reduzir lesões do trem inferior no basquetebol, foram previamente testadas no contexto dos clubes [5][6][7] . Por exemplo, tem sido possível reduzir o risco de rotura do ligamento cruzado anterior 5 , bem como de entorses do tornozelo e dor lombar 6 . ...
... O programa de prevenção de lesões em circuito, consistiu em 18 exercícios (Tabela 1), foi desenhado e conduzido por um preparador físico qualificado e um fisioterapeuta certificado. Estes exercícios foram selecionados por serem reconhecidos como os mais importantes para a prevenção de lesões de não contacto nos membros inferiores [5][6][7]19 e melhoria das ações de alta intensidade 20 ...
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Os objetivos deste estudo foram (i) avaliar a perceção subjetiva de esforço de um programa de prevenção de lesões e, (ii) analisar os efeitos agudos do programa de prevenção de lesões na carga externa e interna durante as sessões de treino de campo. Treze jovens basquetebolistas participaram no estágio na seleção nacional de sub-16, num total de 12 sessões. Em 6 sessões de treino, os atletas apenas completaram as sessões de treino de campo, enquanto nas restantes completaram o programa de prevenção de lesões antes da das sessões de treino de campo. A perceção subjetiva de esforço foi avaliada após a realização do programa de prevenção de lesões. A avaliação da carga de treino durante as sessões de treino de campo foi realizada através de um sistema de rastreamento indoor, microsensores e monitores de frequência cardíaca. Teste t para médias de duas amostras e análise de covariância foram utilizados para comparar a carga de treino entre sessões e testar o efeito principal da perceção subjetiva de esforço na carga de treino. A média da perceção subjetiva de esforço para todas das sessões do programa de prevenção lesões foi 14.7 ± 0.8. Foram encontrados, menores valores absolutos de carga externa e interna após a participação no programa de prevenção de lesões (ES:-0.20-0.79), e o efeito principal da perceção subjetiva de esforço nos valores absolutos de deslocamentos da alta intensidade (p ≤ 0.01), e nos impactos corporais muito fortes (p ≤ 0.05) e severos (p ≤ 0.01). Este programa de prevenção de lesões poderá servir como uma estratégia adequada para implementar durante a preparação da seleção nacional. Palavras-chave: Treino de sobrecarga
... Interestingly, the effects of flywheel training on performance outcomes in basketball are scarce. To the best of the authors knowledge, only one study [21] reported significant improvements in countermovement jump and squat power after implementing one session a week of flywheel training (four sets of eight repetitions of the squat, 24 weeks) in a sample of 26 regional level adult basketball players (males and females). Change of direction, muscular strength, vertical jumping ability and repetitive short-distance sprints are all important fitness attributes required for the physical demands of a basketball game [22]. ...
... For half squat exercise, the subject begins with concentric phase caried out from about 90-degree knee angle to near full extension and then continues, without stopping, the phase of eccentric contraction. Participants were briefed to perform the concentric phase with maximum effort, while applying maximal force after the first third of the lengthening phase in order to stop the flywheel at about 90 of knee flexion, thus achieving eccentric overload [21]. It has been recognized that special eccentric strategies are required to apply breaking force over the entire range of motion at certain joint angles to achieve the desired eccentric overload [35]. ...
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The main aim of the present study was to compare the effects of flywheel strength training and traditional strength training on fitness attributes. Thirty-six well trained junior basketball players (n = 36; 17.58 ± 0.50 years) were recruited and randomly allocated into: Flywheel group (FST; n = 12), traditional strength training group (TST; n = 12) and control group (CON; n = 12). All groups attended 5 basketball practices and one official match a week during the study period. Experimental groups additionally participated in the eight-week, 1–2 d/w equivolume intervention conducted using a flywheel device (inertia = 0.075 kg·m−2 ) for FST or free weights (80%1 RM) for TST. Pre-to post changes in lower limb isometric strength (ISOMET), 5 and 20 m sprint time (SPR5m and SPR20m), countermovement jump height (CMJ) and change of direction ability (t-test) were assessed with analyses of variance (3 × 2 ANOVA). Significant group-by-time interaction was found for ISOMET (F = 6.40; p = 0.000), cmJ (F = 7.45; p = 0.001), SPR5m (F = 7.45; p = 0.010) and T test (F = 10.46; p = 0.000). The results showed a significantly higher improvement in cmJ (p = 0.006; 11.7% vs. 6.8%), SPR5m (p = 0.001; 10.3% vs. 5.9%) and t-test (p = 0.045; 2.4% vs. 1.5%) for FST compared to the TST group. Simultaneously, th FST group had higher improvement in ISOMET (p = 0.014; 18.7% vs. 2.9%), cmJ (p = 0.000; 11.7% vs. 0.3%), SPR5m (p = 0.000; 10.3% vs. 3.4%) and t-test (p = 0.000; 2.4% vs. 0.6%) compared to the CON group. Players from the TST group showed better results in cmJ (p = 0.006; 6.8% vs. 0.3%) and t-test (p = 0.018; 1.5% vs. 0.6%) compared to players from the CON group. No significant group-by-time interaction was found for sprint 20 m (F = 2.52; p = 0.088). Eight weeks of flywheel training (1–2 sessions per week) performed at maximum concentric intensity induces superior improvements in cmJ, 5 m sprint time and change of direction ability than equivolumed traditional weight training in well trained junior basketball players. Accordingly, coaches and trainers could be advised to use flywheel training for developing power related performance attributes in young basketball players.
... Specifically, light inertial loads allow for greater concentric and eccentric power to be produced, while eccentric overload (eccentric/concentric ratio) is maximized when using high loads. Studies utilizing flywheel training have most commonly implemented 2 min RI's (Gual et al., 2016;Tous-Fajardo et al., 2016;Sabido et al., 2017). However, other studies using flywheel training have implemented 1 min RI's (Askling et al., 2003) and 3 min RI's (Maroto-Izquierdo et al., 2017). ...
Article
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The use of flywheel devices has increased in popularity during the last few years. Flywheel training is an attractive alternative to traditional resistance exercise because it allows for the loading stimulus to be manipulated. Some of the benefits associated with flywheel training include increases in muscle hypertrophy, muscular strength and reductions in injury risk. Nevertheless, there is a lack of research about how basic training variables [i.e., rest intervals (RI) between sets], or variables associated with manipulation of the loading stimulus (i.e., different inertial loads), influence the acute responses during a flywheel session. Thus, the aim of this study was to assess the influence of three different RI between sets (1, 2, or 3 min), during a flywheel squat session with two different inertial loads: light (0.025 kg·m 2) and high (0.075 kg·m 2). Twenty-three participants performed six exercise sessions (two inertial loads × three RI) consisting of four sets of 11 repetitions. Concentric and eccentric power, lactate concentration ([La]) and ratings of perceived exertion (RPE) were measured during the exercise session, and delayed onset muscular soreness (DOMS) were recorded 24 h post-exercise. Both concentric (9.1 and 22.1% at light and high load respectively; p = 0.022 and 0.005) and eccentric peak power (17.5% at high load; p = 0.02) decreased across sets when the 1 min RI was used. Concentric peak power was decreased (11.1%, p = 0.041) from the 2 min RI only with the high inertial load. RPE was higher during the 1 min compared with the 3 min RI protocol when using the high inertial load (p = 0.028). [La] was higher when using the 2 min RI compared with the 3 min RI at light load (p = 0.03). In conclusion, during flywheel training sessions, a short RI (1 min) was insufficient to maintain power output across all four sets and was linked to greater perceptual variables. A 2 min RI allowed for power to be maintained, but only when training with light inertial loads. Based on these results, coaches should consider prescribing 3 min RI's when performing flywheel squat exercises regardless the inertial load. In contrast, when using 2 min RI's the inertial load should be light.
... This exercise device uses the inertia of a spinning flywheel (moment of inertia = 0.11 kg m −2 ). An encoder attached to the rotation axis of the conic-pulley was connected to hardware (SmartCoach, SmartCoach Europe AB, Stockholm, Sweden) with associated SmartCoach software (SmartCoach v.5.2.0.5) to measure the power (w) for each repetition [24]. The SmartCoach Pro system (SmartCoach, SmartCoach Europe AB, Stockholm, Sweden) was developed to monitor several football players using six conic-pulleys simultaneously. ...
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Coaches at the professional level are often concerned about negative side effects from testing and intensive resistance training periods, and they are not willing to base their training prescriptions on data obtained from semiprofessional or amateur football players. Consequently, the purpose of this study was to analyze the reliability and effectiveness of two adductor injury active prevention programs using the adductor/abductor ratio and deficit between legs, on the basis of adduction-abduction power output during the exercises proposed, in professional football players. Forty-eight professional football players undertook complementary strength training for the adductor and abductor muscles in their dominant and non-dominant legs, once or twice a week throughout the playing season. The volume of the session was determined by the adductor/abductor ratio and the deficit between legs in the last session training measured. The number and severity of muscle injuries per 1000 h of exposure were recorded. Both prevention programs showed a very low rate of adductor injury (0.27 and 0.07 injuries/1000 h) with mild-to-moderate severity, maintaining a balance in percentage asymmetry between dominant and non-dominant legs for adductor (10.37%) and in the adductor/abductor ratio (0.92) in top professional football players throughout the season. The strength conditioning program proposed can help to prevent adductor muscle injuries in top professional football players.
... The high prevalence of patellar tendinopathy is noted in sports with high impact ballistic loading of the knee extensor mechanism (7,17). Repetitive dynamic loads on the patellar tendon enhance the risk of developing jumper's knee, especially in athletes performing jumping and landing (28). ...
Article
The main purpose of the study was to compare the muscle strength between the involved knee (IK) and uninvolved knee (UK) in 12 female volleyball players with stage 1 chronic patellar tendinopathy. Evaluation included the isometric maximal strength to body mass (MS/BM) of the lower extremities extensors for unilateral and bilateral conditions, concentric isokinetic peak torque to body mass (PT/BM) of the hamstrings and quadriceps at 60°·s and 180°·s, IK to UK extensors maximal strength ratio (SR), IK to UK hamstrings (or quadriceps) peak torque ratio (TR), and hamstrings to quadriceps peak TR (H/Q). The results indicated a significantly lower unilateral and bilateral MS/BM of lower extremities extensors for IK than UK (p < 0.001). However, there were no significant differences in SR variable between the unilateral condition and bilateral condition (p = 0.448). Only at the 60°·s velocity, significantly lower quadriceps PT/BM for IK compared with the UK (p < 0.001) and the control group (p < 0.001) were observed. Torque ratio related to the quadriceps group was significantly lower at 60°·s than 180°·s (p = 0.004). Furthermore, significantly higher H/Q for IK compared with UK (p < 0.001) and control group (p = 0.008) only at 60°·s was found. These findings show a significant isometric strength asymmetry for both unilateral and bilateral conditions and a significant concentric strength asymmetry at the low velocity. This study suggests strengthening the weaker quadriceps group and balancing the strength between hamstrings and quadriceps within the knee with patellar tendinopathy.
... In practical terms, the efficacy of the FD in team-sports has been confirmed by enhancing hypertrophy [12,23], jumping ability [24,25], sprint time [24,26], and change of direction ability [23,27] involving athletes in flywheel training programs over 6 and 27 weeks. In addition, this kind of stimulus has been shown to be beneficial in injury prevention programs [12,24] and rehabilitation programs [28] since literature has demonstrated the reduction of injury incidence and the burden values in soccer players. Thus, power training based on the FD constitutes an attractive strategy to implement with soccer players [29], which is being widely used by professional soccer teams [30,31]. ...
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This study aimed to evaluate the differences in power production between movement phases (i.e., concentric and eccentric) during the execution of resistance exercises with a flywheel device, differentiating between execution regimes (i.e., bilateral, unilateral dominant leg and unilateral non-dominant leg). Twenty young elite soccer players (U−17) performed two sets of six repetitions of the bilateral half-squat (inertia 0.025 kg·m−2) and the lateral-squat exercise (inertia 0.010 kg·m−2) on a flywheel device. During the testing sessions, mean and peak power in concentric (MPcon) and eccentric (MPecc) phases were recorded. The non-dominant leg showed higher values in all power variables measured, although substantial differences were only found in MPecc (ES = 0.40, likely) and PPcon (ES = 0.36, possibly). On the other hand, for both exercises, MPcon was higher than MPecc (ES = −0.57 to −0.31, possibly/likely greater), while only PPecc was higher than PPcon in the dominant lateral-squat (ES = 0.44, likely). These findings suggest that young soccer players have difficulty in reaching eccentric-overload during flywheel exercises, achieving it only with the dominant leg. Therefore, coaches should propose precise preventive programs based on flywheel devices, attending to the specific characteristics of each limb, as well as managing other variables to elicit eccentric-overload.
... Of note, the term "eccentric overload" appears in the title of several papers related to FRTD [8,19,27,34]. However, EO has not been evidenced in all works using FRTD. ...
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Objectives: This systematic review and meta-analysis aimed to analyze the technologies and main training variables used in the literature to monitor flywheel training devices in real-time. In addition, as the main research question, we investigated how eccentric overload can be effectively monitored in relation to the training variable, flywheel shaft type device and the moment of inertia selected. Methods: The initial search resulted in 11,621 articles that were filtered to twenty-eight and seventeen articles that met the inclusion criteria for the systematic review and meta-analysis, respectively. Results: The main used technologies included force sensors and rotary/linear encoders, mainly to monitor Peak-or Mean-Force,-Power or-Speed. Not always an eccentric overload was achieved using flywheel devices. The eccentric overload measurement was related to the main outcome selected. While Mean-Force (p = 0.011, ES=-0.84) and Mean-Power (p<0.001, ES=-0.30) favored the concentric phase, Peak-Power (p<0.001, ES= 0.78) and Peak-Speed (p<0.001, ES= 0.37) favored the eccentric phase. In addition, the lower moments of inert (i.e., vs conical pulley) showed higher possibilities to achieve the eccentric overload. Conclusions: a wide variety of technologies can be used to monitor flywheel devices, but to achieve eccentric overload, a flywheel cylindrical shaft type with low moments of inertia are advised to be used.
... Also, six weeks of FIT leg press exercise in adult males suffering with chronic patellar tendinopathy improved tendon pain symptoms as well as strength and neuromuscular activation [362]. Interestingly, the inclusion of FIT in adults who are at risk of patellar tendinopathy have shown it to be appropriate during the in-season of basketball and volleyball players in which no complaints regarding patellar tendon pain were provided as well as displaying improvements in lower limb muscle power [363]. Therefore, training modalities that can provide an increase in tendon stiffness that as well as the force generating capacity of the neuromuscular system may be efficacious to help protect against increased strain during maximum muscle actions [347]. ...
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The purpose of this narrative review is to discuss the role of eccentric resistance training in youth and how this training modality can be utilized within long-term physical development. Current literature on responses to eccentric exercise in youth has demonstrated that potential concerns, such as fatigue and muscle damage, compared to adults are not supported. Considering the importance of resistance training for youth athletes and the benefits of eccentric training in enhancing strength, power, speed, and resistance to injury, its inclusion throughout youth may be warranted. In this review we provide a brief overview of the physiological responses to exercise in youth with specific reference to the different responses to eccentric resistance training between children, adolescents, and adults. Thereafter, we discuss the importance of ensuring that force absorption qualities are trained throughout youth and how these may be influenced by growth and maturation. In particular, we propose practical methods on how eccentric resistance training methods can be implemented in youth via the inclusion of efficient landing mechanics, eccentric hamstrings strengthening and flywheel inertia training. This article proposes that the use of eccentric resistance training in youth should be considered a necessity to help develop both physical qualities that underpin sporting performance, as well as reducing injury risk. However, as with any other training modality implemented within youth, careful consideration should be given in accordance with an individual's maturity status, training history and technical competency as well as being underpinned by current long-term physical development guidelines.
... There have been improvements in the implications that it may have on actions in team sports [139] as well as in direction changes [140]. This type of exercise has also proven beneficial for older people, in achieving an improvement in balance and mobility [141], more specifically, in patellar tendinopathies [142] and in terms of injury reduction [143]. ...
Chapter
Tendinopathy is a common clinical problem which affects a substantial portion of recreational and professional athletes and those in many occupations involving repetitive work [1].
... The aforementioned acute responses to eccentric training most likely account for the unique chronic adaptations evident following extended bouts of eccentric training [24]. The lower relative eccentric load achieved through traditional resistance training, where an identical load is used during both the concentric and eccentric phases [22], has generated interest in eccentric overload techniques for achieving greater structural adaptations, improving physical performance and resistance to injury [24,25,[27][28][29]. ...
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Background: Numerous studies have reported accelerated muscle hypertrophy, strength, and power adaptations following chronic bouts of isoinertial Flywheel Resistance Training (FRT). These factors contribute to Change of Direction (CoD) speed and sprinting performance, which are key determinants of performance in football. Progression through to the senior elite level dictates the necessity to develop these qualities in adolescent populations. Aim: To determine whether ≥ 4 weeks' FRT enhances CoD and sprinting performance in adolescent football players versus traditional strength training. Methods: PubMed and SPORT Discus electronic databases were used in February 2021. The search strategy identified randomised controlled trials, randomised crossover trials, and controlled non-randomised, full-text peer-reviewed publications written in English. Study quality was assessed by conducting a modified Downs and Black checklist. Results: A total of 21 studies were found, and following the removal of duplicates and studies based on title and abstract screening, eight studies remained. Following eligibility screening, three studies were included in the systematic review. A total of 67 subjects participated in the included studies. FRT training provides evidence that sprint performance over distances from 10 to 40-m can be improved (effect sizes: 10m = -1.8 ± 2.4%); 20m (ES = 0.37); 30m (ES = -1.5 ± 1.1%); 40m (ES = -1.1 ± 1.0%); and flying 10m (ES = 0.77) and that FRT induces significant improvements in CoD (different distances and for dominant and non-dominant limbs) compared to a control condition where subjects continued with their football training. Conclusion: Although the included studies suggest that 10-27 weeks' FRT may improve CoD and sprint performance in adolescent football players, paucity in the available literature makes such a conclusion premature. Further research in the area would ideally account for the device, moment of inertia, and transfer mechanism.
... However, neither group reported any patellofemoral injuries, and the authors were unable to comment on the training regimen's utility as a prevention program. 7 PFPS was the most commonly reported injury in women's field hockey, women's lacrosse, and women's softball. Patellar subluxation was the most prevalent injury in men's hockey, and prepatellar bursitis was the most common injury in men's wrestling. ...
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Background As many as 30% of patients with knee pain seen in sports medicine clinics have complaints related to the patellofemoral joint. There is a paucity of research available regarding patellofemoral injuries, mechanism of injury, and playing time lost in collegiate athletes. Purpose To describe the rates, mechanisms, severity, and potential sex-based differences of patellofemoral injuries in collegiate athletes across 25 National Collegiate Athletic Association (NCAA) sports. Study Design Descriptive epidemiology study. Methods Data from the 2009-2010 through the 2013-2014 academic years were obtained from the NCAA Injury Surveillance Program and were analyzed to calculate patellofemoral injury rates, mechanisms of injury, time lost, and need for surgery. Rate ratios and injury proportion ratios were used to quantify discernible differences between sex-comparable sports and timing of injury (ie, practice vs competition), respectively. Results The overall patellofemoral injury incidence rate was 16.10 per 100,000 athlete-exposures (AEs). Women’s volleyball had the highest incidence of all sports (39.57 per 100,000 AEs). Injuries were 66% more likely to occur in competition than during practice. Female athletes experienced significantly more patellofemoral injuries than males in similar sports. Patellar tendinitis accounted for 49.2% of all patellofemoral injuries and was the most common injury in 20 of 25 studied sports. Patellar subluxation accounted for the most total days missed, and patellar dislocation had the highest mean days missed per injury (11.42 days). Patella fracture was the most likely injury to require surgery (80%). Conclusion Patellofemoral injuries were most common in sports that require jumping and quick changes of direction, specifically women’s volleyball, men’s and women’s basketball, and women’s soccer. The majority of patellofemoral injuries in this cohort were classified as patellar tendinitis caused by overuse. Most injuries resulted in no competition or practice time lost. This information may contribute to the development of prevention programs aimed at addressing the most prevalent types and mechanisms of injury in each sport to reduce the incidence of patellofemoral injury in these athletes.
... The use of the FW squatting devices is a popular and effective tool for resistance training in athletes [15] and in rehabilitation [16]. The reliability of different outcome measures during FW squatting such as force output [17] and force-velocity outcome parameters [18] has already been confirmed. ...
Article
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Assessment of lateral symmetries (LS) of lower limbs has been widely investigated. However, there are no studies about LS during exposure to high eccentric and concentric loads during flywheel (FW) squats. A total of 422 young, physically active participants performed squats on an FW device with different equidistant loads (0.05, 0.125 and 0.2 kg∙m2). The mean and peak force of the left and right leg were assessed for the concentric and eccentric contaction phase. LS values were calculated for each load and phase of squat. Our results showed that the absolute mean and peak force of the concentric and eccentric phase of contraction had excellent reliability, while LS values were more reliable when eccentric force was used for their calculation. Mean and peak forces were increased with the higher FW load. In general, we found a decrease in LS values in the concentric phase of contraction with the higher load. Moreover, values of LS are similar to a wide range of other functional movements. Nevertheless, symmetrical force application during squatting on a FW device should be satisfied regardless of the FW load. Due to the large sample size, our results are valuable as a reference point when athletes are evaluated during training.
... Differences in outcomes may also be due to the limited (weekly) flywheel training sessions, which may not always be sufficient to stimulate enhancement of jumping ability (Raya-González et al., 2020b). In support of this, weekly flywheel squat and lunge training sessions did not enhance jumping performance of volleyball and basketball players or handball players, respectively (Gual et al., 2016;Sabido et al., 2017). The literature suggests that 2-3 weekly flywheel sessions ideally be performed to enhance jump performance parameters in team sports (Maroto-Izquierdo et al., 2017b;Raya-González et al., 2020b), although weekly application of flywheel training in soccer populations has also shown to be effective (Coratella et al., 2019;Fiorilli et al., 2020;Gonzalo-Skok et al., 2019;De Hoyo et al., 2015;Raya-González et al., 2021a). ...
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The aims of the current systematic review were to evaluate the current literature surrounding the chronic effect of flywheel training on the physical capacities of soccer players, and to identify areas for future research to establish guidelines for its use. Studies were identified following a search of electronic databases (PubMed and SPORTDiscus) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA). Eleven studies met the inclusion criteria and were included. The methodological quality of the included studies ranged between 10 and 18 with an average score of 15 points using the PEDro scale. The training duration ranged from 6 weeks to 27 weeks, with volume ranging from 1 to 6 sets and 6 to 10 repetitions, and frequency from 1 to 2 times a week. This systematic review reported that a diverse range of flywheel training interventions can effectively improve strength, power, jump, and changes of direction in male soccer players of varying levels. Flywheel training interventions improve the physical capacities of soccer players of varying levels. Nonetheless, the current literature suggests contrasting evidence regarding flywheel training induced changes in sprint speed and acceleration capacity of soccer players.
... Jumping performance was evaluated in seven studies Gual et al., 2016;Maroto-Izquierdo et al., 2019;Naczk et al., 2016;Sabido et al., 2017;Tous-Fajardo et al., 2016), all by means of the countermovement jump (CMJ). The overall effect size showed a moderate and significant effect for FRT interventions. ...
Article
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The purpose of the present meta-analysis was to examine the effect of flywheel resistance training (FRT) on main sport action (i.e. jumping performance, sprinting time and change of direction performance) improvements in athletes and healthy active people. A Boolean search strategy adapted for each of the databases employed was conducted to identify all studies measuring change in sport actions performance after FRT interventions up to July 2019. Outcomes were analysed using an average effect size (D+) and a 95% confidence interval (CI), which was calculated assuming a random-effects model. A total of 9 studies with 283 participants met the inclusion criteria and were selected for the analysis. The mean quality score (PEDro scale) of the articles included in the meta-analysis was 5.67. The meta-analysis showed significant positive effects on jumping performance (SMC 0.65; 95% CI, 0.11-1.19; p = 0.02), sprinting time (SMC 1.33; 95% CI, 0.39-2.28; p < 0.01) and change of direction performance (SMC 1.36; 95% CI, 0.58-2.14; p < 0.01) after FRT interventions compared to control/traditional resistance training groups. The results of the present meta-analysis provide evidence of the usefulness of FRT to improve variables related to sport performance in athletes and a healthy population.
... Strength training programs, particularly those emphasizing eccentric (ECC) muscle actions, have been considered as potential aids in the treatment of tendinopathy, 1 which is why there has been increasing interest in the use of rotational inertia devices (RIDs) in the tendinopathy rehab process. [1][2][3][4] RIDs are designed to use the moment of inertia of a rotating flywheel to provide a maximal resistance overload during concentric (CON) and ECC phases of movement. 5 These systems provide a source of linear resistance via a tether wrapped around a horizontal cylinder-shaped (YY) 6 or a vertical cone-shaped shaft (CP). ...
Article
High intraset variability has been considered as a potential aid in the treatment of tendinopathy by producing forces in variable and unpredictable contexts that allow the athlete to return to sport pain free. The aim of this study was to compare the intraset variability in force profiles between different rotational inertia devices (RIDs) during concentric and eccentric (ECC) phases of movement and between different moments of inertia. Thirty-nine men performed a half-squat incremental test on 2 different RIDs: a horizontal cylinder and a vertical cone-shaped axis. Intraset variabilities in vertical force and velocity were analyzed using average coefficients of variation. RID squat exercise produced force intraset variability. The ECC phase of the movement showed more intraset variability in force output than the concentric phase. ECC vertical cone-shaped shaft showed a higher intraset variability in force than ECC horizontal cylinder-shaped shaft. This study demonstrated that using an RID to provide resistance in squat training of athletes produced a high intraset variability in the application of force.
... The magnitude and frequency of variations in the training content define the periodization model used. In this regard, previous studies have used linear periodization models (i.e., maintaining training load components stable throughout the program) (Gual et al., 2016;Sabido et al., 2017;Núñez et al., 2018), but most of them have applied non-linear periodization models (Askling et al., 2003;de Hoyo et al., 2015;Gonzalo-Skok et al., 2017;Raya-González et al., 2021a). In this sense, variations of weekly frequency or training volume throughout the flywheel program are the main common strategies. ...
... The potential benefits of isolated or overloaded eccentric (ECC) resistance exercise, compared with concentric (CON) or conventional CON-ECC exercise regimens, have been widely studied (Maroto-Izquierdo, Garcia-Lopez, Fernandez-Gonzalo et al., 2017;Roig et al., 2009). Among different technologies allowing for eccentric overload (EO), iso-inertial flywheel resistance exercise is one of the most utilized exercise paradigms with established efficacy in different scenarios such as injury prevention/ rehabilitation Gual, Fort-Vanmeerhaeghe, Romero-Rodriguez, & Tesch, 2016;Monajati, Larumbe-Zabala, Goss-Sampson, & Naclerio, 2018) and performance (de Hoyo, de la Torre et al., 2015;Naczk et al., 2017;Sabido, Hernandez-Davo, Botella, Navarro, & Tous-Fajardo, 2017). Furthermore, iso-inertial flywheel resistance exercise has been suggested to improve muscle function, and functionality in elderly subjects (Brzenczek-Owczarzak et al., 2013) and stroke patients (Fernandez-Gonzalo et al., 2016). ...
Article
This study aimed to analyse whether increasing the eccentric overload (EO) during resistance training, in terms of range of motion and/or velocity using an electric-motor device, would induce different muscle adaptations than conventional flywheel-EO resistance training. Forty physically active university students (21.7 ± 3.4 years) were randomly placed into one of the three training groups (EX1, EX2, FW) and a control group without training (n = 10 per group). Participants in the training groups completed 12 sessions (4 sets of 7 repetitions) of iso-inertial single-leg squat training over 6 weeks for the dominant leg. Resistance was generated either by an electric-motor device at two different velocities for the eccentric phase; 100% (EX1) or 150% (EX2) of concentric speed, or by a conventional flywheel device (FW). Thigh lean tissue mass, unilateral leg press one-repetition maximum (1-RM), unilateral muscle power at different percentages of the 1-RM and bilateral/unilateral vertical jump were assessed before and after the 6-week training. There were significant (p < 0.05–0.001) main effects of time in the 3 training groups, indicating increased thigh lean tissue mass (2.5–5.8%), 1-RM load (22.4–30.2%), vertical jump performance (9.1–32.9%) and muscle power (8.8–21.7%), without differences across experimental groups. Participants in the control group did not improve any of the variables measured. In addition, EX2 showed greater gains in eccentric average peak power during training than EX1 and FW (p < 0.001). Despite the different EO offered, 6 weeks of resistance training using flywheel or electric-motor devices induced similar significant gains in muscle mass, strength, muscle power and vertical jump.
... Flywheel (FW) inertial resistance training has gained attention in recent years due to all the positive acute [1,2] and short-term [3] neuromuscular performance effects, and long-term effects derived from FW training interventions on strength, power (P), performance-related variables [4][5][6][7][8][9][10][11], and clinical outcomes [12][13][14]. There are many different FW devices on the market, all of which follow the same principle-by accelerating and then consequently braking the mass moment of inertia (I) of the FW. ...
Article
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Research into flywheel (FW) resistance training and force–velocity–power (F–v–P) profiling has recently gained attention. Ground reaction force (GRF) and velocity (v) during FW squats can be predicted from shaft rotational data. Our study aimed to compare the inter-set reliability of GRF, v, and F–v–P relationship output variables calculated from force plates and linear encoder (presumed gold-standard) and rotary encoder data. Fifty participants performed two sets of FW squats at four inertias. Peak and mean concentric and eccentric GRF, v, and F–v–P outcomes from mean variables during the concentric phase of the squat were calculated. Good to excellent reliability was found for GRF and v (ICC > 0.85), regardless of the measure and the variable type. The F–v–P outcomes showed moderate to good reliability (ICC > 0.74). Inter-measure bias (p < 0.05) was found in the majority of GRF and v variables, as well as for all the calculated F–v–P outcomes (trivial to large TEs) with very large to perfect correlations for v (r 0.797–0.948), GRF (r 0.712–0.959), and, finally, F–v–P outcomes (ICC 0.737–0.943). Rotary encoder overestimated the force plates and linear encoder variables, and the differences were dependent on the level of inertia. Despite high reliability, FW device users should be aware of the discrepancy between the measures.
... Several studies have confirmed the efficacy of flywheel training devices for improving hypertrophy [5], power [6], countermovement jump (CMJ) performance [4,7,8], 10 m sprint time and changes of direction (COD) [4,[7][8][9], and injury prevention or rehabilitation [4,10,11]. Most studies agree that familiarization processes, adequate progression, and load control (encoder) are required. ...
Article
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Several studies have confirmed the efficacy of flywheel training, mainly in the bilateral half-squat exercise. The aim of the present study was to analyze the effects of single-leg Romanian deadlift flywheel training on speed, jumping and change of direction performance. Seventeen young healthy males underwent two periods of 3-week training based on two weekly sessions of 3 sets × 7 repetitions or 4 sets × 7 repetitions of single-leg Romanian deadlifts (0.037 kg/m² moment inertia) with their dominant and non-dominant leg. After the first three weeks of the program, the CMJ, the 10 m, 30 m and total sprint times, as well as the COD-90 test, presented likely substantial beneficial effects and a small decrease in the relationship between the sprint and COD-90 test performance. After the second period of the three-week training, likely detrimental effects were observed in some of the change of direction conditions and an increase in the relationship between the sprint and the COD-180 performance. It could be hypothesized that most of the flywheel training effects reported in the traditional protocols lasting a minimum of 5–6 weeks would occur in the first weeks of training.
... Resultantly, neuromuscular functioning may be impaired (if not properly managed), so close monitoring of daily fluctuations in such movements is crucial to ensuring desirable training adaptations are achieved rather than overtraining. Based on the repeated bout effect, athletes may better prepare for these volumes of decelerations during basketball competition by slowly progressing training strategies that optimize eccentric loading (i.e., greater eccentric velocities and power with lower exercise induced muscle damage) (Merrigan and Jones, 2021), as well as the elastic properties that maximize the utilization of the stretchshortening (Gual et al., 2016;Schelling and Torres-Ronda, 2016). Of course, a comprehensive training regimen for basketball athletes extends well-beyond the sole purpose of enhancing declarative ability. ...
Article
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The primary purpose was to simplify external load data obtained during Division-I basketball competitions via principal component analysis (PCA). A secondary purpose was to determine if the PCA results were sensitive to load demands of different positional groups (POS). Data comprised 229 observations obtained from 10 men’s basketball athletes participating in NCAA DI competitions. Each athlete donned an inertial measurement unit that was affixed to the same location on their shorts prior to competition. The PCA revealed two factors that possessed eigenvalues greater than 1.0 and explained 81.42% of the total variance. The first factor comprised total decelerations (totDEC, 0.94), average speed (avgSPD, 0.90), total accelerations (totACC, 0.85), total mechanical load (totMECH, 0.84), and total jump load (totJUMP, 0.78). Maximum speed (maxSPD, 0.94) was the lone contributor to the second factor. Based on the PCA, external load variables were included in a multinomial logistic regression that predicted POS (Overall model, p < 0.0001; AUCcenters = 0.93, AUCguards = 0.88, AUCforwards = 0.80), but only maxSPD, totDEC, totJUMP, and totMECH were significant contributors to the model’s success (p < 0.0001 for each). Even with the high significance, the model still had some issues differentiating between guards and forwards, as in-game demands often overlap between the two positions. Nevertheless, the PCA was effective at simplifying a large external load dataset collected on NCAA DI men’s basketball athletes. These data revealed that maxSPD, totDEC, totJUMP, and totMECH were the most sensitive to positional differences during competitions. To best characterize competition demands, such variables may be used to individualize training and recovery regimens most effectively.
... A combination of high-load training with a low speed can be one important countermeasure to the occurrence of this condition. Flywheel resistance training has also been tested in the past to prevent and heal tendon injuries showing good results, with studies presenting increased leg strength and decreased pain perception of patients using this technology in the treatment of patellar tendinopathy (16,53). It has also been demonstrated that flywheel resistance training can cause greater effects in muscle activation than traditional resistance training (44). ...
Article
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Patellar tendinopathy is an overuse injury commonly known as “jumper’s knee” that causes pain in the inferior region of the patella. This pathology is recurrent in team sports and has more impact on male athletes. Some anatomical intrinsic factors and several extrinsic factors seem to be key in triggering this condition that is also increasingly appearing in children and adolescents. The aim of this article is to provide coaches and practitioners with some useful practice-based exercises that can be helpful in preventing these disabling tendon injuries in sports such as volleyball, basketball, soccer, american football, and team handball.
... [8][9][10] Nowadays, the available evidence about which type of exercise is the most indicated for the treatment of PT is inconclusive, but it is known that exercises and control/ administration of loads are fundamental for the treatment. 11 Over the years, eccentric exercise (EE) has been postulated as one of the most beneficial interventions for the prevention and treatment of PT, [12][13][14][15][16] although new training protocols (such as those using high resistance at low speed) seem to give very good results. 17 In physiotherapy, minimally invasive treatments, such as percutaneous needle electrolysis (PNE) and dry needling (DN), are being increasingly used based on research showing them to be effective for the treatment of tendinous injuries, 18,19 although recent studies have shown that adding minimally invasive techniques does not provide any additional benefit over only performing an EE programme. ...
Article
Objective To compare the cost-effectiveness of three patellar tendinopathy treatments. Design Secondary (cost-effectiveness) analysis of a blinded, randomised controlled trial, with follow-up at 10 and 22 weeks. Settings Recruitment was performed in sport clubs. The diagnosis and the intervention were carried out at San Jorge University. Participants The participants were adults between 18 and 45 years (n = 48) with patellar tendinopathy. Interventions Participants received percutaneous needle electrolysis, dry needling or sham needling, all of which were combined with eccentric exercise. Main outcome measures Costs, quality-adjusted life years and incremental cost-effectiveness ratio were calculated for each group. Results The total cost per session was similar in the three groups: €9.46 for the percutaneous needle electrolysis group; €9.44 for the dry needling group; and €8.96 for the sham group. The percutaneous needle electrolysis group presented better cost-effectiveness in terms of quality-adjusted life years and 96% and 93% probability of being cost-effective compared to the sham and dry needling groups, respectively. Conclusion Our study shows that percutaneous needle electrolysis has a greater probability of being cost-effective than sham or dry needling treatment.
... In a sample of 81 jumping athletes who were at high risk for developing patellar tendinopathy due to repetitive tendon loading, a once weekly IFRT protocol added to normal in-season sports training led to strength and power improvements, along with no increases in patellar tendon pain or diagnoses of patellar tendinopathy within the sample. 51 Given the high prevalence and incidence of patellar tendinopathy in elite jumping athletes, 52,53 this evidence of a prophylactic effect of IFRT is a potentially significant finding. Although more studies are required to confirm the efficacy of IFRT in preventing patellar tendinopathy, the evidence is nonetheless encouraging given the lack of preventative patellar tendinopathy interventions available, 54 and the high number of associated risk factors identified in jumping athletes. ...
Article
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Background Inertial Flywheel Resistance Training (IFRT) has recently emerged as a beneficial rehabilitation option for some musculoskeletal disorders. Although the use of resistance training as treatment for tendinopathy has become widespread, it is unclear if IFRT has efficacy as a treatment option for tendinopathies. Objective To identify current evidence on IFRT in the treatment of tendinopathy, evaluating intervention parameters and outcomes. Methods This scoping review was reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Databases searched included MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, Cochrane library (Controlled trials, Systematic reviews), and five trial registries. Two independent reviewers screened studies at title, abstract and full text. Following screening, data were extracted and charted, and presented as figures and tables alongside a narrative synthesis. Any study design conducted on adults, investigating the effects of IFRT for tendinopathy were included. Data were extracted on intervention parameters and outcomes of IFRT interventions. Results Four studies on patellar tendinopathy were included. A variety of outcomes were assessed, including pain, function, strength, power, and tendon morphological and mechanical properties, particularly changes in tendon thickness. IFRT intervention parameters were largely homogenously prescribed, with slight variances. Conclusion Despite a paucity of studies to date on the effects of IFRT for treating tendinopathy, preliminary evidence for beneficial effects of IFRT on clinical outcomes in patellar tendinopathy is encouraging. As IFRT is a relatively new and unexplored method in tendinopathy rehabilitation, definitive conclusions, and recommendations cannot be made at present, which should be addressed in future research, due to the potential therapeutic benefits highlighted in this review.
... Later, patients will go to the platform forces and will perform each jump three times (squat jump, Abalakov jump and countermovement jump test) with 60 seconds between jumps and 2 minutes between different jumps (table 1). [26][27][28] The maximum height of the jump will be analysed via the measurement of the flight time recorded on the force platforms, the eccentric power and the maximum concentric force performed. The Abalakov jump will be performed with the subject standing in an upright position with a full arm swing. ...
Article
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Introduction Patellar tendinopathy is a degenerative disease of the patellar tendon, which affects athletes from a variety of sports, and is especially predominant in sports involving high-impact jumping. The aim of this study is to determine the additional effect of two interventions combined with eccentric exercise and compare which one is the most effective at short-term and long-term follow-up for patients with patellar tendinopathy. Methods and analysis This study is a randomised controlled trial with blinded participants. Measurements will be carried out by a specially trained blinded assessor. A sample of 57 patients with a medical diagnosis of patellar tendinopathy will participate in this study and will be divided into three treatment groups. Eligible participants will be randomly allocated to receive either: (a) treatment group with percutaneous needle electrolysis, (b) treatment group with dry needling or (c) treatment group with placebo needling. In addition, all groups will perform eccentric exercise. Functionality and muscle strength parameters, pain, ultrasound appearances and patient perceived quality of life shall be evaluated using the Victorian Institute of Sports Assessment for patellar (VISA-P), jump tests, Visual Analogue Scale, ultrasound images and Short Form-36 (SF-36), respectively. Participants will be assessed at baseline, at 10 weeks and at 22 weeks after baseline. The expected findings will allow us to advance in the treatment of this injury, as they will help determine whether a needling intervention has additional effects on an eccentric exercise programme and whether any of the needling modalities is more effective than the other. Ethics and dissemination This protocol has been approved by the Ethics Committee of Aragon (N° PI15/0017). The trial will be conducted in accordance with the Declaration of Helsinki. Trial registration number NCT02498795
Article
BACKGROUND: Eccentric overload training (EOT) has been proposed as an effective stimulus to optimize dynamic athletic performance. Nevertheless the appropriate intensity during EOT remains unknown. The purpose of this study was to evaluate the influence of the inertial load used during an EOT programme on performance adaptations in rugby union players. METHODS: Fifteen rugby players were divided into a low (0.025 kg·m2; G 0.025) or a high (0.075 kg·m2; G 0.075) inertial load for training. Both groups trained using the flywheel half squat exercise twice a week during the seven-week EOT. Athletic performance was evaluated by testing the half squat maximum repetition (1RM), countermovement jump (CMJ), 40 m linear sprint, the modified agility T-Test, and power output in the flywheel squat exercise. Data were analysed using magnitude-based inferences. RESULTS: Both groups improved their 1RM and CMJ to a similar extent. Nevertheless, the G 0.025 showed likely trivial changes in linear sprint (ES = -0.02), and possibly positive effects on the agility T-Test (ES = 0.16), while the G 0.075 showed possibly negative effects on 40 m linear sprint (ES = - 0.23) and likely trivial effects on the T-Test (ES = 0.07). CONCLUSIONS: Due to the similar gains in 1RM and CMJ, and the superior maintenance in linear sprint, the use of low inertial loads during EOT may be a better option when looking for athletic performance optimization.
Article
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Strength training is a key strategy to improve performance and injury prevention in team-sports. Accordingly, several methods have been used, although due to the benefits reported after training based on eccentric contractions, the use of flywheel devices (FW) has extended within the periodization of strength training of team-sports. However, nowadays, there is no clear consensus about the parameters used to optimize the training effects. This article examines the research behind these claims and attempts to draw evidence-based conclusions as to the practical implications for a precise use of FW with team-sports players, attending to their specific demands and objectives.
Article
Background: The aim of this study was to analyse the effects of an inter-repetition variable rotational flywheel training program (Variable) over standard rotational flywheel training (Standard). Methods: Twenty-four youth female team-sports players were randomly assigned to both training groups (Variable, n = 12; Standard, n = 12), which consisted of 1 set of 3 rotational flywheel exercises x 10-12 repetitions, biweekly for a period of 6-weeks. The participants included in Variable group were instructed to perform the movement randomly in one of the three directions (0o, 45o right, and 45o left). Measurements included reactive strength, jumping, change of direction, and sprinting tests; patellar tendon condition was also assessed. Results: Substantial improvements were found in vertical jump with left leg (16.9%), lateral jump with right leg (13.6%), and patellar condition in left leg (4.1%) for Standard group, but also in reactive strength index in right leg landing (33.9%), vertical jump with right (10.1%) and left leg (12.0%) for Variable group. A significant interaction effect (group x time) wasobserved on patellar condition in right leg (F = 10.02, p < 0.01, η 2 = 0.37), favoring Variable group. Conclusions: Rotational flywheel training programs were beneficial for youth-female team-sports athletes, although the movement variability may play a key role to develop different and specific physical adaptations.
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Objective The objective of this study is to summarise and analyse the current literature about what progression criteria are applied in loading exercise programmes in lower limb tendinopathies and their evidence and effectiveness. Design Systematic review. Methods PubMed, Embase, Scopus and PEDro were searched from inception to 24 September 2020. The inclusion criteria were randomised controlled trials that included patients with midportion Achilles, patellar or gluteal tendinopathy; assessed function, pain or performance; included at least one group where progressive physical exercise was administered as monotherapy; included at least a control group. We excluded studies that included subjects with previous tendon surgical treatment; studies with control group that conducted a supplemented modality of the exercise performed in the intervention group. A narrative synthesis was conducted. Cohen’s d and the percentage of change of main clinical and performance outcomes were obtained. Methodological quality was assessed using the PEDro scale. Results Thirty studies that described progression criteria were included. Six types of criteria grouped in two categories were identified and included in a new classification proposal: pain as a primary criterion (evoking and avoid-pain based), and pain and symptom control as a secondary criterion (conditioning stages, fatigue-based, subjective perception and temporary linear increase). Most of the studies applied a pain-based criterion. Criteria based on conditioning stages were also commonly applied. Other criteria such as fatigue, a temporary linear increase, or the subjective perception of the patient’s abilities were occasionally applied. Conclusions There is a predominant use of pain-based criteria, but the utilisation of these criteria is not supported by strong evidence. This review evidences the need for studies that compare the same exercise programme using different progression criteria. A new classification of the existing progression criteria is proposed based on the use of pain as the primary or secondary criterion.
Article
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endinopathy refers to the clinical diagnosis of activity-related pain resulting in a decline in tendon function. In the last few years, much has been published concerning the basic science and clinical investigation of tendinopathy and debates and discussions to new questions and points of view started many years ago. This advances review will discuss the current thinking on the basic science and clinical management of tendinopathy and in particular new findings in the tendon repair space that are relevant to the pathophysiology of tendinopathy. We will further discuss potential novel therapies on the horizon in human tendon disease.
Article
Background: The aim was to compare the effects of two lower extremity strengthening programs using iso-inertial resistance or free weights on amateur soccer players' physical performance indicators. Methods: Thirty-five amateur soccer players (average age 22.6±5.1 years) were randomly assigned to iso-inertial group (n=11) or free-weight group (n=11), or control group (n=13). The groups performed two training sessions per week for six weeks. Before and after the strengthening implementation, physical performance indicators were evaluated, including the isokinetic knee extensors and flexors' strength, power, speed, and agility. The significance level was set at p<0.05. Results: The iso-inertial training resistance led to an increase in the hamstrings' eccentric strength at 60°/s and 150°/s (p<0.05) compared to the free-weight resistance (p>0.05) and the controls (p>0.05). No other significant adaptations were observed in the other isokinetic strength, power, speed (10-m, p=0.052) and agility measurements (Illinois agility test, p=0.059). In ratio (knee flexors/knee extensors) the only differences observed was at 150 o/s for iso-inertial group (p<0.05). Conclusions: Iso-inertial resistance training during semi squatting can enhance the hamstrings' eccentric performance andthe soccer players' speed and agility compared to the classic free-weight training program, which should considered when designing strength and injury prevention programs.
Article
Objectives To compare the efficacy of inertial flywheel and heavy slow resistance training in reducing pain and improving function in patellar tendinopathy. Design Randomised clinical trial. Methods Fourty two participants (1 woman, 41 men) with longstanding (>3 months) patellar tendinopathy were randomised into inertial flywheel resistance (N = 21) or heavy slow resistance (N = 21) group. Both programmes consisted of three supervised inertial flywheel or heavy slow resistance exercise sessions per week in a fitness center during 12 weeks. Primary outcome was pain and function, assessed by the Spanish Victorian Institute of Sport Assessment for Patella (VISA-P) score at 6 and 12 weeks. Secondary outcomes were activity limitation using Patient Specific Functional Scale (PSFS), health status (EuroQol-5D), patient impression of change on pain and function, adherence, adverse events, pain provocation test for the patellar tendon (numerical rating score of pain between 0 and 10), physical test, patellar tendon thickness and doppler signal on ultrasound. Secondary outcomes were taken at 0 and 12 weeks. Results Both groups showed significant improvements in VISA-P scores from 0 to 12 weeks but there was not statistically significant between-group difference (P = 0.506). No adverse events or side effects occurred in any of the groups during the intervention period. Conclusions Inertial flywheel resistance three times a week during 12 weeks resulted in similar pain and function benefit at 12 weeks compared with the heavy slow resistance training among people with patellar tendinopathy. Flywheel training is another exercise option for managing people with patellar tendinopathy. ClinicalTrials.gov Registry NCT03917849.
Chapter
It is known that muscle fibres have a greater capacity to generate force during the eccentric phase of a movement compared with the concentric phase of the same movement. Thus, some authors argue that training protocols where exercise is overloaded during the eccentric phase of movement achieve greater strength gains than those in which the load is constant during the eccentric and concentric phases. Different training devices, using the inertia of rotating flywheels, have been designed to increase the eccentric overload during movement. The use of flywheel resistance training devices during short periods of training may improve muscle force more than traditional methodologies. In this chapter we will respond to the main questions about how to use the flywheel device and discuss how to optimize athletes’ performance with it.
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Tendinopathy is chronic tendon disease which can cause significant pain and functional limitations for individuals and collectively place a tremendous burden on society. Resistance training has long been considered the treatment of choice in the rehabilitation of chronic tendinopathies, with both eccentric and heavy slow resistance training demonstrating positive clinical effects. The application of progressive tendon loads during rehabilitation is essential to not compromise tendon healing, with the precise dosing parameters of resistance training and external loading a critical consideration. Blood-flow restriction training (BFRT) has become an increasingly popular method of resistance training in recent years and has been shown to be an effective method for enhancing muscle strength and hypertrophy in healthy populations and in musculoskeletal rehabilitation. Traditional resistance training for tendinopathy requires the application of heavy training loads, whereas BFRT utilises significantly lower loads and training intensities, which may be more appropriate for certain clinical populations. Despite evidence confirming the positive muscular adaptations derived from BFRT and the clinical benefits found for other musculoskeletal conditions, BFRT has received a dearth of attention in tendon rehabilitation. Therefore, the purpose of this narrative review was threefold: firstly, to give an overview and analysis of the mechanisms and outcomes of BFRT in both healthy populations and in musculoskeletal rehabilitation. Secondly, to give an overview of the evidence to date on the effects of BFRT on healthy tendon properties and clinical outcomes when applied to tendon pathology. Finally, a discussion on the clinical utility of BFRT and its potential applications within tendinopathy rehabilitation, including as a compliment to traditional heavy-load training, will be presented.
Article
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The aim of this umbrella review was to provide a detailed summary of how flywheel training enhances strength and physical capacities in healthy and athletic populations. The eleven reviews included were analyzed for methodological quality according to the Assessing the Methodological Quality of Systematic Review 2 (AMSTAR 2) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Two were systematic reviews, six were systematic reviews with meta-analyses and three were narrative reviews. Although the included reviews support use of flywheel training with athletic and healthy populations, the umbrella review highlights disparity in methodological quality and over-reporting of studies (38 studies were included overall). Flywheel post-activation performance enhancement protocols can effectively enhance strength and physical capacities acutely with athletes and healthy populations. All relevant reviews support flywheel training as a valid alternative to traditional resistance training for enhancing muscular strength, power, and jump performance with untrained and trained populations alike. Similarly, reviews included report flywheel training enhances change of direction performance—although conclusions are based on a limited number of investigations. However, the reviews investigating the effect of flywheel training on sprint performance highlight some inconsistency in attained improvements with elite athletes (e.g., soccer players). To optimize training outcomes, it is recommended practitioners individualize ( i . e ., create inertia-power or inertia-velocity profiles) and periodize flywheel training using the latest guidelines. This umbrella review provides an analysis of the literature’s strengths and limitations, creating a clear scope for future investigations.
Article
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Introduction: Patellar tendinopathy (PT) has a high prevalence in jumping athletes and presents a significant burden on athletes and clinicians due to its long-lasting duration and persistent symptoms. This scoping review aimed to map existing evidence on prevention and in-season management interventions for PT in athletes, evaluating intervention parameters and outcomes. Methods: This scoping review was reported in accordance with the PRISMA-ScR. Databases searched included MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library (Controlled trials, Systematic reviews). All primary study designs investigating prevention or in-season management interventions for PT, while maintaining athletes in sport were considered for inclusion. Results: 5987 articles were identified with 29 included in the review. Five studies investigated exercise-based prevention interventions on athletes at risk for PT, including two randomized controlled trials (RCTs), two cohort studies and one case-control study. 24 studies investigated in-season management or rehabilitation in athletes with PT, including 18 RCTs, three case reports, one cohort study, one case series, and one retrospective review. Of these 24 studies, 22 used various resistance training interventions, one used ESWT and one used patellar strapping and taping. The types of resistance training included eccentric, heavy-slow, isometric, inertial flywheel, blood-flow restriction, and isotonic training. Eccentric training was used in 9 studies, with single leg decline squats the most common exercise used in 7 studies. Outcome measures and intervention parameters were heterogenous throughout studies. Conclusion: Despite a dearth of studies on preventative interventions for athletes with PT, resistance training may be a useful prophylactic method. Eccentric, heavy slow and isometric resistance training have been found to be feasible and clinically beneficial in-season. There are a lack of studies showing that ESWT offers any additional benefit over resistance training in competing athletes. Patellar strapping and taping may offer short-term pain relief during training and competition. Systematic reviews are required to make definitive recommendations for PT.
Article
Background: This study aimed to evaluate the clinical outcomes of arthroscopic decortication of the inferior patellar pole in athletes with refractory chronic patellar tendinopathy. Methods: Thirty-seven athletes in whom conservative management for at least six months failed underwent arthroscopic patellar tendon debridement and decortication of the inferior pole of the patella. Clinical outcomes were evaluated using subjective knee scores and isokinetic muscle strength tests. The average duration taken and sports participation level were also assessed. Results: The mean follow-up period was 51.3 ± 14.8 months. At the last follow-up, all improvements in subjective knee scores including Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Victorian Institute of Sport Assessment -Patella (VISA-P) score, and Kujala score were statistically significant (p<.001). Tegner activity scale improved from 6.5±1.0 to 8.9±0.8 (p<.001). Limb symmetry index for extensor peak torque improved from 71.4±19.6% to 92.7±21.7% (p<.001). Thirty-two (86.5 %) athletes were able to return to full sports activities in a mean 3.5±1.7months, and 27 (73%) athletes maintained their previous sports activity level at the last follow-up. Symptoms recurred in two (5.2%). Conclusions: Arthroscopic decortication of the inferior pole of the patella showed satisfactory clinical results and high rates of return to sports at mid-term follow-up in professional athletes with refractory chronic patellar tendinopathy. This technique could be an invasive, safe, and effective treatment for chronic patellar tendinopathy in professional athletes who want a faster return to sports. Level of evidence: Level IV, case series.
Article
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Background Reduced flexibility has been documented in athletes with lower limb injury, however stretching has limited evidence of effectiveness in preventing injury or reducing the risk of recurrence. In contrast, it has been proposed that eccentric training can not only improve strength and reduce the risk of injury, but also facilitate increased muscle flexibility via sarcomerogenesis. Objective This systematic review was undertaken to examine the evidence that eccentric training has demonstrated effectiveness as a means of improving lower limb flexibility. Design Systematic Review. 6 electronic databases were systematically searched by two independent reviewers to identify randomised clinical trials comparing the effectiveness of eccentric training to either a different intervention, or a no-intervention control group. Studies evaluating flexibility using both joint range of motion (ROM) and muscle fascicle length (FL) were included. 6 studies met the inclusion/exclusion criteria, and were appraised using the PEDro scale. Differences in the muscles studied, and the outcome measures used, did not allow for pooled data analysis. Results There was consistent, strong evidence from all six trials in three different muscle groups that eccentric training can improve lower limb flexibility, as assessed using either joint ROM or muscle FL. Conclusions The results support the hypothesis that eccentric training is an effective method of increasing lower limb flexibility. Therefore eccentric training is associated with improved flexibility, and not only with gains in strength, performance and injury reduction. Further research is required to compare the increased flexibility obtained after eccentric training to that obtained with static stretching and other exercise interventions.
Article
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The aim of the study was to investigate the efficacy of rehabilitation protocol applied during competitive period for the treatment of patellar tendinopathy. A total of sixteen male volleyball players were divided into 2 groups. Fifteen from experimental group (E) and 13 from control group (C) fulfilled the same tests three times: before the training program started (1 measurement), after 12 weeks (2 measurement) and after 24 weeks (3 measurement). The above-mentioned protocol included: USG imagining with color Doppler function, clinical testing, pain intensity evaluation with VISA-P questionnaire, leg muscle strength, power and jumping ability measurements. The key element of the rehabilitation program was eccentric squat on decline board with additional unstable surface. The essential factor of the protocol was a set of preventive functional exercises, with focus on eccentric exercises of hamstrings. Patellar tendinopathy was observed in 18% of the tested young volleyball players. Implementation of the presented rehabilitation protocol with eccentric squat on decline board applied during sports season lowered the pain level of the young volleyball players. Presented rehabilitation protocol applied without interrupting the competitive period among young volleyball players together with functional exercises could be an effective method for the treatment of patellar tendinopathy.
Article
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Patellar tendinopathy is a common, painful, overuse disorder. Although many different treatment methods have been described, there is no consensus regarding the optimal treatment for this condition. The purpose of this study was to systematically review, summarize, and compare treatments for patellar tendinopathy from published randomized controlled trials. Database searches were performed for randomized prospective controlled trials comparing treatment methods for patellar tendinopathy. The thirteen articles considered relevant were scrutinized according to quality assessment guidelines and levels of evidence. Strong evidence was found for the use of eccentric training to treat patellar tendinopathy. Moderate evidence was found for conservative treatment (heavy slow resistance training) as an alternative to eccentric training. Moderate evidence suggests that low-intensity pulsed ultrasound treatment did not influence treatment outcomes. Limited evidence was found for surgery, sclerosing injections, and shockwave therapy. Physical training, and particularly eccentric training, appears to be the treatment of choice for patients suffering from patellar tendinopathy. However, type of exercise, frequency, load, and dosage must also be analyzed. Other treatment methods, such as surgical treatment, sclerosing injections, and shockwave therapy, must be investigated further before recommendations can be made regarding their use. Ultrasound can likely be excluded as a treatment for patellar tendinopathy. There is a persistent lack of well-designed studies with sufficiently long-term follow-up and number of patients to draw strong conclusions regarding therapy. II.
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Case-series study with pre- vs. post-test measurements design. Strength training programs emphasizing eccentric muscle actions have received much attention in the treatment of tendinopathies. The current study reports on the efficacy of a novel strength training paradigm using inertial eccentric-concentric resistance to treat chronic patellar tendinopathy. Ten athletes with chronic patellar tendinopathy (15 tendons) volunteered for the study. Subjects completed a 6-week training program employing a leg press flywheel ergometer. Pre and post measurements assessed lower limb maximal strength and vertical counter-movement-jump (CMJ) height. Surface electromyography (SEMG) analysis of paraspinal, rectus femoris, biceps femoris and medial gastrocnemius muscles were collected. All measurements were performed one week before and after the training period. Clinical measures of pain and tendon function were assessed by means of a visual analogue scale (VAS) and a patellar tendinopathy questionnaire (VISA) at baseline, post-training and follow-up (12 wk). The Wilcoxon signed-rank test was employed for data comparisons. Eccentric strength increased after training (90%, p < 0.05). Similarly, VAS and VISA scores improved after training as well (60% and 86%, respectively, p < 0.01). There were no changes in CMJ height. Short-term training using inertial eccentric overload, resulted in improved muscle function and reduced subjective pain in long-lasting patellar tendinopathy.
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Changes in muscle activation and performance were studied in healthy men in response to 5 weeks of resistance training with or without "eccentric overload". Subjects, assigned to either weight stack (grp WS; n = 8) or iso-inertial "eccentric overload" flywheel (grp FW; n = 9) knee extensor resistance training, completed 12 sessions of four sets of seven concentric-eccentric actions. Pre- and post-measurements comprised maximal voluntary contraction (MVC), rate of force development (RFD) and training mode-specific force. Root mean square electromyographic (EMG(RMS)) activity of mm. vastus lateralis and medialis was assessed during MVC and used to normalize EMG(RMS) for training mode-specific concentric (EMG(CON)) and eccentric (EMG(ECC)) actions at 90°, 120° and 150° knee joint angles. Grp FW showed greater (p < 0.05) overall normalized angle-specific EMG(ECC) of vastii muscles compared with grp WS. Grp FW showed near maximal normalized EMG(CON) both pre- and post-training. EMG(CON) for Grp WS was near maximal only post-training. While RFD was unchanged following training (p > 0.05), MVC and training-specific strength increased (p < 0.05) in both groups. We believe the higher EMG(ECC) activity noted with FW exercise compared to standard weight lifting could be attributed to its unique iso-inertial loading features. Hence, the resulting greater mechanical stress may explain the robust muscle hypertrophy reported earlier in response to flywheel resistance training.
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An ergometer, to be used for resistance training in space, has been developed and validated. It is designed to activate the extensor muscles of the knee and ankle joints while performing the leg press exercise. Resistance is provided independent of gravity by using the inertial focus of a flywheel. Eleven men performed two series of consecutive maximal voluntary concentric and eccentric muscle actions. Force, power, work and electromyographic (EMG) activity, measured during exercise on this ergometer and a traditional leg press resistive apparatus were similar. This mechanical ergometer seems to meet the operational and technical requirements of equipment that can be flown and used in space. Also, the physiological responses to acute exercise suggest that adaptations similar to those achieved by traditional weight training can be produced. Exercise using the inertia ergometer would, therefore, probably also be effective in combating the muscle atrophy and loss of strength that occur in microgravity.
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To compare the therapeutic effect of two different exercise protocols in athletes with jumper's knee. Randomised clinical trial comparing a 12 week programme of either drop squat exercises or leg extension/leg curl exercises. Measurement was performed at baseline and after six and 12 weeks. Primary outcome measures were pain (visual analogue scale 1-10) and return to sport. Secondary outcome measures included quadriceps and hamstring moment of force using a Cybex II isokinetic dynamometer at 30 degrees/second. Differences in pain response between the drop squat and leg extension/curl treatment groups were assessed by 2 (group) x 3 (time) analysis of variance. Two by two contingency tables were used to test differences in rates of return to sport. Analysis of variance (2 (injured versus non-injured leg) x 2 (group) x 3 (time)) was also used to determine differences for secondary outcome measures. Over the 12 week intervention, pain diminished by 2.3 points (36%) in the leg extension/curl group and 3.2 points (57%) in the squat group. There was a significant main effect of both exercise protocols on pain (p<0.01) with no interaction effect. Nine of 10 subjects in the drop squat group returned to sporting activity by 12 weeks, but five of those subjects still had low level pain. Six of nine of the leg extension/curl group returned to sporting activity by 12 weeks and four patients had low level pain. There was no significant difference between groups in numbers returning to sporting activity. There were no differences in the change in quadriceps or hamstring muscle moment of force between groups. Progressive drop squats and leg extension/curl exercises can reduce the pain of jumper's knee in a 12 week period and permit a high proportion of patients to return to sport. Not all patients, however, return to sport by that time.
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We have developed a non-gravity dependent mechanical device, which provides resistance during coupled concentric and eccentric muscle actions, through the inertia of a spinning fly-wheel (Fly-Wheel Ergometry; FWE). Our research shows that lower-limb FWE exercise can produce forces and thus muscular stress comparable to what is typical of advanced resistance training using free weights. FWE also offers greater training stimuli during eccentric relative to concentric muscle actions, as evidenced by force and electromyographic (EMG) measurements. Muscle use of specific muscle groups, as assessed by the exercise-induced contrast shift of magnetic resonance images, is similar during lower-limb FWE and the barbell squat. Unlike free-weight exercise, FWE allows for maximal voluntary effort in each repetition of an exercise bout. Likewise, FWE exercise, not unassisted free-weight exercise, produces eccentric "overload". Collectively, the inherent features of this resistive exercise device and the results of the physiological evaluations we have performed, suggest that resistance exercise using FWE could be used as an effective exercise counter-measure in space. The flywheel principle can be employed to any exercise configuration and designed into a compact device allowing for exercises stressing those muscles and bone structures, which are thought to be most affected by long-duration spaceflight.
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To compare the effectiveness of an exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Randomized controlled trial. Rheumatology and Rehabilitation Centre. This study was carried out with 30 patients who had chronic patellar tendinopathy. They were randomized into three groups. Group A (n = 10) was treated with exercise programme. Pulsed ultrasound was given to group B (n = 10). Group C (n = 10) received transverse friction. All patients received three treatments per week for four weeks. Patients' pain was evaluated at the end of the four-week course of treatment (week 4), one month (week 8) and three months (week 16) after the end of treatment. The exercise programme was statistically significantly better than the other two treatments at the end of treatment (chi2 = 12.21, p < 0.01), one month (chi2 = 23.2, p < 0.001) and three months (chi2 = 23.2, p < 0.001) after the end of the treatment. Although the results suggested that the exercise programme was more effective treatment than ultrasound and transverse friction at the end of the treatment as well as at the follow-ups, future controlled studies are needed to establish the relative and absolute effectiveness of each of the three treatment interventions.
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This non-randomised pilot study investigated the effect of eccentric quadriceps training on 17 patients (22 tendons) with painful chronic patellar tendinopathy. Two different eccentric exercise regimens were used by subjects with a long duration of pain with activity (more than six months). (a) Nine consecutive patients (10 tendons; eight men, one woman; mean age 22 years) performed eccentric exercise with the ankle joint in a standard (foot flat) position. (b) Eight patients (12 tendons; five men, three women; mean age 28 years) performed eccentric training standing on a 25 degrees decline board, designed to increase load on the knee extensor mechanism. The eccentric training was performed twice daily, with three sets of 15 repetitions, for 12 weeks. Primary outcome measures were (a) 100 mm visual analogue scale (VAS), where the subject recorded the amount of pain during activity, and (b) return to previous activity. Follow up was at 12 weeks, with a further limited follow up at 15 months. Good clinical results were obtained in the group who trained on the decline board, with six patients (nine tendons) returning to sport and showing a significantly reduced amount of pain over the 12 week period. Mean VAS scores fell from 74.2 to 28.5 (p = 0.004). At 15 months, four patients (five tendons) reported satisfactory results (mean VAS 26.2). In the standard squat group the results were poor, with only one athlete returning to previous activity. Mean VAS scores in this group were 79.0 at baseline and 72.3 at 12 weeks (p = 0.144). In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced encouraging results in terms of pain reduction and return to function in the short term. Eccentric exercise using standard single leg squats in a similar sized group appeared to be a less effective form of rehabilitation in reducing pain and returning subjects to previous levels of activity.
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The prevalence of jumper's knee across different sports has not been examined, and it is not known if there is a gender difference. Data from surgical case series indicate that there may be a high prevalence in sports with high speed and power demands. The aim of this study was to estimate the prevalence of jumper's knee in different sports among female and male athletes and to correlate the prevalence to the loading characteristics of the extensor mechanism in these sports. Cross-sectional study; Level of evidence, 4. The authors examined approximately 50 Norwegian male and female athletes at the national elite level from each of the following 9 sports: athletics (male athletes: high jump, 100- and 200-m sprint), basketball (male athletes), ice hockey (male athletes), volleyball (male athletes), orienteering (male athletes), road cycling (male athletes), soccer (male and female athletes), team handball (male and female athletes), and wrestling (male athletes). The examination included an interview on individual characteristics (weight, age, height, and training background), a clinical examination, and self-recorded Victorian Institute of Sport Assessment score from 0 (worst) to 100 (best). The overall prevalence of current jumper's knee was 14.2% (87 of 613 athletes), with a significant difference between sports with different performance characteristics (range, 0%-45%). In addition, 51 athletes (8%) reported previous symptoms. The prevalence of current symptoms was highest in volleyball (44.6%+/-6.6%) and basketball (31.9%+/-6.8%), whereas there were no cases in cycling or orienteering. The prevalence of current jumper's knee was lower among women (5.6%+/-2.2%) compared with men (13.5%+/-3.0%; chi2 test, P=.042). The duration of symptoms among athletes with current jumper's knee (n=87) was 32+/-25 (standard deviation) months, with a Victorian Institute of Sport Assessment score of 64+/-19. The prevalence of jumper's knee is high in sports characterized by high demands on speed and power for the leg extensors. The symptoms are often serious, resulting in long-standing impairment of athletic performance.
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The effect of surgery on patellar tendinopathy (jumper's knee) is questionable, and conservative treatment protocols have not been properly documented. : The aim of this study was to investigate the effect of a newly developed eccentric training program for patellar tendinopathy in volleyball players during the competitive season. Randomized clinical trial. Patients were recruited from male and female elite volleyball teams in Norway, and the diagnosis was based on clinical examination alone. Of 51 players diagnosed with patellar tendinopathy, 29 could be included in the study. The training group (n = 13) performed squats on a 25 degrees decline board as a home exercise program (3 x 15 repetitions twice daily) for a 12-week intervention period during the final half of the competitive season. The eccentric (downward) component was done on the affected leg. The control group (n = 16) trained as usual. The primary outcome was a symptom-based questionnaire developed specifically for patellar tendinopathy (Victorian Institute of Sport Assessment score), and patients were followed up before and after the intervention period, as well as after 6 and 30 weeks. All subjects self-recorded training to document their activity level (eccentric training, volleyball training, matches, other training). There was no change in Victorian Institute of Sport Assessment score during the intervention period in the training (pre, 71.1 +/- 11.3; post, 70.2 +/- 15.4) or control group (pre, 76.4 +/- 12.1; post, 75.4 +/- 16.7), nor was there any change during the follow-up period at 6 weeks or 6 months. The training group completed 8.2 +/- 4.6 weekly sessions of eccentric training during the intervention period (59% of the recommended volume), and there was no difference between groups in training or competition load. There was no effect on knee function from a 12-week program with eccentric training among a group of volleyball players with patellar tendinopathy who continued to train and compete during the treatment period. Whether the training would be effective if the patients did not participate in sports activity is not known.
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A recent study reported promising clinical results using eccentric quadriceps training on a decline board to treat jumper's knee (patellar tendinosis). In this prospective study, athletes (mean age 25 years) with jumper's knee were randomised to treatment with either painful eccentric or painful concentric quadriceps training on a decline board. Fifteen exercises were repeated three times, twice daily, 7 days/week, for 12 weeks. All patients ceased sporting activities for the first 6 weeks. Age, height, weight, and duration of symptoms were similar between groups. Visual analogue scales (VAS; patient estimation of pain during exercise) and Victorian Institute of Sport Assessment (VISA) scores, before and after treatment, and patient satisfaction, were used for evaluation. In the eccentric group, for 9/10 tendons patients were satisfied with treatment, VAS decreased from 73 to 23 (p<0.005), and VISA score increased from 41 to 83 (p<0.005). In the concentric group, for 9/9 tendons patients were not satisfied, and there were no significant differences in VAS (from 74 to 68, p<0.34) and VISA score (from 41 to 37, p<0.34). At follow up (mean 32.6 months), patients in the eccentric group were still satisfied and sports active, but all patients in the concentric group had been treated surgically or by sclerosing injections. In conclusion, eccentric, but not concentric, quadriceps training on a decline board, seems to reduce pain in jumper's knee. The study aimed to include 20 patients in each group, but was stopped at the half time control because of poor results achieved in the concentric group.
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Eccentric training has become a popular treatment for patellar tendinopathy. Our purpose was to review the evolution of eccentric strength training programmes for patellar tendinopathy with a focus on the exercise prescriptions used, to help clinicians make appropriate choices and identify areas needing further research. A computerised search of the entire MEDLINE database was performed on 1 September 2006 to identify prospective and randomised clinical trials with a focus on clinical outcome of eccentric training for patellar tendinopathy. 7 articles with a total of 162 patients and in which eccentric training was one of the interventions, all published after 2000, were included. The results were positive, but study quality was variable, with small numbers or short follow-up periods. The content of the different training programmes varied, but most were home-based programmes with twice daily training for 12 weeks. A number of potentially significant differences were identified in the eccentric programmes used: drop squats or slow eccentric movement, squatting on a decline board or level ground, exercising into tendon pain or short of pain, loading the eccentric phase only or both phases, and progressing with speed then loading or simply loading. Most studies suggest that eccentric training may have a positive effect, but our ability to recommend a specific protocol is limited. The studies available indicate that the treatment programme should include a decline board and should be performed with some level of discomfort, and that athletes should be removed from sports activity. However, these aspects need further study.
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To compare the efficacy and safety of two eccentric rehabilitation protocols for patients with symptomatic patellar tendinopathy. A new eccentric overload training device was compared with the present standard eccentric rehabilitation programme on a decline board. Prospective, randomised clinical trial. Sports rehabilitation clinic, university sports laboratory, supplemented with home exercises. 20 competitive and recreational athletes, all with clinical diagnosis of patellar tendinopathy, verified by MRI or ultrasound imaging. A 12-week rehabilitation period, either with bilateral eccentric overload strength training using the Bromsman device twice a week or with unilateral eccentric body load training using a decline board twice a week, supplemented with daily home exercises. The primary outcome was pain and function, assessed by the Swedish Victorian Institute of Sport Assessment for Patella (VISA-P) score. Secondary outcome measures were isokinetic muscle torque, dynamic function and muscle flexibility, as well as pain level estimations using visual analogue scale (VAS). Side effects were registered. Both treatment groups improved in the short term according to the VISA-P scores during the 12-week rehabilitation period. However, there were no significant differences between the groups in terms of pain and function. After a 3-month rehabilitation period, most patients could be regarded as improved enough to be able to return to training and sports. No serious side effects were detected in either group. In patients with patellar tendinopathy pain, two-legged eccentric overload training twice per week, using the new device (Bromsman), was as efficient and safe as the present standard daily eccentric one-legged rehabilitation-training regimen using a decline board.