European Journal of Sport Science, July 2008; 8(4): 183192

ORIGINAL ARTICLE

Effect of a preventive intervention programme on the prevalence of anterior knee pain in volleyball players

E. CUMPS1, E. A. VERHAGEN2, S. DUERINCK1, A. DEVILLE1, L. DUCHENE1, & 1 R. MEEUSEN

Department of Human Physiology and Sports Medicine, Vrije Universiteit Brussel, Brussels, Belgium, and 2EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
1

Abstract Chronic knee disorders, such as patellofemoral pain syndrome and patellar tendinosis, are common injuries in volleyball players. Using a randomized clinical trial, the aim of the present study was to determine the effect of a 4-month in-season intervention programme on the prevalence of anterior knee pain in volleyball players. No significant differences were observed between the intervention and control group for the prevalence of anterior knee pain after the intervention programme (odds ratio 01.58 [95% confidence interval: 0.604.20]). Also, no significant differences were observed for individuals with previously sustained anterior knee pain (OR 00.81 [95% CI: 0.332.20]). It was revealed that the risk for recurrent anterior knee pain is significantly higher than the risk for newly sustained anterior knee pain (OR 05.79 [95% CI: 1.5921.00]). In conclusion, we were unable to confirm any preventive effect of the intervention programme on the prevalence of anterior knee pain. However, a previous study using the same intervention and measuring the effect on the intrinsic risk factors of anterior knee pain showed a positive effect.

Keywords: Anterior knee pain, patellofemoral pain syndrome, patellar tendinosis, prevention

Introduction Knee injuries sustained across various sport disciplines, which account for 1550% of all sports injuries (de Loes, Dahlstedt, & Thomee, 2000), have often been reported on (Backx, Beijer, Bol, & Erich, 1991; Kujala et al., 1995). A high incidence of knee injuries has been observed in volleyball (Aagaard & Jorgensen, 1996; Bahr, Reeser, & Federation Internationale de Volleyball, 2003; Hewett, Stroupe, Nance, & Noyes, 1996; Kujala et al., 1995; Schafle, Requa, Patton, & Garrick, 1990; Verhagen, Van der Beek, Bouter, Bahr, & van Mechelen, 2004), where chronic knee injuries (50 88%) are more common than acute knee injuries (1235%) (Aagaard & Jorgensen, 1996; Aagaard, Scavenius, & Jorgensen, 1997; Bahr et al., 2003; Briner & Benjamin, 1999; Schafle et al., 1990). A common chronic knee disorder in athletic popula-

tions is the patellofemoral pain syndrome (Fairbank, Pynsent, Van Poortvliet, & Phillips, 1984; Kujala et al., 1995; Roush et al., 2000; Thomee, Augustsson, & Karlsson, 1999). Patellofemoral pain syndrome is a term believed to encompass all painrelated problems of the anterior part of the knee excluding intra-articular pathologies, peripatellar tendonitis or bursitis, plica syndromes, Sinding Larsens and Osgood Schlatters disease, neuromas and other rarely occurring pathologies (Thomee, Renstrom, Karlsson, & Grimby, 1995). Patellar tendinosis or jumpers knee is an anterior knee pain pathology most frequently found in volleyball players (Aagaard & Jorgensen, 1996; Bahr et al., 2003; Ferretti, Ippolito, Mariani, & Puddu, 1983; Lian, Engebretsen, & Bahr, 2005; Lian, Engebretsen, Ovrebo, & Bahr, 1996; Schafle et al., 1990), with an incidence of 9% (Bahr et al., 2003) to 64% (Schafle et al., 1990).

Correspondence: R. Meeusen, Department of Human Physiology and Sports Medicine, Vrije Universiteit Brussel, Pleinlaan 2, 1050 Brussels, Belgium. E-mail: rmeeusen@vub.ac.be ISSN 1746-1391 print/ISSN 1536-7290 online # 2008 European College of Sport Science DOI: 10.1080/17461390802067711

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E. Cumps et al. medialis obliquus (Cowan, Bennell, Hodges, Crossley, & McConnel, 2001; McConnel, 2002; Voight & Wieder, 1991; Witvrouw, Sneyers, Lysens, Victor, & Bellemans, 1996; Witvrouw et al., 2000). Strengthening of the vastus medialis obliquus has been advocated as a treatment for patellofemoral pain syndrome, as weakness of this component of the quadriceps muscle is postulated to contribute to malalignment of the patella (Laprade, Culham, & Brouwer, 1998). Since anterior knee pain especially patellofemoral pain syndrome and patellar tendinosis is a major concern of volleyball players, we aimed at developing an intervention programme to prevent the prevalence of self-reported anterior knee pain. The purpose of this study was to determine the effect of a 4-month intervention programme on the prevalence of anterior knee pain in volleyball players.

In spite of the high incidence of this injury, there are no studies on its prevention. Only the effect of brace application among military recruits to prevent anterior knee pain has been investigated, with the authors reporting a lower incidence of such pain in individuals who wore the brace (Van Tiggelen et al., 2004). A wide variety of treatment options has been proposed, but the conservative treatment protocols have not been properly documented (Visnes, Hoksrud, Cook, & Bahr, 2005). Eccentric training in individuals with patellar tendinosis, which has a very promising effect in the treatment of chronic Achilles tendinosis (Kingma, de Knikker, Wittink, & Takken, 2007), also shows positive results but is inconclusive because of methodological shortcomings of the trials (Visnes & Bahr, 2007). In-depth knowledge of the intrinsic risk factors is also important when designing treatment strategies. Few authors have found an association between muscle tightness and tendinosis (Cook, Kiss, Khan, Purdam, & Webster, 2004; Ekstrand, Gillquist, & Liljedahl, 1983; Witvrouw, Bellemans, Lysens, Danneels, & Cambier, 2001) or patellofemoral pain syndrome (Sommer, 1988; Witvrouw, Lysens, Bellemans, Cambier, & Vanderstraeten, 2000). Decreased flexibility leads to an increase in tendon strain with joint movements and therefore predisposes athletes to tendon overload (Fyfe & Stanish, 1992). Witvrouw et al. (2001) believe that it is crucial to emphasize the use of proper stretching in both the treatment and prevention of patellar tendinosis. Individuals with symptoms of patellofemoral pain syndrome also show lower strength of the quadriceps (Duffey, Martin, Canon, Craven, & Messier, 2000; Messier, Davis, Curl, Lowery, & Pack, 1991; Salsich, Brechter, Farwell, & Powers, 2002; Thomee et al., 1995; Van Tiggelen et al., 2004; Witvrouw et al., 2000), hamstrings (Duffey et al., 2000; Messier et al., 1991), hip abduction and hip external rotation muscles (Ireland, Willson, Ballantyne, & Davis, 2003; Mascal, Landel, & Powers, 2003). One of the compensatory strategies to minimize joint loading and pain is the break phenomenon during quadriceps contraction, which is mainly seen during eccentric contractions (Anderson & Herrington, 2003) and has been described as a saving reflex to prevent further stress. Rehabilitation exercises of the quadriceps in patients with patellofemoral pain syndrome should be chosen with regard to joint loading and range of movement to facilitate quadriceps activation rather than inhibiting it (Anderson & Herrington, 2003). Another phenomenon that has been proposed in the aetiology of the patellofemoral pain syndrome is the imbalance between the activation patterns of the vastus lateralis muscle and vastus

Materials and methods Study design A randomized clinical trial was initiated to measure the effectiveness of an intervention programme on the prevalence of anterior knee pain.

Power analysis Previous research, involving the same participants, revealed that the 1-year prevalence of anterior knee pain, according to the definition outlined below, is 52.2%. An a priori power analysis showed that for a 15% improvement in the prevalence of anterior knee pain, with a 00.05 and b00.90, a sample of 226 individuals is required.

Recruitment During preparation for the 20052006 volleyball season, inclusion criteria for teams to take part in the study and in the randomization procedure were as follows: (1) the members of the team should be Dutch speaking, (2) they should be located within an hours drive from Brussels, and (3) playing in Division 1, Division 2 or National 1. Sixty-nine of 136 teams met the inclusion criteria and were randomized into a control or an intervention group. Of these, 54 initially agreed to participate. Written informed consent was obtained from each player and the study was performed in accordance with the institutional rules for human research and the Declaration of Helsinki for Medical Research involving humans.

Prevention of anterior knee pain Injury registration and injury definition A questionnaire recorded demographic data, information on intrinsic and extrinsic risk factors, and the point-, one-year-, and lifetime-prevalence of anterior knee pain. In the present study, anterior knee pain was defined as an overuse injury that causes physical discomfort in the anterior part of the knee (Thomee et al., 1995), and pain and/or stiffness of the musculoskeletal system, which has an insidious onset and is present during and/or after volleyball activity. Such a complaint has to persist for at least three volleyball active days. Malaise and illness were excluded (Cumps, Verhagen, & Meeusen, 2007). The prevalence of pain used was self-reported anterior knee pain, as per the definition above.

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Guidelines on how to correct the exercises were also explained. All this information was passed on to each trainer/coach by means of a CD-ROM containing video recordings and a manual with the complete programme and detailed explanation for each individual exercise. Statistical analysis Both groups were compared at baseline for demographic variables using an independent samples t-test (PB0.05) in the case of normal distribution of the variables and with the Mann-Whitney U-test (P B0.05) if the variables were not normally distributed. The Kolmogorov-Smirnov test (P B0.05) was used to determine the distribution of the demographic variables. All statistical analyses were performed using SPSS v. 14.0 (SPSS Inc., Chicago, IL, USA). The effectiveness of the intervention programme, using an intention-to-treat approach, was determined by calculating odds ratios (OR) and their 95% confidence intervals (CI). All participants, including those who did not conform to the intervention throughout the intervention period, were included in the statistical analysis.

Intervention The intervention programme had to cover a broad spectrum of anterior knee pain disorders, especially patellofemoral pain syndrome and patellar tendinosis, since an exact diagnosis is often hard to establish, especially in self-reported anterior knee pain. The intervention programme is presented in Table I. The intervention programme developed was derived from literature concerning treatment strategies and intrinsic risk factors for anterior knee pain in general and patellofemoral pain syndrome and patellar tendinosis in particular. The intervention programme covered 16 weeks of the 20052006 volleyball season and was performed twice a week during the practice session in addition to the normal training routine of the intervention group. The control group only executed their normal training routine. The effect of injury awareness was minimized by giving both groups exactly the same information on the background and the procedures of the study at baseline. The only difference in information was instruction on the intervention programme, which was withheld from the control group. The main goal of the first month was to train isometric strength using open kinetic chain exercises. During the second month, the programme mainly emphasized isometric strength using closed kinetic chain exercises. Eccentric exercises performed during the third and fourth months also involved sport-specific exercises and jump training or plyometrics, with the emphasis on the quality of landing techniques. After each practice session, passive stretching exercises of the quadriceps, hamstring, iliotibial band, gastrocnemius, soleus, and gluteal muscles were performed. Active hamstring muscle stretching was performed starting in week 3. The coaches received thorough information on the complete programme as well as on all its individual exercises and on how to execute them correctly.

Results Participants and drop-out The flow chart of the selection procedures and the number of participants is presented in Figure 1. From the 54 teams that initially agreed to participate, 30 completed the pre- and post-measurements properly, resulting in 167 participants with complete data. Teams and players dropped out because they were not able to attend the post-measurement, suffered from injuries, quit playing volleyball, transferred to another team or withdrawal of the entire team. Table II presents the demographic variables for both the intervention and control groups and those who dropped out. There were no significant differences (independent samples t-test: P B0.05) between the control and intervention group, or between those who dropped out and those who completed the intervention. Effectiveness Inclusion of individuals with symptoms of anterior knee pain at baseline. At baseline, the prevalence of anterior knee pain was higher in the intervention group than in the control group, but no significant differences were observed for the prevalence of anterior knee pain, for the total sample (OR 01.51 [95% CI: 0.703.26), the women only (OR 00.69 [95% CI: 0.202.41]) or the men only (OR 02.05

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Table I. The intervention programme developed based on a literature review concerning the rehabilitation of patellar tendinosis and patellofemoral pain syndrome

E. Cumps et al.

Month 1 Isometric strength in OKC Week 1 Q-ceps setting 3 )10 (7 s) Oscillating exercise Q-ceps with tubing with knee angle 1208 3 )20 s SLR lifting up and down 3 )10 Week 2 Q-ceps setting 3 )10 (7 s) Co-contraction with knee angle 1208 3 )10 (7 s) SLR lifting inside and outside 3 )10 Q-ceps setting 3 )10 (7 s) Oscillating exercise Q-ceps with tubing with knee angle 1208 3 )20 s SLR in abduction lying on the side 3 )10 Q-ceps setting 3 )10 (7 s) Oscillating exercise Q-ceps with tubing with knee angle 1208 3 )20 s Co-contraction with knee angle 908 3 )10 (7 s)

Month 2 Isometric strength in CKC Oscillating bilateral squat back against wall, knee angle max. 1208 3)20 s SLR circles clockwise and not clockwise 3)10 Oscillating exercise H prone with tubing 3)20 s Q-ceps setting 3)10 (7 s) Oscillating exercise Q-ceps with tubing with knee angle 1208 Oscillating lunge with knee angle 1208 3)20 s Co-contraction with knee angle 1208 3)10 (7 s) Oscillating lunge with knee angle 1208 3)20 s Oscillating exercise H prone with tubing 3)20 s SLR in abduction lying on the side 3)10 Oscillating bilateral squat back against wall, knee angle max. 1208 3)20 s Oscillating lunge with knee angle 1208 3)20 s

Month 3 Sports specific skills and plyometrics

Month 4 Eccentric load exercise

Oscillating bilateral squat back 1/3 (01208 knee angle) unilateral against wall, knee angle max. 1208 squat 3)20 s 3 )10 Oscillating exercise H prone with tubing Lateral step up & down 3)20 s 3 )10 1/3 (01208 knee angle) bilateral squat 3)10 1/3 (01208 knee angle) bilateral squat with tubing 3)10 Oscillating lunge with knee angle until 1208 3)20 s Lateral step up & down 3)10 Dropsquat knee angle until 908 3)10 Frontal step up & down 3)10 Lunge knee angle until 1208 3)10 SLR in abduction lying on the side 3)10 Oscillating jump lunge with knee angle until 1008 3 )20 s Dropsquat knee angle until 908 3 )12 Sliding/shuffle sideways with knee angle around 1008 3 )20 Jump and reach 3 )15 Jump lunge knee angle until 908 3 )10 Oscillating drop jump knee angle until 908 3 )30 s 1/3 (01208 knee angle) bilateral squat with tubing 3 )20 Oscillating drop jump knee angle until 908 4 )30 s Frontal step up & down 3 )10

Week 3

Week 4

1/3 (01208 knee angle) bilateral squat against wall 3)10 Sliding/shuffle sideways with knee angle 1/2 (0908 knee angle) unilateral around 1008 squat against wall 3)20 3 )10

Note: OKC0open kinetic chain; CKC0closed kinetic chain; Q-ceps0quadriceps; SLR0straight leg raise; H0hamstring; oscillating0small repetitive swinging movements within a range of 58; tubing 0exercise with elastic bands.

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Figure 1. Flow chart of selection procedures and the number of players and teams nally participating in the study. AKP0anterior knee pain, IG 0intervention group, CG 0control group.

[95% CI: 0.686.20]). Figure 2 shows the percentage of participants with anterior knee pain after the 4-month intervention period with the associated odds ratio (95% confidence interval). No significant differences in prevalence of anterior knee pain were found between the control and intervention group as a result of the intervention programme. The prevalence of anterior knee pain did not decrease significantly baseline and post-intervention, either in the intervention group (OR 00.86 [95% CI: 0.461.60]) or in the control group (OR 00.91 [95% CI: 0.382.17]). Exclusion of individuals with symptoms of anterior knee pain at baseline. There was no significant difference

between the intervention and control group after the 4-month intervention. Figure 3 presents odds ratios (95% confidence intervals) and the percentages of players with anterior knee pain. In the control group, 60.4% of the participants had presented with anterior knee pain in the past, whereas 59.2% of the intervention group had experienced such pain before. Again no significant differences were observed after the intervention between the intervention and control group for the occurrence of new anterior knee pain (OR 01.21 [95% CI: 0.314.76]) or recurrent anterior knee pain (OR 00.81 [95% CI: 0.332.20]). Figure 4 presents the percentages of new and recurrent anterior knee pain for both groups. In the control

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Table II. Demographic variables for the intervention and control groups for effectiveness with inclusion and exclusion of participants with symptoms of anterior knee pain before the intervention period Effectivenessa Number (n) Height (m) Weight (kg) BMI (kg m (2) Age (years) Number (n) Height (cm) Effectivenessb Weight (kg) BMI (kg m (2) Age (years)

Female Male Total Female Male Total Female Male Total Female Male Total

38 64 102 39 28 67 20 7 27 17 8 25

1.73 (0.06) 1.87 (0.07) 1.82 (0.10)

Intervention group 64.6 (9.4) 21.6 (2.4) 23.3 (6.2) 33 1.73 (0.06) 64.2 (9.8) 21.4 (2.4) 23.4 (6.5) 82.7 (11.4) 23.6 (2.5) 26.8 (5.7) 43 1.87 (0.07) 82.5 (11.1) 23.5 (2.5) 26.9 (5.8) 76.0 (13.8) 22.8 (2.6) 25.5 (6.1) 76 1.81 (0.10) 74.5 (13.9) 22.6 (2.6) 25.4 (6.3) 1.73 (0.06) 64.5 (6.6) 21.6 (1.7) 23.9 (6.2) 1.88 (0.07) 82.7 (10.5) 23.4 (2.7) 26.4 (7.4) 1.79 (0.09) 72.0 (12.3) 22.4 (2.3) 24.9 (5.7)

Control group 1.73 (0.06) 65.8 (7.5) 22.1 (2.1) 24.4 (5.9) 32 1.088 (0.06) 84.0 (9.9) 23.7 (2.7) 26.5 (6.5) 21 1.79 (0.09) 73.4 (12.4) 22.8 (2.5) 25.3 (8.5) 53 1.75 (0.06) 1.86 (0.07) 1.83 (0.08) 1.75 (0.05) 1.89 (0.08) 1.80 (0.09)

Intervention group (drop-out) 67.8 (5.25) 22.2 (1.5) 26.2 (6.1) 5 1.75 (0.06) 62.0 (7.1) 20.3 (0.8) 24.1 (6.9) 80.2 (9.8) 23.1 (2.2) 26.2 (7.7) 21 1.87 (0.08) 83.3 (12.2) 23.8 (2.6) 26.7 (5.7) 76.9 (10.4) 22.9 (2.1) 26.2 (6.9) 26 1.86 (0.09) 81.4 (13.2) 23.5 (2.7) 26.5 (5.7) Control group (drop-out) 67.2 (7.5) 21.9 (2.9) 23.3 (6.7) 7 1.88 (0.09) 89.3 (4.6) 25.3 (2.0) 27.0 (5.6) 84.8 (13.7) 23.8 (3.9) 25.8 (5.7) 7 1.73 (0.04) 71.4 (9.4) 24.0 (2.8) 26.5 (4.6) 73.0 (12.9) 22.6 (3.3) 24.1 (6.4) 14 1.79 (0.10) 78.8 (11.9) 24.5 (2.5) 26.7 (5.2)
b

Note: a Participants with symptoms of anterior knee pain during the PRE measurements are included; anterior knee pain during the PRE measurements are excluded.

Participants with symptoms of

group, the risk for recurrent anterior knee pain was significantly higher than the risk for new anterior knee pain (OR 05.79 [95% CI: 1.5921.00]). Exclusion of individuals without symptoms of anterior knee pain at baseline. Before the intervention, 25.5% of the intervention group and 20.9% of the control group reported anterior knee pain. The number of participants with anterior knee pain pre-intervention diminished, with 34.6% in the intervention group and 14.3% in the control group. There was no significant decrease in the number of participants with anterior knee pain in the intervention compared

with the control group (OR 00.41 [95% CI: 0.07 2.18]).

Discussion The main purpose of this study was to develop a preventive intervention programme to cover a broad range of pathologies, defined as anterior knee pain, in volleyball players. This approach appeared necessary, since patellofemoral pain syndrome is difficult to define and diagnose, as patients experience a variety of symptoms from the patellofemoral joint with different levels of pain and physical impairment

Figure 2. The percentages of players with anterior knee pain (AKP) post-intervention are presented. Participants with symptoms of anterior knee pain during the pre-measurements were included. IG 0intervention group, CG0control group.

Figure 3. The percentages of players with anterior knee pain (AKP) post-intervention are presented. Participants with symptoms of anterior knee pain during the pre-measurements were excluded. IG0intervention group, CG0control group.

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Figure 4. The percentages of players with recurrent and new anterior knee pain (AKP) post-intervention are presented. Participants with symptoms of anterior knee pain during the premeasurements are excluded. IG 0intervention group, CG 0 control group.

(Thomee et al., 1999). The term patellofemoral is appropriate, as it is hard to pinpoint which specific structure is affected and pain is the symptom that all patients experience (Thomee et al., 1999). Many treatment options have been proposed, ranging from conservative rehabilitation programmes to eccentric training programmes (Visnes et al., 2005; Visnes & Bahr, 2007), yet the results are inconclusive due to poorly documented protocols and methodological shortcomings of the studies respectively.

Intervention programme Decreased strength of the quadriceps (Duffey et al., 2000; Messier et al., 1991; Salsich et al., 2002; Thomee et al., 1995; Van Tiggelen et al., 2004; Witvrouw et al., 2000), hamstrings (Duffey et al., 2000; Messier et al., 1991), hip adduction and hip external rotation muscles (Ireland et al., 2003; Mascal et al., 2003) have been observed in individuals with symptoms of patellofemoral pain syndrome. The imbalance in activation pattern of the vastus medialis obliquus and vastus lateralis has been found to be an important factor in patients with patellofemoral pain syndrome (Cowan et al., 2001; McConnel, 2002; Voight & Wieder, 1991; Witvrouw et al., 1996, 2000). It has been implied that reduced motor unit activity of the vastus medialis obliquus relative to the vastus lateralis could be the cause of lateral patellar subluxation and dislocation (Sakai, Luo, Rand, & An, 2000). This is why re-education of the vastus medialis obliquus is considered an essential component of a non-operative approach to patellofemoral pain (LaBrier & ONeill, 1993; Souza & Gross, 1991). The vastus medialis obliquus is believed to be stimulated most during isometric quadriceps contractions in combination with adduc-

tion and internal rotation of the hip (Gyf & Man, 1996), although some authors did not report preferential activation of this muscle with associated hip adduction (Cerny, 1995; Coqueiro et al., 2005; Davlin, Holcomb, & Guadagnoli, 1999). Bilateral semi-squats together with hip adduction do reveal an increase in vastus medialis obliquus and vastus lateralis activation patterns (Cerny, 1995; Coqueiro et al., 2005; Dursun, Dursun, & Kilic, 2001; Heitkamp, Horstmann, Mayer, Weller, & Dickhuth, 2001; Hertel, Eral, Tsang, & Miller, 2004). In our intervention programme, strengthening of the quadriceps and hamstrings was achieved by starting with an emphasis on isometric strength in an open kinetic chain evolving to isometric strength in a closed kinetic chain in the second month, starting with eccentric exercises in a closed kinetic chain in the third month, and introducing sport-specific exercises and jump alignment training during month 4. Both open and closed kinetic chain exercises were integrated in the intervention programme, because Cohen et al. (2001) revealed that throughout the entire flexion range, open kinetic chain stresses are neither supra-physiological nor significantly greater than closed kinetic chain exercise stresses. Instructions on jump-landing techniques were incorporated in the intervention programme due to the recent surge of lower extremity injury prevention programmes (Hewett et al., 1996), which produced promising results in reducing knee injuries among young female athletes who took part in a jumplanding instructional programme (Onate et al., 2005). Although these jump-landing techniques have focused on the prevention of ACL injuries, it is known that a knee valgus and an internally rotated knee position are unfavourable for the development of patellofemoral pain syndrome (Sommer, 1988). Each session of the intervention programme ended with stretching exercises because muscle tightness is often associated with patellofemoral pain syndrome (Duffey et al., 2000; Ireland et al., 2003; Mascal et al., 2003; Messier et al., 1991; Salsich et al., 2002; Thomee et al., 1995; Van Tiggelen et al., 2004; Witvrouw et al., 2000). Because the intervention programme needs to be cost-beneficial and easy to implement during practice sessions, treatment options such as taping, bracing, isokinetic strength training, electro-stimulation, ultrasound therapy, and biofeedback training were excluded. Effectiveness The main aim of the present study was to assess the effectiveness of a preventive intervention programme on the prevalence of anterior knee pain in volleyball players. We found no effect of the 4-month

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E. Cumps et al. As a result, the programme can be seen as being too long on top of the normal training routine. Whether the programme should be performed in-season or pre-season and how long it should last remains to be determined. Terminology for anterior knee pain Another factor that could have resulted in the noneffectiveness of the programme is the purpose it was developed for. Anterior knee pain is a wide-ranging complaint that involves many different pathologies and encompasses a diverse terminology (Thomee et al., 1999). The fact that the symptoms of patellofemoral pain syndrome and patellar tendinosis are similar complicates the establishment of an exact diagnosis. In other words, there is a discrepancy since on the one hand the intervention programme should cover both pathologies because there is often no exact diagnosis, but on the other a more specific approach would probably result in better results regarding prevalence and symptoms. Conclusion Patellofemoral pain syndrome and patellar tendinosis are of major concern among volleyball players (Aagaard & Jorgensen, 1996; Bahr et al., 2003; Ferretti et al., 1983; Lian et al., 1996, 2005; Schafle et al., 1990). There are conflicting results regarding the intrinsic risk factors and treatment options proposed for these knee disorders. This is probably a consequence of the varying terminology used in the literature (Thomee et al., 1999). The lack of preventive studies of anterior knee pain is probably a result of these inconsistencies. A research question for the future is whether the prevention of anterior knee pain should be reached using a general approach covering both patellofemoral pain syndrome and patellar tendinosis, or if it should concentrate on a single pathology, with the inherent difficulties and costs in establishing the diagnosis. Although the present study was unable to determine the effectiveness of the intervention programme, a previous study showed a positive effect on the intrinsic risk factors associated with patellofemoral pain syndrome and patellar tendinosis (Cumps et al., 2007). This lack of effectiveness can be ascribed to the power of the sample or to the broad approach, which included both patellofemoral pain syndrome and patellar tendinosis.

intervention on the prevalence of anterior knee pain in the intervention group, for the total sample, for the women alone or men alone. There were also no significant differences in recurrent and new cases of anterior knee pain. An a priori power analysis revealed that to achieve a 15% improvement in the prevalence of anterior knee pain (a 00.05; b 00.90), a sample of 226 would be necessary. Initially, 54 teams (232 players) agreed to participate and were randomized into a control or intervention group. There was a drop-out rate of 27.2%, reducing the total number of participants to 169. Of those 169 participants, 40 dropped out of the study because of anterior knee pain at the inception of the intervention programme. So, one possible reason for the ineffectiveness of the programme can be attributed to the insufficient observed power of the study, which was 69.5% (a 00.05; b 00.70). We aimed to keep injury awareness as low as possible by providing both groups with exactly the same information on the study at baseline, except for the intervention programme, which was kept from the control group. Nevertheless, a higher prevalence of anterior knee pain was seen in the intervention group after the intervention, although this was not significant. This phenomenon can be attributed to the higher prevalence of anterior knee pain in the intervention group during the inception of the intervention on the one hand, and by the so-called medical student syndrome on the other. This syndrome is a form of hypochondria frequently seen in medical students, in which they perceive themselves to be experiencing the symptoms of whatever disease they are studying. These persons figure that they are victim of a certain disease, whereas in reality no medical condition is present (Morrison & Bennet, 2006). Compliance In the intervention group, 22 participants (including players with anterior knee pain) and 8 participants (excluding players with anterior knee pain) admitted that they had not performed the intervention programme. This resulted in a drop-out rate of 21.6% and 11.9% respectively. The players did not perform the intervention programme because of a lack of interest or time, according to the trainer/coach. Towards the end of the 20052006 season, some teams approached promotion or degradation periods. As a result, the intervention programme was sometimes performed inaccurately or was skipped altogether. As mentioned by the participants, the intervention programme lasted 20 min per session. This can be considered quite a long time, since the majority of the teams only train twice a week for 2 h.

References
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