Journal of Sport Rehabilitation, 2020, 2 9 , 8 6 0 -8 65

https://doi.org/10.1123/jsr.2019-0046 Human Kinetics £Qll

© 2020 Human Kinetics, Inc. ORIGINAL RESEARCH REPORT

Deep Friction Massage in the Management of Patellar Tendinopathy

in Athletes: Short-Term Clinical Outcomes
Paula Chaves, Daniela Simoes, Maria Pa?o, Sandra Silva, Francisco Pinho,
Jose Alberto Duarte, and Fernando Ribeiro

Context: Deep friction massage (DFM) is often used in the treatment of tendinopathies; however, the pressure applied may vary
and interfere with the obtained results. Objective: To assess whether the immediate effects of DFM on pain (pain intensity and
time to onset of analgesia) and muscle strength are dependent on the pressure applied during the DFM application in athletes with
patellar tendinopathy. Design: Randomized, controlled, cross-over trial. Setting: University research laboratory (institutional).
Participants: Ten athletes with diagnosis of unilateral patellar tendinopathy (age 27.90 [5.24] y). Interventions: All participants
attended 4 sessions, 3 treatment sessions with DFM applied with different pressures (the mean pressure—previously determined
for each participant—and the mean pressure ± 25%) and a control session, each of which was separated by 48 hours. Main
Outcome Measures: Pain (intensity upon palpation and time to onset of analgesia), and muscle strength of knee extensors were
assessed before and immediately after each session. Results: Pain intensity changed significantly over time (F 1j9 = 52.364;
F <.001; rjp = .853) and among sessions (F 3>27 = 82.588; F <.001; rj~ = .902), with a significant interaction for groupxtime
(^ 3,27 = 19.841; P< .001; rj^ = .688). The knee extensors strength did not change significantly over time (Fj ,9 = 2.240; P - . 17;
r]p = .199), nor a significant interaction for session x time was observed (F 3-27 = 3.276; P - .07; ?/2 = .267). Regardless of the
pressure applied, the time to onset of analgesia was not significantly different (F2,ig = 1.026; P> .05; = .102). Conclusion: It
was shown that DFM induces an immediate reduction in pain intensity upon palpation, regardless of the pressure performed.
Notwithstanding, the reader should take into account the small sample size and the caution needed in the results’ interpretation.

Keywords: Cyriax, manual therapy, muscle strength, pain

Patellar tendinopathy, also known as jumper’s knee, is a still one of the therapeutic resources frequently used in this
condition associated with load demands and excessive use of condition . 11-21 DFM aims to reduce adhesions, enhance realign­
the patellar tendon, which results in a pathologic cascade of events ment of collagen fibers, and improve pain . 12,14,15,17,21-26 The pain
including neovascularization, nerve ingrowth, tendon degenera­ reduction attributed to DFM seems to be triggered by the
tion, and, ultimately, a painful tendon. 1-3 Patellar tendinopathy can mechanical stimulus provided by the application of deep pressure
thus be considered a failed healing process of this structure. 1,4-6 during DFM ,27 regardless of the mechanism involved in its
Clinically, this condition is characterized by a combination of pain, reduction .21,22,27-33
diffuse or localized swelling, impaired proprioception, and perfor­ The description of DFM defines that the pressure should be
mance.2' 4,7,8 performed in accordance with the target tissue and considering the
The treatment of tendinopathy is often multifactorial and patient feedback; nonetheless, it is not known if and how the
should consider the chronicity of the problem, the potential intensity of the pressure applied during DFM treatment influences
abnormal movement patterns of the athlete, and the functional the technique’s effect on pain and consequently on function.34-36 It
and structural impairments associated with the tendon pain .9 A is known that strength may be impaired by nociception, which
panoply of physical therapy modalities is available, although leads to inhibition of motor cortex or even develop peripheral
some with scarce evidence to support their use, to treat tendon sensitization.37-40
pain such as physical agents, deep friction massage (DFM), Thus, assuming the importance of the pressure during DFM,
counterforce bracing, education and abnormal movement pattern we hypothesize that the immediate effect of DFM on pain and
correction, and exercise namely eccentric training .9 -1 1 Regarding function, namely muscle strength, is modulated by the magni­
DFM, despite the lack of definitive clinical evidence to support tude of pressure, with higher pressures inducing better out­
its use in the management of chronic tendinopathy and the comes. To test this hypothesis, this study aims to assess
absence of studies describing the tissue effects of DFM, it is whether the immediate effects of DFM on clinical outcomes,
namely pain (pain intensity upon palpation and time to onset of
analgesia), and muscle strength are dependent on the pressure
Chaves, Pago, Silva, and Pinho are with the Institute of Research and Advanced
applied during the DFM application in athletes with patellar
Training in Health Sciences and Technologies, CESPU, Gandra, Portugal. Simoes tendinopathy.
is with Santa Maria Health School, Porto, Portugal. Pinho is also with the School
of Health Sciences, University of Aveiro, Aveiro, Portugal. Duarte is with the Methods
Research Centre in Physical Activity, Health and Leisure, Faculty of Sport,
University of Porto, Porto, Portugal. Ribeiro is with the School of Health Sciences Design
and Institute of Biomedicine— iBiMED, University of Aveiro, Aveiro, Portugal.
Chaves (paulamchaves@gmail.com) is corresponding author. A randomized, controlled, cross-over trial was conducted.
860
 Deep Friction Massage in Patellar Tendinopathy 861

Participants
A nonprobabilistic convenience sample of young athletes with
patellar tendinopathy was recruited from local sports clubs after
direct contact with the physiotherapists working there. First, the
physiotherapists were contacted and asked to refer potential parti­
cipants; after that, the athletes were invited to participate in the
study. Ten athletes with diagnosis of unilateral patellar tendino­
pathy (6 males and 4 females, 5 with tendinopathy at the left and 5
with tendinopathy at the right lower limb) with a mean age of 27.90
(5.24) years, weight of 73.30 (6.00) kg, height of l .75 (0.07) m, and
a body mass index of 23.90 (1.73) kg/cm2, volunteered to partici­
pate in the study. To be included, the participants should be aged
18yearsold or above, have a history of training-related and/or
competition-related pain in the patellar tendon, pain on palpation
of the patellar tendon, and symptoms persisting for more than 12
weeks. Furthermore, the participants should have never been Figure 1 — Instrument to monitor and register the pressure.
treated with DFM and should have unilateral patellar tendon
pain.41 The exclusion criteria were history of other injuries or
pathologies to the lower limbs, intake of medication that could frequency of 100 samples per second, coupled with a Bluetooth
interfere with pain mechanisms or with strength production, active 2.1+EDR module for wireless data transmission at 23,0400 bps.
skin disease, deep vein thrombosis, and the presence of any factors Under these specifications, the sensor full scale bandwidth from 0 to
or conditions that could interfere with the awareness and sensibility 3.3 V achieves a resolution of 0.0068N (680 pg). A Windows'"
to pain or preclude the production of maximal muscle contractions. (Windows Microsoft, Redmond, WA) based application was used for
Ethical approval was guaranteed by the ethics committee of the data recording and real-time visualization (Figure 1). The sensor was
Faculty of Sports, University of Porto (Process CEFADE 15.2017), calibrated with 2 standard weights before each acquisition.
and the participants agreed to participate in the study by signing an In the following 4 visits to the laboratory, the participants were
informed consent, which respects all the ethical considerations as randomly assigned to one of the following sessions: control session
stated in the Declaration of Helsinki. (P0), mean pressure obtained in the basal assessment for each of the
participants decremented by 25% (PI), mean pressure (P2), and
Procedures mean pressure +25% (P3). The treatment sessions had a duration of
10 minutes after the onset of analgesia. In the control session, the
All participants attended 5 sessions: 1 session for basal assessment participants were positioned in the treatment position for 12 to
and 4 sessions comprising 1 control session and 3 DFM intervention 14 minutes (the individual time to onset of analgesia found in the
sessions (applied with different pressures); separated by 48 hours to basal assessment followed by 10 min); the length of this session
avoid any carryover effect. These 4 sessions were randomly assigned was defined to match the duration of the DFM sessions. During
using a random sequence generator (www.random.org). each intervention session, the pressure was plotted in real time to
In the first session, height (Seca 206; Seca, Hamburg, give visual and auditory feedback to the physiotherapist (Figure 1);
Germany); body composition (Tanita BC-545N; Tanita, Tokyo, when variations in pressured occurred, these were corrected by way
Japan); and the mean pressure performed during DFM application of visual and auditory feedback so that mean pressure remained
were evaluated in all participants. To assess the pressure applied consistent across all treatment interventions. The position of the
during a standard DFM treatment, the participant was positioned in participant and the DFM procedures were the same as in the basal
supine lying, with 15° of knee flexion (controlled by a goniometer), assessment; likewise, in the DFM sessions, the participants were
and the application point of DFM was defined, and registered, asked to report the time to onset of analgesia.
according to the pain location at palpation22'24-42; then, the phys­
iotherapist applied a regular DFM session, comprising 10 minutes
of DFM after analgesia was obtained. DFM was performed with Outcome Measures
slow and rhythmic movements of small amplitude applied trans­ Before and immediately after each session, the following outcomes
versely to the orientation of the tendon fibres.42 The time to onset of were assessed: pain intensity upon palpation and muscle strength of
analgesia (reported by the participant) was measured by the investi­ knee extensors. All measures were obtained by the same 2 exam­
gator using a chronometer (NIKE Inc, Beaverton, OR). During the iners who were blind to the session allocation. The participants were
DFM session, the physiotherapist used a pressure sensor placed at also questioned regarding the presence of any adverse event.
the tip of his finger to continuously register the pressure applied
(Figure 1). First, data were low-pass filtered through a fourth-order Pain Intensity Upon Palpation. A standardized pressure of
finite impulse response filter at 5 Hz using Hamming window, and 2 kg/cm2 (controlled by the pressure device previously described)
then, the mean pressure of the DFM session was calculated for each was applied over the most painful point (identified in the basal
participant; this value was used to determine the pressure to be assessment), and then, the participant was asked to graduate pain
applied to each participant in DFM intervention sessions. intensity through an 11-point numeric scale. The 11-point numeric
The pressure sensor used during DFM application consisted of scale is a unidimensional measure of pain intensity, in which a
a piezoresistive sensor (A201 FlexiForce™; Tekscan, Boston, MA) respondent selects a whole number (0-10 integers) that best reflects
with an active area of 9.53 mm2 in a pressure range of 0 to 445 N. the intensity of their pain, with 0 representing one pain extreme
The pressure data were acquired with a microcontroller-based (“no pain”), and 10 representing the other pain extreme (“pain as
platform (Teensy 3.2; Teensy, PJRC, Sherwood, OR), at a sampling bad as you can imagine”).43
JSR Vol. 29, No. 7, 2020
862 Chaves et al

M uscle Strength o f Knee Extensors. Knee extensors muscle 10

strength was measured isometrically using a dynamometer C Q.
(Baxtran, UCS; Girona, Spain). Participants were seated in the $ o
plinth with hips at 90° and knees flexed at 60°, without any back n
IS '—
P=.01

support or contact of the lower limbs with the floor.44-46 Partici­ <o =
03 . 9

pants were instructed to hold the side of the plinth for stabilization,
and the dynamometer was placed on the inferior pail of the leg,
proximal to the ankle joint. Then, they performed a warm-up test C CO

with 2 submaximal and 1 maximal contractions, followed by 18- -2

H- "O
3 maximal isometric tests in the extension direction (5 s of O c
CO -4
O c
contraction with 120 s of rest between tests) .47 All participants CO 0
c 9 -6
received the same verbal instructions and encouragement.44’48 The CO ©
© £
average of the 3 repetitions was used. Muscle strength (in newton 2 © -8
c
meter) was recorded. 0)
Q. -1 0
C o n tro l s e s s io n M e an p re s s u re M ean p re s s u re M e a n p re ssure
-25% +25%

Statistical Analyses
Figure 2 — Mean (SD) of deep friction massage effect on pain.
Descriptive statistics comprised absolute and relative frequencies
for categorical variables and mean SD for numerical data.
Shapiro-W ilk test was used to assess the normality of data
distribution. To compare the effects of the sessions on pain DFM sessions the score of pain was constant (zero), there was a
and muscle strength a repeated-measures general linear model notorious decrease in pain scores after all DFM sessions, whereas
of 2 factors was used: session (control and 3 different pressures) in the control session, there were no statistically significant differ­
and time (presession and postsession). A repeated-measures ences (P > .05). When the knee extensors strength was analyzed, it
general linear model with Bonferroni correction for pairwise was observed that it did not change significantly over time ( F 19 =
comparisons was also used to compare data at baseline (preses­ 2.240; P= .17; f/j; = .199), and there was no observed interaction
sion) between interventions, pain intensity during DFM, and for session x time (F 3i27 = 3.276; P - . 074; rj~ = .267) (Table 1).
time to onset of analgesia. Effect size was reported using the The comparison of the differences between interventions
partial eta squared ( ify where values .01 < ^ < . 0 6 represent (Figure 2) showed that there was only a statistically significant
a small effect, values .06 < 77p < .14 represent a medium effect, difference between DFM sessions and control session for pain
and values rj~ > .14 represent a large effect. All statistical analy­ intensity (P< .001).
ses were conducted considering an a = .0 5 . Analyses were When compared the time to onset of analgesia between
performed on IBM® SPSS® statistics (version 24.0; IBM Corp, sessions (Figure 3), it was shown that regardless of the pressure
Armonk, NY). applied, the lime to onset of analgesia was not affected {F 2 18 =
1.026; P > .05; t/2 = .102).

Results
Adverse Events
Before the interventions, no differences between sessions were
None of the participants reported the presence of any adverse event.
observed regarding pain intensity (F 3j27 = 2.927; P > . 05; rjj =
.245) and muscle strength of knee extensors (F 3 27 = 0.144;
P > .0 5 ; f/p = .016). Discussion
Pain intensity changed significantly over time (F ]>9 = 52.364;
P < .001; t)~ = .853) and among sessions (F 3i27 = 82.588; P < .001; The aim of the present study was to assess the immediate effect of
r/p = .902), with a significant interaction for group x time (F 3-27 = different pressures applied during DFM in pain (pain intensity
19.841;P<.001;?7“ = ,6 8 8 )(Table 1). Despite the fact that after the upon palpation and time to onset of analgesia during the

Table 1 Immediate Effects of the Sessions on Pain and Muscle Strength

P rein terventio n assessm en t Postinterven tion ass es sm e n t
M ean (SD) M ean (SD)
Pain intensity upon palpation (0-10) P0: control session 6.3 (1.57) 6.4 (2.17)
PI: -25% of the mean pressure 4.7 (2.36) 0.0 (0.0)
P2: mean pressure 4.5 (2.22) 0.0 (0.0)
P3: +25% of the mean pressure 4.9 (1.60) 0.0 (0.0)
Muscle strength, N-m P0: control session 169.0 (38.28) 170.3 (36.85)
PI: -25% of the mean pressure 173.4 (49.89) 185.1 (50.62)
P2: mean pressure 179.1 (48.24) 209.2 (53.08)
P3: +25% of the mean pressure 172.8 (81.40) 197.06 (79.16)

JSR Vol. 29, No. 7, 2020

 Deep Friction Massage in Patellar Tendinopathy 863

300 P - .22 C onsidering that, globally, our data indicate that higher
3 CD P > .99 P = .95 pressure did not translate into b etter outcom es, the p h y siothera­
*D T3
.2
cd
§
o
250 pist should take into consideration that a m ost distressful tech­
CD Q)
J J ) CD nique is n ot related w ith pain reduction or m uscle strength
2 c im provem ent. H ow ever, the reader should bear in m ind that
03 .9 200
o | the application o f low er pressures may com prom ise the m orpho­
CD -Q_
logical changes attributed to the technique, w hich w ere not
150
o 03 evaluated in our study.
2o ®
a)
03
®
CO
CD The present study had som e lim itations. The lack o f differ­
^ £ 100
ences betw een sessions in the m uscle strength change could be
c related with the small sam ple size. Only the im m ediate effects o f
o
50
the technique w ere m easured, it is not know n for how long the
Q£
CO CL
CD
effects o f DFM last. Future studies could overcom e these lim ita­
C CD
03 T3
CD
tions by assessing different tim e points (eg, at 1 h, 6 h, 24 h) after
M e a n p re s s u re M e a n p re s s u re M e a n p re s s u re
- 25% ♦ 25% the application o f the technique as well as having higher intensities
o f D FM pressure. Future studies should encom pass larger sample
sizes, follow the protocol regarding treatm ent frequency recom ­
Figure 3 — Mean (SD) of time to onset of analgesia during deep friction
massage by intervention. m ended by the author o f DFM, analyze its effectiveness with a
follow -up period, and should include instruments for functional
outcom es (such as VISA-P).

technique) and m uscle strength o f knee extensors in athletes with

patellar tendinopathy.
Conclusion
O ur findings do not confirm our hypothesis, as our results
T he p resen t study has show n th at D FM in d u ces an im m ediate
show ed that the im m ediate effects o f DFM are not dependent on the
reduction in pain intensity upon p alpation, regardless o f the
pressure applied during the DFM application. A lthough it was
pressure perform ed. N o tw ith stan d in g , the read er sh o u ld take
show n an im m ediate reduction on pain intensity, regardless o f the
into acco u n t the sm all sam ple size and the caution need ed in
pressure applied, this fact was not verified in the time to onset of the resu lts’ in terp retatio n . M oreover, fu rth er studies are needed
analgesia nor in the functional outcom es evaluated. to determ in e the tissue response to d ifferen t pressures and
A s far as the authors know, this is the first study aim ing to
determ in e if the rep air pro cess o f the tendon is influenced by
evaluate in isolation, DFM effects’ in pain and function as well as
pressure.
to quantify the effects o f different intensities o f pressure applied in
the previously m entioned outcom es. O ur results have show n that
DFM prom otes an im m ediate pain reduction. N otw ithstanding, this Acknowledgments
reduction in pain intensity and tim e to onset o f analgesia were not The iBiMED is a research unit supported by the Portuguese Foundation
affected by the m agnitude o f the pressure used during D FM ; this is, for Science and Technology (REF: UID/BIM/04501/2013) and FEDER/
the m echanical stim ulus perform ed during DFM seem s to trigger Compete2020 funds. The European Regional Development Fund through
an analgesic response independently o f the pressure applied. the Operational Competitiveness Program and the Portuguese Foundation
This response may be explained by different m echanism s such for Science and Technology supports the research unit CIAFEL within
as the induction o f hyperem ia produced by m echanical stim u­ the projects FCOMP-01-0124-FEDER- 020180 (References FCT: PTDC/
lus,21-22-24’28-49 the “gate control theory,”21-28-29-33-49-50 and/or the DES/122763/2010) and UID/DTP/00617/2013, respectively.
descending m echanism s o f pain m odulation.21-22-27*30-32-49 Specific
considerations regarding the different pain m echanism s are beyond
the scope o f this article, and the readers should look for further References
explanations on the available literature.22-27-31'32
Regarding m uscle strength, there were no statistically signifi­ 1. Abate M, Gravare-Silbemagel K, Siljeholm C, et al. Pathogenesis of
cant differences betw een the change induced by DFM sessions and tendinopathies: inflammation or degeneration? Arthritis Res Ther.
that observed in the control session. It is know n that strength may 2009;11(3):235. PubMed ID: 19591655 doi:10.1186/ar2723
be im paired by nociception, w hich leads to inhibition o f motor 2. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology
cortex or even develop peripheral sensitization.37-40 Flaving this, model to explain the clinical presentation of load-induced tendino­
and considering that our results have show n that when DFM was pathy. BrJSports Med. 2009;43(6):409-416. PubMed ID: 18812414
perform ed there was a decrease in pain intensity scores, we doi: 10.1136/bjsm.2008.051193
hypothesize that DFM has triggered an analgesic response through 3. Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical
the activation o f descending nociceptive inhibition, should have diagnosis, load management, and advice for challenging case pre­
reduced the nociceptive input to the central nervous system, and sentations. J Orthop Sports Phys Ther. 2015:45(11 ):887—898.
consequently, it w ould be expectable that the m otor output (m uscle PubMed ID: 26390269 doi: 10.2519/jospt.2015.5987
strength) w ould be enhanced.40-51 H ow ever, the fact that o ur results 4. Cook JL, Khan KM, Purdam CR. Conservative treatment of patellar
did not present statistically significant changes in this outcom e tendinopathy. Phys Ther Sport. 2001 ;2(2):54—65. doi: 10.1054/ptsp.
may be explained by the great interindividual variability found 2001.0069
(reflected in the small effect size). Furtherm ore, it should be noted 5. D’Addona A, Maffulli N, Formisano S, Rosa D. Inflammation in
that this study only evaluated im m ediate effects and from a single tendinopathy. Surgeon. 2017; 15(5):297—302. doi: 10.1016/j.surge.
DFM intervention session. 2017.04.004

JSR Vol. 29, No. 7, 2020

864 Chaves et al

6. Maffulli N, Longo UG, Denaro V. Novel approaches for the man­ 25. Davidson CJ, Ganion LR, Gehlsen GM, Verhoestra B, Roepke JE,
agement of tendinopathy. J Bone Joint Surg Am. 2010;92( 15):2604— Sevier TL. Rat tendon morphologic and functional changes resulting
2613. PubMed ID: 21048180 from soft tissue mobilization. Med Sci Sports Exerc. 1997;29(3):313—
7. Rudavsky A, Cook J. Physiotherapy management of patellar tendino­ 319. PubMed ID: 9139169 doi: 10.1097/00005768-199703000-
pathy (jumper’s knee). J Physiolher. 2014:60(3): 122-129. PubMed 00005
ID: 25092419 doi: 10.1016/j.jphys.2014.06.022 26. Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation
8. Torres R, Ferreira J, Silva D. Rodrigues E, Bessa IM. Ribeiro F. in soft tissue mobilization pressure. Med Sci Sports Exerc. 1999;
Impact of patellar tendinopathy on knee proprioception: a cross- 31 (4):531—535. PubMed ID: 10211847 doi: 10.1097/00005768-
sectional study. Clin J Sport Med. 2017;27(1 ):31-36. PubMed ID: 199904000-00006
26829609 doi: 10.1097/JSM.0000000000000295 27. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The
9. Reinking M. Tendinopathy in athletes. Phys Ther Sport. 2012; 13(1): mechanisms of manual therapy in the treatment of musculoskeletal
3-10. PubMed ID: 22261424 doi: 10.1016/j.ptsp.2011.06.004 pain: a comprehensive model. Man Ther. 2009; 14(5):531—538.
10. Andres BM, Murrell GA. Treatment of tendinopathy: what works, PubMed ID: 19027342 doi:10.1016/j.math.2008.09.001
what does not, and what is on the horizon. Clin Orthop Relat 28. Gregory MA, Deane MN, Mars M. Ultrastructural changes in un­
Res. 2008;466(7): 1539-1554. PubMed ID: 18446422 doi:10.1007/ traumatised rabbit skeletal muscle treated with deep transverse fric­
si 1999-008-0260-1 tion. Physiotherapy. 2003;89(7):408-416. doi: 10.1016/S0031-9406
11. Blackwood J. Ghazi F. Can the addition of transverse friction (05)60074-0
massage to an exercise programme in treatment of infrapatellar 29. Hassan S, Hafez A, Seif H, Kachanathu S. The effect of deep friction
tendinopathy reduce pain and improve function? A pilot study. massage versus stretching of wrist extensor muscles in the treatment
Int Musculoskelet Med. 2012;34(3): 108-114. doi: 10.1179/ of patients with tennis elbow. Open J Ther Rehabil. 2016;4:48-54.
1753615412Y.0000000005 doi: 10.4236/ojtr.2016.41004
12. Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction 30. Llorca-Torralba M, Borges G, Neto F, Mico JA, Berrocoso E.
massage for treating tendinitis. Cochrane Database Syst Rev. Noradrenergic locus coeruleus pathways in pain modulation. Neuro­
2002(4):CD003528. science. 2016:338:93-113. PubMed ID: 27267247 doi: 10.1016/j.
13. Chaves P, Sirnoes D, Pa^o M, Pinho F, Duarte JA, Ribeiro F. Cyriax’s neuroscience.2016.05.057
deep friction massage application parameters: evidence from a cross- 31. Pud D, Granovsky Y, Yarnitsky D. The methodology of experimen­
sectional study with physiotherapists. Musculoskelet Sci Pract. tally induced diffuse noxious inhibitory control (DNIC)-like effect in
2017;32(32):92—97. doi:10.10l6/j.msksp.2017.09.005 humans. Pain. 2009; 144(1-2): 16-19. PubMed ID: 19359095 doi:10.
14. Joseph MF, Taft K, Moskwa M, Denegar CR. Deep friction massage to 1016/j.pain.2009.02.015
treat tendinopathy: a systematic review of a classic treatment in the face 32. Vigotsky AD, Bruhns RP. The role of descending modulation in
of a new paradigm of understanding. J Sport Rehabil. 2012;21 (4):343- manual therapy and its analgesic implications: a narrative review.
353. PubMed ID: 22234925 doi: 10.1123/jsr.21.4.343 Pain Res Treat. 2015;2015:1-11. doi: 10.1155/2015/292805
15. Loew LM. Brosseau L, Tugwell P, et al. Deep transverse friction 33. Viswas R. Ramachandran R, Korde Anantkumar P. Comparison of
massage for treating lateral elbow or lateral knee tendinitis. Cochrane effectiveness of supervised exercise program and Cyriax physiother­
Database Syst Rev. 2014;11:CD003528. apy in patients with tennis elbow (lateral epicondylitis): a randomized
16. Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: aetiol­ clinical trial. ScientificWorldJournal. 2012;2012:1-8. PubMed ID:
ogy and management. J R Soc Med. 2004:97(10):472476. PubMed 22629225 doi: 10.1100/2012/939645
ID: 15459257 doi: 10.1177/0141076809701004 34. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum
17. Prabhakar AJ, Kage V, Anap D. Effectiveness of cyriax physiother­ model of tendon pathology: what is its merit in clinical practice and
apy in subjects with tennis elbow ../ Nov Physiother. 2013;3(3): 156. research? Br J Sports Med. 2016;50( 19): 1187-1191. PubMed ID:
doi: 10.4172/2165-7025.1000156 27127294 doi: 10.1136/bjsports-2015-095422
18. Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J 35. Graven-Nielsen T, Arendt-Nielsen L. Impact of clinical and experi­
Sports Med. 2009;37(9): 1855-1867. PubMed ID: 19188560 doi: 10. mental pain on muscle strength and activity. Curr Rheumatol Rep.
1177/0363546508324283 2008; 10(6):475— 481. PubMed ID: 19007539 doi: 10.1007/s 11926-
19. Rees JD, Wilson AM, Wolman RL. Current concepts in the manage­ 008-0078-6
ment of tendon disorders. Rheumatology. 2006;45(5):508—521. 36. Silbemagel KG, Gustavsson A, Thomee R, Karlsson J. Evaluation of
PubMed ID: 16490749 doi: 10.1093/rheumatology/kel046 lower leg function in patients with Achilles tendinopathy. Knee Surg
20. Reinking MF. Current concepts in the treatment of patellar tendino­ Sports Traumatol Arthrosc. 2006; 14(11): 1207—1217. PubMed ID:
pathy. Int J Sports Phys Ther. 2016; 11 (6):854. PubMed ID: 27904789 16858560 doi: 10.1007/s00167-006-0150-6
21. Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/ 37. Farina S, Valeriani M, Rosso T, et al. Transient inhibition of
lateral epicondylitis. Br J Sports Med. 2004;38(6):675—677. PubMed the human motor cortex by capsaicin-induced pain. A study with
ID: 15562158 doi: 10.1136/bjsm.2004.013573 transcranial magnetic stimulation. Neurosci Lett. 2001:314(1-2):
22. Atkins E, Kerr J, Goodlad E. A Practical Approach to Orthopaedic 97-101. PubMed ID: 11698155 doi: 10.1016/S0304-3940(01)
Medicine: Assessment, Diagnosis, Treatment. 3rd ed. London, UK: 02297-2
Churchill Livingstone, Elsevier; 2010. 38. Farina S, Tinazzi M, Le Pera D, Valeriani M. Pain-related modulation
23. Begovic H, Zhou GQ, Schuster S. Zheng YP. The neuromotor effects of the human motor cortex. Neurolog Res. 2003;25(2): 130-142.
of transverse friction massage. Man Ther. 2016:26(1532-2769 (Elec- doi: 10.1179/016164103101201283
tronic)):70-76. doi:10.1016/j.math.2016.07.007 39. Lund JP, Donga R, Widmer CG, Stohler CS. The pain-adaptation
24. Chamberlain GJ. Cyriax’s friction massage: a review. J Orthop Sports model: a discussion of the between chronic musculoskeletal pain and
Phys Ther. 1982;4(1): 16-22. PubMed ID: 18810110 doi:10.25!9/ motor activity. Can J Physiol Pharmacol. 1991 ;69(5):683—694.
jospt. 1982.4.1.16 PubMed ID: 1863921 doi: 10.1139/y91-102

JSR Vol. 29, No. 7, 2020

 Deep Friction Massage in Patellar Tendinopathy 865

40. Struyf F, Lluch E, Falla D, Meeus M, Noten S, Nijs J. Influence of 45. Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani
shoulder pain on muscle function: implications for the assessment WA. Muscles Testing and Function With Posture and Pain. 5th ed.
and therapy of shoulder disorders. Eur J Appl Physiol. Baltimore, MD: Lippincott Williams & Wilkins; 2005.
2014; 115(2):225—234. PubMed ID: 25431129 doi: 10.1007/ 46. Hislop HJ, Montgomery J. Daniels & Worthingham’s Muscle Test­
s00421-014-3059-7 ing: Techniques o f Manual Examination. 8th ed. St. Louis, MO:
4 1. Crossley KM, Thancanamootoo K, Metcalf BR, Cook JL, Purdam Saunders Elsevier; 2007.
CR, Warden SJ. Clinical features of patellar tendinopathy and their 47. Mentiplay BF, Perraton LG, Bower KJ, et al. Assessment of lower limb
implications for rehabilitation. J Orthop Res. 2007;25(9): 1164-1175. muscle strength and power using hand-held and fixed dynamometry: a
PubMed ID: 17469196 doi: 10.1002/jor.20415 reliability and validity study. PLoS ONE. 2015; 10( 10):e0140822.
42. Cyriax JH, Cyriax PJ. Cyriax’s Illustrated Manual o f PubMed ID: 26509265 doi:10.1371/journal.pone.0140822
Orthopaedic Medicine. 2nd ed. Oxford, UK: Butterworth- 48. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme
Heinemann; 1993. B. An isokinetic eccentric programme for the management of chronic
43. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult lateral epicondylar tendinopathy. Br .1 Sports Med. 2007 ;41(4):269—
pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating 275. PubMed ID: 17224433 doi: 10.1136/bjsm.2006.033324
Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), 49. Goats GC. Massage-the scientific basis of an ancient art: part 2.
Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Physiological and therapeutic effects. Br J Sports Med. 1994;28(3):
Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 153-156. PubMed ID: 8000810 doi: 10.1136/bjsm.28.3.153
BPS), and Measure of Intermittent and Constant Osteoarthritis 50. De Bruijn R. Deep transverse friction: its analgesic effect. Ini J Sports
Pain (ICOAP). Arthritis Care Res. 201 l;63(suppl 11):S240—S252. Med. 1984;5:S35—S36. doi: 10.1055/s-2008-1025944
doi: 10.1002/acr.20543 51. Nijs J, Daenen L, Cras P, Struyf F, Roussel N, Oostendorp RA.
44. Shenoy S, Mishra P, Sandhu JS. Peak torque and IEMG activity of Nociception affects motor output: a review on sensory-motor
quadriceps femoris muscle at three different knee angles in a colle­ interaction with focus on clinical implications. Clin J Pain.
giate population../ Exerc Sci Fitness. 2011 ;9( 1):40^45. doi: 10.1016/ 2012;28(2): 175-181. PubMed ID: 21712714 doi:10.1097/AJP.
S1728-869XG 1)60005-1 0b013e3I8225daf3

JSR Vol. 29, No. 7, 2020

Copyright of Journal of Sport Rehabilitation is the property of Human Kinetics Publishers,
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.