Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials. Issue 5 (10th June 2020)

• Record Type: Journal Article
• Authors: van der Vlist, Arco C; Winters, Marinus; Weir, Adam; Ardern, Clare L; Welton, Nicky J; Caldwell, Deborah M; Verhaar, Jan A N; de Vos, Robert-Jan
• Is Part Of: British journal of sports medicine. Volume 55:Issue 5(2021)
• Page Start: 249
• Page End: 256
• Publication Date: 2020-06-10
• Subjects: tendinopathy -- Achilles tendon -- efficacy -- intervention; Sports medicine -- Periodicals; 617.1027
• DOI: 10.1136/bjsports-2019-101872
• Languages: English
• ISSNs: 0306-3674

Abstract

Abstract : Objective: To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy. Design: Living systematic review and network meta-analysis. Data sources: Multiple databases including grey literature sources were searched up to February 2019. Study eligibility criteria: Randomised controlled trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy. We excluded trials with 10 or fewer participants per treatment arm or trials investigating tendon ruptures. Data extraction and synthesis: Reviewers independently extracted data and assessed the risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of evidence. Primary outcome measure: The validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire. Results: 29 trials investigating 42 different treatments were included. 22 trials (76%) were at high risk of bias and 7 (24%) had some concerns. Most trials included patients with midportion tendinopathy (86%). Any treatment class seemed superior to wait-and-see for midportion Achilles tendinopathy at 3 months (very low to low certainty of evidence). At 12 months, exercise therapy, exercise+injection therapy and exercise+night splint therapy were all comparable with injection therapy for midportion tendinopathy (very low to low certainty). No network meta-analysis could be performed for insertional Achilles tendinopathy. Summary/conclusion: In our living network meta-analysis no trials were at low risk of bias and there was large uncertainty in the comparative estimates. For midportion Achilles tendinopathy, wait-and-see is not recommended as all active treatments seemed superior at 3-month follow-up. There seems to be no clinically relevant difference in effectiveness between different active treatments at either 3-month or 12-month follow-up. As exercise therapy is easy to prescribe, can be of low cost and has few harms, clinicians could consider starting treatment with a calf-muscle exercise programme. PROSPERO registration number: CRD42018086467.