Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials

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.

Keywords: Achilles tendon; efficacy; intervention; tendinopathy.

Figure 1

PRISMA flow diagram of the study selection process. IPD, individual patient data; LPLV, last patient last visit; PRISMA, preferred reporting items for systematic reviews and meta-analyses.

Figure 2

Network plots for treatment classes on the VISA-A score at 3 and 12 months in patients with midportion Achilles tendinopathy. The size of the dots is proportional to the number of participants who received the treatment, respectively. Blue numbers indicate the number of trials the classes were compared in. Note that intraclass comparisons are not included in the plot (eg, eccentric exercises vs heavy slow resistance exercises); all treatment comparisons can be found in online supplementary appendix 9. (A) VISA-A score at 3 months. (B) VISA-A score at 12 months. VISA-A, Victorian Institute of Sport Assessment-Achilles.

Figure 3

Comparative treatment class effects expressed with a mean difference for the VISA-A score at 3 months (A) and at 12 months (B) in patients with midportion Achilles tendinopathy. Mean differences on the VISA-A score with their 95% credible intervals from the network meta-analysis. For any cell, a negative mean difference favours the upper-left treatment, and a positive mean difference favours the lower-right treatment. Comparative treatment class effect differences are shown in bold. VISA-A, Victorian Institute of Sport Assessment-Achilles.

Figure 4

Treatment class rankings from the network meta-analysis for the VISA-A score at 3 months in patients with midportion Achilles tendinopathy. The asterix indicates that the 95% credible interval was rank 10 to 10 for wait-and-see therapy. MPS, mucopolysaccharides supplement; VISA-A, Victorian Institute of Sport Assessment-Achilles.

Figure 5

Treatment class rankings from the network meta-analysis for the VISA-A score at 12 months in patients with midportion Achilles tendinopathy. VISA-A, Victorian Institute of Sport Assessment-Achilles.