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

Abstract

ObjectiveTo provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy.DesignLiving systematic review and network meta-analysis.Data sourcesMultiple databases including grey literature sources were searched up to February 2019.Study eligibility criteriaRandomised 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 synthesisReviewers 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 measureThe validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire.Results29 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/conclusionIn 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 numberCRD42018086467.

Risk of bias in systematic reviews of tendinopathy management: Are we comparing apples with oranges?

“…These are exactly the aims of the revised Cochrane Collaboration tool, the creators of which state that they expect the new tool to be more likely to rate studies as "low overall RoB." 5 This was clearly not the case with the example SR used in the present review by van der Vlist et al 8 who rated none of the 29 RCTs as "low risk." Reasons for that might be either the actual presence of bias in all the included RCTs, strict thresholds used by the SR authors or poor performance of the tool itself.…”

“…Table 1 summarizes the key characteristics of the eligible SRs. 8, Of the 46 included SRs, 31 used the Cochrane Collaboration tool, 13 the PEDro scale, 2 the revised Cochrane Collaboration tool (RoB 2), and 2 both the Cochrane Collaboration tool and the PEDro scale. Modified versions of the PEDro scale and the Cochrane Collaboration tool were used by two and one SRs, respectively.…”

“…Secondly, in light of the newly published RoB 2 tool by the Cochrane Collaboration and its use by the most recently published SR of RCTs in Achilles tendinopathy by van der Vlist et al, 8 we assessed RoB of its 29 included RCTs using the two other RoB assessment tools, the Cochrane Collaboration tool and the PEDro scale. We then compared the reliability among the three tools (Cochrane Collaboration and PEDro as performed by the authors of the present review and RoB 2 by the authors of the original SR) at determining overall RoB.…”

Conservative management of acute lower limb tendinopathies: A systematic review

“…Given this absence, we cannot exclude the possibility that the specific type of intervention for acute LLT is less of a concern, but rather that the named intervention is superior to no intervention at all. This concept is currently recommended in other acute musculoskeletal conditions (Crossley et al, 2016; Foster et al, 2018) and is not unprecedented in the tendinopathy literature (Van Der Vlist et al, 2020). However, the outcome of a ‘ wait‐and‐ see’ approach for acute LLT is uncertain as no studies in this systematic review included this as an intervention.…”

Partial Achilles Tendon Rupture—A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options

“…A further pathology is the acute Achilles tendon rupture with a sudden onset of pain and functional disability. For both Achilles tendinopathy and Achilles tendon rupture, there are several evidence-based nonsurgical and surgical treatment options and diagnostic pathways based on meta-analyses, randomized controlled trials, and consensus statements [ 2 , 3 , 4 ].…”