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Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials
  1. Arco C van der Vlist1,
  2. Marinus Winters2,
  3. Adam Weir1,3,
  4. Clare L Ardern4,
  5. Nicky J Welton5,
  6. Deborah M Caldwell5,
  7. Jan A N Verhaar1,
  8. Robert-Jan de Vos1
  1. 1Department of Orthopaedics and Sports Medicine, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
  2. 2Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
  3. 3Aspetar Sports Groin Pain Centre, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar
  4. 4Division of Physiotherapy, Karolinska Institute, Stockholm, Stockholm County, Sweden
  5. 5Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
  1. Correspondence to Arco C van der Vlist, Department of Orthopaedics and Sports Medicine, Erasmus University Rotterdam, 3000 CA Rotterdam, Zuid-Holland, The Netherlands; a.vandervlist{at}


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.

  • tendinopathy
  • Achilles tendon
  • efficacy
  • intervention

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  • Twitter @ArcoVlist, @marinuswinters, @clare_ardern, @rj_devos

  • Contributors MW, AW and R-JV came up with the study idea. ACV, MW, AW, CLA, NJW, DMC, JANV and R-JV were involved in designing the study. ACV and R-JV performed the literature search and screened trials for inclusion. ACV, MW, AW, CLA and R-JV performed the risk of bias assessment and data extraction. MW, NJW and DMC designed the statistical analysis plan and analysed the data. ACV, MW, AW and R-JV interpreted the results of the data analyses. ACV, MW, AW and R-JV drafted the manuscript. R-JV is the study guarantor. All authors reviewed the final manuscript and agreed to be accountable for all aspects of the work and approved the final manuscript for submission. The corresponding author attests that all listed authors meet the authorship criteria and that no others meeting the criteria have been omitted.

  • Funding This research received a grant from the Dutch Association of Medical Specialists to develop a clinical guideline for the treatment of patients with Achilles tendinopathy. The Dutch Patient Federation is involved in this guideline development and assisted in sending out patient surveys.

  • Competing interests NJW led a research project in collaboration with Pfizer (project ended 31 December 2018). Pfizer part-funded a junior researcher. The projects were purely methodological, using historical data on pharmacological treatments for pain relief.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.