Table 4

Conservative interventions, quality of evidence and recommendation

Conservative Interventions		« Traffic Light » statements and comments of the authors. Note: the quality of the evidence is very low and we have but very little confidence in the effect size estimate: The true effect size is likely to be substantially different from the estimated effect size. This does not mean that our results and conclusions are meaningless. Future research might change the conclusions and therefore, practitioners need to reconsider our conclusions if new research becomes available. For all interventions, the readers should bear in mind that due to the insufficient reporting of unexpected adverse effects, no advice can be given with regard to potential harms.
	Green	Do it—this intervention is effective.
	Orange	Uncertain effect—the effect of this intervention must be monitored, and alternative interventions need to be considered if the effect is not satisfactory.
	Red	Don’t do it—this intervention is ineffective.
Corticosteroid injections	Orange	Corticosteroids were superior to doing nothing (pain −0.65, 95% CI −1.04 to −0.26; function −0.56, 95% CI −1.06 to −0.05). Compared with active control (physical therapy modalities), corticosteroids were superior only at the shortest follow-up (pain −0.25, 95% CI −0.46 to −0.05). Corticosteroids may be an alternative treatment if a patient disagrees on the use of other effective treatment options with less side effects, such as exercise. Ultrasound guided corticosteroid injections were superior to blind injections for pain (−0.51, 95% CI-0.89 to −0.13) and for function (−0.43, 95% CI −0.71 to −0.15). For active range of motion (AROM), local steroids were superior to systemic steroids (AROM 0.72, 95% CI 0.32 to 1.11). There was no conclusive evidence for the comparison between corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs).
Medicaments, other than corticosteroid injections	Orange	NSAIDs were superior to placebo (pain −0.29, 95% CI −0.53 to −0.05; AROM 2.62, 95% CI 2.25 to 3.00) but there is no evidence about how they compare to other treatments such as exercise. Local anaesthetics were inferior to corticosteroids at the shortest follow-up (pain 0.45, 95% CI 0.17 to 0.73).
Exercise	Orange	Exercise was superior to doing nothing (pain −0.94. 95% CI −1.69 to −0.19; function −0.57, 95% CI −0.85 to −0.29). Specific exercise was superior to non-specific exercise (pain −0.65, 95% CI −0.99 to −0.32; function −0.68, 95% CI −1.26 to −0.10; AROM 0.59, 95% CI 0.08 to 1.10). Exercise was less effective than surgery for pain but not for function (pain 31% risk difference, 95% CI 13% to 49%), supporting surgery if indication for surgery is given (ie, tears). Exercise was superior to non-exercise physical therapy (AROM 1.00, 95% CI 0.25 to 1.76).
Manual Therapy	Orange	Manual therapy was superior to doing nothing for pain (−0.35, 95% CI −0.69 to −0.01). Manual therapy plus exercise was superior to sham ultrasound and placebo gel for function (−0.42, 95% CI −0.78 to −0.06). Manual therapy combined with exercise was superior to exercise alone only for shortest follow-up (pain −0.32, 95% CI −0.62 to −0.01; function −0.41, 95% CI −0.71 to −0.11). There were immediate effects (after one session) for manual therapy versus placebo for pain (−0.62, 95% CI −0.97 to −0.28).
Laser	Orange	Laser plus exercise was superior to exercise plus sham laser for pain (−0.65, 95% CI −0.99 to −0.31). Laser was superior to sham laser for pain (−0.88, 95% CI −1.48 to −0.27).
Ultrasound	Orange	There was very low statistical precision for the effect estimates of ultrasound; the only significant effect was for long duration ultrasound (8 min) versus short duration (4 min) (pain −1.32, 95% CI −1.76 to −0.89; function −0.42, 95% CI −0.82 to −0.02).
Extracorporeal shockwave therapy (ECSWT)	Orange	ECSWT was superior to sham ECSWT for pain (−0.39, 95% CI −0.78 to −0.01) but there was not enough evidence for or against the use in combination with exercise. Because exercise showed the best effects, the use of ECSWT as stand-alone therapy may be questionable.
Tape	Orange	Tape was superior to sham tape for pain (−0.64, 95% CI −1.16 to −0.12).
Hyaluronate	Orange	Insufficient evidence for or against the use of hyaluronate.
Pulsed electromagnetic field	Orange	Insufficient evidence for or against the use of pulsed electromagnetic field.
Transcutaneous electrical nerve stimulation	Orange	Insufficient evidence for or against the use of transcutaneous electrical nerve stimulation.
Surgery (vs conservative treatment)	Orange	Very low evidence that surgery was superior to exercise or physiotherapy for pain (−0.66, 95% CI −1.06 to −0.26). We cannot exclude that a subset of patients will have a large benefit from surgery.
Acupuncture	Orange	Insufficient evidence for or against the use of acupuncture.
Diacutaneous fibrolysis	Orange	Insufficient evidence for or against the use of diacutaneous fibrolysis.
Nerve block	Orange	Nerve block was superior to control for pain and function (pain −0.91, 95% CI −1.27 to −0.54; function −0.55, 95% CI −1.01 to −0.08).
Myofascial trigger point	Orange	Insufficient evidence for or against the use of myofascial trigger point therapy.
Microwave	Orange	Insufficient evidence for or against the use of microwave.
Comprehensive physiotherapy	Orange	Insufficient evidence for or against the use of comprehensive physiotherapy.
Platelet rich plasma	Orange	Insufficient evidence for or against the use of platelet rich plasma therapy.
Interferential light therapy	Orange	Insufficient evidence for or against the use of interferential light therapy.
Massage	Orange	Insufficient evidence for or against the use of massage.
Microcurrent electrical stimulation	Orange	Insufficient evidence for or against the use of microcurrent electrical stimulation.
US guided percutaneous electrolysis	Orange	Not enough evidence for or against the use of US guided percutaneous electrolysis and eccentric exercises.