Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: A systematic review with meta-analysis

ObjectiveTo assess the effectiveness of heavy eccentric calf training (HECT) in comparison with natural history, traditional physiotherapy, sham interventions or other exercise interventions for improvements in pain and function in mid-portion Achilles tendinopathy.DesignA systematic review and meta-analysis were conducted as per the PRISMA guidelines.Data sourcesPUBMED, CINAHL (Ovid) and CINAHL (EBSCO) were searched from inception until 24 September 2018.Eligibility criteriaRandomised controlled trials comparing HECT to natural history, sham exercise, traditional physiotherapy and other exercise interventions were included. Primary outcome assessing pain and function was the Victorian Institute of Sports Assessment-Achilles.ResultsSeven studies met the inclusion criteria. This review suggests HECT may be superior to both natural history, mean difference (MD) (95% CI) of 20.6 (11.7 to 29.5, one study) and traditional physiotherapy, MD (95% CI) of 17.70 (3.75 to 31.66, two studies). Following removal of one study, at high risk of bias, due to pre-planned sensitivity analysis, this review suggests HECT may be inferior to other exercise interventions, MD (95% CI) of −5.65 (-10.51 to −0.79, three studies). However, this difference is unlikely to be clinically significant.ConclusionCurrent evidence suggests that HECT may be superior to natural history and traditional physiotherapy while HECT may be inferior to other exercise interventions. However, due to methodological limitations, small sample size and a lack of data we are unable to be confident in the results of the estimate of the effect, as the true effect is likely to be substantially different.Systematic review registryPROSPERO registration number: CRD4201804493Protocol referenceThis protocol has been published open access: Murphy M, Travers MJ, Gibson, W. Is heavy eccentric calf training superior to natural history, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy? Systematic Reviews 2018; 7: 58

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Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis

Gait & Posture ◽

10.1016/j.gaitpost.2019.07.121 ◽

2019 ◽

Vol 73 ◽

pp. 189-201 ◽

Cited By ~ 3

Author(s):

Igor Sancho ◽

Peter Malliaras ◽

Christian Barton ◽

Richard W. Willy ◽

Dylan Morrissey

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Achilles Tendinopathy

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Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis

British Journal of Sports Medicine ◽

10.1136/bjsports-2017-098913 ◽

2018 ◽

Vol 52 (24) ◽

pp. 1564-1574 ◽

Cited By ~ 18

Author(s):

Fiona Wilson ◽

Margaret Walshe ◽

Tom O’Dwyer ◽

Kathleen Bennett ◽

David Mockler ◽

...

Keyword(s):

Systematic Review ◽

Eccentric Exercise ◽

Meta Analysis ◽

Exercise Programme ◽

Achilles Tendinopathy ◽

Moderate Level ◽

Exercise Protocol ◽

Low Level ◽

Significant Difference ◽

And Function

ObjectivesTo assess the efficacy of exercise, orthoses and splinting on function, pain and quality of life (QoL) for the management of mid-portion and insertional Achilles tendinopathy, and to compare different types, applications and modes of delivery within each intervention category.DesignSystematic review and meta-analysis.Data sourcesMedline, CINAHL, Embase, AMED, WHO ICTRP, Web of Science, PEDro and Cochrane Library from inception to October 2017. Citation tracking of published studies and conference proceedings and contacting experts in the field.Study eligibility criteriaControlled clinical trials evaluating either exercise, orthoses or splinting for the management of Achilles tendinopathy.MethodsIndependent reviewers undertook searches, screening and risk of bias appraisal. Primary outcomes of interest were function, pain and QoL.ResultsTwenty-two studies were included (1137 participants). Moderate level evidence favoured eccentric exercise over control for improving pain and function in mid-portion tendinopathy. Moderate level evidence favoured eccentric exercise over concentric exercise for reducing pain. There was moderate level evidence of no significant difference in pain or function between eccentric exercise and heavy slow resistance exercise. There was low level evidence that eccentric exercise was not superior to stretching for pain or QoL. There was moderate level evidence that a combined exercise protocol was not superior to a lower dosage protocol for improving functional performance. There was moderate to low level evidence of a significant difference in pain (mean difference (MD) 6.3 mm, 95% CI −4.45 to 17.04, moderate) or function (MD 1.83 Victoria Institute of Sport Assessment points, 95% CI −7.47 to 11.12, low) between high-dose and low-dose eccentric training. There was high to moderate level evidence of no difference in pain (moderate) or function (high) between orthoses and control. There was low level evidence of no significant benefit in adding a night splint to an eccentric exercise programme for function, and moderate level evidence for no reduction in pain (MD −3.50, 95% CI −10.49 to 3.48). Eccentric exercise was not superior to splinting for pain (moderate evidence) or function (low level evidence).SummaryWe conditionally recommend exercise for improving pain and function in mid-portion Achilles tendinopathy. The balance of evidence did not support recommendation of one type of exercise programme over another. We conditionally recommend against the addition of a splint to an eccentric exercise protocol and we do not recommend the use of orthoses to improve pain and function in Achilles tendinopathy.

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A systematic review and meta-analysis of conservative management of Achilles tendinopathy

Journal of Foot and Ankle Research ◽

10.1186/1757-1146-4-s1-p32 ◽

2011 ◽

Vol 4 (S1) ◽

Cited By ~ 1

Author(s):

Samuel P Leitch ◽

Andrea E Bialocerkowski ◽

Stuart J Warden ◽

Natalie J Collins ◽

Andy W Chien ◽

...

Keyword(s):

Systematic Review ◽

Conservative Management ◽

Meta Analysis ◽

Achilles Tendinopathy

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Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy: A Systematic Review With Network Meta-analysis

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120930567 ◽

2020 ◽

Vol 8 (7) ◽

pp. 232596712093056 ◽

Cited By ~ 1

Author(s):

Hye Chang Rhim ◽

Min Seo Kim ◽

Seungil Choi ◽

Adam S. Tenforde

Keyword(s):

Systematic Review ◽

Safety Profile ◽

Meta Analysis ◽

High Volume ◽

Achilles Tendinopathy ◽

Comparative Efficacy ◽

Short Term ◽

Level Of Evidence ◽

Shockwave Therapy ◽

High Level

Background: Achilles tendinopathy (AT) is a common cause of overuse injury in both athletes and nonactive individuals, especially at older ages. Due to the limited number of direct comparisons among interventions, determining the best treatment option can be difficult. Purpose: To evaluate the comparative efficacy and tolerability of nonsurgical therapies for midportion AT. Study Design: Systematic review; Level of evidence, 1. Methods: PubMed, MEDLINE, EMBASE, and Google Scholar were searched from database inception through June 20, 2019. Randomized controlled trials investigating the effect of nonsurgical therapies for midportion AT using the Victorian Institute of Sports Assessment–Achilles (VISA-A) assessment were eligible for inclusion. Primary outcome was mean change in VISA-A score from baseline. Comparisons between interventions were made through use of random-effects network meta-analysis over the short term (≤3 months) and longer term (>3 to <12 months). A safety profile was defined for each intervention by rate of all-cause discontinuation (dropout) during follow-up. Relative ranking of therapies was assessed by the surface-under-the–cumulative ranking possibilities. Results: A total of 22 studies with 978 patients met the inclusion criteria. In short-term studies, high-volume injection with corticosteroid (HVI+C) along with eccentric exercise (ECC) significantly improved the change of VISA-A score compared with that of ECC alone (standardized mean difference [SMD], 1.08; 95% CI, 0.58-1.58). Compared with ECC, acupuncture showed benefits over both the short term (SMD, 1.57; 95% CI, 1.00-2.13) and longer term (SMD, 1.23; 95% CI, 0.69-1.76). In longer-term studies, the wait-and-see approach resulted in unfavorable outcomes compared with ECC (SMD, −1.51; 95% CI, −2.02 to −1.01). Improvement was higher when ECC was combined with HVI+C (SMD, 0.53; 95% CI, 0.05-1.02) and extracorporeal shockwave therapy (ESWT) (SMD, 0.99; 95% CI, 0.48-1.49). All interventions had a similar safety profile. Conclusion: From available high-level studies, HVI+C and ESWT may be possible interventions to add along with ECC to improve longer-term outcomes.

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12 Identification of prognostic factors for patient outcomes during exercise intervention for achilles tendinopathy: a systematic review and meta-analysis

10.1136/bjsports-2018-099334.12 ◽

2018 ◽

Author(s):

Kenneth Färnqvist ◽

Amit Chauhan Anuj ◽

Dylan Morrissey ◽

Peter Malliaras

Keyword(s):

Systematic Review ◽

Prognostic Factors ◽

Patient Outcomes ◽

Exercise Intervention ◽

Meta Analysis ◽

Achilles Tendinopathy

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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

British Journal of Sports Medicine ◽

10.1136/bjsports-2019-101872 ◽

2020 ◽

pp. bjsports-2019-101872 ◽

Cited By ~ 3

Author(s):

Arco C van der Vlist ◽

Marinus Winters ◽

Adam Weir ◽

Clare L Ardern ◽

Nicky J Welton ◽

...

Keyword(s):

Systematic Review ◽

Exercise Therapy ◽

Randomised Controlled Trials ◽

Meta Analysis ◽

Achilles Tendinopathy ◽

Risk Of Bias ◽

Controlled Trials ◽

Wait And See ◽

Randomised Controlled

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.

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