What we do
About our project
Patients with Achilles tendinopathy assisted in the design of the study. They were involved in focus interviews, and a survey among patients was used to identify relevant outcomes. The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire was defined as primary outcome of this review, as the items measured in this questionnaire were regarded as most important for patients.
This living systematic review with network meta-analysis was prospectively registered. State-of-the-art methodology and guidelines were followed in the design phase. Multiple databases were searched up to February 2019. Large randomised clinical trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy were eligible. A number of treatment classes were pre-defined, which was based on the assumption that some treatments have a similar effect because of a comparable working mechanism. Reviewers independently extracted data and assessed risk of bias. Network plots were constructed using Stata software to visualise all head-to-head comparisons. Treatment-level and class-level models were fitted in a Bayesian framework using specific simulations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to appraise the quality of evidence.
Conclusions
In this living systematic review and network meta-analysis:
None of the trials were at low risk of bias
All evaluated treatments had large uncertainty in the estimates
Active treatment classes seemed to have patient-important benefits (mean difference exceeded the minimum important difference of 15 points on the VISA-A score) at 3 months compared to wait-and-see
For two classes (acupuncture therapy and shockwave therapy combined with exercise therapy), the credible intervals exceeded the minimum important difference of 15 points on the VISA-A score at 3 months. However, these results were based on two small at high risk of bias. There were no estimates for effectiveness of wait-and-see at 12 months
The effectiveness of most active treatments in the long term is uncertain. At 12 months, there was no difference between exercise therapy, injection therapies and combined therapies
Clinical implications
Wait-and-see should not be recommended as strategy for Achilles tendinopathy
Active treatments had overlapping comparative effects, leaving uncertainty about which treatment is best for Achilles tendinopathy
Shared decision making between healthcare providers and patients therefore plays an important role in the choice of treatments. Preferences of patients, safety profile, availability of the treatment, and costs should be taken into account in this clinical decision-making process
Clinicians should consider starting with calf-muscle exercise therapy as initial treatment. Calf-muscle exercise therapy may be easy to prescribe because it is easy to instruct, it is suggested to be cheap, is available everywhere and has a low risk of harm.
Funds & Grants
Collaborations
- Patients who suffered self- reported Achilles tendinopathy
- Aspetar Orthopaedic and Sports Medicine Hospital
- Aalborg University, Centre for General Practice, Aalborg, Denmark
- Karolinska Institute, Division of Physiotherapy, Stockholm, Sweden
- Bristol Medical School, Population Health Sciences, Bristol, United Kingdom
Our team
Team Members
- M. Winters
- C.L. Ardern
- N.J. Welton
- D.M. Caldwell
- J.A.N. Verhaar
- A. van der Vlist
