Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies

Abstract

ObjectivesWe performed a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to provide insights into the effectiveness of available treatment modalities in patellar tendinopathy(PT).MethodsSeveral databases were searched in May 2021 for RCTs assessing the effectiveness of any intervention compared with any other intervention, placebo or no treatment for pain and/or function in PT. The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE (Grading of Recommendations, Assessment, Development and Evaluations)/GRADE-NMA tools.ResultsA total of 37 RCTs were eligible that assessed 33 different interventions and their combinations, most represented by single studies. Based on pairwise meta-analyses of two RCTs, extracorporeal shockwave therapy (ESWT) does not appear to be superior to sham ESWT (eccentric exercise in both groups) for short-term pain (mean differences (MD) +0.1, 95% CI (−0.8 to 1), p=0.84) or function (MD −1.8, 95% CI (–8 to 4.4), p=0.57). Based on a pairwise meta-analysis of three RCTs, isometric exercise appears as effective as isotonic exercise for immediate postintervention pain relief (MD −1.03, 95% CI (−2.6 to 0.5), p=0.19). Our NMA showed that topical glyceryl trinitrate (GTN) and hyaluronic acid injection, both combined with eccentric exercise and moderate, slow resistance exercise had the highest probability of being the most effective interventions (low/very low strength of evidence).ConclusionsPromising interventions with inadequate evidence, such as topical GTN, hyaluronic acid injections and isometric and slow resistance exercise, should be further investigated through high-quality RCTs. Meanwhile, eccentric loading with or without adjuncts should remain the first-line treatment for all individuals with patellar tendinopathy.

Knee Extensor Mechanism Tendinopathy: Evaluation, Treatment, and Prevention

“…Current expert consensus is to use focused ESWT over a discrete area of tendinopathy with radial ESWT over associated structures and myofascial trigger points (42,44,45). A protocol consisting of three weekly sessions (2000 to 3000 shocks), between 3 and 4 bars of pressure (to pain tolerance) at an average frequency of 1 to 4 Hz (36,39,40) is currently best practice.…”

Nearly half of patients with chronic tendinopathy may have a neuropathic pain component, with significant differences seen between different tendon sites: a prospective cohort of more than 300 patients

“…10 For patients who fail to improve with rehabilitation alone, many treatment options are available to treat different tendinopathies, with many of the same treatments being offered to tendon pathologies of different anatomical locations. [11][12][13] These different treatments may conceptually address nociceptive pain and/or functional impairments, although any molecular or structural effects of these interventions may remain unclear. 14 Depending on the tendon location, these treatments may include tension night splints (TNS), [15][16][17] guided injections-including high-volume image-guided injections (HVIGI) [18][19][20] or autologous blood injections (ABI), [21][22][23][24] extracorporeal shock wave therapy (ESWT) [25][26][27][28][29] or surgery in recalcitrant cases.…”

“…For patients who fail to improve with rehabilitation alone, many treatment options are available to treat different tendinopathies, with many of the same treatments being offered to tendon pathologies of different anatomical locations 11–13. These different treatments may conceptually address nociceptive pain and/or functional impairments, although any molecular or structural effects of these interventions may remain unclear 14.…”

Inertial Flywheel Resistance Training in Tendinopathy Rehabilitation: A Scoping Review

“…25 Traditional eccentric training has been the gold standard first-line management approach for tendinopathies for the last two decades, due to its documented beneficial clinical effects for both upper and lower limb tendinopathies. 26,27 Despite the largest body of evidence existing for eccentric training, heavy slow resistance training (HSRT) involving both concentric and eccentric actions has been shown to have comparable positive clinical outcomes. 28,29 Due to these findings, some experts have suggested there is no scientific rationale for eliminating concentric actions in tendinopathy rehabilitation, with IFRT a potentially efficacious rehabilitation method due to having both a concentric and eccentric overload component and therefore requiring less overall training exposure, which may improve adherence.…”