Accepted Article

DR ADAM B. ROSEN (Orcid ID : 0000-0002-1204-2289)

Article type : Review Article

Clinical Management of Tendinopathy: A Systematic Review of Systematic Reviews Evaluating

the Effectiveness of Tendinopathy Treatments

Running Title: Effectiveness of Tendinopathy Treatments

Alyssa Irby, School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE

Jacqueline Gutierrez, School of Health and Kinesiology, University of Nebraska at Omaha, Omaha,
NE

Claressa Chamberlin, School of Health and Kinesiology, University of Nebraska at Omaha, Omaha,
NE

Stephen J. Thomas, Department of Health and Rehabilitation Sciences, Temple University,

Philadelphia, PA

Adam B. Rosen*, School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE

Acknowledgments
The authors report no conflicts of interest or funding sources related to this project.

*Corresponding Author:
Adam B. Rosen, PhD, ATC

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/SMS.13734
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 School of Health and Kinesiology
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College of Education
University of Nebraska at Omaha
6001 Dodge Street, Omaha, NE 68182
Phone number: (402) 554-2670
Fax: (402) 552-3693
Email: arosen@unomaha.edu

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 Abstract
Accepted Article
While the pathoetiology is disputed, a wide array of treatments are available to treat tendinopathy.
The most common treatments found in the literature include therapeutic modalities, exercise
protocols, and surgical interventions, however their effectiveness remains ambiguous. The purpose of
this study was to perform a systematic review of systematic reviews to determine the ability of
therapeutic interventions to improve pain and dysfunction in patients with tendinopathy regardless of
type or location. Five databases were searched for systematic reviews containing only randomized
control trials to determine the effectiveness of treatments for tendinopathies based on pain and
patient-reported outcomes. Systematic reviews were assessed via the Assessment of Multiple
Systematic Reviews (AMSTAR) for methodological quality. From the database search, 3,295 articles
were found, 107 passed the initial inclusion criteria. After further review, 25 systematic reviews were
included in the final qualitative analysis. The AMSTAR scores were relatively high (8.8±1.0) across
the 25 systematic reviews. Eccentric exercises were the most common and consistently effective
treatment for tendinopathy across systematic reviews. Low-level laser therapy and extracorporeal
shockwave therapy demonstrated moderate effectiveness, while platelet-rich plasma injections
demonstrated inconclusive evidence on their ability to decrease tendinopathy related pain and
improve function. Corticosteroids also showed some effectiveness for short-term pain, but for the
long-term use deemed ineffective and at times contraindicated. Regarding surgical options, minimally
invasive procedures were more effective compared to open surgical interventions. When treating
tendinopathy regardless of location, eccentric exercises were the best treatment option to improve
tendinopathy related pain and improve self-reported function.
Key Terms: Tendinopathy; eccentric exercises; treatment; VAS scores

Introduction
Tendinopathy is among the most common musculoskeletal conditions within physically active
populations.1, 2 Patients with tendinopathy often report mild to moderate persistent symptoms that
disrupt physical activity and decrease quality of life.3-6 The onset and pathoetiology of tendinopathy is
disputed, however it is often characterized by failed healing and degeneration of tendon tissue.7
Many believe the primary cause of tissue degeneration is due to mechanical overload without

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 adequate recovery that causes a tensile failure and strain of the collagen fibers within the tendon.8,9
Accepted Article
During physical activity, repetitive contraction of the muscle precipitates persistent micro-trauma of
tendons that then lack appropriate recovery time due to slow collagen turnover.10 Overtime this may
lead to significant degenerative changes that present clinical symptoms upon evaluation.
Although tendinitis usually occurs with an initial inflammatory response, most chronic
tendinopathies are often devoid of inflammation.11 When viewed both macro and microscopically, the
affected areas of the tendons’ collagen fibers are seen to be thinner, disorganized, and with associated
fibrosis.12,13 Injured tendons have also been shown to have a larger concentration of type III collagen,
as opposed to healthy tendon tissue which is comprised of mainly type I collagen.14 At the cellular
level, changes occur including hyper-cellularity characterized by cell proliferation and increased
fibroblast activity.15,16 Neovascularization commonly seen in rheumatoid arthritis and osteoarthritis
can also observed in imaging.12,17-19 The cell proliferation and neovascularization suggest an attempt
of the tendon to heal itself, with a lack of an inflammatory response.20,21 This pathogenesis makes it
difficult for clinicians to effectively treat tendons.
While many treatments have been explored to improve and standardize treatment protocols,
the best interventions to improve patient outcomes in those with tendinopathy is still unknown. These
protocols include treatments ranging from cellular level treatments such as injection therapies to
physical rehabilitation exercises.22 Due to the variety of treatments, there are many factors that need
to be considered when determining the appropriate course of intervention. Treatments vary depending
on a number of issues including severity, compliance, pain and duration of symptoms. Traditionally,
conservative treatment involves a battery of interventions including rest, cryotherapy, therapeutic
exercise and modalities.23 Surgical interventions may be appropriate for more advanced and severe
tendonopathies. However, there is a lack of consensus across the literature despite several high-
quality systematic reviews. Therefore, the purpose of this study was to perform a systematic review
of systematic reviews to determine the best therapeutic interventions and their ability to improve pain
and dysfunction in patients with any type of tendinopathy.

Methods
Search Methods

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 Three investigators performed a systematic search of the literature in PubMed, EMBASE,
Accepted Article
CINAHL, Physiotherapy Evidence Database (PEDro), and the Cochrane Database. The search terms
used included: (systematic review[Title/Abstract])) AND ((tendinopathy[Title/Abstract]) OR
tendinitis[Title/Abstract]). The search was completed on each of the databases from inception to
February 1, 2020. During the initial searches, the titles and abstracts were reviewed to ensure that they
fit the inclusion and exclusion criteria. Of the remaining articles, full-texts were acquired and
independently evaluated by three authors to determine their ability to meet inclusion and exclusion
criteria. All disagreements were then discussed with additional authors until a consensus was reached.
Duplicates were removed manually. The reference lists of all included articles were also manually
searched by the authors to find additional texts that were not produced by the original searches.
Selection of Studies
Systematic reviews were included if they were (1) a systematic review that used randomized
control trials (RCTs) to evaluate the effectiveness of treatments for tendinopathy; (2) the treatment for
tendinopathy was monitored by a patient-reported outcome (e.g. Victorian Institute of Sport
Assessment (VISA) score, Pain scales, etc.); (3) written in English and (4) published in a peer-
reviewed journal. Systematic reviews were included regardless of tendinopathy type or location.
Systematic reviews were excluded if they evaluated study designs other than RCTs, if they included
other pathologies in addition to tendinopathies, or if they did not include any type of tendinopathy as
the primary pathology. Studies were also excluded if they assessed pharmacological agents such as
non-steroidal anti-inflammatory drugs (NSAIDs). Demographic characteristics (e.g. age, sex, etc.)
were not determining factors for included studies.

Data Extraction and Data Analysis

Data was extracted from each study by two independent authors including the author list,
publication year, title, possible conflicts of interest, number and publication dates of primary studies,
inclusion and exclusion criteria, sample sizes, tendinopathy type, primary and secondary outcome
measures, and the major results. Based on this data, a descriptive analysis of each manuscript was
conducted to identify the effectiveness of treatment and interventions at improving patient-reported
outcomes based on the included systematic reviews.

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Accepted Article
Internal Validity and Primary Overlap
The Assessment of Multiple Systematic Reviews (AMSTAR) was used to determine the
internal validity of each systematic review. The AMSTAR is a tool used for measurement of both
reporting techniques and the level of methodological quality for systematic reviews. The maximum
score on the AMSTAR is an 11.24-26 AMSTAR scores were categorized as 0-4=low, medium=5-8, and
high=9-11.27 Articles were evaluated independently by two authors and any disputes were settled with
a third author via consensus. To assess primary overlap between studies the names and authors of
individual studies from the included systematic reviews were extracted. The corrected covered area
(CCA) was then calculated according to previous guidelines for the overall overlap across included
systematic reviews.28 CCA values of less than 5% indicate minimal overlap while values of greater
than 15% indicate high overlap.28

Results
The flow diagram (Figure 1) outlines the entire search process. There was significant overlap
across the four databases searched and a large portion of studies were excluded after title and abstract
review. From the full-text search, the majority of studies were excluded for at least one of the; 1)
systematic reviews included articles other than RCTs, 2) other pathologies were included or
tendinopathy was a secondary pathology evaluated, and 3) Pain or PROs were not directly assessed. A
total of 25 systematic reviews assessing 228 RCTs and enrolling over 15000 patients met all inclusion
criteria and were included in the study (Table 1).29-53 The CCA was 1.14% indicating minimal overlap
across the 25 included systematic reviews. Of the 228 individual studies across the 25 systematic
reviews, 173 were unique, 38 were repeated in 2 primary reviews, while 6 were repeated in 3 primary
reviews, 4 were repeated in 4 primary reviews, 5 studies were repeated in 5 primary reviews, and 1
was repeated in 7 primary reviews (Supplementary Data File 1).
Study Design Characteristics of included Systematic Reviews
All systematic reviews included in the current study utilized PubMed/Medline to search for
their included literature. Several of the other common databases used by the systematic review
authors included: Embase (n=23), Cochrane Library (n=16), Cinahl (n=16), and PedRo (n=7). While

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 there was limited congruency in the databases used, the number of databases searched ranged from 2-
Accepted Article
11, offering significant variety in search procedures and data extraction. There were between 2 and 41
(mean±SD=12.6±9.5) randomized control trials that made up the primary data extracted from the 25
systematic reviews. The 25 included systematic reviews primarily assessed treatment effectiveness
for patient populations with Achilles (n=12),29,30,33,34,36,41-43,47-49,53 lateral elbow (n=11),32-
34,36,38,40,41,43,47,50,52 patellar (n=12),29,33-37,41,44,46,47,50,51and rotator cuff (n=10)29,31,34,36,39,41,44,45,47,50
tendinopathy.
Patient-reported outcomes varied across the included systematic reviews. The majority of the
systematic reviews used a visual analogue scale (VAS) for pain (n=22).29,31-47,49-52 While, the most
common patient reported outcomes included were the Victorian Institute Assessment-Patella
(n=10),29,33-37,41,46,50,51 Disabilities of the Arm, Shoulder, and Hand Score (n=6),38,40,41,44,47 36 Victorian
Institute Assessment-Achilles (n=5), 30,36,41,48,53 University of California Los Angeles (UCLA)
Shoulder Rating Scale (n=4)31,33,39,45, and Patient Rated Tennis Elbow Evaluation (n=6)29,33,41,43,47,50.
Treatments for Tendinopathy Results
Treatments evaluated across the included systematic reviews included eccentric exercise,
surgical interventions, low-level laser therapy (LLLT), dry needling, topical glyceryl trinitrate,
extracorporeal shockwave therapy (ESWT), corticosteroids, night splints, platelet rich plasma therapy
(PRP), therapeutic ultrasound, iontophoresis and ultrasound-guided lavage. Specific comparisons
made by each investigation can be found in Supplementary Data File 2. The majority of studies found
the treatment(s) studied were relatively effective in treating tendinopathy as assessed by pain and
patient-reported outcomes.29-32,34-37,40-52,54
Overall, exercise therapies particularly eccentrics appeared to be the most consistently
effective treatment across all tendinopathies.42,48,49,51 One review found eccentric exercises to be
effective both as their own treatment and in conjunction with ESWT in lateral elbow tendinopathy.52
When eccentric exercise was paired with a heel brace, it did not provide any further benefit for
patients with Achilles tendinopathy.49 One study addressed the potential for selection bias and
identified the possibility that eccentric exercise is more beneficial for athletic populations than non-
athletic populations with Achilles tendinopathy.42 Kingma et al. found that eccentric overloading in
patients with chronic Achilles tendinopathy resulted in 29-94% decrease in pain intensity, while

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 Sussmilch- Leitch et al. found that patients had additional benefits in decreasing pain when
Accepted Article
performing eccentric exercises with laser treatment.42,49 Murphy et al. found that heavy eccentrics
may be better compared to traditional physiotherapy in patients with Achilles tendinopathy.48
Sussmilch-Leitch et al. also found evidence to show ESWT as an alternative treatment method to
eccentric exercises in Achilles tendinopathy, both decreased pain similarly on patient-reported
outcomes.49 Similarly, Lee et al. and Bannuru et al. demonstrated improvements in pain and function
in patients with chronic calcific rotator cuff tendinitis when treated with ESWT.31,45
Multiple studies demonstrated LLLT as an effective intervention to improve pain and
function.32,39,49 Evidence showed positive results after utilizing LLLT along with exercise and
stretching regimens for lateral elbow tendinopathy.32 Bjordal et. al. found that using LLLT at 904 nm
wavelength decreased pain significantly on a VAS.32 However, Desmeules et al. found that
therapeutic ultrasound demonstrated no improvements in pain or function and is not effective
treatment for rotator cuff tendinopathy.39
Injection and needling procedures revealed mixed results. Krey et al. demonstrated tendon
needling alone produced reductions in pain and improvements in function for Achilles, lateral elbow,
and rotator cuff tendinopathy.43 PRP provided the most conflicting evidence with some systematic
reviews showing benefits while others showed no effect on tendinopathy patients.29,35,36,38,47,50,51,53 For
chronic lateral epicondyle tendinopathy, de Vos et al. one study supporting PRP use, but the evidence
for its effectiveness was poor in patients with lateral elbow tendinopathy.38 Whereas, Miller et al.
found that PRP decreased pain in patients with symptomatic lateral elbow tendinopathy and that it
may be more effective in women.47 In patients with chronic Achilles tendinopathy, PRP did not
improve function compared to saline injections.53 However, leukocyte rich PRP showed promise over
non-specified or leukocyte-poor PRP regardless of location of the tendinopathy.35,41 When compared
to dry-needling or placebo, PRP showed slightly greater improvement in function and pain regardless
of location.50 For short-term use corticosteroids were deemed moderately effective and may show
greater benefits when combined with ultrasound-guided lavage.36,44 Comparatively, for long-term use
they are ineffective and potentially contraindicated.32 For lateral epicondyle tendinopathy, alternative
injection therapies (scelerosing, prolotherapy and sodium hyaluronate) may provide benefits, but
more research is needed.36,40

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 Surgical approaches for more advanced tendinopathies may be warranted, but they showed
Accepted Article
mixed results in improvements in both function and pain.30,33,37 Baltes and colleagues, found evidence
to support minimally invasive and endoscopic procedures when compared to open surgical procedures
in patients with Achilles tendinopathy.30 Baltes et. al. demonstrated moderate to excellent success
rates for a variety of surgical types including autologous tendon transfer (86%), open surgery:
gastrocnemius lengthening (92.3%), endoscopic procedures (73-100%), and minimally invasive
tendon stripping/tenotomies (69-100%).30 In contrast, Challoumas and colleagues found that surgery
was no better than sham surgery at improving pain and function in a variety of tendinopathy
locations.33 For patellar tendinopathy specifically, Dan et al. found arthroscopic surgical outcomes
were better than sclerosing injections, but open surgical interventions were no better at improving
outcomes when compared to eccentric exercise.37

Study Reporting and Quality Assessment (Validity)

Table 2 summarizes the AMSTAR results for each of the included systematic reviews. The
AMSTAR scores were relatively high (8.8±1.0) and consistent across included systematic reviews.
All 25 studies included a comprehensive literature search, addressed the scientific quality of each
included study, used the scientific quality in an appropriate manner, and used the appropriate methods
for assessing their data.

Discussion
The purpose of this study was to comprehensively assess the effectiveness of treatment
options for tendinopathies and systematically compile best practice techniques for treating
tendinopathies. This systematic review of systematic reviews showed evidence to support a variety of
conservative methods to treat tendinopathy. Strong, consistent findings suggest that eccentric
exercises are the most effective treatment option for tendinopathies, particularly heavy eccentrics
when compared to a variety of modalities and other exercise regimens.42,48,49,51 Other modalities
showing moderate effectiveness to improve pain and function including ESWT and LLLT when
compared to sham treatments and other modalities.31,32,39,45,49 PRP demonstrated mixed results,

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 however leukocyte rich PRP showed promise to improve patient function when compared to other
Accepted Article
injection therapies.29,35,36,38,47,50,51,53 Corticosteroids may have benefits for short-term pain relief, but
appear ineffective long-term.36,38,40,44,52 For surgical options, minimally invasive options were more
effective compared to more invasive methods.30,33,37. Ineffective options to improve tendinopathy
related pain and function include night splints when compared to eccentric exercise and therapeutic
ultrasound when compared to placebo as well as other modalities.39,49 This systematic review of
systematic reviews may have significant implications on the clinical treatment of tendinopathy.
The quality of evidence based on AMSTAR scores ranged from 7-11 and demonstrating
medium (n=8, 32%) to high (n=17, 68%) quality. From the 25 included systematic reviews, there
were differences in both the types of tendinopathies treated and the type of treatment interventions
assessed. In terms of reporting, all 25 articles performed a comprehensive literature search, addressed
the scientific quality of the included studies and then appropriately used them in formulating
conclusions after using appropriate methods to combine the findings of their studies. Whereas the two
most common missing items from studies were an a priori design and the status of grey literature,
reported in 16.0% and 33.3% of systematic reviews, respectively. As the AMSTAR scores were
relatively high, the included systematic reviews demonstrated relatively low bias and demonstrated
adequate internal validity.
While there is a consensus reached by this review, this assessment is not without limitations.
One limitation that arose was the limited inclusion of outcome measures. The current review only
assessed interventions and their effect on patient reported outcome measures of pain and disability,
rather than biological and clinical markers of tendon healing. These measures are usually less
subjective than patient-reported outcome measures, which rely on patients’ perceptions of pain and
self-reported function. A second limitation present in this study is that all tendinopathy types were
included giving this review a broad spectrum for treatment options and leading to a less focused
review. However, this can also be considered a strength as the approach incorporated a wide range of
systematic reviews to come to a more overarching conclusion for the treatment for tendinopathies.
While previous systematic reviews produce conclusions depending on individual pathologies for each
joint or body part, this systematic review produced a conclusion on the pathology as a whole. A
further limitation was the strict inclusion of randomized control trials. This limited the inclusion of

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 some treatment modalities which have not been assessed with as rigorous of research designs, such as
Accepted Article
joint mobilizations.55 In addition, the majority of included studies identified adult patients,
adolescents and children may respond differently.54
Perspective
In conclusion, this systematic review of systematic reviews demonstrates that the best
treatment option for tendinopathy is eccentric exercises, especially when combined with the use of
other therapeutic modalities. While positive improvements were found across the treatment
interventions, mixed and inconclusive evidence was still pervasive despite an expansive systematic
review. Further high-quality research needs to be conducted to compare interventions, as well as on
different types of tendinopathies to improve clinical outcomes in this population.

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Table 1: Summary of qualitative data from each individual systematic review (n=25) included from the systematic search of the literature.
Databases Searched Inclusion Criteria Included studies Outcome Measures of Directions of Findings
Authors, Year, (n) patient totals Included studies
Title

Balasubramaniam 1. EBSCO 1. Patients 9 RCTs 1. Visual Analog Scale for 1. PRP was an effective
et al 2015 2. Medline diagnosed with pain course of treatment for
3. Cochrane tendinopathy 494 total patients 2. Shoulder Pain and patellar and lateral
Efficacy of 4. Ovid 2. Patients treated with Achilles, Disability Index epicondylar
platelet-rich 5. Embase with either PRP Lateral 3. Victorian Institute of tendinopathy in the
plasma injections or a control Epicondyle, Sport Assessment- short term.
in pain associated 3. Randomized Patellar or Achilles 2. Evidence found was
with chronic control trials Rotator Cuff 4. Western Ontario conflicting, with some
tendinopathy: A Tendinopathy Rotator Cuff Index supporting use and
systematic review 5. Victorian Institute of others with no effect.
Sport Assessment-
Patella
6. Patient-Related Tennis
Elbow Evaluation

Baltes et al. 2017 1. Medline 1. Surgical 23 RCTs 1. Patient Satisfaction 1. Large variation in
2. Embase Treatment for 2. Complication Rates surgical techniques
Surgical 3. Cochrane Midportion 1177 Total 2. Minimally invasive
treatment for Achilles Patients with procedures have lower
midportion Tendinopathy Achilles complication rates
Achilles 2. Assessed an Tendinopathy
tendinopathy: a outcome
systematic measure of
review. patient
satisfaction or
complication
rates
3. Written in
English, French
or German

Bannuru et al. 1. Medline 1. Randomized 28 RCTs 1. Visual Analog Scale 1. High energy
2014 2. Cochrane control trials. for pain Extracorporeal Shock
3. EMBASE 2. Humans with 1307 Total 2. Constant-Murley Score Wave Therapy was
High-Energy 4. Web of Science shoulder Patients with 3. Range of moation effective in treating
Extracorporeal 5. Google Scholar calcific and Shoulder 4. Shoulder Pain and calcifications in
Shock-Wave Tendinopathy Disability Index shoulder tendinitis.
Therapy for non-calcific 5. UCLA Shoulder 2. Low energy
Treating Calcific tendinitis. Rating Scale Extracorporeal Shock
Tendinitis of the 3. Clinical, Wave Therapy was not
Shoulder radiological, as effective as high
diologic, or energy Extracorporeal
sonographic Shock Wave Therapy .
outcomes.
Bjordal et al. 1. Medline 1. Diagnosis of 13 RCTs 1. Visual Analog Scale for 1. Low-Level Laser
2008 2. Embase Lateral Elbow pain Therapy is safe and
3. Cochrane Tendinopathy 730 Total 2. Global Health Status effective
A systematic 4. CINAHL 2. Low- Level Patients with 2. Low-Level Laser is
review with 5. PedRo Laser Treatment Lateral Elbow dose-dependent and
procedural 3. Randomized Tendinopathy modulates tendon
assessments and Control or inflammation and
meta-analysis of Crossover Trial repair processes
low-level laser 4. Blinding of 3. Long-term,
therapy in lateral outcome corticosteroids
elbow assessors injections are worse
tendinopathy than placebo
(tennis elbow). 4. Low-Level Laser is
better alternative for
treating lateral elbow
pain than
corticosteroid
injections and NSAIDs
5. Low-Level Laser
should be combined
with exercise and
stretch regimens
Challoumas et al. 1. Medline 1. Randomized 10 RCTs 1. Visual Analogue Scale 1. Good evidence for the
2019a 2. Embase Control Trials for pain effectiveness of
3. Scopus 2. Compared 584 Total 2. Victorian Institute of glyceral trinitrate in
Topical glyceryl 4. CINAHL effects of Patients with Sport Assessment- short and immediate
trinitrate for the topical glyceral Achilles, Lateral Patella term treatment of
treatment of trinitrate with Epicondyle, 3. 5-point pain scale tendinopathy.
tendinopathies: a placebo or other Patellar or 2. Use of topical GTN
systematic review treatment on Rotator Cuff should be considered
tendinopathy Tendinopathy for all chronic
tendinopathies.
Challoumas et al 1. Medline 1. Randomized 12 RCTs 1. Neer shoulder score 1. Surgery did not
2019b 2. Embase control trials 2. Visual analog scale for provide better results
3. Scopus pain than sham surgery
How does 4. CINAHL 2. Patients with 1051 Total 3. Orthopaedic Research
surgery compare diagnosed Patients with Institute Tennis Elbow
to sham surgery tendinopathies Achilles, Lateral Testing System
or physiotherapy 3. Compared Epicondyle, or 4. UCLA Shoulder
as a treatment for surgery to other Patellar Rating Scale
tendinopathy? A non-surgical Tendinopathy 5. Oxford Shoulder Score
systematic review management 6. Strengths and
of randomized procedures Difficulties
trials 4. Identified Questionnaire
outcomes in 7. Equro Quality of Life
terms of pain, Visual Analog Score
function, ROM, 8. Victorian Institute of
force/strength, Sport Assessment-
patient Patella
satisfaction, 9. Likert based scale for
treatment pain
success, quality
of life, and
complications
Chen et al. 2019 1. Central 1. Randomized 11 RCTs 1. Victorian Institute of 1. Leukocyte Rich-
2. Medline control trials Sport Assessment- Platelet Rich Plasma
Comparative 3. Embase 2. Patients with 420 Total Patella provided the most
Effectiveness of 4. Web of Science clinically or Patients with 2. Visual Analog Scale pain reduction, but
Different 5. Physiotherapy image Patellar for pain there is a chance of
Nonsurgical Evidence diagnosed Tendinopathy 3. Numeric Rating Scale bias with the results.
Treatments for Database patellar
Patellar 6. SPORTDiscus tendinopathy
Tendinopathy: A
Systematic
Review and
Network Meta-
analysis
Coombes et al. 1. Medline 1. Comparison of 41 total RCTs 1. Visual Analogue Scale 1. Corticosteroid
2010 2. Cinahl peritendinous for pain injections are effective
3. Embase injections with >2300 patients, 2. Numerical rating scale in the short term.
Efficacy and 4. Web of placebo or other patients per RCT for pain 2. Non-corticosteroid
safety of Knowledge intervention. not reported for 3. Patient perceptions of injections (Sclerosing,
corticosteroid 5. Allied 2. Patients with any every trial in change platelet-rich plasma,
injections and 6. and form of patients with 4. Disabilities of the Arm, prolotherapy or sodium
other injections Complementary tendinopathy. Achilles Shoulder and Hand hyaluronate) might be a
for management Medicine Tendinopathy, 5. Shoulder Pain and benefit for long-term
of tendinopathy: 7. SPORTDiscus Lateral Disability Index
a systematic 8. Cochrane Epicondyle, 6. Patient rated forearm treatment of lateral
review of Controlled Trial Medial evaluation epicondylalgia.
randomised Register Epicondyle, questionnaire
controlled trials. 9. PEDro Patellar or 7. Patient Global
Rotator Cuff Impression of Change
Tendinopathy 8. American Shoulder and
Elbow Surgeons
9. Oxford Shoulder Score
10. Victorian Institute of
Assessment-Patella
11. Victorian Institute of
Assessment-Achilles

Dan et al. 2019 1. Cochrane Central 1. Adults with 2 RCTs 1. Visual analogue scale 1. Arthroscopic surgery
Register of patellar for knee pain improved pain levels,
Surgical Controlled Trials tendinopathy. 92 Total patients 2. Victorian Institute of when compared to
interventions for (CENTRAL) 2. Comparison of with Patellar Sport Assessment- sclerosing injections.
patellar 2. Ovid MEDLINE surgical Tendinopathy Patella 2. Surgery may still be
tendinopathy 3. Ovid Embase. techniques both 3. Overall quality of life necessary if
open and score conservative
arthroscopic and techniques are
compared with exhausted.
placebo, exercise
or modality.
de Vos et al. 1. PubMed 1. Patients with 6 RCTs 1. Visual analogue Scale 1. Only one study showed
2014 2. EMBASE chronic lateral for pain positive effects of
3. CINAHL epicondyle Patients per RCT 2. Disabilities of the Arm, platelet-rich plasma
Strong evidence 4. Medline OvidSP tendinopathy. not reported Shoulder and Hand compared to
against platelet- 5. Scopus 2. Interventions of range of each 3. Liverpool elbow score corticosteroid
rich plasma 6. Google Scholar platelet-rich RCT was 4. The Patient-Rated injections.
injections for 7. Web of Science plasma reported as 13- Elbow Evaluation 2. There is not strong
chronic lateral 8. Cochrane Library injection. 115 per trial with evidence to show the
epicondylar 3. Outcomes had Lateral effect of treating lateral
tendinopathy: a to measure pain Epicondyle epicondylitis with
systematic and/or function. Tendinopathy platelet rich plasma.
review.
Desmeules et al. 1. PubMed 1. Patients with 11 RCTs 1. Visual Analogue Scale 1. Ultrasound therapy is
2015 2. PEDro rotator cuff for pain not better than a
3. CINAHL tendinopathy. 792 Total patients 2. Pain index score placebo, there was no
The efficacy of 4. EMBASE 2. Ultrasound or with Rotator Cuff 3. UCLA shoulder rating added benefit when
therapeutic ultrasound Tendinopathy score added to exercise.
ultrasound for combined with
rotator cuff other 2. Laser therapy may
tendinopathy: A interventions provide more benefit
systematic review compared to than US for pain
and meta-analysis placebo or other reduction.
treatments.

Dong et al. 2016 1. MEDLINE 1. Adults with 27 RCTs 1. Disabilities of the arm, 1. Botulinum toxin (BT),
2. EMBASE lateral shoulder, and hand platelet-rich plasma
Injection 3. Cochrane Central epicondylalgia 1965 Total 2. Visual Analog Scale therapy, and
therapies for Register of 2. Minimum of patients with for pain autologous blood
lateral Controlled Trials two injections Lateral 3. Numerical Rating (AB) injections are
epicondylalgia: a (CENTRAL) 3. Outcome Epicondylitis Scale recommended for
systematic review measures of 4. Likert scale 0-10 immediate-term
and Bayesian pain or function effects of lateral
network meta- epicondylalgia
analysis 2. Corticosteroid
injection is not
recommended.
3. Hyaluronate injections
and prolotherapy need
more evidence before
their effectiveness can
be determined.
Fitzpatrick et al. 1. PubMed 1. Adult patients 18 RCTs 1. Patient Rated Tennis 1. Strong evidence that
2017 2. EMBASE who received Elbow Evaluation leokocyte rich-
3. CINAHL Platelet Rich- 1146 Total 2. Visual analogue scale platelet-rich plasma
The Effectiveness 4. Medline Plasma patients with for pain improves outcomes in
of Platelet-Rich Injections. Achilles, Lateral 3. Victorian Institute of tendinopathy.
Plasma in the 2. Trials assessing Epicondyle, Sport Assessment- 2. Technique for
Treatment of surgery or non- Patellar, or Achilles injection of Leukocyte
Tendinopathy: A tendon injuries Rotator Cuff 4. Disabilities of the Arm, Rich- platelet-rich
Meta-analysis of were excluded. Tendinopathy Shoulder, and Hand includes use of 1-2mL
Randomized 3. Injections of 5. Victorian Institute of local anesthetic first.
Controlled any autologous Sport Assessment-
Clinical Trials blood product Patella
regardless of 6. Modified Mayo Clinic
dosage, volume, Performance Index for
or number of the Elbow
injections. 7. Shoulder Pain and
Disability Index
8. Nirschi
 9. Western Ontario
Rotator Cuff Index
Kingma et al. 1. CINAHL 1. Diagnosis of 9 RCTs 1. Foot and Ankle 1. Eccentric training
2007 2. PubMED Achilles Outcome Score shows promising
3. Medline Tendinopathy 484 Total patients 2. Visual Analog Scale for results
Eccentric 4. Cochrane 2. Randomized with Achilles pain 2. Magnitude of results
overload training 5. EMBASE Control Trial 3. Ordinal Scale can not be determined
in patients with 6. PedRo 3. Eccentric 3. Eccentric exercise may
chronic Achilles 7. Google Scholar Overload not be as effective in
tendinopathy: a Training non-athletic
systematic review 4. Patient Oriented populations
Outcome
Measure
5. Dutch or English
Language
6. Full Text
7. Peer Reviewed
Krey et al. 2015 1. Medline 1. Level I or Level 4 Random 1. Visual Analog Scale for 1. There are benefits
2. Cochrane II evidence Control Trials pain from tendon needling
Tendon needling 2. Dry Needling 2. Shoulder Pain and based on patient
for treatment of 3. Needling 452 Total patients Disability Index oriented outcomes
tendinopathy: A Tendons with Achilles, 3. Patient Related Tennis
systematic review 4. Needle Lateral Elbow Evaluation
Fenestration Epicondyle, or
5. Tendon Rotator Cuff
Fenestraton Tendinopathy.
Lafrance et al 1. Medline 1. Randomized 3 RCTs 1. Visual Analog Scale 1. US-guided lavage can
2019 2. Embase control trials for pain be more effective in
3. Cochrane Central 2. Patients 226 Total patients 2. Western Ontario decreasing pain when
Is ultrasound- 4. CINAHL diagnosed with with Rotator Cuff Rotator Cuff Index combined with a
guided lavage an rotator cuff Tendinopathy 3. Disabilities of the arm, corticosteroid
effective tendinopathy Shoulder, and Hand injection than is
intervention for 3. Patients with 4. Constant-Murley Score shockwave therapy.
rotator cuff symptoms for
calcific 3-6 months
tendinopathy? A 4. Intervention
systematic review including US-
with a meta- guided lavage
analysis of with another
randomized intervention
control trials
 5. Treatment
compared with
a placebo
6. Use of at least
one POOM
7. Written in
English or
French
Lee et al 2011 1. Cochrane 1. Randomized 9 RCTs 1. Visual Analog Scale 1. Extracorporeal Shock
Controlled control trials for pain Wave Therapy could
The midterm Trials 2. Adults with 431 Total patients 2. UCLA Shoulder be an alternative to
effectiveness of Register chronic calcific with Rotator Cuff Rating Scale surgery for patients
extracorporeal 2. Medline rotator cuff Tendinopathy Recurrence of pain suffering from chronic
shockwave 3. CINAHL tendinitis of the 3. Constant-Murley Score calcific tendinitis
therapy in the 4. PubMed shoulder 4. Rest vs. activity
management of 5. EMBASE 3. Extracorporeal 5. Function
chronic calcific 6. Sports Discus Shock Wave
shoulder 7. PEDro Therapy as a
tendinitis treatment
4. Outcome
measures that
looked at pain
or shoulder
functional score
5. Follow up ≥ 6
months
Mendonça et al. 1. Medline 1. Randomized 9 RCTs 1. Visual analog scale for 1. Single studies showed
2019 2. EMBASE control trials pain iontophoresis and dry
3. Cochrane 2. Compared 339 Total patients 2. Victorian Institute of needling may reduce
How strong is the 4. PEDro conservative with Patellar Sport Assessment- short-term pain.
evidence that 5. SPORTDiscus treatment to Tendinopathy Patellar 2. Low evidence was
conservative 6. CINAHL minimal 3. Kujala scales produced to show that
treatment reduces 7. AMED intervention exercise improves
pain and function.
improves
function in
individuals with
patellar
tendinopathy? A
systematic review
of randomized
controlled trials
including
GRADE
recommendations
Miller et al. 2017 1. Medline 1. Random 16 RCTs 1. Visual Analog Scale 1. Platelet Rich Plasma
2. EMBASE Control Trials for pain Injection is successful
Efficacy of with 3-month 2. Patient Rated Tennis in patients with
platelet-rich follow up 998 Total patients Elbow Evaluation symptomatic
plasma injections 2. Evaluation of with Achilles, 3. Shoulder Pain and tendinopathy
for symptomatic Pain Reduction Lateral Disability Index 2. Platelet Rich Plasma
tendinopathy: Epicondyle, 4. American Shoulder and showed meaningful
systematic review Patellar, and Elbow Score improvements to
and meta-analysis Rotator Cuff 5. Disabilities of the Arm, patient symptoms and
of randomised Tendinopathy Shoulder, and Hand may be more effective
injection- Score in women.
controlled trials.

Murphy et al. 1. PubMed 1. Randomized 7 RCTs 1. Victorian Institute of 1. Heavy Eccentric Calf
2019 2. CINAHL (Ovid) control trials Sport Assessment- Training may be better
3. CINAHL 2. Exercise 241 Total patients Achilles than traditional
Efficacy of heavy (EBSCO) intervention with Achilles physiotherapy, but the
eccentric calf 4. OpenGrey with a control Tendinopathy evidence is low in
training for 5. Proquest or sham/placebo quality.
treating mid- 6. SPORTDiscus intervention
portion Achilles 3. Modified
tendinopathy: a version of
systematic review Heavy
and meta-analysis Eccentric Calf
Training
4. Published and
non-published
Sussmilch- 1. National Health 1. Diagnosis of 23 RCTs 1. Visual Analog Scale 1. Eccentric Exercise is
Leitch et al. 2012 and Medical Achilles for pain effective.
Research Council Tendinopathy 976 Total patients 2. American Orthopedic 2. Shock wave therapy
Physical 2. Medline 2. Random with Achilles Foot and Ankle Society and eccentric exercises
therapies for 3. EMBASE Control Trials Tendinopahy 3. Functional Index of the have similar effects
Achilles 4. Web of Science assessing non- Leg and Lower Limb 3. Laser therapy is more
tendinopathy: 5. CINAHL surgical, non- effective than a
systematic review 6. Proquest pharmacological placebo
and meta-analysis 7. Health and intervention 4. Night splints and
Medical Complete 3. Altered function eccentric exercises do
8. Australian associated with not increase benefits
Medical Index
 9. AUSPORT Achilles
Database Tendinopathy
10. PedRo
11. Clinical Evidence
Databases
Tsikopoulos et al. 1. PubMed 1. Compared 5 RCTs 1. Visual Analogue Scale 1. Slightly greater
2016 2. CENTRAL effects of for Pain clinical improvement
3. Web of Science platelet rich 342 Total patients 2. Patient-Related Tennis in function in platelet
The clinical 4. Scopus plasma versus a with Lateral Elbow Evaluation rich plasma therapy
impact of 5. ClinicalTrials.gov placebo or dry Epicondyle, 3. Nirschi Score compared to dry-
platelet-rich 6. Australian New needling. Patellar and 4. Shoulder Pain and needling and placebo
plasma on Zealand Clinical 2. Tendinopathy Rotator Cuff Disability Index in patients with rotator
tendinopathy Trials Registry diagnosis Tendinopathy. 5. Western Ontario cuff tendinopathy.
compared to 7. International confirmed with Rotator Cuff Index
placebo or dry Standard ultrasound or 6. Neer test
needling Randomized magnetic 7. Victorian Institute of
injections: A Controlled Trial resonance Sport Assessment-
meta-analysis Number Register imaging Patella
8. Tegner activity scale
9. Lysholm scale
Vander Doelen et 1. Medline 1. Randomized 9 RCTs 1. Visual analog scale for 1. Isometric exercises,
al. 2019 2. CINAHL control trials pain eccentric exercises,
3. Embase 2. Patients 336 Total patients 2. Victorian Institute of patellar strapping, dry
Non-surgical 4. Sportdiscus diagnosed with with Patellar Sport Assessment- needling, and certain
treatment of 5. Cochrane patellar Tendinopathy Patellar injections provided
patellar tendinopathy short term pain relief.
tendinopathy: A between Jan Long term relief was
systematic review 2012-Sept 2017 provided by Platelet
of randomized 3. Use of visual Rich Plasma
controlled trials analog scale injections, dry
(VAS) for pain needling, and
and an outcome eccentric exercises.
measure
Xiong et al. 2019 1. PubMed 1. Random 4 RCTs 1. Visual Analog Scale for 1. Both shock-wave
2. Medline Control Trials pain therapy and
Shock-wave 3. EMBASE 2. Minimum 12- 237 Total patients 2. Shortform McGill Pain corticosteroid
therapy versus 4. Cochrane week follow up with Lateral Questionnaire injections relieved
corticosteroid 5. SpringerLink 3. Patient Oriented Epicondyle 3. Upper Extremity pain and improved
injection on 6. Clinical Trials.gov Outcome Tendinopathy Functional Scalachille function.
lateral 7. OVID Measures 2. Better improvements
epicondylitis: a to visual analog scale
meta-analysis of and grip strength
randomized found in shockwave
controlled trials group.
Zhang et al. 2018 1. PubMed 1. Randomized 4 RCTs 1. Victorian Institute of 1. Platelet-rich plasma
2. Web of Science control trials Sport Assessment- injections did not
Is platelet-rich 3. EMBASE 2. Adults 170 Total patients Achilles score improve function or
plasma injection diagnosed with with Achilles alter the tendon
effective for Achilles Tendinopathy structure when
Chronic Achilles tendinopathy compared to saline
Tendinopathy? A 3. Compared PRP injection.
Meta-analysis with saline
injections
4. Use Victorian
Institute of
Sport
Assessment-
Achilles, score
tendon
thickness
change, color
doppler
activity, and
other functional
measures
Accepted Article
Table 2. AMSTAR Scores of included systematic reviews.

Balasubramaniam et al. 2015

Sussmilch- Leitch et al. 2012

Tsikopoulous et al. 2016

Challoumas et al. 2018

Challoumas et al. 2019

Fitzpatrick et al. 2017

Desmeules et al. 2015

Mendonca et al. 2019

Coombes et al. 2010
Coombes et al. 2010

Lafrance et al. 2019

Bannuru et al. 2014

Murphy et al. 2019

Kingma et al. 2007
Bjordal et al. 2008

Doelen et al. 2019

de Vos et al. 2014
Baltes et. al. 2017

Zhang et al. 2018

Miller et al. 2012

Xiong et al. 2019

Chen et al. 2019

Dong et al. 2016

Krey et al. 2015

Dan et al. 2019

Lee et al. 2011

AMSTAR criteria

Was an "a priori" design provided? 0 0 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0

Was there duplicate selection and 1 0 1 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1

data extraction?
Was a comprehensive literature 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1 1 1 1 1
search performed?
Was the status of publication used as 0 0 0 0 0 0 1 0 1 0 0 1 0 1 1 0 0 0 0 1 1 0 1 0 0 0
an inclusion criterion ?
Was a list of included/excluded 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
studies provided?
Was the methodological quality of 1 1 1 1 1 1 1
the included studies evaluated and 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

documented?
Was the specific quality of the 1 1 1 1 1 1 1
included studies used appropriately 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

in formulating conclusions?

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Accepted Article
Were the methods used to combine 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
the findings of studies appropriate?

Was the publication bias evaluated? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Were the conflicts of interest stated? 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 0 1 1 1 1 1 1 1 1

Total 9 7 10 9 8 8 9 7 11 7 9 9 9 10 10 8 9 8 9 9 10 8 10 9 9 9

This article is protected by copyright. All rights reserved

Accepted Article

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