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Meta-Analysis
. 2015 May 26;2015(5):CD010960.
doi: 10.1002/14651858.CD010960.pub2.

Injection therapies for Achilles tendinopathy

Rebecca S Kearney  1 , Nick Parsons, David Metcalfe, Matthew L Costa
Affiliations
Meta-Analysis

Injection therapies for Achilles tendinopathy

Rebecca S Kearney et al. Cochrane Database Syst Rev. .

Abstract

Background: Achilles tendinopathy is a common condition, often with significant functional consequences. As a wide range of injection treatments are available, a review of randomised trials evaluating injection therapies to help inform treatment decisions is warranted.

Objectives: To assess the effects (benefits and harms) of injection therapies for people with Achilles tendinopathy.

Search methods: We searched the following databases up to 20 April 2015: the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and SPORTDiscus. We also searched trial registers (29 May 2014) and reference lists of articles to identify additional studies.

Selection criteria: We included randomised and quasi-randomised controlled trials evaluating injection therapies in adults with an investigator-reported diagnosis of Achilles tendinopathy. We accepted comparison arms of placebo (sham) or no injection control, or other active treatment (such as physiotherapy, pharmaceuticals or surgery). Our primary outcomes were function, using measures such as the VISA-A (Victorian Institute of Sport Assessment-Achilles questionnaire), and adverse events.

Data collection and analysis: Two review authors independently extracted data from the included studies. We assessed treatment effects using mean differences (MDs) and 95% confidence intervals (CIs) for continuous variables and risk ratios (RRs) and 95% CIs for dichotomous variables. For follow-up data, we defined short-term as up to six weeks, medium-term as up to three months and longer-term as data beyond three months. We performed meta-analysis where appropriate.

Main results: We included 18 studies (732 participants). Seven trials exclusively studied athletic populations. The mean ages of the participants in the individual trials ranged from 20 years to 50 years. Fifteen trials compared an injection therapy with a placebo injection or no injection control, four trials compared an injection therapy with active treatment, and one compared two different concentrations of the same injection. Thus no trials compared different injection therapies. Two studies had three trial arms and we included them twice in two different categories. Within these categories, we further subdivided injection therapies by mode of action (injury-causing versus direct repair agents).The risk of bias was unclear (due to poor reporting) or high in six trials published between 1987 and 1994. Improved methodology and reporting for the subsequent trials published between 2004 and 2013 meant that these were at less risk of bias.Given the very low quality evidence available from each of four small trials comparing different combinations of injection therapy versus active treatment and the single trial comparing two doses of one injection therapy, only the results of the first comparison (injection therapy versus control) are presented.There is low quality evidence of a lack of significant or clinically important differences in VISA-A scores (0 to 100: best function) between injection therapy and control groups at six weeks (MD 0.79, 95% CI -4.56 to 6.14; 200 participants, five trials), three months (MD -0.94, 95% CI -6.34 to 4.46; 189 participants, five trials) or between six and 12 months (MD 0.14, 95% CI -6.54 to 6.82; 132 participants, three trials). Very low quality evidence from 13 trials showed little difference between the two groups in adverse events (14/243 versus 12/206; RR 0.97, 95% CI 0.50 to 1.89), most of which were minor and short-lasting. The only major adverse event in the injection therapy group was an Achilles tendon rupture, which happened in a trial testing corticosteroid injections. There was very low quality evidence in favour of the injection therapy group in short-term (under three months) pain (219 participants, seven trials) and in the return to sports (335 participants, seven trials). There was very low quality evidence indicating little difference between groups in patient satisfaction with treatment (152 participants, four trials). There was insufficient evidence to conclude on subgroup differences based on mode of action given that only two trials tested injury-causing agents and the clear heterogeneity of the other 13 trials, which tested seven different therapies that act directly on the repair pathway.

Authors' conclusions: There is insufficient evidence from randomised controlled trials to draw conclusions on the use, or to support the routine use, of injection therapies for treating Achilles tendinopathy. This review has highlighted a need for definitive research in the area of injection therapies for Achilles tendinopathy, including in older non-athletic populations. This review has shown that there is a consensus in the literature that placebo-controlled trials are considered the most appropriate trial design.

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Conflict of interest statement

Rebecca S Kearney, Nick Parsons, David Metcalfe and Matthew L Costa: the authors' institution, University of Warwick, has received research grants and PRP (platelet‐rich plasma) materials at cost price for studies related to the treatment of Achilles tendinopathy and rupture, including injection studies.

Rebecca S Kearney, Nick Parsons and Matthew L Costa were authors on one of the included study (Kearney 2013). Risk of bias for this trial was independently assessed by David Metcalfe, who had no involvement in this earlier study.

Figures

1
1
Study flow diagram
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each study.
1.1
1.1. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 1 VISA‐A (score 0 to 100; 100 = no problems): at 6 weeks.
1.2
1.2. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 2 VISA‐A (score 0 to 100; 100 = no problems): at 3 months.
1.3
1.3. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 3 VISA‐A (score 0 to 100; 100 = no problems): after 3 months.
1.4
1.4. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 4 Patients achieving increased VISA‐A scores (20 points or more from baseline).
1.5
1.5. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 5 Adverse events.
1.6
1.6. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 6 Pain (VAS; score 0 to 100; 0 = no pain) up to 3 months.
1.7
1.7. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 7 Return to sports.
1.8
1.8. Analysis
Comparison 1 Injection therapies versus placebo injection or no injection control, Outcome 8 Patient satisfaction with treatment (an event represents satisfaction with treatment).
2.1
2.1. Analysis
Comparison 2 Injection therapies versus active treatment, Outcome 1 VISA‐A (score 0 to 100; 100 = no problems).
2.2
2.2. Analysis
Comparison 2 Injection therapies versus active treatment, Outcome 2 Patients achieving increased VISA‐A scores (20 points or more from baseline).
2.3
2.3. Analysis
Comparison 2 Injection therapies versus active treatment, Outcome 3 Adverse events.
2.4
2.4. Analysis
Comparison 2 Injection therapies versus active treatment, Outcome 4 Quality of life: EQ‐5D (scores up to 1: full health).
2.5
2.5. Analysis
Comparison 2 Injection therapies versus active treatment, Outcome 5 Patient satisfaction with treatment (satisfied patients).
3.1
3.1. Analysis
Comparison 3 High‐dose versus low‐dose injection therapy, Outcome 1 Adverse events.
3.2
3.2. Analysis
Comparison 3 High‐dose versus low‐dose injection therapy, Outcome 2 Pain during activity (VAS; score 0 to 100; 0 = no pain) after maximum of 3 treatments.
3.3
3.3. Analysis
Comparison 3 High‐dose versus low‐dose injection therapy, Outcome 3 Patient satisfaction (satisfied patients).
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Update of

  • doi: 10.1002/14651858.CD010960

References

References to studies included in this review

Alfredson 2005 {published data only}
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Willberg 2008 {published data only}
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References to studies excluded from this review

Ferrero 2012 {published data only}
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References to studies awaiting assessment

EUCTR2010‐020513‐87 {published data only}
    1. FIDIA. A randomized, placebo‐controlled, double‐blind study on the intensity and duration of efficacy of sodium hyaluronate therapy (500‐730 KDa) (HYALGAN) in the conservative treatment of Achilles tendinopathy. https://www.clinicaltrialsregister.eu/ctr‐search/trial/2010‐020513‐87/IT (accessed 17 November 2014).
Petrella 2013 {published data only}
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References to ongoing studies

ISRCTN85334402 {published data only}
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NCT01343836 {published data only}
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NCT01954108 {published data only}
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References to other published versions of this review

Kearney 2014
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