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

Abstract

Objectives: We 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).

Methods: Several 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.

Results: A 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).

Conclusions: Promising 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.

Keywords: exercise; tendinopathy; treatment.

Figure 1

Meta-analysis results and forest plot of ‘ESWT+eccentric exercise versus sham ESWT+eccentric exercise’ comparison for (A) short-term pain and (B) VISA-P. ESWT, extracorporeal shockwave therapy; VISA-P, Victorian Institute of Sports Assessment-Patellar.

Figure 2

Meta-analysis results and forest plot of ‘isometric exercise versus isotonic exercise’ comparison for immediate postintervention pain.

Figure 3

Network maps of the studies included in the network meta-analysis for (A) short-term VAS pain and (B) short-term VISA-P. The size of the circle is proportional to the number of studies that represented each intervention and the thickness of the line between interventions is proportional to the number of studies assessing that comparison. All comparisons are assessed by one study only, except for eccentric exercise–decline squat versus concentric exercise and eccentric exercise–decline squat versus focal extracorporeal shockwave therapy+eccentric exercise which are assessed by two studies. VAS, Visual Analogue Scale; VISA-P, Victorian Institute of Sports Assessment-Patellar.

Figure 4

Comparative treatment class effects expressed as mean difference with 95% CI for (A) short-term pain VAS and (B) short-term VISA-P. Each cell represents the result of the comparison of the intervention of that column versus the intervention of that row. A negative value in a cell favours the column intervention in (A) and the row intervention in (B). fESWT, focal extracorporeal shock wave therapy; GTN, glyceryl trinitrate; PNE, percutaneous needle electrolysis; PRP, platelet-rich plasma; rESWT, radial extracorporeal shock wave therapy; VAS, Visual Analogue Scale; VISA-P, Victorian Institute of Sports Assessment-Patellar.

Figure 5

Median rank of the effectiveness of interventions included in the network meta-analysis for (A) short-term pain VAS and (B) VISA-P for chronic patellar tendinopathy. GTN, glyceryl trinitrate; fESWT, focal extracorporeal shock wave therapy; PRP, platelet-rich plasma; rESWT, radial extracorporeal shock wave therapy; VAS, Visual Analogue Scale; VISA-P, Victorian Institute of Sports Assessment-Patellar.