LSR for Achilles tendinopathy

Background 

An international team of researchers, led by Dr R.J. de Vos, sports physician at Erasmus MC completed a large review of the scientific evidence on the best treatment for Achilles tendinopathy.
This large project took more than 2 years to complete, and was funded by the Dutch government as part of the process to create a clinical management guideline. The guideline is due to be published in Dutch later in 2020. Once this in completed you will be able to access the guideline here.

Our aim was to evaluate the comparative effectiveness of all available treatments for Achilles tendinopathy in a regularly updated (“living”) systematic review using a network meta-analysis. We plan to keep updating this review every 2 years. Future results will be posted here every 2 years. When there are clinically relevant changes that impact clinical decision-making, we will plan to publish a new update as scientific article.

Description

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 and Grants

This research received a grant from the Dutch Association of Medical Specialists to develop a clinical guideline for the treatment of patients with Achilles tendinopathy. The Dutch Patient Federation is involved in this guideline development and assisted in sending out patient surveys.

Collaboration 

• 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

Team Members 

• M. Winters
• C.L. Ardern
• N.J. Welton
• D.M. Caldwell