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Which treatment classes and combinations are more effective for the management of common tendinopathies? A systematic review and network meta-analysis.

Swinton, Paul A.; Shim, Joanna; Pavlova, Anastasia V.; Moss, Rachel A.; MacLean, Colin; Brandie, David; Mitchell, Laura; Tzortziou Brown, Victoria; Greig, Leon; Parkinson, Eva; Morrissey, Dylan; Alexander, Lyndsay; Cooper, Kay


Rachel A. Moss

Colin MacLean

David Brandie

Laura Mitchell

Victoria Tzortziou Brown

Dylan Morrissey


The aim of this research was to quantify the comparative effectiveness of treatment classes used for the management of the most common tendinopathies. The project studied network meta-analyses comparing combinations of exercise, non-exercise, and non-active treatments across a range of tendinopathy locations and outcome domains. The review covered randomised and quasi-randomised controlled trials including an exercise arm and persons with a tendinopathy diagnosis at any location, and of any severity or duration. Outcome measures included outcomes assessing disability, function, pain, shoulder range of motion, physical function capacity, or quality of life. Through network meta-analyses, broad (exercise/non-exercise/combined/non-active) and more specific (exercise/biomechanics/injection/electrotherapy/manual-therapy/non-active/surgery) treatment class models were fitted with hierarchical Bayesian models. Results were interpreted using pooled standardised mean difference effect sizes and ranking through Surface Under the Cumulative Ranking curves (SUCRA). Treatment hierarchies were assessed using the GRADE minimally contextualised framework. Two-hundred studies comprising 458 treatments arms were identified. Many comparisons were within the same class reducing data available to assess comparative effectiveness. Data from 85 studies generating 140 pairwise comparisons consistently identified the superiority of combining exercise and non-exercise treatment classes (SUCRA: 0.70 to 0.88). Central estimates indicated that combining exercise and non-exercise treatments increased effect sizes by ~0.1 to 0.3 compared with exercise alone. Analysis of more specific treatment classes identified with low/very low certainty the superiority of combining exercise with either biomechanical (e.g. taping, bracing or splinting; SUCRA: 0.73) or injection therapies (SUCRA: 0.72). The study concluded that clinicians should consider combining exercise and non-exercise therapies as a starting point for tendinopathy management. The most effective treatment combinations include exercise with the use of biomechanical or injection therapies.


SWINTON, P.A., SHIM, J., PAVLOVA, A.V., MOSS, R.A., MACLEAN, C., BRANDIE, D., MITCHELL, L., TZORTZIOU BROWN, V., GREIG, L., PARKINSON, E., MORRISSEY, D., ALEXANDER, L. and COOPER, K. 2022. Which treatment classes and combinations are more effective for the management of common tendinopathies? A systematic review and network meta-analysis. SportRxiv [online]. Available from:

Deposit Date May 26, 2022
Publicly Available Date May 26, 2022
Keywords Tendinopathy; Exercise therapy; Physiotherapy
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