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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


  • Paul Swinton
  • Joanna Shim
  • Anastasia Pavlova
  • Rachel Moss
  • Colin Maclean
  • David Brandie
  • Victoria Tzortziou Brown
  • Leon Greig
  • Eva Parkinson
  • Lyndsay Alexander
  • Kay Cooper



Tendinopathy, Exercise therapy, Physiotherapy, Effect size


Objective To quantify the comparative effectiveness of treatment classes used for the management of the most common tendinopathies.

Design Network meta-analyses comparing combinations of exercise, non-exercise, and non-active treatments across a range of tendinopathy locations and outcome domains.

Eligibility criteria 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 Outcomes assessing disability, function, pain, shoulder range of motion, physical function capacity, or quality of life.

Methods Network meta-analyses of 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.  

Results 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).

Summary/Conclusion Clinicians should consider as a starting point for tendinopathy management combining exercise and non-exercise therapies. The most effective treatment combinations include exercise with the use of biomechanical or injection therapies.


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