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Comparative Effectiveness of Different Nonsurgical Treatments for Patellar Tendinopathy: A Systematic Review and Network Meta-analysis

      Purpose

      To investigate the functional improvement and pain reduction of different nonsurgical treatments for patellar tendinopathy (PT), a systematic review with network meta-analysis was performed.

      Methods

      Studies were comprehensively searched for without language restrictions in the CENTRAL, MEDLINE, EMBASE, Web of Science, Physiotherapy Evidence Database, and SPORTDiscus databases from inception to May 2018. Randomized controlled trials about nonsurgical treatments for PT were included. The outcome measurements were the Victorian Institute of Sports Assessment (VISA) scale and pain scores (such as the visual analog scale or Numerical Rating Scale). Study quality was evaluated using the Physiotherapy Evidence Database score. Direct comparisons were performed using pairwise meta-analysis, whereas network meta-analysis was performed using a frequentist method in a multivariate random-effects model.

      Results

      Eleven studies with 430 affected patellar tendons were included in the systematic review. The summary mean difference of improvement in the VISA scale versus the control group for corticosteroid injection was –23.00 (95% confidence interval [CI] –36.73 to -9.27), for leukocyte-rich platelet-rich plasma (LR-PRP) was 13.22 (95% CI 2.37-24.07), for focused extracorporeal shockwave therapy (ESWT) was –1.28 (95% CI –6.25 to 3.68), for radial ESWT was –6.68 (95% CI –20.20 to 6.84), for ultrasound was –0.70 (95% CI –11.23 to 9.83), for autologous blood injection was –0.60 (95% CI –9.30 to 8.10), for dry needling was 17.51 (95% CI –2.57 to 37.60), for topical glyceryl trinitrate was –0.90 (95% CI –13.07 to 11.27), and for skin-derived tendon-like cells was 10.40 (95% CI –1.59 to 22.39). LR-PRP (Surface Under the Cumulative Ranking curve [SUCRA] = 87.5%) or dry needling (SUCRA = 90.5%) was most likely to be ranked the best in terms of improvement on the VISA scale. Compared with the control group, the summary mean difference of the change in pain score for corticosteroid injection was 0.80 (95% CI –3.48 to 5.08), for LR-PRP was –1.87 (95% CI –3.28 to –0.46), for focused ESWT was 0.13 (95% CI –0.68 to 0.93), for radial ESWT was 0.03 (95% CI –1.92 to 1.98), for ultrasound was –0.20 (95% CI –1.49 to 1.09), for autologous blood injection was 0.60 (95% CI –0.73 to 1.93), for dry needling was –0.37 (95% CI –2.71 to 1.97), and for topical glyceryl trinitrate was –0.50 (95% CI –2.55 to 1.55). The treatment most likely to be ranked the best in terms of change in pain score was LR-PRP (SUCRA = 94.9%).

      Conclusions

      The network meta-analysis demonstrated that LR-PRP has the greatest functional improvement and pain reduction for PT compared with other treatment options. However, the treatment effect estimates can be biased by the possible intransitivity and should not be overestimated.

      Level of Evidence

      Level I, meta-analysis of Level I studies.
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      Linked Article

      • Editorial Commentary: Network Geometry of Nonoperative Management of Patellar Tendinopathy—Can the Shape of the Evidence Inform Practice?
        ArthroscopyVol. 35Issue 11
        • Preview
          Recent research has examined the comparative effectiveness of nonoperative treatments for patellar tendinopathy using a network meta-analysis method. This method allows analysis of a network of clinical trials individually studying different treatment options in comparison to an eccentric exercise control; however, most treatments have not been compared head to head. Although leukocyte-rich platelet-rich plasma is statistically ranked as the treatment with the highest improvements in pain and function, concerns over the assumption of transitivity (on which network meta-analysis is based) and the lack of connection or comparisons among treatments suggest that future studies comparing treatments head to head are needed.
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