Article Text

Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies
  1. Dimitris Challoumas1,
  2. Carles Pedret2,
  3. Mairiosa Biddle3,
  4. Nigel Yong Boon Ng3,
  5. Paul Kirwan4,5,
  6. Blair Cooper6,
  7. Patrick Nicholas6,
  8. Scott Wilson3,
  9. Chris Clifford7,
  10. Neal L Millar1,3
  1. 1Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
  2. 2Sports Medicine and Imaging Department, Clinica Mapfre de Medicina del Tenis, Barcelona, Spain
  3. 3Department of Trauma & Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
  4. 4School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
  5. 5Physiotherapy Department, Connolly Hospital Blanchardstown, Blanchardstown, Ireland
  6. 6Department of Trauma & Orthopaedic Surgery, Ayr University Hospital, Ayr, UK
  7. 7Physiotherapy Department, NHS Greater Glasgow and Clyde, Glasgow, UK
  1. Correspondence to Dr Neal L Millar; neal.millar{at}


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.

  • treatment
  • exercise
  • tendinopathy

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  • Contributors NLM and DC conceived and designed the study. DC, MB, NYBN, BC, PN and SW performed analysis. CP, PK and CC provided expert advice. All authors analysed the data. DC, NLM, PK, CC and CP wrote the paper.

  • Funding This work was funded by a grant from the Medical Research Council UK (MR/R020515/1).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.