Nonoperative treatment of midportion Achilles tendinopathy: a systematic review.

OBJECTIVE: The aim of this systematic review is to provide an easily accessible, clear summary of the best available evidence for nonoperative treatment of midportion Achilles tendinopathy.

DATA SOURCES: MEDLINE, CINAHL, and Embase through April 2007. Search terms: achilles tendon or tendo achilles or triceps surae or tendoachilles or tendo-achilles or achilles AND tendinopathy or tendinosis or tendonitis or tenosynovitis.

STUDY SELECTION: Of 707 abstracts reviewed, 16 randomized trials met our inclusion criteria.

DATA EXTRACTION: Data extracted from each paper included: patient demographics (age and sex), duration of symptoms, method of diagnosis, treatments, cohort size, length of follow-up, pain-related outcome data, and secondary outcome data.

DATA SYNTHESIS: The primary outcome measurement was change in numeric pain score. Focal tenderness, tendon thickness, and validated outcome scores were used secondarily. Eccentric exercises were noted to be equivalent to extracorporeal shockwave therapy (1 study) and superior to wait-and-see treatment (2 trials), traditional concentric exercise (2 of 3 trials), and night splints (1 study). Extracorporeal shockwave therapy was shown to be superior to a wait-and-see method in 1 study but not superior to placebo in another. Sclerosing injections were shown to be superior to placebo in 1 study, but local steroid treatment was beneficial in 2 of 3 studies. Injection of deproteinized hemodialysate and topical glyceryl nitrate application were beneficial in 1 trial each.

CONCLUSIONS: Eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy. More investigation is needed into the utility of extracorporeal shockwave therapy, local corticosteroid treatments, injections of sclerosing agents or deproteinized hemodialysate, and topical glyceryl nitrate application.