Physical Therapy in Sport 46 (2020) 30e46

Contents lists available at ScienceDirect

Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Review Article

Physical therapy for tendinopathy: An umbrella review of systematic

reviews and meta-analyses
Beshoy Girgis*, Jose

Alberto Duarte

cido Costa, 91, 4200-450, Porto, Portugal
CIAFEL, Faculty of Sport, University of Porto, R. Dr. Pla

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To summarize evidence in the last decade regarding the efficacy of physical therapy in-
Received 30 April 2020 terventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs)
Received in revised form and/or meta-analyses (MAs).
1 August 2020
Methods: Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to
Accepted 4 August 2020
January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool.
Studies scoring 9 points or higher were further analyzed using GRADE principles.
Keywords:
Results: 40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in
Tendon injuries
Tendinopathy
quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain
Conservative treatment reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I2 ¼ 1.9%, p ¼ 0.361) on visual analogue scale, and grip strength
Review of 9.59 kg; 95% CI, [5.90, 13.27].
Conclusions: Moderate-quality evidence may support these following interventions: LLLT revealed a
statistically and potentially clinically significant improvement in pain and function on the short-term.
Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function
at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was
supported by qualitative evidence only. Caution is advised when interpreting results due to possible
pathological differences in tendinopathy at each region.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction et al., 2004; Xu & Murrell, 2008). Conservative treatment is

considered the mainstay in the treatment of tendinopathy (Andres
Tendinopathy is a clinical syndrome characterized by pain, & Murrell, 2008; Mead et al., 2018). Ultrasound therapy (US),
swelling, and reduced performance (Maffulli, 1998; Scott et al., manual therapy (MT), low-level laser therapy (LLLT), extracorporeal
2020). It may involve any tendon, however, it commonly involves shockwave therapy (ESWT), and exercise therapy (ET) are common
wrist flexors and extensors at the elbow, Rotator cuff, and Patellar interventions for tendinopathy, among others. Nevertheless, most
and Achilles tendons (Maffulli, Wong, & Almekinders, 2003; Xu & of the available therapeutic modalities are supported by weak ev-
Murrell, 2008). The incidence of tendinopathy in sport is rising idence (Cardoso, Pizzari, Kinsella, Hope, & Cook, 2019; Maffulli,
due to increased training frequency and participation in sports Longo, Loppini, & Denaro, 2010). ET is regarded as an essential
(Ackermann & Renstro € m, 2012; Mead, Gumucio, Awan, Mendias, & part of the treatment of tendinopathy (Dilger & Chimenti, 2019;
Sugg, 2018; Renstrom & Woo, 2008). The pathophysiology of ten- Littlewood, May, & Walters, 2013; Mead et al., 2018). The efficacy of
dinopathy is not fully understood but recent evidence has indicated eccentric exercise (EE), in particular, is supported by several studies
a potential role of inflammation (Dean, Gettings, Dakin, & Carr, (Andres & Murrell, 2008; Jayaseelan, Mischke, & Strazzulla, 2019;
2016; Mosca et al., 2018). Several reviews, however, have sup- Magnussen, Dunn, & Thomson, 2009; Rutland et al., 2010). The
ported the histopathological similarity in tendinopathy at various optimal treatment protocol, nonetheless, is yet undefined (Couppe
,
€rvinen et al., 1997; Maffulli
anatomical sites (Abate et al., 2009; Ja Svensson, Silbernagel, Langberg, & Magnusson, 2015; Dilger &
Chimenti, 2019; Dimitrios & Malliaras, 2016; Littlewood,
Malliaras, & Chance-Larsen, 2015; Meyer, Tumilty, & Baxter,
* Corresponding author. 2009). Since there are many reviews on the topic in literature,
E-mail addresses: [email protected], [email protected], begirgis@ summarizing existing evidence may facilitate the intervention
gmail.com, [email protected] (B. Girgis), [email protected] (J.A. Duarte).

https://doi.org/10.1016/j.ptsp.2020.08.002
1466-853X/© 2020 Elsevier Ltd. All rights reserved.
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

decision-making process. Furthermore, nearly all of these reviews 2.4. Data items
are modality-oriented rather than disease-oriented reviews. The
objective of the present review was to summarize evidence in the The data extracted from each study were study title, search
last decade regarding the efficacy of physical therapy interventions methodology, number and type of included studies, patient popu-
to treat tendinopathy, as a single disease entity, as determined in lation, intervention(s) and parameters of intervention(s); if appli-
systematic reviews and/or meta-analyses. cable, outcome(s) and/or outcome measure(s); if applicable, follow-
up period(s), results, limitations, and conclusion(s). Pooled esti-
mates of effect size(s), if applicable, were also extracted.
2. Methods
2.5. Methodological quality assessment
2.1. Eligibility criteria
The methodological quality of the identified systematic reviews
Inclusion was limited to systematic reviews and/or meta- and/or meta-analyses were assessed using the Assessment of
analyses with the objective to determine the efficacy of physical Multiple Systematic Reviews tool (AMSTAR 2) (a measurement tool
therapy intervention(s) in treating tendinopathy (without restric- to assess systematic reviews) (Shea et al., 2017). The AMSTAR in-
tion to a specific anatomical site). Moreover, studies had to involve strument has been developed and validated to assess the quality of
adequate description of methodology to be included; defined as: a systematic reviews of randomized and non-randomized studies of
systematic review and/or a meta-analysis involving an explicitly healthcare interventions (Shea et al., 2007a, 2007b, 2009). The
stated search strategy and search terms, explicitly described eligi- AMSTAR 2 guidance document was used to aid the evaluation
bility criteria, and explicitly defined methods of statistical synthesis process. The AMSTAR 2 instrument has a total of 16 items and in-
(if applicable). Only studies published in peer reviewed journals, cludes more simple response categories than the original AMSTAR.
since year 2010, and written in English language were included. All items on the AMSTAR 2 tool were weighted equally. The
Studies including invasive, pharmacologic, and/or surgical inter- assessment results were arbitrarily divided into four categories,
ventions(s), non-efficacy studies involving physical therapy in- similar to other studies using the AMSTAR tool (Flodgren et al.,
tervention(s), and protocols of studies were excluded (Table 1). 2011; Ryan et al., 2014). The rating of overall confidence (OC) was
categorized, depending on fulfilled criteria, as follows; critically low
(1-4), low (5-8), moderate (9-12), and high (13-16). Studies scoring
2.2. Information sources and search strategy 9 points or higher were further analyzed using Grading of Rec-
ommendations Assessment, Development, and Evaluation (GRADE)
Electronic search of the National Institutes of Health (NIH) principles (Group, 2004) to determine the quality of evidence.
PubMed, the Physiotherapy Evidence Database PEDro, and Scopus
database was performed from year 2010 to January 2020. Inspec- 2.6. Outcome measures
tion of bibliographic references complemented the electronic
search. The terms used in the electronic search were: systematic Since pain with movement is a characteristic feature of ten-
review, meta-analysis, tendinitis, tendinosis, and tendinopathy. The dinopathy, pain is often measured in the context of a physical task
search strategy of PubMed database was: ((“Tendinopathy/reha- that induces pain (MacDermid & Silbernagel, 2015). Moreover, pain
bilitation"[Mesh] OR “Tendinopathy/therapy"[Mesh]) AND ((sys- commonly reduces patient’s activity levels, impairs range of mo-
tematic[sb] OR Meta-Analysis[ptyp]) AND English[lang])) AND tion, strength and function (MacDermid & Silbernagel, 2015). The
(“2010/01/19"[PDat]: “2020/01/16"[PDat]). The search strategy of outcomes were pain and function. Pain, as determined through;
Scopus database was: TITLE-ABS (tendinopathy) OR TITLE-ABS patient-reported pain scores using the visual analogue scale (VAS)
(tendinitis) OR TITLE-ABS (tendinosis) AND PUBYEAR > 2010 AND or the numeric pain rating scale (NPRS) (Carlsson, 1983; Dixon &
(LIMIT-TO ( DOCTYPE, “re")). Bird, 1981; Hawker, Mian, Kendzerska, & French, 2011; Johnson,
2005).
Function, as determined through; lateral elbow tendinopathy
2.3. Study selection process (LET): grip strength (pain-free grip strength) (Blanchette &
Normand, 2011; Hamilton, Balnave, & Adams, 1994; Innes, 1999;
A standard data sheet was used for data collection and man- Lim, 2013; Mathiowetz, Weber, Volland, & Kashman, 1984; Smidt
agement. Duplicates were identified and removed electronically et al., 2002; Stratford, 1987; Stratford et al., 1989, 1993; Stratford
using EndNote X9.2 software (Bld13018). Following the removal of & Levy, 1994) and patient-rated tennis elbow evaluation (PRTEE)
duplicates and non-matching studies, full-text articles were questionnaire (Evans et al., 2019; MacDermid, 2005; Newcomer,
reviewed for possible inclusion. Full-text articles, moreover, were Martinez-Silvestrini, Schaefer, Gay, & Arendt, 2005; Overend,
checked for eligibility in cases of abstracts. None of the authors Wuori-Fearn, Kramer, & MacDermid, 1999; Rompe, Overend, &
were contacted for additional data. MacDermid, 2007; Vincent & MacDermid, 2014); Achilles

Table 1
Summary of eligibility criteria.

Inclusion criteria Exclusion criteria

 Systematic review and/or meta-analysis assessing the efficacy of physical therapy in-  Including invasive, pharmacologic, and/or surgical intervention(s)
tervention(s) for tendinopathy
 Systematic review and/or meta-analysis with adequate description of methodology  Non-efficacy systematic review and/or meta-analysis involving physical
therapy intervention(s)
 Published in peer reviewed journal  Protocol of a systematic review and/or a meta-analysis
 Published since year 2010
 Written in English language

31
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

tendinopathy (AT): the heel-rise test (Lunsford & Perry, 1995; Ross & Grimmer-Somers, 2011; Joseph, Taft, Moskwa, & Denegar, 2012;
Fontenot, 2000), the hopping and drop counter movement jump Littlewood, Ashton, Chance-Larsen, May, & Sturrock, 2012; Rowe
tests (MacDermid & Silbernagel, 2015), and the Victorian Institute et al., 2012; Sussmilch-Leitch, Collins, Bialocerkowski, Warden, &
of Sport Assessment-Achilles (VISA-A) questionnaire (Iversen, Crossley, 2012; Al-Abbad & Simon, 2013; Cullinane, Boocock, &
Bartels, & Langberg, 2012; Robinson et al., 2001); Patellar tendin- Trevelyan, 2014; Dimitrios, Konstantinos, & Antonis, 2013;
opathy (PT): the Victorian Institute of Sport Assessment-Patella Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013;
(VISA-P) questionnaire (Dauber, Ball, Lewis, & Neidermeyer, Ioppolo et al., 2013; Bannuru, Flavin, Vaysbrot, Harvey, &
2018); hip-region tendinopathies (HT): the Victorian Institute of McAlindon, 2014; Dingemanse, Randsdorp, Koes, & Huisstede,
Sport Assessment-Proximal Hamstring Tendons (VISA-H) (Cacchio, 2014; Haslerud, Magnussen, Joensen, Lopes-Martins, & Bjordal,
De Paulis, & Maffulli, 2014), the Victorian Institute for Sport 2015; Loew et al., 2014; Mani-Babu, Morrissey, Waugh, Screen, &
Assessment for Gluteal Tendinopathy (VISA-G) (Fearon et al., 2015), Barton, 2015; Desjardins-Charbonneau, Roy, Dionne, & Des-
and the Copenhagen Hip and Groin Outcome Score (HA-GOS) meules, 2015; Desjardins-Charbonneau et al., 2015; Desmeules
(Thorborg, Ho€ lmich, Christensen, Petersen, & Roos, 2011); Rotator et al., 2015; Krey, Borchers, & McCamey, 2015; Nogueira Júnior &
cuff tendinopathy (RT): the Functional Impairment Test-Head and Júnior, 2015; Scott, Munteanu, & Menz, 2014; Weber, Thai,
Neck/Shoulder/Arm (FIT-HaNSA) (Evans, Adkins, Clarke, & Cox, Neuheuser, Groover, & Christ, 2015; 1017Boudreault, Desmeules,
2018), disabilities of the arm, shoulder and hand (DASH) ques- Roy, Dionne, & Fre
mont, ; Desmeules et al., 2016a; Desmeules et al.,
tionnaire and the QuickDASH questionnaire (Gummesson, Ward, & 2016b; Ortega-Castillo & Medina-Porqueres, 2016; McKivigan,
Atroshi, 2006; Jester, Harth, Wind, Germann, & Sauerbier, 2005), Yamashita, & Smith, 2017; Punnoose, Norrish, & Pak, 2017; Liao
the Rotator Cuff Quality-of-Life measure (RC-QoL) (Eubank, et al., 2018a; Liao et al., 2018b; Lim & Wong, 2018; Lucado, Dale,
Mohtadi, Lafave, Wiley, & Emery, 2017; Razmjou, Bean, van Vincent, & Day, 2018; Wilson et al., 2018; Hickey, Walker, Lee, &
Osnabrugge, MacDermid, & Holtby, 2006), Constant-Murley score Vitato, 2019; Murphy et al., 2019; Yan et al., 2019), whereas only
(CMS) (Rocourt et al., 2008), and strength and range of motion 5 MAs (out of 19) were included in quantitative synthesis. The flow
(ROM); and for calcific tendinopathy, calcific deposit size. of the review is presented according to preferred reporting items
for systematic reviews and meta-analyses (PRISMA) in Fig. 1.
2.7. Synthesis of results
3.2. Methodological quality assessment results
The results were classified by intervention modality and therapy
for practical reasons and simplification. Only MAs with moderate The AMSTAR 2 tool was used to appraise the included SRs; the
rating of OC or higher were included in the statistical synthesis in rating of overall confidence (OC) in the results ranged from criti-
order to reach accurate and reliable results. Meta-analysis of results cally low to high (Table 2). One study had a high rating of OC
was performed using comprehensive meta-analysis software (Murphy et al., 2019), Sixteen studies had a moderate rating of OC
V3.3.070 (CMA; Biostat, NJ) to calculate a weighted mean difference (Tumilty et al., 2010; Lee et al., 2011; Al-Abbad & Simon, 2013;
(WMD) and 95% confidence interval (CI). Mean differences (MD) Bannuru et al., 2014; Haslerud et al., 2015; Loew et al., 2014;
and 95% CI, or standardized mean differences (SMD) and 95% CI Desjardins-Charbonneau et al., 2015; Desmeules et al., 2015; Scott
were utilized as reported in each study. Variability, between et al., 2014; Boudreault et al., 1017; Desmeules et al., 2016b;
studies, in units of measurement were resolved through converting Ortega-Castillo & Medina-Porqueres, 2016; Liao et al., 2018a; Liao
results to a standardized unit. Random-effects model was used due et al., 2018b; Lim & Wong, 2018; Wilson et al., 2018), twenty one
to the small number of included studies. Confidence intervals, in studies had a low rating of OC (Chang et al., 2010; Cullinane et al.,
contrast to p-value, reflect the direction and the strength of the 2014; Desjardins-Charbonneau et al., 2015; Desmeules et al.,
studied effect (du Prel, Hommel, Ro €hrig, & Blettner, 2009; 2016a; Dingemanse et al., 2014; Hickey et al., 2019; Hoogvliet
Shakespeare, Gebski, Veness, & Simes, 2001). Heterogeneity was et al., 2013; Huisstede et al., 2011; Hutchison et al., 2011; Ioppolo
calculated using I2 and p-value; I2 values of 25%, 50%, 75% corre- et al., 2013; Joseph et al., 2012; Krey et al., 2015; Littlewood et al.,
spond to low, moderate, high heterogeneity, respectively (Higgins, 2012; Lucado et al., 2018; Mani-Babu et al., 2015; McKivigan
Thompson, Deeks, & Altman, 2003). et al., 2017; Punnoose et al., 2017; Rowe et al., 2012; Sussmilch-
Leitch et al., 2012; Weber et al., 2015; Yan et al., 2019), and two
3. Results studies had a critically low rating of OC (Dimitrios et al., 2013;
Nogueira Júnior & Júnior, 2015). Few studies included an explicit
3.1. Results of the systematic review statement that the review methods were established prior to the
conduct of the review; five studies included a published protocol
A total of 886 citations, including title and abstract, were iden- (Liao et al., 2018a; Lim & Wong, 2018; Murphy et al., 2019; Ortega-
tified using electronic search of databases; PubMed, n ¼ 166; Castillo & Medina-Porqueres, 2016; Wilson et al., 2018), while three
PEDro, n ¼ 55; Scopus, n ¼ 634; and bibliography, n ¼ 31. 769 ci- studies partially fulfilled this criterion (criterion 2) (Hutchison
tations were assessed for eligibility following the elimination of et al., 2011; Krey et al., 2015; Littlewood et al., 2012). Three
duplicates, n ¼ 117. 67 full-text articles were further examined for studies explained their selection of the study designs in the in-
eligibility after non-matching records were excluded, n ¼ 702, and clusion criteria (criterion 3) (Al-Abbad & Simon, 2013; Chang et al.,
subsequently 27 full-text articles (out of 67) were excluded, with 2010; Lee et al., 2011). Five studies provided a list of excluded
reasons; non-efficacy studies, n ¼ 7; protocols of studies, n ¼ 3; studies and justified exclusion (criterion 7) (Haslerud et al., 2015;
studies including invasive, pharmacologic, surgical interventions, Loew et al., 2014; Desmeules et al., 2015; Boudreault et al., 1017;
n ¼ 12; and written in languages other than English, n ¼ 5. A list of Desmeules et al., 2016b). Seven studies did not describe the
excluded studies is provided in supplementary data. Forty sys- included studies in adequate detail (criterion 8) (Chang et al., 2010;
tematic reviews (SRs) and/or meta-analyses (MAs) matched the Dimitrios et al., 2013; Dingemanse et al., 2014; Hoogvliet et al.,
eligibility criteria and were included in qualitative synthesis 2013; Lucado et al., 2018; Nogueira Júnior & Júnior, 2015; Wilson
(Tumilty et al., 2010; Chang, Wu, Yang, & Jiang, 2010; Huisstede, et al., 2018). Two studies reported on the sources of funding for
Gebremariam, van der Sande, Hay, & Koes, 2011; Hutchison, the included studies (criterion 10) (Liao et al., 2018b; Loew et al.,
Beard, Pallister, Topliss, & Williams, 2011; Lee, Cheng, & 2014).
32
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Fig. 1. Study flow diagram according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

3.3. Findings of included studies Tsauo et al. (Liao et al., 2018a) reported a significant reduction in
pain (SMD) of 1.41; 95% CI, [-2.01, 0.82], and improvement in
3.3.1. Low level laser therapy function (SMD) of 2.59; 95% CI, [1.54, 3.64] at all follow-up periods.
Three studies with moderate rating of OC (Tumilty et al., 2010; Liao and Xie et al. (Liao et al., 2018b) concluded that ESWT had
Haslerud et al., 2015; Boudreault et al., 1017), two studies with low significant effect on pain reduction (SMD) of 1.49; 95% CI,
rating of OC (Rowe et al., 2012; Sussmilch-Leitch et al., 2012), and [-2.11, 0.87] and range of motion restoration (SMD) of 1.76; 95% CI,
one study with critically low OC (Nogueira Júnior & Júnior, 2015) [1.43, 2.09]. Two studies with moderate rating of OC (Lee et al.,
supported the application of LLLT, both as monotherapy and in 2011; Bannuru et al., 2014) supported the application of ESWT for
conjunction with other physical therapy interventions, for pain calcific tendinitis of the shoulder. Ioppolo et al. (Ioppolo et al., 2013)
relief in patients with RT and AT. Tumilty et al. (Tumilty et al., 2010) reported a total resorption ratio of 27.19; 95% CI, [7.20, 102.67] and a
reported a reduction in pain scores of 13.64 mm; 95% CI, [-26.17, partial resorption ratio of 16.22; 95% CI, [3.33, 79.01]. Moreover,
1.11] on VAS and improvement in grip strength of 9.59 kg; 95% CI, two studies with low rating of OC (Huisstede et al., 2011; Ioppolo
[5.90, 13.27]. Haslerud et al. (Haslerud et al., 2015) mentioned sig- et al., 2013) also supported the use of ESWT for shoulder calcific
nificant pain relief of 20.41 mm; 95% CI, [12.38 to 28.44] of LLLT as tendinitis. Two studies with low rating of OC (Mani-Babu et al.,
monotherapy, and 16.00 mm; 95% CI, [11.88, 20.12] of LLLT in 2015; Punnoose et al., 2017) showed conflicting results regarding
addition to ET on VAS. Boudreault et al., (Boudreault et al., 1017) the efficacy of ESWT for AT and PT. Punnoose et al. (Punnoose et al.,
described an improvement in overall pain of 1.38 cm; 95% CI, [0.91, 2017) indicated no significant differences between intervention
1.85] on VAS. One study with low rating of OC (Chang et al., 2010) and control groups on VISA-A scores 5.74; 95% CI, [-15.02, 26.51]
reported that applying LLLT on myofascial trigger points improved and VISA-P scores 10.01; 95% CI, [-7.86, 27.87], for AT and PT,
pain, grip strength and ROM (p < 0.05) in patients with LET. respectively. Yan et al. (Yan et al., 2019) reported lower pain (VAS
Nonetheless, one study with low rating of OC (Dingemanse et al., score) in ESWT group at 1 month of 1.42; 95% CI, [-2.14, 0.70], at
2014) concluded that evidence regarding the efficacy of LLLT vs 3 months of 1.65; 95% CI, [-1.81, 1.49], and at 6 months of 0.73;
placebo, in patients with LET, was conflicting. One study with 95% CI, [-1.06, 0.40], and higher grip strength scores at 3 months
moderate rating of OC (Boudreault et al., 1017) indicated that of 1.53; 95% CI, [1.17, 1.88] after intervention compared to US.
existing evidence did not support the effects of LLLT on function in
patients with RT. A study with moderate rating of OC (Desmeules
3.3.3. Exercise therapy
et al., 2015) indicated that LLLT was found to be more effective
Three studies with moderate rating of OC (Ortega-Castillo &
than US in reducing pain in patients with RT.
Medina-Porqueres, 2016; Lim & Wong, 2018; Wilson et al., 2018)
and three with low rating of OC (Littlewood et al., 2012; Hoogvliet
3.3.2. Extracorporeal shockwave therapy et al., 2013; Desmeules et al., 2016a) concluded that ET reduced
Three studies with moderate rating of OC (Al-Abbad & Simon, pain and improved function in patients with LET, AT, PT, and RT. One
2013; Liao et al., 2018a, 2018b), and one with low rating of OC study with high rating of OC (Murphy et al., 2019), three studies
(Rowe et al., 2012) concluded that ESWT was effective in reducing with moderate rating of OC (Ortega-Castillo & Medina-Porqueres,
pain and improving function in patients with AT and PT. Liao and 2016; Lim & Wong, 2018; Wilson et al., 2018), and three studies
33
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Table 2
Summary of methodological quality assessment of studies. 1. Did the research questions and inclusion criteria for the review include the components of PICO? 2. Did the report
of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations
from the protocol? 3. Did the review authors explain their selection of the study designs for inclusion in the review? 4. Did the review authors use a comprehensive literature
search strategy? 5. Did the review authors perform study selection in duplicate? 6. Did the review authors perform data extraction in duplicate? 7. Did the review authors
provide a list of excluded studies and justify the exclusions? 8. Did the review authors describe the included studies in adequate detail? 9. Did the review authors use a
satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review? 10. Did the review authors report on the sources of funding for
the studies included in the review? 11. If meta-analysis was performed, did the review authors use appropriate methods for statistical combination of results? 12. If meta-
analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?
13. Did the review authors account for RoB in primary studies when interpreting/discussing the results of the review? 14. Did the review authors provide a satisfactory
explanation for, and discussion of, any heterogeneity observed in the results of the review? 15. If they performed quantitative synthesis did the review authors carry out an
adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? 16. Did the review authors report any potential sources of
conflict of interest, including any funding they received for conducting the review? The rating of overall confidence (OC) was categorized, depending on fulfilled criteria, as
follows; critically low (1-4), low (5-8), moderate (9-12), and high (13-16); 1, met; 0, unmet; P, partially met; N/A, inapplicable.

Studies AMSTAR 2 items

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 OC

Tumilty et al. (Tumilty et al., 2010) 1 0 0 1 1 1 0 1 1 0 1 1 1 1 1 0 Moderate

Chang et al. (Chang et al., 2010) 1 0 1 1 0 0 0 0 1 0 0 0 0 0 0 1 Low
Huisstede et al. (Huisstede et al., 2011) 1 0 0 1 1 1 0 1 1 0 N/A N/A 1 1 N/A 0 Low
Hutchison et al. (Hutchison et al., 2011) 1 P 0 1 1 1 0 1 1 0 N/A N/A 0 1 N/A 0 Low
Lee et al. (Lee et al., 2011) 1 0 1 1 1 1 0 1 1 0 N/A N/A 0 1 N/A 1 Moderate
Joseph et al. (Joseph et al., 2012) 1 0 0 1 1 1 0 1 1 0 N/A N/A 0 1 N/A 0 Low
Littlewood et al. (Littlewood et al., 2012) 1 P 0 1 1 1 0 1 1 0 N/A N/A 1 1 N/A 0 Low
Rowe et al. (Rowe et al., 2012) 1 0 0 1 0 0 0 1 1 0 N/A N/A 1 1 N/A 1 Low
Sussmilch-Leitch et al. (Sussmilch-Leitch et al., 2012) 1 0 0 1 1 0 0 1 1 0 0 1 0 1 0 1 Low
Al-Abbad et al. (Al-Abbad & Simon, 2013) 1 0 1 1 1 1 0 1 1 0 N/A N/A 1 1 N/A 1 Moderate
Cullinane et al. (Cullinane et al., 2014) 1 0 0 1 0 0 0 1 1 0 N/A N/A 1 1 N/A 1 Low
Dimitrios et al. (Dimitrios et al., 2013) 1 0 0 1 0 0 0 0 1 0 N/A N/A 0 1 N/A 0 C. Low
Hoogvliet et al. (Hoogvliet et al., 2013) 1 0 0 1 1 1 0 0 1 0 N/A N/A 1 1 N/A 1 Low
Ioppolo et al. (Ioppolo et al., 2013) 1 0 0 1 0 1 0 1 1 0 0 0 0 0 0 0 Low
Bannuru et al. (Bannuru et al., 2014) 1 0 0 1 1 1 0 1 1 0 N/A N/A 1 1 N/A 1 Moderate
Dingemanse et al. (Dingemanse et al., 2014) 1 0 0 1 1 1 0 0 1 0 N/A N/A 1 1 N/A 1 Low
Haslerud et al. (Haslerud et al., 2015) 1 0 0 1 1 1 1 1 1 0 1 0 0 1 1 0 Moderate
Loew et al. (Loew et al., 2014) 1 0 0 1 1 1 1 1 1 1 N/A N/A 1 1 N/A 1 Moderate
Mani-Babu et al. (Mani-Babu et al., 2015) 0 0 0 1 1 0 0 1 1 0 N/A N/A 0 1 N/A 1 Low
D-Charbonneau et al. (Desjardins-Charbonneau et al., 2015) 1 0 0 1 1 0 0 1 1 0 1 0 1 1 0 1 Moderate
D-Charbonneau et al. (Desjardins-Charbonneau et al., 2015) 1 0 0 1 1 0 0 1 1 0 1 0 1 1 0 0 Low
Desmeules et al. (Desmeules et al., 2015) 1 0 0 1 1 0 1 1 1 0 1 0 1 1 0 1 Moderate
Krey et al. (Krey et al., 2015) 0 P 0 1 0 1 0 1 0 0 N/A N/A 0 1 N/A 1 Low
Nogueira Júnior et al. (Nogueira Júnior & Júnior, 2015) 0 0 0 1 0 0 0 0 0 0 N/A N/A 0 1 N/A 0 C. Low
Scott et al. (Scott et al., 2014) 1 0 0 1 1 1 0 1 1 0 1 0 0 1 0 1 Moderate
Weber et al. (Weber et al., 2015) 1 0 0 1 0 1 0 1 1 0 0 0 0 1 1 1 Low
Boudreault et al., (Boudreault et al., 1017) 1 0 0 1 1 0 1 1 1 0 1 0 1 1 0 0 Moderate
Desmeules et al. (Desmeules et al., 2016a) 1 0 0 1 1 0 0 1 1 0 N/A N/A 1 1 N/A 0 Low
Desmeules et al. (Desmeules et al., 2016b) 1 0 0 1 1 0 1 1 1 0 N/A N/A 1 1 N/A 1 Moderate
Ortega-Castillo et al. (Ortega-Castillo & Medina-Porqueres, 2016) 1 1 0 1 1 1 0 1 1 0 N/A N/A 0 1 N/A 1 Moderate
McKivigan et al. (McKivigan et al., 2017) 0 0 0 1 1 1 0 1 1 0 N/A N/A 0 0 N/A 0 Low
Punnoose et al. (Punnoose et al., 2017) 1 0 0 1 1 1 0 1 1 0 1 0 0 0 0 1 Low
Liao et al. (Liao et al., 2018a) 1 1 0 1 1 1 0 1 1 0 0 0 0 1 1 1 Moderate
Liao et al. (Liao et al., 2018b) 1 0 0 1 1 1 0 1 1 1 0 0 0 1 1 1 Moderate
Lim et al. (Lim & Wong, 2018) 1 1 0 1 1 1 0 1 1 0 N/A N/A 1 1 N/A 1 Moderate
Lucado et al. (Lucado et al., 2018) 1 0 0 1 1 0 0 0 1 0 0 0 1 1 1 1 Low
Wilson et al. (Wilson et al., 2018) 1 1 0 1 1 1 0 0 1 0 1 1 1 1 1 1 Moderate
Hickey et al. (Hickey et al., 2019) 1 0 0 1 0 0 0 1 1 0 0 0 0 1 0 0 Low
Murphy et al. (Murphy et al., 2019) 1 1 0 1 1 1 0 1 1 0 1 1 1 1 1 1 High
Yan et al. (Yan et al., 2019) 1 0 0 1 1 1 0 1 1 0 0 0 0 1 0 1 Low

with low rating of OC (Rowe et al., 2012; Cullinane et al., 2014; 95% CI, [e2.21, 1.11]), or other physical therapy modalities.
Hickey et al., 2019) supported EE for treating LET, AT and PT. Mur-
phy et al. (Murphy et al., 2019) suggested that heavy eccentric calf
3.3.4. Manual therapy
training may be superior to both natural history by VISA-A: 20.6;
One study with moderate rating of OC (Loew et al., 2014) and
95% CI, [11.7, 29.5] and traditional physiotherapy by VISA-A: 17.70;
another with low rating of OC (Joseph et al., 2012) have concluded
95% CI, [3.75, 31.66], but may be inferior to other exercise in-
that existing evidence is insufficient to determine the efficacy of
terventions (very-low to low quality of evidence). A meta-analysis
deep friction massage in patients with tendinopathy. Two studies
with low rating of OC (Sussmilch-Leitch et al., 2012) identified
with low rating of OC (Hoogvliet et al., 2013; Lucado et al., 2018)
positive effects of EE in addition to LLLT at 12 weeks in patients with
supported joint mobilization and manipulation techniques for LET.
AT (pain VAS: 0.59, 95% CI, [1.11, 0.07]). A systematic review
Lucado et al. (Lucado et al., 2018) reported positive effects of
with low rating of OC (Hutchison et al., 2011) indicated that
mobilization with movement on pain reduction (VAS) of 0.43; 95%
beneficial effects of EE in combination with LLLT or ESWT was
CI, [0.15, 0.71] and grip strength improvement of 0.31; 95% CI, [0.11,
supported by some evidence. Nevertheless, the latter studies
0.51]. A study with low rating of OC (Desjardins-Charbonneau et al.,
(Hutchison et al., 2011; Sussmilch-Leitch et al., 2012) stated that EE
2015) indicated that MT may reduce pain in patients with RT,
was not superior to shockwave therapy at 16 weeks (VISA-A:e0.55;
however, whether it can improve function is unclear. Desjardins-
34
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Charbonneau et al. (Desjardins-Charbonneau et al., 2015) reported intervention ranged between (2e12 weeks) (Fig. 2).
a small but statistically significant reduction in pain of 1.1; 95% CI, ESWT intervention, either alone or combined with other in-
[0.6, 1.6] on VAS. A study with low rating of OC (Krey et al., 2015) terventions versus placebo or other interventions, revealed an
stated that current evidence suggest that tendon dry needling improvement (SMD) in pain reduction of 1.27; 95% CI, [0.89, 1.65]
improved patient-reported outcome measures in patients with (I2 ¼ 0.000%, p ¼ 0.560) at 1 month; 0.93; 95% CI, [0.55, 1.31]
tendinopathy. (I2 ¼ 0.000%, p ¼ 0.688) at > 1 month and 3 months; 1.91; 95% CI,
[1.17, 2.66] (I2 ¼ 0.000%, p ¼ 0.913) at > 3 months and 6 months;
3.3.5. Ultrasound therapy and 1.99; 95% CI, [0.84, 3.15] (I2 ¼ 26.152%, p ¼ 0.245) at  12
A study with moderate rating of OC (Desmeules et al., 2015) months (Fig. 3). Moreover, ESWT intervention, either alone or
concluded that US therapy was not superior to placebo, LLLT, or ET. combined with other interventions versus placebo or other in-
Desmeules et al. (Desmeules et al., 2015) reported that US in terventions, demonstrated positive effects (SMD) on function of
conjunction with ET was not superior to ET alone (Constant-Murley 2.41; 95% CI, [1.66, 3.17] (I2 ¼ 0.000%, p ¼ 0.649) at 1 month, 1.41;
score: 0.26; 95% CI, [-3.84, 3.32]). One study with low rating of OC 95% CI, [0.83, 1.99] (I2 ¼ 0.000%, p ¼ 0.763) at > 1 month and 3
(Dingemanse et al., 2014) stated that US therapy was potentially months, 2.38; 95% CI, [1.41, 3.35] (I2 ¼ 0.000%, p ¼ 0.907) at > 3
effective for the management of LET. A study with low rating of OC months and 6 months, and 3.44; 95% CI, [1.45, 5.44] (I2 ¼ 43.51%,
(Yan et al., 2019) compared US therapy to ESWT and indicated that p ¼ 0.183) at  12 months (Fig. 4).
US therapy was less effective in reducing pain and improving
function in patients with LET. Inconclusive evidence regarding the 4. Discussion
efficacy of US for the treatment of AT was reported in one study
with low rating of OC (Rowe et al., 2012). The identified reviews assessed the efficacy of a variety of
physical therapy interventions for tendinopathy. Nonetheless, the
3.3.6. Orthotic therapy identified evidence was insufficient to discuss all of these in-
A study with moderate rating of OC (Desjardins-Charbonneau terventions. The GRADE principles (Group, 2004) were subse-
et al., 2015) stated that there was insufficient evidence to deter- quently used to appraise results of the present review in order to
mine the efficacy of kinesiology taping or non-elastic taping used determine the quality of evidence. Moderate-quality evidence that
alone or in addition to other interventions for the management of may support the efficacy of low-level laser therapy, extracorporeal
RT. Desjardins-Charbonneau et al. (Desjardins-Charbonneau et al., shockwave therapy, and exercise therapy was found. The discussion
2015) reported that kinesiology taping alone improved pain-free section, therefore, will cover these interventions primarily.
flexion by 8.7; 95% CI, [8.0, 9.5] and pain-free abduction by 10.3; Exercise therapy (ET) demonstrated positive effects in reducing
95% CI, [9.1, 11.4]. Another study with moderate rating of OC (Scott pain and improving function (Lim & Wong, 2018; Ortega-Castillo &
et al., 2014) concluded that foot orthoses were equivalent to Medina-Porqueres, 2016; Wilson et al., 2018). The efficacy of
physical therapy or no treatment (weak evidence), and that the use eccentric exercise (EE), in particular, was supported by several SRs
of adhesive taping alone or combined with foot orthoses was (Lim & Wong, 2018; Murphy et al., 2019; Ortega-Castillo & Medina-
supported by very weak evidence. Conflicting evidence regarding Porqueres, 2016; Wilson et al., 2018). EE seems to be more suitable
the efficacy of AirHeel™ brace was reported (Rowe et al., 2012; for long-term pain reduction and improvement in function, while
Scott et al., 2014), whereas the addition of night splints to EE was isometric exercises appear to more effective for short-term pain
opposed by one study with moderate rating of OC (Wilson et al., relief (Lim & Wong, 2018). Moderate-quality evidence, moreover,
2018) and two studies with low rating of OC (Rowe et al., 2012; recommended EE over concentric exercise for reducing pain
Sussmilch-Leitch et al., 2012). In-shoe foot orthoses was supported (Wilson et al., 2018). No significant difference was found between
by limited evidence (Rowe et al., 2012). EE and heavy slow resistance exercise in reducing pain or
improving function (Wilson et al., 2018). Nonetheless, a
3.3.7. Transcutaneous electrical nerve stimulation statistically-significant difference was found between high-dose
One study with moderate rating of OC (Desmeules et al., 2016b) and low-dose eccentric training in pain reduction of 6.3 mm; 95%
and one study with low rating of OC (Dingemanse et al., 2014) CI, [4.45, 17.04] (Wilson et al., 2018) on VAS. This difference,
indicated that existing evidence was inadequate to support the however, may not be clinically significant since the minimal clini-
effectiveness of TENS to treat RT or LET. cally important difference (MCID) in pain reduction was reported to
be 1.4 cm (Tashjian, Deloach, Porucznik, & Powell, 2009).
3.3.8. Iontophoresis The results of the current review regarding EE are consistent
One study with low rating of OC (McKivigan et al., 2017) and one with literature (Carcia et al., 2010; Burcal, Rosen, Taylor, & Nicola,
with critically low rating of OC (Dimitrios et al., 2013) concluded 2019). Even-though ET, EE in particular, seems to be the most
that evidence to determine the efficacy of iontophoresis in treating supported intervention in literature, it was merely supported by
patients with LET was inconclusive. A Summary of characteristics of qualitative evidence. In the current review, likewise, no quantita-
studies is provided in Table 3. tive evidence for the efficacy of ET was found. Several potential
mechanisms have been proposed to explain the efficacy of EE,
3.4. Results of the meta-analysis including neuromuscular alterations (O’Neill, Watson, & Barry,
2015), increased collagen synthesis, and pain habituation
Only 5 MAs with moderate rating of OC (Tumilty et al., 2010; (Murtaugh & Ihm, 2013). The optimal protocol and dosage of ex-
Haslerud et al., 2015; Boudreault et al., 1017; Liao et al., 2018a; Liao ercise, however, remain unknown (Couppe
et al., 2015; Littlewood
et al., 2018b) showed sufficient quality and homogeneity for the et al., 2015; Meyer et al., 2009; Raman, MacDermid, & Grewal,
meta-analytic procedures to be plausible and meaningful. Sensi- 2012; Young, Rhon, de Zoete, Cleland, & Snodgrass, 2018).
tivity analysis was not performed due to the small number of Notably, since the pathogenesis of tendinopathy may include
studies. LLLT intervention, either alone versus placebo or combined overuse and the optimal protocol is currently unknown, the
with exercise versus exercise plus placebo, showed an improve- “appropriate” dosage of exercise may be difficult to establish, which
ment (MD) in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] may hinder the applicability and safety of ET.
(I2 ¼ 1.9%, p ¼ 0.361) on VAS. The follow-up period for LLLT Extracorporeal shockwave therapy (ESWT) showed a
35
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Table 3
Summary of characteristics of studies. LLLT: Low-level laser therapy; LE, Lateral epicondylitis; MTrPs, Myofascial trigger points; RCTs, Randomized controlled trials; ESWT,
Extracorporeal shockwave therapy; RC, Rotator cuff; DFM, Deep friction massage; AT, Achilles tendinopathy; VAS, Visual analogue scale; CONSORT; Consolidated Standards of
Reporting Trials; LET, Lateral elbow tendinopathy; KT, Kinesiology taping; NET, Non-elastic taping; MT, Manual therapy; GTPS, Greater trochanteric pain syndrome; PT, Patellar
tendinopathy; MD, Mean difference; RR, Risk ratio; US, Ultrasound therapy; TENS, Transcutaneous electrical nerve stimulation; VISA-P, the Victorian Institute of Sport
Assessment-Patella questionnaire; VISA-A, the Victorian Institute of Sport AssessmenteAchilles Questionnaire; TSR, Treatment success rate; ROM, Range of motion; KSTDs,
knee soft tissue disorders; CI, Confidence interval; HSR, Heavy slow resistance; MWM, Mobilization with movement; HECT, Heavy eccentric calf training; The rating of overall
confidence (OC) was categorized, depending on fulfilled criteria, as follows; critically low (1-4), low (5-8), moderate (9-12), and high (13-16).

Studies Title Search strategy Results Conclusion OC

Tumilty et al. Low Level Laser Treatment of The following databases were Twenty-five controlled clinical LLLT can potentially be effective Moderate
(Tumilty et al., Tendinopathy: A Systematic searched from inception to trials met the inclusion criteria. in treating tendinopathy when
2010) Review with Meta-analysis August 1, 2008: MEDLINE, There were conflicting findings recommended dosages are used.
PubMed, CINAHL, AMED, from multiple trials: 12 showed The 12 positive studies provide
EMBASE, All EBM reviews, PEDro positive effects and 13 were strong evidence that positive
(Physiotherapy Evidence inconclusive or showed no effect. outcomes are associated with the
Database), SCOPUS. Controlled In two instances where pooling of use of current dosage
clinical trials evaluating LLLT as a data was possible, LLLT showed a recommendations for the
primary intervention for any positive effect size. treatment of tendinopathy.
tendinopathy were included in
the review.
Chang et al. (Chang Therapeutic Effects of Low-Level We searched several electronic We selected ten articles, and in We suggest that using LLLT on Low
et al., 2010) Laser on Lateral Epicondylitis databases, including Medline, seven of them the irradiation was tender points or MTrPs of LE
from Differential Interventions of PubMed, and CINAHL, and conducted on tender points or could effectively improve
Chinese-Western Medicine: explored studies that were MTrPs in the experimental therapeutic effects.
Systematic Review randomized controlled trials on groups. The results revealed that
the therapeutic effects of LLLT on applying LLLT on tender points or
LE from 1990 to February 2009. MTrPs is an effective means to
improve the effect size (ES) of
pain release after treatment
(pooled ES: 0.71, 95% CI: 0.82
e0.60) and follow-up (pooled ES:
1.05, 95% CI: 1.16e0.94).
Huisstede et al. Evidence for effectiveness of The Cochrane Library, PubMed, Seventeen RCTs (11 calcific, 6 This review shows that only high- Low
(Huisstede et al., Extracorporal Shock-Wave Embase, Pedro, and Cinahl were non-calcific) were included. For ESWT is effective for treating
2011) Therapy (ESWT) to treat calcific searched for relevant systematic calcific RC-tendinosis, strong calcific RC-tendinosis. No
and non-calcific rotator cuff reviews and RCTs. evidence was found for evidence was found for the
tendinosis e A systematic review effectiveness in favour of high- effectiveness of ESWT to treat
ESWT versus low-ESWT in short- non-calcific RC-tendinosis.
term. Moderate evidence was
found in favour of high-ESWT
versus placebo in short-, mid- and
long-term and versus low-ESWT
in mid- and long-term.
Hutchison et al. Is physiotherapy effective for A search of the following Nine publications met the review There is an insufficient evidence Low
(Hutchison et al., patients with a chronic mid-body electronic databases was inclusion criteria. Methodological to determine which method of
2011) Achilles tendinopathy? A conducted: Medline, CINAHL, quality was adequate for all nine physiotherapy is most
systematic review of non-surgical EMBASE, AMED, sports discuss, studies; however, blinding was a appropriate for a chronic mid-
and non-pharmacological web of knowledge, rehabilitation limitation for most. Interventions body Achilles tendinopathy.
interventions and sports medicine sources, investigated were; exercises
cochrane library, and PEDro (n ¼ 2), low-level laser therapy
(physiotherapy evidence (n ¼ 1), low-energy shockwave
database) (January 1999 to treatment (SWT) (n ¼ 3), air cast
January 2011). brace (n ¼ 2), and insoles (n ¼ 1).
Lee et al. (Lee et al., The midterm effectiveness of Articles were electronically Six of the nine included studies Our review suggests that ESWT is Moderate
2011) extracorporeal shockwave searched from the Cochrane scored 7 or more for moderately effective in reducing
therapy in the management of Controlled Trials Register, methodologic quality. All studies pain and improving function in
chronic calcific shoulder MEDLINE, CINAHL, PUBMED, had follow-up periods of at least 6 individuals with chronic shoulder
tendinitis EMBASE, SPORTSDiscus and months. Common methodologic calcific tendinitis, for up to a year
PEDro using a comprehensive flaws were insufficient blinding of after its application (Level of
search strategy. Studies were clinicians and assessors. There Evidence B).There is no clear
included if they were randomized was consistent evidence of evidence regarding the optimal
controlled trials testing the midterm effectiveness of ESWT in dosage in energy level, intervals
midterm effectiveness of ESWT reducing pain and improving between sessions, and number of
for chronic calcific tendonitis. shoulder function for patients sessions required for optimal
with chronic calcified tendinitis. recovery from the condition.
Joseph et al. Deep Friction Massage to Treat The authors surveyed research Nine studies met the inclusion The varied locations, study Low
(Joseph et al., Tendinopathy: A Systematic articles in all languages by criteria. Evidence Synthesis: The designs, etiopathogenesis, and
2012) Review of a Classic Treatment in searching PubMed, Scopus, Pedro, heterogeneity of dependent outcome tools used to examine
the Face of a New Paradigm of CINAHL, PsycINFO, and the measures did not allow for meta- the efficacy of DFM make a
Understanding Cochrane Library. analysis. unified conclusion tenuous.
Littlewood et al. Exercise for rotator cuff An electronic search of AMED, Five articles detailing four studies The available literature is Low
(Littlewood tendinopathy: a systematic CiNAHL, Cochrane Central were included, all of which were supportive of the use of exercise
et al., 2012) review Register of Controlled Trials regarded as presenting a low risk but due to the paucity of research
(CENTRAL), MEDLINE, PEDro and of bias. Overall, the literature was and associated limitations further
SPORTDiscus was undertaken supportive of the use of exercise study is indicated.
from their inception to November in terms of pain and functional
2010 and supplemented by hand disability.

36
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Table 3 (continued )

Studies Title Search strategy Results Conclusion OC

searching related articles and

contact with topic experts.
Rowe et al. (Rowe Conservative management of Searches of the electronic 47 studies fulfilled the inclusion Empirical research indicates Low
et al., 2012) mid-portion Achilles databases, criteria. Evidence was strong for strong evidence for eccentric
tendinopathy: a mixed methods PubMed, ISI Web of Science, eccentric loading exercises and loading exercises and extra-
study, integrating systematic PEDro, CINAHL, Embase, and extracorporeal shockwave corporeal shockwave therapy and
review and clinical reasoning Google Scholar were conducted therapy; moderate for, splinting/ moderate evidence for low-level
for all papers published from bracing, active rest, low-level laser therapy. Additionally, the
inception to November 2011. laser therapy and concentric physiotherapists interviewed
exercises (i.e. inferior to eccentric reported anecdotal evidence for
exercise). In-shoe foot orthoses concentric exercises, soft-tissue
and therapeutic ultrasound had mobilizations and foot orthoses.
limited evidence.
Sussmilch-Leitch Physical therapies for Achilles Reference lists of eligible papers Four studies were excluded due Practitioners can consider Low
et al. tendinopathy: systematic review were hand-searched. to high risk of bias, leaving 19 eccentric exercise as an initial
(Sussmilch- and meta-analysis Randomized controlled trials studies, the majority of which intervention for AT, with the
Leitch et al., (RCTs) were included if they evaluated midportion AT. Effect addition of laser therapy as
2012) evaluated at least one non- sizes from individual RCTs appropriate. Shock wave therapy
pharmacological, non-surgical support the use of eccentric may represent an effective
intervention for AT using at least exercise. Meta-analyses identified alternative. High-quality RCTs
one outcome of pain and/or significant effects favouring the following CONSORT guidelines
function. addition of laser therapy to are required to further evaluate
eccentric exercise at 12 weeks the efficacy of physical therapies
(pain VAS: standardized mean and determine optimal clinical
difference 0.59, 95% confidence pathways for AT.
interval 1.11 to 0.07).
Al-Abbad et al. (Al- The Effectiveness of Articles were electronically Four of the included studies were Overall, our review showed Moderate
Abbad & Simon, Extracorporeal Shock Wave searched from the Cochrane randomized controlled trials, and satisfactory evidence for the
2013) Therapy on Chronic Achilles Controlled Trials Register, 2 were pre-post study designs. effectiveness of low-energy ESWT
Tendinopathy: A Systematic MEDLINE, CINAHL, EMBASE, and Common methodological in the treatment of chronic
Review SPORTDiscus using a deficiencies included not blinding insertional and noninsertional
comprehensive search strategy. the clinician and participants. Achilles tendinopathies at a
There was consistent evidence minimum 3 months’ follow-up
from 4 reviewed studies on the before considering surgery if
effectiveness of ESWT in the other conservative management
management of patients with fails.
chronic Achilles tendinopathies at
a minimum 3 months’ follow-up.
Cullinane et al. Is eccentric exercise an effective Six electronic databases were Twelve studies met the inclusion The majority of consistent Low
(Cullinane et al., treatment for lateral searched (ProQuest, Medline via criteria. Following treatment, all findings support the inclusion of
2014) epicondylitis? A systematic EBSCO, AMED, Scopus, Web of groups inclusive of eccentric eccentric exercise as part of a
review Science, and CINAHL). A exercise reported decreased pain multimodal therapy programme
systematic review was and improved function and grip for improved outcomes in
undertaken to identify strength from baseline. Seven patients with lateral
randomized and controlled studies reported improvements epicondylitis.
clinical trials incorporating in pain, function, and/or grip
eccentric exercise as a treatment strength for therapy treatments
for patients diagnosed with inclusive of eccentric exercise
lateral epicondylitis. when compared with those
excluding eccentric exercise.
Dimitrios et al. Effectiveness of Iontophoresis for Randomized controlled trials Four RCTs fulfilled the criteria and Iontophoresis need not be ruled C. Low
(Dimitrios et al., Lateral Elbow Tendinopathy (RCTs) identified by a search were included in the review. out for LET as it is a dose-response
2013) strategy in six databases were Although these studies had modality, and the optimal
used in combination with satisfactory methodology, treatment dose has obviously not
reference checking. RCTs that shortcomings were not absent; yet have been discovered. Further
included iontophoresis, patients conflicting results were revealed research with well-designed RCTs
with LET, and at least one of the as to the effectiveness of is needed to establish the
clinically relevant outcome iontophoresis for LET absolute and relative
measures were selected. A management. effectiveness of this intervention
qualitative analysis of the for LET.
selected studies was conducted
using the Chalmers’ technique.
Hoogvliet et al. Does effectiveness of exercise Searches in PubMed, Embase, One review and 12 RCTs, all Although not yet conclusive, Low
(Hoogvliet et al., therapy and mobilization Cinahl and Pedro were performed studying lateral epicondylitis, these results support the belief
2013) techniques offer guidance for the to identify relevant randomized were included. Different that strength training decreases
treatment of lateral and medial clinical trials (RCTs) and therapeutic regimes were symptoms in tendinosis. The
epicondylitis? A systematic systematic reviews. evaluated: stretching, short-term analgesic effect of
review strengthening, concentric/ manipulation techniques may
eccentric exercises and allow more vigorous stretching
manipulation of the cervical or and strengthening exercises.
thoracic spine, elbow or wrist. No
statistical pooling of the results
could be performed owing to
(continued on next page)

37
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Table 3 (continued )

Studies Title Search strategy Results Conclusion OC

heterogeneity of the included

studies.
Ioppolo et al. Clinical Improvement and Articles were searched from the 6 studies were included for SWT increases shoulder function, Low
(Ioppolo et al., Resorption of Calcifications in Cochrane Library, MEDLINE, review. We found a clinical reduces pain, and is effective in
2013) Calcific Tendinitis of the Shoulder Embase, CINAHL, and Ovid improvement with a pooled total dissolving calcifications. These
After Shock Wave Therapy at database. resorption ratio of 27.19 (95% results were maintained over the
6 Months’ Follow-Up: A confidence interval [CI], following 6 months.
Systematic Review and Meta- 7.20e102.67) and a pooled partial
Analysis resorption ratio of 16.22 (95% CI,
3.33e79.01).
Bannuru et al. High-Energy Extracorporeal MEDLINE, Cochrane Central Twenty-eight RCTs met the High-energy ESWT is effective for Moderate
(Bannuru et al., Shock-Wave Therapy for Treating Register of Controlled Trials, inclusion criteria. Studies were improving pain and shoulder
2014) Chronic Calcific Tendinitis of the EMBASE, Web of Science, and heterogeneous. Twenty RCTs function in chronic calcific
Shoulder Google Scholar were searched up compared ESWT energy levels shoulder tendinitis and can result
to November 1, 2013. and placebo and consistently in complete resolution of
showed that high-energy ESWT calcifications
was significantly better than
placebo in decreasing pain and
improving function and
resorption of calcifications in
calcific tendinitis.
Dingemanse et al. Evidence for the effectiveness of Searches in PubMed, EMBASE, A total of 2 reviews and 20 RCTs Potential effectiveness of Low
(Dingemanse electrophysical modalities for CINAHL and Pedro were were included, all of which ultrasound and laser for the
et al., 2014) treatment of medial and lateral performed to identify relevant concerned LE. Moderate evidence management of LE was found. To
epicondylitis: a systematic review randomized clinical trials (RCTs) was found for the effectiveness of draw more definite conclusions
and systematic reviews. ultrasound versus placebo on high-quality RCTs examining
mid-term follow-up. Ultrasound different intensities are needed as
plus friction massage showed well as studies focusing on long-
moderate evidence of term follow-up results.
effectiveness versus laser therapy
on short-term follow-up.
Haslerud et al. The Efficacy of Low-Level Laser A literature search for Seventeen randomized controlled This review shows that optimal Moderate
(Haslerud et al., Therapy for Shoulder randomized controlled clinical trials met the inclusion criteria. LLLT can offer clinically relevant
2015) Tendinopathy: A Systematic trials was performed on Medline, Significant and clinically pain relief and initiate a more
Review and Meta-Analysis of PubMed, Embase, CINAHL, PEDro important pain relief was found rapid course of improvement,
Randomized Controlled Trials and the Cochrane Controlled Trial with weighted mean differences both alone and in combination
Register databases. (WMD) over placebo, for LLLT as with physiotherapy
monotherapy at 20.41 mm (95% interventions.
CI: 12.38 to 28.44) and as adjunct
to exercise therapy at 16.00 mm
(95% CI: 11.88 to 20.12) pain
reduction on VAS.
Loew et al. (Loew Deep transverse friction massage We searched the following Two RCTs met the inclusion We do not have sufficient Moderate
et al., 2014) for treating lateral elbow or electronic databases: the criteria. No statistically significant evidence to determine the effects
lateral knee tendinitis (Review) specialized central registry of the differences were reported within of deep transverse friction on
Cochrane Field of Physical and five weeks for mean change in pain, improvement in grip
Related Therapies, the Cochrane pain (VAS) (MD -6.60, 95%CI strength, and functional status for
Central Register of Controlled -28.60 to 15.40; 7% absolute patients with lateral elbow
Trials (CENTRAL), MEDLINE, improvement), grip strength (MD tendinitis or knee tendinitis, as no
EMBASE, the Cumulative Index to 0.10, 95% CI -0.16 to 0.36) and evidence of clinically important
Nursing and Allied Health function (MD -1.80, 95% CI benefits was found.
Literature (CINAHL), Clinicaltrials. -0.18.64 to 15.04; 2%
gov, and the Physiotherapy improvement), pain-free function
Evidence Database (PEDro), up index (MD 1.10, 95% CI -1.00 to
until July 2014. 3.20) and functional status (RR
3.3, 95% CI 0.4 to 24.3).
Mani-Babu et al. The Effectiveness of PubMed (Medline), Embase, Web A total of 20 studies were Extracorporeal shock wave Low
(Mani-Babu Extracorporeal Shock Wave of Knowledge, Cochrane, and identified. Moderate evidence therapy is an effective
et al., 2015) Therapy in Lower Limb CINAHL were searched from indicates that ESWT is more intervention and should be
Tendinopathy. A Systematic inception to February 2013 for effective than eccentric loading considered for GTPS, PT, and AT
Review studies of any design for insertional AT and equal to particularly when other
investigating the effectiveness of eccentric loading for midportion nonoperative treatments have
ESWT in GTPS, PT, and AT. AT in the short term. Additionally, failed.
there is moderate evidence that
combining ESWT and eccentric
loading in midportion AT may
produce superior outcomes to
eccentric loading alone.
Desjardins- THE EFFICACY OF TAPING FOR An electronic bibliographical Ten RCTs were included in the Although KT significantly Moderate
Charbonneau ROTATOR CUFF TENDINOPATHY: search in MEDLINE, EMBASE, the present review. Based on pooled improved pain free range of
et al. A SYSTEMATIC REVIEW AND Physiotherapy Evidence Database results of two studies (n ¼ 72), KT motion, there is insufficient
(Desjardins- META-ANALYSIS (PEDro) and the Cumulative Index used alone resulted in significant evidence to formally conclude on
Charbonneau to Nursing & Allied Health gain in pain free flexion (MD: 8.7 the efficacy of KT or NET used
et al., 2015) Literature (CINAHL) was 95%CI 8.0 e9.5 ) and in pain free alone or in conjunction with
conducted in order to identify

38
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Table 3 (continued )

Studies Title Search strategy Results Conclusion OC

citations indexed until October abduction (MD: 10.3 95%CI 9.1 other interventions in patients
2014. e11.4 ). with RC tendinopathy.
Desjardins- The Efficacy of Manual Therapy An electronic bibliographical Twenty-one studies were For patients with RC Low
charbonneau for Rotator Cuff Tendinopathy: search was conducted in included. A small but statistically tendinopathy, based on low- to
et al. A Systematic Review and Meta- MEDLINE, Embase, PEDro, and significant overall effect for pain moderate-quality evidence, MT
(Desjardins- analysis CINAHL from their dates of reduction of MT compared with a may decrease pain; however, it is
Charbonneau inception to June 2014. placebo or in addition to another unclear whether it can improve
et al., 2015) intervention was observed function.
(n ¼ 406), which may or may not
be clinically important.
Desmeules et al. The efficacy of therapeutic We searched four bibliographical Eleven RCTs were included. Based on low to moderate level Moderate
(Desmeules ultrasound for rotator cuff databases: PubMed, PeDRO, Therapeutic US did not provide evidence, therapeutic US does not
et al., 2015) tendinopathy: A systematic CINAHL, EMBASE, from their date greater benefits than a placebo provide any benefit compared to
review and meta-analysis of inception to December 2013. intervention or advice in terms of a placebo or advice, to laser
Reference lists of retrieved pain reduction and functional therapy or when combined to
studies and previous systematic improvement. exercise
reviews were also searched to
identify additional relevant
publications
Krey et al. (Krey Tendon needling for treatment of A literature review was In 2 studies evaluating tendon The evidence suggests that Low
et al., 2015) tendinopathy: A systematic completed using Medline and needling in lateral epicondylosis, tendon needling improves
review Cochrane Database searches up to one showed an improvement in a patient-reported outcome
November 2013 to identify all subjective visual analogue scale measures in patients with
English-language and translated score of 34% (significant change tendinopathy. There is a trend
clinical papers that evaluated the >25%) from baseline at 6 months. that shows that the addition of
use of tendon needling for the The other showed an autologous blood products may
treatment of tendinosis. improvement of 56.1% in a visual further improve theses outcomes.
analogue scale score from
baseline.
Nogueira Júnior THE EFFECTS OF LASER A search was performed in the Three studies were included. After the analysis, we selected C. Low
et al. (Nogueira TREATMENT IN TENDINOPATHY: electronic databases Pub-Med, Conclusions about the three articles that showed that
Júnior & Júnior, A SYSTEMATIC REVIEW Medline, Capes Journals Database effectiveness of low-intensity the use of low-level laser therapy,
2015) and Latin American and laser therapy cannot be made due compared to placebo, is effective
Caribbean Health Sciences to the low statistical power of the in treatment of tendinopathy.
Literature (LILACS), without study. The low intensity laser in
restrictions regarding the period this dosage can reduce
of publication. inflammation in activated
Achilles tendinitis. There was an
acceleration of the recovery
process when laser was
associated with an eccentric
exercise program.
Scott et al. (Scott Effectiveness of Orthotic Devices Electronic bibliographic Twelve studies satisfied the The findings of this study indicate Moderate
et al., 2014) in the Treatment of Achilles databases (MEDLINE, EMBASE, inclusion criteria; nine studies that foot orthoses, the AirHeel
Tendinopathy: A Systematic Current Contents, CINAHL and investigated mid-portion AT, brace, and ankle joint dorsiflexion
Review SPORTDiscus) were searched in whilst three studies did not night splints are equivalent to calf
May 2014. distinguish between mid-portion muscle eccentric exercises in the
and insertional pathology. Weak management of mid-portion AT.
evidence showed that foot
orthoses were equivalent to
physical therapy, and equivalent
to no treatment.
Weber et al. Efficacy of physical therapy for We searched PUBMED, EMBASE 16 studies met inclusion criteria. Differences between treatment Low
(Weber et al., the treatment of lateral and the Cochrane Database until Analyses were conducted for and control groups were larger
2015) epicondylitis: a meta-analysis April 2012 using medical subject overall pain relief, pain relief than differences between
headings related to epicondylitis during maximum handgrip treatments. Control group gains
when possible. strength tests, and maximum were 50e66% as high as
handgrip strength. There were treatment group gains.
not enough studies to conduct an
analysis of physical function or
other outcome variables.
Boudreault et al., The Efficacy of Laser Therapy for A literature search was conducted Thirteen RCTs were included. It Low to moderate grade evidence Moderate
(Boudreault Rotator Cuff Tendinopathy: in Pubmed, CINAHL, Embase and was concluded that LT may supports that LT may reduce pain
et al., 1017) A Systematic Review and Meta- PEDro databases for randomized provide short-term pain relief of in the short term in adults with
Analysis controlled trials (RCTs) published minimally significant clinical RC tendinopathy, while its effects
until May 2014, comparing the importance compared to placebo, on function and ROM are not
efficacy of LT to any other ultrasound therapy, or clinical supported.
intervention. recommendations alone.
Desmeules et al. Efficacy of exercise therapy in A literature search in four Ten studies were included. Three There is low to moderate-grade Low
(Desmeules workers with rotator cuff bibliographical databases RCTs of moderate methodological evidence that therapeutic
et al., 2016a) tendinopathy: a systematic (Pubmed, CINAHL, EMBASE, and quality concluded that exercises exercises provided in a clinical
review PEDro) was conducted from were superior to a placebo or no setting are an effective modality
inception up to February 2015. intervention in terms of function to treat workers suffering from RC
and return-to-work outcomes.
(continued on next page)

39
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Table 3 (continued )

Studies Title Search strategy Results Conclusion OC

tendinopathy and to promote

return-to-work.
Desmeules et al. Efficacy of transcutaneous A literature search was conducted Six studies were included in this Due to the limited number of Moderate
(Desmeules electrical nerve stimulation forin four databases (CINAHL, review. One placebo-controlled studies and the overall high risk
et al., 2016b) rotator cuff tendinopathy: a Embase, Pubmed and PeDRO) for trial reported that a single TENS of bias of the studies included in
systematic review randomized controlled trials session provided immediate pain this review, no conclusions can be
published from date of inception reduction for patients with drawn on the efficacy of TENS for
until April 2015, comparing the rotator cuff tendinopathy, but did the treatment of rotator cuff
efficacy of TENS for the treatment not follow the participants in the tendinopathy.
of rotator cuff tendinopathy with short, medium or long term.
placebo or any other intervention.
Ortega-Castillo Effectiveness of the eccentric Relevant randomized controlled In 11 studies, pain decreased Eccentric exercise may reduce Moderate
et al. (Ortega- exercise therapy in physically trials (RCTs) were sourced using significantly with eccentric pain and improve strength in
Castillo & active adults with symptomatic MEDLINE, SPORT Discus, exercise, but only in five studies, upper limb tendinopathies, but
Medina- shoulder impingement or lateral Physiotherapy Evidence Database the reduction was significantly whether its effectiveness is much
Porqueres, epicondylar tendinopathy: A (PEDro) and CINAHL databases. better than in the non-eccentric better than other forms of
2016) systematic review group (in all or some of the treatment remains questionable.
parameters).
McKivigan et al. A Systematic Review on the The following databases were Fourteen relevant studies were Based on this review, it is not Low
(McKivigan Efficacy of Iontophoresis as a searched for relevant articles: identified. Twelve were conclusive that iontophoresis be
et al., 2017) Treatment for Lateral PubMed, Cochrane Library, experimental in vivo studies, two recommended as a treatment
Epicondylitis PEDro, SPORT Discus, Google were review studies. All studies approach for the management of
Scholar, and the APTA library. were published 2002 through epicondylitis, however
2015, providing a robust iontophoresis should not be ruled
overview of treatments over the out in treating epicondylitis as it
last 15 years. is a dose-response modality.
Punnoose et al. Extracorporeal Shock Wave A systematic review and meta- Nine studies met the inclusion The meta-analysis did not Low
(Punnoose et al., Therapy for Achilles and Patellar analysis was conducted using criteria. Meta-analysis showed no demonstrate a statistically
2017) Tendinopathy: Meta-Analysis and MEDLINE, EMBASE, AMED, significant differences between significant improvement in
a Systematic Review of the CINAHL, PEDro and Cochrane the intervention and control symptoms or load induced pain
Literature databases and bibliographic group on the pooled VISA-A for ESWT compared to other
searches from inception until scores (p ¼ 0.59, 95% CI-15.02, treatments or control. Adequately
April 2013 to identify randomized 26.51) or load-induced pain powered, high quality studies
control trials comparing ESWT (p ¼ 0.51, 95% CI-3.15, 1.56) for with longer follow-ups are
with other treatment methods. Achilles tendinopathy and no required.
significant differences between
the pooled VISA-P scores for
patellar tendinopathy (p ¼ 0.27,
CI-7.86, 27.87).
Liao et al. (Liao Efficacy of Extracorporeal Shock The articles were obtained from 29 RCTs were included. General ESWT exerted a positive overall Moderate
et al., 2018a) Wave Therapy for Lower the following online databases ESWT showed significant effects effect on pain and function for LE
Extremity Tendinopathy: A Meta- and search engines: Medline, at the immediate follow-up [pain tendinopathy. Shock wave types
analysis of Randomized PubMed, the Excerpta Medica score: standardized mean and dosage levels may have
Controlled Trials dataBASE, the Cochrane Library difference (SMD) ¼ 1.41, 95% different contributions to
Database, the Physiotherapy confidence interval (CI) ¼ 2.01 treatment efficacy.
Evidence Database (PEDro), the to 0.82, P < 0.00001; function:
China Knowledge Resource SMD ¼ 2.59, 95% CI ¼ 1.54e3.64,
Integrated Database, and Google P < 0.00001] as well as at 3, 6, and
Scholar. 12 months.
Liao et al. (Liao Efficacy of extracorporeal shock A comprehensive search of online 19 RCTs were included. ESWT had The ESWT exerts an overall effect Moderate
et al., 2018b) wave therapy for knee databases and search engines was overall significant effects on the on the TSR, pain reduction, and
tendinopathies and other soft performed up to June 2018. TSR (OR: 3. ROM restoration in patients with
tissue disorders: a meta-analysis Primary sources were MEDLINE, 36, 95% CI: 1.84e6.12, KSTDs. Shock-wave types and
of randomized controlled trials PubMed, the Excerpta Medica P < 0.0001), pain reduction application levels have different
dataBASE, the (SMD:  1.49, 95% CI:  2.11 contributions to treatment
Cochrane Library, the to  0.87, P < 0.00001), and ROM efficacy for KSTDs, which must be
Physiotherapy Evidence Database restoration (SMD: 1.76, 95% CI: investigated further for
(PEDro), the China Knowledge 1.43e2.09, P < 0.00001). optimizing these treatments in
Resource Integrated Database, clinical practice.
and Google Scholar.
Lim et al. (Lim & Effects of isometric, eccentric, or Academic journals from CINAHL, Fifteen studies (3 isometric, 2 Findings from isometric exercises Moderate
Wong, 2018) heavy slow resistance exercises Embase, MEDLINE, Scopus, HSR, and 10 eccentric) were can be trusted to guide clinical
on pain and function in SPORTDiscus™, and The included for this review. Nine practice (Grade A), whereas
individuals with patellar Cochrane Library were searched studies were randomized eccentric exercises can be trusted
tendinopathy: A systematic from inception to August 2017. controlled trials, which provided to guide clinical practice in most
review good Level II evidence; four clinical situations (Grade B). It is
studies were of satisfactory Level recommended that HSR exercises
III evidence; and two studies should be applied carefully to
were case series (Level IV individual clinical circumstances
evidence). (Grade C) and interpreted with
care.
Lucado et al. Do joint mobilizations assist in A comprehensive English A total of 20 studies met the There is compelling evidence that Low
(Lucado et al., the recovery of lateral elbow language literature search was inclusion criteria; 7 were joint mobilizations directed at the
2018) tendinopathy? A systematic performed using the following included in the meta-analysis. elbow improve both pain and
review and meta-analysis computerized databases: CINAHL, Pooled data across all time functional grip scores across all

40
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Table 3 (continued )

Studies Title Search strategy Results Conclusion OC

PubMed, and PEDro up to June periods demonstrated a mean time frames compared to control
2017. effect size of 0.43 (95% confidence groups in the management of LET.
interval [CI]: 0.15e0.71) for
MWM on improving pain rating,
and 0.31 (95% CI: 0.11e0.51) for
MWM on improving grip
strength, 0.47 (95% CI: 0.11e0.82)
for Mill’s manipulation on
improving pain rating
Wilson et al. Exercise, orthoses and splinting Medline, CINAHL, Embase, AMED, Twenty-two studies were We conditionally recommend Moderate
(Wilson et al., for treating Achilles WHO-ICTRP, Web of Science, included. Moderate level exercise for improving pain and
2018) tendinopathy: a systematic PEDro and Cochrane Library from evidence favoured eccentric function in mid-portion Achilles
review with meta-analysis inception to October 2017. exercise over control for tendinopathy. The balance of
improving pain and function in evidence did not support
mid-portion tendinopathy. recommendation of one type of
Moderate level evidence favoured exercise programme over
eccentric exercise over concentric another.
exercise for reducing pain. There
was moderate level evidence of
no significant difference in pain
or function between eccentric
exercise and heavy slow
resistance exercise.
Hickey et al. The Long-Term Effects of Search procedures followed A fixed effects model was used to Eccentric exercise is the Low
(Hickey et al., Eccentric Exercise Vs. PRISA guidelines using the compare the interventions. treatment of choice for athletes
2019) Extracorporeal Shockwave PubMed, CINAHL, and Cochrane Eccentric Exercise was found to with patellar tendinopathy, while
Therapy in Athletes Aged 18-50 Library databases. have very large effect sizes of extracorporeal shockwave
with Lower Extremity 2.363 (1.075, 3.651) and 18.790 therapy is a viable secondary
Tendinopathy: A Meta-Analysis (8.604, 28.977) for improving option for patients that fail to
and Systematic Review pain and function respectively respond to eccentrics alone.
when compared with
extracorporeal shockwave
therapy.
Murphy et al. Efficacy of heavy eccentric calf PUBMED, CINAHL (Ovid) and Seven studies met the inclusion Current evidence suggests that High
(Murphy et al., training for treating mid-portion CINAHL (EBSCO) were searched criteria. This review suggests HECT may be superior to natural
2019) Achilles tendinopathy: a from inception until September HECT may be superior to both history and traditional
systematic review and meta- 24, 2018. natural history, mean difference physiotherapy while HECT may
analysis (MD) (95% CI) of 20.6 (11.7e29.5, be inferior to other exercise
one study) and traditional interventions.
physiotherapy, MD (95% CI) of
17.70 (3.75e31.66, two studies).
Yan et al. (Yan A comparative study of the RCTs published in the PubMed, Five RCTs comprising five Although there was no significant Low
et al., 2019) efficacy of ultrasonics and Embase, Cochrane Library, and patients were included in the difference in the elbow function
extracorporeal shock wave in the SpringerLink databases present meta-analysis. The evaluation scores between ESWT
treatment of tennis elbow: a comparing ESWT and US in results revealed a significantly and US, the superiority of the
metaanalysis of randomized treating tennis elbow were lower VAS score of pain in the ESWT group in the VAS of pain
controlled trials identified by a software and ESWT group (1 month: (both at 1 month, 3months, and 6
manual search. MD ¼ 4.47, p ¼ 0.0001; 3months: months follow-ups) raised grip
MD ¼ 20.32, p < 0.00001; and 6 strength in ESWT group and the
months: MD ¼ 4.32, p < 0.0001) scores for subjective evaluation of
compared to US. efficacy indicated that ESWT
offers more effective therapy for
lateral epicondylitis than US
therapy.

statistically-significant reduction of pain and improvement of expression of MMP-1, MMP-13 and IL-6 in vitro (Han et al., 2009),
function (Liao et al., 2018a, 2018b) at all follow-up periods (<1 but an elevation of IL-6, IL-8, MMP-2, and MMP-9 concentrations
month to >12 months). The clinical significance of these results, were reported immediately after ESWT in vivo (Waugh et al., 2015).
nonetheless, was undetermined, since the reported values were not Low-level laser therapy (LLLT) revealed a pooled reduction in
absolute values (standardized mean differences). The beneficial pain of 1.53 cm on VAS scale (Tumilty et al., 2010; Haslerud et al.,
effects of ESWT for calcific tendinitis was supported by two studies 2015; Boudreault et al., 1017) and an improvement in function;
(Bannuru et al., 2014; Lee et al., 2011). Shockwave type and appli- grip strength of 9.59 kg (Tumilty et al., 2010). The reported reduc-
cation parameters may contribute differently to treatment efficacy tion in pain may be clinically significant, since the MCID has been
(Al-Abbad & Simon, 2013; Liao et al., 2018a, 2018b; Verstraelen, determined to be a reduction of 1.4 cm in patients with RT (Tashjian
Jansen, & Morrenhof, 2014). The results of the current review are et al., 2009). Other studies, however, have stated that the MCID for
consistent with a systematic review by Burcal et al. (Burcal et al., pain may range between 13 mm and 28 mm, depending on the
2019) regarding the efficacy of ESWT for pain reduction. The effi- severity of the condition (Bird & Dickson, 2001; Todd, 2001). The
cacy of ESWT in treating tendinopathy has been also reported by stated improvement in grip strength may also be clinically signifi-
other studies (Gerdesmeyer et al., 2015; Ko & Wang, 2018, pp. cant, as the MCID in grip strength was estimated to be 6e6.5 kg
27e41), but the optimal parameters of treatment were not identi- (Kim, Park, & Shin, 2014; Nitschke, McMeeken, Burry, & Matyas,
fied (Ko & Wang, 2018, pp. 27e41). ESWT was shown to reduce the 1999). It must be highlighted that these beneficial effects were

41
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Fig. 2. Forest plot of studies assessing the efficacy of LLLT intervention, either alone versus placebo or combined with exercise versus exercise plus placebo, in pain reduction
measured on the VAS scale. The follow-up period for LLLT intervention ranged between (2e12 weeks).

Fig. 3. Forest plot of studies evaluating the efficacy of ESWT intervention, either alone or combined with other interventions versus placebo or other interventions, in pain reduction
at different follow-up durations (Immediate: 1 month; Short-term: > 1 month and 3 months; Medium-term > 3 months and 6 months; Long-term:  12 months).

observed on the short-term (2e12 weeks), but the long-term ef- in several reviews in literature (Bjordal, Lopes-Martins, & Frigo,
fects are yet to be determined. The recommended doses must be 2015; Cotler, Chow, Hamblin, & Carroll, 2015; Posten et al., 2005).
applied to achieve these positive results (Tumilty et al., 2010; LLLT at low-doses was shown to enhance fibroblast proliferation
Haslerud et al., 2015; Boudreault et al., 1017). Moreover, LLLT was (Lubart, Wollman, Friedmann, Rochkind, & Laulicht, 1992), collagen
shown to be more effective than US in reducing pain (Desmeules synthesis, and tensile strength (Woodruff et al., 2004).
et al., 2015). The results of the current review regarding LLLT are Low to moderate level evidence showed that ultrasound therapy
consistent with the guidelines (Carcia et al., 2010). An umbrella did not provide benefit compared to placebo, LLLT, or combined to
review (Mamais, Papadopoulos, Lamnisos, & Stasinopoulos, 2018), exercise (Desmeules et al., 2015). Current evidence was insufficient
nevertheless, found poor results for the efficacy of LLLT in the to determine the efficacy of kinesiology taping or non-elastic taping
management of LET. Mechanisms of action of LLLT were proposed used alone or in conjunction with other interventions (Desjardins-

42
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Fig. 4. Forest plot of studies evaluating the efficacy of ESWT intervention, either alone or combined with other interventions versus placebo or other interventions, in function
improvement at different follow-up durations (Immediate: 1 month; Short-term: > 1 month and 3 months; Medium-term > 3 months and 6 months; Long-term:  12
months).

Charbonneau et al., 2015) (moderate-quality evidence). The results  Some of the identified reviews included the same studies.
for manual therapy, orthotic therapy, transcutaneous electric nerve However, it is unlikely that this has influenced the results since
stimulation, and iontophoresis were either inconclusive or con- the determining criteria of the overall quality of evidence
tradictory. Clar et al. (Clar, Tsertsvadze, Hundt, Clarke, & Sutcliffe, necessitate at least one systematic review of corresponding
2014), similarly, reported limited evidence for the efficacy of quality (Group, 2004).
manual therapy; particularly mobilization/manipulation with ex-
ercise in the treatment of Rotator cuff disorders. Ethical approval
Further research is required as optimal protocols of in-
terventions and the superior intervention remain unknown. Using None declared.
standardized treatment parameters, outcome measures, and
follow-up durations are advised to improve homogeneity and Funding source
facilitate statistical treatment of results.
This work was supported by an FCT grant - Foundation for Sci-
ence and Technology (Fundaça ~o para Cie ^ncia e Tecnologia) -
4.1. Limitations Portugal, with reference number SFRH/BD/144090/2019. The
funding source had no involvement in the study design; in the
 The main limitation in the present review and most of the collection, analysis and interpretation of data; in the writing of the
included studies is that the follow-up assessment durations report; and in the decision to submit the article for publication.
were too short to determine long-term effects of the identified
interventions. Declaration of competing interest
 Low methodological quality, within and across studies, may
reduce confidence in results. Twenty-three of the identified None declared.
reviews had a low or critically low rating of overall confidence.
Therefore, only studies scoring 9 points or higher on the Appendix A. Supplementary data
AMSTAR 2 scale were further analyzed using the GRADE prin-
ciples in attempt to reach accurate results. Supplementary data to this article can be found online at
 Statistical pooling of results was not feasible for many of the https://doi.org/10.1016/j.ptsp.2020.08.002.
interventions, due to heterogeneity within and across results
regarding outcome measures, treatment protocols and follow- References
up durations. To reach meaningful results, only meta-analyses
with moderate rating of overall confidence or higher and Abate, M., Silbernagel, K. G., Siljeholm, C., Di Iorio, A., De Amicis, D., Salini, V., et al.
(2009). Pathogenesis of tendinopathies: inflammation or degeneration?
adequate homogeneity were included in the meta-analysis of
Arthritis research & therapy, 11(3), 1e15.
the present review. Ackermann, P. W., & Renstro €m, P. (2012). Tendinopathy in sport. Sports Health, 4(3),
 Despite the reported histopathological similarities (Abate et al., 193e201. https://doi.org/10.1177/1941738112440957
2009; Ja €rvinen et al., 1997; Maffulli et al., 2004), caution is Al-Abbad, H., & Simon, J. V. (2013). The effectiveness of extracorporeal shock wave
therapy on chronic achilles tendinopathy: a systematic review. Foot & ankle
advised when interpreting results due to possible pathological international, 34(1), 33e41. https://doi.org/10.1177/1071100712464354
differences in tendinopathy at each region. Andres, B. M., & Murrell, G. A. (2008). Treatment of tendinopathy: what works,

43
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

what does not, and what is on the horizon. Clinical orthopaedics and related 10.1016/j.fcl.2019.04.004
research, 466(7), 1539e1554. https://doi.org/10.1007/s11999-008-0260-1 Dimitrios, S., Konstantinos, P., & Antonis, K. (2013). Effectiveness of iontophoresis
Bannuru, R. R., Flavin, N. E., Vaysbrot, E., Harvey, W., & McAlindon, T. (2014). High- for lateral elbow tendinopathy. Journal of Novel Physiotherapies S, 2, 2. https://
energy extracorporeal shock-wave therapy for treating chronic calcific tendi- doi.org/10.4172/2165-7025.S2-005
nitis of the shoulder: A systematic review. Annals of Internal Medicine, 160(8), Dimitrios, S., & Malliaras, P. (2016). It is time to abandon the myth that eccentric
542e549. https://doi.org/10.7326/M13-1982 training is best practice. Biology of Exercise, 12(1), 15e21. https://doi.org/
Bird, S. B., & Dickson, E. W. (2001). Clinically significant changes in pain along the 10.4127/jbe.2016.0097
visual analog scale. Annals of Emergency Medicine, 38(6), 639e643. https:// Dingemanse, R., Randsdorp, M., Koes, B. W., & Huisstede, B. M. (2014). Evidence for
doi.org/10.1067/mem.2001.118012 the effectiveness of electrophysical modalities for treatment of medial and
Bjordal, J. M., Lopes-Martins, R. A. B., & Frigo, L. (2015). Low level laser lateral epicondylitis: A systematic review. British Journal of Sports Medicine,
therapyemechanism of action: Inflammatory Process. In Lasers in dentistry: 48(12), 957e965. https://doi.org/10.1136/bjsports-2012-091513
Guide for clinical practice (pp. 27e33). Dixon, J., & Bird, H. (1981). Reproducibility along a 10 cm vertical visual analogue
Blanchette, M.-A., & Normand, M. C. (2011). Impairment assessment of lateral scale. Annals of the Rheumatic Diseases, 40(1), 87e89. https://doi.org/10.1136/
epicondylitis through electromyography and dynamometry. Journal of the Ca- ard.40.1.87
nadian Chiropractic Association, 55(2), 96e106. PMC3095584. Eubank, B. H., Mohtadi, N. G., Lafave, M. R., Wiley, J. P., & Emery, J. H. (2017). Further
Boudreault J, Desmeules F, Roy J, Dionne C, Fre
mont P. The efficacy of laser therapy validation and reliability testing of the rotator cuff quality of life index (RC-QOL)
for rotator cuff tendinopathy: A systematic review and meta-analysis. J Nov according to the consensus-based standards for the selection of health mea-
Physiother Phys Rehabil 3 (1): 001-015 DOI: 1017352/2455. 2016;5487(001). surement instruments (COSMIN) guidelines. Journal of Shoulder and Elbow
https://doi.org/7352/2455-5487.000029. Surgery, 26(2), 314e322. https://doi.org/10.1016/j.jse.2016.07.030
Burcal, C. J., Rosen, A. B., Taylor, T., & Nicola, M. (2019). Evidence to practice review: Evans, N. A., Adkins, S., Clarke, K., & Cox, W. C. (2018). Functional impairment test-
Best practices in patellar tendinopathy management. Clinical Practice in Athletic hand and neck/shoulder/arm. Critical Reviews in Physical and Rehabilitation
Training, 2(1), 4e10. https://doi.org/10.31622/2019/0001.2 Medicine, 30(3). https://doi.org/10.1615/CritRevPhysRehabilMed.2018028936
Cacchio, A., De Paulis, F., & Maffulli, N. (2014). Development and validation of a new Evans, J. P., Porter, I., Gangannagaripalli, J. B., Bramwell, C., Davey, A., Smith, C. D.,
visa questionnaire (VISA-H) for patients with proximal hamstring tendinopathy. et al. (2019). Assessing patient-centred outcomes in lateral elbow tendinop-
British Journal of Sports Medicine, 48(6), 448e452. https://doi.org/10.1136/ athy: A systematic review and standardised comparison of English language
bjsports-2012-091552 clinical rating systems. Sports Medicine-Open, 5(1), 10. https://doi.org/10.1186/
Carcia, C. R., Martin, R. L., Houck, J., Wukich, D. K., Altman, R. D., Curwin, S., et al. s40798-019-0183-2
(2010). Achilles pain, stiffness, and muscle power deficits: Achilles tendinitis: Fearon, A., Ganderton, C., Scarvell, J. M., Smith, P. N., Neeman, T., Nash, C., et al.
Clinical practice guidelines linked to the international classification of func- (2015). Development and validation of a VISA tendinopathy questionnaire for
tioning, disability, and health from the orthopaedic section of the American greater trochanteric pain syndrome, the VISA-G. Manual Therapy, 20(6),
physical therapy association. Journal of Orthopaedic & Sports Physical Therapy, 805e813. https://doi.org/10.1016/j.math.2015.03.009
40(9), A1eA26. https://doi.org/10.2519/jospt.2010.0305 Flodgren, G., Eccles, M. P., Shepperd, S., Scott, A., Parmelli, E., & Beyer, F. R. (2011). An
Cardoso, T. B., Pizzari, T., Kinsella, R., Hope, D., & Cook, J. L. (2019). Current trends in overview of reviews evaluating the effectiveness of financial incentives in
tendinopathy management. Best Practice & Research Clinical Rheumatology. changing healthcare professional behaviours and patient outcomes. Cochrane
https://doi.org/10.1016/j.berh.2019.02.001 Database of Systematic Reviews, (7)https://doi.org/10.1002/14651858.CD009255
Carlsson, A. M. (1983). Assessment of chronic pain. I. Aspects of the reliability and Gerdesmeyer, L., Mittermayr, R., Fuerst, M., Al Muderis, M., Thiele, R., Saxena, A.,
validity of the visual analogue scale. Pain, 16(1), 87e101. https://doi.org/10.1016/ et al. (2015). Current evidence of extracorporeal shock wave therapy in chronic
0304-3959(83)90088-X Achilles tendinopathy. International Journal of Surgery, 24, 154e159. https://
Chang, W. D., Wu, J. H., Yang, W. J., & Jiang, J. A. (2010). Therapeutic effects of low- doi.org/10.1016/j.ijsu.2015.07.718
level laser on lateral epicondylitis from differential interventions of Chinese- Group, G. W. (2004). Grading quality of evidence and strength of recommendations.
western medicine: Systematic review. Photomed Laser Surg, 28(3), 327e336. BMJ British Medical Journal, 328(7454), 1490. https://doi.org/10.1136/
https://doi.org/10.1089/pho.2009.2558 bmj.328.7454.1490
Clar, C., Tsertsvadze, A., Hundt, G. L., Clarke, A., & Sutcliffe, P. (2014). Clinical Gummesson, C., Ward, M. M., & Atroshi, I. (2006). The shortened disabilities of the
effectiveness of manual therapy for the management of musculoskeletal and arm, shoulder and hand questionnaire (quick DASH): Validity and reliability
non-musculoskeletal conditions: Systematic review and update of UK evidence based on responses within the full-length DASH. BMC Musculoskeletal Disorders,
report. Chiropractic & Manual Therapies, 22(1), 12. https://doi.org/10.1186/2045- 7(1), 44. https://doi.org/10.1186/1471-2474-7-44
709X-22-12 Hamilton, A., Balnave, R., & Adams, R. (1994). Grip strength testing reliability.
Cotler, H. B., Chow, R. T., Hamblin, M. R., & Carroll, J. (2015). The use of low level Journal of Hand Therapy, 7(3), 163e170. https://doi.org/10.1016/S0894-1130(12)
laser therapy (LLLT) for musculoskeletal pain. MOJ Orthopedics & Rheumatology, 80058-5
2(5). https://doi.org/10.15406/mojor.2015.02.00068 Han, S. H., Lee, J. W., Guyton, G. P., Parks, B. G., Courneya, J.-P., & Schon, L. C. (2009).
Couppe
, C., Svensson, R. B., Silbernagel, K. G., Langberg, H., & Magnusson, S. P. J. Leonard goldner award 2008: Effect of extracorporeal shock wave therapy on
(2015). Eccentric or concentric exercises for the treatment of tendinopathies? cultured tenocytes. Foot & Ankle International, 30(2), 93e98. https://doi.org/
Journal of Orthopaedic & Sports Physical Therapy, 45(11), 853e863. https:// 10.3113/FAI-2009-0093
doi.org/10.2519/jospt.2015.5910 Haslerud, S., Magnussen, L. H., Joensen, J., Lopes-Martins, R. A., & Bjordal, J. M.
Cullinane, F. L., Boocock, M. G., & Trevelyan, F. C. (2014). Is eccentric exercise an (2015). The efficacy of low-level laser therapy for shoulder tendinopathy: A
effective treatment for lateral epicondylitis? A systematic review. Clinical systematic review and meta-analysis of randomized controlled trials. Physio-
Rehabilitation, 28(1), 3e19. https://doi.org/10.1177/0269215513491974 therapy Research International, 20(2), 108e125. https://doi.org/10.1002/pri.1606
Dauber, J. A., Ball, M. O., Lewis, A. M., & Neidermeyer, C. R. (2018). Victorian Institute Hawker, G. A., Mian, S., Kendzerska, T., & French, M. (2011). Measures of adult pain:
of sport assessment questionnaire, patellar tendon (VISA-P). Critical Reviews in Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain),
Physical and Rehabilitation Medicine, 30(3). mcgill pain questionnaire (mpq), short-form mcgill pain questionnaire (sf-
Dean, B. J. F., Gettings, P., Dakin, S. G., & Carr, A. J. (2016). Are inflammatory cells mpq), chronic pain grade scale (cpgs), short form-36 bodily pain scale (sf-36
increased in painful human tendinopathy? A systematic review. British Journal bps), and measure of intermittent and constant osteoarthritis pain (icoap).
of Sports Medicine, 50(4), 216e220. https://doi.org/10.1136/bjsports-2015- Arthritis Care & Research, 63(S11), S240eS252. https://doi.org/10.1002/
094754 acr.20543
Desjardins Charbonneau, A., Roy, J.-S., Dionne, C. E., Fre
mont, P., MacDermid, J. C., & Hickey, C., Walker, D., Lee, S., & Vitato, N. (2019). The long-term effects of eccentric
Desmeules, F. (2015). The efficacy of manual therapy for rotator cuff tendin- exercise vs. Extracorporeal shockwave therapy in athletes aged 18-50 with
opathy: A systematic review and meta-analysis. Journal of Orthopaedic & Sports patellar tendinopathy: A meta-analysis and systematic review. Ann Physiother
Physical Therapy, 45(5), 330e350. https://doi.org/10.2519/jospt.2015.5455 Occup Ther, 2(3), Article 000130.
Desjardins Charbonneau, A., Roy, J. S., Dionne, C. E., & Desmeules, F. (2015). The Higgins, J. P., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring
efficacy of taping for rotator cuff tendinopathy: A systematic review and meta- inconsistency in meta-analyses. BMJ British Medical Journal, 327(7414), 557.
analysis. International Journal of Sports Physical Therapy, 10(4), 420. https://doi.org/10.1136/bmj.327.7414.557
Desmeules, F., Boudreault, J., Dionne, C. E., Fre
mont, P., Lowry, V., MacDermid, J. C., Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M.
et al. (2016). Efficacy of exercise therapy in workers with rotator cuff tendin- (2013). Does effectiveness of exercise therapy and mobilisation techniques offer
opathy: A systematic review. Journal of Occupational Health. https://doi.org/ guidance for the treatment of lateral and medial epicondylitis? A systematic
10.1539/joh.15-0103-RA, 15-0103-RA. review. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2012-
Desmeules, F., Boudreault, J., Roy, J.-S., Dionne, C., Fre
mont, P., & MacDermid, J. C. 091990. bjsports-2012-091990.
(2015). The efficacy of therapeutic ultrasound for rotator cuff tendinopathy: A Huisstede, B. M., Gebremariam, L., van der Sande, R., Hay, E. M., & Koes, B. W. (2011).
systematic review and meta-analysis. Physical Therapy in Sport, 16(3), 276e284. Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to
https://doi.org/10.1016/j.ptsp.2014.09.004 treat calcific and non-calcific rotator cuff tendinosisea systematic review.
Desmeules, F., Boudreault, J., Roy, J. S., Dionne, C. E., Fre
mont, P., & MacDermid, J. C. Manual Therapy, 16(5), 419e433. https://doi.org/10.1016/j.math.2011.02.005
(2016). Efficacy of transcutaneous electrical nerve stimulation for rotator cuff Hutchison, A.-M., Beard, D., Pallister, I., Topliss, C. J., & Williams, P. (2011). Is phys-
tendinopathy: A systematic review. Physiotherapy, 102(1), 41e49. https:// iotherapy effective for patients with a chronic mid-body achilles tendinopathy?
doi.org/10.1016/j.physio.2015.06.004 A systematic review of non-surgical and non-pharmacological interventions.
Dilger, C. P., & Chimenti, R. L. (2019). Nonsurgical treatment options for insertional International Musculoskeletal Medicine, 33(4), 152e160. https://doi.org/10.1179/
achilles tendinopathy. Foot and Ankle Clinics, 24(3), 505e513. https://doi.org/ 1753615411Y.0000000010

44
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Innes, E. (1999). Handgrip strength testing: A review of the literature. Australian jospt.2015.6054
Occupational Therapy Journal, 46(3), 120e140. https://doi.org/10.1046/j.1440- Maffulli, N. (1998). Overuse tendon conditions: Time to change a confusing ter-
1630.1999.00182.x minology. Arthroscopy, 14(8), 840e843. https://doi.org/10.1016/S0749-8063(98)
Ioppolo, F., Tattoli, M., Di Sante, L., Venditto, T., Tognolo, L., Delicata, M., et al. (2013). 70021-0
Clinical improvement and resorption of calcifications in calcific tendinitis of the Maffulli, N., Longo, U. G., Loppini, M., & Denaro, V. (2010). Current treatment options
shoulder after shock wave therapy at 6 months’ follow-up: A systematic review for tendinopathy. Expert Opinion on Pharmacotherapy, 11(13), 2177e2186.
and meta-analysis. Archives of Physical Medicine and Rehabilitation, 94(9), https://doi.org/10.1517/14656566.2010.495715
1699e1706. https://doi.org/10.1016/j.apmr.2013.01.030 Maffulli, N., Testa, V., Capasso, G., Ewen, S. W., Sullo, A., Benazzo, F., et al. (2004).
Iversen, J. V., Bartels, E. M., & Langberg, H. (2012). The victorian Institute of sports Similar histopathological picture in males with Achilles and patellar tendin-
assessmenteachilles questionnaire (VISA-A)ea reliable tool for measuring opathy. Medicine & Science in Sports & Exercise, 36(9), 1470e1475. https://
achilles tendinopathy. International Journal of Sports Physical Therapy, 7(1), 76. doi.org/10.1249/01.MSS.0000139895.94846.8D
J€
arvinen, M., Jozsa, L., Kannus, P., Ja €rvinen, T., Kvist, M., & Leadbetter, W. (1997). Maffulli, N., Wong, J., & Almekinders, L. C. (2003). Types and epidemiology of
Histopathological findings in chronic tendon disorders. Scandinavian Journal of tendinopathy. Clinics in Sports Medicine, 22(4), 675e692. https://doi.org/
Medicine & Science in Sports, 7(2), 86e95. 10.1016/s0278-5919(03)00004-8
Jayaseelan, D. J., Mischke, J. J., & Strazzulla, R. L. (2019). Eccentric exercise for achilles Magnussen, R. A., Dunn, W. R., & Thomson, A. B. (2009). Nonoperative treatment of
tendinopathy: A narrative review and clinical decision-making considerations. midportion achilles tendinopathy: A systematic review. Clinical Journal of Sport
Journal of Functional Morphology and Kinesiology, 4(2), 34. https://doi.org/ Medicine, 19(1), 54e64. https://doi.org/10.1097/JSM.0b013e31818ef090
10.3390/jfmk4020034 Mamais, I., Papadopoulos, K., Lamnisos, D., & Stasinopoulos, D. (2018). Effectiveness
Jester, A., Harth, A., Wind, G., Germann, G., & Sauerbier, M. (2005). Disabilities of the of low level laser therapy (LLLT) in the treatment of lateral elbow tendinopathy
arm, shoulder and hand (DASH) questionnaire: Determining functional activity (LET): An umbrella review. Laser Therapy, 27(3), 174e186. https://doi.org/
profiles in patients with upper extremity disorders. The Journal of Hand Surgery, 10.5978/islsm.27_18-OR-16
30(1), 23e28. https://doi.org/10.1016/J.JHSB.2004.08.008 Mani-Babu, S., Morrissey, D., Waugh, C., Screen, H., & Barton, C. (2015). The effec-
Johnson, C. (2005). Measuring pain. Visual analog scale versus numeric pain scale: tiveness of extracorporeal shock wave therapy in lower limb tendinopathy: A
What is the difference? Journal of Chiropractic Medicine, 4(1), 43. https://doi.org/ systematic review. The American Journal of Sports Medicine, 43(3), 752e761.
10.1016/S0899-3467(07)60112-8 https://doi.org/10.1177/0363546514531911
Joseph, M. F., Taft, K., Moskwa, M., & Denegar, C. R. (2012). Deep friction massage to Mathiowetz, V., Weber, K., Volland, G., & Kashman, N. (1984). Reliability and validity
treat tendinopathy: A systematic review of a classic treatment in the face of a of grip and pinch strength evaluations. The Journal of Hand Surgery, 9(2),
new paradigm of understanding. Journal of Sport Rehabilitation, 21(4), 343e353. 222e226. https://doi.org/10.1016/S0363-5023(84)80146-X
Kim, J. K., Park, M. G., & Shin, S. J. (2014). What is the minimum clinically important McKivigan, J. M., Yamashita, B., & Smith, D. (2017). A systematic review on the ef-
difference in grip strength? Clinical Orthopaedics and Related Research, 472(8), ficacy of iontophoresis as a treatment for lateral epicondylitis. Research & In-
2536e2541. https://doi.org/10.1007/s11999-014-3727-2 vestigations in Sports Medicine, 1(3). https://doi.org/10.31031/
Ko, J.-Y., & Wang, F.-S. (2018). Extracorporeal shockwave therapy for tendinopathy. RISM.2017.01.000512 [Article RISM. 000512].
Shockwave Medicine. Karger Publishers. Mead, M. P., Gumucio, J. P., Awan, T. M., Mendias, C. L., & Sugg, K. B. (2018). Path-
Krey, D., Borchers, J., & McCamey, K. (2015). Tendon needling for treatment of ogenesis and management of tendinopathies in sports medicine. Translational
tendinopathy: A systematic review. The Physician and Sportsmedicine, 43(1), Sports Medicine, 1(1), 5e13. https://doi.org/10.1002/tsm2.6
80e86. https://doi.org/10.1080/00913847.2015.1004296 Meyer, A., Tumilty, S., & Baxter, G. (2009). Eccentric exercise protocols for chronic
Lee, S. Y., Cheng, B., & Grimmer-Somers, K. (2011). The midterm effectiveness of non-insertional achilles tendinopathy: How much is enough? Scandinavian
extracorporeal shockwave therapy in the management of chronic calcific Journal of Medicine & Science in Sports, 19(5), 609e615. https://doi.org/10.1111/
shoulder tendinitis. Journal of Shoulder and Elbow Surgery, 20(5), 845e854. j.1600-0838.2009.00981.x
https://doi.org/10.1016/j.jse.2010.10.024 Mosca, M. J., Rashid, M. S., Snelling, S. J., Kirtley, S., Carr, A. J., & Dakin, S. G. (2018).
Liao, C.-D., Tsauo, J.-Y., Chen, H.-C., & Liou, T.-H. (2018). Efficacy of extracorporeal Trends in the theory that inflammation plays a causal role in tendinopathy: A
shock wave therapy for lower-limb tendinopathy: A meta-analysis of ran- systematic review and quantitative analysis of published reviews. BMJ Open
domized controlled trials. American Journal of Physical Medicine and Rehabili- Sport & Exercise Medicine, 4(1), Article e000332. https://doi.org/10.1136/
tation, 97(9), 605e619. https://doi.org/10.1097/PHM.0000000000000925 bmjsem-2017-000332
Liao, C.-D., Xie, G.-M., Tsauo, J.-Y., Chen, H.-C., & Liou, T.-H. (2018). Efficacy of Murphy, M. C., Travers, M. J., Chivers, P., Debenham, J. R., Docking, S. I., Rio, E. K.,
extracorporeal shock wave therapy for knee tendinopathies and other soft et al. (2019). Efficacy of heavy eccentric calf training for treating mid-portion
tissue disorders: A meta-analysis of randomized controlled trials. BMC achilles tendinopathy: A systematic review and meta-analysis. British Journal
Musculoskeletal Disorders, 19(1), 278. https://doi.org/10.1186/s12891-018-2204- of Sports Medicine, 53(17), 1070e1077. https://doi.org/10.1136/bjsports-2018-
6 099934
Lim, E. C. W. (2013). Pain free grip strength test. Journal of Physiotherapy, 59(1), 59. Murtaugh, B., & Ihm, J. M. (2013). Eccentric training for the treatment of tendino-
https://doi.org/10.1016/S1836-9553(13)70152-8 pathies. Current Sports Medicine Reports, 12(3), 175e182. https://doi.org/
Lim, H. Y., & Wong, S. H. (2018). Effects of isometric, eccentric, or heavy slow 10.1249/JSR.0b013e3182933761
resistance exercises on pain and function in individuals with patellar tendin- Newcomer, K. L., Martinez-Silvestrini, J. A., Schaefer, M. P., Gay, R. E., & Arendt, K. W.
opathy: A systematic review. Physiotherapy Research International, 23(4), Article (2005). Sensitivity of the patient-rated forearm evaluation questionnaire in
e1721. https://doi.org/10.1002/pri.1721 lateral epicondylitis. Journal of Hand Therapy, 18(4), 400e406. https://doi.org/
Littlewood, C., Ashton, J., Chance-Larsen, K., May, S., & Sturrock, B. (2012). Exercise 10.1197/j.jht.2005.07.001
for rotator cuff tendinopathy: A systematic review. Physiotherapy, 98(2), Nitschke, J. E., McMeeken, J. M., Burry, H. C., & Matyas, T. A. (1999). When is a
101e109. https://doi.org/10.1016/j.physio.2011.08.002 change a genuine change?: A clinically meaningful interpretation of grip
Littlewood, C., Malliaras, P., & Chance-Larsen, K. (2015). Therapeutic exercise for strength measurements in healthy and disabled women. Journal of Hand Ther-
rotator cuff tendinopathy: A systematic review of contextual factors and pre- apy, 12(1), 25e30. https://doi.org/10.1016/S0894-1130(99)80030-1
scription parameters. International Journal of Rehabilitation Research, 38(2), Nogueira Júnior, A. C., & Júnior, M. J. M. (2015). The effects of laser treatment in
95e106. https://doi.org/10.1097/MRR.0000000000000113 tendinopathy: A systematic review. Acta Ortopedica Brasileira, 23(1), 47e49.
Littlewood, C., May, S., & Walters, S. (2013). A review of systematic reviews of the https://doi.org/10.1590/1413-78522015230100513
effectiveness of conservative interventions for rotator cuff tendinopathy. Ortega-Castillo, M., & Medina-Porqueres, I. (2016). Effectiveness of the eccentric
Shoulder & Elbow, 5(3), 151e167. https://doi.org/10.1111/sae.12009 exercise therapy in physically active adults with symptomatic shoulder
Loew, L. M., Brosseau, L., Tugwell, P., Wells, G. A., Welch, V., Shea, B., et al. (2014). impingement or lateral epicondylar tendinopathy: A systematic review. Journal
Deep transverse friction massage for treating lateral elbow or lateral knee of Science and Medicine in Sport, 19(6), 438e453. https://doi.org/10.1016/
tendinitis. Cochrane Database of Systematic Reviews, 11. https://doi.org/10.1002/ j.jsams.2015.06.007
14651858.CD003528.pub2. CD003528. Overend, T. J., Wuori-Fearn, J. L., Kramer, J. F., & MacDermid, J. C. (1999). Reliability of
Lubart, R., Wollman, Y., Friedmann, H., Rochkind, S., & Laulicht, I. (1992). Effects of a patient-rated forearm evaluation questionnaire for patients with lateral epi-
visible and near-infrared lasers on cell cultures. Journal of Photochemistry and condylitis. Journal of Hand Therapy, 12(1), 31e37. https://doi.org/10.1016/S0894-
Photobiology B: Biology, 12(3), 305e310. https://doi.org/10.1016/1011-1344(92) 1130(99)80031-3
85032- ONeill, S., Watson, P. J., & Barry, S. (2015). Why are eccentric exercises effective for
Lucado, A. M., Dale, R. B., Vincent, J., & Day, J. M. (2018). Do joint mobilizations assist achilles tendinopathy? International Journal of Sports Physical Therapy, 10(4),
in the recovery of lateral elbow tendinopathy? A systematic review and meta- 552.
analysis. Journal of Hand Therapy. https://doi.org/10.1016/j.jht.2018.01.010 Posten, W., Wrone, D. A., Dover, J. S., Arndt, K. A., Silapunt, S., & Alam, M. (2005).
Lunsford, B. R., & Perry, J. (1995). The standing heel-rise test for ankle plantar Low-level laser therapy for wound healing: Mechanism and efficacy. Derma-
flexion: Criterion for normal. Physical Therapy, 75(8), 694e698. https://doi.org/ tologic Surgery, 31(3), 334e340. https://doi.org/10.1111/j.1524-4725.2005.31086
10.1093/ptj/75.8.694 du Prel, J.-B., Hommel, G., Ro€ hrig, B., & Blettner, M. (2009). Confidence interval or p-
MacDermid, J. (2005). Update: The patient-rated forearm evaluation questionnaire value?: Part 4 of a series on evaluation of scientific publications. Deutsches
is now the patient-rated tennis elbow evaluation. Journal of Hand Therapy, 18(4), €
Arzteblatt International, 106(19), 335. https://doi.org/10.3238/arztebl.2009.0335
407e410. https://doi.org/10.1197/j.jht.2005.07.002 Punnoose, A., Norrish, A., & Pak, K. (2017). Extracorporeal shock wave therapy for
MacDermid, J. C., & Silbernagel, K. G. (2015). Outcome evaluation in tendinopathy: achilles and patellar tendinopathy: Meta-analysis and a systematic review of
Foundations of assessment and a summary of selected measures. Journal of the literature. Journal of Physiotherapy and Physical Rehabilitation, 2(1). https://
Orthopaedic & Sports Physical Therapy, 45(11), 950e964. https://doi.org/10.2519/ doi.org/10.4172/2573-0312.1000124

45
B. Girgis and J.A. Duarte Physical Therapy in Sport 46 (2020) 30e46

Raman, J., MacDermid, J. C., & Grewal, R. (2012). Effectiveness of different methods Stratford, P. (1987). Extensor carpi radialis tendonitis: A validation of selected
of resistance exercises in lateral epicondylosisda systematic review. Journal of outcome measures. Physiotherapie Canada, 39, 250e255.
Hand Therapy, 25(1), 5e26. Stratford, P., Lavy, D., & Gowland, C. (1993). Evaluative properties of measures used
Razmjou, H., Bean, A., van Osnabrugge, V., MacDermid, J. C., & Holtby, R. (2006). to assess patients with lateral epicondylitis at the elbow. Physiotherapie Canada,
Cross-sectional and longitudinal construct validity of two rotator cuff disease- 45, 160.
specific outcome measures. BMC Musculoskeletal Disorders, 7(1), 26. https:// Stratford, P. W., & Levy, D. R. (1994). Assessing valid change over time in patients
doi.org/10.1186/1471-2474-7-26 with lateral epicondylitis at the elbow. Clinical Journal of Sport Medicine, 4(2),
Renstrom, P., & Woo, S. L. Y. (2008). Tendinopathy: A major medical problem in 88e91. https://doi.org/10.1097/00042752-199404000-00004
sport. Tendinopathy in athletes, 2008, 1e9. Stratford, P. W., Norman, G. R., & McIntosh, J. M. (1989). Generalizability of grip
Robinson, J., Cook, J. L., Purdam, C., Visentini, P., Ross, J., Maffulli, N., et al. (2001). The strength measurements in patients with tennis elbow. Physical Therapy, 69(4),
VISA-A questionnaire: A valid and reliable index of the clinical severity of 276e281. https://doi.org/10.1093/ptj/69.4.276
achilles tendinopathy. British Journal of Sports Medicine, 35(5), 335e341. https:// Sussmilch-Leitch, S. P., Collins, N. J., Bialocerkowski, A. E., Warden, S. J., &
doi.org/10.1136/bjsm.35.5.335 Crossley, K. M. (2012). Physical therapies for achilles tendinopathy: Systematic
Rocourt, M. H., Radlinger, L., Kalberer, F., Sanavi, S., Schmid, N. S., Leunig, M., et al. review and meta-analysis. Journal of Foot and Ankle Research, 5(1), 15. https://
(2008). Evaluation of intratester and intertester reliability of the Constant- doi.org/10.1186/1757-1146-5-15
Murley shoulder assessment. Journal of Shoulder and Elbow Surgery, 17(2), Tashjian, R. Z., Deloach, J., Porucznik, C. A., & Powell, A. P. (2009). Minimal clinically
364e369. https://doi.org/10.1016/j.jse.2007.06.024 important differences (MCID) and patient acceptable symptomatic state (PASS)
Rompe, J. D., Overend, T. J., & MacDermid, J. C. (2007). Validation of the patient- for visual analog scales (VAS) measuring pain in patients treated for rotator cuff
rated tennis elbow evaluation questionnaire. Journal of Hand Therapy, 20(1), disease. Journal of Shoulder and Elbow Surgery, 18(6), 927e932. https://doi.org/
3e11. https://doi.org/10.1197/j.jht.2006.10.003 10.1016/j.jse.2009.03.021
Ross, M. D., & Fontenot, E. G. (2000). Testeretest reliability of the standing heel-rise Thorborg, K., Ho €lmich, P., Christensen, R., Petersen, J., & Roos, E. M. (2011). The
test. Journal of Sport Rehabilitation, 9(2), 117e123. https://doi.org/10.1123/ copenhagen hip and Groin outcome score (HAGOS): Development and valida-
jsr.9.2.117 tion according to the COSMIN checklist. British Journal of Sports Medicine, 45(6),
Rowe, V., Hemmings, S., Barton, C., Malliaras, P., Maffulli, N., & Morrissey, D. (2012). 478e491. https://doi.org/10.1136/bjsm.2010.080937
Conservative management of midportion achilles tendinopathy: A mixed Todd, K. H. (2001). Patient-oriented outcome measures: The promise of definition.
methods study, integrating systematic review and clinical reasoning. Sports Annals of Emergency Medicine, 38(6), 672e674. https://doi.org/10.1067/
Medicine, 42(11), 941e967. https://doi.org/10.2165/11635410-000000000- mem.2001.119746
00000 Tumilty, S., Munn, J., McDonough, S., Hurley, D. A., Basford, J. R., & Baxter, G. D.
Rutland, M., O’Connell, D., Brisme
e, J.-M., Sizer, P., Apte, G., & O’Connell, J. (2010). (2010). Low level laser treatment of tendinopathy: A systematic review with
Evidenceesupported rehabilitation of patellar tendinopathy. North American meta-analysis. Photomed Laser Surg, 28(1), 3e16. https://doi.org/10.1089/
Journal of Sports Physical Therapy: NAJSPT, 5(3), 166. pho.2008.2470
Ryan, R., Santesso, N., Lowe, D., Hill, S., Grimshaw, J. M., Prictor, M., et al. (2014). Verstraelen, F., Jansen, L., & Morrenhof, J. (2014). High-energy versus low-energy
Interventions to improve safe and effective medicines use by consumers: An extracorporeal shock wave therapy for calcifying tendinitis of the shoulder:
overview of systematic reviews. Cochrane Database of Systematic Reviews, (4) Which is superior? A meta-analysis. Clinical Orthopaedics and Related Research,
https://doi.org/10.1002/14651858.CD007768.pub3 472(9), 2816e2825.
Scott, L. A., Munteanu, S. E., & Menz, H. B. (2014). Effectiveness of orthotic devices in Vincent, J., & MacDermid, J. C. (2014). Patient-rated tennis elbow evaluation ques-
the treatment of achilles tendinopathy: A systematic review. Sports Medicine, tionnaire. Journal of Physiotherapy, 60(4), 240. https://doi.org/10.1016/
45(1), 95e110. https://doi.org/10.1007/s40279-014-0237-z j.jphys.2014.08.002
Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., et al. (2020). Icon Waugh, C., Morrissey, D., Jones, E., Riley, G., Langberg, H., & Screen, H. (2015). In vivo
2019: International scientific tendinopathy symposium consensus: Clinical biological response to extracorporeal shockwave therapy in human tendinop-
terminology. British Journal of Sports Medicine, 54(5), 260e262. https://doi.org/ athy: Response of tendinopathy to shockwave therapy. European Cells and
10.1136/bjsports-2019-100885 Materials, 3(29), 268e280. https://doi.org/10.22203/ecm.v029a20
Shakespeare, T. P., Gebski, V. J., Veness, M. J., & Simes, J. (2001). Improving inter- Weber, C., Thai, V., Neuheuser, K., Groover, K., & Christ, O. (2015). Efficacy of physical
pretation of clinical studies by use of confidence levels, clinical significance therapy for the treatment of lateral epicondylitis: A meta-analysis. BMC
curves, and risk-benefit contours. The Lancet, 357(9265), 1349e1353. https:// Musculoskeletal Disorders, 16, 223. https://doi.org/10.1186/s12891-015-0665-4.
doi.org/10.1016/S0140-6736(00)04522-0 PMC4549077
Shea, B. J., Bouter, L. M., Peterson, J., Boers, M., Andersson, N., Ortiz, Z., et al. (2007). Wilson, F., Walshe, M., O’Dwyer, T., Bennett, K., Mockler, D., & Bleakley, C. (2018).
External validation of a measurement tool to assess systematic reviews Exercise, orthoses and splinting for treating achilles tendinopathy: A systematic
(AMSTAR). PloS One, 2(12). https://doi.org/10.1371/journal.pone.0001350 review with meta-analysis. British Journal of Sports Medicine, 52(24), 1564e1574.
Shea, B. J., Grimshaw, J. M., Wells, G. A., Boers, M., Andersson, N., Hamel, C., et al. https://doi.org/10.1136/bjsports-2017-098913
(2007). Development of AMSTAR: A measurement tool to assess the method- Woodruff, L. D., Bounkeo, J. M., Brannon, W. M., Dawes, K. S., Barham, C. D.,
ological quality of systematic reviews. BMC Medical Research Methodology, 7(1), Waddell, D. L., et al. (2004). The efficacy of laser therapy in wound repair: A
10. https://doi.org/10.1186/1471-2288-7-10 meta-analysis of the literature. Photomedicine and Laser Surgery, 22(3), 241e247.
Shea, B. J., Hamel, C., Wells, G. A., Bouter, L. M., Kristjansson, E., Grimshaw, J., et al. https://doi.org/10.1089/1549541041438623
(2009). AMSTAR is a reliable and valid measurement tool to assess the meth- Xu, Y., & Murrell, G. A. (2008). The basic science of tendinopathy. Clinical Ortho-
odological quality of systematic reviews. Journal of Clinical Epidemiology, 62(10), paedics and Related Research, 466(7), 1528e1538.
1013e1020. https://doi.org/10.1016/j.jclinepi.2008.10.009 Yan, C., Xiong, Y., Chen, L., Endo, Y., Hu, L., Liu, M., et al. (2019). A comparative study
Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., et al. (2017). of the efficacy of ultrasonics and extracorporeal shock wave in the treatment of
Amstar 2: A critical appraisal tool for systematic reviews that include rando- tennis elbow: A meta-analysis of randomized controlled trials. Journal of Or-
mised or non-randomised studies of healthcare interventions, or both. Bmj, 358, thopaedic Surgery and Research, 14(1). https://doi.org/10.1186/s13018-019-1290-
j4008. https://doi.org/10.1136/bmj.j4008 y
Smidt, N., van der Windt, D. A., Assendelft, W. J., Mourits, A. J., Deville, W. L., de Young, J. L., Rhon, D. I., de Zoete, R. M., Cleland, J. A., & Snodgrass, S. J. (2018). The
Winter, A. F., et al. (2002). Interobserver reproducibility of the assessment of influence of dosing on effect size of exercise therapy for musculoskeletal foot
severity of complaints, grip strength, and pressure pain threshold in patients and ankle disorders: A systematic review. Brazilian Journal of Physical Therapy,
with lateral epicondylitis. Archives of Physical Medicine and Rehabilitation, 83(8), 22(1), 20e32.
1145e1150. https://doi.org/10.1053/apmr.2002.33728

46