The Effect of Extracorporeal Shockwave Therapy in Tendinopathy: A Systematic Review and Network Meta-Analysis of...

In recent years, numerous meta-analyses have been published on the effectiveness of ESWT in treating various tendinopathies. However, due to limitations such as the small number of included studies, it remains unclear whether ESWT is definitively effective for all types of tendinopathies and what its comparative value is relative to other conservative treatments. The objective of this meta-analysis is to compare ESWT with other conservative treatments to determine its effectiveness in alleviating pain and improving the severity of tendinopathies. Additionally, through network meta-analysis, we aim to compare the efficacy of ESWT and other conservative treatments across different types of tendinopathies. This will help establish the value of ESWT in each type of tendinopathy, providing a theoretical basis for clinical decision-making regarding ESWT treatment for various tendinopathies.

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed, Embase, and Cochrane Library databases along with other databases were searched to identify relevant randomized controlled trials (RCTs). The quality of the selected studies was evaluated using risk of bias assessments, and the data were extracted. Network meta-analysis was performed using random effects models to evaluate the effects of different treatment modalities on reducing pain and improving functional outcomes, reduction and functional improvement. The evidence of the included studies was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework.

This study included 65 publications from 2002 to 2024, with a total sample size of 3,921 cases. The included studies covered five types of tendinopathies: lateral epicondylitis, rotator cuff tendinopathy, Achilles tendinopathy, greater trochanteric pain syndrome, and patellar tendinopathy. Through pairwise subgroup meta-analyses, we obtained the following representative results: for VAS in lateral epicondylitis, ESWT versus US, SMD -2.53 [95% CI -3.03 to -2.03], I² = 64.7%; ESWT versus PLACEBO, SMD -0.53 [95% CI -0.76 to -0.30], I² = 39.0%; for VAS in Achilles tendinopathy, ESWT versus PLACEBO, SMD -0.49 [95% CI -0.83 to -0.16], I² = 0; for VISA-P in patellar tendinopathy, ESWT versus PLACEBO, SMD -0.15 [95% CI -0.42 to 0.12], I² = 0; for VAS in rotator cuff tendinopathy, ESWT versus PLACEBO, SMD -1.25 [95% CI -1.61 to -0.89], I² = 89.1%; for GTPS, ESWT versus EX, SMD -0.41 [95% CI -0.70 to -0.11], I² = 10.2%. In the network meta-analysis, the following representative results were obtained: in LE, ESWT ranked second in SUCRA for improving VAS and PRTEE, with no significant difference from the first rank (ESWT vs. PDRN, MD 0.44 [95% CI -2.76 to 3.64]; ESWT vs. KT, MD 0.39 [95% CI -0.88 to 1.66]); in RCT, ESWT ranked second in SUCRA for improving SPADI, with no significant difference from the first rank (ESWT vs. EX, MD 0.15 [95% CI -0.24 to 0.55]); in AT, ESWT ranked second in SUCRA for improving VAS, with a significant difference from the first rank (ESWT vs. LT, MD 2.55 [95% CI 1.86-3.24]).

Current limited evidence suggests that, compared to control groups, ESWT effectively improves pain and tendinopathy severity indicators in various tendinopathies except for patellar tendinopathy. However, its efficacy may vary across different tendinopathy types. Compared to other conservative treatments, ESWT holds a favorable position in treating lateral epicondylitis (LE), Achilles tendinopathy (AT), and rotator cuff tendinopathy (RCT). Notably, we found that ESWT does not show a significant therapeutic effect over placebo in the treatment of patellar tendinopathy.