Tendon pain in the Achilles, kneecap tendon or outside of the hip is stubborn, common and surrounded by a confusing menu of treatments. This large review set out to work out what actually helps, and whether high-tech add-ons beat plain exercise.
The authors pooled 68 randomised controlled trials of the three most common lower limb tendinopathies, each with at least one exercise arm, and used a network meta-analysis to rank treatments for pain and function over the short, mid and longer term.
Patients and clinicians are often tempted by add-on treatments for tendon pain. Knowing whether those add-ons actually beat well-dosed exercise helps focus treatment and spending on what works.
Loading the tendon with structured exercise, including eccentric protocols and slow heavy resistance, generally prescribed as first-line treatment.
Extra treatments such as shockwave therapy, injections and topical glyceryl trinitrate, used on their own or added to exercise.
The headline was refreshingly simple: exercise is the foundation, and the add-ons do not reliably beat it.
Loading the tendon with exercise remained the core, recommended treatment across Achilles, patellar and gluteal tendinopathy.
There was no convincing evidence that any adjunct, alone or added to exercise, was more effective than exercise alone.
Moderate-load slow resistance exercise had the highest probability of being the most effective option for pain, though on low-certainty evidence.
Most differences between treatments rested on low or very low certainty evidence, so exact rankings should be held loosely.
For common tendon pain, progressively loading the tendon with exercise is the core, evidence-based treatment, and slow heavy resistance work looks especially promising, while high-tech add-ons do not reliably outperform well-dosed exercise.
This backs a patient, consistent, exercise-led approach to tendon pain over a scattergun of passive add-ons. For clients, the most effective thing is usually a well-designed, progressive loading programme they do themselves, guided and adjusted by their clinician.
It also reframes patience as part of the treatment. Tendons respond to gradual, monitored loading over time, and complete rest or chasing quick-fix add-ons tends to disappoint.
Strongly supports prescribing progressive tendon-loading exercise as first-line care and being cautious about passive add-ons.
Guides active clients toward structured loading programmes with a gradual, monitored return to load.
Reinforces combining hands-on symptom management with a prescribed loading programme and realistic timelines.
Hands-on work can ease associated muscle tension, but exercise loading is the core driver of tendon recovery.
The authors are careful that most differences between treatments rested on low or very low certainty evidence, so the precise rankings should not be over-interpreted. Tendinopathy trials also vary widely in loading protocols, dosing and outcome measures.
Even so, the central message, load the tendon with exercise and adjuncts add little, is well supported and clinically practical. Please confirm the citation details against the source before publishing.
Pooling 68 trials, this network meta-analysis confirmed exercise as first-line for tendon pain, found no convincing evidence that adjuncts beat exercise alone, and identified moderate-load slow resistance exercise as the most promising option for pain.
For physiotherapists, sports treatment providers and myotherapists, it supports an exercise-led, progressive-loading approach, with hands-on care as a supportive complement and realistic expectations about recovery time.
Effectiveness of Exercise Treatments With or Without Adjuncts for Common Lower Limb Tendinopathies: A Living Systematic Review and Network Meta-Analysis. Challoumas D, Crosbie G, O’Neill S, Pedret C, Millar NL. Sports Medicine – Open, 2023; 9: 71.
