Exercise, orthoses and splinting for treating Achilles tendinopathy: a systematic review with meta-analysis

Fiona Wilson, Margaret Walshe, Tom O’Dwyer, Kathleen Bennett, David Mockler,
Christopher Bleakley

Br J Sports Med 2018;52:1564–1574.

Abstract
Objectives To assess the efficacy of exercise, orthoses
and splinting on function, pain and quality of life (QoL)
for the management of mid-portion and insertional
Achilles tendinopathy, and to compare different
types, applications and modes of delivery within each
intervention category.
Design Systematic review and meta-analysis.
Data sources Medline, CINAHL, Embase, AMED, WHO
ICTRP, Web of Science, PEDro and Cochrane Library from
inception to October 2017. Citation tracking of published
studies and conference proceedings and contacting
experts in the field.
Study eligibility criteria Controlled clinical trials
evaluating either exercise, orthoses or splinting for the
management of Achilles tendinopathy.
Methods Independent reviewers undertook searches,
screening and risk of bias appraisal. Primary outcomes of
interest were function, pain and QoL.
Results Twenty-two studies were included (1137
participants). Moderate level evidence favoured eccentric
exercise over control for improving pain and function
in mid-portion tendinopathy. Moderate level evidence
favoured eccentric exercise over concentric 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.
There was low level evidence that eccentric exercise
was not superior to stretching for pain or QoL. There
was moderate level evidence that a combined exercise
protocol was not superior to a lower dosage protocol for
improving functional performance. There was moderate
to low level evidence of a significant difference in pain
(mean difference (MD) 6.3 mm, 95% CI −4.45 to 17.04,
moderate) or function (MD 1.83 Victoria Institute of
Sport Assessment points, 95% CI −7.47 to 11.12, low)
between high-dose and low-dose eccentric training.
There was high to moderate level evidence of no
difference in pain (moderate) or function (high) between
orthoses and control. There was low level evidence of no
significant benefit in adding a night splint to an eccentric
exercise programme for function, and moderate level
evidence for no reduction in pain (MD −3.50, 95% CI
−10.49 to 3.48). Eccentric exercise was not superior to
splinting for pain (moderate evidence) or function (low
level evidence).
Summary We conditionally recommend exercise for
improving pain and function in mid-portion Achilles
tendinopathy. The balance of evidence did not support
recommendation of one type of exercise programme
over another. We conditionally recommend against the
addition of a splint to an eccentric exercise protocol and
we do not recommend the use of orthoses to improve
pain and function in Achilles tendinopathy.