The effect of extracorporeal shockwave therapy in tendinopathy: A systematic review and network meta-analysis of randomized controlled trials

The effect of extracorporeal shockwave therapy in tendinopathy: A systematic review and network meta-analysis of randomized controlled trials | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of extracorporeal shockwave therapy in tendinopathy: A systematic review and network meta-analysis of randomized controlled trials Ning-Yi Guo, Si-Qi Wang, Wei Liu, Jian-quan Wang, Bing-bing Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5689415/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background 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. Methods 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. Results 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 vs US, SMD − 2.53 [95% CI -3.03 to -2.03], I²=64.7%; ESWT vs PLACEBO, SMD − 0.53 [95% CI -0.76 to -0.30], I²=39.0%; for VAS in Achilles tendinopathy, ESWT vs PLACEBO, SMD − 0.49 [95% CI -0.83 to -0.16], I²=0; for VISA-P in patellar tendinopathy, ESWT vs PLACEBO, SMD − 0.15 [95% CI -0.42 to 0.12], I²=0; for VAS in rotator cuff tendinopathy, ESWT vs PLACEBO, SMD − 1.25 [95% CI -1.61 to -0.89], I²=89.1%; for GTPS, ESWT vs 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 to 3.24]). Conclusions 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. tendinopathy extracorporeal shock wave therapy conservative treatment Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 1. Background Tendinopathy (also known as tendinitis, tenosynovitis, and tendinosis) refers to pain and dysfunction in the tendons [ 1 , 2 ]. It can be categorized into upper limb and lower limb tendinopathies, primarily including conditions such as lateral epicondylitis and rotator cuff tendinopathy for the upper limb, and greater trochanteric pain syndrome, patellar tendinopathy, and Achilles tendinopathy for the lower limb [ 3 ]. Currently, the prevalence of tendinopathy is increasing globally, with an incidence rate of 10.52 per 1,000 person-years for lower limb tendinopathies [ 4 , 5 ]. Tendinopathy is even more common among athletes compared to the general population [ 6 ]. The associated pain and dysfunction from tendinopathy can significantly impact patients’ quality of life and physical abilities, potentially resulting in long-term or permanent functional impairments. The pathological changes and mechanisms underlying tendinopathy remain incompletely understood [ 1 ]. A widely accepted model suggests that tendons are primarily composed of tenocytes, type I collagen, and proteoglycans [ 7 ]. When tendons are subjected to excessive load or overstretching, the typically orderly collagen fibers may fragment [ 8 , 9 ], leading to tenocyte activation and proliferation. This cascade subsequently damages the collagen matrix and increases angiogenesis [ 10 ], ultimately reducing tendon performance and load-bearing capacity [ 9 ], resulting in pain and functional impairment in patients. Due to the complexity of these pathological changes and the lack of a unified understanding of its mechanisms, treating tendinopathy remains challenging. Current therapeutic approaches targeting various potential mechanisms have yet to achieve complete cure rates [ 11 ], and the benefits of similar treatments can vary among different types of tendinopathies. Extracorporeal shock wave therapy (ESWT) is a mechanical treatment that utilizes pulsed pressure waves to alter the chemical environment of the injury site [ 12 ]. This approach helps reduce local inflammation, reverse tissue damage, and promote tendon remodeling [ 13 ]. ESWT has become a widely accepted conservative alternative to surgery for treating tendinopathies in various areas such as the shoulder, elbow, hip, and ankle [ 14 , 15 ]. It has been proven effective in relieving pain and enhancing motor function in patients with tendinopathy, with additional benefits including being noninvasive, low-cost, and carrying relatively minimal treatment risk [ 15 , 16 ]. In recent years, numerous meta-analyses have examined ESWT's effectiveness in treating Achilles tendinopathy, lateral epicondylitis, patellar tendinopathy, and other types of tendinopathy [ 17 – 21 ]. However, due to factors like limited study numbers, inconsistent inclusion criteria, and a lack of comprehensive comparisons of ESWT's relative value across different types of tendinopathy, conclusions remain inconsistent. This leaves uncertainty regarding ESWT's efficacy across various tendinopathies and its comparative value as a conservative treatment option in different types of tendinopathy. The objective of this meta-analysis is to systematically synthesize and evaluate evidence from randomized controlled trials (RCTs) to verify the therapeutic efficacy of ESWT in treating tendinopathy. Specifically, this study aims to achieve three goals: first, to compare ESWT with other conservative treatments in order to determine its effectiveness in alleviating pain and reducing the severity of tendinopathy; second, to evaluate and compare the efficacy of ESWT with other conservative treatments across different types of tendinopathies, thereby establishing the value of ESWT in each tendinopathy type; and finally, to thoroughly investigate potential sources of heterogeneity. Ultimately, our findings aim to provide theoretical support for the application of ESWT in tendinopathy treatment and offer a theoretical basis for clinical decision-making on ESWT for various types of tendinopathy, potentially aiding further research on conservative treatments for tendinopathy. 2. Methods 2.1Registration This systematic review and network meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 22 ]. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under ID: CRD42024583025. 2.2Literature search strategy The published and registered studies were retrieved from PubMed, Embase, Cochrane Library, Web of Science, and EBSCO databases. The registered but unpublished studies were obtained from the U.S. Clinical Trial registry. When conducting the search for published studies, MeSH and Entry terms were utilized. Detailed information regarding the search strategy implemented by each database is provided in Supplement Table 3. The search strategy is based on keywords associated with the PICO tool: (P) Population - individuals with tendinopathies; (I) Intervention - extracorporeal shock wave therapy(ESWT); (C) Comparator -sham treatments or other conservative therapy such as injection therapy, physical therapy or exercise ; (O) Outcome measures - indicators of pain, functional or the severity of tendinopathies. Additionally, a manual search through references of selected articles and reviews was conducted to identify any relevant studies that may have been overlooked during electronic searches. Finally, all pertinent English-language studies published before July 2024 were included. 2.3Eligibility criteria Studies were eligible if they (1) were RCTs; (2) included patients with five types of tendinopathy(Lateral epicondylitis, Patellar tendinopathy, Achilles tendinopathy,Rotator Cuff Tendinosis, and Greater trochanter pain syndrome) without age restriction; the patients needed to be clinically diagnosed by a physiotherapist or medical doctor; the trials for network meta analysis needed to report follow-up data for at least one of the outcome measures of interest(pain, patient-reported physical function, or questionnaire to assess the severity of tendinopathies) (3) compared an experimental group receiving extracorporeal shock wave therapy for at least three weeks; (4) comparator: blank control, sham treatment or other conservative treatment such as injection therapy, physical therapy or exercise; (5) assessed the degree of pain, functional or the severity of tendinopathies before and after the intervention, with no restrictions on the measurement method. Studies were excluded if they (1) were duplicate publications, were literature review papers, were letters to the editor, were case reports, had abstracts published in conference proceedings, reported acute effects of a single intervention session, and were animal model studies; or (2) were combination of extracorporeal shock wave therapy(ESWT) and other conservative treatments (e.g. ESWT combined with an exercise intervention, but there was no exercise intervention control group).(3) Simply comparing different types of extracorporeal shock wave, e.g., comparing radial extracorporeal shock wave(r-ESWT) to focused extracorporeal shock wave(f-ESWT). (4)have patients with previous tendon surgery. Two researchers independently screened the articles based on inclusion and exclusion criteria. Multiple publications of the same trial were collated and the first or most complete report was used as a reference. If studies report men and women separately, the different genders are combined into one group. 2.4Data extraction Two researchers independently extracted data from the included studies. Disagreements were resolved by consensus or by consulting a third author. The following data were extracted: first author, year of publication, subject characteristics (type of tendinopathy, number of experimental and control groups, sex, age, degree of pain, index of dysfunction, etc.), intervention information (type of intervention, duration, frequency, cycle, supervised or unsupervised), and the measurement method and unit of reported results. If any data were missing, the authors of the included studies were contacted by email. 2.5Risk of bias and certain of evidence assessments Two investigators independently assessed the risk of bias (ROB) of the included studies using the Cochrane Risk of Bias Tool [ 23 ], which includes seven domains: (a) allocation generation, (b) concealment of allocation, (c) blinding of participants and personnel, (d) blinding of outcome assessment, (e) incomplete outcome data addressed, (f) freedom from selective reporting bias, and (g) other sources of bias. We subsequently rated the overall ROB of each study as follows: studies were classified as having an overall low ROB if none of the domains above were rated as having high ROB and three or fewer domains were rated as having an unclear risk; studies were classified as having an overall moderate ROB if one of the above domains was rated as having a high ROB or if four of the domains were rated as having an unclear risk of bias; otherwise, studies were classified as having an overall high ROB [ 24 ]. We assessed the certainty of evidence contributing to the network estimates of the outcome measures using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework [ 25 ]. 2.6 Data synthesis and statistical analysis The pre-to-post changes in the experimental and control groups were pooled to estimate the effects. Given the inherent heterogeneity of the interventions, pairwise meta-analytic estimates are also reported alongside the network estimates to account for variability among studies, using STATA 15.1 software (StataCorp, College Station, TX, USA). Heterogeneity was analyzed through sensitivity analysis. A random effects model was used to obtain pooled estimates. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for patient-reported pain, measured by the Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS), as well as for tendinopathy severity, measured by the Victoria Institute of Sport—Patellar score (VISA-P), Victoria Institute of Sport—Achilles score (VISA-A), Shoulder Pain and Disability Index (SPADI) [ 26 ], and Patient-Rated Tennis Elbow Evaluation (PRTEE) [ 27 ]. The I² statistic and Cochran's Q test were used to quantify heterogeneity, with I² values above 50% or a p-value of 0.10 or less for the Q test indicating substantial heterogeneity [ 28 ]. Publication bias was evaluated by inspecting funnel plots and performing Egger's test. STATA 15.1 software (StataCorp, College Station, TX, USA) was used to conduct random effects multivariate network meta-analysis (NMA) within a frequentist framework [ 29 ], following current PRISMA NMA guidelines [ 22 ]. Given that different tools and units were used to measure pain and dysfunction in the included studies, the mean difference (MD) was used to represent the effect size across outcome measures. The relationships among ESWT and other conservative interventions are illustrated in a network diagram, where the lines connecting nodes represent direct head-to-head comparisons between interventions, and the size of each node and the thickness of each connecting line are proportional to the number of studies. A network contribution graph was created to calculate the contribution of each direct comparison. The transitivity assumption was assessed by reviewing the inclusion criteria of individual studies, determining whether all participants in the network could have been randomly assigned to any intervention, and by applying consistency models [ 30 ]. Transitivity, a key assumption of NMA, indicates that indirect comparisons are valid estimates of unobserved direct comparisons [ 29 ] and that effect modifiers are homogeneously distributed across studies [ 31 ]. Inconsistency factors (IFs) with 95% CIs were calculated to assess the consistency of each closed loop, with consistency indicated if the lower limit of the 95% CI was equal to 0 [ 32 ]. The inconsistency model was used to test for inconsistency, and the consistency model was applied when inconsistency was nonsignificant (p > 0.05) [ 33 ]. Node-splitting analysis was conducted to check for local inconsistency, with reliable results indicated by p > 0.05. The surface under the cumulative ranking curve (SUCRA) was used to rank and compare the effectiveness of different conservative interventions [ 34 ]. SUCRA values range from 0 to 100, where 100 signifies the best treatment with no uncertainty, and 0 signifies the worst treatment with no uncertainty [ 35 ]. Thus, higher SUCRA values indicate more favorable outcomes for ESWT or other conservative interventions in treating tendinopathies. To examine NMA publication bias due to small-scale studies, a network funnel plot was generated, and visual analysis of symmetry was performed. 3. Results 3.1 Result of search In the initial search, a total of 1,374 articles were retrieved. After removing 576 duplicates and 340 studies that did not meet the inclusion criteria (such as reviews, systematic evaluations, and animal studies), 458 articles remained for title and abstract screening. During this process, 235 articles were excluded due to issues with study design or intervention methods. Subsequently, the remaining 223 articles were reviewed in full, and an additional 158 were excluded due to lack of access to full texts, data that did not meet study requirements, or incorrect study design. Ultimately, 65 randomized controlled trials (RCTs) on the effects of extracorporeal shock wave therapy (ESWT) for tendinopathy were included in this meta-analysis [ 36 – 100 ]. The selection process of included studies is illustrated in the PRISMA flowchart (Fig. 1 ). 3.2 Characteristics of the Included Studies This meta-analysis included 65 studies published between 2002 and 2024, with a total sample size of 3,921 participants (details on the gender ratio and mean age in each study can be found in the supplementary file). The studies cover five types of tendinopathies: lateral epicondylitis (n = 27), rotator cuff tendinopathy (n = 12), Achilles tendinopathy (n = 11), greater trochanteric pain syndrome (GTPS, n = 7), and patellar tendinopathy (n = 8). Six outcome measures were included in this study: VAS, NRS, VISA-P, VISA-A, PRTEE, and SPADI. In the included studies, the intervention for the experimental group was extracorporeal shock wave therapy (ESWT), while the control groups received one of 14 different conservative treatments: Laser Therapy (LT, n = 4), corticosteroid injection (CSI, n = 6), exercise (EX, n = 6), ultrasound therapy (US, n = 9), placebo (n = 32), needle puncture (NP, n = 1), kinesiotaping (KT, n = 3), platelet-rich plasma (PRP, n = 3), polydeoxyribonucleotide (PDRN, n = 1), neural therapy (NT, n = 1), photobiomodulation therapy (PBMT, n = 1), prolotherapy (PLT, n = 1), mobilization (ML, n = 1), and wrist splint (WS, n = 1). The agreement between the two assessors was 84.4% for study selection and 86.1% for data extraction 3.3 Quality Assessment of the Included Studies The overall risk of bias (ROB) for the 65 included studies is illustrated in Fig. 2. Most studies demonstrated a low risk of bias in the areas of random sequence generation, allocation concealment, and handling of incomplete outcome data, with 63, 49, and 56 studies, respectively, meeting these criteria (accounting for 96.9%, 75.4%, and 86.2%). Additionally, all studies had a low risk of bias for selective reporting. However, because many of the interventions required participants and researchers to have prior knowledge of the treatment protocols, 15 studies had an unclear risk of bias in participant blinding, and one study had a high risk. In terms of researcher blinding, 14 studies had an unclear risk, and 13 had a high risk of bias. In summary, 36 studies were judged to have a low ROB, 23 had a moderate ROB, and 6 had a high ROB. 3.4 Pariwise meta-analysis First, we assessed heterogeneity across all 65 included studies (all of which involved pain-related measures, though not standardized to a single scale), and found significant heterogeneity. An initial subgroup analysis was conducted on 45 studies using the 0–10 VAS pain scale as the outcome measure, but heterogeneity remained high. Next, we grouped studies by control intervention and tendinopathy type to assess heterogeneity, but this also failed to significantly reduce heterogeneity (forest plots and publication bias tests are detailed in the supplementary files). Finally, we conducted a subgroup analysis based on specific outcome measures, tendinopathy types, and control interventions, with the results presented by tendinopathy type for each subgroup. 3.4.1 Lateral Epicondylitis VAS : We performed a subgroup analysis on 13 studies involving lateral epicondylitis with available VAS score data, dividing them into three subgroups based on control interventions: ultrasound therapy (US), placebo control (PLACEBO), and kinesiotaping (KT). As shown in the forest plot, ESWT demonstrated a significant reduction in VAS scores when compared to US and placebo, with a marked decrease in heterogeneity (ESWT vs. US, SMD − 2.53 [95% CI -3.03 to -2.03], I² = 64.7%, p for heterogeneity = 0.059; ESWT vs. PLACEBO, SMD − 0.53 [95% CI -0.76 to -0.30], I² = 39.0%, p for heterogeneity = 0.132). However, when compared to KT, ESWT did not significantly impact VAS scores, and high heterogeneity was observed (ESWT vs. KT, SMD 0.64 [95% CI 0.14 to 1.13], I² = 96.5%, p for heterogeneity = 0.00). PRTEE : We conducted a subgroup analysis on 10 studies involving lateral epicondylitis with PRTEE score data, using the same grouping method as described above. As shown in the forest plot, ESWT significantly reduced PRTEE scores compared to placebo, with a notable reduction in heterogeneity (ESWT vs. PLACEBO, SMD − 0.61 [95% CI -0.85 to -0.37], I² = 55.8%, p for heterogeneity = 0.045). However, ESWT did not significantly impact PRTEE scores when compared to US or KT (ESWT vs. US, SMD 0.11 [95% CI -0.36 to 0.58], I² = 20.6%, p for heterogeneity = 0.262; ESWT vs. KT, SMD 0.38 [95% CI -0.16 to 0.93], I² = 87.9%, p for heterogeneity = 0.004). In summary, the meta-analysis results indicate that for patients with lateral epicondylitis, ESWT significantly improves VAS and PRTEE scores compared to placebo. When compared to ultrasound therapy (US), ESWT shows a significant improvement in VAS scores but has no significant effect on PRTEE scores. 3.4.2 Achilles tendinopathy VAS : We conducted a subgroup analysis on five studies involving Achilles tendinopathy with available VAS score data, dividing them into two subgroups based on control interventions: exercise therapy (EX) and placebo or blank control (PLACEBO). As shown in the forest plot, ESWT significantly reduced VAS scores compared to placebo, with no heterogeneity observed (ESWT vs. PLACEBO, SMD − 0.49 [95% CI -0.83 to -0.16], I² = 0, p for heterogeneity = 0.478). In contrast, ESWT did not significantly impact VAS scores when compared to exercise therapy, and heterogeneity remained absent (ESWT vs. EX, SMD − 0.06 [95% CI -0.35 to 0.23], I² = 0, p for heterogeneity = 0.781). VISA-A : We conducted a subgroup analysis on six studies involving Achilles tendinopathy with VISA-A score data, using the same grouping method as described above. As shown in the forest plot, ESWT significantly improved VISA-A scores compared to placebo, with no notable heterogeneity (ESWT vs. PLACEBO, SMD 0.90 [95% CI 0.52 to 1.28], I² = 0, p for heterogeneity = 0.524). However, ESWT did not significantly affect VISA-A scores compared to exercise therapy, and heterogeneity was minimal (ESWT vs. EX, SMD − 0.10 [95% CI -0.34 to 0.13], I² = 13.1%, p for heterogeneity = 0.327). In summary, the meta-analysis results indicate that for patients with Achilles tendinopathy, ESWT demonstrates a significant improvement in both VAS and VISA-A scores compared to placebo. However, there is no significant difference in therapeutic effect between ESWT and exercise therapy. 3.4.3 patellar tendinopathy VAS : A subgroup analysis was conducted on six studies concerning patellar tendinopathy that included VAS score data. The studies were divided into two subgroups based on control measures: ultrasound therapy (US) and placebo or blank control (PALCEBO). The results indicate that ESWT significantly reduced VAS scores compared to both US and placebo in patients with patellar tendinopathy. Furthermore, the US subgroup showed no heterogeneity (ESWT vs. US, SMD − 3.52 [95% CI -4.14 to -2.90], I² = 0, p for heterogeneity = 0.993; ESWT vs. PALCEBO, SMD − 0.40 [95% CI -0.69 to -0.12], I² = 69.2%, p for heterogeneity = 0.021). VISA-P : An analysis was performed on six studies concerning patellar tendinopathy with VISA-P score data, involving only one control measure: placebo or blank control (PALCEBO). The results indicated that ESWT did not have a significant effect on the VISA-P scores of patients with patellar tendinopathy compared to placebo, and there was no heterogeneity in the results (ESWT vs. PALCEBO, SMD − 0.15 [95% CI -0.42 to 0.12], I² = 0%, p for heterogeneity = 0.412). In summary, the meta-analysis on patellar tendinopathy indicates that ESWT has a significant effect on improving VAS scores when compared to both ultrasound therapy and placebo treatment. However, regarding the VISA-P scores, there is no significant difference between ESWT and placebo. 3.4.4 Rotator Cuff Tendinosis VAS : A subgroup analysis was conducted on four studies on rotator cuff tendinopathy with VAS score data. Based on the control measures, the studies were divided into two subgroups: exercise therapy (EX) and a blank control or placebo (PLACEBO). The results indicated that ESWT showed a significant effect in reducing VAS compared to PLACEBO, while there was no significant difference when compared to EX. However, both groups exhibited considerable heterogeneity (ESWT vs. EX, SMD − 0.08 [95% CI -0.44 to 0.28], I²=94.2%, p for heterogeneity = 0.00; ESWT vs. PLACEBO, SMD − 1.25 [95% CI -1.61 to -0.89], I²=89.1%, p for heterogeneity = 0.00).(Fig. 6 A-B) SPADI : A subgroup analysis was conducted on three studies on rotator cuff tendinopathy with SPADI score data, involving only one type of control measure: blank control or placebo (PLACEBO). The results indicated that ESWT had a significant effect in reducing SPADI scores compared to PLACEBO, with no heterogeneity in the results (ESWT vs. PLACEBO, SMD − 0.46 [95% CI -0.71 to -0.22], I²=0, p for heterogeneity = 0.979).(Fig. 6 C) In summary, the meta-analysis of rotator cuff tendinopathy showed that ESWT had a significant effect in improving SPADI scores compared to placebo treatment, with no heterogeneity in the results. 3.4.5 Greater trochanter pain syndrome(GTPS) NRS : A subgroup analysis was conducted on two studies on greater trochanteric pain syndrome (GTPS) with NRS score data, involving only one type of control measure: exercise therapy (EX). The results indicated that ESWT had a significant effect in reducing NRS scores in GTPS patients compared to EX, with no significant heterogeneity in the results (ESWT vs. EX, SMD − 0.41 [95% CI -0.70 to -0.11], I²=10.2%, p for heterogeneity = 0.291). 3.5Network meta-analysis(NMA) We first conducted a network meta-analysis on all studies with 0–10 scale VAS score data. Subsequently, based on differentiated outcome measurement scales, network meta-analyses were performed separately for five types of tendinopathy. The results were presented in multiple forms, including network evidence plots, SUCRA (Surface Under the Cumulative Ranking) scores, and ranking tables based on the area under the SUCRA curve. 3.5.1 All types of tendinopathy VAS : A network meta-analysis was conducted on 42 studies (88 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 44) and 14 other conservative treatment methods: Laser Therapy (LT, n = 2), corticosteroid injection (CSI, n = 1), Exercise (EX, n = 6), Ultrasound Therapy (US, n = 4), PLACEBO (n = 19), Needle Puncture (NP, n = 1), kinesiotaping (KT, n = 3), Platelet-rich plasma (PRP, n = 2), Polydeoxyribonucleotide (PDRN, n = 1), Neural Therapy (NT, n = 1), Photobiomodulation Therapy (PBMT, n = 1), Prolotherapy (PLT, n = 1), mobilization (ML, n = 1), and Wrist Splint (WS, n = 1). The results of the network meta-analysis, as shown in the Fig. 8 , indicated that among the 15 conservative treatment methods, Laser Therapy ranked first in terms of the area under the SUCRA curve (SUCRA 82.7%), while ESWT ranked fourth (65.5%). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for risk of bias assessment for this network meta-analysis, as detailed in the supplementary files. 3.5.2 Lateral Epicondylitis VAS : A network meta-analysis was conducted on 21 studies (42 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 21) and 11 other conservative treatment methods: Laser Therapy (LT, n = 1), Exercise (EX, n = 1), Ultrasound Therapy (US, n = 3), PLACEBO (n = 7), kinesiotaping (KT, n = 3), Platelet-rich plasma (PRP, n = 1), Polydeoxyribonucleotide (PDRN, n = 1), Neural Therapy (NT, n = 1), Photobiomodulation Therapy (PBMT, n = 1), Prolotherapy (PLT, n = 1), and Wrist Splint (WS, n = 1).The results of the network meta-analysis, as shown in the figure, indicated that among the 12 conservative treatment methods, Polydeoxyribonucleotide (PDRN) ranked first in terms of the area under the SUCRA curve (SUCRA 71.0%), while ESWT ranked second. There was no significant difference between the two treatments (SUCRA 67.8%; ESWT vs. PDRN, MD 0.44 [95% CI -2.76 to 3.64]). PRTEE : A network meta-analysis was conducted on 14 studies (28 arms) containing PRTEE score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 14) and six other conservative treatment methods: Laser Therapy (LT, n = 1), Ultrasound Therapy (US, n = 3), PLACEBO (n = 6), kinesiotaping (KT, n = 2), Platelet-rich plasma (PRP, n = 1), and Wrist Splint (WS, n = 1).As shown in the results figure, among the seven conservative treatments, kinesiotaping (KT) ranked first in terms of the area under the SUCRA curve (SUCRA 79.1%), while ESWT ranked second, with no significant difference between the two treatments (SUCRA 67.5%; ESWT vs. KT, MD 0.39 [95% CI -0.88 to 1.66]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for risk of bias assessment for this network meta-analysis, as detailed in the supplementary files. In summary, the network meta-analysis for patients with lateral epicondylitis demonstrated that Extracorporeal Shock Wave Therapy showed prominent effects in improving both VAS and PRTEE scores, ranking second in the SUCRA curve area among the included conservative treatment methods. 3.5.3 patellar tendinopathy VAS : A network meta-analysis was conducted on eight studies (16 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 8) and four other conservative treatments: Exercise (EX, n = 1), Ultrasound Therapy (US, n = 1), Placebo (n = 5), and Platelet-Rich Plasma (PRP, n = 1). As shown in the network meta-analysis results figure, among the five conservative treatments, Platelet-Rich Plasma (PRP) ranked first in the SUCRA curve area (SUCRA 88.5%), with ESWT ranking second. There was no significant difference between the two (SUCRA 75.3%; ESWT vs. PRP, MD 0.37 [95% CI -0.87 to 1.61]). VISA-P : A network meta-analysis was conducted on eight studies (16 arms) containing VISA-P score data, including ESWT (n = 8) and three other conservative treatments: Exercise (EX, n = 1), Placebo (n = 6), and Platelet-Rich Plasma (PRP, n = 1). As shown in the network meta-analysis results figure, among the four conservative treatments, Platelet-Rich Plasma (PRP) ranked first in the SUCRA curve area (SUCRA 79.2%), with ESWT ranking second. There was no significant difference between the two (SUCRA 67.4%; ESWT vs. PRP, MD -0.27 [95% CI -1.46 to 0.92]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for bias assessment for this network meta-analysis, as detailed in the supplementary files. In summary, in the network meta-analysis for patients with patellar tendinopathy, we found that Extracorporeal Shock Wave Therapy demonstrated a significant effect in improving both VAS and VISA-P scores, ranking second in the SUCRA curve area among the included conservative treatments, only behind PRP therapy. 3.5.4 Achilles tendinopathy VAS : A network meta-analysis was conducted on six studies (12 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 6) and three other conservative treatments: Laser Therapy (LT, n = 1), Exercise (EX, n = 2), and Placebo (n = 3). As shown in the network meta-analysis results figure, among the four conservative treatments, Laser Therapy (LT) ranked first in the SUCRA curve area (SUCRA 100.0%), with ESWT ranking second. There was a significant difference between the two (SUCRA 75.3%; ESWT vs. LT, MD 2.55 [95% CI 1.86 to 3.24]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for bias assessment for this network meta-analysis, as detailed in the supplementary files. 3.5.5 Rotator Cuff Tendinosis VAS : A network meta-analysis was conducted on seven studies (14 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 7) and four other conservative treatments: Exercise (EX, n = 2), Placebo (n = 3), Needle Puncture (NP, n = 1), and Mobilization (ML, n = 1). As shown in the network meta-analysis results figure, among the five conservative treatments, ESWT ranked first in the SUCRA curve area (SUCRA 82.3%). SPADI : A network meta-analysis was conducted on five studies (10 arms) containing SPADI score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 5) and three other conservative treatments: corticosteroid injection (CSI, n = 1), Exercise (EX, n = 1), and Placebo (n = 3). As shown in the network meta-analysis results figure, among the four conservative treatments, ESWT ranked second in the SUCRA curve area (SUCRA 61.6%), following Exercise (SUCRA 84.5%), with no significant difference between them (ESWT vs. EX, MD 0.15 [95% CI -0.24 to 0.55]). In summary, in the network meta-analysis for rotator cuff tendinopathy patients, we found that Extracorporeal Shock Wave Therapy showed excellent efficacy in improving VAS scores, ranking first in SUCRA curve area among the included conservative treatments. For improvement in SPADI scores, it ranked second, following exercise therapy. 3.5.6 Greater trochanter pain syndrome(GTPS) VAS : A network meta-analysis was conducted on two studies (4 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n = 2) and two other conservative treatments: corticosteroid injection (CSI, n = 1) and placebo (n = 1). As shown in the network meta-analysis results figure, among the three conservative treatments, ESWT ranked second in SUCRA curve area (SUCRA 54.4%), following CSI (SUCRA 95.6%), with no significant difference between them (ESWT vs. CSI, MD 0.36 [95% CI -0.16 to 0.87]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for bias assessment for this network meta-analysis, as detailed in the supplementary files. 3.5.7 Publication Bias For the network meta-analyses across all groups, we conducted Egger’s test and generated funnel plots (in supplementary materials). The results indicated that no significant publication bias was present in any of the network meta-analyses.s 4. Discussion This study is the first to comprehensively analyze the efficacy of Extracorporeal Shock Wave Therapy (ESWT) across various common types of tendinopathies using both pairwise meta-analysis and network meta-analysis. It compares the therapeutic effects of ESWT with other conservative treatments within each tendinopathy type. Our findings indicate that ESWT not only provides pain relief for multiple tendinopathy types but also contributes to improving the severity of tendinopathy.Tendinopathy efficacy can be assessed from multiple perspectives, including pain, joint mobility, and imaging studies [ 1 , 101 – 104 ]. Previous meta-analyses on tendinopathy have predominantly focused on pain indicators, primarily due to challenges in quantifying other indicators or a lack of sufficient RCTs. However, conclusions from such meta-analyses carry considerable bias and may lack clinical significance. Therefore, this study also includes various scores assessing tendinopathy severity as outcome indicators. These scores provide a multidimensional evaluation of patients, covering aspects such as pain, disability, impact on daily activities, and mental health, as seen with the SPADI score for rotator cuff tendinopathy [ 26 ] and the PRTEE score for lateral epicondylitis. Currently, ESWT is increasingly applied in sports medicine for treating various musculoskeletal injuries, including tendinopathy. Although the precise mechanism of action remains unclear, it is widely believed that ESWT’s efficacy may vary across different tendinopathy types. In line with this theoretical background, our study observed substantial heterogeneity when performing an overall pairwise meta-analysis on all 65 included studies or subgroup analyses based solely on outcome measure scales. Therefore, the primary analysis method in this study involves subgroup analyses that account for both tendinopathy type and outcome measure scale, comparing ESWT with different control interventions to minimize heterogeneity as much as possible. 4.1 Lateral Epicondylitis (LE) In the subgroup analysis for lateral epicondylitis (LE), our main conclusion is that ESWT is effective in improving both pain and PRTEE scores in patients compared to placebo, with heterogeneity at 55.8% and 39.0%, respectively. This represents a notable reduction in heterogeneity relative to pre-subgroup analysis, though some heterogeneity remains, likely due to variations in shockwave frequency, intensity, and patient factors such as gender, age, and BMI. This finding aligns with the randomized controlled trial (RCT) by Rompe et al. [ 97 ], which demonstrated that ESWT improved upper limb function and significantly alleviated pain in LE patients. In contrast, the ultrasound and kinesiotaping subgroups showed higher heterogeneity, primarily due to the limited number of RCTs and variations in the implementation of control treatments. In the network meta-analysis for LE, we observed that ESWT had a relative advantage over other conservative treatments in reducing pain and severity in lateral epicondylitis. However, the therapeutic effect of ESWT in LE remains controversial in published research. Some studies have asserted that ESWT is either ineffective for LE or inferior to other conservative treatments. For instance, Crowther’s 2002 prospective clinical study suggested that corticosteroid injections were more effective than ESWT [ 105 ], and a 2005 Cochrane review concluded that ESWT had little to no benefit in terms of pain and functional outcomes for LE patients [ 106 ]. We noted that these studies were published relatively early (2005 or earlier), when fewer high-quality RCTs were available, and lacked a consistent treatment protocol across studies. Additionally, Crowther’s study only involved short-term follow-up, without considering the long-term limitations of corticosteroid injections, which weakens the argument against ESWT. As highlighted by Rompe’s study [ 97 ], high-quality research on ESWT efficacy for LE requires standardized LE diagnostic criteria (such as MRI), the avoidance of local anesthesia before ESWT, and consistent treatment protocols (targeting the most tender area of the patient). This RCT’s findings, showing ESWT’s effectiveness surpassing that of placebo, directly contradicted earlier studies. Subsequent high-quality studies [ 19 , 107 ] also confirmed that ESWT is effective for LE patients, with advantages over injections in terms of pain relief and grip strength recovery. Synthesizing this information with the results of our network meta-analysis, we conclude that ESWT, as a safe and non-invasive conservative treatment, holds clear therapeutic value for lateral epicondylitis and should be prioritized as a conservative treatment option. Our viewpoint differs from the focus of Angela et al.'s review [ 2 , 108 ], which described LE as the tendinopathy subtype with the least effective response to ESWT. We argue that a comparison of treatment modalities within the same condition is more meaningful, and therefore, we do not dismiss the therapeutic value of ESWT in LE based on the conclusions of previous studies. Moreover, further research is needed to establish the optimal frequency, energy level, treatment duration, and cycles of ESWT specifically for LE. 4.2 Achilles Tendinopathy (AT) Subgroup analysis revealed that ESWT significantly improved both pain and VISA-A scores in patients with Achilles tendinopathy (AT) compared to placebo, with no heterogeneity observed in either outcome. However, compared to exercise therapy, ESWT showed no significant advantage in either measure, which aligns with the 2008 clinical study by Rompe et al. [ 91 ]. In the network meta-analysis, we also found that ESWT demonstrated a certain advantage within conservative treatments for AT. These results are generally consistent with published studies [ 82 , 109 ], supporting the therapeutic value of ESWT in treating Achilles tendinopathy. Achilles tendinopathy can be classified anatomically into insertional and non-insertional types [ 110 ], each with distinct characteristics [ 111 ]. Non-insertional AT patients typically experience a more diffuse area of tendon pain, whereas insertional AT patients have a more concentrated pain point [ 112 ]. Consequently, during ESWT, insertional AT patients may benefit from more targeted treatment as the shock waves can be directed precisely at the most painful area. Additionally, non-insertional AT is often associated with more severe ischemia in the mid-portion of the tendon [ 112 ], while ESWT has a relatively modest effect on promoting neovascularization. Based on these theoretical considerations and our meta-analysis findings, we conclude that ESWT has a confirmed therapeutic value for AT, with more pronounced efficacy for insertional AT. Due to the limited number of RCTs included in this study, we were unable to perform a subgroup analysis based on insertional versus non-insertional AT. Therefore, the precise therapeutic value of ESWT in AT requires further validation through high-quality RCTs and meta-analyses. 4.3 Patellar Tendinopathy(PT) In subgroup analysis, we found that ESWT provided pain relief for patellar tendinopathy (PT) when compared to placebo or ultrasound therapy (with heterogeneity at 0.00% and 69.2%, respectively). However, for improvements in VISA-P scores, ESWT showed no significant difference compared to placebo (with 0.00% heterogeneity). In the network meta-analysis, ESWT demonstrated a certain advantage among conservative treatments for PT, though its SUCRA curve area was similar to that of placebo. Our meta-analysis results indicate that ESWT has no significant therapeutic advantage over placebo for PT, which aligns with current consensus. This conclusion is consistent with the high-quality systematic review by Korakakis et al. [ 113 ], which stated that "there is no short- or mid-term efficacy difference between ESWT and placebo." Supporting this view, a randomized controlled trial by Karin et al. [ 114 ] showed that adding ESWT to eccentric exercise did not significantly enhance efficacy for PT patients. We believe this is associated with the distinct characteristics of PT, or "jumper’s knee," which differs from other tendinopathies. The symptoms of PT are generally not due to acute inflammation but are instead caused by long-term degenerative changes resulting from repetitive stress, such as jumping, with a pathogenesis of chronic repetitive tendon overload. Consequently, eccentric exercise, which targets this mechanism, is currently recognized as an effective treatment for PT.Nonetheless, we believe that there are still aspects worth exploring regarding the use of ESWT in PT. For example, a study by Williams et al. [ 115 ] suggested that MRI should be used to accurately assess intratendinous lesions in PT patients. They found that ESWT is effective for patients without fat pad involvement, while those with fat pad involvement might benefit more from arthroscopic debridement, with ESWT providing no significant effect. Additionally, a review by Molly et al. [ 101 ] noted that current placebo treatments often struggle to achieve both effective blinding and complete isolation from the effects of shockwave therapy, which may mean that most placebo treatments do not achieve the expected placebo effect. In summary, our meta-analysis supports the conclusion that ESWT has no significant difference in efficacy compared to placebo in PT patients. However, whether ESWT has potential therapeutic value for PT requires further investigation, particularly with studies focusing on specific PT subtypes (e.g., distinguishing athletes from the general population, disease duration, and fat pad involvement) and on the development of precise ESWT treatment protocols to reach definitive conclusions. 4.4 Rotator Cuff Tendinopathy(RCT) In subgroup analysis, we found that ESWT significantly improved SPADI scores and VAS pain scores in patients compared to placebo. Although the subgroup analysis for VAS scores showed high heterogeneity, we believe this primarily stems from the limited number of included RCTs. In the network meta-analysis, ESWT demonstrated a clear advantage in the conservative treatment of rotator cuff tendinopathy (RCT), showing favorable effects in improving pain-related SPADI scores. Previously, Xue et al. published the first meta-analysis and systematic review on the efficacy of ESWT in RCTs [ 116 ], concluding similarly that ESWT had therapeutic effects on shoulder pain and function in RCT patients. However, due to insufficient studies, this research was also unable to conduct subgroup analyses based on shockwave dosage and specific types of RCT. ESWT can alleviate shoulder pain by stimulating local vasodilation and reducing inflammation through mechanical vibration, as well as releasing adhesions in the affected area [ 117 ]. When combined with appropriate exercise training, it may significantly aid in the recovery of shoulder joint mobility, which aligns with our network meta-analysis results on SPADI scores for RCT patients. Both exercise training and ESWT ranked among the top two in the SUCRA curve area, with no statistical difference between them. Thus, we reasonably hypothesize that combining ESWT with exercise training could potentially yield better outcomes in pain and functional recovery for RCT patients. Furthermore, the efficacy of ESWT for non-calcific rotator cuff tendinopathy (NCST) remains controversial. Some studies have reported that ESWT is ineffective for NCST regardless of the energy dosage (EFD) used, without providing a clear explanation for this mechanism [ 118 , 119 ]. However, a double-blind randomized controlled trial by Galasso et al. [ 120 ] included NCST patients who had failed conservative treatment for at least four months and met the clinical criterion of at least six months of shoulder pain. Although their study only demonstrated short-term symptomatic improvement with ESWT, it still holds potential clinical significance. Therefore, although ESWT is more widely accepted for calcific rotator cuff tendinopathy, we believe that, due to its mechanisms of promoting local angiogenesis and stimulating the release of growth factors, ESWT may also provide therapeutic value in NCST [121]. Further high-quality experimental studies are needed to determine whether the specific dosage for NCST should differ from that used for calcific tendinopathy. 4.5 Greater Trochanteric Pain Syndrome(GTPS) In subgroup and network meta-analyses, we found that ESWT had a significant effect in reducing pain severity in patients with greater trochanteric pain syndrome (GTPS) compared to exercise training, although corticosteroid injections (CSI) may be more effective than ESWT. Consistent with our findings, existing research has shown that isolated gluteal tendon exercise training may be ineffective for GTPS patients [122, 123]. Regarding the comparative efficacy of CSI and ESWT, a previously published meta-analysis [122, 123] indicated that CSI provides superior short-term pain relief and functional improvement compared to ESWT. However, CSI may not have an advantage in pain relief and functional improvement over a 2–4 month period. This could be due to corticosteroids further weakening tendon strength in already damaged tendons, leading to reduced collagen synthesis and decreased mechanical properties in tendon cells [122, 124, 125]. However, due to the limited number of RCTs on the application of ESWT in GTPS, with mostly inconsistent outcome measures, only one related meta-analysis has been published [122], which also showed considerable heterogeneity in its findings. Therefore, more RCT data are needed to refine the conclusions of this meta-analysis and provide meaningful guidance for the clinical application of ESWT in GTPS. 4.6 Limitation Firstly, due to the limited number of included studies, our research lacks detailed differentiation and subgroup analyses of specific types of tendinopathies, such as insertional versus non-insertional Achilles tendinopathy, and calcific versus non-calcific rotator cuff tendinopathy. Since the effectiveness of ESWT may vary across these tendinopathy types, this limitation may introduce bias into our findings. Secondly, this study did not differentiate between f-ESWT and r-ESWT or conduct subgroup analyses for these variations, leading to potential bias in the analysis conclusions. Thirdly, although we reduced within-group heterogeneity through subgroup analysis, a certain degree of heterogeneity remained in each subgroup due to the lack of standardized control measures, as well as the absence of subgroup analyses based on other important variables, such as disease duration, age, BMI, and the presence of other musculoskeletal disorders.Fourthly, due to the nature of ESWT, placebo treatments, and exercise therapy, it was challenging to implement blinding for patients, which introduced a certain degree of bias. Fifthly, this study included only studies published in English, resulting in some degree of information bias. Lastly, we did not discuss the combined use of multiple conservative treatments, which is common in clinical practice; this omission introduces bias and creates a gap between our analysis conclusions and practical clinical application. 5. Conclusion The results of this meta-analysis and network meta-analysis confirm the overall effectiveness of ESWT in the treatment of tendinopathies. Although ESWT holds a favorable position compared to other conservative treatments across various types of tendinopathies, its therapeutic efficacy may vary depending on the specific type of tendinopathy. Notably, we found that ESWT did not show a significant effect compared to placebo in the treatment of patellar tendinopathy. Through this systematic review, we analyzed the conclusions and limitations of currently published studies, providing insights for future research on the efficacy of ESWT in tendinopathy. Researchers should conduct in-depth studies on the efficacy differences among various types and doses of shock waves, refine the differentiation of patient-specific indicators, such as tendinopathy type and disease duration, and investigate the therapeutic value of ESWT in under-researched types of tendinopathy (e.g., non-calcific rotator cuff tendinopathy and GTPS). Additionally, exploring the combined use of ESWT with other conservative treatments could help provide personalized ESWT treatment plans for patients in clinical practice, as well as guide decisions regarding the need for combined therapy. Abbreviations RCTs : randomized controlled trials ESWT : extracorporeal shock wave therapy GTPS : greater trochanteric pain syndrome AT : achilles tendinopathy PT : patellar tendinopathy RCT : rotator cuff tendinopathy LE : lateral epicondylitis LT : Laser Therapy CSI : corticosteroid injection EX : exercise US : ultrasound therapy NP : needle puncture KT : kinesiotaping PRP : platelet-rich plasma PDRN : polydeoxyribonucleotide NT : neural therapy PBMT : photobiomodulation therapy PLT : prolotherapy ML : mobilization WS : wrist splint Declarations Ethics approval and consent to participate Not applicable Consent for publication Written informed consent for publication was obtained from all participants. Availability of data and material Not applicable Competing interests Not applicable Funding This paper is supported by the following funds. 1.Peking University Third Hospital clinical subject talent project(Y92519-03). 2.Natural Science Foundation of China (Grant Nos. 82272571). Authors' Contributions All authors carried out the screenings and reviews, and the analysis of the articles. Ningyi Guo and Siqi Wang drafted the manuscript, and Bingbing Xu and Jianquan Wang revised the manuscript, Wei Liu prepared figures and tables. All authors read and approved the final manuscript. Acknowledgements Not applicable References Millar N L, Silbernagel K G, Thorborg K, et al. Tendinopathy[J]. Nat Rev Dis Primers,2021,7(1):1. Chen Y, Lyu K, Lu J, et al. Biological response of extracorporeal shock wave therapy to tendinopathy in vivo (review)[J]. Front Vet Sci,2022,9:851894. Hopkins C, Fu S C, Chua E, et al. Critical review on the socio-economic impact of tendinopathy[J]. Asia Pac J Sports Med Arthrosc Rehabil Technol,2016,4:9-20. Riel H, Lindstrøm C F, Rathleff M S, et al. Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study[J]. BMC Musculoskelet Disord,2019,20(1):239. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5689415","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":406901274,"identity":"0c0cea77-b5ec-4023-a479-459a8e65b7c3","order_by":0,"name":"Ning-Yi Guo","email":"","orcid":"","institution":"Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing, China.","correspondingAuthor":false,"prefix":"","firstName":"Ning-Yi","middleName":"","lastName":"Guo","suffix":""},{"id":406901275,"identity":"8d0380f1-bada-4cd6-ba40-9e2f745e6220","order_by":1,"name":"Si-Qi 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5","display":"","copyAsset":false,"role":"figure","size":92812,"visible":true,"origin":"","legend":"\u003cp\u003eHeterogeneity analysis for VAS(A) and VISA-P(B) of patella tendinopathy.(VAS:visual analogue scale; VISA-p:The Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy; US:ultrasound therapy)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5689415/v1/6f487e7c8d4c18867aa98c04.png"},{"id":74948053,"identity":"bd99aabf-91b3-4291-a01e-30e366016506","added_by":"auto","created_at":"2025-01-28 15:52:29","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":144723,"visible":true,"origin":"","legend":"\u003cp\u003eHeterogeneity analysis for VAS(A) and SPADI(B) of rotator cuff tendinopathy; Heterogeneity analysis for NRS of GTPS(C).(VAS:visual analogue scale; SPADI:Patient-Rated Tennis Elbow Evaluation; NRS:numerical rating scale; 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Epicondylitis；Network diagrams (D), cumulative probability graphs (E), and Efficacy Ranking Table (Treatment-Relative Ranking) (F) for VISA-P in patellar tendinopathy.\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-5689415/v1/d43c1fde8664a67abc90725e.png"},{"id":74948044,"identity":"66d34d6f-f028-4bfb-94c0-a5dab8b9b96c","added_by":"auto","created_at":"2025-01-28 15:52:28","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":54797,"visible":true,"origin":"","legend":"\u003cp\u003eNetwork diagrams (A), cumulative probability graphs (B), and Efficacy Ranking Table (Treatment-Relative Ranking) (C) for VAS in achilles tendinopathy.\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-5689415/v1/a62a6ae73a8b53550129a717.png"},{"id":74948026,"identity":"cf234335-0edf-4172-b824-9c2f9f63fc5d","added_by":"auto","created_at":"2025-01-28 15:52:27","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":64604,"visible":true,"origin":"","legend":"\u003cp\u003eNetwork diagrams (A), cumulative probability graphs (B), and Efficacy Ranking Table (Treatment-Relative Ranking) (C) for the VAS in rotator cuff tendinopathy；Network diagrams (D), cumulative probability graphs (E), and Efficacy Ranking Table (Treatment-Relative Ranking) (F) for the SPADI in rotator cuff tendinopathy；\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-5689415/v1/1c32ede6c33c12972e93d535.png"},{"id":74950045,"identity":"f59ac529-3cf9-41f9-be28-b692a1d41eaf","added_by":"auto","created_at":"2025-01-28 16:08:29","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":43877,"visible":true,"origin":"","legend":"\u003cp\u003eNetwork diagrams (A), cumulative probability graphs (B), and Efficacy Ranking Table (Treatment-Relative Ranking) (C) for NES in GTPS.\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-5689415/v1/b4d1a9c6205180ff7aa87685.png"},{"id":96454182,"identity":"a4b39b99-7c90-4c48-b345-5c23dc312f0e","added_by":"auto","created_at":"2025-11-21 10:02:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2010023,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5689415/v1/f731985f-6fe9-4c53-bf6a-6d20acbf2c7d.pdf"},{"id":74950038,"identity":"babadd10-1a1c-45d5-bc57-991200f2ab72","added_by":"auto","created_at":"2025-01-28 16:08:29","extension":"doc","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":85363348,"visible":true,"origin":"","legend":"","description":"","filename":"supplement.doc","url":"https://assets-eu.researchsquare.com/files/rs-5689415/v1/605a1a4993d9fafc90932eda.doc"}],"financialInterests":"","formattedTitle":"The effect of extracorporeal shockwave therapy in tendinopathy: A systematic review and network meta-analysis of randomized controlled trials","fulltext":[{"header":"1. Background","content":"\u003cp\u003eTendinopathy (also known as tendinitis, tenosynovitis, and tendinosis) refers to pain and dysfunction in the tendons [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It can be categorized into upper limb and lower limb tendinopathies, primarily including conditions such as lateral epicondylitis and rotator cuff tendinopathy for the upper limb, and greater trochanteric pain syndrome, patellar tendinopathy, and Achilles tendinopathy for the lower limb [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Currently, the prevalence of tendinopathy is increasing globally, with an incidence rate of 10.52 per 1,000 person-years for lower limb tendinopathies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Tendinopathy is even more common among athletes compared to the general population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The associated pain and dysfunction from tendinopathy can significantly impact patients\u0026rsquo; quality of life and physical abilities, potentially resulting in long-term or permanent functional impairments.\u003c/p\u003e \u003cp\u003eThe pathological changes and mechanisms underlying tendinopathy remain incompletely understood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A widely accepted model suggests that tendons are primarily composed of tenocytes, type I collagen, and proteoglycans [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. When tendons are subjected to excessive load or overstretching, the typically orderly collagen fibers may fragment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], leading to tenocyte activation and proliferation. This cascade subsequently damages the collagen matrix and increases angiogenesis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], ultimately reducing tendon performance and load-bearing capacity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], resulting in pain and functional impairment in patients. Due to the complexity of these pathological changes and the lack of a unified understanding of its mechanisms, treating tendinopathy remains challenging. Current therapeutic approaches targeting various potential mechanisms have yet to achieve complete cure rates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and the benefits of similar treatments can vary among different types of tendinopathies.\u003c/p\u003e \u003cp\u003eExtracorporeal shock wave therapy (ESWT) is a mechanical treatment that utilizes pulsed pressure waves to alter the chemical environment of the injury site [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This approach helps reduce local inflammation, reverse tissue damage, and promote tendon remodeling [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. ESWT has become a widely accepted conservative alternative to surgery for treating tendinopathies in various areas such as the shoulder, elbow, hip, and ankle [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It has been proven effective in relieving pain and enhancing motor function in patients with tendinopathy, with additional benefits including being noninvasive, low-cost, and carrying relatively minimal treatment risk [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In recent years, numerous meta-analyses have examined ESWT's effectiveness in treating Achilles tendinopathy, lateral epicondylitis, patellar tendinopathy, and other types of tendinopathy [\u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, due to factors like limited study numbers, inconsistent inclusion criteria, and a lack of comprehensive comparisons of ESWT's relative value across different types of tendinopathy, conclusions remain inconsistent. This leaves uncertainty regarding ESWT's efficacy across various tendinopathies and its comparative value as a conservative treatment option in different types of tendinopathy.\u003c/p\u003e \u003cp\u003eThe objective of this meta-analysis is to systematically synthesize and evaluate evidence from randomized controlled trials (RCTs) to verify the therapeutic efficacy of ESWT in treating tendinopathy. Specifically, this study aims to achieve three goals: first, to compare ESWT with other conservative treatments in order to determine its effectiveness in alleviating pain and reducing the severity of tendinopathy; second, to evaluate and compare the efficacy of ESWT with other conservative treatments across different types of tendinopathies, thereby establishing the value of ESWT in each tendinopathy type; and finally, to thoroughly investigate potential sources of heterogeneity. Ultimately, our findings aim to provide theoretical support for the application of ESWT in tendinopathy treatment and offer a theoretical basis for clinical decision-making on ESWT for various types of tendinopathy, potentially aiding further research on conservative treatments for tendinopathy.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1Registration\u003c/h2\u003e \u003cp\u003eThis systematic review and network meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under ID: CRD42024583025.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2Literature search strategy\u003c/h2\u003e \u003cp\u003eThe published and registered studies were retrieved from PubMed, Embase, Cochrane Library, Web of Science, and EBSCO databases. The registered but unpublished studies were obtained from the U.S. Clinical Trial registry. When conducting the search for published studies, MeSH and Entry terms were utilized. Detailed information regarding the search strategy implemented by each database is provided in Supplement Table\u0026nbsp;3. The search strategy is based on keywords associated with the PICO tool: (P) Population - individuals with tendinopathies; (I) Intervention - extracorporeal shock wave therapy(ESWT); (C) Comparator -sham treatments or other conservative therapy such as injection therapy, physical therapy or exercise ; (O) Outcome measures - indicators of pain, functional or the severity of tendinopathies. Additionally, a manual search through references of selected articles and reviews was conducted to identify any relevant studies that may have been overlooked during electronic searches. Finally, all pertinent English-language studies published before July 2024 were included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3Eligibility criteria\u003c/h2\u003e \u003cp\u003eStudies were eligible if they (1) were RCTs; (2) included patients with five types of tendinopathy(Lateral epicondylitis, Patellar tendinopathy, Achilles tendinopathy,Rotator Cuff Tendinosis, and Greater trochanter pain syndrome) without age restriction; the patients needed to be clinically diagnosed by a physiotherapist or medical doctor; the trials for network meta analysis needed to report follow-up data for at least one of the outcome measures of interest(pain, patient-reported physical function, or questionnaire to assess the severity of tendinopathies) (3) compared an experimental group receiving extracorporeal shock wave therapy for at least three weeks; (4) comparator: blank control, sham treatment or other conservative treatment such as injection therapy, physical therapy or exercise; (5) assessed the degree of pain, functional or the severity of tendinopathies before and after the intervention, with no restrictions on the measurement method.\u003c/p\u003e \u003cp\u003eStudies were excluded if they (1) were duplicate publications, were literature review papers, were letters to the editor, were case reports, had abstracts published in conference proceedings, reported acute effects of a single intervention session, and were animal model studies; or (2) were combination of extracorporeal shock wave therapy(ESWT) and other conservative treatments (e.g. ESWT combined with an exercise intervention, but there was no exercise intervention control group).(3) Simply comparing different types of extracorporeal shock wave, e.g., comparing radial extracorporeal shock wave(r-ESWT) to focused extracorporeal shock wave(f-ESWT). (4)have patients with previous tendon surgery.\u003c/p\u003e \u003cp\u003eTwo researchers independently screened the articles based on inclusion and exclusion criteria. Multiple publications of the same trial were collated and the first or most complete report was used as a reference. If studies report men and women separately, the different genders are combined into one group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4Data extraction\u003c/h2\u003e \u003cp\u003eTwo researchers independently extracted data from the included studies. Disagreements were resolved by consensus or by consulting a third author. The following data were extracted: first author, year of publication, subject characteristics (type of tendinopathy, number of experimental and control groups, sex, age, degree of pain, index of dysfunction, etc.), intervention information (type of intervention, duration, frequency, cycle, supervised or unsupervised), and the measurement method and unit of reported results. If any data were missing, the authors of the included studies were contacted by email.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5Risk of bias and certain of evidence assessments\u003c/h2\u003e \u003cp\u003eTwo investigators independently assessed the risk of bias (ROB) of the included studies using the Cochrane Risk of Bias Tool [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which includes seven domains: (a) allocation generation, (b) concealment of allocation, (c) blinding of participants and personnel, (d) blinding of outcome assessment, (e) incomplete outcome data addressed, (f) freedom from selective reporting bias, and (g) other sources of bias. We subsequently rated the overall ROB of each study as follows: studies were classified as having an overall low ROB if none of the domains above were rated as having high ROB and three or fewer domains were rated as having an unclear risk; studies were classified as having an overall moderate ROB if one of the above domains was rated as having a high ROB or if four of the domains were rated as having an unclear risk of bias; otherwise, studies were classified as having an overall high ROB [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe assessed the certainty of evidence contributing to the network estimates of the outcome measures using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data synthesis and statistical analysis\u003c/h2\u003e \u003cp\u003eThe pre-to-post changes in the experimental and control groups were pooled to estimate the effects. Given the inherent heterogeneity of the interventions, pairwise meta-analytic estimates are also reported alongside the network estimates to account for variability among studies, using STATA 15.1 software (StataCorp, College Station, TX, USA). Heterogeneity was analyzed through sensitivity analysis. A random effects model was used to obtain pooled estimates. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for patient-reported pain, measured by the Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS), as well as for tendinopathy severity, measured by the Victoria Institute of Sport\u0026mdash;Patellar score (VISA-P), Victoria Institute of Sport\u0026mdash;Achilles score (VISA-A), Shoulder Pain and Disability Index (SPADI) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and Patient-Rated Tennis Elbow Evaluation (PRTEE) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The I\u0026sup2; statistic and Cochran's Q test were used to quantify heterogeneity, with I\u0026sup2; values above 50% or a p-value of 0.10 or less for the Q test indicating substantial heterogeneity [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Publication bias was evaluated by inspecting funnel plots and performing Egger's test.\u003c/p\u003e \u003cp\u003eSTATA 15.1 software (StataCorp, College Station, TX, USA) was used to conduct random effects multivariate network meta-analysis (NMA) within a frequentist framework [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], following current PRISMA NMA guidelines [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Given that different tools and units were used to measure pain and dysfunction in the included studies, the mean difference (MD) was used to represent the effect size across outcome measures.\u003c/p\u003e \u003cp\u003eThe relationships among ESWT and other conservative interventions are illustrated in a network diagram, where the lines connecting nodes represent direct head-to-head comparisons between interventions, and the size of each node and the thickness of each connecting line are proportional to the number of studies. A network contribution graph was created to calculate the contribution of each direct comparison.\u003c/p\u003e \u003cp\u003eThe transitivity assumption was assessed by reviewing the inclusion criteria of individual studies, determining whether all participants in the network could have been randomly assigned to any intervention, and by applying consistency models [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Transitivity, a key assumption of NMA, indicates that indirect comparisons are valid estimates of unobserved direct comparisons [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and that effect modifiers are homogeneously distributed across studies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Inconsistency factors (IFs) with 95% CIs were calculated to assess the consistency of each closed loop, with consistency indicated if the lower limit of the 95% CI was equal to 0 [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The inconsistency model was used to test for inconsistency, and the consistency model was applied when inconsistency was nonsignificant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Node-splitting analysis was conducted to check for local inconsistency, with reliable results indicated by p\u0026thinsp;\u0026gt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eThe surface under the cumulative ranking curve (SUCRA) was used to rank and compare the effectiveness of different conservative interventions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. SUCRA values range from 0 to 100, where 100 signifies the best treatment with no uncertainty, and 0 signifies the worst treatment with no uncertainty [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Thus, higher SUCRA values indicate more favorable outcomes for ESWT or other conservative interventions in treating tendinopathies. To examine NMA publication bias due to small-scale studies, a network funnel plot was generated, and visual analysis of symmetry was performed.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Result of search\u003c/h2\u003e\n \u003cp\u003eIn the initial search, a total of 1,374 articles were retrieved. After removing 576 duplicates and 340 studies that did not meet the inclusion criteria (such as reviews, systematic evaluations, and animal studies), 458 articles remained for title and abstract screening. During this process, 235 articles were excluded due to issues with study design or intervention methods. Subsequently, the remaining 223 articles were reviewed in full, and an additional 158 were excluded due to lack of access to full texts, data that did not meet study requirements, or incorrect study design. Ultimately, 65 randomized controlled trials (RCTs) on the effects of extracorporeal shock wave therapy (ESWT) for tendinopathy were included in this meta-analysis [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e100\u003c/span\u003e]. The selection process of included studies is illustrated in the PRISMA flowchart (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Characteristics of the Included Studies\u003c/h2\u003e\n \u003cp\u003eThis meta-analysis included 65 studies published between 2002 and 2024, with a total sample size of 3,921 participants (details on the gender ratio and mean age in each study can be found in the supplementary file). The studies cover five types of tendinopathies: lateral epicondylitis (n\u0026thinsp;=\u0026thinsp;27), rotator cuff tendinopathy (n\u0026thinsp;=\u0026thinsp;12), Achilles tendinopathy (n\u0026thinsp;=\u0026thinsp;11), greater trochanteric pain syndrome (GTPS, n\u0026thinsp;=\u0026thinsp;7), and patellar tendinopathy (n\u0026thinsp;=\u0026thinsp;8). Six outcome measures were included in this study: VAS, NRS, VISA-P, VISA-A, PRTEE, and SPADI.\u003c/p\u003e\n \u003cp\u003eIn the included studies, the intervention for the experimental group was extracorporeal shock wave therapy (ESWT), while the control groups received one of 14 different conservative treatments: Laser Therapy (LT, n\u0026thinsp;=\u0026thinsp;4), corticosteroid injection (CSI, n\u0026thinsp;=\u0026thinsp;6), exercise (EX, n\u0026thinsp;=\u0026thinsp;6), ultrasound therapy (US, n\u0026thinsp;=\u0026thinsp;9), placebo (n\u0026thinsp;=\u0026thinsp;32), needle puncture (NP, n\u0026thinsp;=\u0026thinsp;1), kinesiotaping (KT, n\u0026thinsp;=\u0026thinsp;3), platelet-rich plasma (PRP, n\u0026thinsp;=\u0026thinsp;3), polydeoxyribonucleotide (PDRN, n\u0026thinsp;=\u0026thinsp;1), neural therapy (NT, n\u0026thinsp;=\u0026thinsp;1), photobiomodulation therapy (PBMT, n\u0026thinsp;=\u0026thinsp;1), prolotherapy (PLT, n\u0026thinsp;=\u0026thinsp;1), mobilization (ML, n\u0026thinsp;=\u0026thinsp;1), and wrist splint (WS, n\u0026thinsp;=\u0026thinsp;1). The agreement between the two assessors was 84.4% for study selection and 86.1% for data extraction\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Quality Assessment of the Included Studies\u003c/h2\u003e\n \u003cp\u003eThe overall risk of bias (ROB) for the 65 included studies is illustrated in Fig.\u0026nbsp;2. Most studies demonstrated a low risk of bias in the areas of random sequence generation, allocation concealment, and handling of incomplete outcome data, with 63, 49, and 56 studies, respectively, meeting these criteria (accounting for 96.9%, 75.4%, and 86.2%). Additionally, all studies had a low risk of bias for selective reporting. However, because many of the interventions required participants and researchers to have prior knowledge of the treatment protocols, 15 studies had an unclear risk of bias in participant blinding, and one study had a high risk. In terms of researcher blinding, 14 studies had an unclear risk, and 13 had a high risk of bias.\u003c/p\u003e\n \u003cp\u003eIn summary, 36 studies were judged to have a low ROB, 23 had a moderate ROB, and 6 had a high ROB.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4 Pariwise meta-analysis\u003c/h2\u003e\n \u003cp\u003eFirst, we assessed heterogeneity across all 65 included studies (all of which involved pain-related measures, though not standardized to a single scale), and found significant heterogeneity. An initial subgroup analysis was conducted on 45 studies using the 0\u0026ndash;10 VAS pain scale as the outcome measure, but heterogeneity remained high. Next, we grouped studies by control intervention and tendinopathy type to assess heterogeneity, but this also failed to significantly reduce heterogeneity (forest plots and publication bias tests are detailed in the supplementary files). Finally, we conducted a subgroup analysis based on specific outcome measures, tendinopathy types, and control interventions, with the results presented by tendinopathy type for each subgroup.\u003c/p\u003e\n \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.1 Lateral Epicondylitis\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: We performed a subgroup analysis on 13 studies involving lateral epicondylitis with available VAS score data, dividing them into three subgroups based on control interventions: ultrasound therapy (US), placebo control (PLACEBO), and kinesiotaping (KT). As shown in the forest plot, ESWT demonstrated a significant reduction in VAS scores when compared to US and placebo, with a marked decrease in heterogeneity (ESWT vs. US, SMD \u0026minus;\u0026thinsp;2.53 [95% CI -3.03 to -2.03], I\u0026sup2; = 64.7%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.059; ESWT vs. PLACEBO, SMD \u0026minus;\u0026thinsp;0.53 [95% CI -0.76 to -0.30], I\u0026sup2; = 39.0%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.132). However, when compared to KT, ESWT did not significantly impact VAS scores, and high heterogeneity was observed (ESWT vs. KT, SMD 0.64 [95% CI 0.14 to 1.13], I\u0026sup2; = 96.5%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.00).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePRTEE\u003c/em\u003e: We conducted a subgroup analysis on 10 studies involving lateral epicondylitis with PRTEE score data, using the same grouping method as described above. As shown in the forest plot, ESWT significantly reduced PRTEE scores compared to placebo, with a notable reduction in heterogeneity (ESWT vs. PLACEBO, SMD \u0026minus;\u0026thinsp;0.61 [95% CI -0.85 to -0.37], I\u0026sup2; = 55.8%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.045). However, ESWT did not significantly impact PRTEE scores when compared to US or KT (ESWT vs. US, SMD 0.11 [95% CI -0.36 to 0.58], I\u0026sup2; = 20.6%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.262; ESWT vs. KT, SMD 0.38 [95% CI -0.16 to 0.93], I\u0026sup2; = 87.9%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e\n \u003cp\u003eIn summary, the meta-analysis results indicate that for patients with lateral epicondylitis, ESWT significantly improves VAS and PRTEE scores compared to placebo. When compared to ultrasound therapy (US), ESWT shows a significant improvement in VAS scores but has no significant effect on PRTEE scores.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.2 Achilles tendinopathy\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: We conducted a subgroup analysis on five studies involving Achilles tendinopathy with available VAS score data, dividing them into two subgroups based on control interventions: exercise therapy (EX) and placebo or blank control (PLACEBO). As shown in the forest plot, ESWT significantly reduced VAS scores compared to placebo, with no heterogeneity observed (ESWT vs. PLACEBO, SMD \u0026minus;\u0026thinsp;0.49 [95% CI -0.83 to -0.16], I\u0026sup2; = 0, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.478). In contrast, ESWT did not significantly impact VAS scores when compared to exercise therapy, and heterogeneity remained absent (ESWT vs. EX, SMD \u0026minus;\u0026thinsp;0.06 [95% CI -0.35 to 0.23], I\u0026sup2; = 0, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.781).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eVISA-A\u003c/em\u003e: We conducted a subgroup analysis on six studies involving Achilles tendinopathy with VISA-A score data, using the same grouping method as described above. As shown in the forest plot, ESWT significantly improved VISA-A scores compared to placebo, with no notable heterogeneity (ESWT vs. PLACEBO, SMD 0.90 [95% CI 0.52 to 1.28], I\u0026sup2; = 0, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.524). However, ESWT did not significantly affect VISA-A scores compared to exercise therapy, and heterogeneity was minimal (ESWT vs. EX, SMD \u0026minus;\u0026thinsp;0.10 [95% CI -0.34 to 0.13], I\u0026sup2; = 13.1%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.327).\u003c/p\u003e\n \u003cp\u003eIn summary, the meta-analysis results indicate that for patients with Achilles tendinopathy, ESWT demonstrates a significant improvement in both VAS and VISA-A scores compared to placebo. However, there is no significant difference in therapeutic effect between ESWT and exercise therapy.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.3 patellar tendinopathy\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A subgroup analysis was conducted on six studies concerning patellar tendinopathy that included VAS score data. The studies were divided into two subgroups based on control measures: ultrasound therapy (US) and placebo or blank control (PALCEBO). The results indicate that ESWT significantly reduced VAS scores compared to both US and placebo in patients with patellar tendinopathy. Furthermore, the US subgroup showed no heterogeneity (ESWT vs. US, SMD \u0026minus;\u0026thinsp;3.52 [95% CI -4.14 to -2.90], I\u0026sup2; = 0, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.993; ESWT vs. PALCEBO, SMD \u0026minus;\u0026thinsp;0.40 [95% CI -0.69 to -0.12], I\u0026sup2; = 69.2%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.021).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eVISA-P\u003c/em\u003e: An analysis was performed on six studies concerning patellar tendinopathy with VISA-P score data, involving only one control measure: placebo or blank control (PALCEBO). The results indicated that ESWT did not have a significant effect on the VISA-P scores of patients with patellar tendinopathy compared to placebo, and there was no heterogeneity in the results (ESWT vs. PALCEBO, SMD \u0026minus;\u0026thinsp;0.15 [95% CI -0.42 to 0.12], I\u0026sup2; = 0%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.412).\u003c/p\u003e\n \u003cp\u003eIn summary, the meta-analysis on patellar tendinopathy indicates that ESWT has a significant effect on improving VAS scores when compared to both ultrasound therapy and placebo treatment. However, regarding the VISA-P scores, there is no significant difference between ESWT and placebo.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.4 Rotator Cuff Tendinosis\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A subgroup analysis was conducted on four studies on rotator cuff tendinopathy with VAS score data. Based on the control measures, the studies were divided into two subgroups: exercise therapy (EX) and a blank control or placebo (PLACEBO). The results indicated that ESWT showed a significant effect in reducing VAS compared to PLACEBO, while there was no significant difference when compared to EX. However, both groups exhibited considerable heterogeneity (ESWT vs. EX, SMD \u0026minus;\u0026thinsp;0.08 [95% CI -0.44 to 0.28], I\u0026sup2;=94.2%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.00; ESWT vs. PLACEBO, SMD \u0026minus;\u0026thinsp;1.25 [95% CI -1.61 to -0.89], I\u0026sup2;=89.1%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.00).(Fig. \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eA-B)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSPADI\u003c/em\u003e: A subgroup analysis was conducted on three studies on rotator cuff tendinopathy with SPADI score data, involving only one type of control measure: blank control or placebo (PLACEBO). The results indicated that ESWT had a significant effect in reducing SPADI scores compared to PLACEBO, with no heterogeneity in the results (ESWT vs. PLACEBO, SMD \u0026minus;\u0026thinsp;0.46 [95% CI -0.71 to -0.22], I\u0026sup2;=0, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.979).(Fig. \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003eC)\u003c/p\u003e\n \u003cp\u003eIn summary, the meta-analysis of rotator cuff tendinopathy showed that ESWT had a significant effect in improving SPADI scores compared to placebo treatment, with no heterogeneity in the results.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.5 Greater trochanter pain syndrome(GTPS)\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eNRS\u003c/em\u003e: A subgroup analysis was conducted on two studies on greater trochanteric pain syndrome (GTPS) with NRS score data, involving only one type of control measure: exercise therapy (EX). The results indicated that ESWT had a significant effect in reducing NRS scores in GTPS patients compared to EX, with no significant heterogeneity in the results (ESWT vs. EX, SMD \u0026minus;\u0026thinsp;0.41 [95% CI -0.70 to -0.11], I\u0026sup2;=10.2%, p for heterogeneity\u0026thinsp;=\u0026thinsp;0.291).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003e3.5Network meta-analysis(NMA)\u003c/h2\u003e\n \u003cp\u003eWe first conducted a network meta-analysis on all studies with 0\u0026ndash;10 scale VAS score data. Subsequently, based on differentiated outcome measurement scales, network meta-analyses were performed separately for five types of tendinopathy. The results were presented in multiple forms, including network evidence plots, SUCRA (Surface Under the Cumulative Ranking) scores, and ranking tables based on the area under the SUCRA curve.\u003c/p\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003e3.5.1 All types of tendinopathy\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A network meta-analysis was conducted on 42 studies (88 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;44) and 14 other conservative treatment methods: Laser Therapy (LT, n\u0026thinsp;=\u0026thinsp;2), corticosteroid injection (CSI, n\u0026thinsp;=\u0026thinsp;1), Exercise (EX, n\u0026thinsp;=\u0026thinsp;6), Ultrasound Therapy (US, n\u0026thinsp;=\u0026thinsp;4), PLACEBO (n\u0026thinsp;=\u0026thinsp;19), Needle Puncture (NP, n\u0026thinsp;=\u0026thinsp;1), kinesiotaping (KT, n\u0026thinsp;=\u0026thinsp;3), Platelet-rich plasma (PRP, n\u0026thinsp;=\u0026thinsp;2), Polydeoxyribonucleotide (PDRN, n\u0026thinsp;=\u0026thinsp;1), Neural Therapy (NT, n\u0026thinsp;=\u0026thinsp;1), Photobiomodulation Therapy (PBMT, n\u0026thinsp;=\u0026thinsp;1), Prolotherapy (PLT, n\u0026thinsp;=\u0026thinsp;1), mobilization (ML, n\u0026thinsp;=\u0026thinsp;1), and Wrist Splint (WS, n\u0026thinsp;=\u0026thinsp;1). The results of the network meta-analysis, as shown in the Fig. \u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e, indicated that among the 15 conservative treatment methods, Laser Therapy ranked first in terms of the area under the SUCRA curve (SUCRA 82.7%), while ESWT ranked fourth (65.5%). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for risk of bias assessment for this network meta-analysis, as detailed in the supplementary files.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\n \u003ch2\u003e3.5.2 Lateral Epicondylitis\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A network meta-analysis was conducted on 21 studies (42 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;21) and 11 other conservative treatment methods: Laser Therapy (LT, n\u0026thinsp;=\u0026thinsp;1), Exercise (EX, n\u0026thinsp;=\u0026thinsp;1), Ultrasound Therapy (US, n\u0026thinsp;=\u0026thinsp;3), PLACEBO (n\u0026thinsp;=\u0026thinsp;7), kinesiotaping (KT, n\u0026thinsp;=\u0026thinsp;3), Platelet-rich plasma (PRP, n\u0026thinsp;=\u0026thinsp;1), Polydeoxyribonucleotide (PDRN, n\u0026thinsp;=\u0026thinsp;1), Neural Therapy (NT, n\u0026thinsp;=\u0026thinsp;1), Photobiomodulation Therapy (PBMT, n\u0026thinsp;=\u0026thinsp;1), Prolotherapy (PLT, n\u0026thinsp;=\u0026thinsp;1), and Wrist Splint (WS, n\u0026thinsp;=\u0026thinsp;1).The results of the network meta-analysis, as shown in the figure, indicated that among the 12 conservative treatment methods, Polydeoxyribonucleotide (PDRN) ranked first in terms of the area under the SUCRA curve (SUCRA 71.0%), while ESWT ranked second. There was no significant difference between the two treatments (SUCRA 67.8%; ESWT vs. PDRN, MD 0.44 [95% CI -2.76 to 3.64]).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePRTEE\u003c/em\u003e: A network meta-analysis was conducted on 14 studies (28 arms) containing PRTEE score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;14) and six other conservative treatment methods: Laser Therapy (LT, n\u0026thinsp;=\u0026thinsp;1), Ultrasound Therapy (US, n\u0026thinsp;=\u0026thinsp;3), PLACEBO (n\u0026thinsp;=\u0026thinsp;6), kinesiotaping (KT, n\u0026thinsp;=\u0026thinsp;2), Platelet-rich plasma (PRP, n\u0026thinsp;=\u0026thinsp;1), and Wrist Splint (WS, n\u0026thinsp;=\u0026thinsp;1).As shown in the results figure, among the seven conservative treatments, kinesiotaping (KT) ranked first in terms of the area under the SUCRA curve (SUCRA 79.1%), while ESWT ranked second, with no significant difference between the two treatments (SUCRA 67.5%; ESWT vs. KT, MD 0.39 [95% CI -0.88 to 1.66]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for risk of bias assessment for this network meta-analysis, as detailed in the supplementary files.\u003c/p\u003e\n \u003cp\u003eIn summary, the network meta-analysis for patients with lateral epicondylitis demonstrated that Extracorporeal Shock Wave Therapy showed prominent effects in improving both VAS and PRTEE scores, ranking second in the SUCRA curve area among the included conservative treatment methods.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003e3.5.3 patellar tendinopathy\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A network meta-analysis was conducted on eight studies (16 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;8) and four other conservative treatments: Exercise (EX, n\u0026thinsp;=\u0026thinsp;1), Ultrasound Therapy (US, n\u0026thinsp;=\u0026thinsp;1), Placebo (n\u0026thinsp;=\u0026thinsp;5), and Platelet-Rich Plasma (PRP, n\u0026thinsp;=\u0026thinsp;1). As shown in the network meta-analysis results figure, among the five conservative treatments, Platelet-Rich Plasma (PRP) ranked first in the SUCRA curve area (SUCRA 88.5%), with ESWT ranking second. There was no significant difference between the two (SUCRA 75.3%; ESWT vs. PRP, MD 0.37 [95% CI -0.87 to 1.61]).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eVISA-P\u003c/em\u003e: A network meta-analysis was conducted on eight studies (16 arms) containing VISA-P score data, including ESWT (n\u0026thinsp;=\u0026thinsp;8) and three other conservative treatments: Exercise (EX, n\u0026thinsp;=\u0026thinsp;1), Placebo (n\u0026thinsp;=\u0026thinsp;6), and Platelet-Rich Plasma (PRP, n\u0026thinsp;=\u0026thinsp;1). As shown in the network meta-analysis results figure, among the four conservative treatments, Platelet-Rich Plasma (PRP) ranked first in the SUCRA curve area (SUCRA 79.2%), with ESWT ranking second. There was no significant difference between the two (SUCRA 67.4%; ESWT vs. PRP, MD -0.27 [95% CI -1.46 to 0.92]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for bias assessment for this network meta-analysis, as detailed in the supplementary files.\u003c/p\u003e\n \u003cp\u003eIn summary, in the network meta-analysis for patients with patellar tendinopathy, we found that Extracorporeal Shock Wave Therapy demonstrated a significant effect in improving both VAS and VISA-P scores, ranking second in the SUCRA curve area among the included conservative treatments, only behind PRP therapy.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003e3.5.4 Achilles tendinopathy\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A network meta-analysis was conducted on six studies (12 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;6) and three other conservative treatments: Laser Therapy (LT, n\u0026thinsp;=\u0026thinsp;1), Exercise (EX, n\u0026thinsp;=\u0026thinsp;2), and Placebo (n\u0026thinsp;=\u0026thinsp;3). As shown in the network meta-analysis results figure, among the four conservative treatments, Laser Therapy (LT) ranked first in the SUCRA curve area (SUCRA 100.0%), with ESWT ranking second. There was a significant difference between the two (SUCRA 75.3%; ESWT vs. LT, MD 2.55 [95% CI 1.86 to 3.24]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for bias assessment for this network meta-analysis, as detailed in the supplementary files.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\n \u003ch2\u003e3.5.5 Rotator Cuff Tendinosis\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A network meta-analysis was conducted on seven studies (14 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;7) and four other conservative treatments: Exercise (EX, n\u0026thinsp;=\u0026thinsp;2), Placebo (n\u0026thinsp;=\u0026thinsp;3), Needle Puncture (NP, n\u0026thinsp;=\u0026thinsp;1), and Mobilization (ML, n\u0026thinsp;=\u0026thinsp;1). As shown in the network meta-analysis results figure, among the five conservative treatments, ESWT ranked first in the SUCRA curve area (SUCRA 82.3%).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSPADI\u003c/em\u003e: A network meta-analysis was conducted on five studies (10 arms) containing SPADI score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;5) and three other conservative treatments: corticosteroid injection (CSI, n\u0026thinsp;=\u0026thinsp;1), Exercise (EX, n\u0026thinsp;=\u0026thinsp;1), and Placebo (n\u0026thinsp;=\u0026thinsp;3). As shown in the network meta-analysis results figure, among the four conservative treatments, ESWT ranked second in the SUCRA curve area (SUCRA 61.6%), following Exercise (SUCRA 84.5%), with no significant difference between them (ESWT vs. EX, MD 0.15 [95% CI -0.24 to 0.55]).\u003c/p\u003e\n \u003cp\u003eIn summary, in the network meta-analysis for rotator cuff tendinopathy patients, we found that Extracorporeal Shock Wave Therapy showed excellent efficacy in improving VAS scores, ranking first in SUCRA curve area among the included conservative treatments. For improvement in SPADI scores, it ranked second, following exercise therapy.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003e3.5.6 Greater trochanter pain syndrome(GTPS)\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eVAS\u003c/em\u003e: A network meta-analysis was conducted on two studies (4 arms) containing VAS score data, including Extracorporeal Shock Wave Therapy (ESWT, n\u0026thinsp;=\u0026thinsp;2) and two other conservative treatments: corticosteroid injection (CSI, n\u0026thinsp;=\u0026thinsp;1) and placebo (n\u0026thinsp;=\u0026thinsp;1). As shown in the network meta-analysis results figure, among the three conservative treatments, ESWT ranked second in SUCRA curve area (SUCRA 54.4%), following CSI (SUCRA 95.6%), with no significant difference between them (ESWT vs. CSI, MD 0.36 [95% CI -0.16 to 0.87]). Additionally, we generated a comparison-adjusted funnel plot, contribution plot, network forest plot, and funnel plot for bias assessment for this network meta-analysis, as detailed in the supplementary files.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n \u003ch2\u003e3.5.7 Publication Bias\u003c/h2\u003e\n \u003cp\u003eFor the network meta-analyses across all groups, we conducted Egger\u0026rsquo;s test and generated funnel plots (in supplementary materials). The results indicated that no significant publication bias was present in any of the network meta-analyses.s\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study is the first to comprehensively analyze the efficacy of Extracorporeal Shock Wave Therapy (ESWT) across various common types of tendinopathies using both pairwise meta-analysis and network meta-analysis. It compares the therapeutic effects of ESWT with other conservative treatments within each tendinopathy type. Our findings indicate that ESWT not only provides pain relief for multiple tendinopathy types but also contributes to improving the severity of tendinopathy.Tendinopathy efficacy can be assessed from multiple perspectives, including pain, joint mobility, and imaging studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR102 CR103\" citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e]. Previous meta-analyses on tendinopathy have predominantly focused on pain indicators, primarily due to challenges in quantifying other indicators or a lack of sufficient RCTs. However, conclusions from such meta-analyses carry considerable bias and may lack clinical significance. Therefore, this study also includes various scores assessing tendinopathy severity as outcome indicators. These scores provide a multidimensional evaluation of patients, covering aspects such as pain, disability, impact on daily activities, and mental health, as seen with the SPADI score for rotator cuff tendinopathy [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and the PRTEE score for lateral epicondylitis.\u003c/p\u003e \u003cp\u003eCurrently, ESWT is increasingly applied in sports medicine for treating various musculoskeletal injuries, including tendinopathy. Although the precise mechanism of action remains unclear, it is widely believed that ESWT\u0026rsquo;s efficacy may vary across different tendinopathy types. In line with this theoretical background, our study observed substantial heterogeneity when performing an overall pairwise meta-analysis on all 65 included studies or subgroup analyses based solely on outcome measure scales. Therefore, the primary analysis method in this study involves subgroup analyses that account for both tendinopathy type and outcome measure scale, comparing ESWT with different control interventions to minimize heterogeneity as much as possible.\u003c/p\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Lateral Epicondylitis (LE)\u003c/h2\u003e \u003cp\u003eIn the subgroup analysis for lateral epicondylitis (LE), our main conclusion is that ESWT is effective in improving both pain and PRTEE scores in patients compared to placebo, with heterogeneity at 55.8% and 39.0%, respectively. This represents a notable reduction in heterogeneity relative to pre-subgroup analysis, though some heterogeneity remains, likely due to variations in shockwave frequency, intensity, and patient factors such as gender, age, and BMI. This finding aligns with the randomized controlled trial (RCT) by Rompe et al. [\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e], which demonstrated that ESWT improved upper limb function and significantly alleviated pain in LE patients. In contrast, the ultrasound and kinesiotaping subgroups showed higher heterogeneity, primarily due to the limited number of RCTs and variations in the implementation of control treatments.\u003c/p\u003e \u003cp\u003eIn the network meta-analysis for LE, we observed that ESWT had a relative advantage over other conservative treatments in reducing pain and severity in lateral epicondylitis. However, the therapeutic effect of ESWT in LE remains controversial in published research. Some studies have asserted that ESWT is either ineffective for LE or inferior to other conservative treatments. For instance, Crowther\u0026rsquo;s 2002 prospective clinical study suggested that corticosteroid injections were more effective than ESWT [\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e], and a 2005 Cochrane review concluded that ESWT had little to no benefit in terms of pain and functional outcomes for LE patients [\u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e]. We noted that these studies were published relatively early (2005 or earlier), when fewer high-quality RCTs were available, and lacked a consistent treatment protocol across studies. Additionally, Crowther\u0026rsquo;s study only involved short-term follow-up, without considering the long-term limitations of corticosteroid injections, which weakens the argument against ESWT. As highlighted by Rompe\u0026rsquo;s study [\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e], high-quality research on ESWT efficacy for LE requires standardized LE diagnostic criteria (such as MRI), the avoidance of local anesthesia before ESWT, and consistent treatment protocols (targeting the most tender area of the patient). This RCT\u0026rsquo;s findings, showing ESWT\u0026rsquo;s effectiveness surpassing that of placebo, directly contradicted earlier studies. Subsequent high-quality studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR107\" class=\"CitationRef\"\u003e107\u003c/span\u003e] also confirmed that ESWT is effective for LE patients, with advantages over injections in terms of pain relief and grip strength recovery.\u003c/p\u003e \u003cp\u003eSynthesizing this information with the results of our network meta-analysis, we conclude that ESWT, as a safe and non-invasive conservative treatment, holds clear therapeutic value for lateral epicondylitis and should be prioritized as a conservative treatment option. Our viewpoint differs from the focus of Angela et al.'s review [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e], which described LE as the tendinopathy subtype with the least effective response to ESWT. We argue that a comparison of treatment modalities within the same condition is more meaningful, and therefore, we do not dismiss the therapeutic value of ESWT in LE based on the conclusions of previous studies. Moreover, further research is needed to establish the optimal frequency, energy level, treatment duration, and cycles of ESWT specifically for LE.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Achilles Tendinopathy (AT)\u003c/h2\u003e \u003cp\u003eSubgroup analysis revealed that ESWT significantly improved both pain and VISA-A scores in patients with Achilles tendinopathy (AT) compared to placebo, with no heterogeneity observed in either outcome. However, compared to exercise therapy, ESWT showed no significant advantage in either measure, which aligns with the 2008 clinical study by Rompe et al. [\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]. In the network meta-analysis, we also found that ESWT demonstrated a certain advantage within conservative treatments for AT. These results are generally consistent with published studies [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e], supporting the therapeutic value of ESWT in treating Achilles tendinopathy.\u003c/p\u003e \u003cp\u003eAchilles tendinopathy can be classified anatomically into insertional and non-insertional types [\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e], each with distinct characteristics [\u003cspan citationid=\"CR111\" class=\"CitationRef\"\u003e111\u003c/span\u003e]. Non-insertional AT patients typically experience a more diffuse area of tendon pain, whereas insertional AT patients have a more concentrated pain point [\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e]. Consequently, during ESWT, insertional AT patients may benefit from more targeted treatment as the shock waves can be directed precisely at the most painful area. Additionally, non-insertional AT is often associated with more severe ischemia in the mid-portion of the tendon [\u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e112\u003c/span\u003e], while ESWT has a relatively modest effect on promoting neovascularization. Based on these theoretical considerations and our meta-analysis findings, we conclude that ESWT has a confirmed therapeutic value for AT, with more pronounced efficacy for insertional AT. Due to the limited number of RCTs included in this study, we were unable to perform a subgroup analysis based on insertional versus non-insertional AT. Therefore, the precise therapeutic value of ESWT in AT requires further validation through high-quality RCTs and meta-analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec30\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Patellar Tendinopathy(PT)\u003c/h2\u003e \u003cp\u003eIn subgroup analysis, we found that ESWT provided pain relief for patellar tendinopathy (PT) when compared to placebo or ultrasound therapy (with heterogeneity at 0.00% and 69.2%, respectively). However, for improvements in VISA-P scores, ESWT showed no significant difference compared to placebo (with 0.00% heterogeneity). In the network meta-analysis, ESWT demonstrated a certain advantage among conservative treatments for PT, though its SUCRA curve area was similar to that of placebo. Our meta-analysis results indicate that ESWT has no significant therapeutic advantage over placebo for PT, which aligns with current consensus. This conclusion is consistent with the high-quality systematic review by Korakakis et al. [\u003cspan citationid=\"CR113\" class=\"CitationRef\"\u003e113\u003c/span\u003e], which stated that \"there is no short- or mid-term efficacy difference between ESWT and placebo.\"\u003c/p\u003e \u003cp\u003eSupporting this view, a randomized controlled trial by Karin et al. [\u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e114\u003c/span\u003e] showed that adding ESWT to eccentric exercise did not significantly enhance efficacy for PT patients. We believe this is associated with the distinct characteristics of PT, or \"jumper\u0026rsquo;s knee,\" which differs from other tendinopathies. The symptoms of PT are generally not due to acute inflammation but are instead caused by long-term degenerative changes resulting from repetitive stress, such as jumping, with a pathogenesis of chronic repetitive tendon overload. Consequently, eccentric exercise, which targets this mechanism, is currently recognized as an effective treatment for PT.Nonetheless, we believe that there are still aspects worth exploring regarding the use of ESWT in PT. For example, a study by Williams et al. [\u003cspan citationid=\"CR115\" class=\"CitationRef\"\u003e115\u003c/span\u003e] suggested that MRI should be used to accurately assess intratendinous lesions in PT patients. They found that ESWT is effective for patients without fat pad involvement, while those with fat pad involvement might benefit more from arthroscopic debridement, with ESWT providing no significant effect. Additionally, a review by Molly et al. [\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e] noted that current placebo treatments often struggle to achieve both effective blinding and complete isolation from the effects of shockwave therapy, which may mean that most placebo treatments do not achieve the expected placebo effect.\u003c/p\u003e \u003cp\u003eIn summary, our meta-analysis supports the conclusion that ESWT has no significant difference in efficacy compared to placebo in PT patients. However, whether ESWT has potential therapeutic value for PT requires further investigation, particularly with studies focusing on specific PT subtypes (e.g., distinguishing athletes from the general population, disease duration, and fat pad involvement) and on the development of precise ESWT treatment protocols to reach definitive conclusions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Rotator Cuff Tendinopathy(RCT)\u003c/h2\u003e \u003cp\u003eIn subgroup analysis, we found that ESWT significantly improved SPADI scores and VAS pain scores in patients compared to placebo. Although the subgroup analysis for VAS scores showed high heterogeneity, we believe this primarily stems from the limited number of included RCTs. In the network meta-analysis, ESWT demonstrated a clear advantage in the conservative treatment of rotator cuff tendinopathy (RCT), showing favorable effects in improving pain-related SPADI scores. Previously, Xue et al. published the first meta-analysis and systematic review on the efficacy of ESWT in RCTs [\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e], concluding similarly that ESWT had therapeutic effects on shoulder pain and function in RCT patients. However, due to insufficient studies, this research was also unable to conduct subgroup analyses based on shockwave dosage and specific types of RCT.\u003c/p\u003e \u003cp\u003eESWT can alleviate shoulder pain by stimulating local vasodilation and reducing inflammation through mechanical vibration, as well as releasing adhesions in the affected area [\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e]. When combined with appropriate exercise training, it may significantly aid in the recovery of shoulder joint mobility, which aligns with our network meta-analysis results on SPADI scores for RCT patients. Both exercise training and ESWT ranked among the top two in the SUCRA curve area, with no statistical difference between them. Thus, we reasonably hypothesize that combining ESWT with exercise training could potentially yield better outcomes in pain and functional recovery for RCT patients.\u003c/p\u003e \u003cp\u003eFurthermore, the efficacy of ESWT for non-calcific rotator cuff tendinopathy (NCST) remains controversial. Some studies have reported that ESWT is ineffective for NCST regardless of the energy dosage (EFD) used, without providing a clear explanation for this mechanism [\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e, \u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e]. However, a double-blind randomized controlled trial by Galasso et al. [\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e] included NCST patients who had failed conservative treatment for at least four months and met the clinical criterion of at least six months of shoulder pain. Although their study only demonstrated short-term symptomatic improvement with ESWT, it still holds potential clinical significance. Therefore, although ESWT is more widely accepted for calcific rotator cuff tendinopathy, we believe that, due to its mechanisms of promoting local angiogenesis and stimulating the release of growth factors, ESWT may also provide therapeutic value in NCST [121]. Further high-quality experimental studies are needed to determine whether the specific dosage for NCST should differ from that used for calcific tendinopathy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Greater Trochanteric Pain Syndrome(GTPS)\u003c/h2\u003e \u003cp\u003eIn subgroup and network meta-analyses, we found that ESWT had a significant effect in reducing pain severity in patients with greater trochanteric pain syndrome (GTPS) compared to exercise training, although corticosteroid injections (CSI) may be more effective than ESWT. Consistent with our findings, existing research has shown that isolated gluteal tendon exercise training may be ineffective for GTPS patients [122, 123]. Regarding the comparative efficacy of CSI and ESWT, a previously published meta-analysis [122, 123] indicated that CSI provides superior short-term pain relief and functional improvement compared to ESWT. However, CSI may not have an advantage in pain relief and functional improvement over a 2\u0026ndash;4 month period. This could be due to corticosteroids further weakening tendon strength in already damaged tendons, leading to reduced collagen synthesis and decreased mechanical properties in tendon cells [122, 124, 125]. However, due to the limited number of RCTs on the application of ESWT in GTPS, with mostly inconsistent outcome measures, only one related meta-analysis has been published [122], which also showed considerable heterogeneity in its findings. Therefore, more RCT data are needed to refine the conclusions of this meta-analysis and provide meaningful guidance for the clinical application of ESWT in GTPS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Limitation\u003c/h2\u003e \u003cp\u003eFirstly, due to the limited number of included studies, our research lacks detailed differentiation and subgroup analyses of specific types of tendinopathies, such as insertional versus non-insertional Achilles tendinopathy, and calcific versus non-calcific rotator cuff tendinopathy. Since the effectiveness of ESWT may vary across these tendinopathy types, this limitation may introduce bias into our findings. Secondly, this study did not differentiate between f-ESWT and r-ESWT or conduct subgroup analyses for these variations, leading to potential bias in the analysis conclusions. Thirdly, although we reduced within-group heterogeneity through subgroup analysis, a certain degree of heterogeneity remained in each subgroup due to the lack of standardized control measures, as well as the absence of subgroup analyses based on other important variables, such as disease duration, age, BMI, and the presence of other musculoskeletal disorders.Fourthly, due to the nature of ESWT, placebo treatments, and exercise therapy, it was challenging to implement blinding for patients, which introduced a certain degree of bias. Fifthly, this study included only studies published in English, resulting in some degree of information bias. Lastly, we did not discuss the combined use of multiple conservative treatments, which is common in clinical practice; this omission introduces bias and creates a gap between our analysis conclusions and practical clinical application.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe results of this meta-analysis and network meta-analysis confirm the overall effectiveness of ESWT in the treatment of tendinopathies. Although ESWT holds a favorable position compared to other conservative treatments across various types of tendinopathies, its therapeutic efficacy may vary depending on the specific type of tendinopathy. Notably, we found that ESWT did not show a significant effect compared to placebo in the treatment of patellar tendinopathy. Through this systematic review, we analyzed the conclusions and limitations of currently published studies, providing insights for future research on the efficacy of ESWT in tendinopathy. Researchers should conduct in-depth studies on the efficacy differences among various types and doses of shock waves, refine the differentiation of patient-specific indicators, such as tendinopathy type and disease duration, and investigate the therapeutic value of ESWT in under-researched types of tendinopathy (e.g., non-calcific rotator cuff tendinopathy and GTPS). Additionally, exploring the combined use of ESWT with other conservative treatments could help provide personalized ESWT treatment plans for patients in clinical practice, as well as guide decisions regarding the need for combined therapy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRCTs : randomized controlled trials\u003c/p\u003e\n\u003cp\u003eESWT : extracorporeal shock wave therapy\u003c/p\u003e\n\u003cp\u003eGTPS : \u0026nbsp;greater trochanteric pain syndrome\u003c/p\u003e\n\u003cp\u003eAT : achilles tendinopathy\u003c/p\u003e\n\u003cp\u003ePT : patellar tendinopathy\u003c/p\u003e\n\u003cp\u003eRCT : rotator cuff tendinopathy\u003c/p\u003e\n\u003cp\u003eLE : lateral epicondylitis\u003c/p\u003e\n\u003cp\u003eLT : Laser Therapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCSI : corticosteroid injection\u003c/p\u003e\n\u003cp\u003eEX : exercise\u003c/p\u003e\n\u003cp\u003eUS : ultrasound therapy\u003c/p\u003e\n\u003cp\u003eNP : needle puncture\u003c/p\u003e\n\u003cp\u003eKT : kinesiotaping\u003c/p\u003e\n\u003cp\u003ePRP : platelet-rich plasma\u003c/p\u003e\n\u003cp\u003ePDRN : polydeoxyribonucleotide\u003c/p\u003e\n\u003cp\u003eNT : neural therapy\u003c/p\u003e\n\u003cp\u003ePBMT : photobiomodulation therapy\u003c/p\u003e\n\u003cp\u003ePLT : prolotherapy\u003c/p\u003e\n\u003cp\u003eML : mobilization\u003c/p\u003e\n\u003cp\u003eWS : wrist splint\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper is supported by the following funds.\u003c/p\u003e\n\u003cp\u003e1.Peking University Third Hospital clinical subject talent project(Y92519-03).\u003c/p\u003e\n\u003cp\u003e2.Natural Science Foundation of China (Grant Nos. 82272571).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors carried out the screenings and reviews, and the analysis of the articles. Ningyi Guo and Siqi Wang drafted the manuscript, and Bingbing Xu and Jianquan Wang\u0026nbsp;revised the manuscript, Wei Liu prepared figures and tables. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMillar N L, Silbernagel K G, Thorborg K, et al. Tendinopathy[J]. Nat Rev Dis Primers,2021,7(1):1.\u003c/li\u003e\n\u003cli\u003eChen Y, Lyu K, Lu J, et al. Biological response of extracorporeal shock wave therapy to tendinopathy in vivo (review)[J]. Front Vet Sci,2022,9:851894.\u003c/li\u003e\n\u003cli\u003eHopkins C, Fu S C, Chua E, et al. Critical review on the socio-economic impact of tendinopathy[J]. Asia Pac J Sports Med Arthrosc Rehabil Technol,2016,4:9-20.\u003c/li\u003e\n\u003cli\u003eRiel H, Lindstr\u0026oslash;m C F, Rathleff M S, et al. 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Semin Arthritis Rheum,2014,43(4):570-576.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"tendinopathy, extracorporeal shock wave therapy, conservative treatment","lastPublishedDoi":"10.21203/rs.3.rs-5689415/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5689415/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis 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 vs US, SMD \u0026minus;\u0026thinsp;2.53 [95% CI -3.03 to -2.03], I\u0026sup2;=64.7%; ESWT vs PLACEBO, SMD \u0026minus;\u0026thinsp;0.53 [95% CI -0.76 to -0.30], I\u0026sup2;=39.0%; for VAS in Achilles tendinopathy, ESWT vs PLACEBO, SMD \u0026minus;\u0026thinsp;0.49 [95% CI -0.83 to -0.16], I\u0026sup2;=0; for VISA-P in patellar tendinopathy, ESWT vs PLACEBO, SMD \u0026minus;\u0026thinsp;0.15 [95% CI -0.42 to 0.12], I\u0026sup2;=0; for VAS in rotator cuff tendinopathy, ESWT vs PLACEBO, SMD \u0026minus;\u0026thinsp;1.25 [95% CI -1.61 to -0.89], I\u0026sup2;=89.1%; for GTPS, ESWT vs EX, SMD \u0026minus;\u0026thinsp;0.41 [95% CI -0.70 to -0.11], I\u0026sup2;=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 to 3.24]).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCurrent 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.\u003c/p\u003e","manuscriptTitle":"The effect of extracorporeal shockwave therapy in tendinopathy: A systematic review and network meta-analysis of randomized controlled trials","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-28 15:52:20","doi":"10.21203/rs.3.rs-5689415/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a566bf62-888c-4b54-af66-511c0d540489","owner":[],"postedDate":"January 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-20T15:44:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-28 15:52:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5689415","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5689415","identity":"rs-5689415","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}