BACKGROUND: Achilles tendinopathy (AT) is a common cause of overuse injury in both athletes and nonactive individuals, especially at older ages. Due to the limited number of direct comparisons among interventions, determining the best treatment option can be difficult. PURPOSE: To evaluate the comparative efficacy and tolerability of nonsurgical therapies for midportion AT. STUDY DESIGN: Systematic review; level of evidence, 1. METHODS: PubMed, Medline, Embase, and Google Scholar were searched from database inception through June 20, 2019. Randomized controlled trials investigating the effect of nonsurgical therapies for midportion AT using the Victorian Institute of Sports Assessment-Achilles (VISA-A) assessment were eligible for inclusion. Primary outcome was mean change in VISA-A score from baseline. Comparisons between interventions were made through use of random-effects network meta-analysis over the short term (<= 3 months) and longer term (> 3 to < 12 months). A safety profile was defined for each intervention by rate of all-cause discontinuation (dropout) during follow-up. Relative ranking of therapies was assessed by the surface-under-the-cumulative ranking possibilities. RESULTS: A total of 22 studies with 978 patients met the inclusion criteria. In short-term studies, high-volume injection with corticosteroid (HVI+C) along with eccentric exercise (ECC) significantly improved the change of VISA-A score compared with that of ECC alone (standardized mean difference (SMD) 1.08; 95% CI 0.58 to 1.58). Compared with ECC, acupuncture showed benefits over both the short term (SMD 1.57; 95% CI 1.00 to 2.13) and longer term (SMD 1.23; 95% CI 0.69 to 1.76). In longer-term studies, the wait-and-see approach resulted in unfavorable outcomes compared with ECC (SMD -1.51; 95% CI -2.02 to -1.01). Improvement was higher when ECC was combined with HVI+C (SMD 0.53; 95% CI 0.05 to 1.02) and extracorporeal shockwave therapy (ESWT) (SMD 0.99; 95% CI 0.48 to 1.49). All interventions had a similar safety profile. CONCLUSION: From available high-level studies, HVI+C and ESWT may be possible interventions to add along with ECC to improve longer-term outcomes.

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