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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Open surgical excision vs eccentric exercises, Outcome 1 Knee Pain‐ standing jump.
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Analysis 1.1

Comparison 1 Open surgical excision vs eccentric exercises, Outcome 1 Knee Pain‐ standing jump.

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Comparison 1 Open surgical excision vs eccentric exercises, Outcome 2 Function (VISA) 0 to 100, 100 best.
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Analysis 1.2

Comparison 1 Open surgical excision vs eccentric exercises, Outcome 2 Function (VISA) 0 to 100, 100 best.

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Comparison 1 Open surgical excision vs eccentric exercises, Outcome 3 Global success ‐ Proportion with no symptoms at 12 months.
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Analysis 1.3

Comparison 1 Open surgical excision vs eccentric exercises, Outcome 3 Global success ‐ Proportion with no symptoms at 12 months.

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Comparison 1 Open surgical excision vs eccentric exercises, Outcome 4 Global assessment of success.
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Analysis 1.4

Comparison 1 Open surgical excision vs eccentric exercises, Outcome 4 Global assessment of success.

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Comparison 1 Open surgical excision vs eccentric exercises, Outcome 5 Return to sport.
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Analysis 1.5

Comparison 1 Open surgical excision vs eccentric exercises, Outcome 5 Return to sport.

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Comparison 2 Surgery (arthroscopic) vs sclerosing injection, Outcome 1 Knee pain‐ functional VAS.
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Analysis 2.1

Comparison 2 Surgery (arthroscopic) vs sclerosing injection, Outcome 1 Knee pain‐ functional VAS.

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Comparison 2 Surgery (arthroscopic) vs sclerosing injection, Outcome 2 Global outcome of success‐ Satisfaction VAS.
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Analysis 2.2

Comparison 2 Surgery (arthroscopic) vs sclerosing injection, Outcome 2 Global outcome of success‐ Satisfaction VAS.

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Comparison 2 Surgery (arthroscopic) vs sclerosing injection, Outcome 3 Withdrawal rate.
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Analysis 2.3

Comparison 2 Surgery (arthroscopic) vs sclerosing injection, Outcome 3 Withdrawal rate.

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Summary of findings for the main comparison. Open surgical excision compared to eccentric exercises for patella tendinopathy

Open surgical excision compared to eccentric exercises for patella tendinopathy

Patient or population: adult participants with patellar tendinopathy
Setting: chronic patellar tendinopathy
Intervention: open surgical excision
Comparison: eccentric exercises

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with eccentric exercises

Risk with open surgical excision

Knee pain

Scale from: 0 to 10 (0 is no pain)
Follow‐up: 12 months

The mean pain was 1.7 points

The mean pain in the intervention group was 0.4 points better
(0.4 worse to 1.2 better)

‐

40
(1 RCT)

⊕⊕⊝⊝
LOW1,2

Absolute change 4% better (4% worse to 12% better); relative change 10% better (30% better to 10% worse)3,4

Function
Scale from: 0 to 100 (100 is best function)
Follow‐up: 12 months

The mean function in the control group was 65.7

The mean function was 7.2 points higher
(4.5 lower to 18.8 higher)

‐

40
(1 RCT)

⊕⊕⊝⊝
LOW1,2

Absolute change 7% better (4% worse to 19% better); relative change 25% better (15% worse to 65% better)3,4

Participant global assessment of success
(People who perceived their pain as none)
Follow‐up: 12 months

350 per 1000

250 per 1000

(95 to 658)

RR 0.71 (0.27 to 1.88)

40
(1 RCT)

⊕⊕⊝⊝
LOW1,2

Absolute risk difference of 10% less success (38% less to 18% more); relative change 29% fewer experience no pain at 12 months (73% fewer to 88% more)4

Quality of life

not measured

not measured

‐

‐

Not measured

Withdrawal rate

5/20 crossed over to surgery

No withdrawals or cross‐overs were possible from surgery

No estimate

40
(1 RCT)

⊕⊕⊝⊝
LOW1,2

We cannot estimate comparative withdrawal rates, as no or cross‐overs were possible from surgery to exercise.

Adverse event

None

One participant developed chronic quadriceps pain

40
(1 RCT)

⊕⊕⊕⊝
VERY LOW1,2

Not estimable

Tendon rupture

Not reported

Not reported

‐

‐

‐

Not reported, unclear if this outcome was measured

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; NNTB: number needed to treat for an additional beneficial outcome; NNTH: number needed to treat for an additional harmful outcome; RCT: randomised controlled trial; RR: risk ratio; VAS: Visual Analogue Scale; VISA: Victorian Institute of Sport Assessment

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded one level for significant detection bias and reporting bias
2 Downgraded one level for Imprecision — evidence from a single small trial, confidence intervals do not confirm or rule out a clinically important benefit. For adverse events, downgraded twice as only one event was reported in one group
3 Relative changes calculated as absolute change (mean difference) divided by mean at baseline in the eccentric exercises group from Bahr 2006 (values were 3.9 points on a zero‐ to 10‐point VAS for pain; and 29 points on a zero‐ to 100‐point VISA scale)
4 NNNTB or NNTH were not calculated as there were no clinically important between‐group differences for any outcome.

Figuras y tablas -
Summary of findings for the main comparison. Open surgical excision compared to eccentric exercises for patella tendinopathy
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Summary of findings 2. Arthroscopic surgery compared to sclerosing injection for patella tendinopathy

Arthroscopic surgery compared to sclerosing injection for patella tendinopathy

Patient or population: adult participants with patellar tendinopathy
Setting: chronic patellar tendinopathy
Intervention: arthroscopic surgery
Comparison: sclerosing injection

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with sclerosing injection

Risk with arthroscopic surgery

Knee pain

Scale from: 0 to 100 (0 is no pain)
Follow‐up: 12 months

Mean pain was 41.1 points.

The mean pain was 28.3 points better in the intervention group (14.8 to 41.8 points better).

‐

50
(1 RCT)

⊕⊕⊝⊝
LOW1,2

Absolute difference 28% better (15% to 42% better); relative change 41% better (21% to 61% better)3, NNTB 2 (1 to 4)

Function

Not reported

Not reported

‐

‐

‐

Not reported

Participant global assessment of success
Scale from: 0 to 100 (higher is greater satisfaction)

Follow‐up: 12 months

Mean satisfaction was 52.9 points.

The mean patient satisfaction was 33.9 points better (18.7 to 49.1 points better).

‐

50
(1 RCT)

⊕⊕⊝⊝
LOW1,2

Absolute improvement of 34% (19% to 49%)4

Quality of life

Not measured

Not measured

‐

Not measured

Withdrawal rate

1 event

1 event, no reliable estimate

‐

40
(1 RCT)

⊕⊝⊝⊝

VERY LOW1,2

Not related to treatment (pregnancy)

Adverse event

Not reported

Not reported

‐

‐

‐

Not reported, unclear if this outcome was measured

Tendon rupture

Not reported

Not reported

‐

‐

‐

Not reported, unclear if this outcome was measured

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; NNTB: number needed to treat for an additional beneficial outcome; RCT: randomised controlled trial; RR: risk ratio; VAS: Visual Analogue Scale

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded one level for significant detection bias and reporting bias
2 Downgraded one level for imprecision — evidence from a single small trial, confidence intervals do not confirm or rule out a clinically important benefit. For withdrawal rate, downgraded twice as only one event per group reported
3 Relative changes calculated as absolute change (mean difference) divided by mean at baseline in the sclerosing injection group from Willberg 2011 (value was 69 points on a zero‐ to 100‐point VAS for pain)
4 Unable to calculate relative change as no baseline measure of satisfaction was reported, or no dichotomised outcomes reported

Figuras y tablas -
Summary of findings 2. Arthroscopic surgery compared to sclerosing injection for patella tendinopathy
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Comparison 1. Open surgical excision vs eccentric exercises

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Knee Pain‐ standing jump Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.1 12 months

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Function (VISA) 0 to 100, 100 best Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 6 months

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2.2 12 months

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Global success ‐ Proportion with no symptoms at 12 months Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

4 Global assessment of success Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.1 6 months

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.2 12 months

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5 Return to sport Show forest plot

1

Risk Ratio (IV, Fixed, 95% CI)

Totals not selected

5.1 12 months

1

Risk Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 1. Open surgical excision vs eccentric exercises
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Comparison 2. Surgery (arthroscopic) vs sclerosing injection

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Knee pain‐ functional VAS Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 12 months

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Global outcome of success‐ Satisfaction VAS Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.1 12 months

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Withdrawal rate Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.1 12 months

1

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 2. Surgery (arthroscopic) vs sclerosing injection
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