REF-1787 · Judd et al., 2026 · BMJ Military Health, · Paper · PubMed

Exercise-based rehabilitation has the strongest evidence as the first-line treatment for Achilles and patellar tendinopathy, and medical treatments and adjuncts have limited evidence, in a UK defence rehabilitation systematic review of 143 studies (PubMed, May 2017 to July 2023, no meta-analysis) that favours a progressive tendon-loading framework fitted to the person over any single loading method

Main caveat: One database (PubMed) and a six-year window; earlier foundational trials are outside it.
moderate evidenceMeasured on non-athletes to trained athletesRead from the abstract only

A team from UK defence rehabilitation reviewed recent evidence on non-surgical care of Achilles and patellar tendinopathy, a common problem in active and military populations. They searched PubMed for studies from May 2017 to July 2023 across four areas: diagnosis and outcome measures, medical treatments, exercise, and adjuncts.

Of 840 records, 143 studies were reviewed in full and graded by Oxford Centre for Evidence-Based Medicine levels; the spread of topics and the heterogeneity of the studies ruled out a meta-analysis. The authors found the strongest evidence for exercise-based rehabilitation as the first-line treatment and limited evidence for medical treatments and adjuncts.

They report that newer work challenges the primacy of any single stand-alone loading method in favour of a progressive tendon loading exercise protocol (PTLE), a framework that picks exercise types according to the person's capacity and function. New treatments, they advise, should be used with caution and not on their own.

Participants

143 included studies; their designs, sample sizes and populations (athletes, military personnel, general patients) are not in the abstract.
Conditions: Achilles and patellar tendinopathy.

Protocol

Search: PubMed only, May 2017 to July 2023.
Areas: diagnosis and outcome measures; medical; exercise; adjuncts.
Selection: 840 records screened, 143 studies included for full review; PRISMA used for the screening report.
Appraisal: Oxford Centre for Evidence-Based Medicine levels of evidence; what the grading found is not in the abstract.
Synthesis: narrative; meta-analysis not feasible.
Not in the abstract: inclusion criteria, which medical treatments and adjuncts were assessed, the content and dosing of the progressive loading framework, registration and funding.

Key Results

Exercise-based rehabilitation: the strongest evidence, as first-line treatment (no effect sizes in the abstract).
Medical interventions and adjuncts: limited evidence (which ones is not in the abstract).
Single stand-alone loading modalities (which ones is not in the abstract): their primacy is challenged by newer evidence for a progressive tendon loading exercise protocol in which exercise types are chosen by the individual's capacity and function.
Novel interventions: use with caution, not as monotherapy.
Diagnosis is clinical with no gold-standard test; imaging and functional subgrouping are research areas (background, not a tested result).

Practical Application

For Achilles or patellar tendon pain, loading exercise progressed to what the person can tolerate is the first-line treatment; injections, medicines and other add-on treatments have limited evidence and are not a stand-alone fix. This is the direction of a broad review of 143 studies; it gives no effect sizes.
This is not treatment advice; a physiotherapist or physician diagnoses the tendon problem and builds the loading programme.
Agrees with [SYNTH-73] and [SYNTH-94]: both put clinician-led progressive loading first and use a pain scale to steer the return; this review adds that no single stand-alone loading method should be treated as the answer (eccentric heel drops alone would be one, our reading) — consistent with REF-1790, where an unsupervised home eccentric programme did not differ significantly from a sham of upper-limb exercise at 12 weeks.
Not from this paper: whether training through pain or resting is better; the review abstract does not address the pain-monitoring rule.

Limitations

One database (PubMed) and a six-year window; earlier foundational trials are outside it.
Oxford CEBM levels grade study design, not risk of bias within studies; the results of that grading are not in the abstract.
Four broad areas in one narrative synthesis; no pooled estimates, and the progressive loading framework is described, not tested here against single methods.
Written for military rehabilitation; the populations of the included studies are not described.
Written from the abstract only: inclusion criteria, which treatments had which evidence, the framework's content, registration and funding are unknown.
How this entry was checked and changed
Why this level

a systematic review capped because only the abstract was read: risk of bias not read (abstract only); the abstract names an evidence-level hierarchy (Oxford CEBM), not a risk-of-bias tool, and gives no result of the grading; one database searched