APPENDIX 3 Achilles tendinopathy Effects of interventions mid-portion Achilles tendinopathy Functional disability Two studies(Rompe et al., 2009a, Rompe et al., 2007) reported VISA-A scores(Robinson et al., 2001) to assess the functional disability of the participants with mid-portion AT at mid-term follow-up and results are presented in Figure 1. There was no significant difference between ECSWT and eccentric training group.(Rompe et al., 2007) The quality of evidence was low (only one high-quality RCT, 50 participants, MD=5.20, 95%CI -14.92 to 4.52). Between those who received ECSWT and those following a wait-and-see policy, low-quality evidence revealed a significant difference in disability scores in favour of ECSWT (one RCT(Rompe et al., 2007), 50 participants, MD=15.4, 95%CI 7.25 to 23.55). This difference was clinically relevant as the MCID in the VISA-A is considered 12 points. The difference between ECSWT and ECSWT combined with eccentric training reached the criteria of MCID for the group with combined treatment. The level of evidence was very low-quality, because of the indirect comparison (Table 3)(one RCT(Rompe et al., 2009a), 68 participants, MD=13.50, 95%CI 5.15 to 21.85) Self-perceived recovery In both studies(Rompe et al., 2007, Rompe et al., 2009a) self-perceived recovery was assessed on a 6-point Likert scale. For the computation of success rates, patients who rated themselves as completely recovered and much improved were counted as successes. Low quality evidence suggests that there was no significant difference between radial ECSWT and eccentric training (one high-quality RCT(Rompe et al., 2007), 50 participants, OR=0.72, 95%CI 0.24 to 2.21). Between those who received ECSWT and those following a wait-and-see policy, low-quality evidence revealed marginally significant difference in favour of ECSWT (one RCT(Rompe et al., 2007), 50 participants, OR=3.43, 95%CI 1.03 to 11.48). The difference between ECSWT and ECSWT combined with eccentric training presented very low quality of evidence in favour of ECSWT. The level of evidence had to be decreased because of the indirect comparison (Figure 1 and Table 3)(one RCT(Rompe et al., 2009a), 68 participants, OR=12.96, 95%CI 4.04 to 41.57). Pain reduction in NRS Pain reduction was assessed in NRS and showed no significant difference between ECSWT and eccentric training group.(Rompe et al., 2007) The quality of evidence was low (only one high-quality RCT, 50 participants, MD=0.40, 95%CI -0.85 to 1.65). Between those who received ECSWT and those following a wait-and-see policy, low- quality evidence revealed a significant difference in pain scores in favour of ECSWT (one RCT(Rompe et al., 2007), 50 participants, MD=-1.90, 95%CI -3.01 to -0.79). This difference was not clinically relevant as the MCID in the NRS was set at 2.0 points. The significant difference between ECSWT and ECSWT combined with eccentric training did not reach the criteria of MCID for the group with combined treatment. The level of evidence was very low-quality, because of the indirect comparison (one RCT(Rompe et al., 2009a), 68 participants, MD=1.50, 95%CI -2.50 to -0.50) (Figure 1 and Table 3). Figure 1 Forest plots for the effectiveness of ECSWT in mid-portion Achilles tendinopathy. Data are depicted according to follow-up time and outcome measures. 1.1. Functional outcomes as measured by VISA-A questionnaire. 1.2. Self-perceived recovery in a 6-point Likert scale. 1.3. Pain scores in a NRS. Abbreviations: ECSWT, extracorporeal shock wave therapy; SD, standard deviation; Ecc load, eccentric load; Wait, wait-and-see policy; NRS, numeric rating scale. Patient-rated pain reduction Equal results were measured when ECSWT was compared with eccentric load.(Rompe et al., 2007) The reduction in NRS effect size of ECSWT at 4 months was found to be 2.8 points compared to 3.4 for the controls, which is a patient rating of “much improved” in both groups (Figure 4 – main text).(Farrar et al., 2001)The group following wait-and-see policy had a mean pain reduction of 2.0 points corresponding to “minimally improved.” Nevertheless, the effectiveness of ECSWT was significantly improved when combined with eccentric exercises.(Rompe et al., 2009a) Considering the reduction in NRS effect size, in eccentric loading alone or combined with ECSWT (3.1 and 4.4, respectively) both groups were improved in terms of patient rating, with the combined treatment group having more significant results (“much improved” compared to “very much improved”).(Farrar et al., 2001) Effects of interventions insertional Achilles tendinopathy Functional disability Rompe et al,(Rompe et al., 2008) evaluated the effectiveness of radial ECSWT compared to 12-weeks eccentric training in patients with insertional AT and assessed the functional improvement by using VISA-A questionnaire at mid-term follow-up. Between those who received ECSWT and those following eccentric training programme, low-quality evidence revealed a significant difference in functional disability scores that exceeded the MCID of 12 points in favour of radial ECSWT (one RCT(Rompe et al., 2008) 50 participants, MD=16.0, 95%CI 9.78 to 22.22) (Figure 2 and Table 4). Self-perceived recovery Rompe et al,(Rompe et al., 2008) assessed the self-perceived recovery on a 6-point Likert scale and for the computation of success rates, patients who rated themselves as completely recovered and much improved were counted as successes. Low quality evidence suggests that there was a significant difference favouring radial ECSWT compared to eccentric training (one high-quality RCT(Rompe et al., 2008), 50 participants, OR=4.57, 95%CI 1.38 to 15.11) (Figure 2 and Table 4). Pain reduction in NRS Pain reduction in load-induced pain was assessed in NRS and showed significant difference between ECSWT and eccentric training group.(Rompe et al., 2008) The quality of evidence was low (only one high-quality RCT, 50 participants, MD=2.00, 95%CI -3.28 to -07.2), but this difference met the MCID criterion adding clinical significance to these results (Figure 2 and Table 4). Patient-rated pain reduction Clinically significant results were found in patient-rated pain in favour of ECSWT compared with eccentric loading.(Rompe et al., 2008) The reduction in NRS effect size of ECSWT at 4 months was found to be 4.0 points compared to 1.8 for the eccentric training group, which is a patient rating of “much improved” compared to “minimally improved” (Figure 4 – main text).(Farrar et al., 2001) Figure 2 Forest plots for the effectiveness of ECSWT in insertional Achilles tendinopathy. Data are depicted according to follow-up time and outcome measures. 1.1. Functional outcomes as measured by VISA-A questionnaire. 1.2. Self-perceived recovery in a 6-point Likert scale. 1.3. Pain scores in a NRS. Abbreviations: ECSWT, extracorporeal shock wave therapy; SD, standard deviation; IV, inverse variance; Ecc load, eccentric loading; NRS, numeric rating scale. Effects of interventions mixed/non-specified Achilles tendinopathy Functional disability Investigators used different disability questionnaires between the studies included in this review. Costa et al,(Costa et al., 2005) reported Functional index of lower limb activity (FIL) scores, while Rasmussen et al,(Rasmussen et al., 2008) reported American Orthopaedic Foot and Ankle Society scores (AOFAS). We provided pooled estimates of one RCT(Costa et al., 2005) by calculating standardised mean differences in FIL scores. Between those who received ECSWT and those receiving placebo ECSWT, very low-quality of evidence shows a significant difference regarding disability scores in favour of ECSWT in short-term follow-up (two RCTs, 97 participants, SMD=0.77, 95%CI 0.25 to 1.30) (Figure 3 and Table 5). The quality of evidence had to be decreased because of inconsistent results among studies, bias in reporting (Appendix 2), and indirect comparison in one RCT.(Rasmussen et al., 2008) The mean difference (calculated 35.68 points) reached the criteria of a MCID. Self-perceived recovery Only Costa et al,(Costa et al., 2005) assessed the recovery of patients with AT in terms of activities of daily living (EQ-5D). Very low level of evidence suggests no significant difference between ECSWT and placebo ECSWT groups (one RCT, 49 participants, MD=0.04, 95%CI -0.10 to 0.18). The level of evidence had to be decreased due to the possibility of reporting bias (Figure 3 and Table 5). Pain reduction in VAS Both RCTs(Costa et al., 2005, Rasmussen et al., 2008) reported no statistically significant difference between groups. However, the pain scores reported by Rasmussen et al,(Rasmussen et al., 2008) are not included in this comparison because we were unable to derive means and standard deviations from the figures that were presented. Very low level of evidence revealed no difference in VAS score during sports participation between ECSWT and placebo groups (one high quality RCT, 49 participants, MD=-1.02, 95%CI -2.69 to 0.92). The quality of evidence had to be decreased because of the exclusion of one high quality study from data synthesis (Figure 3 and Table 5). Patient-rated pain reduction The reduction in VAS effect size for pain in sports participation of the treatment groups at 3 months follow-up was not significantly different.(Costa et al., 2005)  However, according to patient’s rating was “much improved” for the ECSWT group compared to “minimally improved” for the placebo shock wave group (Figure 4 – main text).(Farrar et al., 2001) Figure 3 Forest plots for the effectiveness of ECSWT in patients with mixed/non specified Achilles tendinopathy. Data are depicted according to follow-up time and outcome measures. 1.1. Functional outcomes as measured by AOFAS and FIL questionnaires. 1.2. Self-rated improvement in activities of daily living measured by EQ-5D questionnaire 1.3. Pain scores in a VAS. Note. Standardised values for FIL converted to 0-100 scale.(Costa et al., 2005) *Indirect comparison: both groups receive a stretching and eccentric training programme. Abbreviations: ECSWT, extracorporeal shock wave therapy; SD, standard deviation; IV, inverse variance; AOFAS, American Orthopaedic Foot and Ankle Society score; FIL, Functional index of lower limb activity; EQ-5D, Euro Quality of life 5 dimensions questionnaire; VAS, visual analogue scale.   Greater Trochanteric Pain Syndrome Effects of interventions Functional disability Only one case-control study(Furia et al., 2009) that met all the predefined criteria to pool data reported functional disability outcomes. Between those who received radial ECSWT and those receiving traditional non-operative treatment (i.e. stretching and strengthening, physical therapy modalities, iontophoresis, rest), very low-quality of evidence shows a significant difference regarding HHS in favour of ECSWT in short- term and long-term follow-up (one good quality study(Furia et al., 2009), 66 participants, short-term MD=16.75, 95%CI 14.31 to 19.19 and long-term MD=22.3, 95%CI 19.40 to 25.20) (Figure 4, Table 6). The mean difference met the MCID of 10 points threshold for clinical significance. Self-perceived recovery Investigators used different assessment tools for recovery between the studies included in this review. Rompe et al,(Rompe et al., 2009b) used a 6-point Likert scale, while Furia et al,(Furia et al., 2009) used the Roles and Maudsley score. Despite this difference we proceeded to quantitative synthesis due to both studies for the computation of success rates implemented the same criteria; patients who rated themselves as completely recovered and much improved were counted as successes (Figure 4, Table 6). There is low quality of evidence from only one RCT(Rompe et al., 2009b) reporting significantly bigger recovery rate between those who received corticosteroid injection (CI) and those received radial ECSWT, but the CI effect was washed out at mid and long-term follow-up in favour of ECSWT (one RCT(Rompe et al., 2009b), 153 participants, short-term OR=0.05, 95%CI 0.02 to 0.12; mid-term OR=2.06, 95%CI 1.07 to 3.98; long-term OR=3.14, 95%CI 1.59 to 6.21). Between those who were treated with radial ECSWT and those received conservative treatment(Furia et al., 2009) or home exercise program (HT)(Rompe et al., 2009b), low quality of evidence suggests a significant difference in self-perceived recovery in favour of ECSWT at mid-term follow-up (two studies(Furia et al., 2009, Rompe et al., 2009b), 220 participants, OR=5.02, 95%CI 1.62 to 15.56). Regarding the self-perceived recovery at long-term follow-up the studies reported conflicting results. One trial showed evidence of self-perceived recovery in favour of ECSWT, while the other no difference between ECSWT and HT. When the two studies were pooled, low quality of evidence revealed no significant difference between the groups (two studies(Furia et al., 2009, Rompe et al., 2009b), 220 participants, OR=2.08, 95%CI 0.24 to 18.10). The quality of evidence had to be decreased because of the inclusion in analysis of a case-control study.(Furia et al., 2009) Pain reduction in NRS We did not plot pain scores and combine in quantitative synthesis both studies due to substantial statistical heterogeneity and poor overlapping of 95% CIs in created forest plots. We found low quality evidence from one RCT(Rompe et al., 2009b) reporting significant pain reduction at 1-month follow-up for the corticosteroid injection group compared to the ECSWT group, this result was reversed at the 4- month and 15-month follow-up (one RCT(Rompe et al., 2009b), 153 participants, short-term MD=3.40, 95%CI 2.46 to 4.34; mid-term MD=-1.30, 95%CI -2.16 to -0.44; long-term MD=-2.90, 95%CI -3.92 to -1.88). All differences were statistically significant, but only the short-term and long-term pain reduction values reached a MCID. The comparison of ECSWT to HT did not reveal statistically nor clinically significant results in terms of pain reduction at 1-month and 15-month follow-up (one RCT(Rompe et al., 2009b), 153 participants, short-term MD=-0.30, 95%CI -1.33 to 0.73; long-term MD=-0.30, 95%CI -1.22 to 0.62) Low quality of evidence suggests that improvement in pain was statistically and clinically significantly bigger in the ECSWT group at 4 months compared to the HT group (one RCT(Rompe et al., 2009b), 153 participants, mid-term MD=-2.00, 95%CI -2.84 to -1.16).(Figure 4, Table 6) Patient-rated pain reduction Regarding the comparison of radial ECSWT with traditional non-operative treatment,(Furia et al., 2009) the reduction in VAS effect size of ECSWT group at 1, 3 and 12 months was seen to be 3.4, 4.8 and 5.8 points respectively (compared to 0.9, 1.5 and 2.2 for the controls) which is a patient rating of “much improved” and “very much improved” (compared to “minimally improved” and “much improved” (12 months), respectively).(Farrar et al., 2001) In the study that compared CI and HT to ECSWT,(Rompe et al., 2009b) the reduction in NRS effect size of CI group at 1 month was seen to be 3.6 points compared to 0.7 for ECSWT and 0.3 for the HT group, which is a patient rating of “much improved” compared to “no change” and “no change”, respectively.(Farrar et al., 2001) Interestingly, ECSWT and home training groups presented comparable results at long term (both “much improved”) (Figure 4 – main text).(Farrar et al., 2001) Figure 4 Forest plots for the effectiveness of ECSWT in patients with greater trochanteric pain syndrome.  Data are depicted according to follow-up time and outcome measures. 1.1. Functional outcomes as measured by HHS questionnaire. 1.2. Self-rated improvement measured a 6-point Likert scale and Roles and Maudsley score 1.3. Pain scores in a NRS. Abbreviations: ECSWT, extracorporeal shock wave therapy; SD, standard deviation; IV, inverse variance; HHS, Harris Hip Score; HT, home training; CI, corticosteroid injection.   Effectiveness of interventions in Patellar tendinopathy Focused ECSWT compared to placebo shock-wave Two multicentre double-blinded RCTs compared ECSWT to placebo shock-wave with(Thijs et al., 2016) or without(Zwerver et al., 2011) additive eccentric training. Functional disability Both studies(Thijs et al., 2016, Zwerver et al., 2011) evaluated functional disability of the participants by using VISA-P questionnaire. When data were pooled into a summary estimate, we found moderate quality of evidence (initially high level of evidence due to both RCTs were multi-centre and had low-risk of bias) revealing no difference between ECSWT and placebo shock-wave in both short-term (two RCTs,