Extracorporeal shock wave therapy for lateral epicondylitis--a double blind randomised controlled trial

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

BACKGROUND

Lateral elbow tendinopathy (LET) is a common complaint causing characteristic pain in the lateral elbow and upper forearm, and tenderness of the forearm extensor muscles. It is thought to be an overuse injury and can have a major impact on the patient's social and professional life. The condition is challenging to treat and prone to recurrent episodes. The average duration of a typical episode ranges from 6 to 24 months, with most (89%) reporting recovery by 1 year.

OBJECTIVES

This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET.

DATA SOURCES

A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases.

METHODS AND OUTCOMES

We conducted an overview of systematic reviews to summarise the current evidence concerning the clinical effectiveness and a systematic review for the cost-effectiveness of conservative interventions for LET. We identified additional randomised controlled trials (RCTs) that could contribute further evidence to existing systematic reviews. We searched MEDLINE, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Web of Science, The Cochrane Library and other important databases from inception to January 2013.

RESULTS

A total of 29 systematic reviews published since 2003 matched our inclusion criteria. These were quality appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist; five were considered high quality and evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach. A total of 36 RCTs were identified that were not included in a systematic review and 29 RCTs were identified that had only been evaluated in an included systematic review of intermediate/low quality. These were then mapped to existing systematic reviews where further evidence could provide updates. Two economic evaluations were identified.

LIMITATIONS

The summary of findings from the review was based only on high-quality evidence (scoring of > 5 AMSTAR). Other limitations were that identified RCTs were not quality appraised and dichotomous outcomes were also not considered. Economic evaluations took effectiveness estimates from trials that had small sample sizes leading to uncertainty surrounding the effect sizes reported. This, in turn, led to uncertainty of the reported cost-effectiveness and, as such, no robust recommendations could be made in this respect.

CONCLUSIONS

Clinical effectiveness evidence from the high-quality systematic reviews identified in this overview continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new RCT evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them because of the small sample size. Conclusions regarding cost-effectiveness are also unclear. We consider that, although updated or new systematic reviews may also be of value, the primary focus of future work should be on conducting large-scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003593.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Mechanical Stimulation (Pulsed Electromagnetic Fields "PEMF" and Extracorporeal Shock Wave Therapy "ESWT") and Tendon Regeneration: A Possible Alternative

The pathogenesis of tendon degeneration and tendinopathy is still partially unclear. However, an active role of metalloproteinases (MMP), growth factors, such as vascular endothelial growth factor (VEGF) and a crucial role of inflammatory elements and cytokines was demonstrated. Mechanical stimulation may play a role in regulation of inflammation. In vitro studies demonstrated that both pulsed electromagnetic fields (PEMF) and extracorporeal shock wave therapy (ESWT) increased the expression of pro-inflammatory cytokine such as interleukin (IL-6 and IL-10). Moreover, ESWT increases the expression of growth factors, such as transforming growth factor β(TGF-β), (VEGF), and insulin-like growth factor 1 (IGF1), as well as the synthesis of collagen I fibers. These pre-clinical results, in association with several clinical studies, suggest a potential effectiveness of ESWT for tendinopathy treatment. Recently PEMF gained popularity as adjuvant for fracture healing and bone regeneration. Similarly to ESWT, the mechanical stimulation obtained using PEMFs may play a role for treatment of tendinopathy and for tendon regeneration, increasing in vitro TGF-β production, as well as scleraxis and collagen I gene expression. In this manuscript the rational of mechanical stimulations and the clinical studies on the efficacy of extracorporeal shock wave (ESW) and PEMF will be discussed. However, no clear evidence of a clinical value of ESW and PEMF has been found in literature with regards to the treatment of tendinopathy in human, so further clinical trials are needed to confirm the promising hypotheses concerning the effectiveness of ESWT and PEMF mechanical stimulation.

Focused and Radial Shock Wave Therapy in the Treatment of Tennis Elbow: A Pilot Randomised Controlled Study

The purpose of this article was to evaluate and compare the efficacy of radial and focused shock wave therapies applied to treat tennis elbow. Patients with tennis elbow were randomized into two comparative groups: focused shock wave therapy (FSWT; n=25) and radial shock wave therapy (RSWT; n=25). Subjects in the FSWT and RSWT groups were applied with a focused shock wave (3 sessions, 2000 shocks, 4 Hz, 0.2 mJ/mm²) and a radial shock wave (3 sessions, 2000 + 2000 shocks, 8 Hz, 2.5 bar), respectively. The primary study endpoints were pain relief and functional improvement (muscle strength) one week after therapy. The secondary endpoint consisted of the results of the follow-up observation (3, 6 and 12 weeks after the study). Successive measurements showed that the amount of pain patients felt decreased in both groups. At the same time grip strength as well as strength of wrist extensors and flexors of the affected extremity improved significantly. Both focused and radial shock wave therapies can comparably and gradually reduce pain in subjects with tennis elbow. This process is accompanied by steadily improved strength of the affected extremity.

Lateral epicondylitis: This is still a main indication for extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is used in a number of indications in the medical field. A number of tendinopathies show good and excellent results due to evidence based medicine. The treatment of lateral epicondylitis is known to show conflicting results. This overview of the published RCT's on ESWT for lateral epicondylitis tries to show the reasons for this conflicting data-base and point out, why we think that this is still a main indication for extracorporeal shockwave therapy.

Short- to mid-term follow-up effectiveness of US-guided focal extracorporeal shock wave therapy in the treatment of elbow lateral epicondylitis

BACKGROUND

Lateral epicondylitis of the elbow is a common and disabling overuse syndrome. Several treatment modalities are currently available for this condition, but the optimal treatment method remains undefined. Extracorporeal shock wave therapy (ESWT) has been widely used in the last 10 years, although conflicting results are present in the literature.

MATERIALS AND METHODS

In this study, we evaluated 36 patients (37 elbows), with a mean follow-up time of 24.8 months. Focal ESWT was administered by means of an electromagnetic generator equipped with in-line ultrasound guidance, during one or more cycles of 3-4 weekly sessions. In the setting of the study, patients were clinically evaluated and subjective satisfaction and rate of relapse were investigated.

RESULTS

A positive response was described in 75.7 % of the patients after treatment. Mean quickDASH score and VAS attested at 5.5 and 1.1, respectively. Roles and Maudsley score was rated as I or II in 33 cases. Four patients resulted not responders to the therapy, while 5 patients complained one or more episodes of symptoms relapse. No influence on the final outcome was evident with respect to demographic features and previous therapies as well. Response rate to further ESWT cycles in patients refractory to the first cycle of ESWT was 33.3 %.

CONCLUSIONS

Focal ESWT represents a valuable and safe solution in case of elbow lateral epicondylitis, both in newly diagnosed and previously treated cases, representing a definitive treatment in the majority of patients. Patients refractory to a 3- to 4-session ESWT cycle have lower chances of positive response after further ESWT cycles.

Efficacy of physical therapy for the treatment of lateral epicondylitis: a meta-analysis

Background

Physical therapy for the treatment of lateral epicondylitis (LE) often comprises movement therapies, extracorporeal shockwave therapy (ECSWT), low level laser therapy (LLLT), low frequency electrical stimulation or pulsed electromagnetic fields. Still, only ECSWT and LLLT have been meta-analytically researched.

Methods

PUBMED, EMBASE and Cochrane database were systematically searched for randomized controlled trials (RCTs). Methodological quality of each study was rated with an adapted version of the Scottish Intercollegiate Guidelines Network (SIGN) checklist. Pain reduction (the difference between treatment and control groups at the end of trials) and pain relief (the change in pain from baseline to the end of trials) were calculated with mean differences (MD) and 95 %-Confidence intervals (95 % CI).

Results

One thousand one hundred thirty eight studies were identified. One thousand seventy of those did not meet inclusion criteria. After full articles were retrieved 16 studies met inclusion criteria and 12 studies reported comparable outcome variables. Analyses were conducted for overall pain relief, pain relief during maximum handgrip strength tests, and maximum handgrip strength. There were not enough studies to conduct an analysis of physical function or other outcome variables.

Conclusions

Differences between treatment and control groups were larger than differences between treatments. Control group gains were 50 to 66 % as high as treatment group gains. Still, only treatment groups with their combination of therapy specific and non-therapy specific factors reliably met criteria for clinical relevance. Results are discussed with respect to stability and their potential meaning for the use of non-therapy specific agents to optimize patients’ gain.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0665-4) contains supplementary material, which is available to authorized users.

Effects of extracorporeal shock wave therapy on functional recovery and neurotrophin-3 expression in the spinal cord after crushed sciatic nerve injury in rats

The study described here investigated the effects of extracorporeal shock wave therapy (ESWT) on functional recovery and neurotrophin-3 expression in the spinal cord after sciatic nerve injury in rats. Forty-five 8-wk-old rats were used and randomly divided into three groups: An experimental group, a control group and a sham group. The experimental group received ESWT after the nerve-crushing damage. The sciatic functional index and Dartfish Software were used to determine the effect of sciatic nerve damage on functional changes. A 1-cm length of spinal cord encompassing the L4-6 level was removed for Western blot analysis. The sciatic functional index significantly changed in both the ESWT and control groups after impairment. In the time course evaluation of the ankle angle in the toe off, the ESWT group had statistically significant increases from day 21 onward. There was a significant difference in neurotrophin-3 expression between the groups on days 1, 7 and 14 after impairment. Early application of ESWT increased the expression of neurotrophin-3 and neurotrophin-3 mRNA, and daily therapy facilitated the activity of macrophages and Schwann cells, which affect the survival and regeneration of neurons.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

Effects of extracorporeal shock wave therapy on functional and strength recovery of handgrip in patients affected by epicondylitis

Extracorporeal shock wave therapy (ESWT) is effective in the treatment of tendinopathy. We designed a prospective observational clinical study to assess the correlation between clinical and functional measures and recovery of strength after ESWT for epicondylitis. We analyzed 26 patients. We measured progressive improvement in visual analogue scale values (p < 0.0005) and Mayo Elbow Performance Index scores (p = 0.004) for the pathologic limb. Monitoring of handgrip failed to reveal changes in values at any follow-up (p > 0.05). We found no correlation between degree of clinical function and muscle deficit during follow-up. After ESWT, there was a tendency toward a decrease in grip strength, especially in the dominant limb. This could be related to the effects of ESWT, which reduces spasticity in painful hypertonic muscles. These data may be useful in defining the expectations for function during ESWT for epicondylitis, particularly for elite athletes.

Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials

BACKGROUND

Non-surgical approaches to treatment of lateral epicondylitis are numerous. The aim of this systematic review is to examine randomized, controlled trials of these treatments.

METHODS

Numerous databases were systematically searched from earliest records to February 2013. Search terms included "lateral epicondylitis," "lateral elbow pain," "tennis elbow," "lateral epicondylalgia," and "elbow tendinopathy" combined with "randomized controlled trial." Two reviewers examined the literature for eligibility via article abstract and full text.

RESULTS

Fifty-eight articles met eligibility criteria: (1) a target population of patients with symptoms of lateral epicondylitis; (2) evaluation of treatment of lateral epicondylitis with the following non-surgical techniques: corticosteroid injection, injection technique, iontophoresis, botulinum toxin A injection, prolotherapy, platelet-rich plasma or autologous blood injection, bracing, physical therapy, shockwave therapy, or laser therapy; and (3) a randomized controlled trial design. Lateral epicondylitis is a condition that is usually self-limited. There may be a short-term pain relief advantage found with the application of corticosteroids, but no demonstrable long-term pain relief. Injection of botulinum toxin A and prolotherapy are superior to placebo but not to corticosteroids, and botulinum toxin A is likely to produce concomitant extensor weakness. Platelet-rich plasma or autologous blood injections have been found to be both more and less effective than corticosteroid injections. Non-invasive treatment methods such as bracing, physical therapy, and extracorporeal shockwave therapy do not appear to provide definitive benefit regarding pain relief. Some studies of low-level laser therapy show superiority to placebo whereas others do not.

CONCLUSIONS

There are multiple randomized controlled trials for non-surgical management of lateral epicondylitis, but the existing literature does not provide conclusive evidence that there is one preferred method of non-surgical treatment for this condition. Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions to Authors for a complete description of level of evidence.

Lateral epicondylitis treatment: international survey of surgeons' preferences and literature review

BACKGROUND

Lateral epicondylitis (LE) is a common cause of elbow pain. Despite a relatively high prevalence and morbidity, there is still no single effective ('gold standard') treatment for LE. We hypothesised that a surgeon's experience, country of origin and area of expertise would influence choices concerning patient management. The purpose of this survey was to describe the current trends and common practices in treating LE worldwide.

MATERIAL AND METHODS

A total of 291 orthopaedic surgeons of 12 subspecialties from 57 countries were surveyed on their choice of LE treatment modalities. Their preferences were analysed according to country of origin, field of expertise and seniority. The results were compared with current published level-1 evidence.

RESULTS

The most popular modalities of treatment among all of the surveyed orthopaedic surgeons were non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid (CS) injection (38% of recommendations each). The most popular Modalities of treatment among the hand surgeons was NSAIDs (48%) and CS injection (30%). There was no significant difference in recommendations based on geography, seniority or specialisation (i.e., hand surgeons among others).

CONCLUSIONS

Neither geography, seniority nor medical specialty affects surgeons' preferences in the treatment of LE. There appears to be little correlation between scientific evidence and therapeutic choices for managing LE.

LEVEL OF EVIDENCE

Level V, Study.

Elbow tendinopathy

Overuse injuries of the lateral and medial elbow are common in sport, recreational activities, and occupational endeavors. They are commonly diagnosed as lateral and medial epicondylitis; however, the pathophysiology of these disorders demonstrates a lack of inflammation. Instead, angiofibroblastic degeneration is present, referred to as tendinosis. As such, a more appropriate terminology for these conditions is epicondylosis. This is a clinical diagnosis, and further investigations are only performed to rule out other clinical entities after conventional therapy has failed. Yet, most patients respond to conservative measures with physical therapy and counterforce bracing. Corticosteroid injections are effective for short-term pain control but have not demonstrated long-term benefit.

Tratamento fisioterapêutico para epicondilite lateral: uma revisão sistemática

INTRODUÇÃO: Embora o tratamento conservador ainda seja a melhor conduta inicial para a epicondilite lateral do cotovelo, há pouca evidência científica de que o tratamento fisioterapêutico altere o curso natural da doença e seja efetiva no tratamento dessa patologia. OBJETIVO: Avaliar a efetividade e a segurança das diversas intervenções fisioterapêuticas utilizadas no tratamento conservador da epicondilite lateral. MATERIAIS E MÉTODOS: Foram incluídos apenas ensaios clínicos aleatorizados e quase aleatorizados que utilizaram pelo menos uma modalidade fisioterapêutica como uma das intervenções. Foi realizada uma busca nas bases de dados eletrônicos MEDLINE; Embase; LILACS e SciELO até dezembro de 2010. Não houve restrição do período de publicação dos artigos. Com o objetivo de aumentar a sensibilidade e a precisão, a estratégia de busca utilizada foi adaptada para cada base de dados. Foi utilizada a pontuação da escala PEDro para avaliação da qualidade metodológica dos ensaios clínicos aleatorizados. RESULTADOS: 26 artigos foram incluídos na revisão sistemática e a avaliação da maioria desses artigos apresentou qualidade metodológica satisfatória (6,4 pontos). Em relação aos aspectos mensurados, todos os artigos avaliaram a dor, 18 (69%) examinaram a força de preensão e 11 (42%) a função dos pacientes. Quanto à duração do acompanhamento dos pacientes apenas nove (35%) artigos realizaram acompanhamento a longo prazo. CONCLUSÃO: A melhor opção para o tratamento da epicondilite lateral parece ser a combinação de modalidades terapêuticas, o que condiz com a realidade clínica do fisioterapeuta. Porém, mais ensaios clínicos com boa qualidade metodológica são necessários para determinar a efetividade da maioria das modalidades terapêuticas encontradas.

A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence

BACKGROUND

'Shock wave' therapies are now extensively used in the treatment of musculoskeletal injuries. This systematic review summarises the evidence base for the use of these modalities.

METHODS

A thorough search of the literature was performed to identify studies of adequate quality to assess the evidence base for shockwave therapies on pain in specific soft tissue injuries. Both focused extracorporeal shockwave therapy (F-ESWT) and radial pulse therapy (RPT) were examined.

RESULTS

23 appropriate studies were identified. There is evidence for the benefit of F-ESWT and of RPT in a number of soft tissue musculoskeletal conditions, and evidence that both treatment modalities are safe. There is evidence that F-ESWT is effective in the treatment of plantar fasciitis, calcific tendinitis, and that RPT is effective in plantar fasciitis. Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. There is low level evidence for lack of benefit of low-dose F-ESWT and RPT in non-calcific rotator cuff disease and mixed evidence in lateral epicondylitis.

Mechanical solution for a mechanical problem: Tennis elbow

Lateral epicondylitis is a relatively common clinical problem, easily recognized on palpation of the lateral protuberance on the elbow. Despite the “itis” suffix, it is not an inflammatory process. Therapeutic approaches with topical non-steroidal anti-inflammatory drugs, corticosteroids and anesthetics have limited benefit, as would be expected if inflammation is not involved. Other approaches have included provision of healing cytokines from blood products or stem cells, based on the recognition that this repetitive effort-derived disorder represents injury. Noting calcification/ossification of tendon attachments to the lateral epicondyle (enthesitis), dry needling, radiofrequency, shock wave treatments and surgical approaches have also been pursued. Physiologic approaches, including manipulation, therapeutic ultrasound, phonophoresis, iontophoresis, acupuncture and exposure of the area to low level laser light, has also had limited success. This contrasts with the benefit of a simple mechanical intervention, reducing the stress on the attachment area. This is based on displacement of the stress by use of a thin (3/4-1 inch) band applied just distal to the epicondyle. Thin bands are required, as thick bands (e.g., 2-3 inch wide) simply reduce muscle strength, without significantly reducing stress. This approach appears to be associated with a failure rate less than 1%, assuming the afflicted individual modifies the activity that repeatedly stresses the epicondylar attachments.

Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review

BACKGROUND

Several treatments are available to treat epicondylitis. Among these are instrumental electrophysical modalities, ranging from ultrasound, extracorporeal shock wave therapy (ESWT), transcutaneous electrical nerve stimulation (TENS) to laser therapy, commonly used to treat epicondylitis.

OBJECTIVES

To present an evidence-based overview of the effectiveness of electrophysical modality treatments for both medial and lateral epicondylitis (LE).

METHODS

Searches in PubMed, EMBASE, CINAHL and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results.

RESULTS

A total of 2 reviews and 20 RCTs were included, all of which concerned LE. Different electrophysical regimes were evaluated: ultrasound, laser, electrotherapy, ESWT, TENS and pulsed electromagnetic field therapy. Moderate evidence was found for the effectiveness of ultrasound versus placebo on mid-term follow-up. Ultrasound plus friction massage showed moderate evidence of effectiveness versus laser therapy on short-term follow-up. On the contrary, moderate evidence was found in favour of laser therapy over plyometric exercises on short-term follow-up. For all other modalities only limited/conflicting evidence for effectiveness or evidence of no difference in effect was found.

CONCLUSIONS

Potential effectiveness of ultrasound and laser for the management of LE was found. To draw more definite conclusions high-quality RCTs examining different intensities are needed as well as studies focusing on long-term follow-up results.

Stem cell therapy for tendon injury

Tendon injury may occur suddenly or progressively, and can be divided into tendon rupture or tendinopathy based on the severity of injury. It is frequently found in professional or nonprofessional people who are making repetitive movements. In aged people, tendon degeneration becomes obvious; their tendon injuries are then frequently evident. No effective therapies for tendon injury are currently available. In this article, we review the tendon structure, mechanisms of tendon injury, and tendon healing process. More importantly, cell-based therapies for tendon injury are fully addressed, which will play an important role for tendon therapy in the near future.

Effectiveness of initial extracorporeal shock wave therapy on the newly diagnosed lateral or medial epicondylitis

OBJECTIVE

To evaluate the effectiveness of initial extracorporeal shock wave therapy (ESWT) for patients newly diagnosed with lateral or medial epicondylitis, compared to local steroid injection.

METHOD

An analysis was conducted of twenty-two patients who were newly confirmed as lateral or medial epicondylitis through medical history and physical examination. The ESWT group (n=12) was treated once a week for 3 weeks using low energy (0.06-0.12 mJ/mm(2), 2,000 shocks), while the local steroid injection group (n=10) was treated once with triamcinolone 10 mg mixed with 1% lidocaine solution. Nirschl score and 100 point score were assessed before and after the treatments of 1st, 2nd, 4th and 8th week. And Roles and Maudsley score was assessed one and eight weeks after the treatments.

RESULTS

Both groups showed significant improvement in Nirschl score and 100 point score during the entire period. The local steroid injection group improved more in Nirschl score at the first week and in 100 point score at the first 2 weeks, compared to those of the ESWT group. But the proportion of excellent and good grades of Roles and Maudsley score in the ESWT group increased more than that of local steroid injection group by the final 8th week.

CONCLUSION

The ESWT group improved as much as the local steroid injection group as treatment for medial and lateral epicondylitis. Therefore, ESWT can be a useful treatment option in patients for whom local steroid injection is difficult.

Tendinopathy treatment: where is the evidence?

Tendinopathy is a common and debilitating condition that results in significant deficits in performance and prolonged time away from activity. For this reason, much effort has been placed in defining beneficial and cost-effective treatments. This review has outlined the current literature on some of the most widely used therapies for cases of tendinopathy. As such, recommendations remain limited by the evidence available. The variability in both quantity and quality of research into tendinopathy treatments makes it difficult to make definitive treatment recommendations. In general, however, a reasonable first line of treatment for tendinopathy should include a course of NSAIDs and eccentric exercise-based physical therapy. Corticosteroid injections seem to offer excellent short-term pain relief but lack long term efficacy. Alternative injections, such as PRP, have shown short-term efficacy for tendinopathy sufferers; data are lacking to support sclerosing agents and proteinase inhibitors. Operative management seems to offer some benefit in symptomatic relief but carries a higher complication rate than other treatment options and should be reserved only for patients recalcitrant to other more conservative options. Although the inability to make definitive therapeutic recommendations in some instances is discouraging, it is important to note that a lack of high-quality evidence supporting specific treatments does not necessarily imply that they are inherently ineffective. Given the growing prevalence of tendinopathy and the impact it has on the general public, it is more important now than ever to continue the search for the most effective and accessible treatment modalities.

Extracorporeal shock wave therapy (ESWT) for wound healing: technology, mechanisms, and clinical efficacy

For almost 30 years, extracorporeal shock wave therapy has been clinically implemented as an effective treatment to disintegrate urinary stones. This technology has also emerged as an effective noninvasive treatment modality for several orthopedic and traumatic indications including problematic soft tissue wounds. Delayed/nonhealing or chronic wounds constitute a burden for each patient affected, significantly impairing quality of life. Intensive wound care is required, and this places an enormous burden on society in terms of lost productivity and healthcare costs. Therefore, cost-effective, noninvasive, and efficacious treatments are imperative to achieve both (accelerated and complete) healing of problematic wounds and reduce treatment-related costs. Several experimental and clinical studies show efficacy for extracorporeal shock wave therapy as means to accelerate tissue repair and regeneration in various wounds. However, the biomolecular mechanism by which this treatment modality exerts its therapeutic effects remains unclear. Potential mechanisms, which are discussed herein, include initial neovascularization with ensuing durable and functional angiogenesis. Furthermore, recruitment of mesenchymal stem cells, stimulated cell proliferation and differentiation, and anti-inflammatory and antimicrobial effects as well as suppression of nociception are considered important facets of the biological responses to therapeutic shock waves. This review aims to provide an overview of shock wave therapy, its history and development as well as its current place in clinical practice. Recent research advances are discussed emphasizing the role of extracorporeal shock wave therapy in soft tissue wound healing.

Extracorporeal shockwave therapy in musculoskeletal disorders

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

Current treatment options for tendinopathy

IMPORTANCE OF THE FIELD

Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.

AREAS COVERED IN THIS REVIEW

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy.

WHAT THE READER WILL GAIN

The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.

TAKE-HOME MESSAGE

Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.

Extracorporeal shock wave therapy for calcific tendinitis at unusual sites around the hip

Extracorporeal shock wave therapy has been considered to be an effective treatment for various pathogenic orthopedic conditions. However, it is not generally recognized in treatment for calcific tendinitis around the hip region. This article presents 2 cases of calcific tendinitis at the hip, located in the pectineus muscle and the rectus femoris muscle, where successful treatment was achieved using extracorporeal shock wave therapy. In 1 case, a 60-year-old woman presented with pain in her right thigh of 1 month's duration that had become severe in intensity for 1 week. Physical examination revealed marked localized tenderness over the posterolateral aspect of the right thigh when positioned in flexion, abduction, and external rotation. Anteroposterior and frog-leg lateral radiographs revealed nodular-shaped calcium deposits at the posterolateral aspect of the proximal thigh. T1- and T2-weighted magnetic resonance imaging of the hip joint revealed a 2.7×1.3-cm, low-signal density area near the femoral insertion of pectineus and gluteus maximus muscle with inflammatory infiltration in the surrounding soft tissue. Treatment was started in the form of extracorporeal shock wave therapy, doses of which were administered in 3 sessions with an interval of 7 days. Radiographs of the affected thigh taken 4 weeks after therapy showed disintegration of the calcium deposits.

New options in the management of tendinopathy

Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an "acute tendinopathy" is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy.

Autologous blood and corticosteroid injection and extracoporeal shock wave therapy in the treatment of lateral epicondylitis

Lateral epicondylitis is a common disorder characterized by pain and tenderness over the lateral epicondyle. It occurs most frequently as a result of minor, unrecognized trauma during sports activities and occupation-related physical activities. The goal of this study was to evaluate the short-, medium-, and long-term effects of corticosteroid injection, autologous blood injection, and extracorporeal shock wave therapy in the treatment of lateral epicondylitis.Sixty patients (32 women, 28 men) with lateral epicondylitis were randomly divided into 3 groups: group 1 received a corticosteroid injection; group 2, an autologous blood injection, and group 3, extracorporeal shock wave therapy. Thomsen provocative testing, upper extremity functional scores, and maximal grip strength were used for evaluation. Outcomes were assessed at 4, 12, 26, and 52 weeks. Corticosteroid injection gave significantly better results for all outcome measures at 4 weeks; success rates in the 3 groups were 90%, 16.6%, and 42.1%, respectively. Autologous blood injection and extracorporeal shock wave therapy gave significantly better Thomsen provocative test results and upper extremity functional scores at 52 weeks; the success rate of corticosteroid injection was 50%, which was significantly lower than the success rates for autologous blood injection (83.3%) and extracorporeal shock wave therapy (89.9%). Corticosteroid injection provided a high success rate in the short term. However, autologous blood injection and extracorporeal shock wave therapy gave better long-term results, especially considering the high recurrence rate with corticosteroid injection. We suggest that the treatment of choice for lateral epicondylitis be autologous blood injection.

Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome

BACKGROUND

Greater trochanteric pain syndrome is often a manifestation of underlying gluteal tendinopathy. Extracorporeal shock wave therapy is effective in numerous types of tendinopathies.

HYPOTHESIS

Shock wave therapy is an effective treatment for chronic greater trochanteric pain syndrome.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Thirty-three patients with chronic greater trochanteric pain syndrome received low-energy shock wave therapy (2000 shocks; 4 bars of pressure, equal to 0.18 mJ/mm(2); total energy flux density, 360 mJ/mm(2)). Thirty-three patients with chronic greater trochanteric pain syndrome were not treated with shock wave therapy but received additional forms of nonoperative therapy (control). All shock wave therapy procedures were performed without anesthesia. Evaluation was by change in visual analog score, Harris hip score, and Roles and Maudsley score.

RESULTS

Mean pretreatment visual analog scores for the control and shock wave therapy groups were 8.5 and 8.5, respectively. One, 3, and 12 months after treatment, the mean visual analog score for the control and shock wave therapy groups were 7.6 and 5.1 (P < .001), 7 and 3.7 (P < .001), and 6.3 and 2.7 (P < .001), respectively. One, 3, and 12 months after treatment, mean Harris hip scores for the control and shock wave therapy groups were 54.4 and 69.8 (P < .001), 56.9 and 74.8 (P < .001), and 57.6 and 79.9 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 10 and 0 (P < .001), 16 and 12 (P < .001), 4 and 13 (P < .001), and 3 and 8 (P < .001), respectively. Chi-square analysis showed the percentage of patients with excellent (1) or good (2) Roles and Maudsley scores (ie, successful results) 12 months after treatment was statistically greater in the shock wave therapy than in the control group (P < .001).

CONCLUSION

Shock wave therapy is an effective treatment for greater trochanteric pain syndrome.

Primary Osteoblasts Response to Shock Wave Therapy Using Different Parameters

Over the past decade extracorporeal shock-wave therapy (ESWT) has been increasingly applied to orthopaedic and musculoskeletal pathologies, the aim of this study was to assess how the energy density of the shock waves and the number of impulses affect viability, differentiation and synthetic activity of osteoblasts. Primary sheep osteoblasts cultures were treated with ESWT with an electro-hydraulic shock wave generator by selecting three different energy levels (14-21-28 kV corresponding at 0.15-0.31-0.40 mJ/mm2) and two different total numbers of impulses (500, 1000) for each level. At the end of treatment, cell counts and viability were recorded. Cells were then cultivated for 48 hours starting from a concentration of 1 x 10(4) cells/ml. The biological activity and viability were evaluated at 24 and 48 hours after treatment. No cytodestructive effects were observed in Group A, while a cytodestructive effect of ESWT was seen in cultures receiving the highest energy treatments. The different shock wave treatment induced differences in MTT assays after 24 and 48 hours, in particular the highest level showed a detrimental effect on cell respiration at both experimental times as compared to the Control Group and the protein metabolism was generally depressed by ESWT with impulses at the highest energy level. After 24 hours such effect further increased with the growing number of impulses. The lowest energy level appeared to significantly improve the metabolic parameter in primary cell cultures as compared to controls when 500 impulses were selected. The current study has demonstrated that one of the most important aspects to be considered is not the total number of impulses used but the energy level of the shock waves, thus confirming that ESWT has a dose-dependent effect on cells.

Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial

BACKGROUND

Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.

PURPOSE

To compare the effectiveness of 2 management strategies--group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis.

RESULTS

At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.

CONCLUSION

At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.

Nonoperative treatment of midportion Achilles tendinopathy: a systematic review

OBJECTIVE

The aim of this systematic review is to provide an easily accessible, clear summary of the best available evidence for nonoperative treatment of midportion Achilles tendinopathy.

DATA SOURCES

MEDLINE, CINAHL, and Embase through April 2007. Search terms: achilles tendon or tendo achilles or triceps surae or tendoachilles or tendo-achilles or achilles AND tendinopathy or tendinosis or tendonitis or tenosynovitis.

STUDY SELECTION

Of 707 abstracts reviewed, 16 randomized trials met our inclusion criteria.

DATA EXTRACTION

Data extracted from each paper included: patient demographics (age and sex), duration of symptoms, method of diagnosis, treatments, cohort size, length of follow-up, pain-related outcome data, and secondary outcome data.

DATA SYNTHESIS

The primary outcome measurement was change in numeric pain score. Focal tenderness, tendon thickness, and validated outcome scores were used secondarily. Eccentric exercises were noted to be equivalent to extracorporeal shockwave therapy (1 study) and superior to wait-and-see treatment (2 trials), traditional concentric exercise (2 of 3 trials), and night splints (1 study). Extracorporeal shockwave therapy was shown to be superior to a wait-and-see method in 1 study but not superior to placebo in another. Sclerosing injections were shown to be superior to placebo in 1 study, but local steroid treatment was beneficial in 2 of 3 studies. Injection of deproteinized hemodialysate and topical glyceryl nitrate application were beneficial in 1 trial each.

CONCLUSIONS

Eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy. More investigation is needed into the utility of extracorporeal shockwave therapy, local corticosteroid treatments, injections of sclerosing agents or deproteinized hemodialysate, and topical glyceryl nitrate application.

Treatment of tendinopathy: what works, what does not, and what is on the horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

LEVEL OF EVIDENCE

Level II, systematic review.

Selective loss of unmyelinated nerve fibers after extracorporeal shockwave application to the musculoskeletal system

Application of extracorporeal shockwaves (ESW) to the musculoskeletal system may induce long-term analgesia in the treatment of chronic tendinopathies of the shoulder, heel and elbow. However, the molecular and cellular mechanisms behind this phenomenon are largely unknown. Here we tested the hypothesis that long-term analgesia caused by ESW is due to selective loss of nerve fibers in peripheral nerves. To test this hypothesis in vivo, high-energy ESW were applied to the ventral side of the right distal femur of rabbits. After 6 weeks, the femoral and sciatic nerves were investigated at the light and electron microscopic level. Application of ESW resulted in a selective, substantial loss of unmyelinated nerve fibers within the femoral nerve of the treated hind limb, whereas the sciatic nerve of the treated hind limb remained unaffected. These data might indicate that alleviation of chronic pain by selective partial denervation may play an important role in the effects of clinical ESW application to the musculoskeletal system.

Extracorporeal shockwave application to the distal femur of rabbits diminishes the number of neurons immunoreactive for substance P in dorsal root ganglia L5

Application of extracorporeal shockwaves to the musculoskeletal system can induce long-term analgesia in the treatment of chronic painful diseases such as calcifying tendonitis of the shoulder, tennis elbow and chronic plantar fasciitis. However, the molecular and cellular mechanisms underlying this phenomenon are largely unknown. Recently it was shown that application of extracorporeal shockwaves to the distal femur of rabbits can lead to reduced concentration of substance P in the shockwaves' focal zone. In the present study we investigated the impact of extracorporeal shockwaves on the production of substance P within dorsal root ganglia in vivo. High-energy shockwaves were applied to the ventral side of the right distal femur of rabbits. After six weeks, the dorsal root ganglia L5 to L7 were investigated with high-precision design-based stereology. The application of extracorporeal shockwaves caused a statistically significant decrease in the mean number of neurons immunoreactive for substance P within the dorsal root ganglion L5 of the treated side compared with the untreated side, without affecting the total number of neurons within this dorsal root ganglion. No effect was observed in the dorsal root ganglia L6 and L7, respectively. These data might further contribute to our understanding of the molecular and cellular mechanisms in the induction of long-term analgesia by extracorporeal shockwave application to the musculoskeletal system.

High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional Achilles tendinopathy

BACKGROUND

High-energy extracorporeal shock wave therapy has been shown to be an effective treatment for chronic insertional Achilles tendinopathy. The results of high-energy shock wave therapy for chronic noninsertional Achilles tendinopathy have not been determined.

HYPOTHESIS

Shock wave therapy is an effective treatment for noninsertional Achilles tendinopathy.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated with a single dose of high-energy shock wave therapy (shock wave therapy group; 3000 shocks; 0.21 mJ/mm(2); total energy flux density, 604 mJ/mm(2)). Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated not with shock wave therapy but with additional forms of nonoperative therapy (control group). All shock wave therapy procedures were performed using regional anesthesia. Evaluation was by change in visual analog score and by Roles and Maudsley score.

RESULTS

One month, 3 months, and 12 months after treatment, the mean visual analog scores for the control and shock wave therapy groups were 8.4 and 4.4 (P < .001), 6.5 and 2.9 (P < .001), and 5.6 and 2.2 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 12 and 0 (P < .001), 17 and 9 (P < .001), 5 and 17 (P < .001), and 0 and 8 (P < .001), respectively. A chi(2) analysis revealed that the percentage of patients with excellent ("1") or good ("2") Roles and Maudsley scores, that is, successful results, 12 months after treatment was statistically greater in the shock wave therapy group than in the control group (P < .001).

CONCLUSION

Shock wave therapy is an effective treatment for chronic noninsertional Achilles tendinopathy.

No effect of forearm band and extensor strengthening exercises for the treatment of tennis elbow: a prospective randomised study

The objective of this prospective randomised study was to analyse the effect of the forearm support band and of strengthening exercises for the treatment of tennis elbow. Twenty-nine patients with 30 tennis elbows were randomised into 3 groups of treatment: (I) forearm support band, (II) strengthening exercises and (III) both methods. The patients had a standardised examination at their first visit, and then after 6 weeks, 3 months and 1 year. At the latest follow-up, there was a significant improvement of the symptoms compared to before treatment (p<0.0001), considering all patients independently of the methods of treatment. However, no differences in the scores were found between the 3 groups of treatment (p=0.27), indicating that no beneficial influence was found either for the strengthening exercises or for the forearm support band. Improvement seems to occur with time, independent of the method of treatment used.

Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example

BACKGROUND

The Oxford Levels of Evidence are now routinely assigned at many orthopaedic journals. One disadvantage of this approach is that study designs with a higher level of evidence may be given greater weight than the overall quality of the study merits. In other words, there is no guarantee that research is scientifically valid simply because a more sophisticated study design was employed. The aim of this study was to review Level-I and II therapeutic studies on lateral epicondylitis to measure variation in quality among the highest-level study designs.

METHODS

Fifty-four prospective randomized therapeutic trials involving patients with lateral epicondylitis were evaluated by two independent reviewers according to the Oxford Levels of Evidence, a modification of the Coleman Methodology Score (a 0 to 100-point scale), and the revised CONSORT (Consolidated Standards of Reporting Trials) score.

RESULTS

The two reviewers were consistent in their use of the Oxford Levels of Evidence (kappa = 0.73, p < 0.01), the modified Coleman Methodology Score (kappa = 0.73; p < 0.01), and the CONSORT score (kappa = 0.53; p < 0.01). Both reviewers rated the majority of studies as Level II (91% and 94%) and as unsatisfactory according to the Coleman Methodology Score (87% and 89%) and the CONSORT score (62% and 63%). Areas of deficiency included poor descriptions of recruitment (>90% of the trials), power-level calculations (73%), randomization (58%), blinding (90%), and participant flow (50%) as well as inadequate follow-up, sample size, and blinding.

CONCLUSIONS

The use of the gold-standard trial design, the prospective randomized therapeutic study (Level-I or II evidence), does not ensure quality research or reporting. Critical analysis of scientific work is important regardless of the study design. Clinical scientists should be familiar with the CONSORT criteria and adhere to them when reporting clinical trials.

Extracorporeal shockwave for chronic patellar tendinopathy

BACKGROUND

Chronic patellar tendinopathy is an overuse syndrome with pathologic changes similar to tendinopathies of the shoulder, elbow, and heel. Extracorporeal shockwave was shown effective in many tendinopathies.

HYPOTHESIS

Extracorporeal shockwave therapy may be more effective than conservative treatment for chronic patellar tendinopathy.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

This study consisted of 27 patients (30 knees) in the study group and 23 patients (24 knees) in the control group. In the study group, patients were treated with 1500 impulses of extracorporeal shockwave at 14 KV (equivalent to 0.18 mJ/mm(2) energy flux density) to the affected knee at a single session. Patients in the control group were treated with conservative treatments including nonsteroidal anti-inflammatory drugs, physiotherapy, exercise program, and the use of a knee strap. The evaluation parameters included pain score, Victorian Institute of Sports Assessment score, and ultrasonographic examination at 1, 3, 6, and 12 months and then once a year.

RESULTS

At the 2- to 3-year follow-up, the overall results for the study group were 43% excellent, 47% good, 10% fair, and none poor. For the control group, the results were none excellent, 50% good, 25% fair, and 25% poor. The mean Victorian Institute of Sports Assessment scores were 42.57 +/- 10.22 and 39.25 +/- 10.85, respectively, before treatment (P = .129) and 92.0 +/- 10.17 and 41.04 +/- 10.96, respectively, after treatment (P < .001). Satisfactory results were observed in 90% of the study group versus 50% of the control group (P < .001). Recurrence of symptoms occurred in 13% of the study group and 50% of the control group (P = .014). Ultrasonographic examination showed a significant increase in the vascularity of the patellar tendon and a trend of reduction in the patellar tendon thickness after shockwave treatment compared with conservative treatments. However, no significant difference in the appearance, arrangement, and homogeneity of tendon fibers was noted between the 2 groups. There were no systemic or local complications or device-related problems.

CONCLUSION

Extracorporeal shockwave therapy appeared to be more effective and safer than traditional conservative treatments in the management of patients with chronic patellar tendinopathy.

Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial

BACKGROUND

Few randomized controlled trials compare different methods of management in chronic tendinopathy of the main body of tendo Achillis.

PURPOSE

To compare the effectiveness of 3 management strategies-group 1, eccentric loading; group 2, repetitive low-energy shock-wave therapy (SWT); and group 3, wait and see-in patients with chronic tendinopathy of the main body of tendo Achillis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Seventy-five patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on intention-to-treat basis.

RESULTS

At 4 months from baseline, the Victorian Institute of Sport Assessment (VISA)-A score increased in all groups, from 51 to 76 points in group 1 (eccentric loading), from 50 to 70 points in group 2 (repetitive low-energy SWT), and from 48 to 55 points in group 3 (wait and see). Pain rating decreased in all groups, from 7 to 4 points in group 1, from 7 to 4 points in group 2, and from 8 to 6 points in group 3. Fifteen of 25 patients in group 1 (60%), 13 of 25 patients in group 2 (52%), and 6 of 25 patients in Group 3 (24%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 did not differ significantly. For all outcome measures, groups 1 and 2 showed significantly better results than group 3.

CONCLUSION

At 4-month follow-up, eccentric loading and low-energy SWT showed comparable results. The wait-and-see strategy was ineffective for the management of chronic recalcitrant tendinopathy of the main body of the Achilles tendon.

Targeting shock waves in human tissue for extracorporeal shock wave therapy

Extracorporeal Shock Wave Therapy is a relatively new alternative method to surgery for the treatment of many bone and muscle disorders. Currently, targeting of shock waves in the human body is done using either ultrasound or x-ray imaging. Many studies have shown controversial treatment results with conclusions that criticize ultrasound targeting. Here it is shown that targeting of the shock waves inside the body is crucial to the result of a treatment. The two different coupling methods of the shock wave generator onto the patient's body are used with gelatin phantoms to give insight into the actual treatments. As a conclusion, x-ray imaging or inline ultrasound with direct coupling should be preferred. In addition, the path of the shock waves should be vertical to the bone surfaces in order to preserve a focal region in the treated area.

Extracorporeal shock wave therapy for tendinopathies

Shock waves, as applied in urology and gastroenterology, were introduced in the middle of the last decade in Germany to treat different pathologies of the musculoskeletal system, including epicondylitis of the elbow, plantar fasciitis, and calcifying and noncalcifying tendinitis of the rotator cuff. With the noninvasive nature of these waves and their seemingly low complication rate, extracorporeal shock wave therapy (ESWT) seemed a promising alternative to the established conservative and surgical options in the treatment of patients with chronically painful conditions. However, the apparent advantages of the method led to a rapid diffusion and even inflationary use of ESWT; prospective, randomized studies on the mechanisms and effects of shock waves on musculoskeletal tissues were urgently needed to define more accurate indications and optimize therapeutic outcome. This review covers recent international research in the field and presents actual indications and results in therapy of musculoskeletal conditions with ESWT.

Extracorporeal shock wave therapy in the treatment of chronic tendinopathies

Many clinical trials have evaluated the use of extracorporeal shock wave therapy for treating patients with chronic tendinosis of the supraspinatus, lateral epicondylitis, and plantar fasciitis. Although extracorporeal shock wave therapy has been reported to be effective in some trials, in others it was no more effective than placebo. The multiple variables associated with this therapy, such as the amount of energy delivered, the method of focusing the shock waves, frequency and timing of delivery, and whether or not anesthetics are used, makes comparing clinical trials difficult. Calcific tendinosis of the supraspinatus and plantar fasciitis have been successfully managed with extracorporeal shock wave therapy when nonsurgical management has failed. Results have been mixed in the management of lateral epicondylitis, however, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. Extracorporeal shock wave therapy has consistently been more effective with patient feedback, which enables directing the shock waves to the most painful area (clinical focusing), rather than with anatomic or image-guided focusing, which are used to direct the shock wave to an anatomic landmark or structure.

Second application of low-energy shock waves has a cumulative effect on free nerve endings

Some physicians recommend treating tendinopathies with multiple sessions of shock waves. Some evidence, however, suggests shock wave application can induce nerve fiber degeneration. We questioned whether repeated shock wave application provides a cumulative effect on nerve fibers compared with the effect of one application. One thousand shock wave impulses of an energy flux density of 0.08 mJ/mm were applied to the foot pad of 32 rats. After 14 days, 16 rats received a second application. The foot pads were resected on Days 7, 14, 28, and 42. Sections were processed immunohistochemically using antibodies for sensory nerve. We compared the number of epidermal nerve fibers in rats that received one application of shock waves with the fibers in rats that received two applications. During the first 4 weeks, there was nearly complete degeneration of epidermal nerve fibers in both groups. By the end of 6 weeks, reinnervation of the epidermis began in the single-treatment group. Reinnervation occurred slower in the repeated-treatment group. These data show that a second application has a cumulative effect on nerve fibers. Our data suggest multiple applications of low-energy shock waves might a provide longer-lasting antinociceptive effect.

Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial

OBJECTIVES

Pulsed low-intensity ultrasound therapy (LIUS) has been found to be beneficial in accelerating fracture healing and has produced positive results in animal tendon repair. In the light of this we undertook a randomized, double-blind, placebo controlled trial to assess the effectiveness of LIUS vs placebo therapy daily for 12 weeks in patients with chronic lateral epicondylitis (LE).

METHODS

Patients with LE of at least 6 weeks' duration were recruited from general practice, physiotherapy and rheumatology clinics, and had to have failed at least one first-line treatment including non steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injection. Participants were assigned either active LIUS or placebo. Treatment was self-administered daily for 20 min over a 12-week period. The primary end-point was a 50% improvement from baseline in elbow pain measured at 12 weeks using a patient-completed visual analogue scale.

RESULTS

Fifty-five subjects aged 18-80 were recruited over a 9-month period. In the active group 64% (16/25) achieved at least 50% improvement from baseline in elbow pain at 12 weeks compared with 57% (13/23) in the placebo group (difference of 7%; 95% confidence interval -20 to 35%). However, this was not statistically significant (chi(2) = 0.28, P = 0.60).

CONCLUSION

In this study LIUS was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.

[Shock wave treatment for tennis elbow]

Randomized controlled trials were evaluated to assess the effectiveness of extracorporeal shock wave treatment in the management of tennis elbow. Five trials had a mediocre methodology and four trials had a high-quality design. Well-designed randomized control trials have provided evidence of the effectiveness of shock wave intervention for tennis elbow.