Shock wave-enhanced neovascularization at the tendon-bone junction: an experiment in dogs

Hierarchical Chiral Calcium Silicate Hydrate Films Promote Vascularization for Tendon-to-Bone Healing

Revascularization after rotator cuff repair is crucial for tendon-to-bone healing. The chirality of materials has been reported to influence their performance in tissue repair. However, data on the use of chiral structures to optimize biomaterials as a revascularization strategy remain scarce. Here, calcium silicate hydrate (CSO) films with hierarchical chirality on the atomic to micrometer scale are developed. Interestingly, levorotatory CSO (L-CSO) films promote the migration and angiogenesis of endothelial cells, whereas dextral and racemic CSO films do not induce the same effects. Molecular analysis demonstrates that L-chirality can be recognized by integrin receptors and leads to the formation of focal adhesion, which activates mechanosensitive ion channel transient receptor potential vanilloid 4 to conduct Ca2+ influx. Consequently, the phosphorylation of serum response factor is biased by Ca2+ influx to promote the vascular endothelial growth factor receptor 2 signaling pathway, resulting in enhanced angiogenesis. After implanted in a rat rotator cuff tear model, L-CSO films strongly enhance vascularization at the enthesis, promoting collagen maturation, increasing bone and fibrocartilage formation, and eventually improving the biomechanical strength. This study reveals the mechanism through which chirality influences angiogenesis in endothelial cells and provides a critical theoretical foundation for the clinical application of chiral biomaterials.

Effect of extracorporeal shockwave therapy on plantar fascia thickness in plantar fasciitis: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Extracorporeal shockwave therapy (ESWT) has been used as a therapeutic option for plantar fasciitis. The objective was to investigate the effect of ESWT over the plantar fascia thickness.

METHODS

MEDLINE, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials evaluating the effect of ESWT in patients with plantar fasciitis, comparing ESWT with another treatment. Meta-analysis was conducted using a random-effects model and the generic inverse variance method. Meta-regression and subgroup analyses were also carried out.

RESULTS

A total of 14 studies (867 participants) were included. ESWT significantly decreased plantar fascia thickness (weighted mean difference [WMD], -0.21 mm [95% CI -0.39, -0.02]; p = 0.03). No significant improvement in pain was observed (WMD, -0.51 cm [95% CI -1.04, 0.01]; p = 0.06) compared with non-surgical interventions.

CONCLUSIONS

Our results suggest that plantar fascia thickness is significantly decreased after ESWT intervention in patients with plantar fasciitis. However, pain relief was not significantly improved compared to other non-surgical interventions.

Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review

OBJECTIVE

To determine the efficacy of extracorporeal shockwave therapy (ESWT) and investigate outcomes following the use of ESWT for athletes and physically active individuals.

DESIGN

Systematic review.

DATA SOURCES

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and searched four databases: PubMed (NLM), Embase (Elsevier), CINAHL Complete (EBSCO) and Web of Science (Clarivate).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies were randomised controlled trials, cohort and case-control studies, cases series and reports that evaluated outcomes following ESWT for athletes, physically active individuals and occupational groups requiring regular physical activity such as military cadets.

RESULTS

56 studies with 1874 athletes or physically active individuals were included. Using the Oxford level of evidence rating, included studies were 18 level I (32.1%), 3 level II (5.4%), 10 level III (17.9%), 13 level IV (23.2%) and 12 level V (21.4%). Based on the level I studies, ESWT may be effective alone in plantar fasciitis, lateral epicondylitis and proximal hamstring tendinopathy and as an adjunct to exercise treatment in medial tibial stress syndrome and osteitis pubis in athletes or physically active individuals. In most studies, athletes were allowed to continue activities and training and tolerated ESWT with minimal side effects.

CONCLUSION

ESWT may offer an efficacious treatment alone or as an adjunct to concurrent exercise therapy in selected sports-related injuries and without major adverse events. Further high-level research is needed to better define the role and clinical outcomes of ESWT.

Radial extracorporeal shock wave therapy as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. A randomized controlled study

PURPOSE

To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients.

METHODS

100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients.

RESULTS

After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I.

CONCLUSION

ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients.

Extracorporeal Shockwave Therapy (ESWT) in the Management of Diabetic Foot Ulcer: A Prospective Randomized Clinical Trial

Diabetic foot ulcer (DFU) is the most common cause of prolonged hospitalization with a high cost of care due to unsatisfactory outcomes with the current mode of therapy. Extracorporeal shockwave therapy (ESWT) is a new technology in the care of nonhealing wounds. The study's main objective was to compare the healing parameters of DFUs between patients undergoing the standard of care (SOC) alone and ESWT + SOC. The secondary objective was to assess inflammatory markers in both study groups. The study was designed as a single-center, randomized trial to provide evidence on the effects of ESWT on DFU healing. Informed consent was obtained from all participants before enrolment. Forty-eight participants were recruited, enrolled, and randomly allocated into the 2 study groups. Twenty-five patients were allocated to the ESWT + SOC group, and 23 patients were allocated into the SOC-only group for a treatment period of 6 weeks. The univariate binary analysis showed more patients with healed DFU in the ESWT + SOC group than the SOC-only group at 6 weeks, though the difference did not reach statistical significance (OR = 3.2, p = .07). The adjusted multivariate binary analysis confirmed this finding; however, the effect size did not reach statistical significance at 6 weeks (OR = 3.9, p = .08). The level of circulating inflammatory markers was similar in both groups of patients. It is the author's opinion that there is a potential benefit of ESWT on diabetic wound healing with further research warranted to determine its role in treatment of DFU. A larger trial with a more extended treatment period is, however, needed to substantiate our findings.

Polydeoxyribonucleotide and Shock Wave Therapy Sequence Efficacy in Regenerating Immobilized Rabbit Calf Muscles

This study primarily aimed to investigate the combined effects of polydeoxyribonucleotide (PDRN) and extracorporeal shock wave therapy (ESWT) sequences on the regenerative processes in atrophied animal muscles. Thirty male New Zealand rabbits, aged 12 weeks, were divided into five groups: normal saline (Group 1), PDRN (Group 2), ESWT (Group 3), PDRN injection before ESWT (Group 4), and PDRN injection after ESWT (Group 5). After 2 weeks of cast immobilization, the respective treatments were administered to the atrophied calf muscles. Radial ESWT was performed twice weekly. Calf circumference, tibial nerve compound muscle action potential (CMAP), and gastrocnemius (GCM) muscle thickness after 2 weeks of treatment were evaluated. Histological and immunohistochemical staining, as well as Western blot analysis, were conducted 2 weeks post-treatment. Staining intensity and extent were assessed using semi-quantitative scores. Groups 4 and 5 demonstrated significantly greater calf muscle circumference, GCM muscle thickness, tibial nerve CMAP, and GCM muscle fiber cross-sectional area (type I, type II, and total) than the remaining three groups (p < 0.05), while they did not differ significantly in these parameters. Groups 2 and 3 showed higher values for all the mentioned parameters than Group 1 (p < 0.05). Group 4 had the greatest ratio of vascular endothelial growth factor (VEGF) to platelet endothelial cell adhesion molecule-1 (PECAM-1) in the GCM muscle fibers compared to the other four groups (p < 0.05). Western blot analysis revealed significantly higher expression of angiogenesis cytokines in Groups 4 and 5 than in the other groups (p < 0.05). The combination of ESWT and PDRN injection demonstrated superior regenerative efficacy for atrophied calf muscle tissue in rabbit models compared to these techniques alone or saline. In particular, administering ESWT after PDRN injection yielded the most favorable outcomes in specific parameters.

The Effect of Radial Extracorporeal Shock Wave Therapy (rESWT) on the Skin Surface Temperature of the Longissimus Dorsi Muscle in Clinically Healthy Racing Thoroughbreds: A Preliminary Study

Radial extracorporeal shock wave therapy (rESWT) is increasingly being used to treat musculoskeletal injuries in horses. The aim of this study was to assess the influence of rESWT on the skin surface temperature of the longissimus dorsi muscle in clinically healthy racing horses. A total of 24 thoroughbreds were divided into a study group (n = 12) and an rESWT-sham group (n = 12). The study group underwent rESWT, whereas the rESWT-sham group had rESWT without probe activation in the treated area. Both groups underwent thermographic examination before and just after rESWT to determine and compare skin surface temperatures. Palpation examination was performed after the first and second thermography examination to assess longissimus dorsi muscle tone. Additionally, thermographic examination was repeated 10 min after the rESWT. In both groups, there was an increase in skin surface temperature just after rESWT, and a decrease 10 min after it to below the initial value. In the study group, the skin surface temperature just after rESWT was higher than in the rESWT-sham group. Additionally, in the study group the average muscle tone before rESWT was significantly higher than just after the procedure, whereas in the rESWT-sham group the average change in muscle tone was not significant. The results proved that rESWT increases skin surface temperature of the longissimus dorsi muscle in clinically healthy horses. Further research is necessary in order to configure shockwave treatment with appropriate parameters for effective and safe therapy.

Utilizing Extracorporeal Shockwave Therapy for in-Season Athletes

An athlete’s health and availability to train and compete at an optimal performance level is a growing focus for professional sports organizations [...]

Shockwave Therapy in Veterinary Rehabilitation

Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment that involves the transcutaneous delivery of high-energy sound waves into tissue creating therapeutic effects. Shockwaves are nonlinear, high-pressure, high-velocity acoustic waves characterized by low tensile amplitude, short rise time to peak pressure, and a short duration (less than 10 milliseconds). ESWT has been shown to increase the expression of cytokines and growth factors leading to decreased inflammation, neovascularization, and cellular proliferation; activation of osteogenesis by osteoblast differentiation and then by increased proliferation; inhibition of cartilage degeneration and rebuilding of subchondral bone; and increased serotonin in the dorsal horn and descending inhibition of pain signals. Musculoskeletal conditions that can benefit from ESWT include osteoarthritis, tendinopathies, fracture/bone healing, and wound healing.

Shock waves modulate corticospinal excitability: A proof of concept for further rehabilitation purposes?

Background

Focal extracorporeal shock wave therapy (fESWT) is a physical therapy vastly studied and used for various musculoskeletal disorders. However, the effect of fESWT on central nervous system is still to be determined.

Objective

To elucidate spinal and supra-spinal mechanisms of fESWT in healthy subjects, in order to widen the spectrum of its clinical applications.

Methods

In this quasi-experimental, unblinded, proof-of-concept clinical study, 10 voluntary healthy subjects underwent fESWT and were assessed immediately before (T0), immediately after (T1) and seven days after (T2) the intervention. As neurophysiological outcomes, motor evoked potentials (resting motor threshold, maximal motor evoked potential and maximal compound muscle action potential ratio, cortical silent period, total conduction motor time, direct and indirect central motor conduction time), F-waves (minimal and mean latency, persistence and temporal dispersion) and H-reflex (threshold, amplitude, maximal H reflex and maximal compound muscle action potential ratio, latency) were considered.

Results

Resting motor threshold and F-waves temporal dispersion significantly decreased, respectively, from T1 and T2 and from T0 and T2 (for both, p <  0.05). H-reflex threshold increase between T0 and T1. Analysis disclosed a strong negative correlation between Δ3 cortical silent period (i.e., T2 -T1 recordings) and Δ1 Hr threshold (i.e., T1 -T0 recordings) (r = -0.66, p <  0.05), and a positive strong relationship between Δ3 cortical silent period and Δ3 Hr threshold (r = 0.63, p <  0.05).

Conclusions

fESWT modulates corticospinal tract excitability in healthy volunteers, possibly inducing an early inhibition followed by a later facilitation after one week.

Biological effects of extracorporeal shockwave therapy in tendons: A systematic review

Extracorporeal shockwave therapy was initially used for kidney stone disintegration and its application was then extended to calcific tendinitis. The therapeutic field expanded and included numerous types of tendinopathies, from shoulder to plantar fascia. The clinical benefits were documented in trials and the effects and mechanisms were studied on models including animal and human tendons. The present systematic review outlines a large spectrum of biological effects. First, an optimal dose is adapted for each species and each tendon; exceeding the optimal dose may lead to structural injury. Furthermore, the biological effects may be grouped into neovascularization induction, cellularity and extracellular matrix changes, metalloprotease and cytokine modulation, as well as lubricin production. As a result, the remodeled tendon displays improved biomechanical properties to resist stress.

Case study: Treating infraspinatus and supraspinatus trigger points and supraspinatus tendinopathy utilizing piezoelectric shockwave

Two individual case studies demonstrate piezoelectric shockwave treatment for the resolution of a supraspinatus tendinopathy and supraspinatus and infraspinatus myofascial trigger points (MTPs) via musculoskeletal ultrasound. This is the first documentation of improvement of both tendon and muscle fiber patterns in canine patients treated with piezoelectric shockwave. These cases validate the use of piezoelectric shockwave during the rehabilitation of common canine shoulder injuries.

Biological response of extracorporeal shock wave therapy to tendinopathy in vivo (review)

Tendinopathy is a degenerative disease of the tendons caused by prolonged overstretching or overuse of the tendons. It accounts for a large proportion of musculoskeletal disorders which can occur in all age groups. The management of tendinopathy is typically conservative. In clinical practice, when other conservative treatments fail, extracorporeal shock wave therapy (ESWT) is normally used as an efficient alternative to surgical management. Several basic studies have shown that ESWT with lower energy flux densities can produce some biological responses in vivo to tendinopathy and may accelerate the initiation of the healing process in injured tendons. ESWT has a positive impact on the interactive chain of biological response, enhancing the signaling pathways of angiogenesis through mechanical conduction, and promoting cell proliferation and collagen formation. Finally, it helps tissue regeneration by controlling inflammation. The purpose of this review is to summarize the biological responses generated by ESWT in tendinopathy through a comprehensive review of the published literature. Although ESWT has been used clinically for the treatment of tendinopathies for nearly decades, less is known about the experimental studies of its biological effects on tendon tissue. Further studies on the biological response of ESWT for tendon injuries in vivo are needed in the future in order to provide better management to patients.

Comparative Efficacy of Nonoperative Treatments for Greater Trochanteric Pain Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

An evolved understanding of the pathophysiology of greater trochanteric pain syndrome has led to a number of proposed nonoperative management strategies. The objective of this review was to compare the efficacy of the various nonoperative treatments for greater trochanteric pain syndrome (GTPS).

DESIGN

Systematic review and network meta-analysis.

SETTING

PubMed, Embase, CENTRAL, SCOPUS, and Web of Science were searched to January 2020.

PATIENTS

Patients undergoing nonoperative treatment for GTPS.

INTERVENTIONS

Nonoperative treatment strategies for GTPS including injections of corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs and extracorporeal shockwave therapy.

MAIN OUTCOME MEASURES

Pain and functional outcomes. Bayesian random-effects model was performed to assess the direct and indirect comparison of all treatment options.

RESULTS

Thirteen randomized controlled trials and 1034 patients were included. For pain scores at 1 to 3 months follow-up, both platelet-rich plasma (PRP) and shockwave therapy demonstrated significantly better pain scores compared with the no treatment control group with PRP having the highest probability of being the best treatment at both 1 to 3 months and 6 to 12 months. No proposed therapies significantly outperformed the no treatment control group for pain scores at 6 to 12 months. Structured exercise had the highest probability of being the best treatment for improvements in functional outcomes and was the only treatment that significantly improved functional outcome scores compared with the no treatment arm at 1 to 3 months.

CONCLUSION

Current evidence suggests that PRP and shockwave therapy may provide short-term (1-3 months) pain relief, and structured exercise leads to short-term (1-3 months) improvements in functional outcomes.

The Effects of the Exposure of Musculoskeletal Tissue to Extracorporeal Shock Waves

Extracorporeal shock wave therapy (ESWT) is a safe and effective treatment option for various pathologies of the musculoskeletal system. Many studies address the molecular and cellular mechanisms of action of ESWT. However, to date, no uniform concept could be established on this matter. In the present study, we perform a systematic review of the effects of exposure of musculoskeletal tissue to extracorporeal shock waves (ESWs) reported in the literature. The key results are as follows: (i) compared to the effects of many other forms of therapy, the clinical benefit of ESWT does not appear to be based on a single mechanism; (ii) different tissues respond to the same mechanical stimulus in different ways; (iii) just because a mechanism of action of ESWT is described in a study does not automatically mean that this mechanism is relevant to the observed clinical effect; (iv) focused ESWs and radial ESWs seem to act in a similar way; and (v) even the most sophisticated research into the effects of exposure of musculoskeletal tissue to ESWs cannot substitute clinical research in order to determine the optimum intensity, treatment frequency and localization of ESWT.

Systematic Review and Meta-Analysis of 16 Randomized Controlled Trials of Clinical Outcomes of Low-Intensity Extracorporeal Shock Wave Therapy in Treating Erectile Dysfunction

We conducted a meta-analysis to evaluate the efficacy of low-intensity extracorporeal shock wave therapy (LI-ESWT) in the treatment of erectile dysfunction (ED). From July 2011 to June 2021, we finally selected 16 randomized controlled trials (RCTs) including 1,064 participants to evaluate the efficacy of LI-ESWT in the treatment of ED from PubMed, EMBASE, and Cochrane databases. The data are analyzed by Review Manager Version 5.4. Fifteen articles mentioned International Index of Erectile Function (IIEF), in the follow-up of 1 month (mean difference [MD] = 3.18, 95% confidence interval [CI] = [1.38, 4.98], p = .0005), 3 months (MD = 3.01, 95% CI = [2.04, 3.98], p < .00001), and 6 months (MD = 3.20, 95% CI = [2.49, 3.92], p < .00001). After treatment, the improvement of IIEF in the LI-ESWT group was better than that in the control group. Besides, eight of the 16 trials provided data on the proportion of patients with baseline Erectile Hardness Score (EHS) ≤ 2 improved to EHS ≥ 3. The LI-ESWT group was also significantly better than the placebo group (odds ratio [OR] = 5.07, 95% CI = [1.78, 14.44], p = .002). The positive response rate of Questions 2 and 3 of the Sexual Encounter Profile (SEP) was not statistically significant (SEP2: OR = 1.27, 95% CI = [0.70, 2.30], p = .43; SEP3: OR = 4.24, 95% CI = [0.67, 26.83], p = .13). The results of this meta-analysis suggest that treatment plans with an energy density of 0.09 mJ/mm² and pulses number of 1,500 to 2,000 are more beneficial to IIEF in ED patients. In addition, IIEF improvement was more pronounced in patients with moderate ED after extracorporeal shockwave therapy.

Use of the Shock Wave Therapy in Basic Research and Clinical Applications-From Bench to Bedsite

Shock Waves (SW) are acoustic disturbances that propagate through a medium carrying the energy. These specific sonic pulses are composed of two phases—high positive pressure, a rise time < 10 ns, and a tensile wave. Originally Shock Waves were introduced to clinical practice as a part of the lithotripsy therapy focused on disrupting calcific deposits in the body. Since that time, shock wave therapy (SWT) has gone far beyond the original application related to the destruction of kidney stones. In this narrative Review, we present basic clinical applications of the SWT along with the potential therapeutic application in clinical practice.

Functional Gains Using Radial and Combined Shockwave Therapy in the Management of Achilles Tendinopathy

Achilles tendinopathy is a common condition and many patients have functional limitations after initial conservative treatment. Shockwave therapy has been shown to improve function within patients; however, comparative outcomes for different forms of shockwave are poorly described. In this retrospective cohort study, we describe findings from a quality improvement initiative evaluating safety and functional outcomes after treatment with radial shockwave therapy (n = 58) or combined radial and focused shockwave therapy (n = 29) for patients with Achilles tendinopathy refractory to exercise therapy. All patients were prescribed an eccentric exercise program. We hypothesized both groups would see improvements in function quantified using the Victorian Institute of Sports Assessment-Achilles with similar safety outcomes. Overall, the minimal clinically important difference (defined at 7 for insertional and 12 for noninsertional Achilles tendinopathy) was met in a greater proportion of patients treated with combined shockwave compared to radial shockwave (26 [89.7%] vs 37 [63.8%], p = .022). The change in Victorian Institute of Sports Assessment-Achilles from baseline to final treatment was not different between combined and radial-only groups (23.3 ± 12.6 vs 19.9 ± 18.7, p = .2). Within group differences from baseline to final follow-up measures (mean duration 17.9 ± 14.8 weeks) demonstrated overall functional improvement for both groups (both p < .0001). No serious adverse effects were observed. Our findings suggest combined radial and focused shockwave therapy may provide more predictable functional gains for treatment of Achilles tendinopathy compared to radial shockwave therapy.

Extracorporeal Shockwave Therapy Versus Ultrasound Therapy for Plantar Fasciitis: A Systematic Review and Meta-Analysis

The objective of this study was to compare the outcomes of extracorporeal shockwave therapy (ESWT) versus ultrasound therapy (UST) in plantar fasciitis. A systematic review and meta-analysis were performed. An electronic search identifying studies comparing ESWT and UST for plantar fasciitis was conducted. Primary outcomes were morning and activity pain, functional impairment, and the American Orthopaedic Foot and Ankle Society (AOFAS) scale score. Secondary outcomes included the fascial thickness, primary efficacy success rate, activity limitations, pain intensity, and satisfaction. Seven studies enrolling 369 patients were identified. No significant difference was found between ESWT and UST for functional impairment (mean difference [MD] = −2.90, P = 0.22), AOFAS scale score (MD = 35, P = 0.20), and pain in the first steps in the morning (MD = −4.72, P = 0.39). However, there was a significant improvement in pain during activity for the ESWT group (MD = −1.36, P = 0.005). For secondary outcomes, ESWT had improved results in terms of primary efficacy success rate, activity limitations, and patient satisfaction. The reduction of plantar fascia thickness showed no significant difference. Pain intensity after treatment had varied results amongst included studies. In conclusion, ESWT is superior to UST for plantar fasciitis as it improves pain activity and intensity, primary efficacy success rate, and activity limitations.

Shockwave Therapy Plus Eccentric Exercises Versus Isolated Eccentric Exercises for Achilles Insertional Tendinopathy: A Double-Blinded Randomized Clinical Trial

BACKGROUND

There remains a lack of consensus regarding the treatment of Achilles insertional tendinopathy. The condition is typically treated with eccentric exercises despite the absence of satisfactory and sustained results. Shockwave therapy was presented as an alternative, but there is a paucity of literature, with good outcomes, supporting its use. The purpose of the present single-center, double-blinded, placebo-controlled, randomized trial was to determine if the use of shockwave therapy in combination with eccentric exercises improves pain and function in patients with Achilles insertional tendinopathy.

METHODS

A total of 119 patients with Achilles insertional tendinopathy were evaluated and enrolled in the study from February 2017 to February 2019. Patients were allocated to 1 of 2 treatment groups, eccentric exercises with extracorporeal shockwave therapy (SWT group) and eccentric exercises with sham shockwave therapy (control group). Three sessions of radial shockwaves (or sham treatment) were performed every 2 weeks and eccentric exercises were undertaken for 3 months. The primary outcome was the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) at 24 weeks. Secondary outcomes included the visual analogue scale, algometry, the Foot and Ankle Outcome Score, and the 12-Item Short Form Health Survey.

RESULTS

Both groups showed significant improvement during the study period; however, there were no between-group differences in any of the outcomes (all p >0.05). At the 24-week evaluation, the SWT group exhibited a mean VISA-A of 63.2 (95% confidence interval, 8.0) compared with 62.3 (95% confidence interval, 6.9) in the control group (p = 0.876). There was a higher rate of failure (38.3%) but a lower rate of recurrence (17.0%) in the SWT group compared with the control group (11.5% and 34.6%, respectively; p = 0.002 and p = 0.047). There were no complications reported for either group.

CONCLUSIONS

Extracorporeal shockwave therapy does not potentiate the effects of eccentric strengthening in the management of Achilles insertional tendinopathy.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Nonsurgical Approach in Management of Tibialis Posterior Tendinopathy With Combined Radial Shockwave and Foot Core Exercises: A Case Series

Tibialis posterior tendinopathy is a common debilitating condition seen by foot and ankle providers. Non-operative management is difficult as patients often present in later stages of the disease. This case series evaluated the combination of radial shockwave therapy and a foot core progression exercise regimen on 10 patients who had failed standard conservative treatment techniques. Median follow-up time was 4 months. Clinically important differences in the Foot and Ankle Ability Measure were met in 9 (90%) and 8 (80%) of patients for activities of daily living and sport sub-scores, respectively. No adverse effects were observed.

Therapeutic modality of induced uterine leiomyoma with shock waves in rats: The uterine blood flow, circulating ovarian hormones and histopathological findings

Uterine leiomyoma is the most common benign pelvic tumor and the primary indication for hysterectomy. We hypothesized tumor softening and shrinking through shock waves mechanobiological influence on fibroblasts of the induced leiomyoma in rats. Three rats served as control from thirty-three female Wistar rats subjected to leiomyoma induction using mono-sodium glutamate and estradiol benzoate. After assessing uterine leiomyoma development with Doppler ultrasonography, blood and tissue samples were collected for hormonal and histopathological analysis. Of the fifteen rats treated with shock waves, five rats were sacrificed after receiving two sessions (2S), another five rats were sacrificed after receiving four sessions (4S), and the last five rats were sacrificed after two weeks recovery period (recovered 4S). From the fifteen non-treated leiomyoma group, five rats were sacrificed after Doppler ultrasound assessment (Leiomyoma), another five rats were sacrificed with the 4S group (Leiomyoma 1Wk recovery), and the last five rats were sacrificed with the recovered 4S group (Recovered leiomyoma). The collected blood samples, estradiol (E2), Estrogen receptor, progesterone (P4), and progesterone receptor (PGR), were assayed. Total cholesterol, protein, albumin, and globulin were measured. Uterine arteries' blood flow velocities, indices, and volume were obtained. Tissue samples were stained with smooth muscle actin (SMA), trichrome-three, and (hematoxylin and eosin). Rats developed leiomyoma had the highest (P = 0.0001) gross and sonographic uterine horns diameters, uterine weight, uterine coefficient, E2, and ER. Both trichrome-three and SMA staining confirmed the leiomyoma development and the response to shock waves treatment. In conclusion, low-intensity shock waves proved curative to the induced leiomyoma.

Achilles tendinopathy: Exploring injury characteristics and current treatment modalities

Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities.

Shockwave Therapy Modulates the Expression of BMP2 for Prevention of Bone and Cartilage Loss in the Lower Limbs of Postmenopausal Osteoporosis Rat Model

Osteoporosis (OP) causes bone loss and weakness, increasing the risk of bone fracture. In this study, rats were divided into Sham, OP, SW(F) (0.25 mJ/mm² with 1600 impulses to the left medial femur), and SW(T) (0.25 mJ/mm² with 1600 impulses to the left medial tibia). The bone strength results following SW(T) were better than SW(F) in the modulus, extension at peak load, handleability, and strain at break. SW(T) had the best prevention for bone loss in both lower limbs of ovariectomized (OVX) rats. The cartilage cellular matrixes of both knees were improved in SW(T) and SW(F) compared to that of OP. Serum bone morphogenetic protein 2 (BMP2) in rats undergoing SW(T) or SW(F) was significantly improved compared to that in Sham and OP. The expressions of BMP2, BMP4, and SMAD family member 4 (Smad4) in addition to the Wnt family member 3A (Wnt3a) and Cyclin D1 signaling key factors were significantly induced in the cartilage of both knees by shockwave (SW). SW(T) presented the best efficacy to induce serum BMP2 to prevent bone loss from both lower limbs. Here, we display the protective effects of SW therapy to induce BMP2, BMP4, Smad4, Wnt3a, and Cyclin D1 signaling factors for cartilage loss in both knees of OVX rats.

It Comes As a Shock: Kidney Repair Using Shockwave Therapy

Chronic kidney disease is a global health care burden, yet clinically-proven treatments are limited. Low-intensity shockwave, which utilizes ≈10% of the energy levels used in clinically indicated shockwave lithotripsy, is a promising technique to ameliorate ischemia and regenerate tissues. It has been demonstrated to improve healing in tissues such as bone, muscle, myocardium, and kidney via several mechanisms, particularly through promoting neovascularization. Low-intensity shockwave stimulates mechanoreceptors located primarily in endothelial and proximal tubular cells and subsequently upregulates vascular endothelial growth factors. This, in turn, promotes angiogenesis and ameliorates renal hypoxia, inflammation, and fibrosis, and ultimately preserves renal function. Furthermore, low-intensity shockwave can stimulate release of homing factors to attract endothelial progenitor or stem cells into injured kidneys for tissue repair. These effects may be beneficial in several kidney disease models, including renal artery stenosis, diabetic kidney disease, and various chronic kidney diseases, although most studies reported to date have been performed in animal models. Because of its low energy intensity, the procedure is relatively tolerable and safe, yet, more clinical studies are needed to establish its efficacy beyond currently existing strategies. Therefore, low-intensity shockwave therapy emerges as an alternative therapeutic approach that may offer a promising noninvasive intervention for treating renal diseases. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02515461; NCT03602807; and NCT03445247.

In Vivo Modulation of Angiogenesis and Immune Response on a Collagen Matrix via Extracorporeal Shockwaves

The effective management of tissue integration and immunological responses to transplants decisively co-determines the success of soft and hard tissue reconstruction. The aim of this in vivo study was to evaluate the eligibility of extracorporeal shock wave therapy (ESWT) with respect to its ability to modulate angiogenesis and immune response to a collagen matrix (CM) for tissue engineering in the chorioallantoic membrane (CAM) assay, which is performed with fertilized chicken eggs. CM were placed on the CAM on embryonic development day (EDD) 7; at EDD-10, ESWT was conducted at 0.12 mJ/mm² with 500 impulses each. One and four days later, angiogenesis represented by vascularized area, vessel density, and vessel junctions as well as HIF-1α and VEGF gene expression were evaluated. Furthermore, immune response (iNOS2, MMP-9, and MMP-13 via qPCR) was assessed and compared between ESWT- and non-ESWT-groups. At EDD-14, the vascularized area (+115% vs. +26%) and the increase in vessel junctions (+751% vs. +363%) were significantly higher in the ESWT-group. ESWT significantly increased MMP-9 gene expression at EDD-11 and significantly decreased MMP-13 gene expression at EDD-14 as compared to the controls. Using the CAM assay, an enhanced angiogenesis and neovascularization in CM after ESWT were observed. Furthermore, ESWT could reduce the inflammatory activity after a latency of four days.

Extracorporal shock wave therapy for the treatment of arthrodesis non-unions

INTRODUCTION

Non-union is a regular complication of arthrodeses. Standard treatment includes revision surgery with frequent need for re-revision due to persistent non-union. Particularly patients with concomitant diseases are at risk of secondary complications. There is a need for evaluation of alternative treatment options. The aim of this study is to provide first evidence on union-rate and pain course after focussed extracorporeal shock-wave therapy of arthrodesis non-unions.

PATIENTS AND METHODS

In a retrospective single-centre study, 25 patients with non-union following arthrodesis received one session of focussed extracorporeal shock-wave therapy (energy flux density 0.36 mJ/mm², 3000 impulses, 23 kV, 4 Hz). Radiographic and clinical results were recorded 6, 12 and 24 weeks after treatment.

RESULTS

24 patients were followed-up. After 24 weeks arthrodeses of the hand healed in 80%, of the upper ankle in 50%, of subtalar joint in 27.2% and of the midfoot in 0% of the cases. Pain decreased from 4.8 (± 2.8) points on the visual analogue scale to 3.4 (± 2.3), 2.9 (± 2.5) and 2.4 (± 2.8) points after 6, 12 and 24 weeks, respectively (p < 0.0001).

CONCLUSION

Our data indicate that the effect of focussed, high-energy shock wave therapy depends on body region and is effective for the treatment of non-unions of the hand as well as for pain relief.

LEVEL OF EVIDENCE

Level IV.

The effect of extracorporeal shockwave on liposomal bupivacaine in a tibial plateau leveling osteotomy model

OBJECTIVE

To determine the effect of extracorporeal shock wave (ESWT) on liposomal bupivacaine in a tibial-plateau-leveling osteotomy model.

STUDY DESIGN

In vitro study.

SAMPLE POPULATION

Ten samples per group.

METHODS

In addition to a control group (sham treatment), five treatment groups were defined as A, energy (E) 3 (0.22 mJ/mm² ), 360 pulses per minute (p/m); B, E6 (0.29 mJ/mm² ), 360 p/m; C, E8 (0.39 mJ/mm² ), 360 p/m; D, E6, 480 p/m; E, E8 480 p/m. Two-milliliter aliquots of liposomal bupivacaine were placed in a gelatin chamber and treated with 1000 pulses according to group. All samples remained in the chamber for 170 seconds to reflect the longest treatment group. Free bupivacaine concentrations were determined after treatment with high-performance liquid chromatography.

RESULTS

The median free bupivacaine concentration was reported as control, 1.90 mg/mL; A, 2.10 mg/mL; B, 2.03 mg/mL; C, 2.94 mg/mL; D, 2.71 mg/mL; E, 4.35 mg/mL. Groups C (P = .027), D (P = .034), and E (P = .002) were different from the control group. Groups C (P = .0025) and D (P = .0025) were different from group E. Additional intertreatment group differences were found.

CONCLUSION

Extracorporeal shock wave therapy caused a dose-dependent release of bupivacaine; however, there was no significant release of bupivacaine from liposomes when ESWT was applied at currently recommended therapeutic settings in this model.

CLINICAL SIGNIFICANCE

This in vitro study provides evidence that concurrent electrohydraulic ESWT and liposomal bupivacaine is likely safe at currently recommended settings, however, higher energy and pulse frequency settings should be avoided.

The Impact of Extracorporeal Shock Wave Therapy on Microcirculation in Diabetic Feet: A Pilot Study

BACKGROUND

Patients with diabetic foot commonly experience vascular insufficiency and compromised tissue perfusion. Extracorporeal shockwave therapy (ESWT) reportedly promotes wound healing and angiogenesis, but clinical studies on the effect of ESWT on angiogenesis are scarce and the exact mechanism remains unclear.

OBJECTIVE

To investigate the effect of ESWT on cutaneous microcirculation in diabetic feet.

METHODS

Ten patients with diabetic feet received ESWT twice weekly for a total of six sessions. Transcutaneous partial oxygen pressure (TcPO2) and cutaneous blood flow were measured before and after ESWT.

MAIN RESULTS

The treated feet showed statistically significant improvements in the mean TcPO2 (P < .01) and cutaneous blood flow level (P < .05) compared with control feet. In treated feet, TcPO2 increased by 19.6%, from 41.4 ± 9.9 to 49.5 ± 8.7 mm Hg (P < .05). In control feet, TcPO2 decreased by 11.6%, from 39.5 ± 14.0 to 34.9 ± 14.5 mm Hg (P = .059). The average cutaneous blood flow level of treated feet before ESWT was 36.9 ± 25.6, which increased to 48.3 ± 32.4 AU after ESWT (30.9% increase; P = .646). In control feet, the cutaneous blood flow level decreased from 80.5 ± 36.7 to 60.4 ± 38.8 AU, a decrease of 25.0% (P = .241).

CONCLUSIONS

These results demonstrate that ESWT may have beneficial effects on microcirculation in diabetic feet.

Extracorporeal Shock Wave Therapy Immediately Affects Achilles Tendon Structure and Widespread Pressure Pain Thresholds in Healthy People: A Repeated-Measures Observational Study

OBJECTIVE

Extracorporeal shockwave therapy is a common clinical treatment for tendinopathy, yet negative effects on tendon structure have been shown in animal studies. This study aimed to investigate the effect of extracorporeal shockwave therapy in healthy participants (i.e., no Achilles tendon pain or pathology).

DESIGN

This study examined the effect of three bouts of weekly extracorporeal shockwave therapy for 3 wks in 13 healthy participants. Outcomes measures assessed were as follows: (a) Achilles tendon structure, quantified using ultrasound tissue characterization (before and 3 hrs after extracorporeal shockwave therapy), (b) pressure pain thresholds, over the Achilles tendon and common extensor tendon origin (before, immediately after, and 3 hrs after extracorporeal shockwave therapy), and (c) hop pain (before and immediately after extracorporeal shockwave therapy).

RESULTS

There was a significant reduction in echo type I (P < 0.05) and increase in echo type II (P < 0.05) at 3 hrs after the first extracorporeal shockwave therapy session that recovered to baseline levels before week 2. There were no significant changes in ultrasound tissue characterization echo pattern observed in subsequent sessions. There were increased pressure pain thresholds immediately after extracorporeal shockwave therapy at the common extensor tendon origin but no significant change at the Achilles tendon. Pressure pain thresholds returned to baseline at 3 hrs after extracorporeal shockwave therapy. There were no significant changes in pressure pain threshold in subsequent sessions.

CONCLUSIONS

Extracorporeal shockwave therapy resulted in transient changes to tendon structure and widespread hyperalgesia.

Efficacy of Extracorporeal Shock Wave Therapy for Lateral Epicondylitis: A Systematic Review and Meta-Analysis

Background

Lateral epicondylitis (LE) is a common elbow problem. Extracorporeal shock wave therapy (ESWT) was widely used in the treatment of LE and has been shown to relieve the pain and functional impairment (loss of grip strength) caused by tennis elbow. However, the evidence with regard to whether ESWT has better clinical efficacy over other method is not clear. The aim of the study was to compare the effectiveness of ESWT with other techniques in the treatment of LE.

Methods

Literature searches of PubMed, OVID, Embase, Cochrane Library, and Web of Science were searched up to 30^th June, 2019. Only RCTs comparing ESWT with other methods for LE were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards.

Results

A total of 13 articles with 1035 patients were included. Of which, 501 underwent ESWT and 534 underwent other methods. The result of meta-analysis showed that pooled VAS (P = 0.0004) and grip strength (P < 0.00001) were better in the ESWT group.

Conclusion

Based on the existing clinical evidence, extracorporeal shock wave therapy can effectively relieve the pain and functional impairment (loss of grip strength) caused by tennis elbow, with better overall safety than several other methods. However, owing to the limited quality and quantity of the included studies, more high-quality RCTs are needed to support the trend towards better functional outcomes with ESWT.

Sonoelastographic evaluation of plantar fascia after shock wave therapy for recalcitrant plantar fasciitis: A 12-month longitudinal follow-up study

Extracorporeal shockwave therapy (ESWT) is proposed to be effective in reducing pain and improving functional outcome in chronic plantar fasciitis. However, no long-term reports exist on the changes in plantar fascia (PF) elasticity after ESWT. We aimed to evaluate the changes in PF stiffness in patients with plantar fasciitis undergoing ESWT. The visual analogue scale (VAS, 0–100) was used for evaluating heel pain severity. B-mode sonography and strain sonoelastography were used for evaluating the PF thickness and stiffness. The sonoelastogram was analyzed using hue histogram analysis (value: 0–255, from stiffer to softer). All evaluations were recorded before ESWT, and 1 week, 1 month, 3 months, 6 months, and 12 months after ESWT. Repeated measures ANOVA was used to compare pain VAS, PF thickness, and PF hue value at different follow-up time-points. Twenty-two participants (8 men, 14 women) completed all measurements for 12 months. The VAS of heel pain, PF thickness, and PF hue values at pre-ESWT, and 1-week, 1-month, 3-month, 6-month, and 12-month evaluations after ESWT were 62.4 ± 4.2, 49.3 ± 5.8, 38.3 ± 5.7, 27.9 ± 5.3, 18.9 ± 4.7, and 13.2 ± 3.0 (p < 0.01 in all measurements post ESWT versus pre-ESWT); 5.57 ± 0.22 mm, 5.64 ± 0.18 mm, 5.45 ± 0.24 mm, 5.37 ± 0.20 mm, 5.08 ± 0.20 mm, and 4.62 ± 0.15 mm (p < 0.01 at 6-month; otherwise p > 0.05); and 24.5 ± 2.4, 35.2 ± 3.1, 31.0 ± 4.1, 30.5 ± 3.9, 21.4 ± 2.1, and 15.9 ± 1.6 (p < 0.01 at 1-week and 6-month; otherwise p > 0.05), respectively. In conclusion, the heel pain intensity and PF thickness reduced gradually over 12 months after ESWT. The PF stiffness decreased during the first week and increased thereafter; at the 12-month follow-up, stiffness was more than at pre-ESWT.

Blood Flow in the Scaphoid Is Improved by Focused Extracorporeal Shock Wave Therapy

BACKGROUND

Extracorporeal shock wave therapy (ESWT) has shown benefits in patients with nonunion or delayed bone healing, pseudarthrosis, and avascular necrosis of bone. Until now, these effects were explained by the release of growth factors, activation of cells, and microfractures occurring after ESWT. Microcirculation is an important factor in bone healing and may be compromised in fractured scaphoids because its blood supply comes from the distal end. Due to this perfusion pattern, the scaphoid bone is prone to nonunion after fracture. The ability of ESWT to enhance microcirculation parameters in soft tissue was of interest to determine if it improves microcirculation in the scaphoid.

QUESTIONS/PURPOSES

(1) Does capillary blood flow increase after a single session of ESWT in the scaphoid? (2) Do oxygen saturation in the bone and postcapillary venous filling pressure increase after a single session of ESWT in the scaphoid?

METHODS

ESWT (0.3 mJ/mm, 8Hz, 1000 impulses) was applied to the intact scaphoid of 20 volunteers who were without wrist pain and without any important metabolic disorders. Mean age was 43 ± 14 years, 12 men and eight women (40% of total). Volunteers were recruited from January 2017 to May 2017. No anesthetic was given before application of ESWT. An innovative probe designed for measurements in bone by compressing soft tissue and combining laser-Doppler flowmetry and spectrophotometry was used to noninvasively measure parameters of microcirculation in the scaphoid. Blood flow, oxygenation, and venous filling pressure were assessed before and at 1, 2, 3, 5, 10, 15, 20, 25, and 30 minutes after ESWT application. Room temperature, humidity, ambient light and measuring sequences were kept consistent. A paired t-test was performed to compare experimental data with baseline (p < 0.05 taken as significant).

RESULTS

At baseline, capillary blood flow of the bone was 108 ± 46 arbitrary units (AUs) (86 to 130). After treatment with ESWT, it was 129 ± 44 AUs (106 to 150; p = 0.011, percentage change of 19 %) at 1 minute, 138 ± 46 AUs (116 to 160; p = 0.002, percentage change of 28%) at 2 minutes, 146 ± 54 AUs (121 to 171; p = 0.002, percentage change of 35%) at 3 minutes and 150 ± 52 AUs (126 to 174; p < 0.001, percentage change of 39%) at 5 minutes. It remained elevated until the end of the measuring period at 30 minutes after treatment at 141 ± 42 AUs (121 to 161; p = 0.002) versus baseline). Oxygen saturation and postcapillary venous filling pressure in bone showed no change, with the numbers available.

CONCLUSIONS

A single session of ESWT increased capillary blood flow in the scaphoid during measuring time of 30 minutes. Bone oxygenation and postcapillary venous filling pressure, however, did not change. Because increased oxygenation is needed for improved bone healing, it remains unclear if a sole increase in capillary blood flow can have clinical benefits. As the measuring period was limited to only 30 minutes, bone oxygenation and postcapillary filling pressure may subsequently show change only after the measuring-period ended.

CLINICAL RELEVANCE

Further studies need to evaluate if increased capillary blood flow can be sustained for longer periods and if bone oxygenation and postcapillary venous filling pressure remain unchanged even after prolonged or repetitive ESWT applications. Moreover, clinical studies must validate if increased microcirculation has a positive impact on bone healing and to determine if ESWT can be therapeutically useful on scaphoid fractures and nonunions.

Shockwave Therapy Associated With Eccentric Strengthening for Achilles Insertional Tendinopathy: A Prospective Study

Background. The usual initial treatment for insertional Achilles tendinopathy is nonsurgical. Yet there is no standard conservative treatment for Achilles insertional tendinopathy. Shockwave therapy (SWT) has become a reliable option for the management of this illness over the past years. The aim of this study is to report the effectiveness of low-energy SWT associated with an eccentric strengthening protocol in 19 consecutive patients. Methods. This is a prospective study with 19 patients aged between 26 and 72 years diagnosed with insertional Achilles tendinopathy. The protocol consisted of SWT associated with eccentric exercises for 12 weeks. All patients were evaluated on the first day and after 24 weeks (final follow-up) with the Victorian Institute of Sports Assessment-Achilles (VISA-A) score, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire, and by algometry. At the last follow-up, patients were also assessed for adherence to the protocol, complications and final outcome (in their perception as success or fail). Results and Conclusion. Fifteen (79%) patients were fully adherent to the Alfredson protocol, and 13 (68%) patients considered the treatment protocol successful. At the last evaluation, patients demanded higher pressure on calcaneus to trigger pain (algometry 1), reported less pain when the algometer was applied with 3 kg (algometry 2), had less global pain (VAS), and had higher AOFAS and VISA-A scores. This study evidences that eccentric loading associated with SWT can dramatically improve patients' symptoms. We can conclude that eccentric loading associated with SWT is an effective treatment for Achilles insertional tendinopathy. Levels of Evidence: Therapeutic, Level III: Prospective cohort.

Comparative Effectiveness of Different Nonsurgical Treatments for Patellar Tendinopathy: A Systematic Review and Network Meta-analysis

PURPOSE

To investigate the functional improvement and pain reduction of different nonsurgical treatments for patellar tendinopathy (PT), a systematic review with network meta-analysis was performed.

METHODS

Studies were comprehensively searched for without language restrictions in the CENTRAL, MEDLINE, EMBASE, Web of Science, Physiotherapy Evidence Database, and SPORTDiscus databases from inception to May 2018. Randomized controlled trials about nonsurgical treatments for PT were included. The outcome measurements were the Victorian Institute of Sports Assessment (VISA) scale and pain scores (such as the visual analog scale or Numerical Rating Scale). Study quality was evaluated using the Physiotherapy Evidence Database score. Direct comparisons were performed using pairwise meta-analysis, whereas network meta-analysis was performed using a frequentist method in a multivariate random-effects model.

RESULTS

Eleven studies with 430 affected patellar tendons were included in the systematic review. The summary mean difference of improvement in the VISA scale versus the control group for corticosteroid injection was -23.00 (95% confidence interval [CI] -36.73 to -9.27), for leukocyte-rich platelet-rich plasma (LR-PRP) was 13.22 (95% CI 2.37-24.07), for focused extracorporeal shockwave therapy (ESWT) was -1.28 (95% CI -6.25 to 3.68), for radial ESWT was -6.68 (95% CI -20.20 to 6.84), for ultrasound was -0.70 (95% CI -11.23 to 9.83), for autologous blood injection was -0.60 (95% CI -9.30 to 8.10), for dry needling was 17.51 (95% CI -2.57 to 37.60), for topical glyceryl trinitrate was -0.90 (95% CI -13.07 to 11.27), and for skin-derived tendon-like cells was 10.40 (95% CI -1.59 to 22.39). LR-PRP (Surface Under the Cumulative Ranking curve [SUCRA] = 87.5%) or dry needling (SUCRA = 90.5%) was most likely to be ranked the best in terms of improvement on the VISA scale. Compared with the control group, the summary mean difference of the change in pain score for corticosteroid injection was 0.80 (95% CI -3.48 to 5.08), for LR-PRP was -1.87 (95% CI -3.28 to -0.46), for focused ESWT was 0.13 (95% CI -0.68 to 0.93), for radial ESWT was 0.03 (95% CI -1.92 to 1.98), for ultrasound was -0.20 (95% CI -1.49 to 1.09), for autologous blood injection was 0.60 (95% CI -0.73 to 1.93), for dry needling was -0.37 (95% CI -2.71 to 1.97), and for topical glyceryl trinitrate was -0.50 (95% CI -2.55 to 1.55). The treatment most likely to be ranked the best in terms of change in pain score was LR-PRP (SUCRA = 94.9%).

CONCLUSIONS

The network meta-analysis demonstrated that LR-PRP has the greatest functional improvement and pain reduction for PT compared with other treatment options. However, the treatment effect estimates can be biased by the possible intransitivity and should not be overestimated.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I studies.

[Extracorporal shock wave therapy for the treatment of pseudarthrosis : New experiences with an old technology]

BACKGROUND

Between 5 and 10 % of all fractures show disturbed healing or nonunion formation. Extracorporeal shock wave therapy (ESWT) has been described as a non-surgical treatment option. Even though the outcome has shown promising results, the procedure is not commonly used in clinical practice. The purpose of this study was to analyze the union rate of pseudarthrosis and the cost savings after ESWT.

METHODS

In this study 42 nonunions were treated with shock waves (LithSpaceOrtho, JenaMedtech). The follow up examinations were performed over a period of six months. Outcome measurement included radiological fracture union and pain (VAS). The study group contained 39 pseudarthrosis in the six-week follow-up (93 %), 41 after three months (98 %) and 41 after six months (98 %).

RESULTS

After six weeks, 13 % of patients showed fracture union. After three months 61 % and after six months 73 % of the fractures were completely healed. The fracture healing was significantly lower in older nonunions. All patients presented significantly lower pain levels six weeks after ESWT. Shock wave treatment of all 42 pseudarthrosis made up less than one quarter of the overall operative costs.

CONCLUSION

We established the ESWT as an important treatment option for fracture nonunion in our clinic. Considering the selection of patients in this study with a high mean time from injury to ESWT and multiple prior operations, the fracture healing rate of 73 % after ESWT is comparable with operative healing rates of nonunions. Further prospective, randomized and controlled studies are needed to show the effectiveness of ESWT in the treatment of nonunions on a higher level of evidence and to identify pseudarthrosis that particularly responds to the EWST.

Ultrasound-Guided Minimally Invasive Surgical Resection of Retrocalcaneal Bursitis: A Preliminary Comparison With Traditional Open Surgery

Posterior heel pain is a common complaint that is often caused by overuse injuries. In such cases, the retrocalcaneal bursa is compressed and chafed repeatedly, leading to local inflammation. Sonography is a popular imaging tool used to study the pathology of soft tissues, and it can be used to assist in diagnosing bursitis because of its accuracy. Herein, we report an innovative method to treat retrocalcaneal bursitis under ultrasound guidance. Ten patients with posterior heel pain for >6 months who failed conservative treatment received this ultrasound-guided minimally invasive surgery. An endoscopic puncher and burr were inserted under ultrasound guidance via a stabbing wound, and the swollen retrocalcaneal bursa and bony prominence were resected. The patients were able to ambulate and undergo a rehabilitation program 2 weeks postoperatively. In the patients who underwent this ultrasound-guided minimally invasive surgery, both the average surgical time and average hospital stay were shorter than in those (n = 12) who underwent open surgery. In outcome rating assessment, the American Orthopaedic Foot & Ankle Society (AOFAS) pain score and total AOFAS ankle-hindfoot score were improved in the ultrasound-guided minimally invasive surgery group compared to the open surgery group at 2 months postoperatively. Other advantages included lesser wound pain, shorter hospital stay, faster recovery time, and minimal blood loss. Accordingly, ultrasound-guided surgery appears to be a good option for the treatment of retrocalcaneal bursitis.

Power Doppler Ultrasound Findings before and after Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Pilot Study on Pain Reduction and Neovascularization Effect

Extracorporeal shock wave therapy (ESWT) has been found to have a positive effect in the treatment of pain in Achilles tendinopathy, although the exact mechanism is not yet completely understood. Among the mechanisms suggested to underlie ESWT effects are direct stimulation of healing, neovascularization and direct suppressive effects on nociceptors and hyperstimulation, which would block the gate-control system. The neovascularization observed in flogistic tissue is associated with stimulated nerve fibers around tendons and induces a painful condition. The objectives of the present study were to evaluate the effect of ESWT on pain and function in patients with non-insertional Achilles tendinopathy (NIAT) and to assess the neovascularization phenomenon using power Doppler ultrasound (PDU). Twelve patients with NIAT underwent five sessions of focused ESWT over 5 wk. Outcome measures were the visual analogue scale, the Victorian Institute of Sport Assessment-Achilles questionnaire and active dorsiflexion and plantar flexion ankle articular range of motion. Moreover, the patients' clinical impressions of treatment results after ESWT were investigated using the Roles and Maudsley score. Patients were assessed at baseline and 1 and 3 mo after treatment. They had a significant reduction in pain with improvement of arthrokinematic motion and functionality and a positive clinical impression of treatment outcome (50% of patients considered their clinical picture as good/excellent after 3 mo). However, the pulse Doppler ultrasound exam did not reveal neovascularization in 91.7% of the patients 1 and 2 mo after focused ESWT, and in some patients there was a reduction in blood vessels related to flogistic processes. The present observational study confirmed the efficacy of ESWT in pain reduction in NIAT, with a higher degree of patient satisfaction, although doubt persists over the neovascularization effect on the Achilles tendons treated.

Sesamoidectomy for Hallux Sesamoid Disorders: A Systematic Review

Studies have shown that sesamoidectomy provides good clinical outcomes; however, concern exists regarding complications occurring after resection of 1 or both sesamoid bones. The purpose of the present systematic review was to evaluate the current evidence on sesamoidectomy for the treatment of hallux sesamoid disorders. A systematic search of the MEDLINE, Embase, and Cochrane Library databases was performed during October 2017. The included studies were evaluated for the level of evidence and quality of evidence using the Coleman Methodology Score. Variable reporting outcomes data, clinical outcomes, and percentage of patients returning to sports at their previous level were evaluated. Ten studies, totaling 196 feet, were included. The weighted mean patient age was 36.6 ± 11.0 years, and the weighted mean follow-up duration was 45.1 ± 19.3 months. The mean visual analog scale score improved from 6.5 ± 0.3 to 1.2 ± 0.5. The mean postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score was 92.7 ± 2.7. Six studies demonstrated that 94.4% of patients returned to sports, with 90.0% returning to their previous level, at a mean of 11.8 ± 1.8 weeks. The mean hallux valgus angle increased from 13.1° ± 2.1° preoperatively to 14.8° ± 3.7° postoperatively (p = .470), and the mean intermetatarsal angle increased from 8.7° ± 0.8° to 9.7° ± 0.8° (p = .180). Overall complication rate was 22.5% and the revision rate was 3.0%. The present systematic review has demonstrated that sesamoidectomy for hallux sesamoids disorders yields good clinical outcomes and a high rate of return to sports in the short term, albeit with a high complication rate of 22.5%.

Effect of extracorporeal shock wave therapy on improving burn scar in patients with burnt extremities in Isfahan, Iran

Background:

Pathologic scarring is a common problem after burn injury that has functional and esthetic limitations. Conservative and surgical treatments available for these scars are not always satisfactory. Extracorporeal shock wave therapy (ESWT) is a noninvasive modality that has proven positive effects on burn scars and wound healing in few studies. This study was conducted to evaluate the effects of ESWT on improving burn scar in extremities.

Materials and Methods:

This study was a prospective quasi-experimental on burn patients with burn scar in their extremities that underwent ESWT sessions once a week for 6 weeks. For evaluating pain and itching, visual analog scale (VAS) and for scar appearance, Vancouver Scar Scale (VSS) were used. These scales were measured and compared at the beginning of the treatment, at the end of the treatment, and 1 and 3 months after the end of the intervention.

Results:

In this study, 17 patients were treated with ESWT with a mean age of 37.94 ± 7.25 years that 47.1% of them were male. The mean of VAS score for pain and itching and VSS score were decreased significantly after the treatment and during follow-ups (All P < 0.001).

Conclusion:

ESWT can improve the pain, itching, and appearance of the burn scar in human extremities in burn patients.

Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions: A Narrative Review

Extracorporeal shockwave therapy (ESWT) is a technology that was first introduced into clinical practice in 1982 for urologic conditions. Subsequent clinical applications in musculoskeletal conditions have been described in treatment of plantar fasciopathy, both upper and lower extremity tendinopathies, greater trochanteric pain syndrome, medial tibial stress syndrome, management of nonunion fractures, and joint disease including avascular necrosis. The aim of this review is to summarize the current understanding of treatment of musculoskeletal conditions with ESWT, accounting for differences in treatment protocol and energy levels. Complications from ESWT are rare but include 2 reported cases of injury to bone and Achilles tendon rupture in older adults using focused shockwave. Collectively, studies suggest ESWT is generally well-tolerated treatment strategy for multiple musculoskeletal conditions commonly seen in clinical practice. LEVEL OF EVIDENCE: III.

Shock wave-induced permeabilization of mammalian cells

Controlled permeabilization of mammalian cell membranes is fundamental to develop gene and cell therapies based on macromolecular cargo delivery, a process that emerged against an increasing number of health afflictions, including genetic disorders, cancer and infections. Viral vectors have been successfully used for macromolecular delivery; however, they may have unpredictable side effects and have been limited to life-threatening cases. Thus, several chemical and physical methods have been explored to introduce drugs, vaccines, and nucleic acids into cells. One of the most appealing physical methods to deliver genes into cells is shock wave-induced poration. High-speed microjets of fluid, emitted due to the collapse of microbubbles after shock wave passage, represent the most significant mechanism that contributes to cell membrane poration by this technique. Herein, progress in shock wave-induced permeabilization of mammalian cells is presented. After covering the main concepts related to molecular strategies whose applications depend on safer drug delivery methods, the physics behind shock wave phenomena is described. Insights into the use of shock waves for cell membrane permeation are discussed, along with an overview of the two major biomedical applications thereof-i.e., genetic modification and anti-cancer shock wave-assisted chemotherapy. The aim of this review is to summarize 30 years of data showing underwater shock waves as a safe, noninvasive method for macromolecular delivery into mammalian cells, encouraging the development of further research, which is still required before the introduction of this promising tool into clinical practice.

Tendinopathy: injury, repair, and current exploration

Both acute and chronic tendinopathy result in high morbidity, requiring management that is often lengthy and expensive. However, limited and conflicting scientific evidence surrounding current management options has presented a challenge when trying to identify the best treatment for tendinopathy. As a result of shortcomings of current treatments, response to available therapies is often poor, resulting in frustration in both patients and physicians. Due to a lack of understanding of basic tendon-cell biology, further scientific investigation is needed in the field for the development of biological solutions. Optimization of new delivery systems and therapies that spatially and temporally mimic normal tendon physiology hold promise for clinical application. This review focuses on the clinical importance of tendinopathy, the structure of healthy tendons, tendon injury, and healing, and a discussion of current approaches for treatment that highlight the need for the development of new nonsurgical interventions.

Low Intensity Shock Wave Treatment for Erectile Dysfunction-How Long Does the Effect Last?

PURPOSE

We studied the long-term efficacy of penile low intensity shock wave treatment 2 years after an initially successful outcome.

MATERIALS AND METHODS

Men with a successful outcome of low intensity shock wave treatment according to the minimal clinically important difference on the IIEF-EF (International Index of Erectile Function-Erectile Function) questionnaire were followed at 6, 12, 18 and 24 months. Efficacy was assessed by the IIEF-EF. Failure during followup was defined as a decrease in the IIEF-EF below the minimal clinically important difference.

RESULTS

We screened a total of 156 patients who underwent the same treatment protocol but participated in different clinical studies. At 1 month treatment was successful in 99 patients (63.5%). During followup a gradual decrease in efficacy was observed. The beneficial effect was maintained after 2 years in only 53 of the 99 patients (53.5%) in whom success was initially achieved. Patients with severe erectile dysfunction were prone to earlier failure than those with nonsevere erectile dysfunction. During the 2-year followup the effect of low intensity shock wave treatment was lost in all patients with diabetes who had severe erectile dysfunction at baseline. On the other hand, patients with milder forms of erectile dysfunction without diabetes had a 76% chance that the beneficial effect of low intensity shock wave treatment would be preserved after 2 years.

CONCLUSIONS

Low intensity shock wave treatment is effective in the short term but treatment efficacy was maintained after 2 years in only half of the patients. In patients with milder forms of erectile dysfunction the beneficial effect is more likely to be preserved.