Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy

Effectiveness of extracorporeal shockwave therapy in treatment of upper and lower limb tendinopathies: A systematic review and meta-analysis

BACKGROUND

Tendinopathy is caused by repetitive motion, excessive stress on the tendon, overstretch, and motion past the critical angle of rotation or translation. There are various treatment options available for tendinitis, including those affecting both the upper and lower limbs and those of calcific and non-calcific types.

HYPOTHESIS/PURPOSE

Few reviews have analyzed the efficacy of Extracorporeal Shockwave Therapy (ESWT) in treating upper and lower limb tendinopathies while considering calcific and non-calcific-type tendinitis. This paper provides a review and meta-analysis on Randomized Controlled Trials (RCTs), which compared results from a group undergoing ESWT treatment to another group under different treatments.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search was conducted on PubMed, Web of Science, Embase, the Cochrane Central Register of Control Trials (CENTRAL), and Physiotherapy Evidence Database (PEDro) databases for articles published up to January 2022. The reference lists of identified articles were further scanned. Twenty-two studies were included in the meta-analysis.

RESULTS

Meta-analysis showed no difference in pain reduction in ESWT when compared with a comparison group at 4 (p = 0.26) and 12 weeks (p = 0.33). There were no differences in DASH scores at 12 months between the two groups (p = 0.32).

CONCLUSION

Extracorporeal Shockwave Therapy (ESWT) is effective when used to treat lower limb and calcific tendinitis. It does not yield any better results than other treatment options in managing upper limb tendinopathies and non-calcific tendinopathies.

The Efficacy of Extracorporeal Shock Wave Therapy as a Monotherapy for Achilles Tendinopathy: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review and meta-analysis was to determine the therapeutic efficacy of extracorporeal shock wave therapy (ESWT) for Achilles tendinopathy.

Methods

We searched PubMed, EBSCOHost, Ovid, and Embase for randomized controlled trials. Databases were searched from their inception until the last entry (July 16, 2022). The methodological quality of the randomized controlled trials was rated with the Physiotherapy Evidence Database scale. For continuous data, we presented the mean difference (D) and 95% confidence interval (CI). Heterogeneity was assessed with I2 statistics. The random effects model was applied for the pooled effect estimates. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation tool.

Results

The very-low-quality evidence suggested that ESWT was no more effective in decreasing pain than any other conservative treatment (D: -0.8; 95% CI: -3.15, 1.56; P > .5; I² = 85.62%). No significant differences were found between the ESWT and control groups on the pooled Victorian Institute of Sport Assessment-Achilles scores (D: 5.74; 95% CI: -15.02, 26.51; P = .58; I2  = 92.28%), but the quality of evidence was very low.

Conclusion

At present, the quality of the evidence is low; thus, the therapeutic efficacy of ESWT for Achilles tendinopathy is inconclusive.

[Achilles tendon pathologies]

Achilles tendon pathologies are a frequent problem in the clinical practice. A distinction must be made between insertional and noninsertional tendinopathies. In addition to intrinsic risk factors, such as diabetes mellitus, there are also extrinsic risk factors, such as overuse and running. Sonography, X‑ray imaging and magnetic resonance imaging (MRI) are established imaging methods, depending on the question. The primary treatment includes a conservative approach. First-line treatment includes administration of nonsteroidal anti-inflammatory drugs (NSAID), physical rest and the use of assistive devices. Established conservative treatment procedures include eccentric stretching, shockwave therapy and infiltration with, e.g., platelet-rich plasma. There are numerous other conservative treatment options. After exhausting the conservative treatment options, a surgical approach can be considered. The surgical procedure depends on the clinical symptoms and findings. Established procedures are minimally invasive or endoscopic procedures or even open debridement.

The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis

Background

Tendinopathy is a growing global concern affecting many people, like athletes, workers, and the elderly. Despite its commonality among the sporting population, there is no practical clinical guideline for patellar tendinopathy (PT). Furthermore, there is conflicting evidence between clinical guidelines on shockwave therapy's application and clinical utility for Achilles tendinopathy (AT) and plantar fasciitis (PF). Thus, our aim of this study is to evaluate the evidence for shockwave therapy; to provide a Grading of Recommendation, Assessment, Development and Evaluation (GRADE) level of the evidence and effectiveness of shockwave therapy for patellar tendinopathy, Achilles tendinopathy, and Plantar fasciitis.

Method

Medical Literature Analysis and Retrieval System Online (Medline), Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro) and China National Knowledge Infrastructure database (CNKI) were searched to find relevant studies published before December 14th, 2022.

Results

Our study showed that for PT in the short term, extracorporeal shockwave therapy (ESWT) or ESWT + eccentric exercise (EE) has a negligible effect on pain and function compared to a placebo or placebo + EE. On the contrary, ESWT significantly affects pain compared to conservative treatment (CT). For AT, ESWT has a small inconclusive effect on pain and function in the short term compared to EE. On the other hand, a placebo outperformed ESWT in improving function for AT but not pain outcomes. PF showed that ESWT significantly affects short- and long-term pain and function. When ESWT was compared to other interventions such as low laser therapy (LLLT), corticosteroid injection (CSI), or CT, there was a small inconclusive effect on pain and function in the short term.

Conclusion

There is low-moderate evidence that ESWT has a negligible effect on pain and function for PT and AT. However, high-quality evidence suggests ESWT has a large effect on pain and function for PF.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023396835, identifier CRD42023396835.

Feasibility Using Telehealth for Planning Use of Extracorporeal Shockwave Therapy in a Sports Medicine Clinic

(1) Background: The purpose of this study is to describe whether telehealth compared with in-person visits, led to a similar agreement of primary diagnosis reached at the time of procedure using extracorporeal shockwave therapy. (2) Methods: This retrospective study consisted of chart reviews of all new patients evaluated in a sports medicine clinic prior to performing extracorporeal shockwave therapy from April 2020 to March 2021. The primary outcome of the study was describing agreement in primary diagnosis at the time of evaluation (telehealth and in-person) and during the procedure using extracorporeal shockwave therapy. Logistic regression was utilized to identify patient characteristics that may predict agreement of diagnosis using telehealth. (3) Results: The chart review identified 166 patients (45 telehealth and 121 in-person) evaluated for extracorporeal shockwave therapy. Agreement of diagnosis was similar for patients evaluated using telehealth compared to in-person visits (84% vs. 92%, Χ² = 1.90, p = 0.168). Agreement on diagnosis was more likely in patients who started shockwave within the 1 week of initial visit (OR = 8.27, 95% CI = 1.69-45.29), patients over age 60 (OR = 0.94, 95% CI = 0.90-0.99), and in patients without a history of osteoarthritis (OR = 14.00, 95% CI = 1.88-113.46). (4) Conclusions: Telehealth resulted in a similar agreement to in-person visits to identify a primary diagnosis for planning extracorporeal shockwave therapy. Telehealth may be a reasonable alternative to in-person visits for procedural planning of extracorporeal shockwave therapy.

Analysis of pain intensity and postural control for assessing the efficacy of shock wave therapy and sonotherapy in Achilles tendinopathy - A randomized controlled trial

BACKGROUND

The troublesome symptoms of Achilles tendinopathy prompt patients to seek effective forms of conservative treatment. The main aim of the study was to determine the therapeutic efficacy of shock wave and ultrasound therapies for Achilles tendinopathy in reducing pain intensity. Treatment efficacy was also assessed using objective posturographic measurements.

METHODS

Thirty-nine patients patients were randomly allocated to one of three experimental groups that received shock wave therapy (group A), ultrasound therapy (group B) and placebo ultrasound (group C). Posturographic measurements and subjective assessment of pain intensity were taken prior to therapy and at weeks 1 and 6 of therapy completion.

FINDINGS

A comparison of percentage change in activity-related pain from baseline to 6 weeks post-therapy revealed a significantly greater pain reduction in group A compared to group B. The three-way ANOVA demonstated an effect of treatment type on all posturographic variables. The Bonferroni post-hoc test showed the means of all variables were significantly smaller for group A than group B. Limb condition also had an effect on the center-of-pressure trajectories in anteroposterior plane; the post-hoc test showed the mean values of the variables were significantly greater for the non-affected compared to affected limb.

INTERPRETATION

Shock wave therapy was significantly more effective than sonotherapy for alleviation of activity-related pain of Achilles tendinopathy. An association was also shown between shock wave therapy and more efficient postural control in patients with Achilles tendinopathy. The parameters of center-of-pressure trajectories in the sagittal plane were significantly greater for the non-affected compared to affected limb. The trial was prospectively registered in the Australian and New Zealand Clinical Trials Registry (no. ACTRN12617000860369; registration date: 9.06.2017).

Does additional extracorporeal shock wave therapy improve the effect of isolated percutaneous radiofrequency coblation in patients with insertional Achilles tendinopathy? Study protocol for a randomized controlled clinical trial

BACKGROUND

No conclusive evidence recommends a prior treatment for insertional Achilles tendinopathy (IAT). It is theorized that both percutaneous radiofrequency coblation and extracorporeal shockwave therapy (ESWT) relieve pain within the insertion. However, no clinical evidence shows that either treatment promotes the regeneration of the tendon or if the combination of these 2 interventions offers better function and less pain than one therapy.

METHODS

The study is a randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients with insertional Achilles tendinopathy who are not satisfied with the effect of conservative treatment will be screened. A minimum of 38 patients will be enrolled after deciding to participate in the trial on an informed basis. Then the intervention group and the control group perform radial ESWT and sham-ESWT respectively at 6 months after percutaneous radiofrequency coblation. The primary outcome will be the Victorian Institute of Sports Assessment Achilles (VISA-A) Score. Secondary outcome measures will be Foot and Ankle Outcome Score (FAOS) scale, visual analog scale (VAS), Tegner Score, and MRI ultra-short echo time (UTE) T2* value. The assessments will occur in 6 months, 1 year, and 2 years, post-operatively. The differences between the 2 groups will be conducted as intention-to-treat basis.

DISCUSSION

We aim to investigate if radiofrequency coblation associated with ESWT can provide more encouraging imaging findings as well as functional and clinical outcomes regarding the treatment of the IAT comparing to the single radiofrequency coblation treatment.

TRIAL REGISTRATION

ChiCTR1800017898; pre-results. Registered on 20 August 2018.

The Effectiveness of Extracorporeal Shockwave Therapy for Midportion Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy is one of the most common lower limb injuries in both athletes and the general population. Despite the plethora of conservative treatment options available for the management of Achilles tendinopathy, as many as one in four patients will go on to require surgery. Extracorporeal shockwave therapy (ESWT) has emerged as a promising treatment option and has been successful in the management of other common musculoskeletal injuries such as plantar fasciitis. However, the evidence for ESWT in the management of Achilles tendinopathy remains inconclusive. Therefore, the aim of this systematic review was to evaluate the current evidence for the use of ESWT in the management of midportion Achilles tendinopathy.

A comprehensive literature search was conducted using the databases MEDLINE (Pubmed), AMED, EMBASE, CINAHL, and CENTRAL. The databases were searched from their inception to December 2021. This was conducted to identify randomised control trials (RCTs) evaluating the effectiveness of ESWT versus control treatment in the management of midportion Achilles tendinopathy.

Following a comprehensive search of the literature, a total of 283 articles were identified. Following the screening of titles and abstracts, 236 articles were excluded. The main reasons for exclusion were the identification of duplicates, non-randomised studies, and the use of ESWT on other pathology. Following the exclusion of 236 articles, 47 articles were retrieved for full-text review. Of these 47 articles, 40 were excluded leaving a total of 7 RCTs eligible for inclusion in this review. There was consistent evidence from 4 RCTs that ESWT is effective in the management of midportion Achilles tendinopathy.

This review suggests that ESWT is a safe and effective modality for treating midportion Achilles tendinopathy as it reduces pain and improves function. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT alone. Further research is required to confirm this and to determine the optimum ESWT treatment protocol.

Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is used commonly to treat pain and function in Achilles tendinopathy (AT). The aim of this study was to synthesize the evidence from (non-) randomized controlled trials, to determine the clinical effectiveness of ESWT for mid-portion Achilles tendinopathy (mid-AT) and insertional Achilles tendinopathy (ins-AT) separately.

METHODS

We searched PubMed/Medline, Embase (Ovid), and Cochrane Central, up to January 2021. Unpublished studies and gray literature were searched in trial registers (ACTRN, ChiCTR, ChiCtr, CTRI, DRKS, EUCTR, IRCT, ISRCTN, JPRN UMIN, ClinicalTrials.gov, NTR, TCTR) and databases (OpenGrey.eu, NARCIS.nl, DART-Europe.org, OATD.org). Randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs) were eligible when investigating the clinical effectiveness of ESWT for chronic mid-AT or chronic ins-AT. We excluded studies that focused on treating individuals with systemic conditions, and studies investigating mixed cohorts of mid-AT and ins-AT, when it was not possible to perform a subgroup analysis for both clinical entities separately. Two reviewers independently performed the study selection, quality assessment, data extraction, and grading of the evidence levels. Discrepancies were resolved through discussion or by consulting a third reviewer when necessary.

RESULTS

We included three RCTs on mid-AT and four RCTs on ins-AT. For mid-AT, moderate quality of evidence was found for the overall effectiveness of ESWT compared to standard care, with a pooled mean difference (MD) on the VISA-A of 9.08 points (95% CI 6.35-11.81). Subgroup analysis on the effects of ESWT additional to standard care for mid-AT resulted in a pooled MD on the VISA-A of 10.28 points (95% CI 7.43-13.12). For ins-AT, we found very low quality of evidence, indicating that, overall, ESWT has no additional value over standard care, with a standardized mean difference (SMD) of - 0.02 (95% CI - 0.27 to 0.23). Subgroup analysis to determine the effect of ESWT additional to standard care for ins-AT showed a negative effect (SMD - 0.29; 95% CI - 0.56 to - 0.01) compared to standard care alone.

CONCLUSIONS

There is moderate evidence supporting the effectiveness of ESWT additional to a tendon loading program in mid-AT. Evidence supporting the effectiveness of ESWT for ins-AT is lacking.

TRIAL REGISTRATION

PROSPERO Database; No. CRD42021236107.

Is Tecar Therapy Effective on Biceps Femoris and Quadriceps Rehabilitation? A Cadaveric Study

BACKGROUND

Capacitive-resistive electric transfer therapy is an interesting rehabilitation treatment to use in musculoskeletal injuries. The purpose is to analyze the temperature change and current flow in superficial and deep biceps femoris and quadriceps tissues when applying different protocols of capacitive-resistive electric transfer therapy.

METHODS

Five cryopreserved cadavers (10 legs) were included in this study. Four interventions (high/low power) were performed for 5 minutes. Dynamic movements were performed to the biceps femoris and quadriceps. Superficial, middle, and deep temperature were recorded at 1-minute intervals and 5 minutes after the treatment using invasive temperature meters placed with ultrasound guidance.

RESULTS

Low-power applications have generated a very low thermal effect and an important current flow. The high-power capacitive application achieves a greater increase in superficial temperature compared with low power (P < .001). The high-power resistive application recorded a greater increase in superficial, middle, and deep temperatures with a greater current flow compared with the other applications (P < .001).

CONCLUSION

This study could serve as basic science data to justify the acceleration of the processes of muscle recovery, improving cell proliferation without increasing the temperature in acute muscle injuries and increasing the temperature and viscoelasticity of the tissues in chronic processes with this therapy.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

The clinical diagnosis of Achilles tendinopathy: a scoping review

Background

Achilles tendinopathy describes the clinical presentation of pain localised to the Achilles tendon and associated loss of function with tendon loading activities. However, clinicians display differing approaches to the diagnosis of Achilles tendinopathy due to inconsistency in the clinical terminology, an evolving understanding of the pathophysiology, and the lack of consensus on clinical tests which could be considered the gold standard for diagnosing Achilles tendinopathy. The primary aim of this scoping review is to provide a method for clinically diagnosing Achilles tendinopathy that aligns with the nine core health domains.

Methodology

A scoping review was conducted to synthesise available evidence on the clinical diagnosis and clinical outcome measures of Achilles tendinopathy. Extracted data included author, year of publication, participant characteristics, methods for diagnosing Achilles tendinopathy and outcome measures.

Results

A total of 159 articles were included in this scoping review. The most commonly used subjective measure was self-reported location of pain, while additional measures included pain with tendon loading activity, duration of symptoms and tendon stiffness. The most commonly identified objective clinical test for Achilles tendinopathy was tendon palpation (including pain on palpation, localised tendon thickening or localised swelling). Further objective tests used to assess Achilles tendinopathy included tendon pain during loading activities (single-leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. The VISA-A questionnaire as the most commonly used outcome measure to monitor Achilles tendinopathy. However, psychological factors (PES, TKS and PCS) and overall quality of life (SF-12, SF-36 and EQ-5D-5L) were less frequently measured.

Conclusions

There is significant variation in the methodology and outcome measures used to diagnose Achilles tendinopathy. A method for diagnosing Achilles tendinopathy is proposed, that includes both results from the scoping review and recent recommendations for reporting results in tendinopathy.

Line- and Point-Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Placebo-Controlled RCT Study

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is a widely considered treatment option for Achilles tendinopathy. Line-focused ESWT is a novel technique treating a larger tendon area than point-focused ESWT. Monitoring capacities of clinical symptoms with ultrasound under ESWT treatment are unknown.

HYPOTHESIS

Point- and line-focused ESWT have a superior outcome than placebo ESWT. ESWT leads to morphological tendon changes detectable with ultrasound.

STUDY DESIGN

Single-blinded placebo-controlled randomized contolled trial.

LEVEL OF EVIDENCE

Level 1.

METHODS

The study was conducted in 3 cohorts, namely ESWT point (n = 21), ESWT line (n = 24), and ESWT placebo (n = 21). Victorian Institute of Sports Assessment-Achilles (VISA-A) score was measured before the intervention (T0), after 6 weeks (T1), and after 24 weeks (T2). All cohorts performed daily physiotherapy for 24 weeks and received 4 sessions of point-focused, line-focused, or placebo ESWT in the first 6 weeks. Ultrasound was performed with B-mode, power Doppler, shear wave elastography (SWE) at T0 and T2 and with ultrasound tissue characterization (UTC) at T0, T1, and T2. Data were analyzed with a mixed analysis of variance and t test.

RESULTS

There was a significant VISA-A improvement over time for all groups (P < 0.001). ESWT point had the strongest VISA-A score improvement +23 (ESWT line: +18; ESWT placebo: +15), but there was no significant interaction between time and any of the groups: F(4, 116) = 1.393; P = 0.24. UTC, power Doppler, and B-mode could not show significant alterations over time. SWE revealed a significant increase of elastic properties for ESWT point in the insertion (t = -3.113, P = 0.03) and midportion (t = -2.627, P = 0.02) over time.

CONCLUSION

There is a significant VISA-A score improvement for all study groups without a statistically significant benefit for ESWT point or ESWT line compared with ESWT placebo. Tendon adaptation could only be detected with SWE for ESWT point.

CLINICAL RELEVANCE

The present study could not detect any statistically relevant effect of ESWT compared to placebo. SWE is able to demonstrate tendon adaptation.

Clinical and Radiological Outcomes of Operative Therapy in Insertional Achilles Tendinopathy With Debridement and Double-Row Refixation

BACKGROUND

Insertional Achilles tendinopathy (IAT) is a painful pathology in which the strongest and thickest tendon of the human body is affected. Different conservative and operative treatments have been described to address this pathology. This study aimed to evaluate the medium-term clinical and radiological outcomes of patients who underwent a surgical therapy via a longitudinal tendon-splitting approach with debridement and double-row refixation.

METHODS

All patients were assessed pre- and postoperatively using a visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score, the Foot and Ankle Outcome Score (FAOS), and the Foot Function Index (FFI). Additionally, a lateral radiograph of the foot was performed to assess the postoperative result. Forty-two patients with confirmed IAT who underwent surgery between 2013 and 2017 with a longitudinal tendon-splitting approach and tendon refixation using a double-row refixation system were evaluated. The average follow-up was 32.8 (range, 18-52) months. We included 26 female and 16 male patients with an average age of 56.8 (range, 27-73) years.

RESULTS

The mean VAS improved from 8.91 ± 1.0 preoperatively to 1.47 ± 2.5 postoperatively (P< .01). AOFAS scores improved significantly from 51.0 ± 12.5 preoperatively to 91.3 ± 14.3 postoperatively (P< .01). All total and subscores of the FFI and FAOS saw a significant improvement at follow-up (P< .01). Lateral radiographs showed recurrent calcification in 30 patients (71.4%).

CONCLUSION

We found that, at an average of 33 months posttreatment, insertional Achilles tendinopathy via a longitudinal tendon-splitting approach resulted in good outcomes for patients after failure of initial conservative therapy. Recurrent calcification seems to be very common but shows no association with inferior outcomes or the return of symptoms.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Extracorporeal Shockwave Therapy in the Management of Sports Medicine Injuries

ABSTRACT

Treatment of musculoskeletal conditions in athletes with extracorporeal shockwave therapy (ESWT) is gaining popularity as greater evidence supports its use. ESWT protocols (describing energy flux density, number of impulses, type of shockwave (focused or radial), number/frequency/duration of treatment session, area of application, and postprocedural therapy protocols) can be adjusted in the clinical setting. Protocols vary across studies, and optimal protocols for most indications are yet to be determined. ESWT can safely be used to treat various musculoskeletal conditions in athletes, including rotator cuff tendinopathy, lateral elbow epicondlyopathy, greater trochanteric pain syndrome, hamstring tendinopathy, patellar tendinopathy, Achilles tendinopathy, other tendinopathies, plantar fasciopathy, bone stress injuries, and medial tibial stress syndrome. ESWT can be used to treat in-season athletes, as it often requires no/minimal time away from sport and may result in rapid benefits. ESWT should be used in conjunction with physical therapy to facilitate longer-term gains in function and to optimize healing.

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.

Short- and Intermediate-Term Results of Extracorporeal Shockwave Therapy for Noninsertional Achilles Tendinopathy

BACKGROUND

Earlier randomized controlled trials (RCTs) reported only midterm (3-4 months) results of extracorporeal shockwave therapy (ESWT) as a treatment for noninsertional Achilles tendinopathy (NAT). This study compared the effectiveness of an eccentric loading program followed by stretching exercises combined with ESWT (study group) or sham ESWT (control group) for treating chronic NAT in both the short and long term.

METHODS

This double-blind RCT was conducted between 2018 and 2020. Adult patients with unilateral NAT who failed standard conservative treatment were randomly allocated to either group. Function and pain were assessed at baseline, 1 month, and 16 months using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) and visual analog scale (VAS), respectively. Mixed-design analysis of variance and nonparametric statistics were performed. Twenty-two men and 28 women aged 18 to 40 years were allocated into 2 equally matched groups.

RESULTS

Function and pain scores in the study group were not significantly different from control group scores at baseline (VISA-A: 22.2 ± 6.5 vs 21.0 ± 5.2 and VAS: 8 ± 1 vs 8 ± 1, respectively). Both groups significantly improved posttreatment (VISA-A: 85 ± 6.2 vs 53.4 ± 7.7 and VAS: 1 ± 2 vs 7 ± 2, respectively). At the 16-month follow-up, outcome scores declined slightly but significantly in the study group (VISA-A: 80 ± 5.3; VAS: 3 ± 2) and improved in the control group (VISA-A: 67 ± 5.6; VAS: 5 ± 1). However, both groups were significantly better than baseline. At both time points, the study group had significantly superior scores (statistically and clinically) than the control group (P = .0001).

CONCLUSION

Combining calf eccentric loading with stretching exercises resulted in significant improvements in the pain and functional scores in patients with NAT. Adding ESWT to this combined protocol resulted in significantly greater improvements in both the short and long term.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

[Current evidences in shockwave treatment. SETOC (Spanish Society of Shockwave Treatment) recommendations]

This SETOC consensus document shows the scientific evidence of the technology in shockwaves (SW) and radial pressure waves (RPW) in a variety of spasticity disorders, musculoskeletal, skin, urological diseases, etc. SW and RPW, without anesthesia, are an effective, safe, non-invasive, cost-effective treatment, which reduces the need for surgery, lower risk of complications, faster recovery and greater acceptability to patients than surgery. Consequently, SW and RPW should be the first therapeutic option in the aforementioned chronic pathologies, when conservative alternatives have failed. SETOC advises to follow the recommendations given in this article, including the ones given by SW scientific societies and best evidence for each technology as well.

Extracorporeal shockwave therapy versus musculoskeletal mesotherapy for Achilles tendinopathy in athlete

Background

Achilles tendinopathy (AT) is considered the commonest tendon pathology, occurring mainly in athletes. Different conservative treatment options have been introduced but with short-term effects; however, extracorporeal shockwave therapy (ESWT) and mesotherapy (MT) injections were claimed to provide longer effects and could be used in cases failure of response to conservative treatments.

The objective of our prospective 12-week study was to compare the effect of ESWT and MT on chronic Achilles tendinopathy in athletes by both clinical and ultrasonographical assessment.

Results

Forty patients with chronic AT diagnosed clinically and with high-resolution ultrasound (US) randomly allocated in two groups first received weekly ESWT session, and the other group underwent weekly MT sessions for 4 consecutive weeks. Both groups improved during the treatment and follow-up period. The mean visual analogue score (VAS) decreased in both the ESWT group and the MT group. Mean American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score and VAS scores were not significantly different between ESWT and MT groups at the 4th and the 12th week of follow-up. However, US assessment significantly improved after 12 weeks in the ESWT group (as regards tendon thickness, calcifications, and Doppler signal), and for the mesotherapy group, there was the only improvement of tendon thickness.

Conclusion

ESWT showed improvement of pain and inflammation and calcifications of AT than MT injections, which was documented by US improved findings at week 12 follow up.

Achilles Tendon Lesions - Part 1: Tendinopathies

Calcaneal tendon injuries are extremely common in the general population and in orthopedics routine care. Its increasing incidence, which is motivated by an aging population, improved access to the health care system, increased prescription of continuous-use medication, erratic participation in sports and other factors, has had a direct impact on society. Consolidated treatment options for tendinopathies lack quality scientific support for many modalities. New therapies have emerged to enhance nonsurgical approach outcomes and to reduce the number of patients requiring surgery. Although these operative procedures provide good pain relief and functional outcomes, they are costly and may lead to complications.

Extracorporeal shock wave therapy: an update

Extracorporeal shock wave therapy (ESWT) is a safe therapy and there are only a few side effects known (such as pain during ESWT and minor haematomata), but no severe complications are to be expected if it is performed as recommended.

Contraindications are severe coagulopathy for high-energy ESWT, and ESWT with focus on the foetus or embryo and focus on severe infection.

The effect mechanism of ESWT is still a component of diverse studies, but as far as we can summarize today, it is a similar process to a cascade triggered by mechano-transduction: mechanical energy causes changes in the cellular skeleton, which provokes a reaction of the cell core (for example release of mRNA) to influence diverse cell structures such as mitochondria, endoplasmic reticulum, intracellular vesicles, etc., so the enzymatic response leads to the improvement of the healing process.

The usage of ESWT should be taught, to improve the outcome. Courses should be organized by national societies, since the legal framework conditions are different from one country to another.

In this update the musculoskeletal indications are addressed (mainly bone and tendons): pseudoarthrosis, delayed fracture healing, bone marrow oedema and osteonecrosis in its early stages, insertional tendinopathies such as plantar fasciitis and Achilles tendon fasciitis, calcifying tendonitis of the rotator cuff, tennis elbow, and wound healing problems.

Cite this article: EFORT Open Rev 2020;5:584-592. DOI: 10.1302/2058-5241.5.190067

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.

Intramuscular stimulation vs sham needling for the treatment of chronic midportion Achilles tendinopathy: A randomized controlled clinical trial

Background

The insertion of filiform needles intramuscularly (a.k.a. intramuscular stimulation/dry needling) has been suggested as a possible treatment for various painful musculoskeletal conditions. Our aim was to answer the question, is intramuscular stimulation more effective than sham intramuscular stimulation/dry needling for the treatment of Achilles tendinopathy?

Methods

52 participants with persistent midportion Achilles tendinopathy began and 46 completed one of three treatment protocols which were randomly assigned: (G3) a 12-week rehabilitation program of progressive tendon loading plus intramuscular stimulation (n = 25), (G2) the same rehabilitation program but with sham intramuscular stimulation (n = 19), or (G1) a reference group of rehabilitation program alone (as an additional control) (n = 8). The a priori primary outcome measure was change in VISA-A score at 12 weeks–VISA-A was also measured at 6 weeks, and at 6 and 12 months. Secondary outcome measures include the proportion of patients who rated themselves as much or very much improved (%), dorsiflexion range of motion (degrees), and tendon thickness (mm).

Results

The study retention was 94% at 12 weeks and 88% at 1 year. VISA-A score improved in all three groups over time (p<0.0001), with no significant difference among the three groups in VISA-A score at the start of the study (mean ± SD: G3 59 ± 13, G2 57 ± 17, G1 56 ± 22), at 12 weeks (G3 76 ± 14, G2 76 ± 15, G1 82 ± 11) or at any other timepoint. The percentage of patients who rated themselves as much or very much improved (i.e. treatment success) was not different after 12 weeks (G3 70%, G2 89%, G1 86% p = 0.94), or at 26 (p = 0.62) or 52 weeks (p = 0.71). No clinically significant effects of intervention group were observed in any of the secondary outcome measures.

Conclusion

The addition of intramuscular stimulation to standard rehabilitation for Achilles tendinopathy did not result in any improvement over the expected clinical benefit achieved with exercise-based rehabilitation alone.

Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine

Extracorporeal shockwave therapy (ESWT) is a popular non-invasive therapeutic modality in the medical field for the treatment of numerous musculoskeletal disorders. This technique first emerged around the 1980s as extracorporeal shockwave lithotripsy and has been studied since then for its application towards orthopedics and traumatology. ESWT works by the emission of acoustic waves (shockwaves) that carry energy and can propagate through tissues. Shockwaves can generate interstitial and extracellular responses, producing many beneficial effects such as: pain relief, vascularization, protein biosynthesis, cell proliferation, neuro and chondroprotection, and destruction of calcium deposits in musculoskeletal structures. The combination of these effects can lead to tissue regeneration and significant alleviation of pain, improving functional outcomes in injured tissue. Considering these facts, ESWT shows great potential as a useful regenerative medicine technique for the treatment of numerous musculoskeletal injuries.

Efficacy of Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Meta-analysis

Background:

Achilles tendinopathy is a frequent sports injury, and extracorporeal shock wave therapy (ESWT) has been proposed as a treatment.

Purpose:

To compare outcomes between ESWT and other nonsurgical intervention (including sham shock wave therapy) in Achilles tendinopathy patients.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

We included 5 randomized controlled trials and 3 case-control studies published between 2005 and 2018. We analyzed pain scores and other outcomes that were reported in more than 3 of the 8 studies.

Results:

ESWT was associated with significantly better scores than comparison therapy on the visual analog scale for pain (P < .01), American Orthopaedic Foot & Ankle Society scale (P = .01), Likert scale for satisfaction (P = .03), Roles and Maudsley scale (P < .01), Victorian Institute of Sports Assessment–Achilles questionnaire (P < .01), and numerical rating scale (P = .02). The 2 patient groups did not differ significantly in tenderness (P = .34) or pain threshold (P = .24). Subgroup analysis showed that ESWT led to better VAS pain scores than comparison treatments at both low-energy level (0.06-0.11 mJ/mm²) and medium-energy level (0.12-0.25 mJ/mm²) and at both shorter (<6 months) and longer (≥6 months) follow-up.

Conclusion:

ESWT improves pain and functional outcomes in patients with Achilles tendinopathy. Further research is needed to determine the optimal energy level.

Thermal and non-thermal effects off capacitive-resistive electric transfer application on the Achilles tendon and musculotendinous junction of the gastrocnemius muscle: a cadaveric study

Background

Calf muscle strain and Achilles tendon injuries are common in many sports. For the treatment of muscular and tendinous injuries, one of the newer approaches in sports medicine is capacitive-resistive electric transfer therapy. Our objective was to analyze this in vitro, using invasive temperature measurements in cadaveric specimens.

Methods

A cross-sectional study designed with five fresh frozen cadavers (10 legs) were included in this study. Four interventions (capacitive and resistive modes; low- and high-power) was performed for 5 min each by a diathermy “T-Plus” device. Achilles tendon, musculotendinous junction and superficial temperatures were recorded at 1-min intervals and 5 min after treatment.

Results

With the low-power capacitive protocol, at 5 min, there was a 25.21% increase in superficial temperature, a 17.50% increase in Achilles tendon temperature and an 11.27% increase in musculotendinous junction temperature, with a current flow of 0.039 A ± 0.02.

With the low-power resistive protocol, there was a 1.14% increase in superficial temperature, a 28.13% increase in Achilles tendon temperature and an 11.67% increase in musculotendinous junction temperature at 5 min, with a current flow of 0.063 A ± 0.02. With the high-power capacitive protocol there was an 88.52% increase in superficial temperature, a 53.35% increase in Achilles tendon temperature and a 39.30% increase in musculotendinous junction temperature at 5 min, with a current flow of 0.095 A ± 0.03. With the high-power resistive protocol, there was a 21.34% increase in superficial temperature, a 109.70% increase in Achilles tendon temperature and an 81.49% increase in musculotendinous junction temperature at 5 min, with a current flow of 0.120 A ± 0.03.

Conclusion

The low-power protocols resulted in only a very slight thermal effect at the Achilles tendon and musculotendinous junction, but current flow was observed. The high-power protocols resulted in a greater temperature increase at the Achilles tendon and musculotendinous junction and a greater current flow than the low-power protocols. The high-power resistive protocol gave the greatest increase in Achilles tendon and musculotendinous junction temperature. Capacitive treatments (low- and high-power) achieved a greater increase in superficial temperature.

Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Extracorporeal shock wave therapy (ESWT) is among the conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been determined that would ensure ESWT effectiveness in this condition. The aim of the paper is to use research reports on ESWT in patients with Achilles tendinopathy to help practising physiotherapists establish the most effective intervention parameters. A search was conducted using the following databases: PubMed, Scopus, EBSCOhost, and Web of Science. The papers were checked for relevant content and were included based on the following criteria: full-text article published in English and including comprehensive description of shock wave application. Twenty-two articles met the inclusion criteria. Most studies on the effectiveness of ESWT for Achilles tendinopathy included in this narrative review were randomized controlled trials. Two case-control studies, a case series study, prospective audit, clinical trial protocol, and a pilot study were also considered. The majority were prospective studies. Only a few authors presented the findings from retrospective observations. The two modalities of shock wave therapy used for Achilles tendinopathy are focused shock waves and radial shock waves. The literature contains reports presenting mainly beneficial effects of ESWT in patients with Achilles tendinopathy.

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.

Efficacy of Extracorporeal Shock Wave Therapy for Lower-Limb Tendinopathy: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Extracorporeal shock wave therapy, including radial shock wave and focused shock wave types, is widely used for managing tendinopathies. The difference in efficacy between the 2 shock wave characteristics with different dosage levels remains controversial, and the purpose of this meta-analysis was to examine it for patients with lower-limb tendinopathy.

DESIGN

A comprehensive search of online databases and search engines was performed. This study included randomized controlled trials reporting the efficacy of extracorporeal shock wave therapy in treating lower-limb tendinopathy. The included randomized controlled trials were subjected to a meta-analysis and risk of bias assessment.

RESULTS

In total, 29 randomized controlled trials were included, all of which had a good methodological quality, with a PEDro score of ≥6/10. General extracorporeal shock wave therapy showed significant effects at the immediate follow-up [pain score: standardized mean difference = -1.41, 95% confidence interval = -2.01 to -0.82, P < 0.00001; function: standardized mean difference = 2.59, 95% confidence interval = 1.54 to 3.64, P < 0.00001] as well as at 3, 6, and ≥12 months. In sequence, high-dosage focused shock wave, high-dosage radial shock wave, and low-dosage radial shock wave had superior pooled effects on overall clinical outcomes.

CONCLUSIONS

Extracorporeal shock wave therapy exerted a positive overall effect on pain and function for lower-limb tendinopathy. Shock wave types and dosage levels may have different contributions to treatment efficacy.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe benefits of extracorporeal shock wave therapy for individuals with lower-limb tendinopathy; (2) Understand the impact of dosing and type of extracorporeal shock wave therapy has on treatment efficacy; and (3) Identify appropriate indications for incorporating extracorporeal shock wave therapy into the treatment plan for patients with lower-limb tendinopathy.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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.

Effectiveness of extracorporeal shockwave therapy for chronic Achilles tendinopathy: A randomized clinical trial

Background:

In this study, we aimed to evaluate the effectiveness of extracorporeal shockwave treatment (ESWT) on pain and ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS) score of patients with chronic Achilles tendinopathy (AT).

Materials and Methods:

In this double-blind clinical trial, 43 patients with chronic AT were selected and randomly allocated in two groups to receive a basic treatment with ESWT or sham SWT (radial and focused shock waves, four sessions once a week for 4 weeks). AOFAS and pain scores for each patient were recorded at baseline (before intervention), immediately after intervention, and 4 and 16 weeks after intervention using AOFAS and visual analog scale (VAS) scaling method.

Results:

A total of 43 patients (22 ESWT and 21 sham SWT) were participated in this study. Both groups improved during the treatment and follow-up period. The mean VAS score decreased from 7.55 to 3 in the intervention group and from 7.70 to 4.30 in the sham SWT group. Mean AOFAS and VAS scores were significantly different between ESWT and no ESWT groups at 16 weeks of follow-up (P = 0.013) (P = 0.47). There was no significant difference in terms of AOFAS and VAS scores between both the groups in the other follow-up times.

Conclusion:

Overall, ESWT causes decrease in VAS score and increase in AOFAS score. However, due to the small sample size, the results were not statistically significant. It is recommended to plan more interventional studies with larger sample size in the future.

Effectiveness and Safety of Shockwave Therapy in Tendinopathies

Introduction:

People suffering from tendinopathies exhibit reduced mobility due to the pain caused by the movement of the tendons involved. Recently, shockwave therapy has been used as a treatment option, which is non-invasive, simpler, faster and safer.

Aims:

To record the intensity of the pain, the functionality of the upper and lower limbs and quality of life before treatment with shock waves, immediately after the treatment and the 4-week follow-up.

Methodology:

The sample consisted of 384 patients, suffering from a tendinopathy. 326 patients constituted the shockwave intervention groups and 58 patients made up the control groups. The researchers created a self-administered questionnaire (University of Peloponnese Pain, Functionality and Quality of Life Questionnaire) in which the intensity of pain, functionality and quality of life were evaluated on a five-point Likert scale, before, immediately after the treatment and at a 4-week follow-up.

Results:

The pain reduction and the improvement of functionality and quality of life after shockwave treatment increased by at least two points on the five-point Likert scale both post-treatment (p<0,001) and at a 4-week follow-up (p<0,001) compared to post-treatment in elbow tendinopathy, Achilles tendinopathy, plantar fasciitis and rotator cuff tendinopathy.

Conclusions:

Shockwave therapy significantly reduced the pain that accompanies tendinopathies and improves functionality and quality of life. It might be first choice because of its effectiveness and safety.

Editorial Commentary: The Amsterdam Achilles Tendinopathy Endoscopic Treatment: Should We Start Booking Our Patients for Surgery?

Mid-portion Achilles tendinopathy remains an elusive clinical and pathologic condition, with only a limited treatment algorithm to guide us. Although the risk factors and natural history have been documented, the exact etiology and source of pain generation remains unclear in the literature. Several Level I studies have shown reasonable success with a myriad of nonoperative treatments over the long term. Surgery is often reserved as the last resort for those who have failed nonoperative treatment, with mixed techniques and results. The endoscopic surgery literature for this condition is lacking, and more studies are needed to clarify the proper indications, techniques, and results of this disabling problem.

The Short Term Effects of Shock-Wave Therapy for Tennis Elbow: a Clinical Trial Study

BACKGROUND

Tennis elbow is one of the most often diagnosed pathology of the upper extremity and different treatments have been suggested for this disease, so this study was to investigate the effects of extracorporeal shock wave therapy in Tennis elbow treatment.

MATERIALS AND METHODS

We design a before and after clinical trial study (registry number: IRCT2012072610405N1) and investigated 40 patients with tennis elbow disease. All patients received 2000 pulses extracorporeal shock wave by piezoelectric device (WOLF Company) daily for one-week. The severity of pain was the primary outcome and measured with visual analogue scale (VAS). Secondary outcome was the ability to perform daily activities using questionnaire's quick DASH (Disabilities of the Arm, Shoulder and Hand). Primary and secondary outcomes at baseline, 30 and 60 days after intervention were measured.

RESULTS

The mean age of patients was 43.80±8.97 years and 28 patients (70%) were female. The mean duration of disease was 6.5 ± 7.9 month. The mean score of VAS pain score reduced from 7.25±1.54cm (median=7cm) before treatment to 2.76±2.08cm (median=2cm) at 60 days after the end of treatment (P<0.001). The Quick Dash score reduced significantly from 25.20±5.31 (median=25) before treatment to 8.69±8.32 (median=6) at 60 days after the treatment (P<0.001).

CONCLUSION

For newly diagnosed patients with tennis elbow, extracorporeal shock wave therapy can reduce the severity of pain and improve daily activity.

A review of the cellular and molecular effects of extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is a novel therapeutic modality and its use in promoting connective tissue repair and analgesic effect has been advocated in the literature. It is convenient, cost-effective, and has negligible complications; it therefore bypasses many of the problems associated with surgical interventions. This paper reviews the proposed mechanisms of action in promoting tissue repair and regeneration as well as analysing its efficacy providing an analgesic effect in clinical applications. Further research will be required to not only identify the underlying mechanisms more precisely, but will also be critical for ensuring consistency across the literature so that the most beneficial treatment protocol can be developed. Extracorporeal shockwave therapy stands as a promising alternative modality in promoting tissue repair.

The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction

OBJECTIVE

To evaluate extracorporeal shockwave therapy (ESWT) in treating Achilles tendinopathy (AT), greater trochanteric pain syndrome (GTPS), medial tibial stress syndrome (MTSS), patellar tendinopathy (PT) and proximal hamstring tendinopathy (PHT).

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Randomised and non-randomised studies assessing ESWT in patients with AT, GTPS, MTSS, PT and PHT were included. Risk of bias and quality of studies were evaluated.

RESULTS

Moderate-level evidence suggests (1) no difference between focused ESWT and placebo ESWT at short and mid-term in PT and (2) radial ESWT is superior to conservative treatment at short, mid and long term in PHT. Low-level evidence suggests that ESWT (1) is comparable to eccentric training, but superior to wait-and-see policy at 4 months in mid-portion AT; (2) is superior to eccentric training at 4 months in insertional AT; (3) less effective than corticosteroid injection at short term, but ESWT produced superior results at mid and long term in GTPS; (4) produced comparable results to control treatment at long term in GTPS; and (5) is superior to control conservative treatment at long term in PT. Regarding the rest of the results, there was only very low or no level of evidence. 13 studies showed high risk of bias largely due to methodology, blinding and reporting.

CONCLUSION

Low level of evidence suggests that ESWT may be effective for some lower limb conditions in all phases of the rehabilitation.

Nonsurgical Management of Midsubstance Achilles Tendinopathy

Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.

Midsubstance Tendinopathy, Surgical Management

Noninsertional Achilles tendinopathy often responds to nonoperative treatment. When nonoperative treatment fails, the clinician must distinguish between paratendinopathy and noninsertional tendinopathy. In paratendinopathy, myofibroblasts synthesize collagen, causing adhesions, and the paratenon may be released or excised. If a core area of tendinopathy is identified on MRI, the area is excised longitudinally and repaired with a side-to-side suture. If greater than 50% of the tendon diameter is excised, the authors recommend a short flexor hallucis longus tendon transfer with an interference screw. A turndown flap of the gastrocnemius aponeurosis is also described with good results.

Midsubstance Tendinopathy, Percutaneous Techniques (Platelet-Rich Plasma, Extracorporeal Shock Wave Therapy, Prolotherapy, Radiofrequency Ablation)

The focus of this article is to present the current options available for noninvasive and percutaneous treatment options for noninsertional Achilles tendinopathy. An attempt is made to offer recommendations for both the treatment techniques as well as postprocedure protocols to be considered. Additionally, because there are numerous treatment options in this category, the different techniques are summarized in a chart format with a short list of pros and cons as well as the levels of evidence in the literature to support the different modalities.

Long-Term Outcome and Factors Affecting Prognosis of Extracorporeal Shockwave Therapy for Chronic Refractory Achilles Tendinopathy

Objective

To investigate the factors affecting prognosis of extracorporeal shockwave therapy (ESWT) for chronic refractory Achilles tendinopathy (AT).

Methods

Thirty-six patients (48 consecutive feet) with chronic AT (>6 months) and who underwent ESWT for ‘poor’ or ‘fair’ grade in Roles-Maudsley Score (RMS) after unsuccessful conservative treatment were included in the present study. A maximum of 12 sessions of ESWT were conducted until treatment success: RMS reached ‘good’ or ‘excellent’. Termination of ESWT for no response, or ‘poor’ or ‘fair’ grade was regarded as treatment failure. Immediate outcome, long-term outcome (telephone interview after mean 26 months), and factors affecting treatment success were analyzed.

Results

Numeric Rating Scale was significantly decreased at immediate and long-term follow-up. Success rate was 71.1% and 90.3%, respectively. Univariate logistic regression identified that immediate treatment success was associated with retrocalcaneal enthesophyte on X-ray (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.01–0.28), pretreatment abnormal ultrasonography echogenicity within Achilles tendon (OR, 18.89; 95% CI, 2.08–171.96), mean duration of ‘post-treatment soreness’ (OR, 0.55; 95% CI, 0.33–0.94), and duration of ‘post-treatment soreness after first ESWT’ (OR, 0.06; 95% CI, 0.01–0.34). The duration of ‘post-treatment soreness after first ESWT’ was found to be the only factor associated with long-term success (OR, 0.32; 95% CI, 0.10–0.99).

Conclusion

ESWT appears to be effective in achieving long-term success in chronic refractory AT. Immediate success was associated with absence of retrocalcaneal enthesophyte on X-ray, presence of pretreatment abnormal ultrasonography echogenicity, shorter mean duration of ‘post-treatment soreness’, and shorter duration of ‘post-treatment soreness after first ESWT’. The shorter duration of ‘post-treatment soreness after first ESWT’ was identified as the only positive prognostic parameter in achieving long-term success.

Shock wave therapy associated with eccentric strengthening versus isolated eccentric strengthening for Achilles insertional tendinopathy treatment: a double-blinded randomised clinical trial protocol

BACKGROUND

There is no consensus regarding the treatment of Achilles insertional tendinopathies. Eccentric training remains the main choice in the conservative treatment of this illness; however, the good results in the management of non-insertional Achilles tendinopathy were not replicated in the insertional condition. Low energy shock wave therapy has been described as an alternative to these patients, but has yet to be empirically tested.

HYPOTHESIS

Shock wave therapy, adjunctive to the eccentric strengthening protocol, will improve measures of pain and function.

DESIGN

Double blind, placebo-controlled, parallel groups, randomised clinical trial.

MATERIALS AND METHODS

93 patients with a diagnosis of chronic insertional tendinopathy, referred from primary or secondary healthcare services, will be assessed and enrolled in this study. They will be divided into two groups (randomised by sequentially numbered identical envelopes, which will be administered serially to participants), one containing the combination of low energy shock wave and eccentric exercises, as treatment and the other comprehending the exercises and the placebo treatment (an apparatus placed in the therapeutic head). The assessments will occur in 2, 4, 6, 12 and 24 weeks. Patients will be evaluated primarily by the Victorian Institute of Sport Assessment-Achilles questionnaire and secondarily by the visual analogue scale, Algometry, the American Orthopedic Foot and Ankle Society scale, the Foot and Ankle Outcome Score and the 12-item Short Form Health Survey. We will use comparison of two proportions via relative frequency analysis, the Pearson Correlation the χ² test and the analysis of variance for statistical analyses.

DISCUSSION

This study intends to demonstrate if the association of the eccentric exercise programme with the shock wave therapy can produce good results regarding the treatment of the Achilles insertional tendinopathy. In an attempt to prevent the high costs and complications associated with the surgical intervention, we will try to prove this combination as a viable therapeutic option in the conservative management of this prevalent condition. The strengths of the study are the design and the novelty of the combination of methods. The main limitation is the short follow-up course.

ETHICS AND DISSEMINATION

The study is registered in the Clinical Trials database (protocol number: 8094833648737701) and was approved by the University Ethics Committee (number: 1373481).

TRIAL REGISTRATION NUMBER

8094833648737701 (NCT02757664); Pre-results.