Cross-sectional outcome analysis of athletes with chronic patellar tendinopathy treated surgically and by extracorporeal shock wave therapy

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.

Patellar ligament desmopathy in the horse – a review and comparison to human patellar tendinopathy (‘Jumper’s knee’)

Patellar ligament desmopathy in horses is regarded as an uncommon condition with unclear aetiology. Of the three patellar ligaments in the horse, the intermediate is the one most often diagnosed with desmopathy in horses presenting with chronic lameness. This structure corresponds to the patellar tendon in humans. As diagnostic imaging modalities continuously improve, changes in echogenicity of the patellar ligaments are identified ultrasonographically with increasing frequency. However, disruption of the normal fibre pattern may be present also in patellar ligaments in horses that show no signs of lameness. Similarly, there is a poor correlation between pain and diagnostic imaging findings in human patellar tendinopathy. Consequently, there appears to be a knowledge gap pertaining to normal ultrasonographic variation and diagnostic criteria for disease of the patellar ligaments in horses. Furthermore, local anaesthetic techniques to verify the diagnosis are poorly described, and due to the low number of treated cases, no specific treatment modality can be recommended on a scientific basis. The aim of this paper is to review the current knowledge regarding the pathogenesis, diagnosis and management of patellar ligament desmopathy in horses, compare this condition with patellar tendinopathy in humans, and identify areas for further research to increase the diagnostic accuracy in horses. We conclude that there is a profound need for better descriptions of ultrasonographic variation and pathological changes of the equine patellar ligaments. Identification of areas of maximal ligament strain and descriptions of early histopathological changes could render more information on the possible aetiology, preventive measurements and treatment options of desmopathy. Description of regional innervation could aid in development of methods for diagnostic anaesthesia to verify pain originating from the ligaments.

Treatment of Jumper’s Knee with Extracorporeal Shockwave Therapy: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to determine the therapeutic efficacy of extracorporeal shockwave therapy (ESWT) for athletes with patellar tendinopathy. We searched PubMed, EBSCOHost and Ovid for randomized controlled trials (RCTs) which evaluated the therapeutic efficacy of ESWT in athletes with jumper’s knee. The methodological quality of RCTs was rated with the Physiotherapy Evidence Database scale. Data in the meta-analysis were expressed as standardized mean difference (SMDs) and 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Of 192 records identified, a total of seven articles met the inclusion criteria. The ESWT and control groups with any other conservative treatment did not differ significantly with respect to the Visual Analogue Scale (VAS) long-term scores obtained at ≥ 6 months of therapy completion (SMD: -0.33; 95% CI: -4.64 to 3.98; p = 0.87; I2= 98%). Furthermore, no significant differences were found between the ESWT and control groups regarding the pooled Victorian Institute of Sports Assessment for Patella (VISA-P) scores for long-term outcomes (SMD: 8.21; 95% CI: -39.3 to 55.73; p = 0.73; I2= 99%). The ESWT and control groups did not differ significantly on the VAS and VISA-P scores for long-term outcomes. In both cases, heterogeneity was considered to be high. Hence, no clear and generalized conclusions can be drawn regarding ESWT effectiveness in athletes with patellar tendinopathy.

Surgical Management of Patellar Tendinopathy Results in Improved Outcomes and High Rates of Return to Sport: A Systematic Review

Although the majority of patients with patellar tendinopathy (PT) can be treated nonoperatively, operative management may be indicated for recalcitrant cases. While several surgical techniques have been described, there is limited understanding of postoperative outcomes and expectations regarding return to activity and sport. The purpose of this study was to characterize the clinical outcomes associated with the surgical management of PT with an emphasis on return to sport (RTS) rates. We hypothesized that surgical management would lead to clinically important improvements in patient-reported outcomes (PROs) with high rates of RTS and RTS at the same level. A comprehensive search of the PubMed, Medline, and Embase databases was performed in December 2020. Level of evidence studies I through IV, investigating results of surgical management for PT (PRO, functional outcomes, pain, and/or RTS), were included. The search was performed in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Forty clinical studies reporting on surgery for PT satisfied inclusion criteria, with 1,238 total knees undergoing surgery for PT. A comparison of pre- and postoperative Victorian Institute of Sport Assessment, patellar tendon (VISA-P) scores (mean difference: 41.89, p < 0.00001), Lysholm scores (mean difference: 41.52, p < 0.00001), and visual analogue scale (VAS) pain scores (mean difference: 5, p < 0.00001) demonstrated clinically and statistically significant improvements after surgery. The overall RTS rate following operative management was 89.8% (95% confidence interval [CI]: 86.4-92.8, I ² = 56.5%) with 76.1% (95% CI: 69.7.5-81.9, I ² = 76.4%) of athletes returning to the same level of activity. Surgery for PT provides meaningful improvement in patient reported outcomes and pain while allowing athletes to RTS at high rates with levels of participation similar to that of preinjury. Comparative studies of open and/or arthroscopic surgery are still limited but current evidence suggests better rates of RTS for arthroscopic surgery compared with open surgery. This is a systematic review of level-I to -IV studies.

Efficacy of Extracorporeal Pulse-Activated Therapy in the Management of Lower-Extremity Running-Related Injuries: Findings From a Large Case Cohort

Running is one of the most popular sports worldwide, with many health benefits. Injuries are also common, with running-related injuries reported in up to 79% of runners annually. Extracorporeal shockwave treatment can be used to treat soft tissue conditions, with the strongest level of evidence for management of plantar fasciitis. However, most studies have focused on nonathletes or studied a single condition, and few investigations have reported outcomes for extracorporeal pulse-activated therapy. In this case series, we evaluated the outcomes of 94 runners receiving extracorporeal pulse-activated therapy for lower-extremity running-related injuries, including plantar fasciitis and lower-extremity tendinopathy (Achilles, posterior tibialis, patellar, hamstring). We hypothesized that most runners with foot and ankle injuries would respond favorably to treatment and that success rates would be similar across conditions. Overall, 74 runners (79%) met their respective minimal clinically important difference for functional outcome measures, with no differences in response by age, sex, body mass index, or chronicity of condition. Further, no differences were noted in proportion achieving the minimal clinically important difference between foot and ankle (Achilles, posterior tibialis, and plantar fascia) compared with proximal injuries (53 [84.3%] versus 31 [72%], p = .15). A mean of 4 treatments resulted in achieving the minimal clinically important difference, with 95% achieving it by 5 treatments. No differences in bars of pressure, frequency, or other aspects of treatments were observed to predict response. Our findings suggest that a majority of runners with lower-extremity injuries respond favorably to extracorporeal pulse-activated therapy, including those with foot and ankle injuries.

Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis

BACKGROUND

Patellar tendinopathy is a condition characterized by anterior knee activity-related pain. It has a high incidence among athletes engaged in jumping sports and may become a chronic condition. Nonoperative management is the first choice in these patients, and several nonsurgical treatment options have been proposed. Nonetheless, clear indications on the most effective approach to address patellar tendinopathy are still lacking.

PURPOSE

To analyze the evidence on nonoperative options to treat chronic patellar tendinopathy through a systematic review of the literature and to perform a meta-analysis to identify the most effective nonsurgical option.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The search was conducted with the PubMed and Cochrane databases on January 4, 2017. All clinical English-language reports of any level of evidence on nonsurgical treatment of patellar tendinopathy were included. The quality of each article was assessed by use of the Coleman score. A meta-analysis was performed on all articles reporting the Victorian Institute of Sport Assessment scale for patellar tendinopathy to evaluate the results of the most described treatments.

RESULTS

A total of 70 studies involving 2530 patients were included in the qualitative data synthesis. The Coleman score showed an overall poor study quality. The most described treatment groups that could be included in the meta-analysis were reported in 22 studies on eccentric exercise, extracorporeal shockwave therapy (ESWT), and platelet-rich plasma (PRP). Single and multiple PRP injections were evaluated separately. Eccentric exercise therapies obtained the best results ( P < .05) at short-term (<6 months, mean 2.7 ± 0.7 months). However, multiple injections of PRP obtained the best results ( P < .05), followed by ESWT and eccentric exercise, at long-term follow-up (≥6 months, mean 15.1 ± 11.3 months).

CONCLUSION

The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality. The available evidence showed an overall positive outcome, but some differences have been highlighted. Eccentric exercises may seem the strategy of choice in the short-term, but multiple PRP injections may offer more satisfactory results at long-term follow-up and can be therefore considered a suitable option for the treatment of patellar tendinopathy.

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.

The Royal London Hospital Test for the clinical diagnosis of patellar tendinopathy

Purpose

To ascertain whether the Royal London Hospital test is reproducible, sensitive, and specific for diagnosis of patellar tendinopathy.

Methods

Fifteen consecutive athletes with patellar tendinopathy were prospectively enrolled and compared with a control group of 15 non consecutive athletes with Achilles tendinopathy. Two testers examined separately each patient, using manual palpation and the Royal London Hospital test for diagnosis of patellar tendinopathy. High resolution real time ultrasonography was used as standard for diagnosis of tendinopathy and assessment of tendon thickness.

Results

The palpation test presented significantly higher sensitivity compared to the Royal London Hospital test (98 vs 88%; P=0.01); specificity was 94% for the palpation test and 98% for the Royal London Hospital test (P>0.05). Positive and negative predictive values were 94 and 98% for palpation test, 98 and 89% for the Royal London Hospital test, respectively. The two tests showed good to very good intra-tester and inter-tester agreement. At ultrasonography, pathological patellar tendons were significantly thicker compared to controlateral healthy tendon (P<0.001).

Conclusions

In symptomatic patients with patellar tendinopathy, the Royal London Hospital test showed lower sensitivity and higher specificity than manual palpation. Both tests should be performed for a correct clinical diagnosis of patellar tendinopathy. Imaging assessment should be performed as a confirmatory test.

Level of Evidence

III.

Platelet-Rich Plasma Injections as a Treatment for Refractory Patellar Tendinosis: A Meta-Analysis of Randomised Trials

Purpose

Patellar tendinosis (PT) is a common condition amongst athletes. In this study, we perform a meta-analysis on randomised controlled trials (RCTs) to evaluate the use of platelet-rich plasma (PRP) for refractory PT.

Methods

A literature search was undertaken in various databases from their year of inception to October 2015. The primary outcome measure was the Victorian Institute of Sports Assessment-Patella (VISA-P) score.

Results

We identified 2 RCTs comparing PRP injections to alternative treatment options (extracorporeal shockwave therapy [ESWT] and dry needling of the tendon). Meta-analysis showed no significant difference in mean VISA-P scores between PRP injection and control at early assessment (2 or 3 months; estimated difference in means, 11.9; standard error [SE], 7.4; 95% confidence interval [CI], -2.7 to 26.4; p=0.109). However, PRP was statistically better than control with regards to VISA-P scores at longer follow-up (6 months or longer; estimated difference in means, 12.7; SE, 4.4; 95% CI, 4.1 to 21.3; p=0.004).

Conclusions

There is a paucity of RCTs evaluating the role of PRP in PT. Our results suggest that, based on limited evidence, PRP is superior over other established non-surgical treatments (dry needling and ESWT) for refractory PT. Larger RCTs may allow better characterisation of the role of PRP in this condition.

Treatment Options for Patellar Tendinopathy: A Systematic Review

PURPOSE

To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies.

METHODS

A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively.

RESULTS

A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P = .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI -20% to 60%).

CONCLUSIONS

Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6 months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Refractory patella tendinopathy with failed conservative treatment-shock wave or arthroscopy?

AIM

To identify whether the location of refractory patella tendinopathy (PT) has an effect on treatment modality (radial extracorporeal shock wave therapy (rESWT) or arthroscopic debridement).

METHODS

Between 2012 and 2014, 40 patients with PT underwent a magnetic resonance imaging (MRI) scan. This confirmed the diagnosis as either involving the tendon itself (group A, 20) or with retropatella fat pad extension (group B, 20). All patients underwent rESWT. If there was no improvement patients proceeded with surgery in the form of arthroscopic debridement (by senior authors CW and AG). Outcomes were assessed before and after treatment using the Victorian Institute of Sports Assessment-Patella (VISA-P) score.

RESULTS

There were 18 males and 2 females in group A and 15 males and 5 females in group B. The mean age was 41.4 years in group A (23-59) and 34.7 in group B (19-52). Seventeen of 20 in group A reported good or excellent outcomes and did not require surgical intervention (remaining three improved after second course of ESWT). All patients in group B failed to improve with rESWT, resulting in arthroscopic debridement and reported good or excellent outcomes. After 6 months, group A mean VISA-P score increased from 50.2 to 65.0 ( p = 0.01) and group B from 39.6 to 78.4 ( p = <0.001).

CONCLUSION

An MRI should be performed to determine the precise location of tendinosis in patients with refractory PT who fail standard conservative management. If the MRI scan shows intratendon changes only, ESWT should be performed and those with extension into the fat pad should proceed to arthroscopic debridement without rESWT.

Historical ESWT Paradigms Are Overcome: A Narrative Review

Extracorporeal Shock Wave Therapy (ESWT) is a conservative treatment modality with still growing interest in musculoskeletal disorders. This narrative review aims to present an overview covering 20-year development in the field of musculoskeletal ESWT. Eight historical paradigms have been identified and put under question from a current perspective: energy intensity, focus size, anesthesia, imaging, growth plates, acuteness, calcifications, and number of sessions. All paradigms as set in a historical consensus meeting in 1995 are to be revised. First, modern musculoskeletal ESWT is divided into focused and radial technology and the physical differences are about 100-fold with respect to the applied energy. Most lesions to be treated are easy to reach and clinical focusing plays a major role today. Lesion size is no longer a matter of concern. With the exception of nonunion fractures full, regional, or even local anesthesia is not helpful in musculoskeletal indications. Juvenile patients can also effectively be treated without risk of epiphyseal damage. Further research is needed to answer the question about if and which acute injuries can be managed effectively. Treatment parameters like the number of sessions are still relying on empirical data and have to be further elucidated.

Results of Surgical Treatment of Chronic Patellar Tendinosis (Jumper's Knee): A Systematic Review of the Literature

PURPOSE

To review the literature concerning surgical treatment options for chronic patellar tendinosis (jumper's knee), a common problem among athletes. When conservative treatment fails, surgical treatment is required.

METHODS

Systematic review of the literature concerning the results of current surgical treatment options for chronic patellar tendinosis. All articles of studies with an evidence level ≥IV from January 2000 until February 2015 presenting the surgical outcome after arthroscopic as well as open treatment of chronic patellar tendinosis were included. The literature research of the PubMed database was performed using the following key words: "patellar" and "tendinitis," "tendonitis," "tendinosis" or "tendinopathy"; "inferior patellar pole"; "jumper's knee"; "surgical treatment" and "open" or "arthroscopic patellar tenotomy."

RESULTS

A systematic review of the literature was performed especially to point out the effectiveness of arthroscopic treatment of chronic patellar tendinosis. The results revealed good clinical results for arthroscopic as well as open treatment of chronic patellar tendinosis that is refractory to conservative treatment in athletes. An average success rate of 87% was found for the open treatment group and of 91% for the arthroscopic treatment group. However, after open surgery, the mean time of return to the preinjury level of activity is 8 to 12 months, with a certain number of patients/athletes who cannot return to the preinjury level of activity.

CONCLUSIONS

Minimally invasive, arthroscopically assisted or all-arthroscopic procedures may lead to a significantly faster return to sporting activities and may, therefore, be the preferred method of surgical treatment.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

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

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

Patellar tendon: From tendinopathy to rupture

Patellar tendinopathy is very common in patients complaining of anterior knee pain. Its aetiology is still unclear, but neovascularisation seems to play a role. Different treatments have been proposed overtime, from rehabilitation to platelet-rich-plasma injections, but there is no agreement on the best treatment protocol. The final stage of patellar tendinopathy is patellar tendon rupture. In these cases surgical treatment is often required. The aim of this literature review is to focus on the aetiology, diagnosis, and treatment of both patellar tendinopathy and rupture. We report the conservative treatments proposed for patellar tendinopathy and the surgical techniques described for its rupture.

The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review

BACKGROUND

There is accumulating evidence for the effectiveness of extracorporeal shock wave therapy (ESWT) when treating lower limb tendinopathies including greater trochanteric pain syndrome (GTPS), patellar tendinopathy (PT), and Achilles tendinopathy (AT).

PURPOSE

To evaluate the effectiveness of ESWT for lower limb tendinopathies.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed (Medline), Embase, Web of Knowledge, Cochrane, and CINAHL were searched from inception to February 2013 for studies of any design investigating the effectiveness of ESWT in GTPS, PT, and AT. Citation tracking was performed using PubMed and Google Scholar. Animal and non-English language studies were excluded. A quality assessment was performed by 2 independent reviewers, and effect size calculations were computed when sufficient data were provided.

RESULTS

A total of 20 studies were identified, with 13 providing sufficient data to compute effect size calculations. The energy level, number of impulses, number of sessions, and use of a local anesthetic varied between studies. Additionally, current evidence is limited by low participant numbers and a number of methodological weaknesses including inadequate randomization. Moderate evidence indicates that ESWT is more effective than home training and corticosteroid injection in the short (<12 months) and long (>12 months) term for GTPS. Limited evidence indicates that ESWT is more effective than alternative nonoperative treatments including nonsteroidal anti-inflammatory drugs, physical therapy, and an exercise program and equal to patellar tenotomy surgery in the long term for PT. Moderate evidence indicates that ESWT is more effective than eccentric loading for insertional AT and equal to eccentric loading for midportion AT in the short term. Additionally, there is moderate evidence that combining ESWT and eccentric loading in midportion AT may produce superior outcomes to eccentric loading alone.

CONCLUSION

Extracorporeal shock wave therapy is an effective intervention and should be considered for GTPS, PT, and AT particularly when other nonoperative treatments have failed.

Patellar Tendinopathy

Context:

Patellar tendinopathy is a common condition. There are a wide variety of treatment options available, the majority of which are nonoperative. No consensus exists on the optimal method of treatment.

Evidence Acquisition:

PubMed spanning 1962-2014.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

The majority of cases resolve with nonoperative therapy: rest, physical therapy with eccentric exercises, cryotherapy, anti-inflammatories, corticosteroid injections, extracorporeal shockwave therapy, glyceryl trinitrate, platelet-rich plasma injections, and ultrasound-guided sclerosis. Refractory cases may require either open or arthroscopic debridement of the patellar tendon. Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture. Anti-inflammatories and injectable agents have shown mixed results. Surgical treatment is effective in many refractory cases unresponsive to nonoperative modalities.

Conclusion:

Physical therapy with an eccentric exercise program is the mainstay of treatment for patellar tendinopathy. Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. In the event that nonoperative treatment fails, surgical intervention has produced good to excellent outcomes in the majority of patients.

Platelet-rich plasma for the treatment of patellar tendinopathy: clinical and imaging findings at medium-term follow-up

PURPOSE

The purpose of this study was to evaluate the efficacy of multiple platelet-rich plasma (PRP) injections on the healing of chronic refractory patellar tendinopathy, and report the quality and duration of the clinical improvement up to a medium-term follow-up.

METHODS

Forty-three patients (mean age, 30.6 years; mean BMI, 24.7; 42 men, one woman) affected by chronic patellar proximal tendinopathy were enrolled in this trial. Eleven patients were affected by bilateral tendinopathy. They underwent three ultrasound guided intra-tendinous injections of five millilitres PRP, two weeks apart from each other. Patients were prospectively evaluated initially, then after two, six, and up to mean 48.6 ± 8.1 months of follow-up (minimum evaluation at 36 months). The following evaluation tools were used: Blanzina, VISA-P, EQ-VAS for general health, and Tegner scores. Patients' overall satisfaction and time to return to sport were also reported.

RESULTS

Good and stable results were documented over time, with the VISA-P score increasing from 44.1 ± 15.6 at baseline to 61.4 ± 22.2 at two months, 76.6 ± 25.4 at six months, and 84.3 ± 21.6 at four years' follow-up. The same trend was confirmed by the other scores used, and 80 % of the patients were satisfied and returned to previous sports activities. Significantly poorer results were obtained in patients with a longer history of symptoms, and poor results were also observed in bilateral lesions. No correlation between ultrasonographic and clinical findings could be found.

CONCLUSIONS

Multiple injections of PRP provided a good clinical outcome for the treatment of chronic recalcitrant patellar tendinopathy with stable results up to medium-term follow-up. Patients affected by bilateral pathology and presenting a long history of pain obtained significantly poorer results.

Overuse injuries

Tendinopathy and chronic tendon issues related to tendinosis are conditions difficult to treat. These conditions often lead to patients' quality of life declining because of the inability to participate in exercise, occupation-related activities, and activities of daily living. By better understanding the pathophysiology related to the development of tendinosis, clinicians will be better able to understand the treatment options available and their limitations while allowing novel therapies to be developed. Conservative treatment of tendinosis starting with a sound rehabilitation program seems to be the best place to start while reserving surgical approaches for cases that have failed conservative management.

A single application of low-energy radial extracorporeal shock wave therapy is effective for the management of chronic patellar tendinopathy

PURPOSE

Extracorporeal shock wave therapy (SWT) is effective for the management of chronic recalcitrant tendinopathy. The objective of the current study was to assess whether a standardized, single treatment SWT is effective for the management of chronic patellar tendinopathy

METHODS

Thirty-three patients with chronic patellar tendinopathy received low-energy SWT. Thirty-three patients with chronic patellar tendinopathy received other forms of non-operative therapy (control group). Evaluation was by change in Visual Analogue Scale (VAS), Victoria Institute of Sport Assessment score for patellar tendinopathy (VISA-P) score and by Roles and Maudsley Score.

RESULTS

Mean pre-treatment VAS scores for the control and SWT groups were 7.5 and 7.8, respectively. One month, 3 months, and 12 months after treatment, the mean VAS for the control and SWT groups were 6.7 and 4.3 (p < 0.001), 5.9 and 3.5 (p < 0.001), and 5.1 and 2.7 (p < 0.001), respectively. One month, 3 months, and 12 months after treatment, the mean VISA for the control and SWT groups were 50.7 and 65.5 (p < 0.001), 52.1 and 71 (p < 0.001), and 54.9 and 74.5 (p < 0.001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the SWT and control groups were 8 and 3 (p < 0.001), 17 and 10 (p < 0.001), 5 and 16 (p < 0.001), and 3 and 4 (p < 0.001), respectively. The percentage of patients with excellent ("1") or good ("2") Roles and Maudsley Scores (i.e. successful results) 12 months after treatment was statistically greater in the SWT group compared to the control group (p < 0.001).

CONCLUSION

A single application of radial SWT is an effective treatment for chronic patellar tendinopathy.

LEVEL OF EVIDENCE

III.

Open versus arthroscopic surgical treatment of chronic proximal patellar tendinopathy. A systematic review

PURPOSE

A general agreement on the best surgical treatment option of chronic proximal patellar tendinopathy is still lacking. The purpose of this systematic review was to investigate if arthroscopically assisted procedures have been reported better results compared to open surgery and to assess the methodology of studies.

METHODS

Twenty-one studies were included in the review. Surgical outcomes were defined referring to the functional classification described by Kelly et al. (Am J Sports Med 12(5):375-380, [11]): return to sport was regarded as the ability of training at the original level before injury with mild or moderate pain and success as the improvement after surgery with symptom reduction. Methodological analysis was performed by two reviewers adopting the Coleman Methodology Score (CMS) (range 0-100, best score 100).

RESULTS

Only one randomized controlled trial (RCT) met inclusion criteria; all other included studies were case series. Median sample size 24, range 11-138, mean age at surgery 26.8 ± 3.2 years, mean follow-up 32.5 ± 18.4 (median 31, range 6-60) months. Return to sport rate: global 78.5 %, open group 76.6 % and arthroscopic group 84.2 %. Success rate: global 84.6 %, open group 87.2 % and arthroscopic group 92.4 %. Differences between groups were not statistically significant. CMSs were positively correlated with the year of publication (P < 0.05).

CONCLUSIONS

Minimally invasive arthroscopically assisted procedures have not reported better statistically significant results when compared to open surgery in the treatment of chronic proximal patellar tendinopathy. The methodology of studies in this field has improved over the past 15 years, but well-designed RCTs using validated patient-based outcome measures are still lacking.

LEVEL OF EVIDENCE

Systematic Review, Level IV.

Extracorporeal shockwave therapy for treatment of delayed tendon-bone insertion healing in a rabbit model: a dose-response study

BACKGROUND

Tendon-bone insertion (TBI) consists of both hard and soft tissues. TBI injury with delayed repair is not uncommon. High-dose extracorporeal shockwave (ESW) is effective for treating nonunion fracture, whereas low-dose ESW is used for tendinopathy therapy. The dosing effect of ESW on delayed TBI healing is lacking.

HYPOTHESIS

Low-dose ESW might have a healing enhancement effect comparable to that of high-dose ESW in treating delayed TBI healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Partial patellectomy was adopted to create a delayed TBI healing model by shielding the healing interface between tendon and bone. Ninety-six female New Zealand White rabbits with unilateral delayed TBI healing at the knee joint were divided into 3 groups: controls, low-dose ESW (LD-ESW; 0.06 mJ/mm(2), 4 Hz, 1500 impulses), and high-dose ESW (HD-ESW; 0.43 mJ/mm(2), 4 Hz, 1500 impulses). The TBI shielding was removed at week 4 after partial patellectomy, followed by treatment with control or ESW at week 6. The rabbits were euthanized at week 8 and week 12 for radiological, microarchitectural, histological, and mechanical assessments of healing tissues.

RESULTS

Radiologically, both the LD-ESW group and the HD-ESW group showed larger new bone area than the controls at week 8 and week 12. Microarchitectural measurements showed that the LD-ESW and HD-ESW groups had larger new bone volume than the controls at week 12. Histological assessments confirmed osteogenesis enhancement. Both the LD-ESW and HD-ESW groups showed significantly higher failure load at the TBI healing complex than the control group at week 12. No significant difference was detected between the 2 ESW treatment groups at week 8 or week 12.

CONCLUSION

Extracorporeal shockwave, a unique noninvasive physical modality, had similar effects between the low and high dose for treating delayed TBI healing.

CLINICAL RELEVANCE

Low-dose ESW for TBI delayed healing might be more desirable and have better compliance in clinical applications.

Long-Term Effectiveness of Combined Mechanotransduction Treatment in Jumper's Knee

The aim of the study was to show that the addition of extracorporeal shockwave therapy (ESWT) may significantly improve beneficial effects of eccentric training together with high efficiency focused acoustic waves for jumper's knee. We speculate that such an effect may be due to increased mechanotransduction effects on affected tissues. We assessed changes in pain and function in 42 male football players (aged 1834 years) after a treatment protocol consisting of I session with focused ESWT per week combined with 3 physiotherapy sessions per week, for 3 consecutive weeks. While treatment protocol was administered, ordinary activities, but not playing football were permitted. Their condition was evaluated before treatment, at the end of the rehabilitation period (3 weeks) and at 2 months, 4 months and 6 months after the end of treatment by clinical examination, instrumental analysis and VAS for pain assessment. Functional ability related to symptoms was assessed with VISA score. At the end of 2005,2006,2007,2008 and 2009 we carried out a telephone interview to investigate changes in pain and function and the efficacy of the treatment over time. Follow-up controls showed a reduction of average VAS score; after 6 months, tendons showed a structure closer to normal at ultrasonographic investigation. At the last telephone interview in 2009 many patients reported to consider ESWT as an effective treatment and described a significant improvement in their functional abilities, a significant reduction in drug consumption and 88% of subjects continued to play agonistic football. In conclusion, our results showed that, through the addition of ESWT, the effects of the classic vibration and eccentric training combination were improved compared to those found in our experience without ESWT. Although a control group was not included in the study (vibration and eccentric training without ESWT), results show a promising improvement and justify future prospective studies with a control group and more case series.

Extracorporeal shockwave therapy in musculoskeletal disorders

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

High-energy extracorporeal shockwave therapy in a patellar tendon animal model: a vascularization focused study

OBJECTIVE

The aim of this study was to analyze the effect of high-energy extracorporeal shockwave therapy on tendon angiogenesis in the patellar tendons of rabbits. We sought to investigate whether different voltage and number pulses modify the angiogenesis pattern.

INTRODUCTION

High-energy extracorporeal shockwave therapy is an option in the treatment of orthopedic diseases such as chronic tendonitis. Despite its potential clinical applicability, there have been few studies on this technique that examine both its clinical effectiveness and its effect on angiogenesis.

METHODS

High-energy extracorporeal shockwave therapy was applied at the tibial insertion of the left patellar ligament in 30 rabbits that were separated into six groups that differed in terms of the voltage and number of pulses that were applied by high-energy extracorporeal shockwave therapy. The tibial insertion in the right legs of the animals was used as the control. After six weeks, we performed histological analysis on the region and quantified the number of blood vessels.

RESULTS

No significant differences in the number of blood vessels between the left and right patellar tendons were found within groups. Additionally, no significant differences in the number of blood vessels in the left patellar tendons were found between groups.

CONCLUSIONS

The application of high-energy extracorporeal shockwave therapy did not cause a change in vascularization in the patellar tendon in rabbits.

Use of platelet-rich plasma for the treatment of refractory jumper's knee

The aim of this study was to evaluate the efficacy of multiple platelet-rich plasma (PRP) injections on the healing of chronic refractory patellar tendinopathy after previous classical treatments have failed. We treated 15 patients affected by chronic jumper's knee, who had failed previous nonsurgical or surgical treatments, with multiple PRP injections and physiotherapy. We also compared the clinical outcome with a homogeneous group of 16 patients primarily treated exclusively with the physiotherapy approach. Multiple PRP injections were performed on three occasions two weeks apart into the site of patellar tendinopathy. Tegner, EQ VAS and pain level were used for clinical evaluation before, at the end of the treatment and at six months follow-up. Complications, functional recovery and patient satisfaction were also recorded. A statistically significant improvement in all scores was observed at the end of the PRP injections in patients with chronic refractory patellar tendinopathy and a further improvement was noted at six months, after physiotherapy was added. Moreover, comparable results were obtained with respect to the less severe cases in the EQ VAS score and pain level evaluation, as in time to recover and patient satisfaction, with an even higher improvement in the sport activity level achieved in the PRP group. The clinical results are encouraging, indicating that PRP injections have the potential to promote the achievement of a satisfactory clinical outcome, even in difficult cases with chronic refractory tendinopathy after previous classical treatments have failed.

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

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

LEVEL OF EVIDENCE

Level II, systematic review.

Ultrasound guided dry needling and autologous blood injection for patellar tendinosis

OBJECTIVE

To evaluate the efficacy of ultrasound guided dry needling and autologous blood injection for the treatment of patellar tendinosis.

DESIGN

Prospective cohort study.

SETTING

Hospital/clinic based.

PATIENTS

47 knees in 44 patients (40 men, 7 women, mean age 34.5 years, age range 17 to 54 years) with refractory tendinosis underwent sonographic examination of the patellar tendon following referral with a clinical diagnosis of patellar tendinosis (mean symptom duration 12.9 months).

INTERVENTIONS

Ultrasound guided dry needling and injection of autologous blood into the site of patellar tendinosis was performed on two occasions four weeks apart.

MAIN OUTCOME MEASURES

Pre- and post-procedure Victorian Institute of Sport Assessment scores (VISA) were collected to assess patient response to treatment. Follow up ultrasound examination was done in 21 patients (22 knees).

RESULTS

Therapeutic intervention led to a significant improvement in VISA score: mean pre-procedure score = 39.8 (range 8 to 72) v mean post procedure score = 74.3 (range 29 to 100), p<0.001; mean follow up 14.8 months (range 6 to 22 months). Patients were able to return to their sporting interests. Follow up sonographic assessment showed a reduction in overall tendon thickness and in the size of the area of tendinosis (hypoechoic/anechoic areas within the proximal patellar tendon). A reduction was identified in interstitial tears within the tendon substance. Neovascularity did not reduce significantly or even increased.

CONCLUSIONS

Dry needling and autologous blood injection under ultrasound guidance shows promise as a treatment for patients with patellar tendinosis.

Surgical treatment of chronic patellar tendinosis: a systematic review

There is no consensus in the literature on the best surgical procedure for patellar tendinosis when nonoperative treatment fails. With a systematic review, we asked whether surgical treatment of the inferior pole of the patella, closing of the paratenon, or immobilization affected the percentage of patients reporting good to excellent results (percent success). We completed a systematic review of surgical treatment for patellar tendinosis. A literature search of Medline, CINAHL, and Sport Discus revealed 30 articles on treatment of patellar tendinosis. Ten met our initial inclusion criteria. Most studies were retrospective and used varying techniques. Outcome measures were individual to the specific article, making it difficult to compare the results of the studies. Studies that described surgical treatment of the inferior pole of the patella had 70.9% success compared to 91.7% for those that performed no patella bony work. Closure of the paratenon was reported in seven studies with 84.8% success compared to 91.5% for the other studies. Immobilization was used in four studies with 82.4% success compared to 94.9% success for four studies that did not immobilize postoperatively. Care must be taken when comparing these weighted averages since only two of the nine studies described exactly the same technique. Ideally, prospective controlled studies with validated assessment tools and activity scores are required to determine the best treatment for our patients.

Recalcitrant patellar tendinosis in elite athletes: surgical treatment in conjunction with aggressive postoperative rehabilitation

BACKGROUND

Recalcitrant patellar tendinosis is difficult to treat, and results are varied.

HYPOTHESIS

Surgical removal of necrotic tissue, surgical stimulation of remaining tendon, and aggressive and specific rehabilitation after patellar tendonectomy will allow athletes to return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From December 1996 to July 2002, 16 high-level athletes (4 professional, 2 Olympic, 9 collegiate, 1 preparatory), aged 16 to 25 years (mean, 19.7 years), with 22 symptomatic patellar tendons had failed nonoperative care of their patellar tendinosis symptoms and were unable to compete effectively in their sports. Magnetic resonance imaging showed confirmation of disease, with typical findings being necrosis in the posterior half of an abnormally thick patellar tendon, often in conjunction with partial tearing of the posterior half with a compensatory enlargement of the anterior half. Each patient then underwent tendonectomy of the necrotic portion in conjunction with stimulation of the remaining tendon by making multiple longitudinal cuts in the tendon. Patients participated in a postoperative rehabilitation protocol that included immediate range of motion, full flexion, and immediate high-repetition, low-resistance quadriceps muscle exercise.

RESULTS

Subjective improvement was noted in all athletes. Return to the same sport at prior level of intensity was accomplished by 14 of 16 patients (87.5%) at a mean of 8.1 months (range, 3-12 months).

CONCLUSION

Overall, tendonectomy, surgical tendon stimulation, and aggressive postoperative rehabilitation were found to be a safe, effective way to return high-level athletes to their sports.

Extracorporeal shock wave therapy in the treatment of chronic tendinopathies

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

Arthroscopic patellar release for the treatment of chronic patellar tendinopathy

We describe an arthroscopic technique for the treatment of chronic patellar tendinopathy (jumper's knee). Preoperatively, tendon necrosis or rupture is excluded by sonography. Diagnostic arthroscopy is performed and hypertrophic synovitis around the inferior patellar pole is removed with a bipolar cautery system. Two outside-in cannulas mark the clinically symptomatic region, mainly found between the tendon insertion site and the lateral aspects of the patellar tendon. The bipolar cautery is used for a release of the paratenon and a bone denervation at the inferior patellar pole including the tendon insertion site within the marked area. No tendon or bone material is removed or excised throughout the procedure. We treated 15 athletes with stage 3 and 4 chronic patellar tendinopathies on a modified version of the Blazina score (0-5). Patients' mean age was 29 years and the mean follow-up period was 41 months. In 13 cases, clinical symptoms subsided completely within 3 months after surgery. The mean preoperative Blazina score was 3.7 (SD, 0.5) and the mean postoperative Blazina score was 0.4 (SD, 1.0; paired 2-tailed t test, P < .01). Ultrasound showed a reduction of tendon edema within 3 weeks and no signs of edema within a mean period of 5 weeks after surgery. The minimal surgical impact to the tendon allows early and functional rehabilitation. The technique is effective, easy to perform, and safe to apply.

Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis

BACKGROUND

Plantar fasciitis is a common foot disorder that may be resistant to nonoperative treatment. This study evaluated the use of electrohydraulic high-energy shock waves in patients who failed to respond to a minimum of six months of antecedent nonoperative treatment.

METHODS

A randomized, placebo-controlled, multiply blinded, crossover study was conducted. Phase 1 consisted of twenty patients who were nonrandomized to treatment with extracorporeal shock waves to assess the phase-2 study protocol. In phase 2, 293 patients were randomized and an additional seventy-one patients were nonrandomized. Following ankle-block anesthesia, each patient received 100 graded shocks starting at 0.12 to 0.22 mJ/mm(2), followed by 1400 shocks at 0.22 mJ/mm(2) with use of a high-energy electrohydraulic shock-wave device. Patients in the placebo group received minimal subcutaneous anesthetic injections and nontransmitted shock waves by the same protocol. Three months later, patients were given the opportunity to continue without further treatment or have an additional treatment. This allowed a patient in the active treatment arm to receive a second treatment and a patient who received the placebo to cross over to the active treatment arm. Patients were followed at least one year after the final treatment.

RESULTS

Treatment was successful in seventeen of the twenty phase-1 patients at three months. This improved to nineteen (95%) of twenty patients at one year and was maintained at five years. In phase 2, three months after treatment, sixty-seven (47%) of the 144 actively treated patients had a completely successful result compared with forty-two (30%) of the 141 placebo-treated patients (p = 0.008). At one year, sixty-five of the sixty-seven actively treated, randomized patients maintained a successful result. Thirty-six (71%) of the remaining fifty-one nonrandomized patients had a successful result at three months. For all 289 patients who had one or more actual treatments, 222 (76.8%) had a good or excellent result. No patient was made worse by the procedure.

CONCLUSIONS

The application of electrohydraulic high-energy shock waves to the heel is a safe and effective noninvasive method to treat chronic plantar fasciitis, lasting up to and beyond one year.