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Mansur NSB, Baumfeld T, Villalon F, Aoyama BT, Matsunaga FT, Dos Santos PRD, Dos Santos BS, Tamaoki MJS. Shockwave Therapy Associated With Eccentric Strengthening for Achilles Insertional Tendinopathy: A Prospective Study. Foot Ankle Spec 2019; 12:540-545. [PMID: 30712379 DOI: 10.1177/1938640019826673] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Tiago Baumfeld
- UNIFESP-Escola Paulista de Medicina, São Paulo, SP, Brazil
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Lipman K, Wang C, Ting K, Soo C, Zheng Z. Tendinopathy: injury, repair, and current exploration. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:591-603. [PMID: 29593382 PMCID: PMC5865563 DOI: 10.2147/dddt.s154660] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Both acute and chronic tendinopathy result in high morbidity, requiring management that is often lengthy and expensive. However, limited and conflicting scientific evidence surrounding current management options has presented a challenge when trying to identify the best treatment for tendinopathy. As a result of shortcomings of current treatments, response to available therapies is often poor, resulting in frustration in both patients and physicians. Due to a lack of understanding of basic tendon-cell biology, further scientific investigation is needed in the field for the development of biological solutions. Optimization of new delivery systems and therapies that spatially and temporally mimic normal tendon physiology hold promise for clinical application. This review focuses on the clinical importance of tendinopathy, the structure of healthy tendons, tendon injury, and healing, and a discussion of current approaches for treatment that highlight the need for the development of new nonsurgical interventions.
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Affiliation(s)
| | - Chenchao Wang
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA.,First Hospital of China Medical University, Shenyang, China.,Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, University of California, Los Angeles, CA, USA
| | - Kang Ting
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA
| | - Chia Soo
- Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, University of California, Los Angeles, CA, USA
| | - Zhong Zheng
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA
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Mansur NSB, Faloppa F, Belloti JC, Ingham SJM, Matsunaga FT, dos Santos PRD, dos Santos BS, Carrazzone OL, Peixoto G, Aoyama BT, Tamaoki MJS. Shock wave therapy associated with eccentric strengthening versus isolated eccentric strengthening for Achilles insertional tendinopathy treatment: a double-blinded randomised clinical trial protocol. BMJ Open 2017; 7:e013332. [PMID: 28132005 PMCID: PMC5278235 DOI: 10.1136/bmjopen-2016-013332] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
| | - Flávio Faloppa
- Orthopedics and Traumatology—Division of Hand Surgery and Upper Limb, Federal University of São Paulo (UNIFESP/EPM), São Paulo, SP, Brazil
| | - João Carlos Belloti
- Orthopedics and Traumatology—Division of Hand Surgery and Upper Limb, Federal University of São Paulo (UNIFESP/EPM), São Paulo, SP, Brazil
| | | | - Fabio Teruo Matsunaga
- Orthopedics and Traumatology—Division of Hand Surgery and Upper Limb, Federal University of São Paulo (UNIFESP/EPM), São Paulo, SP, Brazil
| | | | | | | | - Gabriel Peixoto
- Department of Orthopaedics, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | - Bruno Takeshi Aoyama
- Department of Orthopaedics, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
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Tammachote N, Kanitnate S, Yakumpor T, Panichkul P. Intra-Articular, Single-Shot Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial. J Bone Joint Surg Am 2016; 98:885-92. [PMID: 27252432 DOI: 10.2106/jbjs.15.00544] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of knee osteoarthritis with hyaluronic acid or corticosteroid injection has been widely used. The purpose of this study was to compare the efficacy of hyaluronic acid (hylan G-F 20) with triamcinolone acetonide as a single intra-articular injection for knee osteoarthritis. METHODS This study was a prospective, randomized, double-blind clinical trial. Participants with symptomatic knee osteoarthritis were recruited. They were randomized to receive a single-shot, intra-articular injection of either 6 mL of hylan G-F 20 or 6 mL of a solution comprising 1 mL of 40-mg triamcinolone acetonide and 5 mL of 1% lidocaine with epinephrine. The primary outcomes were knee pain severity, knee function, and range of motion at 6 months. Ninety-nine patients were assessed before injection and underwent a 6-month follow-up. Patients and evaluators were blinded. Multilevel regression models were used to estimate differences between the groups. RESULTS At the 6-month follow-up, compared with patients who took hylan G-F 20, patients who took triamcinolone acetonide had similar improvement in knee pain, knee function, and range of motion. The difference in mean outcome scores between groups was, with regard to knee pain, a visual analog scale (VAS) score of 3 points (95% confidence interval [95% CI], -6 to 11 points); with regard to knee function, a modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of 0 points (95% CI, -8 to 6 points); and, with regard to range of motion, flexion of -1° (95% CI, -5° to 2°) and extension of 0° (95% CI, -0.5° to 0.5°). However, patients who took triamcinolone acetonide had better pain improvement from 24 hours until 1 week after injection; the mean difference between groups with regard to the VAS score was 12 points (95% CI, 5 to 20 points; p = 0.002) at 24 hours and 9 points (95% CI, 1 to 15 points; p = 0.018) at 1 week. At 2 weeks after injection, patients who took triamcinolone acetonide also had better knee functional improvement; the mean difference between groups for the modified WOMAC score was 6 points (95% CI, 0.7 to 12 points; p = 0.03). Both groups had improvement in pain, knee function, and range of motion during the 6-month follow-up (p < 0.0001). CONCLUSIONS Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nattapol Tammachote
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand
| | - Supakit Kanitnate
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand
| | - Thanasak Yakumpor
- Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Department of Orthopaedics, Faculty of Medicine, Burapha University, Saen Sook Sub-district, Mueang District, Chonburi, Thailand
| | - Phonthakorn Panichkul
- Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Hip and Knee Center, Bangkok Hospital Medical Center, Bangkok, Thailand
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