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

The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Tendinopathy is a common condition that affects the body's tendon structures, causing discomfort, restricted movement, and reduced functionality. In this study, we looked at how extracorporeal shock wave therapy (ESWT) affected pain levels in individuals with various forms of tendinopathy around the world.

DESIGN

This study is a comprehensive review and meta-analysis of previously published randomized controlled trials. To gather relevant data, the researchers performed keyword searches in international databases, including PubMed (Medline), Scopus, Web of Sciences, Cochrane Central Register of Controlled Trials (CENTRAL), Research Registers of ongoing trials (ClinicalTrials.gov), as well as Embase. The search was conducted up until March 2023. The quality of the selected articles was assessed using the Cochrane risk-of-bias method for randomized trials (RoB2).

RESULTS

Based on the results of the meta-analysis, which included 45 clinical studies, the use of ESWT was found to have a significant impact on reducing pain in various conditions. The standardized mean difference (SMD) in patients with plantar fasciitis (PF) was reduced by 1.63 (SMD: -1.63, 95% CI: -3.04, -0.21; I2: 77.36%; P heterogeneity: 0.0001). For lateral epicondylitis (LE), the SMD was 0.63 (SMD: -0.63, 95% CI: -1.11, -0.16; I2: 67.50%; P heterogeneity: 0.003). In the case of chronic Achilles tendinopathy, the SMD was 1.38 (SMD: -1.38, 95% CI: -1.66, -1.10; I2: 96.44%; P heterogeneity: 0.0001). Additionally, in individuals with rotator cuff tendinopathy, the SMD for pain reduction was 2.37 units (SMD: -2.37, 95% CI: -3.58, -1.15; I2: 98.46%; P heterogeneity: 0.0001).

CONCLUSION

This study suggests that ESWT can be a highly effective therapy option for relieving pain in people with tendinopathy. Nonetheless, it is encouraged to make additional recommendations based on high-quality clinical research and more accurate information in order to define the optimal therapeutic options for each type of tendinopathy.

Recurrence rates for surgically treated insertional Achilles tendinopathy

INTRODUCTION

Insertional Achilles tendinopathy (IAT) is a challenge for every orthopedic surgeon. Although surgical intervention is difficult to avoid after frustrating conservative therapy, little is known about recurrence of this disorder. Therefore the aim of the study was to assess the recurrence rate after primary IAT surgery.

MATERIALS AND METHODS

The authors previous published cohort on primary IAT surgery was reanalyzed. Patients with a follow-up Foot and Function Index (FFI) at one year and final follow-up were included. IAT recurrence was defined as a FFI worsening between one year and final follow-up of > 6.5 points. General demographics, surgical details, complications, and the patient reported outcome (PROM) were assessed.

RESULTS

Out of 58 included patients (51 ± 14 years), 8 patients (14%) suffered IAT recurrence after an average of 50 ± 25 months. None of the assessed factors was predictive for an IAT recurrence.

CONCLUSION

IAT recurrence after primary surgery occurs in up to 14% of patients.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

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.

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.

Victorian Institute of Sport Assessment-Achilles thresholds for minimal important change and return to presymptom activity level in active soldiers with mid-portion Achilles tendinopathy

INTRODUCTION

Mid-portion Achilles tendinopathy (mid-AT) is common in soldiers, significantly impacting activity levels and operational readiness. Currently, Victorian Institute of Sport Assessment-Achilles (VISA-A) represents the gold standard to evaluate pain and function in mid-AT. Our objective was to estimate VISA-A thresholds for minimal important change (MIC) and patient-acceptable symptom state for return to the presymptom activity level (PASS-RTA), in soldiers treated with a conservative programme for mid-AT.

METHODS

A total of 40 soldiers (40 unilateral symptomatic Achilles tendons) were included in this prospective cohort study. Pain and function were evaluated using VISA-A. Self-perceived recovery was assessed with the Global Perceived Effect scale. The predictive modelling method (MIC-predict) was used to estimate MIC VISA-A post-treatment (after 26 weeks) and after 1 year of follow-up. The post-treatment PASS-RTA VISA-A was estimated using receiver operating characteristic statistics. The PASS-RTA was determined by calculating Youden's index value closest to 1.

RESULTS

The adjusted MIC-predict was 6.97 points (95% CI 4.18 to 9.76) after 26 weeks and 7.37 points (95% CI 4.58 to 10.2) after 1 year of follow-up post-treatment.The post-treatment PASS-RTA was 95.5 points (95% CI 92.2 to 97.8).

CONCLUSIONS

A VISA-A change score of 7 points, post-treatment and at 1 year of follow-up, can be considered a minimal within-person change over time, above which soldiers with mid-AT perceive themselves importantly changed. Soldiers consider their symptoms to be acceptable for return to their presymptom activity level at a post-treatment VISA-A score of 96 points or higher.

TRIAL REGISTRATION NUMBER

NL69527.028.19.

Poor association between tendon structure and self-reported symptoms following conservative management in active soldiers with mid-portion Achilles tendinopathy

Introduction

Mid-portion Achilles tendinopathy (mid-AT) is currently the preferred term for persistent Achilles tendon pain, defined as located 2–7 cm proximal to the calcaneus, and with loss of function related to mechanical loading. Histologically, mid-AT is considered to represent a degenerative condition. Therefore, monitoring of tendon structure additional to pain and function may be warranted, to prevent progression of degeneration or even tendon rupture. The aim of this study was to determine the association between pain and function, relative to the Achilles tendon structure, in soldiers treated with a conservative programme for mid-AT.

Methods

A total of 40 soldiers (40 unilateral symptomatic tendons) were included in this study. Pain and function were evaluated with the Victorian Institute of Sports Assessment -Achilles (VISA-A) questionnaire. Tendon structure was quantified using ultrasound tissue characterisation (UTC). We quantified both the Achilles tendon mid-portion (2–7 cm) and the area of maximum degeneration (AoMD) within the tendon mid-portion. VISA-A and UTC measurements were taken at baseline and after 26 weeks of follow-up. Spearman’s rho was used to determine the correlation between VISA-A and UTC. Correlations were calculated for baseline, follow-up and change score values.

Results

Negligible correlations were found for all analyses, ranging from −0.173 to 0.166 between mid-portion tendon structure and VISA-A, and from −0.137 to 0.150 between AoMD and VISA-A. While VISA-A scores improved, on average, from 59.4 points at baseline to 93.5 points at follow-up, no detectable improvement in aligned fibrillar structure was observed in our population.

Conclusion

Pain and function are poorly associated with Achilles tendon structure in soldiers treated with a conservative programme for mid-AT. Therefore, we advise clinicians to use great caution in communicating relationships between both clinical entities.

Trial registration number

NL69527.028.19.