Eccentric loading vs shockwave for achilles tendonitis

NewsBot · Jan 24, 2007

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Eccentric Loading, Shock-Wave Treatment, or a Wait-and-See Policy for Tendinopathy of the Main Body of Tendo Achillis: A Randomized Controlled Trial
Jan D. Rompe, Bernhard Nafe, John P. Furia, Nicola Maffulli,
American Journal of Sports Medicine 2007

Background: Few randomized controlled trials compare different methods of management in chronic tendinopathy of the main body of tendo Achillies.

Purpose: To compare the effectiveness of 3 management strategies--group 1, eccentric loading; group 2, repetitive low-energy shock-wave therapy (SWT); and group 3, wait and see--in patients with chronic tendinopathy of the main body of tendo Achillis.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Seventy-five patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on intention-to-treat basis.

Results: At 4 months from baseline, the Victorian Institute of Sport Assessment (VISA)-A score increased in all groups, from 51 to 76 points in group 1 (eccentric loading), from 50 to 70 points in group 2 (repetitive low-energy SWT), and from 48 to 55 points in group 3 (wait and see). Pain rating decreased in all groups, from 7 to 4 points in group 1, from 7 to 4 points in group 2, and from 8 to 6 points in group 3. Fifteen of 25 patients in group 1 (60%), 13 of 25 patients in group 2 (52%), and 6 of 25 patients in Group 3 (24%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 did not differ significantly. For all outcome measures, groups 1 and 2 showed significantly better results than group 3.

Conclusion: At 4-month follow-up, eccentric loading and low-energy SWT showed comparable results. The wait-and-see strategy was ineffective for the management of chronic recalcitrant tendinopathy of the main body of the Achilles tendon
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Admin2 · Jan 24, 2007

Related threads:
Achilles tendon strap
Anderson "prescription" for achilles tendinopathy
Genetic component to achilles tendon pathology
Aprotinin for Achilles tendinopathy?
Ibuprofin injection in Achilles tendinopathy

Extracorporeal Shock Wave Therapy

NewsBot · Mar 30, 2007

Chronic tendinopathy: effectiveness of eccentric exerciseBrett L Woodley, Richard J Newsham-West and G David Baxter
British Journal of Sports Medicine 2007;41:188-198

Objectives: To determine the effectiveness of eccentric exercise (EE) programmes in the treatment of common tendinopathies.

Data sources: Relevant randomised controlled trials (RCTs) were sourced using the OVID website databases: MEDLINE (1966–Jan 2006), CINAHL (1982–Jan 2006), AMED (1985–Jan 2006), EMBASE (1988–Jan 2006), and all EBM reviews – Cochrane DSR, ACP Journal Club, DARE, and CCTR (Jan 2006). The Physiotherapy Evidence Database (PEDro) was also searched using the keyword: eccentric.

Review methods: The PEDro and van Tulder scales were employed to assess methodological quality. Levels of evidence were then obtained according to predefined thresholds: Strong–consistent findings among multiple high-quality RCTs. Moderate–consistent findings among multiple low-quality RCTs and/or clinically controlled trials (CCTs) and/or one high-quality RCT. Limited–one low-quality RCT and/or CCT. Conflicting–inconsistent findings among multiple trials (RCTs and/or CCTs). No evidence–no RCTs or CCTs.

Results: Twenty relevant studies were sourced, 11 of which met the inclusion criteria. These included studies of Achilles tendinopathy (AT), patella tendinopathy (PT) and tendinopathy of the common wrist extensor tendon of the lateral elbow (LET). Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound. Levels of evidence were found to be variable across the tendinopathies investigated.

Conclusions: This review demonstrates the dearth of high-quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies. Further adequately powered studies that include appropriate randomisation procedures, standardised outcome measures and long-term follow-up are required.
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NewsBot · Jan 2, 2008

Eccentric Loading Compared with Shock Wave Treatment for Chronic Insertional Achilles Tendinopathy
A Randomized, Controlled Trial
Jan D. Rompe, John Furia, Nicola Maffulli
The Journal of Bone and Joint Surgery (American). 2008;90:52-61.

Background: Nonoperative management of chronic tendinopathy of the Achilles tendon insertion has been poorly studied. With the recently demonstrated effectiveness of eccentric loading and of repetitive low-energy shock wave therapy in patients with midsubstance Achilles tendinopathy, the aim of the present randomized, controlled trial was to verify the effectiveness of both procedures exclusively in patients with insertional Achilles tendinopathy.
Methods: Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized, controlled study. All patients had received treatment, including local injections of an anesthetic and/or corticosteroids, a prescription of nonsteroidal anti-inflammatory drugs, and physiotherapy, without success for at least three months. A computerized random-number generator was used to draw up an allocation schedule. Twenty-five patients were allocated to receive eccentric loading (Group 1), and twenty-five patients were allocated to treatment with repetitive low-energy shock wave therapy (Group 2). Analysis was on an intention-to-treat basis. Primary follow-up was at four months, and afterward patients were allowed to cross over. The last follow-up evaluation was at one year after completion of the initial treatment. The patients were assessed for pain, function, and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire).

Results: At four months from baseline, the mean VISA-A score had increased in both groups, from 53 to 63 points in Group 1 and from 53 to 80 points in Group 2. The mean pain rating decreased from 7 to 5 points in Group 1 and from 7 to 3 points in Group 2. Seven patients (28%) in Group 1 and sixteen patients (64%) in Group 2 reported that they were completely recovered or much improved. For all outcome measures, the group that received shock wave therapy showed significantly more favorable results than the group treated with eccentric loading (p = 0.002 through p = 0.04). At four months, eighteen of the twenty-five patients from Group I had opted to cross over, as did eight of the twenty-five patients from Group 2. The favorable results after shock wave therapy at four months were stable at the one-year follow-up evaluation.

Conclusions: Eccentric loading as applied in the present study showed inferior results to low-energy shock wave therapy as applied in patients with chronic recalcitrant tendinopathy of the insertion of the Achilles tendon at four months of follow-up. Further research is warranted to better define the indications for this treatment modality.
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NewsBot · May 20, 2008

Shockwave therapy for chronic Achilles tendinopathy: A double-blind, randomized clinical trial of efficacy.
Rasmussen S, Christensen M, Mathiesen I, Simonson O.
Acta Orthop. 2008 Apr;79(2):249-56

Background and purpose Chronic Achilles tendinopathy is a painful condition and there are often unsatisfactory results with conservative treatment. Extracorporal shock-wave therapy (ESWT) has been introduced for the management of various soft tissue conditions. The objective of the study was to compare the effect of supplementing conservative treatment of chronic Achilles tendinopathy with ESWT or placebo.

Patients and methods This was a randomized, double-blind, placebo-controlled trial. Patients assigned to nonoperative treatment of chronic achilles tendinopathy were randomized to receive either active ESWT or sham ESWT over 4 weeks. There were 48 patients (28 men) with a mean age of 47 (19-80) years. American Orthopaedic Foot and Ankle Society (AOFAS) score and pain were assessed before treatment, during the 4-week treatment period, and at 4, 8, and 12 weeks of follow-up.

Results Both groups improved during the treatment and follow-up period. The mean AOFAS score increased from 74 (SD 12) to 81 (16) in the placebo group and from 70 (6.8) to 88 (10) in the intervention group (p = 0.05). Better results were seen in the intervention group at 8 and 12 weeks of follow-up (p = 0.01 and p = 0.04, respectively).

Interpretation Extracorporal shock-wave therapy appears to be a supplement for the treatment of chronic Achilles tendinopathy.
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NewsBot · Oct 31, 2008

Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain—A pilot study
Rachel Chester, Mathew L. Costa, Lee Shepstone, Adele Cooper and Simon T. Donell
Manual Therapy; Volume 13, Issue 6, December 2008, Pages 484-491

A number of studies have indicated that eccentric calf muscle training has beneficial effects in the management of Achilles tendon pain for recreational athletes. The purpose of this prospective randomised single blind pilot study was to investigate their potential effectiveness compared with therapeutic ultrasound in subjects with relatively sedentary lifestyles in an NHS hospital setting. Eleven men and five women (mean age 53±21 years) with Achilles tendon pain of minimum duration 4 months were randomised to one of two treatment groups; either eccentric loading or ultrasound. Administration of ultrasound and regular supervision of exercises occurred over a period of 6 weeks, with unsupervised exercises continuing for another 6 weeks. Outcome measurements were taken prior to and after 2, 4, 6 and 12 weeks after commencing treatment. They included: pain on a visual analogue scale, functional index of the leg and lower limb, and the five question EuroQol generalised health questionnaire. The difference in mean score was calculated together with 95% confidence intervals assuming a normal distribution. There were no statistically significant differences between groups or clear trends over time. In addition there was considerable overlap between the confidence intervals. This is not unexpected given the small sample size. Both interventions proved acceptable to the patients with no adverse effects. On this basis we intend conducting a full multi-centred study.
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NewsBot · Dec 16, 2008

Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy: A Randomized Controlled Trial
Jan D. Rompe, John Furia, Nicola Maffulli
American Journal of Sports Medicine; First published on December 15, 2008

Background: Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.

Purpose: To compare the effectiveness of 2 management strategies—group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis.

Results: At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.

Conclusion: At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.
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alessandro costa · Feb 28, 2012

NewsBot said: ↑

Eccentric Loading, Shock-Wave Treatment, or a Wait-and-See Policy for Tendinopathy of the Main Body of Tendo Achillis: A Randomized Controlled Trial
Jan D. Rompe, Bernhard Nafe, John P. Furia, Nicola Maffulli,
American Journal of Sports Medicine 2007
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thank you, but what about shock wawes in INSERTIONAL TENDINOPATHY of tendo achillis (not the main body)

NewsBot · Jan 15, 2013

The Effectiveness of Extracorporeal Shock Wave Therapy on Chronic Achilles Tendinopathy:A Systematic Review
Hani Al-Abbad, Joel Varghese Simon
Foot & Ankle International January 2013 vol. 34 no. 1 33-41

Background: Achilles tendinopathy is a pathological state resulting from repetitive loading or stress on the tendon. Extracorporeal shock wave therapy (ESWT) is hypothesized to be an effective alternative intervention to surgery when other conservative therapies fail. This systematic review investigated the effectiveness of ESWT in the treatment of insertional and noninsertional Achilles tendinopathies.

Methods: Articles were electronically searched from the Cochrane Controlled Trials Register, MEDLINE, CINAHL, EMBASE, and SPORTDiscus using a comprehensive search strategy. Studies were included if they were prospective clinical trials examining the effectiveness of ESWT for insertional or noninsertional Achilles tendinopathies. Methodological quality of included studies was assessed using PEDro scale and Modified McMaster tool. The strength of the evidence was reported using the National Health and Medical Research Council body of evidence framework. A narrative summary of the findings was presented.

Results: Four of the included studies were randomized controlled trials, and 2 were pre-post study designs. Common methodological deficiencies included not blinding the clinician and participants. There was consistent evidence from 4 reviewed studies on the effectiveness of ESWT in the management of patients with chronic Achilles tendinopathies at a minimum 3 months’ follow-up.

Conclusion: Overall, our review showed satisfactory evidence for the effectiveness of low-energy ESWT in the treatment of chronic insertional and noninsertional Achilles tendinopathies at a minimum 3 months’ follow-up before considering surgery if other conservative management fails. However, combining ESWT with eccentric loading appears to show superior results.
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NewsBot · May 10, 2014

The Effectiveness of Extracorporeal Shock Wave Therapy in Lower Limb Tendinopathy: A Systematic Review
Sethu Mani-Babu, Dylan Morrissey, Charlotte Waugh, Hazel Screen, and Christian Barton
Am J Sports Med May 9, 2014

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.
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NewsBot · Oct 29, 2016

Low-Energy Extracorporeal Shock-Wave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy: A Case Series
Vito Pavone, Luca Cannavò, Antonio Di Stefano, Gianluca Testa, Luciano Costarella, and Giuseppe Sessa
BioMed Research International
Volume 2016 (2016)

Introduction. We report the results of a series of 40 patients with chronic insertional Achilles tendinopathy treated with low-energy ESWT after the failure of a 3-month program of eccentric exercises alone.
Methods and Materials. 40 patients, 28 (70%) males and 12 (30%) females, were treated between January and December 2014. All patients were previously treated with only eccentric exercises for a 3-month period. The treatment protocol included 4 sessions of ESWT with a 2-week interval, from 800 shots in each one (4 Hz, 14 KeV), together with eccentric exercises. Visual Analogue Scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot score were recorded.
Results. At the 12-month follow-up, 26 (65.0%) patients did not complain about pain (VAS < 2), 11 (27.5%) patients got back to normal activities despite residual pain (VAS 2–4), and 3 (7.5%) of the patients still complained about pain (VAS > 4). There was no significative improvement in both scores after eccentric exercises alone. Mean VAS improvement was SD points (). Mean AOFAS Hindfoot score improvement was SD points ().
Conclusions. ESWT is recommended, in combination with an eccentric exercise program, in patients with chronic Achilles tendinopathy being both insertional and not.
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NewsBot · Dec 6, 2016

Outcome of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy with and without Haglund’s Deformity
Ziying Wu, Wei Yao, Shiyi Chen, and Yunxia Li
BioMed Research International; Volume 2016 (2016), Article ID 6315846, 6 pages

Purpose. To compare the results of extracorporeal shock wave therapy (ESWT) for insertional Achilles tendinopathy (IAT) with or without Haglund’s deformity.
Methods. Between September 2014 and May 2015, all patients who underwent ESWT were retrospectively enrolled in this study. A total of 67 patients were available for follow-up and assigned intonondeformtiy group () and deformtiy group (). Clinical outcomes were evaluated by VISA-A Score and 6-point Likert scale.
Results. The VISA-A score increased in both groups, from at baseline to at months after treatment in nondeformity group () and from at baseline to at months after treatment in deformity group (). However, there was a greater improvement in VISA-A Score for the nondeformity group compared with deformity group (). For the 6-point Likert scale, there were decreases from at baseline to at the follow-up time point in nondeformity group () and from at baseline to at the follow-up time point in deformity group (). There was no significant difference in improvement of the 6-point Likert scale between both groups ().
Conclusions. ESWT resulted in greater clinical outcomes in patients without Haglund’s deformity compared with patients with Haglund’s deformity.
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NewsBot · Mar 9, 2017

Comparison of Clinical Efficacy Among Endoscopy-Assisted Radio-Frequency Ablation, Extracorporeal Shockwaves, and Eccentric Exercises in Treatment of Insertional Achilles Tendinosis.
Min Wei, PhD, Yujie Liu, MD, Zhongli Li, PhD, Zhigang Wang, PhD
Journal of the American Podiatric Medical Association: January 2017, Vol. 107, No. 1, pp. 11-16.

Background: We sought to compare clinical efficacy among endoscopy-assisted radio-frequency ablation under local anesthesia, extracorporeal shockwaves (ESWs), and eccentric exercises in treating insertional Achilles tendinosis.

Methods: In this retrospective study, 78 patients diagnosed as having unilateral insertional Achilles tendinosis were enrolled. These participants underwent endoscopy-assisted radio-frequency ablation, ESWs, and eccentric calf muscle exercises between March 1, 2006, and February 28, 2011. Clinical efficacy was evaluated by the visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot scale, and the Victorian Institute of Sport Assessment–Achilles (VISA-A) scale before and after treatment.

Results: Before treatment, there were no statistically significant differences in VAS, AOFAS ankle/hindfoot scale, and VISA-A scale scores among the different groups (all P > .05). For the endoscopy and ESW groups, VAS, AOFAS ankle/hindfoot scale, and VISA-A scale scores were significantly improved after 18 months of treatment (all P < .05). The VAS, AOFAS ankle/hindfoot scale, and VISA-A scale scores in the endoscopy group were significantly higher than those in the ESW and eccentric exercise groups after 18 months of therapy (all P < .05).

Conclusions: Combined with synovectomy and tendon debridement, endoscopy-assisted radio-frequency ablation yields better clinical efficacy compared with ESWs in treating insertional Achilles tendinosis.
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Craig Payne · Mar 9, 2017

More evidence of just how bad JAPMA's peer review and editorial process has become

NewsBot said: ↑

Comparison of Clinical Efficacy Among Endoscopy-Assisted Radio-Frequency Ablation, Extracorporeal Shockwaves, and Eccentric Exercises in Treatment of Insertional Achilles Tendinosis.
Min Wei, PhD, Yujie Liu, MD, Zhongli Li, PhD, Zhigang Wang, PhD
Journal of the American Podiatric Medical Association: January 2017, Vol. 107, No. 1, pp. 11-16.
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Used a t-test on 3 groups. Fail.

NewsBot · Mar 14, 2017

Long-Term Outcome and Factors Affecting Prognosis of Extracorporeal Shockwave Therapy for Chronic Refractory Achilles Tendinopathy
Joon-Youn Lee et al
Ann Rehabil Med. 2017 Feb;41(1):42-50.

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.
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NewsBot · Jun 1, 2017

Manual therapy and eccentric exercise in the management of Achilles tendinopathy.
Jayaseelan DJ et al
J Man Manip Ther. 2017 May;25(2):106-114. doi: 10.1080/10669817.2016.1183289.

Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT.
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NewsBot · Jun 7, 2017

Healing of Achilles tendon partial tear following focused shockwave: a case report and literature review.
Hsu YC et al
J Pain Res. 2017 May 19;10:1201-1206. doi: 10.2147/JPR.S132951. eCollection 2017.

Achilles tendinopathy is a common cause of posterior heel pain and can progress to partial tendon tear without adequate treatment. Effects of traditional treatments vary, and many recent reports focus on the use of extracorporeal shockwave therapy (ESWT) for Achilles tendinopathy but not for Achilles tendon partial tear. Here, we report the case of a 64-year-old female suffering from severe left heel pain for half a year. All treatment and rehabilitation were less effective until ESWT was applied. Each course of focused shockwave therapy included 2500 shots with energy flux density from 0.142 mJ/mm2 to 0.341 mJ/mm2. The visual analog scale decreased from nine to one degree. High-resolution musculoskeletal ultrasonography was performed before and 1 month after the treatment, which revealed healing of the torn region and decrease in inflammation. ESWT had shown to be an alternative treatment for Achilles tendon partial tear under safety procedure and ultrasound observation.
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NewsBot · May 20, 2018

Novel Interventions for Recalcitrant Achilles Tendinopathy: Benefits Seen Following High-Volume Image-Guided Injection or Extracorporeal Shockwave Therapy—A Prospective Cohort Study
Wheeler, Patrick et al
Clinical Journal of Sport Medicine: May 16, 2018 - Volume Publish Ahead of Print - Issue - p

Objective: To compare the outcomes for patients with chronic noninsertional Achilles tendinopathy following extracorporeal shockwave therapy (ESWT) and high-volume image-guided injection (HVIGI).

Design: Prospective cohort study.

Setting: Hospital-based Sports Medicine Outpatient Clinic.

Patients: Sixty-three consecutive patients with chronic noninsertional Achilles tendinopathy, treated with ESWT (n = 22) or HVIGI (n = 41), with minimum 3-month follow-up. Mean age was 51.2 years, and mean duration of symptoms was 27.8 months.

Interventions: Patients received either 3 sessions of ESWT (1 session per week) or a single ultrasound-guided HVIGI (10 mL of 1% lidocaine and 40 mLs of sterile saline). All patients received standardized aftercare, including continuation of a structured home exercise program of flexibility and eccentric strengthening exercises.

Main Outcome Measures: Zero to 10 visual analog scale (VAS) for self-reported “average pain” and “average stiffness” values. In addition, Victoria Institute of Sport—Achilles questionnaire, (VISA-A), and Manchester-Oxford Foot Questionnaire (MOXFQ).

Results: This study demonstrated statistically significant improvements in self-reported measures of pain and stiffness following either procedure. At 3 months, VAS (pain) was improved from 6.74 ± 1.31 to 3.57 ± 2.37 (P < 0.001) following HVIGI and from 6.57 ± 1.61 to 4.35 ± 2.55 (P = 0.002) following ESWT. At 3 months, VISA-A improved from 35% ± 17% to 51% ± 22% (P < 0.001) following HVIGI and from 34% ± 15% to 49% ± 15% (P < 0.001) following ESWT. Statistically significant improvements were only recorded at 6 weeks for ESWT and at 3 months for HVIGI using MOXFQ. No statistically significant differences were seen between the groups at any period studied.

Conclusions: Patients improved to statistically significant extent following either a HVIGI or ESWT procedure, with no significant differences seen between the groups. The small sample sizes in this pragmatic study are noted, which limit interpretation, and larger more robust studies are required to investigate this further.

Clinical Relevance: This pragmatic prospective cohort study demonstrates improvements following either ESWT or HVIGI procedures, with no significant differences seen between the groups.
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NewsBot · Jun 12, 2018

Effectiveness of extracorporeal shockwave therapy for chronic Achilles tendinopathy: A randomized clinical trial.
Vahdatpour B et al
J Res Med Sci. 2018 Apr 26;23:37.

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.
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NewsBot · Feb 5, 2019

Shockwave Therapy Associated With Eccentric Strengthening for Achilles Insertional Tendinopathy: A Prospective Study
Nacime Salomão Barbachan Mansur, MD, Tiago Baumfeld, MD, Fernando Villalon, MD, ...
Foot & Ankle Specialist February 2, 2019

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.
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NewsBot · Mar 24, 2019

Extracorporeal Shock Wave Therapy Plus Rehabilitation for Insertionaland Noninsertional Achilles Tendinopathy Shows Good Results Across a Range of Domains of Function
Patrick C. Wheeler
JFAS: Article in Press

Achilles tendinopathy, both insertional and noninsertional, is a common cause of posterior ankle pain. Although the condition of most patients improves with simple conservative measures, a proportion will go on develop chronic symptoms. This study examines the outcomes of patients following extracorporeal shock wave therapy plus a home exercise program. This prospective case series study involves a total of 39 patients, with a mean follow-up duration of 163 (range 65 to 385) days. This has demonstrated significant benefits in pain, stiffness, and a range of measures of local and global function. Median (interquartile range [IQR]) values for average self-reported pain improved from 6.5 of 10 (IQR 5.0 to 7.8) at baseline to 3.5 of 10 (IQR 2.0 to 5.1) at 3 months and to 2.0 of 10 (IQR 0.6 to 4.8) at 6 months for patients with insertional Achilles tendinopathy. This compares to improvements from 7.0 of 10 (IQR 7.0 to 8.0) at baseline to 6.0 of 10 (IQR 5.6 to 6.8) at 3 months and to 6.0 of 10 (IQR 3.0 to 7.0) at 6 months for patients with noninsertional Achilles tendinopathy. Statistically significant improvements were seen in insertional tendinopathy across a range of outcome measures; however, these were less apparent for patients with noninsertional tendinopathy. Despite these figures, no significant differences were seen in the outcomes for patients with insertional and noninsertional tendinopathy. Despite the improvements seen in the aspects of pain and function, physical activity levels had not increased following the treatment.
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NewsBot · Jun 1, 2019

EXTRACORPOREAL SHOCKWAVE VERSUS MUSCULOSKELETAL MESOTHERAPY FOR ACHILLES TENDINOPATHY IN ATHLETES FREE
Reem Elmallah, Enas Elattar
Annals of the Rheumatic Diseases

Background Achilles tendinopathy (AT) is considered as one of the common tendon pathologies, which occurs mainly in athletes. Different conservative treatment options have been introduced and used for symptoms relief of At but with short-term effect.1 Extracorporeal shockwave treatment (ESWT) provides longer effects and could be used in cases fail to respond to conservative treatments.2 Mesotherapy is widely practiced in sports medicine as multiple injections, often of anti-inflammatory medications into the subcutaneous fat overlying a region of musculoskeletal pain. The effect appears unclear but may be due to localized tissue uptake of anti-inflammatory medication which may provide symptomatic relief especially in insertional Achilles tendinopathy 3

Objectives In this study, we aimed to evaluate the effect of extracorporeal shockwave treatment

(ESWT)and mesotherapy on chronic Achilles tendinopathy in athletes

Methods 40 patients with chronic AT were diagnosed clinically & using high resolution ultrasound (US) according to the Eular guide lines and randomly allocated in two groups, first receive ESWT, other group underwent mesotherapy (MT) one session once a week for 4 weeks to the 2 groups. Pain, ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS) 4 & US were recorded at baseline, 4 and 12 weeks after intervention

Results Both groups improved during the treatment and follow-up period. The mean VAS score decreased from 7.55 to 3 in the ESWT group and from 7.70 to 4.30 in MT group. There was no significant difference in terms of AOFAS and VAS scores between both groups at 4 weeks follow up while Mean AOFAS & VAS scores were significantly different between ESWT and MT groups at 12 weeks of follow-up (P = 0.013) (P = 0.47). US assessment significantly improved after 12 weeks in ESWT group as regards tendon thickness, calcifications(figure1,2) and doppler signal.

Conclusion ESWT showed improvement of pain and inflammation of AT than MT injections which was documented by the decreased VAS, increased AOFAS scores as well as US improved findings shortly after the treatment as well as on late follow up.
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NewsBot · Jan 12, 2020

Effectiveness of Extracorporeal Shockwave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy.
Pinitkwamdee S etal
Foot Ankle Int. 2020 Jan 10

BACKGROUND:
Extracorporeal shockwave therapy (ESWT) has been proposed as a conservative treatment for insertional Achilles tendinopathy from limited evidence without placebo controls. Our objective was to assess the effectiveness of ESWT compared with sham controls in chronic insertional Achilles tendinopathy.

METHODS:
A double-blind, randomized sham-controlled trial was conducted between 2016 and 2018. The inclusion criteria were patients aged 18 to 70 years diagnosed with chronic insertional Achilles tendinopathy who failed standard conservative treatment. After computerized randomization, patients were allocated into either low-energy ESWT or sham control. Pain, function, and other complaints were assessed using visual analog scale (VAS) and VAS foot and ankle (VAS-FA) at preintervention and weeks 2, 3, 4, 6, 12, and 24. Intention-to-treat analysis and repeated measurement were performed using STATA 15.0.

RESULTS:
Sixteen patients in ESWT and 15 patients in sham control groups had nonsignificant different baseline characteristics with preintervention VAS (6.0 ± 2.6 vs 5.2 ± 2.2) and VAS-FA (64.8 ± 16.6 vs 65.3 ± 12.7). There was no significant difference in VAS, VAS-FA, and its domains in the long term between the 2 groups. In addition, the ESWT group had significant improvement in VAS (2.9 ± 2.2) at weeks 4 to 12, and sham controls group had significantly improved VAS (2.3 ± 2.6) at weeks 12 to 24. Complications were found only after ESWT treatment.

CONCLUSION:
There was no difference at 24 weeks with the use of low-energy ESWT for chronic insertional Achilles tendinopathy, especially in elderly patients. However, it may provide a short period of therapeutic effects as early as weeks 4 to 12.
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NewsBot · Jan 29, 2020

Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up
Shurong Zhang, MD, PhD, Hong Li, MD, PhD, Wei Yao, PT, ...
Orthopaedic Journal of Sports Medicine January 22, 2020

Background:
Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain. Extracorporeal shock wave therapy (ESWT) has proven to be an effective treatment, but the relationship between therapeutic responses and sports activity levels has not been studied.

Purpose:
To compare the clinical outcomes of ESWT used to treat IATs between sports-active and nonsports-active patients over 5 years.

Study Design:
Cohort study; Level of evidence, 3.

Methods:
A retrospective study was conducted on 33 patients with IAT who received ESWT from October 2012 to September 2013. Patients were classified into 2 groups according to their preinjury Tegner activity level: a sports-active group, defined as patients who self-reported to be regular joggers (SA group; Tegner activity level >3; n = 16), and a nonsports-active group (control group; Tegner activity level ≤3; n = 17). The mean age was 31 ± 7 years for the SA group and 37 ± 10 years for the control group. The Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire scores and visual analog scale (VAS) pain scores were used to evaluate the clinical outcomes before treatment, immediately after treatment, and 5 years after treatment. Ultrasonography was also used to assess the insertional Achilles tendon quality.

Results:
Before treatment, there were no significant differences between the groups with regard to VAS scores, while the VISA-A score in the SA group was higher than that in the control group. After ESWT, both groups had increased VISA-A scores and decreased VAS scores, indicating improvement. At 5-year follow-up, the SA group had a significantly lower mean VAS score (0.3 ± 0.8 vs 1.6 ± 1.3; P = .001) and a significantly higher mean VISA-A score (90 ± 4 vs 78 ± 7; P < .001) compared with the control group. There was no significant difference between the groups regarding the calcification and neovascularization of the Achilles tendon based on ultrasonography.

Conclusion:
ESWT can improve the symptoms of Achilles tendinopathy, and patients with IAT who had greater sports activity levels had better therapeutic responses than nonsports-active patients after 5-year follow-up.
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NewsBot · Mar 2, 2020

Efficacy of Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Meta-analysis
Yifei Fan, MBBS, Ziyan Feng, MBBS, Jun Cao, BSMed, ...
Orthopaedic Journal of Sports Medicine February 27, 2020

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.
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NewsBot · May 5, 2020

Effectiveness of Extracorporeal Shockwave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy
Siwadol Pinitkwamdee, MD, Sukij Laohajaroensombat, MD, Jakrapong Orapin, MD, ...
Foot & Ankle International January 10, 2020

Background:
Extracorporeal shockwave therapy (ESWT) has been proposed as a conservative treatment for insertional Achilles tendinopathy from limited evidence without placebo controls. Our objective was to assess the effectiveness of ESWT compared with sham controls in chronic insertional Achilles tendinopathy.

Methods:
A double-blind, randomized sham-controlled trial was conducted between 2016 and 2018. The inclusion criteria were patients aged 18 to 70 years diagnosed with chronic insertional Achilles tendinopathy who failed standard conservative treatment. After computerized randomization, patients were allocated into either low-energy ESWT or sham control. Pain, function, and other complaints were assessed using visual analog scale (VAS) and VAS foot and ankle (VAS-FA) at preintervention and weeks 2, 3, 4, 6, 12, and 24. Intention-to-treat analysis and repeated measurement were performed using STATA 15.0.

Results:
Sixteen patients in ESWT and 15 patients in sham control groups had nonsignificant different baseline characteristics with preintervention VAS (6.0 ± 2.6 vs 5.2 ± 2.2) and VAS-FA (64.8 ± 16.6 vs 65.3 ± 12.7). There was no significant difference in VAS, VAS-FA, and its domains in the long term between the 2 groups. In addition, the ESWT group had significant improvement in VAS (2.9 ± 2.2) at weeks 4 to 12, and sham controls group had significantly improved VAS (2.3 ± 2.6) at weeks 12 to 24. Complications were found only after ESWT treatment.

Conclusion:
There was no difference at 24 weeks with the use of low-energy ESWT for chronic insertional Achilles tendinopathy, especially in elderly patients. However, it may provide a short period of therapeutic effects as early as weeks 4 to 12.
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NewsBot · Aug 28, 2020

Extracorporeal Shockwave Therapy for Patients with Chronic Achilles Tendinopathy in Long or Short Course
BaiLi Yan et al
Biomed Res Int. 2020 Aug 11;2020

Methods: The data of 66 patients with CAT received ESWT was reviewed. According to the disease courses, those cases were allocated to short-term group (ST group, symptom duration 3-6 months) and long-term group (LT group, symptom duration >6 months). Propensity scores match (PSM) method was conducted to eliminate the confound factors in baseline features including gender, sport history, sides, type of CAT, BMI (body mass index), age, and scores evaluated by AOFAS (American Orthopedic Foot and Ankle Society) and VAS (Visual Analogue Scale) before ESWT. After balancing the features between ST and LT group, postinterventional VAS, AOFAS, and rate of Likert satisfaction scale at the 3rd month after first ESWT was statistically analyzed.

Results: Among the baseline features in ST and LT group, gender (female ratio, 44.4% vs 71.4%, p = 0.041) and BMI (23.26 ± 2.15 vs 24.63 ± 2.41, p = 0.024) were identified as confound factors. After elimination of biased features with PSM, 3 months after first ESWT, AOFAS and VAS in both groups are significantly improved, when compared with their scores at baseline (p < 0.01). Moreover, at postintervention month 3 (PIM3), AOFAS in ST group is significantly higher than LT group (85.08 ± 9.83 vs 76.76 ± 9.85, t = 76.76 ± 9.85, p = 0.019), and the rate of Likert satisfaction in ST group is better than LT group; although, it did not reach but close to significant level (70.6% vs 47.1%, χ 2 = 1.943, p = 0.163). However, there is no statistical difference of VAS scores between two groups after ESWT (1.96 ± 0.98 vs 2.24 ± 1.29, t = 0.703, p = 0.487).

Conclusions: ESWT could effectively relieve pain and improve function of hind foot in patients with chronic Achilles tendinopathy, and especially, it could offer better benefit on functional improvement in patients with short duration of CAT symptom.
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NewsBot · Nov 11, 2020

The Efficacy of Unfocused Extracorporeal Shock Waves for the Treatment of Achilles Tendinopathy
Ashraf M. Fansa, MB BCh, Martin J. O’Malley, MD, Eoghan T. Hurley, MB BCh BAO, ...
Foot & Ankle Orthopaedics November 6, 2020

Introduction/Purpose:
Extracorporeal shock wave therapy (ESWT) may be a viable non-invasive treatment modality for patients suffering from Achilles Tendinopathy. There seems to be a relationship between the ESWT protocol and patient outcomes. Data suggest that higher energy levels of shock waves together with adequate treatment delivery to the affected area is necessary to achieve favorable outcomes. The aim of this study is present our experience with the use of electrohydraulically produced unfocused extracorporeal shock waves for the treatment of Achilles Tendinopathy.

Methods:
A retrospective analysis of prospectively collected data was performed, including all patients who had received ESWT for plantar fasciitis heel pain between January 2013 and September 2018. The primary outcomes included change in pain intensity on the visual analog pain scale and patient satisfaction at final follow-up. Pre and post-procedure Foot and Ankle Outcome Scores were also assessed for change.

Results:
A total of 158 patients (179 heels) were followed-up for a mean duration of 17 +- 6.8 months post ESWT. The mean pre-ESWT pain VAS improved from 7.2 +- 1.4 to 2.3 +- 2.1 (p< 0.001) at final follow-up. The FAOS Symptoms, Pain, Function of Daily Living, Function of Sports and Recreational activities and Quality of Life domains improved from 57.7 +- 12.7 to 79.7 +- 13.6 (p< 0.001), from 35 +- 15.8 to 72.6 +- 22 (p< 0.001), from 43.8 +- 15.3 to 81.4 +- 11 (p< 0.001), from 41.2 +- 21.3 to 66.4 +- 18.3

(p< 0.001) and from 33.9 +- 17.4 to 78 +- 24.4 (p< 0.001), respectively. Overall, 85.4% were satisfied with the procedure at final follow-up.

Conclusion:
For patients with Achilles tendinopathy, unfocussed extracorporeal shock wave therapy appears to be a safe and viable non-invasive treatment option with a patient satisfaction rate of 85.4% and a 68% reduction in patient reported pain intensity.
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NewsBot · Dec 9, 2020

Efficacy of Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Meta-analysis
Yifei Fan et al
Orthop J Sports Med. 2020 Feb 27;8(2)

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.
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NewsBot · Jan 16, 2021

Short- and Intermediate-Term Results of Extracorporeal Shockwave Therapy for Noninsertional Achilles Tendinopathy
Nasr Awad Abdelkader, PhD, Mohamed Nasser Kise Helmy, BSc PT, Nadia Abdelazem Fayaz, PhD, ...
Foot & Ankle International January 15, 2021

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).

Conclusions:
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.
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NewsBot · Feb 22, 2021

Immediate and long-term effects of mechanical loading on Achilles tendon volume: A systematic review and meta-analysis
EmanMerza et al
Journal of Biomechanics Volume 118, 30 March 2021, 110289

The Achilles tendon (AT) may experience changes in dimensions related to fluid flow under load. The extent to which fluid flow involves redistribution within or flow out of the tendon is not known and could be determined by investigating volume changes. This study aimed to synthesize data on immediate and long-term effects of loading on tendon volume among people with a healthy AT and midportion Achilles tendinopathy (MAT). A secondary aim was to synthesise data from the included studies investigating parallel change in cross-sectional area and length. Systematic electronic search was performed in MEDLINE, EMBASE, CINAHL, AMED, and Scopus from inception until May 2020. Standardized mean differences (SMDs) were calculated for intervention-induced changes from baseline for all outcomes. Methodological quality was assessed using modified version of Newcastle Ottawa Scale (NOS). Twelve studies were included in meta-analysis. For healthy AT, there were negligible to small changes in volume following cross-country running (−0.33 [95% CI = −1.11 to 0.45] (P = 0.41)) and isometric exercise (0.01 [95% CI = −0.54 to 0.55] (P = 0.98)) and a large increase at the short-term with 12-week isometric protocol (0.88 [95% CI = −0.10 to1.86] (P = 0.08)). For MAT, there was an immediate large reduction in volume with isometric exercise (−1.24 [95% CI = −1.93 to −0.55] (P = 0.0004)), small increase with eccentric exercise (0.41 [95% CI = −0.18 to 1.01](P = 0.18)) and small reduction at the short-term with long-term interventions (−0.46 [95% CI = −0.87 to −0.05] (P = 0.03)). This meta-analysis suggests that healthy AT remain isovolumetric with acute interventions while MAT exhibit immediate and short-term volume reductions in response to different interventions.
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NewsBot · May 26, 2021

Shockwave Therapy Plus Eccentric Exercises Versus Isolated Eccentric Exercises for Achilles Insertional Tendinopathy: A Double-Blinded Randomized Clinical Trial
Nacime Salomão Barbachan Mansur et al
J Bone Joint Surg Am. 2021 May 24

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.
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NewsBot · Oct 25, 2021

Functional Gains Using Radial and Combined Shockwave Therapy in the Management of Achilles Tendinopathy
David M Robinson et al
J Foot Ankle Surg. 2021 Jun 24

Achilles tendinopathy is a common condition and many patients have functional limitations after initial conservative treatment. Shockwave therapy has been shown to improve function within patients; however, comparative outcomes for different forms of shockwave are poorly described. In this retrospective cohort study, we describe findings from a quality improvement initiative evaluating safety and functional outcomes after treatment with radial shockwave therapy (n = 58) or combined radial and focused shockwave therapy (n = 29) for patients with Achilles tendinopathy refractory to exercise therapy. All patients were prescribed an eccentric exercise program. We hypothesized both groups would see improvements in function quantified using the Victorian Institute of Sports Assessment-Achilles with similar safety outcomes. Overall, the minimal clinically important difference (defined at 7 for insertional and 12 for noninsertional Achilles tendinopathy) was met in a greater proportion of patients treated with combined shockwave compared to radial shockwave (26 [89.7%] vs 37 [63.8%], p = .022). The change in Victorian Institute of Sports Assessment-Achilles from baseline to final treatment was not different between combined and radial-only groups (23.3 ± 12.6 vs 19.9 ± 18.7, p = .2). Within group differences from baseline to final follow-up measures (mean duration 17.9 ± 14.8 weeks) demonstrated overall functional improvement for both groups (both p < .0001). No serious adverse effects were observed. Our findings suggest combined radial and focused shockwave therapy may provide more predictable functional gains for treatment of Achilles tendinopathy compared to radial shockwave therapy.
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NewsBot · Dec 2, 2022

Analysis of pain intensity and postural control for assessing the efficacy of shock wave therapy and sonotherapy in Achilles tendinopathy – A randomized controlled trial
Magdalena Stania et al
November 30, 2022

Highlights
•Pain-relieving effects of shock wave therapy in Achilles tendinopathy were observed.
•Relationship existed between radial shock wave therapy and better postural control.
•Posturography may contribute to functional assessment of the Achilles tendon.
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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.
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NewsBot · Jun 15, 2023

The Efficacy of Extracorporeal Shock Wave Therapy as a Monotherapy for Achilles Tendinopathy: A Systematic Review and Meta-Analysis
Magdalena Stania et al
Journal of Chiropractic Medicine; 14 June 2023

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.
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NewsBot · Jun 27, 2023

A preliminary investigation into the impact of shock wave therapy and sonotherapy on postural control of stepping tasks in patients with Achilles tendinopathy
Magdalena Stania et al
Front Neurol. 2023 Jun 2

Objective: The outcomes of physical therapy are commonly assessed with subjective scales and questionnaires. Hence, a continuous search to identify diagnostic tests that would facilitate objective assessment of symptom reduction in those patients with Achilles tendinopathy who undergo mechanotherapy. The main aim of this study was to evaluate and compare the effectiveness of shock wave and ultrasound treatments, using objective posturographic assessment during step-up and step-down initiation.

Materials and methods: The patients with non-insertional Achilles tendinopathy and pain lasting for more than 3 months were randomly assigned to one of the experimental groups, i.e., radial shock wave therapy (RSWT), ultrasound therapy, or placebo ultrasound. All groups also received deep friction massage as the primary therapy. The transitional locomotor task was performed with the affected and unaffected limb in random order, on two force platforms under two conditions (step-up and step-down). The recording of center of foot pressure displacements was divided into three phases: quiet standing before step-up/step-down, transit, and quiet standing until measurement completion. Pre-intervention measurements were performed and then short-term follow-ups at weeks 1 and 6 post-therapy.

Results: The three-way repeated measures ANOVA showed few statistically significant two-factor interactions between therapy type, time point of measurement and the type of the locomotor task. Significant increases in postural sway were observed in the entire study population throughout the follow-up period. Three-way ANOVAs revealed a group effect (shock wave vs. ultrasound) on almost all variables of the quiet standing phase prior to step-up/step-down initiation. Overall, postural stability before the step-up and step-down tasks appeared to be more efficient in patients who had undergone RSWT compared to the ultrasound group.

Conclusion: Objective posturographic assessment during step-up and step-down initiation did not demonstrate therapeutic superiority of any of the three therapeutic interventions used in patients with non-insertional Achilles tendinopathy.
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NewsBot · Apr 24, 2024 at 11:28 PM

Does Radial Extracorporeal Shockwave Therapy Applied to the Achilles Tendon Influence Ankle Functionality?
Younglan Joo et al
J Funct Morphol Kinesiol. 2024 Apr 8;9(2):67

This study aimed to determine the effectiveness of radial extracorporeal shockwave therapy (rESWT) in enhancing ankle function in patients with Achilles tendon injuries. The choice of rESWT was based on previous success in the treatment of musculoskeletal conditions. The study involved an intervention group that received rESWT, and a control group that received sham therapy. The results revealed that rESWT led to significant improvements in single-leg vertical jump (d = 0.55, p < 0.05), indicating enhanced power generation and ankle functionality that were not observed in the control group. Additionally, the therapy resulted in increased ankle mobility, as observed by improvements in plantar flexion and heel-rise tests. Interestingly, these functional gains were not accompanied by changes in the Achilles tendon stiffness, suggesting that the benefits of rESWT may be more functional than structural. This study highlights rESWT as a promising tool for rehabilitation, particularly following Achilles tendon injuries. The study concluded that, although rESWT appears to improve certain aspects of ankle function, further studies with a larger and more diverse population over a longer period are necessary to confirm these findings and establish comprehensive treatment protocols.
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