Hyaluronan Injections Versus Extracorporeal Shock Wave Therapy For Achilles Tendinopathy

NewsBot · Sep 20, 2016

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Comparison of peritendinous hyaluronan injections versus extracorporeal shock wave therapy in the treatment of painful Achilles tendinopathy: A randomized clinical efficacy and safety study
Nils Lynen, MD, Thierry De Vroey, MD, Imke Spiegel, MD, Frederik Van Ongeval, MD, Niels-Jan Hendrickx, MD, Gaëtane Stassijns, MD, PhD
Archives of Physical Medicine and Rehabilitation; Article in Press

Highlights
•Two peritendinous HA injections are safe and effective in treating symptomatic Achilles midportion tendinopathy
•HA injections are superior to standard ESWT application and result in clinically relevant findings
•Administration of HA was less painful to the patients compared to ESWT
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Objective
To compare the safety and efficacy of hyaluronan (HA) injections with standard extracorporeal shock wave therapy (ESWT) in the treatment of painful midportion Achilles tendinopathy.

Design
Multinational, prospective, randomized controlled, blinded-observer trial.

Setting
Ambulatory care.

Participants
Adults presenting Achilles midportion tendinopathy for at least 6 weeks and a pain score of at least 40 mm (Huskisson, visual analogue scale (VAS), 100 mm). 62 participants were randomized and 59 analyzed in the ITT-data set. No withdrawals due to adverse effects.

Interventions
Two peritendinous HA injections versus three ESWT applications at weekly intervals.

Main Outcome Measures
Primary efficacy criterion was changed from VISA-A score to percent change in pain (VAS) at 3 months post-treatment, compared to baseline values. Main secondary parameters were VISA-A, Clinical Global Impression (CGI) and clinical parameters.

Results
HA treatment provided a clinically relevant improvement in Achilles midportion tendinopathy. A large superiority of the HA-group, compared to ESWT application, was observed for percent change in pain (VAS) and this superiority was proven to be statistically significant (Mann-Whitney statistic (MW) = 0.7507 with p = 0.0030 lower than required alpha = 0.025 significance level one-sided; Mann-Whitney-U test) at 3 months post-treatment. Similar findings for HA were also observed at 4 weeks (MW = 0.6425, p = 0.0304) and 6 months (MW = 0.7172, p = 0.0018). Advantage of HA treatment was confirmed by VISA-A, CGI and clinical parameters. Ten adverse events, 4 in HA-group and 6 in ESWT-group were reported, but none were classified as serious.

Conclusions
Two peritendinous HA injections showed greater treatment success in Achilles midportion tendinopathy compared to standard ESWT.
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NewsBot · Oct 10, 2016

Comparison of Clinical Efficacy Among Endoscopy-Assisted Radio-Frequency Ablation, Extracorporeal Shockwaves, and Eccentric Exercises in Treatment of Insertional Achilles Tendinosis
Min Wei, Yujie Liu, Zhongli Li, and Zhigang Wang
Journal of the American Podiatric Medical Association In-Press.

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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NewsBot · Nov 16, 2016

Low-Energy Extracorporeal Shock-Wave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy: A Case Series.
Pavone Vet al
Biomed Res Int. 2016;2016:7123769

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 5.8 ± 1.3 SD points (P < 0.001). Mean AOFAS Hindfoot score improvement was 19.8 ± 5.0 SD points (P < 0.001). 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 · Jun 3, 2017

Comparison of the Acute Effect of Radial Shock Wave Therapy and Ultrasound Therapy in the Treatment of Plantar Fasciitis: A Randomized Controlled Study.
Akinoglu B et al
Pain Med. 2017 May 29. doi: 10.1093/pm/pnx113.

OBJECTIVE. :
This study compared the effectiveness of radial extracorporeal shock wave therapy (r-ESWT) with ultrasound (US) therapy in the treatment of plantar fasciitis (PF).
STUDY DESIGN. :
Level II, randomized controlled study.
DESIGN. :
A total of 54 female patients with unilateral PF were randomly assigned to two study groups and one control group. All groups performed home exercises. In addition, the first study group received three sessions of r-ESWT treatment and the second study group received seven sessions of US treatment. The Foot Function Index (FFI) and the American Orthopedic Foot and Ankle Association (AOFAS) hind foot score were determined. Static and dynamic equilibrium were evaluated with the single leg standing test and the functional reach test. Ankle proprioception sense was determined with the Biodex III isokinetic device. Patients were evaluated before and four weeks after the first treatment.
RESULTS. :
According to the evaluation results, there was a decrease in FFI values in all groups and these decreases were more prominent in the US group than the other groups ( P < 0.05). It was observed that the hind foot AOFAS scores increased in all groups, but this increase was less in the control group ( P < 0.05). Static and dynamic balance increased in all groups ( P < 0.05). Ankle proprioception sense increased only in the r-ESWT group ( P <0.05).
CONCLUSIONS. :
All groups and particularly the r-ESWT and US groups' symptoms were decreased after treatment. However; FFI parameters were reduced more in the US groups than the other two groups, the ankle proprioception sense increased in the r-ESWT group, and there was no change in the other groups.
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NewsBot · Feb 11, 2020

Autologous Blood-Derived Products Compared With Corticosteroids for Treatment of Plantar Fasciopathy: A Systematic Review and Meta-Analysis.
Chen YJ et al
Am J Phys Med Rehabil. 2019 May;98(5):343-352

OBJECTIVE:
This review article evaluated the efficacy of autologous blood-derived products, including whole blood and platelet-rich plasma, in reducing pain and improving function compared with corticosteroids for plantar fasciopathy patients.

DESIGN:
Literature comparing autologous blood-derived product and corticosteroids for the treatment of plantar fasciopathy was systematically reviewed. Twelve randomized controlled trials and four quasi-experimental studies were included. The visual analog scale pain score and American Orthopedic Foot and Ankle Society hindfoot score were evaluated at 1.5, 3, and 6 mos' follow-up. Subgroup analyses were performed concerning platelet-rich plasma preparation techniques, injection regiments, and study designs.

RESULTS:
Corticosteroids were found to reduce pain more effectively than whole blood at 1.5 and 3 mos, but the effect disappeared at 6 mos. Platelet-rich plasma reduced pain more effectively at 6 mos' postinjection than corticosteroids. However, there was no significant difference in the American Orthopedic Foot and Ankle Society score between platelet-rich plasma and corticosteroids injections at any time point. In the subgroup analyses, pain was significantly reduced at 6 mos by self-prepared platelet-rich plasma, one-step separation platelet-rich plasma, platelet-rich plasma of more than 3 ml, and platelet-rich plasma without local analgesics.

CONCLUSIONS:
The results of this meta-analysis suggest that platelet-rich plasma may provide a long-term effect in relieving pain in plantar fasciopathy patients.
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NewsBot · May 15, 2022

Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials
Marc A. Paantjens, Pieter H. Helmhout, Frank J. G. Backx, Faridi S. van Etten-Jamaludin & Eric W. P. Bakker
Sports Medicine - Open volume 8, Article number: 68 (2022)

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

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

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

Conclusions
There is moderate evidence supporting the effectiveness of ESWT additional to a tendon loading program in mid-AT. Evidence supporting the effectiveness of ESWT for ins-AT is lacking.
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NewsBot · Aug 1, 2022

The Effectiveness of Extracorporeal Shockwave Therapy for Midportion Achilles Tendinopathy: A Systematic Review
Kaylem M. Feeney
Cureus 14(7): e26960. doi:10.7759/cureus.26960

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

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

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

This review suggests that ESWT is a safe and effective modality for treating midportion Achilles tendinopathy as it reduces pain and improves function. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT alone. Further research is required to confirm this and to determine the optimum ESWT treatment protocol.
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NewsBot · Aug 23, 2022

The Effectiveness of Extracorporeal Shockwave Therapy for Midportion Achilles Tendinopathy: A Systematic Review
Kaylem M Feeney et al
Cureus. 2022 Jul 18;14(7):e26960

Achilles tendinopathy is one of the most common lower limb injuries in both athletes and the general population. Despite the plethora of conservative treatment options available for the management of Achilles tendinopathy, as many as one in four patients will go on to require surgery. Extracorporeal shockwave therapy (ESWT) has emerged as a promising treatment option and has been successful in the management of other common musculoskeletal injuries such as plantar fasciitis. However, the evidence for ESWT in the management of Achilles tendinopathy remains inconclusive. Therefore, the aim of this systematic review was to evaluate the current evidence for the use of ESWT in the management of midportion Achilles tendinopathy. A comprehensive literature search was conducted using the databases MEDLINE (Pubmed), AMED, EMBASE, CINAHL, and CENTRAL. The databases were searched from their inception to December 2021. This was conducted to identify randomised control trials (RCTs) evaluating the effectiveness of ESWT versus control treatment in the management of midportion Achilles tendinopathy. Following a comprehensive search of the literature, a total of 283 articles were identified. Following the screening of titles and abstracts, 236 articles were excluded. The main reasons for exclusion were the identification of duplicates, non-randomised studies, and the use of ESWT on other pathology. Following the exclusion of 236 articles, 47 articles were retrieved for full-text review. Of these 47 articles, 40 were excluded leaving a total of 7 RCTs eligible for inclusion in this review. There was consistent evidence from 4 RCTs that ESWT is effective in the management of midportion Achilles tendinopathy. This review suggests that ESWT is a safe and effective modality for treating midportion Achilles tendinopathy as it reduces pain and improves function. The best available evidence suggests that a combination of ESWT with eccentric exercises and stretching may be even more effective than ESWT alone. Further research is required to confirm this and to determine the optimum ESWT treatment protocol.
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