Radial versus Combined Shockwave Therapy in the Management of Proximal Hamstring Tendinopathy: Similar Functional Outcomes in Running Cohort

Abstract

Background. Proximal hamstring tendinopathy is a common cause of gluteal pain. Extracorporeal shockwave therapy may be an effective treatment in proximal hamstring tendinopathy. However, published outcomes are primarily limited to evaluating radial shockwave, and the use of combined treatment (focus and radial treatment) and outcomes for management in runners are not well described. The purpose of this report was to characterize functional outcomes using radial and combined shockwave in the management of proximal hamstring tendinopathy in runners. We hypothesized that runners who received R-SWT or C-SWT would experience improvement in functional outcomes using the VISA-H. Methods. This study is a quality improvement initiative evaluating clinical outcomes in a single outpatient clinic. Sixty-three runners (mean and standard deviation for age and duration of symptoms 42.8 ± 14.7 years and 16.9 ± 23.8 months, respectively), were identified as receiving treatment for management of unilateral or bilateral proximal hamstring tendinopathy. Patients were treated with either radial (n = 40) or combined shockwave therapy (n = 23) using similar post-procedure protocols, including recommendations to complete physical therapy exercises of core and lumbopelvic stabilization with gradual progression to eccentric strengthening of the hamstring complex. Victorian Institute of Sport Assessment -Proximal Hamstring Tendons (VISA-H) was used to assess treatment outcomes, evaluated as differences between treatment cohorts by mean values from baseline to follow-up after shockwave treatment. The number in both treatment groups who met minimal clinical important difference (MCID) was defined as a gain of 22 points or more on VISA-H. Results. Patients in both radial and combined shockwave groups received a similar average number of treatments (5.0 ± 2.2 vs 5.2 ± 1.9; p = 0.740). The radial and combined shockwave groups' mean VISA-H scores were similar at baseline (39.4 ± 17.4 vs 40.7 ± 17.0) and achieved similar final scores (62.6 ± 19.7 vs 63.4 ± 21.3; p = 0.812), and nearly all had measured increases of VISA-H with treatment (P < 0.0001). The MCID was met in a majority of patients who received either radial (62.5%) or combined treatment (56.5%). Conclusions. Overall findings suggest radial and combined shockwave treatment with physical therapy exercises can be effective in the management of proximal hamstring tendinopathy in runners.

Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review

“…One case series showed that 22 of 32 runners with proximal hamstring tendinopathy and 3 of 4 runners with distal/mid-hamstring tendinopathy met MCID after ESWT treatment 45. Another case series with some overlapping participants with Mitchkash et al 45 demonstrated that both R-SWT and combined ESWT (focused and radial) resulted in similar gains in VISA-Hamstring in management of proximal hamstring tendinopathy 65. Two case reports described an elite female para swimming athlete with bilateral hamstring pain66 and a female ultramarathon runner67 successfully returning to sport following ESWT.…”

Comparison of Conservative Interventions for Proximal Hamstring Tendinopathy: A Systematic Review and Recommendations for Rehabilitation

“…Other variables that warrant further investigation that may have affected clinical outcomes include load intensity specificity and tempo with exercise selection. Of the 13 studies, only two studies were specific in their load intensities either by RPE or by the percentage of 1RM [ 6 , 20 ], with six studies lacking specificity of either “moderate/high load” or “progressive” [ 7 , 15 , 16 , 17 , 22 , 35 ], and five studies lacking the reporting of exercise intensity in general [ 5 , 18 , 21 , 23 , 24 ]. Furthermore, of the 13 studies, only two [ 6 , 7 ] commented on loading rates associated with exercise, making it difficult to further analyze differences observed in clinical outcomes across studies.…”

“… Summary of risk of bias assessment for non-randomized control trials. Note: Domains: D1: bias due to confounding, D2: bias due to selection of participants, D3: bias in classification of interventions, D4: bias due to deviations from intended interventions, D5: bias due to missing data, D6: bias in measurement of outcomes, D7: bias in selection of the reported result [ 21 , 24 , 25 ]. …”