Shockwave Therapy Plus Eccentric Exercises Versus Isolated Eccentric Exercises for Achilles Insertional Tendinopathy

Abstract

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.Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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

“…We identified 14 studies for full-text review. Among these was one trial protocol [ 33 ] that we later included because it was published [ 34 ] before submitting this systematic review. Following full-text screening, seven studies were excluded for not meeting our eligibility criteria: In four studies, ESWT was investigated in a mixed cohort from which subgroup analysis for mid-AT and ins-AT separately was not possible [ 20 , 35 – 37 ], one study did not meet the required symptom duration prior to inclusion [ 38 ], one study was not a (randomized) controlled clinical trial [ 39 ], and one study was excluded due to use of local anesthesia in the experimental group [ 40 ].…”

“…Patients were recruited from an orthopedic hospital unit Inclusion criteria 18–80 years ins-AT symptoms ≥ 6 months functional VAS score > 4 Exclusion criteria (imaging) signs of mid-AT, partial rupture, calcaneal spurs or calcifications contraindications to laser therapy or ESWT (neoplasia, current or previous infections of the affected area, history of epilepsy, coagulopathies, cardiac pacemaker, pregnancy, intolerance to cold) previous Achilles tendon surgery peritendinous injection within the previous 4 weeks ESWT or laser therapy within the previous 2 months congenital or acquired deformities of the lower limb F-ESWT + eccentric loading + stretching (n = 30) F-ESWT consisted of 1600 pulses, EFD 0.05–0.07 mJ/mm 2 , 3 sessions, at 3–4 day intervals Eccentric loading consisted of 3 sets of 10 repetitions using a TheraBand (i.e., a thin ribbon of stretchy material that enables resistance during movement exercises), 2–3 weekly sessions for 2 months Calf and Achilles stretching consisted of 4 sets of 15–20 s, 2–3 weekly sessions for 2 months Cold air and high-energy laser therapy (CHELT) + eccentric loading + stretching (n = 30) CHELT consisted of simultaneous wavelengths (1,064, 810 and 980 nm; total dosage 1,200 J) together with a flow of cold air (− 30 °C), 10 daily sessions Eccentric loading consisted of 3 sets of 10 repetitions using a TheraBand, 2–3 weekly sessions for 2 months Calf and Achilles stretching consisted of 4 sets of 15–20 s, 2–3 weekly sessions for 2 months 10–15 days (end of complete session of treatment), 2 months, and 6 months VAS (range 0–10, mean ± SD) ESWT + standard care Baseline: 7 ± 1.2 10th-15th days: 4.9 ± 0.9 2 months: 5.4 ± 2.7 6 months: 3.3 ± 2.4 CHELT + standard care Baseline: 7 ± 1.0 10th–15th days: 2.3 ± 1.1 2 months: 2.4 ± 1.6 6 months: 1.7 ± 1.0 Results No baseline differences between groups Both groups improved over time CHELT achieved better than ESWT Conclusion CHELT gave quicker and better pain relief. It also gave the patient a full functional recovery and greater satisfaction Not reported Mansur et al [ 34 ] Population and setting Tertiary teaching hospital in São Paulo, Brazil Inclusion criteria 18–75 years pain at the calcaneal tendon insertion for ≥ 3 months diagnosis of ins-AT Exclusion criteria bilateral tendinopathy previous surgery autoimmune conditions neuropathy inflammatory diseases non-insertional or mixed tendinopathy previous infiltration pregnancy use of a pacemaker coagulopathies local infection R-ESWT + ...…”

“…We included 4 RCTs that investigated the effectiveness of ESWT for ins-AT [ 34 , 43 – 45 ]. Study characteristics, results of primary outcomes, and conclusions are summarized in Table 1 .…”

“…Mansur et al [ 34 ] performed a double-blind RCT comparing eccentric exercises and ESWT to eccentric exercises and sham-ESWT. Eligible secondary outcomes were the VAS for pain, the Foot and Ankle Outcome Score (FAOS) to evaluate pain and function, and the 12-item Short Form Health Survey to assess health-related quality of life.…”

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

“…A total of 194 studies were included (Table 3), of which 109 were randomized controlled trials (RCTs), 32 were cohort studies, 15 were case series, 26 were case reports, with 12 being other designs, quasiexperimental (4), before-after design (2), case-control (4), and observational (2). e publication year ranged from 1989 to 2021, with 42 of the included studies being published since the year 2020, and 62 since 2019. e tendinopathy most frequently treated was Achilles (99), followed by patellar (58), plantar heel pain (16), gluteal (8), posterior tibial (6), hamstring (5), peroneal (1), extensor hallucis longus (1), and iliopsoas (1). e sample sizes of included studies ranged from 1 to 204 patients.…”