Title: Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Authors:

• Magdalena Stania (corresponding author)
• Grzegorz Juras
• Daria Chmielewska
• Anna Polak
• Cezary Kucio
• Piotr Król

Author Information:

• Magdalena Stania: [Author 1’s Affiliation]
• Grzegorz Juras: [Author 1’s Affiliation]
• Daria Chmielewska: [Author 2’s Affiliation]
• Anna Polak: [Author 2’s Affiliation]
• Cezary Kucio: [Author 2’s Affiliation]
• Piotr Król: [Author 1’s Affiliation]

Abstract: Extracorporeal shock wave therapy (ESWT) is among the conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been determined that would ensure ESWT effectiveness in this condition. The aim of the paper is to use research reports on ESWT in patients with Achilles tendinopathy to help practicing physiotherapists establish the most effective intervention parameters.

A search was conducted using the following databases: PubMed, Scopus, EBSCOhost, and Web of Science. The papers were checked for relevant content and were included based on the following criteria: full-text article published in English and including a comprehensive description of shock wave application. Twenty-two articles met the inclusion criteria. Most studies on the effectiveness of ESWT for Achilles tendinopathy included in this narrative review were randomized controlled trials. Two case-control studies, a case series study, prospective audit, clinical trial protocol, and a pilot study were also considered. The majority were prospective studies. Only a few authors presented the findings from retrospective observations.

The two modalities of shock wave therapy used for Achilles tendinopathy are focused shock waves and radial shock waves. The literature contains reports presenting mainly beneficial effects of ESWT in patients with Achilles tendinopathy.

1. Introduction

Järvinen et al. mentioned tendinopathy as being among the most common clinical diagnoses of Achilles disorders (55–65%) [1]. In the Netherlands, the incidence of Achilles tendinopathy is 1.85 per 1,000 Dutch patients registered with general practitioners [2]. Achilles tendinopathy is frequently diagnosed in athletes and physical workers whose activity is associated with major mechanical loading that exceeds the tendon’s capacity. Men have a higher prevalence of Achilles tendinopathy compared to premenopausal women, which is probably due to higher levels of physical activity [3]. Also, patients with unilateral Achilles tendinopathy are at high risk of developing contralateral symptoms [4].

Achilles tendinopathy is confirmed by a clinical symptom triad of pain, swelling, and limited function [5]. Achilles tendon injuries are classified by the anatomical area into noninsertional and insertional. The major symptom of noninsertional tendinopathy is pain located 2 to 6 cm proximal to the insertion of the tendon into the calcaneus [6, 7]. Patients suffering from insertional pathology usually present with lesions in the distal portion of the structure, i.e., posterosuperior calcaneal protuberance [8].

2. Etiology of Achilles Tendinopathy

The aetiology of Achilles tendinopathy is associated with several intrinsic and extrinsic factors. The intrinsic factors include impaired blood supply, gastrocnemius-soleus dysfunction, age, sex, body weight, metabolic disorders, lateral ankle instability, foot joint hypermobility, and foot deformities. The extrinsic factors that might contribute to Achilles tendinopathy are several sport disciplines (volleyball, basketball, and running), changes in training schedules, training errors, past injuries, inadequate footwear, and unsuitable training surfaces [1, 5, 9–12]. Repetitive tendon strain (3–8%) promotes cumulative microtrauma [1]. When the reparative capacity of the tendon is exceeded, the tendon sheath may become inflamed, resulting in oedema, pain, and/or tendon degeneration [1, 9].

3. Histological Characteristics of Tendinopathy

Histologically, tendinopathy is characterized by the absence of inflammatory cells, poor healing, noninflammatory intratendinous collagen degeneration, collagen fibre disorientation and thinning, hypercellularity with high concentrations of glycosaminoglycans and proteoglycans, and neovascularization [9, 12, 13].

4. Treatment Options for Achilles Tendinopathy

Pain and oedema within the Achilles tendon as well as structure stiffness preclude vigorous physical activity, making the patient seek effective treatments. Initial therapies include conservative interventions, e.g., a variety of physical modalities (laser therapy, ultrasound, electrotherapy, and shock waves) and exercises (also eccentric exercise) [14]. The authors of a recently published meta-analysis do not recommend splints and orthoses to patients with Achilles tendinopathy [15]. If the patient does not benefit from conservative treatment, he or she is referred to surgery, which, in the case of insertional tendinopathy, involves tendon debridement via a medial, midline, or lateral approach with variable detachment of the tendon insertion [8]. Those with noninsertional Achilles tendinopathy undergo minimally invasive procedures, e.g., ventral scraping of the tendon or multiple percutaneous longitudinal tenotomies [16]. The initial results seem encouraging.

5. Extracorporeal Shock Wave Therapy (ESWT)

Extracorporeal shock wave therapy (ESWT) is among the more conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been determined that would ensure ESWT effectiveness in this condition. The aim of this paper is to present research reports on the use and efficacy of extracorporeal shock wave therapy in patients with Achilles tendinopathy. We believe this narrative review will help practicing physiotherapists establish the most effective intervention parameters.

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2.1. Data Sources and Searches

The aim of the present paper is to describe the research reports, analyzing the use and effectiveness of ESWT in patients with Achilles tendinopathy. A search was conducted using the following databases: PubMed, Scopus, EBSCOhost, and Web of Science (the last search was on the 12th of February 2019). Keywords including “Achilles tendinopathy,” “shock wave therapy,” “extracorporeal shock wave,” “focused extracorporeal shock wave,” “radial extracorporeal shock wave therapy,” “Achilles tendon,” and “treatment” were used in various configurations. Reference lists of all the retrieved articles were manually checked for additional studies.

2.2. Study Selection

The papers were checked for relevant content and were included based on the following criteria: full-text article published in English, including a comprehensive description of the shock wave application. Conference abstracts, proceedings, case reports, systematic reviews, meta-analyses, and narrative reviews were excluded.

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Title: The Effectiveness of Extracorporeal Shockwave Therapy for Midportion Achilles Tendinopathy

Authors: Kaylem M. Feeney (corresponding author)

Monitoring Editors: Alexander Muacevic and John R. Adler

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Abstract: 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.

Keywords: non insertional, midportion, tendinopathy, chronic, shockwave, eswt, tendon, achilles

Introduction and Background:

The Achilles tendon, the largest and strongest tendon in the human body, plays a crucial role in ankle joint movement through the force generated by the gastrocnemius and soleus muscles [1]. Surprisingly, despite its strength, the Achilles tendon is one of the most frequently injured tendons, accounting for approximately 9% of general sports injuries and up to 18% of running injuries [3,4]. It’s worth noting that Achilles tendon injuries are not exclusive to athletes, with as many as 33% of such injuries occurring in sedentary individuals [5].

Achilles tendinopathy includes two conditions: Achilles paratenonitis, which refers to inflammation of the paratenon surrounding the Achilles tendon, and Achilles tendinosis, which describes tendon fiber degeneration without intratendinous inflammation. Tendinosis can occur at the insertion (insertional) or in the body of the tendon (midportion or non-insertional) [6-8]. Clinically, the most suitable term is Achilles tendinopathy, as definitive diagnosis often requires imaging or histopathological examination [6,8].

While conservative management is the primary approach for Achilles tendinopathy, approximately 25%-29% of patients eventually require surgery [9,10]. There’s a wide range of conservative treatment options available, including eccentric loading exercises, heavy slow resistance training, activity modification, non-steroidal anti-inflammatory medications, friction massage, therapeutic ultrasound, orthoses, injection therapy, night splints, calf stretching, taping, heel lifts, and extracorporeal shockwave therapy (ESWT) [4,7,10-21]. Despite this array of options, there’s no consensus on the most effective conservative treatment for midportion Achilles tendinopathy. However, systematic reviews suggest that eccentric loading programs have the highest level of supporting evidence [4,10,15,16]. Despite these conservative options, a significant number of patients still require surgery [10]. ESWT has garnered attention from healthcare professionals as it gains popularity in Achilles tendinopathy management, although evidence of its effectiveness remains inconclusive [19-24].

The most recent topical review on treatments for midportion Achilles tendinopathy, published in 2020 by Jarin et al. [25], supported the use of ESWT as a second-line treatment. However, their review only included four out of six available randomized controlled trials (RCTs) evaluating ESWT’s effectiveness in midportion Achilles tendinopathy. They also included one case-control study and one prospective cohort study, potentially affecting their results. They didn’t assess study quality or risk of bias (ROB). Moreover, since their review, another RCT on this topic has been published [33].

In 2020, Rhim et al. conducted a systematic review and meta-analysis of nonsurgical therapies for midportion Achilles tendinopathy. They recommended ESWT in conjunction with eccentric exercises for improved clinical outcomes but included only two out of six available RCTs from the literature. This omission leaves a significant portion of current evidence unaccounted for in their recommendations [28,29].

Conversely, Punnoose et al. conducted a systematic review and meta-analysis and found that ESWT did not significantly improve pain or function compared to control, although they included articles only up to their 2013 search, rendering their recommendations outdated. Therefore, the primary aim of this review is to assess and critically appraise the current evidence from all RCTs regarding the effectiveness of ESWT in managing midportion Achilles tendinopathy in adults.

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Title: Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Authors: 1 Magdalena Stania 1 Grzegorz Juras 2,3 Daria Chmielewska 2,4 Anna Polak 2,5 Cezary Kucio 1 Piotr Król

Abstract

Extracorporeal shock wave therapy (ESWT) is a conservative treatment option for Achilles tendinopathy. However, there is no consensus on the optimal application parameters for ESWT in this condition. This paper aims to provide practicing physiotherapists with insights from research reports on ESWT in patients with Achilles tendinopathy to establish effective intervention parameters. A comprehensive search was conducted using databases such as PubMed, Scopus, EBSCOhost, and Web of Science, up to February 12, 2019. Inclusion criteria involved full-text articles in English with a comprehensive description of shock wave application. Twenty-two articles met these criteria, primarily consisting of randomized controlled trials. Additionally, two case-control studies, a case series study, prospective audit, clinical trial protocol, and a pilot study were considered. Most of the studies were prospective, with a few presenting findings from retrospective observations. Two modalities of shock wave therapy were identified for Achilles tendinopathy: focused shock waves and radial shock waves. The literature predominantly reports beneficial effects of ESWT in patients with Achilles tendinopathy.

1. Introduction

Järvinen et al. reported tendinopathy as one of the most common clinical diagnoses of Achilles disorders, affecting 55–65% of cases [1]. In the Netherlands, the incidence of Achilles tendinopathy is 1.85 per 1,000 Dutch patients registered with general practitioners [2]. Athletes and physical workers, exposed to significant mechanical loading exceeding the tendon’s capacity, are frequently diagnosed with Achilles tendinopathy. Men have a higher prevalence of Achilles tendinopathy compared to premenopausal women, likely due to higher physical activity levels [3]. Furthermore, patients with unilateral Achilles tendinopathy are at a high risk of developing contralateral symptoms [4].

Achilles tendinopathy manifests as a clinical triad of pain, swelling, and limited function [5]. It can be classified anatomically into noninsertional and insertional types. Noninsertional tendinopathy is characterized by pain located 2 to 6 cm proximal to the tendon’s insertion into the calcaneus [6, 7]. In contrast, insertional pathology involves lesions in the distal portion of the structure, specifically the posterosuperior calcaneal protuberance [8].

The etiology of Achilles tendinopathy involves both intrinsic and extrinsic factors. Intrinsic factors include impaired blood supply, gastrocnemius-soleus dysfunction, age, sex, body weight, metabolic disorders, lateral ankle instability, foot joint hypermobility, and foot deformities. Extrinsic factors contributing to Achilles tendinopathy include participation in certain sports (e.g., volleyball, basketball, and running), changes in training schedules, training errors, previous injuries, inadequate footwear, and unsuitable training surfaces [1, 5, 9–12]. Repetitive tendon strain (3–8%) leads to cumulative microtrauma, and when the tendon’s reparative capacity is exceeded, it can result in inflammation, leading to symptoms such as edema, pain, and tendon degeneration [1, 9].

Histologically, tendinopathy is characterized by the absence of inflammatory cells, poor healing, noninflammatory intratendinous collagen degeneration, collagen fiber disorientation and thinning, hypercellularity with high concentrations of glycosaminoglycans and proteoglycans, and neovascularization [9, 12, 13].

The pain, edema, and stiffness associated with Achilles tendinopathy limit physical activity, prompting patients to seek effective treatments. Initial therapies encompass conservative interventions, including various physical modalities (laser therapy, ultrasound, electrotherapy, and shock waves) and exercises, notably eccentric exercise [14]. A recent meta-analysis did not recommend splints and orthoses for Achilles tendinopathy [15]. If conservative treatment proves ineffective, surgery may be considered, involving tendon debridement via different approaches for insertional tendinopathy or minimally invasive procedures like ventral scraping of the tendon or multiple percutaneous longitudinal tenotomies for noninsertional Achilles tendinopathy [8, 16]. Initial results for these approaches appear promising.

Extracorporeal shock wave therapy (ESWT) is a conservative treatment option for Achilles tendinopathy. However, there is no consensus on the optimal application parameters for ESWT in this condition. The aim of this paper is to present research reports on the use and efficacy of extracorporeal shock wave therapy in patients with Achilles tendinopathy, aiding physiotherapists in establishing effective intervention parameters.

2. Methods

2.1. Data Sources and Searches This paper aims to describe research reports analyzing the use and effectiveness of ESWT in patients with Achilles tendinopathy. A comprehensive search was conducted in databases such as PubMed, Scopus, EBSCOhost, and Web of Science, with the last search conducted on February 12, 2019. Various keywords, including “Achilles tendinopathy,” “shock wave therapy,” “extracorporeal shock wave,” “focused extracorporeal shock wave,” “radial extracorporeal shock wave therapy,” “Achilles tendon,” and “treatment,” were used in different combinations. Reference lists of all retrieved articles were manually reviewed to identify additional studies.

2.2. Study Selection The selected papers were evaluated for relevance and included based on specific criteria: full-text articles published in English with a comprehensive description of shock wave application. Conference abstracts, proceedings, case reports, systematic reviews, meta-analyses, and narrative reviews were excluded. The results of this study selection procedure are summarized in a flow diagram (Figure 1).

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