Extracorporeal shockwave therapy (ESWT) in Achilles tendinopathy. A long-term follow-up observational study

Orthopedic Unit and Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, La Sapienza University, School of Medicine, Rome, Italy.
The Journal of sports medicine and physical fitness (Impact Factor: 0.97). 07/2009; 49(2):171-6.
Source: PubMed


The etiology, pathogenesis and natural course of Achilles tendinopathy are not yet completely known. Various forms of therapies, either conservative or surgical, have been proposed for its treatment. In the last few years, extracorporeal shockwave therapy (ESWT) has been proposed in the treatment of these tendinopathies and has shown encouraging short-term results. The purpose of this type-C study was to evaluate the effectiveness of ESWT in the symptomatic treatment of Achilles tendinopathies over time.
One hundred five patients (127 tendons) aged between 18 and 74 years (mean age 47.8) were enrolled in this study. All patients underwent clinical and instrumental diagnosis (ultrasonography, magnetic resonance imaging and X-rays) in order to identify presence, location and seriousness of the specific tendinopathy. The symptomatology was classified using the Visual Analogical Scale (VAS) and according to a five-stage clinical evaluation range. Shock wave treatment was applied with an electromagnetic shock wave generator. The protocol consisted in an average of four sessions (minimum three, maximum five), at a 2/7-day interval. In each session 1 500-2 500 impulses were administered with an energy varying between 0.08 and 0.40 mJ/mm2. All patients were evaluated before therapy and two months after the last ESWT session. Also, all patients were assessed and evaluated at medium-term (6 to 12 months), and 121 patients also at long-term (13 to 24 months).
Authors obtained satisfactory results in 47.2% of cases (60 out of 127 tendons) at two-months follow-up, which increased to 73.2% at medium-term follow-up (93 out of 127 tendons), and then reaching 76% in the last evaluation (92 out of 121 tendons).
The outcome of the described shock wave treatment appears to be satisfactory and confirms the role of this alternative treatment in the management of the tendon disorders.

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Available from: Mario Vetrano, Oct 10, 2015
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    • "To better understand HEST as a modality for the treatment of soft-tissue musculoskeletal disorders, basic science research should focus on local changes induced by HEST and seek to determine which are responsible for the improvements demonstrated in clinical studies.13-16 One possibility for such an HEST-induced change is that HEST could stimulate the formation of new blood vessels in the tendon and that it is this increased vascularization that leads to clinical improvement.6,15,16 "
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    ABSTRACT: The aim of this study was to analyze the effect of high-energy extracorporeal shockwave therapy on tendon angiogenesis in the patellar tendons of rabbits. We sought to investigate whether different voltage and number pulses modify the angiogenesis pattern. High-energy extracorporeal shockwave therapy is an option in the treatment of orthopedic diseases such as chronic tendonitis. Despite its potential clinical applicability, there have been few studies on this technique that examine both its clinical effectiveness and its effect on angiogenesis. High-energy extracorporeal shockwave therapy was applied at the tibial insertion of the left patellar ligament in 30 rabbits that were separated into six groups that differed in terms of the voltage and number of pulses that were applied by high-energy extracorporeal shockwave therapy. The tibial insertion in the right legs of the animals was used as the control. After six weeks, we performed histological analysis on the region and quantified the number of blood vessels. No significant differences in the number of blood vessels between the left and right patellar tendons were found within groups. Additionally, no significant differences in the number of blood vessels in the left patellar tendons were found between groups. The application of high-energy extracorporeal shockwave therapy did not cause a change in vascularization in the patellar tendon in rabbits.
    Clinics (São Paulo, Brazil) 09/2011; 66(9):1611-4. DOI:10.1590/S1807-59322011000900018 · 1.19 Impact Factor
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    • "Thus the current understanding of the relationship of structural changes and functional impairments is still inadequate to assure the degenerative features as specific "markers" for tendinopathy. Biophysical intervention such as extracorporeal shockwave therapy exhibited significant improvement especially for calcified tendinopathy [70,71]. It suggests that the pathological tissues might be responsive to mechanical stimulation. "
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    ABSTRACT: Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments.
    Sports Medicine Arthroscopy Rehabilitation Therapy & Technology 12/2010; 2(1):30. DOI:10.1186/1758-2555-2-30
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    ABSTRACT: Background Clinicians manage midportion Achilles tendinopathy (AT) using complex clinical reasoning underpinned by a rapidly developing evidence base. Objectives The objectives of the study were to develop an inclusive, accessible review of the literature in combination with an account of expert therapists’ related clinical reasoning to guide clinical practice and future research. Methods Searches of the electronic databases, PubMed, ISI Web of Science, PEDro, CINAHL, EMBASE, and Google Scholar were conducted for all papers published from inception to November 2011. Reference lists and citing articles were searched for further relevant articles. Inclusion required studies to evaluate the effectiveness of any conservative intervention for midportion AT. Exclusion criteria included in vitro, animal and cadaver studies and tendinopathies in other locations (e.g. patella, supraspinatus). From a total of 3497 identified in the initial search, 47 studies fulfilled the inclusion criteria. Studies were scored according to the PEDro scale, with a score of ≥8/10 considered of excellent quality, 5–7/10 good, and ≤4/10 poor. The strength of evidence supporting each treatment modality was then rated as ‘strong’, ‘moderate’, ‘limited’, ‘conflicting’ or ‘no evidence’ according to the number and quality of articles supporting that modality. Additionally, semi-structured interviews were conducted with physiotherapists to explore clinical reasoning related to the use of various interventions with and without an evidence base, and their perceptions of available evidence. Results Evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy; moderate for splinting/bracing, active rest, low-level laser therapy and concentric exercises (i.e. inferior to eccentric exercise). In-shoe foot orthoses and therapeutic ultrasound had limited evidence. There was conflicting evidence for topical glycerin trinitrate. Taping techniques and soft-tissue mobilization were not yet examined but featured in case studies and in the interview data. Framework analysis of interview transcripts yielded multiple themes relating to physiotherapists’ clinical reasoning and perceptions of the evidence, including the difficulty in causing pain while treating the condition and the need to vary research protocols for specific client groups — such as those with the metabolic syndrome as a likely etiological factor. Physiotherapists were commonly applying the modality with the strongest evidence base, eccentric loading exercises. Barriers to research being translated into practice identified included the lack of consistency of outcome measures, excessive stringency of some authoritative reviews and difficulty in accessing primary research reports. The broad inclusion criteria meant some lower quality studies were included in this review. However, this was deliberate to ensure that all available research evidence for the management of midportion AT, and all studies were evaluated using the PEDro scale to compensate for the lack of stringent inclusion criteria. Conclusion Graded evidence combined with qualitative analysis of clinical reasoning produced a novel and clinically applicable guide to conservative management of midportion AT. This guide will be useful to novice clinicians learning how to manage this treatment-resistant condition and to expert clinicians reviewing their evidence-based practice and developing their clinical reasoning. Important areas requiring future research were identified including the effectiveness of orthoses, the effectiveness of manual therapy, etiological factors, optimal application of loading related to stage of presentation and how to optimize protocols for different types of patients such as the older patient with the metabolic syndrome as opposed to the athletically active.
    Sports Medicine 11/2012; 42(11). DOI:10.1007/BF03262305 · 5.04 Impact Factor
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