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Three Part Question

[Is shock-wave therapy beneficial in the treatment of achilles tendinopathy?] [x] [x]

Clinical Scenario

33 year old male presented to the ED with pain around the Achilles tendon and decreased physical performance whilst training for a marathon. His symptoms had been gradually worsening as his training progressed, but now he was struggling to walk. He had seen a physiotherapist and was carrying out regular strengthening exercises. Furthermore, he had seen a podiatrist and now had specialised in-soles in his running trainers. You wonder if extra-corporeal shock-wave therapy (ESWT) conducted via referral is likely to improve his symptoms?

Search Strategy

OvidSP
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Search Outcome

11 papers identified which were relevant to the question posed.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Vulpiani et al 2009 2009 Italy	105 patients (127 achilles tendons) treated with ESWT. All patients underwent clinical and instrumental diagnosis. Symptomatology classified using Visual Analogical Scale (VAS) and 5 stage clinical evaluation range. Shock wave therapy consisted of an average of 4 sessions at 2/7 day intervals.	Follow up, type C study.	VAS score Subjective clinical evaluation score	Satisfactory results in 47.2% of cases (60/127 tendons) at 2 months follow up Satisfactory results in 73.2% at medium term (2-12 months) follow up (93/127) Satisfactory results in 76% at long term (13-24 months) follow up (92/121).	There was not a control group in this study undergoing a placebo and they were unable to achieve 100% patient recall.
Rasmussen et al. 2008 Denmark	48 patients assigned to non-operative treatment of Achilles tendinopathy were randomised to either receive extra corporeal shock-wave therapy (ESWT) or sham ESWT over 4 weeks. Assessed before treatment, during 4-week treatment block and at 4,8 and 12 weeks of follow up.	Randomised, double-blind, placebo-controlled trial.	American Orthopaedic Foot and Ankle Society (AOFAS) score Pain score	Both groups increased during the treatment and follow up period Mean AOFAS score increased from 74 (SD 12) to 81 (16) in placebo group Mean AOFAS score increased from 70 (6.8) to 88 (10) in ESWT group Better results were seen in intervention group at 8 and 12 weeks Pain reduced in both groups, but not significant difference between the groups.	ESWT treatment area was too small compared to extent of tendinopathy. Also the location of the lesion and energy level used was not documented.
Rompe et al 2009 USA	68 patients with chronic Achilles tendinopathy were enrolled. All of these had undergone unsuccessful management for >3 months, including at least: peritendinous local injection, non-steroidal anti-inflammatory drugs (NSAIDs) and physiotherapy. They were randomly assigned to receive either eccentric loading only or eccentric loading plus shock-wave treatment.	Randomised controlled trial Level of evidence, 1.	Victorian Institute of Sport Assessment- Achilles (VISA-A) score.	VISA-A score increased in both groups at 4 months. 50 to 73 points in group 1 (eccentric loading) 51 to 87 points in group 2 (eccentric loading plus shock wave treatment).	Patients were fully aware of the active treatment they received Relatively small numbers of patients included in the study.
Furia et al 2005 USA	35 patients with chronic insertional Achilles tendinopathy were treated with one dose of high energy shock wave therapy whilst 33 patients were managed with traditional non-operative methods. All shock wave therapy performed with local analgesic field block or a non-local anaesthesia.	Case control study Level of evidence,3	Mean visual analogue score (VAS), Roles and Maudsley score. These were recorded at 1, 3 and 12 months after surgery.	The VAS score for control group at 1, 3 and 12 months was 8.2, 7.2 and 7 respectively. The VAS score for shock wave group at 1,3 and 12 months was 4.2, 2.9 and 2.8 respectively. At 12 months after treatment, the number of patients with successful Roles and Maudsley scores was statistically greater in shock wave group compared with control group.	Subjective assessment scores MRI scans not performed Relatively small numbers involved.
Costa et al 2005 UK	49 patients with Achilles tendinopathy consented to participate in the trial. 22 randomised to shock wave therapy. 20 of these patients were followed up for 1 year. 27 patients were randomised to placebo- control group. 23 of these patients were followed up at 1 year. Each patient treated once a month for 3 months.	Randomised, placebo-controlled trial Level of evidence, 1	Primary outcome was a reduction in Achilles tendon pain during walking.	At end of trial, no difference in pain relief between the shock wave therapy group and the control group. 2 patients in the treatment group with tendon ruptures. These patients were aged 62 and 65 respectively.	Relatively small numbers and number of patients lost to follow up Large confidence intervals, making it difficult to establish effect
Lakshmanan and O’Doherty 2004 UK	16 affected tendons in 15 patients who had recalcitrant non-insertional Achilles tendinopathy and had been listed for surgery were treated. These patients had not responded to traditional conservative management. The treatment was given in 3 sessions with one week between each session.	Case control study.	Ankle hind-foot scale (AHS) and Victorian institute of sport assessment- achilles (VISA-A) score were performed before therapy and again at most recent follow up. Mean follow up was 20.7 months.	Shock wave therapy associated with significant improvement in AHS (57.2 to 87.2) and VISA-A score (46.6 to 75.9).	Variation in follow up Relatively small numbers No control group.
Rompe et al. 2007 Germany/USA/UK	75 patients were enrolled in the study, all of which had been unsuccessfully treated for Achilles tendinopathy for at least 3 months. Patients were randomly allocated to 3 management strategies. Group 1- eccentric loading, group 2-repetitive low energy shock wave therapy (SWT) and group 3- wait and see.	Randomised controlled trial Level of evidence, 1.	VISA-A score General assessment, Likert Load induced pain, NRS Pain threshold, Kg AP diameter of Achilles tendon of affected/unaffected leg.	At 4 months from baseline, VISA-A score increased in all groups VISA-A score increased from 51 to 76 points in group 1 (eccentric loading) VISA-A score increased from 50 to 70 points in group 2 (repetitive low energy SWT) VISA-A score increased from 48 to 55 in group 3 (wait and see) 15/25 in group 1 (60%), 13/25 in group 2 (52%) and 6/25 in group 2 (24%) reported a Likert score of 1 or 2 points (“completely recovered” or “much improved”) For all outcomes, group 1 and 2 did not differ significantly and were both significantly better than group 3.	Implementation of a blinded and unbiased assessment of outcome was difficult Relatively small numbers Eccentric training technique dependent.
Rompe et al 2008 Germany	50 patients with chronic recalcitrant insertional achilles tendinopathy were enrolled. All had received traditional conservative treatments for at least 3 months without success. 25 were allocated to receive eccentric loading (group 1) and 25 allocated to shock wave therapy (group 2). Patients followed up firstly at 4 months and the last follow up was after a year.	Randomised controlled trial. Level of evidence, 1.	Patients were assessed for pain, function and activity with use of VISA-A questionnaire	At 4 months, mean VISA-A score increased for both groups- 53 to 63 in group 1 and 53 to 80 in group 2 Mean pain rating decreased from 7 to 5 points in group 1 and from 7 to 3 in group 2 For all outcome measures, the group that received shock wave therapy showed significantly more favourable results than the group with eccentric loading. These results were stable at 12 months.	Small sample size Study was not blinded.
Fridman et al. 2008 USA	23 patients (23 feet) treated with shockwave therapy for Achilles tendinosis, insertional tendonitis or both. To be eligible, patients had to have a minimum of 6 months unsuccessful conservative treatment and Baker FACES visual analog pain score >5. Follow up was between 4 and 35 months.	Prospective study.	All patients completed a pre-treatment questionnaire regarding VAS score for morning and activity pain, duration of symptoms and previous treatment. Post-operative questionnaires were completed at 4 months and VAS score re-assessed as well as general satisfaction.	91 % (14 patients) were satisfied or very satisfied (23 patients) with treatment 87% (20 patients) said it improved their condition, 13% (3 patients) said it did not affect the condition and none stated that it made them worse At 4 months post-treatment, the mean visual analog score for morning pain decreased from 7 to 2.3, and activity pain decreased from 8.1 to 3.1.	No control group Small numbers Subjective assessment, potential for bias.
Furia et al 2008 USA	34 patients with chronic non-insertional Achilles tendinopathy were treated with a single dose of high energy shock wave therapy. 34 patients with chronic non-insertional achilles tendinopathy were treated with additional forms of non-operative therapy, but not with shock wave.	Case control study. Level of evidence, 3.	Assessed by change in visual analog score and Roles and Maudsley score. These were assessed at 1,3 and 12 months after treatment.	Visual analog scores for control group at 1,3 and 12 months were 8.4, 6.5 and 5.6 Visual analog scores for shockwave group at 1, 3 and 12 months were 4.4, 2.9 and 2.2 Percentage of patients with excellent or good Roles and Maudsley scores at 12 months was statistically greater in the shock wave group than the control group.	Only one dose of shockwave therapy was used rather than a course Not a blinded study No randomisation and no placebo-arm to study.
Saxena et al. 2011 USA	74 tendons in 60 patients were assessed at baseline and at 1 year post treatment. 3 weekly shock wave treatments were performed in patients with achilles tendinopathy.	Prospective cohort study. Level of evidence, 2.	Roles and Maudsley scores.	Overall, 58 (78.38%) tendons improved by at least 1 year post treatment Roles and Maudsley scores improved from 3.22 to 1.84 in the paratendinosis group, 3.39 to 1.57 in the proximal tendinopathy group and 3.32 to 1.47 in the insertional tendinopathy group.	High number of dropouts No control Potential for bias.

Comment(s)

Overall the evidence points to a positive effect of shock wave therapy in those with Achilles tendinopathy. It has been found to yield positive results in those who have not improved with traditional conservative management and as an adjunct to an eccentric loading programme. Only one study did not show benefit from shock wave therapy. However, in this case the confidence intervals included the potential for a clinically relevant treatment effect. ESWT circumvents the need for immobilisation and for reduced weight bearing and has virtually no side effects or morbidity. Whilst pain has been reported as an issue with therapy, studies that used local anaesthetic to administer the shock wave therapy showed less positive results. Several studies showed improvement but did not have a control group and as such it was difficult to establish true causation. The number of participants were relatively small, and a variety of subjective grading techniques were used to measure outcomes. The current evidence is limited in its nature and significance. Large scale randomised controlled trials are necessary to establish the true extent of benefit of this treatment to decide if this treatment mode should be utilised to a greater extent.

Clinical Bottom Line

Shock wave therapy appears to be a safe and beneficial treatment either as a sole treatment or as an adjunct to traditional conservative measures and where traditional methods have failed.

References

1. Vulpiani et al Extracorporeal shock wave therapy (ESWT) in achilles tendinopathy. A long term follow up observational study
2. Rasmussen et al. Shockwave therapy for chronic achilles tendinopathy. A double-blind randomised clinical trial of efficacy.
3. Rompe et al Eccentric loading versus eccentric loading plus shock-wave treatment for mid-portion achilles tendinopathy.
4. Furia et al High energy extracorporeal shock wave therapy as a treatment for insertional achilles tendinopathy.
5. Costa et al Shock wave therapy for chronic achilles tendon pain. A randomised placebo-controlled trial.
6. Lakshmanan and O’Doherty Chronic achilles tendinopathy: treatment with extracorporeal shock waves.
7. Rompe et al. Eccentric loading, shock-wave treatment, or a wait and see policy for tendinopathy of the main body of tendo achillis.
8. Rompe et al Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy.
9. Fridman et al. Extracorporeal shockwave therapy for the treatment of achilles tendinopathies: a prospective study.
10. Furia et al High-energy extracorporeal shock wave therapy as a treatment for chronic noninsertional achilles tendoinopathy.
11. Saxena et al. Extra-corporeal pulsed-activated therapy (“EPAT” sound wave) for achilles tendinopathy: a prospective study.