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Three Part Question

In [patients with Achilles tendinopathy] Is [shock-wave therapy] [beneficial in terms of treatment] ?

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

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
Vulpiari et al, 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.
Rasumussen 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,	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 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

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. Vulpiari et al. Extracorporeal shock wave therapy (ESWT) in achilles tendinopathy. A long term follow up observational study. J sports med phys fitness 2009;49:171-175
2. Rasumussen et al. Shockwave therapy for chronic achilles tendinopathy. A double-blind randomised clinical trial of efficacy. Acta orthopaedica 2008;79(2):249-256
3. Rompe et al. Eccentric loading versus eccentric loading plus shock-wave treatment for mid-portion achilles tendinopathy. American journal of sports medicine 2009;37(3):463-470
4. Furia High energy extracorporeal shock wave therapy as a treatment for insertional achilles tendinopathy. Orthopaede 2005;34:571-578.
5. Costa et al. Shock wave therapy for chronic achilles tendon pain. A randomised placebo-controlled trial. Clinical orthopaedics 2005;440:199-204