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 practising 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 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.

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Extracorporeal Shock Wave Therapy for Achilles Tendinopathy.

Achilles tendon pathology is a most common musculoskeletal condition in active individuals and athletes. Almost 6% of the general population will suffer from such ailment in their lifetime. Insertional Achilles tendinopathy (IAT) differs in its physiopathology, clinical features and treatment from midportion tendinopathy. The literature has mainly focused on assessment, outcome evaluation and treatment of IAT, although differences in management according to different geographical regions have not been addressed. The principles of clinical evaluation and imaging assessment of IAT are well established, with a major role of clinical assessment and soft tissue imaging, including ultrasonography and MRI. Conservative management options include eccentric training, extracorporeal shockwave therapy and prolotherapy, or a combination of these modalities. Recently, regenerative medicine has been more widely used, with at times dubious results. Surgery is advocated where conservative treatment is not beneficial within 6 months. Surgery includes more or less extensive debridement of peritendinous bony and soft tissue structures. To improve our knowledge about IAT, more evidence should be provided concerning innovative treatments, especially considering growth factors injections and percutaneous surgery.

https://jisakos.bmj.com/content/jisakos/early/2018/10/19/jisakos-2017-000144.full.pdf

Achilles insertional tendinopathy: state of the art

Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT. A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects. Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis (n = 11), plantar fasciitis (n = 7) and osteonecrosis of the femoral head (n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI 4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI 0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes. SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.

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The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression.

Background:Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain. Extracorporeal shock wave therapy (ESWT) has proven to be an effective treatment, but the relationship b...

https://journals.sagepub.com/doi/pdf/10.1177/2325967119898118

Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up.

Background Insertional tendinopathy is likely caused by different pathologies. This variation could account for the recalcitrant nature of this condition to treatment. Ultrasound imaging may assist in identifying underlying pathology to inform patient management. Hypothesis/Purpose The primary purpose of this study was to quantify the presence of underlying pathology using ultrasound in individuals with a clinical diagnosis of insertional Achilles tendinopathy. Secondarily, we sought to examine the relationship of abnormal ultrasound findings to age and body mass index (BMI). Study Design Cross-sectional study. Methods Fifty-six individuals with insertional tendinopathy were included in this study. B-mode ultrasound imaging was used to descriptively and quantitatively describe tendon pathology. Results A greater proportion of bone defect (p<0.001), intratendinous calcifications (p = 0.01) and midportion tendinosis (p<0.001) were observed on the injured side compared to the uninjured side. Higher BMI was associated with presence of bone deformity, intratendinous calcifications and distal tendinosis (p = 0.001-0.04); adding age did not significantly improve the regression model. Conclusion Patients with insertional tendinopathy present with multiple underlying pathologies. This may account for variable response to treatment. It may be helpful to include imaging to better identify underlying pathology when trying to determine an appropriate treatment strategy. Level of Evidence Level 3.

Frequency of pathology on diagnostic ultrasound and relationship to patient demographics in individuals with insertional achilles tendinopathy

Introduction. The aim of this study was to investigate the utility of ultrasonography (US) for predicting and assessing the effectiveness of extracorporeal shock wave therapy (ESWT) in insertional Achilles tendinopathy (IAT). Methods. A total of 42 patients with an established diagnosis of chronic IAT were examined by US before ESWT and at 4 weeks and 12 weeks after ESWT. The thickness and cross-sectional area (CSA) of the Achilles tendon, size of calcific plaques, tendon structure score, and neovascularization score were measured at each time point. Results. After therapy, Victorian Institute of Sport Assessment-Achilles (VISA-A) scores increased significantly, and the size of calcific plaques decreased (P < 0.05). Neovascularization scores increased at the 4th week and then decreased at the 12th week (P < 0.05). The thickness, CSA, and structure of the Achilles tendon did not change. Variables observed by US at baseline were not associated with changes in VISA-A scores at follow-up. However, the changes in calcific plaque size and neovascularization scores were related to the improvement of VISA-A scores between pre- and posttherapy (P < 0.01). Conclusion. Ultrasonography can reveal some changes in the insertion of the Achilles tendon after ESWT, but the outcome of ESWT in IAT cannot be predicted by the variables observed by US.

https://downloads.hindawi.com/journals/bmri/2016/2580969.pdf

Utility of Ultrasonography in Assessing the Effectiveness of Extracorporeal Shock Wave Therapy in Insertional Achilles Tendinopathy.

Systemic sclerosis (SSc) is an incurable autoimmune disease characterized by progressive skin fibrosis and organ failure. Tenosynovitis is a common musculoskeletal manifestation, but tendon rupture has seldom reported in SSc.We present a rare case of a 49-year-old female with SSc who has suffered from bilateral tendon rupture of the fourth and fifth digits with positive antinuclear antibody (ANA) and anti-centromere B antibody, but negative rheumatoid factor in serum. In the extensor tendons of the patient's hands, inflammation, edema, hypertrophy and tendon interruption were detected with ultrasound and magnetic resonance imaging(MRI). Tendon transfer repair surgery was performed and 10 mg/week methotrexate was then used in this patient. Her hand function was improved well with methotrexate and rehabilitation treatment postoperatively.Early detection of tenosynovitis is necessary to prevent tendon rupture in SSc patients. Ultrasound and Magnetic Resonance Imaging appear to be useful examinations for evaluating tendon pathology for early detection. 

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Yi Cheng

Papers

Utility of Ultrasonography in Assessing the Effectiveness of Extracorporeal Shock Wave Therapy in Insertional Achilles Tendinopathy.

Spontaneous tendon rupture in a patient with systemic sclerosis: a case report