Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy A Randomized Controlled Trial

doi:10.1177/0363546508326983

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Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy A Randomized Controlled Trial

Journal Article•DOI•

Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy A Randomized Controlled Trial

Jan D. Rompe, John P. Furia, Nicola Maffulli¹•Institutions (1)

Keele University¹

01 Mar 2009-American Journal of Sports Medicine (Am J Sports Med)-Vol. 37, Iss: 3, pp 463-470

TL;DR: At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.

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Abstract: BackgroundResults of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.PurposeTo compare the effectiveness of 2 management strategies—group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.Study DesignRandomized controlled trial; Level of evidence, 1.MethodsSixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule...

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Journal Article•

Current Opinions on Tendinopathy

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Jean-François Kaux, Bénédicte Forthomme¹, Caroline Le Goff, Jean-Michel Crielaard¹, Jean-Louis Croisier¹ - Show less +1 more•Institutions (1)

University of Liège¹

01 Jun 2011-Journal of Sports Science and Medicine

TL;DR: The word "tendinopathy" is the correct term for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon, which is one of the most frequently self reported musculoskeletal diseases in physical workers and sports people.

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Abstract: Tendinopathy is characterized by pain in the tendon and impaired performance sometimes associated with swelling of the tendon. Its diagnosis is usually clinical but ultrasonography and magnetic resonance imaging can refine the diagnosis. Tendinopathy is highly prevalent and is one of the most frequently self reported musculoskeletal diseases in physical workers and sports people. Nevertheless, it is very difficult to carry out general epidemiologic studies on tendinopathy because of the varying sports cultures and sports habits in different countries. The aetiology of tendinopathy seems to be multi-factorial, involving intrinsic and extrinsic factors. The role of inflammation is still debated but the absence of inflammatory cells does not mean that inflammatory mediators are not implicated. Different theories have been advanced to explain pain and chronicity mechanisms, but these mechanisms remain largely unknown. "Conventional "treatments are generally employed empirically to fight pain and inflammation but they do not modify the histological structure of the tendon. However, these treatments are not completely satisfactory and the recurrence of symptoms is common. Currently, eccentric training remains the treatment of choice for tendinopathy, even though some studies are contradictory. Moreover, many interesting new treatments are now being developed to treat tendinopathy, but there is little evidence to support their use in clinical practice. Key pointsThe word "tendinopathy "is the correct term for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon.The aetiology of tendinopathy seems to be a multi-factorial process, involving promoting factors that are intrinsic or extrinsic, working either alone or in combination.US (with color Doppler) and MRI are usually prescribed when tendinopathy is unresponsive to treatment and entails lingering symptoms.Eccentric training is currently considered to be the most efficient treatment for tendinopathy; nevertheless, in order to be effective, this treatment needs specific modalities: slow speed, low intensity and gradual intensification, with minimum 20 to 30 sessions of exercises often being needed.Many interesting new treatments are now being developed to treat tendinopathy, but currently there is little evidence to support their use in clinical practice.

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253 citations

Cites background from "Eccentric Loading Versus Eccentric ..."

...However, in our opinion, ESWT could be a good complementary treatment to EET for Achilles tendinopathies, as confirmed by a new article (Rompe et al., 2009)....
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Journal Article•DOI•

Novel Approaches for the Management of Tendinopathy

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Nicola Maffulli¹, Umile Giuseppe Longo², Vincenzo Denaro²•Institutions (2)

Queen Mary University of London¹, Università Campus Bio-Medico²

03 Nov 2010-Journal of Bone and Joint Surgery, American Volume

TL;DR: Overall results suggest a trend for a positive effect of eccentric exercises, with no reported adverse effects, and combining eccentric training and shock wave therapy produces higher success rates compared with eccentric loading alone or shock wave Therapy alone.

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Abstract: Tendinopathy is a failed healing response of the tendon. Despite an abundance of therapeutic options, very few randomized prospective, placebo-controlled trials have been carried out to assist physicians in choosing the best evidence-based management. Eccentric exercises have been proposed to promote collagen fiber cross-link formation within the tendon, thereby facilitating tendon remodeling. Overall results suggest a trend for a positive effect of eccentric exercises, with no reported adverse effects. Combining eccentric training and shock wave therapy produces higher success rates compared with eccentric loading alone or shock wave therapy alone. The use of injectable substances such as platelet-rich plasma, autologous blood, polidocanol, corticosteroids, and aprotinin in and around tendons is popular, but there is minimal clinical evidence to support their use. The aim of operative treatment is to excise fibrotic adhesions, remove areas of failed healing, and make multiple longitudinal incisions in the tendon to detect intratendinous lesions and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New operative procedures include endoscopy, electrocoagulation, and minimally invasive stripping. The aim of these techniques is to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. Randomized controlled trials are necessary to better clarify the best therapeutic options for the management of tendinopathy.

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220 citations

Journal Article•DOI•

Radial Extracorporeal Shock Wave Therapy Is Safe and Effective in the Treatment of Chronic Recalcitrant Plantar Fasciitis Results of a Confirmatory Randomized Placebo-Controlled Multicenter Study

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Ludger Gerdesmeyer¹, Carol Frey, Johannes C. Vester, Markus A. Maier², Lowell Weil³, Martin Russlies, John Stienstra, Barry Scurran, Keith Fedder, Peter Diehl⁴, Heinz Lohrer, Mark Henne¹, Hans Gollwitzer¹ - Show less +9 more•Institutions (4)

Technische Universität München¹, Ludwig Maximilian University of Munich², Weil, Gotshal & Manges³, University of Rostock⁴

01 Nov 2008-American Journal of Sports Medicine

TL;DR: Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.

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Abstract: Background:Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials.Hypothesis:There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis.Study Design:Randomized, controlled trial; Level of evidence, 1.Methods:Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm2; 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks' follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Mauds...

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199 citations

Journal Article•DOI•

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

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Christoph Schmitz¹, Nikolaus B. M. Császár¹, Stefan Milz¹, Matthias Schieker¹, Nicola Maffulli², Jan-Dirk Rompe, John P. Furia - Show less +3 more•Institutions (2)

Ludwig Maximilian University of Munich¹, Queen Mary University of London²

01 Dec 2015-British Medical Bulletin

TL;DR: There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome, and future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol.

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Abstract: Background Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

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156 citations

Additional excerpts

...3 7 1000 + − + − − + − − + + Rompe et al.103 + Sonocur (Siemens) EM 0.16 (?)...
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...1 1500 − − + + + + + − + + Plantar fasciopathy Rompe et al.107 + Osteostar (Siemens) EM 0.08 (?)...
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...3 7 2000 + − + − − − + − + + Lateral and medial epicondylitis Lee et al.6 + DolorClast (EMS) R 0.06–0.12 (EFD+) 3 7 2000 + − + − − − + − + + Greater trochanteric pain syndrome Rompe et al.40 + DolorClast (EMS) R 0.12 (EFD+) 3 7 2000 − − + − − − + + + + Plantar fasciopathy Grecco et al.41 + DolorClast (EMS) R 0.12 (EFD+) 3 7 2000 + − + − − − + − + + Greve et al.42 + DolorClast (EMS) R 0.12 (EFD+) 3 7 2000 + − + − − − + − + + Marks et al.43 − DolorClast (EMS) R 0.16 (EFD+) 3 3 2000 + − + − − + + − − + 4 Plantar fasciopathy and tennis elbow Mehra et al.44 + DolorClast (EMS) R 0.10 (EFD+) 3 14 2000 + − − − − − + − + + Spasticity Vidal et al.45 + DolorClast (EMS) R 0.10 (EFD+) 3 7 2000 + − − − − + − − + + Ps, PEDro score; O, outcome; +, rESWT significantly better statistically than either placebo or alternative treatment modalities; −, rESWT not significantly better statistically than either placebo or alternative treatment modalities; T, shock wave technology; R, radial; EFD, energy flux density; EFD+, positive EFD; EFDtotal, total EFD; (?)...
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...However, using the same rESWT and fESWT devices than in Ref.12 and the same EFD in fESWT and rESWT, other authors found no difference in effectiveness between rESWT and fESWT for patients with patellar tendinopathy.134* The distinction between radial ESWT as ‘low-energy ESWT’ and focused ESWT as ‘high-energy ESWT’ is not correct and should be abandoned Rompe et al.8 arbitrarily defined an EFD of 0.2 mJ/ mm2 as the margin between low- and high-energy shock wave treatments....
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...1 1500 + − + + − + + − + − Rompe et al.93 + Osteostar (Siemens) EM 0.08 (?)...
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Journal Article•DOI•

Physical therapies for Achilles tendinopathy: systematic review and meta-analysis

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Samuel P Sussmilch-Leitch¹, Natalie J. Collins¹, Andrea Bialocerkowski², Stuart J. Warden³, Kay M. Crossley¹, Kay M. Crossley⁴ - Show less +2 more•Institutions (4)

University of Melbourne¹, University of Western Sydney², Indiana University – Purdue University Indianapolis³, University of Queensland⁴

02 Jul 2012-Journal of Foot and Ankle Research

TL;DR: Practitioners can consider eccentric exercise as an initial intervention for AT, with the addition of laser therapy as appropriate, with limited evidence from an individual RCT suggests microcurrent therapy to be an effective intervention.

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Abstract: Background: Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. The aim of this study was to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management. Methods: A comprehensive strategy was used to search 11 electronic databases from inception to September 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies, and assessed methodological quality and risk of bias using a modified PEDro scale. Effect size calculation and meta-analyses were based on fixed and random effects models respectively. Results: Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies, the majority of which evaluated midportion AT. Effect sizes from individual RCTs support the use of eccentric exercise. Meta-analyses identified significant effects favouring the addition of laser therapy to eccentric exercise at 12 weeks (pain VAS: standardised mean difference −0.59, 95% confidence interval −1.11 to −0.07), as well as no differences in effect between eccentric exercise and shock wave therapy at 16 weeks (VISA-A:–0.55,–2.21 to 1.11). Pooled data did not support the addition of night splints to eccentric exercise at 12 weeks (VISA-A:–0.35,–1.44 to 0.74). Limited evidence from an individual RCT suggests microcurrent therapy to be an effective intervention. Conclusions: Practitioners can consider eccentric exercise as an initial intervention for AT, with the addition of laser therapy as appropriate. Shock wave therapy may represent an effective alternative. High-quality RCTs following CONSORT guidelines are required to further evaluate the efficacy of physical therapies and determine optimal clinical pathways for AT.

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152 citations

Cites background or methods from "Eccentric Loading Versus Eccentric ..."

...Visual analogue scales (VAS) (79% of studies) [25-27,29-32,35,39,40,42,43,45,46] and the Victorian Institute of Sport Assessment–Achilles (VISA-A) questionnaire (37% of studies) [25,26,33,39,43,44,47] were the most frequently used tools....
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...A further study by Rompe and colleagues [27] examined the effects of SWT when added to eccentric exercise, with effect sizes showing moderate significant effects favouring combined SWT...
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...It is only when SWT is used in conjunction with eccentric exercise that moderate effect sizes for pain and function are observed [27], suggesting that utilising SWT in combination with eccentric exercise is likely to produce superior patient outcomes than eccentric exercise or SWT alone....
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...Electrophysical therapies: Five studies [25-27,32,42] evaluated the efficacy of SWT on AT (Table 3), with a mean methodological quality of 11....
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...Seven studies (37%) [26,29,33,34,44-46] included participants with a mean age of 40 years or less, and six studies (32%) [25,26,27,32,35,42] utilised groups with at least 50 percent females....
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Journal Article•DOI•

Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis

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Håkan Alfredson¹, Tom Pietilä¹, Per Jonsson¹, Ronny Lorentzon¹•Institutions (1)

Umeå University¹

01 May 1998-American Journal of Sports Medicine

TL;DR: The treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early forties.

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Abstract: We prospectively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes (12 men and 3 women; mean age, 44.3 +/- 7.0 years) who had the diagnosis of chronic Achilles tendinosis (degenerative changes) with a long duration of symptoms despite conventional nonsurgical treatment. Calf muscle strength and the amount of pain during activity (recorded on a visual analog scale) were measured before onset of training and after 12 weeks of eccentric training. At week 0, all patients had Achilles tendon pain not allowing running activity, and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the noninjured side. After the 12-week training period, all 15 patients were back at their preinjury levels with full running activity. There was a significant decrease in pain during activity, and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the noninjured side. A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally, i.e., rest, nonsteroidal antiinflammatory drugs, changes of shoes or orthoses, physical therapy, and in all cases also with ordinary training programs. In no case was the conventional treatment successful, and all patients were ultimately treated surgically. Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early forties.

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1,062 citations

"Eccentric Loading Versus Eccentric ..." refers background in this paper

...Although there are several possible explanations for the effectiveness of eccentric exercise, none has been fully investigated, including affecting type I collagen production, increasing the tendon volume over the longer term, “lengthening” of the muscle-tendon unit having an effect on capacity of the musculotendinous unit to effectively absorb load, and alteration of neovascularization and accompanying nerves.(2,12) The modern model of eccentric training involves no concentric loading and emphasizes the need for patients to complete the exercise protocol despite pain in the tendon....
[...]

Journal Article•DOI•

Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial.

[...]

Nynke Smidt¹, Daniëlle A W M van der Windt¹, Willem J. J. Assendelft², Walter Devillé¹, Ingeborg B C Korthals-de Bos¹, Lex M. Bouter¹ - Show less +2 more•Institutions (2)

VU University Amsterdam¹, University of Amsterdam²

23 Feb 2002-The Lancet

TL;DR: C corticosteroid injections were significantly better than all other therapy options for all outcome measures, and physiotherapy had better results than a wait-and-see policy, but differences were not significant.

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648 citations

"Eccentric Loading Versus Eccentric ..." refers methods in this paper

...General assessment was scored by the patient on a 6-point Likert scale from 1 to 6.(24) For the computation of success rates, patients who rated themselves 1 or 2 (ie, completely recovered or much improved) were counted as successes; patients who rated themselves 3 (somewhat improved), 4 (hardly improved), 5 (not improved), or 6 (worse) were rated as failures....
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Journal Article•DOI•

The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy

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Jane E. Robinson¹, Jill Cook, Craig Purdam, Paul J. Visentini, J. Ross, Nicola Maffulli, Jack E. Taunton, Karim M. Khan - Show less +4 more•Institutions (1)

University of British Columbia¹

01 Oct 2001-British Journal of Sports Medicine

TL;DR: The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects and has the potential to provide utility in both the clinical setting and research.

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Abstract: Background—There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective—To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods—Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results—The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59‐69), in presurgical patients 44 (28‐60), and in control subjects it exceeded 96 (94‐99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions—The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis. (Br J Sports Med 2001;35:335‐341)

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633 citations

"Eccentric Loading Versus Eccentric ..." refers methods in this paper

...At each visit, every patient completed a pain score validated for Achilles tendon problems (VISA-A).(15) The VISA-A questionnaire contains 8 questions that cover the 3 domains of pain (questions 1-3), function (questions 4-6), and activity (questions 7 and 8)....
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Journal Article•DOI•

Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits.

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Ching-Jen Wang¹, Feng-Sheng Wang¹, Kuender D. Yang¹, Lin-Hsiu Weng¹, Chia-Chen Hsu¹, Chun-Shun Huang¹, Lin-Cheng Yang¹ - Show less +3 more•Institutions (1)

Memorial Hospital of South Bend¹

01 Nov 2003-Journal of Orthopaedic Research

TL;DR: In conclusion, shock wave therapy induces the ingrowth of neovascularization associated with early release of angiogenesis‐related markers at the Achilles tendon–bone junction in rabbits, which may play a role to improve blood supply and tissue regeneration at the tendon-bone junction.

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597 citations

Additional excerpts

...Visa-A score [0-100] 73....
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...(%) NSAIDs 34 (100) 34 (100) Physical therapy 34 (100) 34 (100) Orthotics 34 (100) 34 (100) Conventional stretching exercises 34 (100) 34 (100) Injections 34 (100) 34 (100) ≥2 cortisone injections 22 (65) 30 (88) SWT 0 (0) 0 (0) Surgery 0 (0) 0 (0) VISA-A score [0-100], mean (SD) 50....
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Journal Article•DOI•

Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up

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Lars Öhberg¹, Ronny Lorentzon, Håkan Alfredson•Institutions (1)

Umeå University¹

01 Feb 2004-British Journal of Sports Medicine

TL;DR: Ulasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients.

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Abstract: Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up

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435 citations

"Eccentric Loading Versus Eccentric ..." refers background or result in this paper

...Although evidence of actual histological adaptations after an adapted program of eccentric exercise is lacking, and the mechanisms by which a program of eccentric exercise may help to resolve the pain of tendinopathy remain unclear, clinical results after such an exercise program appear promising.(1,12) Although effective in a Scandinavian population, the results of eccentric exercises observed from other study groups(10,21,23) were less convincing, with only up to 60% of good and excellent outcome after a regimen of eccentric training both in athletic and sedentary patients....
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...Although there are several possible explanations for the effectiveness of eccentric exercise, none has been fully investigated, including affecting type I collagen production, increasing the tendon volume over the longer term, “lengthening” of the muscle-tendon unit having an effect on capacity of the musculotendinous unit to effectively absorb load, and alteration of neovascularization and accompanying nerves.(2,12) The modern model of eccentric training involves no concentric loading and emphasizes the need for patients to complete the exercise protocol despite pain in the tendon....
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