Title: Eccentric Loading, Shock-Wave Treatment, or a Wait-and-See Policy for Tendinopathy of the Main Body of Tendo Achilles
Authors: Jan D. Rompe MD; Bernard Nafe MD; John Fura MD PhD; Nicola Muffulli MD PhD FRCS
Source: American Journal of Sports Medicine 2007 Mar; 35(3):374-83. Epub 2007 Jan 23
PODIATRIC RELEVANCE:
Achilles tendinopathy is a commonly faced problem for the podiatric surgeon. A magnitude of conservative treatment options are available for the management of noninsertional Achilles tendinopathy.
Several studies have supported the use of eccentric calf muscle training for the treatment of both acute and chronic tendinopathy. Shock-wave therapy (SWT) has also been the focus of recent studies in the treatment of this problem in Achilles tendon and other tendons around the body; while a wait-and-see approach has been a proven method in conditions such as lateral epicondylopathy.
By developing a solid and proven conservative therapy regimen the podiatric surgeon can either efficiently treat Achilles tendinopathy or feel confident in his or her decision for surgical intervention.
METHODS:
Level 1 randomized controlled trial. Seventy-five patients with chronic (> 6 months) noninsertional Achilles tendinopathy participated in this study. All patients were recalcitrant to conservative measures for > 3 months. A computerized random number generator formulated an allocation schedule for the patients meeting the selection criteria. Enrollment was determined by an assistant not directly involved in the study.
Patients were asked to avoid pain provoking activities for 12 weeks. They were allowed light activity and jogging on flat ground after 4-6 weeks.
Eccentric loading (group 1) was performed twice a day, 7 days per week for 12 weeks. They used a proven program that called for 3 sets of 15 repetitions of eccentric loading of the gastroc-soleus complex. SWT (group 2) therapy was provided by a radial shock-wave device (EMS Swiss DolorClast). Therapy took place in 3 sessions at weekly intervals. Each session consisted of 2000 pulses applied at a pressure of 0.1 mJ/mm2 .
Wait and see (group 3) therapy consisted of exactly that for 12 weeks with the addition of oral NSAID therapy.
Crossover was available to all groups if after 6 weeks of therapy limited progress was witnessed. This allowed patients to either combine eccentric loading with SWT or progress to surgical intervention.
RESULTS:
A total of 5 patients were lost to follow-up, 1 patient from each group were pain free and refused to complete the study. Two patients (eccentric load and wait and see) dropped out after continued pain after six weeks. A total of 56 patients where available for final evaluation at 12 weeks.
Visa-A score: (asymptomatic score 100) All groups showed similar pre-intervention scores. Groups 1 and 2 showed similar improvement from 51 to 76 and 50 to 70 points respectively. Group 3 therapy was statistically less improved from 48 to 55 points.
Pain rating decreased in each group from 7 to 4 in group 1, from 7 to 4 in group 2 and 8 to 6 in group 3.
The Likert Scale (1-6, 1 complete recovery, 6 much worse) resulted in 60% of group 1, 52% in group 2 and 24% in group 3 reporting a score of 1 or 2.
For all measurement, groups 1 and 2 did not differ significantly. For all outcomes groups 1 and 2 showed significantly better results than group 3.
COMMENTS:
This paper utilized low energy SWT and found a 50%-60% improvement rate as opposed to a 75% improvement rate found with high energy SWT studies. This is an important distinction when using this paper as a source of reference. Low energy SWT can be performed in your office without sedation or local anesthetic. The fact that eccentric loading and SWT showed similar results leads one to believe that a 3 week therapy (SWT) would be preferred over a 12 week program.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.