SLR - April 2019 - Diana Le

Shockwave Therapy Associated with Eccentric Strengthening for Achilles Insertional Tendinopathy: A Prospective Study

Reference: Mansur NSB, Baumfeld T, Villalon F, Aoyama BT, Matsunaga FT, Dos Santos PRD, Dos Santos BS, Tamaoki MJS. Shockwave therapy associated with eccentric strengthening for Achilles insertional tendinopathy: a prospective study. Foot Ankle Spec. 2019 Feb 2:1938640019826673. doi: 10.1177/1938640019826673. PMID: 30712379

Scientific Literature Review

Reviewed By: Diana Le, DPM
Residency Program: Long Beach Memorial Medical Center Residency Program, Long Beach, CA

Podiatric Relevance: Achilles insertional tendinopathy is one of the most common conditions seen in podiatry. Shockwave therapy and eccentric exercises have been independently shown in previous literature to have a success rate of 60 percent and 52 percent, respectively, for Achilles insertional tendinopathy. However, very limited studies are available. The purpose of this study was to evaluate the effectiveness of low-energy shockwave therapy in combination with eccentric stretching for insertional Achilles tendinopathy.

Methods: A level III evidence, prospective cohort study was conducted. Patients diagnosed with insertional Achilles tendinopathy were included. The treatment protocol included shockwave therapy sessions with eccentric exercise for 12 weeks, a 20-minute cold compress three times a day with a minimum two-hour break and pain medication. The outcome was evaluated at the first day and after 24 weeks by using the following: Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire score, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score and a digital pressure algometry that measures pressure pain with ±0.2 percent accuracy. Secondary outcomes included patients’ adherence to protocol, complications and perceptions of final outcome as success or failure.

Results: A total of 19 patients were enrolled in a single tertiary center. Of 19 patients, eight patients were female and 11 patients were male. Their average age was 51 years old, ranging from 26 to 72 years old. There were statistically significant differences found in pretreatment and posttreatment outcome in terms of AOFAS, VISA-A and VAS values. The outcome revealed improving AOFAS scores from 63.58 to 77.56, VISA-A scores from 49.05 to 62.58 and pain improvement VAS from 5.26 to 3.16, which was statistically significant. Of the 19 patients who participated, 15 patients (79 percent) fully adhered to protocol, and 13 patients (68 percent) considered the treatment successful. By adhering to the protocol completely, successful outcome increased 6.5 times. The following did not influence the outcome: BMI, gender and ethnicity.

Conclusions: This study presents evidence that eccentric exercises in combination with low-energy shockwave therapy is an effective treatment for Achilles insertional tendinopathy in 19 consecutive patients, who were undergoing same treatment protocol. The authors of this study concluded successful management (68 percent) by combining shockwave therapy and eccentric exercises for Achilles insertional tendinopathy. Limitations to this prospective study design included small sample size and short follow-up duration. This prospective study did not provide evidence that combination therapy is more effective in comparison to other treatment modalities, due to the lack of a control group. Therefore, a randomized controlled trial is needed to conclude that combination therapy is more effective than other common modalities for Achilles insertional tendinopathy.

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