SLR - July 2009 - Sona Ramdath, Jr.
Reference:
Rompe, J., Furia, J., Maffulli, N. (2009). Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy. The American Journal of Sports Medicine, 37(3), 463-470.
Scientific Literature Reviews
Reviewed By: Sona Ramdath Jr, DPM
Residency Program: Miami VA Medical Center
Podiatric Relevance:
The focus of this study was to compare the effectiveness of two management strategies for the treatment of midportion Achilles tendinopathy: the first eccentric loading and the second eccentric loading with the addition of low-energy shock-wave therapy.
Methods:
This randomized controlled trial considered 68 patients with chronic recalcitrant (> 6 months) noninsertional Achilles tendinopathy. These patients had previously failed conservative therapies which included peritendinous local injections, nonsteriodal anti-inflammatory drugs and physiotherapy. Patients were separated into two groups. Group 1 consisted of a formal eccentric training regiment. The exercises were performed with a straight knee to load the gastrocnemius, and with the knee flexed to
eccentrically load the soleus. 3 sets of 15 repetitions with 1 minute rest between sets twice a day 7 days per week for 12 weeks was performed. At 6 weeks the patients were told to slowly return to their previous activity, and paracetamol (2000-4000mg daily) or naproxen (1000mg daily) was prescribed if necessary. The second group (group 2) underwent the above treatment in addition to low energy shock wave therapy. The treatment took place three times per week at the point maximal tenderness in a circumferential pattern with no local anesthesia.
Results:
At the conclusion of the study (4mths) 7 patients were lost to follow-up. VISA –A (Victorian Institue of Sport Assessment-Achilles questionanaire) scores showed significant improvement from 50 to 73 points in group 1 and 51 to 87 points in group 2. Additionally, 19 of 34 (56%) and 28 of 34 (82%) reported a Likert scale of 1 or 2 points in groups 1 and 2 respectively (completely recovered or much improved). At the 1 year follow up there were no significant differences between the groups with
these outcome measures, and 15 patients of group 1opted for cross-over therapy and 6 patients of group 2 transitioned to surgery.
Discussion:
When considering the eccentric exercises, some of the postulated reasons for their outcome include: alteration of type I collagen production, increasing tendon volume, increasing the load absorption of the tendon by ‘lengthening’ of the muscle-tendon unit and alteration of neovascularization and related nerves. In comparison, the low energy shock wave therapy does not have an elucidated mode of action. In animal experiments, bone healing was observed, modulation of the endogenous pain control system, decrease in the number of sensory free nerve endings and enhanced angiogenesis. The success rate of 82% in group 2 coupled with no complication was significant but cannot be extrapolated the athletic community.