Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy

Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achilles: a randomized controlled trial. Rompe JD, Nafe B, Furia JP, Maffulli N. Am J Sports Med. 2007 Mar;35(3):374-83. Epub 2007 Jan 23.

BACKGROUND: Few randomized controlled trials compare different methods of management in chronic tendinopathy of the main body of tendo Achillis.
PURPOSE: To compare the effectiveness of 3 management strategies-group 1, eccentric loading; group 2, repetitive low-energy shock-wave therapy (SWT); and group 3, wait and see-in patients with chronic tendinopathy of the main body of tendo Achillis.
STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.
METHODS: Seventy-five 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. Analysis was on intention-to-treat basis.
RESULTS: At 4 months from baseline, the Victorian Institute of Sport Assessment (VISA)-A score increased in all groups, from 51 to 76 points in group 1 (eccentric loading), from 50 to 70 points in group 2 (repetitive low-energy SWT), and from 48 to 55 points in group 3 (wait and see). Pain rating decreased in all groups, from 7 to 4 points in group 1, from 7 to 4 points in group 2, and from 8 to 6 points in group 3. Fifteen of 25 patients in group 1 (60%), 13 of 25 patients in group 2 (52%), and 6 of 25 patients in Group 3 (24%) reported a Likert scale of 1 or 2 points (“completely recovered” or “much improved”). For all outcome measures, groups 1 and 2 did not differ significantly. For all outcome measures, groups 1 and 2 showed significantly better results than group 3.
CONCLUSION: At 4-month follow-up, eccentric loading and low-energy SWT showed comparable results. The wait-and-see strategy was ineffective for the management of chronic recalcitrant tendinopathy of the main body of the Achilles tendon.

Diagnosis: Mid portion Achilles tendinitis (2-6 cm above insertion)

Outcome: VISA-A etc. Eccentric group improved from 50.6 to 75.6, shock-wave treatment from 50.3 to 70.4 and wait and see from 48.2 to 55. Eccentric and shock wave treatment were not significantly different but both were significantly better than the wait and see group.

When Assessed: 16 week after start of treatment, intervention was for only 12 weeks.

Subjects: 75 patients, 25 per group, average age 48 in eccentric group, 51 in SWT group, and 46 in wait and see. Most ~2/3 were not athletic.

Protocol: Subjects worked up 3 sets of 15 reps with knee bent and with knee straight, twice per day, 7 days a week for 12 weeks. Allowed to work through mild to moderate pain, starting with body weight (1 set of 10 reps) and adding 5 kg at a time if 3rd set painless. Speed was not varied.

Other Activity: “Patients were asked to avoid pain-provoking activities throughout the 12-week treatment period. Walking and bicycling was allowed if it could be performed with only mild discomfort or pain. Light jogging on flat ground and at a slow pace was allowed after 4 to 6 weeks, but only if it could be undertaken without pain. Thereafter, activities could be gradually increased if no severe tendon pain occurred.”

Chad’s Comments:  Interesting in that it compares eccentric exercise to wait and see and found significantly better improvements, which is good as previous research looking at traditional physical therapy exercises were not noticeably better than wait and see. Still the results were not as good as the Scandinavian studies. This study had the fewer number of athletes stop running for first 6 weeks but Scandinavians had done that too in some studies, however the proportion who were runners was less in this study.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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