Eccentric vs Eccentric Plus Shock-Wave Treatment for Achilles Tendinopathy

Eccentric loading versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: a randomized controlled trial. Rompe JD, Furia J, Maffulli N. Am J Sports Med. 2009 Mar;37(3):463-70. Epub 2008 Dec 15.

BACKGROUND: Results 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.
PURPOSE: To compare the effectiveness of 2 management strategies–group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.
STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.
METHODS: Sixty-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. Analysis was on an intention-to-treat basis.
RESULTS: At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points (“completely recovered” or “much improved”). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.
CONCLUSION: 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.

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

Outcome: VISA-A score improved from 50 to 73 in eccentric group, while combined eccentric exercise and shock-wave treatment group improved from 50 to 86.5. Combined group had slightly less women in it 53% vs. 59% but were on average older 53 years vs. 46 years. Only 26% in group eccentric and 35% in combined groups performed some sort of sporting activity at least once per week.

When Assessed: 4 months, treatment was 12 weeks.

Subjects:  34 patients per group, average age 46 in eccentric, and 53 in combined. 59% women in eccentric and 53% in combined.

Protocol: Eccentric group: 2 exercises (one with knee straight and one with knee bent) 3×15 each, 2 x per day, 7 days per week for 12 weeks, starting with full body weight on one leg, train with pain unless “disabling”, no indication of varied speed. Combination group also had SWT 3 times, at weekly intervals. Exercises were demonstrated once by author and subjects were instructed to add 5kg of books at a time to their backpacks.

Other Activity: “After 6 weeks, the patients were told to slowly return to their previous sports/recreational activity.”

Chad’s Comments:  Subjects were told to increase resistance by putting books in a backpack at home, which I think might have decreased compliance regarding increasing resistance levels as eventually it will be difficult to keep adding books to a backpack, thus patients might max out before optimal strength levels are reached. Also no recording of BMI, such that less fit individuals might be starting off with higher resistance levels and less strength than more fit counterparts. Only 9/34 in group 1 and 12/34 performed some sort of sporting activity at least once per week. Appears to less athletic than the Scandinavian studies. I think that though differences between groups were statistically significant, but relatively minor and may be due to the increased females and lesser number of athletes of eccentric group, so it is hard to say how much effect the SWT had on outcomes.

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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