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Table 1 Individual study characteristics of the included studies

From: Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials

References

Population and setting, inclusion and exclusion criteria

Experimental group

Control group(s)

Follow-up

Primary outcome, results and conclusions

Industry funding

Rompe et al. [21]

Population and setting

Primary care setting in Gruenstadt, Germany

Inclusion criteria

18–70 years

mid-AT symptoms ≥ 6 months

failure of non-operative management

Exclusion criteria

peritendinous injection within the last 4 weeks

bilateral mid-AT

symptoms ≤ 6 months

concomitant painful ankle conditions

congenital or acquired deformities of ankle or knee

prior surgery to the ankle or the Achilles tendon

prior Achilles tendon rupture

prior dislocations or fractures in the area in the preceding 12 months

R-ESWT (n = 25)

2000 pulses, 8 pulses/sec, 3 bar pressure, equals an energy flux density (EFD) of 0.1 mJ/mm2, 3 sessions, weekly intervals

Eccentric loading (n = 25)

Progressive buildup from 1 set of 10 repetitions to 3 sets of 15 repetitions (1 min rest between sets), twice a day, 7 days a week, for 12 weeks (mild–moderate pain was allowed), starting with body weight and continuing pain-free training with 5 kg rucksack

Wait-and-see (n = 25)

1 visit to their orthopedic physician for load management, stretching and ergonomic advice. Pain medication was prescribed if necessary

4 months

VISA-A (range 0–100, mean ± SD)

ESWT

Baseline: 50.3 ± 11.7

4 months: 70.4 ± 16.3

Eccentric loading

Baseline: 50.6 ± 11.5

4 months: 75.6 ± 18.7

Wait & see

Baseline: 48.2 ± 9.0

4 months: 55.0 ± 12.9

Results

No baseline differences between all groups

ESWT & eccentric loading improved over time; no differences between treatments

The ESWT & eccentric loading groups achieved better VISA-A scores than wait-and-see group

Conclusions

ESWT & eccentric loading showed comparable results at 4 month follow-up. The wait-and-see strategy was ineffective

No potential conflict of interest declared

Rompe et al. [41]

Population and setting

Primary care setting in Gruenstadt, Germany. Enrollment via orthopedic physician

Inclusion criteria

18–70 years

mid-AT symptoms ≥ 6 months

failure of non-operative management

Exclusion criteria

professional athletes

peritendinous injection within the last 4 weeks

bilateral mid-AT

symptoms ≤ 6 months

concomitant painful ankle conditions

congenital or acquired deformities of ankle or knee

prior surgery to the ankle or Achilles tendon

prior Achilles tendon rupture

prior dislocations or fractures in the area in the preceding 12 months

Eccentric loading + R-ESWT (n = 34)

Loading consisted of progressive buildup from 1 set of 10 repetitions to 3 sets of 15 repetitions (1 min rest between sets), twice a day, 7 days a week, for 12 weeks (mild–moderate pain was allowed), starting with body weight and continuing pain-free training with 5 kg rucksack

R-ESWT consisted of 2000 pulses, 8 pulses/sec, 3 bar pressure (equals EFD 0.1 mJ/mm2),

3 sessions for each participant, weekly intervals after 4 weeks of eccentric training

Eccentric loading (n = 34)

Progressive buildup from 1 set of 10 repetitions to 3 sets of 15 repetitions (1 min rest between sets), twice a day, 7 days a week, for 12 weeks (mild–moderate pain was allowed), starting with body weight and continuing pain-free training with 5 kg rucksack

4 months

VISA-A (range 0–100, mean ± SD)

Eccentric loading + ESWT

Baseline: 50.2 ± 11.1

4 months: 86.5 ± 16.0

Eccentric loading

Baseline: 50.6 ± 10.3

4 months: 73.0 ± 19.0

Results

No baseline differences between groups

Both groups improved over time

Eccentric loading + ESWT achieved better VISA-A scores than eccentric loading alone

Conclusions

At 4 month follow-up, eccentric loading alone was less effective than eccentric loading combined with shockwave treatment

No potential conflict of interest declared

Abdelkader et al. [42]

Population and setting

Faculty of Physical Therapy in Cairo, Egypt. Referral by the orthopedic department physician

Inclusion criteria

unilateral mid-AT symptoms for ≥ 6 months

failure of conservative treatment for at least 3 months

Exclusion criteria

physical therapy or peritendinous injection within the previous 4 weeks

use of NSAIDs in the previous week

bilateral AT

concomitant painful ankle conditions

previous injury or surgical treatment to the ankle

Eccentric loading + stretching + R-ESWT (n = 25)

Loading consisted of 3 sets of 15 repetitions (1 min rest between sets), twice a day, seven days a week, for 4 weeks

Gastrocnemius and soleus stretches were performed twice a day, 3 repetitions (30 s stretch, 30 s rest)

R-ESWT consisted of 2000 pulses, 8 pulses/second, 3 bar pressure (equals EFD 0.1 mJ/mm2),

4 sessions, weekly intervals

Eccentric loading + stretching + sham R-ESWT

(n = 25)

Loading consisted of 3 sets of 15 repetitions (1 min rest between sets), twice a day, seven days a week, for 4 weeks

Gastrocnemius and soleus stretches were performed twice a day, 3 repetitions (30 s stretch, 30 s rest)

sham-ESWT was administrated in the same way as ESWT. Machine settings were adjusted to generate zero energy, while producing the same sound effect

1 month and 16 months

VISA-A (range 0–100, mean ± SD)

Eccentric loading, stretching & ESWT

Baseline: 24.2 ± 6.5

1 month: 85 ± 6.2

16 months: 80 ± 5.3

Eccentric loading, stretching & sham-ESWT

Baseline: 21.0 ± 5.2

1 months: 53.4 ± 7.7

16 months: 67 ± 5.6

Results

Both groups were comparable at baseline

Both groups improved over time

The experimental group achieved better VISA-A scores than the control group

Conclusion

Adding ESWT to an eccentric loading and stretching program resulted in greater improvements in both the short and long term

No funding

Rompe et al. [45]

Population and setting

Primary care setting in Gruenstadt, Germany. Enrollment via orthopedic physician

Inclusion criteria

18–70 years

ins-AT ≥ 6 months

failure of non-operative management

Exclusion criteria

(imaging) signs of mid-AT, retrocalcaneal bursitis, and Haglund deformity

peritendinous injection within the last 4 weeks

bilateral mid-AT

symptoms ≤ 6 months

concomitant painful ankle conditions

congenital or acquired deformities of ankle or knee

prior surgery to the ankle or Achilles tendon

prior Achilles tendon rupture

prior dislocations or fractures in the area in the preceding 12 months

R-ESWT

(n = 25)

2000 pulses, 8 pulses/sec, 2.5 bar pressure (equals EFD 0.12 mJ/mm2),

3 sessions, weekly intervals

Eccentric loading (n = 25)

Progressive buildup from 1 set of 10 repetitions to 3 sets of 15 repetitions (1 min rest between sets), twice a day, 7 days a week, for 12 weeks (mild to moderate pain was allowed), starting with own body weight and continuing pain-free training with 5 kg rucksack

4 months

VISA-A (range 0–100, mean ± SD)

ESWT

Baseline: 53.2 ± 5.8

4 months: 79.4 ± 10.4

Eccentric loading

Baseline: 52.7 ± 8.4

4 months: 63.4 ± 12.0

Results

No baseline differences between groups

Both groups improved over time

The ESWT group achieved better VISA-A scores than the eccentric loading group

Conclusion

Eccentric loading showed inferior results to ESWT

No funding

Pinitkwamdee et al. [44]

Population and setting

Orthopedic outdoor clinic in Bangkok, Thailand

Inclusion criteria

18–70 years

clinical or radiographical diagnosis of ins-AT

symptoms > 6 months

failed other standard conservative care for 3 months (e.g., rest, medication, activity modification, stretching exercise, and heel lift orthosis)

Exclusion criteria

injection to the insertion within the previous 4 weeks

mid-AT symptoms

neurological deficit

history of foot and ankle infection or trauma

foot or ankle deformity

history of foot or ankle surgery

contraindications for ESWT (hemophilia, coagulopathy, or foot and ankle malignancy)

R-ESWT + standard care (n = 16)

R-ESWT consisted of 2000 pulses, 8–12 Hz, 2.5–3.5 bar pressure (equals EFD 0.12–.16 mJ/mm2), 4 sessions, weekly intervals

Standard care consisted of rest, medication, activity modification, stretching, and heel lift orthosis

sham-ESWT + standard care (n = 15)

sham-ESWT was administered by disconnecting the treatment probe while connecting a second probe that generated the shockwave sound (without patient contact)

Standard care consisted of rest, medication, activity modification, stretching, and heel lift orthosis

2,3,4,6,12, and 24 weeks

VAS (range 0–10, mean ± SD)

ESWT + standard care

Baseline: 6.0 ± 2.6

2 weeks: 4.6 ± 3.1

3 weeks: 3.7 ± 3.0

4 weeks: 2.9 ± 2.2

6 weeks: 3.0 ± 2.3

12 weeks: 2.3 ± 2.5

24 weeks: 2.8 ± 3.3

sham-ESWT + standard care

Baseline: 5.2 ± 2.2

2 weeks: 2.9 ± 1.9

3 weeks: 3.1 ± 2.3

4 weeks: 2.6 ± 2.2

6 weeks: 3.7 ± 2.9

12 weeks: 2.3 ± 2.6

24 weeks: 2.0 ± 2.6

Results

No baseline differences between groups

ESWT showed significant improvements at weeks 4, 6, and 12

sham-ESWT showed significant improvements at weeks 12 and 24

No differences between groups at 24 weeks

Conclusion

There was no difference at 24 weeks with the use of ESWT for chronic insertional Achilles tendinopathy, especially in elderly patients. However, it may provide a short period of therapeutic effects as early as weeks 4 to 12

No funding

Notarnicola et al. [43]

Population and setting

Hospital in Bari, Italy. Patients were recruited from an orthopedic hospital unit

Inclusion criteria

18–80 years

ins-AT symptoms ≥ 6 months

functional VAS score > 4

Exclusion criteria

(imaging) signs of mid-AT, partial rupture, calcaneal spurs or calcifications

contraindications to laser therapy or ESWT (neoplasia, current or previous infections of the affected area, history of epilepsy, coagulopathies, cardiac pacemaker, pregnancy, intolerance to cold)

previous Achilles tendon surgery

peritendinous injection within the previous 4 weeks

ESWT or laser therapy within the previous 2 months

congenital or acquired deformities of the lower limb

F-ESWT + eccentric loading + stretching (n = 30)

F-ESWT consisted of 1600 pulses, EFD 0.05–0.07 mJ/mm2, 3 sessions, at 3–4 day intervals

Eccentric loading consisted of 3 sets of 10 repetitions using a TheraBand (i.e., a thin ribbon of stretchy material that enables resistance during movement exercises), 2–3 weekly sessions for 2 months

Calf and Achilles stretching consisted of 4 sets of 15–20 s, 2–3 weekly sessions for 2 months

Cold air and high-energy laser therapy (CHELT) + eccentric loading + stretching (n = 30)

CHELT consisted of simultaneous wavelengths (1,064, 810 and 980 nm; total dosage 1,200 J) together with a flow of cold air (− 30 °C), 10 daily sessions

Eccentric loading consisted of 3 sets of 10 repetitions using a TheraBand, 2–3 weekly sessions for 2 months

Calf and Achilles stretching consisted of 4 sets of 15–20 s, 2–3 weekly sessions for 2 months

10–15 days (end of complete session of treatment), 2 months, and 6 months

VAS (range 0–10, mean ± SD)

ESWT + standard care

Baseline: 7 ± 1.2

10th-15th days: 4.9 ± 0.9

2 months: 5.4 ± 2.7

6 months: 3.3 ± 2.4

CHELT + standard care

Baseline: 7 ± 1.0

10th–15th days: 2.3 ± 1.1

2 months: 2.4 ± 1.6

6 months: 1.7 ± 1.0

Results

No baseline differences between groups

Both groups improved over time

CHELT achieved better than ESWT

Conclusion

CHELT gave quicker and better pain relief. It also gave the patient a full functional recovery and greater satisfaction

Not reported

Mansur et al. [34]

Population and setting

Tertiary teaching hospital in

São Paulo, Brazil

Inclusion criteria

18–75 years

pain at the calcaneal tendon insertion for ≥ 3 months

diagnosis of ins-AT

Exclusion criteria

bilateral tendinopathy

previous surgery

autoimmune conditions

neuropathy

inflammatory diseases

non-insertional or mixed tendinopathy

previous infiltration

pregnancy

use of a pacemaker

coagulopathies

local infection

R-ESWT + Eccentric loading (n = 58)

R-ESWT consisted of 2000–3000 pulses, 7–10 Hz, and 1.5–2.5 bars of pressure, 3 sessions: at baseline, after two weeks, and after 4 weeks

Loading consisted of 3 sets of 15 repetitions with a stretched knee, and 3 sets of 15 repetitions with a 20° flexed knee were performed twice a day, 7 days per week, for 3 consecutive months

Sham R-ESWT + Eccentric loading (n = 61)

sham-ESWT was administered in the same way as in the experimental group, except that the firing transmission piece was removed from the therapeutic pistol head prior to initiation of ESWT

Loading consisted of 3 series of 15 repetitions with a 20° flexed knee, twice a day, 7 days per week, for 3 months

2,4,6,12, and 24 weeks

VISA-A (range 0–100, mean ± SD)

ESWT + eccentric loading

Baseline: 43.9 ± 23.2

2 weeks: 43.8 ± 21.3

4 weeks: 50.2 ± 19.6

6 weeks: 49.3 ± 21.2

12 weeks: 53.7 ± 22.0

24 weeks: 63.2 ± 27.5

sham-ESWT + eccentric loading

Baseline: 40.6 ± 21.1

2 weeks: 47.6 ± 19.8

4 weeks: 52.9 ± 20.6

6 weeks: 54.8 ± 19.4

12 weeks: 61.8 ± 23.2

24 weeks: 62.3 ± 25.1

Results

No baseline differences between groups

Both groups improved significantly from baseline

No differences between the groups at any time point in the study

Conclusion

ESWT does not potentiate the effects of eccentric strengthening in the management of insertional Achilles tendinopathy

No funding