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 |