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Eccentric Loading, Shock-Wave Treatment, or a Wait-and-See Policy for Tendinopathy of the Main Body of Tendo Achillis: A Randomized Controlled Trial
Jan D. Rompe, Bernhard Nafe, John P. Furia, Nicola Maffulli, American Journal of Sports Medicine 2007
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Background: Few randomized controlled trials compare different methods of management in chronic tendinopathy of the main body of tendo Achillies.
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
Objectives: To determine the effectiveness of eccentric exercise (EE) programmes in the treatment of common tendinopathies.
Data sources: Relevant randomised controlled trials (RCTs) were sourced using the OVID website databases: MEDLINE (1966–Jan 2006), CINAHL (1982–Jan 2006), AMED (1985–Jan 2006), EMBASE (1988–Jan 2006), and all EBM reviews – Cochrane DSR, ACP Journal Club, DARE, and CCTR (Jan 2006). The Physiotherapy Evidence Database (PEDro) was also searched using the keyword: eccentric.
Review methods: The PEDro and van Tulder scales were employed to assess methodological quality. Levels of evidence were then obtained according to predefined thresholds: Strong–consistent findings among multiple high-quality RCTs. Moderate–consistent findings among multiple low-quality RCTs and/or clinically controlled trials (CCTs) and/or one high-quality RCT. Limited–one low-quality RCT and/or CCT. Conflicting–inconsistent findings among multiple trials (RCTs and/or CCTs). No evidence–no RCTs or CCTs.
Results: Twenty relevant studies were sourced, 11 of which met the inclusion criteria. These included studies of Achilles tendinopathy (AT), patella tendinopathy (PT) and tendinopathy of the common wrist extensor tendon of the lateral elbow (LET). Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound. Levels of evidence were found to be variable across the tendinopathies investigated.
Conclusions: This review demonstrates the dearth of high-quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies. Further adequately powered studies that include appropriate randomisation procedures, standardised outcome measures and long-term follow-up are required.
Background: Nonoperative management of chronic tendinopathy of the Achilles tendon insertion has been poorly studied. With the recently demonstrated effectiveness of eccentric loading and of repetitive low-energy shock wave therapy in patients with midsubstance Achilles tendinopathy, the aim of the present randomized, controlled trial was to verify the effectiveness of both procedures exclusively in patients with insertional Achilles tendinopathy.
Methods: Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized, controlled study. All patients had received treatment, including local injections of an anesthetic and/or corticosteroids, a prescription of nonsteroidal anti-inflammatory drugs, and physiotherapy, without success for at least three months. A computerized random-number generator was used to draw up an allocation schedule. Twenty-five patients were allocated to receive eccentric loading (Group 1), and twenty-five patients were allocated to treatment with repetitive low-energy shock wave therapy (Group 2). Analysis was on an intention-to-treat basis. Primary follow-up was at four months, and afterward patients were allowed to cross over. The last follow-up evaluation was at one year after completion of the initial treatment. The patients were assessed for pain, function, and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire).
Results: At four months from baseline, the mean VISA-A score had increased in both groups, from 53 to 63 points in Group 1 and from 53 to 80 points in Group 2. The mean pain rating decreased from 7 to 5 points in Group 1 and from 7 to 3 points in Group 2. Seven patients (28%) in Group 1 and sixteen patients (64%) in Group 2 reported that they were completely recovered or much improved. For all outcome measures, the group that received shock wave therapy showed significantly more favorable results than the group treated with eccentric loading (p = 0.002 through p = 0.04). At four months, eighteen of the twenty-five patients from Group I had opted to cross over, as did eight of the twenty-five patients from Group 2. The favorable results after shock wave therapy at four months were stable at the one-year follow-up evaluation.
Conclusions: Eccentric loading as applied in the present study showed inferior results to low-energy shock wave therapy as applied in patients with chronic recalcitrant tendinopathy of the insertion of the Achilles tendon at four months of follow-up. Further research is warranted to better define the indications for this treatment modality.
Re: Eccentric loading vs shockwave for achilles tendonitis
Shockwave therapy for chronic Achilles tendinopathy: A double-blind, randomized clinical trial of efficacy.
Rasmussen S, Christensen M, Mathiesen I, Simonson O. Acta Orthop. 2008 Apr;79(2):249-56
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Background and purpose Chronic Achilles tendinopathy is a painful condition and there are often unsatisfactory results with conservative treatment. Extracorporal shock-wave therapy (ESWT) has been introduced for the management of various soft tissue conditions. The objective of the study was to compare the effect of supplementing conservative treatment of chronic Achilles tendinopathy with ESWT or placebo.
Patients and methods This was a randomized, double-blind, placebo-controlled trial. Patients assigned to nonoperative treatment of chronic achilles tendinopathy were randomized to receive either active ESWT or sham ESWT over 4 weeks. There were 48 patients (28 men) with a mean age of 47 (19-80) years. American Orthopaedic Foot and Ankle Society (AOFAS) score and pain were assessed before treatment, during the 4-week treatment period, and at 4, 8, and 12 weeks of follow-up.
Results Both groups improved during the treatment and follow-up period. The mean AOFAS score increased from 74 (SD 12) to 81 (16) in the placebo group and from 70 (6.8) to 88 (10) in the intervention group (p = 0.05). Better results were seen in the intervention group at 8 and 12 weeks of follow-up (p = 0.01 and p = 0.04, respectively).
Interpretation Extracorporal shock-wave therapy appears to be a supplement for the treatment of chronic Achilles tendinopathy.
Re: Eccentric loading vs shockwave for achilles tendonitis
Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain—A pilot study
Rachel Chester, Mathew L. Costa, Lee Shepstone, Adele Cooper and Simon T. Donell Manual Therapy; Volume 13, Issue 6, December 2008, Pages 484-491
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A number of studies have indicated that eccentric calf muscle training has beneficial effects in the management of Achilles tendon pain for recreational athletes. The purpose of this prospective randomised single blind pilot study was to investigate their potential effectiveness compared with therapeutic ultrasound in subjects with relatively sedentary lifestyles in an NHS hospital setting. Eleven men and five women (mean age 53±21 years) with Achilles tendon pain of minimum duration 4 months were randomised to one of two treatment groups; either eccentric loading or ultrasound. Administration of ultrasound and regular supervision of exercises occurred over a period of 6 weeks, with unsupervised exercises continuing for another 6 weeks. Outcome measurements were taken prior to and after 2, 4, 6 and 12 weeks after commencing treatment. They included: pain on a visual analogue scale, functional index of the leg and lower limb, and the five question EuroQol generalised health questionnaire. The difference in mean score was calculated together with 95% confidence intervals assuming a normal distribution. There were no statistically significant differences between groups or clear trends over time. In addition there was considerable overlap between the confidence intervals. This is not unexpected given the small sample size. Both interventions proved acceptable to the patients with no adverse effects. On this basis we intend conducting a full multi-centred study.
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.
Eccentric loading vs shockwave for achilles tendonitis
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