High-Energy Extracorporeal Shock Waves May Help Achilles Tendinopathy
A common cause of heel pain that is occurring with increasing frequency is Achilles tendinopathy, or Achilles tendonitis. Tendonitis is the inflammation or swelling of the tendon.
People at highest risk for Achilles tendinopathy are those who are obese, hypertensive, or who have diabetes or other endocrine disorders. External factors that raise the risk included training errors (for athletes), excessive mileage, excessive hill training, and sudden increases in training intensity. Other risk factors include being older, male, or exposed to steroids and fluoroquinolones.
The treatment of Achilles tendinopathy centers on relieving the pain and allowing the patient to resume proper range-of-motion and ability to bear weight so he or she can return to usual activity. The standard first-line treatments for this include anti-inflammatory medications, strengthening exercises, heel-lift orthosis, custom orthosis, or immobilization. IF these do not work, which happens in about 29 percent of patients, surgery becomes an option.
Unfortunately, complications from surgery include such problems as delayed wound healing, tendon rupture, scarring and nerve irritation. Also, the success rate ranges from 67 percent to 97 percent. Earlier research has found that patients who were not athletic experience more complications and a longer recovery period than did athletes. As well, non-athletic patients did not have as high a success rate as did the athletic patients.
The authors of this study wanted to see if shock wave therapy (SWT), already used with success to treat other musculoskeletal disorders, would be a good treatment option for Achilles tendinopathy. Earlier studies did show some success with this treatment. In one study, pain and function scores improved among patients who received multiple-treatment low-energy SWT. Patients who undergo low-energy SWT do not need anesthesia to the area and multiple treatments are performed. On the other hand, high-energy SWT is more painful and does require some sort of local or regional anesthesia. However, usually it is performed in one session only.
Patients who were included in the study had a minimum of six months history of chronic noninsertional Achilles tendinopathy and had undergone a minimum of three nonsurgical treatments without obtaining relief.
There were 34 patients in the treatment group, ranging in age from 27 to 76 years. The subjects had the tendinopathy on average, 12.7 months. Eighteen subjects participated in regular athletics and nine were manual laborers. The 34 patients in the control group ranged in age from 18 to 75 years and had the tendonitis for an average of 11.7 months. Sixteen of the subjects participated in athletics and six were manual laborers.
The treatment was performed with a regional anesthetic (block) to the ankle, with or without intravenous anesthesia, depending on the patients' choice. Local anesthesia was not used so as not to interfere with the function of the SWT. Following the procedure, the patients' heels were assessed for bleeding, bruising, or swelling. Discharge instructions were that they were allowed limited activity for the first 24 hours following the procedure but then could resume activity as symptoms were relieved.
The patients were assessed using the Visual Analog Scale (VAS), which measures pain on a scale from one to 10, with 10 being the most severe pain ever. The Roles and Maudsley scores were measured by a subjective four-point scale, with one being "excellent," and four being "poor."
Before treatment, the SWT group reported a VAS mean score of 8.2 +/-0.9. This decreased to 4.4 +/-0.9 after one month. In the control group, the mean VAS score before treatment was 8.4 +/-0.9 and 7.1 +/-0.9 at three months. After 12 months, the VAS of the control group was 2.2 +/-1.2 and the control group was 5.6 +/-0.7.
Using the Roles and Maudsley score, the SWT and control groups both had a mean of 4 before treatment. This dropped at one month to 2.3 for the SWT and 3 for the controls. At three months, the scores were 1.9 and 2.9, respectively, and at 12 months, the scores were 1.9 and 3, respectively.
In reviewing the findings, the authors write that this study showed that there were no significant complications (two patients complained of pain during treatment and one had redness of the skin that resolved on its own) and that the treatment was effective for this group of patients for whom traditional treatments did not work.
John P. Furia, MD. High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Noninsertional Achilles Tendinopathy. In The American Journal of Sports Medicine. February 2008. Vol. 36. No. 3. Pp. 501-508.