Rompe, J Bone Joint Surg Am 2008 - Eccentric Loading Compared with Shock Wave Treatment for Chronic Insertional Achilles Tendinopathy

Eccentric Loading Compared with Shock Wave Treatment for Chronic Insertional Achilles Tendinopathy

Rompe, Maffulli, et al.·J Bone Joint Surg Am·2008·246 citations·RCT

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

50 patients with chronic (6 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 3 months.
A computerized random-number generator was used to draw up an allocation schedule.
25 patients were allocated to receive eccentric loading (Group 1), and 25 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 4 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 4 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.
7 patients (28%) in Group 1 and 16 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 4 months, 18 of the 25 patients from Group I had opted to cross over, as did 8 of the 25 patients from Group 2.
The favorable results after shock wave therapy at 4 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.

Supplemental

Eccentric Loading Compared with Shock Wave Treatment for Chronic Insertional Achilles Tendinopathy

Rompe, Maffulli, et al.J Bone Joint Surg Am2008246 citationsRCT