Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Table 2

Studies on the effectiveness of extracorporeal shock wave therapy for Achilles tendinopathy.

Reference	Sample size	Groups	Duration of symptoms	Type of shock wave therapy	Number of shocks/frequency	Energy flux density	Number of sessions	Outcome measure	Follow-up	Study conclusions
Rompe et al. [6]	68	I: eccentric loading training; II: eccentric loading training + ESWT	>6 months	RSWT	2000; 8 Hz	3 bars; 0.1 mJ/mm^2	3 sessions, once a week	VISA-A; general assessment by 6-point Likert scale; 11-point NRS; anteroposterior diameter of Achilles tendon of affected and unaffected leg	6 and 16 weeks	At the 4-month follow-up, for all outcome measures, the ESWT + eccentric loading training group showed significantly more favorable results than the group I
Furia [7]	68	I: ESWT; II: control group	>6 months	FSWT	3000 shocks; 1–4 Hz	0.21 mJ/mm^2	1 session	VAS; Roles and Maudsley score	1, 3, and 12 months	ESWT group exhibited better therapy outcomes compared to control participants
Vahdatpour et al. [17]	43	I: ESWT; II: sham ESWT	>6 months	Combination of RSWT + FSWT in one session	RSWT: 3000; 2.21 Hz; FSWT: 1500; 2.3 Hz	RSWT: 1.8–2.6 mJ/mm^2; ESWT: 0.25–0.4 mJ/mm^2	4 sessions, once a week	AOFAS; VAS	Immediately after the end of treatment, 4 and 16 weeks	Mean AOFAS and VAS scores differed significantly between ESWT and sham ESWT groups at 16 weeks of therapy completion
Maffulli et al. [26]	80	I: ESWT	Not known	RSWT	500 + 2500	1.5 + 2.5 bars	3 sessions, once a week	VAS; VISA-A; EuroQolt 5D	3, 6, 12, and 24 months	Significant improvement of VAS, EQ-5D mobility, EQ-5D pain/discomfort, and EQ-5D usual activities scores at 3 months of therapy completion. VISA-A improvement at 12 months of therapy completion
Njawaya et al. [18]	31	I: patient-guided ESWT; II: ultrasound guided	Effect of ultrasound evaluated irrespective of symptom duration	RSWT	2000; 15 Hz	1.4–1.8 bars	3 to 5 sessions	VAS; VISA-A	6 weeks, 3 and 6 months	No difference between group I and II results in terms of pain or function outcome at 3 or 6 months of follow-up
Lynen et al. [27]	59	I: hyaluronan injections; II: ESWT	>6 weeks	Not known	1500; 4 Hz	Not known	3 sessions, once a week	VAS; VISA-A; CGI; power Doppler ultrasonography; the intensity of clinical parameters	4 weeks, 3 and 6 months	Two hyaluronan injections yielded greater treatment success in Achilles tendinopathy than standard ESWT
Notarnicola et al. [19]	60	I: CHELT therapy (Cold air and High-Energy Laser Therapy); II: ESWT	>6 months	Not known	1600	0.05–0.07 mJ/mm^2	3 sessions at 3- to 4-day intervals	VAS; ankle-hindfoot scale; Roles and Maudsley score	Immediately after the end of treatment, 2 and 6 months	Compared to ESWT, CHELT therapy more effectively reduces pain and improves function in patients with insertional Achilles tendinopathy
Notarnicola et al. [28]	64	I: ESWT + dietary supplements; II: ESWT + placebo (control group)	>6 months	Not known	1600	0.05–0.07 mJ/mm^2	At 3- to 4-day intervals	VAS; ankle-hindfoot scale; Roles and Maudsley score; oximetry	2 and 6 months	Patients with insertional Achilles tendinopathy showed greater improvement in clinical and functional condition as well as reduced tendon perfusion following a combination of ESWT dietary supplements compared to ESWT alone
Rompe et al. [20]	50	I: eccentric loading training II: ESWT	Over 6 months	RSWT	2000; 8 Hz	2.5 bars; 0.12 mJ/mm^2	3 sessions, once a week	VISA-A; general assessment by 6-point Likert scale; 11-point numeric rating scale (NRS); pain threshold; tenderness at 3 kg assessed on a NRS from 0 to 10	6 and 16 weeks	For all outcome measures, the ESWT group showed significantly more favorable results than group I with eccentric loading only
Rasmussen et al. [21]	48	I: ESWT; II: sham ESWT	>3 months	RSWT	ESWT: 2000; 50 Hz; Sham ESWT: 2000; 50 Hz	ESWT: 0.12–0.51 mJ/mm^2; Sham ESWT: 0 mJ/mm^2	4 sessions, once a week	AOFAS score; VAS	4, 8, and 12 weeks	ESWT resulted in functional improvement but did not have a clear impact on pain severity
Rompe et al. [22]	75	I: eccentric loading training; II: low-energy ESWT; III: wait-and-see policy	>6 months	RSWT	2000; 8 Hz	3 bars; 0.1 mJ/mm^2	3 sessions, once a week	VISA-A; general assessment by 6-point Likert scale; 11-point numeric rating scale (NRS); pain threshold; tenderness; anteroposterior diameter of Achilles tendon of affected and unaffected leg	6 and 16 weeks	For all outcome measures, group I (eccentric loading) and II (ESWT) showed significantly better results than group III (wait-and-see policy)
Costa et al. [23]	49	I: ESWT; II: placebo	>4 months	FSWT	1500; not known	Max 0.2 mJ/mm^2	3 sessions, once a month	VAS; ranges of motion at the ankle joint; calf diameter; tendon diameter; single-leg heel rise; single-leg tiptoe jump; FIL; EuroQol generalized health status questionnaire	3 months, 1 year	There was no difference between the groups in pain relief, range of motion at the ankle or differences in the FIL or EQol scores
Furia [29]	68	I: ESWT; Ia: local anaesthesia field block; Ib: nonlocal anaesthesia; II: control group	>6 months	FSWT	3000 shocks; 1–4 Hz	0.21 mJ/mm^2	1 session	VAS; Roles and Maudsley score	1, 3, and 12 months	ESWT proved an effective treatment for chronic insertional Achilles tendinopathy. Local field block anaesthesia may decrease the effectiveness of this procedure
Pavone et al. [30]	40	I: ESWT + eccentric exercises	>3 months	RSWT	800; 4 Hz	14 keV	4 sessions, with a 2-week interval	VAS; AOFAS hindfoot score	2, 6, and 12 months	ESWT combined with eccentric exercises proved effective in patients with chronic insertional Achilles tendinopathy
Taylor et al. [31]	46	I: insertional Achilles tendinopathy; II: noninsertional Achilles tendinopathy	>3 months	RSWT	2500; 10 Hz	1.5 bars–2.5 bars	3 sessions, once a week	VAS at rest and on activity; VISA-A; Likert satisfaction score	6 and 16 weeks, 2 years	ESWT appeared to be beneficial in the long-term improvement of pain and functional outcome in patients with refractory insertional and noninsertional Achilles tendinopathy
Mansur et al. [32]	19	I: ESWT + eccentric exercises	Not known	RSWT	2000–3000; 7–10 Hz	1.5–2.5 bars	2 sessions, once every two weeks	VAS; VISA-A; AOFAS; algometry	24 weeks	Eccentric exercises combined with ESWT significantly improved patients’ symptoms
Santamato et al. [33]	12	I: ESWT	>4 weeks	FSWT	1600; 4 Hz	0.12 mJ/mm^2	5 sessions, once a week	VAS; VISA-A; range of motion active dorsiflexion and plantar flexion ankle; Roles and Maudsley score	1 and 3 months	ESWT significantly improved clinical condition but did not cause neovascularization
Wheeler and Tattersall [34]	63	I: ESWT; II: high-volume image-guided injection	Not known	Not known	2000; 10 Hz	2.1 ± 0.3–2.9 ± 0.4	3 sessions, once a week	VAS; VISA-A; MOXFQ	6 weeks, 3 and 6 months	Statistically significant improvement in groups I and II. No significant intergroup differences
Erroi et al. [35]	45	I: ESWT; II: platelet-rich plasma	>6 months	FSWT	2400; not known	0.17–0.25 mJ/mm^2	3 sessions, once a week	VISA-A; VAS; Roles and Maudsley score	Immediately after the end of treatment, 2, 4, and 6 months	Both therapeutic modalities are safe and effective
Wei et al. [36]	78	I: endoscopy-assisted radiofrequency ablation; II: ESWT; III: eccentric exercises	>6 months	Not known	2000; 10 Hz	0.12 mJ/mm^2	3 sessions, once a week	AOFAS; VAS; VISA-A	6, 12, and 18 months	Endoscopy-assisted radiofrequency ablation yielded better outcome than ESWT
Wu et al. [38]	67	I: with Haglund’s deformity; II: without Haglund’s deformity	Not known	RSWT	2000; 8 Hz	0.12 mJ/mm^2	5 sessions, once a week	VISA-A score; 6-point Likert scale		Haglund’s deformity adversely affected ESWT outcome
Carulli et al. [40]	102	I: ESWT	>3 months	Not known	2400	0.08–0.33 mJ/mm^2	3 sessions, once a month	NRS; AOFAS	1, 6, and 12 months	ESWT reduces pain and improves function in patients with chronic Achilles tendinopathy

ESWT, extracorporeal shock wave therapy; FSWT, focused shock wave therapy; RSWT, radial shock wave therapy; VAS, Visual Analog Scale; VISA-A, Victorian Institute of Sport Assessment-Achilles questionnaire; AOFAS, American Orthopaedic Foot and Ankle Society score; NRS, numeric rating scale; FIL, Functional Index of Lower Limb Activity; CGI, Clinical Global Impression; MOXFQ, Manchester-Oxford Foot Questionnaire.