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Abstract
Introduction There is accumulating evidence for the effectiveness of extracorporeal shock wave therapy (ESWT) when treating lower limb tendinopathies including greater trochanteric pain syndrome (GTPS), patellar tendinopathy (PT) and Achilles tendinopathy (AT). The aim of this study was to evaluate the effectiveness of ESWT for lower limb tendinopathies
Methods PubMed (Medline), Embase, Web of Knowledge, Cochrane and CINAHL were searched from inception to February 2013 for studies of any design investigating the effectiveness of ESWT in GTPS, PT and AT. Citation tracking was performed using PubMed and Google Scholar. Animal and non-English language studies were excluded. Quality assessment was performed by two independent reviewers and effect size calculations were completed where sufficient data were provided.
Results 20 studies were identified with 13 providing sufficient data to complete effect size calculations. The energy level, number of impulses, number of sessions, and the use of local anaesthetic varied between studies. Evidence is limited by low participant numbers and methodological weaknesses including inadequate randomisation. Moderate evidence indicates ESWT is more effective than home training and corticosteroid injection in the short (<12 months) and long (>12 months) term for GTPS. Limited evidence indicates ESWT is more effective than alternative conservative managements including non-steroidal anti-inflammatory drugs, physiotherapy and an exercise programme and equal to patellar tenotomy surgery in the long term for PT [Furia, 2013]. Moderate evidence indicates ESWT is more effective than eccentric loading for insertional AT and equal to eccentric loading for mid-portion AT in the short term. Additionally, there is moderate evidence that combining ESWT and eccentric loading in mid-portion AT may produce superior outcomes to eccentric loading alone [Rompe, 09] (Figure 1).
Achilles Tendinopathy: Comparison of pain and functional outcome at <12 months
Discussion ESWT can play a role in treatment of patients with lower limb tendinopathy alongside progressive load and flexibility management. Both forms of treatment serve to induce tendon regeneration with rehabilitation exercise tending to be carried out over a period of many weeks, whereas ESWT treatment is typically administered weekly for 3 weeks. A suitable pathway would be using ESWT as an initial starting treatment to be followed by an exercise programme, with some evidence that combined treatments confer additional benefit the effect is even greater. More robust RCTs with larger sample sizes and control groups that include objective functional tests are needed to build upon the limited/moderate evidence that currently exists for ESWTs effectiveness in lower limb tendinopathy. Additionally, further RCTs specifically comparing the different elements of ESWT – energy levels, number of applications and number of days between applications are needed to identify the optimum protocol.
References Furia et al. Knee Surg Sports Traumatol Arthrosc. 2013;21:346–50
Rompe et al. Am J Sports Med. 2009;37:463–70