CHELT therapy in the treatment of chronic insertional Achilles tendinopathy

The Role of Bone Edema in Plantar Fasciitis Treated with Temperature-Controlled High-Energy Adjustable Multi-Mode Emission Laser (THEAL) and Exercise: A Prospective Randomized Clinical Trial

Plantar fasciitis is one of the most common causes of foot pain; in 35% of cases, it is also associated with bone edema of the heel. The aim of this study was to investigate the relationship between bone edema and the outcomes of temperature-controlled high-energy adjustable multi-mode emission laser (THEAL) and/or exercises in patients with plantar fasciitis. A prospective randomized clinical trial was designed, in which 48 patients suffering from plantar fasciitis, with or without bone edema, were treated with temperature-controlled high-energy adjustable multi-mode emission laser and exercises (the laser group) or with exercises only (the control group). The patients were evaluated at recruitment (T0) and at 2 (T1) and 6 months (T2), monitoring pain (with the Visual Analogue Scale), functionality (with the Foot Function Index), perception of improvement (with the Roles and Maudsley Score), and fascia thickness (with ultrasound examination). In both groups, there was a significant improvement in pain, functional recovery, perception of remission, and a reduction in plantar fascia thickness at T1 and T2. The laser group presented statistically better values at T2 for the Roles and Maudsley Score (z: 2.21; 0.027). The regression analysis showed that a greater reduction in fascia thickness occurred in the laser group (p-value: 0.047). In conclusion, the two conservative treatments were effective in patients suffering from plantar fasciitis, even in the presence of bone edema, but with lesser results.

Efficacy of shock wave therapy and ultrasound therapy in non-insertional Achilles tendinopathy: a randomised clinical trial

Objective

Physiotherapists and physicians continue to seek effective conservative treatments for Achilles tendinopathy. This study aimed to subjectively and objectively determine the therapeutic efficacy of radial shock wave therapy (RSWT) and ultrasound therapy in non-insertional Achilles tendinopathy.

Materials and methods

Thirty-nine patients with non-insertional Achilles tendinopathy were randomly assigned to three experimental groups, i.e., RSWT (group A), ultrasound therapy (group B), and placebo ultrasound (group C) groups. Before the intervention and at weeks 1 and 6 after the treatment, the patients were assessed using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire and posturographic measurements of step initiation performed on the force platforms under two different conditions (non-perturbed transit and perturbed transit).

Results

Six weeks after therapy, all groups exhibited significantly increased VISA-A scores against the measurement at week 1 after therapy. The post-therapy percentage changes in VISA-A scores were significantly greater in group A compared to group B. The three-way ANOVA demonstrated that treatment type affected sway range in the frontal plane and mean velocity of the centre of foot pressure displacements in the sagittal and frontal planes during quiet standing before step initiation. The Bonferroni post-hoc test showed that the means of all those variables were significantly smaller for group A than for group B patients. The three-way ANOVA revealed an effect of the platform arrangement on transit time and double-support period. The Bonferroni post-hoc test revealed statistically longer transit time for the perturbed vs. non-perturbed trials; a reverse relationship was observed for the double-support period.

Conclusion

The VISA-A showed that RSWT was significantly more effective than sonotherapy for alleviation of pain intensity as well as function and activity improvement in patients with non-insertional Achilles tendinopathy. Therefore, RSWT therapy can be used in clinical practice by physiotherapists to alleviate the symptoms of non-insertional Achilles tendinopathy. Objective data registered by force platforms during quiet standing before and after step initiation did not prove useful for monitoring the progress of treatment applied to patients with non-insertional Achilles tendinopathy between consecutive therapy interventions.Clinical trial registration:https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000860369, identifier (ACTRN12617000860369).

The Efficacy of Extracorporeal Shock Wave Therapy as a Monotherapy for Achilles Tendinopathy: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review and meta-analysis was to determine the therapeutic efficacy of extracorporeal shock wave therapy (ESWT) for Achilles tendinopathy.

Methods

We searched PubMed, EBSCOHost, Ovid, and Embase for randomized controlled trials. Databases were searched from their inception until the last entry (July 16, 2022). The methodological quality of the randomized controlled trials was rated with the Physiotherapy Evidence Database scale. For continuous data, we presented the mean difference (D) and 95% confidence interval (CI). Heterogeneity was assessed with I2 statistics. The random effects model was applied for the pooled effect estimates. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation tool.

Results

The very-low-quality evidence suggested that ESWT was no more effective in decreasing pain than any other conservative treatment (D: -0.8; 95% CI: -3.15, 1.56; P > .5; I² = 85.62%). No significant differences were found between the ESWT and control groups on the pooled Victorian Institute of Sport Assessment-Achilles scores (D: 5.74; 95% CI: -15.02, 26.51; P = .58; I2  = 92.28%), but the quality of evidence was very low.

Conclusion

At present, the quality of the evidence is low; thus, the therapeutic efficacy of ESWT for Achilles tendinopathy is inconclusive.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis

Background

Tendinopathy is a growing global concern affecting many people, like athletes, workers, and the elderly. Despite its commonality among the sporting population, there is no practical clinical guideline for patellar tendinopathy (PT). Furthermore, there is conflicting evidence between clinical guidelines on shockwave therapy's application and clinical utility for Achilles tendinopathy (AT) and plantar fasciitis (PF). Thus, our aim of this study is to evaluate the evidence for shockwave therapy; to provide a Grading of Recommendation, Assessment, Development and Evaluation (GRADE) level of the evidence and effectiveness of shockwave therapy for patellar tendinopathy, Achilles tendinopathy, and Plantar fasciitis.

Method

Medical Literature Analysis and Retrieval System Online (Medline), Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro) and China National Knowledge Infrastructure database (CNKI) were searched to find relevant studies published before December 14th, 2022.

Results

Our study showed that for PT in the short term, extracorporeal shockwave therapy (ESWT) or ESWT + eccentric exercise (EE) has a negligible effect on pain and function compared to a placebo or placebo + EE. On the contrary, ESWT significantly affects pain compared to conservative treatment (CT). For AT, ESWT has a small inconclusive effect on pain and function in the short term compared to EE. On the other hand, a placebo outperformed ESWT in improving function for AT but not pain outcomes. PF showed that ESWT significantly affects short- and long-term pain and function. When ESWT was compared to other interventions such as low laser therapy (LLLT), corticosteroid injection (CSI), or CT, there was a small inconclusive effect on pain and function in the short term.

Conclusion

There is low-moderate evidence that ESWT has a negligible effect on pain and function for PT and AT. However, high-quality evidence suggests ESWT has a large effect on pain and function for PF.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023396835, identifier CRD42023396835.

The Efficacy of Temperature-Controlled High-Energy Polymodal Laser Therapy in Tendinopathy of the Shoulder

Background: Rotator cuff tendinopathy is a common diagnosis among patients with shoulder pain and dysfunction. Laser therapy is recommended for the treatment of this tendon disease due to the possibility of increasing tissue biostimulation. The aim of this study was to investigate the effects of HELT (high-energy laser therapy) in relation to the wavelengths of 650 nm, 810 nm, 980 nm, and 1064 nm administered. Methods: The study design was prospective and observational. Thirty patients with shoulder tendinopathy were recruited and treated in one of two high-energy laser therapy groups (5 Watt/cm2, 450 Joule, super-pulsed mode). Group A received a high-energy laser therapy protocol with a single wavelength (1064 nm); group B received a high-energy laser therapy program with four wavelengths (650 nm, 810 nm, 980 nm, and 1064 nm). Pain (VAS), function (ASES), and disability (DASH) were monitored at the time of recruitment (T0), 1 month later (T1), and 6 months later (T2). Roles and Maudsley scores were also evaluated at T1 and T2. Results: Both protocols resulted in improvement of pain and in functional and disability recovery at the two times of assessment, without statistically significant differences. In group B, treated with the four wavelengths, a trend emerged, bordering on statistical significance, for a greater reduction in pain. Conclusions: The high-energy laser proved to be an effective therapy for the treatment of rotator cuff tendinopathy. The possibility of modulating the choice of wavelengths could allow the customization of the protocol in relation to the patient’s clinical condition.

Comparative short-term effectiveness of non-surgical treatments for insertional Achilles tendinopathy: a systematic review and network meta-analysis

BACKGROUND

The incidence of Achilles tendinopathy has risen over the past decades. Insertional Achilles tendinopathy is characterised by tissue degeneration of the Achilles tendon from its insertion in the calcaneus to up to 2 cm proximally. This clinical condition is accompanied by pain, loss of function and diminished exercise tolerance. Numerous conservative treatment modalities are available to participants with insertional Achilles tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, laser therapy, cryotherapy, therapeutic ultrasound, and orthotics. Eccentric exercise and extracorporeal shockwave therapy may reduce pain in participants with non-calcified insertional Achilles tendinopathy. However, no specific treatment is recommended over another due to the low methodological quality of trials. Given the lack of standard or preferred non-surgical treatment and the potential risks of surgical treatment, there is an imminent need to reassess different non-surgical treatments based on the newest evidence. Thus, this systematic review aims to evaluate the clinical effectiveness of the various non-surgical treatments for insertional Achilles tendinopathy.

METHODS

AMED EBSCOhost, CINAHL, EBSCOhost, EMBASE, PEDro, PubMed, Web of Science, and Clinicaltrials.gov were searched from 1992 to 14th October 2022, randomised controlled trials of adults with insertional Achilles tendinopathy investigating non-surgical treatments compared with each other or no treatment, placebo/sham control. Two reviewers independently screened and extracted the data. Random effects of network meta-analysis immediately after treatments were used to report comparative treatment effects. The surface under the cumulative ranking probabilities was calculated to assess the relative ranking of treatments.

RESULTS

Nine trials (total n = 464 participants) were included. This review recommended the combination of eccentric exercise and soft tissue therapy to manage insertional Achilles tendinopathy. With the highest SUCRA values of 84.8, and the best mean rank of 1.9, Eccentric exercise plus soft tissue treatment ranked as the most effective treatment for short-term pain.

CONCLUSIONS

This is the first NMA of non-surgical treatment focusing on short-term pain control for IAT which eccentric exercise plus soft-tissue therapy was found to be the most effective treatment combination. However, the overall confidence in non-surgical treatments from all included trials was very low. No recommendation of the best treatment option can be made from this review.

Analysis of pain intensity and postural control for assessing the efficacy of shock wave therapy and sonotherapy in Achilles tendinopathy - A randomized controlled trial

BACKGROUND

The troublesome symptoms of Achilles tendinopathy prompt patients to seek effective forms of conservative treatment. The main aim of the study was to determine the therapeutic efficacy of shock wave and ultrasound therapies for Achilles tendinopathy in reducing pain intensity. Treatment efficacy was also assessed using objective posturographic measurements.

METHODS

Thirty-nine patients patients were randomly allocated to one of three experimental groups that received shock wave therapy (group A), ultrasound therapy (group B) and placebo ultrasound (group C). Posturographic measurements and subjective assessment of pain intensity were taken prior to therapy and at weeks 1 and 6 of therapy completion.

FINDINGS

A comparison of percentage change in activity-related pain from baseline to 6 weeks post-therapy revealed a significantly greater pain reduction in group A compared to group B. The three-way ANOVA demonstated an effect of treatment type on all posturographic variables. The Bonferroni post-hoc test showed the means of all variables were significantly smaller for group A than group B. Limb condition also had an effect on the center-of-pressure trajectories in anteroposterior plane; the post-hoc test showed the mean values of the variables were significantly greater for the non-affected compared to affected limb.

INTERPRETATION

Shock wave therapy was significantly more effective than sonotherapy for alleviation of activity-related pain of Achilles tendinopathy. An association was also shown between shock wave therapy and more efficient postural control in patients with Achilles tendinopathy. The parameters of center-of-pressure trajectories in the sagittal plane were significantly greater for the non-affected compared to affected limb. The trial was prospectively registered in the Australian and New Zealand Clinical Trials Registry (no. ACTRN12617000860369; registration date: 9.06.2017).

Calcaneal osteotomy due to insertional calcaneal tendinopathy: preoperative planning

Purpose

Dorsal closing wedge calcaneal osteotomy (DCWCO) is indicated in patients with insertional tendinopathy of the calcaneal (Achilles) tendon. The Chauveaus-Liet’s (CL) angle is represented by the difference between the angle of verticalization (α) and morphological angle (β) of the calcaneus (CL angle = α − β). The purpose of the study was to assess whether the DCWCO affects the Chauveaus-Liet’s angle.

Methods

The study included 12 patients indicated to DCWCO. Three directions of close wedge osteotomy were designed for each patient—horizontal, vertical and in the middle type of osteotomy and a virtual osteotomy was created in each of them in the ABAQUS system in cooperation with Czech Technical University. The most used directions of osteotomy according to the available literature were used. We evaluated α and β angles before and after osteotomy, changes of the length plantar aponeurosis and the elevation of distal insertional point of the calcaneal tendon. The changes of grades, median and standard deviation were observed.

Results

The change of the alfa angle was dependent on the direction of the osteotomy and the change of the beta angle was affected by the size of the osteotomy. The greatest elevation of the distal insertional point of the calcaneal tendon occurred in the horizontal type of the osteotomy.

Conclusion

Our study shows that the more we want to reduce the tension in the calcaneal tendon, the more we have to perform an osteotomy horizontally. This study could serve as a preoperative guide for osteotomy planning.

Extracorporeal Shockwave Therapy for Foot and Ankle Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Extracorporeal shockwave therapy (ESWT) was first introduced into clinical practice in 1982 and has been a beneficial inclusion to the noninvasive treatment option of numerous orthopaedic pathologies. However, clinical evidence of the use of ESWT for various foot and ankle disorders has been limited with a consensus on its efficacy yet available. Therefore, the purpose of this study is to systematically review the literature, to provide a critical evaluation and meta-analysis for the use of ESWT in foot and ankle disorders.

METHODS

The PubMed and Embase databases were systematically reviewed and clinical studies that reported ESWT use for various foot and ankle disorders included.

RESULTS

A total of 24 clinical studies that included 12 randomized controlled trials and 12 case series were identified. Analysis of the evidence has indicated that ESWT can help manage plantar fasciitis, calcaneal spur, Achilles tendinopathy and Morton's neuroma. Meta-analysis of the change in pre- to post-VAS overall scores for plantar fasciitis significantly favored ESWT compared to placebo/conservative treatment with a MD -3.10 (95% CI, -4.36 to -1.83; I2 = 68%; P < 0.00001).

CONCLUSIONS

The current evidence has suggested that ESWT can provide symptomatic benefit to plantar fasciitis treatment, with minimal and unremarkable side effects. Overall, ESWT has been demonstrated to be a safe treatment option with a favorable complication profile. Further well-designed studies of ESWT for the treatment of calcaneal spurs, Achilles tendinopathy and Morton's neuroma are warranted to more soundly and safely support its current use. Future studies are suggested to investigate the optimization of ESWT treatment protocols.

Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison

BACKGROUND

the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy.

METHODS

33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery.

RESULTS

At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups.

CONCLUSIONS

fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.

Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is used commonly to treat pain and function in Achilles tendinopathy (AT). The aim of this study was to synthesize the evidence from (non-) randomized controlled trials, to determine the clinical effectiveness of ESWT for mid-portion Achilles tendinopathy (mid-AT) and insertional Achilles tendinopathy (ins-AT) separately.

METHODS

We searched PubMed/Medline, Embase (Ovid), and Cochrane Central, up to January 2021. Unpublished studies and gray literature were searched in trial registers (ACTRN, ChiCTR, ChiCtr, CTRI, DRKS, EUCTR, IRCT, ISRCTN, JPRN UMIN, ClinicalTrials.gov, NTR, TCTR) and databases (OpenGrey.eu, NARCIS.nl, DART-Europe.org, OATD.org). Randomized controlled trials (RCTs) and non-randomized controlled clinical trials (CCTs) were eligible when investigating the clinical effectiveness of ESWT for chronic mid-AT or chronic ins-AT. We excluded studies that focused on treating individuals with systemic conditions, and studies investigating mixed cohorts of mid-AT and ins-AT, when it was not possible to perform a subgroup analysis for both clinical entities separately. Two reviewers independently performed the study selection, quality assessment, data extraction, and grading of the evidence levels. Discrepancies were resolved through discussion or by consulting a third reviewer when necessary.

RESULTS

We included three RCTs on mid-AT and four RCTs on ins-AT. For mid-AT, moderate quality of evidence was found for the overall effectiveness of ESWT compared to standard care, with a pooled mean difference (MD) on the VISA-A of 9.08 points (95% CI 6.35-11.81). Subgroup analysis on the effects of ESWT additional to standard care for mid-AT resulted in a pooled MD on the VISA-A of 10.28 points (95% CI 7.43-13.12). For ins-AT, we found very low quality of evidence, indicating that, overall, ESWT has no additional value over standard care, with a standardized mean difference (SMD) of - 0.02 (95% CI - 0.27 to 0.23). Subgroup analysis to determine the effect of ESWT additional to standard care for ins-AT showed a negative effect (SMD - 0.29; 95% CI - 0.56 to - 0.01) compared to standard care alone.

CONCLUSIONS

There is moderate evidence supporting the effectiveness of ESWT additional to a tendon loading program in mid-AT. Evidence supporting the effectiveness of ESWT for ins-AT is lacking.

TRIAL REGISTRATION

PROSPERO Database; No. CRD42021236107.

Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review

OBJECTIVES

1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool.

DATA SOURCES

We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases.

REVIEW METHODS

Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies.

RESULTS

We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies.

CONCLUSION

The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy,  (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Functional Outcomes of Insertional Achilles Tendinopathy Treatment: A Systematic Review

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional, and effective treatment of each type can vary. We sought to investigate the current evidence on different treatment methods for insertional Achilles tendinopathy with a focus on functional outcomes.

METHODS

We performed a systematic review of the available literature using the PubMed/MEDLINE and Cochrane Central Register of Controlled Trials databases. Data from included studies were categorized according to treatment method and reported with respect to functional outcomes and complications.

RESULTS

A total of 1,457 abstracts were reviewed; 54 studies with 2,177 patients met the inclusion criteria. Among the 54 studies, 6 operative techniques and 6 nonoperative treatments were evaluated.

CONCLUSIONS

Eccentric exercises and low-energy extracorporeal shockwave therapy (ESWT) have the greatest evidence for the initial management of insertional Achilles tendinopathy. ESWT has been increasingly studied in recent years, but more high-quality evidence is needed. Operative treatment with tenotomy, debridement, retrocalcaneal bursectomy, and calcaneal exostectomy is effective. Flexor hallucis longus tendon transfer may benefit cases of more severe disease. Minimally invasive procedures have a potential role in the treatment algorithm and require more rigorous study.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative treatment of insertional Achilles tendinopathy: a systematic review

BACKGROUND

Insertional Achilles tendinopathy is difficult to manage, and there is no definite consensus on which nonoperative treatment is superior over the others. We aim to provide a clear summary of the best available evidence for nonoperative treatment specific to insertional Achilles tendinopathy.

METHODS

Literatures were searched in PubMed, Embase, and Web of Science databases from inception to October 2020. The results were evaluated independently by two reviewers and assessed against the inclusion/exclusion criteria. All included articles were assessed for methodological quality, and study characteristics were extracted.

RESULTS

Twenty-three studies (containing 35 groups) were eligible for the final review. The treatments included eccentric training, extracorporeal shockwave therapy (ESWT), injections, and combined treatment. Visual analog scale (VAS), Victorian Institute of Sport Assessment-Achilles questionnaire, AOFAS, satisfaction rate, and other scales were used to assess the clinical outcome.

CONCLUSION

Current evidence for nonoperative treatment specific for insertional Achilles tendinopathy favors ESWT or the combined treatment of ESWT plus eccentric exercises.

Extracorporeal Shockwave Therapy for Patients with Chronic Achilles Tendinopathy in Long or Short Course

Methods

The data of 66 patients with CAT received ESWT was reviewed. According to the disease courses, those cases were allocated to short-term group (ST group, symptom duration 3-6 months) and long-term group (LT group, symptom duration >6 months). Propensity scores match (PSM) method was conducted to eliminate the confound factors in baseline features including gender, sport history, sides, type of CAT, BMI (body mass index), age, and scores evaluated by AOFAS (American Orthopedic Foot and Ankle Society) and VAS (Visual Analogue Scale) before ESWT. After balancing the features between ST and LT group, postinterventional VAS, AOFAS, and rate of Likert satisfaction scale at the 3rd month after first ESWT was statistically analyzed.

Results

Among the baseline features in ST and LT group, gender (female ratio, 44.4% vs 71.4%, p = 0.041) and BMI (23.26 ± 2.15 vs 24.63 ± 2.41, p = 0.024) were identified as confound factors. After elimination of biased features with PSM, 3 months after first ESWT, AOFAS and VAS in both groups are significantly improved, when compared with their scores at baseline (p < 0.01). Moreover, at postintervention month 3 (PIM3), AOFAS in ST group is significantly higher than LT group (85.08 ± 9.83 vs 76.76 ± 9.85, t = 76.76 ± 9.85, p = 0.019), and the rate of Likert satisfaction in ST group is better than LT group; although, it did not reach but close to significant level (70.6% vs 47.1%, χ ² = 1.943, p = 0.163). However, there is no statistical difference of VAS scores between two groups after ESWT (1.96 ± 0.98 vs 2.24 ± 1.29, t = 0.703, p = 0.487).

Conclusions

ESWT could effectively relieve pain and improve function of hind foot in patients with chronic Achilles tendinopathy, and especially, it could offer better benefit on functional improvement in patients with short duration of CAT symptom.

Effects of High Intensity Laser Therapy in the Treatment of Tendon and Ligament Injuries in Performance Horses

Simple Summary

High intensity laser therapy (HILT) has been introduced as a non-invasive therapy for musculoskeletal diseases in horses, but little is known about the impact of HILT in the treatment of tendon and ligament injuries. The aim of this study was to evaluate the effects of HILT on tendon and ligament injury treatment in horses. Twenty six horses with tendinopathies and desmopathies were randomly assigned to a HILT treated or to a non-treated group. Each horse from the treatment group underwent a series of fifteen HILT treatments. Clinical and ultrasound assessments were carried out. Clinical evaluation included: pain, swelling and lameness of the affected limb. The ultrasound examination evaluated lesion echogenicity and lesion percentage. In our study, HILT promoted analgesic and anti-oedema effects, with visual lameness reduction in horses with tendon and ligament injuries, and reduced lesion percentage but did not influence change in lesion echogenicity. HILT appears justifiable for its anti-inflammatory effects and can be used as a physiotherapeutic technique for supportive treatment of tendon and ligament injuries in horses. The introduction of laser therapy to veterinary medicine, particularly to analgesic therapy in horses, gives hope of improving the quality of life of patients with chronic musculoskeletal pain.

Abstract

The aim of this study was to evaluate the effects of high intensity laser therapy (HILT) on tendon and ligament injury treatment in horses. Twenty six horses with tendinopathies were randomly assigned to a HILT treated or to a non-treated group. Each horse was subjected to the same rehabilitation programme. Horses from the treatment group underwent a series of fifteen HILT treatments with the same parameters. Clinical and ultrasound assessments were performed by the same veterinarian and were carried out before (day 0), during (day 13–15) and after treatment (day 38–40). Clinical evaluation included: pain, swelling and lameness of the affected limb. The ultrasound examination evaluated lesion echogenicity and lesion percentage. After the treatment, pain, swelling and lameness were significantly improved by HILT compared with the control group (p = 0.023, 0.008 and 0.044, respectively). No significant changes were found in lesion echogenicity degree between both groups in measurements taken during treatment (p = 0.188) and after treatment (p = 0.070). For lesion percentage reduction, the statistical modelling showed a significant improvement in the HILT group compared with the control group during (p = 0.038) and after treatment (p = 0.019). In conclusion, HILT promoted analgesic and anti-oedema effects, with visual lameness reduction in horses with tendon and ligament injuries, and reduced lesion percentage but did not influence change in lesion echogenicity.

Extracorporeal Shock Wave Therapy for Achilles Tendinopathy

Extracorporeal shock wave therapy (ESWT) is among the conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been determined that would ensure ESWT effectiveness in this condition. The aim of the paper is to use research reports on ESWT in patients with Achilles tendinopathy to help practising physiotherapists establish the most effective intervention parameters. A search was conducted using the following databases: PubMed, Scopus, EBSCOhost, and Web of Science. The papers were checked for relevant content and were included based on the following criteria: full-text article published in English and including comprehensive description of shock wave application. Twenty-two articles met the inclusion criteria. Most studies on the effectiveness of ESWT for Achilles tendinopathy included in this narrative review were randomized controlled trials. Two case-control studies, a case series study, prospective audit, clinical trial protocol, and a pilot study were also considered. The majority were prospective studies. Only a few authors presented the findings from retrospective observations. The two modalities of shock wave therapy used for Achilles tendinopathy are focused shock waves and radial shock waves. The literature contains reports presenting mainly beneficial effects of ESWT in patients with Achilles tendinopathy.

Nonsurgical Treatment Options for Insertional Achilles Tendinopathy

Most nonoperative treatments for insertional Achilles tendinopathy (IAT) have insufficient evidence to support treatment recommendations. Exercise has the highest level of evidence supporting the ability of this treatment option to reduce IAT pain. The effects of exercise may be enhanced by a wide variety of other treatments, including soft tissue treatment, nutritional supplements, iontophoresis, education, stretching, and heel lifts. When exercise is unsuccessful, extracorporeal shock wave therapy seems to be the next best nonoperative treatment option to reduce IAT pain. After other nonoperative treatment options have been exhausted, injections may be considered, particularly to facilitate participation in an exercise program.

[Insertional Achilles tendinopathy : Differentiated diagnostics and therapy]

Achilles tendinopathy at the calcaneal insertion is classified into insertional tendinopathy, retrocalcaneal and superficial bursitis. The aim of this study was to present the current evidence on conservative and surgical treatment of insertional tendinopathy of the Achilles tendon. Conservative first-line therapy includes reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization. In addition, further conservative therapy options are also available. Eccentric stretching exercises should be integral components of physiotherapy and can achieve a 40% reduction in pain. Extracorporeal shock wave therapy has been shown to reduce pain by 60% with a patient satisfaction of 80%. Due to the limited evidence, injections with platelet-rich plasma (PRP), dextrose (prolotherapy) or polidocanol (sclerotherapy) cannot currently be recommended. Operative therapy is indicated after 6 months of unsuccessful conservative therapy. Open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis. The success rate of over 70% is contrasted by complication rates of up to 40%. The Achilles tendon should be reattached, if detached by >50%. No valid data are available for the transfer of the tendon of the flexor hallucis longus (FHL) muscle but it is frequently applied in cases of more than 50% debridement of the diameter of the Achilles tendon. Lengthening of the gastrocnemius muscle cannot be recommended because insufficient data are available. Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis and has shown similar success rates to open debridement with significantly lower complication rates.

Predicting Failure of Nonoperative Treatment for Insertional Achilles Tendinosis

Nonoperative treatment for midportion Achilles tendinosis is well defined by the literature. Multiple modalities are described for the management of insertional Achilles pathology, but no consensus exists regarding efficacy. Surgical intervention for insertional Achilles tendinosis (IAT) is successful greater than 80% of the time. Our objective was to risk stratify patients who would fail nonsurgical management of IAT and thus benefit progressing to surgery. We reviewed the records of 664 patients with IAT. The cohort was 53% male and 80% obese. Mean age was 53.7 years (standard deviation 14.7 years). Average duration of symptoms was 10.4 months (standard deviation 28 months). Of the parameters collected, 4 were found to correlate with failing nonoperative treatment: visual analog scale, limited ankle range of motion, previous corticosteroid injection, and presence of Achilles tendon enthesophyte. We found that as the number of risk factors increased so did the chance of failing nonoperative treatment. With all 4 parameters, chance of failing conservative treatment was only 55%. Thus, nonoperative management should be exhausted until surgery is the only remaining option. However, the presence of one of the aforementioned risk factors can aid a surgeon in the decision to pursue surgery in the appropriate clinical scenario.

LEVELS OF EVIDENCE

Level IV: Retrospective Case series.

The Effectiveness of Radial Extracorporeal Shock Wave Therapy for Chronic Achilles Tendinopathy: A Case Report with 18 Months Follow-Up

BACKGROUND

Achilles tendinopathy (AT) is a pathological state resulting from repetitive loading or stress on the tendon. The article aims to evaluate the effects of the low - energy radial extracorporeal shockwave therapy (RESWT) in the treatment of the adult with chronic insertional Achilles tendinopathy (AT) after the unsuccessful conservative treatment, with 18 months follow - up evaluation.

CASE REPORT

We report the case of a 55 years - old male suffering from severe right posterior heel pain for 4 months. For his chronic insertional Achilles tendinopathy on the right heel, he received conservative treatment in the Institute of Physical Medicine and Rehabilitation. For outcome assessment, Numerical Rating Scale (NRS) for pain, the range of motion in the ankle, and Roles-Maudsley Score (RMS) for assessment of function were used. At the baseline the pain was severe, and he received physical therapy treatment. After unsuccessful conservative treatment, he underwent RESWT treatment. Numeric Rating Scale was significantly decreased at immediate, short-term and long-term follow-up. After the last treatment, the patient had no pain, and function assessed by Roles-Maudsley Score was excellent. At the follow-up check-up at 3, 6, 12 and 18 months the patient had no pain and excellent functional results.

CONCLUSION

Radial ESWT is a safe and effective treatment even for a longer period for patients with chronic insertional Achilles tendinopathy.

Conservative treatment for Insertional Achilles Tendinopathy: platelet-rich plasma and focused shock waves. A retrospective study

BACKGROUND

Insertional Achilles tendinopathy (IAT) represents a serious challenge for both physiatrists and surgeons. Here we analyse the results obtained by two conservative treatments [platelet-rich plasma (PRP) injections and focused extracorporeal shock-wave therapy (ESWT)] in physically active patients with IAT.

METHODS

During two consecutive periods, 45 consecutive patients with IAT were treated with 3 sessions of ESWT (2400 impulses at 0.17-0.25 mJ/mm² per session) (24 cases between September 2011 and July 2013) or with 2 autologous PRP injections over two weeks (21 cases between September 2013 and July 2015). All patients were evaluated at 0, 2-, 4-, 6-month follow-up after therapy. The outcome measures were VISA-A, VAS, Patient Satisfaction.

RESULTS

Intra-group analysis showed a significant improvement of VISA-A and VAS scores in both groups at all time-points. No differences between groups were observed for VAS and VISA-A scores at all time-points, excepted for VISA-A at 4-months in favour of ESWT group (P=0.049). Patient satisfaction increased progressively (>70% at 6 months) and with no differences between two groups.

CONCLUSION

Both ESWT and PRP therapy are effective and safe. Our study confirms the success of these conservative treatments in Achilles tendinopathy, even in the insertional one.

LEVEL OF EVIDENCE

IIIa.

Low Level Laser Therapy in patients with chronic foot and ankle joint pain

BACKGROUND AND AIMS

Chronic foot and ankle joint pain is one of the most frequent complaints which is regularly seen in the out-patient clinic of our medical institute. In previous studies we have reported on the benefits of low level laser therapy (LLLT) for chronic pain in the elbow, hand, finger and the lower back. The present study examined the effects of LLLT on chronic foot and ankle joint pain.

MATERIALS AND METHODS

Over the past 5 years, 17 subjects visited the out-patient clinic with complaints of chronic foot and ankle joint pain of a variety of aetiologies. The patients received LLLT using a 1000 mW semi-conductor laser device, delivering 20.1 J/cm2 per point at 830 nm in continuous wave. Each patient was given four shots per session per foot twice a week for 4 weeks.

RESULTS

A visual analogue scale (VAS) was used to determine the effects of LLLT for the chronic pain and after the end of the treatment regimen a significant improvement was observed (p < 0.01). All but 2 of the patients showed improvement: excellent (2) and good (13). After treatment, no significant differences were observed in the ankle joint range of motion, however. Discussions with the patients revealed that it was important for them to learn how to avoid overuse of the ankle when walking, poor walking posture and a poor pacing technique that would caused them foot and ankle pain in everyday life. Following these postural guidelines could ensure continuous benefits from the treatment.

CONCLUSION

The present study demonstrated that LLLT was an effective form of treatment for chronic foot and ankle joint pain, in conjunction with postural education during all activities of daily living.

The Effectiveness of Physical Agents for Lower-Limb Soft Tissue Injuries: A Systematic Review

Study Design Systematic review. Background Soft tissue injuries to the lower limb bring a substantial health and economic burden to society. Physical agents are commonly used to treat these injuries. However, the effectiveness of many such physical agents is not clearly established in the literature. Objective To evaluate the effectiveness and safety of physical agents for soft tissue injuries of the lower limb. Methods We searched 5 databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies. Paired reviewers independently screened the retrieved literature and appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a high risk of bias were excluded. We synthesized low-risk-of-bias studies according to principles of best-evidence synthesis. Results We screened 10261 articles. Of 43 RCTs identified, 20 had a high risk of bias and were excluded from the analysis, and 23 RCTs had a low risk of bias and were included in the analysis. The available higher-quality evidence suggests that patients with persistent plantar fasciitis may benefit from ultrasound or foot orthoses, while those with persistent midportion Achilles tendinopathy may benefit from shockwave therapy. However, the current evidence does not support the use of shockwave therapy for recent plantar fasciitis, low-Dye taping for persistent plantar fasciitis, low-level laser therapy for recent ankle sprains, or splints for persistent midportion Achilles tendinopathy. Finally, evidence on the effectiveness of the following interventions is not established in the current literature: (1) shockwave therapy for persistent plantar fasciitis, (2) cryotherapy or assistive devices for recent ankle sprains, (3) braces for persistent midportion Achilles tendinopathy, and (4) taping or electric muscle stimulation for patellofemoral pain syndrome. Conclusion Almost half the identified RCTs that evaluated the effectiveness of physical agents for the management of lower-limb soft tissue injuries had a high risk of bias. High-quality RCTs are still needed to assess the effectiveness of physical agents for managing the broad range of lower-limb soft tissue injuries. The effectiveness of most interventions remains unclear. Level of Evidence Therapy, 1a. Protocol registered July 10, 2014 with PROSPERO (CRD42014010621). J Orthop Sports Phys Ther 2016;46(7):523-554. Epub 6 Jun 2016. doi:10.2519/jospt.2016.6521.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

Tri-length laser therapy associated to tecar therapy in the treatment of low-back pain in adults: a preliminary report of a prospective case series

Low-back pain is very frequent, especially in active adult population. There are several different orthopaedic condition that can cause low-back pain, and the pain worsen the quality of life significantly. The treatments vary from drugs, physical therapies, kinesiology, local infiltrations, and so on. Laser therapy has an important role in the treatment of the inflammatory causes of pain, with several studies that demonstrate the efficacy of low and high energy laser therapy in the treatment of low-back pain. Sixty-six consecutive patients with low-back pain with or without leg pain were treated using a combination of Tri-length laser I-Triax® (Mectronic Medicale, Bergamo, Italy) and Pharon® tecar therapy (Mectronic Medicale, Bergamo, Italy). The patients were treated three times a week, every other day, for a total of 10 sessions. Clinical results were evaluated using visual analogic scale for individual pain (0 to 10) and the Oswestry disability scale (ODS). Tests started before the beginning of therapies and 8 weeks after the end of the therapies. Visual analogic scale (VAS) score significantly improved from an average value of 8.1 ± 1.58 pre-treatment to an average value 8-weeks post-treatment of 2.63 ± 2.74 (P < .01). ODS values start from a pre-treatment average value of 53.0 ± 13.0 to a post-treatment average value of 23.5 ± 19.8 (P < .01). A higher improvement both in VAS and in ODS was denoted in the group of patient with low-back pain and leg pain (respectively, VAS from 8.66 ± 1.58 to 2.86 ± 2.94 and ODS from 57.8 ± 15.5 to 23.7 ± 19.5). Low-back pain, associated or not with leg pain, is a very common clinical situation. The treatments of this condition are different, and an important role can be given to the laser therapy. The conclusion of this study is that the association between laser therapy iLux-Triax® and tecar therapy Pharon® in the treatment of low-back pain, with or without leg pain, can significantly reduce pain and improve the quality of life in patients with degenerative and inflammatory problems.