Radial extracorporeal shockwave therapy compared with manual therapy in runners with iliotibial band syndrome

Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review

OBJECTIVE

To determine the efficacy of extracorporeal shockwave therapy (ESWT) and investigate outcomes following the use of ESWT for athletes and physically active individuals.

DESIGN

Systematic review.

DATA SOURCES

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and searched four databases: PubMed (NLM), Embase (Elsevier), CINAHL Complete (EBSCO) and Web of Science (Clarivate).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies were randomised controlled trials, cohort and case-control studies, cases series and reports that evaluated outcomes following ESWT for athletes, physically active individuals and occupational groups requiring regular physical activity such as military cadets.

RESULTS

56 studies with 1874 athletes or physically active individuals were included. Using the Oxford level of evidence rating, included studies were 18 level I (32.1%), 3 level II (5.4%), 10 level III (17.9%), 13 level IV (23.2%) and 12 level V (21.4%). Based on the level I studies, ESWT may be effective alone in plantar fasciitis, lateral epicondylitis and proximal hamstring tendinopathy and as an adjunct to exercise treatment in medial tibial stress syndrome and osteitis pubis in athletes or physically active individuals. In most studies, athletes were allowed to continue activities and training and tolerated ESWT with minimal side effects.

CONCLUSION

ESWT may offer an efficacious treatment alone or as an adjunct to concurrent exercise therapy in selected sports-related injuries and without major adverse events. Further high-level research is needed to better define the role and clinical outcomes of ESWT.

PLAR: a combined percutaneous and arthroscopic treatment for iliotibial band syndrome description of surgical technique and short-term results: description of surgical technique and short-term results

INTRODUCTION

Description of a new surgical procedure (percutaneous lengthening and arthroscopic release, PLAR) that combines all the possible interventions on the iliotibial band (ITB), and evaluates its outcomes in a group of distance runners diagnosed with ITBS.

METHODS

A prospective observational study was made of distance runners diagnosed with ITBS and operated upon using the PLAR technique between 1 and 2018 and 31 June 2020. The surgical technique is described in detail, and the demographic data and functional outcomes measured by the sports performance scales Activity Rating Scale (ARS) and International Knee Documentation Committee (IKDC) are presented.

RESULTS

A total of 14 patients were included, with a mean follow-up of 16 months (range 12-42 months). All the patients resumed their previous sporting activity after an average of 4 (range 2.5-6) months, and no complications were recorded. In all cases, statistically significant improvement was evidenced by the ARS and IKDC scales following PLAR (p < 0.001), with excellent outcomes in 71% of the cases according to the ARS scale and in 86% according to the IKDC scale (mean difference between preoperative and final follow-up scores of 12.1/16 and 34.2/100 points, respectively).

CONCLUSION

The PLAR technique is effective in allowing a return to previous sports performance levels in a short period of time among patients with ITBS refractory to conservative management, with a high satisfaction rate and the absence of complications.

Conservative treatment for iliotibial band syndrome: Are we facing a research gap? A scoping review of 98 studies with clinical perspectives

OBJECTIVES

To identify which treatment modalities are described in the literature for the conservative management of ITBS (1) and to identify research gap (2).

DATABASES

The following electronic databases were searched: MEDLINE/Pubmed, Embase, Scopus and Cochrane Library.

ELIGIBILITY CRITERIA

The included studies had to report at least one conservative treatment on a human population suffering from ITBS.

RESULTS

98 studies reached the included criteria and seven categories of treatment were identified, i.e., stretching, adjuvants, physical modalities, injections, strengthening, manual techniques and education. Only 32 studies were designed as original clinical studies within which only 7 were randomized controlled trials, while 66 were review studies. Education, injections and medications as well as stretching were the most cited therapies. However, there was a clear discrepancy design. For example, stretching modalities were reported in 31% and 78% for clinical and review studies, respectively.

CONCLUSIONS

There is an objective research gap in the literature concerning conservative ITBS management. The recommendations are mostly based on expert opinions and review article. More high-quality research studies should be performed for enhancing the ITBS conservative management understanding.

Strategies to prevent and manage running-related knee injuries: a systematic review of randomised controlled trials

OBJECTIVE

To evaluate the effectiveness of interventions to prevent and manage knee injuries in runners.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Web of Science and SPORTDiscus up to May 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials (RCTs) with a primary aim of evaluating the effectiveness of intervention(s) to prevent or manage running-related knee injury.

RESULTS

Thirty RCTs (18 prevention, 12 management) analysed multiple interventions in novice and recreational running populations. Low-certainty evidence (one trial, 320 participants) indicated that running technique retraining (to land softer) reduced the risk of knee injury compared with control treadmill running (risk ratio (RR) 0.32, 95% CI 0.16 to 0.63). Very low-certainty to low-certainty evidence from 17 other prevention trials (participant range: 24 -3287) indicated that various footwear options, multicomponent exercise therapy, graduated running programmes and online and in person injury prevention education programmes did not influence knee injury risk (RR range: 0.55-1.06). In runners with patellofemoral pain, very low-certainty to low-certainty evidence indicated that running technique retraining strategies, medial-wedged foot orthoses, multicomponent exercise therapy and osteopathic manipulation can reduce knee pain in the short-term (standardised mean difference range: -4.96 to -0.90).

CONCLUSION

There is low-certainty evidence that running technique retraining to land softer may reduce knee injury risk by two-thirds. Very low-certainty to low-certainty evidence suggests that running-related patellofemoral pain may be effectively managed through a variety of active (eg, running technique retraining, multicomponent exercise therapy) and passive interventions (eg, foot orthoses, osteopathic manipulation).

PROSPERO REGISTRATION NUMBER

CRD42020150630.

Conservative treatment of iliotibial band syndrome in runners: Are we targeting the right goals?

OBJECTIVE

Iliotibial band syndrome (ITBS) is presumably caused by excessive tension in the iliotibial band (ITB) leading to compression and inflammation of tissues lying beneath it. Usually managed conservatively, there is a lack of scientific evidence supporting the treatment recommendations, and high symptom recurrence rates cast doubt on their causal effectiveness. This review discusses the influence of common physiotherapeutic measures on risk factors contributing to tissue compression beneath the ITB.

METHODS

The potential pathogenic factors are presented on the basis of a simple biomechanical model showing the forces acting on the lateral aspect of the knee. Existent literature on the most commonly prescribed physiotherapeutic interventions is critically discussed against the background of this model. Practical recommendations for the optimization of physiotherapy are derived.

RESULTS

According to biomechanical considerations, ITBS may be promoted by anatomical predisposition, joint malalignments, aberrant activation of inserting muscles as well as excessive ITB stiffness. Hip abductor strengthening may correct excessive hip adduction but also increase ITB strain. Intermittent stretching interventions are unlikely to change the ITB's length or mechanical properties. Running retraining is a promising yet understudied intervention.

CONCLUSIONS

High-quality research directly testing different physiotherapeutic treatment approaches in randomized controlled trials is needed.

Operative Versus Nonoperative Management of Distal Iliotibial Band Syndrome-Where Do We Stand? A Systematic Review

Purpose

To systematically review the operative versus nonoperative methods for management of iliotibial band syndrome (ITBS) with comparison of the respective clinical outcomes.

Methods

By adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, 3 databases (Medline, Scopus, Web of Science) searched from inception to October 2019 for randomized clinical trials (RCTs) and observational studies on humans that reported the outcomes following operative or nonoperative management of ITBS. Excluded were case reports, case series with <5 participants, review articles, non-English articles, and non–peer-reviewed articles. The Methodological Index for Non-Randomized Studies (MINORS) criteria for observational studies and the Cochrane Risk of Bias Tool for RCTs were used for quality control.

Results

There were 15 eligible studies (9 for operative,6 for nonoperative treatment) examining 179 athletes (mean age 27.3 years, range: 17-53) who received conservative therapy for ITBS and 200 athletes (mean age 30.1 years, range: 14-63) who underwent surgical treatment. Most athletes were runners (65%). The mean follow-up time was significantly longer in studies reporting the outcomes following operative compared with nonoperative ITBS treatment (33.5 vs 2 months, respectively, P < .05). Significant variability in the methods used to assess the clinical outcomes precluded meta-analysis. The most commonly reported (7/9 studies, 77.7%) variable for postoperative evaluation in athletes was the return to sport rate (range: 81%-100%). Significant reduction in pain was consistently (6/6 studies,100%) found among the studies reporting the results of conservative ITBS treatment. The included RCTs were of good (1/5, 20%), fair (2/5, 40%), or poor (2/5, 40%) quality, whereas the average MINORS score was 7.4 (range: 3-13) for observational studies. The level of evidence ranged from Level II (6/15 studies) to IV (9/15 studies).

Conclusions

Based on the current literature and at a maximum follow-up time of 6 months, conservative therapy can effectively reduce ITBS symptoms in athletes. Multiple surgical options exist for athletes who do not respond to nonoperative measures, with a reported return to sport rate between 81% and 100%.

Level of Evidence

Systematic review of Level II and IV studies

Efficacy of Extracorporeal Shock Wave Therapy for Lower-Limb Tendinopathy: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Extracorporeal shock wave therapy, including radial shock wave and focused shock wave types, is widely used for managing tendinopathies. The difference in efficacy between the 2 shock wave characteristics with different dosage levels remains controversial, and the purpose of this meta-analysis was to examine it for patients with lower-limb tendinopathy.

DESIGN

A comprehensive search of online databases and search engines was performed. This study included randomized controlled trials reporting the efficacy of extracorporeal shock wave therapy in treating lower-limb tendinopathy. The included randomized controlled trials were subjected to a meta-analysis and risk of bias assessment.

RESULTS

In total, 29 randomized controlled trials were included, all of which had a good methodological quality, with a PEDro score of ≥6/10. General extracorporeal shock wave therapy showed significant effects at the immediate follow-up [pain score: standardized mean difference = -1.41, 95% confidence interval = -2.01 to -0.82, P < 0.00001; function: standardized mean difference = 2.59, 95% confidence interval = 1.54 to 3.64, P < 0.00001] as well as at 3, 6, and ≥12 months. In sequence, high-dosage focused shock wave, high-dosage radial shock wave, and low-dosage radial shock wave had superior pooled effects on overall clinical outcomes.

CONCLUSIONS

Extracorporeal shock wave therapy exerted a positive overall effect on pain and function for lower-limb tendinopathy. Shock wave types and dosage levels may have different contributions to treatment efficacy.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe benefits of extracorporeal shock wave therapy for individuals with lower-limb tendinopathy; (2) Understand the impact of dosing and type of extracorporeal shock wave therapy has on treatment efficacy; and (3) Identify appropriate indications for incorporating extracorporeal shock wave therapy into the treatment plan for patients with lower-limb tendinopathy.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Efficacy of extracorporeal shock wave therapy for knee tendinopathies and other soft tissue disorders: a meta-analysis of randomized controlled trials

Background

Extracorporeal shock-wave therapy (ESWT), which can be divided into radial shock-wave therapy (RaSWT) and focused shock-wave therapy (FoSWT), has been widely used in clinical practice for managing orthopedic conditions. The aim of this study was to determine the clinical efficacy of ESWT for knee soft tissue disorders (KSTDs) and compare the efficacy of different shock-wave types, energy levels, and intervention durations.

Methods

We performed a comprehensive search of online databases and search engines without restrictions on the publication year or language. We selected randomized controlled trials (RCTs) reporting the efficacy of ESWT for KSTDs and included them in a meta-analysis and risk of bias assessment. The pooled effect sizes of ESWT were estimated by computing odds ratios (ORs) with 95% confidence intervals (CIs) for the treatment success rate (TSR) and standardized mean differences (SMDs) with 95% CIs for pain reduction (i.e., the difference in pain relief, which was the change in pain from baseline to the end of RCTs between treatment and control groups) and for restoration of knee range of motion (ROM).

Results

We included 19 RCTs, all of which were of high or medium methodological quality and had a Physiotherapy Evidence Database score of ≥5/10. In general, ESWT had overall significant effects on the TSR (OR: 3.36, 95% CI: 1.84–6.12, P < 0.0001), pain reduction (SMD: − 1.49, 95% CI: − 2.11 to − 0.87, P < 0.00001), and ROM restoration (SMD: 1.76, 95% CI: 1.43–2.09, P < 0.00001). Subgroup analyses revealed that FoSWT and RaSWT applied for a long period (≥1 month) had significant effects on pain reduction, with the corresponding SMDs being − 3.13 (95% CI: − 5.70 to − 0.56; P = 0.02) and − 1.80 (95% CI: − 2.52 to − 1.08; P < 0.00001), respectively. Low-energy FoSWT may have greater efficacy for the TSR than high-energy FoSWT, whereas the inverse result was observed for RaSWT.

Conclusions

The ESWT exerts an overall effect on the TSR, pain reduction, and ROM restoration in patients with KSTDs. Shock-wave types and application levels have different contributions to treatment efficacy for KSTDs, which must be investigated further for optimizing these treatments in clinical practice.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2204-6) contains supplementary material, which is available to authorized users.