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

Marc A Paantjens; Pieter H Helmhout; Frank J G Backx; Faridi S van Etten-Jamaludin; Eric W P Bakker

doi:10.1186/s40798-022-00456-5

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

Sports Med Open. 2022 May 13;8(1):68. doi: 10.1186/s40798-022-00456-5.

Authors

Marc A Paantjens^{1

2}, Pieter H Helmhout³, Frank J G Backx⁴, Faridi S van Etten-Jamaludin⁵, Eric W P Bakker⁶

Affiliations

¹ Sports Medicine Centre, Training Medicine and Training Physiology, Royal Netherlands Army, Utrecht, The Netherlands. achillestendonimaging@gmail.com.
² Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands. achillestendonimaging@gmail.com.
³ Centre of Excellence, Training Medicine and Training Physiology, Royal Netherlands Army, Utrecht, The Netherlands.
⁴ Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands.
⁵ Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
⁶ Division EPM, Department Epidemiology and Data Science, University Medical Center Amsterdam, Amsterdam, The Netherlands.

Abstract

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 Unpublished studies and gray literature were searched in trial registers (ACTRN, ChiCTR, ChiCtr, CTRI, DRKS, EUCTR, IRCT, ISRCTN, JPRN UMIN, ClinicalTrials.gov, NTR, TCTR)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.

Keywords: Achilles tendinopathy; Extra corporeal shockwave therapy; Insertional Achilles tendinopathy; Mid-portion Achilles tendinopathy; Sports medicine.

Publication types

Systematic Review