Extra-corporeal Pulsed-activated Therapy (“EPAT” Sound Wave) for Achilles Tendinopathy: A Prospective Study
The Journal of Foot & Ankle Surgery
1067-2516/$ – see front matter ! 2011 by the American College of Foot and Ankle Surgeons. All rights reserved. doi:10.1053/j.jfas.2011.01.003
Amol Saxena, DPM, FACFAS 1, Sona Ramdath Jr., DPM 2, Patrick O’Halloran, MS 3, Ludger Gerdesmeyer, MD, PhD 4, Hans Gollwitzer, MD 5
Achilles tendinopathy is common and extracorporeal shockwaves have become a popular treatment for this condition, even though previous research has not provided conclusive results regarding its efficacy in cases of Achilles tendinopathy. Our aim was to evaluate 3 weekly shockwave treatments in patients with Achilles tendinopathy, as quantified by the Roles and Maudsley score. A total of 74 tendons in 60 patients were assessed at baseline and at least 1 year posttreatment, including 32 (43.24%) paratendinoses, 23 (31.08%) proximal tendinoses, and 19 (25.68%) insertional tendinoses. The mean age of the participants was 48.6 12.94 years, and patients with paratendinosis (41.44 14.01 years) were statistically significantly younger than those with proximal (53 8.9 years) and insertional (54.26 9.74 years) tendinopathy, and these differences were statistically significant (P 1⁄4 .0012 and P 1⁄4 .0063, respectively). Overall, 58 (78.38%) tendons improved by at least 1 year posttreatment, including 75% in the paratendinosis, 78.26% in the proximal tendinosis, and 84.21% in the insertional tendinosis groups, and no adverse effects were observed. The Roles and Maudsley score improved from 3.22 0.55 to 1.84 1.05 (P < .0001) in the paratendinosis group, 3.39 0.5 to 1.57 0.66 (P < .0001) in the proximal tendinopathy group, and 3.32 0.58 to 1.47 0.7 (P 1⁄4 .0001) in the insertional tendinopathy group. Based on these results, we believe that shockwave therapy serves as a safe, viable, and effective option for the treatment of Achilles tendinopathy.
Tables 1 through 4 depict the results obtained in this investigation. A total of 74 Achilles tendons were treated in 60 patients, including 32 (43.24%) left and 42 (56.76%) right tendons, and 14 (23.33%) patients had the treatment performed bilaterally (on both of their Achilles tendons), during the 13-month period extending from August 2008 to August 2009. The range was 12-24 months. Ten other patients (10 tendons) underwent ESWT for Achilles tendinopathy but did not respond to our request to participate in either a telephone interview or clinical follow-up examination and were therefore considered lost to follow-up for no distinctly identifiable reason, hence their data were excluded from the analyses. The overall mean patient age was 48.32 12.94 years (range, 17-74 years), and 30 (40.54%) of the tendons were treated in women and 44 (59.46%) in men. There were 32 (43.24%) tendons treated for paratendinosis, 23 (31.08%) for ten- dinosis, and 19 (25.68%) for insertional tendinopathy, respectively. Of the patients who underwent bilateral shockwave treatment, 8 (13.33%) displayed paratendinous disease, 4 (6.67%) displayed tendi- nosis proximal to the insertion, and 2 (3.33%) displayed insertional tendinosis. There were no complications such as tendon rupture, nerve damage, phlebitis, or chronic pain syndrome identified and attributed to the shockwave treatments.
Table 2 depicts the comparison between the pretreatment and posttreatment R&M scores. The mean age of the patients with the 32 (43.24%) tendons that displayed paratendinosis was 44.2 13.3 years, and they had a pretreatment mean R&M score of 3.22 055, whereas their posttreatment score was 1.84 1.05, and this difference was statistically significant (P < .0001). These patients also noted that 24 (75%) of the tendons were subjectively rated as improved after the treatment. The mean age of the patients with the 23 (31.08%) tendons that displayed proximal tendinopathy was 53.1 14.5 years, and they had a pretreatment mean R&M score of 3.39 0.5, whereas their posttreatment score was 1.57 0.66, and this difference was statis- tically significant (P < .0001). These patients also noted that 18 (78.26%) of the tendons were subjectively rated as improved after the treatment. The mean age of the patients with the 19 (25.68%) tendons that displayed insertional tendinopathy was 53.9 9.9 years, and they had a pretreatment mean R&M score of 3.32 0.58, whereas their posttreatment score was 1.47 0.7, and this difference was statistically significant (P 1⁄4 .0001). These patients also noted that 16 (84.21%) of the tendons were subjectively rated as improved after the treat- ment. Overall, 58 (78.38%) of the tendons were noted by the patients to have subjectively improved after shockwave treatment, and the proportion of patients that improved after the treatment ranged from 75% to 84.21% when stratified by the location of Achilles tendinopathy. Four (5.41%) tendons in 4 (6.67%) separate patients failed to satisfactorily improve and eventually underwent surgical interven- tion by the senior author (A.S.). There were no statistically significant differences in the pretreatment and posttreatment scores between men and women for any of the tendon conditions (Table 3). Inter- estingly, the patients in the paratendinosis (41.44 14.01 years) group were statistically significantly younger than those in the proximal (53 8.9 years) and insertional (54.26 9.74 years) tendinopathy groups, and these differences were statistically significant (P 1⁄4 .0012 and P 1⁄4.0063, respectively) (Table 4). Comparison of the mean ages of those in the noninsertional (53 8.9 years) and insertional (54.26 9.74 years) tendinosis groups did not reveal a statistically significant difference (P 1⁄4 .573).