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Randomized Controlled Trial
. 2021 Sep-Oct;13(5):511-518.
doi: 10.1177/1941738121991791. Epub 2021 Feb 13.

Line- and Point-Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Placebo-Controlled RCT Study

Matthias Gatz  1 , Sebastian Schweda  1 , Marcel Betsch  1 , Timm Dirrichs  2 , Matias de la Fuente  3 , Nina Reinhardt  3 , Valentin Quack  1
Affiliations
Randomized Controlled Trial

Line- and Point-Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Placebo-Controlled RCT Study

Matthias Gatz et al. Sports Health. 2021 Sep-Oct.

Abstract

Background: Extracorporeal shock wave therapy (ESWT) is a widely considered treatment option for Achilles tendinopathy. Line-focused ESWT is a novel technique treating a larger tendon area than point-focused ESWT. Monitoring capacities of clinical symptoms with ultrasound under ESWT treatment are unknown.

Hypothesis: Point- and line-focused ESWT have a superior outcome than placebo ESWT. ESWT leads to morphological tendon changes detectable with ultrasound.

Study design: Single-blinded placebo-controlled randomized contolled trial.

Level of evidence: Level 1.

Methods: The study was conducted in 3 cohorts, namely ESWT point (n = 21), ESWT line (n = 24), and ESWT placebo (n = 21). Victorian Institute of Sports Assessment-Achilles (VISA-A) score was measured before the intervention (T0), after 6 weeks (T1), and after 24 weeks (T2). All cohorts performed daily physiotherapy for 24 weeks and received 4 sessions of point-focused, line-focused, or placebo ESWT in the first 6 weeks. Ultrasound was performed with B-mode, power Doppler, shear wave elastography (SWE) at T0 and T2 and with ultrasound tissue characterization (UTC) at T0, T1, and T2. Data were analyzed with a mixed analysis of variance and t test.

Results: There was a significant VISA-A improvement over time for all groups (P < 0.001). ESWT point had the strongest VISA-A score improvement +23 (ESWT line: +18; ESWT placebo: +15), but there was no significant interaction between time and any of the groups: F(4, 116) = 1.393; P = 0.24. UTC, power Doppler, and B-mode could not show significant alterations over time. SWE revealed a significant increase of elastic properties for ESWT point in the insertion (t = -3.113, P = 0.03) and midportion (t = -2.627, P = 0.02) over time.

Conclusion: There is a significant VISA-A score improvement for all study groups without a statistically significant benefit for ESWT point or ESWT line compared with ESWT placebo. Tendon adaptation could only be detected with SWE for ESWT point.

Clinical relevance: The present study could not detect any statistically relevant effect of ESWT compared to placebo. SWE is able to demonstrate tendon adaptation.

Keywords: Achilles tendinopathy; ESWT; elastography; ultrasound; ultrasound tissue characterization (UTC).

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Conflict of interest statement

The authors report no potential conflicts of interest in the development and publication of this article.

Figures

Figure 1.
Figure 1.
Point- and line-focused extracorporeal shock wave therapy (ESWT): the tendon volume treated with line-focused ESWT is larger than in point-focused ESWT. However, the maximum energy density is higher in point-focused ESWT than in line-focused ESWT.
Figure 2.
Figure 2.
Flowchart of the study design. AOFAS, American Orthopaedic Foot and Ankle Society; B-US, B-mode ultrasound; ESWT, extracorporeal shock wave therapy; P-US, power Doppler ultrasound; SWE, shear wave elastography; UTC, ultrasound tissue characterization; VISA-A, Victorian Institute of Sports Assessment–Achilles.
Figure 3.
Figure 3.
(a, b) Box plots illustrating VISA-A, Victorian Institute of Sports Assessment–Achilles (VISA-A) and American Orthopaedic Foot and Ankle Society (AOFAS) score. ESWT, extracorporeal shock wave therapy.
See this image and copyright information in PMC

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