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BioMed Research International 2019Extracorporeal shock wave therapy (ESWT) is among the conservative treatments for Achilles tendinopathy. Unfortunately, no optimal application parameters have been... (Review)
Review
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.
Topics: Achilles Tendon; Extracorporeal Shockwave Therapy; High-Energy Shock Waves; Humans; Tendinopathy; Treatment Outcome
PubMed: 31950037
DOI: 10.1155/2019/3086910 -
British Journal of Sports Medicine Mar 2021To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy.
DESIGN
Living systematic review and network meta-analysis.
DATA SOURCES
Multiple databases including grey literature sources were searched up to February 2019.
STUDY ELIGIBILITY CRITERIA
Randomised controlled trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy. We excluded trials with 10 or fewer participants per treatment arm or trials investigating tendon ruptures.
DATA EXTRACTION AND SYNTHESIS
Reviewers independently extracted data and assessed the risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of evidence.
PRIMARY OUTCOME MEASURE
The validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire.
RESULTS
29 trials investigating 42 different treatments were included. 22 trials (76%) were at high risk of bias and 7 (24%) had some concerns. Most trials included patients with midportion tendinopathy (86%). Any treatment class seemed superior to wait-and-see for midportion Achilles tendinopathy at 3 months (very low to low certainty of evidence). At 12 months, exercise therapy, exercise+injection therapy and exercise+night splint therapy were all comparable with injection therapy for midportion tendinopathy (very low to low certainty). No network meta-analysis could be performed for insertional Achilles tendinopathy.
SUMMARY/CONCLUSION
In our living network meta-analysis no trials were at low risk of bias and there was large uncertainty in the comparative estimates. For midportion Achilles tendinopathy, wait-and-see is not recommended as all active treatments seemed superior at 3-month follow-up. There seems to be no clinically relevant difference in effectiveness between different active treatments at either 3-month or 12-month follow-up. As exercise therapy is easy to prescribe, can be of low cost and has few harms, clinicians could consider starting treatment with a calf-muscle exercise programme.
PROSPERO REGISTRATION NUMBER
CRD42018086467.
Topics: Achilles Tendon; Humans; Randomized Controlled Trials as Topic; Tendinopathy
PubMed: 32522732
DOI: 10.1136/bjsports-2019-101872 -
Danish Medical Journal Apr 2014Acute Achilles tendon rupture is a frequent and potentially disabling injury. Over the past decade a change in treatment of acute Achilles tendon rupture away from... (Review)
Review
BACKGROUND
Acute Achilles tendon rupture is a frequent and potentially disabling injury. Over the past decade a change in treatment of acute Achilles tendon rupture away from operative towards non-operative treatment has taken place. However, the optimal non-operative treatment protocol remains to be clarified, particularly the role of weight-bearing during early rehabilitation. Also, there is a need for a clinically applicable and accurate measurement to detect patients in risk of developing Achilles tendon elongation.
PURPOSE
The aim of this PhD thesis was to evaluate non-operative treatment of acute Achilles tendon rupture.
METHODS
In study I, a cross-sectional survey was performed investigating the chosen treatment protocols across Scandinavia. In study II, the effect of immediate weight-bearing on patient reported and functional outcomes was investigated in a randomized controlled trial (RCT). In study III, the effect of immediate weight-bearing on the biomechanical properties of the plantar flexor muscle-tendon complex was investigated in an RCT. In study IV, validity, reliability and agreement of a novel ultrasound measurement of Achilles tendon length and elongation was tested.
RESULTS
Study I found surgery to be the preferred treatment in 83% of departments in Denmark, 92% in Norway, 65% in Sweden, and 30% in Finland (p < 0.001). Study II and III showed no statistically significant effects of controlled early weight-bearing at one year follow-up except from a better health-related quality of life in the weight-bearing group (p=0.009). Compared to the unaffected limb, the affected limb had decreased stiffness (77%, p < 0.001) and strength (93%, p = 0.009) of the plantar flexor muscle-tendon complex. Study IV showed excellent intra-rater reliability (ICC 0.96, SEM 3.7 mm and MDC 10.3 mm), inter-rater reliability (ICC 0.97, SEM 3.3 mm and MDC 9.3 mm) and validity (measurement error 2%).
CONCLUSION
Treatment algorithms across Scandinavia showed considerable variation, though operative treatment and controlled early weight-bearing was the preferred treatment in Denmark, Norway and Sweden. Immediate weight-bearing was found to be safe and recommendable in non-operative treatment of acute Achilles tendon rupture. The novel ultrasound measurement showed excellent reliability and acceptable validity and agreement.
Topics: Achilles Tendon; Biomechanical Phenomena; Humans; Immobilization; Rupture; Tendon Injuries; Therapeutics; Ultrasonography; Weight-Bearing; Wound Healing
PubMed: 24814601
DOI: No ID Found -
The American Journal of Sports Medicine Aug 2018Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim... (Randomized Controlled Trial)
Randomized Controlled Trial
The Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing in Combination With Ankle Mobilization: A Randomized Clinical Trial.
BACKGROUND
Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period.
HYPOTHESIS
Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome.
STUDY DESIGN
Randomized controlled trial; Level of evidence, 1.
METHODS
75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9.
RESULTS
The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months.
CONCLUSION
Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 ( ClinicalTrials.gov identifier).
Topics: Achilles Tendon; Adolescent; Adult; Aged; Ankle; Biomechanical Phenomena; Early Ambulation; Exercise Therapy; Follow-Up Studies; Humans; Middle Aged; Movement; Muscle Strength; Patient Reported Outcome Measures; Rupture; Treatment Outcome; Weight-Bearing; Young Adult
PubMed: 29965789
DOI: 10.1177/0363546518781826 -
BMC Musculoskeletal Disorders Feb 2019Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no...
BACKGROUND
Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no consensus about diagnostic methods, primary treatment (non-surgical or surgical) and rehabilitation. It is hypothesized that this lack of consensus and guidelines leads to sub-optimal recovery and higher societal costs. The primary aim of this study is to give a broad insight into the recovery after ATR. Secondarily this study aims to explore factors contributing to recovery and gain insight into the cost-effectiveness of ATR management.
METHODS
This multicenter prospective cohort study will include all adult (≥ 18 years) patients with an ATR treated at the three main hospitals in the Northern Netherlands: University Medical Center Groningen, Martini Hospital Groningen and Medical Center Leeuwarden. All subjects will be invited for three visits at 3, 6 and 12 months post-injury. The following data will be collected: patient-reported outcome measures (PROMs), physical tests, imaging and economic questionnaires. At 3 months post-injury personal, injury, and treatment data will be collected through a baseline questionnaire and assessment of the medical file. The PROMs concern the Dutch version of the Achilles Tendon Total Rupture Score, EQ-5D-5 L, Oslo Sport Trauma Research Center Overuse Injury Questionnaire, Injury Psychological Readiness Return to Sport Scale, Tampa Scale of Kinesiophobia, Expectations, Motivation and Satisfaction questionnaire and a ranking of reasons for not returning to sport. The administered physical tests are the heel-rise test, standing dorsiflexion range of motion, resting tendon length and single leg hop for distance. Ultrasound Tissue Characterization will be used for imaging. Finally, economic data will be collected using the Productivity Cost Questionnaire and Medical Consumption Questionnaire.
DISCUSSION
This prospective cohort study will contribute to optimal decision making in the primary treatment and rehabilitation of ATRs by providing insight into (1) ATR recovery (2) novel imaging for monitoring recovery (3) (barriers to) return to sport and (4) cost-effectiveness of management. The analysis of these data strives to give a broad insight into the recovery after ATR as well as provide data on novel imaging and costs, contributing to individualized ATR management.
TRIAL REGISTRATION
Trialregister.nl. NTR6484 . 20/06/2017. 20/07/2017.
Topics: Achilles Tendon; Clinical Decision-Making; Cost-Benefit Analysis; Health Care Costs; Humans; Multicenter Studies as Topic; Netherlands; Patient Reported Outcome Measures; Patient Satisfaction; Physical Examination; Predictive Value of Tests; Prospective Studies; Recovery of Function; Research Design; Tendon Injuries; Time Factors; Treatment Outcome
PubMed: 30744626
DOI: 10.1186/s12891-019-2437-z -
Knee Surgery, Sports Traumatology,... Jun 2017Functional weight-bearing mobilization may improve repair of Achilles tendon rupture (ATR), but the underlying mechanisms and outcome were unknown. We hypothesized that... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
Functional weight-bearing mobilization may improve repair of Achilles tendon rupture (ATR), but the underlying mechanisms and outcome were unknown. We hypothesized that functional weight-bearing mobilization by means of increased metabolism could improve both early and long-term healing.
METHODS
In this prospective randomized controlled trial, patients with acute ATR were randomized to either direct post-operative functional weight-bearing mobilization (n = 27) in an orthosis or to non-weight-bearing (n = 29) plaster cast immobilization. During the first two post-operative weeks, 15°-30° of plantar flexion was allowed and encouraged in the functional weight-bearing mobilization group. At 2 weeks, patients in the non-weight-bearing cast immobilization group received a stiff orthosis, while the functional weight-bearing mobilization group continued with increased range of motion. At 6 weeks, all patients discontinued immobilization. At 2 weeks, healing metabolites and markers of procollagen type I (PINP) and III (PIIINP) were examined using microdialysis. At 6 and 12 months, functional outcome using heel-rise test was assessed.
RESULTS
Healing tendons of both groups exhibited increased levels of metabolites glutamate, lactate, pyruvate, and of PIIINP (all p < 0.05). Patients in functional weight-bearing mobilization group demonstrated significantly higher concentrations of glutamate compared to the non-weight-bearing cast immobilization group (p = 0.045).The upregulated glutamate levels were significantly correlated with the concentrations of PINP (r = 0.5, p = 0.002) as well as with improved functional outcome at 6 months (r = 0.4; p = 0.014). Heel-rise tests at 6 and 12 months did not display any differences between the two groups.
CONCLUSIONS
Functional weight-bearing mobilization enhanced the early healing response of ATR. In addition, early ankle range of motion was improved without the risk of Achilles tendon elongation and without altering long-term functional outcome. The relationship between functional weight-bearing mobilization-induced upregulation of glutamate and enhanced healing suggests novel opportunities to optimize post-operative rehabilitation.
Topics: Achilles Tendon; Adult; Ankle; Casts, Surgical; Female; Humans; Immobilization; Lactic Acid; Male; Microdialysis; Prospective Studies; Range of Motion, Articular; Rupture; Single-Blind Method; Treatment Outcome; Weight-Bearing; Wound Healing
PubMed: 27539402
DOI: 10.1007/s00167-016-4270-3 -
Clinical Orthopaedics and Related... Oct 2021Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence.
QUESTIONS/PURPOSES
We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery?
METHODS
This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar.
RESULTS
We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes.
CONCLUSION
Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations.
LEVEL OF EVIDENCE
Level I, therapeutic study.
Topics: Achilles Tendon; Evidence-Based Medicine; Humans; Randomized Controlled Trials as Topic; Rupture; Tendon Injuries
PubMed: 34180874
DOI: 10.1097/CORR.0000000000001861 -
Sports Health 2021Extracorporeal shock wave therapy (ESWT) is a widely considered treatment option for Achilles tendinopathy. Line-focused ESWT is a novel technique treating a larger... (Randomized Controlled Trial)
Randomized Controlled Trial
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 test.
RESULTS
There was a significant VISA-A improvement over time for all groups ( < 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: (4, 116) = 1.393; = 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 ( = -3.113, = 0.03) and midportion ( = -2.627, = 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.
Topics: Achilles Tendon; Adult; Aged; Elasticity Imaging Techniques; Extracorporeal Shockwave Therapy; Female; Humans; Male; Middle Aged; Physical Therapy Modalities; Single-Blind Method; Tendinopathy; Young Adult
PubMed: 33586526
DOI: 10.1177/1941738121991791 -
Canadian Journal of Surgery. Journal... 2023The treatment of Achilles tendon rupture has recently seen a shift toward non-operative management, as supported by the literature, yet many surgeons continue to treat...
The treatment of Achilles tendon rupture has recently seen a shift toward non-operative management, as supported by the literature, yet many surgeons continue to treat these injuries operatively. The evidence clearly supports non-operative management of these injuries except for Achilles insertional tears and for certain patient groups, such as athletic patients, for whom further research is warranted. This nonadherence to evidence-based treatment may be explained by patient preference, surgeon subspecialty, surgeon era of practice or other variables. Further research to understand the reasons behind this nonadherence would help to promote conformity in the surgical community across all specialties and adherence to evidence-based approaches.
Topics: Humans; Achilles Tendon; Rupture; Tendon Injuries; Orthopedic Procedures; Patient Preference; Treatment Outcome
PubMed: 37402560
DOI: 10.1503/cjs.008321 -
Ugeskrift For Laeger May 2023This case report is about the rare combination of a concomitant ipsilateral occurrence of traumatic Achilles tendon rupture (ATR) and medial malleolar fracture (MMF) in... (Review)
Review
This case report is about the rare combination of a concomitant ipsilateral occurrence of traumatic Achilles tendon rupture (ATR) and medial malleolar fracture (MMF) in a 59-year-old male patient. We have conducted a literature review and found 12 published cases on the same topic with similar trauma mechanism and characteristic clinical findings. Nevertheless, either the ATR or the MMF was missed in the initial clinical examination in two-thirds of the reported cases. In this case report we discuss the trauma mechanism and clinical findings of ATR and MMF and aim to increase the awareness of the combination of both injuries.
Topics: Male; Humans; Middle Aged; Ankle Fractures; Achilles Tendon; Rupture; Ankle Injuries; Tendon Injuries
PubMed: 37264883
DOI: No ID Found