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ESWT and Achilles Tendonitis

Posted by Duston S. on 7/24/03 at 11:07 (125140)

Is EWST effective in the treatment of chronic Achilles tendonitis?

Re: ESWT and Achilles Tendonitis

Scott D. on 7/24/03 at 11:26 (125142)


Here are 2 papers from the last ISMST meeting on the topic.

Application of Electrohydraulic Orthotripsy for Chronic Achilles Tendinopathy.

Authors: J.A. Ogden and G.L. Cross; Atlanta, Georgia

Introduction: Chronic Achilles tendinitis may occur in both athletes as well as older adults. In the latter group, superior calcaneal bone spurs may be present. A group of these patients have both Achilles tendinopathy and plantar fasciopathy. Non-operative therapy is the desired course, especially since cortisone injection is not practical because of potential tendon rupture.

Methods: Sixteen patients were treated with orthotripsy. Three patents had bilateral treatments under the same anesthesia. Five patients had treatment of the Achilles tendon and plantar fascia under the same anesthesia. Orthotripsy was applied to several areas of the distal Achilles tendon, the tendocalcaneal enthesis and the calcaneus distal to the enthesis according to a protocol of graded kV and number of shocks. Patients were assessed at 6 hours and 12 weeks.

Results: One patient (67 years old) with bilateral Achilles tendinopathy and plantar fasciopathy had insignificant release in all four sites. In contrast, a younger patient (32 years old) had complete relief of all four istes by six weeks. The other 3 PF/AT patients had improvement in both treatment sites. Of the 19 tendons (non PF), 7 had complete pain relief and 8 had acceptable relief. Several patients have requested a second treatment.

Conclusion: Electrohydraulic orthotripsy may offer an effective non-surgical alternative for chronic Achilles tendinopathy in all age groups. The bone spurs remain unchanged. Based on the positive results, a formal FDA study has commenced.

Extracorporeal Shockwave Therapy (ESWT) in the Treatment of Achilles Tendinitis

Authors: M.C.Vulpiani, P.Papandrea, M.Ciurluini, E.Monaco, A.Ferretti

Institution: University, 'La Sapienza', Rome, Italy

Overuse syndromes of the Achilles tendon and its contiguous structures are the most common diseases not only among sports players but also among people in normal activities. The aim of the study was to evaluate the efficacy of Extracorporeal Shockwave Therapy (ESWT) in the treatment of Achilles tendinitis. Between December 1997 and July 2002, 84 patients affected by Achilles tendinitis were treated with shockwaves. The treatment consisted of an average of four sessions (Min 3-Max 5) of shockwaves given with a power from 0.04 to 0.07 mmJ/mm2 for tendinitis and with a power from 0.07 to 0.17 mmJ/mm2 for insertional calcifying tendinitis. The treatment was given weekly with 2.500 impulses for each session. An electromagnetic coil lithotriptor provided with in-line ultrasound aiming was used. No anaesthesia was used. 76 patients (20 showed a bilateral pathology with a total of 96 tendons, of which 13 showed insertional calcifications) were interviewed by questionnaire at one month after treatment and at a mean follow-up of 22 months (Min 2-Max 48). This group consisted of 66 males and 10 females. In these patients, standard conservative treatments such as physical therapy, local infiltrations, etc., had proven unsuccessful. Patients had been subjected to ultrasound and/or X-ray and MNR examination before treatment started. Achilles tendon ruptures as well as patients who had undergone surgical treatment, were excluded from the study. At 1 month after ESWT, according to the satisfaction of the patients and to function, excellent results have been obtained in 22 cases (23%); good results in 28 cases (29%); fair results in 18 cases (19%); and poor results in the remaining 28 cases (29%). At follow-up, the results were excellent in 47 cases (49%); good in 21 cases (22%); fair in 3 cases (3%); and poor results in the remaining 25 cases (26%). Even though in the absence of an untreated group the study cannot analyze differences between ESWT-induced effects and spontaneous developments, it was concluded! that, in the treatment of Achilles tendinitis, resistant to any other conservative treatment, shockwave therapy can represent a valid alternative before surgery is considered.

Re: ESWT and Achilles Tendonitis

Duston S. on 7/24/03 at 11:36 (125143)

Thank you for your quick response. It looks like it's not the 'silver bullet' but is worth asking my podiatrist about.

Re: ESWT and Achilles Tendonitis

Duston S. on 7/24/03 at 11:56 (125145)

One question occurs to me, how do the results compare with surgery?

Re: ESWT and Achilles Tendonitis

Dr. Z on 7/24/03 at 14:43 (125156)

I have used ESWT off label with the Dornier Epos with very good results.
Achilles tendon surgery takes up to one year to heal with casting, and non-weighting in many cases. ESWT is non-invasive with none of the complications that can occur with foot surgery. If you would like I can put you in touch with patients I have done with at least a two year post treatment. E-mail Dr. Z at (email removed) if you wish to speak to these patients

Re: ESWT and Achilles Tendonitis

Mark C on 7/29/03 at 21:09 (125609)

I have been told that in the initial FDA trial on Achilles tendons that a rupture lead to the FDA only approving the Ossatron for Plantar Fasciitis. Does anyone know if this is correct. I am unable to find a reference to it.

My doctor has had another patient refered to a Dornier machine have a tendon rupture as well.

I need any advice on the possible issues for this occurring.

Re: ESWT and Achilles Tendonitis

Dr. Z on 7/29/03 at 21:21 (125611)

There were two plantar fascia ruptures with the ossatron post-eswt treatment during the FDA trials. This happened I believe a few months after the treatment. The ossatron or the dornier aren't FDA approved for achilles tendonitis.
If you have a tendon rupture then ESWT shouldn't be used .
We use low energy for non-insertional achilles tendonitis. IF you use high energy for non-insertional achilles tendonitis then you can have a rupture of the achilles tendon due to tendon necrosis.

Are you talking about insertional or non-insertional achilles tendonitis.
Are you saying that your doctor referred two patients that had ESWT and a rupture develeoped ? I am not sure of your questions. Please help me out and I will try to answer your question

Re: ESWT and Achilles Tendonitis

Ed Davis, DPM on 7/30/03 at 23:15 (125746)

Dr. Z:

There are several related entities: retrocalcaneal calcific enthesopathy, achilles tendinitis and achilles tendinosis. I would be comfortable with ESWT on the the first two. Application of ESWT to tendinosis could increase the danger of rupture in the short term but may have significant long term benefits. I would prefer to use low energy on achilles tendinosis.

Re: ESWT and Achilles Tendonitis

Dr. Z on 7/31/03 at 08:30 (125769)

Would you agree that most of the long term non-insertional achilles tendon problem are in the grouping tendonosis and that most of the insertional achilles tendon problems are in the enthesopathy and achilles tendonitis.

Re: ESWT and Achilles Tendonitis

Ed Davis, DPM on 8/01/03 at 11:54 (125888)


Re: ESWT and Achilles Tendonitis

Mark C on 8/05/03 at 06:16 (126252)

In reply to Dr Z

I am talking about non-insertionAL TENDONITIS
My doctor refered a patient to a Dornier machine for treatment on a tendon and it ruptured after the second treatment.

I am looking for advice as I do not want an operation


Re: ESWT and Achilles Tendonitis

Dr. Z on 8/05/03 at 06:49 (126254)

We haven't had that happen. Maybe the quality of the tendon was poor to start with. All of my patients have been very active and healthy. We only use LOW energy for this treatment. The question is whether low energy was used and what was the quality of the tendon. I have never heard of low energy ESWT causing this. High energy I have heard of this.

Re: ESWT and Achilles Tendonitis

Dr. Z on 8/05/03 at 06:52 (126255)

One other comment. I am describing non-insertional tendonitis about 1/3 to 1/2 up the leg. I am not talking about just a few inches above the back
of the heel bone.