title: Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial.
abstract: BACKGROUND
  Nonoperative management of chronic tendinopathy of the Achilles tendon insertion has been poorly studied. With the recently demonstrated effectiveness of eccentric loading and of repetitive low-energy shock wave therapy in patients with midsubstance Achilles tendinopathy, the aim of the present randomized, controlled trial was to verify the effectiveness of both procedures exclusively in patients with insertional Achilles tendinopathy.
  
  
  METHODS
  Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized, controlled study. All patients had received treatment, including local injections of an anesthetic and/or corticosteroids, a prescription of nonsteroidal anti-inflammatory drugs, and physiotherapy, without success for at least three months. A computerized random-number generator was used to draw up an allocation schedule. Twenty-five patients were allocated to receive eccentric loading (Group 1), and twenty-five patients were allocated to treatment with repetitive low-energy shock wave therapy (Group 2). Analysis was on an intention-to-treat basis. Primary follow-up was at four months, and afterward patients were allowed to cross over. The last follow-up evaluation was at one year after completion of the initial treatment. The patients were assessed for pain, function, and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire).
  
  
  RESULTS
  At four months from baseline, the mean VISA-A score had increased in both groups, from 53 to 63 points in Group 1 and from 53 to 80 points in Group 2. The mean pain rating decreased from 7 to 5 points in Group 1 and from 7 to 3 points in Group 2. Seven patients (28%) in Group 1 and sixteen patients (64%) in Group 2 reported that they were completely recovered or much improved. For all outcome measures, the group that received shock wave therapy showed significantly more favorable results than the group treated with eccentric loading (p = 0.002 through p = 0.04). At four months, eighteen of the twenty-five patients from Group I had opted to cross over, as did eight of the twenty-five patients from Group 2. The favorable results after shock wave therapy at four months were stable at the one-year follow-up evaluation.
  
  
  CONCLUSIONS
  Eccentric loading as applied in the present study showed inferior results to low-energy shock wave therapy as applied in patients with chronic recalcitrant tendinopathy of the insertion of the Achilles tendon at four months of follow-up. Further research is warranted to better define the indications for this treatment modality.
authors.affiliation: OrthoTrauma Evaluation Center, Hans-Zoeller Strasse 83, D-55130 Mainz, Germany. profrompe@web.de
authors.forename: Jan D
authors.initials: JD
authors.lastname: Rompe
authors.forename: John
authors.initials: J
authors.lastname: Furia
authors.forename: Nicola
authors.initials: N
authors.lastname: Maffulli
mesh_terms: D000125:Achilles Tendon / Q000293:injuries* / Q000473:pathology; D000328:Adult; D002908:Chronic Disease; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D019220:High-Energy Shock Waves / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D017288:Pain Threshold; D011336:Probability; D020127:Recovery of Function; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D052256:Tendinopathy / Q000175:diagnosis / Q000532:radiotherapy* / Q000534:rehabilitation*; D016896:Treatment Outcome; D016474:Weight-Bearing