Achilles Tendinopathy

A degenerative condition affecting the tendon due to overuse or traumatic injury. It is characterised by pain, swelling, limitation in activity, weakness or stiffness either in the middle part of the tendon or where the tendon attaches into the back of the heel.

Treatment involves manual therapy, eccentric tendon (lengthening under load) loading, orthotics, NSAIDs, injection therapy and possibly surgery.

Current evidence (taken from NICE guidelines) suggest that the use of shockwave therapy for Achilles tendinopathy can help reduce symptoms but the efficacy for the use of shockwave is considered inconsistent.

In a systematic review and meta-analysis on ESWT, evidence for mid-portion Achilles tendinopathy (tendinopathy 2 to 6cm from the insertion into the calcaneus) was reported from 2 randomised controlled trials (RCTs) of 75 and 68 patients respectively (Rompe 2007, Rompe 2009). The RCT of 75 patients (Rompe 2007) compared ESWT with eccentric loading exercise and found no statistically significant effects on pain and functional outcomes at 4‑month follow-up. The study also compared ESWT with a ‘wait and see’ group (no-treatment control) and found statistically significant effects that favoured ESWT at 4‑month follow-up. The RCT of 68 patients (Rompe 2009) comparing combined ESWT and eccentric loading exercise in mid-portion Achilles tendinopathy (n=34) with eccentric loading exercise alone (n=34) found greater improvement in pain and function at 4‑month follow-up.

A systematic review also reported evidence from a case-control study of 68 patients (Furia 2008) comparing ESWT with conservative treatment including rest, footwear modification, anti-inflammatory medication, and gastrocnemius-soleus stretching and strengthening and found that ESWT was statistically significantly better in improving pain and functional outcomes at 3–month follow‑up.

In a systematic review and meta-analysis on ESWT, evidence for insertional Achilles tendinopathy (tendinopathy up to 2 cm from the insertion into the calcaneus) was reported from 1 RCT of 50 patients (Rompe 2008) comparing ESWT to eccentric loading exercise. It found statistically significant improvement for outcomes of pain and function at 4‑month follow-up. The systematic review also reported evidence from 1 case-control study of 68 patients (Furia 2006) comparing ESWT with conservative treatment including rest, footwear modification, anti-inflammatory medication, and gastrocnemius-soleus stretching and strengthening and found that ESWT was statistically significantly better in improving pain and functional outcomes at 3‑month follow‑up. The effect of ESWT was diminished when a local anaesthetic was administered before treatment in this study.

In a systematic review and meta-analysis of 246 patients, evidence from meta-analysis of data from 2 RCTs (Rompe 2007, patients with mid-portion tendinopathy; Rompe 2008, patients with insertional tendinopathy) found no significant effects on pain and functional outcomes at 16‑week follow‑up.

In another systematic review and meta-analysis on ESWT, evidence for mid-portion or insertional Achilles tendinopathy was reported from 2 RCTs of 49 and 48 patients respectively (Costa 2005, Rasmussen 2008) comparing ESWT with no treatment (placebo). The RCT of 49 patients (Costa 2005) found no significant difference between ESWT and sham treatment at 3‑month follow-up. The RCT of 48 patients (Rasmussen 2008) used the same intervention as Costa 2005 but with a higher energy level and an extra treatment session. It found that patients in the ESWT group had significantly better American orthopaedic foot and ankle society (AOFAS) scores than the sham group at 3‑month follow-up. The 3 prospective studies (Firdman 2008, Saxena 2011, Vulpiani 2009) included in this systematic review reported improvements in pain and functional outcomes at an average follow up of 20 to 24 months.

Another systematic review of the use of shockwave therapy in lower limb tendinopathies performed in 2015 also recommended the use of shockwave therapy for Achilles tendinopathy especially if other treatment options have failed.

Therefore, shockwave therapy in combination with exercise therapy may be of benefit for Achilles tendinopathy, particularly for mid-portion tendon pain, especially if other treatment modalities have failed.

For more information check out the link to the NICE website about the procedure.

• Rompe JD, Furia J and Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for mid-portion achilles tendinopathy: a randomised controlled trial. Am J Sports Med. 2009;37(3):463-70.
• Rompe JD, Nafe B, FuriaJP et al. Eccentric loading, shock-wave treatment or a wait-and- see policy for tendinopathy of the main body of tendo Achillis: a randomised controlled trial. Am J Sports Med. 2007;35(3):374-83.
• Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy: a randomised controlled trial. J Bone Joint Surg Am. 2008;90(1):52-61.
• Costa, M. L. et al. Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial. Clin Orthop Relat Res. 2005;440:199-204.
• Fridman, R. et al. Extracorporeal shockwave therapy for the treatment of Achilles tendinopathies: a prospective study. J Am Podiatr Med Assoc. 2008;98(6):466-468.
• Rasmussen, S.et al. Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy. Acta Orthop. 2008;79(2):249-256.
• Vulpiani, M. C. et al. Extracorporeal shockwave therapy (ESWT) in Achilles tendinopathy. A long-term follow-up observational study. J Sports Med Phys Fitness 2009;49(2):171-176.
• Furia JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med. 2006;34(5):733-40.
• Saxena A, Ramdath S, O’halloran P. Extra-corporeal pulsed-activated therapy (EPAT sound wave) for Achilles tendinopathy: a prospective study. J Foot and Ankle surg. 2011:50(3):315-319.
• Mani-Babu S, Waugh C, Barton C et al. the effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. Brit J Sports Med. 2015;48(2).