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      Ultrasonographic appearance of supraspinatus and biceps tendinopathy improves in dogs treated with low-intensity extracorporeal shock wave therapy: a retrospective study


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          This study aimed to determine whether dogs with shoulder tendinopathy diagnosed via musculoskeletal ultrasound would show improvement in imaging after treatment using piezoelectric shockwave therapy and rest.


          Medical records were reviewed for dogs diagnosed with biceps and/or supraspinatus tendinopathy via musculoskeletal ultrasound, treated using piezowave shockwave, and re-imaged post-treatment. Data collected included patient signalment, duration and grade of lameness, prior rest, piezowave dose, and patient outcome, including a return to sport where applicable. Images were scored using an adapted ultrasound grading scale, in addition to obtaining cross-sectional area measurements. Statistics included Shapiro–Wilk tests (normality), Wilcoxon matched pairs signed rank tests (pre- vs. post-treatment comparisons), and Spearman's correlation coefficients (lameness grade vs. ultrasound score) (significant at P < 0.05).


          In total, 26 of 30 dogs had pathology involving both the biceps and supraspinatus tendons in one limb, with 27 of 30 having tendon/s affected bilaterally. For both tendons, post-treatment cross-sectional area and ultrasound score were significantly lower than pre-treatment ( P < 0.001). Lameness decreased clinically ( P < 0.0001) following piezowave shockwave treatment regardless of the tendons involved, but the lameness score did not correlate with the ultrasound score for either tendon.


          Dogs with tendinopathy of the biceps brachii and supraspinatus showed significant improvement on follow-up musculoskeletal ultrasound and lameness evaluation after the treatment of their tendons using piezoelectric shockwave therapy with rest.

          Clinical significance

          Canine biceps brachii and supraspinatus tendinopathy can cause variable lameness and ultrasonographic appearance, which improves after shockwave therapy and rest. The ultrasound scoring system and cross-sectional area assessment provide useful outcome measures for clinical cases.

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          Most cited references45

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          Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits.

          Despite the success in clinical application, the exact mechanism of shock wave therapy remains unknown. We hypothesized that shock wave therapy induces the ingrowth of neovascularization and improves blood supply to the tissues. The purpose of this study was to investigate the effect of shock wave therapy on neovascularization at the tendon-bone junction. Fifty New Zealand white rabbits with body weight ranging from 2.5 to 3.5 kg were used in this study. The right limb (the study side) received shock wave therapy to the Achilles tendon near the insertion to bone. The left limb (the control side) received no shock wave therapy. Biopsies of the tendon-bone junction were performed in 0, 1, 4, 8 and 12 weeks. The number of neo-vessels was examined microscopically with hematoxylin-eosin stain. Neovascularization was confirmed by the angiogenic markers including vessel endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS) expressions and endothelial cell proliferation determined by proliferating cell nuclear antigen (PCNA) expression examined microscopically with immunohistochemical stains. The results showed that shock wave therapy produced a significantly higher number of neo-vessels and angiogenesis-related markers including eNOS, VEGF and PCNA than the control without shock wave treatment. The eNOS and VEGF began to rise in as early as one week and remained high for 8 weeks, then declined at 12 weeks; whereas the increases of PCNA and neo-vessels began at 4 weeks and persisted for 12 weeks. In conclusion, shock wave therapy induces the ingrowth of neovascularization associated with early release of angiogenesis-related markers at the Achilles tendon-bone junction in rabbits. The neovascularization may play a role to improve blood supply and tissue regeneration at the tendon-bone junction.
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            Nitric oxide mediates anti-inflammatory action of extracorporeal shock waves.

            Here, we show that extracorporeal shock waves (ESW), at a low energy density value, quickly increase neuronal nitric oxide synthase (nNOS) activity and basal nitric oxide (NO) production in the rat glioma cell line C6. In addition, the treatment of C6 cells with ESW reverts the decrease of nNOS activity and NO production induced by a mixture of lipopolysaccharides (LPS), interferon-gamma (IFN-gamma) plus tumour necrosis factor-alpha (TNF-alpha). Finally, ESW treatment efficiently downregulates NF-kappaB activation and NF-kappaB-dependent gene expression, including inducible NOS and TNF-alpha. The present report suggests a possible molecular mechanism of the anti-inflammatory action of ESW treatment.
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              The biological effects of extracorporeal shock wave therapy (eswt) on tendon tissue.

              There is currently great interest in the use of Extracorporeal Shock Wave Therapy (ESWT) and in clarifying the mechanisms of action in tendon pathologies. The success rate ranges from 60% to 80% in epicondylitis, plantar fasciitis, cuff tendinitis, trocanteritis, Achilles tendinitis or jumper's knee. In contrast to urological treatments (lithotripsy), where shockwaves are used to disintegrate renal stones, in musculoskeletal treatments (orthotripsy), shockwaves are not being used to disintegrate tissues, but rather to microscopically cause interstitial and extracellular biological responses and tissue regeneration. The researchers are interesting to investigate the biological effects which support the clinical successes. Some authors speculated that shockwaves relieve pain in insertional tendinopathy by hyper-stimulation analgesia. Many recent studies demonstrated the modulations of shockwave treatment including neovascularization, differentiation of mesenchymal stem cells and local release of angiogenetic factors. The experimental findings confirm that ESWT decrease the expression of high levels of inflammatory mediators (matrix metalloproteinases and inter-leukins). Therefore, ESWT produces a regenerative and tissue-repairing effect in musculoskeletal tissues, not merely a mechanical disintegrative effect as generally before assumed. Based on the encouraging results of clinical and experimental studies, the potential of ESWT appears to be emerging. The promising outcome after this non-invasive treatment option in tendinitis care justifies the indication of shockwave therapy. Further studies have to be performed in order or determine optimum treatment parameters and will bring about an improvement in accordance with evidence-based medicine. Finally, meta-analysis studies are necessary to demonstrate the efficacy and safety of ESWT in treating tendinopathies.

                Author and article information

                Front Vet Sci
                Front Vet Sci
                Front. Vet. Sci.
                Frontiers in Veterinary Science
                Frontiers Media S.A.
                07 August 2023
                : 10
                : 1238513
                [1] 1Pawsitive Steps Rehabilitation and Sports Medicine , Rochester Hills, MI, United States
                [2] 2Pathobiology and Diagnostic Investigation, Michigan State University College of Veterinary Medicine , East Lansing, MI, United States
                [3] 3Twin Cities Animal Rehabilitation and Sports Medicine Clinic , Burnsville, MN, United States
                Author notes

                Edited by: Pete Mantis, Dick White Referrals, United Kingdom

                Reviewed by: Abby Caine, Dick White Referrals, United Kingdom; Gregg Mitchell Griffenhagen, Colorado State University, United States; Fintan John McEvoy, University of Copenhagen, Denmark

                *Correspondence: Tari Kern tkerndvm@ 123456yahoo.com
                Copyright © 2023 Kern, Manfredi and Tomlinson.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                : 11 June 2023
                : 14 July 2023
                Page count
                Figures: 5, Tables: 1, Equations: 0, References: 47, Pages: 10, Words: 7318
                Veterinary Science
                Original Research
                Custom metadata
                Veterinary Imaging

                biceps,tendinopathy,supraspinatus,canine,shockwave,diagnostic ultrasound,piezowave,rehabilitation


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