CHELT therapy in the treatment of chronic insertional Achilles tendinopathy

Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results. To compare the effectiveness of 2 management strategies--group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy. Randomized controlled trial; Level of evidence, 1. Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis. At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery. At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.

Chronic Achilles tendinosis is a condition with unknown aetiology and pathogenesis, most often, but not always, associated with painful nodular thickening of the tendon. In this investigation, 28 tendons (21 patients) with a painful nodule located at the 2-6 cm level in the tendon, and 20 normal (pain-free) tendons, were examined with grey-scale ultrasonography combined with colour Doppler examination. In all tendons with a painful nodule, but not in any of the normal pain-free tendons, neovascularisation was seen in the area with tendon changes (localised widening of the tendon with focal hypo-echoic areas). In tendons with advanced changes, vessels were seen through the entire widened part of the tendons, and both arterial and venous blood flows were registered. The neovascularisation found in this investigation might have implications on the pathogenesis of chronic Achilles tendinosis.

The purpose of this study was to determine if a statistical association exists between Achilles tendinopathy (also referred to as tendinosis) and obesity, diabetes mellitus, hypertension, the supplemental use of estrogen, and exposure to local or systemic steroids. From July, 1997, to February, 2003, 82 patients with a diagnosis of Achilles tendinopathy were identified. The diagnosis of Achilles tendinopathy was confirmed by a review of medical records, radiographs, and MRI. There were 44 women and 38 men with an average age of 50 (range 27 to 77) years. For the parameters of obesity, hypertension, diabetes, steroid exposure, and the use of estrogen compounds, all patients were analyzed both cumulatively and stratified into subgroups by gender and age. Chi-square 2 x 2 tables were used to compare the observed prevalence of the parameters in patients with Achilles tendinopathy to the expected prevalence of these disorders and exposures in the population at large. Cumulatively, 98% percent (43 of 44 women; 29 of 38 men) had hypertension, diabetes, obesity, and steroid or estrogen exposure. Seventy-six percent of men (29) had hypertension, diabetes, and obesity, or steroid exposure. Sixty-eight percent of women (15 of 22) had a history of hormone replacement therapy and 44% (8 of 15) had a positive history for use of oral contraceptives. When compared with published national data using Chi-square analysis, the association between tendinopathy and hormone replacement therapy and oral contraceptives was found to be statistically significant with p-values of 0.01 and 0.001, respectively. For both women and men, obesity was statistically associated with Achilles tendinopathy with p-values of 0.025 and. 001, respectively. Hypertension was statistically associated with Achilles tendinopathy only for women. Diabetes mellitus and Achilles tendinopathy were found to have a statistical association only for men younger than 44 years old Obesity, hypertension, and steroids have as their end-organ effect a diminution of local microvascularity. The significant correlation of these factors with Achilles tendinopathy suggests the importance of their effect on microvascularity in the development of Achilles tendinopathy.