Shock Wave Therapy for the Treatment of Achilles Tendonosis
Shock Wave Therapy for the Treatment of Achilles Tendonosis Sunday, January 28, 2014, 8:40-9:00 am Robert J. Dimeff, MD Medical Director of Sports Medicine Professor of Orthopedic Surgery, Pediatrics, and Family Medicine Disclosure I have relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation as follows: Gebauer Company: Physician Advisory Board Ferring Pharmaceuticals: Speakers’ Bureau USADA: Antidoping Review Board Member DePuy Mitek: Member of Physician Alliance Shock Wave Therapy for Achilles Tendonosis Introduction Physics ESWT for Achilles tendonosis Adverse effects My experience Shock Wave Therapy for Achilles Tendonosis Introduction Physics ESWT for Achilles tendonosis Adverse effects My experience Introduction 1966: Shock wave effects on humans Direct mechanical forces vs indirect generation mechanical forces by cavitation 1980: First patient treated with ESWL 1993: Ossatron used to treat lateral epicondylitis, Ca RCT, plantar fasciitis 2000: FDA approved Ossatron PF Wilson 2010 Shock Wave Therapy for Achilles Tendonosis Introduction Physics ESWT for Achilles tendonosis Adverse effects My experience Physics shock wave Sonic pulse Fast rise in pressure High peak pressure Short in duration Followed by period of negative pressure Wilson 2010 Physics effects of shock wave Direct generation of mechanical forces Indirect generation of mechanical forces by cavitation Hematoma and cell death Al-Abbad 2013 Physics shock wave technology Electrohydraulic Electromagnetic Piezoelectric Ballistic Wilson 2010; Al-Abbad 2013 Physics theories of action Change nerve cell permeability, inhibit afferent pain receptors Substance P, CGRP, glutamate Enhance angiogenesis and blood flow Induce inflammatory healing response Increased fibrosis Damage neovascular structures Al-Abbad 2013; Wilson 2010; Yoo 2012 Shock Wave Therapy for Achilles Tendonosis Introduction Physics ESWT for Achilles tendonosis Adverse effects My experience ESWT for Achilles Tendonosis devices Ossatron Dornier Sonocur Dolorcast Storz EPAT Zimmer ESWT for Achilles Tendonosis comparing the research Multiple research variables Patient selection Energy, frequency, # impulses and RX Use of anesthetics Method of shock delivery Hawthorne effect Need for prospective, double-blinded, randomized, placebo controlled studies Sems 2006 ESWT for Achilles Tendonosis conflicting results positive vs placebo Plantar fasciitis Medial and lateral epicondylitis Calcific rotator cuff tendonitis Achilles tendonopathy Quad/patellar tendopathy Stress fractures Non-unions Sems 2006 ESWT for Achilles Tendonosis presentation Paratenon, proximal (2-6cm), insertional Hyperpronation, leg length discrepancy, obese, hypertension, diabetes, genetics Increase training and intensity, hills, surface, mileage, footwear Older, males, steroid use, quinolones Wilson 2010 ESWT for Achilles Tendonosis treatment Relative rest Heel lifts Arch supports Stretch Nsaids Eccentrics High volume NS Cryotherapy Night splint Manual therapy/ART NTG patches Cold laser PT modalities CS, PRP, prolotherapy Kearney 2010; Wilson 2010 ESWT for Achilles Tendonosis treatment 42 rats with collagenase induced AT Controls, shock wave, relative rest 5 weeks Day 12: increased vascularity, fibroblast activity, lymphocyte/plasma cell infiltrate, dense histiocytes, disorganized fibers Day 26: 30% inflammation 70% fibrotic vs 100% chronic inflammation Day 35: more normal collagen fibers Yoo 2012 ESWT for Achilles Tendonosis treatment meta-analyses 83 studies; minimum 3 month f/u 4 RCT, 2 pre-post study design .12-.5 mJ/mm2, 1500-2500 impulses Satisfactory evidence for effectiveness of low energy ESWT to treat both chronic and insertional AT at minimum 3 months Better when combined with eccentrics Al-Abbad 2013 ESWT for Achilles Tendonosis treatment meta-analyses 118 studies; 11 reviewed for insertional AT Excluded case studies, narratives, technical notes, letters and personal opinions 6 surgical and 5 conservative 1 RCT, 10 case series ESWT and eccentics favored Operative retrospective and inconclusive Kearney 2010 ESWT for Achilles Tendonosis noninsertional Perlick 2001 Peers 2003 Astore 2004 Lakshmanan 2004 Costa 2005 DB RCT 49 cases, ESWT vs sham monthly x 3 VAS 55 to 34 vs 55 to 50 at 1 month ESWT for Achilles Tendonosis noninsertional Furia 2005 DB RCT 67 cases high energy ESWT with block vs eccentrics, measured VAS Baseline: 8.1 vs 8.3 1 month: 2.9 vs 8.5 3 months: 4.4 vs 5.6 12 months: 2.2 vs 6.5 More good/excellent results in ESWT group ESWT for Achilles Tendonosis noninsertional Rasmussen 2008 DB RCT 48 cases, ESWT vs sham weekly x 3 Followed at 1, 2, and 3 months ESWT better at all points AOFAS 70 to 88 vs 74 to 81 Women did better ESWT for Achilles Tendonosis noninsertional Rompe 2007 DB RCT 75 cases ESWT vs eccentrics vs W/S At 4 months 52% vs 60% vs 24% were much improved or completely recovered Vulpiani 2009 125 cases EPAT, age 18-74 3-5 RX, 1500-2500 impulses, .08-4, q 2-7 days Sat/Very Sat: 47% at 2m; 73% at 6- 12 m; 76% at 12-24 m ESWT for Achilles Tendonosis insertional Furia 2005 DB RCT 68 cases high energy ESWT with local/regional block vs usual RX, age 50 3000 impulses, 604 mJ/mm2 ESWT for Achilles Tendonosis insertional Rompe 2008 50 pts; >6 months sx; failed rehab & injections Eccentrics 3 sets, 15 reps 2x daily x 3 months RSWT 2000 impulses @ .12mJ/mm2 @ 8 Hz weekly x 3 sessions VISA-A 53 to 80 vs 53 to 63 @ 4 months Pain 7 to 2 vs 7 to 4; 16 vs 7 recovered @ 15 months ESWT for Achilles Tendonosis insertional with supplement Notarnicola 2012 EPAT weekly for 3 sessions with or without Arg, collagen, MSM, vit C, bromelain, Vinitrox 2 month 2 month + supplem 6 month 6 month + supplem VAS 5.1 3.9 2.9 2.0 Pt Satisfaction 2.8 2.3 1.7 1.5 A-H Score 72.1 85.4 76.5 92.4 R-M Score 2.8 1.7 2.3 1.5 ESWT for Achilles Tendonosis EPAT Saxena 2011 74 AT in 60 pts; EPAT weekly for 3 sessions Follow up at 12 months Tendon Age Good Excellent Roles & Maudsley pre Roles & Maudsley post Paretenon 41 75% 3.22 1.84 Proximal AT 53 78% 3.39 1.57 Insertional AT 54 84% 3.32 1.47 Shock Wave Therapy for Achilles Tendonosis Introduction Physics ESWT for Achilles tendonosis Adverse effects My experience Precautions Poorly localized or diffuse pain No recent imaging study Pregnancy Patients younger than 18 years of age Pacemaker, implantable defibrillator Vitamin D, iron, thryoid, hormone deficiencies Precautions Inflammatory or bleeding disorder Coumadin Open wound over treatment site Signs of infection over treatment site Patient uncooperative or unable to follow direction Precautions adverse effects Pain Nausea Diaphoresis Vasovagal Skin reddening or bruising Muscle soreness, cramps, spasms Joint stiffness Radiating pain Paresthesia ESWT for Achilles Tendonosis complications AT rupture 49 yo F, calcaneal osteotomy for Haglunds Develop chronic calcific AT 2 years later ESWT because of continued pain Ruptured 2 months after ESWT >60 yo M, 2 ruptures with minimal action Bad tendonosis Lin 2012, Al-Abad 2013 Shock Wave Therapy for Achilles Tendonosis Introduction Physics ESWT for Achilles tendonosis Adverse effects My experience My Experience Choose patients wisely Rule out metabolic/nutritional issues Obese, perimenopausal, bilateral, with low pain tolerance do not do well High energy is probably better Anesthetics interfere with low energy Better response with more energy My Experience 80% of AT are 80-90% improved at 3 m 25% of IAT do poorly or do well 50% of IAT are improved Every other week for IAT seems better Low risk of severe adverse effects Retreat after minimum of 3 months prn Summary Safe and effective treatment of AT Difference between inactive & active patients Consider lab work up before shock wave Consider shock wave before surgery More research is needed Thank You
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