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The Effectiveness of Extracorporeal Shock Wave Therapy in Lower Limb Tendinopathy: A Systematic
Review
Sethu Mani-Babu, Dylan Morrissey, Charlotte Waugh, Hazel Screen and Christian Barton
Am J Sports Med published online May 9, 2014
DOI: 10.1177/0363546514531911

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 AJSM PreView, published on May 9, 2014 as doi:10.1177/0363546514531911

Clinical Sports Medicine Update

The Effectiveness of Extracorporeal Shock

Wave Therapy in Lower Limb Tendinopathy
A Systematic Review
Sethu Mani-Babu,* MBBS, Dylan Morrissey,*y PhD, Charlotte Waugh,* PhD,
Hazel Screen,z PhD, and Christian Barton,*§k{ PhD
Investigation performed at Queen Mary University of London, London, UK

Background: There is accumulating evidence for the effectiveness of extracorporeal shock wave therapy (ESWT) when treating
lower limb tendinopathies including greater trochanteric pain syndrome (GTPS), patellar tendinopathy (PT), and Achilles tendin-
opathy (AT).
Purpose: To evaluate the effectiveness of ESWT for lower limb tendinopathies.
Study Design: Systematic review and meta-analysis.
Methods: PubMed (Medline), Embase, Web of Knowledge, Cochrane, and CINAHL were searched from inception to February
2013 for studies of any design investigating the effectiveness of ESWT in GTPS, PT, and AT. Citation tracking was performed
using PubMed and Google Scholar. Animal and non–English language studies were excluded. A quality assessment was per-
formed by 2 independent reviewers, and effect size calculations were computed when sufficient data were provided.
Results: A total of 20 studies were identified, with 13 providing sufficient data to compute effect size calculations. The energy
level, number of impulses, number of sessions, and use of a local anesthetic varied between studies. Additionally, current evi-
dence is limited by low participant numbers and a number of methodological weaknesses including inadequate randomization.
Moderate evidence indicates that ESWT is more effective than home training and corticosteroid injection in the short (\12
months) and long (.12 months) term for GTPS. Limited evidence indicates that ESWT is more effective than alternative non-
operative treatments including nonsteroidal anti-inflammatory drugs, physical therapy, and an exercise program and equal to
patellar tenotomy surgery in the long term for PT. Moderate evidence indicates that ESWT is more effective than eccentric loading
for insertional AT and equal to eccentric loading for midportion AT in the short term. Additionally, there is moderate evidence that
combining ESWT and eccentric loading in midportion AT may produce superior outcomes to eccentric loading alone.
Conclusion: Extracorporeal shock wave therapy is an effective intervention and should be considered for GTPS, PT, and AT par-
ticularly when other nonoperative treatments have failed.
Keywords: extracorporeal shock wave therapy; greater trochanteric pain syndrome; patellar tendinopathy; Achilles tendinopathy

Tendinopathies are clinically characterized by localized, limb tendinopathies with varying reports of effectiveness.
painful, and tender tendon thickening, which causes Originally used for the treatment of kidney stones,
a loss of function.27 Lower limb tendinopathies, including ESWT is now being used for several orthopaedic condi-
greater trochanteric pain syndrome2,26 (GTPS; commonly tions, with level 1a evidence recently established for the
due to gluteal tendinopathy),3 patellar tendinopathy15 treatment of calcific rotator cuff tendinosis.12 Despite this
(PT), and Achilles tendinopathy16 (AT), are prevalent early indication of its potential benefit in treating tendino-
among both athletes and sedentary patients. Tendinopa- pathies, the true potential for pain reduction and improved
thies are often difficult to treat, leading to substantial function remains unclear.
impacts on health, sporting activity, physical activity for Decision making about whether to use ESWT and the
health, and occupation.4,27 energy levels, number of treatment sessions, and number
There is no agreement on the best form of management, of impulses to choose is hindered by the diversity of pub-
with extracorporeal shock wave therapy (ESWT) recently lished works. The benefits of using a local anesthetic are
being proposed as a viable treatment option for lower also disputed.14,22 Considering the growing popularity of
ESWT as an intervention for lower limb tendinopathies
in a clinical setting, this review aimed to assess the
The American Journal of Sports Medicine, Vol. XX, No. X short-term (\12 months) and long-term (.12 months)
DOI: 10.1177/0363546514531911
Ó 2014 The Author(s)
effectiveness of ESWT in treating GTPS, PT, and AT.

1
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2 Mani-Babu et al The American Journal of Sports Medicine

MATERIALS AND METHODS Studies identified through

electronic database searching
References (n =255)

A search of PubMed (Medline), Embase, Web of Knowl- Excluded after reading

title/abstract: 183
edge, Cochrane, and CINAHL was performed in February
2013 (for search strategy details, see Appendix 1 Studies remaining after
[available in the online version of this article at reading title/abstract
http://ajsm.sagepub.com/supplemental]). Studies involving (n=72)
animals and those not available in English were excluded. Excluded duplicates: 53
No limit on the publication year was imposed. The titles
and abstracts of all articles identified from this search Studies remaining after
were independently screened by 2 reviewers (S.M.-B. and removing duplicates
C.B.) and the full texts of relevant articles retrieved for fur- (n=19)
1 article added from
ther evaluation. Article reference lists were also searched
searching reference lists
for relevant articles not identified from the search strat-
egy, and citation tracking was performed using PubMed Studies included
in systematic review
and Google Scholar in February 2013. (n=20)

Quality Assessment Figure 1. Flow diagram of study selection.

The quality of each article was assessed independently by 2
raters (S.M.-B. and C.W.) using a modified Downs and prospective studies,7,13,25,31,32,34 and 5 retrospective stud-
Black checklist,6 and the van Tulder criteria30 were used ies.8-11,17 A summary of the characteristics of each study
to grade the level of evidence (Appendix 2, available online). is shown in Table 1 and Appendix 3 (available online).

Data Extraction and Analysis Greater Trochanteric Pain Syndrome

The study design, population, interventions, outcome Two studies11,24 evaluated the effectiveness of ESWT for
measures, and outcomes were extracted from each study. GTPS (Figure 2). Effect size calculations indicated that
Using Review Manager,19 effect sizes were calculated and ESWT was superior to various other nonoperative treat-
presented in forest plots for individual findings, and data ments including rest, anti-inflammatory medication,
pooling was performed whenever possible. stretching and strengthening exercises, and corticosteroid
injections in reducing pain and improving function.11 Addi-
tionally, ESWT produced superior outcomes to home train-
RESULTS ing at 4 months.24 When compared with corticosteroid
injections, ESWT produced inferior outcomes at 1 month
Literature Search
(Figure 2, A and C) but superior outcomes beyond 12
The initial search yielded 255 articles, of which 19 were months (Figure 2, B and D) in relation to pain reduction.24
identified as relevant after screening of titles/abstracts
and removal of duplicates (Figure 1). Full texts were Patellar Tendinopathy
retrieved, and 1 further article was added from searching
reference lists and citation tracking. Seven studies evaluated the effectiveness of ESWT for
The 20 studies included 2 evaluating ESWT in PT.10,17,29,32-35 Four studies10,17,33,35 comparing the effec-
GTPS,11,24 7 in PT,10,17,29,32-35 and 11 in AT.# There were tiveness of ESWT to an alternative intervention for PT
9 randomized controlled trials (RCTs),** 6 single-cohort were included in effect size calculations (Figure 3). There
was no difference in outcomes between ESWT and placebo
#
References 5, 7-9, 13, 18, 20, 21, 23, 25, 31. ESWT at 1, 12, or 22 weeks in the study by Zwerver et al35
**References 5, 18, 20, 21, 23, 24, 29, 33, 35. (Figure 3A). In the study by Furia et al,10 ESWT was

y
Address correspondence to Dylan Morrissey, PhD, NIHR/HEE Senior Clinical Lecturer and Consultant Physiotherapist, Centre for Sports and Exercise
Medicine, Queen Mary University of London, Mile End Hospital, Bancroft Road, London E1 4DG, UK (e-mail: [email protected]).
*Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK.
z
School of Engineering and Materials Sciences, Queen Mary University of London, London, UK.
§
Complete Sports Care, Melbourne, Australia.
k
Pure Sports Medicine, London, UK.
{
Lower Extremity Gait Studies, La Trobe University, Melbourne, Australia.
One or more of the authors has declared the following potential conflict of interest or source of funding: This work was unfunded, being own account
work at all stages. No authors have any conflicts of interest to declare. D.M., C.W., and H.S. have received Engineering and Physical Sciences Research
Council and industry funding for a national clinical audit of the effectiveness of extracorporeal shock wave therapy and an exploration of the mechanisms
using microdialysis.

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Vol. XX, No. X, XXXX ESWT in Lower Limb Tendinopathy 3

TABLE 1
Study Design Characteristics and Main Resultsa
Average Length of
Study (Year) Design Intervention and ESWT Protocol Follow-up Outcome Measures and Results

Greater trochanteric pain syndrome

Rompe et al24 Quasi-RCT ESWT vs corticosteroid injection vs home 15 mo Degree of recovery (Likert scale) and VAS score at 1,
(2009) training 4, and 15 mo after treatment
2000 impulses at 3 bar (0.12 mJ/mm2) at 8 Hz ESWT inferior to corticosteroid injection at 1 mo,
3 sessions (weekly interval) significantly better than home training at 4 mo,
and equal with home training and better than
corticosteroid injection at 15 mo
Furia et al11 Case control ESWT vs control (nonoperative) 12 mo VAS score, Harris Hip Score, and RM score at 1, 3,
(2009) 2000 impulses at 4 bar (0.18 mJ/mm2) at and 12 mo after treatment
10 Hz Improvement in all outcomes for both groups;
1 session however, ESWT significantly better than control
at each time point
Patellar tendinopathy
Peers et al17 Retrospective ESWT vs surgery ESWT: 22.1 mo VAS score, VISA-P score, and RM score
(2003) cross-sectional 1000 impulses (0.08 mJ/mm2) at 4 Hz (range, 17-27 ESWT equal to surgery
outcome 3 sessions (interval not specified) mo) Greater working incapacity for surgical patients
analysis Surgery: 26.3 mo after treatment
(range, 16-48
mo)
Taunton RCT ESWT vs placebo ESWT 12 wk VISA-P score and vertical jump test
et al29 2000 impulses (0.17 mJ/mm2) Significant difference for both outcomes between
(2003) 3-5 sessions (weekly interval) groups; ESWT better than placebo ESWT
Vulpiani Prospective study ESWT follow-up .24 mo VAS score and subjective clinical evaluation range
et al32 1500-2500 impulses (0.08-0.44 mJ/mm2) For both outcome measures, significant differences
(2007) Average of 4 sessions (min, 3; max, 5) at 1 mo after treatment as well as short (\12 mo)
2- to 7-day interval and long term (.24 mo) but not medium term (12
mo \ x \ 24 mo)
Wang et al33 Quasi-RCT ESWT vs control (conservative treatment) ESWT: 32.7 6 VAS score, VISA-P score, and ultrasound
(2007) 1500 impulses (0.18 mJ/mm2) at 1-2 Hz 10.8 mo assessment
1 session; some received second sessions Control: 28.6 6 Significant reduction in VAS score and increase in
if not improving sufficiently 9.8 mo VISA-P score with ESWT
Zwerver Prospective pilot ESWT follow-up 3 mo VAS score and VISA-P score
et al34 study 2000 impulses (session 1: 0.35 mJ/mm2; Significant improvement for both outcome measures
(2010) session 2: 0.52 mJ/mm2; session 3: 0.65 mJ/
mm2) at 4 Hz
Weekly interval
Zwerver RCT ESWT vs placebo ESWT 22 wk VAS score and VISA-P score
et al35 2000 impulses (0.1-0.58 mJ/mm2) at 4 Hz No significant difference between the 2 groups;
(2011) 3 sessions (weekly interval) ESWT not better
Furia et al10 Case control ESWT vs control (conservative treatment) 12 mo VAS score, VISA-P score, and RM score
(2013) 2000 impulses (0.18 mJ/mm2) Significant improvement in all outcome measures
Single session for both groups; significant difference between
groups at each time point
Achilles tendinopathy
Lakshmanan Prospective study ESWT follow-up 20.7 mo (range, VISA-A score and AOFAS score
and 2000 impulses at 2.5 bar at 6-10 Hz 20-22 mo) Significant differences in both scores after
13
O’Doherty 3 sessions (weekly interval) treatment
(2004)
Costa et al5 RCT ESWT vs placebo ESWT Primary outcome VAS score, Functional Index of Lower Limb
(2005) 1500 impulses (maximum, 0.2 mJ/mm2) at 3 mo Activity, and EQoL score
3 sessions (monthly interval) No significant differences between groups
Furia9 (2006) Case control ESWT vs control 12 mo VAS score and RM score at 1, 3, and 12 mo after
3000 impulses for a total energy flux density treatment
of 604 mJ/mm2; 50 shocks were given at each Significant improvement in VAS and RM scores at
power level from 1-4 for a total of 200 shocks; all time points for ESWT when compared with
the final 2800 shocks were given at power baseline
level 5, which corresponds to 0.21 mJ/mm2 At each time point, improvement in VAS score was
1 session less in local anesthetic group compared with
nonlocal anesthetic group
Significant difference for RM score between groups,
favoring ESWT
Rompe et al23 RCT Eccentric loading vs ESWT vs wait-and-see 4 mo VISA-A score, general assessment, and pain
(2007) 2000 impulses at 3 bar (0.1 mJ/mm2) at 8 Hz assessment
3 sessions (weekly interval) Significant differences for ESWT and eccentric
loading for VISA-A score, general assessment,
and pain assessment but no difference between
treatments
ESWT and eccentric loading better than wait-and-
see policy

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4 Mani-Babu et al The American Journal of Sports Medicine

TABLE 1
(continued)
Average Length of
Study (Year) Design Intervention and ESWT Protocol Follow-up Outcome Measures and Results
8
Furia (2008) Case control ESWT vs control 12 mo VAS score and RM score at 1, 3, and 12 mo after
Ankle block with or without sedation treatment
3000 impulses for a total energy flux density Significant differences in VAS and RM scores at all
of 604 mJ/mm2; 50 shocks were given at each time points for ESWT
power level from 1-4 for a total of 200 shocks; Significant differences between groups for VAS and
the final 2800 shocks were given at power RM scores at all time points
level 5, which corresponds to 0.21 mJ/mm2
1 session
Rompe et al20 RCT Eccentric loading vs ESWT 4 mo VISA-A score, general assessment, and pain
(2008) 2000 impulses at 2.5 bar (0.12 mJ/mm2) at 8 assessment
Hz Improvement in all 3 outcomes for both groups;
3 sessions (weekly interval) however, ESWT significantly better than
eccentric loading
Rasmussen RCT ESWT vs placebo ESWT 3 mo VAS score and AOFAS score
et al18 2000 impulses (0.12-0.51 mJ/mm2) at 50 Hz Improvement in AOFAS score in both groups;
(2008) 4 sessions significant differences between groups; ESWT
1-2 weeks between sessions better
VAS score reduced in both groups; no difference
between groups
Fridman et al7 Prospective study ESWT follow-up 20 mo (range, VAS score, improved condition, patient satisfaction,
(2008) Under intravenous sedation and local 4-35 mo) and willingness to repeat procedure
anesthesia Significant reduction in VAS score for morning pain
2000 impulses (21 kV) at 2 Hz as well as activity pain 4 mo after ESWT
1 session
Rompe et al21 RCT Eccentric loading vs eccentric loading 1 ESWT 4 mo VISA-A score, general assessment, and pain
(2009) 2000 impulses at 3 bar (0.1 mJ/mm2) at 8 Hz assessment
3 sessions (weekly interval) Improvement in all 3 outcome measures for both
groups
Significant differences between groups for all 3
outcome measures, favoring combined treatment
Vulpiani Prospective study ESWT follow-up 24 mo VAS score, subjective clinical evaluation range
et al31 1500-2500 impulses (midportion: 0.08-0.33 Significant improvement in outcome measures over
(2009) mJ/mm2; insertional: 0.12-0.40 mJ/mm2) short (2 mo) and medium term (6-12 mo)
Average of 4 sessions (between 3-5)
2- to 7-day interval
Saxena et al25 Prospective study ESWT follow-up 12-24 mo RM score
(2011) 2500 impulses at 2.4 bar at 11-13 Hz Significant improvement in score for proximal,
3 sessions insertional, and paratendinosis
4- to 10-day interval

a
For the ESWT protocol, the number of impulses, the energy level (in bar, mJ/mm2, or kV), the frequency of impulses (in Hz), the number of sessions, and the
interval between sessions are reported if stated in the study. AOFAS, American Orthopaedic Foot and Ankle Society; EQoL, Euro Quality of Life; ESWT, extra-
corporeal shock wave therapy; RCT, randomized controlled trial; RM, Roles and Maudsley; VAS, visual analog scale; VISA-A, Victorian Institute of Sport Assess-
ment Questionnaire–Achilles; VISA-P, Victorian Institute of Sport Assessment Questionnaire–Patellar.

superior to alternative nonoperative treatments at 1, 3, and studies5,8,9,18,20,21,23 compared the effectiveness of ESWT to
12 months. Two studies, which examined the effect of ESWT an alternative intervention (Figure 4). Effect size calcula-
beyond 24 months, showed ESWT to be comparable with tions indicated that ESWT produces greater short-term
patellar tenotomy surgery and better than nonoperative (\12 months) (Figure 4, A and C) and long-term (.12
treatments including nonsteroidal anti-inflammatory drugs, months) (Figure 4, B and D) improvements in pain and
physical therapy, an exercise program, use of a knee strap, function compared with nonoperative treatments including
and modification of activity levels in reducing pain and rest, footwear modification, anti-inflammatory medication,
improving function17,33 (Figure 3, B and C). and gastrocnemius-soleus stretching and strengthening,
with the exception being a short-term RCT by Costa
Achilles Tendinopathy et al,5 which indicated no difference. Short-term studies
by Rompe et al,20,21,23 where primary outcomes were mea-
Eleven studies evaluated the effectiveness of ESWT for sured at 4 months, indicated similar outcomes between
AT.yy Four studies concerned patients with midportion ESWT and eccentric loading in midportion AT (tendinop-
tendinopathy,8,13,21,23 2 concerned patients with insertional athy 2 to 6 cm from the insertion into the calcaneus) and
tendinopathy,9,20 and 5 included both.5,7,18,25,31 Seven superior outcomes to eccentric loading in insertional AT
(tendinopathy up to 2 cm from the insertion into the calca-
yy
References 5, 7-9, 13, 18, 20, 21, 23, 25, 31. neus). Combining ESWT and eccentric loading in

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Vol. XX, No. X, XXXX ESWT in Lower Limb Tendinopathy 5

A Shockwave Therapy Control/Alternative Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
3.2.1 1 Month VAS
0.12 Rompe 2009 SW v CS 5.6 3.7 78 2.2 2 75 1.13 [0.79, 1.47]
0.12 Rompe 2009 SW v HT 5.6 3.7 78 5.9 2.8 76 -0.09 [-0.41, 0.23]
0.18 Furia 2009 SW v Con 5.1 0.9 33 7.6 1 33 -2.60 [-3.26, -1.93]
3.2.2 3 or 4 Month VAS
0.12 Rompe 2009 SW v CS** 3.2 2.4 78 4.5 3 75 -0.48 [-0.80, -0.16]
0.12 Rompe 2009 SW v HT** 3.2 2.4 78 5.2 2.9 76 -0.75 [-1.08, -0.42]
0.18 Furia 2009 SW v Con* 3.7 0.8 33 7 0.8 33 -4.08 [-4.94, -3.21]
3.2.3 1 Month Harris Hip Score
0.18 Furia 2009 SW v Con -69.8 7.3 33 -54.4 5 33 -2.43 [-3.08, -1.79]
3.2.4 3 Month Harris Hip Score
0.18 Furia 2009 SW v Con -74.8 5.9 33 -56.9 5.2 33 -3.18 [-3.92, -2.44]

-4 -2 0 2 4
Favors Shockwave Therapy Favors Control/Alt

B
Shockwave Therapy Control/Alternative Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
3.1.1 VAS
0.12 Rompe 2009 SW v CS 2.4 3 78 5.3 3.4 75 -0.90 [-1.23, -0.57]
0.12 Rompe 2009 SW v HT 2.4 3 78 2.7 2.8 76 -0.10 [-0.42, 0.21]
0.18 Furia 2009 SW v Con 2.7 0.9 33 6.3 1.2 33 -3.35 [-4.12, -2.59]
3.1.2 Harris Hip Score
0.18 Furia 2009 SW v Con -79.9 6.2 33 -57.6 5.8 33 -3.67 [-4.48, -2.86]

-4 -2 0 2 4
Favors Shockwave Therapy Favors Control/Alt

C Shockwave Therapy Control/Alternative Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI
3.4.1 1 Month Roles and Maudsley Score
0.18 Furia 2009 SW v Con 16 33 25 33 0.64 [0.43, 0.96]
3.4.2 3 Month Roles and Maudsley Score
0.18 Furia 2009 SW v Con 7 33 24 33 0.29 [0.15, 0.58]
3.4.3 1 Month Likert Scale (1-6)
0.12 Rompe 2009 SW v CS 68 78 18 75 3.63 [2.41, 5.48]
0.12 Rompe 2009 SW v HT 68 78 71 76 0.93 [0.84, 1.04]
3.4.4 4 Month Likert Scale (1-6)
0.12 Rompe 2009 SW v CS 25 78 37 75 0.65 [0.44, 0.97]
0.12 Rompe 2009 SW v HT 25 78 45 76 0.54 [0.37, 0.79]

0.2 0.5 1 2 5
Favors Shockwave Therapy Favors Control/Alt

D Shockwave Therapy Control/Alternative Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI
3.3.1 Roles and Maudsley Score
0.18 Furia 2009 SW v Con 7 33 21 33 0.33 [0.16, 0.68]
3.3.2 Likert Scale (1-6)
0.12 Rompe 2009 SW v CS 20 78 39 75 0.49 [0.32, 0.76]
0.12 Rompe 2009 SW v HT 20 78 15 76 1.30 [0.72, 2.34]

0.2 0.5 1 2 5
Favors Shockwave Therapy Favors Control/Alt

Figure 2. Greater trochanteric pain syndrome: Comparison of (A) VAS score for pain (10-point rating scale) and Harris Hip Score
(hip function) at \12 months, (B) VAS score and Harris Hip Score at .12 months, (C) successful outcomes at \12 months, and (D)
successful outcomes at .12 months. Alt, alternative treatment; Con, conservative treatment; CS, corticosteroid injection; HT,
home training; SW, extracorporeal shock wave therapy; VAS, visual analog scale. *3 months. **4 months.

midportion AT produced greater improvement in pain and effective than nonoperative treatments including rest,
function compared with eccentric loading alone (Figure 4A).21 anti-inflammatory medication, stretching and strengthen-
ing exercises, and corticosteroid injections in the short-
and long-term management of GTPS. When ESWT was
DISCUSSION compared with a home training regimen, there was moder-
ate evidence that it was as effective at 1 and 15 months in
The aims of this review were to assess the effectiveness of relieving pain and improving function, but effectiveness
ESWT for 3 lower limb tendinopathies. was better at 4 months.24 In the same study, Rompe
et al24 provided moderate evidence that ESWT was less
Greater Trochanteric Pain Syndrome effective than corticosteroid injections at 1 month, but
with time, it became more effective at 4 and 15 months
From the results of the high-quality study by Furia et al,11 after intervention. Moreover, ESWT had a 74% success
there is moderate evidence that ESWT may be more rate at 15 months compared with 35% for the injection.

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6 Mani-Babu et al The American Journal of Sports Medicine

A
Shockwave Therapy Control/Alternative Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
1.2.1 1 Week VAS
Var Zwerver 2011 SW v Pla 2.2 2 31 2.7 2.2 31 -0.23 [-0.73, 0.26]
1.2.2 1 Month VAS
0.18 Furia 2013 SW v Con 4.3 1.3 33 6.7 1 33 -2.05 [-2.65, -1.44]
1.2.3 12 Week VAS
Var Zwerver 2011 SW v Pla 2.2 2 31 2.9 2.5 31 -0.31 [-0.81, 0.20]
0.18 Furia 2013 SW v Con 3.5 1.2 33 5.9 0.8 33 -2.33 [-2.96, -1.69]
1.2.4 22 Week VAS
Var Zwerver 2011 SW v Pla 2.1 2.5 31 2.3 1.9 31 -0.09 [-0.59, 0.41]
1.2.5 1 Week VISA-P
Var Zwerver 2011 SW v Pla -66.8 16.2 31 -66.3 19 31 -0.03 [-0.53, 0.47]
1.2.6 12 Week VISA-P
Var Zwerver 2011 SW v Pla -66.7 17.5 31 -68.9 20.3 31 0.11 [-0.38, 0.61]
1.2.7 22 Week VISA-P
Var Zwerver 2011 SW v Pla -70.5 18.9 31 -72.7 18 31 0.12 [-0.38, 0.62]

-4 -2 0 2 4
Favors Shockwave Therapy Favors Control/Alt

B
Shockwave Therapy Control/Alternative Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
1.1.1 VAS
0.08 Peers 2003 SW v Surg 9 2 14 8 3 13 0.38 [-0.38, 1.15]
0.18 Furia 2013 SW v Con 2.7 1 33 5.1 0.8 33 -2.62 [-3.29, -1.95]
0.18 Wang 2007 SW v Con 0.59 1.01 30 4.72 1.35 24 -3.47 [-4.34, -2.60]
1.1.2 VISA-P
0.08 Peers 2003 SW v Surg -83.9 28.6 14 -70.7 22.2 13 -0.50 [-1.27, 0.27]
0.18 Wang 2007 SW v Con -92 10.17 30 -41.04 10.96 24 -4.77 [-5.85, -3.69]

-4 -2 0 2 4
Favors Shockwave Therapy Favors Control/Alt

C
Shockwave Therapy Control/Alternative Risk Ratio Risk Ratio
Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.3.1 Roles and Maudsley Score
0.08 Peers 2003 SW v Surg 4 14 5 12 0.69 [0.24, 1.99]
0.18 Wang 2007 SW v Con 3 30 12 24 0.20 [0.06, 0.63]

0.2 0.5 1 2 5
Favors Shockwave Therapy Favors Control/Alt

Figure 3. Patellar tendinopathy: (A) Comparison between ESWT and placebo using the VAS score (pain rating scale) and VISA-P
score (questionnaire assessing symptoms, function, and ability to participate in sport; maximum score = 100) at \12 months. (B) Com-
parison of ESWT and surgery and usual conservative care using the VAS and VISA-P scores at .12 months. (C) Comparison of suc-
cessful outcomes at .12 months. Alt, alternative treatment; Con, conservative treatment including nonsteroidal anti-inflammatory
drugs, physical therapy, an exercise program, use of a knee strap, and modification of activity levels; Pla, placebo ESWT; Surg, sur-
gery; SW, extracorporeal shock wave therapy; Var, variable energy level from 0.10-0.58 mJ/mm2; VAS, visual analog scale; VISA-P,
Victorian Institute of Sport Assessment Questionnaire–Patellar.

These results indicate that ESWT is a viable short- and analog scale (VAS) scores between treatment groups. The
long-term treatment option for GTPS and may be used as vertical jump test, a functional test used for assessing the
an alternative to home training and corticosteroid impairment of tendinopathy, is one of the few objective out-
injections. comes found by this review, highlighting the need for
a greater emphasis on objective outcome measures in future
Patellar Tendinopathy research evaluating the effectiveness of ESWT. Zwerver
et al34 and Vulpiani et al32 conducted prospective studies
The 5 studies presenting evidence of the short-term effec- that both demonstrated clinically significant short-term
tiveness of ESWT consisted of 2 RCTs,29,35 2 prospective improvements in pain and function, noted by a 3-cm reduc-
studies,32,34 and 1 retrospective study.10 Taunton et al29 tion in the VAS score and a 14-point increase in the VISA-P
noted significantly greater improvements with ESWT com- score. The retrospective study by Furia et al10 showed that
pared with sham ESWT, with an 8-point difference in the ESWT produced a clinically significant improvement in the
Victorian Institute of Sport Assessment Questionnaire– VAS and VISA-P scores at 1 and 3 months in comparison to
Achilles/Patellar (VISA-A/P) score and a 1.5-inch difference alternative nonoperative treatments, which did not. Over-
in the vertical jump test score between groups. In compari- all, these results show that ESWT may be an effective inter-
son, Zwerver et al35 found no difference in VISA-P or visual vention in the short term for PT.

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Vol. XX, No. X, XXXX ESWT in Lower Limb Tendinopathy 7

A Shockwave Therapy Control/Alternative Std. Mean Difference Std. Mean Difference

B Shockwave Therapy Control/Alternative Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI Study or Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
2.2.1 Mid-Portion or Insertional Tendinopathy 2.1.1 Mid-Portion Tendinopathy
2.2.2 3 Month VAS
0.20 Costa 2005 SW v P 34.5 34.2 22 50.3 36.3 27 -0.44 [-1.01, 0.13] 0.21 Furia 2008 SW v Cons 2.2 1.2 34 5.6 0.7 34 -3.42 [-4.18, -2.66]
2.2.3 FIL 2.1.3 Insertional Tendinopathy
0.20 Costa 2005 SW v P -0.95 0.96 22 -0.24 0.24 27 -1.05 [-1.65, -0.45]
2.2.4 EQol 2.1.2
0.21VAS
Furia 2006 SW v Cons 2.8 2 35 7 1.4 33 -2.39 [-3.02, -1.76]
0.20 Costa 2005 SW v P -1.55 35 22 4.23 20 27 -0.21 [-0.77, 0.36]
-4 -2 0 2 4
2.2.5 AOFAS Favors Shockwave Therapy Favors Control/Alt
Var Rasmussen 2008 SW v P -88 10 24 -81 16 24 -0.52 [-1.09, 0.06] 2.1.4 VAS

2.2.6 Mid-Portion Tendinopathy

2.2.7 1 Month VAS C Shockwave Therapy Control/Alt Risk Ratio Risk Ratio
0.21 Furia 2008 SW v Cons 4.4 0.9 34 7.1 0.9 34 -2.97 [-3.67, -2.27] Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI
2.2.8 3 Month VAS 2.4.1 Mid-Portion Tendinopathy
0.21 Furia 2008 SW v Cons 2.9 1.2 34 6.5 0.6 34 -3.75 [-4.56, -2.95] 2.4.2 1 Month Roles and Maudsley Score
2.2.9 4 Month VAS 0.21 Furia 2008 SW v Cons 10 34 27 34 0.37 [0.21, 0.64]
0.10 Rompe 2007 SW v Ec 4 2.2 25 3.6 2.3 25 0.17 [-0.38, 0.73] 2.4.3 3 Month Roles and Maudsley Score
0.10 Rompe 2007 SW v Wait 4 2.2 25 5.9 1.8 25 -0.93 [-1.52, -0.34] 0.21 Furia 2008 SW v Cons 5 34 25 34 0.20 [0.09, 0.46]
0.10 Rompe 2009 EcSW V Ec 2.1 1.1 34 2.9 1.8 34 -0.53 [-1.01, -0.05]
2.4.4 Likert Scale (1-6)
2.2.10 VISA-A
0.10 Rompe 2007 SW v Ec 12 25 10 25 1.20 [0.64, 2.25]
0.10 Rompe 2007 SW v Ec -70.4 16.3 25 -75.6 18.7 25 0.29 [-0.27, 0.85]
0.10 Rompe 2007 SW v Wait 12 25 19 25 0.63 [0.40, 1.00]
0.10 Rompe 2007 SW v Wait -70.4 16.3 25 -55 12.9 25 -1.03 [-1.62, -0.44]
0.10 Rompe 2009 EcSW V Ec 6 34 15 34 0.40 [0.18, 0.91]
0.10 Rompe 2009 EcSW V Ec -86.5 16 34 -73 19 34 -0.76 [-1.25, -0.27]
2.4.5 Insertional Tendinopathy
2.2.11 Insertional Tendinopathy
2.4.6 1 Month Roles and Mausdley Score
2.2.12 1 Month VAS
0.21 Furia 2006 SW v Cons 22 35 21 33 0.99 [0.69, 1.42]
0.21 Furia 2006 SW v Cons 4.2 2.4 35 8.2 1.1 33 -2.10 [-2.70, -1.50]
2.4.7 3 Month Roles and Maudsley Score
2.2.13 3 Month VAS
0.21 Furia 2006 SW v Cons 6 35 20 33 0.28 [0.13, 0.62]
0.21 Furia 2006 SW v Cons 2.9 2.1 35 7.2 1.3 33 -2.42 [-3.05, -1.78]
2.4.8 Likert Scale (1-6)
2.2.14 4 Month VAS
0.12 Rompe 2008 SW v Ec 9 25 18 25 0.50 [0.28, 0.89]
0.12 Rompe 2008 SW v Ec 3 2.3 25 5 2.3 25 -0.86 [-1.44, -0.27]
2.2.15 VISA-A 0.2 0.5 1 2 5
0.12 Rompe 2008 SW v Ec -79.4 10.4 25 -63.4 10 25 -1.54 [-2.18, -0.91] Favors Shockwave Therapy Favors Control/Alt

-4 -2 0 2 4
D Shockwave Therapy Control/Alt Risk Ratio Risk Ratio
Favors Shockwave Therapy Favors Control/Alt Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI
2.3.1 Mid-Portion Tendinopathy
2.3.2 Roles and Maudsley Score
0.21 Furia 2008 SW v Cons 5 34 25 34 0.20 [0.09, 0.46]
2.3.3 Insertional Tendinopathy
2.3.4 Roles and Mausdley Score
0.21 Furia 2006 SW v Cons 6 35 20 33 0.28 [0.13, 0.62]

0.2 0.5 1 2 5
Favors Shockwave Therapy Favors Control/Alt

Figure 4. Achilles tendinopathy: Comparison of (A) pain and functional outcomes at \12 months, (B) pain outcomes at .12
months, (C) successful outcomes at \12 months, and (D) successful outcomes at .12 months. Alt, alternative treatment; AOFAS,
American Orthopaedic Foot and Ankle Society; Cons, conservative treatment; Ec, eccentric loading; EcSW, combined extracor-
poreal shock wave therapy and eccentric loading; EQoL, Euro Quality of Life; FIL, Functional Index of Lower Limb Activity; P,
placebo; SW, extracorporeal shock wave therapy; Var, variable energy level from 0.12-0.51 mJ/mm2; VAS, visual analog scale;
VISA-A, Victorian Institute of Sport Assessment Questionnaire–Achilles (questionnaire assessing severity of Achilles tendinop-
athy); Wait, wait-and-see policy.

The results from Vulpiani et al32 indicated that ESWT treating PT, the majority of evidence is limited. Further
was effective at reducing pain in the long term for PT, research with a more robust study design will help to iden-
with a satisfactory result in 68.8% of cases. However, it tify the true effectiveness of ESWT for patients with PT.
is unclear whether the improvements were purely as
a result of ESWT, as there was no documentation of co- Achilles Tendinopathy
interventions. The long-term results from the study by
Furia et al10 mirrored the short-term results, with clini- There is conflicting evidence for the effectiveness of ESWT in
cally significant changes in the VAS and VISA-P scores. comparison to sham ESWT for AT. Costa et al5 found no dif-
There is some evidence that ESWT is a more effective ference in pain or function between patients treated with
long-term intervention than nonoperative treatments and ESWT or sham ESWT. However, an important potential con-
as effective as surgery for PT. Wang et al33 showed that founding factor is that the average age of patients in the
patients treated with ESWT had clinically significant ESWT group was 10 years older than those in the sham
improvements in the VAS and VISA-P scores after 12 ESWT group. Considering that increasing age is associated
months compared with patients who received a combina- with lower tendon healing rates,28 the absence of a difference
tion of anti-inflammatory medication, physical therapy, between groups may be explained. Conversely, Rasmussen
and an exercise intervention. However, ESWT treatment et al,18 who used the same intervention treatments as Costa
was not standardized, as 3 patients whose response was et al5 but used a higher energy level and an extra treatment
deemed inadequate after a single treatment received an session, found that patients in the group treated with ESWT
additional ESWT treatment session. Peers et al17 showed improved their American Orthopaedic Foot and Ankle Soci-
ESWT to be comparable with patellar tenotomy surgery ety score to a significantly greater extent than those in the
in improving pain and function, providing an equivalent sham group, with an increase of 18 points in the ESWT group
successful outcome score in the long term. This would indi- and 7 points in the sham group. These findings were reported
cate that ESWT may be a viable alternative to surgery for at 3 months, suggesting that ESWT may be an effective
long-term sufferers of PT. short-term intervention.
Even though these studies indicate that ESWT may be Eccentric loading is considered the gold-standard nonop-
a promising short- and long-term treatment option for erative treatment for midportion AT.1 However, moderate

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8 Mani-Babu et al The American Journal of Sports Medicine

evidence exists to suggest that ESWT may be a more effec- representative of what patients are normally offered.zz In
tive short-term intervention than eccentric loading for addition, as there was a great degree of heterogeneity in
insertional tendinopathy and equal to eccentric loading in the protocols used (energy level of treatment, number of
midportion AT. Furthermore, RCTs conducted by Rompe impulses, and number of treatment sessions as well as
et al20,23 showed that ESWT was effective at relieving number of days between treatment sessions), it was diffi-
pain and improving function in both midportion and inser- cult to directly compare the results of different studies.
tional AT. In addition, when combining ESWT and eccentric For a number of studies, the outcome measures used
loading, patients with midportion AT showed a significantly were not specific to the condition, unlike the VISA-A/P,
greater improvement in pain and function than with eccen- which focus on the clinical severity of AT and PT, respec-
tric loading alone, reporting a difference of 1.5 cm in the tively. The validity of the results to translate to clinical
VAS score and 14 points in the VISA-A score.21 Further practice from these studies may therefore be ques-
research is needed to confirm this finding; however, these tioned.5,11,18,24 A few studies used suboptimal statistical
results indicate that combining ESWT and eccentric loading tests; therefore, the results of these studies may not be
should be considered in clinical practice, particularly if accurate and indeed misleading.7,29
a patient is slow to respond to eccentric loading.
There is limited evidence for the effectiveness of ESWT
Clinical Relevance
in comparison to other nonoperative interventions for the
treatment of AT. Retrospective studies by Furia8,9 showed From analysis of the higher quality studies, it is evident
ESWT to be significantly better at relieving pain in both that ESWT can play a role in the treatment of patients
insertional and midportion AT and improving outcomes, with lower limb tendinopathies alongside progressive load-
as assessed by the Roles and Maudsley score, than other ing and flexibility management. Both forms of treatment
nonoperative therapies including rest, footwear modifica- serve to induce tendon regeneration, with rehabilitation
tion, anti-inflammatory medication, and gastrocnemius- exercises tending to be carried out over a period of many
soleus stretching and strengthening. Also for patients weeks, whereas ESWT treatment is typically administered
with insertional AT,9 the pain-reducing effect of ESWT weekly for 3 weeks. A suitable pathway may be using
was diminished when a local anesthetic was administered ESWT early in the treatment phase, alongside a progressive
before treatment. Further studies examining the effect of loading program, based on some evidence that this combina-
anesthetics on the outcomes of ESWT are needed to build tion confers additional benefits.21 Hence, it is also important
upon this finding. Altogether, these short-term results for clinicians to be aware of combining treatment modalities
show that ESWT can be beneficial for both midportion when a patient presents with a tendinopathy.
and insertional AT.
The 6 studies looking at long-term ESWT effects included
2 retrospective8,9 and 4 prospective studies.7,13,25,31 Furia8,9 Future Directions
showed that the differences in pain and functional outcomes
between the patient groups receiving ESWT and other non- From this systematic review, it is evident that there are
operative therapies were similar at 3 months. The 4 low- enough high-quality studies evaluating the effectiveness of
quality prospective studies by Lakshmanan and O’Doh- ESWT for lower limb tendinopathies to make initial level 1
erty,13 Fridman et al,7 Vulpiani et al,31 and Saxena et al25 recommendations. Further, the evidence allows us to suggest
all reported patient improvements in pain and function key areas for further work. More robust RCTs with larger
after ESWT treatment. Hence, ESWT may also be consid- sample sizes and control groups that include objective func-
ered a suitable long-term intervention for AT. tional tests are needed to build upon the limited/moderate evi-
Overall, the results indicate ESWT to be an effective dence that currently exists for ESWT’s effectiveness in lower
short-term intervention for both midportion and inser- limb tendinopathies. Additionally, further RCTs specifically
tional AT and that it can be used as an alternative to other comparing the different elements of ESWT, energy levels,
nonoperative forms of management in clinical practice. number of applications, and number of days between applica-
However, RCTs with longer term follow-ups are needed tions, are needed to identify the optimum protocol. Work on
to build upon the evidence for long-term AT management. mechanisms underpinning observed effects is warranted.

Quality Assessment
CONCLUSION
Scores from the Downs and Black quality index6 ranged
from 9 to 26 (of a maximum score of 28) (Appendix 3). Extracorporeal shock wave therapy appears to be an effec-
Ten studies were classified as high quality. The primary tive intervention for lower limb tendinopathies, with mod-
differences between low- and high-quality studies included erate-level evidence of efficacy for all 3 tendinopathies
the following: the absence of a control group, meaning that reviewed. Further, ESWT seems to be a suitable alterna-
it was difficult to say whether it was solely the intervention tive to home training and corticosteroid injection in the
that led to the observed results7,13,25,31,32,34; informal ran- short- and long-term management of GTPS. For PT,
domization, which increased the risk of selection bias24,33; ESWT seems to be superior to other nonoperative
and the difficulty in identifying whether patients were rep-
zz
resentative of the population or whether the treatment was References 5, 7, 8, 10, 13, 20, 21, 25, 29, 31-34.

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Vol. XX, No. X, XXXX ESWT in Lower Limb Tendinopathy 9

treatments and equal to surgery in the long term. For AT, 15. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among
the results suggest that ESWT is superior to eccentric elite athletes from different sports: a cross-sectional study. Am J
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tion tendinopathy, and superior to various alternative non- 17. Peers KH, Lysens RJ, Brys P, Bellemans J. Cross-sectional outcome
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2003;13(2):79-83.
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19. Review Manager [computer program]. Version 5.1. Copenhagen: The
The authors acknowledge Dr Manuela Angioi, who taught Nordic Cochrane Centre; 2011.
20. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock
literature-reviewing techniques to the first author, and
wave treatment for chronic insertional Achilles tendinopathy: a ran-
Professor Nicola Maffulli, who was center lead at the domized, controlled trial. J Bone Joint Surg Am. 2008;90(1):52-61.
time the work was started. We also acknowledge the indus- 21. Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric load-
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