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Novel Interventions for Recalcitrant Achilles Tendinopathy

Benefits Seen Following High-Volume Image-Guided Injection or Extracorporeal Shockwave Therapy—A Prospective Cohort Study

Wheeler, Patrick C. MBChB, MSc, FFSEM*,†,‡; Tattersall, Chloe RN*

doi: 10.1097/JSM.0000000000000580
Original Research: PDF Only

Objective: To compare the outcomes for patients with chronic noninsertional Achilles tendinopathy following extracorporeal shockwave therapy (ESWT) and high-volume image-guided injection (HVIGI).

Design: Prospective cohort study.

Setting: Hospital-based Sports Medicine Outpatient Clinic.

Patients: Sixty-three consecutive patients with chronic noninsertional Achilles tendinopathy, treated with ESWT (n = 22) or HVIGI (n = 41), with minimum 3-month follow-up. Mean age was 51.2 years, and mean duration of symptoms was 27.8 months.

Interventions: Patients received either 3 sessions of ESWT (1 session per week) or a single ultrasound-guided HVIGI (10 mL of 1% lidocaine and 40 mLs of sterile saline). All patients received standardized aftercare, including continuation of a structured home exercise program of flexibility and eccentric strengthening exercises.

Main Outcome Measures: Zero to 10 visual analog scale (VAS) for self-reported “average pain” and “average stiffness” values. In addition, Victoria Institute of Sport—Achilles questionnaire, (VISA-A), and Manchester-Oxford Foot Questionnaire (MOXFQ).

Results: This study demonstrated statistically significant improvements in self-reported measures of pain and stiffness following either procedure. At 3 months, VAS (pain) was improved from 6.74 ± 1.31 to 3.57 ± 2.37 (P < 0.001) following HVIGI and from 6.57 ± 1.61 to 4.35 ± 2.55 (P = 0.002) following ESWT. At 3 months, VISA-A improved from 35% ± 17% to 51% ± 22% (P < 0.001) following HVIGI and from 34% ± 15% to 49% ± 15% (P < 0.001) following ESWT. Statistically significant improvements were only recorded at 6 weeks for ESWT and at 3 months for HVIGI using MOXFQ. No statistically significant differences were seen between the groups at any period studied.

Conclusions: Patients improved to statistically significant extent following either a HVIGI or ESWT procedure, with no significant differences seen between the groups. The small sample sizes in this pragmatic study are noted, which limit interpretation, and larger more robust studies are required to investigate this further.

Clinical Relevance: This pragmatic prospective cohort study demonstrates improvements following either ESWT or HVIGI procedures, with no significant differences seen between the groups.

*Department of Sport & Exercise Medicine, University Hospitals of Leicester NHS Trust, United Kingdom;

School of Sport, Exercise and Health Sciences, Loughborough University, United Kingdom; and

National Centre of Sport and Exercise Medicine, Loughborough, United Kingdom.

Corresponding Author: Patrick C. Wheeler, MBChB, MSc, FFSEM, Department of Sport & Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester General Hospital Gwendolen Rd, Leicester LE5 4PW, United Kingdom (

The authors report no conflicts of interest.

Received August 14, 2017

Accepted December 14, 2017

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