SECTION III: REGULAR AND SPECIAL FEATURES: Orthopaedic • Radiology • Pathology Conference: Letters to the Editor
To the Editor:
I read with great interest the article “Shock Wave Therapy for Chronic Achilles Tendon Pain” by Costa et al,2 in which the authors stated that the results of an earlier trial by Rompe et al7 using extracorporeal shock wave therapy (ESWT) for plantar fasciitis were used to determine their sample size. The technique used by Rompe et al7 for producing a placebo effect also was used by Costa et al in their study.2
However, “in the absence of evidence to guide the number and frequency of treatment,” the authors decided not to test the parameters given in the trial by Rompe et al7 (three applications of 1000 impulses of low-energy ESWT, weekly interval, and main outcome measurement 3 months after last application). Instead they relied “on the experience of the senior author.”
However, they do not state the experiences of the senior author or what data justified changing the previous treatment protocol.7
Speed et al11,12 showed that repetitive low-energy shock wave treatment applied in monthly intervals had no relevant treatment effect within 4 weeks after the last ESWT. Why did Costa et al choose a treatment concept already proven ineffective under randomized controlled conditions? Why did they choose a main followup period of only 4 weeks after the last ESWT? In numerous studies published regarding use of ESWT for treatment of tendinopathy, the main followup has been 12-14 weeks after the last ESWT.1, 3-10
Level I therapeutic studies have provided evidence for a distinct treatment effect of ESWT for lateral epicondylitis and plantar fasciitis5-10 under the following circumstances:
(1) application of 1500-2000 shocks of low-energy flux density (0.08-0.15 mJ/mm2); (2) application to the site of maximal discomfort (patient guidance); (3) no local anesthesia; (4) weekly intervals (3-4 applications); and (5) at least 3 months followup after the last application.
Treatment success (reduction of pain by ≥ 50%) can be expected to be approximately 60% compared with approximately 30% after placebo treatment.5,6,8,10 Therefore, the abstract should state that shock wave therapy as applied did not produce a clinically relevant effect over placebo.
The pilot trial by Costa et al2 is valuable by clarifying how not to treat patients with recalcitrant Achilles tendinopathy using ESWT.
Jan D. Rompe, MD
Orthopaedic Surgery, OrthoTrauma Clinic, Gruenstadt, Germany
1. Chung B, Wiley JP. Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med
2. Costa ML, Shepstone L, Donell ST, Thomas TL. Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial. Clin Orthop Relat Res
3. Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, Hausdorf J, Zamzow K, Schade-Brittinger C, Mueller HH. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ
4. Haake M, Konig IR, Decker T, Riedel C, Buch M, Muller HH. Extracorporeal Shock Wave Therapy Clinical Trial Group. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis. J Bone Joint Surg
5. Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg
6. Rompe JD, Decking J, Schoellner C, Theis C. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med
7. Rompe JD, Hopf C, Nafe B, Burger R. Low-energy extracorporeal shock wave therapy for the painful heel: a prospective controlled single-blind study. Arch Orthop Trauma Surg
8. Rompe JD, Meurer A, Nafe B, Hofmann A, Gerdesmeyer L. Repetitive low-energy shock wave application without local anesthesia is more efficient than repetitive low-energy shock wave application with local anesthesia in the treatment of chronic plantar fasciitis. J Orthop Res
9. Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application and treatment in chronic plantar fasciitis. J Bone Joint Surg
10. Spacca G, Necozione S, Cacchio A. Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study. Eura Medicophys
11. Speed CA, Nichols D, Richards C, Humphreys H, Wies JT, Burnet S, Hazleman BL. Extracorporeal shock wave therapy for lateral epicondylitis: a double blind randomised controlled trial. J Orthop Res
12. Speed CA, Nichols D, Wies J, Humphreys H, Richards C, Burnet S, Hazleman BL. Extracorporeal shock wave therapy for plantar fasciitis: a double blind randomised controlled trial. J Orthop Res