The purpose of this systematic review was to examine clinical outcomes following extracorporeal shockwave therapy (ESWT) in patients with Achilles tendinopathy and if outcomes differed between patients with insertional Achilles tendinopathy (IAT) and non-insertional Achilles tendinopathy (NAT). The quality of evidence (QoE) and level of evidence (LoE) was also evaluated.
In January 2022, the MEDLINE and EMBASE databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following data was collected and analysed: patient demographics, follow-up time, duration of symptoms prior to ESWT, treatment characteristics, subjective clinical scoring tools, return to work and sport data and complications.
Twelve studies were included in this review, 3 with LoE I, 4 with LoE II, 4 with LoE III, and 1 with LoE IV. There were 369 cases of AT:: 248 patients with IAT and 121 with NAT. There were 148 (40.1%) female patients, 159 (43.1%) male patients, and 62 (16.8%) patients whose sex was not recorded. In the IAT cohort, the weighted mean age was 46.8 ± 9.0 years (range, 37.0-59.5) and the weighted mean follow-up for patients with IAT was 8.4 ± 7.1 months (range, 3.0-24.0). In the NAT cohort, the weighted mean age was 50.2 ± 6.7 years (range, 37.4-54.0) and the weighted mean follow-up time was 13.0 ± 9.7 months (range, 3.0-24.0). The most commonly used subjective scoring tool was the Victorian Institute of Sports Assessment Achilles questionnaire (VISA-A) in 8 studies (66.7%). For the IAT cohort, the weighted mean pre-ESWT VISA-A score was 51.3 ± 4.1 (range, 43.0-54.0) and the weighted mean post-ESWT score was 81.7 ± 5.7 (range, 70.0-86.5). For the NIAT cohort, the weighted mean pre-ESWT VISA-A score was 45.2 ± 10.2 (range, 34.1-56.8) and the weighted mean post-ESWT score was 70.2 ± 7.2 (range, 66.0-81.4). Return to sport and return to work were only reported in two studies. In the IAT cohort, 90.9% of patients returned to sport and 75.0% returned to work. In the NIAT cohort, 77.8% of patients returned to sport and 66.7% of patients returned to work. Ninety five (25.7%) complications were reported, the most common of which transient cutaneous erythema (24.4%).
This current review demonstrated that ESWT leads to improvement in subjective clinical outcomes and high rate of return to sport at short-term follow-up. Interestingly, superior outcomes were found in the IAT cohort compared to the NAT cohort. Further studies with longer follow-up are required to assess the optimal role of ESWT in the management of Achilles tendinopathy.