Clinical Study Outcome of Extracorporeal Shock Wave ...downloads.hindawi.com/journals/bmri/2016/6315846.pdflateral radiograph of ankle to identify Haglund s deformity. e diagnosis

Clinical StudyOutcome of Extracorporeal Shock Wave Therapy for InsertionalAchilles Tendinopathy with and without Haglundrsquos Deformity

Ziying Wu Wei Yao Shiyi Chen and Yunxia Li

Department of Sports Medicine Huashan Hospital Fudan University Shanghai China

Correspondence should be addressed to Yunxia Li yunxialihuashan163com

Received 30 June 2016 Revised 26 October 2016 Accepted 30 October 2016

Academic Editor Giuseppe Filardo

Copyright copy 2016 Ziying Wu et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Purpose To compare the results of extracorporeal shock wave therapy (ESWT) for insertional Achilles tendinopathy (IAT) withor without Haglundrsquos deformity Methods Between September 2014 and May 2015 all patients who underwent ESWT wereretrospectively enrolled in this study A total of 67 patients were available for follow-up and assigned into nondeformtiy group(119899 = 37) and deformtiy group (119899 = 30) Clinical outcomes were evaluated by VISA-A Score and 6-point Likert scale ResultsThe VISA-A score increased in both groups from 4957 plusmn 998 at baseline to 8386 plusmn 859 at 145 plusmn 72 months after treatmentin nondeformity group (119875 lt 0001) and from 4870 plusmn 938 at baseline to 6778 plusmn 1135 at 153 plusmn 67 months after treatment indeformity group (119875 lt 0001) However there was a greater improvement in VISA-A Score for the nondeformity group comparedwith deformity group (119875 = 0005) For the 6-point Likert scale there were decreases from 392 plusmn 080 at baseline to 157 plusmn 073 atthe follow-up time point in nondeformity group (119875 lt 0001) and from 40 plusmn 076 at baseline to 237 plusmn 103 at the follow-up timepoint in deformity group (119875 lt 0001) There was no significant difference in improvement of the 6-point Likert scale between bothgroups (119875 = 0062) Conclusions ESWT resulted in greater clinical outcomes in patients without Haglundrsquos deformity comparedwith patients with Haglundrsquos deformity

1 Introduction

Insertional Achilles tendinopathy (IAT) is among the mostcommon posterior heel conditions while walking and run-ning and is located at the insertion of the Achilles tendononto the calcaneus involving pain and swelling of theAchillestendon itself the formation of bone spurs and calcificationsat the insertion site [1] Nonoperative management consistsof rest activity modification anti-inflammatory medicationphysical therapy eccentric exercise and corticosteroid injec-tions [2] Recent several studies have shown that extracorpo-real shock wave therapy (ESWT) for the treatment of IAT hasachieved good functional and clinical outcomes [3 4] Severalfundamental studies have shown biological effects of ESWTfor IAT van der Worp et al claimed that the nonexclusivetheories about the mechanisms of ESWT involve pain relieftissue regeneration and destruction of calcifications [5]Waugh et al observed the increase of IL-6 and IL-8 whichcould promote fibroblast production of collagen and ECMcomponents and demonstrated that the mechanical stimulus

provided by ESWTmight contribute to injured tendon tissueremodeling in tendinopathy [6] Moreover improved bloodsupply and early vascularity make use of ECM-degradingenzymes to promote the initial leukocyte infiltration andthe subsequent metabolism of the fibers in the damagedtendon area [7]The ESW-driven transitory increase in TGF-szlig1 expression and persistent IGF-I expression could lead tosome important changes including controlled inhibition ofmacrophages-induced ECM degradation and inflammationand an enhanced ECM and collagen type I synthesis [8]The other therapeutic effects of ESWT consist of tendon cellsproliferation and endogenous lubricin production by fibrob-lasts and tenocytes resulting from growth factors stimulation[9] Therefore the ESWT ultimately effectively bring aboutpromotion of cell metabolism and the latter may acceleratehealing process in the pathological Achilles tendon tissue[10]

IATmay be associated with a Haglundrsquos deformity whichis defined as a complex of symptoms involving a superolateralcalcaneal prominence retrocalcaneal bursitis and superficial

Hindawi Publishing CorporationBioMed Research InternationalVolume 2016 Article ID 6315846 6 pageshttpdxdoiorg10115520166315846

2 BioMed Research International

Allocated to deformity groupn = 30

Allocated to nondeformity groupn = 37

Refused to participate (n = 7)

Not meeting inclusion criteria (n = 9)

Excluded (n = 16)

Included in follow-upn = 67

Insertional Achilles tendinopathyn = 83

Figure 1 Flow chart of patients included in follow-up Deformity Haglundrsquos deformity

adventitious Achilles tendon bursitis [11ndash13] The study ofSundararajan and Wilde exhibited that Haglundrsquos deformitywas present in 25 of IAT patients [13]

To our knowledge it remains unclear if IAT concomitantwith Haglundrsquos deformity could achieve great clinical efficacyor not when treated with ESWT Therefore the purpose ofthis study was to reveal clinical outcomes following ESWTbetween IAT patients with or without Haglundrsquos deformityWe hypothesized that patients with Haglundrsquos deformitywill have inferior clinical outcomes compared with patientswithout Haglundrsquos deformity

2 Materials and Methods

21 Participants This studywas approved by the Ethics Com-mittee of FudanUniversity Between September 2014 andMay2015 participants who received shock wave therapy for IATwere recruited retrospectively in this study The diagnosisof IAT was confirmed by the following definition pain andlocalized tenderness at the insertion region of the Achillestendon and decreased activity levels secondary to Achillestendon pain [3 14ndash16] All patients underwent preoperativelateral radiograph of ankle to identify Haglundrsquos deformityThe diagnosis of Haglundrsquos deformity was confirmed bythe following definition remarkable osseous prominence atthe region of the posterosuperior part of the calcaneus andFowler-Philip angle of gt75∘ on lateral plain radiographs[3 11] According to the presence of Haglundrsquos deformityall patients were retrospectively classified into two groupsdeformity group if patients have concomitant Haglundrsquosdeformity and nondeformity group if patients have noHaglundrsquos deformity (Figure 1)

All patients included in this study failed to respond tononsurgical treatment for at least six months Nonoperativetreatment included activity modification (119899 = 65) phys-iotherapy (119899 = 35) nonsteroidal anti-inflammatory drugs(119899 = 62) and the use of orthotics (119899 = 27) Steroid injectionswere not used because of the risk of Achilles tendon ruptureand in some cases unwillingness to try Exclusion criteria for

this research included priorAchilles tendon rupture previoussurgery of the ankle or the Achilles tendon on the involvedside ankle arthritis radiculopathy or systemic neurologicalconditions congenital or acquired deformities of the kneeand ankle peripheral neuropathy lumbar radiculopathyand inability to comply with the recommended treatmentregimen

22 Shock Wave Therapy The shock wave therapy was per-formedwith the patient in the prone position andwas admin-istered once a week for 5 sessions All patients completedall 5 sessions And no patients received more sessions Aradial shock wave device (EMS Swiss Dolor-Clast MunichGermany) was used Radial shock wave is created ballisticallywith the pressurized air source accelerating a bullet to strike ametal applicatorThe kinetic energy produced is transformedinto radially expanding shock waves from the application siteinto the tissue to be treated [3] At each treatment session2000 pulses with an energy flux density of 012mJmm2 anda rate of 8 pulses per second were applied The applicator ofhand-piece was located on the maximal tenderness point andwas properly placed and adjusted according to patientsrsquo feed-back during treatment if necessary [17] No local anestheticwas applied

23 Clinical Evaluation Patients researchers evaluating theclinical outcome and treating physicians were blinded to thepresence of deformity or not Clinical functional evaluationincluded VISA-A score (see Figure 2) and 6-point Likertscale (see Figure 3) collected before treatment and at thefollow-up time point As a self-administered questionnairethe VISA-A score (Appendix) is used to evaluate the severityof Achilles tendinopathy It has previously been shown tobe valid reliable and clinically relevant [18] The content ofVISA-A questionnaire is as follows pain (questions (1)ndash(3))function (questions (4)ndash(6)) and activity (questions (7) and(8)) VISA-A scores have a range of 0 to 100 The 6-pointLikert scale is interpreted as success if patients rate themselves1 or 2 and as failure if patients rate themselves 3 4 5 or 6 [19]

BioMed Research International 3

A B C D

Scor

e

VISA-A score100

80

60

40

20

0

lowastlowastlowast

Figure 2 Results of VISA-A score for both groups A at baselinein nondeformity group B at follow-up in nondeformity group Cat baseline in deformity group D at follow-up in deformity grouplowastlowastlowastamp119875 lt 0001

A B C D

Scor

e

lowastlowastlowast

6

4

2

0

6-point Likert score

Figure 3 Results of 6-point Likert score for both groups A atbaseline in nondeformity group B at follow-up in nondeformitygroupC at baseline in deformity groupD at follow-up in deformitygroup lowastlowastlowastamp119875 lt 0001

24 Statistical Analysis Data analysis is performed usingStata 100 software (StataCorp College Station TX USA) andall data are expressed asmean and standard deviation (SD) fordescription

The improvement between pretreatment and at thefollow-up time point was calculated by paired 119905-test (seeFigure 3)The difference between groups was compared by 119905-test Statistical significance was set at119875 lt 005The odds ratio(OR) was calculated to figure out the influence of deformityon treatment failure The 95 confidence interval (CI) wasalso calculated

3 Results

31 PatientDemographics At the follow-up timepoint a totalof 67 patients were available for follow-up 30 patients indeformity group and 37 in nondeformity group Participantsrsquodemographic data are shown in Table 1 The two groupsdid not differ significantly in age body mass index sex

therapeutic side and follow-up time All patients underwentextracorporeal shock wave therapy (ESWT)

32 Clinical Outcomes At the follow-up time point thefunctional outcomes with regard to VISA-A score and 6-point Likert scale achieved significant improvements in bothgroups However there was a greater improvement in VISA-A score for the nondeformity group comparedwith deformitygroup (119875 = 0005) (Tables 2 and 3) According to the 6-point Likert scale grading system there were 34 graded assuccess and 3 graded as failure in the nondeformity groupand there were 23 graded as success and 7 graded as failurein the deformity group There were no serious complicationsincluding infection and Achilles tendon rupture excepttransient reddening of the skin in all patients

TheORwas 345 with a 95CI of [081 1474] indicatingthat patients with deformity had a 345 times higher risk toexperience treatment failure compared with those who arewithout However the difference was not significant (119875 =009)

4 Discussion

The current study validated that ESWT for IAT concomitantwith or without Haglundrsquos deformity exhibited improvedclinical outcomes However the VISA-A scores in patientswith Haglundrsquos deformity were inferior to those in patientswithout Haglundrsquos deformityThe results of this study suggestthatHaglundrsquos deformitymayworsen therapeutic effect of theESWT for IAT

Recent numerous studies have reported that satisfactoryclinical results in the treatments of IAT could be achievedwith the use of ESWT [3 4] Furia concluded that shockwave therapy could obtain satisfactory clinical outcome in thetreatment of the chronic insertional Achilles tendinopathyFollow-up was performed at 1 3 and 12 months after treat-ment and the mean visual analog score for the nonoperativetherapy and ESWT groups were 82 and 42 (119875 lt 0001) 72and 29 (119875 lt 0001) and 70 and 28 (119875 lt 0001) respectivelyTwelve months after treatment more patients in the ESWTgroup (83 of ESWT group patients) have successful Rolesand Maudsley scores compared to those in the control group[4] In addition in a randomized controlled study Rompe etal showed shock wave therapy could provide more favorableresults compared to eccentric loading for chronic IAT At 4months after treatment both groups have improvement inthe mean VISA-A score increasing from 53 to 63 points ineccentric loading group and 53 to 80 points in shock wavetherapy group Moreover this clinical result after shock wavetherapy remained stable at the one-year follow-up evaluation[3] In our present study all the participants in both groupsobtain pain relief and significant improvement in clinicaloutcomes (see Figure 4)

However significant differences between both groupswere observed in the current study suggesting that Haglundrsquosdeformity in the posterior calcaneus has negative influ-ence on clinical results of ESWT for IAT The calcanealposterosuperior prominence is called Haglundrsquos deformityRepetitive squeezing of the retrocalcaneal bursa at dorsal


Table 1 Participant demographic data of the study groups

Variable Nondeformity group (119899 = 37) Deformity group (119899 = 30) 119875 value 95 CIAge mean plusmn SD y 376 plusmn 92 358 plusmn 74 0228 minus217ndash517Sex mean plusmn SD 119899 0789 043ndash304

Male 21 18Female 16 12

Body mass index mean plusmn SD kgm2 237 plusmn 20 229 plusmn 22 0591 minus022ndash182Therapeutic side mean plusmn SD 119899 0818 042ndash289

left 15 13right 22 17

Follow-up time mean plusmn SD months 145 plusmn 72 153 plusmn 67 0705 minus414ndash254CI confidence interval

Table 2 Clinical outcome scores for both groups

Outcome Score Nondeformity group119875 value 95 CI Deformity group

119875 value 95 CIBaseline Follow-up Baseline Follow-up

VISA-A 4957 plusmn 998 8386 plusmn 859 lt0001 3005ndash3853 4870 plusmn 938 6778 plusmn 1135 lt0001 1381ndash24356-point Likert 392 plusmn 080 157 plusmn 073 lt0001 200ndash270 40 plusmn 076 237 plusmn 103 lt0001 117ndash209CI confidence interval

Table 3 Comparison of differences in improvement of clinicaloutcome scores between nondeformity and deformity group

Improvement of clinical outcome scoresNondeformity

groupDeformitygroup 119875 value 95 CI

VISA-A 3430 plusmn 1196 1908 plusmn 708 0005 1061ndash19836-point Likert 229 plusmn 090 200 plusmn 064 0062 minus008ndash066CI confidence interval

flexion of ankle resulting from impingement between theposterosuperior prominence of the calcaneus and the anterioraspect of the Achilles tendon can sometimes cause painfulbursitis [20] Sundararajan and Wilde found 25 frequencyof Haglundrsquos syndrome within the IAT population accordingto both the clinical examination and magnetic resonanceimaging [13] The previous study has reported that thepresence of Haglundrsquos deformity has influence on the clinicaloutcomes of other treatments including eccentric trainingwhich was consistent with the results of our current studyFahlstrom et al found that only 32 of the patients withinsertional Achilles tendon pain had good clinical resultswith usage of painful eccentric training beyond plantar gradeThe unfavourable outcomes in patients with insertionalAchilles tendon pain may be attributable to mechanicalimpingement between the prominent calcaneus and thetendon and bursa when the ankle was in the dorsiflexedposition [15] Following the findings from Fahlstrom et alJonsson et al made modification and used an eccentrictrainingmodelwithout dorsiflexion in the ankle joint to avoidpossible mechanical impingement which resulted in 67satisfied patients compared with the study of Fahlstrom et al

A B

lowastlowast50

40

30

20

10

0

Improvement of score

Impr

ovem

ent o

f sco

re

A998400 B998400

Figure 4 Improvement of clinical scores between nondeformityand deformity group A improvement of VISA-A in nondefor-mity group A1015840 improvement of VISA-A in deformity group Bimprovement of 6-point Likert score in nondeformity group B1015840improvement of 6-point Likert score in deformity group lowastlowast119875 =0005

[21] The presence of Haglundrsquos deformity could explain thepoorer clinical evaluation in deformity group compared withnondeformity group in the current study

There are still some limitations in our studyThefirst is thesmall number of patients Larger patient series are needed toverify whether the clinical outcomes could be underminedby Haglundrsquos deformity Secondly a longer follow-up isnecessary to determine whether ESWT for IAT with orwithout Haglundrsquos deformity may persist in symptomaticrelief Lastly a major limitation of the current study is theretrospective study-design which makes it hard to perform


a power analysis to ensure the statistical efficacy Future trialswith higher quality are required to reveal the influence ofdeformity on failure ratesThe odds ratio (OR) was calculatedto figure out the influence of deformity on treatment failureWe found that the ORwas 345 with a 95CI of [081 1474]indicating that patients with deformity had a 345 timeshigher risk to experience treatment failure compared withthose who are without However the difference was notsignificant (119875 = 009) Future trials with higher quality arerequired to reveal the influence of deformity on failure rates

5 Conclusion

The clinical results of ESWT for IAT with and withoutHaglundrsquos deformity showed significant improvement How-ever IAT without Haglundrsquos deformity had significantlygreater VISA-A score compared with IAT with Haglundrsquosdeformity

Appendix

The VISA-A Questionnaire An Index of theSeverity of Achilles Tendinopathy

In this questionnaire the term pain refers specifically to painin the Achilles tendon region

(1) For how many minutes do you have stiffness in theAchilles region on first getting up

Points

0 1 2 3 4 5 6 7 8 9 10

100mins 0mins

(2) Once you are warmed up for the day do you have painwhen stretching the Achilles tendon fully over the edge of astep (keeping knee straight)

Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10

(3) After walking on flat ground for 30 minutes do youhave pain within the next 2 hours (If unable to walk onflat ground for 30 minutes because of pain score 0 for thisquestion)

Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10

(4) Do you have pain walking downstairs with a normalgait cycle

Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10

(5) Do you have pain during or immediately after doing10 (single leg) heel raises from a flat surface

Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10

(6) How many single leg hops can you do without pain

0 10Points

0 1 2 3 4 5 6 7 8 9 10

(7) Are you currently undertaking sport or other physicalactivity

Points0

4

7

10

Not at all

Modified training plusmn modified competition

Full training plusmn competition but not at

Competing at the same or higher levelthe same level as when symptoms began

than when symptoms began(8) Please complete EITHER (A) (B) or (C) in this

question(i) If you have no pain while undertaking Achilles tendon

loading sports please complete Q8a only(ii) If you have pain while undertaking Achilles tendon

loading sports but it does not stop you from completing theactivity please complete Q8b only

(iii) If you have pain that stops you from completingAchilles tendon loading sports please complete Q8c only

(A) If you have no painwhile undertakingAchilles tendonloading sports for how long can you trainpractise

Points

0 7 14 21 30

NIL 1ndash10mins 11ndash20mins 21ndash30mins gt30mins

OR(B) If you have some pain while undertaking Achilles

tendon loading sport but it does not stop you from completingyour trainingpractice for how long can you trainpractise

Points

0 4 10 14 20


OR(C) If you have pain that stops you from completing your

trainingpractice in Achilles tendon loading sport for howlong can you trainpractise

Points

0 2 5 7 10


()Total score (( 100)

Competing Interests

All authors declare that there is no conflict of interestsregarding the publication of this paper


Authorsrsquo Contributions

Ziying Wu and Wei Yao contributed equally to this work

References

[1] C N van Dijk M N van Sterkenburg J IWiegerinck J Karls-son and N Maffulli ldquoTerminology for Achilles tendon relateddisordersrdquo Knee Surgery Sports Traumatology Arthroscopy vol19 no 5 pp 835ndash841 2011

[2] A J Roche and J D F Calder ldquoAchilles tendinopathy a reviewof the current concepts of treatmentrdquo The Bone and JointJournal vol 95 no 10 pp 1299ndash1307 2013

[3] J D Rompe J Furia and N Maffulli ldquoEccentric loadingcompared with shock wave treatment for chronic insertionalachilles tendinopathy a randomized controlled trialrdquo Journal ofBone and Joint SurgerymdashSeries A vol 90 no 1 pp 52ndash61 2008

[4] J P Furia ldquoHigh-energy extracorporeal shock wave therapy as atreatment for insertional Achilles tendinopathyrdquoThe AmericanJournal of Sports Medicine vol 34 no 5 pp 733ndash740 2006

[5] H van der Worp I van den Akker-Scheek H van Schie andJ Zwerver ldquoESWT for tendinopathy technology and clinicalimplicationsrdquo Knee Surgery Sports Traumatology Arthroscopyvol 21 no 6 pp 1451ndash1458 2013

[6] C M Waugh D Morrissey E Jones G P Riley H Langbergand H R C Screen ldquoIn vivo biological response to extracorpo-real shockwave therapy in human tendinopathyrdquoEuropeanCellsand Materials vol 29 pp 268ndash280 2015

[7] G Bosch M de Mos R V van Binsbergen H T M van SchieCHA van de Lest and P R vanWeeren ldquoThe effect of focusedextracorporeal shock wave therapy on collagenmatrix and geneexpression in normal tendons and ligamentsrdquoEquineVeterinaryJournal vol 41 no 4 pp 335ndash341 2009

[8] V ViscoM C VulpianiM R Torrisi A Ferretti A Pavan andM Vetrano ldquoExperimental studies on the biological effects ofextracorporeal shock wave therapy on tendonmodels A reviewof the literaturerdquo Muscles Ligaments and Tendons Journal vol4 no 3 pp 357ndash361 2014

[9] Y E Zhang ldquoA special issue on TGF-120573 signaling and biologyrdquoCell and Bioscience vol 1 no 1 article 39 2011

[10] Y-J Chen C-J Wang K D Yang et al ldquoExtracorporealshock waves promote healing of collagenase-induced Achillestendinitis and increase TGF-1205731 and IGF-I expressionrdquo Journalof Orthopaedic Research vol 22 no 4 pp 854ndash861 2004

[11] C N van Dijk G E van Dyk P E Scholten and N PKort ldquoEndoscopic calcaneoplastyrdquo American Journal of SportsMedicine vol 29 no 2 pp 185ndash189 2001

[12] C A Uquillas M S Guss D J Ryan L M Jazrawi and EJ Strauss ldquoEverything achilles knowledge update and currentconcepts in management AAOS exhibit selectionrdquoThe Journalof Bone amp Joint SurgerymdashAmerican Volume vol 97 no 14 pp1187ndash1195 2015

[13] P P Sundararajan and T S Wilde ldquoRadiographic clinicalandmagnetic resonance imaging analysis ofinsertional Achillestendinopathyrdquo Journal of Foot and Ankle Surgery vol 53 no 2pp 147ndash151 2014

[14] J R McCormack F B Underwood E J Slaven and T ACappaert ldquoEccentric exercise versus eccentric exercise and softtissue treatment (Astym) in the management of insertionalachilles tendinopathy a randomized controlled trialrdquo SportsHealth vol 8 no 3 pp 230ndash237 2016

[15] M Fahlstrom P Jonsson R Lorentzon and H Alfred-son ldquoChronic Achilles tendon pain treated with eccen-tric calf-muscle trainingrdquo Knee Surgery Sports TraumatologyArthroscopy vol 11 no 5 pp 327ndash333 2003

[16] M K Sayana and N Maffulli ldquoInsertional achilles tendinopa-thyrdquo Foot and Ankle Clinics vol 10 no 2 pp 309ndash320 2005

[17] S Rasmussen M Christensen I Mathiesen and O Simon-son ldquoShockwave therapy for chronic Achilles tendinopathya double-blind randomized clinical trial of efficacyrdquo ActaOrthopaedica vol 79 no 2 pp 249ndash256 2008

[18] J M Robinson J L Cook C Purdam et al ldquoThe VISA-Aquestionnaire a valid and reliable index of the clinical severityof Achilles tendinopathyrdquoBritish Journal of SportsMedicine vol35 no 5 pp 335ndash341 2001

[19] N Smidt D A W M van der Windt W J J Assendelft WL J M Deville I B C Korthals-de Bos and L M BouterldquoCorticosteroid injections physiotherapy or a wait-and-seepolicy for lateral epicondylitis a randomised controlled trialrdquoLancet vol 359 no 9307 pp 657ndash662 2002

[20] Z Wu Y Hua Y Li and S Chen ldquoEndoscopic treatment ofHaglundrsquos syndrome with a three portal techniquerdquo Interna-tional Orthopaedics vol 36 no 8 pp 1623ndash1627 2012

[21] P Jonsson H Alfredson K Sunding M Fahlstrom and JCook ldquoNew regimen for eccentric calf-muscle training inpatients with chronic insertional Achilles tendinopathy resultsof a pilot studyrdquo British Journal of Sports Medicine vol 42 no9 pp 746ndash749 2008

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

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Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


Allocated to deformity groupn = 30

Allocated to nondeformity groupn = 37

Refused to participate (n = 7)

Not meeting inclusion criteria (n = 9)

Excluded (n = 16)

Included in follow-upn = 67

Insertional Achilles tendinopathyn = 83

Figure 1 Flow chart of patients included in follow-up Deformity Haglundrsquos deformity

adventitious Achilles tendon bursitis [11ndash13] The study ofSundararajan and Wilde exhibited that Haglundrsquos deformitywas present in 25 of IAT patients [13]

To our knowledge it remains unclear if IAT concomitantwith Haglundrsquos deformity could achieve great clinical efficacyor not when treated with ESWT Therefore the purpose ofthis study was to reveal clinical outcomes following ESWTbetween IAT patients with or without Haglundrsquos deformityWe hypothesized that patients with Haglundrsquos deformitywill have inferior clinical outcomes compared with patientswithout Haglundrsquos deformity

2 Materials and Methods

21 Participants This studywas approved by the Ethics Com-mittee of FudanUniversity Between September 2014 andMay2015 participants who received shock wave therapy for IATwere recruited retrospectively in this study The diagnosisof IAT was confirmed by the following definition pain andlocalized tenderness at the insertion region of the Achillestendon and decreased activity levels secondary to Achillestendon pain [3 14ndash16] All patients underwent preoperativelateral radiograph of ankle to identify Haglundrsquos deformityThe diagnosis of Haglundrsquos deformity was confirmed bythe following definition remarkable osseous prominence atthe region of the posterosuperior part of the calcaneus andFowler-Philip angle of gt75∘ on lateral plain radiographs[3 11] According to the presence of Haglundrsquos deformityall patients were retrospectively classified into two groupsdeformity group if patients have concomitant Haglundrsquosdeformity and nondeformity group if patients have noHaglundrsquos deformity (Figure 1)

All patients included in this study failed to respond tononsurgical treatment for at least six months Nonoperativetreatment included activity modification (119899 = 65) phys-iotherapy (119899 = 35) nonsteroidal anti-inflammatory drugs(119899 = 62) and the use of orthotics (119899 = 27) Steroid injectionswere not used because of the risk of Achilles tendon ruptureand in some cases unwillingness to try Exclusion criteria for

this research included priorAchilles tendon rupture previoussurgery of the ankle or the Achilles tendon on the involvedside ankle arthritis radiculopathy or systemic neurologicalconditions congenital or acquired deformities of the kneeand ankle peripheral neuropathy lumbar radiculopathyand inability to comply with the recommended treatmentregimen

22 Shock Wave Therapy The shock wave therapy was per-formedwith the patient in the prone position andwas admin-istered once a week for 5 sessions All patients completedall 5 sessions And no patients received more sessions Aradial shock wave device (EMS Swiss Dolor-Clast MunichGermany) was used Radial shock wave is created ballisticallywith the pressurized air source accelerating a bullet to strike ametal applicatorThe kinetic energy produced is transformedinto radially expanding shock waves from the application siteinto the tissue to be treated [3] At each treatment session2000 pulses with an energy flux density of 012mJmm2 anda rate of 8 pulses per second were applied The applicator ofhand-piece was located on the maximal tenderness point andwas properly placed and adjusted according to patientsrsquo feed-back during treatment if necessary [17] No local anestheticwas applied

23 Clinical Evaluation Patients researchers evaluating theclinical outcome and treating physicians were blinded to thepresence of deformity or not Clinical functional evaluationincluded VISA-A score (see Figure 2) and 6-point Likertscale (see Figure 3) collected before treatment and at thefollow-up time point As a self-administered questionnairethe VISA-A score (Appendix) is used to evaluate the severityof Achilles tendinopathy It has previously been shown tobe valid reliable and clinically relevant [18] The content ofVISA-A questionnaire is as follows pain (questions (1)ndash(3))function (questions (4)ndash(6)) and activity (questions (7) and(8)) VISA-A scores have a range of 0 to 100 The 6-pointLikert scale is interpreted as success if patients rate themselves1 or 2 and as failure if patients rate themselves 3 4 5 or 6 [19]


A B C D

Scor

e

VISA-A score100

80

60

40

20

0

lowastlowastlowast


A B C D

Scor

e

lowastlowastlowast

6

4

2

0





3 Results





4 Discussion




















A B

lowastlowast50

40

30

20

10

0


Impr

ovem

ent o

f sco

re

A998400 B998400






5 Conclusion


Appendix




Points

0 1 2 3 4 5 6 7 8 9 10

100mins 0mins


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


0 10Points

0 1 2 3 4 5 6 7 8 9 10


Points0

4

7

10

Not at all










Points

0 7 14 21 30




Points

0 4 10 14 20




Points

0 2 5 7 10



Competing Interests





References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















A B C D

Scor

e

VISA-A score100

80

60

40

20

0

lowastlowastlowast


A B C D

Scor

e

lowastlowastlowast

6

4

2

0





3 Results





4 Discussion




















A B

lowastlowast50

40

30

20

10

0


Impr

ovem

ent o

f sco

re

A998400 B998400






5 Conclusion


Appendix




Points

0 1 2 3 4 5 6 7 8 9 10

100mins 0mins


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


0 10Points

0 1 2 3 4 5 6 7 8 9 10


Points0

4

7

10

Not at all










Points

0 7 14 21 30




Points

0 4 10 14 20




Points

0 2 5 7 10



Competing Interests





References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
































A B

lowastlowast50

40

30

20

10

0


Impr

ovem

ent o

f sco

re

A998400 B998400






5 Conclusion


Appendix




Points

0 1 2 3 4 5 6 7 8 9 10

100mins 0mins


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


0 10Points

0 1 2 3 4 5 6 7 8 9 10


Points0

4

7

10

Not at all










Points

0 7 14 21 30




Points

0 4 10 14 20




Points

0 2 5 7 10



Competing Interests





References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















5 Conclusion


Appendix




Points

0 1 2 3 4 5 6 7 8 9 10

100mins 0mins


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


Strongseverepain

No painPoints

0 1 2 3 4 5 6 7 8 9 10


0 10Points

0 1 2 3 4 5 6 7 8 9 10


Points0

4

7

10

Not at all










Points

0 7 14 21 30




Points

0 4 10 14 20




Points

0 2 5 7 10



Competing Interests





References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















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