Table 1.
Studies investigating combined ESWT and exercise interventions for tendinopathies.
| Study and design | Sample | Interventions | Outcome Measures | Results |
|---|---|---|---|---|
| Achilles tendinopathy | ||||
|
Rompe 2009 RCT |
n = 68 | 1: 12-week eccentric exercise protocol. 2: eccentric exercise plus R-ESWT for 3 sessions. | VISA-A, VAS. | Combination more effective for pain and function at 4 months, no difference between groups at 1 year. |
| Mansur 2017 Prospective cohort |
n = 19 | 2 sessions of R-ESWT, and 12-week eccentric strengthening protocol. | VAS, AOFAS, VISA-A | Intervention considered effective for pain and function at 24 weeks. |
| Pavone 2016 Case series |
n = 40 | 4 sessions of F-ESWT combined with eccentric exercises. | VAS, AOFAS | Combined intervention effective at 12 months and recommended as superior to eccentric exercise only. |
| Wheeler 2019 Case series |
n = 39 | 3 sessions of R-ESWT and Home exercise: stretching, isometric and eccentric strengthening, core stability and proprioception exercises. | VISA-A | Significant improvements in insertional tendinopathy pain and function at 6 months but not for non-insertional tendinopathy. |
| Wheeler 2020 Prospective Cohort |
n = 63 | 1: 3 sessions of ESWT. 2: High volume image guided injection. Both groups received home eccentric strengthening. | VAS, VISA-A, MOXFQ. | Significant improvements for pain and function in both groups, no significant differences between groups at 3 months. |
| Patellar tendinopathy | ||||
|
Thijs et al. 2017 RCT |
n= 52 | 1: 3 sessions of F-ESWT. 2: 3 sessions of sham ESWT. Both groups received eccentric squat exercises for 3 months | VISA-P | Both groups effective at 24 weeks, no additional effect of ESWT to eccentric exercises. |
| van der worp 2014 RCT |
n = 43 (57 tendons) | 1. 3 sessions of F-ESWT 2. 3 sessions of R-ESWT Both groups received eccentric training based on decline squats. |
VISA-P | Both treatments effective at 14 weeks. No statistically significant differences in effectiveness between F-ESWT and R-ESWT. |
| van Rijn 2019 Secondary analysis from 3 RCTs |
n = 138 | 1. ESWT 2. ESWT plus eccentric training 3. eccentric training 4. topical glyceryl trinitrate patch plus eccentric training 5. Placebo | VISA-P | Clinical improvements were significantly higher in the eccentric training and ESWT plus eccentric training groups compared to other groups. |
| Vetrano 2013 RCT |
n = 46: athletes only. | 1. 2 PRP injections. 2. 3 sessions of F-ESWT Both groups received stretching and strength exercise for 2 weeks |
VAS, VISA-P, Modified Blazina score. | PRP plus exercise had significantly better improvement at 6 and 12 months. |
| Rotator cuff tendinopathy | ||||
|
Santamato 2016 RCT |
n = 30 | 1: 3 sessions of F-ESWT. 2: F-ESWT plus 10 supervised sessions of isokinetic exercise. | VAS, CMS | Combined group had greater reduction of pain, and superior functional recovery and muscle endurance at 2 months compared with F-ESWT |
| Kvalvaag 2018 RCT |
n = 142 | 1. 4 sessions of Sham R-ESWT 2. 4 sessions of R-ESWT. Both groups received supervised exercise for 12-weeks. |
SPADI | Both groups improved at 24 weeks and 1 year but there were no differences between the groups. Patients with calcification had a greater improvement at 24 weeks but not 1 year with R-ESWT plus exercise. |
| Carlisi 2018 Pilot RCT |
n = 22 | 1. F-ESWT plus supervised eccentric training 2. F-ESWT only |
p-NRS, DASH | Both groups improved pain and function at 9 weeks with no difference between groups. F-ESWT no benefit to eccentric exercise. |
| Lateral elbow tendinopathy | ||||
|
Celik 2019 RCT |
n = 43 | 1. 12 sessions of PBMT 2. 4 sessions of F-ESWT. Both groups received home stretching and eccentric strengthening exercises. |
VAS, Strength, GRC | Improvements for VAS, elbow extension and shoulder flexion strength were superior in the PBMT group. Handgrip strength improved in both groups. More patients in PBMT group reported improvement with GRC. Both treatments effective with PBMT superior to ESWT. |
| Eraslan 2018 RCT |
n = 45 | 1: 15 sessions of physiotherapy with home exercise including stretching and eccentric strengthening 2: physiotherapy plus kinesio taping for 3 weeks. 3. physiotherapy plus 3 sessions of ESWT | VAS, Grip strength, PRTEE | Pain and function improved in all groups. The kinesio taping and ESWT groups improved function better than the physiotherapy group. |
| Testa 2020 Case series |
n = 60 | 4 sessions of F-ESWT combined with eccentric exercises 4 times per week for one month. | VAS, PRTEE-1 | Combined treatment effective for pain and function at 1, 6 and 12 months. |
| Plantar heel pain | ||||
|
Akinoglu 2017 RCT |
n = 54 females only. | 1. Home exercise including PFSS for 4 weeks 2. 3 sessions of R-ESWT plus exercise 3. 7 sessions of US plus exercise |
FFI, AOFAS. | Improved pain and function in all groups with US more effective than other groups. R-ESWT plus exercise superior to exercise alone. |
| Chew 2013 RCT |
n = 53 | 1. Home gastrocnemius stretching and PFSS 2. ACP injection plus stretching 3. 2 sessions of ESWT plus stretching | VAS, AOFAS, VAS, plantar fascia thickness | ACP and ESWT plus stretching more effective for pain and function than stretching at 6 months. No significant difference between ACP and ESWT. |
| Cinar 2018 RCT |
n = 66 | 1. Insoles for 3 months and stretching. 2. 3 sessions of R-ESWT, insoles and stretching. 3. 10 sessions LLLT, insoles and stretching | FFI-p, NRS-p. | All groups effective, LLLT and ESWT more effective than usual care, LLLT more effective than ESWT in reducing pain at 3 months. |
| Vahdatpour 2018 RCT |
n = 80 | 1. 4 sessions of ESWT plus topical corticosteroid and home stretching 2. 4 sessions of ESWT plus Vaseline and stretching | VAS, RMS. | Both groups effective, combined group more effective than control at 1 month for pain and function, no difference at 3 months. |
| Takla 2019 RCT |
n = 120 | 1. sham-PBMT plus stretching for 3 weeks 2. 9 sessions of PBMT plus stretching 3. 3 sessions of ESWT plus stretching 4. 3 sessions ESWT, 9 sessions of PBMT and stretching. | VAS, FFI-d, PPT. | Both ESWT and PBMT were effective for pain and function at 12 weeks. PBMT with ESWT was superior to ESWT and PBMT alone, and ESWT was superior to PBMT. |
| Grecco 2013 RCT |
n = 40 | 1. 10 sessions of US plus home stretching 2. 3 sessions of R-ESWT plus home stretching. | VAS, PPT | Both treatments effective for pain and function. R-ESWT superior at 3 months, no difference between groups at 12 months. |
| Eslamian 2016 RCT |
n = 40 | 1. 5 sessions of R-ESWT and home stretching 2. Single CSI and stretching | VAS, FFI | Both groups effective for pain and function at 8 weeks, ESWT superior to CSI. |
| Rompe 2015 RCT |
n = 152, PHP 12 months | 1. 3 sessions of ESWT plus PFSS 2. 3 sessions of ESWT |
FFI, Morning pain | Combined group more effective for pain and function at 4 months, no difference between groups at 24 months. |
| Ulusoy 2017 RCT |
n = 60, PHP 6 months or longer | 1. 15 sessions of LLLT and home stretching 2. 15 sessions of US and home stretching 3. 3 sessions of ESWT and home stretching | VAS, AOFAS. | All groups effective for pain and function. LLLT and ESWT resulted in similar outcomes and were more successful than US. |
| Okur 2019 RCT |
n = 83 | 1. 3 sessions of R-ESWT plus home stretching for 4 weeks. 2. Custom orthotics plus home stretching for 4 weeks | VAS | Both groups effective in reducing pain with neither group superior at 24 nor 48 weeks. |
| Wheeler 2018 Case series |
n = 35, PHP duration 24 months | 3 sessions of R-ESWT and home exercise: stretching, foot and calf strengthening, balance exercises for 3 weeks. | VAS, FFI, MOXFQ | Intervention effective for pain and function at 3 months, but not in overall markers of health, anxiety/depression scores, or activity levels. |
Abbreviations: AOFAS = American Orthopaedic Foot and Ankle Society; CMS = Constant-Murley score; CSI = Corticosteroid injection; DASH = disabilities of the arm, shoulder, and hand; ESWT = extracorporeal shockwave therapy; F-ESWT = focused extracorporeal shockwave therapy; FFI = Foot function index; GRC = Global Rating of Change; LLLT = low level laser therapy; MOXFQ = The Manchester-Oxford Foot Questionnaire; n = number; PBMT = photobiomodulation therapy; PRP = Platelet-rich plasma; PRTEE-1 = Patient Rated Tennis Elbow Evaluation Test; PHP = Plantar heel pain; p-NRS = pain numeric rating scale; PPT = Pain pressure threshold; RCT = randomised controlled trial; R-ESWT = radial extracorporeal shockwave therapy; RMS = Roles and Maudsley score; SPADI = The Shoulder Pain and Disability Index; US = ultrasound; VAS = Visual Analogue Scale; VISA-A = Victorian Institute of Sport Assessment-Achilles score; VISA-P = Victorian Institute of Sport Assessment-Patella score.