Effectiveness of various interventions for non-traumatic osteonecrosis: a pairwise and network meta-analysis.

Background: Osteonecrosis of the femoral head (ONFH) is acknowledged as a prevalent, challenging orthopedic condition for patients. Purpose: This study aimed to evaluate the efficacy of various interventions for non-traumatic ONFH and provide guidance for clinical decision-makers. Methods: We searched PubMed, Embase, Cochrane Library, and Web of Science databases from inception to February 2023 for relevant randomized controlled trials evaluating treatments for femoral head necrosis, without language restrictions. Quality evaluation was performed using the Cochrane risk-of-bias assessment tool, and analysis was performed using Stata 15.1. Results: Eleven randomized controlled trials were included in this study. The meta-analysis results revealed that CellTherapy [MD= -3.46, 95%CI= (-5.06, -1.85)], InjectableMed [MD= -3.68, 95%CI= (-6.11, -1.21)], ESWT [MD= -2.84, 95%CI= (-4.23, -1.45)], ESWT+InjectableMed [MD= -3.86, 95%CI= (-6.22, -1.53)] were significantly more effective in improving VAS pain score than CD+PTRI, as well as CD+BG+CellTherapy, and CD+BG. Furthermore, CD+BG+CellTherapy was better than CD+BG [MD= -0.97, 95%CI= (-1.71, -0.19)]. The SUCRA ranking for HHS score indicated that CellTherapy (77%) has the best effectiveness rate, followed by ESWT+InjectableMed (72.2%), ESWT (58.3%), InjectableMed (50%), CD+PTRI (31.4%), and CD+BG (11%). In terms of WOMAC and Lequesne scores, the meta-analysis showed no statistically significant differences between the experimental group CD+BG+CellTherapy and the control group CD+BG. Conclusion: CellTherapy and non-surgical ESWT combined with medication or CellTherapy have the best effect on ONFH. Surgical CD+BG combined with CellTherapy is more effective than CD+BG alone. ESWT+InjectableMed is recommended for short-term or acute onset patients, while ESWT is recommended for long-term patients. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024540122.

Comparison of the Effects of Low-Dye and Kinesiology Taping in Plantar Fasciitis on Pain and Function: A Randomized Double-Blind Study.

BACKGROUND: Plantar fasciitis (PF) is becoming an increasingly common source of limitation in people's daily activities. As such, this study sought to investigate the effects of kinesiology taping (KT) and low-Dye taping treatments, used in conjunction with extracorporeal shockwave therapy (ESWT), on pain and function in patients with PF. METHODS: To conduct this randomized controlled study, 45 individuals with PF aged 18 to 65 years were included, with 15 individuals assigned to each group: the KT, low-Dye, and control groups. Pain intensity was evaluated using the visual analog scale, and functionality was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scale before and after the study. Each group received three sessions of ESWT. RESULTS: When pretreatment and post-treatment differences were analyzed, first-step pain in the morning, pain with palpation, and pain after prolonged standing were reduced in the KT, low-Dye, and control groups (P < .05 for all). There were differences in the AOFAS total score in the KT (P <.001; r = 2.03), low-Dye (P < .001; r = 1.49), and control (P = .003; r = 0.92) groups. Low-Dye taping was more effective than the control in reducing pain with standing and improving AOFAS function scores (P < .05). Low-Dye taping and KT were effective in improving AOFAS total scores (P < .05) but were not superior to each other (P > .05). CONCLUSIONS: Based on these findings, taping techniques such as KT and low-Dye, combined with conventional treatments such as ESWT, may be beneficial for improving pain and function in individuals with PF. Further randomized controlled trials with longer follow-up are needed to confirm this hypothesis.

Treatment Optimization with Ultrasound for Chronic Heel Pain.

Plantar fasciitis is the most common cause of chronic heel pain. It is characterized by localized inflammation and degeneration of the proximal part of the plantar aponeurosis. Treatment is mainly conservative. Herein, a 54-year-old woman with chronic heel pain was diagnosed as having plantar fascia rupture by ultrasound, probably after extracorporeal shock wave therapy. Corticosteroid injection was avoided after ultrasound imaging. Plantar fascia rupture after extracorporeal shock wave therapy is an unexpected complication. This case report highlights the importance of ultrasound imaging for both diagnosis and injection guidance in patients with plantar fasciitis.

Effects of radial extracorporeal shock wave with different frequencies on acute skeletal muscle injury in rabbits.

To study the efficacy and possible mechanisms of radial extracorporeal shock wave (rESW) with different frequencies for the treatment of acute skeletal muscle injury in rabbits, 48 rabbits of acute injured biceps femoris were randomly divided into 4 groups. Except for the control group, the other groups were treated by rESW with 5 Hz, 10 Hz and 15 Hz, respectively. The injury symptom index scores (ISISs) in the rESW group were significantly lower than those in the control group, with the lowest in the 10 Hz rESW group. Histomorphological features demonstrated a decrease in mononuclear cells and an increase in new myocytes across all groups, with the rESW group showing the most significant changes. The concentrations of PGE2 and IL-1ß were significantly lower in all rESW groups by ELISA compared to the control group. Additionally, the 10 Hz group had lower concentrations than the 5 Hz and 15 Hz group. Compared with the control group, MyoD of the rESW groups was significantly increased, and the expression level of the 10 Hz group was higher than that of the other groups. In conclusion, rESW with 5 Hz, 10 Hz and 15 Hz take certain curative effects on acute biceps femoris injury in rabbits, and the 10 Hz rESW takes advantage over 5 Hz and 15 Hz rESW.

Efficacy of different analgesic strategies combined with conventional physiotherapy program for treating chronic shoulder pain: a systematic review and network meta-analysis.

BACKGROUND: This study aims to investigate the efficacy of five analgesic strategies combined with conventional physiotherapy program (CPT) in managing chronic shoulder pain. METHODS: Two authors independently screened studies, extracted data using a pre-formatted chart, and assessed bias using the Cochrane Risk of Bias tool. A network meta-analysis was performed by the Stata 17.0 and R 4.3.2 software. RESULTS: A total of 14 studies with 862 subjects were identified. These analgesic strategies included extracorporeal shock wave therapy (ESWT), suprascapular nerve block (SSNB), corticosteroid injection (CSI), hyaluronic acid injection (HAI), and kinesio taping (KT). ESWT plus CPT was the most efficient intervention in alleviating pain intensity and improving physical function. SSNB plus CPT was the optimal intervention in improving shoulder mobility. Compared to CPT alone, CSI + CPT only significantly improved the SPADI total score, but showed no difference in pain intensity or shoulder mobility. HAI + CPT showed no significant difference in improving pain intensity, physical function, or shoulder mobility compared to CPT alone. Adding KT to CPT did not yield additional benefits in improving shoulder mobility. CONCLUSION: Overall, in managing chronic shoulder pain, ESWT + CPT was the most effective intervention for reducing pain intensity and improving physical function. SSNB + CPT was optimal for enhancing shoulder mobility. Future rigorous clinical trials with larger sample sizes and higher methodological rigor are strongly required to confirm the current results.

Assessment of Clinical Analgesic Levels and Serum Biomarkers in Patients with Rheumatoid Arthritis: A Randomized Controlled Trial Comparing the Efficacy of Diclofenac and Methotrexate Combined Therapy with Extracorporeal Shockwave Therapy.

Background: Rheumatoid arthritis (RA) is one of the most common forms of arthritis. Extracorporeal shockwave therapy (ESWT) has been identified as a viable alternative therapeutic approach in light of the present protracted clinical course of pharmacological treatment, and changes in levels of marker proteins in the blood samples of RA patients can be utilized to assess treatment outcomes. Methods: A randomized controlled trial was conducted involving forty patients diagnosed with rheumatoid arthritis (RA) who were assigned randomly to two groups. The first group received a combination of diclofenac and methotrexate (MTX) consisting of 25 mg of diclofenac administered thrice daily and 15 mg of MTX administered once weekly. Individual follow-up assessments were carried out after 7 and 14 days. Meanwhile, patients in the second group underwent two sessions of Extracorporeal Shockwave Therapy (ESWT), with a 7-day interval between sessions. Evaluations were conducted on day 7 and day 14. Patients who displayed pain control and stability were advised to continue the treatment, whereas those who had inflammation and discomfort were administered specific medications, and their progress was closely monitored until day 28. Blood samples were collected from both groups prior to treatment, after the first treatment, and after the second treatment. Four marker proteins (NRP-1, CELF-6, COX-2, and RGS-1) and two inflammatory cytokines (IL-6 and IL-17) were measured using western blot and RT-PCR techniques. A statistical analysis was conducted on the levels of specific proteins and inflammatory factors before and after treatment to evaluate its impact. Result: Both groups exhibited statistically significant differences in the serum level of target biomarkers before and after the intervention. However, the ESWT group demonstrated a more noticeable effect, while the diclofenac + MTX group exhibited a delayed anti-inflammatory effect compared to ESWT. Conclusion: Both treatments significantly improved joint function, relieved pain, and reduced inflammation in patients. However, ESWT demonstrated a more prominent clinical analgesic effect compared to the combination treatment of diclofenac and MTX. Furthermore, ESWT produced a more immediate and noteworthy anti-inflammatory impact by regulating NRP-1 expression, a trophic factor receptor that facilitates vascular endothelial cell migration and tissue repair through angiogenesis, and regulating RGS-1 to limit inflammatory signal transmission and immune cell activation.

Safety of low-intensity extracorporeal shock wave therapy in prostate disorders: in vitro and in vivo evidence.

ABSTRACT: Recent evidence suggests that low-intensity extracorporeal shock wave therapy (Li-ESWT) is a promising treatment for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS); however, its safety in pelvic organs, particularly prostate tissues and cells, remains unclear. The current study evaluates the risks of prostate cell damage or oncogenesis following the administration of Li-ESWT for prostatitis. To this end, a robust in vitro model (Cell Counting Kit-8 [CCK-8] assay, clone formation assay, cell scratch assay, lactate dehydrogenase [LDH] release assay, flow cytometry, and immunoblotting assay) was designed to examine the effects of Li-ESWT on cell proliferation, clonogenicity, migration, membrane integrity, and DNA damage. Exome sequencing of Li-ESWT-treated cells was performed to determine the risk of carcinogenesis. Furthermore, an in vivo rat model ( n = 20) was employed to assess the effects of Li-ESWT on cancer biomarkers (carcinoembryonic antigen [CEA], Ki67, proliferating cell nuclear antigen [PCNA], and gamma-H2A histone family member X, phosphorylation of the H2AX Ser-139 [ γ -H2AX]) in prostate tissue. Based on our findings, Li-ESWT promotes cellular growth and motility without inducing significant cell membrane or DNA damage or alterations. Genetic analyses did not demonstrate an increase in mutations, and no damage to prostate tissue or upregulation of cancer biomarkers was detected in vivo. This comprehensive in vitro and in vivo assessment confirms the safety of Li-ESWT in managing prostate disorders.

Evidence of restorative therapies in the treatment of Peyronie disease: A narrative review.

OBJECTIVE: To describe the evidence of Platelet Rich Plasma (PRP), Stem cells therapy (SCT) and Extracorporeal shockwave therapy (ESWL) for the treatment of Peyronies disease (PD), including information from the main urological society guidelines. MATERIALS AND METHODS: A literature review of PubMed articles published between 2000 and 2023 was conducted, utilizing keywords such as "Peyronie's Disease", "Penile curvature", "Platelet Rich Plasma", "Stem cells", and "Extracorporeal shockwave therapy". Only full-text articles in English were included, excluding case reports and opinions. RESULTS: A considerable number of clinical trials were conducted using PRP penile injections for therapy of PD, showing reduction of curvature, plaque size and improvement in quality of life. Preclinical studies in rats have shown the potential benefit of adipose-derived stem cells, with improvements in erectile function and fibrosis. Human studies with mesenchymal stem cells demonstrated promising results, with reduction of curvature and plaque size. ESWL effects on PD were investigated in randomized clinical trials and demonstrated no significant impact in curvature or plaque size, but reasonable effect on pain control. CONCLUSION: Restorative therapies has emerged as an innovative treatment option for PD and the results from current studies appear to be promising and demonstrated good safety profile. Unfortunately, due to scarce evidence, PRP and SCT are still considered experimental by American Urological Association (AUA) and European Association of Urology (EAU) guidelines. ESWT is recommended, by the same guidelines, for pain control only. More high-quality studies with long-term follow-up outcomes are needed to evaluate efficacy and reproducibility of those therapies.

The application of extracorporeal shock wave therapy on stem cells therapy to treat various diseases.

In the last ten years, stem cell (SC) therapy has been extensively used to treat a range of conditions such as degenerative illnesses, ischemia-related organ dysfunction, diabetes, and neurological disorders. However, the clinical application of these therapies is limited due to the poor survival and differentiation potential of stem cells (SCs). Extracorporeal shock wave therapy (ESWT), as a non-invasive therapy, has shown great application potential in enhancing the proliferation, differentiation, migration, and recruitment of stem cells, offering new possibilities for utilizing ESWT in conjunction with stem cells for the treatment of different systemic conditions. The review provides a detailed overview of the advances in using ESWT with SCs to treat musculoskeletal, cardiovascular, genitourinary, and nervous system conditions, suggesting that ESWT is a promising strategy for enhancing the efficacy of SC therapy for various diseases.

Shock Wave Therapy Alleviates Hypoxia/Reoxygenation-Induced Cardiomyocyte Injury by Inhibiting Both Apoptosis and Ferroptosis.

Shock wave therapy (SWT) is a new alternative therapy for patients with severe coronary artery disease that improves myocardial ischemic symptoms by delivering low-energy shock wave stimulation to ischaemic myocardium with low-energy pulsed waves. However, the specific mechanism of its protective effect is not fully understood, especially for the protective mechanism in cardiomyocytes after hypoxia/reoxygenation (H/R). We selected a rat H9c2 cardiomyocyte cell line to establish a stable H/R cardiomyocyte injury model by hypoxia/reoxygenation, and then used SWT for therapeutic intervention to explore its cardiomyocyte protective mechanisms. The results showed that SWT significantly increased cell viability and GSH levels while decreasing LDH levels, ROS levels, and MDA levels. SWT also improved mitochondrial morphology and function of cells after H/R. Meanwhile, we found that SWT could increase the expression of GPX4, xCT, and Bcl-2, while decreasing the expression of Bax and cleaved caspase-3, and inhibiting cardiomyocyte apoptosis and ferroptosis. Moreover, this protective effect of SWT on cardiomyocytes could be significantly reversed by knockdown of xCT, a key regulator protein of ferroptosis. In conclusion, our study shows that SWT can attenuate hypoxia-reoxygenation-induced myocardial injury and protect cardiomyocyte function by inhibiting H/R-induced apoptosis and ferroptosis, and this therapy may have important applications in the treatment of clinical myocardial ischemic diseases.

A Treatment Protocol for Achilles Tendinopathy with Extracorporeal Shockwave Therapy.

Achilles tendinopathy is a common musculoskeletal condition characterized by pain, lower muscle strength, gait abnormality, and reduced quality of life. There are two categories of Achilles tendinopathy: insertional Achilles tendinopathy and mid-portion Achilles tendinopathy. Currently, mechanical loading programs are considered the standard of care for the population with Achilles tendinopathy. Extracorporeal shockwave therapy (ESWT) is considered a secondary conservative treatment for tendinopathy as it is effective and safe. It can be used either as a monotherapy or as part of a multimodal treatment plan. ESWT has been extensively studied in orthopedics, where it was shown to intensify fracture healing and successfully treat overuse conditions of tendons and fascia. It is believed that shockwaves have both mechanical and cellular effects that ultimately result in the repair of damaged tendinous tissue and improved function of the Achilles tendon. However, there is a lack of consistency in the literature surrounding the effectiveness, especially the protocols. Therefore, we enrolled 36 patients with a diagnosis of Achilles tendinopathy, using radial ESWT (0.48 mJ/mm2, 2,000 shockwaves, 10 Hz, 1.6 bars, 2 sessions once a week). Freedom from pain was experienced by 16.7% of these participants, and there was a significant decrease in pain in all of them.

Radial extracorporeal shockwave promotes osteogenesis-angiogenesis coupling of bone marrow stromal cells from senile osteoporosis via activating the Piezo1/CaMKII/CREB axis.

Radial extracorporeal shockwave (r-ESW) and bone marrow stromal cells (BMSCs) have been reported to alleviate senile osteoporosis (SOP), but its regulatory mechanism remains unclear. In this study, we firstly isolated human BMSCs from bone marrow samples and treated with varying r-ESW doses. And we found that r-ESW could enhance the proliferation of SOP-BMSCs in a dose-dependent manner by EdU assay. Subsequently, the impact of r-ESW on the proliferation, apoptosis and multipotency of BMSCs was assessed. And the outcomes of flow cytometry, Alizarin red S (ARS), and tube formation test demonstrated that the optimal shockwave obviously boosted SOP-BMSCs osteogenesis and angiogenesis but exhibited no significant impact on cell apoptosis. Additionally, the signaling of Piezo1 and CaMKII/CREB was examined by Western blotting, qPCR and immunofluorescence. And the results showed that r-ESW promoted the expression of Piezo1, increased intracellular Ca2+ and activated the CaMKII/CREB signaling pathway. Then, the application of Piezo1 siRNA hindered the r-ESW-induced enhancement ability of osteogenesis coupling with angiogenesis of SOP-BMSCs. The use of the CaMKII/CREB signaling pathway inhibitor KN93 suppressed the Piezo1-induced increase in osteogenesis and angiogenesis in SOP-BMSCs. Finally, we also found that r-ESW might alleviate SOP in the senescence-accelerated mouse prone 6 (SAMP6) model by activating Piezo1. In conclusion, our research offers experimental evidence and an elucidated underlying molecular mechanism to support the use of r-ESW as a credible rehabilitative treatment for senile osteoporosis.

Extracorporeal shockwave therapy (ESWT) in an outpatient wound care clinic: case series analysis of a non-invasive technology in the management of chronic wounds for wound bed preparation.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) has been shown to reduce wound dimensions and healing time in chronic wounds and should be considered a valuable tool in the healing of chronic complex lower extremity wounds. PURPOSE: The aim of this small case series was to evaluate the effect of ESWT on complex chronic wounds in patients with multiple comorbidities in a medically underserved outpatient wound care clinic setting. METHODS: All patients had baseline wound measurements taken. Pictures of the wounds were also taken at the time of the initial visit. Patients selected for ESWT received weekly treatments for a maximum recorded duration of 12 weeks in the form of focused electro-hydraulic acoustic pulses. Wound beds were cleansed according to standard of care. RESULTS: Thirteen patients were followed with a total of 18 wounds treated. After retrospectively analyzing the data, 3 subjects and a total of 5 wounds were excluded, leaving 10 total subjects and 13 wounds. Out of these wounds, 12 healed completely by or before week 12 of ESWT. All wounds demonstrated significant wound dimension reduction during the first 12 weeks of treatment. CONCLUSION: ESWT could offer accessible, fast, safe, and cost-effective management of some complex chronic wounds. Further research is needed to validate these findings.

Effect of extracorporeal shockwave therapy on the immunomodulatory and anti-inflammatory properties of cultured equine umbilical cord blood mesenchymal stromal cells.

There is a knowledge gap regarding the effect of extracorporeal shockwave treatment (ESWT) on the stress response and immunomodulatory and anti-inflammatory properties of equine umbilical cord blood mesenchymal stromal cells (CB-MSCs). The objective of this study was to investigate the presence of cellular oxidative stress, inflammatory response, and production of growth factors in CB-MSCs after treatment with ESWT. We hypothesized that CB-MSCs treated with ESWT will experience higher levels of cellular stress and increased production of anti-inflammatory cytokines and growth factors compared to untreated CB-MSCs.

Il existe un manque de connaissances concernant l'effet du traitement extracorporel par ondes de choc (ESWT) sur la réponse au stress et les propriétés immunomodulatrices et anti-inflammatoires des cellules stromales mésenchymateuses du sang de cordon ombilical équin (CB-MSCs). L'objectif de cette étude était d'étudier la présence de stress oxydatif cellulaire, de réponse inflammatoire et de production de facteurs de croissance dans les CB-MSCs après un traitement par ESWT. Nous avons émis l'hypothèse que les CB-MSCs traitées par ESWT connaîtront des niveaux plus élevés de stress cellulaire et une production accrue de cytokines anti-inflammatoires et de facteurs de croissance par rapport aux CB-MSCs non traitées.(Traduit par Docteur Serge Messier).

[Micro-energy medicine in the treatment of erectile dysfunction: An update].

Erectile dysfunction (ED) is one of the most common sexual disorders in males, which seriously affects the health of the patient and well-being of the family. The therapeutic strategy of ED is an individualized comprehensive treatment based on phosphodiesterase inhibitors. At present, as a new option for the treatment of ED, micro-energy medicine has attracted more and more attention in its therapeutic effects and advantages. This article presents an overview of the progress in the studies of micro-energy medicine in the treatment of ED.

Effects of extracorporeal shockwave therapy versus ultrasonic therapy and deep friction massage in the management of lateral epicondylitis: a randomized clinical trial.

The study's goal was to compare and evaluate the benefits of deep friction massage and ultrasonic therapy (US) vs extracorporeal shockwave therapy (ESWT) for people with lateral epicondylitis. This double-blind, parallel-arm randomized clinical trial was conducted after ethical approval on a sample of 80 subjects with lateral epicondylitis. Participants were enrolled based on predefined eligibility criteria. They were randomly allocated to groups A and B. Group A received ESWT, while Group B received the US combined with deep friction massage. Data was collected using the Numeric Pain Rating Score (NPRS) and Patient-rated tennis elbow evaluation questionnaire (PRTEE) at baseline, at 3rd, and at 7th week of treatment. On the basis of the normality of the data, a non-parametric test was applied to evaluate between-group and within-group differences. P value ≤ 0.05 was considered significant. There was a significant difference between groups (p < 0.001). Comparisons of PRTEE scores at 3rd week and 7th week of intervention were found significant for both groups (p < 0.001). While considering between-group comparisons based on percentile scores of PRTEE at baseline, 3rd and 7th week of intervention, in group A Median (IQR) at the baseline was 24.00 (5.00), at 3rd week, 10.00 (5.00) and 7th week was 1.50 (2.50) and in group B Median (IQR) at the baseline was 25.00 (4.00), at 3rd week 19.50 (4.50) and at 7th week was 11.50 (2.50). The results were significant in both groups (p = 0.000), but between-group analysis revealed that ESWT is more effective in patients with lateral epicondylitis.

Effectiveness of extracorporeal shock wave therapy on functional ability in grade IV knee osteoarthritis - a randomized controlled trial.

Extracorporeal shockwave therapy (ESWT) is a non-invasive physical therapy intervention that has emerged in the recent past to address the upswing of osteoarthritis (OA). However, insufficient evidence is present to prove the efficacy of ESWT on grade IV knee osteoarthritis (KOA). The present study aimed to examine the effects of ESWT on functional ability in patients suffering from grade IV KOA. Thirty volunteers aged 45-60 years with grade IV primary KOA diagnosed by an orthopaedic surgeon based on the Kellgren-Lawrence score participated in the study. The participants were equally and randomly divided into two groups (i.e. experimental and control), with 15 participants in each group. The participants in the control group performed conventional physiotherapy (CPT) that included ultrasound therapy, isometric quadriceps, SLR and isometric hip adductor strengthening exercises. The participants in the experimental group received ESWT in addition to CPT. Lower extremity functional scale (LEFS) score was measured before and after the four weeks of intervention. In both groups, a statistically significant (p = 0.001) improvement in LEFS was observed. In the experimental groups, it improved by 81.92% and in the control groups by 48.15%. A statistically significant (p < 0.001) difference was observed in LEFS post-intervention values between both groups. As demonstrated by our trial results, the addition of ESWT to the CPT program will yield beneficial results in ameliorating the functional disability in patients with primary KOA (grade IV). Further studies are needed to confirm and apply these findings to a larger cohort.

Is radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses more effective than advice plus customised foot orthoses alone in the treatment of plantar fasciopathy? A double-blind, randomised, sham-controlled trial.

OBJECTIVES: To assess whether radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses is more effective than advice plus customised foot orthoses alone in alleviating heel pain in patients with plantar fasciopathy. METHODS: 200 patients with plantar fasciopathy were included in a four-arm, parallel-group, sham-controlled, observer-blinded, partly patient-blinded trial. At baseline, before randomisation, all patients received advice plus customised foot orthoses. Patients were randomised to rESWT (n=50), sham-rESWT (n=50), exercise (n=50) or advice plus customised foot orthoses alone (n=50). Patients in the rESWT and sham-rESWT groups received three treatments. The exercise programme comprised two exercises performed three times a week for 12 weeks, including eight supervised sessions with a physiotherapist. Patients allocated to advice plus customised foot orthoses did not receive additional treatment. The primary outcome was change in heel pain during activity in the previous week per Numeric Rating Scale (0-10) from baseline to 6-month follow-up. The outcome was collected at baseline, and 3, 6 and 12 months. RESULTS: The primary analysis showed no statistically significant between-group differences in mean change in heel pain during activity for rESWT versus advice plus customised foot orthoses (-0.02, 95% CI -1.01 to 0.96), sham-rESWT versus advice plus customised foot orthoses (0.52, 95% CI -0.49 to 1.53) and exercise versus advice plus customised foot orthoses (-0.11, 95% CI -1.11 to 0.89) at 6 months. CONCLUSION: In patients with plantar fasciopathy, there was no additional benefit of rESWT, sham-rESWT or a standardised exercise programme over advice plus customised foot orthoses in alleviating heel pain. TRIAL REGISTRATION NUMBER: NCT03472989.

Staying in the Game: Interventions for Managing Achilles Tendinopathy in the In-Season Athlete.

ABSTRACT: Achilles tendinopathy is a common overuse injury that is traditionally managed with activity modification and a progressive eccentric strengthening program. This narrative review describes the available evidence for adjunctive procedural interventions in the management of midportion and insertional AT, specifically in the athletic population. Safety and efficacy data from available literature on extracorporeal shockwave therapy, platelet-rich plasma, high-volume injectate with or without tendon scraping, and percutaneous needle tenotomy are used to propose an algorithm for treatment of Achilles tendinopathy for the in-season athlete.