Physical modalities with eccentric exercise are no better than eccentric exercise alone in the treatment of chronic achilles tendinopathy: a systematic review and meta-analysis

The short answer

Does adding a physical modality (shockwave, laser, splint, or orthoses) to eccentric exercise improve pain and function in chronic Achilles tendinopathy more than eccentric exercise alone?

This systematic review pooled 8 randomized trials to test whether adding a physical modality (such as shockwave therapy, laser, night splint, or orthoses) to eccentric exercise helps chronic Achilles tendinopathy more than eccentric exercise alone. Across pain and function measures at both 4 weeks and 12 to 16 weeks, the added modalities produced no statistically significant extra benefit. The authors conclude eccentric exercise alone is an evidence-based strategy and the modalities add nothing clinically meaningful, though heterogeneity was substantial.

ChallengesRead paper

Meta-analysis421 ParticipantsLimited evidence

Key points

Achilles tendinopathy is a degenerative tendon condition causing pain and reduced activity, common in runners and other athletes.
Eccentric exercise (controlled lengthening of the calf muscle) is the mainstay of rehabilitation for this condition.
Adding physical modalities such as shockwave therapy, low-level laser, night splints, or foot orthoses did not significantly outperform eccentric exercise alone.
This held true for the VISA-A function score, numeric pain rating, and load-induced pain, at both short and longer follow-up.
The authors suggest some modality doses used were higher than recommended, which may have limited any added effect.

How it was conducted

Design: Systematic review with random-effects meta-analysis of randomized controlled trials (PRISMA, PROSPERO registered)
Search: PubMed, PEDro, MEDLINE, CINAHL, and Google Scholar from inception to November 2020; 8 of 6,404 records included
Participants: Adults 18 to 70 with chronic (over 12 weeks) Achilles tendinopathy; 199 at short-term and 421 at long-term follow-up
Intervention: Physical modality plus eccentric exercise (PMEE) versus eccentric exercise alone (EE)
Outcomes: VISA-A score, Numeric Pain Rating Scale, and load-induced pain at 4 weeks and 12 to 16 weeks
Analysis: Standardized mean differences with 95% CI; PEDro and Cochrane risk-of-bias tools; all 8 studies rated low risk of bias

What they found

VISA-A short-term (4 weeks): pooled SMD 0.03 (95% CI -0.46 to 0.53, p = 0.89, I2 = 60%), 4 studies, 199 participants; not significant.
VISA-A long-term (12 to 16 weeks): pooled SMD 0.43 (95% CI -0.05 to 0.92, p = 0.08, I2 = 82%), 8 studies, 421 participants; not significant.
NPRS short-term: pooled SMD -0.16 (95% CI -0.72 to 0.40, p = 0.57, I2 = 40%), 3 studies, 91 participants.
NPRS long-term: pooled SMD -0.39 (95% CI -1.11 to 0.32, p = 0.28, I2 = 62%), 3 studies, 91 participants.
Load-induced pain long-term: pooled SMD -0.46 (95% CI -1.08 to 0.15, p = 0.14, I2 = 74%), 3 studies, 168 participants; not significant.

Limitations

Only 8 small trials were included, and several pooled analyses showed substantial to considerable heterogeneity.
Only English-language, peer-reviewed studies were included, raising language and publication bias.
The included trials lacked uniform diagnostic grading of chronic Achilles tendinopathy.
The long-term VISA-A result trended toward favoring exercise alone but narrowly missed significance, so it is not conclusive.

Why it matters

For patients: Doing your eccentric calf exercises is the key part of recovery; adding shockwave, laser, splints, or orthoses is unlikely to speed it up.
For clinicians: Prioritize eccentric loading for chronic Achilles tendinopathy, as current evidence shows added physical modalities give no extra benefit.
For readers: Pooled trial data show physical modalities add no measurable advantage over eccentric exercise alone.

Source

doi:10.1016/j.foot.2022.101927

Read the original paper

Clinically assessing this area? See the ankle & foot special tests.