Rompe Jan D, Furia John, Maffulli Nicola
OrthoTrauma Evaluation Center, Hans-Zoeller Strasse 83, D-55130 Mainz, Germany.
J Bone Joint Surg Am. 2008 Jan;90(1):52-61. doi: 10.2106/JBJS.F.01494.
Nonoperative management of chronic tendinopathy of the Achilles tendon insertion has been poorly studied. With the recently demonstrated effectiveness of eccentric loading and of repetitive low-energy shock wave therapy in patients with midsubstance Achilles tendinopathy, the aim of the present randomized, controlled trial was to verify the effectiveness of both procedures exclusively in patients with insertional Achilles tendinopathy.
Fifty patients with chronic (six months or more) recalcitrant insertional Achilles tendinopathy were enrolled in a randomized, controlled study. All patients had received treatment, including local injections of an anesthetic and/or corticosteroids, a prescription of nonsteroidal anti-inflammatory drugs, and physiotherapy, without success for at least three months. A computerized random-number generator was used to draw up an allocation schedule. Twenty-five patients were allocated to receive eccentric loading (Group 1), and twenty-five patients were allocated to treatment with repetitive low-energy shock wave therapy (Group 2). Analysis was on an intention-to-treat basis. Primary follow-up was at four months, and afterward patients were allowed to cross over. The last follow-up evaluation was at one year after completion of the initial treatment. The patients were assessed for pain, function, and activity with use of a validated questionnaire (the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire).
At four months from baseline, the mean VISA-A score had increased in both groups, from 53 to 63 points in Group 1 and from 53 to 80 points in Group 2. The mean pain rating decreased from 7 to 5 points in Group 1 and from 7 to 3 points in Group 2. Seven patients (28%) in Group 1 and sixteen patients (64%) in Group 2 reported that they were completely recovered or much improved. For all outcome measures, the group that received shock wave therapy showed significantly more favorable results than the group treated with eccentric loading (p = 0.002 through p = 0.04). At four months, eighteen of the twenty-five patients from Group I had opted to cross over, as did eight of the twenty-five patients from Group 2. The favorable results after shock wave therapy at four months were stable at the one-year follow-up evaluation.
Eccentric loading as applied in the present study showed inferior results to low-energy shock wave therapy as applied in patients with chronic recalcitrant tendinopathy of the insertion of the Achilles tendon at four months of follow-up. Further research is warranted to better define the indications for this treatment modality.
对于跟腱附着点慢性肌腱病的非手术治疗，相关研究较少。鉴于最近已证实离心负荷和重复性低能量冲击波疗法对跟腱中段肌腱病患者有效，本随机对照试验的目的是专门验证这两种方法对跟腱附着点肌腱病患者的有效性。
五十例慢性（六个月或更长时间）顽固性跟腱附着点肌腱病患者被纳入一项随机对照研究。所有患者均接受过治疗，包括局部注射麻醉剂和/或皮质类固醇、开具非甾体类抗炎药处方以及物理治疗，但至少三个月未见成效。使用计算机随机数生成器制定分配方案。二十五例患者被分配接受离心负荷治疗（第1组），二十五例患者被分配接受重复性低能量冲击波疗法治疗（第2组）。分析采用意向性分析。主要随访时间为四个月，之后允许患者交叉治疗。最后一次随访评估在初始治疗完成后一年进行。使用经过验证的问卷（维多利亚运动评估-跟腱[VISA-A]问卷）对患者的疼痛、功能和活动情况进行评估。
从基线开始四个月时，两组患者的VISA-A平均评分均有所提高，第1组从53分提高到63分，第2组从53分提高到80分。第1组患者的平均疼痛评分从7分降至5分，第2组从7分降至3分。第1组有7例患者（28%）、第2组有16例患者（64%）报告称他们已完全康复或有很大改善。对于所有结局指标，接受冲击波疗法的组比接受离心负荷治疗的组显示出明显更优的结果（p值从0.002至0.04）。四个月时，第1组的25例患者中有18例选择交叉治疗，第2组的25例患者中有8例选择交叉治疗。冲击波疗法在四个月时取得的良好效果在一年随访评估时保持稳定。
在本研究中应用的离心负荷治疗在随访四个月时，其效果不如应用于慢性顽固性跟腱附着点肌腱病患者的低能量冲击波疗法。有必要进行进一步研究以更好地确定这种治疗方式的适应证。
