Shockwave therapy for Achilles tendinopathy
The Achilles guidance is the newest of the four musculoskeletal assessments NICE has published, and it is also the one that calls the efficacy evidence limited in quantity as well as inconsistent. What that means for a decision about a course is set out below.
What you're seeing
Understanding Achilles tendinopathy
Achilles tendinopathy is pain and thickening in the tendon that runs from the calf to the heel, and it behaves like an overload problem rather than an inflammation. It presents in two distinct places, and the distinction changes the treatment. Midportion pain sits two to six centimetres above the heel bone. Insertional pain sits at the attachment itself and tolerates compression far less well, which is why the same loading programme does not suit both.
NICE assessed shockwave for this condition in interventional procedures guidance IPG571, now HealthTech guidance HTG426, published on 21 December 2016. Recommendation 1.1 concludes that the evidence "raises no major safety concerns", that "current evidence on efficacy of the procedure is inconsistent and limited in quality and quantity", and that the procedure "should only be used with special arrangements for clinical governance, consent and audit or research".
Read the middle clause carefully, because it says more than the plantar fasciitis guidance does. For the heel, NICE called the efficacy evidence inconsistent. For the Achilles it called it inconsistent and thin. Those are different statements, and a clinic that describes the two conditions in identical terms has flattened a real difference in what is known.
Progressive tendon loading remains the first answer and continues throughout any course. Extracorporeal shockwave therapy covers how a course is delivered and shockwave therapy for plantar fasciitis covers the use with the largest trial literature.
Why it happens
What causes Achilles tendinopathy?
- A rise in running volume, hill work or speed work that the tendon had not adapted to
- A rapid return to training after a quiet spell, which is the commonest trigger of all
- Reduced calf strength and endurance, so the tendon takes a greater share of each stride
- A change of footwear that alters heel height and therefore load at the insertion
- Compression at the insertion from firm heel counters, which suits insertional pain badly
- Previous Achilles pain that settled before the tendon was loaded back to capacity
Treatment approach
Where shockwave therapy fits for Achilles tendinopathy
FAQ
Shockwave therapy for Achilles tendinopathy
questions people ask
Does shockwave therapy work for Achilles tendinopathy?
NICE concluded that the safety evidence raises no major concerns and that the efficacy evidence is inconsistent and limited in quality and quantity. That second phrase is stronger than the wording it used for plantar fasciitis. The honest position is that the benefit is uncertain and the safety picture is reassuring.
Does it matter where the Achilles pain is?
Yes, considerably. Midportion pain sits two to six centimetres above the heel bone and insertional pain sits at the attachment, where the tendon tolerates compression poorly. The loading programme differs between them, and so does the way a treated area is likely to respond. Establishing which you have comes first.
Can I keep running during a course of shockwave?
Often in a reduced form, and that is a question for the clinician who examines you. A useful guide with tendon pain is that discomfort during a run stays low and has settled by the next morning. If it is worse the following day, the load was too high for where the tendon is now.
How long before I would know whether it helped?
Six to twelve weeks after the last session. Tendon tissue changes slowly and very little shifts during the course itself. Judging it in the week after the final session is the commonest way people conclude wrongly, in both directions, about whether the treatment did anything.
Is shockwave available for Achilles pain on the NHS?
In some services and not in others. NICE asked that the procedure be used only with special arrangements for clinical governance, consent and audit or research, and trusts have answered that differently. Availability therefore varies by area rather than by diagnosis, so it is worth asking locally before assuming either way.
Get Started
Describe the problem and what has been tried.
UNTIL Health Concierge arranges the examination.
London Shockwave Therapy • UNTIL, 280 Bishopsgate, London EC2M 4RB
BookEnquiries reach UNTIL Health Concierge, who arrange the assessment.