Extracorporeal shockwave therapy for Achilles tendinopathy
Shockwave therapy is the shortened term for extracorporeal shockwave therapy (ESWT). NICE and the NHS endorse it as an effective treatment for chronic ongoing heel pain issues, for both plantar fasciitis and achilles tendinopathy. There is considerable clinical research to demonstrate it’s efficacy.
Compleet Feet have been effectively using ESWT since 2018, to treat chronic heel pain. To treat patients who have tried everything to try and resolve the misery of heel tendon and fascia pain. Posterior heel pain is notoriously difficult to treat, especially if it involves the insertional part of the tendon. The insertional, distal section of the achilles tendon wraps around the heel bone(calcaneum). Difficult to massage, hard to stretch out and harder to rest. Surgery is considered the last resort. A non-surgical treatment route is considered best.
T = achilles tendon, PF = planar fascia, HP = heel pad. Note what a complex insertion the achilles has around the heel with fibres inserting behind the heel pad, which extends up around the heel.
The Compleet Feet insertional achilles treatment plan starts with a musculoskeletal biomechanical assessment. Chronic insertional heel pain is often the result of mechanical stresses placed on the Achilles tendon. It is a major spring in the foot for propulsion. If it loses it’s effectiveness as a spring, unwanted problems and pain can result. It works in conjunction with it’s partner in the foot, the big toe(hallux). The big toe is another spring. Is either the achilles or big toe are structurally or functionally impaired the foot cannot absorb the stresses involved with walking. Inadequate heel lift and toe-off.
Podiatrists will address these common functional causes resulting in poor gait. Predominantly issues with ‘over’ pronating of the foot causing lowering, rolling in of the medial inner arch. Stiffness poor function of the big toe, tight calves and poor footwear. These issues can be treated with orthotic insoles, stretching, heel lifts and functionally good footwear. If after 3 – 6 months there is no relief shockwave therapy is recommended.
Insertional Achilles Pain Hard to Treat
The insertional part of the achilles tendon is hard to treat and resistant to treatment. It has a poor blood supply and the considerable stresses which pass through it mean it is hard to rest. Tendon collagen connective tissue loses its elasticity with age and the insertional point is not elastic to begin with. Calcification can occur within the tendon and the formation of a heel spur. These bony deposits add to generalised achilles stiffening and reduce it’s ability to be a spring. The Achilles is a major functional spring in lifting the heel off the ground.
Shockwave therapy for achilles pain is recommended as it helps to increase blood supply to the achilles insertion. Inflammation is initiated to trigger a cascade of healing. The calcium deposits can be broken down and tissue regeneration stimulated. Interestingly conservative treatment of achilles pain involve reducing inflammatory pain. Prescribing non-steroidal anti-inflammatories (NSAIDS). Reversely, ESWT creates inflammation. Patients are advised not to take NSAIDS during a treatment programme. Inflammation is required for healing.
It is recommended to have between 3 – 6 shockwave treatments. Audible multiple shock waves are targeted to the area of concern by a hand held device. At Compleet Feet we advise an initial 3 treatment sessions spaced at weekly intervals. We then allow a rest period to allow healing to take it’s course, and ascertain how effective the ESWT was. If after 4 – 6 weeks the achilles is still symptomatic; another 3 treatment sessions are performed. Each treatment session will involve tapping and low level laser to expediate healing and optimise results. Low level laser will stimulate healing at a cellular level.
The treatment initially can be uncomfortable. Shockwaves are being administered into a bony area with little absorbing tissue. Fortuitously, ESWT often results in post treatment numbness. This offers some level of localised pain relief for a few hours or days. Pleasant relief for awhile, giving patients a taste of longer term pain relief to come after a course of treatment. Treatment does not impede on normal activities. Higher impact activities are to be restricted until symptoms resolve.
Conclusion: Pain in the Gain!
Shockwave therapy for achilles pain works. The efficacy of shockwave therapy for insertional achilles pain is considerably high, but it must be part of an overall treatment plan. Patients must continue to wear recommended orthotic insoles, appropriate footwear and stretch. Specific achilles insertional stretching is demonstrated by the podiatrist in clinic. It is a counter intuitive treatment whereby inflammation is stirred up and not reduced to get a treatment resolution. Pain in the gain.
