925753
letter2020
FAIXXX10.1177/1071100720925753Foot & Ankle InternationalPinitkwamdee
Letter to the Editor
Response to “Letter Regarding:
Effectiveness of Extracorporeal
Shockwave Therapy in the Treatment of
Chronic Insertional Achilles Tendinopathy”
Dear Editor:
Thank-you to Dr Tenforde for the useful comments
about the study of the effectiveness of shockwave in chronic
insertional Achilles tendinopathy that was published
recently.5 Answering a number of methodologic issues
would be helpful for readers to make a decision in the use of
shockwave for chronic insertional Achilles tendinopathy.
Our response to your points 1 to 5,
1. Type of shockwave device
In our study, we used 4 courses of radial shockwave with 240
to 320 J/mm2 energy flux density (EFD) for the treatment of
chronic insertional Achilles tendinopathy per the protocol of
Rompe7 which showed an improvement in visual analog scale
(VAS) score. In another study by Rompe6 that classified
shockwave into 3 groups based on EFD—low (<0.08 mJ/
mm2), medium (<0.28 mJ/mm2), and high (<0.60 mJ/mm2)—
the study showed that low and medium EFD had positive
effects on pain relief and tendon healing whereas Chao et al1
revealed that a higher energy level had significant inhibitory
effects on tenocyte proliferation and extracellular matrix
metabolism. According to Furia et al,3 the use of single-dose,
high-energy, focus shockwave (604 J/mm2) might have
inhibitory effects on tendon healing and using anesthesia to
avoid discomfort to the patient during operation might cause
confounding of the results. Insertional Achilles calcification
was commonly found in chronic insertional Achilles
tendinopathy (65%-80% in Kang et al,4 100% in our study). In
the study by Rompe et al,7 patients who presented with
Haglund deformity were excluded, but the authors did not
mention if patients with insertional Achilles calcification were
excluded. In addition, Haglund deformity had no significant
clinical correlation to insertional Achilles tendinopathy
because it could be found in asymptomatic patients,4 so it
might not confound the effect of extracorporeal shockwave
therapy (ESWT) on insertional Achilles tendinopathy.
2. Clinical focusing
We also use the clinical focusing technique by applying the
shockwave probe at the point of maximum tenderness of the
Achilles tendon insertion and circumferential area within 2 ×
2 cm2. It usually created pain during the procedure in the
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2020, Vol. 41(6) 757­–758
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shockwave group as you comment, but the 2 patients in our
study who experienced pain could not tolerate it and asked to
withhold the procedure and resume when the pain had subsided.
We had to use the lowest energy they could tolerate but not less
than our shockwave protocol prescribes.
3. Standardized loading program
Because of low patient satisfaction (32%) of traditional
eccentric exercise for insertional Achilles tendinopathy2 and no
Level I evidence evaluated the effectiveness of modified
eccentric exercise protocol in chronic insertional Achilles
tendinopathy and we wanted to evaluate the real effectiveness
of ESWT, so we did not include eccentric exercise into standard
conservative treatments because that might confound the
result.
4. Outcome measures
We used the Visual Analog Scale Foot and Ankle score
(VAS-FA) because it had been validated in comparison to
SF-36 in its Thai version, which patients in our study could
complete it by themselves. Although VAS-FA had less
specificity to Achilles tendinopathy than VISA-A, but it had 20
questions (3 categories: pain 4 questions, function 11 questions,
and other complaints 5 questions) that covered most foot and
ankle problems, including Achilles tendinopathy. Moreover,
VISA-A has not been validated in the Thai version precluding
proper outcome evaluation.
5. Rescue medications
We used nonsteroidal anti-inflammatory drugs as rescue drug
because it was a standard medication for insertional Achilles
tendinopathy. Theoretically, it may reduce efficacy in disrupting
healing as you mentioned, but a few of our patients had used
Naproxen for pain relief although not for a long period, and the
healing had still occurred.
Our study found no significant difference between the
ESWT and sham group outcomes in chronic insertional
Achilles tendinopathy at 24 weeks. Two points of concern
were the age of the patients in our study, which was about 60
years, and could indicate a low potential for tendon healing;
758
in addition, all patients had insertional calcification, which
might indicate the severity of disease that could not benefit
from ESWT. Further studies to evaluate the effectiveness of
ESWT in calcific and noncalcific tendon insertion group or in
young as well as old age groups would be useful.
Siwadol Pinitkwamdee, MD
Department of Orthopaedics, Faculty of Medicine
Ramathibodi Hospital, Bangkok, Thailand.
Email: ouan_edmund85@hotmail.com
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
ICMJE forms for all authors are available online.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Siwadol Pinitkwamdee, MD, https://orcid.org/0000-0002-2211
-6579
Foot & Ankle International 41(6)
References
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3. Furia JP. High-energy extracorporeal shock wave therapy as
a treatment for insertional Achilles tendinopathy. Am J Sports
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