Aims. Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm. 2. However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus. Methods. Patients were randomly enrolled into two groups. At three weeks postoperatively, the rESWT group was given shockwave treatment, once every other day, for five treatments. In the control group the head of the device which delivered the treatment had no energy output. The two groups were evaluated before surgery and at six weeks and three, six and 12 months postoperatively. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Secondary outcome measures included a visual analogue scale (VAS) score for pain and the area of bone marrow oedema of the talus as identified on sagittal fat suppression sequence MRI scans. Results. A total of 40 patients were enrolled and randomly divided into the two groups, with 20 in each. There was no statistically significant difference in the baseline characteristics of the groups. No complications, such as wound infection or neurovascular injury, were found during follow-up of 12 months. The mean AOFAS scores in the rESWT group were significantly higher than those in the control group at three, six, and 12 months postoperatively (p < 0.05). The mean VAS pain scores in the rESWT group were also significantly lower than those in the control group at these times (p < 0.05). The mean area of bone marrow oedema in the rESWT group was significantly smaller at six and 12 months than in the control group at these times (p < 0.05). Conclusion. Local shockwave therapy was safe and effective in patients with osteochondiritis of the talus who were treated with a combination of arthroscopic surgery and rESWT. Preliminary results showed that, compared with arthroscopic microfracture alone, those treated with arthroscopic microfracture combined with rESWT had better relief of pain at three months postoperatively and improved weightbearing and motor function of the ankle. Cite this article: Bone Joint J 2023;105-B(10):1108–1114

Aims. To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration. Methods. The OCD lesion was created on the trochlear groove of left articular cartilage of femur per rat (40 rats in total). The experimental groups were Sham, OCD, and ESWT (0.25 mJ/mm. 2. , 800 impulses, 4 Hz). The animals were euthanized at 2, 4, 8, and 12 weeks post-treatment, and histopathological analysis, micro-CT scanning, and immunohistochemical staining were performed for the specimens. Results. In the histopathological analysis, the macro-morphological grading scale showed a significant increase, while the histological score and cartilage repair scale of ESWT exhibited a significant decrease compared to OCD at the 8- and 12-week timepoints. At the 12-week follow-up, ESWT exhibited a significant improvement in the volume of damaged bone compared to OCD. Furthermore, immunohistochemistry analysis revealed a significant decrease in type I collagen and a significant increase in type II collagen within the newly formed hyaline cartilage following ESWT, compared to OCD. Finally, SRY-box transcription factor 9 (SOX9), aggrecan, and TGF-β, BMP-2, -3, -4, -5, and -7 were significantly higher in ESWT than in OCD at 12 weeks. Conclusion. ESWT promoted the effect of TGF-β/BMPs, thereby modulating the production of extracellular matrix proteins and transcription factor involved in the regeneration of articular cartilage and subchondral bone in an OCD rat model. Cite this article: Bone Joint Res 2024;13(7):342–352

Introduction: Trochanteric bursitis is a common hip problem that can be refractory to treatment. The available modalities of treatment can be less effective. We evaluated the use of extra-corporeal shockwave therapy treatment for trochanteric bursitis. Methodology: 22 patients with the clinical and radiological (in 6 patients) diagnosis of trochanteric bursitis were treated in a dedicated shockwave therapy clinic using Swiss dolocast radial shockwave therapy machine. 3 sessions of treatment were given one week apart, delivering 2000 impulses at 10 Hz at each session. Patients were evaluated prior to treatment, 3 months, 6 months and 12 months following their treatment. The visual analogue score (VAS) was used in all patients pre and post treatment. Hip disability and osteoarthritis score (HOOS) was performed post-treatment. Results: Between December 2005 and November 2008 22 patients were treated for symptoms of trochanteric bursitis. There were 17 women and 5 men. The average age was 55.8 years (range 33–76 years). 6 patients had proven increase signal on MRI scan the rest were mainly clinical diagnosis and after a limited response to steroid injections. Their VAS improved from 10 to 5. Their post-treatment HOOS score averaged 255. Of the 6 patients who had MRI proven increased signal 5 patients had significant improvement. The average improvement in the VAS was 10 to 2.3 and their HOOS scores were 349.2 (range 427–243). Conclusion: Though the number of patients in this study is only 22 it seems that radial shockwave therapy treatment for trochanteric bursitis is promising, especially on those who have got high signal on MRI scans

Acute Achilles tendon pain is a common clinical entity, particularly in sportsmen and women. Fortunately, the majority of such pain is self limiting. However, there are a significant number of people for whom the pain becomes chronic and debilitating. A recent Cochrane review found that there was no randomised controlled evidence of an effective treatment for chronic Achilles pain. The aim of this study was to test the efficacy of shockwave therapy in a double-blind randomised controlled trial. The study has the approval of Local Research Ethics Committees. Forty nine patients with Achilles tendon pain for a minimum of 4 months were included in the study. Patients were randomised to either shockwave therapy (n=27) or sham dose control therapy (n=22). Ultrasound was used to focus the shocks onto the affected area of tendon. The treatment group were given 2000 shocks at upto 1500mJ per shock, titrated to the patients pain tolerance. The control (sham) treatment was applied using the same parametres but with bubble-wrap interposition between the shockwave generator and the Achilles, to disperse the shockwaves. Each patient was treated once a month over 3 months. Primary outcome measure was pain on walking indicated on a 100mm visual analogue score (VAS) at 3 months. Secondary outcome measures included clinical and patient centred questionnaire scores. . An intention-to-treat approach was used for the analysis. Where patients had missing pain scores at 3 month follow-up, the last available pain score was carried forward. The walking pain scores were very similar at baseline between the two groups. In the treatment group the mean (standard deviation) was 55.5mm (30.6) and in the control group 55.6mm (26.5). By 3 months, the pain scores had reduced in both groups to a mean (standard deviation) of 34.5 mm (34.2) and 50.3 mm (36.3). Although lower in the treatment group this difference was not statistically significant at the 5% level (t-test, p = 0.127, 95% C.I. : −4.7 to 36.2). No statistically significant differences were found with respect to any of the other clinical variables. Two elderly patients in the treatment group sustained spontaneous rupture of the tendon after falls, during the course of the trial. The results of this trial provided no evidence for the use of shockwave therapy in the treatment of patients with chronic Achilles tendinopathy. However, a treatment effect cannot be ruled out since the 95% confidence interval was wide and included a potential clinically relevant difference. The 2 cases of rupture suggest extreme caution in treating the elderly

The aim of this study was to test the efficacy of shock-wave therapy for chronic Achilles pain. Forty-nine patients with Achilles tendon pain for a minimum of 4 months were included in the study. Patients were randomised to either shockwave therapy (n=27) or placebo control (n=22). The treatment group were given 2000 shocks at up to 1500 mJ/mm2 per shock. The control (sham) treatment was applied using the same parametres but the shockwaves were dispersed before they reached the patient. Each patient was treated once a month over 3 months. The primary outcome measure was pain on walking indicated on a 100mm visual analogue score (VAS) at 3 months. The walking pain scores were very similar at baseline between the two groups. In the treatment group the mean (standard deviation) was 55.5 mm (30.6) and in the control group 55.6mm (26.5). By 3 months, the pain scores had reduced in both groups to a mean (standard deviation) of 34.5 mm (34.2) and 50.3 mm (36.3). Although lower in the treatment group this difference was not statistically significant at the 5% level (t-test, p=0.127, 95% CI : −4.7 to 36.2). Two elderly patients in the treatment group sustained spontaneous rupture of the tendon after falls during the course of the trial. The results of this trial provided no evidence for the use of shockwave therapy in the treatment of patients with chronic Achilles tendinopathy. However, a treatment effect cannot be ruled out since the 95% confidence interval included a potential clinically relevant difference. The two cases of rupture suggest extreme caution in treating the elderly

Background. Greater trochanteric pain syndrome (GTPS) is a common problem affecting 10–25% of the population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, all with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential management option for this difficult presentation. Method. We ran a prospective, 2 arm, single blinded, randomised control trial comparing focused shockwave therapy to an ultrasound guided corticosteroid injection. The primary outcome measure was the visual analogue pain score. Secondary outcome measures included the Harris hip score and Trendelenburg test for function; the SF-36 for quality of life (QoL); and a Likert scale question for a subjective assessment of symptom improvement. Results. 104 patients (10 males and 94 females), of mean age 61.5 years were recruited. 53 were randomised to receive ESWT and 51 to receive an image guided injection. 11 patients were lost to follow up. Baseline scores were equal between the groups. At 3 months, pain, function and QoL scores had improved in both groups. The Trendelenburg test was significantly improved in the ESWT group with 80% patients being negative compared to 80% positive at baseline (p<0.001). At 12 months, the improvement in Trendelenburg test was maintained in the ESWT group, but the injection group had reverted to baseline. Across all outcomes, the ESWT group had significantly improved scores compared to the injection group; VAS 3.71 versus 5.50 (p=0.007, 95% confidence interval 0.63 to 3.08), HHS 69.7 vs 57.5 (p=0.002, 95% confidence interval −20.0to −4.6) and SF-36 52.4 vs 47.7 (p=0.048, 95% confidence interval −9.31 to −0.04). Conclusions. We have shown focused ESWT is an effective treatment for patients with GTPS. We hope to advocate ESWT as an effective non-invasive treatment modality for this challenging patient population

Aim. To determine the effect of the use of radial extracorporeal shockwave therapy (rESWT) in the treatment of patellar tendinopathy. Methods. Between 2005 and 2010, twenty eight patients (34 knees), who showed poor or no result from conservative management, had rESWT for patellar tendinopathy. The device used is Swiss Dolorclast¯(EMS, Switzerland). All patients received three weekly sessions of 2000 impulses at 3.0 bar (energy flux density = 0.14 mJ/mm. 2. ) and a frequency of 15 Hz. We assessed pain, function and activity and quality of life of the patient before and three months after treatment using KOOS (Knee Injury and Osteoarthritis Outcome Score). Results. There were 21 males (25 knees) and 7 females (9 knees) with a median age of 31 years (18 - 60). Twenty two of the 28 patients (78.6%) reported excellent or good improvement. After three months of treatment with rESWT, the average KOOS score increased from 50.4 to 71.1 (p = 0.004). Conclusion. This study has shown that radial extracorporeal shockwave therapy demonstrated an improvement in the functional activity and reduction in the pain. Patellar tendinopathy that does not respond to conservative management can be successfully treated with rESWT

Background. Previous studies have individually shown extracorporeal shockwave therapy (ESWT) to be beneficial for mid-substance Achilles tendinopathy, insertional Achilles tendinopathy or plantar fasciitis. The purpose of this pragmatic study was to determine the efficacy of ESWT in managing the three main causes of refractory heel pain in our routine clinical practice. Methods. 236 patients (261 feet) aged between 25 – 81 years (mean age 50.4) were treated in our NHS institute with ESWT between April 2014 and May 2016. They all underwent a clinical and radiological assessment (ultrasonography +/− magnetic resonance imaging) to determine the primary cause of heel pain. Patients were subsequently categorized into three groups, mid-substance Achilles tendinopathy (55 cases), insertional Achilles tendinopathy (55 cases) or plantar fasciitis (151 cases). If their symptoms were recalcitrant to compliant first line management for 6 months, they were prescribed three consecutive ESWT sessions at weekly intervals. All outcome measures (foot & ankle pain score, EQ-5D) were recorded at baseline and 3-month follow-up (mean 18.3 weeks, range 11.4 to 41). Results. Complete data sets were obtained for 41% of the ESWT treatments (107/261). EQ-5D scores showed a statistically significant improvement between baseline and follow-up in all three-treatment groups; mid-substance Achilles tendinopathy 0.681 to 0.734, insertional Achilles tendinopathy 0.687 to 0.742 and plantar fasciitis 0.684 to 0.731 (p< 0.05). The foot & ankle pain scores grouped for all causes of heel pain also showed a statistically significant reduction from 6.78 at baseline to 5.36 at follow-up (p< 0.05). Conclusion. Overall our results showed that ESWT is an effective tool for the management of all refractory heel pain in an NHS foot & ankle clinical practice

The purpose of this study was to assess the clinical outcome of two non-invasive techniques used in the treatment of calcific tendinitis of the shoulder. Over the eight month period April 2000 to November 2000 sixty patients who were referred to this hospital with symptomatic calcific tendonitis were treated either with extracorporeal shockwave therapy (ESWT) using the Storz Medical Minilith (Storz Medical AG, Kreuzlingen, Germany) or by barbotage (needle puncture, aspiration and lavage under ultrasound control). All the patients had a long history of shoulder pain (average 42 months), caused by a radiographically evident calcific deposit, that had been unresponsive to conservative treatment including physiotherapy, steroid injections and non-steroidal anti-inflammatory tablets. 15 patients were treated with ESWT and 45 with ultrasound guided barbotage. The patients undergoing ESWT had the application head positioned under real time ultrasound or flouroscopic control. Patients had from one to three treatments with up to 2,500 shocks per treatment at incremental energy levels from 0.1 to 0.2 mJ/ mm2. Patients undergoing real time ultrasound guided barbotage had a single treatment. Clinical outcome was evaluated after a three month period with a postal questionnaire. Thirty-two of 45 patients (71%) in the barbotage group had a marked reduction in symptoms at three months compared to nine out of 15 (64%) of the ESWT group. Shockwave therapy (ESWT) and ultrasound guided barbotage are simple non invasive outpatient procedures which are effective in 64% to 71% of patients. These simple outpatient techniques should be considered for chronic pain due to calcific deposits that have been unresponsive to conservative treatments, and surgery reserved for those who fail to benefit

Aim. Focused high energy extracorporeal shockwave therapy (fhESWT) is used to support fracture healing in non-union cases and has been shown to have antibacterial effects. We trialed fhESWT as an adjunct to conventional treatment in a clinically relevant rabbit model of fracture related infection. Method. A complete humeral osteotomy was performed in 31 rabbits and fixed with a 7-hole-LCP. A fracture-related infection (FRI) was established with Staphylococcus aureus. After two weeks, a revision surgery was performed with debridement, irrigation and implant retention. Rabbits then received: no further treatment (controls); shockwaves (at day 2 and 6 after revision, 4'000 Impulses each time with 23kV); systemic antibiotics (rifampin and nafcillin) over one week in weight adjusted dosages; or the combination of antibiotics and shockwaves. Treatments were applied over one week. Blood cultures were taken before and after shockwave sessions. After an additional week without treatment, rabbits were euthanized, and quantitative bacteriology was performed on implants and tissues to determine infection burden. Indicator organs (brain, heart, liver, lungs, kidneys and spleen) were cultured to assess possible bacteraemia due to fhESWT. Results. All rabbits were infected at revision surgery as determined by bacteriological culture of debrided materials. fhESWT in combination with antibiotic treatment lowered the bacterial burden at euthanasia hundredfold compared to antibiotic treatment alone in all samples (p=0.38). This effect was most prevalent for the implant sample (p=0.08). No significant effect was seen for fhESWT alone compared to untreated controls. No signs of bacteraemia occurred. Conclusions. The additon of systemic antibiotics had the biggest effect on reduction of bacteria. Although further lowering the bacterial burden in our model the effect of fhESWT as an adjunct was not big enough to be statistically secured in this in vivo rabbit model. In certain difficult-to-treat infections the addition of fhESWT might be beneficial. The method appears to be safe in this model of acute FRI as no signs of bacteremia occurred despite the high energy and impulse number. Further investigations are needed to identify the correct indication

Aims: To assess the efþcacy of repeated low-energy extracorporeal shock wave application (ESWA) for chronic plantar fasciitis in runners. Methods: 45 running athletes with intractable plantar heel pain were enrolled in a randomized single-blind trial with a parallel-group design and blinded independent observer, to evaluate the efþcacy of three applications of 2100 impulses of ESWA (Group I) compared with sham treatment (Group II). Follow-up examinations were done at six months, and at one year after ESWA. The primary efþcacy endpoint was reduction of subjectsñ self-assessment of pain on þrst walking in the morning on a visual analog scale (range, 0 Ð 10 points) at six months after shock wave application. Results: After six months self-assessment of pain on þrst walking in the morning as primary efþcacy endpoint showed a signiþcant reduction from an average 6.9 to 2.1 points in Group I, and from an average 6.9 to 4.7 points in Group II on the visual analog scale. The mean difference between both groups was 2.6 points (p= 0.0004; 95% CI: 1.3 Ð 3.9; power = 0.9). After twelve months pain on þrst walking in the morning showed a further reduction in both groups, to an average 1.5 points in Group I, and to 4.4 points in Group II (p < 0.0001). Conclusion: The current study showed that three treatments with 2100 impulses of low-energy ESWA were a safe and effective non-surgical method for treating chronic plantar fasciitis compared with sham therapy

Introduction. Greater trochanteric pain syndrome (GTPS) is a common and disabling condition characterised by pain and tenderness at or around the trochanteric area. Extracorporeal shockwave therapy (ESWT) has been described as a method of treatment. The National Institute for Clinical Excellence (NICE, UK) guidance suggests a possible benefit but with limited evidence. Materials and Methods. We retrospectively identified 71 consecutive patients who underwent ESWT for refractory GTPS over a period of 16 months. The diagnosis was made clinically. ESWT was offered to patients with refractory symptoms despite conservative treatment. Telephone interviews were used to collect data including pain scores (0–10), change in symptoms, discomfort of the procedure, and complications. Results. Fifty-nine patients (83%) were followed up. The mean time to follow up was 8 months (3 to 19). The mean age was 59 (29 to 88) with 86% females. Two-thirds had improvement in their symptoms with a significant drop of 6 points in their pain score (p<0.05); however, symptoms recurred in 60% at a mean of 3.7 months. Most patients (60%) had mild or no discomfort from the treatment. Two patients (3.3%) could not tolerate the treatment. One complication was reported; an exacerbation of sciatica symptoms which settled spontaneously. Conclusion. This study shows an improvement in the symptoms of 67% of patients with refractory GTPS, for up to 15 months, but with frequent relapsed. Further research is required to confirm whether MRI may be useful in selecting patients for ESWT

Purpose of study: Study and prove the benefits and efficacy of the use of extracorporeal shockwave therapy (ESWT)for the treatment of planter fasciitis. Introduction: Planter fasciitis is the second most common cause of heel pain. Conservative treatment modalities for the treatment of planter fasciitis includes NSAIDS, heel cushions, ultrasound, physiotherapy, injections, etc and these often do not offer satisfactory results. We present the results of the use of ESWT in the treatment of planter fasciitis with good results. Methodology: 129 patients, 77 males and 52 females with a 152 heels were treated with ESWT from July 2002 until August 2004 and were included in the study. The average age was 53.2 years (Range 28 to 83 years). All patients had previously undergone other conservative forms of treatment with poor results. Inclusion criteria included age greater than 18 years, male or female, no previous history of surgery on the heel or foot, visual analogue score of over 5 for pain. Treatment was done on an outpatients basis. Each patient received between minimum of one and maximum of three sessions of ESWT at two weeks interval. Results: 116 patients, 69 males and 47 females with 136 heels were reviewed with 13 patients with 16 heels lost to followup. 52 patients (44.8%) with 60 heels (44.1%) had excellent results. 45 patients (38.8%) with 53 heels (38.0%) had good results. 13 patients (11.2%) with 16 heels (11.8%) had fair results. 6 patients (5.2%) with 7 heels (5.1%) had poor results. Overall 104 patients (89.7%) with a 121 heels (89.0%) considered the outcome to be successful. Conclusion: Based on our results, we recommend ESWT fot the treatment of planter fasciitis especially in patients with failed other forms of conservative treatment and as an alternative to surgery with good results

In a prospective study to evaluate the benefits of radial extracorporeal shockwave therapy (ESWT) in patients with longstanding chronic Achilles tendonitis. 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwave sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the final session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A). At short-term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (+/−15) to 22 (+/−17). An improvement in the AOFAS from of 64 (+/−10) to a post-treatment value of 90(+/−7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufficiently to be removed from the waiting list. Conclusion: Short-term results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer-term follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period

ECSWT has been on the medical horizon for last 30 years mainly in urology for urolithiasis and has found a parallel use in orthopaedics for various chronic soft tissue conditions like Tendoachilles tendinoses and plantar fasciitis etc. ECSWT acts a piezoelectric device releasing acoustic energy and causing micro-trauma activating cytokine mediated response stimulating local angiogenesis and tissue repair. Methodology. 56 patients were recruited for the trial after ethics approval was achieved. The diagnosis was confirmed with ultrasound scan and measuring the width of the swelling and the local hypervascularity. The cohort of the patients was randomised in groups for physiotherapy [n=23] and shockwave therapy [n= 23]. The patient groups with shockwave therapy received a 3-week treatment with typical 2000 impulses per session once a week and physiotherapy group was subjected to eccentric loading exercises. Patients were assessed at 12 week with AOFAS, VISA-A scores and repeat ultrasound scan. Results. The average age of the average age was 51 years [36- 73 years] Mean duration of symptoms prior to treatment was 25 months (range 6-60 months). AOFAS scores increased in both groups: from 64□86 in the ECSWT group and 72□79 in the physiotherapy group. VISA-A scores also increased in both groups from 39□73 in the ECSWT group and from 36□56 in the physiotherapy group. Scores were significantly higher in the ECWST group post treatment. The ultrasound scan findings suggested the tendon girth receding from 10.9 mm□9.9 mm in physiotherapy group while 9.8 mm□8.7 mm in the ECSWT group with hypervascularity decreasing from marked to mild in both groups. Statistical significance was established using SPSS 16 p < 0.001in post treatment group. Conclusion. Clinically significant improvement was found in the patients treated with ECSWT as compared to the physiotherapy sessions while radiological evidence showed parallel improvement in both the groups

Aims: A prospective study to evaluate the beneþts of extracorporeal shockwave therapy (ESWT) in patients with chronic Achilles tendonitis. Methods: 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwaves sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the þnal session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A). Results: At short term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (±15) to 22(±17). An improvement in the AOFAS from of 64 (±10) to a post-treatment value of 90(±7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufþciently to be removed from the waiting list. Conclusion: Shortterm results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer Ðterm follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period

Introduction. Proteomic analysis has the ability to reveal both the different types and abundances of proteins in a sample. To date, proteomic analysis has received limited attention in the field of tendon research, with mainly ex vivo investigations being undertaken to characterize the tendon proteome. A significant development would be the ability to detect in vivo changes in the proteomic composition as this could have clearer and more direct understanding on the efficiency of therapies. It is well documented that sample preparation is one of the most crucial steps in obtaining high quality resolution of proteins in mass spectrometry. Biological samples can vary in complexity, and minimization of this through sample handling and cleaning can drastically improve the resolved peptide spectra. During this investigation, samples of microdialysis media from the peritendinous space of the Achilles tendon pre or post shockwave therapy were used to establish whether the in vivo identification and quantification of proteins was possible. Materials and Methods. Six microdialysis samples were obtained from human subjects before (controls) or after shock wave therapy on their achilles tendon. Samples were concentrated and intefering substances removed using StrataClean™ resin. Reduction, alkylation and an In-solution tryptic digestion was performed with the prior addition of 1% Rapigest SF solution. Samples were then analysed by Liquid Chromatography Mass Spectrometry/Mass Spectrometry. Data files were searched using IPI-human database using Mascot Search Engine. Relative quantification was performed between groups by ProgenesisQI. Results. An increase in protein concentration within dialysis media following treatment was observed. Protein identifications included extracellular matrix proteins such as collagens and proteoglycans, and cellular proteins. In total there were 93 quantifiable proteins identified, of these 80 proteins had a p<0.05 and 2 fold change difference; 61 higher and 19 lower in post shock wave therapy. Discussion. We are able to identify a range of differentially expressed proteins in dialysis fluid subsequent to shock-wave therapy of the Achilles tendon. This type of analysis could be used to monitor efficiencies, and identify mechanisms of therapies by detection of specific biomarkers

Purpose: The purpose of this study was to clinically evaluate the efficiency of extracorporal shockwave therapy for enthesopathies. Materials, Methods and Results: 26 patients with mean age of 51 (range: 18–73) which suffered from enthesopathies in different regions were included in this study. Prior to treatment pain and function were assessed subjectively by using a visual analog scale ranging from 1 (maximum pain/minimum function) to 10 (no pain, full function). The follow-up period was 6–18 months with an average follow-up period of 13 months. All patients were treated with ESWT. One to three treatment sessions were provided to each patient with an interval of one week between the sessions. After all sessions were finished, pain and function were reassessed in the same method that was used before the beginning of the treatment. The overall mean pain value was 1.96 before the treatment and 5.92 after the treatment. 8 patients (30.7%) reported no pain at all after the treatment and in 6 patients (23%) a significant improvement in pain was achieved. 7 patients (19%) reported of only slight relief of pain and 4 patients (15.4%) reported no change in pain level. Only in one patient (3.9%) worsening of the pain was observed. The overall mean function capacity was 5.76 before the treatment and 8.65 after the treatment. 11 patients (42%) returned to full functional capacity and in 7 patients (27%) a significant improvement in functional capacity was observed. In 8 patients (30.7%) no change in the functional capacity was noticed. Good results of improvement in pain severity and functional capacity were observed in cases of plantar fasciitis and tennis elbow. Conclusion: We think the EWST is helpful for treatment of enthesopathies, especially plantar fasciitis and tennis elbow, and suggest to include it in treatment algorithms

Aims. Biofilm formation is one of the primary reasons for the difficulty in treating implant-related infections (IRIs). Focused high-energy extracorporeal shockwave therapy (fhESWT), which is a treatment modality for fracture nonunions, has been shown to have a direct antibacterial effect on planktonic bacteria. The goal of the present study was to investigate the effect of fhESWT on Staphylococcus aureus biofilms in vitro in the presence and absence of antibiotic agents. Methods. S. aureus biofilms were grown on titanium discs (13 mm × 4 mm) in a bioreactor for 48 hours. Shockwaves were applied with either 250, 500, or 1,000 impulses onto the discs surrounded by either phosphate-buffered saline or antibiotic (rifampin alone or in combination with nafcillin). The number of viable bacteria was determined by quantitative culture after sonication. Representative samples were taken for scanning electron microscopy. Results. The application of fhESWT led to a ten-fold reduction in bacterial counts on the metal discs for all impulse numbers compared to the control (p < 0.001). Increasing the number of impulses did not further reduce bacterial counts in the absence of antibiotics (all p > 0.289). Antibiotics alone reduced the number of bacteria on the discs; however, the combined application of the fhESWT and antibiotic administration further reduced the bacterial count compared to the antibiotic treatment only (p = 0.032). Conclusion. The use of fhESWT significantly reduced the colony-forming unit (CFU) count of a S. aureus biofilm in our model independently, and in combination with antibiotics. Therefore, the supplementary application of fhESWT could be a helpful tool in the treatment of IFIs in certain cases, including infected nonunions. Cite this article: Bone Joint Res 2021;10(1):77–84

The December 2014 Shoulder & Elbow Roundup. 360 . looks at: cuff tears and plexus injury; . corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?