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Effectiveness of Extracorporeal Shockwave Therapy Combined with Resistance Exercise for the Treatment of Tendinopathy

A Systematic Review and Meta-analysis Protocol


  • Ian Burton NHS



Exercise, Extracorporeal Shockwave Therapy, Resistance Training, High-Energy Shock Waves, Tendinopathy


Review Objective: To synthesize the best available evidence on the effectiveness of interventions that have used a combination of extracorporeal shockwave therapy and resistance exercise to treat any tendinopathy compared to any other treatment intervention.

Introduction: Recent evidence suggests combining shockwave therapy and resistance exercise may be more effective than other treatments for tendinopathy. However, no systematic reviews have been conducted on the topic and optimal treatment protocols and clinical recommendations are lacking.

Inclusion criteria: Randomised controlled trials assessing the effectiveness of combined shockwave therapy and resistance exercise for tendinopathy in adults will be included.

Methods: The authors will search for a wide range of sources to find both published and unpublished studies via EBSCOhost, including, but not limited to, MEDLINE, SPORTDiscus, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), and Allied and Complementary Medicine Database (AMED). Studies published in a language other than English will only be considered if a translation is available. The JBI systematic review methodology will be followed when conducting the review. Data synthesis will be conducted using meta-analysis or narrative synthesis, where appropriate.


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ALBERS, I.S., ZWERVER, J., DIERCKS, R.L., DEKKER, J.H. and VAN DEN AKKER-SCHEEK, I., 2016. Incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population: a cross sectional study. BMC musculoskeletal disorders, 17, pp. 16-016-0885-2.

ARNOLD, M.J. and MOODY, A.L., 2018. Common Running Injuries: Evaluation and Management. American Family Physician, 97(8), pp. 510-516.

BALSHEM, H., HELFAND, M., SCHUNEMANN, H.J., OXMAN, A.D., KUNZ, R., BROZEK, J., VIST, G.E., FALCK-YTTER, Y., MEERPOHL, J., NORRIS, S. and GUYATT, G.H., 2011. GRADE guidelines: 3. Rating the quality of evidence. Journal of clinical epidemiology, 64(4), pp. 401-406.

BEYER, R., KONGSGAARD, M., HOUGS KJAER, B., OHLENSCHLAEGER, T., KJAER, M. and MAGNUSSON, S.P., 2015. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. The American Journal of Sports Medicine, 43(7), pp. 1704-1711.

BOONSTRA, A.M., SCHIPHORST PREUPER, H.R., RENEMAN, M.F., POSTHUMUS, J.B. and STEWART, R.E., 2008. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. International journal of rehabilitation research.Internationale Zeitschrift fur Rehabilitationsforschung.Revue internationale de recherches de readaptation, 31(2), pp. 165-169.

BURTON, I., 2021. Autoregulated heavy slow resistance training combined with radial shockwave therapy for plantar heel pain: Protocol for a mixed-methods pilot randomised controlled trial. Musculoskeletal care, 19(3), pp. 319-330.

CARDOSO, T.B., PIZZARI, T., KINSELLA, R., HOPE, D. and COOK, J.L., 2019. Current trends in tendinopathy management. Best practice & research.Clinical rheumatology, 33(1), pp. 122-140.

CHALLOUMAS, D., CLIFFORD, C., KIRWAN, P. and MILLAR, N.L., 2019. How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials. BMJ open sport & exercise medicine, 5(1), pp. e000528.

CHALLOUMAS, D., PEDRET, C., BIDDLE, M., NG, N.Y.B., KIRWAN, P., COOPER, B., NICHOLAS, P., WILSON, S., CLIFFORD, C. and MILLAR, N.L., 2021. Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies. BMJ open sport & exercise medicine, 7(4), pp. e001110.

CHARROIS, T.L., 2015. Systematic reviews: what do you need to know to get started? The Canadian journal of hospital pharmacy, 68(2), pp. 144-148.

CINAR, E., SAXENA, S., AKKURT, H.E. and UYGUR, F., 2020. Extracorporeal shockwave therapy in the management of plantar fasciitis: A randomized controlled trial. Foot (Edinburgh, Scotland), 44, pp. 101679.

DEAN, B.J.F., DAKIN, S.G., MILLAR, N.L. and CARR, A.J., 2017. Review: Emerging concepts in the pathogenesis of tendinopathy. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland, 15(6), pp. 349-354.

GAIDA, J.E. and COOK, J., 2011. Treatment options for patellar tendinopathy: critical review. Current sports medicine reports, 10(5), pp. 255-270.

GUYATT, G.H., OXMAN, A.D., KUNZ, R., JAESCHKE, R., HELFAND, M., LIBERATI, A., VIST, G.E., SCHUNEMANN, H.J. and GRADE WORKING GROUP, 2008. Incorporating considerations of resources use into grading recommendations. BMJ (Clinical research ed.), 336(7654), pp. 1170-1173.

HERDMAN, M., GUDEX, C., LLOYD, A., JANSSEN, M., KIND, P., PARKIN, D., BONSEL, G. and BADIA, X., 2011. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 20(10), pp. 1727-1736.

IBRAHIM, M.I., DONATELLI, R.A., HELLMAN, M., HUSSEIN, A.Z., FURIA, J.P. and SCHMITZ, C., 2017. Long-term results of radial extracorporeal shock wave treatment for chronic plantar fasciopathy: A prospective, randomized, placebo-controlled trial with two years follow-up. Journal of orthopaedic research : official publication of the Orthopaedic Research Society, 35(7), pp. 1532-1538.

KONGSGAARD, M., KOVANEN, V., AAGAARD, P., DOESSING, S., HANSEN, P., LAURSEN, A.H., KALDAU, N.C., KJAER, M. and MAGNUSSON, S.P., 2009. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine & Science in Sports, 19(6), pp. 790-802.

KORAKAKIS, V., WHITELEY, R., KOTSIFAKI, A., STEFANAKIS, M., SOTIRALIS, Y. and THORBORG, K., 2021. A systematic review evaluating the clinimetric properties of the Victorian Institute of Sport Assessment (VISA) questionnaires for lower limb tendinopathy shows moderate to high-quality evidence for sufficient reliability, validity and responsiveness-part II. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 29(9), pp. 2765-2788.

KORAKAKIS, V., WHITELEY, R., TZAVARA, A. and MALLIAROPOULOS, N., 2018. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. British journal of sports medicine, 52(6), pp. 387-407.

LIM, H.Y. and WONG, S.H., 2018. Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiotherapy Research International : The Journal for Researchers and Clinicians in Physical Therapy, 23(4), pp. e1721.

LITTLEWOOD, C., BATEMAN, M., BROWN, K., BURY, J., MAWSON, S., MAY, S. and WALTERS, S.J., 2016. A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study). Clinical rehabilitation, 30(7), pp. 686-696.

LOU, J., WANG, S., LIU, S. and XING, G., 2017. Effectiveness of Extracorporeal Shock Wave Therapy Without Local Anesthesia in Patients With Recalcitrant Plantar Fasciitis: A Meta-Analysis of Randomized Controlled Trials. American journal of physical medicine & rehabilitation, 96(8), pp. 529-534.

MACDERMID, J.C. and SILBERNAGEL, K.G., 2015. Outcome Evaluation in Tendinopathy: Foundations of Assessment and a Summary of Selected Measures. The Journal of orthopaedic and sports physical therapy, 45(11), pp. 950-964.

MAGNUSSON, S.P. and KJAER, M., 2019. The impact of loading, unloading, ageing and injury on the human tendon. The Journal of physiology, 597(5), pp. 1283-1298.

MALLIARAS, P., BARTON, C.J., REEVES, N.D. and LANGBERG, H., 2013. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports medicine (Auckland, N.Z.), 43(4), pp. 267-286.

MALLOWS, A., DEBENHAM, J., WALKER, T. and LITTLEWOOD, C., 2017. Association of psychological variables and outcome in tendinopathy: a systematic review. British journal of sports medicine, 51(9), pp. 743-748.

MANI-BABU, S., MORRISSEY, D., WAUGH, C., SCREEN, H. and BARTON, C., 2015. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. The American Journal of Sports Medicine, 43(3), pp. 752-761.

MILLAR, N.L., SILBERNAGEL, K.G., THORBORG, K., KIRWAN, P.D., GALATZ, L.M., ABRAMS, G.D., MURRELL, G.A.C., MCINNES, I.B. and RODEO, S.A., 2021. Tendinopathy. Nature reviews.Disease primers, 7(1), pp. 1-020-00234-1.

MOYA, D., RAMON, S., SCHADEN, W., WANG, C.J., GUILOFF, L. and CHENG, J.H., 2018. The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders. The Journal of bone and joint surgery.American volume, 100(3), pp. 251-263.

MURPHY, M.C., TRAVERS, M.J., CHIVERS, P., DEBENHAM, J.R., DOCKING, S.I., RIO, E.K. and GIBSON, W., 2019. Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis. British journal of sports medicine, 53(17), pp. 1070-1077.

MUSTAFA, R.A., SANTESSO, N., BROZEK, J., AKL, E.A., WALTER, S.D., NORMAN, G., KULASEGARAM, M., CHRISTENSEN, R., GUYATT, G.H., FALCK-YTTER, Y., CHANG, S., MURAD, M.H., VIST, G.E., LASSERSON, T., GARTLEHNER, G., SHUKLA, V., SUN, X., WHITTINGTON, C., POST, P.N., LANG, E., THALER, K., KUNNAMO, I., ALENIUS, H., MEERPOHL, J.J., ALBA, A.C., NEVIS, I.F., GENTLES, S., ETHIER, M.C., CARRASCO-LABRA, A., KHATIB, R., NESRALLAH, G., KROFT, J., SELK, A., BRIGNARDELLO-PETERSEN, R. and SCHUNEMANN, H.J., 2013. The GRADE approach is reproducible in assessing the quality of evidence of quantitative evidence syntheses. Journal of clinical epidemiology, 66(7), pp. 736-42; quiz 742.e1-5.

REILLY, J.M., BLUMAN, E. and TENFORDE, A.S., 2018. Narrative Review on the Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions. PM & R : the journal of injury, function, and rehabilitation, .

RIEL, H., LINDSTROM, C.F., RATHLEFF, M.S., JENSEN, M.B. and OLESEN, J.L., 2019. Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study. BMC musculoskeletal disorders, 20(1), pp. 239-019-2629-6.

ROMEO, P., LAVANGA, V., PAGANI, D. and SANSONE, V., 2014. Extracorporeal shock wave therapy in musculoskeletal disorders: a review. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 23(1), pp. 7-13.

ROQUE, M., MARTINEZ-GARCIA, L., SOLA, I., ALONSO-COELLO, P., BONFILL, X. and ZAMORA, J., 2020. Toolkit of methodological resources to conduct systematic reviews. F1000Research, 9, pp. 82.

SCOTT, A., LIAN, O., BAHR, R., HART, D.A., DURONIO, V. and KHAN, K.M., 2008. Increased mast cell numbers in human patellar tendinosis: correlation with symptom duration and vascular hyperplasia. British journal of sports medicine, 42(9), pp. 753-757.

SEITZ, A.L., MCCLURE, P.W., FINUCANE, S., BOARDMAN, N.D.,3RD and MICHENER, L.A., 2011. Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clinical biomechanics (Bristol, Avon), 26(1), pp. 1-12.

SPRAGUE, A.L., SMITH, A.H., KNOX, P., POHLIG, R.T. and GRAVARE SILBERNAGEL, K., 2018. Modifiable risk factors for patellar tendinopathy in athletes: a systematic review and meta-analysis. British journal of sports medicine, 52(24), pp. 1575-1585.

STEINMANN, S., PFEIFER, C.G., BROCHHAUSEN, C. and DOCHEVA, D., 2020. Spectrum of Tendon Pathologies: Triggers, Trails and End-State. International journal of molecular sciences, 21(3), pp. 10.3390/ijms21030844.

STERNE, J.A., HERNAN, M.A., REEVES, B.C., SAVOVIC, J., BERKMAN, N.D., VISWANATHAN, M., HENRY, D., ALTMAN, D.G., ANSARI, M.T., BOUTRON, I., CARPENTER, J.R., CHAN, A.W., CHURCHILL, R., DEEKS, J.J., HROBJARTSSON, A., KIRKHAM, J., JUNI, P., LOKE, Y.K., PIGOTT, T.D., RAMSAY, C.R., REGIDOR, D., ROTHSTEIN, H.R., SANDHU, L., SANTAGUIDA, P.L., SCHUNEMANN, H.J., SHEA, B., SHRIER, I., TUGWELL, P., TURNER, L., VALENTINE, J.C., WADDINGTON, H., WATERS, E., WELLS, G.A., WHITING, P.F. and HIGGINS, J.P., 2016. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ (Clinical research ed.), 355, pp. i4919.

VAN DER WORP, H., VAN DEN AKKER-SCHEEK, I., VAN SCHIE, H. and ZWERVER, J., 2013. ESWT for tendinopathy: technology and clinical implications. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 21(6), pp. 1451-1458.