For orthopaedic specialists Dr Rudolf Lassel and Dr Suchung Kim from Berlin, Extracorporeal Shock Wave Therapy (ESWT) is a fundamental component of their everyday work – particularly in the field of orthopaedic sports medicine. A current case report written by them refers to a 24-year-old professional female volleyball player suffering from acute pain in the Achilles tendon region, who was treated swiftly and successfully with combined ESWT and complementary physiotherapy.
High levels of pain and severe functional limitation
In the middle of the 2023/24 season, the professional volleyball player experienced sudden pain in the Achilles tendon region, which got progressively worse during training and the next match. The results of a consultation at the practice were as follows: persistent pain with swelling in the insertion region of the right Achilles tendon as well as moderate regions of oedema 2 cm proximal to the Achilles tendon insertion. The player was also affected by functional limitations in her everyday life in the form of pain when walking. Jumping and stop-start movements caused the pain to increase to a VAS of 7–8. The Thompson test, which is used to diagnose a possible Achilles tendon rupture, was negative, and ultrasound examination showed no evidence of discontinuity. There were also no signs of calcification, although there was moderate tendon thickening with peritendinous fluid. Based on the examinations, the player was diagnosed with »right Achilles tendinitis associated with chronic overload response«.
Physiotherapy, therapeutic exercise and combined shock wave therapy
The volleyball player initially received physiotherapy treatment, followed by training-focused therapeutic exercise. Focused and radial shock wave therapy was initiated at the start of February 2024 (using the STORZ MEDICAL DUOLITH® SD1 »ultra« system). The following treatment protocol was selected:
Focused ESWT: 2000 pulses with 0.03–0.07 mJ/mm2 in accordance with the DIGEST guidelines directly on the Achilles tendon insertion and proximally along the tendon without stand-off up to an intensity of 0.2 mJ/mm2.
Radial ESWT: Radial shock wave therapy with »Beam« transmitter (Ø 15 mm, Ro40). For each treatment session, the shock waves were applied with an intensity of 1.0–2.0 bareff, a frequency of 12–15 Hz and a total number of 6000 pulses, with no more than the recommended dose of 2000 pulses being administered at any one time. The shock waves were applied at the point of maximum hardening proximal to the insertion while the patient was in the prone position. In addition, up to six trigger points throughout the calf muscles, hamstring muscle group and plantar fascia were treated per session. The low dose of 1.0 to max. 2.0 bareff was selected in order to keep any pain during application to a minimum.
Focused ESWT with the SEPIA® handpiece / Radial ESWT with the FALCON® handpiece
She underwent a total of five treatments at three-day intervals. The total duration of treatment was 15 days. No analgesics or anaesthetics were required. The patient was also instructed to perform specific Achilles tendon stretches, eccentric exercises and fascia therapy. Her training plan was adapted (reduced jumping and impact activities), and she did not need to take a break from playing.
Pain-free with excellent functional scores after five treatments
The pain intensity recorded using the VAS decreased after just one treatment, and after 15 days and five treatments, the athlete was completely pain-free. Throughout the course of the treatments, she reported a continuous decrease in pain during her everyday activities (e.g. climbing the stairs) as well as a functional improvement in training and matches. Once the treatment was completed, the patient had a VAS of 0 and no limitations whatsoever. The patient also had no symptoms and excellent functional scores at the two subsequent follow-up appointments (three and eight weeks after the end of treatment). Throughout this time, she continued to do preventive exercises.
Classification of the treatment result: The combination therapy consisting of low-dose focused and radial ESWT and physiotherapy/therapeutic exercise resulted in an immediate and long-term effect with regard to the acute-onset chronic overload response of the Achilles tendon. The patient experienced no side effects following the application of the shock waves. Due to the accompanying physiotherapy measures, it is not possible to demonstrate an isolated success of the therapy. The results of the subsequent follow-up appointments (three and six months after the end of treatment) are not yet available.
Orthopaedic specialists Dr Rudolf Lassel (left) and Dr Suchung Kim (right)
