RADIAL PROTOCOL
Radial protocol values
Pressure: 2 bar
Impulses: 2,000
Frequency: 10 Hz
Applicator: 15 mm
Total energy flux density dose: 103 mJ/mm²
Number of sessions: 3 (1 per week)
Medical information
The Achilles tendon is formed by the combined tendons of the soleus and gastrocnemius muscles (calf muscles), connecting them to the back of the heel. Insertional Achilles tendinopathy (IAT) is a painful acute or chronic disorder affecting the Achilles tendon at its insertion point on the calcaneus. Various terms have been used to describe this condition, including tendinosis, tendinitis, and peritendinitis.
However, histological examination of tissue samples (biopsies) taken from patients during surgery to treat chronic symptoms has shown that chronic IAT is associated with degenerative changes in the tendon. Accordingly, the condition is more accurately described as a tendinopathy rather than tendinitis or tendinosis.
Diagnosis is based on the clinical characteristics of the condition, with pain location representing an important distinguishing factor. In insertional Achilles tendinopathy (IAT), the point of maximum pain is located at the junction between the tendon and the bone, whereas in non-insertional Achilles tendinopathy, the point of maximum pain is found 2 to 6 cm proximal to the tendon insertion. Symptoms may worsen when running on hard surfaces or when climbing stairs. Imaging studies should be used to rule out other causes of Achilles tendon and heel pain, or to confirm the diagnosis of IAT when uncertainty exists.
The etiology of IAT is likely multifactorial and may include factors such as aging, obesity, hypertension, diabetes, hyperpronation, and steroid use, among others. In athletes in particular, the onset of IAT may also be influenced by harmful training habits, including overtraining, running on hard or inclined surfaces, and sudden changes in training schedules.
It has been hypothesized that healing of Achilles tendon injuries caused by overuse involves the ingrowth of small blood vessels into the tendon to enhance healing through improved blood supply. However, these small blood vessels are accompanied by nerve fibers containing high concentrations of nociceptive substances such as glutamate, substance P, and calcitonin gene-related peptide (CGRP). These nerve fibers are considered to be a major source of pain in chronic IAT.
Runners represent the largest group of patients affected by chronic Achilles tendon pain. The annual incidence of IAT among athletes is approximately 8%. However, individuals of all ages and activity levels may experience similar symptoms. Treatment of IAT should begin with conservative measures such as rest, ice application, physiotherapy, stretching exercises (eccentric loading), exercise therapy, orthotic support, insoles, and the administration of nonsteroidal anti-inflammatory drugs (NSAIDs). In some cases, symptoms may improve with the use of orthoses or immobilization using a cast or pneumatic walking boot.
Patients who do not respond to conservative treatment within six months may be considered for radial shock wave therapy (RSWT®). In more persistent cases of IAT, surgical intervention should be considered, applying the various surgical techniques described in the medical literature. Prevention of recurrence should include appropriate exercise habits, the use of low-heeled footwear, and eccentric strengthening exercises.
STUDIES
Rompe JD, Nafe B, Furia JP, Maffulli N Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med 2007;35:374-383.
Rompe JD, Furia JP, Maffulli N Eccentric loading, compared with shock wave treatment for chronic insertional Achilles tendinopathy: A randomized controlled trial. J Bone Joint Surg Am 2008;90:52-6
Rompe JD, Furia JP, Maffulli N Eccentric loading, versus eccentric loading plus shock-wave treatment for midportion Achilles tendinopathy: A randomized controlled trial. J Bone Joint Surg Am 2009;37:463-470.
FOCAL PROTOCOL
Focal protocol values
Penetration depth: 5–15 mm
Total energy flux density per shock wave emission: 0.089–0.238 mJ/mm²
Number of sessions: 3–5 (1 per week)
Frequency: 2–6 Hz
Impulses: 1,000–3,000
Medical information
Achillodynia is a painful syndrome affecting the Achilles tendon, generally resulting from overload caused by a variety of stresses. It commonly occurs in runners. However, the condition may also be caused by malalignment, Haglund’s deformity, or chronic irritation resulting from inappropriate footwear.
The tendinopathy is attributed to mechanical injury of the tendon with microtrauma caused by tendon overuse. Achillodynia may occur along the entire length of the Achilles tendon as well as at the tendon’s bony insertion. Patients typically complain of severe acute or chronic pain around the Achilles tendon insertion, often accompanied by palpable thickening in certain areas.
