Search Results (75)

Background/Objectives: Knee osteoarthritis is one of the most significant diseases globally and in Portugal. Despite the availability of international guidelines, there is a lack of tailored, evidence-based recommendations specifically for Portuguese physiotherapists to manage their knee osteoarthritis patients with non-pharmacological and non-surgical interventions. This study aimed to develop a clinical practice guideline that integrates the latest international evidence with local clinical practice data to enhance patient outcomes. Methods: To achieve the objective, a comprehensive search was conducted in November 2024 across major health-related databases, to identify robust and recent evidence regarding the efficacy of non-pharmacological and non-surgical interventions, as well as their usage in the national context. Two key sources were identified: An umbrella and a mixed-methods study. Data from both sources were independently reviewed and integrated through a comparative analysis to identify interventions with robust scientific support and high local acceptability. Recommendations were then formulated and categorized into gold (strong), silver (moderate), and bronze (weak) levels based on evidence quality and clinical relevance. A decision-making flowchart was developed to support guideline implementation and clinical usage. Results: The integrated analysis identified three gold-level interventions, namely Nutrition/Weight Loss, Resistance Exercise, and Self-care/Education. Five silver-level recommendations were Aerobic Exercise, Balneology/Spa, Extracorporeal Shockwave Therapy, Electrical Stimulation, and Manual Therapy. Similarly, five bronze-level recommendations comprised Kinesio Taping, Stretching, Ultrasound Therapy, Thermal Agents, and Walking Aids. Conclusions: This clinical practice guideline provides a context-specific, evidence-based framework for Portuguese physiotherapists managing knee osteoarthritis. By bridging international evidence with local clinical practice, the guideline aims to facilitate optimal patient care and inform future research and guideline updates. Full article

Radial extracorporeal shockwave therapy (rESWT) is used in the rehabilitation of patients with shoulder periarthritis (SP) to promote tendon regeneration. This quasi-experimental non-randomized comparative study included 36 cases of SP, divided into two groups, and aimed to comparatively investigate the analgesic and functional effects of two different rESWT protocols. In Group One, the protocol involved an energy level of 210 J/session, a frequency of 10 Hz, and 2500 impulses per session. In Group Two, the protocol used an energy level of 190 J/session, a frequency of 10–15 Hz, and 2000 impulses per session. Treatments were administered over three sessions in Group One and five sessions in Group Two, with one-week intervals between sessions. Both rESWT protocols were combined with a physical therapy program consisting of ten daily sessions of analgesic physiotherapy and kinesiotherapy. Before and after the rehabilitation program, patients were assessed for pain intensity using the visual analog scale (VAS) and shoulder function using range of motion (ROM) measurements (via goniometry) and the Shoulder Pain and Disability Index (SPADI). Significantly better outcomes were observed in Group One (p < 0.001), particularly in terms of pain reduction and improvements in shoulder functionality, especially external rotation. These results support the effectiveness of the rESWT protocol used in Group One, which combined lower energy and frequency levels with a higher number of impulses over fewer sessions. Full article

Background/Objectives: Calcific tendinopathy of the shoulder is a degenerative condition characterized by calcium deposits within the rotator cuff tendons, particularly the supraspinatus. It is a frequent cause of chronic shoulder pain and functional limitation, adversely affecting quality of life. While conservative treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, and corticosteroid injections are commonly used, extracorporeal shock wave therapy (ESWT) has emerged as a promising non-invasive alternative. This interventional clinical trial compared the efficacy of ultrasound-guided versus landmark-based ESWT in treating calcific tendinopathy. Methods: Eighty-four patients with ultrasound-confirmed calcific tendinopathy were randomized into two groups. Group 1 received ultrasound-guided ESWT with real-time targeting of the deposit; Group 2 received landmark-based ESWT based on anatomical palpation. Both groups underwent three sessions (2000 impulses at 2.2 bars, energy level 5, 8 Hz). Clinical outcomes were assessed using the Constant–Murley score (CMS) at baseline, 12 weeks, and 6 months. Calcific deposit resorption was evaluated via ultrasound imaging. Results: The ultrasound-guided group showed a significant improvement in CMS from a median of 50 (range: 30–75) at baseline to 97 (52–100) at 6 months. The landmark-based group also improved, from 48 (32–74) to 79 (40–96). At 6 months post-treatment, 90.9% of patients in the ultrasound-guided group achieved successful outcomes (CMS ≥ 86), compared to 50% in the landmark-based group. Complete calcific resorption occurred in 65.9% of patients in Group 1, compared to 50% in Group 2; 15% of patients in Group 2 showed no resorption. Conclusions: Ultrasound-guided ESWT was significantly more effective than landmark-based ESWT in improving shoulder function, reducing pain, and promoting calcific deposit resorption. These findings support ultrasound guidance as a preferred approach for optimizing ESWT outcomes in patients with calcific tendinopathy of the shoulder. Full article

(1) Background: Tendon and ligament injuries are a leading cause of lameness in horses, with significant economic implications. Platelet-rich plasma (PRP) has gained attention for its regenerative potential, but its efficacy remains uncertain due to inconsistent study designs and reporting. (2) Methods: This systematic review, following the PRISMA guidelines, evaluated 22 studies (clinical and experimental) to assess the safety and efficacy of PRP in treating equine tendon and ligament injuries. The risk of bias was analyzed using the ROBINS-I and RoB 2.0 tools. (3) Results: PRP demonstrated a favorable safety profile, with no severe adverse effects reported. Clinical outcomes included improved lameness scores, ultrasonographic tissue organization, and return-to-work rates. However, variability in PRP formulations (e.g., leukocyte-rich vs. leukocyte-reduced) and activation methods (e.g., calcium chloride, thrombin) contributed to inconsistent results. Experimental studies supported PRP’s role in collagen synthesis and neovascularization, but comparative trials with stem cells or other therapies (e.g., extracorporeal shockwave) showed mixed results. The methodological quality of studies varied, with only 27% achieving “good” scores for PRP reporting. (4) Conclusions: PRP is a safe and potentially effective treatment, but its clinical application is hindered by a lack of standardization. Future research should focus on large, randomized controlled trials with uniform PRP protocols, long-term (≥2 years) efficacy assessments, comparative studies with MSC combinations, and cost-effectiveness analyses. Full article

Background: Non-calcific supraspinatus tendinopathy (SNCCT) is a frequent cause of shoulder pain, often associated with functional impairment and reduced quality of life. Recent advancements in diagnostic imaging, including shear wave elastography (SWE), provide quantitative data on tendon stiffness and thickness, facilitating more precise evaluations. Extracorporeal shockwave therapy (ESWT) has emerged as a minimally invasive and effective treatment for SNCCT, but its effects on tendon properties measured through SWE require further investigation. Objective: This retrospective observational study aimed to evaluate the impact of ESWT on supraspinatus tendon characteristics in patients with SNCCT by assessing tendon thickness, SWE velocity, and clinical outcomes. Methods: This observational study enrolled 39 patients with SNCCT, aged 30–75 years, who received three ESWT sessions over 3 weeks. The intervention was delivered using a Modulith SLK system at an energy level of 0.20 mJ/mm² with 2400 pulses per session. SWE and conventional ultrasound were used to measure tendon thickness and SWEv at baseline (T0) and 6 months post-treatment (T1). Clinical outcomes were assessed using the Visual Analog Scale (VAS), Constant and Murley Score (CMS), and modified Roles and Maudsley scale. Data were analyzed using paired t-tests and correlation analyses. Results: At baseline, affected tendons exhibited increased thickness (7.5 ± 0.9 mm) and reduced SWEv (3.1 ± 0.7 m/s) compared to healthy tendons (4.5 ± 0.7 mm and 6.9 ± 1 m/s, respectively; p < 0.05). Six months after ESWT, tendon thickness decreased significantly (6.2 ± 0.9 mm, p < 0.05), and SWEv increased (5.7 ± 1.8 m/s, p < 0.05), indicating improved elasticity. Clinical outcomes improved significantly, with the VAS scores decreasing from 6.5 ± 1.4 to 3.2 ± 2.1, the CMS score rising from 59.1 ± 17.3 to 78.2 ± 17.7, and the modified Roles and Maudsley scale improving from 2.3 ± 0.6 to 1.5 ± 0.8 (p < 0.05 for all). SWEv positively correlated with the CMS (r = 0.4) and negatively with the VAS and the modified Roles and Maudsley scale (r = −0.6 and r = −0.5, respectively). Conclusions: ESWT significantly reduces tendon thickness and enhances elasticity, correlating with improvements in pain and functional scores. SWE proved to be a reliable method for monitoring structural and clinical changes in SNCCT. Further research, including randomized controlled trials, is recommended to confirm these findings and explore longer-term outcomes. Full article

Background: Shoulder pain is a very common health issue among adults, being 8% due to calcifying tendinopathies (CT) of the shoulder. The evolutionary process of this lesion can be classified according to Bianchi Martinoli, depending on the ultrasound appearance. In 50% of cases, with first-line treatments, they resolve spontaneously. However, in the remaining 50%, they become chronic, requiring other lines of treatment, such as shock waves (ESWT) or ultrasound-guided barbotage (US-PICT). Objectives: The objective focuses on comparing the improvement in pain using the visual analgesic scale (VAS) and shoulder joint balance (ROM) in patients with CT based on the treatment received, stratifying according to the characteristics of the injury, with the aim of protocolizing said treatment. Methods: Randomized analytical controlled clinical trial in blocks with two arms according to the Bianchi Martinolli classification (I or II/III) in 56 patients affected by chronic pain by CT. The decision to treat will be made randomly 1:1, based on the treatment assigned to the previous patient. Results will be evaluated in three moments (1, 3, and 6 months). The following variables will be collected: VAS, Lattinen test, ROM (flexion, abduction, external and internal rotation), patient global improvement impression scale (PGI-I), global improvement impression scale (CGI-C). Discussion: The use of ESWT or US-PICT as treatments is a widely used practice in the daily life of this pathology. However, despite knowing that both treatments are useful in chronic CT, there are no known data or protocols by which one therapy is chosen over another, much less the influence that the evolutionary stage can have of the injury in the results obtained. Full article

Background: Gluteus medius tendinopathy is amongst the most prevalent lower limb tendinopathies and is now recognized as the primary cause of insidious lateral hip pain. Typically affecting middle-aged women, this condition causes disability and reduced quality of life as it negatively impacts most daily life activities. Several studies demonstrate that extracorporeal shockwave therapy is effective in reducing pain and promoting functional recovery in several musculoskeletal disorders including tendinopathies. However, most published data are limited to evaluating focal or radial shockwaves as single interventions. Contrariwise, there is little evidence reporting the use of combined ESWT treatment and outcomes for managing tendon pathologies, and no data are reported on combined ESWT for gluteus medius tendinopathy. Objectives: The aim of this study was to evaluate the clinical outcomes of combined ESWT in gluteus medius tendinopathy. Methods: Medical charts of 11 consecutive patients with gluteal tendinopathy confirmed by ultrasound who underwent a combined ESWT protocol were reviewed. Changes in pain severity and lower limb function were evaluated using the numerical rating scale, the Victorian Institute of Sports Assessment for Gluteal tendinopathy questionnaire, and the Roles and Maudsley score. Clinical outcome measurements were collected at baseline (T0), 2 months after combined ESWT (T1), and at long-term follow-up (T2), at least 10 months post-treatment (mean 26 months). Results: The mean age of the sample was 62.55 ± 3.17 years. A marked prevalence of females was recorded (nine subjects, 81.8%). A significant improvement was observed in all outcome criteria both at short- and long-term follow-up after combined ESWT compared to baseline (p < 0.05). Treatment success rates were 90.9% and 81.8% at T1 and T2, respectively. Conclusions: Combined ESWT is effective and safe for patients with gluteal tendinopathy, with good long-term results in terms of pain relief and improved functional impairment. Full article

Background/Objectives: Low back pain (LBP) is a widespread public health issue, with myofascial pain syndrome (MPS) being a common cause, affecting 67–100% of patients. However, there are significant challenges in the diagnostic process due to the subjective and unreliable nature of manual palpation. Focused Extracorporeal Shockwave Therapy (F-ESWT), traditionally used for MPS treatment, offers a reproducible and non-invasive mechanical stimulus, making it a potential diagnostic tool. This study evaluated F-ESWT’s diagnostic efficiency in chronic LBP patients by focusing on “recognition” and “referral” of pain. Methods: twenty-eight participants were screened for myofascial trigger points (MTrPs) in the lumbar, gluteal, and thigh regions. Identified MTrPs were stimulated using F-ESWT, and patient feedback was recorded. Results: data showed high diagnostic accuracy for muscles such as the quadratus lumborum, gluteus medius, and gluteus minimus muscles, achieving “referral” rates of 96%, 95%, and 92% and “recognition” rates of 84%, 86%, and 85%, respectively. Other structures like adductors, iliopsoas, erector spinae, and biceps femoris muscle showed consistent but lower diagnostic rates. Conclusions: the study’s findings indicate that F-ESWT effectively reproduces pain patterns, offering a precise, reproducible, and non-invasive diagnostic approach for MPS in chronic LBP. However, they also highlight the necessity for detailed diagnostic criteria in managing myofascial pain. Full article

Background: Osteoporosis (OP) is a chronic inflammatory bone disease characterized by reduced bone structure and strength, leading to increased fracture risk. Effective therapies targeting both bone and cartilage are limited. This study compared the therapeutic effects of extracorporeal shockwave therapy (ESWT), bisphosphonate (Aclasta), and human Wharton jelly-derived mesenchymal stem cells (WJMSCs) in a rat model of OP. Methods: Female rats were assigned to four groups: Sham (no surgery or treatment), OP (bilateral ovariectomy, OVX), ESWT (OVX + ESWT on both tibias at 0.25 mJ/mm², 1500 impulses per tibia), Aclasta (OVX + zoledronic acid 0.1 mg/kg via tail vein injection), and WJMSC (OVX + 2 × 10⁶ WJMSCs). Pathological changes, bone microarchitecture (by micro-CT), serum cytokines (by ELISA), and tissue-specific molecular markers (by immunohistochemistry) were evaluated. Results: All treatments improved bone density, preserved cartilage, and modulated cytokines (IL31, IL33, VEGF, and BMP2), with Aclasta showing the greatest improvements in bone parameters and cartilage preservation. ESWT and WJMSC also demonstrated significant effects, with ESWT highlighting non-invasive chondroprotective potential. Conclusions: Aclasta provided the best overall therapeutic response, particularly in bone regeneration. However, ESWT and WJMSC also showed comparable chondroprotective effects. ESWT emerges as a promising non-invasive alternative for OP management when pharmacological or cell-based therapies are not feasible. Full article

Background/Objectives: Achilles and hamstring tendinopathies are common injuries in runners, and extracorporeal shockwave therapy (ESWT) may be an effective treatment. Runners are at risk for lower extremity tendinopathies and the Male and Female Athlete Triad (Triad). The purpose of this study is to evaluate the association of sex, exposure to hormonal contraceptives, menopause, and Triad-related risk factors with ESWT outcomes in the treatment of Achilles and hamstring tendinopathy. Methods: This is a retrospective cohort study of runners with either Achilles or hamstring tendinopathy who received radial or combined radial and focused ESWT. Tendon function was measured using Victorian Institute of Sport Assessment (VISA) questionnaires completed before and following treatment. Treatment success was defined by a change in VISA score that met the minimal clinically important difference (MCID). Results: There were 88 runners (54.5% female, 45.5% male) with Achilles (52.3%) or hamstring (47.7%) tendinopathy. No measurable difference was found in the proportion of females and males overall that achieved the MCID (57.1% and 72.5%, p = 0.17). Similar rates of females and males met MCID for Achilles (77.8% and 75.0%, p = 0.83) and hamstring tendinopathy (46.7% and 66.7%, p = 0.24). However, females with Achilles or hamstring tendinopathy who used oral contraceptive pills (OCPs) were less likely to meet the MCID compared to females not on OCPs (p = 0.031); this finding was present in a subgroup analysis of runners with only Achilles tendinopathy (p = 0.025). No associations were found between achieving the MCID and Triad risk factors, including body mass index, energy availability, weight-related behaviors, bone health, or menstrual function (all p > 0.05). Conclusions: Female and male runners reported similar success rates for ESWT, and Triad risk factors were not found to impact outcomes. However, females who used oral contraceptive pills were less likely to achieve the MCID from ESWT. Full article

Background: Lateral epicondylitis of the elbow, commonly known as tennis elbow, is a musculoskeletal disorder characterized by pain and degeneration of the common extensor tendon. Despite various treatments, optimal management remains debated. Objective: This study aimed to compare the effectiveness of focal extracorporeal shockwave therapy (F-ESWT) alone versus a combination of focal and radial pressure waves (F-ESWT+R-PW) in treating chronic lateral epicondylitis. Methods: This retrospective observational study included 45 patients diagnosed with chronic lateral epicondylitis divided into two groups based on the treatment received: group A (F-ESWT, n = 23) and group B (F-ESWT+R-PW, n = 22). Both groups underwent three weekly sessions of their respective treatments. Patients were also given a home exercise protocol. Primary outcomes were assessed using the Visual Analog Scale (VAS) for pain and the Patient-Rated Tennis Elbow Evaluation (PRTEE) for pain and functional impairment at baseline (T0), 4 weeks (T1), 12 weeks (T2), and 24 weeks (T3) post-treatment. Secondary outcomes included grip strength and ultrasonographic measurements of common extensor tendon (CET) thickness and vascularization. Results: Significant improvements in VAS and PRTEE scores were observed in both groups at all follow-up points. Group B showed greater pain reduction at T1 (VAS: 3.0 ± 1.6 vs. 4.43 ± 1.47; p < 0.005) and T2 (VAS: p < 0.030) compared to group A. Functional outcomes (PRTEE) also favored group B at T1 (p < 0.030) and in the pain section at T2 (p < 0.020). Grip strength improved similarly in both groups. CET thickness showed no significant differences at T3. Vascularization decreased significantly in both groups, with a non-significant trend favoring group B. Conclusions: The combined F-ESWT+R-PW therapy proved more effective than F-ESWT alone in the short- to mid-term management of chronic lateral epicondylitis, significantly enhancing pain reduction and functional outcomes. The combination of focal and radial pressure waves offers a superior therapeutic approach, leveraging the distinct mechanisms of each modality for better clinical results. Further research is needed to confirm these findings and establish long-term efficacy. Full article

Background: Chronic lateral epicondylitis (LE), also known as tennis elbow, affects 1–3% of the population, primarily those over 40 years old. Most cases resolve with conservative treatments, but some require more advanced interventions. Extracorporeal shockwave therapy (ESWT) has emerged as a non-surgical treatment option, utilizing either low- or high-energy levels to alleviate pain and improve function. Objective: This study aimed to compare the efficacy of low-energy versus high-energy ESWT in the treatment of chronic LE, focusing on pain relief and functional improvement. Methods: A retrospective observational study was conducted including patients treated for chronic LE between 2021 and 2024. Participants were divided into two groups: low-energy ESWT (0.10 mJ/mm²) and high-energy ESWT (0.20 mJ/mm²). Both groups received 2400 pulses at a frequency of 6 Hz once a week for three weeks. Pain and functional outcomes were measured using a visual analog scale (VAS) and the Patient-Rated Tennis Elbow Evaluation Questionnaire (PRTEE) at the baseline, three months (T1), and six months (T2) post-treatment. Results: Forty-six patients participated, with 24 in the low-energy group and 22 in the high-energy group. Baseline demographics and clinical characteristics were similar across groups. At T1 and T2, the low-energy group showed significantly greater reductions in the VAS scores (T1: 4.45 ± 0.8 vs. 3.6 ± 1.7, p = 0.04; T2: 3.2 ± 1.2 vs. 2.1 ± 1.1, p = 0.004) and PRTEE scores (T1: 34.3 ± 6.9 vs. 26.8 ± 11.9, p = 0.03; T2: 25.3 ± 6 vs. 17.6 ± 9, p = 0.005). Significant treatment–time interactions were observed for both the VAS and PRTEE scores, indicating sustained improvements in the low-energy group. Conclusions: Low-energy ESWT was more effective than high-energy ESWT in treating chronic LE, providing greater and longer-lasting pain relief and functional improvement. These findings suggest that low-energy ESWT should be preferred in clinical practice for managing this condition. Future research should focus on larger sample sizes and randomized controlled trials to confirm these results and explore the underlying mechanisms of differential efficacy between energy levels. Full article

Background: The purpose of this study is to examine the combination of the mechanical effects of penile therapy with vacuum erection devices (VEDs) plus PDE5i, which improve clinical outcomes after extracorporeal shockwave therapy (ESWT) in men affected by erectile dysfunction (ED) associated with Peyronie’s disease (PD). Methods: A total of 153 medical records of patients affected by PD in stable stage with ED and treated with ESWT were divided into two groups. Group A (GA) included 72 men treated with ESWT, mechanical stretching with VEDs and PDE5ì (Tadalafil 5 mg), and Group B (GB) included 81 men who received only ESWT plus Tadalafil 5 mg with the same protocol of GA. The patients in both groups were assessed at baseline and follow-up for erectile function, painful erections, penile plaque size, and penile curvature. The results were evaluated at baseline and 3, 6, and 12 months after the treatments. Results: Three months after the treatment, GA patients had a reduction in penile curvature degree from a mean ± SD of 33.91 ± 8.34° at baseline to a mean ± SD of 19.46 ± 7.15° after 12 months, whereas pain in an erection or during intercourse was resolved completely in 88.9% of the patients. The mean ± SD IIEF-15 score of patients affected by severe/moderate ED further improved significantly in the GA group (p < 0.001) after 3, 6, and 12 months of treatment. There were no permanent adverse sequelae after treatments. Conclusions: The regular use of a VED plus Tadalafil in patients who had undergone ESWT significantly provided more benefit in patients with PD in terms of penile deformity, pain, and erectile function. Full article

Conservative treatments for plantar fasciitis have different levels of effectiveness, so it is necessary to personalize the therapeutic modality that improves the patients’ symptoms. Methods: A double-blinded randomized clinical trial was designed to evaluate the short-term efficacy of a physical treatment in chronic plantar fasciitis, namely iontophoresis, compared with radial shockwave therapy. Heel pain, health status using the EuroQol-5D questionnaire, and fascia thickness measured with ultrasound were evaluated. In total, 127 patients were randomly selected for group A and treated with iontophoresis therapy (lidocaine 0.4% and dexamethasone 0.5%), or for group B, in which they were treated with radial shockwave therapy (EWST). Measurements were taken at baseline and at follow-up during the 5 weeks of the study. Results: Statistically significant differences were observed to the shockwave therapy group in respect to the final fascia thickness, and the VAS scale (p = 0.001). The differences between groups A and B showed that the shockwave group follow-up after 3 weeks experienced complete pain remission (1.0 ± 0.9; 95%CI 0.8–1.2) and after the 6-week follow-up, complete pain remission of plantar fasciitis was observed for both therapies. Patients had a better perception of the use of EWST at the end of the treatment, although in both groups it was satisfactory (p = 0.001). Conclusions: The results of this study showed a shorter-term effectiveness of shockwave treatment compared with the use of iontophoresis. However, both techniques were effective in satisfactorily reducing pain in this short period. Full article

The supraspinatus tendon is one of the most involved tendons in the development of shoulder pain. Extracorporeal shockwave therapy (ESWT) has been recognized as a valid and safe treatment. Sometimes the symptoms cannot be relieved, or a relapse develops, affecting the patient’s quality of life. Therefore, a prediction protocol could be a powerful tool aiding our clinical decisions. An artificial neural network was run, in particular a multilayer perceptron model incorporating input information such as the VAS and Constant–Murley score, administered at T0 and at T1 after six months. It showed a model sensitivity of 80.7%, and the area under the ROC curve was 0.701, which demonstrates good discrimination. The aim of our study was to identify predictive factors for minimal clinically successful therapy (MCST), defined as a reduction of ≥40% in VAS score at T1 following ESWT for chronic non-calcific supraspinatus tendinopathy (SNCCT). From the male gender, we expect greater and more frequent clinical success. The more severe the patient’s initial condition, the greater the possibility that clinical success will decrease. The Constant and Murley score, Roles and Maudsley score, and VAS are not just evaluation tools to verify an improvement; they are also prognostic factors to be taken into consideration in the assessment of achieving clinical success. Due to the lower clinical improvement observed in older patients and those with worse clinical and functional scales, it would be preferable to also provide these patients with the possibility of combined treatments. The ANN predictive model is reasonable and accurate in studying the influence of prognostic factors and achieving clinical success in patients with chronic non-calcific tendinopathy of the supraspinatus treated with ESWT. Full article