Fractures of the Proximal Femur are a common and disabling injury requiring hospital admission and surgical treatment leading to approximately 86,000 inpatient episodes annually in the UK, with such patients occupying more than 20% of NHS orthopaedic beds. Based on current trends the number of hip fractures may rise to 120,000 per annum by 2015.

As the age of the population increases, so does the prevalence of concomitant medical conditions. Atrial Fibrillation is rising in the general population. Recently, the benefit of treating these patients with warfarin to prevent stroke has been shown; as a consequence, the number of patients being treated with warfarin is on the increase.

We have performed a retrospective study of all patients admitted to our unit with Fractures of the neck of the femur between 2001 and 2006, from the Accident and Emergency department with a primary diagnosis of Proximal Femoral Fracture (1987 patients). 138 patients were on long term warfarin at the time of their admission (6.9% of admissions). 90.4% were being warfarinised for AF, 7.6% for DVT and the rest for other indications. Of these Patients only 12 (8.7%) received active reversal to their warfarin. (All received vitamin K either orally or Intravenously). The average delay to theatre attributable to warfarin therapy was 41.1 hours (p-0.001). Active reversal allowed this delay to be negated (p-0.01), and did not delay the reloading of warfarin post-operatively (p-0.012). It also allowed an average of 10.2 days earlier discharge from the orthopaedic unit (p-0.001).

This study shows that significant delays occur because of Warfarinisation of these patients and that active reversal seems to be beneficial in expediting surgical treatment and discharge from the orthopaedic unit.

We investigated the blood flow to the femoral head during and after Resurfacing Arthroplasty of the hip.

In a previous study, we recorded the intra-operative blood flow in 12 patients who had a posterior approach to the hip and 12 who had a trochanteric flip approach. Using a LASER Doppler flowmeter, we found a 40% drop in blood flow in the posterior group and an 11% drop in the trochanteric flip group (p<0.001). The aim of this current study was to find out whether the intra-operative fall in blood flow persists during the post-operative period.

We therefore conducted a Single Positron Emission Tomography (SPECT) scan on 14 of the same group of patients. The proximal femur was divided into four regions of interest. These were the mid-shaft, proximal shaft, inter-trochanteric and head-neck regions. The data was analysed for bone activity and comparisons made between the two groups for each region of the femur. We found that the bone activity in the mid-shaft, upper-shaft, and head-neck regions was the same eleven months after the surgery irrespective of the approach to the hip. However there was higher activity in the trochanteric flip group in the inter-trochanteric region.

We conclude that the intra-operative deficit in blood flow to the head-neck region of the hip associated with the posterior approach does not seem to persist in the late post-operative period. We believe the reason for increased bone activity in inter-trochanteric region to be due to the healing of the trochanteric flip osteotomy.

Purpose of the study

We report the problems associated with setting up an electronic arthroplasty surveillance plan and suggest some solutions which are appropriate to the modern NHS setting.

The aim of this study was to compare immediate weight-bearing mobilisation with traditional plaster casting in the rehabilitation of non-operatively treated Achilles tendon ruptures.

Forty-eight patients with Achilles tendon rupture were randomised into two groups. The treatment group was fitted with an off-the-shelf carbon-fibre orthotic and the patients were mobilised with immediate full weight-bearing. The control group was immobilised in traditional serial equinus plaster casts. The heel raise within the orthotic and the equinus position of the cast was reduced over a period of eight weeks and then the orthotic or cast was removed. Each patient followed the same rehabilitation protocol. The primary outcome measure was return to the patient's normal activity level as defined by the patient.

There was no statistical difference between the groups in terms of return to normal work [p=0.37] and sporting activity [p=0.63]. Nor was there any difference in terms of return to normal walking and stair climbing. There was weak evidence for improved early function in the treatment group.

There was 1 re-rupture of the tendon in each group and a further failure of healing in the control group. One patient in the control group died from a fatal pulmonary embolism secondary to a DVT in the ipsilateral leg.

Immediate weight-bearing mobilisation provides practical and functional advantages to patients treated non-operatively after Achilles tendon rupture. However, this study provides only weak evidence of faster rehabilitation.

We used a laser Doppler flow-meter with high energy (20 m W) laser (Moor Instruments Ltd. Milwey, UK) to measure the blood flow to the femoral head during resurfacing arthroplasty.

Twenty-four hips were studied; 12 underwent a posterior approach and twelve a Ganz's trochanteric flip osteotomy. The approach was determined according to surgeon preference. Three patients were excluded, The exclusion criteria were previous hip surgery, history of hip fracture and avascular necrosis (AVN). All patients had the hybrid implant with cemented femoral component.

During surgery a 2.0mm drill bit was passed via the lateral femoral cortex to the superior part of the head neck junction. The position was confirmed using fluoroscopy. The measurements were taken during five stages of the operation: when the fascia lata was opened (baseline), at the end of soft tissue dissection, following dislocation of the hip, after relocation back into the socket, after inserting the implants prior to closing the soft tissues and, finally, at the end of soft tissue closure.

The results were analysed and the values were normalised to a percentage of the baseline value. We found a mean drop of 38.6 % in the blood flow during the posterior approach and a drop of 10.34% with the trochanteric flip approach. The significant drop occured between the baseline (1st stage) and the end of the soft-tissue dissection (2nd stage). In both groups the blood flow remained relatively constant afterwards.

Our study shows that there is a highly significant drop in blood flow (p<0.001) during the posterior approach compared with the trochanteric flip approach.

Introduction: Pain and mass lesions around hip resurfacing are reported with increasing frequency. The aetiology is unknown but reaction to metal wear debris and mechanical impingement have both been suggested. We are aware of a group of our patients with significant pain following resurfacing. We sought to correlate metal ion levels with X-ray findings and any local soft tissue reaction around the prosthesis.

Methods: Patients with significant groin pain following hip resurfacing were identified from routine clinics. Blood was tested for cobalt and chromium levels using inductively coupled mass spectrometry in all patients. Cup abduction angle and femoral stem version were estimated from plain radiographs. Patients underwent ultrasound scan (USS) of the affected hip joint. Bilateral prostheses were excluded to avoid confounding.

Results: 47 unilateral painful hip resurfacings (24 female) were identified. USS was performed in 42 patients and was abnormal in 25 (15 female). Abnormalities ranged from simple joint effusion with or without synovial thickening, through to cystic masses in the posterior joint and solid masses related to the ileopsoas tendon similar to the appearances previously described in pseudotumours.

A two sample t-test demonstrated cobalt and chromium ion levels were significantly higher in patients with abnormalities on USS (p=0.038, p=0.05 respectively), patients with normal USS were more likely to have a retroverted femoral component (p=0.01).

Discussion: We describe two groups of patients with a painful hip resurfacing: those with raised metal ions and local soft tissue reaction, and those with lower metal ions and no soft tissue reaction. The retroverted stems in the second group could cause an iatrogenic cam-type impingement. Metal ion levels are useful to guide further imaging. Raised levels should prompt investigation for a soft tissue abnormality with either USS or MRI, lower levels suggest investigation should look for mechanical impingement with imaging such as CT.

Background: Osteoarthritis (OA) is a progressive degenerative condition that causes pain and impairs the mobility of more than 10% of the UK population. Over 50,000 total knee replacements (TKR) are carried out each year for patients with the most severe symptoms. The aim of this study was to assess if markers of protein damage in the synovial fluid and plasma of patients with OA increase with severity of symptoms. These markers may then be of use in assessing disease presence and progression to assist with subsequent management. Proteins damaged by glycation (modified by sugars) and oxidation undergo cellular proteolysis. The proteolytic debris thereby formed - called glycation and oxidation free adducts (glycated and oxidised amino acids) - is released into the synovium and plasma for urinary excretion. In this study the concentrations of the glycation free adducts, Nε-carboxymethyl-lysine (CML) and methylglyoxal-derived hydroimidazolone (MG-H1), and the oxidation free adduct methionine sulfoxide (MetSO) were measured in the synovial fluid and plasma of patients with severe OA (sOA) and early-stage OA (eOA).

Methods: Patients were recruited from those attending the Rheumatology clinics at Ipswich Hospital, Ipswich and the Orthopaedic clinics at University Hospital, Coventry. Volunteer subjects were recruited to the normal healthy control group. The age (years; mean ± SD) for patient and control subject groups was: controls 45 ± 6 (n = 8), sOA 70 ± 12 (n = 8), eOA 50 ± 14 (n = 6). Patients found to have eOA changes (Outerbridge grade I/II) during routine arthroscopy were recruited to the eOA group. Synovial fluid and venous blood samples were taken with informed consent. All synovial fluid samples were taken from the knee joint. The concentrations of glycation and oxidation free adducts were assayed by stable isotopic dilution analysis liquid chromatography with tandem mass spectrometric detection (LC-MS/MS) in ultrafiltrate of synovial fluid and plasma. Significance of difference between study groups was assessed by ANOVA and Student’s t-test.

Results: The concentrations (nM; mean ± SD) of MetSO, CML and MG-H1 in synovial fluid were all markedly increased in OA patients with more severe disease. MetSO free adduct: eOA 459 ± 107 and sOA 2889 ± 1064 (p< 0.001). CML free adduct: eOA 77 ± 24 and 224 ± 51 (p< 0.001). MG-H1 free adduct: eOA 387 ± 182 and sOA 674 ±199 (p< 0.05). Analysis of plasma of these patients also showed increases in the concentrations of corresponding glycation and oxidation free adducts compared to those of normal healthy controls.

Discussion: The concentration of glycation and oxidation free adducts increased with severity of symptoms in the synovial fluid of patients with OA. This probably occurs by down regulation of protective gene expression in OA. Measurement of plasma protein glycation and oxidation free adducts may be useful in assessing progression and severity of OA. In the future, these markers may guide non-operative management and facilitate earlier joint-preserving surgery.

A key factor delaying rehabilitation after a tendo Achillis (TA) rupture is gait abnormality. We quantified changes in planter pressures after a rupture of the TA in four groups of patients:

15 controls subjects, mean 40 years, with no history of lower limb abnormality

Mean and maximum peak planter pressures within the forefoot and heel were measured using in-shoe pressure pads two weeks after removal of the cast/orthosis; five gait cycles were recorded. The terminal stance and pre-swing phases were also measured as a proportion of the total stance phase of the gait cycle. One-way ANOVA was used to compare the difference in means between the groups.

The normal control group had less than 2% difference between the limbs on all of the measured parameters. The patients in the plaster cast and ‘rigid’ orthotic groups had significant deficits (p = 0.04 and < 0.001 compared to control) in mean peak forefoot pressures, implying weakness in the triceps surae. However, the patients in the flexible orthosis group had only an 11% deficit (p = 0.25 compared to control). All of the patients treated for a TA rupture had increased heel pressures but only the ‘rigid’ orthotic group had cadence abnormalities (p = < 0.001). This may be the result of abnormal motor patterns secondary to mobilising in the rigid orthosis.

This study highlights the gait abnormalities associated with triceps surae weakness following rupture of the TA. Accelerated rehabilitation using weight-bearing orthotics may alleviate some of these problems, but new designs for flexible orthotics may be required for maximum benefit.

We report serum metal ion level data in patients with unilateral and bilateral hip resurfacing over a ten-year period. In these patients there is an increase in both cobalt and chromium levels above the accepted reference ranges during the first 18 months after operation. Metal ion levels remain elevated, but decline slowly for up to five years. However, the levels then appear to start rising again in some patients up to the ten-year mark. There was no significant difference in cobalt or chromium levels between men and women. These findings appear to differ from much of the current literature.

The clinical significance of a raised metal ion level remains under investigation.

Introduction: Two major complications of hip resurfacing arthroplasty are avascular necrosis of the femoral head and femoral neck fracture. Both are thought to be precipitated by disruption of the blood supply to the femoral head and neck during the approach to the hip joint. Ganz et al have described their technique of approaching the hip joint using a “trochanteric flip” osteotomy. This has the theoretical advantage of preserving the medial femoral circumflex artery to the femoral head. The aim of this study was to compare the intra-operative femoral head blood flow during the Ganz flip osteotomy to the blood flow during a posterior approach for resurfacing arthroplasty of the hip.

Methods: The intra-operative measurements of blood flow were performed using a DRT laser Doppler flow-meter with a 20 mW laser and a fibreoptic probe. The probe was introduced into the lateral femoral cortex and threaded into the femoral head under image intensifier control. Measurements were recorded before the approach to the hip was performed, after the approach was performed but before the head was dislocated, and after the head was dislocated.

Results: Our initial results indicate that there is on average a 50% drop in the blood flow to the femoral head after a posterior approach to the hip joint. In contrast, the trochanteric flip osteotomy produces a much smaller fall of around 18%. We have used these results to inform a sample size calculation, and are currently recruiting further patients to achieve a total of 42 in order to confirm a statistically significant effect.

Conclusion: The Ganz trochanteric flip osteotomy appears to produce less damage to the blood supply to the femoral head during resurfacing arthroplasty than the posterior approach. This study will inform surgeons in deciding on their preference for a routine approach for hip resurfacing.

Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good.

The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome.

The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded.

Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient.

58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003)

In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection.

Background: Hip resurfacing preserves bone stock on the femoral head. Some authors believe that this is at the expense of sacrificing more bone on the acetabulum and they point out two main reasons for this. Since resurfacing tends to be used in younger and more active individuals a larger head to neck ratio seems desirable in order to provide a better range of movement before impingement. In addition, the acetabular component has to be a minimum of 5 mm thick to prevent deformation on implantation and the subsequent compromise in the congruency of the bearings.

Method: We report the average size of the acetabular components of 220 Cormet resurfacings and 199 Pinnacle cups implanted in our department over a period of 18 months. From these sizes we estimated the mean acetabular bone loss for each procedure.

Results: The mean cup size was 53.7 mm for Cormet and 54.1 mm for Pinnacle i.e. the acetabular component of the resurfacing was smaller than the equivalent uncemented total hip replacement.

Conclusions: These figures show that resurfacing arthroplasty does not necessarily lead to greater acetabular bone loss than a total hip replacement. In our practice, we concentrate upon preserving acetabular bone rather than establishing a large head to neck ratio. In spite of this approach, the occurrence of impingement and dislocation among our patients seems to be as rare as in other comparable series.

Introduction: Many revision hip procedures involve revision of the socket only with retention of the mono block femoral component. Some surgeons choose to reduce metal wear by protecting the femoral head component from scratching by using the cut finger of a Biogel glove

Objective: To investigate whether the use of a finger surgeons glove reduces indentation of femoral (head) components.

Design: Femoral head components (Depuy) made from Ortron 90 stainless steel were fixed onto the Endura TE C 3300 materials testing machine. Indentations were made using scissors with a maximum force of 50 Newtons. Additional scratches were performed using a Jimmy. This procedure was then repeated using the finger of a glove as protection. The surface roughness values for the femoral heads were measured using a Taylor Hobson Talysurf Series 120L stylus instrument.

Conclusion: On the basis of these results we advocate the use of this simple measure to reduce the risk of surface damage to the femoral head. Furthermore, we believe that this is the only laboratory based study to ever investigate the effectiveness of this technique.

One of the factors that influence the outcome after Achilles tendon rupture is gait abnormality. We prospectively assessed 14 patients with Achilles tendon rupture and 15 normal control subjects using an in-shoe plantar pressure measurement system. There was a significant reduction in peak mean forefoot pressure in the early period of rehabilitation (p < 0.001). There was a concomitant rise in heel pressure on the injured side (p=0.05). However, there was no difference in cadence, as determined by the duration of the terminal stance and pre-swing phases as a proportion of the total stance component of the gait cycle. The forefoot pressure deficit in the Achilles tendon rupture group was smaller when assessed six months after the injury but was still significant (p=0.029). Pedobarographic assessment of patients after Achilles tendon rupture confirms that there are marked abnormalities within the gait cycle. Rehabilitation programmes which address these abnormalities may improve outcome.

Introduction: Tendon lengthening is an important cause of morbidity after Achilles tendon rupture. However, direct measurement of the tendon length is difficult. Ankle dorsiflexion has therefore been used as a surrogate measure, on the assumption that it is the Achilles tendon that limits this movement. The aim of this investigation was to assess the relationship between Achilles tendon length and ankle dorsiflexion. The primary research question was whether or not the Achilles tendon is the structure that limits ankle dorsiflexion. The secondary purpose was to quantify the relationship between Achilles tendon lengthening and dorsiflexion at the ankle joint.

Methods: Five cadaveric specimens were dissected to expose the tendons and capsular tissue of the leg and hindfoot. Fixed bony reference points were used as markers for the measurements. In the first specimen, the Achilles tendon was intact and the other structures that may limit ankle dorsiflexion were sequentially divided. In the other specimens the Achilles tendon was lengthened by 1cm intervals and the effect upon ankle dorsiflexion movement was recorded.

Results: Division of the other tendons and the capsular tissue around the ankle joint did not affect the range of ankle dorsiflexion. When the Achilles was divided the foot could be dorsiflexed until the talar neck impinged upon the anterior aspect of the distal tibia. There was a mean increase of 12 degrees of dorsiflexion for each centimetre increase in tendon length.

Conclusion: The Achilles tendon is the anatomical structure that limits ankle dorsiflexion, even when the tendon is lengthened. There was a linear relationship between the length of the Achilles tendon and the range of ankle dorsiflexion in this cadaveric model. Ankle dorsiflexion would appear to be a clinically useful indicator of tendon length.

We performed two independent randomised controlled trials to assess the potential benefits of immediate weight-bearing mobilisation for Achilles tendon ruptures. The first trial on surgically treated patients provides strong evidence of improved functional outcome for patients mobilised fully weight-bearing after operative repair of their Achilles tendon rupture. The two cases of re-rupture in the treatment group suggest that careful patient selection may be required as patients need to follow a structured rehabilitation regime.

The second trial performed upon non-operatively treated patients provides only weak evidence of a functional benefit from immediate weight-bearing mobilisation. However, the practical advantages of immediate weight-bearing did not predispose the patients to a higher complication rate. In particular there was no evidence of tendon lengthening or a higher re-rupture rate. We would therefore advocate the use of immediate weight-bearing mobilisation for the rehabilitation of all patients with rupture of the Achilles tendon.

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.

Aim The aim of this study was to compare immediate weightbearing mobilisation to traditional plaster casting in the rehabilitation of acute repaired Achilles tendon ruptures.

Methods 48 patients with acute repaired Achilles tendon ruptures consented to enter the trial. Patients were randomised into two groups. The treatment group were fitted with an off-the-shelf carbon-fibre orthotic and were mobilised fully weightbearing. The equinus position of the ankle joint was reduced over a period of 8 weeks and the orthotic was then removed. The control group were immobilised in traditional serial equinus plaster casts. The equinus position of the cast was reduced over the same 8 week period with weightbearing for only the last 2 weeks. The primary outcome measure was return to the patient’s normal activity level. An independent observer, blind to treatment, recorded secondary clinical, anthropometric and patient-centred outcomes. Follow-up was for one year.

Results There were 23 patients in the treatment group and 25 in the control group. Results show median in weeks (95% C.I.), p-values are based upon a log-rank test.

Return to sport was 39.0 (18.0 to 60.0) in the treatment group and 26.0 (40.0 to 90.0) in the control group, p = 0.341.

Return to normal walking was 12.0 (10.0 to 18.0) in the treatment group and 18.0 (18.0 to 22.0) in the control group, p < 0.001.

Return to stair climbing was 13.0 (10.0 to 15.0) in the treatment group and 22.0 (18.0 to 22.0) in the control group, p < 0.001.

Return to work was 9.0 (2.0 to 9.0) in the treatment group and 4.0 (1.0 to 13.0) in the control group, p = 0.984.

There were 2 re-ruptures of the tendon in the treatment group. One occurred when the patient slipped on ice whilst wearing the orthotic. The other whilst running 3 months after the initial injury. One patient who had an augmented tendon repair and then plaster casting, required plastic surgery for a major wound complication. In addition, there were 8 minor wound-related complications in the control group and 6 in the treatment group.

Conclusion Immediate weightbearing mobilisation provides practical advantages to patients after Achilles tendon repair. The median return to activity was significantly shorter in the treatment group for return to normal walking and return to stair climbing but not for return to work or sporting activity.

Aims: 1 To assess the histological changes in patients with Achilles tendinopathy. 2 To map the distribution of nerves and nerve endings within the Achilles tendon

Methods: Tendon biopsy specimens were taken from patients with spontaneous (ie previously painless) Achilles rupture patients and chronic painful tendinopathy patients. ‘Normal’ cadaveric /lacerated tendon biopsies were used for comparison. Sections were stained with H& E for basic histology. Immunolocalisation of nerve tissue was performed with 2 anti-neurofilament antibodies. Non-specific immunoglobulin was used as a negative control.

Results: The number of nerves and nerve endings found within the normal tendons and both groups of degenerate tendons was very low

Only 30% of the normal tendon sections showed any positive staining at all

Compared to 36% of ruptured tendon and 43% of the painful tendinopathy sections.

Conclusions: Tendon rupture and chronic painful tendinopathy biopsies ALL show widespread degenerative changes

There is a paucity of nerve tissue within these tendons, which may have implications for the neurogenic hypothesis of tendon degeneration

There appear be more nerve fibres in vascular areas of the painful tendinopathy biopsies

There may be more nerve fibres in the peritendinous tissue

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.