Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering.

NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research.

Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment.

51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance.

This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE.

The aim of this prospective study was to determine the prevalence of bone marrow oedema (BME) in asymptomatic knees of athletes and to investigate the factors associated with appearance of BME in this group.

A total of 25 asymptomatic athletes who competed at an international, national or county level during their most recent sport season were recruited in this study and had MRI scan of both knees (n=50). MRI scans were reported independently by two experienced musculoskeletal radiologists. Statistical analysis included Cohen's kappa test to identify inter-observer agreement for MRI diagnosis of bone marrow oedema and multiple logistic regression model to identify the factors associated with BME on MRI scan.

There was very good agreement between radiologists for diagnosis of BME (Kappa = 0.896). Seven participants (28%) were found to have BME. Six of the participants had BME in unilateral knees and one participant had BME in bilateral knees. The commonest location of BME was medial femoral condyle (62.5%) The amount of time spent in preseason training (34-38 weeks) was significantly associated with appearance of BME (P=0.048)

BME seems to be common in asymptomatic athletes and one should realize that this finding might not be related to the clinical complaints of the patients. The results of the present study show that there is a training effect associated with BME. Knowing what is a ‘normal’ or ‘abnormal’ scan is important for a competitive athlete, as erroneously diagnosing BME as the underlying cause of athletes' symptoms could lead to decreased playing time or inappropriate therapy.

There is debate regarding the most appropriate treatment of calcific tendinitis. Minimally-invasive techniques with image-guided needling of the deposits have been developed to provide an alternative solution. We present the results of fluoroscopically-guided barbotage in 100 patients. One hundred patients with acute or chronic shoulder pain, visible on plane radiographs or ultrasound scan, were referred from the Orthopaedic Department for barbotage over a six-year period. This study is a retrospective review of the results of barbotage in these patients, using a patient-based questionnaire. Forty three patients ultimately required arthroscopy of their painful shoulder. However, at surgery, the calcific deposits were noted to have dispersed in the majority of these patients. In addition there was often a long symptom-free period between the initial barbotage and recurrence of pain. In many cases the nature of their symptoms had changed and at arthroscopy signs of impingement or rotator cuff tears were common. Barbotage eliminated the need for more invasive surgery in over half of the patients in this study. It should be considered in all patients with calcific tendinitis refractory to non-operative treatment.

The purpose of this study was to assess the clinical outcome of two non-invasive techniques used in the treatment of calcific tendinitis of the shoulder.

Over the eight month period April 2000 to November 2000 sixty patients who were referred to this hospital with symptomatic calcific tendonitis were treated either with extracorporeal shockwave therapy (ESWT) using the Storz Medical Minilith (Storz Medical AG, Kreuzlingen, Germany) or by barbotage (needle puncture, aspiration and lavage under ultrasound control). All the patients had a long history of shoulder pain (average 42 months), caused by a radiographically evident calcific deposit, that had been unresponsive to conservative treatment including physiotherapy, steroid injections and non-steroidal anti-inflammatory tablets.

15 patients were treated with ESWT and 45 with ultrasound guided barbotage. The patients undergoing ESWT had the application head positioned under real time ultrasound or flouroscopic control. Patients had from one to three treatments with up to 2,500 shocks per treatment at incremental energy levels from 0.1 to 0.2 mJ/ mm2. Patients undergoing real time ultrasound guided barbotage had a single treatment. Clinical outcome was evaluated after a three month period with a postal questionnaire.

Thirty-two of 45 patients (71%) in the barbotage group had a marked reduction in symptoms at three months compared to nine out of 15 (64%) of the ESWT group.

Shockwave therapy (ESWT) and ultrasound guided barbotage are simple non invasive outpatient procedures which are effective in 64% to 71% of patients. These simple outpatient techniques should be considered for chronic pain due to calcific deposits that have been unresponsive to conservative treatments, and surgery reserved for those who fail to benefit.