Treating a persistent ankle injury with Extracorporeal Shockwave Therapy
Discovering you’ve won a bronze medal in your first ever triathlon, would be a proud moment for anyone.
But for Helen Milne, the impressive result earlier this year had extra resonance.
For the 56-year-old had spent the previous five years battling a persistent ankle injury which left the keen runner and tennis player frustrated and in pain – and she was eventually forced to give up exercising.
‘I was chuffed to bits to win, let alone compete – after so many years of struggling with my Achilles, it is something I never thought I’d be able to do,’ says Helen, who works in human resources for Thames Valley Police and lives in Standlake, Oxfordshire with her husband, Jim and their two grown up daughters.
After injuring her left heel five years ago while running over uneven ground, Helen was diagnosed with Achilles tendonitis – damage to the tough fibres that connect the back of the calf to the heel bone, which affects 150,000 people a year.
Tendonitis is a very common sports injury, resulting from injury or increased or repetitive use of a tendon, and can affect the shoulder, elbow or knee as well as the ankle.
Anything from trying to swim front crawl faster, enthusiastically painting a ceiling or even screwing together a difficult bit of flat-packed furniture can trigger it – or there can be no obvious cause.
Initially, Helen tried to treat the pain and inflammation with rest, ice and a programme of stretch and strengthening exercises from her physiotherapist.
But the inflammation and stiffening in Helen’s ankle never completely disappeared.
‘Just as I thought things were getting better, I’d get back from a dog walk and my ankle would swell and seize up, leaving me hobbling around for the rest of the day,’ she says.
This went on for four years – by which time she’d started experiencing pain in her right heel, too – until she was offered a high-tech, non-invasive treatment called Extracorporeal Shockwave Therapy (ESWT).
This delivers impulses of energy to damaged tissue within the tendon, stimulating stem cells (special cells which generate healthy cells to replace diseased ones) to start the healing process as well as increasing blood supply to the surrounding soft tissues which also helps with healing.
Although this technique has been around for a few years, it has only recently been rolled out widely as a treatment for chronic tendon problems.
Previously, patients with persistent tendon injuries that last for three to six months were given injections of saline, steroid or platelet-rich blood plasma (platelets from your own blood are separated and injected into the area) to kick start the healing process. Alternatively they’ve been offered surgery to remove damaged tissue.
However, these invasive treatments come with potential side-effects such as nerve damage which can actually make the problem worse.
Doctors first identified the power of shockwaves in the 1970s after noticing, when used to blast kidney stones, they appeared to have a healing effect on surrounding tissues.
Since then, the technology has been refined and tested on a wide range of conditions, and has been approved by National Institute for Health and Care Excellence since 2009 for the treatment of chronic tendon conditions such as Achilles tendinopathy, plantar fasciitis (tendon inflammation in the foot), tennis elbow, jumper’s knee (affecting the patellar tendon which holds the knee cap in place) and shoulder pain caused by tendon damage.
This means the technique now forms part of the NHS treatment armoury for tendon problems, when used in conjunction with a rehabilitation programme of physiotherapy.
Over the last few years, it has gained popularity with increasing numbers of hospitals and clinics now offering it as they acquire shockwave machines.
Bob Sharp. consultant orthopaedic surgeon at the Nuffield Orthopaedic Centre in Oxford says: ‘Shockwave is a fairly new treatment option for certain tendon and ligament problems which seems to be safe (with the occasional risk of tendon rupture in rare isolated cases) and it helps many but not all patients . Although it has been offered in the private sector for a few years its use is becoming widespread with many NHS centres now.’
‘It seems to be especially effective in cases where calcium deposits have built up inside ligaments and tendons, especially in the shoulder, and it is moderately good for certain other tendon problems such as the Achilles and plantar fasciitis.’
During the treatment, the therapist moves a hand piece (which looks like a power drill) across the skin of the affected tendon for around five minutes.
Compressed air forces a spring-loaded button in the hand piece to oscillate rapidly against a fixed metal plate, at up to 90km/ hour.
This creates energy that’s converted into shockwaves – these travel into the tissue. The process produces ‘cavitation bubbles’ (small vapour-filled cavities) in the tissue, which form, then instantly collapse, causing secondary shockwaves.
This stimulates stem cells to start the healing process and increases blood supply to the surrounding soft tissues.
Evidence shows that controlled levels of ‘trauma’ to tendon tissue is the best way to prompt healing and help reduce symptoms.
Studies show shockwave therapy also appears to reduce levels of an amino acid associated with inflammation and pain, reducing pain in the area.
Helen was recommended shockwave therapy by her physiotherapist in December 2018 after her tendon problems failed to improve.
‘It was so frustrating – I had to stop playing tennis and reduced my running to the shortest possible distances and endured discomfort, swelling and stiffness afterwards.’
When the pain started to appear in the tendon of her right ankle too, Helen went straight back to doing the physiotherapy exercises.
‘But the inflammation and discomfort was persistent and really rather depressing so when my physio suggested shockwave therapy, I was happy to give it a go,’ she says.
Shockwave treatment is given once a week for three weeks, and Helen admits it was ‘uncomfortable’. ‘It hurt quite a bit,’ says Helen.
‘But it’s hardly surprising because you’re firing pressure into tender swollen tissue.
‘I had to ask the physio to stop and restart every so often and I found myself employing Pilates/yoga breathing techniques to prevent myself from yanking my foot out of her hand.
‘But it is all over very quickly and it was never bad enough to bring tears to my eyes - and better still, the minute the treatment stops the pain relief is miraculous – it was as if my tendon was instantly cured.’
‘Although I hopped off the couch pain-free after every shockwave treatment, the old inflammation and stiffness would reappear after a few days,’ says Helen,
‘But the treatments were easier to endure each time, and the familiar stiffness would take longer to return and seemed reduced.’
Although patients often experience some relief straight away, the full benefits of shockwave treatment usually take six to eight weeks to emerge, explains Clare Lewey, the physiotherapist who treated Helen at Witney Physiotherapy Centre. However she emphasises that it works only if the treatment is conducted alongside a series of rehabilitation exercises.
‘I was really vigilant about applying ice to the area and performing all the exercises specifically as instructed,’ says Helen. ‘I was hugely motivated to do everything possible to ensure the painful treatments were worthwhile.’
Three months after the treatment was completed, the swelling, stiffness and discomfort had completely disappeared.
‘It was a wonderful feeling,’ says Helen. ‘I slowly got back to jogging again and was amazed when the familiar stiffness never recurred.’
In early May this year Helen entered the Oxford 10km ‘Town and Gown’ race and nipped round the course in just over an hour.
She was so thrilled she entered her first triathlon later that month which combined a 5k run, a 400m lake swim and 10k of cycling – with impressive results.
‘It was hilly,’ says Helen, ‘but I really enjoyed myself and it was only when I got home and checked my times online that I realised I’d won the bronze medal for the over-55s. I was delighted.’
* Extracorporeal Shockwave Therapy (ESWT) is available at larger physiotherapy or podiatry practises and some hospitals. For more information see www.cotswoldphysiotherapy.com
Article written by Louise Atkinson