What question did this study set out to answer?

The aim is to assess the effects of resistance training and shockwave therapy on tendon morphology in Achilles tendinopathy.

April 30, 2026Journal of science and medicine in sport0 citationsOpen Access

Ultrasound-Based Evaluation of Changes in Tendon Macro- and Micromorphology Following Exercise and ESWT in Mid-portion Achilles Tendinopathy: A Randomized Clinical Trial with 26-Week Follow-Up

JKJakub KatolickýCharles University TNTomáš NedělkaCzech Technical University in Prague GBGregory BashfordUniversity of Nebraska–Lincoln

Key Points

The aim is to assess the effects of resistance training and shockwave therapy on tendon morphology in Achilles tendinopathy.
41 participants with unilateral chronic midportion Achilles tendinopathy were randomized to receive resistance training alone or in combination with extracorporeal shockwave therapy.
A 12-week progressive loading program was conducted, with examinations at baseline, weeks 6, 12, and 26 to measure macromorphological and micromorphological parameters.
Pain and function were evaluated using NRS and VISA-A concurrently.
Significant pain reduction and VISA-A improvement were observed in both groups (p < 0.001).
A significant reduction in cross-sectional area was found at week 26 in the RT + ESWT group (p = 0.031).
Micromorphological remodeling showed decreased P6 and SUM with increased PPP and Q6, indicating improved collagen organization, especially in the combined group.

Abstract

Study Design: Prospective single-center randomized clinical trial.Objectives: To evaluate the effects of progressive resistance training (RT) alone and in combination with focused extracorporeal shockwave therapy (ESWT) on tendon macromorphology measured by ultrasound (US) and micromorphology using Spatial Frequency Analysis (SFA) in chronic midportion Achilles tendinopathy (AT).Background: RT is the cornerstone of AT management, while ESWT is frequently applied as an adjunct.Both interventions are clinically effective, yet their influence on tendon micromorphology in vivo remains insufficiently characterized.Methods: 41 participants with unilateral chronic midportion AT were randomized to either RT alone or RT + ESWT.Both groups performed a 12-week progressive loading program; the combined group additionally received four ESWT sessions.Examinations were performed at baseline, weeks 6, 12, and 26 to assess tendon thickness (TD), cross-sectional area (CSA), and micromorphological parameters (PSFR, P6, Q6, PPP, SUM).Pain (NRS) and function (VISA-A) were evaluated concurrently.Contralateral asymptomatic tendons served as referenced values.Results: Both groups showed significant pain reduction and VISA-A improvement (p < 0.001).Macromorphological parameters changed minimally; a significant CSA reduction occurred only at week 26 in the RT + ESWT group (p = 0.031).SFA revealed progressive micromorphological remodeling with decreased P6 and SUM and increased PPP and Q6, consistent with improved collagen organization and tissue homogeneity.These changes appeared with greater magnitude in the combined group.

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