Achilles tendon injuries are prevalent in athletes and physically active individuals, with the Achilles being the most commonly injured tendon due to repetitive strain and the high demands placed on it1. Surgical repair is frequently indicated in cases of severe trauma or complete tendon rupture. However, postsurgical complications, such as tightness, scar formation, and functional impairment, pose significant challenges to recovery2,3. These complications can limit physical activity and are often exacerbated by fibrotic changes in the tendon and surrounding tissues, leading to reduced elasticity and increased risk of reinjury4.
Focused extracorporeal shockwave therapy (ESWT) has emerged as an innovative approach for managing both chronic tendinopathies and postsurgical complications by promoting neovascularization and reducing inflammation5. Wang et al.6 demonstrated that ESWT effectively stimulates collagen synthesis and enhances blood flow, which aids in scar tissue remodeling and reduces adhesions around the tendon repair site. Additionally, studies have shown that combining ESWT with eccentric exercises may optimize recovery by improving tendon elasticity and strength, essential for athletes returning to high-impact activities4,7. This report presents a case of postsurgical Achilles tendon tightness treated with ESWT, demonstrating improvements in pain, functional mobility, and tendon structure.
A 28-year-old male physical education teacher presented to the orthopedic clinic with complaints of persistent tightness and discomfort in the Achilles tendon, 6 months after surgical repair for a traumatic laceration. The injury occurred during a basketball game, where the patient collided with another player, resulting in a sharp, direct cut to the posterior lower leg. The impact caused a laceration that extended through the skin into the upper portion of the Achilles tendon. Emergency first aid was administered on-site, and he was transferred to the hospital for immediate surgical repair of the torn tendon and adjacent tissue structures.
Following surgery, the patient underwent routine rehabilitation, including physical therapy and range-of-motion exercises. However, over 4 months, the patient noted increasing tightness and discomfort localized around the repair site, with the symptoms progressively worsening. These issues limited his capacity to perform essential physical activities such as running, jumping, and demonstrating exercises, impacting both his quality of life and professional responsibilities.
On physical examination, limited dorsiflexion and tenderness along the Achilles tendon were noted, along with swelling and discoloration around the tendon area (Fig. 1A), suggesting postsurgical inflammation and adhesion formation. Initial ultrasound evaluation confirmed significant thickening of the Achilles tendon with inflammation (Fig. 2A).
Fig. 1. (A) Posterior view of both Achilles tendons before extracorporeal shockwave therapy (ESWT) treatment, highlighting substantial swelling and discoloration around the left Achilles tendon repair site. The affected area appears visibly thicker and has significant scarring from the previous surgical repair, which is marked by increased redness. (B) Posterior view of both Achilles tendons following 5 weeks of ESWT treatment, showing considerable improvement with reduced swelling and resolution of skin discoloration around the left Achilles tendon. The skin texture and color have normalized, indicating a decrease in postsurgical inflammation.
Fig. 2. (A) Initial ultrasound image of the left Achilles tendon before extracorporeal shockwave therapy (ESWT) treatment. The tendon thickness at the site of injury measures approximately 12 mm (indicated by double-headed arrow, which spans the thickened area of the tendon in the ultrasound image), which is significantly thicker than the normal range for the Achilles tendon (usually around 4-6 mm in healthy individuals). The internal structure shows hypoechoic (dark) areas and irregular tendon fiber alignment, indicating inflammation and scarring. The injured region is marked for clarity, helping readers unfamiliar with musculoskeletal ultrasound to locate the affected area. (B) Follow-up ultrasound image of the left Achilles tendon after 5 weeks of ESWT. The tendon thickness has decreased to approximately 5 mm, showing a return to near-normal dimensions. The internal structure has also improved, with better-defined, parallel tendon fibers and reduced hypoechoic regions, indicating resolved inflammation and tissue healing. The area corresponding to the previous thickening is marked to assist in visual comparison.
Written informed consent was obtained from the patient for publication of this case report.
Conservative treatments, including stretching and physical therapy, offered minimal relief. Thus, focused ESWT was initiated using a Storz Medical Duolith SD1 machine (Storz Medical AG), given its efficacy in tendon recovery. The ESWT protocol involved 10 sessions over 5 weeks, with each session delivering 2,000 shocks at a frequency of 2–4 Hz and an energy flux density of 0.21 mJ/mm2. Although standard protocols typically recommend weekly sessions, the patient’s pronounced adhesions and swelling necessitated a higher frequency of treatment to expedite tissue relaxation and reduce scarring.
In addition to ESWT, eccentric loading exercises were incorporated into the treatment plan to enhance tendon elasticity and strengthen surrounding musculature. Numerous studies have shown that combining ESWT with eccentric exercises can provide a synergistic effect, yielding superior outcomes in the management of Achilles tendinopathy compared to either intervention alone. This combination targets both the mechanical and biological aspects of tendon healing, promoting improved functional recovery and reduced risk of recurrence1-3.
Following the 5-week ESWT treatment regimen, the patient experienced significant symptomatic improvement. The visual analog scale (VAS) score for pain decreased from 6 to 1, and the Victorian Institute of Sport Assessment-Achilles (VISA-A) score also showed marked improvement, indicating reduced pain and better functionality. Swelling around the Achilles tendon was visibly reduced (Fig. 1B), and follow-up ultrasound imaging showed normalized tendon thickness and inflammation resolution (Fig. 2B). After 8 weeks of rehabilitation, the patient was able to return fully to his physical education duties, engaging in running, jumping, and other athletic activities without discomfort.
The use of ESWT for postsurgical complications, especially Achilles tendon tightness, is supported by multiple studies highlighting its regenerative effects. ESWT operates through mechanical stress, which triggers cellular responses that lead to tissue repair and regeneration. Research has shown that ESWT promotes the release of growth factors like vascular endothelial growth factor and transforming growth factor-beta, which stimulate neovascularization and collagen remodeling in tendinopathic tissue8,9.
In cases of Achilles tendinopathy and other tendon injuries, ESWT has demonstrated efficacy in reducing pain and improving function. Rompe et al.4 conducted a randomized trial comparing eccentric loading with and without ESWT for mid-portion Achilles tendinopathy and found superior results in the group receiving combined therapy. Similarly, a study by Mansur et al.7 demonstrated that ESWT coupled with eccentric strengthening exercises produced favorable outcomes in patients with chronic Achilles tendon issues, highlighting the benefits of a combined approach.
Despite conventional weekly ESWT sessions being the standard, a higher frequency protocol was applied in this case due to the patient’s severe postsurgical adhesions and inflammation. Studies by Stania et al.5 and Gerdesmeyer et al.10 support the flexibility of ESWT frequency based on patient-specific needs, suggesting that twice-weekly sessions may be safe and effective in managing severe cases. This intensified protocol resulted in significant improvements, with the patient’s VAS score for pain dropping from 6 to 1, and the VISA-A score also showing considerable improvement, indicative of reduced pain and enhanced functionality.
The integration of eccentric exercises further contributed to the patient’s recovery, as these exercises have been shown to enhance tendon resilience and facilitate collagen reorganization11. Eccentric loading is widely recognized for strengthening the musculotendinous unit, thus reducing the likelihood of recurrence. Studies indicate that the synergistic effect of ESWT and eccentric loading optimally addresses both structural and symptomatic aspects of tendinopathies4,11.
While the outcomes observed in this case are promising, further research is needed to establish standardized ESWT protocols for postsurgical tendon complications. Randomized controlled trials comparing different ESWT frequencies, energy levels, and combined rehabilitation approaches could provide clearer guidance for clinicians. Overall, this case supports the growing body of evidence advocating for ESWT as a valuable tool in orthopedic rehabilitation, especially when conventional therapies fail to yield satisfactory outcomes.
In conclusion, this case illustrates that focused ESWT can be an effective treatment for Achilles tendon tightness and discomfort following surgical repair. The non-invasive nature of ESWT, combined with its efficacy in reducing scar tissue and improving mobility, makes it a valuable tool in the rehabilitation of physically active individuals. Early intervention with ESWT may prevent long-term complications and help patients return to their professional and athletic activities.
No potential conflict of interest relevant to this article was reported.
Conceptualization, Data curation, Formal analysis: IL, HIC. Investigation, Project administration, Methodology, Resources, Software, Supervision, Validation, Visualization: all authors. Writing–original draft: all authors. Writing–review & editing: all authors.
