Eccentric Loading Versus Eccentric Loading Plus Shock-Wave Treatment for Midportion Achilles Tendinopathy:
A Randomized Controlled Trial
Jan D. Rompe, MD1*, John Furia, MD2, Nicola Maffulli, MD, PhD, FRCS(Orth)3
1 OrthoTrauma Evaluation Center
2 Sun Orthopaedics Group
3 Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine
Abstract
Background: Results of a previous randomized controlled trial have shown comparable effectiveness of a standardized eccentric loading training and of repetitive low-energy shock-wave treatment (SWT) in patients suffering from chronic midportion Achilles tendinopathy. No randomized controlled trials have tested whether a combined approach might lead to even better results.
Purpose: To compare the effectiveness of 2 management strategies—group 1: eccentric loading and group 2: eccentric loading plus repetitive low-energy shock-wave therapy.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: Sixty-eight patients with a chronic recalcitrant (>6 months) noninsertional Achilles tendinopathy were enrolled in a randomized controlled study. All patients had received unsuccessful management for >3 months, including at least (1) peritendinous local injections, (2) nonsteroidal anti-inflammatory drugs, and (3) physiotherapy. A computerized random-number generator was used to draw up an allocation schedule. Analysis was on an intention-to-treat basis.
Results: At 4 months from baseline, the VISA-A score increased in both groups, from 50 to 73 points in group 1 (eccentric loading) and from 51 to 87 points in group 2 (eccentric loading plus shock-wave treatment). Pain rating decreased in both groups, from 7 to 4 points in group 1 and from 7 to 2 points in group 2. Nineteen of 34 patients in group 1 (56%) and 28 of 34 patients in group 2 (82%) reported a Likert scale of 1 or 2 points ("completely recovered" or "much improved"). For all outcome measures, groups 1 and 2 differed significantly in favor of the combined approach at the 4-month follow-up. At 1 year from baseline, there was no difference any longer, with 15 failed patients of group 1 opting for having the combined therapy as cross-over and with 6 failed patients of group 2 having undergone surgery.
Conclusion: At 4-month follow-up, eccentric loading alone was less effective when compared with a combination of eccentric loading and repetitive low-energy shock-wave treatment.
Monday, December 22, 2008
Tuesday, December 9, 2008
Heel Pain
Severe recalcitrant heel pain, resulting from repetitive trauma to the plantar fascia, is a commonly observed phenomenon. Although this condition is frequently referred to as ‘heel spurs’ and plantar fasciitis (acute inflammatory stage) and plantar fasciosis (chronic degeneration) are currently accepted as the more accurate terms. Symptoms most often occur during the first few steps in the morning but may also be effected during intense activity or with prolonged standing. The source of pain symptoms, which are usually perceived as a gradual onset of burning, is located at the origin of the plantar fascia at the calcaneous (heel bone). Risk factors such as low or high arches or over-pronation of the foot, gastrocnemius equines (tight calf muscle), systemic disease, or obesity may exacerbate pain.
The plantar fascia, or aponeurosis, is a multi-layered fibrous structure consisting three discreet sections: medial, central, and lateral. The plantar fascia fans out distally from the mid-portion of the heel and connects to the five digits of the foot. The function of the plantar fascia is to provide support to the arch of the foot and stability to the joint in the largest toe, where most weight bearing occurs during the heel rise phase of walking. The cause of the pain mechanism in recalcitrant plantar fasciitis is not yet clear, but is believed to be associated with a degenerative response linked to chronic overuse. On magnetic resonance imaging (MRI), acute plantar fasciitis exhibits microtears in the fascia and concomitant signs of acute inflammation such as marked thickening of the insertion of the plantar fascia, edema at the fascia-muscle and fascia-fat interfaces, and inflammation of the adjacent subcutaneous fat. Over time, unresolved recalcitrant plantar fasciitis shows relatively less edema in the fascia and histological evidence of localized fibrosis and/or degeneration, including fibrovascular hyperplasia and fibroblastic proliferation, with no evidence of classic inflammation. Several authors have suggested that this condition is more accurately described as ‘plantar fasciosis’. The physical characteristics of plantar fasciosis are similar to those observed with refractory tendinosis, which is recognized as a non-inflammatory, degenerative condition distinct from tendonitis. The current school of thought is that tendinosis, and similarly plantar fasciosis, may be a result of a ‘failed healing’ process, thus a principal objective in treatment is to initiate a localized angiogenic response (increased blood supply) to aid in healing.
Bob Anderson, MD, President of the Orthopedic Foot & Ankle Society has been quoted as stating that 15 million treatments for plantar fasciitis-fasciosis were performed in 2007.
CURRENT TREATMENTS
Conservative treatment options for plantar fasciosis include:
rest, stretching, strengthening, ice water soaks, and massage, progressing to non-steroidal anti-inflammatories, steroid injections with continued recalcitrance. Orthotics, heel cups, night splints, and plantar strapping (taping) are other conservative options frequently recommended by treating physicians. Patient outcomes and response to conservative measures is usually positive with the Weil Foot & Ankle Institute reporting 80% success after six weeks of the basic treatments.
With non-responsive cases, approximately 15% of all presenting cases, cast immobilization and surgical care may be necessary. Extracorporeal shockwave (ESWT) treatment has recently been advocated for the recalcitrant cases.
A study performed by Dr. Lowell Weil, Jr. has shown ESWT to be effective in 70-85 percent in the recalcitrant cases of plantar fasciitis-fasciosis with no complications.
Surgical Plantar fasciotomy or fascia release, either partial or complete is commonly the surgical procedure of choice for treating plantar fasciosis with a reported success of 80-85%.(Dr. Wendy Benton-Weil) However, this surgery has a risk of complications and is thought to alter the biomechanics of the foot, which may be linked to post-operative lateral column pain and medium-term disability. Other complications including nerve damage have also been reported with endoscopic plantar fasciotomy. Plantar, micro-fasciotomy (Radiofrequency Topaz Coblation) of the plantar fascia has also shown a success rate equal to plantar fasciotomy, in a two arm, randomized blinded study. (Dr. Lowell Scott Weil, Sr.)
Lowell Scott Weil, Sr., DPM, FACFAS
Chairman & CEO
Weil Foot & Ankle InstituteDes Plaines, IL
www.weil4feet.com
weil4feet@aol.com
The plantar fascia, or aponeurosis, is a multi-layered fibrous structure consisting three discreet sections: medial, central, and lateral. The plantar fascia fans out distally from the mid-portion of the heel and connects to the five digits of the foot. The function of the plantar fascia is to provide support to the arch of the foot and stability to the joint in the largest toe, where most weight bearing occurs during the heel rise phase of walking. The cause of the pain mechanism in recalcitrant plantar fasciitis is not yet clear, but is believed to be associated with a degenerative response linked to chronic overuse. On magnetic resonance imaging (MRI), acute plantar fasciitis exhibits microtears in the fascia and concomitant signs of acute inflammation such as marked thickening of the insertion of the plantar fascia, edema at the fascia-muscle and fascia-fat interfaces, and inflammation of the adjacent subcutaneous fat. Over time, unresolved recalcitrant plantar fasciitis shows relatively less edema in the fascia and histological evidence of localized fibrosis and/or degeneration, including fibrovascular hyperplasia and fibroblastic proliferation, with no evidence of classic inflammation. Several authors have suggested that this condition is more accurately described as ‘plantar fasciosis’. The physical characteristics of plantar fasciosis are similar to those observed with refractory tendinosis, which is recognized as a non-inflammatory, degenerative condition distinct from tendonitis. The current school of thought is that tendinosis, and similarly plantar fasciosis, may be a result of a ‘failed healing’ process, thus a principal objective in treatment is to initiate a localized angiogenic response (increased blood supply) to aid in healing.
Bob Anderson, MD, President of the Orthopedic Foot & Ankle Society has been quoted as stating that 15 million treatments for plantar fasciitis-fasciosis were performed in 2007.
CURRENT TREATMENTS
Conservative treatment options for plantar fasciosis include:
rest, stretching, strengthening, ice water soaks, and massage, progressing to non-steroidal anti-inflammatories, steroid injections with continued recalcitrance. Orthotics, heel cups, night splints, and plantar strapping (taping) are other conservative options frequently recommended by treating physicians. Patient outcomes and response to conservative measures is usually positive with the Weil Foot & Ankle Institute reporting 80% success after six weeks of the basic treatments.
With non-responsive cases, approximately 15% of all presenting cases, cast immobilization and surgical care may be necessary. Extracorporeal shockwave (ESWT) treatment has recently been advocated for the recalcitrant cases.
A study performed by Dr. Lowell Weil, Jr. has shown ESWT to be effective in 70-85 percent in the recalcitrant cases of plantar fasciitis-fasciosis with no complications.
Surgical Plantar fasciotomy or fascia release, either partial or complete is commonly the surgical procedure of choice for treating plantar fasciosis with a reported success of 80-85%.(Dr. Wendy Benton-Weil) However, this surgery has a risk of complications and is thought to alter the biomechanics of the foot, which may be linked to post-operative lateral column pain and medium-term disability. Other complications including nerve damage have also been reported with endoscopic plantar fasciotomy. Plantar, micro-fasciotomy (Radiofrequency Topaz Coblation) of the plantar fascia has also shown a success rate equal to plantar fasciotomy, in a two arm, randomized blinded study. (Dr. Lowell Scott Weil, Sr.)
Lowell Scott Weil, Sr., DPM, FACFAS
Chairman & CEO
Weil Foot & Ankle InstituteDes Plaines, IL
www.weil4feet.com
weil4feet@aol.com
Wednesday, December 3, 2008
Running & Plantar Fasciitis
PODIATRISTS IN THE NEWS
ILLINOIS Podiatrist Discusses
Prevention and Treatment of Plantar Fasciitis
Whether you are a regular runner, a weekend warrior, or someone knocking around the yard, foot problems can easily cause you pain. Most pain associated with the heel can be tied to one disorder: plantar fasciitis. "There is a ligament called the plantar fascia which attaches at the heel bone and then runs through the arch and into the toes," explains Lowell Weil, Jr., DPM, team podiatrist for the Chicago White Sox. "Its function is to support the arch. If you bend your toes back, you can feel a tight band in your arch. That is the plantar fascia."
A good preventive measure is stretching exercises two or three times a day. "I don't think the importance of stretching can be over-emphasized," stresses Dr. Weil. "Even if you don't have heel pain, you want to maintain some kind of daily stretching routine. These should be done before exercise and absolutely afterwards."While custom-made orthotics provide the most accurate way to direct the foot into the correct position for walking or running, they are often not necessary as a first-line treatment. "I would say about 80% of my patients respond favorably to over-the-counter inserts," notes Dr. Lowell Weil, JR.
Wednesday, November 19, 2008
Extracorporeal Shockwave Therapy for the Treatment of Achilles Tendinopathies
A Prospective Study
Robert Fridman, DPM *, Jarrett D. Cain, DPM, MSc , Lowell Weil, Jr., DPM, MBA and Lowell Weil, Sr., DPM
Weil Foot & Ankle Institute, Des Plaines, IL.
Abstract
Background: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders.
Methods: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score > 5. The mean follow-up was 20 months (range, 4–35 months).
Results: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1.
Conclusion: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy.
Robert Fridman, DPM *, Jarrett D. Cain, DPM, MSc , Lowell Weil, Jr., DPM, MBA and Lowell Weil, Sr., DPM
Weil Foot & Ankle Institute, Des Plaines, IL.
Abstract
Background: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders.
Methods: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score > 5. The mean follow-up was 20 months (range, 4–35 months).
Results: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1.
Conclusion: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy.
Thursday, November 13, 2008
FLAT FEET
Flat Feet describes a position of the foot that has kept numerous people out of the armed forces for decades.
However, a flat foot may neither be painful or bad. It may simply be the natural position for those patients to function in. There are many occasions however, where a flat foot can cause other painful conditions to develop and fester.
As an infant, we are born with a flatter foot than an adult to provide an increased base for stabilization. Over the next several years the arch height gradually increases and reaches its highest point some where between the ages of 7-9. From that point on, as we go through life, the arch height actually decreases.
Genetics has a large part to play in the starting position of the foot and arch height; the maximum height the foot reaches between ages 7-9; and how fast the arch breaks down over a life time.
Obviously, a highly active lifestyle also will accelerate the break down of the arch height and structure of the foot.
As the arch height begins to descend and activity remains high enough, the foot begins to develop instability. This instability is exhibited by movement of the bones of the foot. It is necessary for the ligaments, muscles of the foot and leg and the tendons that cross over the major joints to stabilize the bones. As the bones move around secondary conditions can and will develop such as bunions, hammer toes and tailor bunions as well as arthritis. Stress fractures can also develop if unequal amounts of stress are applied to bones over a specific time frame during a time of instability.
The muscles of the leg and their long tendons which insert onto the foot exert a stabilizing effect onto the foot during function. If the foot is unstable enough and the muscle/tendon complex must exert enough of a force, the ligaments, muscle or tendons may become injured during the process.
Conditions such as Adult Acquired Flat Foot (Posterior Tibial Tendon Insufficiency), Plantar Fasciitis, Tendonosis and Synovitis are all soft tissue strains and injuries that develop when the soft tissue is strained beyond its elastic point.
A Flat Foot therefore should be watched. At the first sign of trouble, intervention should be performed to help stabilize the foot and help prevent irreversible injury. Often times, custom orthotics, custom arch supports, can be utilized to stabilize the foot. At other times, the condition may have gone beyond what an orthotic can reasonably protect and surgical correction is utilized to stabilize what nature cannot.
However, a flat foot may neither be painful or bad. It may simply be the natural position for those patients to function in. There are many occasions however, where a flat foot can cause other painful conditions to develop and fester.
As an infant, we are born with a flatter foot than an adult to provide an increased base for stabilization. Over the next several years the arch height gradually increases and reaches its highest point some where between the ages of 7-9. From that point on, as we go through life, the arch height actually decreases.
Genetics has a large part to play in the starting position of the foot and arch height; the maximum height the foot reaches between ages 7-9; and how fast the arch breaks down over a life time.
Obviously, a highly active lifestyle also will accelerate the break down of the arch height and structure of the foot.
As the arch height begins to descend and activity remains high enough, the foot begins to develop instability. This instability is exhibited by movement of the bones of the foot. It is necessary for the ligaments, muscles of the foot and leg and the tendons that cross over the major joints to stabilize the bones. As the bones move around secondary conditions can and will develop such as bunions, hammer toes and tailor bunions as well as arthritis. Stress fractures can also develop if unequal amounts of stress are applied to bones over a specific time frame during a time of instability.
The muscles of the leg and their long tendons which insert onto the foot exert a stabilizing effect onto the foot during function. If the foot is unstable enough and the muscle/tendon complex must exert enough of a force, the ligaments, muscle or tendons may become injured during the process.
Conditions such as Adult Acquired Flat Foot (Posterior Tibial Tendon Insufficiency), Plantar Fasciitis, Tendonosis and Synovitis are all soft tissue strains and injuries that develop when the soft tissue is strained beyond its elastic point.
A Flat Foot therefore should be watched. At the first sign of trouble, intervention should be performed to help stabilize the foot and help prevent irreversible injury. Often times, custom orthotics, custom arch supports, can be utilized to stabilize the foot. At other times, the condition may have gone beyond what an orthotic can reasonably protect and surgical correction is utilized to stabilize what nature cannot.
Thursday, November 6, 2008
One Man ... Three Perspectives
A college soccer player, athletic trainer and podiatric surgeon: one man, three different perspectives on injuries to the foot and ankle.
Jeff Baker, DPM, AACFAS – Podiatric Surgeon, Weil Foot & Ankle Institute
When it comes to sports related foot and ankle injuries, I have many different perspectives to draw from. At a relatively later age I became interested in soccer. It started with a game during gym class in the 5th grade where I scored 3 goals. My gym teacher at the time was also the high school varsity soccer coach and he encouraged me to play in the local recreational league. My father was a former high school football and wrestling coach, but he was completely supportive in my pursuit of the game of soccer. Soccer became a year-round part of my life, culminating in playing Division 1 varsity soccer for 4 years at Northeastern University in Boston. Little did I know that later on in life I would become a podiatrist as I participated in a sport played almost exclusively with the feet. Soccer players do some weird things when it comes to their feet. Our cleats are an extension of our feet. So the tighter the cleat, the better touch on the ball. Therefore we purchase cleats that are too small, immediately get them wet, and stretch them to the size of our feet. The cleat ends up fitting like a tight slipper. This brings about injuries and deformities that I have myself and now encounter on a daily basis such as hammertoes and blisters.
When deciding in high school as to what profession I would like to pursue in college, I decided on sports medicine. I was an athletic training major at Northeastern University where during my time I was a student athletic trainer for both the Northeastern University and Tufts University basketball teams. After graduation from Northeastern University in 1992, I then spent four years as the head athletic trainer at Westwood High School in Westwood, Massachusetts. It was a wonderful experience that helped to build relationships with patients. The majority of my athletes had ankle injuries and a large portion of my day was spent taping ankles and providing rehabilitation for ankle injuries. The main purpose of my position was to keep athletes participating in their activities as long as it was safe and not going to worsen any injuries. A unique portion of my duties was to determine the balance between injury and performance. If I could get an athlete with an ankle injury to return to playing with the use of a brace at 80%, does that help team performance or is it a detriment.
In 2000 I graduated from the Ohio College of Podiatric Medicine. I completed a three-year reconstructive foot and ankle surgery residency at St. Mary Hospital in Hoboken, New Jersey and a one-year fellowship in reconstructive foot and ankle surgery at the Weil Foot & Ankle Institute.
Jeff Baker, DPM, AACFAS – Podiatric Surgeon, Weil Foot & Ankle Institute
When it comes to sports related foot and ankle injuries, I have many different perspectives to draw from. At a relatively later age I became interested in soccer. It started with a game during gym class in the 5th grade where I scored 3 goals. My gym teacher at the time was also the high school varsity soccer coach and he encouraged me to play in the local recreational league. My father was a former high school football and wrestling coach, but he was completely supportive in my pursuit of the game of soccer. Soccer became a year-round part of my life, culminating in playing Division 1 varsity soccer for 4 years at Northeastern University in Boston. Little did I know that later on in life I would become a podiatrist as I participated in a sport played almost exclusively with the feet. Soccer players do some weird things when it comes to their feet. Our cleats are an extension of our feet. So the tighter the cleat, the better touch on the ball. Therefore we purchase cleats that are too small, immediately get them wet, and stretch them to the size of our feet. The cleat ends up fitting like a tight slipper. This brings about injuries and deformities that I have myself and now encounter on a daily basis such as hammertoes and blisters.
When deciding in high school as to what profession I would like to pursue in college, I decided on sports medicine. I was an athletic training major at Northeastern University where during my time I was a student athletic trainer for both the Northeastern University and Tufts University basketball teams. After graduation from Northeastern University in 1992, I then spent four years as the head athletic trainer at Westwood High School in Westwood, Massachusetts. It was a wonderful experience that helped to build relationships with patients. The majority of my athletes had ankle injuries and a large portion of my day was spent taping ankles and providing rehabilitation for ankle injuries. The main purpose of my position was to keep athletes participating in their activities as long as it was safe and not going to worsen any injuries. A unique portion of my duties was to determine the balance between injury and performance. If I could get an athlete with an ankle injury to return to playing with the use of a brace at 80%, does that help team performance or is it a detriment.
In 2000 I graduated from the Ohio College of Podiatric Medicine. I completed a three-year reconstructive foot and ankle surgery residency at St. Mary Hospital in Hoboken, New Jersey and a one-year fellowship in reconstructive foot and ankle surgery at the Weil Foot & Ankle Institute.
The Toe Bones connected to the Foot Bone...
We have all heard the old refrain, " The toe bone is connected to the foot bone and the foot bone is connected to the ankle bone, the ankle bone is connected to the leg bone...". This is and old rhyme used to teach anatomy to children.
However, most folks do not realize that not only are the bone connected, but they work together as well. What one bone shifts or moves , it will effect the position and structure of other bones that connect to it.
They same is true to groups of bones. Take the foot for instance. The foot connects to the ankle. The ankle connects to the leg. Movement of the foot therefore will effect the action of the leg and visa versa, contracture of the muscles of the leg will effect the movement and position of the foot.
The leg muscles contract normally to help lift the heel bone and push the leg forward during walking. One can see and feel this if they concentrate when they walk. You can feel the calf tighten as the foot gets onto the ball of the foot and the calf squeezes and the foot will push forward. Walking, climbing stairs, running are all activities that will tighten the calf as the muscles must squeeze to help the foot push forward. In fact the only exercise that will stretch the calf is stretching the calf.
Abnormal movement of the foot,usually exhibited by abnormal lowering of the arch which occurs to all of us as we get older from wear and tear as well as by genetics, will cause excessive tightening of the calf muscles. However as the calf muscles tighten, the foot will work more abnormally. This unfortunately will cause the calf muscles to tighten more and the process goes on. Eventually the foot assumes an abnormal position and the calf muscle is excessively tight. This situation usually will cause an overload syndrome of the foot and is a great cause of the development of tendinitis, synovitis, bone bruises, foot fatigue and muscle cramping.
Often times stretching the calf several times a day will help maintain the normal flexibility of the calf and help maintain the normal function of the foot.
However, most folks do not realize that not only are the bone connected, but they work together as well. What one bone shifts or moves , it will effect the position and structure of other bones that connect to it.
They same is true to groups of bones. Take the foot for instance. The foot connects to the ankle. The ankle connects to the leg. Movement of the foot therefore will effect the action of the leg and visa versa, contracture of the muscles of the leg will effect the movement and position of the foot.
The leg muscles contract normally to help lift the heel bone and push the leg forward during walking. One can see and feel this if they concentrate when they walk. You can feel the calf tighten as the foot gets onto the ball of the foot and the calf squeezes and the foot will push forward. Walking, climbing stairs, running are all activities that will tighten the calf as the muscles must squeeze to help the foot push forward. In fact the only exercise that will stretch the calf is stretching the calf.
Abnormal movement of the foot,usually exhibited by abnormal lowering of the arch which occurs to all of us as we get older from wear and tear as well as by genetics, will cause excessive tightening of the calf muscles. However as the calf muscles tighten, the foot will work more abnormally. This unfortunately will cause the calf muscles to tighten more and the process goes on. Eventually the foot assumes an abnormal position and the calf muscle is excessively tight. This situation usually will cause an overload syndrome of the foot and is a great cause of the development of tendinitis, synovitis, bone bruises, foot fatigue and muscle cramping.
Often times stretching the calf several times a day will help maintain the normal flexibility of the calf and help maintain the normal function of the foot.
Thursday, October 9, 2008
Dr. Weil Sr and Dr. Weil Jr Co-Author Important Research on Low Energy Extracorporeal Shock Wave Published in the American Journal of Sports Medicine
Radial Extracorporeal Shock Wave Therapy Is Safe and Effective in the Treatment of Chronic Recalcitrant Plantar Fasciitis: Results of a Confirmatory Randomized Placebo-Controlled Multicenter Study
Ludger Gerdesmeyer, MD, PhD1*, Carol Frey, MD2, Johannes Vester, PhD3, Markus Maier, PhD4, Lowell Weil Jr, DPM5, Lowell Weil Sr, DPM5, Martin Russlies, PhD6, John Stienstra, DPM7, Barry Scurran, DPM7, Keith Fedder, MD2, Peter Diehl, MD8, Heinz Lohrer, MD9, Mark Henne, MD10, Hans Gollwitzer, MD10
1 Technical University Munich and Mare Clinic
2 Orthopaedic Foot and Ankle Center, Manhattan Beach
3 IDV Data Analysis and Study Planning, Biometrics in Medicine
4 Ludwig Maximilian University
5 Weil Foot and Ankle Institute
6 University Schleswig Holstein, Campus Lübeck
7 The Permanente Medical Group Inc
8 University Rostock
9 Institute of Sportsmedicine
10 Technical University Munich
* To whom correspondence should be addressed. E-mail: gerdesmeyer@aol.com.
Abstract
Background: Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials.
Hypothesis: There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis.
Study Design: Randomized, controlled trial; Level of evidence, 1.
Methods: Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm2; 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks' follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients' and investigators' global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy.
Results: Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1sided). No relevant side effects were observed.
Conclusion: Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.
Friday, September 26, 2008
Brazil and Foot & Ankle Surgeons from around the World
Last week, I attended and presented at the International Federation of Foot and Ankle Surgeons Third Annual Congress. This Congress is held every three years and features the premier foot and ankle surgeons (Orthopedic and Podiatric) from around the world. This Congress was held in Bahia, Brazil. Previous Congresses were held in San Francisco, CA and Naples Italy.
Over 500 foot and ankle surgeons from around the World attended this years meeting with less than 50 giving presentations. An incredible amount of interesting research was presented with mid and long term results on emerging techniques and technologies and a wealth of new ideas and procedures.
I was fortunate enough to have two of my papers selected to present. I presented on a new technique that we developed over the last couple of years on repairing the plantar plate of an unstable or dislocated metatarsophalangeal joint. This is a difficult problem without a previous good solution. The paper was well received with most finding this new technique as a good alternative to explore in the future.
Additionally, I presented our longer term results on the Calcaneal Scarf Procedure. This procedure is used to correct painful flatfoot deformity. The benefits of this procedure over others that are currently utilized is that it allows for larger and more stable correction and quicker return to weight bearing.
Dr. Weil, Sr. was an invited speaker who presented his long term experience on the Weil Metatarsal Osteotomy which is a procedure invented by him in the 1980’s and now used worldwide for several specific pathologies of the foot.
Besides the academic aspect of the Congress, it was interesting and enjoyable to spend time with surgeons from all over the World and learning about their countries, cultures and families.
The people of Brazil did an amazing job of putting on a 1st Class Congress and showed the spirit that they are famous.
Lowell Weil, Jr.
Over 500 foot and ankle surgeons from around the World attended this years meeting with less than 50 giving presentations. An incredible amount of interesting research was presented with mid and long term results on emerging techniques and technologies and a wealth of new ideas and procedures.
I was fortunate enough to have two of my papers selected to present. I presented on a new technique that we developed over the last couple of years on repairing the plantar plate of an unstable or dislocated metatarsophalangeal joint. This is a difficult problem without a previous good solution. The paper was well received with most finding this new technique as a good alternative to explore in the future.
Additionally, I presented our longer term results on the Calcaneal Scarf Procedure. This procedure is used to correct painful flatfoot deformity. The benefits of this procedure over others that are currently utilized is that it allows for larger and more stable correction and quicker return to weight bearing.
Dr. Weil, Sr. was an invited speaker who presented his long term experience on the Weil Metatarsal Osteotomy which is a procedure invented by him in the 1980’s and now used worldwide for several specific pathologies of the foot.
Besides the academic aspect of the Congress, it was interesting and enjoyable to spend time with surgeons from all over the World and learning about their countries, cultures and families.
The people of Brazil did an amazing job of putting on a 1st Class Congress and showed the spirit that they are famous.
Lowell Weil, Jr.
Tuesday, September 9, 2008
Fasciitis and the Firefighter
I am a 44 year old firefighter that has suffered with chronic heel pain (Plantar Fasciitis) for over 2 years. I also run a few miles several times a week as part of my regular exercise routine. To say that I was frustrated with my pain and the inability to treat it with all the conventional stretching, exercises, inserts, etc is an understatement.
After a referral from my Orthopedic Surgeon to Dr. Lowell Weil Jr., that was about to change. He was completely thorough in his diagnosis and offered several options for treatment. I had surgery, minimal invasive, last December and was back on my feet in 48 hours. Within a week I was back walking in gym shoes and back to the gym on a light workout within a month.
When I say the recovery was quick, it is amazing how good my feet felt. It took Dr. Weil's caution to take it easy at first to keep me from doing more right away. His options for treatment are not offered by all doctors and that's too bad. I have heard horror stories of multiple surgeries with 6 month recovery time. Nonsense - if you suffer from chronic heel pain, give Dr. Lowell Weil Jr. a call, I have referred several people to him and will continue to do so. It is 9 months since my surgery and I have had NO problems what so ever with my heel.
Thank You again Dr. Weil.
Firefighter - Tom (Chicago, IL)
After a referral from my Orthopedic Surgeon to Dr. Lowell Weil Jr., that was about to change. He was completely thorough in his diagnosis and offered several options for treatment. I had surgery, minimal invasive, last December and was back on my feet in 48 hours. Within a week I was back walking in gym shoes and back to the gym on a light workout within a month.
When I say the recovery was quick, it is amazing how good my feet felt. It took Dr. Weil's caution to take it easy at first to keep me from doing more right away. His options for treatment are not offered by all doctors and that's too bad. I have heard horror stories of multiple surgeries with 6 month recovery time. Nonsense - if you suffer from chronic heel pain, give Dr. Lowell Weil Jr. a call, I have referred several people to him and will continue to do so. It is 9 months since my surgery and I have had NO problems what so ever with my heel.
Thank You again Dr. Weil.
Firefighter - Tom (Chicago, IL)
Appreciation!
Dear Dr. L.S. Weil,
In the twenty years I have been traversing the mazes of medical care, there have been a precious few encounters that measure up to the experience I had last month with you. There have been many who believed they were on top of their game, came highly recommended, splattered with publication, specialization, and honors. Most have schedules requiring weeks of advance booking, with fees to match. You, could teach all of them a thing or two, which, either they never knew or somehow lost along the way.
Thank you. ....for a bedside manner which still emotes curiosity, sensitivity and reasonable rationality... for language that clarified instead of dazzled and dazed...for treating me not only with sharpened professionalism but with kindness, consideration and wisdom you would offer a sister. Thank you for responses to my side-bar chatter, which gave me a glimpse of the man behind the white coat. I left your office informed and encouraged, determined to keep up the good fight, to take the next step, one slightly misaligned foot in front of the other. You delivered the best of what great healers have to offer. And while I know, you know, you are good at your art. You failed miserably the arrogance test.
Great men surround themselves with great subordinates. Every facet of my encounter with your support people; from making the appointment, registering at the desk, giving a history, standing for x-rays, getting copies, or asking follow up questions was handled with patience and professionalism, by individuals who actually felt like they cared enough to get it right and liked what they were doing. There was eye contact, civility, and a sense that one was more than a file or a case to be shuffled. I am still however, undecided about the waiting room. Which do I like best, Boy With Thorn, or cascading water walls? All round, through and through, a class act.
While I don't look forward to the proposed treatment plan, I am reassured and confident that the best man with a great team will be looking out for me.
With My Most Sincere Appreciation,
Mary (Woodstock, IL)
In the twenty years I have been traversing the mazes of medical care, there have been a precious few encounters that measure up to the experience I had last month with you. There have been many who believed they were on top of their game, came highly recommended, splattered with publication, specialization, and honors. Most have schedules requiring weeks of advance booking, with fees to match. You, could teach all of them a thing or two, which, either they never knew or somehow lost along the way.
Thank you. ....for a bedside manner which still emotes curiosity, sensitivity and reasonable rationality... for language that clarified instead of dazzled and dazed...for treating me not only with sharpened professionalism but with kindness, consideration and wisdom you would offer a sister. Thank you for responses to my side-bar chatter, which gave me a glimpse of the man behind the white coat. I left your office informed and encouraged, determined to keep up the good fight, to take the next step, one slightly misaligned foot in front of the other. You delivered the best of what great healers have to offer. And while I know, you know, you are good at your art. You failed miserably the arrogance test.
Great men surround themselves with great subordinates. Every facet of my encounter with your support people; from making the appointment, registering at the desk, giving a history, standing for x-rays, getting copies, or asking follow up questions was handled with patience and professionalism, by individuals who actually felt like they cared enough to get it right and liked what they were doing. There was eye contact, civility, and a sense that one was more than a file or a case to be shuffled. I am still however, undecided about the waiting room. Which do I like best, Boy With Thorn, or cascading water walls? All round, through and through, a class act.
While I don't look forward to the proposed treatment plan, I am reassured and confident that the best man with a great team will be looking out for me.
With My Most Sincere Appreciation,
Mary (Woodstock, IL)
Back to Basketball
I was devastated in February when I came down for a rebound and couldn’t walk off the court. I saw the end of my NCAA All-Conference Basketball career when a previous podiatrist put me in a walking boot, for my tendon strain. I contacted Dr. Amarantos and after a preliminary visit with him devised a more custom plan of treatment for me. After an MRI, which revealed a ruptured Posterior Tibialis we scheduled a surgery.
Two weeks after surgery I started feeling some relief when the cast was taken off and I returned to a walking boot. Six weeks later I was able to wear my gym shoes with a brace, and I could really notice the vast improvement, I was able to walk with next to no pain for the first time in four months! I was recently cleared for full playing and am grateful for the specialized treatment that I received from Dr. Amarantos.
My fears of missing my senior season did not come true, as the prompt quality treatment got me back on the court for pre-season. I will gladly recommend any of my teammates, family, or friends to Dr. Amarantos, in complete confidence that they would receive top-notch treatment.
Thanks Dr. A!
Lady Reds Captain
Carthage College Kenosha, WI
Two weeks after surgery I started feeling some relief when the cast was taken off and I returned to a walking boot. Six weeks later I was able to wear my gym shoes with a brace, and I could really notice the vast improvement, I was able to walk with next to no pain for the first time in four months! I was recently cleared for full playing and am grateful for the specialized treatment that I received from Dr. Amarantos.
My fears of missing my senior season did not come true, as the prompt quality treatment got me back on the court for pre-season. I will gladly recommend any of my teammates, family, or friends to Dr. Amarantos, in complete confidence that they would receive top-notch treatment.
Thanks Dr. A!
Lady Reds Captain
Carthage College Kenosha, WI
Wednesday, August 27, 2008
MRI
Weil Foot & Ankle Institute installs New MRI
New OrthOne Open High Field MRI-- The magnet architecture permits consistent, very high quality imaging of the extremity powered by a formidable 1-Tesla superconducting magnet optimizing musculoskeletal imaging.
Patients requiring an MRI of the foot, ankle or knee/ lower extremity benefit from a totally non-claustrophobic, quiet, quick, comfortable and convenient experience on the high field extremity system. Because it's designed specifically for extremity applications, no attachment of surface coils or other devices to the imaged anatomy is required. The patient's anatomy is always in the "sweet spot" of the magnet.
Patient Convenience and Comfort - A truly open MRI system.
Completely open design – no claustrophobic tube – only the extremity to be imaged is placed in the magnet.
Ergonomically designed movable chair for optimal patient comfort.
Comfortably accommodates patients up to 350 lbs.
Quiet operation – no loud pulses or noise.
Faster scan times comparable to whole body MRI units – 30 minute average patient study time.
Non-threatening environment–ideal for all patients especially elderly clients/children.
Because the OrthOne is a high-field MRI, doctors can perform surgery with confidence based on the high-resolution images.
A modern Windows-based user interface offers detailed control over scan parameters. Presaturation and Fat Saturation (as well as STIR and a full library of sequences) are standard. The Superconducting magnet delivers outstanding image quality at very fast scan speeds.
A comfortable, non-threatening, non-claustrophobic MRI device that creates scans with extremely high quality images. The scan is performed with you sitting in a comfortable chair. The only part of your body to go into the magnet is the part being scanned.
New OrthOne Open High Field MRI-- The magnet architecture permits consistent, very high quality imaging of the extremity powered by a formidable 1-Tesla superconducting magnet optimizing musculoskeletal imaging.
Patients requiring an MRI of the foot, ankle or knee/ lower extremity benefit from a totally non-claustrophobic, quiet, quick, comfortable and convenient experience on the high field extremity system. Because it's designed specifically for extremity applications, no attachment of surface coils or other devices to the imaged anatomy is required. The patient's anatomy is always in the "sweet spot" of the magnet.
Patient Convenience and Comfort - A truly open MRI system.
Completely open design – no claustrophobic tube – only the extremity to be imaged is placed in the magnet.
Ergonomically designed movable chair for optimal patient comfort.
Comfortably accommodates patients up to 350 lbs.
Quiet operation – no loud pulses or noise.
Faster scan times comparable to whole body MRI units – 30 minute average patient study time.
Non-threatening environment–ideal for all patients especially elderly clients/children.
Because the OrthOne is a high-field MRI, doctors can perform surgery with confidence based on the high-resolution images.
A modern Windows-based user interface offers detailed control over scan parameters. Presaturation and Fat Saturation (as well as STIR and a full library of sequences) are standard. The Superconducting magnet delivers outstanding image quality at very fast scan speeds.
A comfortable, non-threatening, non-claustrophobic MRI device that creates scans with extremely high quality images. The scan is performed with you sitting in a comfortable chair. The only part of your body to go into the magnet is the part being scanned.
Friday, August 8, 2008
Boomers not backing down from foot and ankle arthritis
Surgical advances keeping them active, pain-free
They danced to the Beatles, the Rolling Stones and disco. They worked out with Jane Fonda and made jogging their national pastime.
Now approaching retirement, many members of the "Me Generation" aren't ready to slow down, even if their bodies are. Chicago foot and ankle surgeon Lowell Weil, Jr., DPM, MBA, FACFAS says Baby Boomers are more likely than previous generations to seek care when arthritis develops in their toes, feet and ankles.
There are more than 100 different types of arthritis, including gout and rheumatoid arthritis. According to the American College of Foot and Ankle Surgeons (ACFAS), the most common forms to affect the feet are post-traumatic and osteoarthritis, especially in the big toe, ankle and midfoot joints.
Dr. Weil, Jr. says many Boomers who seek treatment for arthritis assume they'll be able to resume activities such as running or playing sports. Seeking treatment early can improve the odds of preventing irreversible joint damage. For many patients with early-stage foot or ankle arthritis, changes in shoes or advanced custom orthotics can make a huge difference. While there is no fountain of youth for arthritis, Dr. Weil says there are more medical options available to Baby Boomers than ever before.
Big toes
Baby Boomers are most likely to develop osteoarthritis in their big toe joint. During walking, the big toe absorbs forces equal to nearly twice a person's body weight. It plays an important role in stooping and standing. Some boomers start to develop big toe stiffness, a condition called hallux limitus, in their forties.
Better surgical procedures now offer improved pain relief and joint movement to Boomers with early stage arthritis at the big toe. Patients with advanced and severe arthritis may need to have the joint fused or replaced. But stronger screws and hardware are helping fusions last longer while slashing recovery times. A new generation of big toe joint replacements shows promise.
Ankles
Ankles are another prime spot for arthritis. Ankles are more likely to develop post-traumatic arthritis than osteoarthritis. For many Baby Boomers, the trauma was an ankle fracture or a bad sprain that may have happened in their teens or twenties. Innovative new surgical techniques allow foot and ankle surgeons to transplant small plugs of cartilage from one part of the ankle to another in some patients, slowing joint deterioration.
Ankle replacements, however, are not as durable as hip and knee replacements. The ankle is a more challenging joint to replace. It's smaller and moves in multiple directions. But better and promising ankle implants are hitting the market.
Please call us at 847-390-7666 to make an appointment with Dr. Weil, Jr., or visit our website to learn more about Weil Foot & Ankle Institute.
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