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.
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