Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial

Platelet-rich plasma injections for chronic plantar fasciitis

PURPOSE

The purpose of this study was to assess the safety and preliminary clinical results of platelet-rich plasma (PRP) injections for treating chronic plantar fasciitis.

METHODS

Fourteen consecutive patients with chronic plantar fasciitis receiving three injections of PRP into the plantar fascia were assessed 12 months after the procedure. The modified Roles and Maudsley score and a visual analogue scale (VAS) for pain were used to evaluate the clinical results.

RESULTS

According to criteria of the Roles and Maudsley score, at 12 months of follow-up, results were rated as excellent in nine (64.3 %), good in two (14.3 %), acceptable in two (14.3 %) and poor in one (7.1 %) patient. VAS for pain was significantly decreased from 7.1 ± 1.1 before treatment to 1.9 ± 1.5 at the last follow-up (p < 0.01).

CONCLUSIONS

In this single-centre, uncontrolled, prospective, preliminary study, results indicate that treating chronic plantar fasciitis with PRP injections is safe and has the potential to reduce pain.

Open technique is more effective than percutaneous technique for TOPAZ radiofrequency coblation for plantar fasciitis

BACKGROUND

Microtenotomy coblation using a radiofrequency (RF) probe is a minimally invasive procedure for treating chronic tendinopathy. It has been described for conditions including tennis elbow and rotator cuff tendinitis. There have been no long term studies to show its effectiveness in plantar fasciitis.

METHODS

A prospective non-randomised trial was conducted on 48 patients who had failed conservative treatment for plantar fasciitis, between 2007 and 2009. The procedure was performed using the TOPAZ microdebrider device (ArthroCare, Sunnyvale, CA), either via an open or a percutaneous method. Fifty-nine feet were treated and followed up for up to 1 year thereafter. Preoperative, 3, 6 and 12 months post-operative VAS pain, American Orthopaedic Foot-Ankle Society (AOFAS) hindfoot and SF-36 scores, patient expectation and satisfaction scores were analysed.

RESULTS

VAS scores improved significantly in both groups at 1-year follow-up. The open group had a more significant improvement in the VAS score at 1-year follow-up. AOFAS hindfoot scores improve significantly for both groups pre- and post-operatively, but there was no significant difference between both groups at the 1-year mark. SF-36 scores showed equally significant improvement in both groups 1 year post-operatively. Expectation and satisfaction scores were equally high in both arms.

CONCLUSIONS

TOPAZ RF coblation is a good and effective method for the treatment of recalcitrant plantar fasciitis. Clinical results improve with time for up to 1-year post-operatively. The open method seems to have a more significant improvement in pain VAS scores at 1-year postoperatively.

Clinical application of extracorporeal shock wave therapy in orthopedics: focused versus unfocused shock waves

For the past decade extracorporeal shock wave therapy has been applied to a wide range of musculoskeletal disorders. The many promising results and the introduction of shock wave generators that are less expensive and easier to handle has added to the growing interest. Based on their nature of propagation, shock waves can be divided into two types: focused and unfocused. Although several physical differences between these different types of shock waves have been described, very little is known about the clinical outcome using these different modalities. The aim of the present review is to investigate differences in outcome in select orthopaedic applications using focused and unfocused shock waves.

Resistant plantar fasciopathy: shock wave versus endoscopic plantar fascial release

PURPOSE

To compare the results of Extracorporeal shock wave (ESWT) with a modified endoscopic plantar fasciotomy technique for the treatment of recalcitrant heel pain.

METHOD

Sixty-five patients suffering from chronic heel pain that failed to respond to standard nonoperative methods were randomized to undergo either high-energy extracorporeal shock wave therapy (group 1), or modified endoscopic plantar fasciotomy (group 2). The primary outcome measure was the reduction of pain in the two groups from base line to month three post intervention at the first few steps in the morning. In addition, patients' functions were assessed using American Orthopedic Foot and Ankle-Hindfoot Scale (AOFAS) at week three, month three, and month 12 post-intervention, and finally, Roles and Maudsley scores were assessed. The primary analysis was intention-to-treat and involved all patients who were randomly assigned.

RESULTS

Both groups achieved improvement from the base line at 3 weeks, 3 months and 12 months post-intervention. The success rate (Roles and Maudsley score excellent and good) in the ESWT group at month 12 was 70.6 %, while in the fasciotomy group, the success rate was 77.4 % (p = 0.19).

CONCLUSION

In patients who had experienced failure of conventional treatment of plantar fasciopathy, both endoscopic plantar fasciotomy and shock wave therapy can be potentially helpful lines of management.

Comparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis: a systematic review and network meta-analysis

OBJECTIVES

To compare the effectiveness of focused shock wave (FSW) therapy of different intensity levels and a new alternative, radial shock wave (RSW) for managing plantar fasciitis.

DATA SOURCES

Electronic databases including MEDLINE and PubMed were searched from January 1996 to June 2011.

STUDY SELECTION

Randomized controlled trials comparing shock wave and placebo therapy were included. Two reviewers independently scrutinized eligible articles, and disagreement was resolved by discussion. Literature searching identified 93 nonduplicate citations, of which 12 trials comprising 1431 participants were included.

DATA EXTRACTION

Information, such as patient characteristics, shock wave intensity, and outcome measures, was extracted by 1 reviewer and checked by another. Both reviewers assessed the trials' quality by using the Jadad scale.

DATA SYNTHESIS

FSW therapy of different intensity ranges was treated as 3 subgroups, whereas studies using RSW therapy were regarded as a separate group. The success rates of treatment and pain reduction magnitudes were used as the outcomes. The traditional meta-analysis showed that medium and high-intensity FSW therapy had reliably higher success rates and pain reduction than the placebo, while the effectiveness of low-intensity FSW therapy and RSW therapy appeared less convincing because of very large confidence intervals. After employing network meta-analysis, the probability of being the best therapy was the highest in RSW therapy, followed by low-, medium-, or high-intensity FSW therapy. The meta-regression indicated that the success rate of FSW therapy was not related to its intensity, whereas elevated energy efflux densities tended to relieve pain more.

CONCLUSIONS

Setting the highest and mostly tolerable energy output within medium intensity ranges is the ideal option when applying FSW therapy on plantar fasciitis. RSW therapy is considered an appropriate alternative because of its lower price and probably better effectiveness.

The influence of comorbidities and etiologies on the success of extracorporeal shock wave therapy for chronic soft tissue wounds: midterm results

Possible effects of comorbidities and of different wound etiologies on the success of extracorporeal shock wave therapy (ESWT) of chronic soft tissue wounds were investigated. From September 2003 until February 2007, 282 patients, being previously treated unsuccessfully were enrolled. Treatment consisted of ESWT occurring at defined intervals. At each treatment session a wound bed score was recorded, also at initial presentation a detailed patient history and wound etiology. Observed comorbidities were pooled according to the chapters of the ICD-10 system. Two hunderd fifty-eight patients were analyzed (91.49%) and underwent follow-up for a median of 31.8 months. Wound closure occurred in 191 patients (74.03%) by a median of two treatment sessions. No wound reappeared at the same location. A multivariate logistic regression model showed that pooled comorbidities and wound etiologies did not have a significant influence on success. Comorbidities and wound etiologies have surprisingly no significant influence on the success of ESWT.

Proximal plantar fibroma as an etiology of recalcitrant plantar heel pain

Prompted by repeated pathology reports of fibromas at the origin of the plantar fascia after fasciectomy for chronic plantar heel pain, this study examined the incidence of proximal plantar fibroma. A retrospective study of 100 pathology specimens from 97 patients with the preoperative diagnosis of recalcitrant plantar fasciitis was performed. Patients ranged in age from 36 to 82, and included 31 males and 66 females. The specimens consisted of medial and central bands of the fascia obtained from transverse plantar fasciectomies. The fasciectomies were performed by 4 surgeons between July 1994 and March 2008. One quarter of the cases studied had a histological appearance of plantar fibroma. This new finding has not been reported in any literature in connection with recalcitrant heel pain. Histologic findings of the specimens were placed into 3 groups: neoplastic involvement (25%, 21 female and 6 male), inflammation without neoplastic involvement (21%, 13 female and 6 male), and other, which consisted of having no inflammatory or neoplastic response (54%, 32 female and 19 male). All of the patients ailed a 3- to 6-month conservative treatment regimen, which included anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom molded orthotics, and physical therapy. Only 3 patients underwent bilateral plantar fasciectomies. No patient required a revisional procedure. The authors conclude that 25% of recalcitrant heel pain is neoplastic in origin, and that patients presenting with these lesions require excision and not fasciotomy.

High-energy Extracorporeal Shock-Wave Therapy (ESWT) for the treatment of chronic plantar fasciitis

BACKGROUND

Few reports about the success of high-energy extracorporeal shock-wave therapy in cases of plantar fasciitis exist, even fewer about long-term results. This study investigated results of high-energy extracorporeal shock wave therapy applied to patients with recalcitrant plantar fasciitis.

MATERIALS AND METHODS

Ninety ESWT were applied to 63 patients (73 heels; 25 male and 38 female; average age 54 (29 to 77) years) from November 1999 to July 2003. All patients had plantar fasciitis for more than 6 months and failure of all non-surgical treatment for more than 3 months. A Dornier Lithotripter S, equipped with an electromagnetic shock-wave emitter was used. Routinely, 1000 shock wave impulses (frequency 2 per second, energy flux density (ED) 0.35 mJ/mm² at 10.5 kV, total dose 350 mJ/mm²) were applied per treatment. Followup was carried out 6 weeks after ESWT, then a second clinic evaluation and a final followup at an average of 73 months after ESWT by telephone.

RESULTS

The success of ESWT, defined as a 30% VAS reduction, was seen in 81% at 6-week followup, at 88% at last clinic followup and in 96% at final phone followup.

CONCLUSION

High-energy ESWT (0.35 mJ/mm²) was successful in the treatment of plantar fasciitis and the good short-term results seemed to be maintained over time.

Can low-intensity extracorporeal shockwave therapy improve erectile function? A 6-month follow-up pilot study in patients with organic erectile dysfunction

BACKGROUND

Low-intensity extracorporeal shockwave therapy (LI-ESWT) is currently under investigation regarding its ability to promote neovascularization in different organs.

OBJECTIVE

To evaluate the effect of LI-ESWT on men with erectile dysfunction (ED) who have previously responded to oral phosphodiesterase type 5 inhibitors (PDE5-I).

DESIGN, SETTING, AND PARTICIPANTS

We screened 20 men with vasculogenic ED who had International Index of Erectile Function ED (IIEF-ED) domain scores between 5-19 (average: 13.5) and abnormal nocturnal penile tumescence (NPT) parameters. Shockwave therapy comprised two treatment sessions per week for 3 wk, which were repeated after a 3-wk no-treatment interval.

INTERVENTION

LI-ESWT was applied to the penile shaft and crura at five different sites.

MEASUREMENTS

Assessment of erectile function was performed at screening and at 1 mo after the end of the two treatment sessions using validated sexual function questionnaires, NPT parameters, and penile and systemic endothelial function testing. The IIEF-ED questionnaire was answered at the 3- and 6-mo follow-up examinations.

RESULTS AND LIMITATIONS

We treated 20 middle-aged men (average age: 56.1 yr) with vasculogenic ED (mean duration: 34.7 mo). Eighteen had cardiovascular risk factors. At 1 mo follow-up, significant increases in IIEF-ED domain scores were recorded in all men (20.9 +/- 5.8 vs 13.5+/- 4.1, p<0.001); these remained unchanged at 6 mo. Moreover, significant increases in the duration of erection and penile rigidity, and significant improvement in penile endothelial function were demonstrated. Ten men did not require any PDE5-I therapy after 6-mo follow-up. No pain was reported from the treatment and no adverse events were noted during follow-up.

CONCLUSIONS

This is the first study that assessed the efficacy of LI-ESWT for ED. This approach was tolerable and effective, suggesting a physiologic impact on cavernosal hemodynamics. Its main advantages are the potential to improve erectile function and to contribute to penile rehabilitation without pharmacotherapy. The short-term results are promising, yet demand further evaluation with larger sham-control cohorts and longer follow-up.

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Chronic plantar fasciitis treated with two sessions of radial extracorporeal shock wave therapy

BACKGROUND

Radial extracorporeal shock wave therapy (RSWT) has been previously demonstrated as an efficient treatment option for chronic plantar fasciitis (PF) when administered in three sessions. The present study tested the hypothesis that chronic PF can also be treated successfully with RSWT when only two treatment sessions are performed.

MATERIALS AND METHODS

A total of 50 patients with unilateral, chronic PF were randomly assigned to either RSWT (n = 25) or placebo treatment (n = 25). RSWT was applied in two sessions 1 week apart (2,000 impulses with energy flux density = 0.16 mJ/mm(2) per session). Placebo treatment was performed with a clasp on the heel. Endpoints were changes in the Visual Analog Scale (VAS) score and the modified Roles & Maudsley (RM) score from baseline to 4 weeks, 12 weeks and 24 weeks followup.

RESULTS

Mean VAS scores were reduced after RSWT from 8.5 +/- 0.3 (mean +/- SEM) at baseline to 0.6 +/- 1.5 at 4 weeks, 1.1 +/- 0.3 at 12 weeks and 0.5 +/- 0.1 at 24 weeks from baseline. Similar changes were found for mean RM scores from baseline after RSWT but were not observed after placebo treatment. Statistical analysis demonstrated that RSWT resulted in significantly reduced mean VAS scores and mean RM scores at all followup intervals compared to placebo treatment (each with p < 0.001). No serious adverse events of RSWT were observed.

CONCLUSION

RSWT was successful in the treatment of chronic PF even when only two sessions with 2,000 impulses each were performed 1 week apart.

Comparison of radial versus focused extracorporeal shock waves in plantar fasciitis using functional measures

BACKGROUND

Recent literature shows evidence for effective treatment for plantar fasciitis using either focused or radial shock waves. Up to now no research has been available which compares these different procedures. We hypothesized (H(0) Hypothesis) that for plantar fasciitis, outcomes following focused or radial shock wave treatment were equal.

MATERIALS AND METHODS

For this pilot study, 39 patients suffering from recalcitrant plantar fasciitis were randomized in two groups. Treatment was performed in three sessions. Once a week 2000 impulses of radial (0.17 mJ/mm(2)) or focused (0.20 mJ/mm(2)) shock waves were applied. Efficacy was determined by multivariate analysis of eight single variables including changes in Foot Functional Index, neuromuscular performance (Single leg drop and long jump, postural stability, isokinetic testing), and by a composite score from baseline to 12 weeks followup. Multivariate Wilcoxon tests (Wei-Lachin procedure) and formal meta-analytic procedure with adjustment for subgroups was performed to determine the adjusted effect sizes with their corresponding confidence intervals.

RESULTS

The overall result (;;Crude Pooling'') shows ;;small'' superiority of the focused extracorporeal shock wave therapy (MW = 0.55, LB-CI = 0.4644). Adjusted for age the focused treatment exhibited ;;more than small'' superiority (MW = 0.59, LB-CI > 0.5) and this result is statistically significant (LB-CI = 0.5067, benchmark for equality = 0.5).

CONCLUSION

This study provides some evidence for focused extracorporeal shock wave treatment being superior to radial extracorporeal shock wave therapy for recalcitrant plantar fasciitis.

Cryosurgery for the treatment of heel pain

BACKGROUND

Although cryosurgery has been used to treat certain conditions, its efficacy for the treatment of heel pain has not been established. The objective of this retrospective case series was to investigate both short- and long-term changes in heel pain after cryosurgery.

MATERIALS AND METHODS

A sample of 137 feet (n = 137) was analyzed over a 24-month period after cryosurgery. The mean age was 56 years and the mean BMI was 33. Subjects in our analysis included only those who had failed 6 months of conservative care prior to cryosurgery. Pain was measured using a Numeric Pain Scale (NPS, zero to 10) at 3 weeks and 24 months. Statistics were calculated using SPSS version 12.0 (Chicago, IL).

RESULTS

A total of 106 subjects had successful pain relief and 31 subjects failed to gain relief; the success and failure rates were 77.4% and 22.6%, respectively. Mean pain before cryosurgery was 7.6, after cryosurgery at three weeks was 1.6 (p < 0.0005), and after cryosurgery at 24 months was 1.1 (p < 0.0005).

CONCLUSION

In subjects who achieved successful pain relief, the significantly lower mean pain score at 3 weeks and 24 months, compared to the initial pain score prior to cryosurgery, suggests that cryosurgery was successful in resolving both short- and long-term heel pain.

An approach to the diagnosis and treatment of plantar fasciitis

Plantar fasciitis is a painful condition affecting many athletes. Anatomic and biomechanical factors combined with overuse can contribute to its genesis. Correction of gait disturbances, changes in footwear, use of tension night splints, and stretching of tight calf and plantar tissues have all be proven to relieve symptoms. Anti-inflammatory modalities, including medications, iontophoresis, and corticosteroid injection generally provide temporary improvement. Recent studies on the efficacy of extracorporeal shock wave therapy are conflicting. Injections with platelet-rich plasma or sclerotic agents are currently under investigation for use in this and other similar conditions. A small percentage of patients with refractory symptoms may benefit from surgical release of the plantar fascia. Diagnosis and correction of biomechanical factors leading to this condition should be a mainstay of treatment and may prevent recurrences.

Safety and effectiveness of extracorporeal shockwave therapy: results of a rabbit model of chronic osteomyelitis

Extracorporeal shockwave therapy (ESWT) is applied successfully in various orthopedic disorders. Since shockwaves have demonstrated significant bactericidal effectiveness in vitro, safety and effectiveness of ESWT in vivo were evaluated in a rabbit model of osteomyelitis. Chronic osteomyelitis was induced by injecting sodium morrhuate and Staphylococcus aureus into the proximal tibia of 12 New Zealand white rabbits. Four and five wk after the initial operation, soft focused ESWT was applied twice to the infected limbs. Clinical parameters and laboratory values were followed and blood samples were taken for culture before and 30 min after ESWT. Following sacrifice after 8 wk, lungs, spleen and kidneys were studied histologically for signs of sepsis and secondary infection. Tibial osteomyelitis was assessed clinically, and by radiologic, microbiologic and histologic procedures. Signs of bacterial spreading were not detectable after ESWT, neither in blood cultures nor in histologic analyses of representative organs. Temperature, body weight, C-reactive protein and white blood cell levels also remained unchanged after ESWT. Of particular interest, histologic scores of osteomyelitis were significantly decreased in the ESWT-group compared to the untreated control (p = 0.019). However, S. aureus was still detectable in tissue samples of all animals. This is the first study investigating the effects of ESWT applied to infected target areas. ESWT of infected bone did neither induce bacterial spreading nor worsening of infection, and the results suggest the reported treatment protocol of ESWT to be beneficial in the treatment of chronic bone infections.

Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-controlled study

BACKGROUND

There is no sufficiently validated therapy for chronic pelvic pain syndrome (CPPS).

OBJECTIVE

To investigate the effects of extracorporeal shock wave therapy (ESWT) in 60 patients suffering from CPPS.

DESIGN, SETTING, AND PARTICIPANTS

Sixty patients suffering from CPPS for at least 3 mo were investigated in two groups. Both groups were treated four times (once per week), each by 3000 impulses; group 2 was performed as a sham procedure. The investigation was designed as a placebo-controlled, prospectively randomised, double-blind phase 2 study. Standardised follow-up was performed 1, 4, and 12 wk after ESWT.

INTERVENTIONS

Low-energy-density ESWT was performed using a perineal approach without anaesthesia. In the placebo group, the same setting was used without shock wave energy transmission.

MEASUREMENTS

ESWT effects on pain, quality of life (QoL), erectile function (EF), and micturition were evaluated. The parameters were investigated using validated questionnaires (National Institutes of Health Chronic Prostatitis Symptom Index [NIH-CPSI], International Prostate Symptom Score [IPSS], International Index of Erectile Function [IIEF]) and the Visual Analog Scale (VAS) for pain evaluation.

RESULTS AND LIMITATIONS

All patients completed outpatient treatments and follow-ups without any problems. All 30 patients in the verum group showed statistically (highly) significant improvement of pain, QoL, and voiding conditions following ESWT in comparison to the placebo group, which experienced a continuous deterioration of the same parameters during the follow-up period. Perineal ESWT was easy and safe to perform without anaesthesia or any side-effects.

CONCLUSIONS

This is the first prospectively randomised, double-blind study to reveal perineal ESWT as a therapy option for CPPS with statistically significant effects in comparison to placebo. ESWT may in particular be interesting because of its easy and inexpensive application, the lack of any side-effects, and the potential for repetition of the treatment at any time.

Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors

Plantar fasciitis can be a chronic and disabling cause of foot pain in the adult population. For refractory cases, extracorporeal shock wave therapy (ESWT) has been proposed as therapeutic option to avoid the morbidity of surgery. We hypothesized that the success of extracorporeal shock wave therapy in patients with chronic plantar fasciitis is affected by patient-related factors. A retrospective review of 225 patients (246 feet) who underwent consecutive ESWT treatment by a single physician at our institution between July 2002 and July 2004 was performed. Subjects were included only if they had plantar fasciitis for more than 6 months and failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Follow-up was 30.2 +/- 8.7 months post procedure. Multivariable analysis was performed to assess factors leading to successful outcomes. Success rates of 70.7% at 3 months and 77.2% at 12 months were noted in this population. Previous cortisone injections, body mass index, duration of symptoms, presence of bilateral symptoms, and plantar fascia thickness did not influence the outcome of ESWT. The presence of diabetes mellitus, psychological issues, and older age were found to negatively influence ESWT outcome. Whereas many factors have been implicated in the development of plantar fasciitis, only diabetes mellitus, psychological issues, and age were found to negatively influence ESWT outcome.

LEVEL OF CLINICAL EVIDENCE

2.

Nonoperative treatment of midportion Achilles tendinopathy: a systematic review

OBJECTIVE

The aim of this systematic review is to provide an easily accessible, clear summary of the best available evidence for nonoperative treatment of midportion Achilles tendinopathy.

DATA SOURCES

MEDLINE, CINAHL, and Embase through April 2007. Search terms: achilles tendon or tendo achilles or triceps surae or tendoachilles or tendo-achilles or achilles AND tendinopathy or tendinosis or tendonitis or tenosynovitis.

STUDY SELECTION

Of 707 abstracts reviewed, 16 randomized trials met our inclusion criteria.

DATA EXTRACTION

Data extracted from each paper included: patient demographics (age and sex), duration of symptoms, method of diagnosis, treatments, cohort size, length of follow-up, pain-related outcome data, and secondary outcome data.

DATA SYNTHESIS

The primary outcome measurement was change in numeric pain score. Focal tenderness, tendon thickness, and validated outcome scores were used secondarily. Eccentric exercises were noted to be equivalent to extracorporeal shockwave therapy (1 study) and superior to wait-and-see treatment (2 trials), traditional concentric exercise (2 of 3 trials), and night splints (1 study). Extracorporeal shockwave therapy was shown to be superior to a wait-and-see method in 1 study but not superior to placebo in another. Sclerosing injections were shown to be superior to placebo in 1 study, but local steroid treatment was beneficial in 2 of 3 studies. Injection of deproteinized hemodialysate and topical glyceryl nitrate application were beneficial in 1 trial each.

CONCLUSIONS

Eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy. More investigation is needed into the utility of extracorporeal shockwave therapy, local corticosteroid treatments, injections of sclerosing agents or deproteinized hemodialysate, and topical glyceryl nitrate application.

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

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/mm(2); 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, 1-sided). 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.

Plantar calcaneal spurs in older people: longitudinal traction or vertical compression?

BACKGROUND

Plantar calcaneal spurs are common, however their pathophysiology is poorly understood. This study aimed to evaluate the prevalence and correlates of plantar calcaneal spurs in a large sample of older people.

METHODS

Weightbearing lateral foot radiographs of 216 people (140 women and 76 men) aged 62 to 94 years (mean age 75.9, SD 6.6) were examined for plantar calcaneal and Achilles tendon spurs. Associations between the presence of spurs and sex, body mass index, radiographic measures of foot posture, self-reported co-morbidities and current or previous heel pain were then explored.

RESULTS

Of the 216 participants, 119 (55%) had at least one plantar calcaneal spur and 103 (48%) had at least one Achilles tendon spur. Those with plantar calcaneal spurs were more likely to have Achilles tendon spurs (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.2 to 3.5). Prevalence of spurs did not differ according to sex. Participants with plantar calcaneal spurs were more likely to be obese (OR = 7.9, 95% CI 3.6 to 17.0), report osteoarthritis (OR = 2.6, 95% CI 1.6 to 4.8) and have current or previous heel pain (OR = 4.6, 95% CI 2.3 to 9.4). No relationship was found between the presence of calcaneal spurs and radiographic measures of foot posture.

CONCLUSION

Calcaneal spurs are common in older men and women and are related to obesity, osteoarthritis and current or previous heel pain, but are unrelated to radiographic measurements of foot posture. These findings support the theory that plantar calcaneal spurs may be an adaptive response to vertical compression of the heel rather than longitudinal traction at the calcaneal enthesis.

Extracorporeal shock wave treatment in nonunions of long bone fractures

We reviewed the clinical results of the past 7 years in order to investigate the effect of extracorporeal shock wave therapy (ESWT) in nonunions of long bone fracture. Sixty-nine patients with 69 nonunions (22 femora, 28 tibiae, 13 humeri, 5 radii, and 1 ulna) were treated with extracorporeal shock waves. The technical parameters were 6,000 to 10,000 impulses at 28 kV (0.62 mJ/mm(2) energy flux density) for the femur and tibia, 4,000 impulses at 24 kV for the humerus (0.56 mJ/mm(2) energy flux density), and 3,000 impulses at 24 kV (0.56 mJ/mm(2) energy flux density) for the radius and ulna. Sixty-six patients were followed up. The total successful rate of bony union was 75.4%. ESWT was successful in hypertrophic nonunions and seemed to have no evident effect in atrophic nonunions. We believe that extracorporeal shock wave therapy may be a good choice for nonunions of long bone fracture especially in hypertrophic nonunions.

The practical application of multimedia technology to facilitate the education and treatment of patients with plantar fasciitis: a pilot study

This study was designed to evaluate the efficacy of a multimedia patient education module when incorporated into the standard treatment protocol for patients diagnosed with plantar fasciitis. A thorough, standardized surgeon-patient education discourse took place following diagnosis. At the conclusion of the consultation, patients viewed the multimedia module. Questionnaires designed to assess understanding and satisfaction with information delivery were completed by patients following the consultation and again after viewing the module. Forty-one patients participated in the study. After viewing the module, patients achieved an average of 87% correct responses on the knowledge questionnaire, a significant improvement (P < .0001) over the 64% achieved following the surgeon-patient discourse. Ease of understanding of the information delivered by the module was rated significantly better (P < .0001) than the surgeon-patient discourse. Ninety-eight percent of patients indicated they felt well informed about plantar fasciitis following viewing the module compared with 68% following the surgeon-patient discourse. Sixty-three percent of patients indicated that the module best answered their questions, 7% preferred the surgeon, and 30% rated both equally. Multimedia plantar fasciitis educational material improved patient understanding of the standard treatment protocol and satisfaction with the information delivery in an orthopedic private practice.

Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device

Published data describing the efficacy of extracorporeal shock wave therapy for the treatment of plantar heel pain provide conflicting results, and optimal treatment guidelines are yet to be determined. To assess the efficacy and safety of extracorporeal shockwave therapy compared with placebo in the treatment of chronic painful heel syndrome with a new electromagnetic device, we undertook a prospective, double-blind, randomized, placebo-controlled trial conducted among 40 participants who were randomly allocated to either active, focused extracorporeal shockwave therapy (0.25 mJ/mm(2)) or sham shockwave therapy. Both groups received 3 applications of 2000 shockwave impulses, each session 1 week apart. The primary outcome was the change in composite heel pain (morning pain, pain with activities of daily living, and pain upon application of pressure with a focal force meter) as quantified using a visual analog pain scale at 12 weeks after completion of the interventions compared with baseline. Secondary endpoints included changes in morning pain, pain with activities of daily living, and pain upon application of pressure with a focal force meter, as measured on a visual analog pain scale, as well as the change in the Roles and Maudsley score, at 12 weeks after the baseline measurement. Active extracorporeal shockwave therapy resulted in a 73.2% reduction in composite heel pain, and this was a 32.7% greater reduction than that achieved with placebo. The difference was not statistically significant (1-tailed Wilcoxon Mann-Whitney U test, P =.0302), but reached clinical relevance (Mann-Whitney effect size = 0.6737). In regard to the secondary outcomes, active extracorporeal shockwave therapy displayed relative superiority in comparison with the sham intervention. No relevant adverse events occurred in either intervention group. The results of the present study support the use of electromagnetically generated extracorporeal shockwave therapy for the treatment of refractory plantar heel pain.