Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis

Effectiveness of therapeutic ultrasound on reducing pain intensity and functional disability in patients with plantar fasciitis: a systematic review of randomised controlled trials

Background

Ultrasound therapy is one of the preferred conservative treatments for patients with plantar fasciitis. This study aims to evaluate the effectiveness of therapeutic ultrasound in decreasing pain intensity and improving functional disability in patients with plantar fasciitis.

Methods

Five randomised control trials (RCT) were selected based on an electronic search in PubMed, Trip Database and PEDro. To be included in the systematic review, the study should be an RCT which investigated the effectiveness of therapeutic ultrasound conducted in patients with plantar fasciitis with pain intensity and functional disability as outcome measures. Only studies published in peer-reviewed journals written in the English language were included. The quality of the selected studies was measured by the PEDro scale.

Results

All the included studies showed that ultrasound therapy is beneficial in reducing pain score and improving functional disability, except one study did not recommend using ultrasound therapy for plantar fasciitis. Moreover, regarding another outcome measure, two studies found that ultrasound therapy reduces thickness and tenderness in plantar fasciitis and improves static and dynamic balance.

Conclusion

After reviewing the five studies, this systematic review support using ultrasound therapy to decrease pain and improve functional disability in patients with plantar fasciitis.

Study Registration

https://osf.io/xftzy/.

Strategies to promote tendon-bone healing after anterior cruciate ligament reconstruction: Present and future

At present, anterior cruciate ligament (ACL) reconstruction still has a high failure rate. Tendon graft and bone tunnel surface angiogenesis and bony ingrowth are the main physiological processes of tendon-bone healing, and also the main reasons for the postoperative efficacy of ACL reconstruction. Poor tendon-bone healing has been also identified as one of the main causes of unsatisfactory treatment outcomes. The physiological process of tendon-bone healing is complicated because the tendon-bone junction requires the organic fusion of the tendon graft with the bone tissue. The failure of the operation is often caused by tendon dislocation or scar healing. Therefore, it is important to study the possible risk factors for tendon-bone healing and strategies to promote it. This review comprehensively analyzed the risk factors contributing to tendon-bone healing failure after ACL reconstruction. Additionally, we discuss the current strategies used to promote tendon-bone healing following ACL reconstruction.

Strategies for promoting tendon-bone healing: Current status and prospects

Tendon-bone insertion (TBI) injuries are common, primarily involving the rotator cuff (RC) and anterior cruciate ligament (ACL). At present, repair surgery and reconstructive surgery are the main treatments, and the main factor determining the curative effect of surgery is postoperative tendon-bone healing, which requires the stable combination of the transplanted tendon and the bone tunnel to ensure the stability of the joint. Fibrocartilage and bone formation are the main physiological processes in the bone marrow tract. Therefore, therapeutic measures conducive to these processes are likely to be applied clinically to promote tendon-bone healing. In recent years, biomaterials and compounds, stem cells, cell factors, platelet-rich plasma, exosomes, physical therapy, and other technologies have been widely used in the study of promoting tendon-bone healing. This review provides a comprehensive summary of strategies used to promote tendon-bone healing and analyses relevant preclinical and clinical studies. The potential application value of these strategies in promoting tendon-bone healing was also discussed.

Intralesional Steroid Injection Versus Extracorporeal Shockwave Therapy in the Treatment of Plantar Fasciitis: A Comparative, Prospective, Case Series Study

Background This study aimed to compare and evaluate the outcomes of intralesional steroid injections (ultrasound-guided) versus extracorporeal shockwave therapy in the treatment of plantar fasciitis. Methodology Between January 2021 and March 2022, 120 (84 male, 36 female) patients with a confirmed diagnosis of plantar fasciitis were identified. Subjective assessment was done using Mayo Clinical Score, and objective evaluation was done by measuring plantar fascia thickness using ultrasonography. For this study, two groups were made, wherein group A was administered a high dose of extracorporeal shockwave therapy, and group B was administered ultrasound-guided intralesional or local steroid injections. Results Plantar fascia thickness was considerably reduced after therapy in both groups; however, the difference in thickness reduction was not statistically significant between both groups. Mayo Clinic Scores showed statistically significant improvement in pain; however, the difference in pain reduction was not statistically significant between both groups. Conclusions A considerable clinical and radiological improvement was noted in both groups; however, we did not record statistically significant and superior results in either group. Intralesional steroid injections provided faster clinical improvement and better patient compliance.

Effects of therapeutic interventions on pain due to plantar fasciitis: A systematic review and meta-analysis

OBJECTIVE

To determine the effects of different therapeutic interventions that have ever been evaluated in randomized controlled trials on pain due to plantar fasciitis.

METHODS

We searched different electronic databases until September 2022. Mean differences (MDs) and 95% confidence intervals (CIs) were calculated. The Grading of Recommendations Assessment, Development and Evaluation was used to evaluate the overall certainty evidence.

RESULTS

A total of 236 studies met the study criteria, including 15,401 patients. Botulinum toxin MD -2.14 (CI: -4.15, -0.14), micronized dehydrated human amnion/chorion membrane injection MD -3.31 (CI: -5.54, -1.08), dry needling MD -2.34 (CI: -4.64, -0.04), low-dye taping MD -3.60 (CI: -4.16, -3.03), low-level laser therapy MD -2.09 (CI: -2.28, -1.90), myofascial releases MD -1.79 (CI: -2.63, -0.94), platelet-rich plasma MD -2.40 (CI: -4.16, -0.63), radiofrequency MD -2.47 (CI: -4.65, -0.29), and stretching MD -1.14 (CI: -2.02, -0.26) resulted in being effective treatments for pain when compared to the control in the short term. In the medium and long term, only extracorporeal shock wave therapy MD -0.97 (CI: -1.13, -0.81)/MD -2.49 (CI: -3.17, -1.82) was effective for improving pain when compared to the control.

CONCLUSIONS

Considering the available studies, this systematic review and meta-analysis showed that different therapeutic interventions seem to be useful strategies for improving pain in patients with plantar fasciitis. In the medium and long term, only extracorporeal shock wave therapy was effective in improving pain when compared to the control.

Therapeutic Ultrasound and Shockwave Therapy for Tendinopathy: A Narrative Review

ABSTRACT

Tendon injury is prevalent and costly in the United States, comprising 45% of the 66 million musculoskeletal injuries and costing $114 billion annually. Surgical and therapeutic methods, such as arthroscopic surgery, dry needling, and physical therapy, produce mixed success in reintroducing a healing response in tendinopathy due in part to inconsistent dosing and monitoring. Ultrasound is one therapeutic modality that has been shown to noninvasively induce bioeffects in tendon that may help promote healing. However, results from this modality have also been mixed. This review compares the current state of the field in therapeutic ultrasound and shockwave therapy, including low-intensity therapeutic ultrasound, extracorporeal shockwave therapy, and radial shockwave therapy, and evaluates the efficacy in treating tendinopathies with ultrasound. We found that the mixed successes may be attributed to the wide variety of achievable parameters within each broader treatment type and the lack of standardization in measurements and reporting. Despite mixed outcomes, all three therapies show potential as an alternative therapy with lower-risk adverse effects than more invasive methods like surgery. There is currently insufficient evidence to conclude which ultrasound modality or settings are most effective. More research is needed to understand the healing effects of these different therapeutic ultrasound and shockwave modalities.

Biological response of extracorporeal shock wave therapy to tendinopathy in vivo (review)

Tendinopathy is a degenerative disease of the tendons caused by prolonged overstretching or overuse of the tendons. It accounts for a large proportion of musculoskeletal disorders which can occur in all age groups. The management of tendinopathy is typically conservative. In clinical practice, when other conservative treatments fail, extracorporeal shock wave therapy (ESWT) is normally used as an efficient alternative to surgical management. Several basic studies have shown that ESWT with lower energy flux densities can produce some biological responses in vivo to tendinopathy and may accelerate the initiation of the healing process in injured tendons. ESWT has a positive impact on the interactive chain of biological response, enhancing the signaling pathways of angiogenesis through mechanical conduction, and promoting cell proliferation and collagen formation. Finally, it helps tissue regeneration by controlling inflammation. The purpose of this review is to summarize the biological responses generated by ESWT in tendinopathy through a comprehensive review of the published literature. Although ESWT has been used clinically for the treatment of tendinopathies for nearly decades, less is known about the experimental studies of its biological effects on tendon tissue. Further studies on the biological response of ESWT for tendon injuries in vivo are needed in the future in order to provide better management to patients.

Extracorporeal Shockwave Therapy Versus Ultrasound Therapy for Plantar Fasciitis: A Systematic Review and Meta-Analysis

The objective of this study was to compare the outcomes of extracorporeal shockwave therapy (ESWT) versus ultrasound therapy (UST) in plantar fasciitis. A systematic review and meta-analysis were performed. An electronic search identifying studies comparing ESWT and UST for plantar fasciitis was conducted. Primary outcomes were morning and activity pain, functional impairment, and the American Orthopaedic Foot and Ankle Society (AOFAS) scale score. Secondary outcomes included the fascial thickness, primary efficacy success rate, activity limitations, pain intensity, and satisfaction. Seven studies enrolling 369 patients were identified. No significant difference was found between ESWT and UST for functional impairment (mean difference [MD] = -2.90, P = 0.22), AOFAS scale score (MD = 35, P = 0.20), and pain in the first steps in the morning (MD = -4.72, P = 0.39). However, there was a significant improvement in pain during activity for the ESWT group (MD = -1.36, P = 0.005). For secondary outcomes, ESWT had improved results in terms of primary efficacy success rate, activity limitations, and patient satisfaction. The reduction of plantar fascia thickness showed no significant difference. Pain intensity after treatment had varied results amongst included studies. In conclusion, ESWT is superior to UST for plantar fasciitis as it improves pain activity and intensity, primary efficacy success rate, and activity limitations.

The Impact of Extracorporeal Shock Wave Therapy and Dry Needling Combination on Pain and Functionality in the Patients Diagnosed with Plantar Fasciitis

This study aimed to evaluate the efficiency of extracorporeal shock wave therapy (ESWT) and dry needling (DN) combination on pain and functionality in plantar fasciitis. Forty patients who were clinically diagnosed with plantar fasciitis were included in the study. The patients were randomly divided into 2 groups. The ESWT-DN group was applied 3 sessions of ESWT to plantar fascia and DN to the trigger points in the gastrosoleus muscles. The ESWT group was applied only ESWT treatment to plantar fascia. We used visual analog scale (VAS) for pain and a pressure algometer for pressure pain threshold. The functionality of the patients was evaluated with Foot Function Index (FFI). Also, maximum painless standing time and maximum painless walking distance were recorded. All assessments were repeated twice; first, pretreatment and second 1 month after the treatment. In both groups, there were statistically significant improvements in VAS, pressure pain threshold, maximum painless standing time, maximum painless walking distance, and FFI's pain, disability, and activity limitation subscales scores (p ≤ .001). In intergroup comparison; it was showed that VAS scores, maximum painless standing time (p = .002), maximum painless walking distance (p ≤ .001), and FFI pain subscale scores (p = .034) were statistically superior in the ESWT-DN group. There was no statistically difference between the groups in pressure pain threshold (p = .132), FFI disability (p = .081), and FFI activity limitation subscale (p = .226) scores. ESWT and DN combination therapy in plantar fasciitis was seen to be superior in the pain scores. Further studies with larger patients' groups and longer term results of this combination are needed for a better comparison.

Radial Extracorporeal Shockwave Therapy versus Ultrasound Therapy in Adult Patients with Idiopathic Scoliosis

BACKGROUND

This study aimed to compare the effectiveness of radial extracorporeal shockwave and ultrasound therapies in adult patients with idiopathic scoliosis in terms of pain, disability, and quality of life.

METHODS

Forty-eight patients with idiopathic scoliosis were randomly divided into three groups of 16: shockwave, ultrasound, and control. The patients were evaluated at admission (day one) and at discharge (day 14) for pain, by using the visual analogue scale; for disability, by using the Oswestry disability index; and for the quality of life, with short form-36.

RESULTS

Radial extracorporeal shockwave therapy was more effective than ultrasound in reducing pain (p = 0.004) and increasing quality of life, bringing extra vitality (p = 0.003) and emotional comfort (p = 0.007) to the patient. Both shockwave therapy (p = 0.001) and ultrasound therapy (p = 0.003) were effective in reducing pain. In terms of disability, both treatments had similar effects (p = 0.439).

CONCLUSION

Radial shockwave was significantly more effective than ultrasound in reducing pain and increasing the quality of life, bringing additional vitality and emotional comfort to the patient with idiopathic scoliosis. In terms of disability, both treatments had similar effects when associated with kinesitherapy.

Immediate effect of foam roller on pain and ankle range of motion in patients with plantar fasciitis: A randomized controlled trial

Background:

Stretching has been proven to be effective on pain and range of motion (ROM) in patients with plantar fasciitis. Despite recent gain in popularity and the proposed theories of effectiveness of foam roller, there is a lack of literature on the effect of foam rolling on plantar fasciitis.

Objective:

The objective of this study was to compare the effects of foam rolling and stretching on pain and ankle ROM in patients with plantar fasciitis.

Methods:

A total of 50 participants were included and randomly allocated to the stretching and foam roller groups. Visual analog scale (VAS), pressure pain thresholds (PPTs) for gastrocnemius, soleus and plantar fascia and weight-bearing lunge test (WBLT) measurements were recorded at baseline and immediately after treatment.

Results:

Within-group analysis has shown there is a statistically significant difference (p<0.001) in all the outcome measures in both foam roller and self-stretching groups. The between-groups analysis showed no statistical significance difference in VAS, plantar fascia PPT and WBLT parameters (with p-values of 0.171, 0.372 and 0.861, respectively); however, significant differences were found in gastrocnemius PPT (p=0.029) and soleus PPT (p=0.013).

Conclusion:

It was seen that both stretching and foam rolling techniques helped in reducing pain and increasing the ROM. However, the effectiveness of foam roller was superior to stretching in terms of increase in PPTs at gastrocnemius and soleus.

Clinical Trial Registration No:

CTRI/2018/01/011398.

Name of registry:

The Clinical Trials Registry — India (CTRI); https://ctri.nic.in.

Plantar pressure distribution and spatiotemporal gait parameters after the radial shock wave therapy in patients with chronic plantar fasciitis

Radial shock wave therapy (RSWT) has been recommended as an appropriate, safe and effective method in the treatment of chronic plantar fasciitis (PF). The main purpose of this study was to examine how RSWT affects gait parameters. This study included 23 patients with unilateral, chronic PF. RSWT were administered in 5 interventions, during a consecutive 3-week period. Objective kinetic (force distribution under the forefoot, midfoot, rearfoot) and spatiotemporal parameters (cadence, step length, stance phase duration) during treadmill walking at, preferred" speed were evaluated on. 4 sessions: before therapy, immediately after (primary endpoint), 3 and 6 weeks after therapy. The mean reduction in the reported pain when taking first steps in the morning from baseline to the primary endpoint, 3- and 6-weeks post procedure was 42.7%, 50.1% and 66.9% respectively. Similar reduction was seen in the reported pain during walking. After the therapy during gait at the preferred speed patients had a significantly higher force beneath the rearfoot and forefoot of both limbs. Force beneath the midfoot was not significantly affected by treatment. The step length in both limbs increased by 3.3-3.6 cm after RSWT. After the therapy stance phase duration in symptomatic foot was longer by 7% and it slightly decreased until POST-6wk. Similar changes were seen in an asymptomatic limb. The spatiotemporal and kinetic results indicate that RSWT therapy induces changes in patient's gait structure and alter regional loading in the affected foot.

Effectiveness of a Double Air-Cushioned Shoe Compared with Physiotherapy in the Treatment of Plantar Fasciitis

Objective

This study was aimed at comparing the plantar fasciitis treatment effect of a double air-cushioned shoe to that of physiotherapy combined with ESWT.

Methods

Retrospective chart review of 40 patients diagnosed with plantar fasciitis was performed. Group 1 wore a double air-cushioned shoe for 2 months, and group 2 underwent physiotherapy with ESWT once/week over a 4-week period. The foot function index (FFI) score was obtained at the initial visit, 1 month, and 2 months.

Results

There were 25 patients in group 1 and 15 patients in group 2. The pretreatment FFI was 62.6 for group 1 and 50 for group 2. The 1-month posttreatment FFI was 45.6 for group 1 and 35.7 for group 2. The 2-month posttreatment FFI was 35 for group 1 and 43.1 for group 2. In both groups 1 and 2, follow-up FFIs were significantly improved from the initial FFI (p < 0.05) and there were no significant differences between two groups (p > 0.05).

Conclusions

The double air-cushioned shoe can be considered an alternative treatment option for noninvasive treatment of early-stage plantar fasciitis.

Radial Extra Corporeal Shockwave Therapy Versus Ultrasound Therapy in the Treatment of Plantar Fasciitis

Introduction:

Patients with plantar fasciitis usually suffer from reduced mobility due to the pain caused by the movement of the tendons involved.

Aim:

This study was aimed to compare both shockwave and ultrasound therapies in patients with plantar fasciitis by assessing the pain intensity, and both the functionality of the lower limbs and the quality of life impairments.

Methods:

Total amount of 88 patients with plantar fasciitis constituted the shockwave group, 56 the ultrasound group and 15 the control group. The self-administered questionnaire “University of Peloponnese Pain, Functionality and Quality of Life Questionnaire” was used. The intensity of pain, functionality impairment and quality of life impairment were evaluated on a five-point Likert scale, before treatment, immediately after and at 4-week follow-up.

Results:

The pain reduction and the improvement of functionality and quality of life after shockwave treatment and ultrasound treatment significantly increased both post-treatment (p<0,001) and at the 4-week follow-up (p<0,001) compared to post-treatment. However, the improvements in the ultrasound group were not as pronounced as in shockwave group (p<0,001).

Conclusions:

Although both radial shockwave and ultrasound therapies were found to be effective in patients with plantar fasciitis, the statistical analysis showed that radial shockwave is significantly more effective than ultrasound therapy.

Comparison of extracorporeal shock-wave therapy and wrist-extensor splint application in the treatment of lateral epicondylitis: a prospective randomized controlled study

Background

Extracorporeal shock-wave therapy (ESWT) and wrist-extensor splints (WESs) are two commonly used methods in the treatment of lateral epicondylitis. In this study, the efficacy of these two methods was compared.

Methods

The study was planned as a prospective randomized controlled study. A total of 67 patients were enrolled. The patients were divided into two groups: group 1 received ESWT (32 patients) and group 2 received WES (35 patients). Patients in group 1 underwent four sessions of ESWT once every week. In each session, an ESWT device at 10–12 Hz, 2,000 pulses, and 1.6–1.8 bar pressure was used. Patients in group 2 used a wrist splint, holding the wrist at 30°–45° extension for 4 weeks. Patients were assessed for handgrip strength, pain at rest, pain while working, and quality of life. Data were collected before and after treatment (at weeks 4, 12, and 24). A visual analog scale was used to evaluate pain at rest and while working, a hand dynamometer for handgrip strength, subscales of the SF36 Health Survey to evaluate quality of life, and the Turkish version of the patient-rated tennis-elbow evaluation was used to evaluate functioning of the affected arm during various daily life activities.

Results

In both ESWT and WES groups, although there were considerably significant improvements (P<0.001) in the parameters evaluated (pain at rest and while working, handgrip strength, Patient-Rated Tennis Elbow Evaluation, Nirschl score, and SF36 subscales) were observed at 4, 12, and 24 weeks compared to pretreatment values, there was no statistically significant difference between the two groups in terms of our evaluation parameters at the three time points (P>0.05).

Conclusion

Both ESWT and WES applications were found to yield significantly superior results when compared to pretreatment values. In comparison of the two groups, on the other hand, there was no statistically significant difference.

A comparison of the acute effects of radial extracorporeal shockwave therapy, ultrasound therapy, and exercise therapy in plantar fasciitis

This study was conducted to compare the acute effects of radial extracorporeal shockwave therapy (r-ESWT), ultrasound (US) therapy and home exercise therapy on pain, fatigue, performance and walking distance in women with plantar fasciitis (PF). Fifty-four female patients diagnosed with PF participated in the study. The patients were randomly divided into 3 groups as r-ESWT and home exercise groups, US and home exercise groups, and only home exercise groups. Patients' pain and fatigue levels were assessed by using a visual analog scale. Also walking distances, walking speed and plantar flexor muscles performance were assessed. Patients' pain at night before bedtime and leg fatigue after the 6-min walking test decreased in the US therapy group in comparison to the other two groups (P<0.05). The 20-m walking speed improved in the US and r-ESWT therapy groups following the treatments (P<0.05) and there was no difference between the groups. After treatment, while the 20-m walking speed was increasing in US and r-ESWT groups (P<0.05), no increase was observed in exercise group. But there was no difference between the 20-m walking speed of 3 groups after treatment (P>0.05). However, all three groups' complaints decreased after treatment. Our study results illustrated that r-ESWT, US, and home exercise therapy have acute effects on the PF treatment and when there is no possibility of practising any treatment to patients, home exercises such as r-ESWT, US treatment are effective therapies for decreasing pain and fatigue levels and improving performance and walking distance.

Corticosteroid injections compared to foot orthoses for plantar heel pain: protocol for the SOOTHE heel pain randomised trial

INTRODUCTION

Corticosteroid injections and foot orthoses are common interventions for plantar heel pain. Previous clinical trials have found that the effectiveness of these interventions differs over time, with corticosteroid injections being more effective in the short-term (i.e. 0-4 weeks) and foot orthoses more effective in the longer-term (i.e. 5-12 weeks). However, some of these trials have methodological weaknesses that could have caused confounding and bias, which may have led to over- or under-estimation of the effectiveness of these interventions. As a result, there is a need to compare the effectiveness of corticosteroid injections and foot orthoses in a robust clinical trial with an appropriate follow-up time.

METHODS

This article describes the protocol for a pragmatic, parallel-group assessor-blinded randomised trial (Steroid injection versus foot orthoses (SOOTHE) heel pain trial). One hundred participants with plantar heel pain will be randomly allocated (i.e. two groups of approximately 50) to receive either an ultrasound-guided corticosteroid injection or prefabricated foot orthoses. Outcome measures will be obtained at baseline, 4, 8 and 12 weeks, with two primary endpoints at 4 and 12 weeks to reflect the hypothesised temporal effects of each intervention. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry number ACTRN12615001266550.

Success and Recurrence Rate after Radial Extracorporeal Shock Wave Therapy for Plantar Fasciopathy: A Retrospective Study

Background and Aims. The exploration of an individualised protocol of radial extracorporeal shock wave therapy (rESWT) for plantar fasciopathy, assessing success rates and the recurrence rate over a 1-year period after treatment, is not yet identified in literature. Methods and Results. Between 2006 and 2013, 68 patients (78 heels) were assessed for plantar fasciopathy. An individualised rESWT treatment protocol was applied and retrospectively analysed. Heels were analysed for mean number of shock wave impulses, mean pressure, and mean frequency applied. Significant mean pain reductions were assessed through Visual Analogue Scale (VAS) after 1-month, 3-month, and 1-year follow-up. Success rates were estimated as the percentage of patients having more than 60% VAS pain decrease at each follow-up. 1-year recurrence rate was estimated. The mean VAS score before treatment at 6.9 reduced to 3.6, 1 month after the last session, and to 2.2 and 0.9, after 3 months and 1 year, respectively. Success rates were estimated at 19% (1 month), 70% (3 months), and 98% (1 year). The 1-year recurrence rate was 8%. Moderate positive Spearman's rho correlation (r = 0.462, p < 0.001) was found between pretreatment pain duration and the total number of rESWT sessions applied. Conclusions. Individualised rESWT protocol constitutes a suitable treatment for patients undergoing rESWT for plantar fasciitis.

Radial Shock Wave Devices Generate Cavitation

BACKGROUND

Conflicting reports in the literature have raised the question whether radial extracorporeal shock wave therapy (rESWT) devices and vibrating massage devices have similar energy signatures and, hence, cause similar bioeffects in treated tissues.

METHODS AND FINDINGS

We used laser fiber optic probe hydrophone (FOPH) measurements, high-speed imaging and x-ray film analysis to compare fundamental elements of the energy signatures of two rESWT devices (Swiss DolorClast; Electro Medical Systems, Nyon, Switzerland; D-Actor 200; Storz Medical, Tägerwillen, Switzerland) and a vibrating massage device (Vibracare; G5/General Physiotherapy, Inc., Earth City, MO, USA). To assert potential bioeffects of these treatment modalities we investigated the influence of rESWT and vibrating massage devices on locomotion ability of Caenorhabditis elegans (C. elegans) worms.

RESULTS

FOPH measurements demonstrated that both rESWT devices generated acoustic waves with comparable pressure and energy flux density. Furthermore, both rESWT devices generated cavitation as evidenced by high-speed imaging and caused mechanical damage on the surface of x-ray film. The vibrating massage device did not show any of these characteristics. Moreover, locomotion ability of C. elegans was statistically significantly impaired after exposure to radial extracorporeal shock waves but was unaffected after exposure of worms to the vibrating massage device.

CONCLUSIONS

The results of the present study indicate that both energy signature and bioeffects of rESWT devices are fundamentally different from those of vibrating massage devices.

CLINICAL RELEVANCE

Prior ESWT studies have shown that tissues treated with sufficient quantities of acoustic sound waves undergo cavitation build-up, mechanotransduction, and ultimately, a biological alteration that "kick-starts" the healing response. Due to their different treatment indications and contra-indications rESWT devices cannot be equated to vibrating massage devices and should be used with due caution in clinical practice.

A randomized controlled trial of custom foot orthoses for the treatment of plantar heel pain

BACKGROUND

Up to 10% of people will experience heel pain. The purpose of this prospective, double-blind, randomized clinical trial was to compare custom foot orthoses (CFO), prefabricated foot orthoses (PFO), and sham insole treatment for plantar fasciitis.

METHODS

Seventy-seven patients with plantar fasciitis for less than 1 year were included. Outcome measures included first step and end of day pain, Revised Foot Function Index short form (FFI-R), 36-Item Short Form Health Survey (SF-36), activity monitoring, balance, and gait analysis.

RESULTS

The CFO group had significantly improved total FFI-R scores (77.4 versus 57.2; P = .03) without group differences for FFI-R pain, SF-36, and morning or evening pain. The PFO and CFO groups reported significantly lower morning and evening pain. For activity, the CFO group demonstrated significantly longer episodes of walking over the sham (P = .019) and PFO (P = .03) groups, with a 125% increase for CFOs, 22% PFOs, and 0.2% sham. Postural transition duration (P = .02) and balance (P = .05) improved for the CFO group. There were no gait differences. The CFO group reported significantly less stretching and ice use at 3 months.

CONCLUSIONS

The CFO group demonstrated 5.6-fold greater improvements in spontaneous physical activity versus the PFO and sham groups. All three groups improved in morning pain after treatment that included standardized athletic shoes, stretching, and ice. The CFO changes may have been moderated by decreased stretching and ice use after 3 months. These findings suggest that more objective measures, such as spontaneous physical activity improvement, may be more sensitive and specific for detecting improved weightbearing function than traditional clinical outcome measures, such as pain and disease-specific quality of life.

Two emerging technologies for Achilles tendinopathy and plantar fasciopathy

Some common overuse injuries, such as Achilles tendinopathy and plantar fasciitis (or fasciopathy), can be refractory to treatment. When standard treatment options fail, operative intervention often becomes the treatment of last resort. Recently, newer technologies have been developed and refined, and can provide potential benefits for these conditions using noninvasive and minimally invasive approaches. Two technologies, extracorporeal shock wave therapy and ultrasound-guided percutaneous tenotomy/fasciotomy are discussed.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

Extracorporeal shockwave enhanced regeneration of fibrocartilage in a delayed tendon-bone insertion repair model

Fibrous tissue is often formed in delayed healing of tendon bone insertion (TBI) instead of fibrocartilage. Extracorporeal shockwave (ESW) provides mechanical cues and upregulates expression of fibrocartilage-related makers and cytokines. We hypothesized that ESW would accelerate fibrocartilage regeneration at the healing interface in a delayed TBI healing model. Partial patellectomy with shielding at the TBI interface was performed on 32 female New Zealand White Rabbits for establishing this delayed TBI healing model. The rabbits were separated into the control and ESW group for evaluations at postoperative week 8 and 12. Shielding was removed at week 4 and a single ESW treatment was applied at week 6. Fibrocartilage regeneration was evaluated histomorphologically and immunohistochemically. Vickers hardness of the TBI matrix was measured by micro-indentation. ESW group showed higher fibrocartilage area, thickness, and proteoglycan deposition than the control in week 8 and 12. ESW increased expression of SOX9 and collagen II significantly in week 8 and 12, respectively. ESW group showed a gradual transition of hardness from bone to fibrocartilage to tendon, and had a higher Vickers hardness than the control group at week 12. In conclusion, ESW enhanced fibrocartilage regeneration at the healing interface in a delayed TBI healing model.

Treatment of chronic plantar fasciopathy with extracorporeal shock waves (review)

There is an increasing interest by doctors and patients in extracorporeal shock wave therapy (ESWT) for chronic plantar fasciopathy (PF), particularly in second generation radial extracorporeal shock wave therapy (RSWT). The present review aims at serving this interest by providing a comprehensive overview on physical and medical definitions of shock waves and a detailed assessment of the quality and significance of the randomized clinical trials published on ESWT and RSWT as it is used to treat chronic PF. Both ESWT and RSWT are safe, effective, and technically easy treatments for chronic PF. The main advantages of RSWT over ESWT are the lack of need for any anesthesia during the treatment and the demonstrated long-term treatment success (demonstrated at both 6 and 12 months after the first treatment using RSWT, compared to follow-up intervals of no more than 12 weeks after the first treatment using ESWT). In recent years, a greater understanding of the clinical outcomes in ESWT and RSWT for chronic PF has arisen in relationship not only in the design of studies, but also in procedure, energy level, and shock wave propagation. Either procedure should be considered for patients 18 years of age or older with chronic PF prior to surgical intervention.

One-year treatment follow-up of plantar fasciitis: radial shockwaves vs. conventional physiotherapy

OBJECTIVE

To compare radial shockwave treatment with conventional physiotherapy for plantar fasciitis after 12 months of follow-up.

METHOD

This was a randomized, prospective, comparative clinical study. Forty patients with a diagnosis of plantar fasciitis were divided randomly into two treatment groups: group 1, with 20 patients who underwent ten physiotherapy sessions comprising ultrasound, kinesiotherapy and guidance for home-based stretching; and group 2, with 20 patients who underwent three applications of radial shockwaves, once a week, and guidance for home-based stretching. All patients were assessed regarding pain and functional abilities before treatment, immediately after and 12 months after treatment. The mean age was 49.6 ±11.8 years (range: 25-68 years), 85% were female, 88% were overweight, 63% were affected bilaterally, and 83% used analgesics regularly.

RESULTS

At the 12-month follow-up, both treatments were effective for improving pain and functional ability among the patients with plantar fasciitis. The improvement with shockwaves was faster.

CONCLUSION

Shockwave treatment was not more effective than conventional physiotherapy treatment 12 months after the end of the treatment.

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.

Effects of radial shock waves therapy on osteoblasts activities

Radial shock waves therapy (RSWT) differs from extracorporeal shock waves therapy (ESWT) in that it produces a non-focused wave that is dissipated radially at the skin. Few studies have yet explored the effects of RSWT on bone tissue. Osteoblasts in culture flasks were studied by polymerase chain reaction after treatment with RSW (500 impulses, 0.05 mJ/mm(2)). An inhibited osteoblastogenesis was observed, with a statistically significant reduction in type 1 collagen, osterix, bone sialoprotein and receptor activator NF kappa ligand expression at 24 and 48 h, of osteocalcin at 24, 48 and 72 h, and osteopontin at 48 and 72 h. These findings show that RSWT is not indicated for treatment of delayed fracture union, pseudoarthrosis, and complex regional pain syndrome. The observed reduction in the receptor activator of nuclear factor-kB ligand/osteoprotegerin ratio suggests that it has an inhibiting effect on osteoclastogenesis, which could make it a useful tool for applications in proliferative diseases.

Extracorporeal shockwave therapy in musculoskeletal disorders

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

Low-dye taping versus medial arch support in managing pain and pain-related disability in patients with plantar fasciitis

Plantar fasciitis is thought to develop because of repeated mechanical stresses. This study aimed to compare 2 means of foot arches support-low-Dye tape (LDT) and medial arch support (MAS)-in patients with plantar fasciitis. Thirty patients with unilateral plantar fasciitis (23 men and 7 women) were randomly assigned to the LDT or MAS groups. Both groups were assessed before and after experiment for pain and foot function. Both groups received 9 sessions over 3 weeks consisting of ultrasound and calf muscles stretching. They were instructed to maintain supportive intervention (LDT or MAS) throughout this period. Pre-post comparison showed reduced pain and improved function in both groups. Between-groups analysis showed non-significant difference in pre-VAS and pre-FPDS. Post-VAS and post-FPDS showed significant improvement in patients in MAS group. Results indicate that MAS is more convenient for short-term management of pain and disability in patients with plantar fasciitis than LDT.

Estudo de publicações em periódicos gerais de artigos sobre ortopedia e aparelho locomotor

Os autores estudam o perfil de publicação de artigos sobre ortopedia e área de interesse em aparelho locomotor em revistas gerais, não específicas de ortopedia, com registro no PUBMED, em um período de dois anos. Selecionados 67 artigos com distribuição heterogênea entre as revistas estudadas foi constatada presença de 26,47% de artigos com desenho de intervenção e 38% com desenho observacional. Os dados são comentados.

Rearfoot alignment and medial longitudinal arch configurations of runners with symptoms and histories of plantar fasciitis

OBJECTIVE

To evaluate and compare rearfoot alignment and medial longitudinal arch index during static postures in runners, with and without symptoms and histories of plantar fasciitis (PF).

INTRODUCTION

PF is the third most common injury in runners but, so far, its etiology remains unclear. In the literature, rearfoot misalignment and conformations of the longitudinal plantar arch have been described as risk factors for the development of PF. However, in most of the investigated literature, the results are still controversial, mainly regarding athletic individuals and the effects of pain associated with these injuries.

METHODS

Forty-five runners with plantar fasciitis (30 symptomatic and 15 with previous histories of injuries) and 60 controls were evaluated. Pain was assessed by a visual analogue scale. The assessment of rearfoot alignment and the calculations of the arch index were performed by digital photographic images.

RESULTS

There were observed similarities between the three groups regarding the misalignments of the rearfoot valgus. The medial longitudinal arches were more elevated in the group with symptoms and histories of PF, compared to the control runners.

CONCLUSIONS

Runners with symptoms or histories of PF did not differ in rearfoot valgus misalignments, but showed increases in the longitudinal plantar arch during bipedal static stance, regardless of the presence of pain symptoms.

Influence of patellofemoral pain syndrome on plantar pressure in the foot rollover process during gait

BACKGROUND

Patellofemoral Pain Syndrome is one of the most common knee disorders among physically active young women. Despite its high incidence, the multifactorial etiology of this disorder is not fully understood.

OBJECTIVES

To investigate the influence of Patellofemoral Pain Syndrome on plantar pressure distribution during the foot rollover process (i.e., the initial heel contact, midstance and propulsion phases) of the gait.

MATERIALS AND METHODS

Fifty-seven young adults, including 22 subjects with Patellofemoral Pain Syndrome (30 ± 7 years, 165 ± 9 cm, 63 ± 12 kg) and 35 control subjects (29 ± 7 years, 164 ± 8 cm, 60 ± 11 kg), volunteered for the study. The contact area and peak pressure were evaluated using the Pedar-X system (Novel, Germany) synchronized with ankle sagittal kinematics.

RESULTS

Subjects with Patellofemoral Pain Syndrome showed a larger contact area over the medial (p = 0.004) and central (p = 0.002) rearfoot at the initial contact phase and a lower peak pressure over the medial forefoot (p = 0.033) during propulsion when compared with control subjects.

CONCLUSIONS

Patellofemoral Pain Syndrome is related to a foot rollover pattern that is medially directed at the rearfoot during initial heel contact and laterally directed at the forefoot during propulsion. These detected alterations in the foot rollover process during gait may be used to develop clinical interventions using insoles, taping and therapeutic exercise to rehabilitate this dysfunction.

Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy

BACKGROUND

Whether plantar fascia-specific stretching or shock-wave therapy is effective as an initial treatment for proximal plantar fasciopathy remains unclear. The aim of this study was to test the null hypothesis of no difference in the effectiveness of these two forms of treatment for patients who had unilateral plantar fasciopathy for a maximum duration of six weeks and which had not been treated previously.

METHODS

One hundred and two patients with acute plantar fasciopathy were randomly assigned to perform an eight-week plantar fascia-specific stretching program (Group I, n = 54) or to receive repetitive low-energy radial shock-wave therapy without local anesthesia, administered weekly for three weeks (Group II, n = 48). All patients completed the seven-item pain subscale of the validated Foot Function Index and a patient-relevant outcome questionnaire. Patients were evaluated at baseline and at two, four, and fifteen months after baseline. The primary outcome measures were a mean change in the Foot Function Index sum score at two months after baseline, a mean change in item 2 (pain during the first few steps of walking in the morning) on this index, and satisfaction with treatment.

RESULTS

No difference in mean age, sex, weight, or duration of symptoms was found between the groups at baseline. At two months after baseline, the Foot Function Index sum score showed significantly greater changes for the patients managed with plantar fascia-specific stretching than for those managed with shock-wave therapy (p < 0.001), as well as individually for item 2 (p = 0.002). Thirty-five patients (65%) in Group I versus fourteen patients (29%) in Group II were satisfied with the treatment (p < 0.001). These findings persisted at four months. At fifteen months after baseline, no significant between-group difference was measured.

CONCLUSIONS

A program of manual stretching exercises specific to the plantar fascia is superior to repetitive low-energy radial shock-wave therapy for the treatment of acute symptoms of proximal plantar fasciopathy.

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.

Examining the degree of pain reduction using a multielement exercise model with a conventional training shoe versus an ultraflexible training shoe for treating plantar fasciitis

Plantar fasciitis is a common injury to the plantar aponeurosis, manifesting as pain surrounding its proximal insertion at the medial calcaneal tubercle. Pain is typically worse in the morning when getting out of bed, and may subside after the tissue is sufficiently warmed up. For running-based athletes and individuals who spend prolonged periods of time on their feet at work, plantar fasciitis may become recalcitrant to conservative treatments such as ice, rest, and anti-inflammatory medication. Exercise-based therapies have received only limited attention in the literature for this common problem, yet they are becoming increasingly validated for pain relief and positive tissue remodeling at other sites of similar soft-tissue overuse injury. This study reports on pain outcomes in individuals experiencing chronic plantar fasciitis while wearing a shoe with an ultraflexible midsole (Nike Free 5.0) (FREE) versus a conventional training (CON) shoe in a 12-week multielement exercise regimen, and after a 6-month follow-up. Adults with >or= 6-month history of painful heel pain were recruited and randomly assigned to wear 1 of the 2 shoes. All subjects completed the same exercise protocol. A visual analogue scale item tracked peak pain in the preceding 24 hours taken at baseline, 6- and 12-week points, and at the 6-month follow-up. Twenty-one subjects completed the program (9 FREE; 12 CON). Both groups reported significant improvements in pain by the 6-month follow-up, and the FREE group reported an overall reduced level of pain throughout the study as a result of lower mean pain scores at the midpoint and post-test compared with the CON group. The exercise regimen employed in this study appears to reduce pain associated with chronic plantar fasciitis, and in doing so, the Nike 5.0 shoe may result in reductions in pain earlier than conventional running shoes.