ESWT

"Shockingly" new treatment for chronic heel pain now available in Central Florida!

What is this new treatment called?
Extracorporeal Shockwave Therapy (ESWT) is a new and innovative way to treat patients with chronic heel pain, which has not responded to traditional therapies. The treatment is based on the healing capabilities of specialized shock waves, which have been used in the U.S. since 1984 for the treatment of kidney stones (Lithotripsy). ESWT for the treatment of heel pain was approved by the FDA in October of 2000 and is quickly becoming the treatment of choice for people who elect NOT to have surgery.

Who would benefit from this new technology?
People who suffer from chronic heel pain. This syndrome is one of the most common types of pain affecting the human body. It is estimated that over 2 million people in the United States alone develop this condition every year! Traditional treatments have been limited to cortisone injections, oral anti-inflammatory medications, shoe inserts, pnysical therapy, and surgery - until now!! Chronic heel pain is defined as pain persisting for at least six months and which has been resistant to at least two of the traditional treatments.

What is involved with ESWT treatment?
The treatment involves the delivery of 2600 electrohydraulic shockwaves administered by a specialized machine to the area of maximal tenderness in the heel area. The procedure is considered non-invasive; which means there is no cutting of tissues or skin. However, the treatment must be administered with the use of local anesthesia and twilight sedation, as the administration of the shockwaves is a painful stimulus. The entire procedure usually takes less than 30 minutes and is performed at an accredited outpatient surgical facility.

What can I expect after the ESWT treatment?
Patients are discharged with either a soft surgical shoe or tennis shoe and can expect some discomfort, bruising, and swelling for a few days afterward. The pain is relatively minor and can be controlled with oral medication prescribed by our doctors. The procedure shows maximum improvement at approximately 12 weeks post-treatment. Follow-up visits with our doctors are scheduled routinely and are geared to individual patients needs.

Are there any complications with the ESWT treatment?
It must be emphasized that the number one complication of treating chronic heel pain (no matter what the treatment) is recurrent heel pain. ESWT treatment has been shown to be effective approximately 90% of the time. People who continue to experience significant pain can elect to undergo traditional surgical treatment or continue to live with the condition. Other potential complications, which are rare, include: numbness, severe bruising, phlebitis, stress fracture, or fascial rupture.

All of our doctors have been certified by Healthtronics, Inc. to perform ESWT treatments. To learn more about this new treatment alternative, please call the office for an appointment

Radial Extracorporeal Shock WaveTherapy 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/mm2; 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks' follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients' and investigators' global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy.

Results: Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 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.

Keywords: heel pain; planter fasciitis; shock wave; lithotripsy; radial extracorporeal shock wave therapy


Effectiveness of Extracorporeal Shock Wave Therapy in the Treatment of Previously Untreated Lateral Epicondylitis

A Randomized Controlled Tria

Abstract
Background
: Extracorporeal shock wave therapy is a relatively new therapy used in the treatment of chronic tendon-related pain. Few randomized controlled trials have been performed on it, and no studies have examined the effectiveness of extracorporeal shock wave therapy as a frontline therapy for tendon-related pain.

Hypothesis: Subjects treated with active extracorporeal shock wave therapy will have higher rates of treatment success than subjects treated with sham extracorporeal shock wave therapy.

Design: Double-blind randomized controlled trial.

Methods: Sixty subjects who had previously untreated lateral epicondylitis for less than 1 year and more than 3 weeks were included in this study. Subjects were randomly allocated to receive 1 session per week for 3 weeks of either sham or active extra-corporeal shock wave therapy. Subjects in the active therapy group received 2000 pulses (energy flux density, 0.03-0.17 mJ/mm2). All subjects were provided with a forearm-stretching program. After 8 weeks of therapy, subjects were classified as either treatment successes or treatment failures according to fulfillment of all 3 criteria: (1) at least a 50% reduction in the overall pain visual analog scale score, (2) a maximum allowable overall pain visual analog scale score of 4.0 cm, and (3) no use of pain medication for elbow pain for 2 weeks before the 8 week follow-up. Visual analog scale scores were also collected for pain at rest, during sleep, during activity, at its worst, and at its least, as well as for quality of life (using the EuroQoL questionnaire) and grip strength.

Results: Success rates in the sham and active therapy groups were 31% and 39%, respectively. No significant difference was detected between groups (χ21= 0.3880, P = .533). Mean change in quality of life over 8 weeks was an increase of 1.3 and 3.3 for sham and active therapy groups, respectively, and mean change in grip strength over 8 weeks was an increase of 7.4 kg and 6.8 kg for sham and active therapy groups, respectively.

Conclusions: Despite improvement in pain scores and pain-free maximum grip strength within groups, there does not appear to be a meaningful difference between treating lateral epicondylitis with extracorporeal shock wave therapy combined with forearm-stretching program and treating with forearm-stretching program alone, with respect to resolving pain within an 8-week period of commencing treatment.


Extracorporeal Shock Wave Therapy in Treatment of Delayed Bone-Tendon Healing
Abstract
Background
: Extracorporeal shock wave therapy is indicated for treatment of chronic injuries of soft tissues and delayed fracture healing and nonunion. No investigation has been conducted to studythe effect of shock wave on delayed healing at the bone-tendon junction.

Hypothesis: Shockwave promotes osteogenesis, regeneration of fibrocartilage zone, and remodeling of healing tissue in delayed healing of bone-tendon junction surgical repair.

Study Design: Controlled laboratory study.

Methods: Twenty-eight mature rabbits were used for establishing a delayed healing model at the patella-patellar tendon complex after partial patellectomy and then divided into control and shock wave groups. In the shock wave group, a single shock wave treatment was given at week 6 postoperatively to the patella-patellar tendon healing complex. Seven samples were harvested at week 8 and 7 samples at week 12 for radiologic, densitometric, histologic, and mechanical evaluations.

Results: Radiographic measurements showed 293.4% and 185.8% more new bone formation at the patella-patellar tendon healing junction in the shock wave group at weeks 8 and 12, respectively. Significantly better bone mineral status was found in the week 12 shock wave group. Histologically, the shock wave group showed more advanced remodeling in terms of better alignment of collagen fibers and thicker and more mature regenerated fibrocartilage zone at both weeks 8 and 12. Mechanical testing showed 167.7% and 145.1% higher tensile load and strength in the shock wave group at week 8 and week 12, respectively, compared with controls.

Conclusion: Extracorporeal shock wave promotes osteogenesis, regeneration of fibrocartilage zone, and remodeling in the delayed bone-to-tendon healing junction in rabbits.

Clinical Relevance: These results provide a foundation for future clinical studies toward establishment of clinical indication for treatment of delayed bone-to-tendon junction healing.


High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Insertional Achilles Tendinopathy

Abstract
Background:
Results of high-energy extracorporeal shock wave therapy for the treatment of insertional Achilles tendinopathy are not determined. It is unclear how local anesthesia alters the outcome of this procedure.

Hypothesis: Extracorporeal shock wave therapy is an effective treatment for insertional Achilles tendinopathy. Local anesthesia field block adversely affects outcome.

Study Design: Case control study; Level of evidence, 3.

Methods: Thirty-five patients with chronic insertional Achilles tendinopathy were treated with 1 dose of high-energy extracorporeal shock wave therapy (ESWT group; 3000 shocks; 0.21 mJ/mm2; total energy flux density, 604 mJ/mm2), and 33 were treated with nonoperative therapy (control group). All extracorporeal shock wave therapy procedures were performed using a local anesthesia field block (LA subgroup, 12 patients) or a nonlocal anesthesia (NLA subgroup, 23 patients). Evaluation was by visual analog score and by Roles and Maudsley score.

Results: One month, 3 months, and 12 months after treatment, the mean visual analog score for the control and ESWT groups were 8.2 and 4.2 (P < .001), 7.2 and 2.9 (P < .001), and 7.0 and 2.8 (P < .001), respectively. Twelve months after treatment, the number of patients with successful Roles and Maudsley scores was statistically greater in the ESWT group compared with the control group (P > .0002), with 83% of ESWT group patients having a successful result, and the mean improvement in visual analog score for the LA subgroup was significantly less than that in the NLA subgroup (F = 16.77 vs F = 53.95, P < .001). The percentage of patients with successful Roles and Maudsley scores did not differ among the LA and NLA subgroups.

Conclusion: Extracorporeal shock wave therapy is an effective treatment for chronic insertional Achilles tendinopathy. Local field block anesthesia may decrease the effectiveness of this procedure.

Ludger Gerdesmeyer, MD, PhD†,‡,*, Carol Frey, MD§, Johannes Vester, PhD||, Markus Maier, PhD¶, Lowell Weil, Jr, DPM#, Lowell Weil, Sr, DPM#, Martin Russlies, PhD**, John Stienstra, DPM††, Barry Scurran, DPM††, Keith Fedder, MD§, Peter Diehl, MD‡‡, Heinz Lohrer, MD§§,Mark Henne, MD†, and Hans Gollwitzer, MD†
+Author Affiliations
From the †Department of Orthopedic and Traumatology, Technical University Munich, Klinikum Rechts der Isar, Germany, the ‡Department of Joint Arthroplasty and Clinical Science, Mare Clinic, Kiel, Germany, §Orthopaedic Foot and Ankle Center, Manhattan Beach, California, ||IDV Data Analyses and Study Planning, Biometrics in Medicine, Gauting, Germany, the ¶Department of Orthopedics, Ludwig Maximilian University, Munich, Germany, the #Weil Foot and Ankle Institute, Des Plaines, Illinois, **University Schleswig Holstein, Campus Lübeck, Lübeck, Germany, the ††Department of Podiatry, The Permanente Medical Group Inc, Union City, California, the ‡‡Department of Orthopedics, University Rostock, Rostock, Germany, and the §§Institute of Sportsmedicine, Frankfurt am Main, Germany
Address correspondence to Ludger Gerdesmeyer, MD, PhD, Department of Joint Arthroplasty and Clinical Science, Mare Clinic, Eckernförder Strasse 219, D-24119 Kiel-Kronshagen (e-mail:[email protected]).
Copyright 2008 by American Orthopaedic Society for Sports Medicine


Effect of extracorporeal shock wave therapy on the biochemical composition and metabolic activity of tenocytes in normal tendinous structures in ponie

Authors: Bosch, G.; Lin, Y.L.; van Schie, H.T.M.; van De Lest, C.H.A.; Barneveld, A.; van Weeren, P.R.

Source: Equine Veterinary Journal, Volume 39, Number 3, May 2007 , pp. 226-231(6)

Publisher: Equine Veterinary Journal Ltd.

Abstract:
Reasons for performing study: Extracorporeal shockwave therapy (ESWT) has recently been introduced as a new therapy for tendon injuries in horses, but little is known about the basic mechanism of action of this therapy.

Objectives: To study the effect of ESWT on biochemical parameters and tenocyte metabolism of normal tendinous structures in ponies.

Methods: Six Shetland ponies, free of lameness and with ultrasonographically normal flexor and extensor tendons and suspensory ligaments (SL), were used. ESWT was applied at the origin of the suspensory ligament and the midmetacarpal region of the superficial digital flexor tendon (SDFT) 6 weeks prior to sample taking, and at the midmetacarpal region (ET) and the insertion on the extensor process of the distal phalanx (EP) of the common digital extensor tendon 3 h prior to tendon sampling. In all animals one front leg was treated and the other front leg was used as control. After euthanasia, tendon explants were harvested aseptically for in vitro cell culture experiments and additional samples were taken for biochemical analyses.

Results: In the explants harvested 3 h after treatment, glycosaminoglycan (GAG) and protein syntheses were increased (P<0.05). The synthesis of all measured parameters was decreased 6 weeks after ESWT treatment. Biochemically, the level of degraded collagen was increased 3 h after treatment (P<0.05). Six weeks after treatment, there was a decrease of degraded collagen and GAG contents. DNA content had not changed in either tendon samples or explants after culturing.

Conclusions: ESWT causes a transient stimulation of metabolism in tendinous structures of ponies shortly after treatment. After 6 weeks metabolism has decreased significantly and GAG levels are lower than in untreated control limbs.

Potential relevance: The stimulating short-term effect of ESWT might accelerate the initiation of the healing process in injured tendons. The long-term effect seems less beneficial. Further research should aim at determining the duration of this effect and at assessing its relevance for end-stage tendon quality.

Keywords: HORSE; PONY; TENDON; TENOCYTE; EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT); GAG; COLLAGEN; CELL METABOLISM
Document Type: Research article
DOI: 10.2746/042516407X180408