http://dlweb01.tzuchi.com.tw/DL/AcdActive/content/research/document/tjc/chen/shockwave%20induced%20neovascularization%20at%20tendon%20bone%20junction---2003%20JOR.pdf

Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits.

Clinical practice. Plantar fasciitis.

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.

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Extracorporeal shockwave therapy in musculoskeletal disorders

Overuse disorders of tendons, or tendinopathies, present a challenge to sports physicians, surgeons, and other health care professionals dealing with athletes. The Achilles, patellar, and supraspinatus tendons are particularly vulnerable to injury and often difficult to manage successfully. Inflammation was believed central to the pathologic process, but histopathologic evidence has confirmed the failed healing response nature of these conditions. Excessive or inappropriate loading of the musculotendinous unit is believed to be central to the disease process, although the exact mechanism by which this occurs remains uncertain. Additionally, the location of the lesion (for example, the midtendon or osteotendinous junction) has become increasingly recognized as influencing both the pathologic process and subsequent management. The mechanical, vascular, neural, and other theories that seek to explain the pathologic process are explored in this article. Recent developments in the nonoperative management of chronic tendon disorders are reviewed, as is the rationale for surgical intervention. Recent surgical advances, including minimally invasive tendon surgery, are reviewed. Potential future management strategies, such as stem cell therapy, growth factor treatment, and gene transfer, are also discussed.

Management of Tendinopathy

Background
Ten percent of people may experience pain under the heel (plantar heel pain) at some time. Injections, insoles, heel pads, strapping and surgery have been common forms of treatment offered. The absolute and relative effectiveness of these interventions are poorly understood.

Objectives
The objective of this review was to identify and evaluate the evidence for effectiveness of treatments for plantar heel pain.

Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (September 2002), the Cochrane Central Register of Controlled Trials Register (The Cochrane Library issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1988 to September 2002) and reference lists of articles and dissertations. Four podiatry journals were handsearched to 1998. We contacted all UK schools of podiatry to identify dissertations on the management of heel pain, and investigators in the field to identify unpublished data or research in progress. No language restrictions were applied.

Selection criteria
Randomised and quasi-randomised trials of interventions for plantar heel pain in adults.

Data collection and analysis
Two reviewers independently evaluated randomised controlled trials for inclusion, extracted data and assessed trial quality. Additional information was obtained by direct contact with investigators. No poolable data were identified. Where measures of variance were available we have calculated the weighted mean differences based on visual analogue scale (VAS) scores.

Main results
Nineteen randomised trials involving 1626 participants were included. Trial quality was generally poor, and pooling of data was not conducted. All trials measured heel pain as the primary outcome. Seven trials evaluated interventions against placebo/dummy or no treatment. There was limited evidence for the effectiveness of topical corticosteroid administered by iontophoresis, i.e. using an electric current, in reducing pain. There was some evidence for the effectiveness of injected corticosteroid providing temporary relief of pain. There was conflicting evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term (6 and 12 weeks) and therefore its effectiveness remains equivocal. In individuals with chronic pain (longer than six months), there was limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. There was no evidence to support the effectiveness of therapeutic ultrasound, low-intensity laser therapy, exposure to an electron generating device or insoles with magnetic foil. No randomised trials evaluating surgery, or radiotherapy against a randomly allocated control population were identified. There was limited evidence for the superiority of corticosteroid injections over orthotic devices.

Authors' conclusions
Although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in randomised controlled trials.

At the moment there is limited evidence upon which to base clinical practice. Treatments that are used to reduce heel pain seem to bring only marginal gains over no treatment and control therapies such as stretching exercises. Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. Orthoses should be cautiously prescribed for those patients who stand for long periods; there is limited evidence that stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than eight hours per day.

Well designed and conducted randomised trials are required.

Interventions for treating plantar heel pain

Three hundred two patients with chronic heel pain caused by proximal plantar fasciitis were enrolled in a study to assess the treatment effects consequent to administration of electrohydraulicall-generated extracorporeal shock waves. Symptoms had been present from 6 months to 18 years. Each treated patient satisfied numerous inclusion and exclusion criteria before he or she was accepted into this study, which was approved by the Food and Drug Administration as a randomized, double-blind evaluation of the efficacy of shock wave therapy for this disorder. Overall, at the predetermined evaluation period 3 months after one treatment, 56% more of the treated patients had a successful result by all four of the evaluation criteria when compared with the patients treated with a placebo. This difference was significant and corroborated the fact that this difference in the results was specifically attributable to the shock wave treatment, rather than any natural improvement caused by the natural history of the condition. The current study showed that the directed application of electrohydraulic-generated shock waves to the insertion of the plantar fascia onto the calcaneus is a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome that has been present for at least 6 months and has been refractory to other commonly used nonoperative therapies. This technology, when delivered using the OssaTron (High Medical Technology, Kreuz-lingen, Switzerland), has been approved by the Food and Drug Administration specifically for the treatment of chronic proximal plantar fasciitis. The results suggest that this therapeutic modality should be considered before any surgical options, and even may be preferable to cortisone injection, which has a recognized risk of rupture of the plantar fascia and recurrence of symptoms.

Shock wave therapy for chronic proximal plantar fasciitis.

Extracorporeal shock wave therapy, which now is used routinely for urolithiasis, has gained increasing acceptance in Europe for some musculoskeletal problems and has led to the inception of clinical studies in the United States. The authors have reviewed the available literature to assess the biologic effects of shock waves on human musculoskeletal tissues, the credibility of published studies on therapeutic applications, and the potential for more widespread application of this modality to various skeletal and near-skeletal disorders. The primary advantage of extracorporeal shock wave therapy is its noninvasive nature and seemingly minimal complications when applied to musculoskeletal tissues.

http://www.shockwave.cc/e107_images/custom/sw-planta_fasciitis.pdf

Shock wave therapy (Orthotripsy) in musculoskeletal disorders.

Background: Plantar fasciitis is a common foot disorder that may be resistant to nonoperative treatment. This study evaluated the use of electrohydraulic high-energy shock waves in patients who failed to respond to a minimum of six months of antecedent nonoperative treatment. Methods: A randomized, placebo-controlled, multiply blinded, crossover study was conducted. Phase 1 consisted of twenty patients who were nonrandomized to treatment with extracorporeal shock waves to assess the phase-2 study protocol. In phase 2, 293 patients were randomized and an additional seventy-one patients were nonrandomized. Fol- lowing ankle-block anesthesia, each patient received 100 graded shocks starting at 0.12 to 0.22 mJ/mm 2 , followed by 1400 shocks at 0.22 mJ/mm 2 with use of a high-energy electrohydraulic shock-wave device. Patients in the pla- cebo group received minimal subcutaneous anesthetic injections and nontransmitted shock waves by the same pro- tocol. Three months later, patients were given the opportunity to continue without further treatment or have an additional treatment. This allowed a patient in the active treatment arm to receive a second treatment and a patient who received the placebo to cross over to the active treatment arm. Patients were followed at least one year after the final treatment. Results: Treatment was successful in seventeen of the twenty phase-1 patients at three months. This improved to nineteen (95%) of twenty patients at one year and was maintained at five years. In phase 2, three months after treat- ment, sixty-seven (47%) of the 144 actively treated patients had a completely successful result compared with forty- two (30%) of the 141 placebo-treated patients (p = 0.008). At one year, sixty-five of the sixty-seven actively treated, randomized patients maintained a successful result. Thirty-six (71%) of the remaining fifty-one nonrandomized pa- tients had a successful result at three months. For all 289 patients who had one or more actual treatments, 222 (76.8%) had a good or excellent result. No patient was made worse by the procedure. Conclusions: The application of electrohydraulic high-energy shock waves to the heel is a safe and effective noninva- sive method to treat chronic plantar fasciitis, lasting up to and beyond one year. Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial (significant difference)). See Instruc- tions to Authors for a complete description of levels of evidence.

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Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis.

Fifteen children with either Charcot-Marie-Tooth disease or Friedreich's ataxia were evaluated in a long-term follow-up after having undergone surgery to correct their foot deformities. Soft-tissue procedures and bone procedures by themselves, excluding triple arthrodesis, did not stand the test of time. The one indication for their use was as a part of a staged plan of treatment. Of the twelve patients with satisfactory results, eleven ultimately had a triple arthrodesis at skeletal maturity. The operative results are discussed in relation to the heredofamilial modes of transmission and the variable progression of the two diseases.

Richard L. Levitt

Papers

Shock wave therapy for chronic proximal plantar fasciitis.

Shock wave therapy (Orthotripsy) in musculoskeletal disorders.

Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis.

The role of foot surgery in progressive neuromuscular disorders in children.

Shock-Wave Therapy for Plantar Fasciitis