Extracorporeal Shockwave Therapy for Interdigital Neuroma
A Randomized, Placebo-Controlled, Double-Blind Trial
Background: We sought to evaluate the safety and effectiveness of extracorporeal shockwave therapy as a therapeutic treatment for destroying Morton’s neuroma.
Methods: Twenty-five patients (25 feet) were included in the study. Indications for participation were more than 8 months of conservative care with a visual analog scale pain score of 4 or greater. The mean overall pain score on a modified visual analog scale was 6.9 preoperatively.
Results: Thirteen patients were randomized to the active group and 12 to the sham group. Two patients in the sham group were lost to follow-up. Post-treatment evaluations were performed at 1, 6, and 12 weeks by a blinded investigator (L.W.). The end point evaluation parameter was the reduction in visual analog scale score. The treatment group showed a significant difference before and after extracorporeal shockwave therapy (P < .0001). The sham group did not have a significant difference after 12 weeks (P = .1218).
Conclusions: Extracorporeal shockwave therapy is a possible alternative to surgical excision for Morton’s neuroma. (J Am Podiatr Med Assoc 99(3): 191–193, 2009)
Background: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders.
Methods: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score > 5. The mean follow-up was 20 months (range, 4–35 months).
Results: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1.
Conclusion: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy. (J Am Podiatr Med Assoc 98(6): 466–468, 2008)
Extracorporeal Shockwave Therapy in Patients with Morton's Neuroma
A Randomized, Placebo-Controlled Trial
Background: The aim of this study was to evaluate the efficacy of extracorporeal shockwave therapy (ESWT) for the treatment of Morton's neuroma by measuring changes in patient pain, function, and neuroma size.
Methods: Patients with Morton's neuroma were randomly assigned to either the ESWT group or the sham stimulation group. Outcome measures, including visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society lesser toes (AOFAS) scores, were assessed at baseline and 1 and 4 weeks after treatment. The Johnson satisfaction test was also performed 1 and 4 weeks after treatment. The neuroma diameter was measured using ultrasonography at baseline and 4 weeks after treatment.
Results: Patients receiving ESWT exhibited significantly decreased VAS scores 1 and 4 weeks after treatment relative to baseline, and AOFAS scores were significantly improved 4 weeks after treatment relative to baseline. In the sham stimulation group, VAS and AOFAS scores showed no significant changes at any time after treatment. Neither group showed significant changes in Johnson satisfaction test results or neuroma diameter.
Conclusions: These results suggest that ESWT may reduce pain in patients with Morton's neuroma.
Extracorporeal shockwave therapy (ESWT) has recently been used as a new treatment modality for plantar fasciitis. We aimed to determine the efficacy of ESWT by magnetic resonance imaging (MRI) findings.
Thirty patients with plantar fasciitis who had received no treatment for 6 months were included. Extracorporeal shockwave therapy was applied once a week for a total of three sessions (frequency of 12–15 Hz, 2–3 bars, and 2,500 pulses). All of the patients were assessed with the visual analog scale, a 6-point evaluation scale, the Foot and Ankle Outcome Score (FAOS), and MRI findings before and 3 months after ESWT. Visual analog scale scores were used in determining the pain level of patients in the morning, during activity, and at rest. Foot and ankle–related problems were evaluated with the FAOS.
The duration of painless walking according to the 6-point rating scale, the FAOS, and pain showed significant improvements after ESWT (P < .05). Significant decreases in MRI findings, including thickening of the plantar fascia, soft-tissue edema, and bone marrow edema, were observed after treatment (P < .05).
Extracorporeal shockwave therapy is a safe and effective treatment that yields favorable results in improvement of pain and function for plantar fasciitis. An MRI is useful for determining response to ESWT for these patients.
Background: The aim of this study was to evaluate the results of high-dose extracorporeal shockwave therapy applied with an ankle block and corticosteroid injection in patients with plantar fasciitis whose symptoms persisted for more than 6 months.
Methods: Sixty patients were assessed clinically at presentation and at 3-month follow-up with a patient-assessed 100-mm visual analog scale of pain and a physician-assessed heel tenderness index. A therapeutic response rate was evaluated. A decrease of at least 50% from baseline to 3 months in visual analog scale or heel tenderness index scores was accepted as a successful result.
Results: Extracorporeal shockwave therapy and corticosteroid injection provided significant improvements in visual analog scale and heel tenderness index scores, but between the two groups there was no significant difference in the visual analog scale score change 3 months after treatment (P > .05). Twenty-seven of 33 patients (82%) in the extracorporeal shockwave therapy group and 23 of 27 (85%) in the corticosteroid injection group had a successful therapeutic response after 3 months.
Conclusions: Corticosteroid injection and extracorporeal shockwave therapy are successful treatment modalities for plantar fasciitis. Corticosteroid injection treatment is cost effective compared with extracorporeal shockwave therapy, and corticosteroid injection may be the first treatment choice according to these results. (J Am Podiatr Med Assoc 100(2): 105–110, 2010)
We compared the long-term clinical and ultrasonographic effects of radial extracorporeal shockwave therapy (rESWT) versus ultrasound-guided corticosteroid injection treatment in patients with plantar fasciitis unresponsive to conservative therapy.
Seventy-two patients with unilateral plantar fasciitis were randomized to receive either rESWT (three times once per week) (n = 36) or corticosteroid treatment (a single 1-mL dose of betamethasone sodium plus 0.5 mL of prilocaine under ultrasound guidance by injection into the plantar fascia) (n = 36). The primary outcome measures were visual analog scale (VAS) and Foot Function Index (FFI) scores. Secondary outcome measures included the heel tenderness index (HTI) score and plantar fascia thickness (PFT) as obtained by ultrasound examination. All of the assessments were performed at baseline and 1, 3, and 6 months after treatment.
Significant improvements were observed in the rESWT group in VAS, HTI, and FFI scores and PFT at the end of treatment and were maintained during follow-up. Posttreatment improvements in VAS, HTI, and FFI scores and PFT were also seen in the corticosteroid group but were not maintained for VAS and FFI scores after the completion of therapy and were lost at 1 and 6 months, respectively. No serious treatment-related complications occurred.
Both rESWT and corticosteroid injection therapy are effective modalities for treatment of chronic plantar fasciitis. However, rESWT seems to be superior to corticosteroid injection therapy due to its longer duration of action.
Plantar heel pain syndrome, which has a multifactorial and widely disputed etiology, affects more than 2 million people annually. A survey was conducted of members of the American Academy of Podiatric Sports Medicine about their strategies for managing plantar heel pain syndrome, especially the role of injectable corticosteroids. The respondents tended to be experienced (10–24 years in practice) podiatric physicians with a concentration in sports medicine. They reported that for early-stage plantar heel pain syndrome they generally recommend avoidance of wearing flat shoes and walking barefoot (92%), use of over-the-counter arch supports and heel cushions (90%), regular stretching of the calf muscles (88%), strapping of the foot (75%), cryotherapy applied directly to the affected part of the foot (67%), and nonsteroidal anti-inflammatory drug therapy (60%). When these measures fail to relieve heel pain, most of the responding podiatric physicians recommend using custom orthotic devices (60%) and corticosteroid injections (60%) as intermediate therapy. Surgical plantar fasciotomy (88%), cast immobilization (77%), and extracorporeal shockwave therapy (69%) are generally recommended as late-stage therapy for resistant cases. A staged approach seems to yield the best results in treatment of this common condition. (J Am Podiatr Med Assoc 97(1): 68–74, 2007)
Plantar fasciitis is one of the most common clinical presentations seen by podiatric clinicians today. With corticosteroid injection being a classic treatment modality and extracorporeal pulse-activated therapy (EPAT) technology improving, the purpose of this study was to retrospectively compare pain and functional outcomes of patients with plantar fasciitis treated with either injection or EPAT.
Between November 1, 2014, and April 30, 2016, 60 patients who met the inclusion criteria were treated with either corticosteroid injection or EPAT. Patients were evaluated with both the visual analog scale (VAS) and the American Orthopaedic Foot & Ankle Society Hindfoot Score at each visit.
The EPAT was found to reduce pain on the VAS by a mean of 1.98 points, whereas corticosteroid injection reduced pain by a mean of 0.94 points. This was a significant reduction in the VAS score for EPAT compared with corticosteroid injection (P = .035).
Extracorporeal pulse-activated therapy is as effective as corticosteroid injection, if not more so, for the treatment of recalcitrant plantar fasciitis and should be considered earlier in the treatment course of plantar fasciitis.
Background: The proximal insertional disorder of the plantar fascia is plantar fasciosis. Although plantar fasciosis is frequently seen by different health-care providers, indistinctness of etiology and pathogenesis is still present. A variety of interventions are seen in clinical practice. Taping constructions are frequently used for the treatment of plantar fasciosis. However, a systematic review assessing the efficacy of this therapy modality is not available.
Methods: To assess the efficacy of a taping construction as an intervention or as part of an intervention in patients with plantar fasciosis on pain and disability, controlled trials were searched for in CINAHL, EMBASE, MEDLINE, Cochrane CENTRAL, and PEDro using a specific search strategy. The Physiotherapy Evidence Database scale was used to judge methodological quality. Clinical relevance was assessed with five specific questions. A best-evidence synthesis consisting of five levels of evidence was applied for qualitative analysis.
Results: Five controlled trials met the inclusion criteria. Three trials with high methodological quality and of clinical relevance contributed to the best-evidence synthesis. The findings were strong evidence of pain improvement at 1-week follow-up, inconclusive results for change in level of disability in the short term, and indicative findings that the addition of taping on stretching exercises has a surplus value.
Conclusions: There is limited evidence that taping can reduce pain in the short term in patients with plantar fasciosis. The effect on disability is inconclusive. (J Am Podiatr Med Assoc 100(1): 41–51, 2010)
Randomized trials must be of high methodological quality to yield credible, actionable findings. The main aim of this project was to evaluate whether there has been an improvement in the methodological quality of randomized trials published in the Journal of the American Podiatric Medical Association (JAPMA).
Randomized trials published in JAPMA during a 15-year period (January 1999 to December 2013) were evaluated. The methodological quality of randomized trials was evaluated using the PEDro scale (scores range from 0 to 10, with 0 being lowest quality). Linear regression was used to assess changes in methodological quality over time.
A total of 1,143 articles were published in JAPMA between January 1999 and December 2013. Of these, 44 articles were reports of randomized trials. Although the number of randomized trials published each year increased, there was only minimal improvement in their methodological quality (mean rate of improvement = 0.01 points per year). The methodological quality of the trials studied was typically moderate, with a mean ± SD PEDro score of 5.1 ± 1.5. Although there were a few high-quality randomized trials published in the journal, most (84.1%) scored between 3 and 6.
Although there has been an increase in the number of randomized trials published in JAPMA, there is substantial opportunity for improvement in the methodological quality of trials published in the journal. Researchers seeking to publish reports of randomized trials should seek to meet current best-practice standards in the conduct and reporting of their trials.