Long-term results of extracorporeal shockwave treatment for plantar fasciitis

BACKGROUND: Extracorporeal shockwave treatment has shown mixed short-term results for plantar fasciitis. However, the long-term results are not available. HYPOTHESIS: Long-term results of shockwave treatment are comparable with short-term results. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: This prospective study consisted of 149 patients (168 heels) with an established diagnosis of chronic plantar fasciitis, including 79 patients (85 heels) in the shockwave treatment group and 70 patients (83 heels) in the control group. In the shockwave group, patients received 1500 impulses of shockwaves at 16 kV to the affected heel in a single session. Patients in the control group received conservative treatment consisting of nonsteroidal anti-inflammatory drugs, orthotics, physical therapy, an exercise program, and/or a local cortisone injection. Patients were evaluated at 60 to 72 months (shockwave group) or 34 to 64 months (control group) with a 100-point scoring system including 70 points for pain and 30 points for function. The clinical outcomes were rated as excellent, good, fair, or poor. RESULTS: Before treatment, the groups showed no significant differences in the scores for pain and function. After treatment, the shockwave group showed significantly better pain and function scores as compared with the control group. The overall results were 69.1% excellent, 13.6% good, 6.2% fair, and 11.1% poor for the shockwave group; and 0% excellent, 55% good, 36% fair, and 9% poor for the control group (P < .001). The recurrence rate was 11% (9/81 heels) for the shockwave group versus 55% (43/78 heels) for the control group (P < .001). There were no systemic or local complications or device-related problems. CONCLUSION: Extracorporeal shockwave treatment is effective and safe for patients with plantar fasciitis, with good long-term results.     

Low-Dose Radiotherapy for Painful Heel Spur

PURPOSE: Retrospective analysis of 117 patients treated between 1996 and 2000 with low-dose radiotherapy (RT) for painful heel spurs. PATIENTS AND METHODS: 71 women and 46 men were irradiated on 136 painful heel spurs in one (n = 104) or two radiation series (n = 13). The painful spurs were located either at the plantar (n = 94), dorsal (n = 5) or bilateral heel (n = 18). 82 patients had prior treatments, in 35 patients RT was the primary treatment. Low-dose RT was performed twice a week with one 6-MV photon field. Ten fractions of 0.5 Gy were applied to a total dose of 5 Gy. Evaluation was done on completion and during follow-up using the four-scale von Pannewitz score. RESULTS: On completion of RT, 27 patients were free of pain, 40 were much improved, 31 reported slight improvement, and 19 experienced no change. After a mean follow-up of 20 months, 75 out of 100 patients were free of pain, twelve had marked and three some improvement. Ten patients reported no change of symptoms. Mean duration of pain before RT was 6 months. RT applied < or = 6 months after the onset of clinical symptoms resulted in improvement in 94%. By contrast, an interval of > 6 months until the initiation of RT resulted in only 73% of patients with clinical improvement. CONCLUSION: Low-dose RT reveals a benefit in > 80% of the patients. RT should start during the first 6 months of symptoms. Prospective clinical studies with validated symptom scores should be conducted to assess optimal dose and fractionation scheme of RT.     

Radiation Therapy for Painful Heel Spurs

PURPOSE: To evaluate the efficacy of two different dose-fractionation schedules for radiation therapy (RT) in patients with painful heel spurs. PATIENTS AND METHODS: 130 patients were randomized into two groups: the low-dose (LD) group (n = 65 heels) received a total dose of 3.0 Gy given in two weekly fractions of 0.5 Gy; in the high-dose (HD) group (n = 65 heels), two weekly fractions of 1.0 Gy were applied over 3 weeks (total dose 6.0 Gy). In 24 sites of the HD group and 17 sites of the LD group, a second RT course was given. The results were assessed using a five-level function score which was documented before RT, at the end of each RT course, and at 6 weeks and 6 months thereafter. RESULTS: At 6-month follow-up, RT led to a highly significant reduction of symptoms in both groups. In the HD group, 31 sites were classified as excellent (score: 90-100), 13 as good (score: 70-85), twelve as moderate (score: 45-65), and nine as poor (score: 0-40). In the LD group, 35 sites were classified as excellent, eight as good, ten as moderate, and twelve as poor. The comparison of the difference of the sum score and the single criteria before RT and at 6 months after RT using the Wilcoxon-Mann-Whitney U-test revealed no statistically significant difference of response to RT between both groups. CONCLUSION: RT is an effective treatment option for the management of inflammatory heel spurs. The dose for an RT course should not exceed 3.0 Gy.     

Ultrasonographic appearance of the plantar fasciitis

PURPOSE: To study high frequency sonographic in the examination of plantar fasciitis (PF), which is a common cause of heel pain. MATERIALS AND METHODS: Our study was done with 25 PF (21 unilateral, 4 bilateral) and 15 control cases of similar age, weight and gender. In this study, the plantar fascial thickness (mainly), fascial echogenity and biconvexity were examined using 7.5 MHz linear phase array transducer. Perifascial fluid collection, fascial rupture and fascial calcification that are rarely seen were also examined. RESULTS: The fascial thickness ranges for the PF cases: for the symptomatic heels: 3.9-9.1 mm (mean: 4.75 +/- 1.52 mm), for the asymptomatic heels: 2.0-5.9 mm (mean: 3.37 +/- 1.0 mm) and for the control group: 2.1-4.7 mm (3.62 +/- 0.68 mm). The results were significantly different in Group I for symptomatic heels and the control group statistically for PF (P < .05). The echogenity of plantar fascia and biconvexity of plantar fascia were the major criteria for symptomatic heels. In three heels (10%), perifascial fluid was diagnosed, in three heels (10%) fascial calcification, in one heel (3%) partial fascial rupture. Subcalcaneal spur was encountered sonographically in both cases of Groups I and II. CONCLUSION: Ultrasonography (US) is the first step for PF, because of its easy and quick performance, availability and high sensitivity of diagnosis, low-cost and free radiation.     

Strahlentherapie beim Morbus Ledderhose—Indikation und klinische Ergebnisse

BACKGROUND: Morbus Ledderhose (ML) is a rare hyperproliferative disorder of the plantar aponeurosis which is similar in its clinical course to Morbus Dupuytren (MD). We examined whether radiotherapy (RT) can effect symptoms and prevent disease progression. PATIENTS AND METHODS: From June 1996 to December 2001, 25 patients (12 female/13 male) aged 9-76 (median: 56) years had radiotherapy (RT) for symptomatic ML. Follow-up (FU) was at least 1 year. 36 feet (16 right/20 left) were treated, as eleven patients had bilateral disease. Twelve (48%) patients had MD. There were 63 nodules (with 0,5-6,5 cm diameter) on all feet and 20 cords (with 1-4 cm length) on 13 (52%) feet prior to RT. 21 (84%) patients had one or more signs: 14 (56%) severe local pain, eight (32%) walking difficulties, twelve (48%) other symptoms, pressure or tension sensation. The RT field involved all nodules and cords plus safety margin. Two RT-series were applied (each 5 3 Gy in 1 week) separated by 8-12 weeks up to a total dose of 30 Gy. Evaluation was performed at the end of RT, after 3 and 12 months FU and in December 2002. The primary endpoint was prevention of disease progression and avoidance of surgery. Secondary endpoints were objective changes of morphological and functional parameters and patient's satisfaction measured on a visual analogue scale (VAS). RESULTS: With a median FU of 38 (12-67) months no patient experienced progression or underwent surgery: 11 of 36 (44%) feet had a reduced number (overall: -16) or size of nodules, 7 of 13 (54%) feet had a reduced number (overall: -9) or length of cords; gait was improved in six of twelve (50%) feet; pain was reduced or had completely disappeared in 9 of 15 (60%) feet, and other symptoms disappeared in 8 of 18 (44%) symptomatic feet. 20 (80%) patients regarded 28 of 36 (78%) treated feet as improved and 8 (22%) in stable condition. The median relative improvement stated by patients on the VAS was 50% (0-100%). Treatment side effects were minimal: During and within 3 months of the RT course only a slight erythema (CTC 1 degrees ) was seen in five treated lesions, while dry skin changes within the RT portal were observed in three cases (11%) in long term FU (> 12 months). CONCLUSIONS: Radiotherapy is effective in treating ML and may prevent otherwise necessary surgical interventions. Nodules, cords and symptoms regress, but long-term outcome of at least 5 years has to be awaited. Prospective phase III studies should confirm these results.     

Chronic plantar fasciitis: acute changes in the heel after extracorporeal high-energy shock wave therapy--observations at MR imaging

PURPOSE: To prospectively evaluate with magnetic resonance (MR) imaging the acute changes in the heel associated with extracorporeal shock wave therapy (ESWT). MATERIALS AND METHODS: Institutional clinical study review board approved the study, and informed consent was obtained. MR imaging was performed within 24 hours before and after ESWT on 18 feet of 12 patients (eight women and four men; age range, 33-63 years; average, 49.9 years) with chronic plantar fasciitis. ESWT was applied to the most painful point on the plantar surface of the heel, with a total of 1500 shocks at 18 kV. The MR imaging protocol consisted of sagittal and coronal T1- and T2-weighted images with and without fat saturation. The images were reviewed to assess the post-ESWT changes in soft-tissue and bone marrow edema, the thickness of the proximal plantar fascia, and the presence of a heel spur. Paired t test was used for the statistical analysis. RESULTS: Soft-tissue edema, which was present in 16 (89%) of 18 heels before ESWT, had increased in severity in 12 (75%) heels after ESWT. Calcaneus bone marrow edema at the insertion site was observed in eight heels before ESWT. After ESWT, the extant of bone marrow edema had increased in one heel and had newly developed in another heel. The heel spur seen in nine (50%) feet was not affected by ESWT. In 17 (94%) heels, the proximal plantar fascia was abnormally thick, with thickness not significantly changed with use of ESWT (P > .05). CONCLUSION: Increase in soft-tissue edema is the most common acute response associated with ESWT.     

Value of percutaneous radiofrequency ablation with or without percutaneous vertebroplasty for pain relief and functional recovery in painful bone metastases

Objective

To evaluate the effectiveness of percutaneous radiofrequency (RF) ablation with or without percutaneous vertebroplasty (PV) on pain relief, functional recovery and local recurrence at 6?months?? follow-up (FU), in patients with painful osseous metastases.

Materials and methods

Thirty RF ablations were performed in 24 patients (mean age: 61?years) with bone metastases. Half of the patients had an additional PV. The primary end point was pain relief evaluated by a visual analogue scale (VAS) before treatment, and at 1 and 6?months?? FU. Functional outcome was assessed according to the evolution of their ability to walk at 6?months?? FU. Imaging FU was available in 20 out of 24 patients with a mean delay of 4.7?months.

Results

Reduction of pain was obtained at 6?months FU in 81% of cases (15 out of 18). Mean pretreatment VAS was 6.4 (±2.7). Mean VAS was 1.9 (±2.4) at 1?month FU, and 2.3 (±2.9) at 6?months?? FU. Pain was significantly reduced at 6?months FU (mean VAS reduction?=?4.1; P?<?0.00001). Functional improvement was obtained in 74% of the cases. Major complications rate was 12.5 % (3 out of 24) with 2 skin burns, and 1 case of myelopathy. Local tumour recurrence or progression was recorded in 5 cases.

Conclusion

Radiofrequency ablation is an effective technique in terms of pain relief and functional recovery for the treatment of bone metastases, which provides a relatively low rate of local recurrence.     

Re-irradiation for painful heel spur syndrome

Purpose

Painful heel spur syndrome is a common disease with a lifetime prevalence of approximately 10?%. One of the most effective treatment options is radiotherapy. Many authors recommend a second or third series of radiation for recurrent pain and partial or no response to the initial treatment. As the results of re-irradiation have not been systematically analyzed the aim of this study was to document the results of repeated radiation treatment and to identify patients who could benefit from this treatment.

Material and methods

The analysis was performed on patients from 2 German radiotherapy institutions and included 101 re-irradiated heels. Pain was documented with the numeric rating scale (NRS) and carried out before and directly after each radiation therapy as well as for the follow-up period of 24 months. The median age of the patients was 56 years with 30.1?% male and 69.9?% female patients. Pain was caused by plantar fasciitis in 72.3?%, Haglund’s exostosis in 15.8?% and Achilles tendinitis in 11.9?%. Repeated radiation was indicated because the initial radiotherapy resulted in no response in 35.6?% of patients, partial response in 39.6?% and recurrent pain in 24.8?%.

Results

A significant response to re-irradiation could be found. For the whole sample the median NRS pain score was 6 before re-irradiation, 2 after 6 weeks and 0 after 12 and 24 months. Of the patients 73.6?% were free of pain 24 months after re-irradiation. All subgroups, notably those with no response, partial response and recurrent pain had a significant reduction of pain.

Conclusion

Re-irradiation of painful heel spur syndrome is an effective and safe treatment. All subgroups showed a good response to re-irradiation for at least 24 months.     

Ultrasound of the plantar aponeurosis (fascia)

Objective. To assess the plantar aponeurosis origin (plantar fascia) using high-resolution ultrasound. Design. The sonographic appearance of the plantar fascia in asymptomatic volunteers was compared with the appearance in: (1) clinical idiopathic plantar fasciitis, (2) inflammatory arthropathy without clinically active plantar fasciitis and (3) Achilles tendon or ankle ligament injury. Patients. There were 48 asymptomatic volunteers (96 heels), 190 patients with idiopathic plantar fasciitis (297 heels), 35 with rheumatoid factor negative spondyloarthropathy (70 heels), 17 with rheumatoid arthritis (34 heels), 62 with clinical Achilles tendinitis (93 heels) and 17 with instability secondary to previous ankle ligament injury (17 heels). Results. Compared with the asymptomatic volunteers, the symptomatic plantar aponeurosis demonstrated significant thickening in patients with clinically unilateral (P<0.001) and bilateral (P<0.001) idiopathic plantar fasciitis as well as in patients with spondyloarthropathy (P<0.001). However, the plantar aponeurosis on the asymptomatic side in patients with unilateral idiopathic plantar fasciitis (P<0.2), rheumatoid arthritis (P<0.2) and ankle injury (P<0.1) demonstrated no significant thickening. In patients with idiopathic plantar fasciitis, abnormal plantar aponeurosis echogenicity was seen in 78% and subcalcaneal bone spurs in 24%. Peritendinous edema was present in 5% of all symptomatic heels, subcalcaneal bone erosion in 4% and intratendinous calcification in 3% of heels. Retrocalcaneal bursitis was present in 7% of patients with idiopathic plantar fasciitis, 40% with spondyloarthropathy and 19% with rheumatoid arthritis. Conclusion. Ultrasound allows confirmation of the clinical diagnosis in plantar fasciitis and may provide information as to its etiology.     

Sonographic evaluation of plantar fasciitis and relation to body mass index

PURPOSE: We have investigated the role of sonography in the diagnosis of plantar fasciitis. MATERIALS AND METHODS: This study evaluates 39 patients with plantar fasciitis and control group of 22 healthy volunteers. The plantar fascia thickness was measured 5 mm distal to the insertion of the calcaneus of plantar aponeurosis. Qualitative parameters such as decreased echogenity, biconvexity, perifascial fluid and calcification of plantar fascia were also noted. RESULTS: Mean plantar fascia thickness was measured 2.9 mm in patients with unilateral heel pain, 2.2 mm for contralateral normal heel and 2.5mm for control group. There was a statistically significant difference between heel with plantar fasciitis, contralateral normal heel and control groups (p=0.009 and 0.0001, respectively). Mean body mass index was 28 kg/m(2) in patients with heel pain and 25 kg/m2 in control group. Body mass index measurements were significantly different between plantar fasciitis and control groups. We found reduced plantar fascia echogenity in 16 cases (41%), calcaneal spur in 20 cases (51%), biconvex appearance in two cases (5.1%) and perifascial fluid in one case (2.5%). CONCLUSION: We conclude that in patients with plantar fasciitis, ultrasound may detect relatively small differences in plantar fascia thickness even in clinically unequivocal plantar fasciitis.     

Retrospective evaluation of radiotherapy in plantar fasciitis

Plantar fasciitis is a common painful syndrome that is usually treated by irradiation with a fraction dose (fd) of 1 Gy up to a total dose (TD) of 6 Gy according to clinical experience. By analysing our experiences with numerous former patients, we have attempted to find the relationship between dose and effect. To evaluate the effectiveness of radiotherapy and assess the impact of fd and TD in plantar fasciitis radiotherapy, we assessed 1624 irradiations (856 patients) performed using a fd of 1-3 Gy and a TD of 1-45 Gy. Analysis was carried out on the 623 irradiations (327 patients) for which complete follow-up data were available. The mean follow-up period was 74 months. The following parameters were evaluated: pain relief level; period of anaesthetic effect preservation after treatment; presence of pain and the timing of its appearance; and the intake of analgesic drugs at the last follow-up. After treatment, 48% of the patients reported a lack of pain, 21% reported pain relief greater than 50% and 17% reported pain relief less than 50%. The mean pain relief duration was 72 months. The last follow-up found that pain at rest afflicted 25% of the patients, and pain during walking afflicted 32%. A dose-effect relationship was not found. In conclusion, radiotherapy is an effective treatment for plantar fasciitis. A fd of 1.5 Gy and TD of 9 Gy should probably not be exceeded.     

High‐load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up

The aim of this study was to investigate the effectiveness of shoe inserts and plantar fascia‐specific stretching vs shoe inserts and high‐load strength training in patients with plantar fasciitis. Forty‐eight patients with ultrasonography‐verified plantar fasciitis were randomized to shoe inserts and daily plantar‐specific stretching (the stretch group) or shoe inserts and high‐load progressive strength training (the strength group) performed every second day. High‐load strength training consisted of unilateral heel raises with a towel inserted under the toes. Primary outcome was the foot function index (FFI) at 3 months. Additional follow‐ups were performed at 1, 6, and 12 months. At the primary endpoint, at 3 months, the strength group had a FFI that was 29 points lower [95% confidence interval (CI): 6–52, P = 0.016] compared with the stretch group. At 1, 6, and 12 months, there were no differences between groups (P > 0.34). At 12 months, the FFI was 22 points (95% CI: 9–36) in the strength group and 16 points (95% CI: 0–32) in the stretch group. There were no differences in any of the secondary outcomes. A simple progressive exercise protocol, performed every second day, resulted in superior self‐reported outcome after 3 months compared with plantar‐specific stretching. High‐load strength training may aid in a quicker reduction in pain and improvements in function.     

The role of bone scintigraphy in determining the etiology of heel pain

In this study we aimed to determine the role of bone scintigraphy as an objective diagnostic method in patients with heel pain. 67 heels of 50 of 182 patients with defined features who attended the orthopedics outpatient clinic with heel pain over a 3-year period, were treated with combined methods such as nonsteroidal anti-inflammatory drugs (NSAID) and contrast baths, stretching exercises and changing of footwear habits. A one year follow-up was established. The criteria identified by Wolgin et al. were used in assessing the results of the treatment. Subcalcaneal spur was demonstrated by radiography in 44 of the 67 heels. There were two different imaging patterns observed on three phase bone scintigraphy. Type I imaging pattern: Focal increased activity in the heel region or normal activity on dynamic and the blood pool phases and focal increased activity at the inferior calcaneal surface in the late static phase. Type II imaging pattern: Diffuse increased activity along the plantar fascia in the dynamic and the blood pool phase, and focal increased activity at the inferior calcaneal surface in the late static phase. There were 34 (50.7%) type I and 18 (26.8%) type II imaging patterns on the scans. Type I and type II imaging patterns were described as osseous and fascial respectively. At the final examination, the results for pattern type I were good in 16 patients (66.7%), fair in 6 patients (25%) and poor in 2 patients (8.3%), whereas in pattern type II results were good in 12 patients (80%) and fair in 3 patients (20%). The recurrence frequency was 4.1% and 6.6%, respectively. Subcalcaneal spur was determined in 70.5% of the patients with osseous pathology and 55.5% of the patients with fascial pathology. Based on this result, it can be ascertained that calcaneal spurs develop during the pathological process causing heel pain. Other findings supporting this claim were the differences in symptom periods of the patients with type I and type II imaging patterns and scintigraphies were normaly in 10 of 44 heels indicating subcalcaneal spurs on radiographies. These findings suggested that metabolic changes contributing to subcalcaneal spur were complete. Three phase bone scintigraphy is an objective method which can be used to diagnose heel pain, especially when determining the etiological factors and prognosis.     

Foot pain after a plantar fasciotomy: an MR analysis to determine potential causes.

PURPOSE: The purpose of this work was to determine potential causes of foot pain in patients who have had a surgical release of the plantar fascia for treatment of fasciitis. METHOD: We studied 17 patients (15 women, 2 men; age range 22-59 years, mean 40 years) with foot pain after undergoing a fasciotomy. Fourteen unilateral and three bilateral procedures accounted for the 20 ankles evaluated. Mean duration after surgery was 22 months (range 3-53 months). Each patient was instructed to localize the pain to a region of the foot; classify the pain as new onset, persistent, or recurrent; and characterize it as to the action that produced the greatest pain. T1-weighted sagittal and dual-echo T2-weighted images in the sagittal, coronal, and axial planes were obtained in a 1.5 T magnet. The MR studies were evaluated for abnormalities of the plantar fascia, perifascial soft tissues, tendons, and osseous structures. RESULTS: The plantar fascia appeared thick in all ankles (mean 8.0 mm, range 6-12 mm). A total of 25 symptomatic sites were assessed. An acute plantar fascia rupture explained plantar symptoms in two feet. In another 16 feet (12 with plantar heel pain and 4 with nonspecific heel pain), 6 had documentation of acute plantar fasciitis and 9 demonstrated perifascial edema. Of the latter nine feet, five demonstrated abnormalities of the posterior tibialis, peroneus longus, and peroneus brevis tendons. The pain localized to the medial arch in six feet; five feet had abnormalities of the posterior tibialis tendon and one foot demonstrated edema in the flexor digitorum brevis muscle. The pain localized to the lateral midfoot in one foot, which had a cuboid stress fracture. CONCLUSION: The cause of foot pain in patients who had a plantar fasciotomy appeared to be multifactorial. Three likely causes of pain were identified: persistent or recurrent acute plantar fasciitis, pathology related to arch instability, and structural failure from overload.     

Funktionelle Ergebnisse nach Megavoltbestrahlung beim Fersensporn

PURPOSE: To evaluate results on the functional outcome and to determine prognostic factors and long-term response to low-dose megavoltage irradiation. PATIENTS AND METHODS: A total dose of 6.0 Gy given in two weekly fractions of 1.0 Gy was applied to 305 sites (252 patients). After 6 weeks, 97 sites (31.8%) received a second radiotherapy (RT) course. Assessment system was a function score which was documented before RT, at the end of each RT course, and at 6 weeks and 6 months after treatment. After an observation period of >/= 24 months, a follow-up examination was attempted to evaluate the late response. RESULTS: At 6-month follow-up, 85.6% responded with a score improvement. The outcome was excellent (score: 90-100) in 135/305 sites (44.3%), good (score: 70-85) in 60/305 sites (19.7%), moderate (score: 45-65) in 63/305 (20.7%) sites, and poor (score: 0-40) in 47/305 sites (15.4%). 231/305 sites (75.7%) had no or mild pain. 296/305 (97,0%) had no or only slight limitations in work and 253/305 (82,9%) in daily activities. 255/305 (83,6%) had no or slight discomfort in gait. The long-term follow-up after a mean observation period of 48.4 months revealed 15 recurrences (7.3%). The patients' age, sex, and the duration of symptoms before initiation of RT ( 6 months) did not prove to be prognostic factors. No early or late toxicity related to the use of RT was detected. CONCLUSION: Megavoltage 6-MV photon-beam irradiation is a safe, effective and long-acting treatment modality in the management of heel spur patients. The function score has been proven to be a feasible method in clinical practice for evaluation of treatment outcome.     

Pressure-relieving properties of various shoe inserts in older people with plantar heel pain

Plantar heel pain is one of the most common musculoskeletal conditions affecting the foot and it is commonly experienced by older adults. Contoured foot orthoses and some heel inserts have been found to be effective for plantar heel pain, however the mechanism by which they achieve their effects is largely unknown. The aim of this study was to investigate the effects of foot orthoses and heel inserts on plantar pressures in older adults with plantar heel pain. Thirty-six adults aged over 65 years with plantar heel pain participated in the study. Using the in-shoe Pedar(?) system, plantar pressure data were recorded while participants walked along an 8 m walkway wearing a standardised shoe and 4 different shoe inserts. The shoe inserts consisted of a silicon heel cup, a soft foam heel pad, a heel lift and a prefabricated foot orthosis. Data were collected for the heel, midfoot and forefoot. Statistically significant attenuation of heel peak plantar pressure was provided by 3 of the 4 shoe inserts. The greatest reduction was achieved by the prefabricated foot orthosis, which provided a fivefold reduction compared to the next most effective insert. The contoured nature of the prefabricated foot orthosis allowed for an increase in midfoot contact area, resulting in a greater redistribution of force. The prefabricated foot orthosis was also the only shoe insert that did not increase forefoot pressure. The findings from this study indicate that of the shoe inserts tested, the contoured prefabricated foot orthosis is the most effective at reducing pressure under the heel in older people with heel pain.     

MRI features of the acromioclavicular joint that predict pain relief from intraarticular injection

OBJECTIVE: Our objective was to evaluate the predictive value of various MRI findings in the acromioclavicular joint for pain relief after intraarticular injection. MATERIALS AND METHODS: The acromioclavicular joint of 50 patients (20 women, 30 men; mean age, 51 years; range, 25-75 years) was evaluated on MRIs of the shoulder. Osteophytes, subchondral cysts and irregularities, bone marrow edema, joint effusion, and joint capsule hypertrophy were assessed by two musculoskeletal radiologists in consensus. Local anesthetics were injected into the acromioclavicular joint with fluoroscopic guidance. Patients graded pain relief on a visual analogue scale (0-100%) after 15 min. The relationship between pain relief and MRI findings was assessed with the Mann-Whitney U test. Pain relief equal to or greater than 70% was rated as a positive response to the injection. This cutoff value was used to calculate sensitivity, specificity, accuracy, and predictive values of the various MRI findings in determining which acromioclavicular joints were responsive to joint injections. RESULTS: Mean pain relief after injection was 38%. Pain relief was significantly related to capsular hypertrophy (p = 0.007) and was equal to or greater than 70% in 11 patients. The sensitivity in diagnosing a successful injection (range, 9-82%) was highest for caudal osteophytes (82%) and capsular hypertrophy (73%). The specificity (range, 51-97%) was highest for subchondral cysts (97%), subchondral bone marrow edema (95%), and joint effusion (92%). CONCLUSION: Pain relief after intraarticular injection is significantly related to capsular hypertrophy diagnosed on MRI. MRI findings have a reasonable sensitivity and a high specificity in predicting relevant short-term pain relief after intraarticular injection.     

Shock wave application for chronic plantar fasciitis in running athletes. A prospective,randomized, placebo-controlled trial

BACKGROUND: Recent articles have reported success with repeated low-energy shock wave application for treatment of chronic plantar fasciitis in runners. HYPOTHESIS: Shock wave treatment for chronic plantar fasciitis is safe and effective. STUDY DESIGN: Prospective, randomized, placebo-controlled trial. METHODS: Forty-five running athletes with intractable plantar heel pain for more than 12 months were enrolled; half were assigned to a treatment group that received three applications of 2100 impulses of low-energy shock waves, and half received sham treatment. Follow-up examinations were performed at 6 months and at 1 year by a blinded observer. RESULTS: After 6 months, self-assessment of pain on first walking in the morning was significantly reduced from an average of 6.9 to 2.1 points on a visual analog scale in the treatment group and from an average of 7.0 to 4.7 points in the sham group. The mean difference between groups was 2.6 points. After 12 months, there was a further reduction of pain in both groups, to an average 1.5 points in the treatment group, and to 4.4 points in the sham group. CONCLUSION: Three treatments with 2100 impulses of low-energy shock waves were a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.     

Decreased Local Control Following Radiation Therapy Alone in Early-Stage Glottic Carcinoma with Anterior Commissure Extension*

PURPOSE: To assess the patterns of failure in the treatment of early-stage squamous cell carcinoma of the glottic larynx. PATIENTS AND METHODS: Between 1983-2000, 122 consecutive patients treated for early laryngeal cancer (UICC T1N0 and T2N0) by radical radiation therapy (RT) were retrospectively studied. Male-to-female ratio was 106 : 16, and median age 62 years (35-92 years). There were 68 patients with T1a, 18 with T1b, and 36 with T2 tumors. Diagnosis was made by biopsy in 104 patients, and by laser vaporization or stripping in 18. Treatment planning consisted of three-dimensional (3-D) conformal RT in 49 (40%) patients including nine patients irradiated using arytenoid protection. A median dose of 70 Gy (60-74 Gy) was given (2 Gy/fraction) over a median period of 46 days (21-79 days). Median follow-up period was 85 months. RESULTS: The 5-year overall, cancer-specific, and disease-free survival amounted to 80%, 94%, and 70%, respectively. 5-year local control was 83%. Median time to local recurrence in 19 patients was 13 months (5-58 months). Salvage treatment consisted of surgery in 17 patients (one patient refused salvage and one was inoperable; total laryngectomy in eleven, and partial laryngectomy or cordectomy in six patients). Six patients died because of laryngeal cancer. Univariate analyses revealed that prognostic factors negatively influencing local control were anterior commissure extension, arytenoid protection, and total RT dose < 66 Gy. Among the factors analyzed, multivariate analysis (Cox model) demonstrated that anterior commissure extension, arytenoid protection, and male gender were the worst independent prognostic factors in terms of local control. CONCLUSION: For early-stage laryngeal cancer, outcome after RT is excellent. In case of anterior commissure extension, surgery or higher RT doses are warranted. Because of a high relapse risk, arytenoid protection should not be attempted.     

The flexor hallucis longus: tenographic technique and correlation of imaging findings with surgery in 39 ankles

PURPOSE: To examine the use of tenography for evaluation of the flexor hallucis longus (FHL) sheath. MATERIALS AND METHODS: Institutional review board approval was waived, patient consent was obtained, and the study was HIPAA compliant. Retrospective review of 192 FHL tenograms and associated surgical records identified 39 ankles in 37 patients (17 male, 20 female; mean age +/- standard deviation, 38 years +/- 13.8; range, 14-68 years) in which both tenography and surgery had been performed. Two radiologists reviewed tenographic findings, including contrast agent extravasation, synovial irregularity, stenosis, fibrous bands, sheath outpouching, extent of opacification, and communications with adjacent structures. Alterations in pain after anesthesia of the tendon sheath were also recorded. Surgical reports were reviewed. RESULTS: Thirty-four of 39 tenograms were diagnostic. Some extravasation occurred in nine (45%) of 20 injections with an initial injection method and in two (11%) of 19 with a new injection technique. Synovial irregularity was present in all 34 studies (15 mild, 16 moderate, three severe). Stenoses were identified in 23 (68%) of 34 ankles, fibrous bands were seen in 16 (47%) of 34 ankles, and outpouching of the sheath above a stenosis was present in 13 (38%) of 34 ankles. Communication of the FHL sheath with the ankle, flexor digitorum longus, or subtalar joint occurred in half the cases. Most patients with pain reported relief; relief was complete (100% reduction from preprocedural pain) in eight of 27, moderate (50%-90% reduction) in nine of 27, and mild (<50% reduction) in eight of 27 patients. CONCLUSION: Tenography of the FHL sheath produced diagnostic images in almost all patients and effectively demonstrated abnormalities of the tendon sheath. Pain relief with anesthetic injection helped confirm the FHL sheath as the pain generator.