Articles
Heel Pain
Heel pain is a stressful condition that effects day to day activities. Running and walking causes stress on the heel because the heel is the part of the foot that hits the ground first. This means that the heel is taking on your entire weight. Diagnosis and treatments for heel pain can be easily found through your podiatrist.
One of the main causes of heel pain is a condition known as plantar fasciitis. The plantar fascia is a band of tissue that extends along the bottom of the foot, from the toe to the bottom of the heel. A rip or tear in this ligament can cause inflammation of these tissues, resulting in heel pain. People who do not wear proper fitting shoes are often at risk of developing problems such as plantar fasciitis. Unnecessary stress from ill fitting shoes, weight change, excessive running, and wearing non-supportive shoes on hard surfaces are all causes of plantar fasciitis.
Achilles tendonitis is another cause of heel pain. Similar to plantar fasciitis, inflammation of the Achilles tendon will cause heel pain due to stress fractures and muscle tearing. A lack of flexibility of the ankle and heel is an indicator of Achilles tendonitis. If left untreated, this condition can lead to plantar fasciitis and cause even more pain on your heel.
A third cause of heel pain is a heel spur. A heel spur occurs when the tissues of the plantar fascia undergo a great deal of stress, leading to a separation of the ligament from the heel bone entirely. This results in a pointed fragment of bone on the ball of the foot, known as a heel spur.
Treatments for heel pain are easy and effective as long as problems are addressed quickly. The most common solution is simply taking stress off the feet, particularly off of the heel. This will ease the pain and allow the tendons and ligaments to relax. In the case of both plantar fasciitis and Achilles tendonitis, icing will reduce swelling of any part of the foot and anti-inflammatory medication is highly recommended. Properly fitting your shoes and wearing heel pads or comfort insoles will also reduce the risk of developing heel pain. Stretching before and after exercises such as running will help the foot muscles prepare for stress and lower the chances of inflammatory pain. In extreme cases, relieving heel pain might require surgery. Always make sure to discuss these symptoms and treatment options with your podiatrist to keep yourself active and pain free.
What is a Podiatrist
The branch of medicine that is focused on the treatment, diagnosis, and study of disorders of the lower leg, ankle and foot is referred to as podiatry. Because people often spend a great deal of their time on their feet, many problems in this area can occur. A person seeks help from the field of podiatry when they need treatment for heel spurs, bunions, arch problems, deformities, ingrown toenails, corns, foot and ankle problems, infections, and problems with the foot that are related to diabetes and additional diseases.
To treat problems of the foot, ankle or lower leg, a podiatrist may prescribe physical therapy, drugs, perform surgery, or set fractures. Individuals may also be recommended to wear corrective shoe inserts, custom-made shoes, plaster casts and strappings in order to correct deformities.
When trying to gather information on a patient problem, a scanner or force plate may be used in order to design orthotics. During this procedure, patients are told to walk across a plate that is connected to a computer; the computer then takes a scan of the foot and indicates weight distribution and pressure points. The computer readouts will give the podiatrist information to help them determine the correct treatment plans.
Diagnosis is also provided through laboratory tests and x-rays. Through the foot, the first signs of serious problems such as heart disease, diabetes and arthritis can show up. For example, individuals that have diabetes may frequently have problems such as infections and foot ulcers because they experience poor circulation in the foot area. A podiatrist can then have consultations with patients when symptoms arise and referrals will be made to specialists that handle the greater health problems.
Some podiatrists have their own solo small private practices or clinics where they have a small staff and administrative personnel but many work within group practices. They usually spend time performing surgery in ambulatory surgical centers or hospitals or visiting patients in nursing homes. They typically spend between 30 to 60 hours of week working. Some podiatrists specialize in public health, orthopedics, surgery, or primary care. Some other fields include specialties in geriatrics, dermatology, pediatrics, diabetic foot care and sports medicine.
Some podiatrist specialists complete extra training in the area of foot and ankle reconstruction that result from the effects of physical trauma or diabetes. There are also surgeons that perform surgery of a cosmetic nature to correct bunions and hammertoes.
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Radial Shock Wave Therapy – Where Do We Stand Today? By Dr. Jon M. Sherman
In the past 15 years the use of extracorporeal shock waves for the treatment of musculoskeletal disorders such as chronic therapy-recalcitrant tendinopathies has become a significant subject of research worldwide. While shock waves were initially categorized according to the way in which they are generated (electromagnetic, electrohydraulic, piezoelectric) or according to energy flow density (high-energy, low-energy), a distinction is also made today between focused, radial and planar applications.
Shock wave technology continues to be plagued by persistent preconceived notions on the part of those who bear the costs of such treatment. The perspective of non-reimbursement has led to a change in orthopaedic shock wave application. Conventional, costly shock wave units – suitable for high-energy shock wave generation as well – are being increasingly replaced by radial shock wave units that are technically simpler, mobile, and economical – particularly for near-surface applications such as tendinopathies.Radial Shock Waves
Radial shock wave therapy utilizes a ballistic technique. A projectile accelerated by compressed air and propelled at high kinetic energy hits an applicator placed on the skin. By using a coupling medium such as ultrasound gel, this impulse is delivered to the tissue in the form of a shock wave. From this point the shock wave continues to spread inside the body in the form of a spherical “radial” wave.
In this generating principle, the applicator surface constitutes the geometric point with the highest pressure and the highest energy density. As opposed to other equipment, radial shock waves do not form an acoustic focus. Gerdesmeyer et al. (2004) pointed out that pressure and energy density of the radial shock wave steadily decrease after leaving the applicator. Based on theoretical considerations, classic indications such as pseudarthrosis or tendinitis calcarea, which are located in the deeper tissue layers, appeared less appropriate for the treatment. However, radial shock wave treatment is to be considered as perfectly suitable for the treatment of indications near the surface.
Studies on Radial Shock Wave Therapy
An Overview
The suitability of radial shock wave therapy (rESWT) for the treatment of chronic plantar fasciitis was first demonstrated in 2004 in an FDA multicenter study by Gerdesmeyer and Weil in 242 patients. 3 months after three sessions of repetitive low-energy application of 2,000 impulses without local anesthesia (Swiss DolorClast®, EMS, Nyon/Switzerland) it showed a > 50% pain reduction in 57% of the verum group versus 40% of the placebo group. Pain perception as measured on the numeric analog scale (NRS) dropped from 7 to 4 points in the verum group, from 7 to 6 in the placebo group. The use of the Swiss DolorClast® (Fig. 1) was well-tolerated by patients even without local anesthesia. The pneumatically generated shock waves were applied to the painful area. An accompanying xray or ultrasound exam was not necessary. The applicator was positioned based on patient feedback in terms of pain perception and pain localization.
In 2005 Spacca et al. conducted a single-blind randomized study on the effectiveness of rESWT in 62 patients suffering from tennis elbow. The verum group received four doses of 2,000 low-energy impulses of rESWT (Physio SWT, Elettronica Pagani Srl, Milan, Italy) at weekly intervals without local anesthesia, the control group four times 20 impulses. After 6 months the authors observed a pain reduction in the verum group from 5 points to 1 point on the NRS scale, and a pain increase from 5 to 6 points in the control group. The validated DASH score normalized from 38 to 10 points in the verum group while it remained stable in the control group (38 vs. 35 points).rESWT applied to the Achilles tendon
In 2006 Cacchio et al. reported on a randomized-controlled study conducted on 90 patients suffering from chronic therapy-recalcitrant tendinosis calcarea of the supraspinatus tendon. 6 months following four sessions of repetitive rESWT of 2,500 low-energy impulses without local anesthesia (verum group) (Physio SWT, Elettronica Pagani Srl), the authors observed a reduction in pain on the NRS from 8 points to 1 point. After four repetitive applications of 25 lowenergy impulses without local anaesthesia (control group), the score dropped from 8 to 6 points. 86% of the verum group saw a complete disintegration of the calcified deposit compared to 9% of the control group. Accordingly, 44/45 patients of the verum group obtained a score of excellent or good on the UCLA Shoulder Rating Scale compared to 0/45 patients of the control group. These results confirm the findings of an uncontrolled prospective study by Magosch et al. (2003) with three sessions of low-energy rESWT (Swiss DolorClast®, EMS) administered to 35 patients. After three sessions of low-energy rESWT the validated Constant Score rose from 69 to 81 points within 12 weeks. While the point value remained stable in subsequent studies, there were clear radiologic differences. The ratio of patients with complete disintegration of the treated calcified deposit rose from 18% after 4 weeks to 75% after 12 months.
Recently, a three-tailed, randomized, controlled study has been completed involving 75 patients with chronic recalcitrant Achilles tendinopathies assigned to different therapy methods. 4 months following inclusion in the study, the validated VISA-A-Score rose in all groups: from 51 to 76 points in Group 1 (eccentric loading exercises), from 50 to 70 points in Group 2 (repetitive low-energy rESWT (Swiss DolorClast®, EMS), and from 48 to 55 points in Group 3 (Wait-and-See). The indication of pain on the NRS went down in all groups, from 7 to 3 points in Group 1, from 7 to 4 points in Group 2, and from 8 to 6 points in Group 3. 60% of the patients in Group 1, 53% of the patients in Group 2, and 24% of the patients in Group 3 were “completey resolved” or “significantly improved” on the Likert scale. Eccentric loading exercises and radial shock wave therapy did not differ in terms of any of the criteria; both were significantly superior to “Wait-and-See”. Whether a combination of eccentric extension and rESWT would deliver even better results is to be examined in a further study. Based on the data obtained from the above studies and without precluding any comparative study, rESWT can deliver results that are similar to those of focused shock wave therapy for the treatment of tendinopathies. In addition, due to the lower price of radial shock wave units, the cost of treatment has dropped significantly – by a factor of 5 in Germany today. The incidence of side effects was equally negligible in both methods. Of critical importance, however, are factors such as the selection of chronic therapy-recalcitrant patients and a repetitive application of 2,000 low-energy impulses at weekly intervals through so-called clinical focusing, the absence of local anesthesia as well as a the need to observe a minimum period of 12 weeks before the appearance of maximum impact.
Conclusion
In summary, radial shock wave therapy is a multi-validated effective treatment option for chronic tendinopathies of the foot, shoulder and elbow. Due to the non-existence of side effects and circumventing the need for immobilization and restricted weight bearing radial shock wave therapy can be recommended to patients as an alternative to surgery.