K. Raveendran MD, Trauma Surgeon
International Journal of Surgery
Volume 24, Part B, December 2015, Pages 113-114
Extracorporeal shock wave therapy (ESWT) was first used in vivo for the disintegration of renal and ureteric calculi in 1980 followed shortly by its use for gallbladder calculi in 1985.
In 1988, the use of these acoustic waves was tried successfully for the treatment of nonunion of long bone fractures in Germany. In the nineties, shock wave therapy was used for the treatment of plantar fasciitis, lateral epicondylitis (tennis elbow) and calcific rotator cuff tendinitis.
Over the last two decades the use of ESWT has grown by leaps and bounds, and this special issue with twenty invited articles will try to inform you of the current concepts in the use of ESWT.
There are five original full-length articles and 15 review articles covering the cellular mechanisms and the clinical uses of ESWT. The first invited article is a prospective study by Gerdesmeyer et al.  showing that bone mineral density (BMD) increased six weeks after ESWT, and was statistically significant at twelve weeks. However it is not clear whether this effect on BMD is permanent or regresses after a few months. This study is very exciting as it indicates the possibility of treating osteoporosis with ESWT.
The experimental study by Santos et al.  from Brazil showed an increase of sulfated glycosaminoglycan in rat femurs after the application of ESWT. This suggests that shock waves can prolong anabolism of GAGs and also may have systemic effects. This study helps us to understand the multifactorial effects of ESWT on bone healing. Sukubo et al.  studied the effect of low dose shock waves on macrophages in vitro and showed their probable role in the prevention of fibrosis.
In this article from Taiwan, Kuo et al.  showed that the union rate was 100 percent after the application of ESWT twelve months from initial surgery (8 out of 8 patients), and 42.9 percent when applied after twelve months (6 out of 14 patients). This study albeit small is very encouraging for this difficult condition of atrophic nonunion. It also showed that ESWT could be followed by additional surgeries without any adverse effects. Atrophic nonunion is due to compromised vascularity, and ESWT through its neovascularization effect facilitates bony union.
This original paper on radial shock wave treatment in patients with plantar heel pain by Rompe et al.  is significant as it validates the successful use of radial as compared to focused shock waves. It also shows that a simple programme of manual stretching exercises after ESWT produces significantly better results at four months after initial therapy.
The blasting of urinary and biliary calculi is purely mechanical but low energy shock waves have shown a mechanotransduction effect on the biochemistry of the cell. This has helped us to understand the healing powers of ESWT in various tissues. Cheng and Wang  acknowledge that the biological mechanism of shock waves in bone is still unknown. In this review they cite many studies on the molecular basis of bone healing, improvement of osteonecrosis and osteochondrogenesis. Shock waves do not induce cracks or micro damage the bone. ESWT may replace surgery for nonunion of long bone fractures without the surgical risks.
The review by d’Agostino et al.  traces the history of ESWT to its present status, where the concept of mechanotransduction helps us to understand why acoustic waves can lead to tendon and bone healing. This article and its many references will help us to understand how ESWT is a healing procedure.
ESWT in Achilles tendinopathy is a well-established indication and this review by Gerdesmeyer et al.  of the current evidence updates our knowledge of this fairly common condition. The article documents the high evidence of published studies of the efficacy of ESWT in Achilles tendinopathy and concludes that shock wave therapy is the most effective modality of treatment for chronic Achilles tendinopathy.
The review of the treatment of chronic patella tendinopathy with ESWT by Leal et al.  reinforces the excellent results of ESWT in the treatment of various tendinopathies in the last fifteen years. The best results are achieved when used in combination with eccentric exercises and standardized physical therapy protocols. The title of this review on lateral condylitis (tennis elbow) says it all. This is an overuse syndrome and is one of the most treated conditions with ESWT. This article by Thiele et al.  documents the historical use of shock wave for lateral condylitis since 1996 with mixed results in initial studies. Later studies showed more positive results. Efficacy has been well demonstrated and treatment procedures standardized. Only Level 1-b studies were included in this overview and the authors concluded that repeated applications of ESWT should be performed before resorting to surgery.
The review by Moya et al.  on current knowledge of evidence based ESWT for shoulder pathology emphasizes the excellent results for calcific shoulder tendinopathy. This is one of the two main indications for the use of ESWT in musculoskeletal disorders together with plantar fasciitis. However shock wave therapy is being increasingly used for non-calcific shoulder tendinopathies. The review also highlights the rare complication of humeral head necrosis (two reports). It has also been often used for frozen shoulder, bicipital tendinitis and postoperative shoulder stiffness. However these indications are still controversial.
Is ESWT the first choice treatment for fracture non-unions? Schaden et al.  believe it to be so after long personal experience and an extensive review of the literature in this article. There are more than twenty publications reporting on the good results of ESWT in fracture non-unions with practically no side effects. A non-union gap of more than 5 mm in long bones is a negative factor for a successful outcome. ESWT should be used after failed internal fixation or with the addition of a plaster cast, orthosis or an external fixator.
Two reviews on the use of ESWT for avascular necrosis of the femoral head by Wang et al.  and Russo et al.  describes this fairly new therapy for this difficult condition. Although the exact mechanism is unknown, histopathological studies of retrieved femoral heads have shown viable bone and cellular proliferation after ESWT. Studies have shown that ESWT is more effective that the gold standard of core decompression and bone grafting for early avascular necrosis of the femoral head.
By: K Ravenndran, MD Trauma Surgeon
International Journal of Surgery
Volume 24, Part B, December 2015, Pages 113-114
The good results have led surgeons to extrapolate the use of ESWT in adult osteochondritis dissecans. This review by Thiele et al.  on osteochondritis of the knee and talus published studies on this relatively new indication. The authors conclude that shock wave should be considered before any surgical intervention in early cases.
We continue on our journey on bone treatment with the use of ESWT in stress fractures by Leal et al. . This comprehensive review of stress fractures in general is worth reading. ESWT is a relatively new treatment modality. There are several case reports and series with encouraging results for the use of ESWT in stress fractures.
Myofascial pain syndrome and fibromyalgia always evokes mixed feelings among doctors and this comprehensive review by Ramon et al.  helps us to understand the pathophysiology of this common disorder. ESWT is a novel therapy for these painful conditions and should be done together with a supervised exercise programme. These indications are still under investigation.
We leave the field of musculoskeletal disorders for other fields like the skin and the heart. ESWT is also used for erectile dysfunction but this special issue did not include this indication as it is still under experimental use.
The review on the use of ESWT for diabetic foot ulcers by Wang et al.  shows that shock wave, both radial and focused is effective in the treatment of diabetic foot ulcers. It has also been used in non-diabetic ulcers and skin flaps to improve flap survival. This review also highlights that ESWT is more effective than hyperbaric oxygen therapy for diabetic foot ulcers.
A metaanalysis of the treatment of cellulite with ESWT by Knobloch and Kraemer  reviews eleven clinical studies with five randomized controlled trials. Both focused and radial devices were used, and there was improvement of the cellulite severity scale (CSS) in the treated groups after twelve weeks. However the studies used various mixed techniques that have been listed in the metaanalysis. Long term follow up beyond one year was lacking.
Shock wave therapy of the heart is still in its infancy and this review by Holfeld et al.  is a comprehensive review of this new and exciting indication. If ESWT can regenerate ischaemic heart muscle, it will be a milestone in cardiac treatment.
In 1997, Haupt  wrote ‘In patients in whom conservative treatment has failed, surgery used to be the only choice, but its success rate barely exceeds that of shock wave therapy and surgery can still be done if shock wave therapy fails. Extracorporeal shock waves will have an impact on orthopedics comparable to its effect in urology.’
Almost twenty years after Haupt wrote this, sadly many surgeons, doctors and allied medical personnel are unaware of ESWT or believe it to be akin to alternative medicine.
The FDA approved the use of ESWT for the treatment of plantar fasciitis in 2000 and the treatment of lateral condylitis in 2002. I hope that this special issue will be a valuable tool and a reference to the further study of ESWT in the coming years.
Knee pain can affect a large range of age groups, ranging from ‘growing’ pains experienced by young people to ‘arthritic’ pain in older persons, and everything in-between. In this Blog we will examine knee meniscus injuries, what causes them and how to treat these injuries.
What is the Meniscus of the Knee?
The meniscus are C-shaped structures in your knee joint which sit between your femur (or thigh bone) and your tibia (or shin bone). They are made of a type of cartilage called fibrocartilage, which is a little bit different to other form of cartilage in your knee called articular cartilage. Articular cartilage is often more affected with arthritis. Your knee has two menisci, the medial meniscus and lateral meniscus. The medial meniscus is located on the inside while the lateral meniscus is on the outside of your knee.
The menisci have a limited blood supply which rely on movement of the knee to keep it strong and healthy. The best thing you can do to prevent your meniscus from injury, is to keep active and keep the knee moving.
What does the Meniscus do?
The main role of the menisci is to help with absorbing and distributing forces through the knee joint. They work together with knee and hip muscles to act as a shock absorber when the knee is active. The menisci also increases the surface area of the knee joint, so it adds some extra stability to the knee.
How do you injure your meniscus?
The majority of meniscus injuries occur as people age (over 50 years). As you get older the limited blood supply to the meniscus becomes further reduced. As people age they develop wrinkles and grey hair. The aging process also occurs in the knee, the menisci begin to degenerate, lose some of their strength and become more prone to injury.
As the menisci become more susceptible to injury with age, the range and types of movements which can damage it become more prevalent. The majority of meniscus injuries occur when you twist your knee over a planted foot. – Sometimes it can be as simple, as turning to look over your shoulder or stepping off a ladder and putting weight on your foot and twisting your knee. You might notice the knee to slowly swell up.
Meniscus injuries in the younger ager group (under 30) are not as prevalent. Simple twisting movements to the knee are unlikely to cause menisci injury in younger persons. You are more likely to see menisci injuries occur with other knee injuries such as ligament damage caused through sport.
What should I do if I damage my meniscus?
So you have injured your knee and you are thinking, what to do next? Alternatively, you have had a scan on your knee and been diagnosed with a meniscus tear and wanting to know what is the best way to treat it?
A 2002 study involving people who had ‘degenerative’ menisci tears, compared the rehabilitation recovery rates of three groups. The first group had meniscus removal surgery (i.e. arthroscopic meniscectomy), the second experienced joint ‘wash-out’ (lavage) and third underwent ‘placebo’ surgery where the surgeon made skin incisions only. All groups undertook the same rehabilitation program. Amazingly they found no difference in between the 3 groups. All groups had the same levels of pain and function, and all improved at the same rate.
Since the initial 2002 study, further published studies have compared meniscus surgery with placebo surgery and physiotherapy treatment. These studies continue to confirm the same result, that is, there is no differences between all of the groups in terms of rehabilitation other than the surgery group having a higher cost of treatment!
The treatment for meniscus tears in the active, younger population (under 30) is more complex with some individuals needing surgery as soon as possible, while others can manage with physiotherapy and exercise.
What does this all mean?
Degenerative meniscus tears are more common as people age. In some cases people who not have any knee pain may have degenerative menisci and not be in any pain. In other words having a degenerative meniscus correlates poorly pain. The good news is, you might not need to have surgery at all if you are able to undertake a comprehensive physiotherapy rehabilitation program.
Will surgery provide you any benefits? Yes it will in the short term. However, arthroscopic meniscus surgery is associated with a ten-fold increase the risk of knee osteoarthritis.
Although most degenerative meniscus tears don’t need surgery, there are always some cases where surgery is going to be more effective than physiotherapy. Some menisci tears can either ‘stick-up’ into the joint or ‘break-off.’ In cases like these the tear can cause the knee to lock when trying to bend or straighten, and surgery is recommended to remove the tear.
What will my physiotherapist work on during my rehabilitation?
The first thing your physiotherapist will undertake is a full assessment of not only your knee, but your legs and even your back to see if you pain is coming from your meniscus or from somewhere else.
If you have hurt your meniscus recently your physiotherapist will start treatment aiming to reduce the swelling and begin to return it to its full range of movement.
If you have full range of movement and no swelling in your knee joint your physiotherapist will begin an exercise program focused on strengthening the muscles around your knee, and from around your hip. Weak quadriceps muscle has been found to place a greater load on your knee joint and your meniscus. Strengthening these muscle groups can reduce the pressure on the meniscus during movement. Weakness in your bottom (gluteal) muscles can also affect your knee function. Weakness in the gluteal muscles is known to place more load through the inside of the knee, which is where the majority of medial injuries occur. Strengthening the quadriceps and gluteal muscles will contribute to reducing the pressure on the knee.
Degenerative meniscus tears areas common as wrinkles and grey hair as you grow older. Although surgery is sometimes required for some knee injuries it often is not the only or best option in most cases. For most knee injuries involving the menisci the best anti-aging medicine is physical activity and exercise.
A very common running injury is a calf strain or a tear. We have two main calf muscles, Gastrocnemius and Soleus, which are under repetitive load when we run. There are two reasons for this, the first one is to absorb the shock of our body weight during landing, and the second is to help move us forward into our next stride.
When we run, we take on average 937 strides per km. Obviously any weakness in the calf complex, or elsewhere in your lower limb or pelvis, will affect your running technique. Any muscle imbalance in your kinetic chain (above and below the calf) will lead to an increased load on the calf and predispose you to injury, strain or tear.
Just as your calf is designed to absorb shock and propel us forwards, the muscles above and below the calf are stabilising muscles. These are responsible for keeping the ankle, knee and hip joints stable during movement, so that your calf can carry out its main function. However, if your muscles aren’t up to the job they were designed for, particularly at the foot and ankle complex, the calf will begin to try and take on a stabilizing role. It isn’t designed to do this so it gets overworked or injured. A common example is over pronation of your foot (rolling inwards) or weak gluteal muscles causing excessive inward rotation of the knee.
A lack of a warm-up session is often a reason why many of us sustain calf injuries. The warmer the muscle, the more elastic it becomes. As we get older, there becomes a decrease in elasticity towards our tendons and muscles, causing an increase risk in calf strains for those more senior to running. Warming down after a run with calf stretches helps maintain the elasticity in your calf muscles.
Don’t forget that dehydration affects your muscle function by reducing blood flow to your muscles and decreasing muscle elasticity, flexibility and endurance. So stay hydrated.
Properly fitted footwear that isn’t worn out and provides adequate cushioning is also an important factor to consider when avoiding calf strain. Calf compression socks or long skins can also assist with keeping muscles warm and increasing circulation.
What to do if you have calf strain or tear?
Initially, the Rest, Ice, Compression, Elevation (R.I.C.E) principal should be followed. Book an appointment with a Physiotherapist for assessment and treatment of your injury so we can start your individual rehabilitation programme. We may refer you to have a scan of your injured calf muscle if we suspect a grade 2 or 3 strain.
Approximate timescales for rest are;
3 weeks for a Grade 1 strain
4-6 weeks for a Grade 2 strain
Grade 3 tears will most likely require surgery followed by a 12-week rehabilitation programme.
As with any injury, it is very important to avoid secondary injuries that occur through compensatory movement patterns. These may have become a habit during the injured period. All the more reason to get self assessed early to avoid this from occurring.
The rehabilitation period is also a good opportunity to target those areas that often get ignored in our weekly training routines. Core stability and gluteal muscles are a great place to focus on when running activity is restricted. At Saanichton Physiotherapy and Sports clinic our Physiotherapists will design a programme to suit your individual needs.
Research conducted has found that the stronger these muscles are, the more likely you will gain a successful outcome in not only injury recovery, injury prevention, but also importantly your performance.
Plantar fasciitis is inflammation of the plantar fascia and is the most common cause of heel pain. The plantar fascia is the thick band of connective tissue under the foot that runs from the heel bone at the back of your foot to the toes at the front. It essentially acts like a sling to support the arch of your foot.
What causes Plantar Fasciitis?
There are a number of causes including:
Age as it is more common in middle-aged people due to ‘sagging’ of the arch of the foot, but can occur in younger people who put a lot of load through their feet.Weaknesses can occur in the muscles that support the arch of the foot, which causes the plantar fascia to take an increased load which can irritate
Poor bio-mechanics can contribute to plantar fasciitis i.e. having flat feet or high archesWeight gain or excess weight can put extra load on the plantar fascia, irritating .
the tissues; this can also occur from the weight gain during pregnancy
Repetitive loading i.e. high level sports or working on your feet
Poor support from footwear i.e. worn or ill-fitting shoes
Arthritic foot joints can irritate the plantar fascia
Diabetic people have an increased chance of suffering from plantar fasciitis
Signs and Symptoms of Plantar Fasciitis
Pain at the base of the foot near the heel with weight-bearing
More pain after getting out of bed, or after prolonged sitting
Heel pain will be worse with the first few steps and will gradually improve as you move more
Generally your physiotherapist will be able to diagnose plantar fasciitis from your history, symptoms and a clinical examination.
Calf stretches often give relief to sufferers – it is important to stretch both calf muscles, so stretch with a straight leg and also a bent leg. Hold each stretch for 30 secs and repeat twice. Try to do this at least morning and night every day.
Freeze some water in an old water bottle and roll the bottom of your foot up and down on this.
Taping can offer you some relief while you are doing your exercises to off-load the plantar fascia.
Strengthening is an important component of treatment for plantar fasciitis as it improves the ability of the foot and ankle muscles to support the arch of your foot hence off-loading the plantar fascia.
Book an appointment with one of our physiotherapists who can help you with ideas for strengthening exercises to help ease the pain caused by plantar fasciitis.