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.
At first it was just a niggle in your knee when you climbed stairs or were squatting. Then the pain and stiffness became more than a niggle and you began to feel it when walking, sitting and resting.
You may be hearing popping or cracking sounds in your knee, and notice that your knee “gives out” every now and again.
The knee is an amazing but complicated joint and knee pain is one of the most common reasons that people visit a physiotherapist.
Pain behind the kneecap is commonly called runner’s knee because it is often seen in athletes and people with an active lifestyle, although it can also be seen in everyone from the young adolescents during growth spurts to elderly people.
The medical term is patellofemoral pain syndrome. It is pain behind the kneecap where your patella (kneecap) slides along the groove in your femur (thighbone) beneath.
Pain and stiffness occurs when the kneecap does not slide smoothly and misaligns causing it to rub against your femur. Repeated mis-tracking causes pain, stiffness, and ultimately can cause damage to your kneecap joint surface.
Knee pain is most commonly noticed during activities that involve knee bending, jarring or weight bearing.
People most at risk are those whose sport or activity includes running, jumping or the need to land in a squatting position. Sports most commonly associated with knee pain include running, netball, volleyball, basketball, tennis, skiing and cycling. Many tradies such as tilers and carpet layers also have problems.
Causes of Runner’s Knee
Overuse – increased activity or increased duration and intensity of the activity
Changes in footwear or playing surfaces
Tight outer thigh muscles and weaker inner thigh muscles causing the kneecap to be pulled to one side
A twisting injury
Flat feet and lack of arch support
Weak hip control muscles
First aid for Runner’s Knee
Generally, knee pain is gradual onset, which means it gradually increases in severity over time.
As with most injuries, the best initial first aid is rest, ice packs (15 minutes at a time every 2-3 hours), and taking anti-inflammatory painkillers such as ibuprofen.
You do not need a referral from a doctor to see a physiotherapist. If the pain is moderate, then you can seek treatment with your Physiotherapist immediately.
Physiotherapy is a proven treatment for runner’s knee. Your physiotherapist may initially tape or strap your kneecap to help pull it back into alignment and reduce pain.
Massage and joint mobilisation techniques are also commonly used to reduce swelling and restore movement.
You will be prescribed exercises to stretch and strengthen muscles that may be contributing to the problem. These exercises will change as you heal and will gradually increase in intensity to match your recovery.
If you wish to continue exercising to maintain your fitness during your treatment, then explore swimming, deep-water running and low-impact gym equipment such as elliptical trainers.
Depending on your knee pain cause, you may also be advised to explore arch supports, orthotics or different footwear. You may also require postural or technique correction in your chosen sport to stop problems from recurring, as well as a strength and conditioning plan to get you back to full competitive fitness.
In our experience, over 90% of runner’s knee physiotherapy clients will be pain free within six weeks of starting treatment. However, for severely damaged joints or arthritic joints, surgery may be required.
Things to Remember
Runner’s knee or patellofemoral pain syndrome is a common cause of knee pain.
It is a gradual onset injury and is most commonly noticed during activities that involve knee bending, jarring or weight bearing.
Physiotherapy is a proven method to speed healing, and prevent recurrence of knee pain.
Future management may also involve assessment of your gait and posture during exercise, and prescription of arch support or custom made orthotics.
Foot Pain OUCH!
You leap out of bed in the morning and you get stabbing pains in your heels or the arches of your feet. You hobble a few steps, and then hobble a few more until the pain reduces. Most of the day your feet feel OK …except when you tackle stairs or when you have been sitting for a while when the pain makes a reappearance.
Pain in your heel or the bottom of your foot is most commonly caused by Plantar Fasciitis. Your Plantar Fascia is the ligament that goes from the underneath of your heel to your toes. If you strain it, micro tears can form, which leads to swelling and sharp pain.
While most people experience the pain in their heel, some also get pain through to the arch of their foot. In about 70% of cases, the pain is in both feet, making walking a very painful experience.
You most commonly notice the pain first thing in the morning when you get out of bed and it reduces as your feet warm up with movement. It can reappear during the day after periods of rest or sitting, if you have been standing for a while, or when climbing stairs or ladders.
Plantar Fasciitis is more common in middle-aged people, although it can also affect younger people who use their feet a lot like joggers, dancers, or soldiers. That’s why it is also often called Joggers Heel.
Causes of Plantar Fasciitis
While the actual causes of plantar fasciitis are not known, there are risk factors that will increase the likelihood of you getting plantar fasciitis.
Overuse – excessive running, walking or dancing, or changing your training pattern so you dramatically increase hill running (for example).
Standing on hard surfaces
Flat feet or high foot arches (this is one time when average is better!)
Tight Achilles tendons or calf muscles
Your feet roll in when you walk or run
Ill-fitting shoes, worn out or unsupportive footwear such as thongs/slides
Walking barefoot on hard surfaces
First aid for Plantar Fasciitis
Generally, plantar fasciitis is gradual onset, which means it gradually increases in severity over time. If you ignore it and try to run through the pain, then the symptoms can get worse, ultimately leading to you changing your gait, limiting your activity or triggering the growth of heel spurs.
For initial symptoms, you need to rest, apply ice packs (15 minutes at a time every 2-3 hours), and take anti-inflammatory painkillers such as ibuprofen.
You don’t need a referral from a doctor to see a physiotherapist. If the pain is moderate then you can seek treatment with your Physiotherapist immediately as the sooner you begin treatment, the sooner you will experience relief.
Occasionally your plantar fascia can snap and you could hear a clicking or snapping sound, accompanied by swelling, intense pain and significant swelling. You need to see a doctor urgently if this occurs.
Physiotherapy & Treatment Options
Your physiotherapist will assess the extent of your injury, and will explore the causes of your injury.
Depending on your symptoms, you may have the soles of your feet taped or strapped to support your feet and reduce pain. You may also need to wear a plantar fasciitis brace or heel cups in the initial stages of healing.
Your physiotherapist will take you through a number of gentle stretching exercises for your feet, as well as exercises to address any tight Achilles tendons or calf muscles.
We will combine these with pain reduction techniques that you can do at home such as rolling your foot on a frozen water bottle or frozen golf ball to help ice your injury site.
Massage, joint mobilisation techniques, dry needling and ultrasound therapy will also be used to reduce swelling and restore movement.
For your footwear, we recommend you replace your joggers every 650km of use, and only wear shoes that support your feet while healing. Definitely no thongs or slides!
It also helps to put your shoes on first thing in the morning, before you take your first steps. Avoid barefoot walking on tiles or hard surfaces while you heal.
If the cause of your injury is your feet shape or foot pronation, you may need special orthotics. If this is indicated, we would conduct a walk/run assessment on you and have your technique analysed.
To maintain your fitness during your treatment, we recommend swimming and cycling. Don’t return to running until you have been pain free for at least one week, and then only run on soft surfaces until you rebuild your strength and stamina. If pain is felt at any time, then go back to swimming and cycling rather than running.
Unfortunately, Plantar Fasciitis is a long-term injury, and may take a number of months to fully heal even with the most aggressive treatments.
Things to Remember
Plantar Fasciitis is the most common cause of heel and arch pain, and is caused by micro tears to the plantar fascia.
It is a gradual onset injury and causes sharp pain when taking the first few steps in the morning or after rest.
Physiotherapy can treat plantar fasciitis, while reducing pain and increasing movement during healing.
Your physiotherapist may advise you of techniques for the improvement of your walk/running style, or provide you with solutions for arch support, to help prevent further reoccurrence.
Healing may take many months for full recovery.
Custom-made insoles known as foot orthoses can reduce foot pain caused by arthritis, overly prominent big toe joints and highly arched feet, a new systematic review shows.
A team of Cochrane Researchers found that custom orthoses were safe interventions for foot pain in a number of different conditions. However, more research is required to develop an in depth understanding of their effectiveness.
Approximately one in four people are affected by foot pain at any given time. It is often disabling and can impair mood, behaviour, self-care ability and overall quality of life. People suffer from foot pain for a variety of reasons, but pain is more common in the elderly and those with chronic conditions such as arthritis. In the majority of cases, patients undergo a combination of different treatments, one of which may be custom-made foot orthoses (insoles moulded to a cast of the foot).
The Cochrane Systematic Review focuses on the results of 11 trials that together involved 1,332 people. Researchers found that custom foot orthoses can relieve pain within three months in adults with rheumatoid arthritis, as well as in children with juvenile idiopathic arthritis, an early onset form of the disease. Adults with painful highly arched feet or painfully prominent big toe joints also benefited from treatment with orthoses over three and six month periods respectively.
“Custom foot orthoses can be an effective treatment for a variety of conditions, but there are still many causes of foot pain for which the benefit of this treatment is unclear. There is also a lack of data on the long term effects of treating with orthoses,” says Fiona Hawke, the lead researcher, who works at the Central Coast campus of the University of Newcastle, Australia.
Wiley-Blackwell. “Foot Pain? Custom-made Insoles Offer Relief.” ScienceDaily. ScienceDaily, 18 July 2008. <www.sciencedaily.com/releases/2008/07/080715204834.htm>.