Electromagnetic Transduction Therapy for Achilles Tendinopathy: A Preliminary Report on a New Technology.

A parallel prospective feasibility study was performed on 53 patients with chronic mid-portion Achilles tendinopathy (age 44.7 ± 9.1 years). Of the 53 patients, 28 (active group) were treated using a new electromagnetic (pulsed electromagnetic field) transduction therapy device (Cellactor® MT1) and heel cushions. The device produces an electromagnetic field of 80 milliTesla; a total of 8 treatments was performed within 4 weeks in an outpatient setting, without anesthesia, immobilization, or rest. A control group of 25 patients with a similar duration of symptoms was treated with heel cushions only. At the 12-week assessment point, the visual analog scale scores in both groups had significantly decreased, although the active group had significantly improved visual analog scale scores compared with those of the controls. The Role-Maudsley scores had also significantly improved in both the active and the control groups (p < .00001 and p = .0002, respectively). Electromagnetic transduction therapy could potentially be a useful modality for the treatment of Achilles tendinopathy. It should be compared with the current reference standard of extracorporeal shockwave therapy/radial soundwave therapy with similar level I, II, and III studies.

Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen.

Two case reports of high-level athletes with medial tibial stress syndrome (MTSS), 1 an Olympian with an actual stress fracture, are presented. Successful treatment included radial soundwave therapy, pneumatic leg braces, relative rest using an antigravity treadmill, and temporary foot orthoses. Radial soundwave therapy has a high level of evidence for treatment of MTSS. We also present recent evidence of the value of vitamin D assessment. Both patients had a successful outcome with minimal downtime. Finally, a suggested treatment regimen for MTSS is presented.

Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study.

BACKGROUND: The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis. METHODS: Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm(2)) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline. RESULTS: Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed. CONCLUSIONS: The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Overuse lower extremity injuries in sports.

When athletes train harder the risk of injury increases, and there are several common overuse injuries to the lower extremity. Three of the most common lower extremity overuse injuries in sports are discussed including the diagnosis and treatments: medial tibal stress syndrome, iliotibial band syndrome, and stress fractures. The charge of sports medicine professionals is to identify and treat the cause of the injuries and not just treat the symptoms. Symptomatology is an excellent guide to healing and often the patient leads the physician to the proper diagnosis through an investigation of the athlete's training program, past injury history, dietary habits, choice of footwear, and training surface.

A unique procedure for treatment of osteochondral lesions of the tarsal navicular: three cases in athletes.

Surgery in the athlete can present unique challenges, particularly when articular damage and osteoarthritic changes are noted. To allow athletes to return to their desired activity level, an alternative to the traditional approach of fusion must be developed. We prospectively reviewed 3 cases of osteochondral lesions and degenerative changes of the tarsal navicular joint involving a unique surgical approach consisting of microfracture of the lesions with concomitant arthrodiastasis. All 3 patients were treated with a miniexternal fixator to provide distraction for 4 weeks. The patients were aged 15, 17, and 21 years, with follow-up ranging from 2 to 4 years, at which point each patient was competing at their desired activity level and pain free. Each patient was initially treated at different stages of a navicular injury with patient 3 having undergone 2 courses of casted non-weightbearing. This new treatment gives more options to a potentially athletic career-ending injury.

Cuboid-navicular tarsal coalition: report of a small case series with description of a surgical approach for resection.

Tarsal coalitions are an uncommon pathology, representing approximately a 1% occurrence in the general population, and most commonly diagnosed in the younger population. Coalitions between the cuboid and navicular are especially rare. In this case series, all patients were young (15-35 years of age), active patients with fibrous coalitions at the cuboid-navicular interface; 3 of the 4 patients related a past history of ankle sprains on the affected side. After conservative treatment was exhausted and a diagnostic injection was performed that eliminated the pain, surgical intervention was used that consisted of coalition resection and interposition of an adipose graft harvested from the lower leg. All patients were able to return to their previous level of activity and remain pain-free at the surgical site. Our series of 4 cases of this coalition suggests that, although rare, cuboid-navicular coalition should be included in the differential diagnosis when patients present with persistent foot pain and suspicion of tarsal coalition is high. We also demonstrate that surgical resection of this coalition with an interpositional adipose graft provides excellent results.

Navicular stress fractures: a prospective study on athletes.

BACKGROUND: Navicular stress fractures of the foot often are difficult to diagnose and treat. METHODS: Nineteen athletic patients seen from 1999 to 2003, were compared to a previously treated group of 22 athletes with similar injuries treated from 1994 to 1998. Based on the frontal plane CT images, a previously described classification system was used to assess the injury: type I dorsal cortical break; type II fracture extending into the navicular body; and type III fracture breaches two cortices. Nonoperative treatment was recommended for patients with type I injuries and open reduction and internal fixation (ORIF) were recommended for those with type II and III injuries. The time to return to activity and ability to return to competition were assessed, along with differences between fracture type and gender. RESULTS: Return to activity (RTA) was 4.0 months for the entire group. RTA for type I (four injuries), type II (eight injuries), and type III (seven injuries) was 3.8, 3.7, and 4.2 months, respectively. Fifteen of 16 competitive athletes returned to full competition, including all who had ORIF. CONCLUSIONS: Navicular stress fractures can take 4 months to heal with nonoperative or operative treatment. Surgery should be considered for more severe injuries, which can be assessed by CT scan.

Plantar fascia ruptures in athletes.

OBJECTIVE: To educate sports medicine practitioners as to length of time for an athlete to return to activity after sustaining a rupture of the plantar fascia. METHODS: Athletic patients sustaining plantar fascia ruptures and subsequent treatment were reviewed. Diagnosis was based on clinical findings, although radiographic studies were done. Patients were treated for 2 to 3 weeks with a below-knee or high-top boot, nonweightbearing, with an additional 2 to 3 weeks of weightbearing in the boot. Patients used physical therapy. RESULTS: Eighteen athletes, including 6 elite athletes, were evaluated. Mean age was 40.9 +/- 13.2 years. There were 12 males and 6 females. Mean postinjury follow-up was 42 months. Duration of prior plantar fascia symptoms ranged from 0 to 52 weeks. All but 2 ruptures were of the medial portion. Four patients had injections prior to rupture. Five patients wore orthoses preinjury; 14 wore orthoses postinjury. All patients returned to activity after 2 to 26 weeks (mean, 9.1 +/- 6.0 weeks). Running athletes predominantly composed the cohort; others played tennis, volleyball, and basketball. CONCLUSION: Using the treatment protocol, patients sustaining plantar fascia rupture can achieve favorable results with complete return to activity. None of the 18 patients sustained reinjury, had postinjury sequelae, or necessitated surgery, contrary to other studies.