Heel Spur Research Articles

Radiation therapy for benign diseases: patterns of care study in Germany

Background: Radiotherapy of benign diseases is controversial and rarely applied in Anglo-American countries, whereas in other parts of the world it is commonly practiced for several benign disorders. Similar to a European survey, a patterns of care study was conducted in Germany. Method: Using a mailed questionnaire, radiation equipment, treatment indication, number of patients, and treatment concepts were assessed in 1994, 1995, and 1996 in 134 of 152 German institutions (88%): 22 in East and 112 in West Germany; 30 in university hospitals and 104 in community hospitals. Average numbers of each institution and of all institutions were analyzed for frequencies and ratios between regions and among institutions. Radiation treatment concepts were analyzed. Results: A mean of 2 (range 1–7) megavoltage and 1.4 (range 0–4) orthovoltage units were available per institution; 32 institutions (24%) had no orthovoltage equipment. A mean of 20,082 patients were treated annually: 456 (2%) for inflammatory diseases (221 hidradenitis, 78 local infection, 23 parotitis; 134 not specified) 12,600 (63%) for degenerative diseases (2711 peritendinitis humeroscapularis, 1555 epicondylitis humeri; 1382 plantar/dorsal heel spur; 2434 degenerative osteoarthritis; 4518 not specified); 927 (5%) for hyperproliferative diseases (146 Dupuytren’s contracture, 382 keloids; 155 Peyronie’s disease; 244 not specified); 1210 (6%) for functional disorders (853 Graves’ orbitopathy; 357 not specified); and 4889 (24%) for other disorders (e.g., 3680 heterotopic ossification prophylaxis). In univariate analysis, there were geographic (West vs. East Germany) differences in using radiation therapy (RT) for inflammatory and degenerative disorders, and institutional differences (university versus community hospitals) in using RT for hyperproliferative and functional disorders ( p < 0.05). The prescribed dose concepts were mostly in the low dose range, <10 Gy but varied widely and inconsistently within geographic regions and institutions. Conclusion: Radiation therapy is a well-accepted and frequently practiced treatment for several benign diseases in Germany; however, there are significant geographic and institutional differences. As the number of orthovoltage units decreases, an increasing patient load will demand more megavoltage units, which may compromise the cost-effectiveness of this treatment. Only 4% of all clinical institutions have been involved in controlled clinical trials. To maintain a high level of RT service to other disciplines, RT treatment guidelines, quality control, and continuing medical education are required.

Extracorporeal shock wave therapy in orthopedics. Assessment of an emerging health technology.

Extracorporeal shock wave therapy (ESWT) as an emerging technology in orthopedics has been assessed in Austria with the objective to establish a scientific basis for pending and pressing health policy decisions. Despite encouraging results within some indications and the promising prospect of a noninvasive treatment for some orthopedic diseases, it seemed crucial to assess this new field of application in the light of evidence-based standards, without forgetting the reality of healthcare decisions. This article presents the results of the above mentioned assessment in the context of the policy-making process in Germany, Austria, and Switzerland. The study is based on an overview of the already existing reviews on the effectiveness of ESWT as carried out by different actors (health insurances and orthopedists), and on an overview of additional literature covering all relevant aspects (mode of action, recommendations, economic estimates). Orthopedic societies, several institutions involved in health technology assessment, and health insurance agencies were contacted in search of further relevant literature, ongoing studies, and assessments. Until now, clear evidence has not been available on the effectiveness of ESWT in four currently recommended indications (tendinosis calcarea of the shoulder, epicondylopathia humeri radialis, calcaneal spur, and pseudarthrosis), although a substantial body of literature has been produced. Despite encouraging results in some indications, the lack of coherent therapy schemes and the poor quality in the design of clinical studies has been serious enough to hinder the drawing of reasonable conclusions. Due to the rapid diffusion of ESWT and the pressure on reimbursement agencies to prove the ineffectiveness of ESWT, the policy option of a pragmatic approach is recommended to control the diffusion of an uncertain health technology, alongside active research that would allow a more comprehensive appraisal of this potentially interesting treatment strategy in orthopedics.

The windlass mechanism of the foot. A mechanical model to explain pathology.

This article presents a mechanical model that can be used to understand the foot, to help develop methods of treatment of foot pathology, and to provide direction for future research in foot mechanics and pathology. The anatomy and mechanical function of the windlass mechanism of the foot are analyzed using principles of mechanical engineering. The principles of force couples and free-body diagrams are explained and then applied to the foot. The relationship of the windlass mechanism to plantar fasciitis or heel spur syndrome, hallux abducto valgus, and hallux limitus is discussed.

Night Splint Treatment for Plantar Fasciitis A Prospective Randomized Study

A prospective randomized study of 116 patients with plantar fasciitis was performed to determine the effectiveness of adjuvant night splint therapy in relieving the acute symptoms of plantar fasciitis. Patients were randomized into one of two groups. Patients in Group 1 were treated with 1 month of oral antiinflammatory medication, Achilles stretching exercises, and shoe recommendations. Patients in Group 2 received identical treatment but also used a dorsiflexion night splint for 3 months. Blinded clinical review of patients was performed at 4, 6, and 12 weeks. Health status data Short Form 36 also was collected at these times and again at an average 19 months of followup. Overall, 68% of patients reported improvement with this nonoperative protocol for a 12-week period. No statistical difference was seen with the presence or absence of a night splint. In addition, no differences in improvement rates were observed with gender, duration of antecedent symptoms, the presence of bilateral symptoms, or the presence of a heel spur. Age older than 45 years did prove to be a statistically significant poor prognostic factor for improvement at the 12-week follow-up. Short Form 36 data obtained at baseline showed significantly lowered perception of health when compared with age matched controls. Patients in both treatment groups had significant improvement in Short Form 36 scores with 12 weeks of conservative care.

The plantar transverse incisional approach for heel spur syndrome. A retrospective study.

The efficacy of the transverse plantar incisional approach for the treatment of recalcitrant heel spur syndrome or plantar fasciitis was investigated by evaluating cases of this procedure performed by the authors from 1991 to 1998. Patient records were reviewed for conservative treatment rendered prior to surgical intervention as well as for the perioperative course of the patient. All patients were asked to complete questionnaires regarding their heel spur syndrome or plantar fasciitis and their opinion of both the conservative and the surgical treatments received.

The mechanical properties of the heel pad in unilateral plantar heel pain syndrome.

Plantar heel pain syndrome has been attributed to entrapment neuropathy, plantar fasciitis, calcaneal spurs, and stress fractures of the calcaneus. Although deteriorated mechanical properties of the heel pads may play an important role in the pathogenesis of heel pain syndrome, this has received little notice. In this study, a specially designed compression relaxation device with a push-pull scale and a 10-MHz linear array transducer was used to determine thickness of the heel pad under different loading conditions. Twenty consecutive patients aged 29 to 77 years with unilateral plantar heel pain syndrome were enrolled. Thickness of heel pad bilaterally was measured when the heel pad was compressed by serial increments of 0.5 kg to a maximum of 3 kg and then relaxed sequentially. The load-displacement curve during a loading-unloading cycle was plotted, and the compressibility index and energy dissipation ratio of the heel pad were calculated accordingly. Phase I displacement of the heel pad (from 0 to 1 kg load) on the painless side was greater than that on the painful side (P < 0.01), but there was no statistically significant difference between painless and painful sides in thickness of unloaded heel pads, compressibility index, or energy dissipation ratio (P > 0.05). In conclusion, the affected heel pad in plantar heel pain syndrome was stiffer under light pressure than the heel pad on the painless side. The changed nature of chambered adipose tissue in a painful heel pad may be responsible for its increased stiffness under light pressure.

Strahlentherapie von gutartigen Erkrankungen: eine Bestandsaufnahme für Deutschland

Radiation therapy of benign diseases is controversially discussed and rarely applied in Anglo-American countries, while in other parts of the world, especially Central and East Europe, it is commonly practised for several benign disorders. Similar to the European Society of Therapeutic Radiology and Oncology survey, a patterns of care study was performed in Germany. A questionnaire was mailed in 3 years (1994, 1995, 1996) to all radiation facilities in Germany, which assessed equipment, indications, number of patients and treatment concepts. A total of 134 (88%) institutions returned all requested data: 22 in East and 112 in West Germany; 30 in university and 104 in community/private hospitals. The average data of each institution and of all institutions were analyzed for frequencies and ratios between different regions and institutions. A mean of 2 (range 1 to 7) megavoltage (Linac/Cobalt 60) and 1.4 (range 0 to 4) orthovoltage units were available per institution; 32 (24%) institutions had no orthovoltage equipment. A mean of 20,082 patients were treated per year: 456 (2%) for inflammatory diseases (221 hidradenitis, 78 nail bed infection, 23 parotitis, 134 not specified), 12,600 (63%) for degenerative diseases (2,711 peritendinitis humeroscapularis, 1,555 epicondylitis humeri, 1,382 heel spur, 2,434 degenerative osteoarthritis, 4,518 not specified), 927 (5%) for hypertrophic diseases (146 Dupuytren's contracture, 382 keloids, 155 Peyronie's disease, 244 not specified), 1,210 (6%) for functional disorders (853 Graves' orbitopathy, 357 not specified), and 4,889 (24%) for other disorders (e.g. 3,680 heterotopic ossification prophylaxis). In univariate analysis, there were significant geographical (West vs East Germany) differences in the use of radiotherapy for inflammatory and degenerative disorders and institutional differences (university vs community/private hospitals) in the use of radiotherapy for hypertrophic and functional disorders (p < 0.05). The prescribed dose concepts were mostly in the low dose range (< 10 Gy), but varied widely and inconsistently within geographic regions and institution types. Radiotherapy is a well accepted and frequently practised treatment for several benign diseases in Germany, however, there are significant geographical and institutional differences. As the number of orthovoltage units decreases, an increasing patient load is in demand of more megavoltage units, which may compromise the cost-effectiveness of this treatment. Only 4% of all clinical institutions are involved in controlled clinical trials. To maintain a high level of radiotherapy service to other disciplines, radiotherapy treatment guidelines, quality control and continuing medical education are required.

The application of shock waves in orthopedic and rheumatologic diseases

The artgives a mini review of the application of shock waves in orthopedics. The basic physical principles, biological effects, mechanisms of operation and results of prospective investigations in the four main indications; i.e. non-union of fractures, calcareous tendinitis, lateral epicondylitis and plantar faciitis, will be presented. Shock wave application produces microfracturing of bony tissue. This effect has been used in non-unions since the early 1990s. Depending on the level of energy used and the sort of non-union, the rate of success varies between 56 and 90% of bony union. In patients with calcifications of the rotator cuff, shock wave therapy is used as a last step before operating. Microfracturing of the deposit and a rupture of the pseudomembrane surrounding the calcification explain this effect. Disintegration of the deposit can be seen in 73% 6 weeks following shock wave therapy. Differences exist concerning the type of calcification (type 2 is better than type 1). Positive effects in chronic cases of enthesopathies (plantar fasciitis, epicondylitis) are explained by improvement in blood supply, alterations in the neuronal cell membrane and the gate control theory. In chronic cases, when other conservative therapy modalities have failed and patients are sent to surgery, positive results can be achieved in 81% (heel spur) and 69% (epicondylitis).

The application of shock waves in orthopedic and rheumatologic diseases

The article gives a mini review of the application of shock waves in orthopedics. The basic physical principles, biological effects, mechanisms of operation and results of prospective investigations in the four main indications; i.e. non-union of fractures, calcareous tendinitis, lateral epicondylitis and plantar faciitis, will be presented. Shock wave application produces microfracturing of bony tissue. This effect has been used in non-unions since the early 1990s. Depending on the level of energy used and the sort of non-union, the rate of success varies between 56 and 90% of bony union. In patients with calcifications of the rotator cuff, shock wave therapy is used as a last step before operating. Microfracturing of the deposit and a rupture of the pseudomembrane surrounding the calcification explain this effect. Disintegration of the deposit can be seen in 73% 6 weeks following shock wave therapy. Differences exist concerning the type of calcification (type 2 is better than type 1). Positive effects in chronic cases of enthesopathies (plantar fasciitis, epicondylitis) are explained by improvement in blood supply, alterations in the neuronal cell membrane and the gate control theory. In chronic cases, when other conservative therapy modalities have failed and patients are sent to surgery, positive results can be achieved in 81% (heel spur) and 69% (epicondylitis).

A comparison of shoe inserts in relieving mechanical heel pain

A longitudinal controlled study was undertaken to evaluate the effectiveness of generic heel pads and functional foot orthotic devices in relieving symptoms of heel spur syndrome. A random sample of 60 patients was selected for the study. An outcome study was administered before and after 3 months of treatment. All results recorded were statistically significant ( P<0.05). Both groups of patients demonstrated a reduction in duration and severity of symptoms post-treatment. Patients receiving functional foot orthotic devices made from a standardized process obtained a better outcome on all measures.

Long-term follow-up of heel spur surgery. A 10-year retrospective study

A comparative retrospective study of 48 open heel spur surgeries and 20 endoscopic plantar fasciotomies was conducted involving 59 patients over a 10-year period. There was a significant reduction in heel pain at the time of follow-up (average, 3 years) for both groups. Overall, 85% of procedures were associated with patient satisfaction with the results, and patients said that they would recommend heel spur surgery for relief of severe heel pain in 94% of cases. Factors influencing the postoperative outcome, such as duration of preoperative symptoms, extent of conservative care, and obesity, are discussed.

Sonographic Evaluation of Plantar Fasciitis

Purpose : To evaluate the sonographic findings of plantar fasciitis. Materials and Methods : Both feet of 30patients(mean age, 44years) in whom plantar fasciitis had been clinically diagnosed, and those of healthyvolunteers(mean age, 34years) were evaluated with ultrasound(US) using a 7.0MHz linear array transducer. Heel painwas unilateral in 26 patients and bilateral in four. Sagittal sonograms were obtained in the prone position, andthe thickness of the plantar fascia was measured at its proximal end near its insertion into the calcaneus. Wealso evaluated hypoechoic fascia, perifascial fluid collection, fiber rupture, calcaneal spur and calcifications.Results : Plantar fascia thickness was significantly greater in the heels of patients with plantarfasciitis(3.2-8mm; mean, 5.1 ±1.12) than in their asymptomatic heels(1.3-5mm; mean, 3.5 ±0.78)(p

Acoustic field of a device for noninvasive pressure wave therapy in orthopedy

The Storz Minilith SL1 is a device specially designed for the treatment of orthopedical indications as tendinosis calcarea, tennis or golf elbow, heel spurs, or supra spinatus syndrome. A cylindrical electromagnetical source generates an intense ultrasonic pulse, which is focused by means of a parabolical reflector. Measurements in the focal region are performed in degassed water using a fiber-optic probe hydrophone. The whole process of pulse radiation from the source over nonlinear propagation including reflection to the focusing is simulated too. The underlying full wave model is based on a specially developed finite difference in time domain method. Excellent agreements of measured and computed pressure wave profiles in the focal region validate the model. The generation of shock waves in dependence on the energy setting of the therapy device is studied. Further investigations are made to consider the interaction of the SL1-pulse with human tissue structures as they occur in medical applications.

Shock waves in orthopedics

Extracorporeal shock waves have revolutionized urological stone treatment. Nowadays shock waves are widely used in orthopedics, too. This article reviews the applications of extracorporeal shock waves on bone and adjacent soft tissue. The osteoneogenetic effect of extracorporeal shock waves has been proven and can be used to treat pseudarthrosis with a success rate of around 75%. Shock waves have a positive effect in tennis and golfer's elbow, calcaneal spur, and the complex called "periarthritis humero-scapularis." The mechanism for this is not yet known, and results from large prospective and randomized studies are still lacking. However, the treatment has been performed many thousands of times. 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. Scientific evaluations, professional certifications, quality assurance and reimbursement issues present great challenges.

Operative Treatment of Subcalcaneal Pain

Twenty of 21 consecutive patients (21 heels) with subcalcaneal pain retractory to conservative treatment managed by resection of the proximal attachment of the plantar fascia and the heel spur, if present, were reviewed retrospectively. The results, at a mean followup of 40 months (range, 12-102 months), using a 100 point scoring system, rated excellent in 8 patients, good in 10, fair in 1, and poor in 1 (90% satisfactory outcome). Time to maximal improvement often was prolonged, yet once reached was maintained over time. The only complication encountered was 1 superficial wound infection. Radiographically it was noted that, despite complete excision, subcalcaneal exostoses often reformed and the fascial transection never did precipitate collapse of the longitudinal arch of the foot. A combination of mucoid and fibrinoid degeneration of the plantar fascia, an acceleration of an age related process, was the principal histopathologic finding. It was concluded that the subcalcaneal pain unresponsive to conservative modalities can be treated effectively by the index procedure. The radiographic and histologic findings of this study suggest that changes within the fascia, rather than the spur, are primarily responsible for the pathogenesis of the syndrome.

Heel spur: radiation therapy for refractory pain--results with three treatment concepts.

To evaluate radiation therapy (RT) to treat refractory pain in plantar heel spur. From 1984 to 1994, 141 patients with refractory painful plantar heel spur (170 heels, because of bilateral disease) underwent RT. Quantitative criteria were used to evaluate heel pain and ankle function prior to RT, 6-12 weeks after RT, and at last follow-up (median, 4 years). Patients were divided into three treatment groups: group A (n = 72 heels [two courses, 1.0-Gy fractions, 12-Gy total RT dose]), group B1 (n = 50 heels [one course, 0.3-Gy fractions, 3-Gy total dose]), and group B2 (n = 48 heels [one course, 0.5-Gy fractions, 5-Gy total dose]). At last follow-up, complete pain relief was achieved in 48 (67%) of 72 group A heels and in 71 (72%) of 98 group B heels. Statistically significant (P < .05) differences between groups were found for insufficient pain relief (< 80%) in patients in whom the response time after RT was longer than 4 weeks or in whom pain recurred during follow-up. The best results were achieved with the 5-Gy total RT dose (P < .05). Prognostic factors for complete pain relief were acute pain and short duration of pain prior to RT. The prognostic factor for insufficient pain relief was total RT dose. Refractory heel pain is effectively treated with RT, which should be considered a primary treatment approach rather than a last resort.

Estimation of sex on the basis of radiographs of the calcaneus

Lateral and anteroposterior radiographs of the ankles of 800 Central Europeans aged 20 to 79 were analyzed with regard to sexual dimorphism. All the distances, but not the angles, of the calcaneus were much larger in males than in females. Approximately 80% of the study sample could be sexed correctly by classifying all specimens greater than 86.0 mm in length as male and those less than 86.0 mm as female. The prevalence of os tibiale externum was 8.0 and 2.6% and the prevalence of plantar heel spur was 16.3 and 6.5% (increasing with age) for males and females, respectively, being significantly more frequent in females. On the other hand, the bone island frequencies were 9.1% in males and 4.8% in females. Our study suggests that radiographs of the ankle are a convenient, rapid, cheap and non-invasive means for estimating sex.

Effectiveness of low-energy extracorporal shock waves for chronic plantar fasciitis

Summary Over a period of 4 years we performed a prospective randomized trial on 100 patients in order to compare the effects of low-energy extracorporal shock-wave therapy (ESWT) in the treatment of painful heel (chronic plantar fasciitis). Patients in group I were treated three times at weekly intervals with 1000 impulses of 0.08 mJ/mm 2 given around the heel spur. Group II received treatment three times with 10 impulses of the same energy density at weekly intervals. Follow-up examinations were done at 12 and 52 weeks, respectively. The main outcomes assessed were reduction in severity of pressure pain, period of pain-free walking, and patient satisfaction. At 12 weeks, 16 of 50 patients in group I were almost or completely pain free, compared to one in group II. The period of pain-free walking increased by 141% in group I, compared to 33% in group II. The subjective assessment showed 10 excellent and 18 good results in group I compared to no excellent and eight good or fair results in group II. Twenty-six patients in group I were satisfied with the treatment compared to six in group II. Several patients had additional treatment after the 12-week assessment. At one year, 20% of group I patients had received combined conservative therapy, and 4% had had an operation, whereas 58% of group II had had combined therapy and 32% had had surgery. At the one-year follow-up there was still a difference in outcome in favour of group I, with 29 patients satisfied in group I versus 18 in group II. We conclude that three treatments with 1000 impulses of low-energy shock waves at 12 and 52 weeks provides an effective therapy for chronic plantar fasciitis.

Low-energy extracorporeal shock wave therapy for painful heel: a prospective controlled single-blind study

The aim of this prospective single-blind pilot study was to explore the pain-alleviating effect of low-energy extracorporeal shock wave therapy (ESWT) in painful heel associated with inferior calcaneal spurs. Thirty patients who suffered from persistent symptoms for more than 12 months qualified for low-energy ESWT and were assigned at random to two groups, real or simulated ESWT. Before beginning the treatment, any other therapy was stopped for a period of 6 weeks. The shock waves were applied by a experimental device allowing exact localization through an integrated fluoroscopy unit. Patients were treated three times at weekly intervals. Each time 1000 impulses of 0.06 mJ/mm2 were given around the heel spur. Follow-ups were done after 3, 6, 12 and 24 weeks. Patients of the placebo group who did not improve at the 6-week follow-up were then offered ESWT therapy and were checked at 3, 6, 12 and 24 weeks after the last treatment. Whereas we noticed no significant differences between the groups before ESWT, there was a significant alleviation of pain and improvement of function at all follow-ups in the treatment group.

Calcaneal spurs and plantar fasciitis

To design a measuring and grading system for calcaneal spurs and determine the incidence and dimensions of calcaneal spurs in plantar fasciitis, hindfoot lateral radiographs were studied, comparing patients who had a consultant diagnosis of plantar fasciitis with controls, matched for age, sex, side and total calcaneal length. Observers graded calcaneal spurs into four groups; (absent to severe), and perpendicular radiographic dimensions were later measured. Plantar fasciitis patients in our group were commonly female, over 30 years. On radiographs of the plantar fasciitis group, 60% of spurs were graded as moderate or severe compared with 2.5% of controls. Spurs over 1 mm long in the longitudinal axis of the calcaneum were present in 25 of 37 cases with fasciitis, and 2 of 40 controls. The observational 4-point grading system correlated with measured spur length. There is a strong correlation with calcaneal spurs over 1 mm long and plantar fasciitis, which may be easily observed radiographically.