Heinz Lohrer

Radial Extracorporeal Shock Wave Therapy Is Safe and Effective in the Treatment of Chronic Recalcitrant Plantar Fasciitis Results of a Confirmatory Randomized Placebo-Controlled

Background Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials. Hypothesis There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis. Study Design Randomized, controlled trial; Level of evidence, 1. Methods Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm2; 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks’ follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients’ and investigators’ global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy. Results Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1-sided). No relevant side effects were observed. Conclusion Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.

Functional Properties of Adhesive Ankle Taping: Neuromuscular and Mechanical Effects Before and After Exercise

The purpose of the study was to investigate effects of adhesive ankle taping. Using electromyographic, gonio-metric, and thermologic methods, different ankle tapes were tested before and after athletic exercise in simulated inversion trauma. Twelve subjects with stable ankle joints performed five trials: with two different materials, with two taping techniques, and one trial without tape as control. After the simulated inversion trauma, approximately 35% of the initial maximum inversion amplitude was decreased by ankle taping. Depending on the technique, there was a loss of tape stability £14% after 30 min of athletic exercise. Thermologic analysis revealed a postexercise 6°C temperature increase in the foot, especially under the tape. Initially, interpreted as the primary effect, the improved joint stabilization is based on mechanical stiffness caused by the adhesive tape. Joint stability was influenced positively by neuromuscular proprioceptive and physiological processes, characterized by relatively increased electromyographic activation.

Neuromuscular Properties and Functional Aspects of Taped Ankles

We used electromyographic and goniometric methods to test 40 subjects to describe the neuromuscular and biomechanical adaptation of the ankle with respect to application of two different adhesive tapes and to exercises. The neuromuscular responses to inversion injury simulation, together with the mechanical displacements of the joint complex, were analyzed before and after controlled athletic exercises. The proprioceptive amplification ratio was calculated on the basis of the integrated reflex electromyographic results and on the maximum inversion amplitude. Relevant stability gains were achieved immediately after applying tape. There was reduced tape stability after athletic exercise for one of the two tape materials tested. No further loosening was detected, even after prolonged wearing of tape (24 hours). Compared with the unprotected ankle, the taped ankle had a significant increase in the proprioceptive amplification ratio. Both fatigue and mechanical loosening may be responsible for the significant reduction in this ratio immediately after exercise. After the 24-hour interval, the ratio was increased, which could be explained by physiologic neuromuscular regeneration and mechanical restabilization of the tape itself. The sensitivity of the proprioceptive amplification ratio, both to external stabilization and to internal fatigue, supports its potential value to quantify functional joint stability.

Translation, Cross-Cultural Adaption and Validation of the German Version of the Foot and Ankle Ability Measure for Patients with Chronic Ankle Instability.

Objectives The evaluation of health-related quality of life and physical function is important for determining therapeutic strategies following ankle injuries. The Anglo-American Foot and Ankle Ability Measure (FAAM) is a valid and reliable self-reported measure to detect functional deficits in chronic lateral ankle instability. The purpose of this study was to translate, cross-culturally adapt and validate the FAAM questionnaire for use with German-speaking patients with chronic lateral ankle instability. Patients/Participants Preoperative and conservatively treated patients with chronic lateral ankle instability. Sport students and volleyball athletes served as control groups. Main Outcome Measurements The FAAM was forward and back translated, cross-culturally adapted and validated. The study population completed the FAAM-G questionnaire twice within 3–5 days. Additionally, the patients were scored with the Good ankle laxity classification system. Test–Retest reliability, construct validity and internal consistency were calculated. Results Reliability and validity of the FAAM-G were examined in presurgical chronic ankle instability patients (n=24), conservatively treated chronic ankle instability patients (n=17), university sport students (n=31) and volleyballers (n=37). Test–retest reliability revealed fair, good, or excellent reliability (inter-class correlation coefficient (ICC)=0.590–0.998; ρ=0.528–1.000). Construct validity, tested between the FAAM-G subscores and the Good et al ankle laxity classification system demonstrated strong correlations (ρ = −0.819 to −0.861). Conclusions The original FAAM questionnaire was successfully translated and cross-culturally adapted from English to German. Corresponding to the Anglo-American version, the FAAM-G is a reliable and valid questionnaire for self-reported assessment of pain and disability in German-speaking patients suffering from chronic ankle instability.

Comparison of Radial Versus Focused Extracorporeal Shock Waves in Plantar Fasciitis Using Functional Measures

Background: Recent literature shows evidence for effective treatment for plantar fasciitis using either focused or radial shock waves. Up to now no research has been available which compares these different procedures. We hypothesized (H0 Hypothesis) that for plantar fasciitis, outcomes following focused or radial shock wave treatment were equal. Materials and Methods: For this pilot study, 39 patients suffering from recalcitrant plantar fasciitis were randomized in two groups. Treatment was performed in three sessions. Once a week 2000 impulses of radial (0.17 mJ/mm 2 ) or focused (0.20 mJ/mm 2 ) shock waves were applied. Efficacy was determined by multivariate analysis of eight single variables including changes in Foot Functional Index, neuromuscular performance (Single leg drop and long jump, postural stability, isokinetic testing), and by a composite score from baseline to 12 weeks followup. Multivariate Wilcoxon tests (Wei-Lachin procedure) and formal meta-analytic procedure with adjustment for subgroups was performed to determine the adjusted effect sizes with their corresponding confidence intervals. Results: The overall result (“Crude Pooling”) shows “small” superiority of the focused extracorporeal shock wave therapy (MW = 0.55, LB-CI = 0.4644). Adjusted for age the focused treatment exhibited “more than small” superiority (MW = 0.59, LB-CI > 0.5) and this result is statistically significant (LB-CI = 0.5067, benchmark for equality = 0.5). Conclusion: This study provides some evidence for focused extracorporeal shock wave treatment being superior to radial extracorporeal shock wave therapy for recalcitrant plantar fasciitis. Level of Evidence: I, Prospective Randomized Study

Comparison of endoscopic and open resection for Haglund tuberosity in a cadaver study.

Background: About half of patients who have Haglund disease may require treatment by surgical resection of the superior portion of the calcaneal tuberosity. Endoscopic techniques have been described as alternatives to open surgery, but only results of uncontrolled retrospective clinical investigations have been reported. Up to now no research is available which compares these different procedures. Methods: A controlled laboratory study was done to evaluate the morphologic appearance of the superior portion of the calcaneal tuberosity after endoscopic or open resection. The tuberosity was resected in 15 isolated fresh-frozen human cadaver lower limb specimens with either open (nine) or endoscopic (six) technique. Outcome was measured radiographically. Iatrogenic soft-tissue lesions of the distal Achilles tendon, plantaris tendon and sural nerve caused by the surgical procedure were evaluated by direct observation after anatomic dissection. Results: Radiographs revealed that the slope of the resection line (osteotomy angle) was steeper (p = 0.017) and the resected protruberance was larger (p = 0.003), while the remaining posterior rim was smaller (p = 0.048) after open resection than after endoscopic resection. Macroscopic analysis indicated that both approaches may damage soft tissues particularly the medial Achilles tendon column and in the plantaris tendon (relative risk = 0.5 in either group). Iatrogenic sural nerve injuries were found after both techniques (relative risk = 0.2 for endoscopic and 0.1 for open resection). Residual bursa tissue was detected only after endoscopy (relative risk = 0.3), while loose bony fragments were present only after open surgery (relative risk = 0.4). Conclusions and clinical relevance: The medial column of the Achilles tendon, the plantaris tendon, and the sural nerve are at risk in both open and endoscopic resection for Haglund disease.

Observer Reliability in Ankle and Calcaneocuboid Stress Radiography

Background Stress radiographic measurements play an important role in assessing the degree of joint instability in scientific investigations and for decision making in treatment. However, their validity and reliability are still a matter of intensive debate. Hypothesis There is no difference regarding interobserver and intraobserver reliability with respect to anterior talar drawer, talar tilt, and calcaneocuboid stress radiographs. Study Design Cohort study (diagnosis); Level of evidence, 4. Methods Eighty-nine anterior talar drawer, 89 talar tilt, and 76 calcaneocuboid stress radiographs were selected. Analyses for anterior talar drawer (1 measurement technique), talar tilt (1 measurement technique), and lateral calcaneocuboid instability (4 measurement techniques) were performed by 4 independent raters. One rater repeated the measurements after 1 month. Intraclass and interclass correlation coefficients (ICCs) with calculated confidence intervals assessed intratester and intertester reliability of each measure. Results Ankle stress radiographic interobserver agreement was ICC = 0.73 to 0.97 for anterior talar drawer test and ICC = 0.78 to 0.97 for talar tilt. Interobserver reliability for calcaneocuboid angle measurement methods was lower (ICC = 0.35–0.91) than for the calcaneocuboid joint-space distance measurements (ICC = 0.81–0.95). Intraobserver ICC varied between 0.78 and 0.97 for ankle stress testing and was 0.67 to 0.94 for calcaneocuboid stress radiography, respectively. Conclusions Ankle stress radiographic measurements were proven to be reliable. Insufficient reproducibility was found for angular calcaneocuboid stress radiography measurements, while lateral calcaneocuboid joint-space distances offered accurate reliability. Clinical Relevance Measurement errors can be avoided using standardized stress radiography and measurement techniques with proven reliability.

Cross-cultural Adaptation and Validation of the VISA-P Questionnaire for German-Speaking Patients With Patellar Tendinopathy

STUDY DESIGN Clinical measurement study. OBJECTIVES To cross-culturally adapt and validate the Victorian Institute of Sports Assessment Patellar Tendinopathy Questionnaire (VISA-P) for German-speaking patients. BACKGROUND Like most questionnaires, the VISA-P was developed for English-speaking patients. There is a need to adapt the scale for German-speaking patients and thereby add to the total body of psychometric evidence relating to this instrument. METHODS The VISA-P questionnaire was translated and cross-culturally adapted into German (VISA-P-G) in 6 steps: translation, synthesis, back translation, expert committee review, pretesting, and advisory committee appraisal. The psychometric properties of the VISA-P-G were determined using 23 patients with patellar tendinopathy and 57 active healthy persons (32 sport students and 25 basketball players). Reliability was evaluated by applying the questionnaire twice within a week to all 80 participants. Known group validity was calculated using a 1-way analysis of variance. Additionally, VISA-P-G results were correlated with the Blazina classification system for patellar tendinopathy, using the Spearman rank correlation coefficient. VISA-P-G ratings from the present study groups were further compared with respective data published in the original English, Dutch, and Swedish versions by a 2-sample t test. Internal consistency for the individual items of the questionnaire was determined within the patient group using a Cronbach alpha. RESULTS Test-retest revealed excellent reliability for the patient and the asymptomatic control group (ICC = 0.88 and 0.87, respectively). Internal consistency for the patients was 0.88. Concurrent validity was almost perfect (ρ = -0.81; P<.001). CONCLUSION The VISA-P-G is a reliable and valid questionnaire for the self-assessment of pain, symptoms, and function in German-speaking patients with patellar tendinopathy. Its psychometric properties are comparable with the original English and international adaptations (Swedish, Dutch, and Italian).

Training effects of two different unstable shoe constructions on postural control in static and dynamic testing situations

OBJECTIVE The aim of this study was to compare training effects on postural control using two different unstable shoe constructions. SUBJECTS AND SETTING Twenty-nine healthy subjects participated in this study and were randomly divided into three groups. Two experimental groups (10 subjects in each group) were assigned to a 6 week training program of specific sensorimotor exercises with unstable shoe constructions, one group using MBT(®) shoes and one group wearing Reflex Control(®) shoes (RC). Subjects in the control group (9 subjects) did not perform balance training. MAIN OUTCOME MEASURES Postural control was measured in one-leg stance in two testing conditions. We recorded postural sway on a force plate (static testing situation) and displacements of a moveable platform (dynamic testing situation) before and after the training period. RESULTS There were no effects of training with unstable shoe constructions on postural sway in the static testing condition (for comparison of groups: p = 0.990 and p = 0.119). However, the RC group showed statistically significant improvements in the dynamic testing situation (p = 0.014 compared to control subjects). In the MBT group improvements were not significantly different in comparison to control group (p = 0.518). CONCLUSIONS Our results indicate that exercises using unstable shoe constructions, particularly the RC, improve postural control only in dynamic conditions.

Calcaneocuboid joint instability: a novel operative technique for anatomic reconstruction.

A case history of a 13-year-old female national top-level gymnast, suffering from calcaneocuboid joint instability, is presented. The procedure was done as an anatomic repair by capsular reefing, which was augmented using a local periosteal flap. Initially, the athlete twisted her ankle. Clinical investigation revealed no sign of a lateral ankle ligament injury, but following this initial examination, recurrent giving-way of the foot occurred. She additionally felt significant but diffuse pain on the lateral side of the foot during loading in training and competition. For 2 months she was unable to run and conservative treatment failed. Diagnosis of a calcaneocuboid instability was established 4 months after the initial lesion by clinical and x-ray stress examination of the calcaneocuboid joint. Open surgery was successfully performed. Early functional posttreatment was done and the patient returned to full high-level gymnastics ability 16 weeks after surgery. Two years later, a similar injury occurred to the opposite calcaneocuboid joint and the same operative procedure again led to full sports ability.