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Alghamdi NH, Pohlig RT, Seymore KD, Sions JM, Crenshaw JR, Grävare Silbernagel K. Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy. Orthop J Sports Med 2024; 12:23259671231221583. [PMID: 38332846 PMCID: PMC10851750 DOI: 10.1177/23259671231221583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 07/31/2023] [Indexed: 02/10/2024] Open
Abstract
Background Physical therapists frequently employ heel lifts as an intervention to reduce Achilles tendon pain and restore function. Purpose To determine the short-term effect of heel lifts on clinical and gait outcomes in participants with insertional Achilles tendinopathy (IAT). Study Design Case series; Level of evidence, 4. Methods Participants with IAT underwent eligibility screening and completed assessments at baseline and 2 weeks later. Primary outcomes included symptom severity (Victoria Institute of Sports Assessment-Achilles [VISA-A]), gait analysis with the 10-m walk-test at 2 speeds (normal and fast), and pain during walking. Pain and gait analysis were assessed under 3 conditions: before fitting 20-mm heel lifts, immediately after heel-lift fitting, and after 2 weeks of wearing heel lifts. Ultrasound images and measurements at the Achilles insertion were obtained from prone and standing positions (with and without heel lifts). Spatiotemporal gait parameters and tibial tilt angles were evaluated at normal speed using inertia measurement units during the 3 study conditions. Differences between the conditions were analyzed using paired t test or analysis of variance. Results Overall, 20 participants (12 female, 13 with bilateral IAT; mean age, 51 ± 9.3 years; mean body mass index 31.6 ± 6.8 kg/m2) completed all assessments. Symptom severity (VISA-A) of the more symptomatic side significantly improved at 2 weeks (60 ± 20.6) compared with baseline (52.2 ± 20.4; P < .01). Pain during gait (Numeric Pain Rating Scale) was significantly reduced immediately after heel-lift fitting (0.7 ± 2.0) when compared with baseline (2.2 ± 2.7, P = .043). Spatiotemporal gait parameters and tibial tilt angle before and after using heel lifts at normal walking speed were not significantly different; however, gait speed, stride length, and tibial tilt angle on both sides increased significantly immediately after using heel lifts and were maintained after 2 weeks of wear. Conclusion Using heel lifts not only improved symptom severity after 2 weeks but also immediately reduced pain during gait and had a positive impact on gait pattern and speed.
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Affiliation(s)
- Nabeel Hamdan Alghamdi
- Department of Physical Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ryan T. Pohlig
- Department of Epidemiology, University of Delaware, Newark, Delaware, USA
| | - Kayla D. Seymore
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, Delaware, USA
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
| | - Jaclyn Megan Sions
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, Delaware, USA
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
| | - Jeremy R. Crenshaw
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark, Delaware, USA
- Biomechanics and Movements Science Program, University of Delaware, Newark, Delaware, USA
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Velagala VR, Velagala NR, Kumar T, Singh A, Mehendale AM. Calcaneal Spurs: A Potentially Debilitating Disorder. Cureus 2022; 14:e28497. [PMID: 36185871 PMCID: PMC9514376 DOI: 10.7759/cureus.28497] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/28/2022] [Indexed: 11/18/2022] Open
Abstract
Feet are often the most neglected part of the body, all the while being the highly dependent part of daily work and mobility. The lack of attention to them can lead to painful conditions such as calcaneal spurs and associated conditions. Calcaneal spurs are bony projections that form around the calcaneal bone, the strongest, most significant, and posterior-most bone in the feet. The classic symptom of the calcaneal spur is talalgia, commonly known as heel pain. There are many causes of heel pain, which are usually associated with calcaneal spurs. Hence it becomes imperative to diagnose and treat them effectively. The development of calcaneal spur is shrouded in mystery, and why a few individuals are more prone to developing the condition than others depends on their gender, age, occupation, and lifestyle. Calcaneal spurs are seen in association with many diseases. It is also regarded as the etiological factor in plantar fasciitis and increasing body weight and as a complication in arthropathies, Gout, pes cavus, and pes planus. This review article aims to highlight a relationship between those factors while also summarizing the treatment modalities present today. Hence, it promotes the usage of a model for administering treatment based on a tier-wise follow-up procedure, where the response to a particular treatment is recorded. If it does not resolve the spur, the treatment progresses to the next tier. This review article hopes to shed light on the understanding and treatment of calcaneal spurs.
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Ribeiro AP, de Souza BL, João SMA. Effectiveness of mechanical treatment with customized insole and minimalist flexible footwear for women with calcaneal spur: randomized controlled trial. BMC Musculoskelet Disord 2022; 23:773. [PMID: 35964021 PMCID: PMC9375309 DOI: 10.1186/s12891-022-05729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKROUND Calcaneal spurs are described as bony outgrowths arising on medial calcaneal, where inappropriate footwear can promote disease progression. OBJECTIVE Investigate the effectiveness of mechanical treatment with customized insole and minimalist flexible footwear during gait training program in women with calcaneal spur. METHODS Design: A single-blinded, randomized and controlled trial. SETTING Biomechanics laboratory. PARTICIPANTS Forty-three women, 29 with calcaneal spur and 14 control. INTERVENTION Gait training program with use of the minimalist flexible footwear (MFG n = 15, age: 48.9 ± 9.4, height: 1.61 ± 0.1, BMI: 32.1 ± 7.0) and customized insole on footwear (COIG n = 14, age: 50.3 ± 5.8, height: 1.62 ± 0.1, BMI: 32.2 ± 4.3) and control (CG n = 14, age: 47.8 ± 8.6, height: 1.63 ± 0.1, BMI: 27.5 ± 4.5), followed of the evaluations: baseline (T0) and after three (T3) and six (T6) months. Duration of the intervention was of the six months consecutive for at least 42 h per week (six hours a day, seven days a week). Outcome primary were calcaneus pain (visual analogue scale), Foot Function Index (FFI), Foot Health Status Questionnaire (FHSQ-Br) and 6-min walk test (6MWT). Secondary was plantar pressure distribution by a pressure platform system during gait and static index foot posture (FPI). STATISTICAL ANALYSIS analysis of variance for repeated measure and between groups were used to detect treatment-time interactions (α = 5%). Effect size with D Cohen's also was used between T0 and after six (T6) months of intervention. RESULTS The MFG and COIG were effective at reducing pain after six months (MFG: 2.5-4.5 CI, p = 0.001; COIG: 1.5-3.5 CI, p = 0.011). The FFI and FHSQ-Br showed improvements with MFG and COIG after T6 (MFG: 13.7-15.4 CI, p = 0.010; COIG: 11.3-15.0 CI, p = 0.001). The 6MWT increased with MFG (589.3-622.7 CI) and COIG (401.3-644.7 CI) and foot pronation was decreased after T3 and T6 MFG (FPI Right: 4.2-5.4 CI; Left: 3.6-5.4 CI) COIG (FPI Right: 3.4-6.8 CI; Left: 3.3-5.7 CI). The contact area reduced on forefoot and rearfoot with MFG and GOIG and midfoot and rearfoot with MFG. Maximum force was reduced on foot with MFG after T3 and T6. The peak pressure was reduced on the forefoot with MFG and COIG and on midfoot and rearfoot with MFG. CONCLUSIONS The mechanical treatment with customized insole and minimalist flexible footwear during gait training program during six months in women with calcaneal spur reduced the calcaneus pain, increased function and health feet and reduced plantar load on the rearfoot, midfoot and forefoot. However, the footwear alone was more effective than when combined customized insole, given the greater efficacy on clinical and biomechanical aspects. TRIAL REGISTRATION ClinicalTrials.gov NCT03040557 (date of first registration: 02/02/2017).
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Affiliation(s)
- Ana Paula Ribeiro
- Physical Therapy Department, Post-Graduate Department, School of Medicine, University of São Paulo, R: Cipotânea, 51, Campus Universitário, São Paulo/SP, Brazil. .,School of Medicine, Post-Graduate in Health Science Department, Biomechanics and Musculoskeletal Rehabilitation Laboratory, University Santo Amaro, São Paulo, Brazil.
| | - Brenda Luciano de Souza
- School of Medicine, Post-Graduate in Health Science Department, Biomechanics and Musculoskeletal Rehabilitation Laboratory, University Santo Amaro, São Paulo, Brazil
| | - Silvia Maria Amado João
- Physical Therapy Department, Post-Graduate Department, School of Medicine, University of São Paulo, R: Cipotânea, 51, Campus Universitário, São Paulo/SP, Brazil
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Djiepmo F, Tamaskovics B, Bölke E, Peiper M, Haussmann J, Neuwahl J, Jazmati D, Maas K, Schmidt L, Gelzhäuser R, Schleich C, Corradini S, Orth K, van Griensven M, Rezazadeh A, Karimi K, Budach W, Matuschek C. Low-dose radiation treatment for painful plantar enthesophyte: a highly effective therapy with little side effects. Eur J Med Res 2022; 27:28. [PMID: 35197107 PMCID: PMC8867737 DOI: 10.1186/s40001-022-00642-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/13/2022] [Indexed: 12/02/2022] Open
Abstract
AIM Plantar enthesophyte is a common degenerative disorder. Surgical and medical treatment options are associated with either poor outcome or high percentage of relapse. Observations have indicated a beneficial effect of radiation therapy. We therefore wanted to evaluate pain reduction using orthovolt or cobalt-based radiation treatment for painful plantar enthesophyte and determine long-term response as well as prognostic parameters in this condition. METHODS We identified a total of 102 consecutive patients treated for a total of 117 symptomatic heel spurs. 59 patients were treated with cobalt radiation, 31 patients with orthovolt therapy and 12 patients with both radiation systems. Primary outcome measure was pain reduction being scored using the modified Rowe Score prior therapy, at the end of each treatment series as well as after 6 weeks. Secondary outcome measure was long-term outcome, evaluated in patients with a follow-up period of longer than 3 years. RESULTS Before radiation therapy, 61 patients (60.4%) had a score of 0, significant strong pain. At the time of completion of radiation treatment, 3 patients (2.7%) were pain-free (score of 30), whereas 8 patients (7.9%) had still severe pain (score 0). 6 weeks after radiation therapy, 33 patients (32.7%) were pain-free and 8 patients (7.9%) had severe pain (score 0), while at the time data of collection, 74 patients (73%) were free of pain and 1 patient (1%) had strong pain (score 0). Duration of pain before the start of radiation treatment was a significant prognostic factor (p = 0.012) for response to treatment. CONCLUSION Radiotherapy of painful plantar enthesophyte is a highly effective therapy with little side effects providing long-term therapeutic response. The only significant prognostic parameter for response to treatment is the duration of pre-radiation therapy pain. Early integration of radiation therapy in the treatment seems to result in superior pain reduction.
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Affiliation(s)
- Freddy Djiepmo
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
- Klinik Für Strahlentherapie Und Radiologische Onkologie, Heinrich-Heine-Universität, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Matthias Peiper
- Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Judith Neuwahl
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Kitti Maas
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Livia Schmidt
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Roman Gelzhäuser
- Institute of Mathematical Statistics and Probability Theory, Heinrich-Heine-University, Dusseldorf, Germany
| | - Christoph Schleich
- Radiology Dusseldorf/Viersen, Ernst-Schneider-Platz 1, Dusseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Klaus Orth
- University of Hannover, Hannover, Germany
| | - Martijn van Griensven
- Department cBITE, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, The Netherlands
| | - Amir Rezazadeh
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Kimia Karimi
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
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Giai Via A, Oliva F, Padulo J, Oliva G, Maffulli N. Insertional Calcific Tendinopathy of the Achilles Tendon and Dysmetabolic Diseases: An Epidemiological Survey. Clin J Sport Med 2022; 32:e68-e73. [PMID: 32976122 DOI: 10.1097/jsm.0000000000000881] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 05/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study reports the incidence of insertional calcific tendinopathy (ICT) of the Achilles tendon in the general population and the percentage of symptomatic patients. The secondary aim is to ascertain whether ICT is associated with diabetes mellitus, thyroid disorders, obesity, and hypercholesterolemia. We hypothesized that metabolic diseases increase the risk of ICT of the Achilles tendon. DESIGN Prospective observational study (level III study). SETTING Orthopedic Outpatients Clinic and Emergency Department of Tor Vergata University Hospital, Rome, Italy. PARTICIPANTS Four hundred thirty-three subjects who met the inclusion criteria. INTERVENTION METHODS We collected the plain radiographs of the foot and ankle of patients who attended the hospital. Personal data were recorded [age, sex, and body mass index (BMI)], and comorbidities investigated (diabetes mellitus, hypothyroidism, hyperthyroidism, obesity, and hypercholesterolemia). Multivariate regression analyses were performed to study the predictors of the occurrence of Achilles ICT. RESULTS A total of 101 patients (23.3%) showed radiographic evidence of ICT, and 3% (13 patients) were symptomatic. Age [odds ratio (OR) 1.05], diabetes (OR 2.95), hypercholesterolemia (OR 2.27), and hypothyroidism (OR 3.32) were significantly associated with the presence of ICT of the Achilles tendon. Independent predictors of ICT were age, diabetes, hypercholesterolemia, and hypothyroidism. A BMI >30 was associated with a higher incidence of calcifications, and patients with 2 or more comorbidities had more than 10 times higher risk to develop ICT. CONCLUSION Insertional calcific tendinopathy of the Achilles tendon is common, but few patients are symptomatic. The incidence of ICT increases with age and is significantly higher in patients with diabetes mellitus and hypothyroidism.
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Affiliation(s)
- Alessio Giai Via
- Department of Orthopaedics and Traumatology, Ospedale Sant'Anna, San Fermo della Battaglia, Como, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Johnny Padulo
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella Oliva
- Department of Internal Medicine, Ospedale del Mare, ASL1, Napoli, Italy; and
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Salerno, Italy
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, United Kingdom
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Effects of intralesional pulsed radiofrequency treatment on pain in patients with calcaneal spur: results of 460 patients. BMC Musculoskelet Disord 2021; 22:1033. [PMID: 34893055 PMCID: PMC8665537 DOI: 10.1186/s12891-021-04926-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to investigate the efficacy of intralesional pulsed radiofrequency (RF) in the treatment of calcaneal spur and the results of patients who underwent single and double sessions of RF treatment. Methods The population of this retrospective study consisted of 460 patients who were diagnosed with calcaneal spur with clinical examination and direct radiography. The Wong-Baker Faces Pain Rating Scale and The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were used to determine the pain status and functional capacities of the patients. Posttreatment evaluation was carried out on average in the 6th week. Results The study involved 460 patients, 76.9% of whom were female, with the average age of 50.8 ± 10.9 years in total. Of the patients 43% was given RF therapy in a single session, and 57% of them in double sessions. After the RF procedure, the number of patients whose pain decreased according to both AOFAS and Wong-Baker pain scoring systems increased statistically significantly (p < 0.001). There was a statistically significant increase in the AOFAS-pain scores and the total AOFAS scores and a significant decrease in the Wong Baker-pain scale after treatment. However, there was no significant change in treatment success with respect to the number of RF sessions. Although not statistically significant, the differences in the AOFAS-pain scores and in the total AOFAS scores were found to be higher in patients who underwent single session RF, while the difference in the Wong Baker-pain ranking was higher in patients who received double sessions RF. Conclusion Intralesional pulsed RF procedure can be preferred as a relatively less invasive method that does not have any serious complications in patients with persistent calcaneal spurs who do not respond to the use of oral anti-inflammatory drugs and shoe insoles, nor corticosteroid injection to the lesion area.
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Başdelioğlu K. Radiologic and Demographic Characteristics of Patients With Plantar Calcaneal Spur. J Foot Ankle Surg 2021; 60:51-54. [PMID: 33172781 DOI: 10.1053/j.jfas.2020.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 02/03/2023]
Abstract
Many people with heel pain in the general population are often diagnosed with plantar calcaneal spurs (PCS). The aim of this study was to evaluate the radiological and demographic characteristics of PCS patients and to compare the differences with the control group. In 2018, 420 patients with weightbearing lateral ankle X-ray images were included in the study. The patients were divided into 2 groups as PCS group and control group. Groups were compared age and age group (20-29, 30-39, 40-49, 50-59, 60-69, 70 and over) weight, height, body mass index (<25, 25-30, >30), chronic diseases as demographically and were also compared radiologically as calcaneal inclination angle (CIA), lateral talocalcaneal angle (LTCA), Bohler angle and Gissane angle. A statistically significant relationship was found between gender and PCS. Plantar calcaneal spur is more common in females than in males (X2:8.101, p < .03). PCS was less common in patients with BMI <25 and 25-29.9, whereas PCS is more common in patients with BMI >30 (X2:7.698, p < .021). Although the CIA angle was within normal limits in both groups, it was significantly lower in patients with PCS than in the control group(p < .05). There was no statistically significant difference between the 2 groups in terms of age, chronic disease, LTCA, Bohler angle, Gissane angle. Female gender and obesity are among the risk factors for PCS formation. CIA may have an important role in PCS formation. In order to clarify the etiology and pathophysiology of PCS, further studies with radiological features are needed.
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Affiliation(s)
- Koray Başdelioğlu
- Clinical Surgeon, Istanbul Oncology Hospital, Department of Orthopaedic and Traumatology, Istanbul, Turkey.
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Radiation-induced DNA double-strand breaks in peripheral leukocytes and therapeutic response of heel spur patients treated by orthovoltage X-rays or a linear accelerator. Strahlenther Onkol 2020; 196:1116-1127. [PMID: 32651595 PMCID: PMC7686210 DOI: 10.1007/s00066-020-01662-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/22/2020] [Indexed: 11/18/2022]
Abstract
Purpose Biodosimetric assessment and comparison of radiation-induced deoxyribonucleic acid (DNA) double-strand breaks (DSBs) by γH2AX immunostaining in peripheral leukocytes of patients with painful heel spur after radiation therapy (RT) with orthovoltage X‑rays or a 6-MV linear accelerator (linac). The treatment response for each RT technique was monitored as a secondary endpoint. Patients and methods 22 patients were treated either with 140-kV orthovoltage X‑rays (n = 11) or a 6-MV linac (n = 11) with two weekly fractions of 0.5 Gy for 3 weeks. In both scenarios, the dose was prescribed to the International Commission on Radiation Units and Measurements (ICRU) dose reference point. Blood samples were obtained before and 30 min after the first RT session. γH2AX foci were quantified by immunofluorescence microscopy to assess the yield of DSBs at the basal level and after radiation exposure ex vivo or in vivo. The treatment response was assessed before and 3 months after RT using a five-level functional calcaneodynia score. Results RT for painful heel spurs induced a very mild but significant increase of γH2AX foci in patients’ leukocytes. No difference between the RT techniques was observed. High and comparable therapeutic responses were documented for both treatment modalities. This trial was terminated preliminarily after an interim analysis (22 patients randomized). Conclusion Low-dose RT for painful heel spurs with orthovoltage X‑rays or a 6-MV linac is an effective treatment option associated with a very low and comparable radiation burden to the patient, as confirmed by biodosimetric measurements.
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Beytemür O, Öncü M. The age dependent change in the incidence of calcaneal spur. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:367-371. [PMID: 30170885 PMCID: PMC6204473 DOI: 10.1016/j.aott.2018.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 10/02/2017] [Accepted: 06/27/2018] [Indexed: 12/21/2022]
Abstract
Objective The aim of the present study was to evaluate the association between the calcaneal spur incidence and age, gender and side. Methods Lateral ankle X-rays of 1335 patients (550 (41.2%) females and 758 (58.8) males; mean age: 46.5 ± 13.5 years) who referred to our hospital because of trauma were reviewed. Incidence of plantar calcaneal spur, posterior calcaneal spur and association of such incidences with age, gender and side were all evaluated. Results Incidences of plantar calcaneal spur and posterior calcaneal spur were detected as 32.2% (male: 31%, female: 34%) and 13.1% (male: 11%, female: 16%), respectively. Incidence of plantar calcaneal spur increased by age whereas there was not any association with gender and location. The highest incidence was detected as 41.8% over 70 years of age. Incidence of posterior calcaneal spur increased by age and female gender whereas no significant association was observed with location. The highest incidence was detected as 22.3% between 61 and 70 years of age. Conclusion Incidences of plantar and posterior calcaneal spur were detected as 32.2% and 13.1%, respectively. Both plantar and posterior calcaneal spur incidence increases by age. Posterior calcaneal spur occurs significantly more frequently in females while, no difference is found between the males and females in incidence of the plantar calcaneal spur. Level of evidence Level IV, diagnostic study.
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Affiliation(s)
- Ozan Beytemür
- Bağcılar Training and Research Hospital, Department of Orthopedics and Traumatology, İstanbul, Turkey.
| | - Mehmet Öncü
- Bağcılar Training and Research Hospital, Department of Radiology, İstanbul, Turkey.
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Krogh TP, Fredberg U, Ammitzbøl C, Ellingsen T. Ultrasonographic Characteristics of the Common Extensor Tendon of the Elbow in Asymptomatic Individuals: Thickness, Color Doppler Activity, and Bony Spurs. Orthop J Sports Med 2017; 5:2325967117704186. [PMID: 28540316 PMCID: PMC5431425 DOI: 10.1177/2325967117704186] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Ultrasonography (US) of the common extensor tendon (CET) of the elbow is often part of the assessment of patients with lateral epicondylitis. This US assessment is currently based on general tendinopathy references and not well-defined US entities. Purpose: To describe CET thickness, color Doppler activity, and bony spurs on US in asymptomatic volunteers and to investigate the influence of sex, age, height, body mass index (BMI), weight, and elbow dominance on the measurements. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Tendon thickness, color Doppler activity, and bony spurs of the CET were measured sonographically in 264 adults (50% women) aged 20 to 96 years. Two different tendon-thickness measuring techniques were applied, labeled the “plateau measure” and the “1-cm measure.” Color Doppler activity was based on a 0 to 4 rating scale (negative, grades 0 and 1; positive, grades 2-4). A bony spur was defined as a bony outgrowth (≥0.3 mm) arising at the insertional site of the CET. Results: With both tendon-thickness measuring techniques, the CET in the dominant elbow was thicker than that in the nondominant elbow, and male tendons were thicker than female tendons (all P ≤ .03). In regression analysis, tendon thickness correlated with weight, color Doppler activity, and arm dominance for both measuring techniques in multiple regression analysis. In addition, the plateau measure correlated with height and the presence of bony spurs. No correlations were observed regarding BMI, sex, or age. Positive color Doppler activity was found in 9% of examined elbows, with no difference between the sexes regarding dominant versus nondominant elbows (all P ≥.20). Bony spurs were found to increase with age, from 23% for people in their 20s to 74% in people older than 70 years. Bony spurs were more common in the dominant elbow (P ≤ .01). Women had a higher prevalence of bony spurs than men, but only in the dominant elbow (P = .03). Conclusion: This study presents the US characteristics and normal values of the CET. In 264 asymptomatic participants, the CET was found to be thicker in men and in the dominant elbow. No difference in tendon thickness could be demonstrated with regard to different age groups. Color Doppler activity was found to be positive in nearly 1 of 10 asymptomatic subjects. Bony spurs were a common finding; they increased in prevalence with every decade in age and were considered part of the aging process. Normal variations in CET morphologic characteristics should therefore be considered when implementing US in trials and clinical practice.
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Affiliation(s)
- Thøger P Krogh
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Torkell Ellingsen
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
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Kirkpatrick J, Yassaie O, Mirjalili SA. The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations. J Anat 2017; 230:743-751. [PMID: 28369929 DOI: 10.1111/joa.12607] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 12/15/2022] Open
Abstract
The plantar calcaneal spur (PCS) is a bony outgrowth from the calcaneal tuberosity and has been studied using various methods including cadavers, radiography, histology and surgery. However, there are currently a number of discrepancies in the literature regarding the anatomical relations, histological descriptions and clinical associations of PCS. Historically, authors have described the intrinsic muscles of the foot and/or the plantar fascia as attaching to the PCS. In this article we review the relationship between the PCS and surrounding soft tissues as well as examining the histology of the PCS. We identify a number of key associations with PCS, including age, weight, gender, arthritides, plantar fasciitis and foot position; these factors may function as risk factors in PCS formation. The etiology of these spurs is a contentious issue and it has been explained through a number of theories including the degenerative, inflammatory, traction, repetitive trauma, bone-formers and vertical compression theories. We review these and finish by looking clinically at the evidence that PCS causes heel pain.
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Affiliation(s)
- Joshua Kirkpatrick
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
| | - Omid Yassaie
- Department of Orthopedic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Seyed Ali Mirjalili
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
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Agarwal S, Garg S, Vasudeva N. Subtalar Joint Instability and Calcaneal Spurs Associated with the Configuration of the Articular Facets of Adult Human Calcaneum in Indian Population. J Clin Diagn Res 2016; 10:AC05-AC09. [PMID: 27790414 PMCID: PMC5071914 DOI: 10.7860/jcdr/2016/20216.8444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/25/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Morphological variations of articular facets of calcaneum may predispose people to joint instability, ligamentous laxity and development of arthritic changes in the subtalar joint. Knowledge of such variations is essential for treatment and diagnostic procedures in orthopaedic surgeries. AIM The aim of this study was to determine patterns of articular facets of calcanei and to establish its correlation with calcaneal spurs. MATERIALS AND METHODS The study was conducted on 580 adult calcanei of Indian origin at Maulana Azad Medical College and pattern of articular facets were observed and classified according to five patterns described in literature. A digital vernier calliper was used to measure separation between anterior and middle facet. Degree of intersecting angle between anterior and medial facets was calculated using UTHSCSA Image Tool software. The calcaneal spurs were observed by visual inspection. RESULTS Out of 580 calcanei, 66.55% had fused anterior and middle facets (Pattern I), 27.59% had all three facets separate (Pattern II), 5.52% had absence of anterior facet (Pattern III), 0.17% had all three facets fused (Pattern IV) and 0.17% had fused middle and posterior facets (Pattern V). A significant side variation was present in Pattern III with predominance on left side. Mean angle of intersection was 147.700 in Pattern I and 133.340 in Pattern II calcaneum. Calcaneal spurs were found in 61.38% out of which it was associated with Pattern I in 43.62%, Pattern II in 14.66% and Pattern III in 2.76%. CONCLUSION Individuals with Pattern I and III calcaneum were found to be at a greater risk of subtalar joint instability than individuals with Pattern II. Angle of intersection was obtuse in Pattern I which resulted in ligament laxity and unstable joint. Pattern I was more common in Indian population and this fact necessitates modifications of the western surgical techniques to suit the Indian scenario. An association between the presence of spur and facet configuration was found to be significant.
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Affiliation(s)
- Shilpi Agarwal
- Senior Resident, Department of Anatomy, Maulana Azad Medical College, New Delhi, India
| | - Shilpi Garg
- Senior Resident, Department of Anatomy, Maulana Azad Medical College, New Delhi, India
| | - Neelam Vasudeva
- Director Professor and Head of Department, Department of Anatomy, Maulana Azad Medical College, New Delhi, India
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Rajkohila J, Daniel P, Suganthy J. Study of calcaneal spurs and lateral tubercular bar in Indian population. J ANAT SOC INDIA 2016. [DOI: 10.1016/j.jasi.2016.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kullar JS, Randhawa GK, Kullar KK. A study of calcaneal enthesophytes (spurs) in Indian population. Int J Appl Basic Med Res 2014; 4:S13-6. [PMID: 25298934 PMCID: PMC4181123 DOI: 10.4103/2229-516x.140709] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 03/28/2014] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Calcaneus or os calcis forms a major component of the skeleton of foot providing posterior pillars for bony arches of the foot. It is largest of seven tarsal bones of foot and forms prominence of heel. Many times anterior to calcaneal tuberosity an osteophytic outgrowth has been observed (calcaneal or heel spur) extending along entire width, for about 2-2.5 cm. The apex of spur seen embedded in plantar fascia, directly anterior to its origin. Hence, the study of calcaneal spurs has been undertaken. MATERIALS AND METHODS The material for the study consisted of 200 dry (100 right and 100 left), adult calcanei of unknown age and sex obtained from Department of Anatomy. The calcaneal enthesophytes/spurs were studied in detail and classified according to types of calcaneum. RESULTS Maximum incidence of calcaneal spurs were found in Type I calcanei (11%) and no calcaneal spurs were found in Type III calcanei. Total incidence of dorsal calcaneal spurs in all types of calcanei was maximal (15.5%). The incidence of plantar spurs was 6.5% being highest in Type I calcanei (4%). The incidence and type of calcaneal spurs were compared with those of previous studies and etiology of heel pain has been discussed. Correlation between type of calcanei and spurs has been studied for the 1(st) time. CONCLUSION Calcaneal spurs are related to type of calcanei with the highest frequency in Type I and least in Type III (no spurs seen in Type III and least in Type IV). Other factors, which contribute toward increase in incidence of spurs, are increasing age and weight, concurrent orthopedic diseases, and heel pain.
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Vulcano E, Mani SB, Do H, Bohne WH, Ellis SJ. Association of Achilles tendinopathy and plantar spurs. Orthopedics 2014; 37:e897-901. [PMID: 25275977 DOI: 10.3928/01477447-20140924-56] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 01/31/2014] [Indexed: 02/03/2023]
Abstract
Plantar spurs and Achilles tendinopathy are common causes of heel pain. In the authors' practice, it was anecdotally noted that patients with Achilles tendinopathy often presented with plantar spurs. Nonetheless, there is a shortage of studies investigating whether Achilles tendinopathy and plantar spurs exist concomitantly. A better understanding of the association between the 2 pathologies might help physicians recognize and treat both conditions, educate patients about Achilles tendinopathy and plantar spurs, and ultimately investigate possible underlying causes of both pathologies that could be addressed together. The authors examined the prevalence of plantar spurs in patients diagnosed with Achilles tendinopathy as well as demographic differences within the unilateral and bilateral Achilles tendinopathy populations. A total of 785 patient records were retrospectively reviewed. Mean patient age was 56.2±15.5 years (46.9% men and 53.1% women). Seventy-two (9.2%) patients were affected bilaterally by Achilles tendinopathy. Lateral radiographs were reviewed by an orthopedic surgeon to identify the presence of plantar spurs. A total of 329 (41.9%) patients with Achilles tendinopathy were found to have a concomitant plantar spur. Patients with unilateral Achilles tendinopathy and a plantar spur were more likely to be women (58.7% vs 49.8%, P=.020) and older (62.7 vs 51.7 years, P<.001). In the bilateral Achilles tendinopathy group, there were 46 (63.9%) patients with at least one foot presenting with a plantar spur. The study's findings suggest a significant association between Achilles tendinopathy and plantar spurs. Older women with Achilles tendinopathy are at greater risk of being affected by plantar spurs.
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Moroney PJ, O'Neill BJ, Khan-Bhambro K, O'Flanagan SJ, Keogh P, Kenny PJ. The conundrum of calcaneal spurs: do they matter? Foot Ankle Spec 2014; 7:95-101. [PMID: 24379452 DOI: 10.1177/1938640013516792] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic plantar heel pain is a common and potentially debilitating condition, often caused by plantar fasciitis. Plantar calcaneal spurs were originally considered the cause of plantar fasciitis but are now regarded as an incidental finding by most authors. We aimed to test this hypothesis and to investigate predisposing factors for the development of spurs. METHODS We reviewed all lateral ankle X rays taken in our institution over a 6-month period and identified all X rays demonstrating calcaneal spurs. Then, we identified a similar number of age- and sex-matched controls without spurs. We contacted both groups by telephone and compared symptoms of heel pain, plantar fasciitis, associated comorbidities, and foot and ankle outcome scores (FAOSs). RESULTS We reviewed the X rays of 1103 consecutive patients and found a spur prevalence of 12.4%, more common in women and older patients. Questioning of the spur group and control group found a higher body mass index in the spur group. Patients with spurs were 4 times more likely to have diabetes mellitus and 10 times more likely to have lower-limb osteoarthritis. Patients with spurs had more foot pain and poorer FAOS than the control group, even when patients with plantar fasciitis were excluded. CONCLUSION Our results demonstrate that the presence of a plantar calcaneal spur may be an indicator of foot pain independent of plantar fasciitis. Although spurs may not cause foot pain themselves, they may be an indication of other associated conditions. CLINICAL RELEVANCE We have demonstrated the relevance of a radiographic finding once considered irrelevant.
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Affiliation(s)
- Paul J Moroney
- Department of Trauma and Orthopaedics, Connolly Hospital Blanchardstown, Dublin, Ireland
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Toumi H, Davies R, Mazor M, Coursier R, Best TM, Jennane R, Lespessailles E. Changes in prevalence of calcaneal spurs in men & women: a random population from a trauma clinic. BMC Musculoskelet Disord 2014; 15:87. [PMID: 24629226 PMCID: PMC3995580 DOI: 10.1186/1471-2474-15-87] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 03/10/2014] [Indexed: 11/23/2022] Open
Abstract
Background This study reports the changing prevalence of ankle (Achilles and plantar) spurs with age, in order to comment on their significance to rheumatologists. Methods 1080 lateral ankle radiographs from each of 9 (50 men and 50 women) age cohorts from 2 to 96 years old of patients attending a trauma clinic were examined and spurs classified as small or large. Results The prevalence of both Achilles and plantar spurs in relation to the age categories and sex was variable. Overall, there was 38% of the population who had a spur (Achilles or plantar) and only third (11%) with spurs at both sites (Achilles and plantar). Large spurs were more prevalent in older individuals (40 to 79 years). There were no large plantar spurs in individuals <40 years of age and only 2% for the Achilles. The prevalence of spurs (Achilles and plantar) was significantly higher for woman than men in individuals <50 years of age. There was a notable moderate positive correlation (r = 0.71) between both plantar and Achilles spurs for women <30 years of age but no correlation for men (r = -0.03). Conclusion Plantar and Achilles spurs are highly prevalent in older people and the radiographic appearance of spurs differs between men and women. In individuals < 50 years of age, spur (Achilles and plantar) formation is more common in women than in men. Additionally, there was a notable moderate positive correlation between Achilles and plantar spurs for women <30 years of age.
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Affiliation(s)
- Hechmi Toumi
- EA4708 Orleans University, IPROS, CHRO, 1, rue Porte-Madeleine, BP 2439, Orleans cedex 1 45032, France.
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Vyce SD, Addis-Thomas E, Mathews EE, Perez SL. Painful prominences of the heel. Clin Podiatr Med Surg 2010; 27:443-62. [PMID: 20691376 DOI: 10.1016/j.cpm.2010.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Heel pain is a common malady, with reported prevalence ranging from 4% to 21%. Referral to foot and ankle specialists for heel pain is also common, but patient awareness of the cause of heel pain may be limited. Many misconceptions about how heel exostoses relate to heel pain exist in the medical community and the general patient population, with many patients referred for or presenting with the simple complaint ''I have a heel spur.'' This article reviews the common exostoses of the heel, including plantar, lateral, and posterior spurs, with specific attention to the cause and treatments.
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Affiliation(s)
- Steven D Vyce
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA.
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Menz HB, Zammit GV, Landorf KB, Munteanu SE. Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? J Foot Ankle Res 2008; 1:7. [PMID: 18822162 PMCID: PMC2553779 DOI: 10.1186/1757-1146-1-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Accepted: 08/11/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Plantar calcaneal spurs are common, however their pathophysiology is poorly understood. This study aimed to evaluate the prevalence and correlates of plantar calcaneal spurs in a large sample of older people. METHODS Weightbearing lateral foot radiographs of 216 people (140 women and 76 men) aged 62 to 94 years (mean age 75.9, SD 6.6) were examined for plantar calcaneal and Achilles tendon spurs. Associations between the presence of spurs and sex, body mass index, radiographic measures of foot posture, self-reported co-morbidities and current or previous heel pain were then explored. RESULTS Of the 216 participants, 119 (55%) had at least one plantar calcaneal spur and 103 (48%) had at least one Achilles tendon spur. Those with plantar calcaneal spurs were more likely to have Achilles tendon spurs (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.2 to 3.5). Prevalence of spurs did not differ according to sex. Participants with plantar calcaneal spurs were more likely to be obese (OR = 7.9, 95% CI 3.6 to 17.0), report osteoarthritis (OR = 2.6, 95% CI 1.6 to 4.8) and have current or previous heel pain (OR = 4.6, 95% CI 2.3 to 9.4). No relationship was found between the presence of calcaneal spurs and radiographic measures of foot posture. CONCLUSION Calcaneal spurs are common in older men and women and are related to obesity, osteoarthritis and current or previous heel pain, but are unrelated to radiographic measurements of foot posture. These findings support the theory that plantar calcaneal spurs may be an adaptive response to vertical compression of the heel rather than longitudinal traction at the calcaneal enthesis.
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Affiliation(s)
- Hylton B Menz
- Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria, 3086, Australia.
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Haupt G. Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendinopathy and other orthopedic diseases. J Urol 1997; 158:4-11. [PMID: 9186313 DOI: 10.1097/00005392-199707000-00003] [Citation(s) in RCA: 174] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The use of shock waves in orthopedic diseases was reviewed with special regard to the clinical applications. MATERIALS AND METHODS Findings in the literature and results from our own studies were analyzed and summarized. RESULTS Extracorporeal shock waves induced osteoneogenesis in animal models with intact and fractured bones. Based on these findings shock waves were used for the treatment of pseudarthrosis in humans. Most patients had at least 1 unsuccessful operation before shock wave therapy. Complete reunion was noted in 62 to 91% of cases and shock waves are recommended by some as the first choice of treatment for hypertrophic pseudarthrosis. After failed nonoperative therapy shock waves were used for the treatment of patients with various diseases as secondary treatment. The success rate for treatment of tendinopathies, such as tennis elbow, periarthritis humeroscapularis or calcaneal spur, was approximately 80%. For calcific tendinitis shock wave therapy seems to be superior to all other minimal or noninvasive techniques without compromising a potential later operation. CONCLUSIONS Shock waves have changed medical therapy substantially. Accounting for the epidemiology of the treated diseases, this new change may equal or even surpass the impact of extracorporeal shock wave lithotripsy.
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Affiliation(s)
- G Haupt
- Department of Urology, Ruhr-University Bochum, Germany
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Riepert T, Drechsler T, Schild H, Nafe B, Mattern R. Estimation of sex on the basis of radiographs of the calcaneus. Forensic Sci Int 1996; 77:133-40. [PMID: 8819988 DOI: 10.1016/0379-0738(95)01832-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- T Riepert
- Institut fur Rechtsmedizin der Johannes Gutenberg-Universitat, Mainz, Germany
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