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Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen.
Saxena, A, Fullem, B, Gerdesmeyer, L
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2017;(5):985-989
Abstract
Two case reports of high-level athletes with medial tibial stress syndrome (MTSS), 1 an Olympian with an actual stress fracture, are presented. Successful treatment included radial soundwave therapy, pneumatic leg braces, relative rest using an antigravity treadmill, and temporary foot orthoses. Radial soundwave therapy has a high level of evidence for treatment of MTSS. We also present recent evidence of the value of vitamin D assessment. Both patients had a successful outcome with minimal downtime. Finally, a suggested treatment regimen for MTSS is presented.
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Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta-analysis.
Sayegh, ET, Strauch, RJ
Clinical orthopaedics and related research. 2015;(3):1093-107
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Abstract
BACKGROUND Lateral epicondylitis is a painful tendinopathy for which several nonsurgical treatment strategies are used. Superiority of these nonsurgical treatments over nontreatment has not been definitively established. QUESTIONS/PURPOSES We asked whether nonsurgical treatment of lateral epicondylitis compared with observation only or placebo provides (1) better overall improvement, (2) less need for escape interventions, (3) better outcome scores, and (4) improved grip strength at intermediate- to long-term followup. METHODS The English-language literature was searched using PubMed and the Cochrane Central Register of Controlled Trials. Randomized-controlled trials (RCTs) comparing any form of nonsurgical treatment with either observation only or placebo at followup of at least 6 months were included. Nonsurgical treatments included injections (corticosteroid, platelet-rich plasma, autologous blood, sodium hyaluronate, or glycosaminoglycan polysulfate), physiotherapy, shock wave therapy, laser, ultrasound, corticosteroid iontophoresis, topical glyceryl trinitrate, or oral naproxen. Methodologic quality was assessed with the Consolidated Standards of Reporting Trials (CONSORT) checklist, and 22 RCTs containing 2280 patients were included. Pooled analyses were performed to evaluate overall improvement; requirement for escape interventions (treatment of any kind, outside consultation, and surgery); outcome scores (Patient-Rated Tennis Elbow Evaluation [PRTEE]; DASH; Pain-Free Function Index [PFFI]; EuroQoL [EQ]-5D; and overall function); and maximum and pain-free grip strength. Sensitivity analyses were performed using only trials of excellent or good quality. Heterogeneity analyses were performed, and funnel plots were constructed to assess for publication bias. RESULTS Nonsurgical treatment was not favored over nontreatment based on overall improvement (risk ratio [RR] = 1.05 [0.96-1.15]; p = 0.32), need for escape treatment (RR = 1.50 [0.84-2.70]; p = 0.17), PRTEE scores (mean difference [MD] = 1.47, [0.68-2.26]; p < 0.001), DASH scores (MD = -2.69, [-15.80 to 10.42]; p = 0.69), PFFI scores (standardized mean difference [SMD] = 0.25, [-0.32 to 0.81]; p = 0.39), overall function using change-from-baseline data (SMD = 0.11, [-0.14 to 0.36]; p = 0.37) and final data (SMD = -0.16, [-0.79 to 0.47]; p = 0.61), EQ-5D scores (SMD = 0.08, [-0.52 to 0.67]; p = 0.80), maximum grip strength using change-from-baseline data (SMD = 0.12, [-0.11 to 0.35]; p = 0.31) and final data (SMD = 4.37, [-0.65 to 9.38]; p = 0.09), and pain-free grip strength using change-from-baseline data (SMD = -0.20, [-0.84 to 0.43]; p = 0.53) and final data (SMD = -0.03, [-0.61 to 0.54]; p = 0.91). CONCLUSIONS Pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo. LEVEL OF EVIDENCE Level II, therapeutic study.
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Nonpharmacologic and pharmacologic management of CPP crystal arthritis and BCP arthropathy and periarticular syndromes.
Rosenthal, AK, Ryan, LM
Rheumatic diseases clinics of North America. 2014;(2):343-56
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Abstract
Calcium crystal arthritis is often unrecognized, poorly managed, and few effective therapies are available. The most common types of calcium crystals causing musculoskeletal syndromes are calcium pyrophosphate (CPP) and basic calcium phosphate (BCP). Associated syndromes have different clinical presentations and divergent management strategies. Acute CPP arthritis is treated similarly to acute gouty arthritis, whereas chronic CPP and BCP arthropathy may respond to strategies used for osteoarthritis. Calcific tendonitis is treated with a variety of interventions designed to dissolve BCP crystals. A better understanding of the causes and larger well-planned trials of current therapies will lead to improved care.
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Safety and efficacy of extracorporeal shock wave myocardial revascularization therapy for refractory angina pectoris.
Cassar, A, Prasad, M, Rodriguez-Porcel, M, Reeder, GS, Karia, D, DeMaria, AN, Lerman, A
Mayo Clinic proceedings. 2014;(3):346-54
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Abstract
OBJECTIVE To assess the safety and efficacy of extracorporeal shockwave myocardial revascularization (ESMR) therapy in treating patients with refractory angina pectoris. PATIENTS AND METHODS A single-arm multicenter prospective trial to assess safety and efficacy of the ESMR therapy in patients with refractory angina (class III/IV angina) was performed. Screening exercise treadmill tests and pharmacological single-photon emission computed tomography (SPECT) were performed for all patients to assess exercise capacity and ischemic burden. Patients were treated with 9 sessions of ESMR to ischemic areas over 9 weeks. Efficacy end points were exercise capacity by using treadmill test as well as ischemic burden on pharmacological SPECT at 4 months after the last ESMR treatment. Safety measures included electrocardiography, echocardiography, troponin, creatine kinase, and brain natriuretic peptide testing, and pain questionnaires. RESULTS Fifteen patients with medically refractory angina and no revascularization options were enrolled. There was a statistically significant mean increase of 122.3±156.9 seconds (38% increase compared with baseline; P=.01) in exercise treadmill time from baseline (319.8±157.2 seconds) to last follow-up after the ESMR treatment (422.1±183.3 seconds). There was no improvement in the summed stress perfusion scores after pharmacologically induced stress SPECT at 4 months after the last ESMR treatment in comparison to that at screening; however, SPECT summed stress score revealed that untreated areas had greater progression in ischemic burden vs treated areas (3.69±6.2 vs 0.31±4.5; P=.03). There was no significant change in the mean summed echo score from baseline to posttreatment (0.4±5.1; P=.70). The ESMR therapy was performed safely without any adverse events in electrocardiography, echocardiography, troponins, creatine kinase, or brain natriuretic peptide. Pain during the ESMR treatment was minimal (a score of 0.5±1.2 to 1.1±1.2 out of 10). CONCLUSION In this multicenter feasibility study, ESMR seems to be a safe and efficacious treatment for patients with refractory angina pectoris. However, larger sham-controlled trials will be required to confirm these findings.
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Update on medical management of Peyronie's disease.
Tan, RB, Sangkum, P, Mitchell, GC, Hellstrom, WJ
Current urology reports. 2014;(6):415
Abstract
The treatment of Peyronie's disease (PD) is a challenge for the clinician. In the quest to straighten the penis, alleviate pain, prevent further shortening, and restore erectile function, many non-surgical treatments have been offered in lieu of an operative approach, which is still considered the gold standard for definitive treatment. This communication is an update on the different approaches used in the minimally invasive management of this frustrating and yet intriguing condition.
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Ultrasound in athletes: emerging techniques in point-of-care practice.
Yim, ES, Corrado, G
Current sports medicine reports. 2012;(6):298-303
Abstract
Ultrasound offers sports medicine clinicians the potential to diagnose, treat, and manage a broad spectrum of conditions afflicting athletes. This review article highlights applications of ultrasound that hold promise as point-of-care diagnostics and therapeutic tools that can be used directly by clinicians to direct real-time management of athletes. Point-of-care ultrasound has been examined most in the context of musculoskeletal disorders in athletes, with attention given to Achilles tendinopathy, patellar tendinopathy, hip and thigh pathology, elbow tendinopathy, wrist pathology, and shoulder pain. More research has focused on therapeutic applications than diagnostic, but initial evidence has been generated in both. Preliminary evidence has been published also on abdominal ultrasound for splenic enlargement in mononucleosis, cardiopulmonary processes and hydration status, deep vein thrombosis, and bone mineral density. Further research will be required to validate these applications and to explore further applications of portable ultrasound that can be used in the care of athletes.
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SWAAT study: extracorporeal shock wave therapy and arginine supplementation and other nutraceuticals for insertional Achilles tendinopathy.
Notarnicola, A, Pesce, V, Vicenti, G, Tafuri, S, Forcignanò, M, Moretti, B
Advances in therapy. 2012;(9):799-814
Abstract
INTRODUCTION Extracorporeal shockwave therapy (ESWT) produces good results in the treatment of insertional Achilles tendinopathy. The efficacy of combined administration of dietary supplements with ESWT has not yet been studied. METHODS In this prospective, randomized clinical trial, Shock Waves therapy and Arginine for Achilles Tendinopathy (SWAAT), subjects affected by insertional Achilles tendinopathy were enrolled. Between January and October 2011, all participants underwent three sessions of ESWT. In addition, the patients in the experimental group received a daily dietary supplement containing arginine, Vinitrox (Bio Serae Laboratories SAS, Bram, France), collagen, methyl-sulfonyl-methane, vitamin C, and bromelain, while the control group patients received placebo. RESULTS There was no statistically significant difference in the visual analog scale (VAS) score between the two groups at 2 months (3.9 vs. 5.1; P=0.07), whereas at 6 months the value was significantly lower in the experimental group (2.0 vs. 2.9; P=0.04). The difference in the Ankle-Hindfoot Scale score at 2 and 6 months of follow-up (FU) was significantly in favor of the experimental group (2 months: 85.4 vs. 72.1; P=0.0035; 6 months: 92.4 vs. 76.5; P=0.0002). The Roles and Maudsley score also showed a statistically significant difference between the two groups in favor of the experimental arm as regards patient satisfaction (at 2 months: 1.7 vs. 2.8; P<0.0001; at 6 months: 1.5 vs. 2.3; P<0.001). There was a statistically significant reduction in tissue oximetry values compared to baseline in both treatment groups at 2 and 6 months of FU. Comparing the groups, only at the last FU, at 6 months, was a significantly lower oximetry value observed in the experimental group versus controls (60.2 vs. 66.0; P=0.007). CONCLUSION On the basis of the results obtained in this study, the authors conclude that in the treatment of insertional Achilles tendinopathy, ESWT induces a hemodynamic re-equilibrium with an amelioration in tendon trophism [corrected]. The addition of specific dietary supplements could improve the therapeutic response.
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Extracorporeal shock-wave therapy for supraspinatus calcifying tendinitis: a randomized clinical trial comparing two different energy levels.
Ioppolo, F, Tattoli, M, Di Sante, L, Attanasi, C, Venditto, T, Servidio, M, Cacchio, A, Santilli, V
Physical therapy. 2012;(11):1376-85
Abstract
BACKGROUND Extracorporeal shock-wave therapy (ESWT) represents a valid intervention in the treatment of people with supraspinatus calcifying tendinitis (SCT), but there is limited evidence for the useful range of ESWT doses. OBJECTIVE The aim of this study was to compare 2 different ranges of energy flux density in treatment of SCT with ESWT. DESIGN This study was designed as a single-blind randomized clinical trial. SETTING This study was performed in a university hospital. PATIENTS Forty-six patients with SCT were randomly assigned to 2 groups that received different therapeutic energy doses of ESWT (1) group A received ESWT at an energy level of 0.20 mJ/mm², and (2) group B received ESWT at an energy level of 0.10 mJ/mm². INTERVENTION The treatment protocol consisted of 4 sessions performed once a week. MEASUREMENTS The change in mean Constant Murley Scale (CMS) scores at 3 and 6 months was the primary endpoint. The change in the mean visual analog scale (VAS) scores from baseline to 3 and 6 months after the intervention and radiographic change in size of calcium deposits were evaluated as secondary endpoints. At 12 months, pain relief was assessed using a numeric rating scale. RESULTS Significant clinical improvement based on mean CMS scores was observed after 6 months in group A (X=79.43, SD=10.33) compared with group B (X=57.91, SD=6.53). Likewise, after 6 months, a significant decrease in VAS scores was found in group A (X=2.09, SD=1.54) compared with group B (X=5.36, SD=0.78). Calcific deposits disappeared in the same percentage of patients in both groups. LIMITATIONS The small sample size and lack of a control group were limitations of the study. CONCLUSIONS In ESWT for SCT, an energy level of 0.20 mJ/mm² appears to be more effective than an energy level of 0.10 mJ/mm² in pain relief and functional improvement.
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Extracorporeal shock wave treatment for shoulder calcific tendonitis: a systematic review.
Mouzopoulos, G, Stamatakos, M, Mouzopoulos, D, Tzurbakis, M
Skeletal radiology. 2007;(9):803-11
Abstract
The treatment of patients with calcific tendonitis is typically conservative, including physical therapy, iontophoresis, deep friction, local or systemic application of noninflammatory drugs, needle irrigation-aspiration of calcium deposit, and subacromial bursal steroid injection. If the pain becomes chronic or intermittent after several months of conservative treatment, arthroscopic and open procedures are available to curette the calcium deposit, and additional subacromial decompression can be performed if necessary. As an alternative, minimally invasive extracorporeal shock wave therapy (ESWT) has been postulated to be an effective treatment option for treating calcific tendinitis of the shoulder, before surgery. Herein we discuss the indications, mechanism of therapeutic effect, efficacy of treatment, and complications after ESWT application.
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Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder.
Krasny, C, Enenkel, M, Aigner, N, Wlk, M, Landsiedl, F
The Journal of bone and joint surgery. British volume. 2005;(4):501-7
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Abstract
We carried out a prospective, randomised controlled trial on two groups of 40 patients with painful calcific tendonitis and a mean age of 48.4 years (32.5 to 67.3). All were to undergo arthroscopic removal of the calcific deposit within six months after randomisation. The 40 patients in group I received ultrasound-guided needling followed by high-energy shock-wave therapy and the 40 in group II had shock-wave therapy alone. In both groups one treatment consisting of 2500 impulses of shock waves with an energy flux density of 0.36 mJ/mm(2) was applied. The clinical and radiological outcome was assessed using the 100-point Constant shoulder scoring system and standardised radiographs. The mean follow-up was 4.1 months and no patient was lost to follow-up. Both groups had significant improvement in their Constant shoulder score. Radiographs showed disappearance of the calcific deposit in 60.0% of the shoulders in group I and in 32.5% of group II (p < 0.05). Significantly better clinical and radiological results were obtained in group I than in group II. Arthroscopic removal of the deposit was avoided in 32 patients of group I and in 22 of group II. No severe side-effects were recorded.Ultrasound-guided needling in combination with high-energy shock-wave therapy is more effective than shock-wave therapy alone in patients with symptomatic calcific tendonitis, giving significantly higher rates of elimination of the calcium deposits, better clinical results and reduction in the need for surgery.