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Searching file 26

Message Number 261712
Re: Haglund's Deformity View Thread
Posted by COOKIE B on 11/03/09 at 21:17

HELLO,

I SUFFERED FROM HAGLUND'S DEFORMITY FOR OVER 7 YEARS BECAUSE THE DOCTOR WOULD NOT X-RAY MY FOOT TO DIAGNOSE THE PROBLEM! MY SPUR HAD BROKEN OFF AND THERE WERE BONE FRAGMENTS INSIDE MY TENDON FLOATING BENEATH THE TENDON. EACH TIME I WOULD TRY TO WALK OR EXERCISE, THE NEXT DAY I COULDN'T WALK ON MY FOOT! I TRIED TAPING THE HEEL TO IMOBILZE IT TO SOME EXTENT, BUT THAT IS SUCH A PROCESS EACH TIME YOU WANT TO GO AND WALK.
I HAD A FRIEND WHO WAS A VET THAT SNEAKED ME IN AND RAN AN X-RAY ON MY FOOT AND THAT IS HOW I FOUND THE BONE FRAGMENTS! I TOOK THE X-RAY TO THE DOCTOR AND HE FINALLY REFERRED ME TO AN ORTHOPEDIC SURGEON WHO SPECIALIZED IN FOOT SURGERY. DR. LINDEN DILLION FROM FORT WORTH, TEXAS PERFORMED THE SURGERY AND I COULDN'T HAVE ASKED FOR A BETTER PHYSICIAN! HE IS INCREDIBLE AT WHAT HE DOES RIGHT DOWN TO SENDING YOU HOME WITH PRESCRIPTIONS FOR PAIN, MEDS FOR CONSTIPATION FROM THE PAIN MEDS, ANTIBIOTICS, MEDS TO CONTROL YEAST INFECTIONS CAUSED BY THE ANITBIOTICS, ETC. HE HAD EVERYTHING READY FOR ANYTHING THAT MIGHT COME UP DUE TO THE SURGERY, HE WAS OUTSTANDING! I WOULD RECOMMEND THE SURGERY BY DR. DILLION TO CHANGE YOUR LIFE FOR THE BETTER!
THE SURGERY RECOVERY IS A LONG PROCESS, BUT I WOULD DO IT ALL OVER AGAIN IF I HAD THE OTHER FOOT TO DO.
THE RECOVERY REQUIRED ME TO BE IN BED FOR 2 WEEKS WITH MY FOOT ELEVATED ON THE 'DILLION PILLOW' THAT WAS CREATED BY DR. DILLION AND THEN 4 MONTHS IN A CAST THAT WAS CHANGED EVERY 2 WEEKS TO SLOWLY RE-POSITION THE HEEL TO EVENTUALLY STRETCH THE TENDON TO A WALKING POSITION. THE SURGERY IS WHERE THEY DETACH THE TENDON AND REMOVE ALL THE BONE FRAGMENTS AND THEN RE-ATTACH THE TENDON USING STAPLES TO ATTACH THE TENDON BACK ONTO THE HEEL, ABOUT 40 STAPLES IN THE HEEL AND ABOUT 30 ON THE OUTSIDE OF THE HEEL. THIS SOUNDS PRETTY ROUGH, BUT THE RELIEF FROM THE PAIN IS WORTH EVERY BIT OF THE PROCESS.

IF YOU CHOOSE TO HAVE THE SURGERY, MAKE SURE YOU HAVE A REPUTABLE SURGEON AND NOT A PODIATRIST! THIS IS NOT A MINOR SURGERY TO BE DONE IN THE DOCTOR'S OFFICE! YOUR FEET ARE EXTREMELY IMPORTANT TO YOU, MAKE SURE YOU ARE DEALING WITH A ORTHOPEDIC FOOT SPECIALIST!

GOOD LUCK TO ALL OF YOU WHO ARE SUFFERING WITH THIS CONDITION! DO NOT TAKE NO FOR AN ANSWER FROM YOUR DOCTOR, THERE IS RELIEF OUT THERE THAT WORKS! I HAD MY SURGERY ABOUT 10 YEARS AGO AND I AM STILL PAIN FREE TODAY! THANK GOD FOR DR. LINDEN DILLION!

Result number: 1

Message Number 261257

Re: Alpha Lipoic Acid View Thread
Posted by Dr. Wedemeyer on 10/12/09 at 18:13

Dr. Wander not to detract from your post and this product, because I believe that it is an excellent one but did you notice that the research that they point to in validating their claims were both Meta-Analyses? One huge problem with these types of studies is that bias cannot be controlled, ie; double-blinded. It makes me question the motive when anyone selling a product controls the studies, especially when no real research was performed.

I simply disagree with the statement that 'Up to 50% of individuals are unable to fully convert folic acid into the active form of folate, L-methylfolate.6,7'. I do however believe that patients with certain medical conditions and that aging affect folate conversion (a simple blood test would solve any doubt obviously, but then neuropathic patients do not to my knowledge exhibit high homocysteine levels, heart patients do).

There is a lot of debate regarding oral vs. injectable vitamins. I also have heard all of the stories about 'natural' whole food vitamins being better than synthetics. Dr. Barry Sears of the Zone Diet fame spent years researching pharmaceutical delivery systems prior to studying blood glucose as a factor in obesity and weight-control. His research led him to believe that synthetics were just as effective in entering the bloodstream and utilization on a case by case basis. He is a knowledgeable researcher and I trust his opinion.

I have advocated oral B-12 for years unless a patient lacks intrinsic factor and never has a patient had a problem switching to an oral supplement in favor of an injectable (unless they lack IF). Studies are underway and will disprove this age old myth:

http://clinicaltrials.gov/ct2/show/NCT00699478

The first pass argument in a healthy individual just doesn't pass the smell test with me. It was created to track drug bioavailability and enhance dosing. I doubt it has a great deal to do with human nutrition, in fact many foods are enhanced by being broken down in the GI tract (B-12 is an example where it requires IF from the stomach and is absorbed in the distal illeum). It is difficult to recreate these chemical interactions in pharmaceuticals and therefore they bypass the gut and favor IV, intramuscular and sublingual delivery for this reason.

Is it always more efficient? Show me the proof please.

Result number: 2

Message Number 261127

Help Me Understand This One View Thread
Posted by Rick R on 10/07/09 at 14:55

House Kills Resolution to Oust Rangel From Chair of Tax-Writing Committee

http://www.foxnews.com/politics/2009/10/07/house-considers-resolution-oust-rangel-ways-means-committee-chair/

This may sound like a contrived request on my part but I have indeed learned by associating with people with differing view points that at times I'm capable of wearing blinders and at times too easily accepting of reinforcement for my points of view.

I hold dear the principle of innocence until proven guilt, and Charlie Rangel is not worth throwing out such a cherished value. But tell me why we shouldn't throw everybody in the house out on their ear or more appropriate anatomical feature that voted against removing Rangel from his committee chair until his tax evasion issue is resolved. This is a far cry from jumping to criminal guilt prior to due process. How much are we going to take from these thieves before we refuse to accept it anymore. I don't care if they are Republicans, Democrats Libertarians, Independents, Whigs, or the Purple Salamander party.

Our politicians are great at adding unrelated tidbits to bills and such forcing others to appear to be against the base issue, when in fact, they are against the superfluous hitch hiker, be it a slab of pork or whatever. So I'll keep a sliver of skepticism open.

Our government is corrupt and CR appears to be the poster boy for corruption. Our House of Reps appears to not give a rats behind. I'll be looking at how Juddy Biggert voted and either be thanking her for her vote or vowing to make sure she doesn’t misrepresent me in the future, unless of course she can enlighten me on that sliver.

Rick

As a footnote: Our government has taken the right to innocence prior to proven guilt away from us when they (Congress) delegate their authority. This was part of the slight of hand when the big agencies were created. Sure theoretically you can appeal to the courts under a presumption of innocence but how real is that after you are broke working your way through the agency. We can thank the “New Deal” for much of this.

Result number: 3
Searching file 25

Message Number 259529

Concerns for safety from Republican Led Violence Cause for Cancellation View Thread
Posted by marie:) on 8/09/09 at 13:03

It's a real shame when honest hard working Americans on both sides of a debate fear fringe members of the Republican Party.......which so far have included local Republican leaders. Why are Republicans afraid of free speech? What kinds of people behave violently on a middle school campus? What's in the tea their drinking? It's not easy watching the GOP fall apart. Well keep the blinders on it only helps things for 2010. ;)

http://www.stltoday.com/blogzone/political-fix/political-fix/2009/08/citing-safety-concerns-u-city-cancels-mccaskills-event/
The school district sent a news release this afternoon stating that the “reasons for the cancellation by the school district are due to concerns for the safety and security of its staff, community members attending the event, and for the students who would be on campus during that time.”

http://www.commercialappeal.com/news/2009/aug/08/hundreds-pack-boisterous-town-hall-meeting/

Within 15 minutes of the start of the event, a nearly nose-to-nose confrontation between individuals with opposing views became so heated they had to be separated as Shelby County sheriff's deputies and Memphis police officers called for reinforcements. No arrests were made.

http://voices.washingtonpost.com/capitol-briefing/2009/08/town_hall_talk_the_latest_bant_1.html?wprss=capitol-briefing

Result number: 4

Message Number 258190

Re: Curious about dry needling View Thread
Posted by Dr. DSW on 6/17/09 at 06:23

Actually, although I usually agree with Dr. W., there was a study by Dr. Sconfienza of Italy presented in the USA (Chicago) this year and he reported his results of 'dry needling'. He is a radiologist and presented his findings at a national radiology conference.

His presentation was a case study, NOT a 'double blinded' study regarding plantar fasciitis patients and I believe his study involved about 46 or 60+ patients with excellent results. The needling was performed under ultrasound guidance.

However, he is not the only doctor performing this procedure. At Jefferson University Hospital in Philadelphia, Dr. Lev Nazarian has been performing this procedure for years. He is a world known radiologist specializing in ultrasound. He has published articles on needling for shoulder and elbow pathology and is presently also using needling for plantar fasciitis. I believe a study or paper will be published soon.

However, he uses no fancy machines or gadgets. He simply uses a 'needle'/syringe under ultrasound guidance to pinpoint the exact area of maximum pain. There are no gizmos, gadgets or fancy websites with claims, patents or special training courses.

Result number: 5

Message Number 257758

Re: PF is gone and I'm running again View Thread
Posted by Ira H on 5/27/09 at 07:56

I did the taping for a few weeks. I would take it off (gently) each night. I followed the pattern for taping shown on this site. I used my own sport tape at first which actually caused a small tear in my skin. I then ordered the tape from this site and avoided that torn area.

I noticed a decrease in walking pain with the tape on immediately. Like from a pain level of 3 to a 1.

For increasing blood flow:
1) I did spin class once a week
2) Did the AMT machine in my gym which is like a cross between an elliptical machine and stepper. This gave me no heel pain.
3) I tried running on a treadmill at an 8% incline. This gave me no or very little heel pain but it was hard work.
4) I have one of those nubby roller cylinders under my desk at work. I'm not sure this helped but it didn't hurt.

I didn't mention before that I also visited a physical therapist a few times recently. She specializes in running and gave me more confidence to get out and run again, slowly, on a rubber track at first.

With PF, it's hard to correlate anything in a scientific manner. It's hard to do controlled experiments on yourself because this thing heals so slowly. You just have to try things that don't hurt you more and stay determined and optimistic...

Result number: 6

Message Number 257600

Re: For the DR's - New European Treatment- Is this valid? View Thread
Posted by Dr. DSW on 5/18/09 at 18:29

Jen is correct. The technique is called dry needling and was originally reported by an Italian doctor, Dr. Sconfienza at a conference of radiologists in Chicago. He reported on approximately 40+ cases. It was simply a case study, not a 'blinded' study.

Additionally, Dr. Lev Nazarian at Jefferson University Hospital in Philadelphia (he's a radiologist specializing in ultrasound) is utilizing this technique for plantar fasciitis, shoulder injuries and elbow injuries.

There IS validity/credibility to this technique. It turns a chronic problem into an 'acute' injury by breaking up the tissue and causing an inflammatory response and causing neo-vascularization, which means new blood vessels form in the area causing the area to heal with newer healthier tissue. The theory is similar to ESWT and Topaz.

Result number: 7

Message Number 257431

Re: Are orthotics even the answer? View Thread
Posted by Dr. Wedemeyer on 5/12/09 at 12:25

Laurie great observation. One commonality is that they all cherry-pick and distort the leading studies and current evidence and try to minimize the competition and sell their own proprietary product. Their straw man arguments are often punctuated by very heated debate and then a rapid departure of the party in question upon which they skulk in the shadows of the internet to sell their goods.

Their illusory physics and anecdotal success tales are a common theme. Generally it becomes an 'I am right and THEY are all wrong' theme.

Almost all of the truly helpful research in pedal biomechanics and the resulting theories that benefit patients are put under the microscope of the leaders in that field and evaluated by double-blinded studies and are repeatable before they are held out as fact. The authors often do not reap any financial benefit from their efforts, it is to benefit the patient and clinical practice.

Result number: 8

Message Number 256336

Re: Nice Tata and only 2000.00 ea. !!!! View Thread
Posted by scott r on 3/24/09 at 07:37

this is test and repost of marie's message.

===============

I love this little car and for 2000.00 it is just what alot of people reallllllllyyyyy need.



http://wheels.blogs.nytimes.com/2009/03/23/tata-nano-launched-in-mumbai/?ref=worldbusiness
The promise Mr. Tata was referring to was his ambitious goal to build a car with a starting price of only 100,000 Indian rupees ($2,000). While the Nano does meet its highly aggressive (and what many industry experts once deemed as totally unrealistic) price point, some hurdles remain to be cleared.

The Nano has been nicknamed “The People’s Car” because its starting price will make it accessible to more Indians than any other new car on the market. But the ultra-cheap, ultra-compact Nano comes with no frills. It runs on a 623-cc 2-cylinder engine with about 30 horsepower. Power steering and power brakes are optional on the base model. Airbags, antilock brakes and even a radio aren’t available at all.

Result number: 9

Message Number 256335

Re: Nice Tata and only 2000.00 ea. !!!! View Thread
Posted by scott r on 3/24/09 at 07:37

this is test and repost of marie's message.

===============

I love this little car and for 2000.00 it is just what alot of people reallllllllyyyyy need.

http://wheels.blogs.nytimes.com/2009/03/23/tata-nano-launched-in-mumbai/?ref=worldbusiness
The promise Mr. Tata was referring to was his ambitious goal to build a car with a starting price of only 100,000 Indian rupees ($2,000). While the Nano does meet its highly aggressive (and what many industry experts once deemed as totally unrealistic) price point, some hurdles remain to be cleared.

The Nano has been nicknamed “The People’s Car” because its starting price will make it accessible to more Indians than any other new car on the market. But the ultra-cheap, ultra-compact Nano comes with no frills. It runs on a 623-cc 2-cylinder engine with about 30 horsepower. Power steering and power brakes are optional on the base model. Airbags, antilock brakes and even a radio aren’t available at all.

Result number: 10

Message Number 256326

Nice Tata and only 2000.00 ea. !!!! View Thread
Posted by marie:) on 3/23/09 at 21:08

I love this little car and for 2000.00 it is just what alot of people reallllllllyyyyy need.


The Effects of Topical Vitamin E on the Cosmetic Appearance of Scars
Authors: Baumann L.S.; Md J.S.

Source: Dermatologic Surgery, Volume 25, Number 4, April 1999 , pp. 311-315(5)

Publisher: Blackwell Publishing


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Abstract:

background.
Vitamin E is a generic term for a group of tocol and tocotrienol derivatives. Since the discovery that vitamin E is the major lipid soluble antioxidant in skin, this substance has been tried for the treatment of almost every type of skin lesion imaginable. Anecdotal reports claim that vitamin E speeds wound healing and improves the cosmetic outcome of burns and other wounds. Many lay people use vitamin E on a regular basis to improve the outcome of scars and several physicians recommend topical vitamin E after skin surgery or resurfacing.

objective.
We attempted to determine whether topically applied vitamin E has any effect on the cosmetic appearance of scars as suggested by multiple anectodal reports.

methods.
Fifteen patients who had undergone skin cancer removal surgery were enrolled in the study. All wounds were primarily closed in 2 layers. After the surgery, the patients were given two ointments each labeled A or B. A was Aquaphor, a regular emollient, and the B was Aquaphor mixed with vitamin E. The scars were randomly divided into parts A and B. Patients were asked to put the A ointment on part A and the B ointment on part B twice daily for 4 weeks. The study was double blinded. The physicians and the patients independently evaluated the scars for cosmetic appearance on Weeks 1, 4, and 12. The criteria was simply to recognize which side of the scar looked better if there was any difference. The patients’ and the physicians’ opinions were recorded. A third blinded investigator was shown photographs of the outcomes and their opinion was also noted.

results.
The results of this study show that topically applied vitamin E does not help in improving the cosmetic appearance of scars and leads to a high incidence of contact dermatitis.

conclusions.
This study shows that there is no benefit to the cosmetic outcome of scars by applying vitamin E after skin surgery and that the application of topical vitamin E may actually be detrimental to the cosmetic appearance of a scar. In 90% of the cases in this study, topical vitamin E either had no effect on, or actually worsened, the cosmetic appearance of scars. Of the patients studied, 33% developed a contact dermatitis to the vitamin E. Therefore we conclude that use of topical vitamin E on surgical wounds should be discouraged.

Language: English

Document Type: Research article

Result number: 12

Message Number 251758

I Finished My List of 30 Reasons View Thread
Posted by cwk on 11/02/08 at 14:13

http://acivilizationworthyofthename.blogspot.com/

1. Barak Obama is-reflective- He embraces country’s virtues and is not afraid to address problems.

2. Barak Obama is a gentleman- He treats others with respect.

3. Obama’s tax plan is a first step toward a responsible budget. The Congressional Budget Office projects that McCain's plan will lead to the biggest growth of the deficit.

4. Obama’s health care plan begins to address serious problems.

5. Obama’s call on the Iraq war was correct and courageous.

6. Obama balances faith and politics. He is a man of faith who respects other spiritual journies.

7. Obama has a history of unifying leadership. He can be a political unifier.

8. Barak Obama has temperament to be president. He has superior intellect and calmness.

9. Obama’s tax plan is a step toward necessary tax reform.

10. Obama has managed a well run campaign.

11. Obama advocates personal and public fiscal responsibility.

12. The vile racism of the Republican party must not win. Our children are watching?

13. Obama understands complexity of foreign policy issues and is realistic about what must be done.

14. Obama is respected around the world and and will represent us well.

15. His position on the difficult subject of abortion is fair and balanced.

16. Sarah Palin is not ready to be president and John McCain is 72.

17. John McCain’s lack of focus on what concerns people most and emphasis on the trival proves he is not capable of managing priorities as President.

18. I do not want more conservative appointments to the Supreme Court. Read Gary Wills and Cass Sunstein.

19. Obama’s Presidency will help bridge the racial and cultural divide.

20. The principles of capitalism support progressive tax. Obama is not a socialist indeed according to the principles of Adam Smith he is a good capitalist.

21. She Blinded Me With Science- Palin attacks necessary research that would help her own cause and rejects research based science.

22. I’m Sick of Divisive, Dishonest Destructive Manipulation by the Media. Let’s show the media that we will not be bamboozled by innuendo, guilt by association, trivia and lies

23. Americans Are Fair and Balanced- we are not ‘afraid’ of a Black man.

24. Democrat presidents have been good for the economy

25. Obama and his family is an authentic example of solid family values I want my children to admire and emulate

26. We are not as divided as our politics suggest; Obama is attracting leading conservative thinkers and leaders who are disgusted with the result of the past eight years and saddened by the McCain campaign

27. Obama understands the importance of net neutrality that will assure innovation, wealth creation and social change will thrive on the net; we need a responsible climate policy governed by science

28. We must defend the Constitution from distortion which allows sweeping executive powers.

29. Because it’s a damn good list.

30. Because it is time--hell it is past time.

Result number: 13
Searching file 24

Message Number 246339

Re: Heel Pain-Plantar Fasciitis View Thread
Posted by Dr. Wedemeyer on 4/26/08 at 14:05

Dr. Wander

Often the research does not reflect clinical outcomes in real practice. If we relied on strictly research trials, especially those funded by say a particular prescription drug manufacturer or orthotic lab the overwhelming bias would impact prescribing decisions in a very negative way. I agree with your concern over the lack of double blinded studies in this review.

I feel that it is important to realize that these studies can either offer solid evidence of the relative efficacy of the prevailing treatments out there or add ammunition to the proponents of proprietary devices and their marketing.

You're dead-on that an assessment of respondents who actually treat the condition should be presented at some point. I will search for such an article and if one is available post it here for comparison.

BTW have you ever offered the Vasyli VHD (Howard Dananberg)prefab insert for PF in your practice (this question is for any of the providers here)? I have begun using this device for PF as a temporary for PF when I attribute the etiology to FHL dysfunction.

They're heat moldable, inexpensive and well designed I believe. I'm having good results with PF patients during the acute phase and when they resolve and if they need a custom orthosis I then move them into that. I'm always searching for a good prefab or OTC temp orthosis.

Result number: 14

Message Number 246205

Axiom Worldwide DRX9000 DRX 9000 View Thread
Posted by Dr. Wedemeyer on 4/22/08 at 11:39

Gary,

You should be not be offended or outraged that a member of the profession, whose table your employer feeds at, would question your companies businesses practices given all of the controversy surrounding this treatment trend. I hope that we can we can finally cut through the personal attacks some are choosing and cut to the meat of Axiom's marketing and claims. I applaud your decision to agree to answer the questions posed on this board.

Scott's decision to disallow further posts on the subject does not change the fact that there are questions regarding Axiom's business practices and several lawsuits pending that will resolve this unfortunate drama. There are also decisions that I have read where Axiom Worldwide is accused of precisely the points that disturb me as a professional.

http://www.doj.state.or.us/releases/2007/rel062907.shtml

and

http://www.mn-chiroboard.state.mn.us/Forms/Decompression%20Therapy%20Oregon%20vs%20Axiom.pdf

I quote:

“The companies stated that the Food and Drug Administration (FDA) approved the devices and substantiated their claims of effectiveness. DOJ found the device had merely been cleared as similar to preexisting devices. They also misrepresented the DRX 9000 by claiming it was a scientific and medical breakthrough that resulted from NASA discoveries when, in fact, NASA discoveries had no relationship with the device.”

and
“The agreement also prohibits the companies from misrepresenting scientific studies and patient testimonials.
Axiom must pay DOJ's Consumer Protection and Education Fund a total of $100,000. If Axiom complies with the AVC, $25,000 will be suspended.”
This appears on the face to be a case where they had you dead to rights and you dodged the bullet by acquiescing to clean up your marketing and paying a paltry fine. I remind everyone that this is a Department of Justice website and not a blog or private web space.
In the following case you are accused of inserting a competitor’s metatags into your webpage to redirect traffic to your site and product. Whether or not this case is resolved in NAM’s favor this is a decidedly despicable and low-brow marketing decision for any company to engage in:
http://www.lawofgoogle.com/2008/04/because-axioms.html

Then there is the special investigation into all of the major players in this market and their use of inappropriate CPT coding to extract higher reimbursement:

http://www.ucg.com/images/APP0512_SpecialReport_001.pdf


I understand your points regarding the marketing but contrasting it to a car dealership is misguided and precisely the sort of response that provokes these responses.

Let’s be very clear here, spinal decompression is NOT chiropractic. It is not a core course in any medical or chiropractic curriculum.

It will be interesting to see what happens to the doctors who injure a patient as a result of spinal decompression treatment in lieu of a medically necessary surgery, or for that matter who could have undergone a more conservative course of care. Will their malpractice insurance cover the DRX9000?

Your biggest competitor in fact sells the majority of its machines to MD's (at least they make this claim). You on the other hand market mainly to DC's. In the past the manner in which patients were marketed to landed your clients and your company in some hot water. What I am expressing is my own distaste for the manner in which that marketing was performed, that CA Attorney is not an actual attorney and your assertion (which may very well be fact) that Oma Z is a plaintiff and a competitor of Axiom Worldwide, belies the point that that type of marketing is seen as distasteful to the public as well as unethical to the professional.

Your assertion that a potential Rolls Royce dealership would not choose a location based on demographics is credible and sound business acumen. We are not talking about cars here though; we are discussing an elective health care procedure that is not covered by major health insurance. The cost is profligate for both the doctor and the patient and to date you can throw around all of the Axiom funded studies that you like (provide me one independent, peer-reviewed, double-blinded study and reproducible study that validates your marketing claims please) that but in truth your machine, like any treatment has a success and failure rate that is overlooked and unreported in both the peer-reviewed literature and advertising

'What good is it to the profession when doctors make bad business decisions and then go out of business?' I would add what good is being marketed a machine that is highly controversial with respect to its success rate, marketing paradigm and procedural billing coding and saddling a doctor with overhead that is often the financial nail in the coffin that drives said doctor out of business? They already possess training in a skill that is beneficial to many patients with chronic spinal conditions, why would they abandon that in lieu of your device except for the promise of a financial windfall when there is such controversy surrounding the device?

Perhaps this will change, perhaps not, but I still maintain that much of the marketing is in fact hyperbole and sleight-of-hand (in the past none of the ads revealed up front that the doctor is in fact a DC and yet the photographs show a doctor wearing a lab coat and stethoscope implying through obfuscation that the ad represents a medical office). If you can succinctly prove with repeatable and independent, peer-reviewed journal studies that the DRX is efficacious for the conditions that you describe then you would not need the accompanying illusory marketing to sell both doctor and patient.

The billing and procedural codes and ensuing litigation are an issue that I will not discuss here until there is a decision rendered in the ongoing lawsuits against Axiom Worldwide. Comparing two competing bankcard companies litigation over fair trade is not reliably related to the matters at hand, which are the efficacy of spinal decompression, the ethics of the advertising employed to promote the business and the pending lawsuits of which there appears to be many surrounding your company’s business practices.

Pending legal issues or not the fact remains that an ominous cloud of suspicion has been raised regarding Axiom’s business and marketing practices. Trust me when I say that I know a lot of chiropractors across the country and that we all have commiserated concern over what is occurring in the new with regard to the advent of these machines in chiropractic practice.

This is of course an opinion and an informed opinion based on the fact that I am a practicing Doctor of Chiropractic who is acquainted with providers who have purchased these machines and have received this marketing through the mail and in print widely available to both the professional and the public.

I would like to ask one last question that is a personal concern and has not come up in other postings that I have seen. It has been asserted that your company has ties or is owned by a marketing arm of The Church of Scientology’s, World Institute of Scientology Enterprises (WISE Industries).

The word Axiom is after all a term coined by L. Ron Hubbard and disseminated in their material is it not?

http://www.bonafidescientology.org/Append/01/page09.htm

I believe Tampa is one of the church’s (sic) major centers and coincidentally that is where Axiom Worldwide is headquartered.

Could you please address this assertion as I feel that it is relevant to the professional to have prior knowledge of this association before attending your seminars or accepting your generous travel offer?

I await your response.

Result number: 15

Message Number 246107

Re: Heel Pain-Plantar Fasciitis View Thread
Posted by Dr. DSW on 4/20/08 at 07:18

Dr. W,

This study is similar to other studies that I've read. It's interesting that they have simply collected data from studies, and not compared data from actual clinical practices.

I think it would be interesting to compare their data against a survey of specialists that treat this condition, to see how the 'data' compares with actual daily experiences.

I believe that we all have seen results better than 'one year' with most of our patients that have received OTC or custom orthoses, and I also have seen significantly better results with other modalities such as stretching (though I do not advocate weight bearing stretching, etc.) It was also very interesting that many of the studies quoted weren't double blinded, etc.

But, the bottom line is that we all have to read the data, but actually do what works for OUR patients in our own individual offices.

I have colleagues that would never even think of dispensing a pair of PowerSteps, and all his patients receive high priced custom orthoses. Whereas, many of my patients do extremely well long term spending about $40 or less on a pair of PowerSteps. Whatever works for your patient population is OK.

And finally, data is often confusing. The data regarding the corticosteroid injections seemed 'scary' when looking at the potential plantar fascia rupture rates from one study, which was then completely 'reversed' by another study.

Result number: 16

Message Number 244229

Re: From OHIO: GOP voters crossing over in large numbers View Thread
Posted by john h on 3/07/08 at 11:13

It is rather well known that mechanization has been the prime reason for job loss. Robotic machines can now work 24 hours a day and do with precision what one man took in a week to do. Actually there was a job increase resulting from NAFTA other than those jobs lost to people being replaced by machines. This is not a NAFTA problem. The auto industry will never be what it once was as well as the steel industry. NAFTA is just being used as a whipping boy for political purposes to gain union votes. The U.S was once the leading manufacturing nation in the world. We are now more of a service, high tech economy. We cannot go back. The genie is out of the bottle.

Barrach was jumped on by Hillary for supposedly winking to Canada on the NAFTA problems he talks about. We cannot back out of NAFTA and close our doors . We need NAFTA more than our partners do. The politicians know that but no one will hold there feet to the fire once the election is over. Ohio and Michigan were once great industrial states. Times have changed and the workers are going to have to retrain or be left behind. Like it or not the Global Economy is here and it is here to stay.

I do not look at this as Republicans vs Democrats as it is not going to be solved with laws no matter what the candidates say. Soon enough McCain and Barrach/Hillary are going to be more specific in their answers to questions such as how to solve loss of jobs due to our change from an industrial nation to one that has lost its position in the industrial world.

I think energy is an area where we are absolutely shooting ourselves in the foot. Some of the more successful nations are now supplying energy with well over 50% nuclear. Because of Three Mile Island we have not built a nuclear plant in decades. Instead we use the high pollution coal as our major source of energy. There was no explosion at Three Mile Island. No one was killed. As a matter of fact you cannot have a nuclear explosion at a nuclear plant. You can have a melt down but Chernobyl was a poorly built plant with few safety guards that we use routinely. I wonder how many coal miners have died over the years from black lung, explosions, cave ins, etc.? We have been blinded by all the anti nuclear propaganda. Japan is the 'ONLY' nation in the world that can build a large major component of a nuclear plant. Right now they have orders extending out to four years for this component and you must have it to build a plant. If we made a decision to build a nuclear plant today it would likely take us over 10 years to bring on line. We have over 25 applications on file to build nuclear plants that are tied up in red tape and the courts. We hear a lot about alternate energy such as wind, water, etc. The facts are these sources will never be able to replace our existing power needs. Nuclear is the only source of energy that ultimately does not depend on the sun.

Result number: 17

Message Number 241667

Re: resveratrol - cure for cancer Dec 29,2007 View Thread
Posted by Dr. Ed on 1/07/08 at 22:27

Sorry Scott but we need a double blinded peer reviewed multicenter trial. Have you come to believe that tissue level evidence is enough?
Ed

Result number: 18

Message Number 241596

Re: Oil cheap at $100 per barrrel? View Thread
Posted by john h on 1/06/08 at 14:14

Scott: I agree with you that oil probably is priced way to cheap at $100 a barrell. We do little to conserve in this country. All one needs to do is look at a big parking lot and you will see more gas guzzling SUV's and pickups than a plain old 6 cylinder or fuel efficient car. In Arkansas we have more registered trucks than cars. Probably because we are an agriculture state. We have know for decades that fossil fuels will run its course. We fight atomic energy when it is the cheapest of what can produce in the quantities we need to drive our economy. We have virtually no user friendly rail system like Europe but I must say our nation is much larger in size than Europe and does not lend itself to a good rail system. Higher oil of course means higher everything that moves by rail or truck and everything in the end moves by truck. There is no quick solution and no one party or President is going to solve it. Presidents or Congress do not control the price of oil, although to listien to politicians talk you thing they could wave a magic wand and all would be well.

'The moving finger writes: and having writ,
Moves on, nor shall thy piety nor wit
Shall lure it back to cancel half a line,
Nor all our tears wash out a word of it'

The Rubaiyat of Omar Kayyam

Result number: 19
Searching file 23

Message Number 239996

Re: Fat pads View Thread
Posted by Dr. Wedemeyer on 11/29/07 at 12:36

I believe that although Julie makes a good point that this board is not the appropriate place for debate, that I, like the other providers on here must respond when we feel that the information being presented is not in line with accepted standards of practice or questionable.

This thread began with a question asked by Maria and was answered appropriately by Dr. Ed and Jeremy. What galled me and forced me to respond was the fact that in spite of the efforts to provide accurate and medically correct information to Maria, Dr. Kiper once again turned this into an 'us and them' schism and promptly went on to not only negate and refute the quality and accuracy of their posts but to sell HIS product.

That is precisely when this thread became a debate and acrimonious to the doctors and providers who post here. Should we as health care providers just up and retreat whenever what many of us would classify as misinformation or absence of factual basis is presented and possibly harmful to the poster? I bet everyone would agree this is not the case and it certainly won't happen when I see it. If I were on here making bold claims and promoting my own ideas and opinions for monetary gain I would hope that I would experience the same objections.

To respond to Dr. Kiper
1. No I was not aware that the SDO has not been advocated by clinical studies in reducing peak plantar pressures. I was asking you since that is ALL that you ever talk about and I have not personally ever seen any studies on the SDO. The researcher has very impressive credentials. Hey tell me if I'm wrong but he does resemble the gentleman that I met who was by your side at the PFOLA conference. Coincidence? Isn't he your business partner?

2. I believe that the TekScan sales rep was the one who was nervously laughing when you asked him several times if the SDO scans appeared to confirm that the device was 'functional'. In all honesty I may have been laughing because it struck me as amusing and predictable that within two minutes of meeting you while I was reviewing the TekScan that the conversation was diverted towards your product. Personally I wasn't comfortable with it given that I don't agree with your claims regarding it. I wasn't at the PFOLA merely to edify your ego or sell my services but to learn. Sorry that didn't work out for you.

From what I recall you had to prompt the salesman several times using the word functional before he relented. Somehow I didn't find the whole scenario convincing. Let me ask you this, did any of the other hundreds of doctors, pedorthists, researchers and vendors demo this test? Did any of them offer to fund a study or become a retailer for you technology? Sorry Dennis but you opened the door on this one, the fact is that the rest of your colleagues view your product and claims with the same skepticism that you have encountered here.

3. Since were making this personal and you're alluding to the training in pedorthics as inadequate, let me ask you this; why do so many podiatrists and health care providers have the initials C.Ped after their name in this field? Maybe it is because not one doctoral level program deals with fabrication, biomechanics and dispensing with the depth of the C.Ped course despite it's comparatively shorter duration. I resent the implications of that remark especially after having spent years studying biomechanics in my own program and proudly being a licensed pedorthist. How would you feel if I made a comment that podiatric training is not equal to medical training? You're comparing apples and oranges and doing so in a very demeaning manner.

4. As for an SDO AFO I do understand the concepts behind stabilization of the foot and ankle well enough to rebut this notion. CMT is not a pathology which needs to be braced but 'ACCOMODATED' and the study probably fell on dear ears because clinically it is overkill. Larry has discussed this foot type with you ad nauseum and he has years of experience with these patients. Ill bet dollars to doughnuts that neither him nor Jemery has ever used silicone as a structural material for an AFO. As for drop foot many of them can be braced with a functional AFO so this is misleading. As Laurie points out the study was a small sample and it only discusses motion in one plane. AFO's are often utilized to control triplanar motion as we know and silicone will NEVER achieve that on it's own. The study is so weak that no mention is even made of the shell or design of the device.

In sum I have listened to your ideas and don't agree that your design is the Holy Grail of altered foot biomechanics and you do. We will never agree and as I pointed out prior you need to convince a larger audience and at least give the appearance that you have the patients best interest in mind and not your own. In the absence of this you will be found not credible and assailed for your broad claims and specious evidence.

I didn't shake your hand, concede and become a disciple of Kiperian logic and physics because I was not convinced, plain and simple. You're so single minded that you don't even see how your dogmatic pursuit of this solitary treatment modality has blinded you to everything else available and proven clinically. You need to take a step back and reassess your sales paradigm and back it up with proof.

Publish some studies and get your product into use and acceptance, heck even find one insurer who will reimburse for it and I will gladly take another look.

You cannot convince the minds of educated people without evidence. Evidence is unbiased.

Lastly I find the practice of stepping on sound and solid advice presented by your colleagues and the providers here to sell your product unquestionably fatuous and inappropriate.

Result number: 20

Message Number 238654

Re: UNLOCKING OVERPRONATION View Thread
Posted by Dr. Wedemeyer on 10/30/07 at 11:00

Just an observation here that I am fairly certain that Pascal was not a podiatrist nor was his research carried out on feet. I also asked a friend of mine who is a professor of at a local university about your claims that Pascals' Principle applies to the foot during gait on your device.

He stated that there are several problems with YOUR science, not the least of which is that the foot is an irregularly shaped object with contours and that the force in an SDO or similar 'closed' container with an object of equal or larger size does not behave in the same way as a liquid in a cylinder under constant pressure and load of an object with a uniform shape.

There is also the problem that the foot motion is triplanar and not static. He said that basically the fluid, gel whatever you use would basically move away from the load into the path of LEAST RESISTANCE period, unless you have devised an as yet unheard of revolutionary silicone composition and redefined accepted laws of physics.

I tend to trust his opinion, he is after all a Yale graduate in physics and computer science.

Your device may help some people and no one here would argue that simple OTC gel inserts do in fact help some people. Your claim that we all 'don't get it' though is getting tired. We do 'get it' and that's why we continue to offer the accepted and standard devices.

You obviously are well versed in gait dynamics Dr. Kiper but your refusal to accept convention and constant ridicule of traditional, proven methods is as proprietary as your device.

Result number: 21

Message Number 238645

Re: UNLOCKING OVERPRONATION View Thread
Posted by Dr Kiper on 10/30/07 at 08:28

What you are not getting is that Pascal’s Principle (PP) applies to the SDO because it is a “closed container” PP refers “specifically” to that. That’s NOT theory, that’s a principle of physics called “fluid mechanics”—there is no theory in how fluid mechanics works based on Pascal’s Principle.

“ when there is an increase in pressure at any point in a confined fluid, there is an equal increase at every other point in the container.”

This is considered one of the “general laws” of science. Somehow, you are not aware of how powerful that is, when applied to functional biomechanics.

You refute what a scan shows, it’s the best computer science we have that quantifies biomechanical efficiency, and you try to relate that as to cushioning and sensor flare.

As the fluid moves under pressure from the footstep (from heel to toe), the pressure is constantly being equalized and redistributed under the available range of motion of each articulation. That is because unlike a traditional orthotic, the SDO is in full and constant contact with the foot. A traditional shell orthotic fits the foot from the heel to behind the metatarsals. Considering that midstance is 67% of the gait cycle, the Root orthotic loses approximately 50% of it’s pronation control throughout the stance phase until forefoot contact, too much time is lost in control of the pronatory force. At this point the tarsus has partially unlocked, and lacks the ability to re-supinate the midfoot.
The SDO automatically sets up the biomechanics (self-posts) of the foot in motion, that’s why It can be said that only the SDO offers “natural pronation control”—no other orthotic can say this.

As the foot moves forward and the maximum fluid fills that space under allowable range of motion, it is as equal in pressure as any other point within the container that the foot is making contact with the orthotic and the ground. The articulations move to their most efficient biomechanical positions. As the fluid reaches it’s maximum pressure and the foot is continuing its motion forward, the tarsus remains stable.

Because the tarsus is maximally supported and stable it disallows any further rearfoot motion (that’s why I don’t need a post, a heel cup or a firm arch support to control the midfoot . The next phase of biomechanical control is to stabilize the 1st met against the ground in order to receive the max forefoot loading— the difference is that control with fluid technology is “dynamic”—HENCE Silicone Dynamic Orthotic.

So, when you refer to the “cushioning” effect and that you can cushion anything with soft stuff, you are forgetting that what is important in a functional orthotic is not just the general cushioning of the foot as a shock absorber, but in redistribution of unequal forces against the ground. That is what separates biomechanical control cushioning versus a pillow cushioning.

Your statement: “the fact that gel flows away from pressure and you dont get the fact that that is not a good way to control function.” Demonstrates to me exactly what it is you don’t understand. Of course fluid moves from high pressure, but in a “closed container” it can only go so far, then it pushes the excessive range of motion of a foot into its best alignment. “Fluid moves from high pressure to the area of least resistance and greatest need”. The excessive range of motion available is the weakest part of the foot and has the greatest need.

When you see the sensors of the computer scan, it’s not the cushioning under the met heads that’s reducing those pressures , there is no fluid directly under the met heads, but the redistribution of forces predicated on midfoot biomechanical control. You are failing each and every time to see this, because you’re blinded by your paradigms.

There is articular motion throughout the foot (don’t get picky with me and talk about anomalies such as fusions etc). When you can reduce or minimize those motions maximally, the foot is in it’s neutral position, I prefer to call this “optimal position”.

You deliver biomechanical control by rigid or semi-rigid devices, I’ve used your technology, I consider it inefficient, even though it works some of the time. The SDO is such a radical departure from what you’re used to, you don’t see that it also delivers biomechanical control, through fluidity.

The big difference for me in efficiency is that control is rendered under the arch, a shell orthotic tries to control the foot outside the arch.

Here is an example of a “daily report” post that one of my patients just sent Mon night.

“Daily report for 10/29/2007
Received the new left orthotic. The fluid seems
right. It pushes agaisnt the ball of my foot, without
pushing it up. There is resistance in the arch, but
not to the point where it pushes my foot to the
outside. Saturday 10/27/07 was the first day I wore
the new scrip. Wore both for four hours from Sat
through Monday the 30th, with no problem. The was no
foot ache in either the arch, ankles, or heel of
either foot. I do feel more pressure under the arch
in the right foot, which is to be expected as it has
more fluid. The right foot doesn't push under the ball
or to the outside of my shoe. The overall feeling is
good but different. It's not hard under either foot:
there is some give but still supportive.”

And BTW—the SDO measuring system was first patented and received an extension of the patent over 30 years ago, the patent is no longer protected.

You know why it hasn’t been ripped off?, because it takes a unique knowledge to understand how to make it work. No one can just come in and replace what has taken me 20 years to learn.

Anyone with a good grasp of biomechanics “and an open mind” can however learn the science and do it in a much shorter time.

Result number: 22

Message Number 237974

Re: Pics View Thread
Posted by Dr Kiper on 10/17/07 at 23:13


It is apparent to me, that every time you and others harp about flipping the SDOs over, it’s a clear indication that you don’t understand the principles of fluid mechanics.

I’ve explained this on several other posts. If you understood the technology and saw how easy it works, you’d be embarrassed, especially if you knew what an advantage it is to be able to do that to fine tune a prescription. Look it up.

Several individuals here have distorted the information, mislead and harped about things I've said or done without the benefit of corrections made. You've accused me of not answering questions, when others have not answered all my questions either, yet that is ignored and I’m held to account. I don’t like to play those games.

You’ve asked me several times what clinical study I’m referring to when I’ve stated that clinical studies have shown that custom foot orthoses have fared poorly against OTC and pre-fab. Why do you ask? You mean you’re not aware of the Landorf Study. This made big news when it came out.

Here is the first part of it: Do a search on Google for the rest:


GINAL INVESTIGATION
Effectiveness of Foot Orthoses
to Treat Plantar Fasciitis
A Randomized Trial
Karl B. Landorf, PhD; Anne-Maree Keenan, MAppSc; Robert D. Herbert, PhD
Background: Plantar fasciitis is one of the most common
foot complaints. It is often treated with foot orthoses;
however, studies of the effects of orthoses are generally
of poor quality, and to our knowledge, no trials
have investigated long-term effectiveness. The aim of this
trial was to evaluate the short- and long-term effectiveness
of foot orthoses in the treatment of plantar fasciitis.
Methods: A pragmatic, participant-blinded, randomized
trial was conducted from April 1999 to July 2001.
The duration of follow-up for each participant was 12
months. One hundred and thirty-five participants with
plantar fasciitis from the local community were recruited
to a university-based clinic and were randomly
allocated to receive a sham orthosis (soft, thin foam), a
prefabricated orthosis (firm foam), or a customized orthosis
(semirigid plastic).
Results: After 3 months of treatment, estimates of effects
on pain and function favored the prefabricated and customized
orthoses over the sham orthoses, although only
the effects on function were statistically significant. Compared
with sham orthoses, the mean pain score (scale,
0-100) was 8.7 points better for the prefabricated orthoses
(95% confidence interval, -0.1 to 17.6; P=.05) and 7.4
points better for the customized orthoses (95% confidence
interval, -1.4 to 16.2; P=.10). Compared with sham
orthoses, the mean function score (scale, 0-100) was 8.4
points better for the prefabricated orthoses (95% confidence
interval, 1.0-15.8; P=.03) and 7.5 points better for
the customized orthoses (95% confidence interval, 0.3-
14.7; P=.04). There were no significant effects on primary
outcomes at the 12-month review.
Conclusions:Footorthosesproducesmall short-term benefits
in function and may also produce small reductions
in pain for people with plantar fasciitis, but they do not
have long-term beneficial effects compared with a sham
device. The customized and prefabricated orthoses used
in this trial have similar effectiveness in the treatment of
plantar fasciitis.
Arch Intern Med. 2006;166:1305-1310

OK, so I answered that question, now go back to the computer scans I presented and you described and tell me how you'd fix it and whether you'd be increasing or decreasing the pronatory forces???

Result number: 23

Message Number 236862

Re: Clinton Picks Up Bayh Endorsement View Thread
Posted by Dr. Ed on 9/28/07 at 15:24

Marie:
No, I do not listen to Limbaugh but you have blinders firmly in place. You have not addressed the fact that that the standard bearer of the Democrat Party will not stand up to Moveon.org as she voted against sanctioning moveon.org. The sanctions have no teeth but they do show where people stand and Hilary stands with moveon.org on this issue. No matter how much you squirm and slide, her vote shows where she stands. You also conveniently ignore the fact that moveon.org has been the attack dog for the Dems in Presidential campaigns and a financier of the
Dems.

Ed

Result number: 24

Message Number 235077

Re: anyone... someone...this is my big reach out to the people at heelspurs.com View Thread
Posted by Kevin L on 8/28/07 at 17:48

Dr DSW
Below are all the Podiatry providers that take my insurance within 30 miles of my zip 11223 (Brooklyn NY) In alphabetical order…then with detailed info address…etc etc..
A
Abady, Robert, DPM 1
Abeles, Jay, DPM 11
Abrahamson, Hal, DPM 11
Alfieri, Donna M., DPM 1
Alongi, Maryanne, DPM 11
Amante, Gregory, DPM 5
Amato, Richard, DPM 11
Amico, Susan G., DPM 5
Archer, Jean V., DPM 5
Aronica, Frank R., DPM 5
Asaro, Carlo S., DPM 1
Assini, Joseph, DPM 5
Axman, Wayne R., DPM 11
B
Babayev, Emil, DPM 5
Bagner, Jerome E., DPM 11
Baird, William T., DPM 5
Balboa, Henry M., DPM 11
Barbaro, Thomas, DPM 11
Bar-David, Tzvi, DPM 1
Barkoff, Matthew W., DPM 11
Barkoff, Steven L., DPM 5
Barlizo, Sharon R., DPM 1
Barone, Salvatore A., DPM 5
Barragan, Juan C., DPM 1
Bartol, David M., DPM 5
Bass, Elliot L., DPM 5
Bass, Fara D., DPM 5
Bautista, Debbie P., MD 1
Bayerbach, Frank, DPM 1
Becker, Jack S., DPM 11
Bell, Burt L., DPM 5
Bendeth, Marc L., DPM 11
Benzakein, Ralph, DPM 5
Berlin, Kim, DPM 11
Bienenfeld, Jay D., DPM 5
Biller, Bob S., DPM 11
Bilotti, Mary A., DPM 11
Birch, Gregory M., DPM 5
Bover, Elina, DPM 5
Braun, Suzanne G., DPM 5
Breitman, Debra, DPM 11
Breth, Evan G., DPM 5
Bubbers, Linda A., DPM 11
Buenahora, Joseph A., DPM 11
Burzotta, John L., DPM 11
Bushansky, Abe A., DPM 1, 5
Butters, Marva, DPM 5
Butts, Bryon G., DPM 1
Buxbaum, Frederick D., DPM 5
Buzermanis, Steven Z., DPM 5
C
Caimano, Francis X., DPM 11
Campbell, Andrew, DPM 1
Campbell, Douglas E., DPM 5
Caprioli, Russell, DPM 11
Caprioni, Enrico P., DPM 5
Carlton, Lawrence S., DPM 5
Castillo, Dennis E., DPM 5
Catanese, Dominic J., DPM 1
Charlot, Giznola J., DPM 1, 5
Cheng, Tung W., DPM 6
Chernick, Stephen B., DPM 11
Chionis, Anthony, DPM 1
Chopra, Jaideep, DPM 1, 6
Cicio, Gary, DPM 6
Ciment, Avraham Y., DPM 1
Cohen, Greg E., DPM 6
Cohen, Richard B., DPM 6
Cohen, Robert J., DPM 1, 11
D
Dacher, Jeffrey, DPM 6
D'Amato, Theodore A., DPM 6
D'Angelo, Nicholas A., DPM 6
Daniel, Lawrence B., DPM 6
Davies, Daniel A., DPM 11
Davies, Gregory F., DPM 11
De Bello, John A., DPM 1
DeCicco, John J., DPM 11
DeLeon, Jose L., DPM 1
Dellolio, Joseph A., DPM 1
DeMeo, James R., DPM 6
Dennis, Lester N., DPM 6
DeSantos, Pasquale, DPM 6
Dhandari, Angeleta, DPM 1
Dharia, Sumit S., DPM 6
Dixit, Chaitanya V., DPM 6
Donovan, Glenn J., DPM 6
Dorazi, Stephen T., DPM 6
Dubov, Spencer F., DPM 11
E
Edelstein, Michael C., DPM 1
Ehrlich, Josh C., DPM 6
Einhorn, Jill L., DPM 6
Elsinger, Elisabeth C., DPM 1
F
Fagen, Leonard, DPM 6
Falcone, Jeffrey J., DPM 6
Feldman, Gary B., DPM 11
Ficke, Henry, DPM 6
Finkelstein, Barry I., DPM 1
Fiorenza, Dominic, DPM 11
Fox, Corey, DPM 11
Fox, Roberta A., DPM 11
Frankel, Bruce, DPM 1
Freiser, Mark A., DPM 1
Fridman, Robert, DPM 1
Friedlander, Bruce W., DPM 6
Fuchs, David B., DPM 11
G
Ganjian, Afshin, DPM 6
Garcia, Sandra P., DPM 1
Garofalo, Alfred A., DPM 6
Garofalo, Gail F., DPM 11
Gasparini, Mark C., DPM 11
Gaudino, Salvatore C., DPM 2, 6
Geiger, Arthur, DPM 6
George, Thomas, DPM 2, 6, 11
Gertsik, Vladimir V., DPM 6
Gervasio, Joseph, DPM 11
Giammarino, Philip A., DPM 6
Ginsberg, Steven E., DPM 2
Giordano, Richard S., DPM 2
Gitlin, David, DPM 2
Glockenberg, Aaron, DPM 2, 6
Goez, Emilio A., DPM 2, 11
Goldenberg, Perry Z., DPM 2
Goldman, Gershon A., DPM 6
Goldstein, Harold L., DPM 2
Goldstein, Israel, DPM 7
Golub, Cary M., DPM 12
Gonzalez, Ivan, DPM 7
Goodman, Warren J., DPM 7
Gottlieb, Robert J., DPM 12
Gramuglia, Vincent J., DPM 2
Greenbaum, Bruce R., DPM 7
Greenbaum, Mitchell A., DPM 12
Greiff, Lance, DPM 2, 12
Grossman, Myles, DPM 12
Guberman, Ronald M., DPM 7
Gutierrez, David, DPM 2
Gventer, Mark, DPM 7
H
Habib, Henry, DPM 7
Harris, Carl F., DPM 2
Heller, David P., DPM 7
Herbert, Scott E., DPM 12
Herman, Craig P., DPM 2, 7
Hershey, Paul E., DPM 12
Herzberg, Abraham, DPM 12
Hickey, John, DPM 12
Honore, Lesly S., DPM 12
Horl, Lawrence, DPM 12
Horowitz, Mitchell L., DPM 7, 12
I
Iorio, Anthony R., DPM 2
Irwin, Robert A., DPM 12
Isaacson, Ernest, DPM 2
Ivanovs, Ray, DPM 7
J
Jackalone, John A., DPM 12
Jacobs, Louis W., DPM 2
Jarbath, John A., DPM 7, 12
Joshi, Pradip M., DPM 2
Jusma, Francoise D., DPM 7
K
Kaiser, Craig A., DPM 7
Kapadwala, Imtiyaz I., DPM 7
Karpe, David E., DPM 12
Kashefsky, Helene P., DPM 12
Kasminoff, June G., DPM 12
Katz, Alex S., DPM 7
Katzman, Barry, DPM 7
Kessler, Howard N., DPM 12
Kisberg, Stephen, DPM 12
Kitton, Stuart E., DPM 12
Klein, Michael S., DPM 12
Klirsfeld, Jeffrey S., DPM 12
Knobel, Jeffrey, DPM 7
Kohn, Arlene F., DPM 12
Kolberg, John J., DPM 2, 12
Koslow, Paul M., DPM 12
Kumrah, Praveen, DPM 2
L
Lafferty, William A., DPM 7
Lai, Katherine M., DPM 2
Landau, Laurence D., DPM 12
Landy, Robert J., DPM 2, 12
LaRocca, Albert, DPM 12
Larsen, Joseph A., DPM 12
LaSalle, Michael, DPM 2
Lepore, Frank L., DPM 7
Levine, Stanley, DPM 12
Levitsky, David A., DPM 12
Levitz, Steven J., DPM 7
Levy, Brian K., DPM 7
Levy, Denise A., DPM 2
Levy, Paul J., DPM 2
Liswood, Paul J., DPM 7
Livingston, Douglas W., DPM 12
Livingston, Leon B., DPM 13
Livingston, Michael D., DPM 13
Locastro, Robert M., DPM 2
Lok, Jonat, DPM 2
Lopiano, Steven N., DPM 2
Losyev, Sergey, DPM 7
Lucido, Jeffrey V., DPM 7
Lynn, Brian P., DPM 2, 13
M
Mahgerefteh, David, DPM 7, 13
Makower, Bryan L., DPM 7
Mandato, Mark, DPM 7
Mantzoukas, Argirios, DPM 7
Marcelonis, Debra A., DPM 7
Marchese, Nicholas A., DPM 13
Marville, Jillion, MD 3, 7
Masani, Farhan, DPM 13
Matthews, Frederick, DPM 8
McElgun, Terence M., DPM 13
Mckay, Douglas J., DPM 8
Mcshane, William J., DPM 13
Meliso, Vincent D., DPM 8
Meller, Edward P., DPM 8
Meshnick, Joel A., DPM 8, 13
Micallef, Joseph, DPM 8, 13
Moazen, Ali, DPM 13
Mollica, Peter W., DPM 8
Mollica, Raymond J., DPM 8
Montag, Richard M., DPM 13
Montalvo, Luis, DPM 8
Morreale, Edward, DPM 8
N
Nachmann, Dennis S., DPM 3
Naik, Hetal B., DPM 8
Nekritin, Vadim, DPM 8
Nester, Elizabeth M., DPM 13
Nester, Matthew J., DPM 13
Newmark, Alan J., DPM 8
Nezaria, Yehuda, DPM 13
Novofastovsky, Raisa, DPM 8
O
Odinsky, Michael E., DPM 8
Odinsky, Wayne Z., DPM 13
Oliva, Imelda A., DPM 3, 8
Orlando, Anthony, DPM 8
Oropall, Robert, DPM 3
Owusu, Stephen E., DPM 8
P
Pace, George N., DPM 8
Pace, John F., DPM 8
Pannell, Richard, DPM 3
Papa, Philip M., DPM 8
Passik, Arthur L., DPM 8
Pawson, John F., DPM 8
Pecora, Maria, DPM 8
Pedro, Helder F., DPM 8, 13
Perez, Walter H., DPM 8
Peterson, Donald T., DPM 13
Pierre, Nadja M., DPM 8
Pierre, Nedjie, DPM 9
Plotka, Steven D., DPM 3
Posner, Jonathan, DPM 3
Prince, Steven L., DPM 9, 13
Purvin, Jay M., DPM 13
R
Rabiei, Payman, DPM 9
Radler, Bruce L., DPM 9
Rampino, Robert, DPM 3
Ransom, Sherry M., DPM 3
Raskin, Simon, DPM 9
Reifer, Howard J., DPM 9
Richardson, Hugh L., DPM 13
Richman, Tara, DPM 3
Romano, Constance A., DPM 9
Rosen, Alan J., DPM 9
Ross, Charles F., DPM 3
S
Saadvandi, Terence M., DPM 9
Sande, Hervey, DPM 9
Scheiner, David M., DPM 9
Schikman, Lana, DPM 9
Schneidermesser, Susan G., DPM 9
Schulman, Leonard B., DPM 3
Scotti, Lorenzo, DPM 3
Shapiro, Eugene, DPM 9
Shechter, David Z., DPM 9
Shechter, Stuart B., DPM 9
Sherman, Gary, DPM 9
Silberstein, Jeffrey, DPM 9
Silverstein, Alan B., DPM 9
Snyder, Robert S., DPM 3
Spector, Donald, DPM 3
Spellman, Dean S., DPM 3
Spielfogel, William D., DPM 9
Spilken, Terry, DPM 3
Spindler, Harlan, DPM 9
Stanimirov, Catherine, DPM 9
Steiner, Richard M., DPM 3, 9
Stern, Stuart M., DPM 3
Strassman, David, DPM 3
Strassman, Lawrence, DPM 3
Stuto, Joseph C., DPM 9
T
Tabari, Issac, DPM 3
Tajerstein, Alan R., DPM 9
Tanenbaum, Mark, DPM 9
Tartack, Ira, DPM 9
Tavroff, Clifford D., DPM 9
Thompson, Michael, DPM 3
Trepal, Michael J., DPM 9
Trivlis, Maryann Z., DPM 9
U
Unger, Leslie M., DPM 9
V
Vader, Bonnie, DPM 9
Velasco, Debra, DPM 3
Vincetic, Anto, DPM 3
Vitale, Thomas, DPM 3
W
Waiss, Samuel M., DPM 9
Wallach, Jacob B., DPM 9
Walter, Eric G., DPM 3
Wexler, Craig, DPM 3
Winston, Wayne, DPM 4
Wolstein, Lewis, DPM 4
Wolstein, Peter D., DPM 4
Woltman, Robert T., DPM 4, 10
Z
Zonenashvili, Merabi, DPM 10
Zwiebel, Neil S., DPM 10

PODIATRY
Abady, Robert, DPM
181172P
731 White Plains Rd
Bronx, NY 10473
(718) 589-8324
181173P
Burnside Medical Center
165 E Burnside Ave
Bronx, NY 10453
(718) 563-0003
St Barnabas Hospital
Alfieri, Donna M., DPM
37006P
4206 Barnes Ave
Bronx, NY 10466
(718) 325-6487
Mount Vernon Hospital, Our
Lady of Mercy Medical Center
Asaro, Carlo S., DPM
37182P
1400 Pelham Pkwy S
Bronx, NY 10461
(718) 918-7224
50629P
3424 Kossuth Ave
Bronx, NY 10467
(718) 519-3589
Jacobi Medical Center, North
Central Bronx Hospital
Speaks Italian
Bar-David, Tzvi, DPM
36919P
3616 Henry Hudson Pkwy E
Bronx, NY 10463
(718) 548-5757
Columbia-Presbyterian
Medical Center
Speaks HebrewSpanish
Barlizo, Sharon R., DPM
357781P
HHC-Lincoln M&MH Center
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center, Metropolitan
Hospital Center
Speaks FrenchSpanish
Barragan, Juan C., DPM
36954P
St. John's Medical Center
1561 Westchester Ave
Bronx, NY 10472
(718) 328-6200
Speaks Spanish
Bautista, Debbie P., MD
301273P
St. Barn Ambulatory Care
4487 3rd Ave
Bronx, NY 10457
(718) 960-1780
301276P
Union Comm Hlth Ctr
2021 Grand Concourse
Bronx, NY 10453
(718) 960-3933
348297P
CCDC/Burnside Med Ctr
731 White Plains Rd
Bronx, NY 10473
(718) 589-8324
Our Lady of Mercy Medical
Center, St Barnabas Hospital
Bayerbach, Frank, DPM
216992P
Mercy Community Care
4234 Bronx Blvd
Bronx, NY 10466
(347) 341-4300
39016P
Metropolitan Podiatry Ass
667 E 233rd St
Bronx, NY 10466
(718) 430-6066
M1246P
2371 Arthur Ave
Bronx, NY 10458
(718) 364-6199
Brunswick General Hospital,
Brunswick Hospital Center, Inc,
Good Samaritan Hospital,
Good Samaritan Hospital (West
Islip)
Speaks
SpanishGermanItalian
Bushansky, Abe A., DPM
368478P
1715 University Ave
Bronx, NY 10453
(718) 960-5616
368491P
1963 Grand Concourse
Bronx, NY 10453
(718) 294-5000
Brooklyn Hospital Center
(Downtown Campus), Interfaith
Medical Center, Parkway
Hospital
Butts, Bryon G., DPM
349336P
421 E 149th St
Bronx, NY 10455
(718) 401-3668
The Mount Sinai Hospital of
Queens
Speaks Spanish
Campbell, Andrew, DPM
36957P
St. Barnabas Hospital
4422 3rd Ave
Bronx, NY 10457
(718) 960-9000
56967P
Union Community Health Ct
260 E 188 St
Bronx, NY 10458
(718) 220-2020
56970P
St. Barnabas Ambulatory C
4487 3rd Ave
Bronx, NY 10457
(718) 960-1780
56972P
Bronx Park Medical Pavill
2016 Bronxdale Ave
Bronx, NY 10462
(718) 863-8695
St Barnabas Hospital
Catanese, Dominic J., DPM
37141P
Orthopedic Surgery Dept.
1695 Eastchester Rd
Bronx, NY 10461
(718) 405-8430
Albert Einstein College of
Medicine, Community Hospital
at Dobbs Ferry, Montefiore
Med Ctr (Henry & Lucy Moses
Div), SAINT MARYS
HOSPITAL
Charlot, Giznola J., DPM
357878P
HHC-Jacobi Medical Center
1400 Pelham Pkwy S
Bronx, NY 10461
(718) 918-6610
357880P
HHC-North Central Bx Hosp
3424 Kossuth Ave
Bronx, NY 10467
(718) 519-2108
Jacobi Medical Center, Kings
County Hospital Center, North
Central Bronx Hospital
Chionis, Anthony, DPM
54771P
1725 Edison Ave
Bronx, NY 10461
(718) 892-5542
Parkway Hospital, St John's
Episcopal Hospital - Far
Rockaway
Speaks Greek, Modern
(1453-)
Chopra, Jaideep, DPM
284748P
NY Westchester Square Med
2475 Saint Raymonds Ave
Bronx, NY 10461
(718) 792-1100
Staten Island University
Hosp-North, University
Hospital of Brooklyn
Speaks Hindi
Ciment, Avraham Y., DPM
351611P
Soundview Healthcare ntwk
731 White Plains Rd
Bronx, NY 10473
(718) 589-8324
351618P
Diallo Medical Center
1760 Westchester Ave
Bronx, NY 10472
(718) 892-8474
351623P
Jessica Guzman Med Ctr
616 Castle Hill Ave
Bronx, NY 10473
(718) 239-9013
351628P
Burnside Medical Center
165 E Burnside Ave
Bronx, NY 10453
(718) 563-0003
Our Lady of Mercy Medical
Center, St Barnabas Hospital,
Westchester Medical Center
Speaks Hebrew
Cohen, Robert J., DPM
M4190P
140-1 Elgar Pl
Bronx, NY 10475
(718) 671-0400
Our Lady of Mercy Medical
Center, Parkway Hospital
Speaks French
De Bello, John A., DPM
289396P
New York Foot Care Srvc
3635 E Tremont Ave
Bronx, NY 10465
(718) 409-0400
3114603P
New York Foot Care Svc
421 E 149th St
Bronx, NY 10455
(718) 365-6363
36995P
New York Foot Care Svc
3201 Grand Concourse
Bronx, NY 10468
(718) 365-6363
Montefiore Med Ctr (Henry &
Lucy Moses Div), Mount Sinai
Hospital of Queens, North
Shore University Hospital, Our
Lady of Mercy Medical Center,
Parkway Hospital
Speaks Spanish
DeLeon, Jose L., DPM
179943P
625 E Fordham Rd
Bronx, NY 10458
(718) 933-1900
37252P
2111 Williamsbridge Rd
Bronx, NY 10461
(718) 828-6060
Our Lady of Mercy Medical
Center
Speaks Spanish
Dellolio, Joseph A., DPM
38329P
4362 White Plains Rd
Bronx, NY 10466
(718) 994-7054
Montefiore Med Ctr (Jack D
Weiler Hosp of A Einst), Our
Lady of Mercy Medical Center,
Westchester Medical Center
Speaks Spanish
Dhandari, Angeleta, DPM
116473P
North Central Bronx Hosp
3424 Kossuth Ave
Bronx, NY 10467
(718) 519-3589
116482P
Jacobi Medical Center
1400 Pelham Pkwy S
Bronx, NY 10461
(718) 918-5700
Jacobi Medical Center, North
Central Bronx Hospital
Edelstein, Michael C., DPM
178750P
3224 Grand Concourse
Bronx, NY 10458
(718) 561-0041
Our Lady of Mercy Medical
Center
Speaks Spanish
Elsinger, Elisabeth C.,
DPM
37257P
MAP-Dept of Ortho Sgy
3400 Bainbridge Ave
Bronx, NY 10467
(718) 920-2060
Montefiore Med Ctr (Henry &
Lucy Moses Div)
Speaks German
Finkelstein, Barry I.,
DPM
169233P
3327 Bainbridge Ave
Bronx, NY 10467
(718) 881-7990
194335P
NY Podiatry & Foot Surg
2425 Eastchester Rd
Bronx, NY 10469
(718) 881-7990
227755P
Wilson Orthopedics
75 E Gun Hill Rd
Bronx, NY 10467
(718) 798-1000
Montefiore Med Ctr (Jack D
Weiler Hosp of A Einst), United
Hospital Medical Center (NY)
Speaks HebrewYiddish
Frankel, Bruce, DPM
200374P
Lincoln Medical & Mental
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center
Freiser, Mark A., DPM
36628P
Bronx Footcare
421 E 149th St
Bronx, NY 10455
(718) 292-5045
New York Westchester Square
Medical Center, Our Lady of
Mercy Medical Center, St
Barnabas Hospital
Speaks SpanishFrench
Fridman, Robert, DPM
351650P
3616 Henry Hudson Pkwy
Bronx, NY 10463
(718) 548-5757
Columbia-Presbyterian
Medical Center
Garcia, Sandra P., DPM
353857P
Happy Feet
953 Southern Blvd
Bronx, NY 10459
(718) 542-0472
Board Certified
Male Female
Wheelchair Accessible
353859P
Uptown Healthcare Mgmt In
930 E Tremont Ave
Bronx, NY 10460
(718) 860-1111
Forest Hills Hospital
Speaks Spanish
Gaudino, Salvatore C.,
DPM
37096P
71 Metropolitan Oval
Bronx, NY 10462
(718) 829-6436
Mount Sinai Medical Center,
Parkway Hospital, Queens
Hospital Center
George, Thomas, DPM
197631P
3219 E Tremont Ave
Bronx, NY 10461
(718) 792-8115
Hempstead General Hospital
Med Ctr., New York
Westchester Square Medical
Center
Ginsberg, Steven E., DPM
132102P
2391 Arthur Ave
Bronx, NY 10458
(718) 365-4141
SVCMC-St Marys Hospital
Brooklyn, St Joseph's Hospital
Division, CMC
Giordano, Richard S.,
DPM
36494P
1217 Castle Hill Ave
Bronx, NY 10462
(718) 828-6982
Northern Westchester Hospital
Center, Our Lady of Mercy
Medical Center
Gitlin, David, DPM
379153P
HHC-Lincoln M&MH Center
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Metropolitan Hospital Center
Glockenberg, Aaron,
DPM
201399P
Lincoln Med & Mental Hlth
234 E 149th St
Bronx, NY 10451
(718) 579-4900
276540P
2445 Arthur Ave
Bronx, NY 10458
(718) 733-1999
Kings County Hospital Center,
Lincoln Medical & Mental
Health Center, Our Lady of
Mercy Medical Center, St
Barnabas Hospital, Union
Hospital of the Bronx (closed)
Speaks PolishHebrew
Goez, Emilio A., DPM
301254P
Union Comm Hlth Ctr
2021 Grand Concourse
Bronx, NY 10453
(718) 960-3933
301255P
St Barn Ambulatory Care
4487 3rd Ave
Bronx, NY 10457
(718) 960-1780
371846P
St. Barnabas Hospital
4422 3rd Ave
Bronx, NY 10457
(718) 960-6105
51028P
Bronx Park Med Pavilion
2016 Bronxdale Ave
Bronx, NY 10462
(718) 863-8695
Nassau University Medical
Center, Saint Catharines
General Hospital, St Barnabas
Hospital
Speaks Spanish
Goldenberg, Perry Z.,
DPM
231271P
3250 3rd Ave
Bronx, NY 10456
(718) 328-3668
St Barnabas Hospital
Goldstein, Harold L.,
DPM
187909P
2016 Bronxdale Ave
Bronx, NY 10462
(718) 863-8695
37017P
St. Barnabas Hospital
4422 3rd Ave
Bronx, NY 10457
(718) 960-6105
371962P
St Barnabas Ambulatory C
4487 3rd Ave
Bronx, NY 10457
(718) 960-6488
371965P
Union Community Health Ct
2021 Grand Concourse
Bronx, NY 10453
(718) 960-3933
371966P
Union Community Health Ct
260 E 188th St
Bronx, NY 10458
(718) 220-2020
St Barnabas Hospital, United
Hospital Medical Center (NY),
White Plains Hospital Center
Speaks SpanishItalian
Gramuglia, Vincent J.,
DPM
216990P
Mercy Community Care
4234 Bronx Blvd
Bronx, NY 10466
(347) 341-4300
49500P
AllMed Medical & Rehab
4377 Bronx Blvd
Bronx, NY 10466
(718) 325-0700
49501P
Metropolitan Podiatry Ass
667 E 233rd St
Bronx, NY 10466
(718) 430-6066
M1576P
3795 E Tremont Ave
Bronx, NY 10465
(718) 828-3333
New York Westchester Square
Medical Center, Our Lady of
Mercy Medical Center
Speaks SpanishItalian
Greiff, Lance, DPM
354487P
3333 Henry Hudson Pkwy
Bronx, NY 10463
(718) 601-2100
Brooklyn Hospital Center
(Downtown Campus), New
York Flushing Hospital &
Medical Center, Parkway
Hospital
Gutierrez, David, DPM
M1570P
2100 Bartow Ave
Bronx, NY 10475
(718) 320-0200
Our Lady of Mercy Medical
Center
Speaks Spanish
Harris, Carl F., DPM
201401P
Lincoln Med & Mental Hlth
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Harlem Hospital Center,
Lincoln Medical & Mental
Health Center
Herman, Craig P., DPM
227774P
Advanced Foot Care
3396 E Tremont Ave
Bronx, NY 10461
(718) 409-2121
300046P
Bronx Health Center
975 Westchester Ave
Bronx, NY 10459
(718) 991-9250
New York Westchester Square
Medical Center, Our Lady of
Mercy Medical Center
Speaks Spanish
Iorio, Anthony R., DPM
357778P
HHC-Lincoln M&MH Center
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center, Metropolitan
Hospital Center
Isaacson, Ernest, DPM
341669P
Parkchester Family Foot
1340 Metropolitan Ave
Bronx, NY 10462
(718) 863-3338
Beth Israel Medical Center
(Petrie Campus), Our Lady of
Mercy Medical Center
Speaks Hebrew
Jacobs, Louis W., DPM
36524P
4240 Hutchinson River Pkwy
E
Bronx, NY 10475
(718) 671-2233
Speaks SpanishHungarian
Joshi, Pradip M., DPM
36975P
1963A Daly Ave
Bronx, NY 10460
(718) 617-6141
39978P
1650 Selwyn Ave
Bronx, NY 10457
(718) 590-1800
Bronx-Lebanon Hospital
Center - Fulton Division, Our
Lady of Mercy Medical Center
Speaks Spanish
Kolberg, John J., DPM
351082P
1387 Grand Concourse
Bronx, NY 10452
(718) 992-9918
New Island Hospital
Speaks Spanish
Kumrah, Praveen, DPM
187664P
2015 Grand Concourse
Bronx, NY 10453
(718) 299-7295
214484P
Uptown HealthCare Mgmt
1778 Jerome Ave
Bronx, NY 10453
(718) 764-1661
221984P
1807 Randall Ave
Bronx, NY 10473
(718) 617-2468
New York Westchester Square
Me, Our Lady of Mercy
Medical Center
Speaks HindiPunjabi
LaSalle, Michael, DPM
200845P
Lincoln Medical & Mental
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center
Lai, Katherine M., DPM
37068P
Center for Podiatric Care
1500 Astor Ave
Bronx, NY 10469
(718) 882-6881
Beth Israel Medical Center
(Petrie Campus), Mount Sinai
Medical Center, Our Lady of
Mercy Medical Center
Landy, Robert J., DPM
37072P
1340 Metropolitan Ave
Bronx, NY 10462
(718) 863-3338
Massapequa General Hospital,
Our Lady of Mercy Medical
Center, Parkway Hospital,
Southside Hospital, Winthrop
University Hospital
Speaks Spanish
Levy, Denise A., DPM
141439P
Hyperbaric Unit
111 E 210th St
Bronx, NY 10467
(718) 920-6655
Montefiore Med Ctr (Henry &
Lucy Moses Div)
Speaks Spanish
Levy, Paul J., DPM
169192P
2545 Wallace Ave
Bronx, NY 10467
(718) 231-2500
36736P
2539 Fish Ave
Bronx, NY 10469
(718) 231-2500
Brooklyn Hospital Center
(Downtown Campus), Our Lady
of Mercy Medical Center
Speaks Spanish
Locastro, Robert M.,
DPM
124212P
731 White Plains Rd
Bronx, NY 10473
(718) 893-7773
Southside Hospital, St
Barnabas Hospital, St
Catherine of Siena, St
Catherine of Sienna Medical
Center
Lok, Jonat, DPM
227010P
East Tremont Medical Ctr
930 E Tremont Ave
Bronx, NY 10460
(718) 860-1111
New York Downtown Hospital
(Beekman), Our Lady of Mercy
Medical Center
Lopiano, Steven N., DPM
36777P
3108 Kingsbridge Ave
Bronx, NY 10463
(718) 548-1102
Our Lady of Mercy Medical
Center
Speaks SpanishItalian
Board Certified
Male Female
Wheelchair Accessible
Lynn, Brian P., DPM
38157P
Ctr for Ortho Specialty
1695 Eastchester Rd
Bronx, NY 10461
(718) 405-8430
38159P
MAP - Dept. of Ortho Surg
3400 Bainbridge Ave
Bronx, NY 10467
(718) 920-2060
Long Island Jewish Medical
Center, Montefiore Med Ctr
(Henry & Lucy Moses Div)
Speaks Spanish
Marville, Jillion, MD
179966P
Morris Heights Hlth Ctr
625 E 137th St
Bronx, NY 10454
(718) 401-6578
49882P
Morris Heights Hlth Cntr
85 W Burnside Ave
Bronx, NY 10453
(718) 716-4400
Nachmann, Dennis S.,
DPM
188735P
Urgent Foot Care,PC
3594 E Tremont Ave
Bronx, NY 10465
(718) 597-5800
37260P
Urgent Foot Care PC
3058 E Tremont Ave
Bronx, NY 10461
(718) 409-0500
37261P
1216 Beach Ave
Bronx, NY 10472
(718) 597-1107
40448P
326 E 204th St
Bronx, NY 10467
(718) 655-3410
53065P
1387 Grand Concourse
Bronx, NY 10452
(718) 992-9918
Bronx-Lebanon Hospital
Center - Fulton Division,
Montefiore Med Ctr (Jack D
Weiler Hosp of A Einst), New
York Westchester Square
Medical Center, Our Lady of
Mercy Medical Center
Speaks Spanish
Oliva, Imelda A., DPM
357238P
HHC Morrisania D & T Ctr
1225 Gerard Ave
Bronx, NY 10452
(718) 960-2781
357786P
HHC-Lincoln M&MH Center
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Kings County Hospital Center,
Metropolitan Hospital Center,
Morrisania Hospital
Speaks TagalogSpanish
Oropall, Robert, DPM
142725P
Metropolitan Podiatry Ass
667 E 233rd St
Bronx, NY 10466
(718) 430-6066
18943P
820 Lydig Ave
Bronx, NY 10462
(718) 792-5900
New York Westchester Square
Medical Center, Our Lady of
Mercy Medical Center
Speaks German
Pannell, Richard, DPM
288046P
HHC-Morrisania D &TC
1225 Gerard Ave
Bronx, NY 10452
(718) 960-2781
Harlem Hospital Center,
Metropolitan Hospital Center
Plotka, Steven D., DPM
200379P
HHC Lincoln Hospital
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center, Mount Sinai
Medical Center, Raritan Bay
Medcal Center, Robert Wood
Johnson University Hosp.
Speaks Spanish
Posner, Jonathan, DPM
105432P
Jonathan Posner, DPM
360 E 193rd St
Bronx, NY 10458
(718) 933-2400
105434P
Jonathan Posner, DPM
1621 Eastchester Rd
Bronx, NY 10461
(718) 405-8040
143124P
MMG - CHCC
305 E 161st St
Bronx, NY 10451
(718) 579-2500
P0052P
2532 Grand Concourse
Bronx, NY 10458
(718) 960-1500
Montefiore Med Ctr (Henry &
Lucy Moses Div)
Rampino, Robert, DPM
157922P
North Central Bronx Hosp
3424 Kossuth Ave
Bronx, NY 10467
(718) 519-3630
157925P
Jacobi Medical Center
1400 Pelham Pkwy S
Bronx, NY 10461
(718) 918-5700
Coney Island Hospital
Ransom, Sherry M., DPM
198963P
Derm & Surgery Associates
3620 E Tremont Ave
Bronx, NY 10465
(718) 792-4700
Mount Vernon Hospital
Richman, Tara, DPM
364345P
Tej Podiatric Group P.C.
1963-A Daly Ave
Bronx, NY 10460
(718) 617-6141
Bronx-Lebanon Hospital
Center - Fulton Division
Ross, Charles F., DPM
3113966P
HHC-Lincoln Med & Mntl HC
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center, Metropolitan
Hospital Center
Schulman, Leonard B.,
DPM
36464P
MMC-Family Care Center
3444 Kossuth Ave
Bronx, NY 10467
(718) 920-2273
Montefiore Med Ctr (Henry &
Lucy Moses Div)
Scotti, Lorenzo, DPM
36715P
North Central Bronx Hosp
3424 Kossuth Ave
Bronx, NY 10467
(718) 519-3589
51545P
Jacobi Medical Center
1400 Pelham Pkwy S
Bronx, NY 10461
(718) 918-7224
Coney Island Hospital, Jacobi
Medical Center, North Central
Bronx Hospital
Speaks ItalianSpanish
Snyder, Robert S., DPM
46604P
3867 E Tremont Ave
Bronx, NY 10465
(718) 792-8790
Forest Hills Hospital, Parkway
Hospital
Speaks Spanish
Spector, Donald, DPM
36812P
Cambridge Podiatry Center
259 W 231st St
Bronx, NY 10463
(718) 548-3080
St Joseph's Medical
Center-Yonkers
Spellman, Dean S., DPM
381596P
Middletown Podiatry Assoc
1200 Waters Pl
Bronx, NY 10461
(718) 863-5511
New York Westchester Square
Medical Center
Spilken, Terry, DPM
200471P
HHC Lincoln Hospital
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center
Steiner, Richard M., DPM
188831P
3530 Henry Hudson Pkwy E
Bronx, NY 10463
(718) 548-3550
379697P
Kingsbridge Community Med
170 W 233rd St
Bronx, NY 10463
(718) 543-0700
SVCMC-St Vincents Manhattan
Stern, Stuart M., DPM
36652P
Morris Park Podiatry
1015 Morris Park Ave
Bronx, NY 10462
(718) 863-3737
New Island Hospital, Plainview
Hospital, Syosset Hospital
Strassman, David, DPM
349822P
MMC - Dept of Surgery
111 E 210th St
Bronx, NY 10467
(718) 920-6603
Montefiore Med Ctr (Jack D
Weiler Hosp of A Einst), New
York Methodist Hospital, New
York Westchester Square
Medical Center
Strassman, Lawrence,
DPM
358330P
MMC - Eastern Vascular
1825 Eastchester Rd
Bronx, NY 10461
(718) 792-8115
Montefiore Med Ctr (Jack D
Weiler Hosp of A Einst), New
York Westchester Square
Medical Center
Tabari, Issac, DPM
208998P
108 E 183rd St
Bronx, NY 10453
(718) 295-4600
Lutheran Medical Center,
Nassau University Medical
Center
Speaks FARSI,
EASTERNPersian
Thompson, Michael, DPM
36705P
2574 Frisby Ave
Bronx, NY 10461
(718) 892-8382
Brooklyn Hospital Center
(Downtown Campus), Our Lady
of Mercy Medical Center
Velasco, Debra, DPM
201409P
HHC Lincoln Hospital
234 E 149th St
Bronx, NY 10451
(718) 579-4900
214314P
Segundo Ruiz Belvis DTC
545 E 142nd St
Bronx, NY 10454
(718) 579-4000
288345P
HHC-Morrisania D &TC
1225 Gerard Ave
Bronx, NY 10452
(718) 960-2781
Lincoln Medical & Mental
Health Center, Metropolitan
Hospital Center
Speaks Spanish
Vincetic, Anto, DPM
231369P
3635 E Tremont Ave
Bronx, NY 10465
(718) 409-0400
Montefiore Med Ctr (Henry &
Lucy Moses Div), Mount
Vernon Hospital
Speaks Croatian
Vitale, Thomas, DPM
201089P
HHC Lincoln Hospital
234 E 149th St
Bronx, NY 10451
(718) 579-4900
Lincoln Medical & Mental
Health Center
Walter, Eric G., DPM
142727P
Metropolitan Podiatry Ass
667 E 233rd St
Bronx, NY 10466
(718) 430-6066
357174P
1619 Pelham Pkwy N
Bronx, NY 10469
(718) 665-3410
36967P
Bronx Foot Rehab Assoc.
326 E 204th St
Bronx, NY 10467
(718) 655-3410
New York Westchester Square
Medical Center, Our Lady of
Mercy Medical Center, SJRH -
St Johns Division, St Barnabas
Hospital
Speaks German
Specialist
Board Certified
Male Female
Wheelchair Accessible
PODIATRY (Continued)
Wexler, Craig, DPM
36647P
2391 Arthur Ave
Bronx, NY 10458
(718) 365-4141
Newton Memorial Hospital,
Our Lady of Mercy Medical
Center
Winston, Wayne, DPM
359588P
Signature Health Center
220 E 161st St
Bronx, NY 10451
(718) 537-1100
Forest Hills Hospital
Wolstein, Lewis, DPM
42408P
100-1 De Kruif Pl
Bronx, NY 10475
(718) 671-7226
New York Westchester Square
Medical Center, United
Hospital Medical Center (NY),
White Plains Hospital Center
Speaks Spanish
Wolstein, Peter D., DPM
19917P
1340 Metropolitan Ave
Bronx, NY 10462
(718) 863-3338
Speaks SpanishTagalog
Woltman, Robert T., DPM
174899P
1488 Metropolitan Ave
Bronx, NY 10462
(718) 823-6239
174900P
Wellness Medical Asso
1180 Morris Park Ave
Bronx, NY 10461
(718) 863-8465
Long Island Jewish Medical
Center, New York Westchester
Square Me, Peninsula Hospital
Center
Board Certified
Male Female
Wheelchair Accessible
PODIATRY
Amante, Gregory, DPM
199177P
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
Coney Island Hospital
Speaks Spanish
Amico, Susan G., DPM
184838P
SL Quality Care Diagnosti
9708 Seaview Ave
Brooklyn, NY 11236
(718) 444-0520
184843P
SL Quality Care Diagnosti
1902 86th St
Brooklyn, NY 11214
(718) 621-9400
184852P
SL Quality Care Diagnosti
1220 Avenue P
Brooklyn, NY 11229
(718) 376-1004
49812P
9731 4th Ave
Brooklyn, NY 11209
(718) 836-1800
SVCMC-St Vincents Staten
Island, Staten Island University
Hosp-North, Victory Memorial
Hospital
Speaks ItalianSpanish
Archer, Jean V., DPM
105663P
Brookdale Family Care Ctr
2554 Linden Blvd
Brooklyn, NY 11208
(718) 240-8600
40532P
Jamaica Hosp Medical Ctr
3080 Atlantic Ave
Brooklyn, NY 11208
(718) 647-0240
Jamaica Hospital
Speaks Spanish
Aronica, Frank R., DPM
36667P
20 Plaza St E
Brooklyn, NY 11238
(718) 638-6387
Catholic Medical Center (NY),
Long Island College Hospital
Speaks SpanishItalian
Assini, Joseph, DPM
36727P
8616 3rd Ave
Brooklyn, NY 11209
(718) 948-3838
Doctors Hosp. of Staten Island,
Lutheran Medical Center,
Staten Island University
Hosp-North, Victory Memorial
Hospital
Speaks Italian
Babayev, Emil, DPM
224479P
Perloff Medical PC
2626 E 14th St
Brooklyn, NY 11235
(718) 368-2626
37241P
Professional Medical Plaz
2269 Ocean Ave
Brooklyn, NY 11229
(718) 339-8200
46696P
421 Ocean Pkwy
Brooklyn, NY 11218
(718) 287-4200
Lutheran Medical Center, New
York Methodist Hospital
Speaks Russian
Baird, William T., DPM
37008P
Plaza Foot Care, PC
5412 Kings Plz Mall
Brooklyn, NY 11234
(718) 377-1212
Peninsula Hospital Center
Speaks
SpanishFrenchRussian
Barkoff, Steven L., DPM
36921P
248 Roebling St
Brooklyn, NY 11211
(718) 599-0505
Brooklyn Hospital Center
(Downtown Campus), New
York Methodist Hospital
Speaks Spanish
Barone, Salvatore A.,
DPM
36884P
1601 Voorhies Ave
Brooklyn, NY 11235
(718) 646-5553
Lutheran Medical Center
Speaks SpanishGerman
Bartol, David M., DPM
139333P
North Star Orthopedics
1408 Ocean Ave
Brooklyn, NY 11230
(718) 338-0909
59239P
North Star Orthopedics
2615 E 16th St
Brooklyn, NY 11235
(718) 745-8787
59240P
North Star Orthopedics
26 Court St
Brooklyn, NY 11242
(718) 935-0311
M6958P
1000 Church Ave
Brooklyn, NY 11218
(718) 826-4000
M6958P
740 64th St
Brooklyn, NY 11220
(718) 439-2000
Parkway Hospital
Bass, Elliot L., DPM
36493P
2381 E 29th St
Brooklyn, NY 11229
(718) 743-1400
49605P
Elliot L Bass, MD
2 W End Ave
Brooklyn, NY 11235
(718) 743-2900
Bass, Fara D., DPM
50123P
2 W End Ave
Brooklyn, NY 11235
(718) 743-1400
M100
2381 E 29th St
Brooklyn, NY 11229
(718) 743-1400
New York Methodist Hospital
Speaks Yiddish
Bell, Burt L., DPM
105602P
7608 20th Ave
Brooklyn, NY 11214
(718) 837-8003
113259P
3065 Brighton 5Th St
Brooklyn, NY 11235
(718) 332-2722
New York Community Hospital
of Brooklyn
Benzakein, Ralph, DPM
36761P
2241 Ocean Ave
Brooklyn, NY 11229
(718) 998-1375
New York Community Hospital
of Brooklyn
Speaks
ArabicHebrewRussianSpani
sh
Bienenfeld, Jay D., DPM
47072P
165 Taylor St
Brooklyn, NY 11211
(718) 599-0753
Peninsula Hospital Center
Speaks
SpanishHebrewYiddish
Birch, Gregory M., DPM
36595P
6419 Bay Pkwy
Brooklyn, NY 11204
(718) 232-6737
Staten Island University
Hosp-North
Bover, Elina, DPM
353725P
A. Amerimed Physician P.C
1655 E 13th St
Brooklyn, NY 11229
(718) 339-3100
353726P
A. Amerimed Physician P.C
1100 Coney Island Ave
Brooklyn, NY 11230
(718) 434-7533
New York Methodist Hospital
Speaks AbkhazianAfam
(Oromo)
Braun, Suzanne G., DPM
142989P
2171 Nostrand Ave
Brooklyn, NY 11210
(718) 758-8920
359508P
710 Parkside Ave
Brooklyn, NY 11226
(718) 270-2075
University Hospital of Brooklyn
Speaks SpanishItalian
Breth, Evan G., DPM
49200P
Evan G. Breth, DPM
2352 Ralph Ave
Brooklyn, NY 11234
(718) 251-0200
M1550P
263 7th Ave
Brooklyn, NY 11215
(718) 369-8080
M1551P
United Medical Assoc
9001 3rd Ave
Brooklyn, NY 11209
(718) 748-2900
M1552P
7124 18th Ave
Brooklyn, NY 11204
(718) 234-3333
Lutheran Medical Center, New
York Methodist Hospital
Bushansky, Abe A., DPM
231380P
734 Pennsylvania Ave
Brooklyn, NY 11207
(718) 493-5986
37057P
711 Eastern Pkwy
Brooklyn, NY 11213
(718) 493-5986
Brooklyn Hospital Center
(Downtown Campus), Interfaith
Medical Center, Parkway
Hospital
Butters, Marva, DPM
343047P
158 Clarkson Ave
Brooklyn, NY 11226
(718) 783-4780
Brooklyn Hospital Center
(Downtown Campus), Kings
County Hospital Center
Buxbaum, Frederick D.,
DPM
36540P
1501 W 6th St
Brooklyn, NY 11204
(718) 837-0442
New York Community Hospital
of Brooklyn, New York
Methodist Hospital, Parkway
Hospital
Buzermanis, Steven Z.,
DPM
57282P
1230 Neptune Ave
Brooklyn, NY 11224
(718) 615-3200
57282P
3245 Nostrand Ave
Brooklyn, NY 11229
(718) 615-3777
57282P
345 Schermerhorn St
Brooklyn, NY 11217
(718) 858-6300
Campbell, Douglas E.,
DPM
37122P
MAIMONDES MED CTR
BROOKLYN, NY 11219
(718) 283-7593
54942P
4801 Fort Hamilton Pkwy
Brooklyn, NY 11219
(718) 853-7469
54944P
241 Willoughby St
Brooklyn, NY 11201
(718) 853-7469
Maimonides Medical Center
Caprioni, Enrico P., DPM
163554P
326 7th St
Brooklyn, NY 11215
(718) 369-7192
New York Methodist Hospital
Speaks ItalianSpanish
Carlton, Lawrence S.,
DPM
36731P
1981 Flatbush Ave
Brooklyn, NY 11234
(718) 338-8715
Brooklyn Hospital Center
(Downtown Campus)
Castillo, Dennis E., DPM
0X190P
345 Clinton Ave
Brooklyn, NY 11238
(718) 783-7300
105747P
450 Clarkson Ave
Brooklyn, NY 11203
(718) 783-7300
376722P
SUNY Downstate Med Ctr
840 Lefferts Ave
Brooklyn, NY 11203
(718) 783-7300
376724P
SUNY Downstate Med Ctr
445 Lenox Rd
Brooklyn, NY 11203
(718) 783-7300
Brooklyn Hospital Center
(Downtown Campus), Interfaith
Medical Center, Kingsbrook
Jewish Medical Center,
University Hospital of Brooklyn
Speaks Spanish
Board Certified
Male Female
Wheelchair Accessible
)
Charlot, Giznola J., DPM
358034P
HHC-Kings County Hospital
451 Clarkson Ave
Brooklyn, NY 11203
(718) 245-3325
Jacobi Medical Center, Kings
County Hospital Center, North
Central Bronx Hospital
Cheng, Tung W., DPM
36670P
299 Livingston St
Brooklyn, NY 11217
(718) 624-2150
Speaks Chinese
Chopra, Jaideep, DPM
283717P
Medical Office
462 Ocean Pkwy
Brooklyn, NY 11218
(718) 856-6010
284749P
1324 Bergen St
Brooklyn, NY 11213
(718) 774-5224
362592P
710 Parkside Ave
Brooklyn, NY 11226
(718) 270-2045
363451P
University Phys of Bklyn
450 Clarkson Ave
Brooklyn, NY 11203
(718) 270-2045
Staten Island University
Hosp-North, University
Hospital of Brooklyn
Speaks Hindi
Cicio, Gary, DPM
36673P
142 Joralemon St
Brooklyn, NY 11201
(718) 624-3003
Beth Israel Med Ctr (Kings
Hwy Division), Long Island
College Hospital, New York
Downtown Hospital (Beekman)
Cohen, Greg E., DPM
168309P
142 Joralemon St
Brooklyn, NY 11201
(718) 624-3003
Cabrini Medical Center, Long
Island College Hospital
Cohen, Richard B., DPM
36732P
1331 E 16th St
Brooklyn, NY 11230
(718) 375-3400
Brooklyn Hospital Center
(Downtown Campus)
D'Amato, Theodore A.,
DPM
369717P
9731 4th Ave
Brooklyn, NY 11209
(718) 745-3177
Staten Island University
Hosp-North, Victory Memorial
Hospital
D'Angelo, Nicholas A.,
DPM
M1613P
6511 20th Ave
Brooklyn, NY 11204
(718) 837-7300
New York Methodist Hospital
Speaks Italian
Dacher, Jeffrey, DPM
36847P
3901 Nostrand Ave
Brooklyn, NY 11235
(718) 648-9104
Woodhull Medical & Mental
Health Ctr
Speaks Yiddish
Daniel, Lawrence B.,
DPM
10292P
2832 Linden Blvd
Brooklyn, NY 11208
(718) 240-2000
58558P
Lawrence B. Daniel, DPM
1576 E 66th St
Brooklyn, NY 11234
(718) 241-3803
Brooklyn Hospital Center
(Downtown Campus),
Montefiore Med Ctr (Henry &
Lucy Moses Div), Montefiore
Med Ctr (Jack D Weiler Hosp
of A Einst)
DeMeo, James R., DPM
169482P
1545 Atlantic Ave
Brooklyn, NY 11213
(718) 613-4856
Cabrini Medical Center,
Interfaith Medical Center,
Mount Vernon Hospital, SJRH -
St Johns Division
DeSantos, Pasquale, DPM
371165P
HHC-Coney Island Hospital
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
Coney Island Hospital
Speaks ItalianSpanish
Dennis, Lester N., DPM
50225P
746 Manhattan Ave
Brooklyn, NY 11222
(718) 389-4404
Catholic Medical Center (NY),
New York Flushing Hospital &
Medical Center, New York
Hospital Medical Center of
Queens, St Joseph's Hospital
Division, CMC, United
Hospital Medical Center (NY),
Wyckoff Heights Medical
Center
Dharia, Sumit S., DPM
349314P
552 Saint Marks Ave
Brooklyn, NY 11238
(516) 359-3339
Speaks Gujarati
Dixit, Chaitanya V., DPM
229092P
NY Medical Associates
98 Avenue U
Brooklyn, NY 11223
(718) 372-0500
39505P
1700 Flatbush Ave
Brooklyn, NY 11210
(718) 692-1120
M1245P
2235 W 9th St
Brooklyn, NY 11223
(718) 372-0400
Jamaica Hospital, New York
Methodist Hospital, Our Lady
of Mercy Medical Center
Speaks SpanishHindiItalian
Donovan, Glenn J., DPM
348058P
HHC-Coney Island Hospital
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
Coney Island Hospital
Dorazi, Stephen T., DPM
144643P
374 Stockholm St
Brooklyn, NY 11237
(718) 963-7233
Franklin Hospital, New York
Hospital Medical Center of
Queens, New York United
Hospital Medic, Sound Shore
Medical Center of Westchester,
Wyckoff Heights Medical
Center
Speaks Spanish
Ehrlich, Josh C., DPM
341691P
Astrocare Medical Center
1669 Bedford Ave
Brooklyn, NY 11225
(718) 467-7200
36823P
1651 Coney Island Ave
Brooklyn, NY 11230
(718) 382-2221
49886P
1535 51st St
Brooklyn, NY 11219
(718) 436-8886
Maimonides Medical Center,
Staten Island University
Hosp-North
Speaks
HebrewYiddishRussian
Einhorn, Jill L., DPM
36976P
2616 Avenue U
Brooklyn, NY 11229
(718) 891-2706
Beth Israel Med Ctr (Kings
Hwy Division), Maimonides
Medical Center
Fagen, Leonard, DPM
36474P
1390 Pennsylvania Ave
Brooklyn, NY 11239
(718) 642-2088
Brookdale Hospital Medical
Center
Speaks Spanish
Falcone, Jeffrey J., DPM
168454P
8012 3rd Ave
Brooklyn, NY 11209
(718) 745-5600
New York Methodist Hospital
Ficke, Henry, DPM
177873P
2875 W 8th St
Brooklyn, NY 11224
(718) 266-3131
288626P
444 Avenue X, Ste 1E
Brooklyn, NY 11223
(718) 375-1616
288630P
2015 Bath Ave
Brooklyn, NY 11214
(718) 375-1616
Long Beach Memorial Hospital
Speaks
GermanItalianSpanish
Friedlander, Bruce W.,
DPM
229664P
567 9th St
Brooklyn, NY 11215
(718) 840-0220
Long Island College Hospital
Speaks SpanishFrench
Ganjian, Afshin, DPM
37177P
146 Sheridan Ave
Brooklyn, NY 11208
(718) 235-6100
Coney Island Hospital, St
Joseph's Hospital Division,
CMC
Speaks
PersianSpanishRussianItalia
n
Garofalo, Alfred A.,
DPM
226023P
Woodhull Med & Ment HC
760 Broadway
Brooklyn, NY 11206
(718) 388-5889
Bellevue Hospital Center,
Gouverneur Hospital, Woodhull
Medical & Mental Health Ctr
Gaudino, Salvatore C.,
DPM
114762P
Boro Medical, PC
540 Atlantic Ave
Brooklyn, NY 11217
(718) 855-4900
37094P
Bensonhurst Fam. Foot Ctr
7819 18th Ave
Brooklyn, NY 11214
(718) 234-7054
51018P
Bensonhurst Family Foot
420 74th St
Brooklyn, NY 11209
(718) 836-1017
Mount Sinai Medical Center,
Parkway Hospital, Queens
Hospital Center
Geiger, Arthur, DPM
52948P
Kings County Hospital Ctr
451 Clarkson Ave
Brooklyn, NY 11203
(718) 245-3325
Kings County Hospital Center
George, Thomas, DPM
197909P
888 Fountain Ave
Brooklyn, NY 11208
(718) 235-0574
Hempstead General Hospital
Med Ctr., New York
Westchester Square Medical
Center
Gertsik, Vladimir V., DPM
193957P
Gertsik Podiatry< PC
415 Ocean View Ave
Brooklyn, NY 11235
(718) 934-4842
New York Methodist Hospital
Speaks Russian
Giammarino, Philip A.,
DPM
149919P
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
199181P
HHC-Sheepshead Bay Ctr
3121 Ocean Ave
Brooklyn, NY 11235
(718) 646-9190
36584P
8607 21st Ave
Brooklyn, NY 11214
(718) 266-1986
Coney Island Hospital,
Lutheran Medical Center
Speaks SpanishItalian
Glockenberg, Aaron,
DPM
36620P
Kings County Hospital Ctr
451 Clarkson Ave
Brooklyn, NY 11203
(718) 245-3325
Kings County Hospital Center,
Lincoln Medical & Mental
Health Center, Our Lady of
Mercy Medical Center, St
Barnabas Hospital, Union
Hospital of the Bronx (closed)
Speaks PolishHebrew
Board Certified
Male Female
Wheelchair Accessible
Goldman, Gershon A.,
DPM
372901P
Fayn Medical PC
1517 Voorhies Ave
Brooklyn, NY 11235
(718) 648-2491
Forest Hills Hospital, Parkway
Hospital
Speaks
HebrewFrenchYiddishSpanis
h
Goldstein, Israel, DPM
169498P
Ezra Medical Center
571 McDonald Ave
Brooklyn, NY 11218
(718) 686-7600
228018P
468 Ocean Pkwy
Brooklyn, NY 11218
(718) 693-0578
Speaks
YiddishRussianRomanianHe
brew
Gonzalez, Ivan, DPM
137870P
East New York D & TC
2094 Pitkin Ave
Brooklyn, NY 11207
(718) 240-0400
Brooklyn Hospital Center
(Downtown Campus), Kings
County Hospital Center, St
Joseph's Hospital Division,
CMC, University Hospital of
Brooklyn
Speaks
SpanishFrenchPortugueseIt
alian
Goodman, Warren J., DPM
213648P
Kings Highway Podiatry
380 Avenue U
Brooklyn, NY 11223
(718) 376-3077
Victory Memorial Hospital
Speaks FrenchSpanish
Greenbaum, Bruce R.,
DPM
P0058P
3000 Ocean Pkwy
Brooklyn, NY 11235
(718) 265-2600
Staten Island University
Hosp-North, Staten Island
University Hosp-South
Guberman, Ronald M.,
DPM
144825P
Wound Healing & Hyperbar
374 Stockholm St
Brooklyn, NY 11237
(718) 381-8402
FLUSHING HOSPITAL
MEDICAL CENTER, Franklin
Hospital, Jackson Heights
Hospital Division (closed),
Sound Shore Medical Center of
Westchester, Wyckoff Heights
Medical Center
Speaks Spanish
Gventer, Mark, DPM
49889P
434 3rd St
Brooklyn, NY 11215
(718) 499-7583
New York Community Hospital
of Brooklyn
Speaks RussianSpanish
Habib, Henry, DPM
44484P
8000 4th Ave
Brooklyn, NY 11209
(718) 833-8136
SVCMC-St Vincents Manhattan
Speaks ItalianArabic
Heller, David P., DPM
36550P
843 Utica Ave
Brooklyn, NY 11203
(718) 345-8923
49818P
2124 Knapp St
Brooklyn, NY 11229
(718) 743-4121
Interfaith Medical Center
Herman, Craig P., DPM
363912P
94-98 Manhattan Avenue
Brooklyn, NY 11206
(718) 388-0390
New York Westchester Square
Medical Center, Our Lady of
Mercy Medical Center
Speaks Spanish
Horowitz, Mitchell L.,
DPM
123582P
Quality Health Center Inc
138 Division Ave
Brooklyn, NY 11211
(718) 387-2408
Ivanovs, Ray, DPM
226092P
Woodhull Med & Ment HC
760 Broadway
Brooklyn, NY 11206
(718) 388-5889
Woodhull Medical & Mental
Health Ctr
Jarbath, John A., DPM
155825P
2051 Flatbush Ave
Brooklyn, NY 11234
(718) 677-1000
Forest Hills Hospital, New York
Hospital Medical Center of
Queens, Parkway Hospital,
Peninsula Hospital Center
Speaks FrenchCreoles and
pidgins, French-based
(Other)
Jusma, Francoise D., DPM
221129P
Cumberland D & T Ctr
100 N Portland Ave
Brooklyn, NY 11205
(718) 260-7500
221130P
Woodhull Med & Ment HC
760 Broadway
Brooklyn, NY 11206
(718) 388-5889
M4204P
100 Parkside Ave
Brooklyn, NY 11226
(718) 940-5288
Brooklyn Hospital Center
(Downtown Campus), Woodhull
Medical & Mental Health Ctr
Speaks FrenchCreoles and
pidgins, French-based
(Other)
Kaiser, Craig A., DPM
361854P
1220 Avenue P
Brooklyn, NY 11229
(718) 376-1004
361888P
19-02 86th St
Brooklyn, NY 11214
(718) 621-9400
361892P
9708 Seaview Ave
Brooklyn, NY 11236
(718) 444-0520
37134P
465 Ocean Pkwy
Brooklyn, NY 11218
(718) 941-3796
Maimonides Medical Center,
New York Methodist Hospital
Kapadwala, Imtiyaz I.,
DPM
37207P
220 A. Saint Nicholas Ave
Brooklyn, NY 11237
(718) 418-8540
50700P
2848 Church Ave
Brooklyn, NY 11226
(718) 703-3000
Kingsbrook Jewish Medical
Center, Wyckoff Heights
Medical Center
Speaks UrduHindi
Katz, Alex S., DPM
291819P
2797 Ocean Pkwy
Brooklyn, NY 11235
(718) 615-4444
New York Community Hospital
of Brooklyn
Speaks
RussianHebrewSpanish
Katzman, Barry, DPM
M0791P
233 Nostrand Ave
Brooklyn, NY 11205
(718) 826-5900
New York Flushing Hospital &
Medical Center, New York
Hospital Medical Center of
Queens, Parkway Hospital
Speaks Spanish
Knobel, Jeffrey, DPM
M4199P
1636 E 14th St
Brooklyn, NY 11229
(718) 336-1800
M4200P
662 Bedford Ave
Brooklyn, NY 11211
(718) 336-1800
Beth Israel Medical Center
(Petrie Campus), Brookdale
Hospital Medical Center,
Jamaica Hospital
Speaks RussianYiddish
Lafferty, William A., DPM
355861P
858 Schenectady Ave
Brooklyn, NY 11203
(718) 604-5574
SVCMC-St Vincents Staten
Island, Staten Island University
Hosp-North
Lepore, Frank L., DPM
194379P
349 Henry St
Brooklyn, NY 11201
(718) 780-8104
Catholic Medical Center (NY),
Long Island College Hospital,
Wyckoff Heights Medical
Center
Speaks ItalianSpanish
Levitz, Steven J., DPM
371880P
3010 Avenue L
Brooklyn, NY 11210
(718) 258-1820
Brooklyn Hospital Center
(Downtown Campus), Wyckoff
Heights Medical Center
Levy, Brian K., DPM
109695P
1390 Pennsylvania Ave
Brooklyn, NY 11239
(718) 642-2088
Brookdale Hospital Medical
Center, Kingsbrook Jewish
Medical Center
Speaks Spanish
Liswood, Paul J., DPM
37131P
Comprehensive Podiatry Sv
7212 4th Ave
Brooklyn, NY 11209
(718) 745-0256
53864P
506 6th St
Brooklyn, NY 11215
(718) 780-5850
Lutheran Medical Center, New
York Methodist Hospital
Speaks RussianSpanish
Losyev, Sergey, DPM
173305P
2005 Ocean Ave
Brooklyn, NY 11230
(718) 645-4324
Lutheran Medical Center
Speaks Russian
Lucido, Jeffrey V., DPM
36833P
441 77th St
Brooklyn, NY 11209
(718) 745-3800
54176P
150 55th St
Brooklyn, NY 11220
(718) 630-7095
Doctors Hosp. of Staten Island,
Lutheran Medical Center
Speaks ItalianSpanish
Mahgerefteh, David, DPM
349781P
4405 16th Ave
Brooklyn, NY 11204
(718) 633-8662
Parkway Hospital
Speaks Yiddish
Makower, Bryan L., DPM
100861P
Downstate Foot &Ankle Pod
121 Dekalb Ave
Brooklyn, NY 11201
(718) 250-8753
101467P
176 Fenimore St
Brooklyn, NY 11225
(718) 940-0400
36786P
100 Parkside Ave
Brooklyn, NY 11226
(718) 768-1906
54693P
Downstate Foot & Ankle Po
322 Linden Blvd
Brooklyn, NY 11226
(718) 768-1906
Brooklyn Hospital Center
(Downtown Campus), New
York Methodist Hospital
Speaks SpanishFrench
Mandato, Mark, DPM
298290P
HHC-Kings County Hospital
451 Clarkson Ave
Brooklyn, NY 11203
(718) 245-3325
Kings County Hospital Center,
Metropolitan Hospital Center
Mantzoukas, Argirios,
DPM
221092P
HHC-Coney Island Hospital
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
Coney Island Hospital
Speaks Greek, Modern
(1453-)
Marcelonis, Debra A.,
DPM
173195P
465 New Lots Ave
Brooklyn, NY 11207
(718) 240-8900
Jamaica Hospital
Board Certified
Male Female
Wheelchair Accessible
PODIATRY (Continued)
Marville, Jillion, MD
49868P
353 Empire Blvd
Brooklyn, NY 11225
(718) 221-9244
Matthews, Frederick, DPM
302146P
Frederick Matthew DPM
1641 Bergen St
Brooklyn, NY 11213
(718) 778-2938
Interfaith Medical Center
Speaks Spanish
Mckay, Douglas J., DPM
54837P
1704 Mermaid Ave
Brooklyn, NY 11224
(718) 265-0900
Staten Island University
Hosp-North
Meliso, Vincent D., DPM
212393P
1029 Manhattan Ave
Brooklyn, NY 11222
(718) 383-3377
37004P
Lorimer Foot Care
411 Graham Ave
Brooklyn, NY 11211
(718) 383-2518
New York Methodist Hospital
Speaks Italian
Meller, Edward P., DPM
112287P
Ambulatory Care Clinic
1 Brookdale Plz
Brooklyn, NY 11212
(718) 240-5045
112288P
Urban Strategies
1873 Eastern Pkwy
Brooklyn, NY 11233
(718) 240-8700
Jamaica Hospital, St Joseph's
Hospital Division, CMC
Meshnick, Joel A., DPM
105804P
Kings Country Medical Doc
2705 Mermaid Ave
Brooklyn, NY 11224
(718) 265-2222
191516P
2876 W 27th St
Brooklyn, NY 11224
(718) 265-2222
57875P
ODA Primary Health Care
14-16 Heyward St
Brooklyn, NY 11211
(718) 260-4600
Lutheran Medical Center,
Staten Island University
Hosp-North
Micallef, Joseph, DPM
106156P
1095 Flatbush Ave
Brooklyn, NY 11226
(718) 240-8800
Brookdale Hospital Medical
Center, Forest Hills Hospital,
Jamaica Hospital, New York
Hospital Medical Center of
Queens
Mollica, Peter W., DPM
36634P
8223 14th Ave
Brooklyn, NY 11228
(718) 875-9357
36635P
410 Clinton St
Brooklyn, NY 11231
(718) 875-9357
36636P
585 Schenectady Ave
Brooklyn, NY 11203
(718) 604-5481
Interfaith Medical Center,
Kingsbrook Jewish Medical
Center, New York Methodist
Hospital
Speaks Italian
Mollica, Raymond J.,
DPM
36621P
8223 14th Ave
Brooklyn, NY 11228
(718) 236-2871
50026P
Raymond J Mollica, MD
410 Clinton St
Brooklyn, NY 11231
(718) 875-1105
Catholic Medical Center (NY),
Kingsbrook Jewish Medical
Center, Lutheran Medical
Center, New York Methodist
Hospital
Montalvo, Luis, DPM
37021P
7523 Fort Hamilton Pkwy
Brooklyn, NY 11228
(718) 745-7266
Lutheran Medical Center,
Wyckoff Heights Medical
Center
Speaks Spanish
Morreale, Edward, DPM
0X185P
736 Ocean Pkwy
Brooklyn, NY 11230
(718) 437-9343
SVCMC-St Vincents Manhattan
Speaks ItalianSpanish
Naik, Hetal B., DPM
113873P
Lafayette Med Office PC
468 Lafayette Ave
Brooklyn, NY 11205
(718) 399-6234
145498P
1417 Foster Ave
Brooklyn, NY 11230
(718) 421-6300
37256P
121 Dekalb Ave
Brooklyn, NY 11201
(718) 250-8753
Brooklyn Hospital Center
(Downtown Campus), Lutheran
Medical Center, Maimonides
Medical Center
Speaks
HindiGujaratiSpanishUrdu
Nekritin, Vadim, DPM
294087P
2306 Avenue U
Brooklyn, NY 11229
(718) 769-8210
St John's Episcopal Hospital
Speaks Russian
Newmark, Alan J., DPM
36637P
34 Plaza St E
Brooklyn, NY 11238
(718) 857-9004
54470P
372 Kingston Ave
Brooklyn, NY 11213
(718) 604-0675
Brooklyn Hospital Center
(Downtown Campus)
Speaks
SpanishHebrewFrench
Novofastovsky, Raisa, DPM
214483P
1812 Quentin Rd
Brooklyn, NY 11229
(718) 382-1773
37025P
3066 Brighton 6
Brooklyn, NY 11235
(718) 382-1773
37026P
8622 Bay Pkwy
Brooklyn, NY 11214
(718) 333-2121
51725P
All Medical Care L.L.P.
8622 Bay Pkwy
Brooklyn, NY 11214
(718) 333-2121
Lutheran Medical Center, New
York Community Hospital of
Brooklyn
Speaks Russian
Odinsky, Michael E.,
DPM
P0019P
200 Montague St
Brooklyn, NY 11201
(718) 422-8000
P0019P
546 Eastern Pkwy
Brooklyn, NY 11225
(718) 604-4800
Oliva, Imelda A., DPM
139001P
Kings County Hospital Ctr
451 Clarkson Ave
Brooklyn, NY 11203
(718) 245-3325
Kings County Hospital Center,
Metropolitan Hospital Center,
Morrisania Hospital
Speaks TagalogSpanish
Orlando, Anthony, DPM
371187P
HHC-Coney Island Hospital
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
Coney Island Hospital, Forest
Hills Hospital, Lutheran
Medical Center, North Shore
University Hospital
Owusu, Stephen E., DPM
208624P
434 Rockaway Ave
Brooklyn, NY 11212
(718) 346-2628
37081P
Mount Zion Podiatry,PC
106 Pennsylvania Ave
Brooklyn, NY 11207
(718) 385-2085
Jamaica Hospital, St Joseph's
Hospital Division, CMC
Pace, George N., DPM
373411P
Manhattan Footcare
133 Smith St
Brooklyn, NY 11201
(718) 330-1117
Cabrini Medical Center, Long
Island College Hospital, New
York Downtown Hospital, New
York Downtown Hospital
(Beekman)
Speaks Spanish
Pace, John F., DPM
45625P
John F. Pace, MD
398 Court St
Brooklyn, NY 11231
(718) 834-0909
Long Island College Hospital,
SVCMC-Bayley Seton
Papa, Philip M., DPM
141176P
Coney Island Hospital
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
Coney Island Hospital
Passik, Arthur L., DPM
45847P
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
Coney Island Hospital,
Massapequa General Hospital,
Plainview Hospital, Syosset
Hospital
Speaks SpanishItalianGreek,
Modern (1453-)
Pawson, John F., DPM
134403P
9229 Flatlands Ave
Brooklyn, NY 11236
(718) 257-1444
202015P
Bay Park Medical, PC
6403 18th Ave
Brooklyn, NY 11204
(718) 621-0800
New York Community Hospital
of Brooklyn
Speaks
SpanishRussianChineseHeb
rew
Pecora, Maria, DPM
40587P
3245 Nostrand Ave
Brooklyn, NY 11229
(718) 615-3777
Forest Hills Hospital, Jamaica
Hospital, New York Hospital
Medical Center of Queens, St
Joseph's Hospital, St Joseph's
Hospital Division, CMC
Speaks Spanish
Pedro, Helder F., DPM
339019P
Family Physician FHC
5616 6th Ave
Brooklyn, NY 11220
(718) 439-5440
339024P
Caribbean American FHC
3414 Church Ave
Brooklyn, NY 11203
(718) 940-9425
54244P
Sunset Park Family Health
150 55th St
Brooklyn, NY 11220
(718) 630-7208
Long Island Jewish Medical
Center, Lutheran Medical
Center
Perez, Walter H., DPM
114659P
Advanced Walkin Foot CAre
2146 Beverley Rd
Brooklyn, NY 11226
(718) 675-1100
216489P
2919 Avenue T
Brooklyn, NY 11229
(718) 336-4390
38123P
Advanced WalkIn Foot Care
1214 Coney Island Ave
Brooklyn, NY 11230
(718) 677-7700
Brooklyn Hospital Center
(Downtown Campus), Interfaith
Medical Center, Jamaica
Hospital
Speaks
SpanishRussianTurkish
Pierre, Nadja M., DPM
225911P
Woodhull Med & Ment HC
760 Broadway
Brooklyn, NY 11206
(718) 388-5889
Brooklyn Hospital Center
(Downtown Campus), Woodhull
Medical & Mental Health Ctr
Speaks French
Pierre, Nedjie, DPM
145469P
552 Saint Marks Ave
Brooklyn, NY 11238
(718) 398-8700
37250P
3400 Snyder Ave
Brooklyn, NY 11203
(718) 693-4060
37251P
The Brooklyn Hospital Cen
121 Dekalb Ave
Brooklyn, NY 11201
(718) 488-3708
Brooklyn Hospital Center
(Downtown Campus)
Speaks FrenchCreoles and
pidgins, French-based
(Other)
Prince, Steven L., DPM
125224P
JHMC DTC - East New York
3080 Atlantic Ave
Brooklyn, NY 11208
(718) 647-0240
Jamaica Hospital, V A Hospital
- St. Albans
Rabiei, Payman, DPM
214667P
Metropolitan Foot Care PC
94-13 Flatlands Ave
Brooklyn, NY 11236
(718) 649-6464
58033P
Metropolitan Foot Care PC
3309 Church Ave
Brooklyn, NY 11203
(718) 209-0013
Kingsbrook Jewish Medical
Center, Long Island Jewish
Medical Center, Parkway
Hospital
Speaks HebrewPersian
Radler, Bruce L., DPM
36518P
6416 17th Ave
Brooklyn, NY 11204
(718) 236-2821
Staten Island University
Hosp-North
Raskin, Simon, DPM
377535P
Simon Raskin, DPM, P.C.
1409 Gravesend Neck Rd
Brooklyn, NY 11229
(718) 332-7771
Reifer, Howard J., DPM
152842P
1670 E 17th St
Brooklyn, NY 11229
(718) 382-9200
174814P
2433 86th St
Brooklyn, NY 11214
(917) 974-8726
174816P
3059 Brighton 13Th St
Brooklyn, NY 11235
(917) 974-8726
198147P
Quentin Medical, PC
280 Quentin Rd
Brooklyn, NY 11223
(718) 336-4499
217778P
157 York St
Brooklyn, NY 11201
(718) 222-0333
Brooklyn Hospital Center
(Downtown Campus), Kings
County Hospital Center
Speaks Spanish
Romano, Constance A.,
DPM
36902P
386 Graham Ave
Brooklyn, NY 11211
(718) 389-9870
Cabrini Medical Center,
Interfaith Medical Center
Speaks Italian
Rosen, Alan J., DPM
36933P
5402 Flatlands Ave
Brooklyn, NY 11234
(718) 444-3338
Brookdale Hospital Medical
Center
Saadvandi, Terence M.,
DPM
349531P
Physicare Multi Services
150 55th St
Brooklyn, NY 11220
(718) 253-3900
349532P
Nostrand Community Medica
220 13th St
Brooklyn, NY 11215
(718) 769-4988
349533P
Brighton Community Medica
9000 Shore Rd
Brooklyn, NY 11209
(718) 646-5500
Lutheran Medical Center
Speaks Arabic
Sande, Hervey, DPM
52950P
Kings County Hospital Ctr
451 Clarkson Ave
Brooklyn, NY 11203
(718) 245-3325
Kings County Hospital Center
Scheiner, David M., DPM
208600P
Good Health Medical, P.C.
3019 Brighton 1St St
Brooklyn, NY 11235
(718) 743-9700
Brunswick Hospital Center Inc,
South Nassau Comm. Hospital,
South Nassau Communities
Hosp., South Nassau
Communities Hospital,
Winthrop University Hospital
Speaks RussianSpanish
Schikman, Lana, DPM
359328P
Kingsbrook Jewish Med Ctr
585 Schenectady Ave
Brooklyn, NY 11203
(718) 604-5388
Kingsbrook Jewish Medical
Center
Speaks Russian
Schneidermesser, Susan
G., DPM
37048P
18 Prospect Park W
Brooklyn, NY 11215
(718) 398-7593
37049P
894 Eastern Pkwy
Brooklyn, NY 11213
(718) 778-7311
Kingsbrook Jewish Medical
Center
Speaks Spanish
Shapiro, Eugene, DPM
36841P
301 Ocean View Ave
Brooklyn, NY 11235
(718) 332-2582
New York Community Hospital
of Brooklyn
Speaks Russian
Shechter, David Z., DPM
49893P
3066 Brighton 6Th St
Brooklyn, NY 11235
(718) 743-0111
New York Hospital Medical
Center of Queens, St Joseph's
Hospital Division, CMC,
Wyckoff Heights Medical
Center
Shechter, Stuart B., DPM
49678P
Stuart B Shechter, MD
3066 Brighton 6Th St
Brooklyn, NY 11235
(718) 743-0111
Island Medical Center (NY)_
Sherman, Gary, DPM
M4643P
7902 Bay Pkwy
Brooklyn, NY 11214
(718) 236-7520
Maimonides Medical Center,
New York Downtown Hospital
(Beekman), SVCMC-St Vincents
Staten Island
Silberstein, Jeffrey, DPM
36639P
1367 51st St
Brooklyn, NY 11219
(718) 438-4305
Speaks YiddishSpanish
Silverstein, Alan B., DPM
36642P
1185 Dean St
Brooklyn, NY 11216
(718) 774-2740
Interfaith Medical Center
Spielfogel, William D.,
DPM
36935P
Hamilton Podiatry PC
369 93rd St
Brooklyn, NY 11209
(718) 680-6276
Columbia-Presbyterian
Medical Center
Spindler, Harlan, DPM
36541P
5412 Kings Plz
Brooklyn, NY 11234
(718) 377-1212
Peninsula Hospital Center,
Wyckoff Heights Medical
Center
Speaks
FrenchRussianSpanish
Stanimirov, Catherine,
DPM
112328P
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
137433P
Ida G Irael Comm Hlth Ctr
2201 Neptune Ave
Brooklyn, NY 11224
(718) 946-3400
Coney Island Hospital
Speaks Spanish
Steiner, Richard M., DPM
101731P
2811 Ocean Ave
Brooklyn, NY 11229
(718) 648-5609
SVCMC-St Vincents Manhattan
Stuto, Joseph C., DPM
36813P
100 Remsen St
Brooklyn, NY 11201
(718) 624-7537
Brooklyn Hospital Center
(Downtown Campus), Long
Island College Hospital, New
York Community Hospital of
Brooklyn
Tajerstein, Alan R., DPM
36951P
1335 54th St
Brooklyn, NY 11219
(718) 972-5000
Brooklyn Hospital Center
(Downtown Campus)
Speaks YiddishHebrew
Tanenbaum, Mark, DPM
36644P
1648 E 14th St
Brooklyn, NY 11229
(718) 627-0585
Tartack, Ira, DPM
187670P
Coney Island Hospital
2601 Ocean Pkwy
Brooklyn, NY 11235
(718) 616-4331
New York Community Hospital
of Brooklyn, Our Lady of Mercy
Medical Center
Speaks
ItalianSpanishRussian
Tavroff, Clifford D., DPM
P0038P
233 Nostrand Ave
Brooklyn, NY 11205
(718) 826-5900
Trepal, Michael J., DPM
183218P
115 Henry St
Brooklyn, NY 11201
(718) 624-8022
Long Island College Hospital,
Metropolitan Hospital Center,
New York Downtown Hospital
(Beekman), SVCMC-St Vincents
Manhattan
Trivlis, Maryann Z., DPM
216717P
248 Avenue P
Brooklyn, NY 11204
(718) 945-0770
Brooklyn Hospital Center
(Downtown Campus)
Speaks Greek, Modern
(1453-)
Unger, Leslie M., DPM
36470P
1405 46th St
Brooklyn, NY 11219
(718) 438-8717
49514P
Lesie M Unger, MD
2315 Mermaid Ave
Brooklyn, NY 11224
(718) 373-1820
Maimonides Medical Center
Speaks SpanishYiddish
Vader, Bonnie, DPM
36966P
621 Amboy St
Brooklyn, NY 11212
(718) 345-2935
Brookdale Hospital Medical
Center, Forest Hills Hospital
Speaks Spanish
Waiss, Samuel M., DPM
351219P
2223 Coney Island Ave
Brooklyn, NY 11223
(718) 375-6096
New York Community Hospital
of Brooklyn
Speaks HebrewYiddish
Board Certified
Male Female
Wheelchair Accessible
PODIATRY (Continued)
Wallach, Jacob B., DPM
15739P
2108 Avenue P
Brooklyn, NY 11229
(718) 951-6399
Maimonides Medical Center
Woltman, Robert T., DPM
205506P
Lyudmila Cavalier Physici
9014 Flatlands Ave
Brooklyn, NY 11236
(718) 209-5353
Long Island Jewish Medical
Center, New York Westchester
Square Me, Peninsula Hospital
Center
Zonenashvili, Merabi,
DPM
293458P
201 Kings Hwy
Brooklyn, NY 11223
(718) 621-1811
Staten Island University
Hosp-North
Speaks
RussianGeorgianSpanish
Zwiebel, Neil S., DPM
363102P
420 Fulton St
Brooklyn, NY 11201
(718) 797-3668
Cabrini Medical Center, Long
Island College Hospital
Kings
PODIATRY
Abeles, Jay, DPM
36958P
4136 Hicksville Rd
Bethpage, NY 11714
(516) 796-2900
Massapequa General Hospital,
New Island Hospital, Syosset
Hospital
Abrahamson, Hal, DPM
54152P
100 Manetto Hill Rd
Plainview, NY 11803
(516) 822-9595
Catholic Medical Center (NY),
Forest Hills Hospital
Speaks Hebrew
Alongi, Maryanne, DPM
36724P
226 7th St
Garden City, NY 11530
(516) 248-9680
Franklin Hospital ,
Massapequa General Hospital,
New Island Hospital
Amato, Richard, DPM
343044P
R.A. Podiatry, P.C.
2116 Merrick Ave
Merrick, NY 11566
(516) 378-9191
New Island Hospital
Axman, Wayne R., DPM
179959P
70 Maple Ave
Rockville Centre, NY 11570
(516) 536-3336
182388P
1420 Broadway
Hewlett, NY 11557
(516) 374-8600
Long Beach Memorial
Hospital, Long Island Jewish
Medical Center, Mount Sinai
Hospital, Mount Sinai of
Queens, New York Hospital
Medical, South Nassau
Communities Hospital
Speaks SpanishGreek,
Modern (1453-)
Bagner, Jerome E., DPM
36499P
30 Hempstead Ave
Rockville Centre, NY 11570
(516) 764-6800
49647P
165 N Village Ave
Rockville Centre, NY 11570
(516) 746-6800
New Island Hospital
Speaks
YiddishItalianJapaneseSpani
sh
Balboa, Henry M., DPM
36506P
100 Manetto Hill Rd
Plainview, NY 11803
(516) 822-9595
Forest Hills Hospital, New
Island Hospital, Syosset
Hospital
Barbaro, Thomas, DPM
36883P
706 Jericho Tpke
New Hyde Park, NY 11040
(516) 326-7979
Long Island Jewish Medical
Center, North Shore University
Hospital
Speaks Italian
Barkoff, Matthew W.,
DPM
36920P
2900 Hempstead Tpke
Levittown, NY 11756
(516) 579-2800
Glen Cove Hospital, New
Island Hospital, North Shore
University Hospital, Plainview
Hospital, Syosset Hospital
Speaks Spanish
Becker, Jack S., DPM
36551P
178 E Rockaway Rd
Hewlett, NY 11557
(516) 596-1700
49835P
Jack S Becker, MD
3000 Hempstead Tpke
Levittown, NY 11756
(516) 579-1700
Franklin Hospital, Franklin
Hospital , Nassau University
Medical Center, South Nassau
Communities Hosp., South
Nassau Communities Hospital
Bendeth, Marc L., DPM
36520P
1226 W Broadway
Hewlett, NY 11557
(516) 374-4444
Berlin, Kim, DPM
36650P
830 Atlantic Ave
Baldwin, NY 11510
(516) 623-4580
Long Beach Memorial
Hospital, South Nassau
Communities Hospital
Speaks Spanish
Biller, Bob S., DPM
M1057P
756 E Park Ave
Long Beach, NY 11561
(516) 432-7470
LONG BEACH MEMORIAL
MEDICAL CENTER, SAINT
JOHNS EPISCOPAL
HOSPITAL-SOUTH SHORE
Bilotti, Mary A., DPM
169106P
Long Island Podiatry Grp
2001 Marcus Ave
New Hyde Park, NY 11042
(516) 327-0074
M0911P
Long Island Podiatry Grp
375 N Central Ave
Valley Stream, NY 11580
(516) 825-4070
Franklin Hospital , Long Island
Jewish Medical Center
Speaks Spanish
Breitman, Debra, DPM
36886P
250 Broadway
Lawrence, NY 11559
(516) 239-4700
Peninsula Hospital Center, St
John's Episcopal Hospital, St
John's Episcopal Hospital -
Far Rockaway
Speaks Spanish
Bubbers, Linda A., DPM
36627P
Sunrise Foot Care
4880 Sunrise Highway
Massapequa Park, NY 11762
(516) 795-6255
Syosset Hospital
Speaks Spanish
Buenahora, Joseph A.,
DPM
M2238P
477 Newbridge Rd
East Meadow, NY 11554
(516) 679-1338
Brunswick General Hospital,
Brunswick Hospital Center Inc,
New Island Hospital, Plainview
Hospital, Syosset Hospital,
Wyckoff Heights Medical
Center
Speaks SpanishYiddish
Burzotta, John L., DPM
36762P
2419 Jericho Tpke
Garden City Park, NY 11040
(516) 294-9540
50161P
Pro Health Care
2800 Marcus Ave
Garden City Park, NY 11042
(516) 622-6040
Long Island Jewish Medical
Center, North Shore University
Hospital
Speaks Italian
Caimano, Francis X.,
DPM
300372P
Francis X Caimano
495 S Broadway
Hicksville, NY 11801
(914) 555-1212
P0014P
350 S Broadway
Hicksville, NY 11801
(516) 938-0100
Syosset Hospital
Speaks Spanish
Caprioli, Russell, DPM
359698P
1999 Marcus Ave
New Hyde Park, NY 11042
(516) 555-1212
36764P
Long Island Podiatry Grp
2001 Marcus Ave
New Hyde Park, NY 11042
(516) 327-0074
Franklin Hospital, Franklin
Hospital , Long Beach
Memorial Hospital, Long
Island Jewish Medical Center
Speaks ItalianSpanish
Chernick, Stephen B.,
DPM
50872P
175 Fulton Ave
Hempstead, NY 11550
(516) 489-2261
Parkway Hospital, St John's
Episcopal Hospital - Far
Rockaway
Speaks SpanishHebrew
Cohen, Robert J., DPM
36557P
72 Covert Ave
Garden City, NY 11530
(516) 354-7222
Our Lady of Mercy Medical
Center, Parkway Hospital
Speaks French
Davies, Daniel A., DPM
36889P
6 Scranton Ave
Lynbrook, NY 11563
(516) 596-0022
Cabrini Medical Center, Good
Samaritan Hospital, Good
Samaritan Hospital (West Islip)
Speaks Italian
Davies, Gregory F., DPM
36657P
Syosset Medical Building
175 Jericho Tpke
Syosset, NY 11791
(516) 496-7676
Glen Cove Hospital, North
Shore University Hospital,
Plainview Hospital, Syosset
Hospital
Speaks Spanish
DeCicco, John J., DPM
36618P
875 Old Country Rd
Plainview, NY 11803
(516) 681-8866
New Island Hospital, Plainview
Hospital, Syosset Hospital
Speaks SpanishGreek,
Modern (1453-)Italian
Dubov, Spencer F., DPM
383227P
New Island Hospital
4295 Hempstead Tpke
Bethpage, NY 11714
(631) 858-0011
Mary Immaculate Hospital,
Massapequa General Hospital
Inc., NY Hospital Medical
Center of Queens, Plainview
Hospital
Speaks
YiddishSpanishItalian
Feldman, Gary B., DPM
36826P
5 Sunrise Plz
Valley Stream, NY 11580
(516) 825-6825
St Joseph's Hospital Division,
CMC
Fiorenza, Dominic, DPM
P0048P
350 S Broadway
Hicksville, NY 11801
(516) 938-0100
Fox, Corey, DPM
37000P
Massapequa Podiatry Assoc
4160 Merrick Rd
Massapequa, NY 11758
(516) 541-9000
Brunswick General Hospital,
Brunswick Hospital Center Inc,
New Island Hospital, Plainview
Hospital, Syosset Hospital
Speaks
SpanishTagalogItalian
Fox, Roberta A., DPM
37003P
410 Lakeville Rd
New Hyde Park, NY 11042
(516) 488-5050
Long Island Jewish Medical
Center
Fuchs, David B., DPM
36704P
855 Cynthia Dr
East Meadow, NY 11554
(516) 292-2372
New Island Hospital, Syosset
Hospital
Garofalo, Gail F., DPM
37140P
NS Podiatric Med & Surger
410 Lakeville Rd
New Hyde Park, NY 11042
(516) 326-4709
Long Island Jewish Medical
Center, St Catherine of Siena,
St Catherine of Sienna Medical
Center, Winthrop University
Hospital, Winthrop-University
Hospital
Gasparini, Mark C., DPM
337162P
119 New York Ave
Massapequa, NY 11758
(516) 804-9038
Speaks Italian
George, Thomas, DPM
141475P
1029 Bellmore Rd
North Bellmore, NY 11710
(516) 679-4636
Hempstead General Hospital
Med Ctr., New York
Westchester Square Medical
Center
Gervasio, Joseph, DPM
36653P
1000 Park Blvd
Massapequa Park, NY 11762
(516) 799-0550
36654P
156 Post Ave
Westbury, NY 11590
(516) 334-8208
Massapequa General Hospital,
Massapequa General Hospital
Inc., New Island Hospital,
Plainview Hospital, Southside
Hospital
Goez, Emilio A., DPM
51027P
Long Island Foot Care
294 W Merrick Rd
Freeport, NY 11520
(516) 378-8383
Nassau University Medical
Center, Saint Catharines
General Hospital, St Barnabas
Hospital
Speaks Spanish
Golub, Cary M., DPM
37076P
854 E Broadway
Long Beach, NY 11561
(516) 889-2200
Long Beach Medical Center,
South Nassau Communities
Hospital
Speaks Hebrew
Gottlieb, Robert J., DPM
36579P
188 W Main St
Oyster Bay, NY 11771
(516) 922-0502
Glen Cove Hospital, Good
Samaritan Hospital (West Islip)
Speaks Spanish
Greenbaum, Mitchell A.,
DPM
36924P
111 Mineola Ave
Roslyn Heights, NY 11577
(516) 484-1444
36925P
525 Woodbury Rd
Plainview, NY 11803
(516) 433-3353
Glen Cove Hospital, Long
Island Jewish Medical Center,
New Island Hospital, North
Shore University Hospital,
Plainview Hospital, Syosset
Hospital
Speaks Spanish
Greiff, Lance, DPM
36988P
29 Barstow Rd
Great Neck, NY 11021
(516) 829-1028
Brooklyn Hospital Center
(Downtown Campus), New
York Flushing Hospital &
Medical Center, Parkway
Hospital
Grossman, Myles, DPM
36831P
2174 Hewlett Ave
Merrick, NY 11566
(516) 379-2560
41745P
156 Post Ave
Westbury, NY 11590
(516) 334-8208
New Island Hospital, Plainview
Hospital
Speaks SpanishHebrew
Herbert, Scott E., DPM
284145P
49 Church St
Freeport, NY 11520
(516) 378-0184
St Catherine of Siena
Hershey, Paul E., DPM
36462P
2110 Northern Blvd
Manhasset, NY 11030
(516) 627-5775
Long Island Jewish Medical
Center, Saint Francis Hospital -
Bronx
Speaks SpanishYiddish
Herzberg, Abraham, DPM
54315P
300 Franklin Ave
Valley Stream, NY 11580
(516) 561-1617
54316P
833 Northern Blvd
Great Neck, NY 11021
(516) 622-7900
Franklin Hospital, Jamaica
Hospital
Speaks Yiddish
Hickey, John, DPM
M4002P
2870 Hempstead Tpke
Levittown, NY 11756
(516) 735-4545
New Island Hospital, Plainview
Hospital, Syosset Hospital
Honore, Lesly S., DPM
132409P
Podiatry Services of New
905 Uniondale Ave
Uniondale, NY 11553
(516) 565-5666
132410P
981 Rosedale Rd
Valley Stream, NY 11581
(516) 295-6307
Cabrini Medical Center, Mercy
Medical Center,
Winthrop-University Hospital
Speaks
SpanishFrenchCreoles and
pidgins (Other)
Horl, Lawrence, DPM
36912P
61 N Park Ave
Rockville Centre, NY 11570
(516) 766-5550
Forest Hills Hospital,
Hempstead General Hospital
Med Ctr., Mercy Medical
Center, Peninsula Hospital
Center, South Nassau
Communities Hospital, St
John's Episcopal Hospital -
Far Rockaway
Speaks Spanish
Horowitz, Mitchell L.,
DPM
M2025P
2720 Jerusalem Ave
North Bellmore, NY 11710
(516) 679-2720
Irwin, Robert A., DPM
37172P
143 Merrick Ave
Merrick, NY 11566
(516) 623-2800
NY Hospital Medical Center of
Queens, New Island Hospital,
New York Hospital Medical
Center of Queens, Syosset
Hospital
Speaks SpanishItalianGreek,
Modern (1453-)
Jackalone, John A., DPM
277559P
Podiatry Offices
4295 Hempstead Tpke
Bethpage, NY 11714
(516) 579-3500
Catholic Medical Center (NY),
Forest Hills Hospital, Long
Beach Memorial Hospital, St
Vincents Medical Center Of
New York
Speaks Spanish
Jarbath, John A., DPM
155828P
50 Hempstead Ave
Lynbrook, NY 11563
(516) 599-0302
Forest Hills Hospital, New York
Hospital Medical Center of
Queens, Parkway Hospital,
Peninsula Hospital Center
Speaks FrenchCreoles and
pidgins, French-based
(Other)
Karpe, David E., DPM
160781P
Howard Kessler & Assoc PC
200 N Village Ave
Rockville Centre, NY 11570
(516) 764-0434
Franklin Hospital, Franklin
Hospital , Peninsula Hospital
Center, South Nassau Comm.
Hospital, South Nassau
Communities Hosp.
Speaks Spanish
Kashefsky, Helene P., DPM
37071P
2201 Hempstead Tpke
East Meadow, NY 11554
(516) 572-0123
Nassau University Medical
Center
Speaks Spanish
Kasminoff, June G.,
DPM
37044P
666 Old Bethpage Rd
Old Bethpage, NY 11804
(516) 777-3668
Massapequa General Hospital,
New Island Hospital, Syosset
Hospital
Kessler, Howard N., DPM
36570P
200 N Village Ave
Rockville Centre, NY 11570
(516) 764-0434
Franklin Hospital, Franklin
Hospital , Mercy Medical
Center, Nassau University
Medical Center, South Nassau
Communities Hosp., South
Nassau Communities Hospital
Kisberg, Stephen, DPM
36519P
11 Franklin Pl
Woodmere, NY 11598
(516) 295-2121
St John's Episcopal Hospital -
Far Rockaway
Kitton, Stuart E., DPM
36573P
41 Woods Dr
Roslyn, NY 11576
(516) 626-3999
MEADOWLANDS HOSPITAL
MEDICAL CENTER, Mount
Sinai Medical Center,
SVCMC-St Vincents
Manhattan, The Mount Sinai
Hospital of Queens
Speaks Spanish
Klein, Michael S., DPM
36893P
East Norwich Podiatry
898 Oyster Bay Rd
East Norwich, NY 11732
(516) 624-2101
36894P
Oceanside Podiatry
3105 Lawson Blvd
Oceanside, NY 11572
(516) 766-8500
Glen Cove Hospital, Long
Beach Memorial Hospital,
Syosset Hospital
Klirsfeld, Jeffrey S.,
DPM
36857P
2870 Hempstead Tpke
Levittown, NY 11756
(516) 731-3300
Massapequa General Hospital,
New Island Hospital, Syosset
Hospital
Speaks Spanish
Kohn, Arlene F., DPM
37113P
Family Footcare
120 Bethpage Rd
Hicksville, NY 11801
(516) 938-6000
Mercy Medical Center, New
Island Hospital, Syosset
Hospital
Speaks Spanish
Kolberg, John J., DPM
37222P
320 Post Ave
Westbury, NY 11590
(516) 338-8802
New Island Hospital
Speaks Spanish
Koslow, Paul M., DPM
50912P
Great Neck Podiatry Asso
29 Barstow Rd
Great Neck, NY 11021
(516) 829-1028
Maimonides Medical Center,
New York Hospital Medical
Center of Queens, New York
Methodist Hospital
LaRocca, Albert, DPM
36594P
2 Raemar Ct
Bethpage, NY 11714
(516) 935-0111
New Island Hospital
Speaks ItalianGerman
Landau, Laurence D., DPM
193059P
86 George St
Roslyn Heights, NY 11577
(516) 731-1900
38312P
160 Hicksville Rd
Bethpage, NY 11714
(516) 731-1900
New Island Hospital, Plainview
Hospital
Landy, Robert J., DPM
123448P
120 Bethpage Rd
Hicksville, NY 11801
(516) 827-4500
123481P
530 Hicksville Rd
Bethpage, NY 11714
(516) 937-5000
Massapequa General Hospital,
Our Lady of Mercy Medical
Center, Parkway Hospital,
Southside Hospital, Winthrop
University Hospital
Speaks Spanish
Larsen, Joseph A., DPM
50624P
National Foot Care
2419 Jericho Tpke
Garden City Park, NY 11040
(516) 294-9540
North Shore University
Hospital
Levine, Stanley, DPM
36477P
4725 Merrick Rd
Massapequa, NY 11758
(516) 799-8545
Brunswick General Hospital,
Brunswick Hospital Center Inc,
Hempstead General Hospital
Med Ctr., Massapequa General
Hospital, New Island Hospital,
Syosset Hospital
Speaks
SpanishGermanItalian
Levitsky, David A., DPM
301933P
161 Orchard St
Plainview, NY 11803
(516) 822-9666
Board Certified
Male Female
Wheelchair Accessible
Livingston, Douglas W.,
DPM
37180P
Livingston Foot Care Spec
1685 Newbridge Rd
North Bellmore, NY 11710
(516) 826-0103
Brunswick Hospital Center Inc,
Massapequa General Hospital
Inc., Nassau University Medical
Center, New Island Hospital,
Plainview Hospital, Syosset
Hospital
Livingston, Leon B., DPM
36486P
Livingston Foot Care Spec
1685 Newbridge Rd
North Bellmore, NY 11710
(516) 826-0103
New Island Hospital, Plainview
Hospital, Syosset Hospital
Livingston, Michael D.,
DPM
37064P
Livingston Foot Care Spec
1685 Newbridge Rd
Bellmore, NY 11710
(516) 826-0103
Brunswick Hospital Center Inc,
Nassau University Medical
Center, New Island Hospital,
Plainview Hospital, Syosset
Hospital
Lynn, Brian P., DPM
108081P
Comprehensive Podiatric
2110 Northern Blvd
Manhasset, NY 11030
(516) 627-5775
355143P
Comprehensive Podiatric
935 Northern Blvd
Great Neck, NY 11021
(516) 627-5775
Long Island Jewish Medical
Center, Montefiore Med Ctr
(Henry & Lucy Moses Div)
Speaks Spanish
Mahgerefteh, David, DPM
349786P
230 Middle Neck Rd
Great Neck, NY 11021
(516) 829-2560
Parkway Hospital
Speaks Yiddish
Marchese, Nicholas A.,
DPM
359291P
1000 Park Blvd
Massapequa Park, NY 11762
(516) 799-0550
New Island Hospital, Southside
Hospital
Masani, Farhan, DPM
37069P
530 Old Country Rd
Westbury, NY 11590
(516) 334-7642
Nassau University Medical
Center, Syosset Hospital,
Wyckoff Heights Medical
Center
Speaks
SpanishFrenchHindiUrdu
McElgun, Terence M.,
DPM
36861P
520 Franklin Ave
Garden City, NY 11530
(516) 746-4732
36862P
1135 N Broadway
Massapequa, NY 11758
(516) 756-0091
380037P
N. Shore Hosp., Plainview
888 Old Country Rd
Plainview, NY 11803
(516) 796-1313
New Island Hospital, Plainview
Hospital, Syosset Hospital
Speaks SpanishItalian
Mcshane, William J., DPM
36802P
Harbor Podiatry PC
131 Main St
East Rockaway, NY 11518
(516) 593-2233
36803P
54 Main St
Hempstead, NY 11550
(516) 538-4531
Franklin Hospital, Island
Medical Center (NY)_
Meshnick, Joel A., DPM
139939P
2574 Hewlett Ln
Bellmore, NY 11710
(516) 781-5440
Lutheran Medical Center,
Staten Island University
Hosp-North
Micallef, Joseph, DPM
36900P
101st Avenue Foot Care PC
287 Northern Blvd
Great Neck, NY 11021
(516) 773-4001
Brookdale Hospital Medical
Center, Forest Hills Hospital,
Jamaica Hospital, New York
Hospital Medical Center of
Queens
Moazen, Ali, DPM
P0033P
226 Clinton St
Hempstead, NY 11550
(516) 483-2020
Speaks Persian
Montag, Richard M.,
DPM
36509P
528 Bellmore Ave
East Meadow, NY 11554
(516) 483-7386
Island Medical Center (NY)_,
Plainview Hospital, Syosset
Hospital
Speaks Spanish
Nester, Elizabeth M., DPM
37243P
3 Walnut Rd
Glen Cove, NY 11542
(516) 674-9661
37244P
Nester Podiatry Associate
267 Lincoln Blvd
Long Beach, NY 11561
(516) 889-0969
57655P
East Coast Podiatry PLLC
680 Merrick Rd
Baldwin, NY 11510
(516) 889-0969
Glen Cove Hospital, Long
Beach Medical Center
Speaks Spanish
Nester, Matthew J., DPM
211451P
Nester Poadiatry Assoc
3227 Long Beach Rd
Oceanside, NY 11572
(516) 431-1600
50871P
Nester Podiatry Asso.
3 Walnut Rd
Glen Cove, NY 11542
(516) 674-9661
Long Beach Medical Center,
Long Beach Memorial
Hospital, St John's Episcopal
Hospital, St John's Episcopal
Hospital - Far Rockaway
Speaks Spanish
Nezaria, Yehuda, DPM
37236P
7 Franklin Ave
Lynbrook, NY 11563
(516) 887-2820
49675P
2053 Bellmore Ave
Bellmore, NY 11710
(516) 887-2820
Franklin Hospital, Franklin
Hospital , Huntington Hospital
Speaks Hebrew
Odinsky, Wayne Z., DPM
P0034P
2035 Lakeville Rd
New Hyde Park, NY 11040
(718) 343-0600
New York Hospital Medical
Center of Queens, Parkway
Hospital, Rockaway Beach
Hospital (closed)
Pedro, Helder F., DPM
54241P
Helder F. Pedro, DPM
1 Willow Pl
Albertson, NY 11507
(516) 621-3721
Long Island Jewish Medical
Center, Lutheran Medical
Center
Peterson, Donald T.,
DPM
36931P
8029 Jericho Tpke
Woodbury, NY 11797
(516) 496-0900
Plainview Hospital, Syosset
Hospital
Prince, Steven L., DPM
124780P
78 Marina Rd
Island Park, NY 11558
(516) 432-1332
Jamaica Hospital, V A Hospital
- St. Albans
Purvin, Jay M., DPM
36608P
467 Merrick Ave
East Meadow, NY 11554
(516) 489-1950
New Island Hospital, Plainview
Hospital
Richardson, Hugh L., DPM
195855P
L.I. Podiatric Grp
2001 Marcus Ave
New Hyde Park, NY 11042
(516) 327-0074
195856P
L.I. Podiatric Grp
375 N Central Ave
Valley Stream, NY 11580
(516) 825-4070
363220P
1999 Marcus Ave
New Hyde Park, NY 11042
(516) 555-1212
Franklin Hospital, Franklin
Hospital , Long Island Jewish
Medical Center, Long Island
Jewish, Manhasset (closed)
Speaks Spanish
Bronx Kings Nassau

Result number: 25

Message Number 234654

Re: Morton's Neuroma View Thread
Posted by Dr. DSW on 8/20/07 at 06:14

So, the bottom line is that Dr. Wishnie, Dr. Z and myself have not had the same experience as Dr. Goldstein when it comes to patients experiencing pain during/after alcohol injections. Dr. Goldstein did experience pain HIMSELF following these injections, but we don't know who injected him!

Dr. Goldstein brings up the point of alcohol injections not being as effective when there is abundant scar tissue, though a true neuroma is a fibrosis of the nerve tissue. However, abundant scar tissue should not be present when prior surgery was not performed. If no surgery was performed, I believe the results with alcohol injections can be excellent with very little discomfort.

Additionally, if time/travel/expense is not an issue, Dr. Lowell Scott Weil Jr. in Chicago is reporting excellent results with ESWT for neuroma pain. I attended a lecture by him yesterday and his double blinded study had impressive results.

Result number: 26

Message Number 234222

Re: Dems flock to affair hosted by "vicious far left website" View Thread
Posted by marie on 8/10/07 at 14:43

Ed,

You may be blinded but I'm not. Limbaugh isn't any worse then KOS. One is on the Internet and one is on talk radio. Both have followers and both criticize the othe party. Trust me I'm not sticking up for KOS. I have found mistakes in his posts and the same with Limbaugh. Unfortunately both excist because they hav a following. KOS has more hits to his site then Limbaugh has listeners and they are activists........meaning if there is an issue they want to push they can and will. There are some really odd posters there but there are some level headed ones as well. I'm not going to label all of them because it wouldn't be right.

Perhaps Limbaugh doesn't bother you but he does and is insulting a large group of Americans. You are bothered by KOS for the same reason. It just depends which side your on. So that's why I don't put much into either one but politicians have to take note. They are a voice just like yours is a voice. No different from what I have read on Free Republic.

Result number: 27

Message Number 232911

Re: Heel Spurs View Thread
Posted by Linde on 7/13/07 at 11:21

Hi I'm thinking of getting ESWT done on my heels in order to be able to walk again- hopefully. Living in Oregon I talked to a clinic in Portland was told yes, the Doctor has performed about 10 of them. I also was told you need two treatments not only one per heel.I had heelspurs about 10years ago.I was wearing higher heels until i had no more pain and even wore flip flops afterwards, but know it is much much worse.What can I do by not ending up in a wheelchair? switching from different shoes during the day so I can walk puts a strain on my right leg.The muscles feel like you just got over a cramp in your leg( a dull pain and weak)so I have to sit down again.What would be best for me? ESWT or Cryo... or, or ??? Does Oregon have more Doctors that would know ESWT?

Result number: 28

Message Number 232876

Re: Heel Spurs View Thread
Posted by Linde on 7/12/07 at 13:29

Yes i have osteoarthritis in my knee's.I can bend my right knee only a bit .Last year my leg muscel's on the right side of my leg from the tigh down thru the calf became very tight and painful for a few month I could not sleep it was so painful.I still have very tight muscels. is that a desease?

Result number: 29

Message Number 232854

Re: Heel Spurs View Thread
Posted by Dr. Wedemeyer on 7/12/07 at 00:43

Linde do you have or have you been tested for any rheumatoid disorders? Was a rheumatoid panel discussed?

The reason I ask is the bilateral complaint and multiple sites.

Result number: 30

Message Number 232851

Re: Heel Spurs View Thread
Posted by Linde on 7/11/07 at 23:32

Thank you,who do I see for that,and how do you feel about ESWT? When I rest I feel fine but when I get up the sharp heelspurs agravate my tendons again and again it is a never ending problem.I have these now for over 2 years and this is getting worse.

Result number: 31

Message Number 232827

Heel Spurs View Thread
Posted by Linde on 7/11/07 at 19:59

Having 5 Heelspurs 3 on the left and 2 on the right and tremendus pain when walking and standing.It feels like a stabbing /burning pain. I have one Heelspur that is on the Left bottom of my heel the rest are in the back of my Heel.(can't wear enclosed Shoes) I went to a Doctor he took x rays and told me that it looks I had a small stress fracture on the bottem of my left foot to.He told me to wear a higher heel and send me home. He is against me having surgery also no shots. Hearing about so much negativety, i dont really want to.I called the Dr Office and asked if someone could look at my chart notes and tell me what I have.She read these letters of to me.ENSTHESOP. Can somebody help me and explain these to me.This office is not very supportive and I will never go back to them.Iam spending houres on the computer and read all these letters in search for something that could help me.I'm considering ESWT or Cryo. I called one Doctors Office here in the Northwest and was told yes the Doctor does ESWT but it will take 2 treatments.Now Ive read that the Machines that are approved by the FDA only require one.My thought on that is...will it be done correctly.Help....

Result number: 32

Message Number 232527

Re: Heelspurs View Thread
Posted by Linde on 7/05/07 at 13:41

Thank you so much for helping me to get started.My Doctor just took exrays and told me get a higher heel shoe 1 to 11/2 inch... and good bye. I will call the office or go there and get more info. thanks again

Result number: 33

Message Number 232378

Re: Heelspurs View Thread
Posted by Linde on 7/01/07 at 21:52

The Doctor advised me to have a 1 to 1 1/2 in heel to take the pressure off the Tendon( forgot the name).I can't wear a flat shoe. He also told me walking is not for me plus going Barefoot is totally out.One year ago i could wear a lower heel shoes, but it seems to get worse as the time goes by.

Result number: 34

Message Number 232361

Heelspurs View Thread
Posted by Linde on 7/01/07 at 19:58

Iam looking for a shoe that could work for me.... 11/2 inch open heel shoe (Heelspurs are in the back of Heel) good support on the side. I dont like to slide and loose my balance, plus a super soft padding under the heel.Is there something out there???? This would be heaven....Thanks

Result number: 35

Message Number 232313

Re: Heelspurs View Thread
Posted by Dr. Goldstein on 6/30/07 at 21:23

Linde: first off you write just fine. I have to answer your question this way. We use the treatments for plantar fasciitis and plantar fasciosis, 2 somewhat different conditions more than we say heel spurs. This maybe somwehat confusing. the spur is never really the cause of the pain, it is the effect on the plantar fascia, fasciitis is an acute inflammation where by fasciosis is more of a thickening of the fascia with more damage to the fascia. based on this I cannot say which is better without my own exam or an ultrasound or MRI of the fascia. i am sorry i cannot give you a directed answer.
dr goldstein

Result number: 36

Message Number 232306

Re: Had ESWT this morning. When will pain ease View Thread
Posted by Linde on 6/30/07 at 18:43

Who would be a good candidate ??? I have 3 spurs on my left heel and 2 on my right heel.
Also where can you find a 'expirienced' Doctor?? it seems to me that the East Cost has most of the Doctors and clinics.Iam from Oregon and would not mind traveling to Washington if there would be a good Doctor.

Result number: 37

Message Number 232304

Re: Heelspurs View Thread
Posted by Linde on 6/30/07 at 18:22

I also have a question???? what works better for heelspurs E.S.W.T or Cryosurgery?

Result number: 38

Message Number 232303

Re: Heelspurs View Thread
Posted by Linde on 6/30/07 at 18:18

Ex rays where taken in the Doctors Office and the conversation went like this: No surgery for you, the healing process is very long 6-8 months also the heelspurs can come back.Putting you in a cast will help for the time beieng, but as soon as you take the cast of, we are back to square one.also that would hurt your right knee worst ( I have a bad knee )My question about a cortisone shot was answered no, not a good Idea. I was told get a 1 to 1 1/2 inch soft slipon shoe and see me when you have a knee replacement. I go to a specialist for my knee and other joynt problems. exrays where taken of my knee and the Doctor said I dont need a knee replacement yet, ( I had sinvisc injections in my knee in the spring),havent gone back yet, but will soon. So here we are.I live in the state of Oregon.I hope I dont make to many mistakes writing this down I was raised in a different country and thought myself how to read and write english.

Result number: 39

Message Number 232277

Re: heel spurs in both feet View Thread
Posted by Linde on 6/30/07 at 12:25

You and I are in the same situation only I have them in the back and on the bottom of the Heel so no enclosed shoes for me.Iam checking out different websites and thinking of having E S W T done.

Result number: 40

Message Number 232269

Re: Heelspurs View Thread
Posted by Linde on 6/30/07 at 10:47

For Dr Goldstein
Iam in great pain and would like to know if Cruosurgery would help me with this condition.I have three Heelspurs on my left heel, 2 in the back and one on the bottom. On my right foot I have two on the back of my heel.

Result number: 41

Message Number 231598

Re: Crosley circa 1940 View Thread
Posted by Bill K on 6/15/07 at 10:59

Nifty little cars. Someone in my little town has/had a wagon. Haven't seen it around for a few years. I see a Nash Metropolitan every once in a while at car shows, usually street rodded, not original. I have a friend who had a couple of German made Goliath two cylinder wagons about the same size as the Crosleys. I always liked the Mopars. I've had a 74 Charger, 72, 74, 75 Dart Swingers, a 73 Duster, a 68 Dart GT, and a very nice 4 speed 66 Satellite. Don't have any collectible cars anymore, they have been replaced by children.

Result number: 42

Message Number 231336

Re: TTS & Cryo/Baxters Entrapment? View Thread
Posted by dr.g on 6/09/07 at 15:28

'double blinded' studies, which are considered a gold standard in medical testing,, may take a very long time to happen. Pts would have to consider 'sham' surgery vs Real cryo without knowing which they were getting.

I would throw in my 2 cents as well. I like cryo for TTS in patients that are not good open candidates. Essentially just give them pain relief and understand they may have much more numbness. I know Dr Goldstein has pretty good results, but I have not found similar success.

Result number: 43

Message Number 230655

Re: John: Are you a blood type O+ - RISK TAKERS View Thread
Posted by john h on 5/27/07 at 14:41

Oma Z: My wife is at least the Chief of the Food Police. Maybe she is feeding me all this chicken for a reason other than health if you are correct. I am taking a break at the moment from watching the Indy 500 (eating low fat yogurt with fruit on the bottom). Especially the big 6 cylinder models.

Result number: 44
Searching file 22

Message Number 229066

Re: itchy left Heel View Thread
Posted by Gerlinde G. on 5/03/07 at 16:56

Hi,
I,too have itchy heels. It is really weird. But after finding this website, I am so glad that I am not alone.

I am 55 and my problem started a couple of years ago and it drives me nuts. I have most discomfort at night in bed, but during the day it's manageable. As long as my feet are cold it's OK, but as soon as they get warm it starts. I also tried every remedy on the market, but to no avail. The doctors could not help me either.

I looked at the website you mentioned. It is really good, but I could not find anything that fits to me. But it's a start and we all have to keep looking and, hopefully, one of these days someone will find an answer.

Result number: 45

Message Number 226317

Re: TO DR ANDREWS--RE: ORTHOTICS AS A HEALTH BENEFIT View Thread
Posted by Dr. Ed on 3/30/07 at 16:32

Dr. Kiper:

Years ago I received a call from an industrial health expert at a Dupont
chemical factory. He made the statement that 'all of our employees at the factory need orthotics.' My reply was that I felt that considering the fact that the factory workers were standing on hard surfaces for long hours that almost all could benefit from some type of supportive device. Those with significant biomechanical deficits may need custom orthotics, others, a good pre-fab device such as Superfeet and yet others a well cushioned insole and that a screening may help determine which employees should be directed to which variety of device. The human foot is not adapted to withstand being on hard surfaces such as concrete for long hours especially with the addition of some heavy lifting. I would consider supportive devices to be protective under such conditions. Some may argue that there is a lack of double blinded peer reviewed studies to back up such an assertion;
but, in doing so are ignoring basic knowledge of biomechanics and common sense.
Dr. Ed

Result number: 46

Message Number 226279

Re: To Hope View Thread
Posted by john h on 3/30/07 at 10:26

As a pilot I had to go through High Altitude training once every 4 years. You are place in a large metal cylinder that will seat 10-15 people. There are two compartments that are connected by a large metal air sealed door. Reminded me of a submarine. You and your buddies enter the chamber with people monitoring you through windows. Pressure begins to drop as you climb to 40,000 feet pressure altitude. You have an automatic oxygen mask on that delivers oxygen in the proper mixture as you ascend. By the time you reach 35,000 or so feet you are on 100 percent oxygen being delivered under pressure. On the way up at around 25,000 or so feet you remove your oxygen mask. You have a buddy who keeps his own to monitor your reactions. We all will react different to a lack of oxygen. Your finger nails will nearly always turn blue very quick. Nothing happens that would panic you if you did not know that your were in an almost oxygen free atmosphere. You may become giddy or have other symptoms you may not know you are having. After a minute or two you begin to lapse into unconsciousness. If you do not recognize it your buddy will put your mask back on other wise you would be dead in very short time. The purpose of this training is to let you learn your own personal symptoms from lack of oxygen. In a single engine jet you always have your oxygen mask on but if the system should fail you may not know it and you could pass out without ever knowing you lacked oxygen. We have had many military pilots crash from lack of oxygen. When oxygen is being delivered under max pressure you really have to have your mask very secure and snug to your face as the pressure is tremendous. If you are in a two seat fighter the pilot in front and radar operator in the back can monitor each others breathing by a small indicator on each others panel. If you happen to have someone who breathes very slowly it can really get you excited. We also did a rapid decompression like you might experience in a civilian airliner. As you have two chambers that can be set at different altitude you can puncture a seal between them and rapidly bring the altitude in your chamber from 8000 feet to 25,000 ft or more where you would die very quickly if you did not put on your oxygen mask. Jets fly at 40,000 ft and up often and I often wondered if a passenger could get enough oxygen from those small mask that drop from the ceiling if you had a rapid decompression at altitude. As i said at that altitude you need 100% oxygen delivered under very high pressure. A small child probably could not even hold the mask on. A adult passenger would even be surprised at the pressure from the mask, that is if these mask have oxygen delivered under pressure. The pilots are well trained and would immediately dive towards lower altitude but to drop 25,000 feet is going to take a few minutes. I think the airliners keep the cabin altitude at around 7000 feet. Above 10,000 feet cabin altitude a mask is required by FAA. I would be interested to know what a chamber will do for PF. I imagine they are taking the patient down rather than up and perhaps forcing blood and oxygen into places such as the fascia (if that what really happens). Of course you face the same things that divers do and that is the bends. When you dive your force gases or solutions into joints,etc. As these fluids come out of their altered state as you rise (rise to fast) you can get horrible pain in your joints which can only be alleviated by going back down under pressure and ascending slowly to allow the gases, etc to return to their normal state. That is why divers have to ascend very slowly and spend time at various levels as you rise.

Result number: 47

Message Number 224145

Re: Had a New Surgery in toe will regrow Cartlidge View Thread
Posted by Linda F on 3/04/07 at 22:07

Yes It is my Big Toe. He put as Cylinder in my Big Toe to regrow
new Cartlidge. Thanks so much for the fast response :) He keeps
saying it is a new Surgery for a year now. If it does not grow back
then I will have to go back and have it fused together.

Result number: 48

Message Number 221660

United States of America Department of Labor View Thread
Posted by marie on 2/06/07 at 09:11

As far as source for my info goes in my previous post....go to http://thomas.loc.gov/ to look up the bills or is using responsible sources out of your realm of abilities? You can look up any of the promises made pre election here: http://www.democrats.org/ Please let me know if you don't understand any of the big college words and I will do my best to assist you.

John's unsited perscentages.......
"The stock market is at an all time high. The unemployment rate is around 4.5% when most economist consider 7% to be full employment as people are constantly moving from one job to another. I sure remember 16-17% treasury bonds and even at that I was afraid to buy them as we had runaway inflation under Jimmy Carter. More people own their own homes than ever before. Interest rates are running around 5% and inflation has been well under control for some years. All of our politicans are afraid to touch the third rail of Social Security even the Democrats."

Like I said before Republicans look around in their own space and say "life is good" but we know that is not true for the Midwest. The Midwest will break and go blue. Republicans fail to see the big picture. Any politician or political junkie understands that the Midwest will cost Republicans dearly.

John does not site a source for his figures so let me help blind Republicans a little. John sites the national average but the national average won't be electing the president. Electorial from each state determines the election. The key states will be in the Midwest. Some parts of the Midwest are doing a little better but not enough has been done. http://www.bls.gov/eag/eag.us.htm

My source is the United States of America's Department of Labor: Bureau of Labor Statistics: http://www.bls.gov/

Labor stats as of Dec. 2006. New stats are forthcoming for the month of January. The stats Most unemployment rates listed have been steadily rising since last May and a few haven't changed at all. It'll be interesting to see what it looks like for jan. 2007.....with Ford and GM calling for massive layoffs.

I won't post them all but lets take a snapshot of Michigan, Ohio, Indiana unemployment rate........

Michigan
Detroit-Livonia-Dearborn, MI: 8.3% unemployment rate
Detroit-Warren-Livonia, MI: 7.2 unemployment rate
Grand Rapids-Wyoming, MI: 5.8 % unemployment rate
Battle Creek, MI: 6.5% unemployment rate
Jackson, MI: 7.3% unemployment rate
Warren-Troy-Farmington Hills, MI: 6.4% unemployment rate
Flint, MI: 7.8% unemployment rate
Niles-Benton Harbor, MI: 7.0% unemployment rate
Ann Arbor, MI: 4.4% unemployment rate (Interesting that the LIBERAL college town has the lowest ue rate in Michigan)

Ohio
Toledo, OH: 6.0% unemployment rate
Akron, OH: 5.3% unemployment rate
Canton-Massillon, OH: 5.7% unemployment rate
Lima, OH: 6.5% unemployment rate
Youngstown-Warren-Boardman, OH-PA: 6.0% unemployment rate
Dayton, OH: 5.7% unemployment rate
Parkersburg-Marietta-Vienna, WV-OH: 5.1% unemployment rate
Weirton-Steubenville, WV-OH: 6.8% unemployment rate
Wheeling, WV-OH: 5.0% unemployment rate
Cleveland-Elyria-Mentor, OH: 5.3% unemployment rate
Sandusky, OH: 6.6% unemployment rate
Springfield, OH: 5.7% unemployment rate
Mansfield, OH: 6.4% unemployment rate
Cincinnati-Middletown, OH-KY-IN: 4.8% unemployment rate

Indiana
Anderson, IN: 5.5% unemployment rate
Terre Haute, IN: 5.6% unemployment rate
Kokomo, IN: 5.5% unemployment rate
Muncie, IN: 5.4% unemployment rate
Michigan City-La Porte, IN: 5.5% unemployment rate
South Bend-Mishawaka, IN-MI: 5.0% unemployment rate

Now if Republicans think they are going to win Ohio with those stats they are wearing blinders. Cinci was the only area with a reasonable unemployment rate.

From their Mass Layoff statistics:
Extended Mass Layoffs Associated with Domestic and Overseas Relocations, First Quarter 2004
ftp://ftp.bls.gov/pub/news.release/reloc.txt
"The Midwest accounted for the largest proportion of workers in extended mass layoff events associated with the movement of work (34 percent) in the first quarter of 2004, followed by the South (31 percent), the West (27 per-cent), and the Northeast (8 percent). (See table 3.) For all extended mass layoff events, separations were concentrated in the West (43 percent), followed by the Midwest (29 percent), the South (16 percent), and the Northeast
(12 percent)."

They have not released a new report since 2004 although they are required to by law. Wonder why?

Lets take a closer look at Manufacturing which comprises 11% of all employment. My source: The United States of America Department of Labor.



Wow this is absolutely unexcusable.........Note the immediate decline after the year 2000......when Bush took over.
http://data.bls.gov/PDQ/servlet/SurveyOutputServlet?&series_id=CEU3000000003

Here is a table to watch as an indicator of the health of the Manufacturing Industry. The latest unemployment rate is UP not down to 5.0% for Jan. 2007.
http://data.bls.gov/PDQ/servlet/SurveyOutputServlet?series_id=LNU04000000

Now lets take a peek at the Automotive industry, the heartbeat of the Midwest and see how their stocks are doing.......

Ford Motor Company
http://finance.yahoo.com/q?s=F&x=65&y=12
Today it's at $8.33 a share
Dec. 2000 it was $18.96 fluctuating around 20.00 per share
http://finance.yahoo.com/q/hp?s=F&a=00&b=3&c=2000&d=01&e=6&f=2007&g=m&z=66&y=66

General Motors
Today it's at 32.71 a share
http://finance.yahoo.com/q?s=GM
Dec. 2000 it was 38.53 fluctuating around 40.00 per share

Check out April 2000 it was at 69.21........dang that Bill Clinton!!!!

Have a nice day. Stay warm and remember Republicans to wear a hat, scarf and your blinders before leaving home.

Result number: 49
Searching file 21

Message Number 219606

Re: Threat Level: Red "Severe" View Thread
Posted by Dr. Ed on 1/13/07 at 11:50

Nice speech but you really see politics with blinders on. How can you speak of hate speech only coming from the right when the left has blanketed the web with sites like moveon.org? Did you hear those on the right bombard the media wiht comparisons of Clinton to Stalin as the left has compared Bush to Hitler?

Result number: 50

Message Number 218168

Re: Both points of view are always needed View Thread
Posted by Dr. Ed on 12/28/06 at 16:29

Dorothy:

Are you and Marie taking turns going on the attack?

There are a lot of good points in your post and I agree with many of them. Nevertheless, you had to take a few potshots at me so I will respond.

Please explain, " I think what we all need to do more of is to consider that Israel and its Jewish citizens have a somewhat diminished claim on the singularity of that existential plight than they did in the past" There are a lot of peoples throughout the world in dire straights but I do not think that the condition of one group of people in any way diminishes the needs of another.

"The Israeli Jews should know, above all people, that oppression and marginalization and deprivation do not lead to anything good."

They do know that. Israel is a democratic and free nation with a free press. There is a massive amount of soul searching and debate that goes on in Israel. You can find a diversity of opinions within Israel. I prefer the Likud Party but that is just my opinion.

I agree with you that Germany got off a bit too easy. Part of the reason for that was the concept that the sanctions against Germany after WW1 were too severe and led to the rise of the Nazis. Nevertheless, to place responsibility for support of Palestinians on Germany still misses the major point. There would be no Palestinian refugee problem if the British did not give a large portion fo the British Mandate of Palestine to the Hashemite royal family to create its own little fiefdom called the Kingdom of Jordan. Furthermore, it was the neighbors of Israel who used the Palestinian Arabs as pawns to keep the conflict going. That is something you already understand. The so-called occupied territories are a real red herring considering that those territories were part of Egypt, syrai and Jordan before 1967. So, the question arises: Was there a so called "occupation" existing before 1967? Did Palestinian Arabs living in the west bank portion of Jordan and the Egyptian Gaza Strip want their own country there? Funny, but there was no mention of it before 1967! Yasser Arafat made it an issue but he was an Egyptian, not a Palestinian Arab.

"Finally I have to say your arrogance and smugness is stunning."

Quite frankly, I have to say that your stupidity and narrow mindedness is amazing.

I am not the only one to accuse your hero, Carter, the worst President in American history, of being an anti-Semite. The press and acacdemia has numerous writers, far more erudite than I making the same observation. Considering the fact that Carter fails to recognize the rights of the Jews in Israel to survive is akin to sentencing them to death and since you agree with him, I would have to place you in the same category despite your claims otherwise.

How can I dispute Carter's use of the term "apartheid?" It is innapropriate because of its definition being accepted by common usage which has been a racially based separation of peoples that occurred in South Africa. It implies that there is a perpetrator of such policies in the area and Carter's finger is pointed at Israel despite his recent attempts to qualify the title.

Here is where your true colors show by the absurd statement:
"Israel cannot prevent an entire "nation" within a nation from making a livelihood, from buying and selling, from moving about - it is called a ghetto, Ed!!" The Jews were forced into the ghettos of Europe for centuries due to prejudice. Making such a comparison is a reprehensible act. You shuld be ashamed of yourself. Israel has NEVER prevented the Palestinian Arabs from mking a living. In fact, Israel acted to engage the Arabs living in the West Bank in commerce and provided significant amonts of monetary aid, money that was not available for Jewish refugees from the Soviet Union arriving penniless. This all occurred while the Saudis and other Arab oil countries were raking in billions in oil money. Saddam offered the Palestinian Arabs a check for $25,000 for every family member died as a suicide bomber, one of the many reasons that Saddam had to be eliminated -- something that people like yourself who choose to have blinders on cannot and will not understand.

I would like to think that your statement about your heart being "with Israel and the Jews is true" but that statement need be better reflected in your posts and the people who you choose to admire.

" I think Jordan and Syria need to be heavily leaned on by the UN and the US to provide homes for the Palestinians but that's not going to happen anytime soon, if ever - and in the meantime.... what? Israel has to deal with it and the world needs to help them get to "detente."

That is a very unclear statement to me. Yes, Jordan and Syria need to be leaned on heavily. But that is not going to happen. It needed to happen for 48 years. So how do you propose that Israel "deal with it" in a way that does not meet the wrath of Carter? Do you really expect the "world" to help Israel and the Arabs get to detente? Again, it has not happened in 48 years. Much of the world needs oil and what is speaking here is oil money. That is why Europe has largely taken the Arab side. Oil money fro mthe Arabs is what helped bail out Jimmy Carter's peanut farm and finance Carter's philanthropic actitivities for the last 16 years. China needs oil even more than Europe so they are selling thier latest missile technology to Iran which ahs transferred such weapons to terrorists.

Result number: 51

Message Number 216247

Re: NBC Saids Iraq In The Midst of "Civil War" View Thread
Posted by marie on 11/27/06 at 21:30

"Once the area is stabilized, we can withdraw our troops via Iran after taking out their nuclear facilities."

I volunteer Ed to lead the troops into Iran. I strongly suggest he take the position to the on the right side of the lead tank.......not in the tank but walking next to it. We all know how eager he is to join up and fight for the cause he believes in. Better yet lets hold off on that a few years so his kids can go instead of him. Here is a link so that you can begin preparing them now. It's never to soon to start.

http://www.goarmy.com/flindex.jsp

Result number: 52

Message Number 214834

Re: Glucosomine Study View Thread
Posted by SA on 11/02/06 at 22:01

As an epidemiologist and a researcher, I would interpret this as a positive finding, despite the lack of statistical significance. In this case, the lack of significance is more likely driven by the small sample size (N=29 patients) rather than by the effect size. A small sample size means that the power to detect a significant difference between the placebo and treatment groups will be low (in scientific jargon, one would say that the probability of a Type 2 error (failing to detect a significant difference when one exists) is high). Think of it like looking for a needle in a haystack with just your eyes (low power) or with an X-ray machine (high power). Notice that the p-value they report is 0.15; while people are familiar with p<0.05 being the cutoff for statistical significance (which, by the way is an arbitrary cutpoint), with a small sample I would be more liberal and consider anything <0.2 as a promising positive finding given the low power. That said, this is a pilot study (usually meaning a first phase of a larger, more sophisticated study that will be conducted to confirm the results).

Also, note that it was a randomized double blinded, placebo-controlled trial (the most rigorous type of study design), so despite the small sample size (N=29 patients); the convenience sample, and the borderline significance I would give this study relatively high marks as a pilot effort.

Since glucosamine has no known side effects, this would push me toward taking it as long as I could afford it (I take it anyhow). However, if this were a study of an invasive surgical procedure, I would definitely wait to see whether other large studies confirmed these pilot findings before acting.

Result number: 53

Message Number 213649

Re: Acronyms View Thread
Posted by Dr. Z on 10/18/06 at 17:40

Dr. Wanders post appears to be a rehash so I will give you a balance side to his take on things. Here is what I went thru to obtain board certification by the American Board of Ambulatory Foot Surgeons which as Dr. Wander explained become a part of the Ambulatory section of the ABPS.
I did a podiatric surgical residency program at John F. Kennedy Univerisity Medical Center in Stratford New Jersey. It was a podiatric and orthopedic surgical residency program
I also an a strong interest in Minimial incision foot surgery and ambulatory foot surgery. This was before there were ASC's and all foot surgery involving bone surgery was done in the hospital.
So I decided to learn both types of podiatric surgery and decided to become board certified in ambulatory foot surgery instead of thru the ABPS hospital based foot surgery.

The examination was both similiar and had some differences. I had to take a written, oral examination, submissiion of 75 foot surgery cases that was NOT done at a hospital. I had to allow two certified podiatrists come to my office INSPECT the office and observe five surgical cases in my office.
After the merger between the ABPS and the ABAFS . I become a member of the ABPS since the ABAFS dissolved.

I have full surgical privileges at local hosptial and ASC's. I do most of my surgery at ASC''s today.
Most of my interests are in ESWT due to its ambulatory nature and non-invasive which I learned how important it was when studying ambulatory surgery 20 years ago.
The ABPS is the premier surgical board today. When I first out of school it had closed blinders with ONLY podiatrists that did surgery in a hospital could be board certified. Today this is a very different picture of podiatric surgery with most of the surgery done in ASC's or office surgical suites. So that is my take.
I hope it helps with understanding this thread.
I am not asking for a rebuttal from Dr. Wander. He has stated what he believes and so has Dr. Parker. This is my take.
The end

Result number: 54

Message Number 211957

Re: ECSWT View Thread
Posted by Dr. Z on 10/02/06 at 07:33

Read the FDA Studies for the dornier,ossatron, the North American Confirmatory Study, and Wang's six year long term follow up with high energy . What is so hard to imagine as a follow up over six years? Double Blind over six years. Hey what are you looking for? Studies are typically unblinded at 12 weeks. ESWT works with the correct protocol and patient selection. If you are doing research it is going to be very difficult to find the perfect study . If your pf and you meet the correct clinical criteria you have found the correct procedure. Good luck. Read the aboved mentioned articles if you wish

Result number: 55

Message Number 211944

Re: ECSWT View Thread
Posted by alfons bedoya on 10/02/06 at 01:25

Hard to know how to respond to a comment refering to unspecified "long term studies"; the article I specifically refered to notes the common failure of allegedly "positive" clinical findings to use double blind procedures and it's hard to imagine your "long term studies...over a six year period" have been double-blinded !(The aricle I refer to also disputes the interpretation of the only well-known favorable double blind trial.)

Result number: 56

Message Number 211099

not much has changed.... View Thread
Posted by Dr. Ed on 9/24/06 at 00:13

http://www.mattmargolis.com/blog/archives/2003/07/27/the-democrats-vision-blinded-by-their-hate-of-the-right/

Result number: 57
Searching file 20

Message Number 209684

Re: Airrosti Treatments View Thread
Posted by Dr. David S. Wander on 9/08/06 at 20:19

As usual, you missed the ENTIRE message in my post.

1) I did NOT attack Airrosti treatments.

2) Your analogy to the ABPS exam or courses to LEARN how to perform laparoscopic procedures have absolutely NOTHING to do with the issue we are speaking about. Don't you get it?

3) We are speaking about a company selling a PROPRIETARY "method" of performing a SPECIFIC procedure LICENSED by them, that can only be performed by THEIR licensed doctors, under THEIR LICENSED agreement. It' not simply a matter of taking a course and performing the procedure. It's MUCH more involved than that, it's a LICENSED AGREEMENT FOR A PROPRIETARY "SECRET".

4) That's a helluva lot different than a surgeon paying for a course to train to learn how to perform a particular procedure that he/she can perform ANYWHERE, ANYTIME on ANYONE, WITHOUT a LICENSING AGREEMENT or WITHOUT A CONTRACT. Do you get it now????

5) Why would I be afraid of Airrosti helping patients?? I welcome any and all treatment modalities that can benefit patients. I've welcomed ART, Grafton, etc., and would welcome Airrosti if I understood why it was TRULY different than these procedures or TRULY different than a form of deep tissue massage, rolfing, etc. As it has been explained, it appears to be another proprietary method of the aforementioned methods, with a few modifications, and a "new" term THIXOTROPY, which is simply AIRROSTI's "theory" of how this method is working, but can not and is not proven.

It is VERY easy to use the word thixotropy and impress people with this "term" and the supposed/proposed "theory" of what is happening. However, without demonstrating this on cadavers or on lab specimens after the procedure has been performed, it is simply an hypothesis that sounds nice. It certainly sounds impressive that tissue can simply be "molded", but tissue isn't silly putty and until proven otherwise, I'd like proof.

Once again, elaborate studies don't have to be performed. This can be demonstrated on fresh cadaver specimens or can be performed on lab animals that can then be placed under anesthesia and examined, etc.

Therefore, these "theories" can be challenged and/or validated and don't necessarily have to be peer reviewed or have long term double blinded studies, etc. It's nice to use the term thixotropy and it certainly SOUNDS impressive, but let's see some concrete evidence OTHER than anecdotal stories or references that "it worked".

I'm not a skeptic, I'm not anti-Airrosti and I'm not antagonistic. Questions have been asked, and I'm not satisfied with the answers received.

And Dr. Z, if you extend the offer to ME to fly to Texas to check out these treatments, I will certainly take you up on your offer.

Result number: 58

Message Number 208894

Re: www.whatreallyhappened.com View Thread
Posted by john h on 8/31/06 at 12:15

I do not know that the U.S. has realized one drop of oil as a result of this war. Iraq cannot supply enough oil for itself at this point. Currently oil prices are falling rather rapidly. It is estimated that by Xmas we will be closer to $2 a gallon than $3 a gallon. Speculators are starting to unload their oil positions due to the decrease in oil demand. I think nearly all our imported oil is from the Oil Cartels and they set the price for the most part. It would be very difficult for the Cartels to cut off the U.S. under any circumstance as they have to sell oil as that is basically all these countries have to sell. The U.S. lives in a world where we waste oil and refuse to use alternative energy. We have not built a nuclear plant since three mile island and have not built a refinery in decades. All this as a result of regulations. At the same time Europe,China and other countries have been building nuclear plants at a record pace. Since it take around 10 years to build a plant we are way behind the power curve. We drive 8 cylinder SUV's like we have all the gas in the world while Europe drives small cars and a lot of diesels. None of this is a Bush, Democrat, or Republican problem. It is largely a people problem as we want our big cars and do not want nuclear plants in our neighborhood. The time will come when we will pay the price for absolute waste of energy.
No politician wants to take on this problem but just chooses to blame the other party.

Result number: 59

Message Number 207241

Re: Obama will if Hillary won't! New Fox Poll up! View Thread
Posted by john h on 8/14/06 at 10:12

The radical Muslims hate anyone who is not Muslim. They also hate some of their own in that the there is a great divide between the major sects of the Muslim religion which could or will lead to a civil war in Iraq. Iran is now the big stick in the Middle East and their goal is to convert all of the Middle East to their brand of Islam. Of course, the U.S., UK, and Israel are high on their list of countries they would like to destroy but make no mistake their ultimate goal is the destruction of Western Civilization as we know it. It is not PC to say we are in a Holy War but the fact is we are in a Holy War. Not very much different than the Crusades. Those who would say that the war in Iraq is not part of this Holy War have blinders on or are playing to politics. The Islamist are blowing up people all around the world and their goals should be evident. We are dealing with an enemy that are so strong in their hatred of the West they will blow them selves up to kill their perceived enemy. An enemy like this will have no problem exploding a nuclear weapon on any Western nation they can. Pulling out of Iraq will solve nothing. It will only make them stronger. They were blowing up western targets years before Iraq. They attempted to bring down the WWTC in the early 90's. Our people had better wake up to the danger before us. Those who would not give our intelligence agencies some of the authority to wire tap, etc in the name of the Constitution need to get their head on straight as to where the REAL Danger lies. Fortunately England gives their MI5 and other police type services the authority to interdict these bad guys or else we might have 12 airliners at the bottom of the Atlantic Ocean. We need to take the politics out of this and stop worrying about whether a Democrat or Republican gets elected. The Islamist could care less as their goals will remain the same. I personally think Israel understands the stakes for them if Iran gets a nuclear weapon and if the U.N. cannot take care of business they will. I am old enough to remember the start of WWII and the bombing of Pearl Harbor and how we allowed the rise of Hitler and the war machine in Japan. Both could have been stopped early on. It sure looks like history is repeating itself with the likes of Iran and Syria and N. Korea. We can talk ourselves to death at the U.N. which ultimately has no real power to do anything. An organization that has a nation like Syria on the Human Rights Commission. Who ever is elected to Congress, who ever is elected to President better understand the stakes here. It is the survival of Western Civilization. I do not care if it is a Republican Congress or Democratic Congress but it is essential they not make this a political event. We are in a real war that is the equal of WWII.

Result number: 60

Message Number 205286

Re: Interesting article about Acetic Acid Iontophoresis View Thread
Posted by amy on 7/25/06 at 16:46





Plantar Fasciitis Responds Well to Acetic Acid Iontophoresis




NEW YORK (Reuters Health) Jul 14 - Iontophoresis with acetic acid is more effective than iontophoresis with dexamethasone in relieving pain and stiffness due to plantar fasciitis, investigators report. However, the effects of treatment are only short-term.

There have been reports that iontophoresis with dexamethasone or acetic acid benefits patients with plantar fasciitis, Drs. H. R. Osborne and G. T. Allison explain in their study, published in the June issue of British Journal of Sports Medicine. However, there have been no comparisons of the two agents, and no reports on the efficacy of LowDye taping, for the treatment of plantar fasciitis.

They therefore conducted a double-blinded, randomized trial among 31 patients with medial calcaneal origin plantar fasciitis that was symptomatic for at least 1 month.

The treatments consisted of iontophoresis with 0.4% dexamethasone (n = 11), 5% acetic acid (n = 10), or saline placebo (n = 10). Six treatments of iontophoresis with each agent were performed over a 2-week period. LowDye taping was replaced at each visit and then discontinued at the end of the 2 weeks.

Patients reported measures of pain and stiffness at baseline, 2 weeks and 4 weeks, using a 10-cm visual analog scale.

At the end of 2 weeks, all groups reported significant improvement in morning pain and average pain in the past week, but acetic acid was the most effective. However, by the 4-week follow-up visit, effects on pain were not maintained in any group. A similar pattern was observed with residual pain and worst pain in the past 2 days.

However, the treatment gains in pain from acetic acid or placebo were lost by the end of 4 weeks.

In terms of morning stiffness, all three treatments reduced morning stiffness, but the difference was statistically significant only in the acetic acid and placebo groups. The reduction in stiffness was maintained only among patients treated with acetic acid.

Five patients developed skin irritation due to the LowDye taping, so the physicians, based at the University of Western Australian in Perth, recommend taping not be used for more than 2 weeks.

Br J Sports Med 2006;40:545-549

Result number: 61

Message Number 201127

Re: Cryoanalgesia: Outcomes for heel pain & Morton's Neuroma View Thread
Posted by Dr. David S. Wander on 6/14/06 at 12:17

We're starting to go down that "old" road again, so why don't we simply change the subject to avoid repitition of the controversy that's already been hashed out on this forum a few months ago. Otherwise this is going to turn into a pissing match of Dr. Goldstein telling Judy and Ralph about his success rates and Judy and Ralph requesting non-biased information. The answer is quite simple. Randomized, blinded studies can take place with cryosurgery and studies like this often do take place at the expense of the patient NOT receiving treatment. Patients are made aware of this when they enter the study group. That's how studies are performed and all participants of a study are notified of that PRIOR to the study. That does not mean it would be easy or practical, but it CAN take place. It's done with life saving medications including cancer medications, so it can certainly be done with cryosurgery.

However, up until now it has not been done, and Dr. Goldstein and Dr. Nordyke have given their honest appraisals of the efficacy rate of cryosurgery in their practices. That's all we can ask of them. You can believe them or not believe them, but I have no reason to not believe them. And until a study comes out, this is the best you're gonna get!

Result number: 62

Message Number 201066

Re: Cryoanalgesia: Outcomes for heel pain & Morton's Neuroma View Thread
Posted by Dr. David S. Wander on 6/13/06 at 18:40

Ralph,
As previously stated, I could not agree with you more. Unfortunately, my opinion led to a significant "battle" in the past between Dr. Goldstein and myself and I really don't want to rehash that again, and I confident that Dr. Goldstein also does not want to get involved with any controversy.

I do believe that Dr. Goldstein and his colleagues that are performing cryosurgery and that are involved in gathering the retrospective data are obtaining very good results and that they are honest with their findings. I know several of the doctors involved and I am confident in their integrity. I believe that if the findings show that they are achieving positive results, then that in fact is true, and that they are reporting the data accurately and NOT fictitiously.

However, this still differs significantly from a randomized blinded study. However, this type of study is difficult to perform, since you basically need a patient population that will have the cryo probe inserted but not activated otherwise the patient will know if the procedure was performed, etc. This is not an easy task and is much more complicated than it sounds. It also means that a group of patients that need treatment are receiving a "sham" treatment, although they do know that they are part of a study. There is cost involved, etc., and it is relatively complicated process.

You must crawl before you walk, and at least Dr. Goldstein is providing some data to attempt to show the efficacy of the treatment. Whether you believe his data is prejudiced is up to you to decide. All he can do is report the numbers that he is provided.

Result number: 63

Message Number 201020

Re: Cryoanalgesia: Outcomes for heel pain & Morton's Neuroma View Thread
Posted by Dr. David S. Wander on 6/13/06 at 08:43

I could not agree more with your comments. Retrospective gathering of information is quite different than performing randomized blinded studies.

Result number: 64
Searching file 19

Message Number 195193

Studies on Nerve Probs View Thread
Posted by M. Beck on 3/09/06 at 09:25

D and I were discussing nerves below and I was wondering if anyone new of good studies on nerve problems posted on line.

My post went something like this.

I had a what the heck is it called. Where they stick little needles in you and run electical currents through your legs. They didn't really notice any slowness of the charges from point a to b in my legs. But I noticed an extra amount of pain around the left ankle as the charge was sent. That's kind of my worse foot. But both feet get real hot real cold with lots of tapping, buzzy, pin pricks, bug bites, calf jumps etc. Not all that painful, I can take it I just don't know where it's building to. I hope it subsides. You know how scary all the stories are on here.

A doc I saw in Manhattan had very little to teach me but this. Right now the medical community is in the stone ages with nerves. One day they will send a plasmodic burst (he made up a Star Trek like term to describe what we don't yet have) through the legs and locate exactly where the nerves are being impinged.

From all I understand nerves that act up are being starved. Nerves provide their own nutrition by forcing it down the length of itself. At our extremeties the nerves are less nourished and therefore starving.

With all the millions floating around for research why are we so in the dark about nerves. But I guess I'm particularly sensitve because of my predicament.

I've also wondered why PF often involves TTS. My theory is that my limited biomechanics that are tight thus stressing the plantar fascia also strangle the nerves. The more loose it all is the less pressure the flesh itself exerts on nerves as I walk.

But I'm still in faith for complete healing. I've faced body shut down before and made it out the other side. One time the left side of my vocal chords shut down eventually to come back. The body is beautiful when it is hitting on all cylinders when it's is broken or breaking down it can be so cantakerous. Ah well one day our body's will be perfect again.

I'm going to post this above to try to elicit nerve talk from the boards.

Result number: 65

Message Number 195191

Re: Going to try taping.... View Thread
Posted by M. Beck on 3/09/06 at 09:21

I had a what the heck is it called. Where they stick little needles in you and run electical currents through your legs. They didn't really notice any slowness of the charges from point a to b in my legs. But I noticed an extra amount of pain around the left ankle as the charge was sent. That's kind of my worse foot. But both feet get real hot real cold with lots of tapping, buzzy, pin pricks, bug bites, calf jumps etc. Not all that painful, I can take it I just don't know where it's building to. I hope it subsides. You know how scary all the stories are on here.

A doc I saw in Manhattan had very little to teach me but this. Right now the medical community is in the stone ages with nerves. One day they will send a plasmodic burst (he made up a Star Trek like term to describe what we don't yet have) through the legs and locate exactly where the nerves are being impinged.

From all I understand nerves that act up are being starved. Nerves provide their own nutrition by forcing it down the length of itself. At our extremeties the nerves are less nourished and therefore starving.

With all the millions floating around for research why are we so in the dark about nerves. But I guess I'm particularly sensitve because of my predicament.

I've also wondered why PF often involves TTS. My theory is that my limited biomechanics that are tight thus stressing the plantar fascia also strangle the nerves. The more loose it all is the less pressure the flesh itself exerts on nerves as I walk.

But I'm still in faith for complete healing. I've faced body shut down before and made it out the other side. One time the left side of my vocal chords shut down eventually to come back. The body is beautiful when it is hitting on all cylinders when it's is broken or breaking down it can be so cantakerous. Ah well one day our body's will be perfect again.

I'm going to post this above to try to elicit nerve talk from the boards.

Result number: 66

Message Number 194198

calculating speed of waves in nanotubes View Thread
Posted by scott r on 2/26/06 at 00:14

I loved the video (see link below) of the argon striking the nanotube. I noticed the wave propagating down the side after each strike and wondered if i could estimate the speed and other qualities of the wave. This is what i came up with: It was 57 Angstroms between the dips in the waves that are 2 picoseconds apart, so the waves are traveling 2850 m/s down the tube. Since the wave is mostly confined to one side and it largely collapses the side, it's very much like a ribbon (string) and so the wave should roughly follow the rule for strings (and rods, and springs) where v=SQRT(T/d) where v is the velocity, T is the tension in the string and d is the density of the string in kg per meter length. I estimated the "ribbon/string" to be between 6 and 10 cells wide so I used 8 cells x 3 carbon atoms per cell x Carbon atom weight / 2.45 Ang section length of the cells, giving me d=2x10-17 kg/m for the density. Solving for T gives 1.6x10-8 N for the tension in the 8-bond (8 cell) ribbon, or 2.5 eV per bond. There could be a +/- 20% error in my choice of 8 cells which i view as the only source of error. In any event, I wouldn't want to go any deeper into wave equations for cylinders. 2.5 eV per bond happens to be the bond strength of these C-C bonds, so i figure the similation must be a little close to breaking the bonds.

http://sinnott.mse.ufl.edu/Movies/29x0-swnt_deflex_Ar10eV.mpg

Result number: 67

Message Number 194189

nanotube news View Thread
Posted by Scott R on 2/25/06 at 19:20

Where to buy nanotubes for $2 a gram:
http://www.cheaptubesinc.com/pricelist.htm
1/2 last year's price (email communication)

A report says production will increase 10 to 100 times for various types in 5 years.

Jan 2006: Patent for making 10^6 nanotube rope of indefinite length at low temps using silicon wafers to start the growing:
http://cnanotech.com/download_files/Issued_Patents/US06986876.pdf
This company is selling 100 pounds per day (but not yet the rope).

Jan 2006: New method to grow forests of nanotubes (with picture)
http://nanotechweb.org/articles/news/5/1/4/1

Nov 2005: liquid flows through an array of nanotubes 5 orders of magnitude faster than theory predicts:
http://nanotechweb.org/articles/news/4/11/8/1

Jan 2006: 280% elasticity at high temp, reducing diameter to 1/15th:
http://nanotechweb.org/articles/news/5/1/12/1
(conductivity also went to zero)

Ropes of nanotubes 10 times stronger and 10 times stiffer than carbon fiber and steel:
http://en.wikipedia.org/wiki/Young's_modulus

Striking a nanotube with 10 sets of 9 argon bullets (with amazing video):
http://sinnott.mse.ufl.edu/sub05b_nanomechanics.html

Diffusion of argon atoms inside a nanotube (video):
http://sinnott.mse.ufl.edu/sub05a_nanofluidics.html

Using applied voltage to vary the section of a nanotube that emits infrared light to within a few atoms:
http://focus.aps.org/story/v14/st8

Changing resistence by bending:
http://focus.aps.org/story/v11/st15

More buckling of nanotubes:
http://sinnott.mse.ufl.edu/sub04b_tribology.html

40% elasticity before breakage
Poisson's ratio and buckling angle not dependent on diameter.

Aug 2005: nanotube sheets...the [carbon nanotube] sheets are produced at up to seven meters per minute by the coordinated rotation of a trillion nanotubes per minute for every centimeter of sheet width.... A trillion nanotubes must be automatically rotated by about 90 degrees and self-assembled in a parallel fashion for every meter-long, 7 centimeter-wide sheet that we make.... The nanotube sheets can be made so thin that a square kilometer of solar sail would weigh only 30 kilograms....A 1 cm length of 245 µm-high forest, for example, produced a 3 m long freestanding nanotube sheet that was about 18 µm thick. By winding the sheet onto a rotating plastic cylinder the researchers were able to increase the production rate to 10 m/min. A densified stack of 18 nanotube sheets that were orthogonally oriented to their neighbours had a strength of 175 MPa/(g/cm3). This compares well to the Mylar and Kapton films used for ultralight air vehicles, which have a strength of about 160 MPa/(g/cm3), and ultra-high-strength steel at about 125 MPa/(g/cm3).

Feb 2006: Drexeler publishes an article (re)describing the need for design/goal modeling for nanotubes in addition to the atom-by-atom fast-computation methods developed in 2002 (see videos above)

2002: Fastest mechanical oscillator ( > 50 GHz):
http://focus.aps.org/story/v9/st4

Result number: 68

Message Number 191441

Re: ESWT did not work for me View Thread
Posted by Ed Davis, dPM on 1/14/06 at 19:11

non-beleiver:

Dr. Rompe is a pure researcher from the University of Mainz in Germany. He does not represent any company nor any particular interests I know of. The FDA means very little outside the US. Beleive me, European and Canadian feet are not that different from feet in the US. Low energy ESWT has a VERY long and successful track record in Europe and Canada, even before the FDA approved high energy machines came to the US. Dr. Rompe has shown that the important statistic is the total amount of energy applied to tissue , not anecessarily applying it all at once. Again, please read the studies on the www.ismst.com website including those of Dr. Rompe and you will see that that indeed is the case.

The initial promoters of high energy ESWT were making it a "big dollar' treatment to be performed in suricenters (Ossatron) so they had the money to invest i nthe types of studies that the FDA wanted. The low cost, low energy ESWT (consider the costs of such treatments in Canada -- call up the Sonorex Treatment Center in Vancouver, BC) did not have the dollars to throw into the big double blinded peer reviewed studies demanded by the FDA and ONLY the US FDA. The regulatory equivalent in Canada which dows not require the big bucks spent by equipment manufacturers and drug companies (why are drugs cheaper in Canada?) had no problem giving the green light to the Siemens Sonocur and various other low energy ESWT machines and there is a paucity of high energy ESWT being done in Canada. There are more manufacturers of low energy ESWT than high energy, primarily European companies although that balance may be tipping due ot demands of the US market for high energy.
Dr. Ed

Result number: 69

Message Number 190930

Re: Finding ESWT Doc's.......? View Thread
Posted by Dr. Z on 1/06/06 at 19:13

David
I am sure Peter will clarify group vs study. His post did appear to mean his group. I was referring to studies. My point being that there are multiple WELL published studies showing HIGH success rates.


Foot Ankle Int. 2004 May;25(5):290-7.
Extracorporeal shock wave therapy for the treatment of plantar fasciitis.
Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C.
Foot and Ankle Surgery, Massachusetts General Hospital, Boston, MA 02114, USA. GTheodore at Partners.org
One hundred fifty patients were enrolled in a multicenter, randomized, placebo-controlled, prospective, double-blind study to assess the clinical safety and effectiveness of extracorporeal shock wave therapy (ESWT) using the Dornier Epos Ultra for the treatment of plantar fasciitis. The Active Group was treated with electromagnetically generated shocks using ultrasound guidance during a single therapy session. The Control Group received a sham treatment under similar clinical conditions. The groups were demographically similar with respect to age, height, and weight. The average duration of symptoms was nearly 2 years in both groups. All patients were evaluated by the visual analog scale for pain, American Orthopaedic Foot and Ankle Society scores, Roles and Maudsley Score, SF-12 health status questionnaire, and physical examination. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment. The Control Group reported 47% success at 3 months posttreatment. Twelve-month data were not collected for the Control Group as they were unblinded at 3 months and offered treatment. ESWT represents a safe treatment option for chronic proximal plantar fasciitis.

Result number: 70
Searching file 18

Message Number 189902

Re: To Dorothy Cryosurgery Lots of doctors seem to be offering it. View Thread
Posted by Ralph on 12/18/05 at 21:38

Dorothy,
I certainly didn't mean to be sarcastic at all. I just thought it was interesting that I was able to find sooooo many Podiatry websites offering this new treatment. To go from 7 doctors when Dr. Wishnie introduced himself and Cryosurgery to us to so many in such a short period of time means to me that Manuf. Reps talked to many doctors and obviously sold them a machine or perhaps they made the contact at a medical convention. Either way there are a lot more doctors providing the treatment now. Maybe several doctors share machines like they do with ESWT too.

What really surprise me was a letter by a doctor in Podiatry Management saying that he'd been using Cryosurgery to treat neuromas since 2003. Since it was just brought to our attention this year I thought it was a brand new podiatric treatment for Neuromas and P.F., but I guess it old.

Some of the letters published in Podiatry Management pointed out that there are no long term or double blind studies published for Podiatric Cryosurgery for either neuromas or P.F.. I got the feeling that many DPM's would like to move toward evidence based medicine and are attempting to do so when they introduce these new treatments by producing their own published studies.

Cryosurgery used in other medical fields has been documented in accepted medical journals and appears to work well. My own personal feeling based on what I'm reading is that cryosurgery treatment for neuromas will show real positive results, but I don't feel the same way yet when it comes to treating P.F. so I guess that I'm HALF skeptical at this point in time.
In the right hands and performed for the right reason Cryosurgery looks very promising.


Here are the letters that I was refering to. They were published this year. You should visit Podiatry Management when you have time. Lots to read. The first two letters were part of a discussion about providing evidence based studies and could it be done for Cryosurgery.

03/25/2005 David E. Gurvis, DPM, David Zuckerman, DPM

Double-blinded Studies and Cryosurgery and ESW Therapy

RE: Double-blinded Studies and Cryosurgery and
ESW Therapy
From: David E. Gurvis, DPM, David Zuckerman ,DPM

They can, and recently have, blinded surgical
studies. It took guts on
the part of the surgeons and the patient, and
hospital administrators
(and probably the medical ethics committee). In
the study, they proved
(with sham surgery) that arthroscopic knee
chrondroplasty and sham
arthroscopic chrondroplasty had statistically
identical results as
measured by pain and functioning.

The study was done with all the required paper
work. Patients knew
they would have one or the other. The surgeon,
upon entering the OR, was passed a sealed
envelope, indicating real or sham surgery was to
be
performed. In the sham surgery, the standard
incisions were made, and sutured, without the
insertion of the arthroscope. Post-op care was
the same in all cases.

Possibly, can this ever be done with the
cryosurgery? It has been done
with the shock wave studies.

David E. Gurvis, DPM
Avon, IN



I agree with Dr. Weil that we need to move to
what is called evidence-
based medicine. It is here and our profession
must becoming part of this new and important
method for treatment efficiency evaluation.
Double blind, randomized , multi-center studies
are the gold standard that we should aim for. It
is possible to use this standard with cry
therapy. There was a study with arthroscopy knee
surgery when they did the actual incision. With
cryotherapy all you would need to do is place a
fake band aid over the fake incision and that
could be sham.

My point is that we need to stop looking for
excuses for this type of testing and think of
ways to actually do the testing. Is this
difficult? Yes. Can it do done. Absolutely. We
will look
back at this someday and think how could I ever
do a procedure without
some level of study. Cryotherapy and ESWT are
two treatments that can be done very easily.
Let’s not fight it
David Zuckerman, DPM
Woodbury, NJ

07/23/2005 Brian Richman, DPM

Cryoablation (G. Stephen Gill, DPM, MBA)

I have been performing cryosurgery procedures
since Sept 2003 with great results. It's about
80 % successful for neuromas, recurrent
neuromas, excessive scar tissue, plantar
fasciitis, Achilles bursitis, hypertrophic
scars, nerve entrapment, and fibromas. The
company is Cryotech 1-800-616-2796 PO Box 1868
Villa Rica Georgia 30180. They have two types of
machines the Cryostar and the Cryopac. If you
have any questions please feel free to call me
at 1-801-825-4709 or e-mail me.

Brian Richman, DPM
Layton, UT

Result number: 71

Message Number 189085

Re: Podiatry Management View Thread
Posted by Ralph on 12/06/05 at 20:25

Dr. Z,
This is the one I was reference posted by Dr.Gurvis

They can, and recently have, blinded surgical
studies. It took guts on
the part of the surgeons and the patient, and
hospital administrators
(and probably the medical ethics committee). In
the study, they proved
(with sham surgery) that arthroscopic knee
chrondroplasty and sham
arthroscopic chrondroplasty had statistically
identical results as
measured by pain and functioning.

The study was done with all the required paper
work. Patients knew
they would have one or the other. The surgeon,
upon entering the OR, was passed a sealed
envelope, indicating real or sham surgery was to
be
performed. In the sham surgery, the standard
incisions were made, and sutured, without the
insertion of the arthroscope. Post-op care was
the same in all cases.

Possibly, can this ever be done with the
cryosurgery? It has been done
with the shock wave studies.

David E. Gurvis, DPM
Avon, IN

Result number: 72

Message Number 189050

Podiatry Management View Thread
Posted by Ralph on 12/06/05 at 14:08

Dr. Z,
You are also "published" in Podiatry Management. While it may not be the New England Journal of Medicine with it's "Original Studies" it does contain discussion type information on various topics. I found it interesting because it contains a variety of topics. If readers have time they my want to go to the Podiatry Management website.

Here is the one that you submitted Dr. Z.

I agree with Dr. Weil that we need to move to
what is called evidence-
based medicine. It is here and our profession
must becoming part of this new and important
method for treatment efficiency evaluation.
Double blind, randomized , multi-center studies
are the gold standard that we should aim for. It
is possible to use this standard with cry
therapy. There was a study with arthroscopy knee
surgery when they did the actual incision. With
cryotherapy all you would need to do is place a
fake band aid over the fake incision and that
could be sham.

My point is that we need to stop looking for
excuses for this type of testing and think of
ways to actually do the testing. Is this
difficult? Yes. Can it do done. Absolutely. We
will look
back at this someday and think how could I ever
do a procedure without
some level of study. Cryotherapy and ESWT are
two treatments that can be done very easily.
Let’s not fight it
David Zuckerman, DPM
Woodbury, NJ

Here is an example of some of the discussions I found. All in all it's an informative site.

81.6%) 03/25/05 Double-blinded Studies and Cryosurgery and ESW Therapy
( 81.6%) 03/24/05 Double-blinded Studies and Cryosurgery and ESW therapy (Drs. Weil and Goldstein)
( 81.6%) 03/29/04 Cyrotherapy for Plantar Fasciitis (John Renard, DPM)
( 79.7%) 03/07/03 CPT 11900 Denial For Fibroma Injection
( 79.7%) 08/02/02 Coding Enucleation of Porokeratotic Lesions
( 77.4%) 09/13/05 Alcohol Injections for Heel Pain (Gary Dockery, DPM)
( 77.4%) 08/28/05 Billing For Multiple Verrucae
( 77.4%) 07/23/05 Cryoablation (G. Stephen Gill, DPM, MBA)
( 77.4%) 05/30/05 Laser Wart Ablation Coding
( 77.4%) 03/26/05 Double-blinded studies, sham surgeries and Evidence Based Medicine (Drs. Gurvis and Zuckerman)
( 77.4%) 03/23/05 Chronic Heel Pain (Lowell Weil, Sr., DPM)
( 77.4%) 03/22/05 Chronic Heel Pain
( 77.4%) 03/21/05 Chronic Heel Pain (Alan Mauser, DPM)
( 77.4%) 03/05/05 Plantar Fasciitis Pain Statistics (Steven Goldstein, DPM)
( 77.4%) 02/21/05 Partial Tear of Plantar Fascia (Jeffrey Kass, DPM)
( 77.4%) 11/11/04 Controlled Studies for Neurolytic Injections (Michael Schneider, DPM)
( 77.4%) 03/27/04 Cyrotherapy for Plantar Fasciitis?
( 77.4%) 10/16/02 Coding For Cyrosurgery Multiple Procedures

Result number: 73

Message Number 188712

Re: The Future of ESWT has finally come to the USA View Thread
Posted by Jan D. Rompe on 12/02/05 at 06:45

Read the official "Commentary & Persepctive" on this trial


Commentary & Perspective on
"Treatment for Osteonecrosis of the Femoral Head: Comparison of Extracorporeal Shock Waves with Core Decompression and Bone-Grafting"
by Ching-Jen Wang, MD, et al.

Commentary & Perspective by
Jan D. Rompe, MD, and Nicola Maffulli, MD, MS, PhD, FRCS(Orth)*,
OrthoTrauma Clinic, Gruenstadt, Germany (J.D.R.), and Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Stoke-on-Trent, Staffordshire, United Kingdom (N.M.)

Dr. Wang and colleagues have reported a randomized-controlled trial in forty-eight adult patients with stage-I, II, or III osteonecrosis of the hip, comparing noninvasive single-treatment high-energy shock-wave application (a total of 6000 impulses; energy flux density equivalent to 0.62 mJ/mm2) to core decompression and nonvascularized fibular grafting. At a minimum of two years of follow-up, the pain and Harris hip scores were significantly better in the shock-wave group than in the surgical group. Total hip replacement was required in 10% of the shock-wave group, and in 32% of the surgery group.

We compliment the authors for a carefully prepared pilot study that provides new, and most importantly, scientifically tested information about the potential role of shock-wave application in the treatment of early stage osteonecrosis of the adult hip.

There are relatively few reports on shock-wave treatment for osteonecrosis of the hip, and certainly this management modality will remain controversial. Even in experienced hands, reproducible application of high-energy shock-wave treatment to the femoral head is not simple, and the results from subsequent reports might not always be as favorable as this report from Wang and colleagues was. We would also caution that because of the critical neurovascular structures that lie in direct anatomical proximity to the femoral head, it is important that the application of high-energy shock-wave treatment be carried out by experienced physicians in this technique.

The authors correctly state that surgical treatment is usually indicated even for early stage osteonecrosis of the hip. However, the prognosis varies considerably depending on the extent of involvement. ARCO (Association Research Circulation Osseous) involvement is potentially reversible, but the point of no return for almost all patients is when stage-II or greater involvement occurs. The prognosis for further progression for stage I or II depends primarily on the extent and location of the lesion. Only the rare, small-to-medium-sized lesions in the medial or central location may have a good prognosis over the course of five years or more. The much more common large-sized and laterally located lesions will have a probability of about 80% of progressing to femoral collapse within two years1.

The efficacy of the treatment might have been easier to discern if the authors had concentrated on one subgroup with a sufficient number of patients. The reader cannot deduce whether all of the treated patients were symptomatic (although one presumes so), nor can the reader know the exact localization (medial, central, lateral) and extent of the lesions (mild [<15% of head affected], moderate [15% to 30%], severe [>30%]) regarding the ARCO stages. This is particularly regrettable when the authors report regression of five of thirteen ARCO stage-I or stage-II lesions after shock-wave treatment. It will be necessary for future trials to have more information on this specific subgroup of successfully treated patients.

According to Table V, the size of the lesion was evaluated on plain radiographs and magnetic resonance images before and after treatment. In patients showing a regression from ARCO stage-II lesions (abnormal radiograph and abnormal magnetic resonance image) and ARCO stage-I lesions (normal radiograph, abnormal magnetic resonance image), it is not clear whether the sizes were measured uniformly by magnetic resonance imaging at all follow-ups or whether a mixture of radiographic and magnetic resonance imaging measurements were used.

The authors state that the radiologist involved in the evaluation of the ARCO stages of patients of both groups was blinded to the nature of treatment. This will have been the case before treatment, but as one of the study arms involved core decompression, the "blinded" radiologist might have been subjected to bias during the postoperative evaluation. This may be an additional potential source for bias in this study, as clinical assessment was not reported to have been performed independent of the treating physician.

It is not entirely clear how the authors approached the treatment of patients with bilateral disease in either group. Because core decompression and nonvascularized fibular graft required up to six months of protected weight-bearing after the operation, compared with only four to six weeks after high-energy shock-wave treatment, it might have been necessary to delay surgery on the contralateral hip for quite some time, thereby allowing the condition to progress and adversely affect the outcome.

A weakness of the study is whether the optimal dose of shock waves was delivered to these patients. Recently, the authors had reported an optimal treatment of 500 impulses of shock waves at a low-energy flux density of 0.16 mJ/mm2 to stimulate complete bone-healing without complications in both in vivo and in vitro experiments in animals2-5. But, without any preliminary clinical investigation described in the article, the rationale for the choice of the particular regimen in human application—6000 impulses of a high-energy flux density—is dubious.

Nevertheless, the take-home message from this pilot study is that there may be a promising way to avoid performing major surgery on patients with osteonecrosis, and thus also avoid the potential concomitant morbidity and complications, such as infection, perforation of the articular cartilage of the femoral head, or graft migration. The authors are to be congratulated for providing the data needed to calculate sample size and power for future randomized controlled trials. These data will be indispensable in assessing the efficacy of high-energy shock-wave application as a novel management for osteonecrosis of the femoral head.

*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References

1. Lieberman JR, Berry DJ, Mont MA, Aaron RK, Callaghan JJ, Rajadhyaksha A, Urbaniak JR. Osteonecrosis of the hip: management in the 21st century. J Bone Joint Surg Am. 2002;84:834-53.
2. Chen YJ, Kuo YR, Yang KD, Wang CJ, Huang HC, Wang FS. Shock wave application enhances pertussis toxin protein-sensitive bone formation of segmental femoral defect in rats. J Bone Miner Res. 2003;18:2169-79.
3. Chen YJ, Kuo YR, Yang KD, Wang CJ, Sheen Chen SM, Huang HC, Yang YJ, Yi-Chih S, Wang FS. Activation of extracellular signal-regulated kinase (ERK) and p38 kinase in shock wave-promoted bone formation of segmental defect in rats. Bone. 2004;34:466-77.
4. Wang CJ, Wang FS, Yang KD, Weng LH, Sun YC, Yang YJ. The effect of shock wave treatment at the tendon-bone interface—an histomorphological and biomechanical study in rabbits. J Orthop Res. 2005;23:274-80.
5. Wang FS, Wang CJ, Chen YJ, Chang PR, Huang YT, Sun YC, Huang HC, Yang YJ, Yang KD. Ras induction of superoxide activates ERK-dependent angiogenic transcription factor HIF-1alpha and VEGF-A expression in shock wave-stimulated osteoblasts. J Biol Chem. 2004;279:10331-7.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.

Result number: 74

Message Number 186415

Re: ESWT Studies View Thread
Posted by Dr. Z on 11/01/05 at 14:23

We do read the same journal. YOU KNOW VERY WELL I WAS TAKING ABOUT 12 WEEKS
The last article is famous. So famous that most insurance companies used it to block ESWT insurance coverage. You know very well that this is the buchblinder study . Which was low energy, paramaters different then the FDA approved Dornier epos.PMA But you knew this or should have known this. Come on take your Healthronics head off.
Now back to the orthospec which was my point from the start. You can't just pull out of your head 85%, We need end point such as 12 weeks, inclusion parameter and exclusion parameter.
The orthospec is an interesting device but the posters on this board know very well what is bull and what is not and they don't like this off the top of your head 85%. You need to give a time frame. There is no ossatron study in the world showing 80% at the 12 week end point. There is a dornier epos 83% 12 week endpoint printed study.
This site can tell when there is bull and 85 % at 12 weeks in bull. Now six months plus maybe

Result number: 75

Message Number 186414

Re: ESWT Studies View Thread
Posted by Dr. Z on 11/01/05 at 14:23

We do read the same journal. YOU KNOW VERY WELL I WAS TAKING ABOUT 12 WEEKS
The last article is famous. So famous that most insurance companies used it to block ESWT insurance coverage. You know very well that this is the buchblinder study . Which was low energy, paramaters different then the FDA approved Dornier epos.PMA But you knew this or should have known this. Come on take your Healthronics head off.
Now back to the orthospec which was my point from the start. You can't just pull out of your head 85%, We need end point such as 12 weeks, inclusion parameter and exclusion parameter.
The orthospec is an interesting device but the posters on this board know very well what is bull and what is not and they don't like this off the top of your head 85%. You need to give a time frame. There is no ossatron study in the world showing 80% at the 12 week end point. There is a dornier epos 83% 12 week endpoint printed study.
This site can tell when there is bull and 85 % at 12 weeks in bull. Now six months plus maybe

Result number: 76

Message Number 186198

Re: antibiotic (quinolone) and tendons View Thread
Posted by d fuller on 10/30/05 at 01:19

This is a list of citations begining in 1965 to date that deal with this "rare" adverse event. I present this not as an argumentative rebuttal but as proofs regarding my previous post. One would think if indeed this was a rare occurence we would not read medical journal articles concerning it each and every year for forty years. Nor does this list inlcude all such citations, only those readily available to the average person. Of special interest is the statements made at the 62 Meeting of the Anti-Infective Drugs Advisory Committee (circa 1994)where quinolone induced joint destruction (requiring complete joint replacement) is discussed as well as irreversible tendon and ligament damage. You will find that towards the end of this response. We find the same documentation when it comes to peripherial neuropathy as well which was first reported in association with Nalidixic Acid in the mid sixties.

1965

1. DE VRIES AC.
[SPONTANEOUS RUPTURE OF THE ACHILLES TENDON]
Ned Tijdschr Geneeskd. 1965 Jan 2;109:59-60. Dutch. No abstract available.
PMID: 14284979 [PubMed - OLDMEDLINE for Pre1966]

2. CROZZOLI NR, MANCA M.
[SUBCUTANEOUS RUPTURE OF THE ACHILLES TENDON. CONSIDERATIONS ON OUR CASE
HISTORIES]
Minerva Ortop. 1965 Jan-Feb;16:21-9. Italian. No abstract available.
PMID: 14303636 [PubMed - OLDMEDLINE for Pre1966]

3. VON GRAFFENRIED, ENGELER V, HEIM U.
[SUBCUTANEOUS RUPTURE OF THE ACHILLES TENDON]
Helv Chir Acta. 1965 Jan;32:253-6. German. No abstract available.
PMID: 14290218 [PubMed - OLDMEDLINE for Pre1966]


1969

1. Rosolleck H.
[Subcutaneous achilles tendon rupture]
Monatsschr Unfallheilkd Versicher Versorg Verkehrsmed. 1969 Dec;72(12):544-7.
German. No abstract available.
PMID: 4248859 [PubMed - indexed for MEDLINE]


1971

1. Auquier L, Siaud JR.
[Nodular tendinitis of the Achilles tendon]
Rev Rhum Mal Osteoartic. 1971 May;38(5):373-81. French. No abstract available.
PMID: 5092370 [PubMed - indexed for MEDLINE]

2. Krahl H, Langhoff J.
[Degenerative tendon changes following local application of corticoids]
Z Orthop Ihre Grenzgeb. 1971 Jul;109(3):501-11. German. No abstract available.
PMID: 4254811 [PubMed - indexed for MEDLINE]


1972

1. Nalidixic Acid arthralgia
Bailey et al (CMA Journal 1972; 107 601-605)

2. Dupuis PR, Uhthoff HK.
In vivo study of the effects of a synthetic steroid, betamethasone (16B methyl-9X fluoroprednisolone) on the calcaneal tendon in rabbits Union Med Can. 1972 Sep;101(9):1763-7. French. No abstract available.
PMID: 5075006 [PubMed - indexed for MEDLINE]


1976

1. Jouirland JP Les ruptures tendineusues. Le tendon normal et patholoqique
Seminar de Monte Carlo 13-14 February 1976


1980

1. Mason JO, Meagher DJ, Sheehan B, O'Doherty CK.
The management of supraspinatus tendinitis in general practice.
Ir Med J. 1980 Jan;73(1):23-40. No abstract available.
PMID: 7380640 [PubMed - indexed for MEDLINE]


1981

1. Jensen KE.
[Bilateral rupture of the Achilles tendon]
Ugeskr Laeger. 1981 Jul 6;143(28):1768. Danish. No abstract available.
PMID: 7292758 [PubMed - indexed for MEDLINE]


1982

1. Fink RJ, Corn RC.
Fracture of an ossified Achilles tendon.
Clin Orthop. 1982 Sep;(169):148-50. No abstract available.
PMID: 6809391 [PubMed - indexed for MEDLINE]

2. Cetti R, Christensen SE.
[Rupture of the Achilles tendon after local steroid injection]
Ugeskr Laeger. 1982 May 10;144(19):1392. Danish. No abstract available.
PMID: 7135524 [PubMed - indexed for MEDLINE]

3. Chechick A, Amit Y, Israeli A, Horoszowski H.
Recurrent rupture of the achilles tendon induced by corticosteroid injection.
Br J Sports Med. 1982 Jun;16(2):89-90. No abstract available.
PMID: 7104562 [PubMed - indexed for MEDLINE]

4. Newmark H 3rd, Olken SM, Mellon WS Jr, Malhotra AK, Halls J
A new finding in the radiographic diagnosis of achilles tendon rupture.
Skeletal Radiol. 1982;8(3):223-4. No abstract available.
PMID: 7112151 [PubMed - indexed for MEDLINE]


1983

1. Norfloxacin induced rheumatic disease
Bailey et al (NZ Med J 1983; 96; 590)

2. Kleinman M, Gross AE.
Achilles tendon rupture following steroid injection. Report of three cases.
J Bone Joint Surg Am. 1983 Dec;65(9):1345-7. No abstract available.
PMID: 6197416 [PubMed - indexed for MEDLINE]


1984

1. Chamot AM, Gobelet C.
[Achilles tendinitis: a pathology of confines]
Rev Med Suisse Romande. 1984 Oct;104(10):783-7. French. No abstract available.
PMID: 6515224 [PubMed - indexed for MEDLINE]


1985

1. Between 1985 and July 1992 100 cases of tendon disorders had been identified in France
Kessler et al (HRG Publication 1399, August 1. 1996)

2. Jones JG.
Achilles tendon rupture following steroid injection.
J Bone Joint Surg Am. 1985 Jan;67(1):170. No abstract available.
PMID: 3968099 [PubMed - indexed for MEDLINE]

3. 100 reported tendinopathies 1985-1992 France
In France, between 1985 and 1992, 100 patients who were being managed with fluoroquinolones had tendon disorders, which included thirty-one ruptures (Royer, R. J.; Pierfitte, C.; and Netter, P.: Features of tendon disorders with fluoroquinolones. Therapie, 49: 75-76, 1994.)
http://www.studiomedico.it/allegati/achille.pdf


1987

1. Ciprofloxacin an update on clinical experience
Areieri et al (Am J of Med 1987 82 381-386)

2. 93 ruptures, 103 tendinopathies, 20 tenasynovitis, 1987-1997
Source: http://www.sma.org/smj1999/junesmj99/harrell.pdf


1988

1. McEwan SR, Davey PG. Ciprofloxacin and tenosynovitis. Lancet 1988; 2: 900.

2. Adverse effects of fluoroquinolones
Halkin et al (Rev Infect Dis 1988 10 258-261)

3. Ciprofloxacin and tenosynovitis
McEwan et al ( Lancet 1988 15 900)

4. Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages


1989

1. Adverse reactions during clinical trials and post marketing surveillance
Janknegt et al (Pharm Weekbl Sci 1989 11(4) 124-127)

2. Arthritis induced by norfloxacin
Jeandel et al (J Rheumatol 1989 16 560-561)

3. Schumacher HR Jr, Michaels R.
Recurrent tendinitis and achilles tendon nodule with positively birefringent crystals in a patient with hyperlipoproteinemia.
J Rheumatol. 1989 Oct;16(10):1387-9.
PMID: 2810266 [PubMed - indexed for MEDLINE]


1990

1. Histologic and Histochemical Changes in Articular Cartilages of Immature Beagle Dogs Dosed with Difloxacin, a Fluoroquinolone
J.E. Kurkhardt et al (Vet Pathol 27;162-170, 1990)


1991

1. Rheumatolgical side effects of quinolones
Ribard et al (Baillere’s Clin Rheumatol 1991 5 175-191)

2. Perrot S, Ziza JM, De Bourran-Cauet G, Desplaces N, Lachand AT.
[A new complication related to quinolones: rupture of Achilles tendon]
Presse Med. 1991 Jul 6-13;20(26):1234. French. No abstract available.
PMID: 1831902 [PubMed - indexed for MEDLINE]


1992

1. Seven Achilles tendinitis including three complicated by rupture during fluoroquinolone therapy
Ribard et al (J Rheumatol 1992; 19; 1479-1481)

2. 704 achilles tendinitis, 38 ruptures 1992-1998 Netherlands
Fluoroquinolone use and the change in incidence of tendon rupture in the Netherlands
Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)
The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture
source: http://bmj.com/cgi/content/full/324/7349/1306

3. 100 reported tendinopathies 1985-1992 France
In France, between 1985 and 1992, 100 patients who were being managed with fluoroquinolones had tendon disorders, which included thirty-one ruptures (Royer, R. J.; Pierfitte, C.; and Netter, P.: Features of tendon disorders with fluoroquinolones. Therapie, 49: 75-76, 1994.)
http://www.studiomedico.it/allegati/achille.pdf

4. Ribard P, Audisio F, Kahn MF, De Bandt M, Jorgensen C, Hayem G, Meyer O, Palazzo E.
Seven Achilles tendinitis including 3 complicated by rupture during fluoroquinolone therapy.
J Rheumatol. 1992 Sep;19(9):1479-81.
PMID: 1433021 [PubMed - indexed for MEDLINE]

5. Perrot S, Kaplan G, Ziza JM.
[3 cases of Achilles tendinitis caused by pefloxacin, 2 of them with tendon rupture]
Rev Rhum Mal Osteoartic. 1992 Feb;59(2):162. French. No abstract available.
PMID: 1604233 [PubMed - indexed for MEDLINE]

6. Lee WT, Collins JF.
Ciprofloxacin associated bilateral achilles tendon rupture.
Aust N Z J Med. 1992 Oct;22(5):500. No abstract available.
PMID: 1445042 [PubMed - indexed for MEDLINE]

7. Blanche P, Sereni D, Sicard D, Christoforov B.
[Achilles tendinitis induced by pefloxacin. Apropos of 2 cases]
Ann Med Interne (Paris). 1992;143(5):348. French. No abstract available.
PMID: 1482040 [PubMed - indexed for MEDLINE]

8. Olivieri I, Padula A, Lisanti ME, Braccini G.
Longstanding HLA-B27 associated Achilles tendinitis.
Ann Rheum Dis. 1992 Nov;51(11):1265. No abstract available.
PMID: 1466609 [PubMed - indexed for MEDLINE]


1993

1. Spontaneous bilateral rupture of the Achille’s tendon in a renal transplant recipient
Mainard et al (Nephron 1993;65- 491-492)

2. Boulay I, Farge D, Haddad A, Bourrier P, Chanu B, Rouffy J
[Tendinopathy caused by ciprofloxacin with possible partial rupture of Achilles tendon]
Ann Med Interne (Paris). 1993;144(7):493-4. French. No abstract available.
PMID: 8141519 [PubMed - indexed for MEDLINE]


1994

1. Royer RJ, Pierfitte C, Netter P.
Features of tendon disorders with fluoroquinolones.
Therapie. 1994 Jan-Feb;49(1):75-6. No abstract available.
PMID: 8091374 [PubMed - indexed for MEDLINE]

2. Armengol S, Moreno JA, Xirgu J, Torrabadella P, Tomas R.
[Ciprofloxacin as a cause of a behavior disorder in a patient admitted into intensive care]
Enferm Infecc Microbiol Clin. 1994 May;12(5):271-2. Spanish. No abstract available.
PMID: 8049295 [PubMed - indexed for MEDLINE]

3. Donck JB, Segaert MF, Vanrenterghem YF.
Fluoroquinolones and Achilles tendinopathy in renal transplant recipients.
Transplantation. 1994 Sep 27;58(6):736-7. No abstract available.
PMID: 7940700 [PubMed - indexed for MEDLINE]

4. Onieal ME.
Achilles injuries.
J Am Acad Nurse Pract. 1994 Mar;6(3):125-6. No abstract available.
PMID: 8003362 [PubMed - indexed for MEDLINE]

5. Scioli MW.
Achilles tendinitis.
Orthop Clin North Am. 1994 Jan;25(1):177-82. Review.
PMID: 8290227 [PubMed - indexed for MEDLINE]

6. Hernandez MV, Peris P, Sierra J, Collado A, Munoz-Gomez J.
[Tendinitis due to fluoroquinolones. Description of 2 cases]
Med Clin (Barc). 1994 Sep 10;103(7):264-6. Review. Spanish.
PMID: 7934295 [PubMed - indexed for MEDLINE]

7. Achilles tenditinis and tendon rupture due to fluoroquinolone therapy
Huston et al (New England Journal of Medicene 1994 331 748)

8. Royer, R. J.; Pierfitte, C.; and Netter, P.: Features of tendon disorders with fluoroquinolones. Therapie, 49: 75-76, 1994.)

9. Dekens-Konter JA, Knol A, Olsson S, Meyboom RH, de Koning GH.
[Tendinitis of the Achilles tendon caused by pefloxacin and other
fluoroquinolone derivatives]
Ned Tijdschr Geneeskd. 1994 Mar 5;138(10):528-31. Dutch.
PMID: 8139714 [PubMed - indexed for MEDLINE]

10. Prantera C, Kohn A, Zannoni F, Spimpolo N, Bonfa M.
Metronidazole plus ciprofloxacin in the treatment of active, refractory Crohn's disease: results of an open study.
J Clin Gastroenterol. 1994 Jul;19(1):79-80. No abstract available.
PMID: 7930441 [PubMed - indexed for MEDLINE]

11. Van Linthoudt D, D'Oro A, Ott H.
[What is your diagnosis? Bilateral Achilles tendinitis associated with
quinolone treatment]
Schweiz Rundsch Med Prax. 1994 Feb 22;83(8):201-2. German. No abstract available.
PMID: 8134743 [PubMed - indexed for MEDLINE]

12. Kawada A, Hiruma M, Morimoto K, Ishibashi A, Banba H.
Fixed drug eruption induced by ciprofloxacin followed by ofloxacin.
Contact Dermatitis. 1994 Sep;31(3):182-3. No abstract available.
PMID: 7821014 [PubMed - indexed for MEDLINE]

13. Guharoy SR.
Serum sickness secondary to ciprofloxacin use.
Vet Hum Toxicol. 1994 Dec;36(6):540-1.
PMID: 7900274 [PubMed - indexed for MEDLINE]


1995

1. Hernandez Rodriguez I, Allegue F.
Achilles and suprapatellar tendinitis due to isotretinoin.
J Rheumatol. 1995 Oct;22(10):2009-10. No abstract available.
PMID: 8992016 [PubMed - indexed for MEDLINE]

2. Szarfman A, Chen M, Blum MD. More on fluoroquinolone antibiotics and tendon rupture. N Engl J Med 1995; 332: 193[Free Full Text].

3. Magnesium Deficiency Induces Joint Cartilage Lesions in Juvenile Rats which are Identical to Quinolone Induced Arthropathy
Stahlmann et al (Antimicrobial Agents and Chemotherapy, Sept., 1995 pg 2013-2018)

4. Crowder SW, Jaffey LH.
Sarcoidosis presenting as Achilles tendinitis.
J R Soc Med. 1995 Jun;88(6):335-6.
PMID: 7629765 [PubMed - indexed for MEDLINE]

5. Pierfitte C, Gillet P, Royer RJ
More on fluoroquinolone antibiotics and tendon rupture.
N Engl J Med. 1995 Jan 19;332(3):193. No abstract available.
PMID: 7800022 [PubMed - indexed for MEDLINE]

6. Szarfman A, Chen M, Blum MD.
More on fluoroquinolone antibiotics and tendon rupture.
N Engl J Med. 1995 Jan 19;332(3):193. No abstract available.
PMID: 7800023 [PubMed - indexed for MEDLINE]

7. Norfloxacin induced arthalgia
Terry et al ( J Rheumatol 1995 22 793-794)

8. Fluoroquinolone Induced Tenosynovitis of the Wrist mimicking de Quervain’s Disease
Gillet et al (British Journal of Rheumatology vol 34 no 6 pg 583-584, Feb 1995)

9. Mirovsky Y, Pollack L, Arlazoroff A, Halperin N.
[Ciprofloxacin-associated bilateral acute achilles tendinitis]
Harefuah. 1995 Dec 1;129(11):470-2, 535. Hebrew.
PMID: 8846955 [PubMed - indexed for MEDLINE]



1996

1. McGarvey WC, Singh D, Trevino SG. Partial Achilles tendon ruptures associated with fluoroquinolone antibiotics: a case report and literature review. Foot Ankle Int 1996; 17: 496-498[ISI][Medline].

2. Pierfitte C, Royer RJ.
Tendon disorders with fluoroquinolones.
Therapie. 1996 Jul-Aug;51(4):419-20. No abstract available.
PMID: 8953821 [PubMed - indexed for MEDLINE]

3. Hugo-Persson M.
[Rupture of the Achilles tendon after ciproxine therapy]
Lakartidningen. 1996 Apr 17;93(16):1520. Swedish. No abstract available.
PMID: 8667750 [PubMed - indexed for MEDLINE]

4. Therapie 1996; 51: 419-420 Tendon disorders with fluoroquinolones 421 cases have been collected by the Centre de Pharmacovigilance, 340 of tendinitis and 81 cases of tendon rupture.

5. McGarvey WC, Singh D, Trevino SG.
Partial Achilles tendon ruptures associated with fluoroquinolone antibiotics: a
case report and literature review.
Foot Ankle Int. 1996 Aug;17(8):496-8. Review.
PMID: 8863030 [PubMed - indexed for MEDLINE]

6. Skovgaard D, Feldt-Rasmussen BF, Nimb L, Hede A, Kjaer M.
[Bilateral Achilles tendon rupture in individuals with renal transplantation]
Ugeskr Laeger. 1996 Dec 30;159(1):57-8. Danish.
PMID: 9012076 [PubMed - indexed for MEDLINE]

7. Jagose JT, McGregor DR, Nind GR, Bailey RR.
Achilles tendon rupture due to ciprofloxacin.
N Z Med J. 1996 Dec 13;109(1035):471-2. No abstract available.
PMID: 9006634 [PubMed - indexed for MEDLINE]

8, Ottosson L.
[An unexpected verdict by the HSAN in a case of Achilles tendon rupture]
Lakartidningen. 1996 Dec 18;93(51-52):4712, 4715. Swedish. No abstract available.
PMID: 9011717 [PubMed - indexed for MEDLINE]

9. Castagnola C, Suhler A.
[Tendinopathy and fluoroquinolones]
Ann Urol (Paris). 1996;30(3):129-30. French.
PMID: 8766149 [PubMed - indexed for MEDLINE]

10. Foot Ankle Int. 1996 Aug;17(8):496-8.
Partial Achilles tendon ruptures associated with fluoroquinolone antibiotics: a case report and literature review.

11. Fluoroquinolone induced arthralgia and Magnetic Resonance Imaging
Loeuille et al (The Journal of Rheumatology volume 23 no 7 , July 1996)

12. Fluoroquinolone Induced Tendinopathy; Report of Six Cases
Zabraniedkl et al (The Journal of Rhuematology 1996; 23; 3)

13. Quinolone induced cartilage lesions are not reversible in rats
Forster et al (Arch Toxicol (1996) 70; 474-481)

14. Maki T, Heinasmaki T, Riutta J, Tikkanen T, Laasonen L, Eklund K.
[Bilateral Achilles tendon rupture caused by oral fluoroquinolones]
Duodecim. 1996;112(19):1818-20. Finnish. No abstract available.
PMID: 10596182 [PubMed - indexed for MEDLINE

15. ENGLAND
130 reported tendon inflammation or rupture (England, France and Belgium, 1996)
The group cited 130 reports of tendon inflammation or rupture in people who used the prescription drug in England, France and Belgium. The FDA has received at least 52 reports of patients in the U.S. who have suffered tendon damage
(from public citizens 1996 petition)
Szarfman et al. recommended that the labeling on packaging for fluoroquinolone be up-dated to include a warning about the possibility of tendon rupture. In its recommendations on the use of
this class of antibiotics, the British National Formulary
suggested that "at the first sign of pain or inflammation, patients should discontinue the treatment and rest the affected limb until the tendon symptoms have resolved."
British National Formulary. No. 32, p. 259. London, British Medical Association, Royal Pharmaceutical Society of Great Britain, 1996.
{Notice how this labeling change has not be altered since 1996 and appears to have been copied word for word in every monograph.}

16. FRANCE
921 reported tendon disorders France
340 reported tendonitis, 81 tendon ruptures 1996, WHO
Adverse drug reactions with fluoroquinolones The French system of drug surveillance has analyzed the reports of adverse drug reactions (ADRs) to fluoroquinolones since they were launched. The frequency of reactions ranges from 1/15000 to 1/208000 case per days of treatment. Cutaneous disorders and tendon disorders dominate in France, whereas cutaneous effects and neuropsychiatric disorders are predominant in the UK; tendon disorders take up only the 5th position. Among the most unexpected ADRs are the following: 1- Shock 2- Acure renal failure Tendon ruptures represent 81 cases for 921 reports of tendon disorders which are related in decreasing order to pefloxacin 1/23130 case per days of treatment, ofloxin, norfloxacin and ciprofloxacin 1/779600 case per days of treatment. Age and corticosteroids increase the risk of tendon rupture. Therapie 1996; 51; 419-420 Tendon disorders with fluoroquinolones 421 cases have been collected by the Centre de Pharmacovigilance: 340 of tendinitis and 81 of tendon rupture. These cases were attributed to Peflacine, Oflocet, Noroxine, Ciflox. Tendinitis was characterized by a bilateral malleolar oedema associated with a sudden pain. Sometimes this oedema evoked phlebitis. The tendon rupture was generally preceded by a tendinitis but in half of the cases it occurred without warning.
Source: http://www.who-umc.org/newsletter/newsltr97_1.html (sic)


1997

1. Australia. The Adverse Drug Reactions Advisory Committee first reported tendinitis in association with fluoroquinolone antibiotics in 1997. The Committee has continued to monitor this adverse reaction, and has now received 60 reports of tendinitis, tensosynovitis and/or tendon rupture in association with these drugs. Ciprofloxacin was most frequently cited (55 reports), as well as norfloxacin (4) and enoxacin (1).
Forty-five reports described tendinitis alone, one report described tensosynovitis, and 14 reports documented tendon tear or rupture. Fifty-five of the 60 reports specified the Achilles tendon, including 20 which described bilateral Achilles tendon damage. All 14 reports of tendon rupture involved the Achilles tendon. The 58 patients ranged in age from 38 to 91 years (median: 69), with no significant difference between those with tendinitis and those with tendon rupture.
The daily doses of ciprofloxacin ranged from 500 mg to 2250 mg, with 46% of patients taking 1500 mg and 46% of patients taking 1000 mg daily. For those who developed tendon rupture, 57% were taking 1500 mg daily. Time to onset varied from within 24 hours after the drug was commenced to 3 months after starting, but the majority of cases of tendinitis occurred within the first week. Time to rupture was longer with a median time of 2-3 weeks. Known risk factors for these reactions include old age, renal dysfunction and concomitant corticosteroid therapy. In the cases reported to the ADRAC, 29 reports documented concomitant corticosteroid use, and in 21 of the other 31 reports the patients were aged 69 years or older. In the reports of tendon rupture, 12 of the 14 described either concomitant steroid use (9) or old age (9).
Prescribers are reminded to be alert for this reaction and to withdraw the fluoroquinolone immediately when symptoms of tendinitis appear in order to reduce the risk of tendon rupture.
[See also Pharmaceuticals Newsletter Nos. 7&8, July&August 1997.]
Tendinitis associated with Fluoroquinolone therapy
(Pharmaceuticals Newsletters Nos 7&8 July & August 1997)
Australia

2. 93 ruptures, 103 tendinopathies, 20 tenasynovitis, 1987-1997
Source: http://www.sma.org/smj1999/junesmj99/harrell.pdf

3. Danesh-Meyer MJ.
Complicated management of a patient with rapidly progressive periodontitis: a case report.
J N Z Soc Periodontol. 1997;(82):25-9. No abstract available.
PMID: 10483437 [PubMed - indexed for MEDLINE]

4. Poon CC, Sundaram NA.
Spontaneous bilateral Achilles tendon rupture associated with ciprofloxacin.
Med J Aust. 1997 Jun 16;166(12):665. No abstract available.
PMID: 9216589 [PubMed - indexed for MEDLINE]

5. Shinohara YT, Tasker SA, Wallace MR, Couch KE, Olson PE.
What is the risk of Achilles tendon rupture with ciprofloxacin?
J Rheumatol. 1997 Jan;24(1):238-9. No abstract available.
PMID: 9002057 [PubMed - indexed for MEDLINE]

6. Movin T, Gad A, Guntner P, Foldhazy Z, Rolf C.
Pathology of the Achilles tendon in association with ciprofloxacin treatment.
Foot Ankle Int. 1997 May;18(5):297-9.
PMID: 9167931 [PubMed - indexed for MEDLINE]

7. Tendons and Fluoroquinolones; Unresolved issues
Kahn et al (Rev Rhum [Engl. Ed.] 1997 64(7-9) 437-439)
(Rev Rhum [Ed. Fr.] 1997 64(7-9) 511-513

8. Fluoroquinolones tendinitis update Australia
Tendinitis associated with Fluoroquinolone therapy
(Pharmaceuticals Newsletters Nos 7&8 July & August 1997)

9. Toxic effects of quinolone antibacterial agents on the musculoskeletal system in juvenile rats
Yoko Kashida et al (Toxicologic Pathology vol 25 number 6 pages 635-643 1997)

10. Tendinitis and tendon rupture with fluoroquinolones
ADRAC (The Achilles heel of fluoroquinolones Aust Adv Drug React Bull 1997;16;7, Szarfman et al)

11. Effects of Ciprofloxacin and Ofloxacin on adult human cartilage in vitro
(Antimicrob Agents Chemother 1997, Vol 41; issue 11; pages 2562-2565)

12. Repeated rupture of the extensor tendons of the hand due to fluoroquinolones, Apropos of a case
Levadoux et al (Ann Chir Main Memb Super 1997, vol 16, issue 2, pgs 130-133)

13. Benizeau I, Cambon-Michot C, Daragon A, Voisin L, Mejjad O, Thomine JM, Le Loet X.
Tendinitis of the tibialis anterior with histologic documentation in a patient under fluoroquinolone therapy.
Rev Rhum Engl Ed. 1997 Jun;64(6):432-3. No abstract available.
PMID: 9513620 [PubMed - indexed for MEDLINE]


1998

1. Khan KM, Cook JL, Bonar SF, Harcourt PR.
Subcutaneous rupture of the Achilles tendon.
Br J Sports Med. 1998 Jun;32(2):184-5. No abstract available.
PMID: 9631234 [PubMed - indexed for MEDLINE]

2. Stafford L, Bertouch J.
Reactive arthritis and ruptured Achilles tendon.
Ann Rheum Dis. 1998 Jan;57(1):61. No abstract available.
PMID: 9536827 [PubMed - indexed for MEDLINE]

3. Kahn MF.
Achilles tendinitis and ruptures.
Br J Sports Med. 1998 Sep;32(3):266. No abstract available.
PMID: 9773187 [PubMed - indexed for MEDLINE]

4. van der Linden PD, van Puijenbroek EP, Feenstra J, Veld BA, Sturkenboom MC, Herings RM, Leufkens HG, Stricker BH.
Tendon disorders attributed to fluoroquinolones: a study on 42 spontaneous reports in the period 1988 to 1998. Arthritis Rheum. 2001 Jun;45(3):235-9.
PMID: 11409663 [PubMed - indexed for MEDLINE]

5. Blanco Andres C, Bravo Toledo R.
[Bilateral tendinitis caused by ciprofloxacin]
Aten Primaria. 1998 Feb 28;21(3):184-5. Spanish. No abstract available.
PMID: 9607242 [PubMed - indexed for MEDLINE]

6. Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages 235-239)

7. Petersen W, Laprell H
[Insidious rupture of the Achilles tendon after ciprofloxacin-induced tendopathy. A case report]
Unfallchirurg. 1998 Sep;101(9):731-4. German.
PMID: 9816984 [PubMed - indexed for MEDLINE]

8. Voorn R.
Case report: can sacroiliac joint dysfunction cause chronic Achilles
tendinitis?
J Orthop Sports Phys Ther. 1998 Jun;27(6):436-43.
PMID: 9617730 [PubMed - indexed for MEDLINE]

9. West MB, Gow P.
Ciprofloxacin, bilateral Achilles tendonitis and unilateral tendon rupture--a case report.
N Z Med J. 1998 Jan 23;111(1058):18-9. No abstract available.
PMID: 9484431 [PubMed - indexed for MEDLINE]

10. Gabutti L, Stoller R, Marti HP.
[Fluoroquinolones as etiology of tendinopathy]
Ther Umsch. 1998 Sep;55(9):558-61. German.
PMID: 9789471 [PubMed - indexed for MEDLINE]

11. NETHERLANDS
704 achilles tendinitis, 38 ruptures 1992-1998 Netherlands
Fluoroquinolone use and the change in incidence of tendon rupture in the Netherlands
Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)
The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture
source: http://bmj.com/cgi/content/full/324/7349/1306

12. 42 spontaneous reports 1988-1998
Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages 235-239) June 2001
http://www.rheumatology.org/arhp/acnr/2001/0106.html


1999

1. Eriksson E.
In vivo microdialysis of painful achilles tendinosis.
Knee Surg Sports Traumatol Arthrosc. 1999;7(6):339. No abstract available.
PMID: 10639649 [PubMed - indexed for MEDLINE]

2. Mousa A, Jones S, Toft A, Perros P.
Spontaneous rupture of Achilles tendon: missed presentation of Cushing's syndrome.
BMJ. 1999 Aug 28;319(7209):560-1. No abstract available.
PMID: 10463901 [PubMed - indexed for MEDLINE]

3. Harrell RM.
Fluoroquinolone-induced tendinopathy: what do we know?
South Med J. 1999 Jun;92(6):622-5. Review.
PMID: 10372859 [PubMed - indexed for MEDLINE]

4. Gibbon WW, Cooper JR, Radcliffe GS.
Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis.
Br J Sports Med. 1999 Apr;33(2):129-30.
PMID: 10205697 [PubMed - indexed for MEDLINE]

5. Lewis JR, Gums JG, Dickensheets DL.
Levofloxacin-induced bilateral Achilles tendonitis.
Ann Pharmacother. 1999 Jul-Aug;33(7-8):792-5.
PMID: 10466906 [PubMed - indexed for MEDLINE]

6. Zambanini A, Padley S, Cox A, Feher M.
Achilles tendonitis: an unusual complication of amlodipine therapy.
J Hum Hypertens. 1999 Aug;13(8):565-6. No abstract available.
PMID: 10455480 [PubMed - indexed for MEDLINE]

7. van der Linden PD, van de Lei J, Nab HW, Knol A, Stricker BH.
Achilles tendinitis associated with fluoroquinolones.
Br J Clin Pharmacol. 1999 Sep;48(3):433-7.
PMID: 10510157 [PubMed - indexed for MEDLINE]

8. Van der Linden PD, van de Lei J, Nab HW, Knol A, Stricker BHCh. Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999; 48: 433-437[CrossRef][ISI][Medline].

9. 60 reported tendonitis August 1999
Fluoroquinolones tendinitis update Australia
Tendinitis associated with Fluoroquinolone therapy
(Pharmaceuticals Newsletters Nos 7&8 July & August 1997)
Australia
ADRAC Bulletin, vol 18, No 3, August 1999
Tendinitis and tendon rupture with
fluoroquinolones
The Adverse Drug Reactions Advisory Committee (ADRAC) first reported tendinitis in association with the fluoroquinolone antibiotics in 1997. The Committee has continued to monitor this adverse
reaction, and has now received 60 reports of tendinitis, tenosynovitis and/or tendon rupture in association with these drugs. Most involved was ciprofloxacin (55), but there were also reports with norfloxacin (4) and enoxacin (1). Fortyfive reports described tendinitis alone, one report described tenosynovitis, and 14 reports documented tendon tear or rupture. Fifty five of the 60 reports specified the Achilles tendon, including 20 which described bilateral
Achilles tendon damage. All 14 reports of tendon rupture
involved the Achilles tendon.
Source: http://www.who.int/medicines/library/pnewslet/pndec99.html

10. 421 reported tendon disorders and 81 tendon ruptures 1999
Therapie 1996; 51: 419-420 Tendon disorders with fluoroquinolones 421 cases have been collected by the Centre de Pharmacovigilance, 340 of tendinitis and 81 cases of tendon rupture.

11. Rev Rhum Engl Ed. 1999 Jul-Sep;66(7-9):419-21.
Suspected role of ofloxacin in a case of arthalgia, myalgia, and multiple tendinopathy.

12. Levofloxacin-induced bilateral Achilles tendonitis
Lewis JR, JG Gums, and DL Dickensheets 1999

13. Inhibition of fibroblast metabolism by a fluoroquinolone antibiotic
Williams et al (American Academy of Orthopedic Surgeons, 1999 Annual meeting, paper number 118, Geb 5, 1999)

14. Levofloxacin induced bilateral achilles tendinitis
Lewis et al (The Annals of Pharmacotherapy 1999 July/August, volume 33 pages 792-795)

15. Fluoroquinolone induced tendinopathy; what do we know?
Harrell et al (South Med J 92(6) 622-625 1999)

16. Ann Pharmacother. 1999 Jul-Aug;33(7-8):792-5.
Levofloxacin-induced bilateral Achilles tendonitis.

17. Schwald N, Debray-Meignan S.
Suspected role of ofloxacin in a case of arthalgia, myalgia, and multiple tendinopathy.
Rev Rhum Engl Ed. 1999 Jul-Sep;66(7-9):419-21.
PMID: 10526383 [PubMed - indexed for MEDLINE]


2000

1. Fluoroquinolone induced tendinopathy; also occurring with levofloxacin
Fleisch et al (Infection 28 2000 no 4 pages 256-257)

2. Infection. 2000 Jul-Aug;28(4):256-7.
Fluoroquinolone-induced tendinopathy: also occurring with levofloxacin.

3. Quinolone and Tendon Ruptures
Casperian et al (Southern Medical Journal May 2000 vol 93 no 5 pages 488-491)

4. Evaluation of toxicokinetic variables and arthropathic changes in juvenile rabbits after oral administration of an ivestigational fluoroquinolone, pd 117596
Johnson et al (AJVR vol 61 no 11, pages, 1396-1402, November 2000)

5. Rupture of the patellar ligament one month after treatment with fluoroquinolone
Rev Chir Orthop Reparatrice Appar Mot. 2000 Sep;86(5):495-7.

6. FINLAND
42 reported tendinopathies 2000
Finland:
Register of adverse drug reactions in 2000

7. The majority of ADR reports received among antibacterials concerned levofloxacin, which is a fluoroquinolone antibiotic. Fourteen of the reports were on tendinitis or rupture of the Achilles tendon. Tendinitis caused by fluoroquinolones was discussed in TABU for the first time in 1996. Since then the ADR register has received a total of 42 reports on tendinopathies caused by
fluoroquinolones, over a third of which were ruptures of the tendon.
The use of fluoroquinolones has in-creased by about 75% since 1996. Levofloxacin is responsible for the major part of this increase. It has been marketed in Finland since mid 1998.
source: www.nam.fi/uploads/english/Publications/Tabu/tabu22001_eng.pdf

8. Casado Burgos E, Vinas Ponce G, Lauzurica Valdemoros R, Olive Marques A.
[Levofloxacin-induced tendinitis]
Med Clin (Barc). 2000 Mar 4;114(8):319. Spanish. No abstract available.
PMID: 10774524 [PubMed - indexed for MEDLINE]

9. Casparian JM, Luchi M, Moffat RE, Hinthorn D.
Quinolones and tendon ruptures.
South Med J. 2000 May;93(5):488-91. Review.
PMID: 10832946 [PubMed - indexed for MEDLINE]

10. Gravlee JR, Hatch RL, Galea AM.
Achilles tendon rupture: a challenging diagnosis.
J Am Board Fam Pract. 2000 Sep-Oct;13(5):371-3. No abstract available.
PMID: 11001009 [PubMed - indexed for MEDLINE]

11. Kouvalchouk JF, Hassan E
[Achilles tendon disorders]
Tunis Med. 2000 Jun-Jul;78(6-7):462-7. Review. French. No abstract available.
PMID: 11043038 [PubMed - indexed for MEDLINE]

12. Ortiz V, Holgado S, Olive A, Fite E.
Ach illes tendinitis as the presentation form of Lofgren's syndrome.
Clin Rheumatol. 2000;19(2):169-70.
PMID: 10791635 [PubMed - indexed for MEDLINE]

13. Vavra-Hadziahmetovic N, Hadziahmetovic Z, Smajlovic F.
Phy sical therapy in conservative (functional) treatment of acute achilles tendon rupture.
Med Arh. 2000;54(2):121-2.
PMID: 10934845 [PubMed - indexed for MEDLINE]

14. Martinelli B.
Rupture of the Achilles tendon.
J Bone Joint Surg Am. 2000 Dec;82-A(12):1804. No abstract available.
PMID: 11130653 [PubMed - indexed for MEDLINE]


2001

1. Rev Clin Esp. 2001 Sep;201(9):539-40.
Achilles pain and functional impotence in a patient with chronic obstructive pulmonary disease with pneumonia. Tendon rupture caused by levofloxacin

2. Pharm World Sci. 2001 Jun;23(3):89-92.
Fluoroquinolone use and the change in incidence of tendon ruptures in the Netherlands.
van der Linden PD, Nab HW, Simonian S, Stricker BH, Leufkens HG, Herings RM.

3. Mennecier D, Thiolet C, Bredin C, Potier V, Vergeau B, Farret O.
[Acute pancreatitis after treatment by levofloxacin and methylprednisolone]
Gastroenterol Clin Biol. 2001 Oct;25(10):921-2. French. No abstract available.
PMID: 11852403 [PubMed - indexed for MEDLINE]

4. Csizy M, Hintermann B.
[Rupture of the Achilles tendon after local steroid injection. Case reports and consequences for treatment]
Swiss Surg. 2001;7(4):184-9. German.
PMID: 11515194 [PubMed - indexed for MEDLINE]

5. Adverse reactions to fluoroquinolones an overview on mechanistic aspects
De Sarro et al (Current Medicinal Chemistry 2001, 8, 371-384)

6. Fluoroquinolone use and the change in incidence of tendon rupture in the Netherlands
Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)

7. Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages 235-239)

8. 1847 reported tendinopathies December 2001
Tabelle 7
Pharmacovigilance: Meldungen von Tendinopathien im Vergleich zu allen gemeldeten unerwünschten Arzneimittelwirkungen (UAW), Stand 17. Dezember 2001.

9. Meldungen Schweiz (IKS-Datenbank) Welt (WHO-Datenbank)
Tendinopathie alle UAW Tendinopathie alle UAW
Ciprofloxacin 8 (5%) 155 649(2,2%) 29 090
Fleroxacin 9 (1,2 %) 754
Norfloxacin 1 (1%) 91 163 (2,1%) 7536
Ofloxacin 2 (6%) 34 432 (1,8%) 23 990
Levofloxacin 32 (41%) 79 576 (7,8%) 7432
Moxifloxacin 18 (4,5 %) 4030
Source: http://www.saez.ch/pdf/2003/2003-02/2003-02-694.PDF
http://www.saez.ch/pdf/2003/2003-02/2003-02-694.PDF

10. U.S. ARMED FORCES
Spontaneous Ruptures of the Achilles Tendon, US Armed Forces, 1998-2001
Methods. The Defense Medical Surveillance System was searched to identify all incident ambulatory visits of active duty servicemembers with a primary diagnosis of non-traumatic rupture of the achilles tendon (ICD-9- CM code 727.67) and other tendon ruptures (ICD-9- CM codes 727.60-727.66, 727.68-727.69) between January 1998 and May 2001.
The most striking finding of this analysis is the sudden and significant increase in rates of achilles tendon ruptures beginning in calendar year 2000. The increase was manifested across all Services and in most demographic subgroups (table 1). Rates
of non-traumatic ruptures of several other tendons also increased during the period; and increases in ruptures of the rotator cuff were comparable to those of the achilles tendon.
Source: http://amsa.army.mil/1Msmr/2002/v08_n01.pdf

11. Nuno Mateo FJ, Noval Menendez J, Suarez M, Guinea O.
[Achilles pain and functional impotence in a patient with chronic obstructive pulmonary disease with pneumonia. Tendon rupture caused by levofloxacin]
Rev Clin Esp. 2001 Sep;201(9):539-40. Spanish. No abstract available.
PMID: 11692412 [PubMed - indexed for MEDLINE]

12. Malaguti M, Triolo L, Biagini M.
Ciprofloxacin-associated Achilles tendon rupture in a hemodialysis patient.
J Nephrol. 2001 Sep-Oct;14(5):431-2. No abstract available.
PMID: 11730281 [PubMed - indexed for MEDLINE]

13. Butler MW, Griffin JF, Quinlan WR, McDonnell TJ.
Quinolone-associated tendonitis: a potential problem in COPD?
Ir J Med Sci. 2001 Jul-Sep;170(3):198-9.
PMID: 12120977 [PubMed - indexed for MEDLINE]

14. Bharani A, Kumar H.
Drug points: Diabetes inspidus induced by ofloxacin.
BMJ. 2001 Sep 8;323(7312):547. No abstract available.
PMID: 11546701 [PubMed - indexed for MEDLINE]

15. Toverud EL, Landaas S, Hellebostad M.
Repeated achilles tendinitis after high dose methotrexate.
Med Pediatr Oncol. 2001 Aug;37(2):156. No abstract available.
PMID: 11496361 [PubMed - indexed for MEDLINE]

16. Oatridge A, Herlihy AH, Thomas RW, Wallace AL, Curati WL, Hajnal JV, Bydder GM.
Magnetic resonance: magic angle imaging of the Achilles tendon.
Lancet. 2001 Nov 10;358(9293):1610-1.
PMID: 11716890 [PubMed - indexed for MEDLINE]

17. Fletcher MD, Warren PJ.
Sural nerve injury associated with neglected tendo Achilles ruptures.
Br J Sports Med. 2001 Apr;35(2):131-2.
PMID: 11273977 [PubMed - indexed for MEDLINE]

18. Humble RN, Nugent LL.
Achilles' tendonitis. An overview and reconditioning model.
Clin Podiatr Med Surg. 2001 Apr;18(2):233-54. Review.
PMID: 11417153 [PubMed - indexed for MEDLINE]

19. Eriksson E.
Achilles tendon surgery and wound healing.
Knee Surg Sports Traumatol Arthrosc. 2001 Jul;9(4):193. No abstract available.
PMID: 11522072 [PubMed - indexed for MEDLINE]

20. Speed CA.
Fortnightly review: Corticosteroid injections in tendon lesions.
BMJ. 2001 Aug 18;323(7309):382-6. No abstract available.
PMID: 11509432 [PubMed - indexed for MEDLINE]

21. Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)
The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture
source: http://bmj.com/cgi/content/full/324/7349/1306


2002

1. Ulreich N, Kainberger F, Huber W, Nehrer S.
[Achilles tendon and sports]
Radiologe. 2002 Oct;42(10):811-7. German.
PMID: 12402109 [PubMed - indexed for MEDLINE]

2. Doral MN, Tetik O, Atay OA, Leblebicioglu G, Oznur A.
[Achilles tendon diseases and its management]
Acta Orthop Traumatol Turc. 2002;36 Suppl 1:42-6. Review. Turkish. No abstract available.
PMID: 12510123 [PubMed - indexed for MEDLINE]

3. Hersh BL, Heath NS.
Achilles tendon rupture as a result of oral steroid therapy.
J Am Podiatr Med Assoc. 2002 Jun;92(6):355-8.
PMID: 12070236 [PubMed - indexed for MEDLINE]

4. [No authors listed]
Side effects of levofloxacin.
Prescrire Int. 2002 Aug;11(60):116-7. No abstract available.
PMID: 12199267 [PubMed - indexed for MEDLINE]

5. Hatori M, Matsuda M, Kokubun S.
Ossification of Achilles tendon--report of three cases.
Arch Orthop Trauma Surg. 2002 Sep;122(7):414-7. Epub 2002 May 03.
PMID: 12228804 [PubMed - indexed for MEDLINE]

6. Pouzaud F, Rat P, Cambourieu C, Nourry H, Warnet JM.
[Tenotoxic potential of fluoroquinolones in the choice of surgical antibiotic prophylaxis in ophthalmology]
J Fr Ophtalmol. 2002 Nov;25(9):921-6. French.
PMID: 12515937 [PubMed - indexed for MEDLINE]

7. Sobel E, Giorgini R, Hilfer J, Rostkowski T.
Ossification of a ruptured achilles tendon: a case report in a diabetic patient.
J Foot Ankle Surg. 2002 Sep-Oct;41(5):330-4.
PMID: 12400718 [PubMed - indexed for MEDLINE]

8. Lohrer H, Scholl J, Arentz S.
[Achilles tendinopathy and patellar tendinopathy. Results of radial shockwave therapy in patients with unsuccessfully treated tendinoses] Sportverletz Sportschaden. 2002 Sep;16(3):108-14. German. No abstract available.
PMID: 12382183 [PubMed - indexed for MEDLINE]

9. Eriksen HA, Pajala A, Leppilahti J, Risteli J.
Increased content of type III collagen at the rupture site of human Achilles tendon.
J Orthop Res. 2002 Nov;20(6):1352-7.
PMID: 12472252 [PubMed - indexed for MEDLINE]

10. Kannus P, Paavola M, Paakkala T, Parkkari J, Jarvinen T, Jarvinen M.
[Pathophysiology of overuse tendon injury]
Radiologe. 2002 Oct;42(10):766-70. German.
PMID: 12402104 [PubMed - indexed for MEDLINE]

11. Summers JB.
Importance of an accurate diagnosis for Achilles rupture.
Am Fam Physician. 2002 Nov 15;66(10):1836. No abstract available.
PMID: 12469956 [PubMed - indexed for MEDLINE]

12. Ulreich N, Huber W, Nehrer S, Kainberger F.
[High resolution magnetic resonance tomography and ultrasound imaging of the Achilles tendon]
Wien Med Wochenschr Suppl. 2002;(113):39-40. German.
PMID: 12621837 [PubMed - indexed for MEDLINE]

13. Dwornik L, Lomasney LM, Demos TC, Lavery LA.
Radiologic case study. Acute Achilles tendon rupture.
Orthopedics. 2002 Nov;25(11):1239, 1318-20. No abstract available.
PMID: 12452339 [PubMed - indexed for MEDLINE]

14. Wood ML, Schlessinger S.
Levaquin induced acute tubulointerstitial nephritis--two case reports.
J Miss State Med Assoc. 2002 Apr;43(4):116-7. No abstract available.
PMID: 11989200 [PubMed - indexed for MEDLINE]

15. McClelland D, Maffulli N.
Percutaneous repair of ruptured Achilles tendon.
J R Coll Surg Edinb. 2002 Aug;47(4):613-8. Review.
PMID: 12363186 [PubMed - indexed for MEDLINE]

16. Eriksson E.
Tendinosis of the patellar and achilles tendon.
Knee Surg Sports Traumatol Arthrosc. 2002 Jan;10(1):1. Epub 2001 Dec 18. No abstract available.
PMID: 11819012 [PubMed - indexed for MEDLINE]

17. Bleakney RR, Tallon C, Wong JK, Lim KP, Maffulli N.
Long-term ultrasonographic features of the Achilles tendon after rupture.
Clin J Sport Med. 2002 Sep;12(5):273-8.
PMID: 12394198 [PubMed - indexed for MEDLINE]

18. Majewski M, Widmer KH, Steinbruck K.
[Achilles tendon ruptures: 25 year's experience in sport-orthopedic treatment]
Sportverletz Sportschaden. 2002 Dec;16(4):167-73. German.
PMID: 12563559 [PubMed - indexed for MEDLINE]

19. Cook JL, Khan KM, Purdam C.
Achilles tendinopathy.
Man Ther. 2002 Aug;7(3):121-30. Review.
PMID: 12372309 [PubMed - indexed for MEDLINE]

20. Shukla DD.
Bilateral spontaneous rupture of achilles tendon secondary to limb ischemia: a case report.
J Foot Ankle Surg. 2002 Sep-Oct;41(5):328-9.
PMID: 12400717 [PubMed - indexed for MEDLINE]

21. Grechenig W, Clement H, Bratschitsch G, Fankhauser F, Peicha G.
[Ultrasound diagnosis of the Achilles tendon]
Orthopade. 2002 Mar;31(3):319-25. German.
PMID: 12017866 [PubMed - indexed for MEDLINE]

22. Mazzone MF, McCue T.
Common conditions of the achilles tendon.
Am Fam Physician. 2002 May 1;65(9):1805-10. Review.
PMID: 12018803 [PubMed - indexed for MEDLINE]

23. Schepsis AA, Jones H, Haas AL.
Achilles tendon disorders in athletes.
Am J Sports Med. 2002 Mar-Apr;30(2):287-305. Review.
PMID: 11912103 [PubMed - indexed for MEDLINE]

24. Fluoroquinolones and risk of Achilles tendon disorders: case-control study BMJ 2002;324:1306-1307 ( 1 June ) P D van der Linden, researcher a, M C J M Sturkenboom, assistant professor a, R M C Herings, associate professor b, H G M Leufkens, professor b, B H Ch Stricker, professor a.
a Pharmaco-epidemiology Unit, Department of Epidemiology & Biostatistics and Internal Medicine, Erasmus Medical Centre Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands, b Department of Pharmaco-epidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands

25. Pai VS, Patel N.
Atypical coronal or sagittal Z ruptures of the achilles tendon: a report of four cases.
J Foot Ankle Surg. 2002 May-Jun;41(3):183-5.
PMID: 12075907 [PubMed - indexed for MEDLINE]

26. van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HG, Stricker BH.
Fluoroquinolones and risk of Achilles tendon disorders: case-control study.
BMJ. 2002 Jun 1;324(7349):1306-7. No abstract available.
PMID: 12039823 [PubMed - indexed for MEDLINE]

27. Tiling T.
[Is an Achilles tendon rupture without degeneration possible?]
Dtsch Med Wochenschr. 2002 Jun 21;127(25-26):1401. German. No abstract available.
PMID: 12075502 [PubMed - indexed for MEDLINE]

28. Med Clin (Barc). 2003 Jan 25;120(2):78-9.
Comment on: Med Clin (Barc). 2002 Jun 8;119(1):38-9.
Levofloxacin and bilateral spontaneous Achilles tendon rupture

29. 4 cases of levaquin induced tendintis (orign spansih)
Mica magazine of Chile Issn0034-9887 versi printed
Rev. m. Chilev.130n.11Santiagonov.2002
Rev Méd Chile 2002; 130: 1277-1281
Associated aquiliana Tendinitis to the levofloxacino use:
communication of four cases
Claudius Hoops And, Claudius Flowers W, Sergio Mezzano A.
Levofloxacin associated Achilles

29. Pedros A, Emilio Gomez J, Angel Navarro L, Tomas A.
[Levofloxacin and acute confusional syndrome]
Med Clin (Barc). 2002 Jun 8;119(1):38-9. Spanish. No abstract available.
PMID: 12062009 [PubMed - indexed for MEDLINE]

30. Maffulli N, Kader D.
Tendinopathy of tendo achillis.
J Bone Joint Surg Br. 2002 Jan;84(1):1-8. Review. No abstract available.
PMID: 11837811 [PubMed - indexed for MEDLINE]

31. Sidorenko SV, Krivitskaia NS
[Use of ciprofloxacin in sequential antibiotic therapy]
Antibiot Khimioter. 2002;47(7):25-30. Review. Russian. No abstract available.
PMID: 12516193 [PubMed - indexed for MEDLINE]

32. Paavola M, Kannus P, Jarvinen TA, Khan K, Jozsa L, Jarvinen M.
Achilles tendinopathy.
J Bone Joint Surg Am. 2002 Nov;84-A(11):2062-76. Review. No abstract available.
PMID: 12429771 [PubMed - indexed for MEDLINE]

33. Roberts C, Deliss L.:
Acute rupture of tendo Achillis.
J Bone Joint Surg Br. 2002 May;84(4):620; author reply 620. No abstract available.
PMID: 12043793 [PubMed - indexed for MEDLINE]

34. Tumia N, Kader D, Arena B, Maffulli N
Achilles tendinopathy during pregnancy.
Clin J Sport Med. 2002 Jan;12(1):43-5. No abstract available.
PMID: 11854590 [PubMed - indexed for MEDLINE]

35. Paffey MD, Faraj AA.
Acute rupture of tendo Achillis.
J Bone Joint Surg Br. 2002 May;84(4):620-1; author reply 621. No abstract available.
PMID: 12043792 [PubMed - indexed for MEDLINE]

36. Chhajed PN, Plit ML, Hopkins PM, Malouf MA, Glanville AR.
Achilles tendon disease in lung transplant recipients: association with ciprofloxacin.
Eur Respir J. 2002 Mar;19(3):469-71.
PMID: 11936524 [PubMed - indexed for MEDLINE]

37. Greene BL.Physical therapist management of fluoroquinolone-induced Achilles tendinopathy.
Phys Ther. 2002 Dec;82(12):1224-31.
PMID: 12444881 [PubMed - indexed for MEDLINE]

38. Breck RW.
"Ciprofloxacin: a warning for clinicians".
Conn Med. 2002 Oct;66(10):635. No abstract available.
PMID: 12448217 [PubMed - indexed for MEDLINE]

39. Hufner T, Wohifarth K, Fink M, Thermann H, Rollnik JD.
EMG monitoring during functional non-surgical therapy of Achilles tendon rupture.
Foot Ankle Int. 2002 Jul;23(7):614-8.
PMID: 12146771 [PubMed - indexed for MEDLINE]

40. Khurana R, Torzillo PJ, Horsley M, Mahoney J.
Spontaneous bilateral rupture of the Achilles tendon in a patient with chronic obstructive pulmonary disease.
Respirology. 2002 Jun;7(2):161-3.
PMID: 11985741 [PubMed - indexed for MEDLINE]

41. Mert G.
Rupture of the Achilles tendon in athletes: do synthetic grass fields play a part?
J Bone Joint Surg Am. 2002 Feb;84-A(2):320-1. No abstract available.
PMID: 11861742 [PubMed - indexed for MEDLINE]

42. Lynch RM
Management of Achilles tendon ruptures.
Am J Sports Med. 2002 Nov-Dec;30(6):917; author reply 917-8. No abstract
available.
PMID: 12435663 [PubMed - indexed for MEDLINE]

43. Amendola N.
Surgical treatment of acute rupture of the tendo Achillis led to fewer
reruptures and better patient-generated ratings than did nonsurgical treatment.
J Bone Joint Surg Am. 2002 Feb;84-A(2):324. No abstract available.
PMID: 11861747 [PubMed - indexed for MEDLINE]

44. Zwar RB.
Utility of musculoskeletal ultrasound.
Aust Fam Physician. 2002 Jun;31(6):559, 561.
PMID: 12154604 [PubMed - indexed for MEDLINE]

45. Cottrell WC, Pearsall AW 4th, Hollis MJ.
Simultaneous tears of the Achilles tendon and medial head of the gastrocnemius muscle.
Orthopedics. 2002 Jun;25(6):685-7. No abstract available.
PMID: 12083581 [PubMed - indexed for MEDLINE]


2003

1. Journal of Antimicrobial Chemotherapy (2003) 51, 747–748
DOI: 10.1093/jac/dkg081
Advance Access publication 28 January 2003
Correspondence
Spontaneous Achilles tendon rupture in patients
treated with levofloxacin
L. J. Haddow, M. Chandra Sekhar, V. Hajela and
G. Gopal Rao

2. Manoj Kumar RV, Rajasekaran S.
Spontaneous tendon ruptures in alkaptonuria.
J Bone Joint Surg Br. 2003 Aug;85(6):883-6.
PMID: 12931812 [PubMed - indexed for MEDLINE]

3. Harris RD, Nindl G, Balcavage WX, Weiner W, Johnson MT.
Use of proteomics methodology to evaluate inflammatory protein expression in tendinitis.
Biomed Sci Instrum. 2003;39:493-9.
PMID: 12724941 [PubMed - indexed for MEDLINE]

4. Milgrom C, Finestone A, Zin D, Mandel D, Novack V.
Cold weather training: a risk factor for Achilles paratendinitis among
recruits.
Foot Ankle Int. 2003 May;24(5):398-401.
PMID: 12801195 [PubMed - indexed for MEDLINE]

5. Schwalm JD, Lee CH.
Acute hepatitis associated with oral levofloxacin therapy in a hemodialysis patient.
CMAJ. 2003 Apr 1;168(7):847-8.
PMID: 12668542 [PubMed - indexed for MEDLINE]

6. Oh YR, Carr-Lopez SM, Probasco JM, Crawley PG.
Levofloxacin-induced autoimmune hemolytic anemia.
Ann Pharmacother. 2003 Jul-Aug;37(7-8):1010-3.
PMID: 12841809 [PubMed - indexed for MEDLINE]

7. Bardin L.
Comments on 'Achilles tendinopathy'.
Man Ther. 2003 Aug;8(3):189; author reply 190-1. No abstract available.
PMID: 12909446 [PubMed - indexed for MEDLINE]

8. Ackermann PW, Li J, Lundeberg T, Kreicbergs A.
Neuronal plasticity in relation to nociception and healing of rat achilles tendon.
J Orthop Res. 2003 May;21(3):432-41.
PMID: 12706015 [PubMed - indexed for MEDLINE]

9. Gotoh M, Higuchi F, Suzuki R, Yamanaka K.
Progression from calcifying tendinitis to rotator cuff tear.
Skeletal Radiol. 2003 Feb;32(2):86-9. Epub 2002 Apr 05.
PMID: 12589487 [PubMed - indexed for MEDLINE]

10. Dalal RB, Zenios M.
The flexor hallucis longus tendon transfer for chronic tendo-achilles ruptures revisited. Ann R Coll Surg Engl. 2003 Jul;85(4):283. No abstract available.
PMID: 12908473 [PubMed - indexed for MEDLINE]

11. Joseph TA, Defranco MJ, Weiker GG.
Delayed repair of a pectoralis major tendon rupture with allograft: A case report.
J Shoulder Elbow Surg. 2003 Jan-Feb;12(1):101-4. No abstract available.
PMID: 12610495 [PubMed - indexed for MEDLINE]

12. [No authors listed]
Tendon abnormalities and hypersensitivity of levofloxacin.
Prescrire Int. 2003 Feb;12(63):20. No abstract available.
PMID: 12602391 [PubMed - indexed for MEDLINE]

13. Magnusson SP, Beyer N, Abrahamsen H, Aagaard P, Neergaard K, Kjaer M.
Increased cross-sectional area and reduced tensile stress of the Achilles tendon in elderly compared with young women.
J Gerontol A Biol Sci Med Sci. 2003 Feb;58(2):123-7.
PMID: 12586849 [PubMed - indexed for MEDLINE]

14. Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L, Taunton JE.
Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study.
Br J Sports Med. 2003 Apr;37(2):149-53.
PMID: 12663358 [PubMed - indexed for MEDLINE]

15. DY, Song JC, Wang CC.
Anaphylactoid reaction to ciprofloxacin.
Ann Pharmacother. 2003 Jul-Aug;37(7-8):1018-23.
PMID: 12841811 [PubMed - indexed for MEDLINE]

16. Ying M, Yeung E, Li B, Li W, Lui M, Tsoi CW.
Sonographic evaluation of the size of Achilles tendon: the effect of exercise and dominance of the ankle.
Ultrasound Med Biol. 2003 May;29(5):637-42.
PMID: 12754062 [PubMed - indexed for MEDLINE]

17. Cook J, Khan K.
The treatment of resistant, painful tendinopathies results in frustration for athletes and health professionals alike.
Am J Sports Med. 2003 Mar-Apr;31(2):327-8; author reply 328. No abstract available.
PMID: 12642274 [PubMed - indexed for MEDLINE]

18. [No authors listed]
Fluoroquinolones in ambulatory ENT and respiratory tract infections: rarely appropriate.
Prescrire Int. 2003 Feb;12(63):26-7.
PMID: 12602405 [PubMed - indexed for MEDLINE]

19. Matsumoto F, Trudel G, Uhthoff HK, Backman DS.
Mechanical effects of immobilization on the Achilles' tendon.
Arch Phys Med Rehabil. 2003 May;84(5):662-7.
PMID: 12736878 [PubMed - indexed for MEDLINE]

20. Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB.
Clinical diagnosis of Achilles tendinopathy with tendinosis.
Clin J Sport Med. 2003 Jan;13(1):11-5.
PMID: 12544158 [PubMed - indexed for MEDLINE]

21. Forslund C.
BMP treatment for improving tendon repair. Studies on rat and rabbit Achilles tendons.
Acta Orthop Scand Suppl. 2003 Feb;74(308):I, 1-30. No abstract available.
PMID: 12640969 [PubMed - indexed for MEDLINE]

22. Cetti R, Junge J, Vyberg M.
Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients.
Acta Orthop Scand. 2003 Feb;74(1):78-84.
PMID: 12635798 [PubMed - indexed for MEDLINE]

23. Mulvaney S.
Calf muscle therapy for Achilles tendinosis.
Am Fam Physician. 2003 Mar 1;67(5):939; author reply 939-40. No abstract available.
PMID: 12643353 [PubMed - indexed for MEDLINE]

24. Khaliq Y, Zhanel GG.
Fluoroquinolone-associated tendinopathy: a critical review of the literature.
Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review.
PMID: 12766835 [PubMed - indexed for MEDLINE]

25. Prasad S, Lee A, Clarnette R, Faull R.
Spontaneous, bilateral patellar tendon rupture in a woman with previous Achilles tendon rupture and systemic lupus erythematosus.
Rheumatology (Oxford). 2003 Jul;42(7):905-6. No abstract available.
PMID: 12826711 [PubMed - indexed for MEDLINE]

26. Gold L, Igra H.
Levofloxacin-induced tendon rupture: a case report and review of the literature.
J Am Board Fam Pract. 2003 Sep-Oct;16(5):458-60. Review. No abstract available.
PMID: 14645337 [PubMed - indexed for MEDLINE]

27. Schindler C, Pittrow D, Kirch W.
Reoccurrence of levofloxacin-induced tendinitis by phenoxymethylpenicillin therapy after 6 months: a rare complication of fluoroquinolone therapy?
Chemotherapy. 2003 May;49(1-2):90-1. No abstract available.
PMID: 12756981 [PubMed - indexed for MEDLINE]

28. de La Red G, Mejia JC, Cervera R, Llado A, Mensa J, Font J.
Bilateral Achilles tendinitis with spontaneous rupture induced by levofloxacin in a patient with systemic sclerosis.
Clin Rheumatol. 2003 Oct;22(4-5):367-8. No abstract available.
PMID: 14579169 [PubMed - indexed for MEDLINE]

29. Tomas ME, Perez Carreras M, Morillasa JD, Castellano G, Solis JA.
[Rupture of the Achilles' tendon secondary to levofloxacin]
Gastroenterol Hepatol. 2003 Jan;26(1):53-4. Spanish. No abstract available.
PMID: 12525331 [PubMed - indexed for MEDLINE]

30. Mathis AS, Chan V, Gryszkiewicz M, Adamson RT, Friedman GS.
Levofloxacin-associated Achilles tendon rupture.
Ann Pharmacother. 2003 Jul-Aug;37(7-8):1014-7.
PMID: 12841810 [PubMed - indexed for MEDLINE]

31. Aros C, Flores C, Mezzano S.[Achilles tendinitis associated to levofloxacin: report of 4 cases]
Rev Med Chil. 2002 Nov;130(11):1277-81. Spanish.
PMID: 12587511 [PubMed - indexed for MEDLINE]

32. Shah P.[Do tendon lesions occur during quinolone administration?]
Dtsch Med Wochenschr. 2003 Oct 17;128(42):2214. German. No abstract available.
PMID: 14562223 [PubMed - indexed for MEDLINE]

33. Melhus A, Apelqvist J, Larsson J, Eneroth M.
Levofloxacin-associated Achilles tendon rupture and tendinopathy.
Scand J Infect Dis. 2003;35(10):768-70.
PMID: 14606622 [PubMed - indexed for MEDLINE]

34. Cebrian P, Manjon P, Caba P.
Ultrasonography of non-traumatic rupture of the Achilles tendon secondary to
levofloxacin.
Foot Ankle Int. 2003 Feb;24(2):122-4.
PMID: 12627618 [PubMed - indexed for MEDLINE]

35. Bernacer L, Artigues A, Serrano A.
[Levofloxacin and bilateral spontaneous Achilles tendon rupture]
Med Clin (Barc). 2003 Jan 25;120(2):78-9. Spanish. No abstract available.
PMID: 12570920 [PubMed - indexed for MEDLINE]

36. Haddow LJ, Chandra Sekhar M, Hajela V, Gopal Rao G.
Spontaneous Achilles tendon rupture in patients treated with levofloxacin.
J Antimicrob Chemother. 2003 Mar;51(3):747-8. No abstract available.
PMID: 12615887 [PubMed - indexed for MEDLINE]

37. Othmani S, Battikh R, Ben Abdallah N.
[The myo-tendinopathy caused by levofloxacin]
Therapie. 2003 Sep-Oct;58(5):463-5. French. No abstract available.
PMID: 14682197 [PubMed - indexed for MEDLINE]

38. Gutierrez E, Morales E, Garcia Rubiales MA, Valentin MO.
[Levofloxacin and Achilles tendon involvement in hemodialysis patients]
Nefrologia. 2003 Nov-Dec;23(6):558-9. Spanish. No abstract available.
PMID: 15002793 [PubMed - indexed for MEDLINE]

40. Spontaneous Achilles tendon rupture in patients treated with levofloxacin
L. J. Haddow, M. Chandra Sekhar, V. Hajela and G. Gopal Rao*
Department of Microbiology, University Hospital Lewisham, Lewisham High Street, London SE13 6LH, UK 2003 The British Society for Antimicrobial Chemotherapy

41. Clinical Infectious Diseases 2003;36:1404-1410
2003 by the Infectious Diseases Society of America. All rights reserved.
Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature
Yasmin Khaliq1 and George G. Zhanel2

42. J Am Podiatr Med Assoc. 2003 Jul-Aug;93(4):333-5.
Fluoroquinolone therapy and Achilles tendon rupture.
Vanek D, Saxena A, Boggs JM.

43. Clin Rheumatol. 2003 Dec;22(6):500-1. Epub 2003 Oct 18.
Ciprofloxacin and Achilles' tendon rupture: a causal relationship.

44. Aten Primaria. 2003 Sep 15;32(4):256
Bilateral Achilles tendinitis as adverse reaction to levofloxacine.

45. Therapie. 2003 Sep-Oct;58(5):463-5.
The myo-tendinopathy caused by levofloxacin

46. Reumatismo. 2003 Oct-Dec;55(4):267-9.
Levofloxacin-induced bilateral rupture of the Achilles tendon: clinical and sonographic findings

47. Gastroenterol Hepatol. 2003 Jan;26(1):53-4.
Rupture of the Achilles' tendon secondary to levofloxacin

48. J Antimicrob Chemother. 2003 Mar;51(3):747-8.
Spontaneous Achilles tendon rupture in patients treated with levofloxacin.

49. Foot Ankle Int. 2003 Feb;24(2):122-4.
Ultrasonography of non-traumatic rupture of the Achilles tendon secondary to levofloxacin.

50. Chemotherapy. 2003 May;49(1-2):90-1.
Reoccurrence of levofloxacin-induced tendinitis by phenoxymethylpenicillin therapy after 6 months: a rare complication of fluoroquinolone therapy?

51. rupture of the Achilles tendon: clinical and sonographic findings]
Reumatismo. 2003 Oct-Dec;55(4):267-9. Italian.
PMID: 14872227 [PubMed - indexed for MEDLINE]

52. Ann Pharmacother. 2003 Jul-Aug;37(7-8):1014-7.
Levofloxacin-associated Achilles tendon rupture.

53. Clin Rheumatol. 2003 Oct;22(4-5):367-8.
Bilateral Achilles tendinitis with spontaneous rupture induced by levofloxacin in a patient with systemic sclerosis.

54. Scand J Infect Dis. 2003;35(10):768-70.
Levofloxacin-associated Achilles tendon rupture and tendinopathy.

55. Levofloxacin-associated Achilles tendon rupture and tendinopathy. Scand J Infect Dis 2003;35(10):768-70 (ISSN: 0036-5548) Melhus A; Apelqvist J; Larsson J; Eneroth M Department of Medical Microbiology, Malmo University Hospital, Malmo, Sweden. asa.melhus at mikrobiol.mas.lu.se.

56. Levofloxacin and trovafloxacin inhibition of experimental fracture-healing. Clin Orthop 2003 Sep;(414):95-100 (ISSN: 0009-921X) Perry AC; Prpa B; Rouse MS; Piper KE; Hanssen AD; Steckelberg JM; Patel R Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA.

57. Levofloxacin-associated Achilles tendon rupture. Ann Pharmacother 2003 Jul-Aug;37(7-8):1014-7 (ISSN: 1060-0280) Mathis AS; Chan V; Gryszkiewicz M; Adamson RT; Friedman GS Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA. smathis at sbhcs.com.

58. Richardson LC, Reitman R, Wilson M.
Achilles tendon ruptures: functional outcome of surgical repair with a "pull-out" wire.
Foot Ankle Int. 2003 May;24(5):439-43.
PMID: 12801203 [PubMed - indexed for MEDLINE]

59. Ultrasonography of non-traumatic rupture of the Achilles tendon secondary to levofloxacin. Foot Ankle Int 2003 Feb;24(2):122-4 (ISSN: 1071-1007) Cebrian P; Manjon P; Caba P Departamento de Radiodiagnostico, Hospital Universitario 12 de Octubre, Madrid, Spain. pcvbb at yahoo.es.

60. J Am Board Fam Pract. 2003 Sep-Oct;16(5):458-60.
Levofloxacin-induced tendon rupture: a case report and review of the literature.


2004

1. Mehra A, Maheshwari R, Case R, Croucher C.
Bilateral simultaneous spontaneous rupture of the Achilles tendon.
Hosp Med. 2004 May;65(5):308-9. No abstract available.
PMID: 15176150 [PubMed - indexed for MEDLINE]

2. Vergara Fernandez I.
[Muscle and tendon problems as a side-effect of levofloxacine: review of a case]
Aten Primaria. 2004 Mar 15;33(4):214. Spanish. No abstract available.
PMID: 15023326 [PubMed - indexed for MEDLINE]

3. McKinley BT, Oglesby RJ.
A 57-year-old male retired colonel with acute ankle swelling.
Mil Med. 2004 Mar;169(3):254-6. No abstract available.
PMID: 15080249 [PubMed - indexed for MEDLINE]

4. Fama U, Irace S, Frati R, de Gado F, Scuderi N.
Is it a real risk to take ciprofloxacin?
Plast Reconstr Surg. 2004 Jul;114(1):267. No abstract available.
PMID: 15220615 [PubMed - indexed for MEDLINE]

5. Kahn F, Christensson B.
[A rapid development of Achilles tendon rupture following quinolone treatment]
Lakartidningen. 2004 Jan 15;101(3):190-1. Swedish. No abstract available.
PMID: 14763088 [PubMed - indexed for MEDLINE]

6. Long term outcome after Fluoroquinolones tendinopathies
13/01/2004 14:11:07 P-0077
C Guy (1); Y Murat (1); MN Beyens (1); M Ratrema (1); G Mounier (1); M Ollagnier (1); (1) Centre de Pharmacovigilance, Hôpital Bellevue - CHU St-Etienne, Sant-Etienne

7. Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature. J Orthop Sci 2004;9(2):186-90 (ISSN: 0949-2658) Kowatari K; Nakashima K; Ono A; Yoshihara M; Amano M; Toh S Department of Orthopaedic Surgery, Aomori Rosai Hospital, 1 Minamigaoka, Shirogane-machi, Hachinohe 031-8551, Japan.

8. Pharmacol Exp Ther. 2004 Jan;308(1):394-402. Epub 2003 Oct 20. In vitro discrimination of fluoroquinolones toxicity on tendon cells: involvement of oxidative stress.

9. Hosp Med. 2004 May;65(5):308-9.
Bilateral simultaneous spontaneous rupture of the Achilles tendon.
Mehra A, Maheshwari R, Case R, Croucher C.

10. Therapie. 2004 Nov-Dec;59(6):653-5.
Ofloxacin-induced achilles tendinitis in the absence of a predisposition

11. An Med Interna. 2004 Mar;21(3):154.
Achilles bilateral tendonitis and levofloxacin

12. J Orthop Sci. 2004;9(2):186-90.
Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature.

13. Scand J Infect Dis. 2004;36(4):315-6.
Recurrent tendinitis after treatment with two different fluoroquinolones.

14. Joint Bone Spine. 2004 Nov;71(6):586-7. Related Articles, Links
Rupture of multiple tendons after levofloxacin therapy.
Braun D, Petitpain N, Cosserat F, Loeuille D, Bitar S, Gillet P, Trechot P.
Pneumology Department, Maillot Hospital, 54150 Briey, France.

15. Aten Primaria. 2004 Mar 15;33(4):214.
Muscle and tendon problems as a side-effect of levofloxacine: review of a case

16. Kowatari K, Nakashima K, Ono A, Yoshihara M, Amano M, Toh S.
Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature.
J Orthop Sci. 2004;9(2):186-90. Review.
PMID: 15045551 [PubMed - indexed for MEDLINE]

17. Gomez Rodriguez N, Ibanez Ruan J, Gonzalez Perez M.
[Achilles bilateral tendonitis and levofloxacin]
An Med Interna. 2004 Mar;21(3):154. Spanish. No abstract available.
PMID: 15043504 [PubMed - indexed for MEDLINE]

18. Filippucci E, Farina A, Bartolucci F, Spallacci C, Busilacchi P, Grassi W.[Levofloxacin-induced bilateral

19. Burkhardt O, Kohnlein T, Pap T, Welte T.
Recurrent tendinitis after treatment with two different fluoroquinolones.
Scand J Infect Dis. 2004;36(4):315-6.
PMID: 15198194 [PubMed - indexed for MEDLINE]


2005

1. Toxicology. 2005 May 9
Fluoroquinolones cause changes in extracellular matrix, signalling proteins, metalloproteinases and caspase-3 in cultured human tendon cells.
Sendzik J, Shakibaei M, Schafer-Korting M, Stahlmann R.

2. Arch Orthop Trauma Surg. 2005 Mar;125(2):124-6. Epub 2005 Jan 12.
Missed Achilles tendon rupture due to oral levofloxacin: surgical treatment and result.

3. An Med Interna. 2005 Jan;22(1):28-30.
Partial bilateral rupture of the Achilles tendon associated to levofloxacin

4. Expert Opin Drug Saf. 2005 Mar;4(2):299-309.
Fluoroquinolones and tendon disorders.
Melhus A.

5. Toxicology. 2005 May 9
Fluoroquinolones cause changes in extracellular matrix, signalling proteins, metalloproteinases and caspase-3 in cultured human tendon cells.
Sendzik J, Shakibaei M, Schafer-Korting M, Stahlmann R.
Institute of Clinical Pharmacology and Toxicology, Department of Toxicology, Charite-Universitatsmedizin Berlin, Campus Benjamin Franklin, Garystr. 5, 14195 Berlin, Germany; Institute of Anatomy, Department of Cell and Neurobiology, Charite-Universitatsmedizin Berlin, Campus Benjamin Franklin, Konigin-Luise-Str. 15, 14195 Berlin, Germany; Musculoskeletal Research Group, Institute of Anatomy, Ludwig-Maximilian-Universitat Munich, Pettenkoferstr. 11, 80336 Munich, Germany.

Additional references:

AUSTRALIA
THE ACHILLES HEEL OF FLUOROQUINOLONES
One of the more unusual adverse reactions known to be associated with the fluoroquinolone antibiotics is the occurrence of tendinitis. This is a serious effect since it may progress to tendon rupture with many weeks of disability as a result. Over 200 cases have been reported in the literature with the majority from France. Most members of the class including ciprofloxacin, enoxacin, ofloxacin, and norfloxacin have been implicated. The Achilles tendon is most often involved.
In Australia, there have been 25 reports of tendinitis in association with fluoroquinolones. Most (22) have been with ciprofloxacin and the other three with norfloxacin. The majority of the patients involved were elderly, ranging in age from 46 to 91 (median 69) years and the sex distribution was equal. For ciprofloxacin, daily dosages ranged from 750 mg to 2250 mg although most (13) patients were taking 1000 mg daily. For norfloxacin, all three patients were taking the usual dose of 800 mg daily. Time to onset ranged from the same day that the drug was commenced (in two patients) to two months although in 13 of the 24 reports which provided the information, the reaction occurred within the first week. Almost all (23) of the reports specified the Achilles tendon as the site of the tendinitis. Tendinitis was described as bilateral in 11 cases. Only 8 patients had recovered at the time the report was submitted and the other patients were being treated with rest and/or physiotherapy. There have been no reports of tendon rupture in Australia although in one severe case, the patient required a plaster cast up to the mid thigh.
A number of risk factors have been identified with regard to this adverse reaction. These include old age, renal dysfunction, and concomitant corticosteroid therapy. Of the patients reported to ADRAC, 72% were older than 60 years. Nine of these patients were taking corticosteroids as were three of the younger patients.
Prescribers are reminded that tendinitis, especially involving the Achilles tendon, is a rare adverse effect of the fluoroquinolones. It is more likely to occur in association with the risk factors referred to above. The antibiotic should be withdrawn immediately to reduce the risk of tendon rupture.


DUTCH
Fluoroquinolones have been associated with tendon disorders, usually during the first month of treatment,1-5 but the epidemiological evidence is scanty. We did a nested case-control study among users of fluoroquinolones in a large UK general practice database to study the association with Achilles tendon disorders.

Participants, methods, and results

We obtained data from the IMS Health database (UK MediPlus), which contains data from general practice on consultations, morbidity, prescriptions, and other interventions in a source population of 1-2 million inhabitants. The base cohort consisted of all patients aged 18 years or over who had received a fluoroquinolone. We excluded people with a history of Achilles tendon disorders, cancer, AIDS, illicit drug use, or alcohol misuse. We identified potential cases by reviewing patient profiles and clinical data and excluded tendon disorders due to direct trauma. We randomly sampled a group of 10 000 control patients from the study cohort.

We defined four categories of exposure to fluoroquinolones: current use, recent use, past use, and no use. We defined current use as when the tendon disorder occurred in the period between the start of the fluoroquinolone treatment and the calculated end date plus 30 days, recent use as when the calculated end date was between 30 and 90 days before the occurrence of the disorder, and past use as when the calculated end date was more than 90 days before the occurrence of the disorder. We used unconditional logistic regression analysis to calculate adjusted relative risks and 95% confidence intervals for Achilles tendon disorders, using the no use group as the reference. We adjusted for age, sex, number of visits to the general practitioner, use of corticosteroid, calendar year, obesity, and history of musculoskeletal disorders.

The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture. Four hundred and fifty three (61%) of the cases were women, and the mean age was 56 years. Cases visited the general practitioner significantly more often than did controls (mean 20 v 17). Cases and controls were similar with respect to indications for use of fluoroquinolone. Age, number of visits to the general practitioner in the previous 18 months, gout, obesity, and use of corticosteroid were determinants of Achilles tendon disorders. The adjusted relative risk of Achilles tendon disorders with current use of fluoroquinolones was 1.9 (95% confidence interval 1.3 to 2.6). The risk for recent and past use was similar to that for no use. The relative risk with current use was 3.2 (2.1 to 4.9) among patients aged 60 and over and 0.9 (0.5 to 1.6) among patients aged under 60 (table). In patients aged 60 or over, concurrent use of corticosteroids and fluoroquinolones increased the risk to 6.2 (3.0 to 12.8).

Relative risk of Achilles tendon disorders associated with use of fluoroquinolones according to age
Current exposure to fluoroquinolones increases the risk of Achilles tendon disorders. This finding is in agreement with a smaller study, in which we found an association between tendinitis and fluoroquinolones.5 Our results indicate that this adverse effect is relatively rare, with an overall excess risk of 3.2 cases per 1000 patient years. The effect seems to be restricted to people aged 60 or over, and within this group concomitant use of corticosteroids increased the risk substantially. The proportion of Achilles tendon disorders among patients with both risk factors that is attributable to their interaction was 87%. Although the mechanism is unknown, the sudden onset of some tendinopathies, occasionally after a single dose of a fluoroquinolone, suggests a direct toxic effect on collagen fibres. Prescribers should be aware of this risk, especially in elderly people taking corticosteroids.

Acknowledgments
We acknowledge the cooperation of IMS Health United Kingdom.
Contributors: PDvdL, MCJMS, and BHChS formulated the design of the study. PDvdL carried out the analyses. PDvdL, MCJMS, and BHChS wrote the paper, and RMCH and HGML edited it. BHChS and HGML are guarantors for the paper.

Funding:
Dutch Inspectorate for Health Care.

Competing interests:
MCJMS is a consultant for Lundbeck (France) and Beaufour (UK) and has previously been a consultant for Pfizer (USA), Roche (Switzerland), and Novartis Consumerhealth (Switzerland). MCJMS is responsible for research conducted with the integrated primary care information database in the Netherlands, which is supported by project specific grants from GlaxoSmithKline, AstraZeneca, Merck Sharp & Dohme, Pharmacia & Upjohn, Bristol-Myers Squibb, Eli Lilly, Wyeth, and Yamanouchi. MCJMS has conducted research projects on use of antibiotics for Merck & Co (USA) and Bayer (Italy).

This is far from being an all inclusive list of such medical journal entries and other such main stream documentation. Starting in 1965 and ending in 2005, almost forty years worth of such reports and the treating physician as well as the patient have no prior knowledge concerning such events. This defies logic but sadly enough this is the true state of affairs. In spite of the overwhelming evidence presented at that 62 Meeting of the Anti-Infective Drugs Advisory Committee that the fluoroquinolones cause irreversible joint damage in the pediatric population the FDA has recently added the use of Ciprofloxacin in the pediatric population, treating children as young as one years of age.

Numerous studies have indicated that such use in a pediatric patient runs the risk of crippling the child for life. Yet additional clinical trials continue aided and abetted by the FDA, for other drugs in this class other than Ciprofloxacin. A disaster that is detailed within the 62nd meeting of the Anti-Infective Drugs Advisory Committee where it was so eloquently stated:

"…when we talk about the issue of arthropathy that potentially includes a number of things, ranging from simple effusion, for instance, of a knee joint, which might rapidly resolve after the conclusion of therapy, to a more permanent disability. .." (sic)

"…in September of 1997 there is now a ciprofloxacin suspension which is available, and although it continues to have the same warning statements about arthropathy in juvenile animals and the potential concern in pediatric populations, obviously, the issue of off label use will extend over to pediatric populations in this formulation…."(sic)

"…An important safety question is, what adverse events should be monitored, and Doctor Goldberger alluded to this earlier. This is some of the examples I present. One is permanent lameness, reversible lameness, joint effusion, joint pain, and even latent articular disease or damage that may occur months or years following drug exposure, and there may be others…."(sic)

"…And, data submitted to the Agency, as well as data from the scientific literature, indicate that these lesions don't appear to be reversible…"(sic)

"…Doctor Stahlmann in Berlin is working on an idea that it may be an effect between the endocrines, the magnesium and the matrix and the quinolone. And that data is just coming out now. But as to the exact mechanism, I think you're right. I don't think we have a handle, as far as I know, on the exact mechanism. If there's anybody else that does, I'd sure like to hear it…"(sic)

"… Relating your personal experience, I was wondering about the potential for a delayed effect that in fact one might have a patient who had some histologic changes that would not be manifest clinically for many years. Is that a potential?" (sic)

"… I think it is a potential…"(sic)

"… In trying to assess toxicity with a very sensitive assay, obviously you've got tissue that you can look at in your animal models. There is some human data that were collected by Doctor Urs Schaad using MRI scanning in children and I'm wondering if you can correlate some of your histopathologic findings with MR in the animal model to give us an idea of how sensitive it would be sort of as a follow-up to Doctor Klein's question is the MR something that will be able to predict long-term outcomes, even if there are no clinical symptoms during therapy…."(sic)

"… That I don't know. I'll just be perfectly frank. I don't know. But on the slides I've seen from the animals from the chronic study, the repaired articular cartilage that is there is principally fibrocartilage yet it will provide the same joint margin and it has a calcified base and when we stain it with safrain O screen there's no proteoglycans there so it's going to make it an extremely chondromalaistic area and beyond the one year I can't tell you what the results will be…"(sic)

"…Anyway, it was by a group in Vienna where they looked at the articular cartilage of postmortem specimens of articular cartilage from kids with cystic fibrosis that had been on quinolones for a period of time and they found that there was damage in the chondrocytes…."(sic)

"…There were no deaths reported in U.S. pediatric zero to 18 year old cases where a flouroquinolone was reported as the suspect drug. However, there are eight deaths in the whole cohort of suspect and concomitant flouroquinolone drug reports in the system. Five of these deaths reported ciprofloxacin as a concomitant drug and not the suspect drug. These five were U.S. cases with ages ranging from seven months to six years. The remaining three deaths were all foreign, all 18 year old patients with either ofloxacin or norfloxacin reported as the suspect drug…."(sic)

"…There are 14 reports of arthropathy or arthralgia in the pediatric zero to 18 year old flouroquinolone reports. One report of a 14 year old girl had both ofloxacin and lomefloxacin as the suspect drug so there is an extra count because of the two flouroquinolones on this one report. This particular report indicates that a pediatric orthopedic surgeon diagnosed femoral anteversion as the cause for the girl's arthralgia, therefore you see it listed twice, and not the flouroquinolones. Most of the reports indicated that either an involved knee or elbow with or without other joints was involved…."(sic)

"…One interesting case which is not included on this slide for arthralgias was a 15 year old boy who received ofloxacin IV for an emergency appendectomy and had not grown more than his 70 inches in height over the last year. The 15th percentile for height for a 15 year old boy however is 66.5 inches and the expected growth rate is about two inches per year…"(sic)

"…Three patients had their seizure after the first dose of flouroquinolone, one on ciprofloxacin and the other two on ofloxacin, one of which had received ofloxacin several months earlier…"(sic)

"…The 15 psychiatric reports are a loose grouping of reports which include events ranging from euphoria to psychosis. The ages range from five to 18 years with the median at 15 years. There were two suicide attempts, one on ofloxacin and the other on norfloxacin, three reports of hallucination, one each on ciprofloxacin, ofloxacin and norfloxacin, and one report of aggressive behavior with confusion in a patient who had a psychiatric history and was on norfloxacin. The seven cases of photosensitivity were reported with lomefloxacin with one case on ciprofloxacin and two cases on ofloxacin. …"(sic)

"…I will mention that there were 152 U.S. cases aged zero to 18 years in the U.S. AERS system suspect flouroquinolones in the WHO line listing. The country with the most pediatric reports in the WHO foreign reports is the United Kingdom with 177 reports followed by Germany with 72 and France with 71. The rest of the countries had 20 or fewer reports…."(sic)

"…And with regards to muscular-skeletal events, 21 percent of the patients had an event in ciprofloxacin…"(sic)

"…We have focused our analysis on joint disorders and pefloxacin. 79 cases were reported and consist mainly of arthralgia. I don't know the pronunciation of hydrarthrosis -- 49 persons. It involved the knee in 52 cases, the wrist in 20 cases, the elbow in 20 cases, the shoulder in 6 cases, the ankle in 5 cases, and the hip once. It is associated with a functional discomfort in all cases, and when the duration of this discomfort is known, it can persist more than one month in 61 percent of these cases. But the outcome was favorable in 58 cases without discontinuation in two cases. …"(sic)

"…There have been sequelae in three cases with knee effusions persisting one year later in one case with discomfort following 8 months later in the second case. The third case is articular. It is a 17-year-old patient who experienced arthropathy and the drug was not suspected and the treatment was continued two following months. It leads to destructive arthropathy of the knees and the hip and prothesis was performed three years later. He was treated for a cerebral abscess. The outcome was unknown in 18 cases. In 9 cases, there was no follow-up. In the 9 last cases, we had a follow-up three months later and patients were not -- were still with disabilities and after we have no evolution…." (sic)

"… It is my understanding that one of the children had a joint replacement, is that correct?"

" Pardon me?"

" One of the children with the complications had an artificial joint replacement?"

"Yes."

"…If an irreversible cartilaginous lesion can occur, it is very likely that is going to cause problems down the line and we can't even anticipate what they are like…" (sic)


Again I state that this is for your reference & review and being made in support of my oppossing opinion that such occurences are not rare. I also take exception to the statement made that there is some kind of obligation to report such events. There is not. Such reports are done strictly on a voluntary basis and no law mandates that this be done by the treating physician. The medwatch program is voluntary and less that 3% of such events are ever reported to the FDA. A full 97% of such events never make it to the FDA. When reviewing the medwatch data base for the fluoroquinolones, joint, tendon and cartilage damage are all the top three events being reported, more so than any other adr.

In addition when a physician fails to recognize such an event it is doubtful that it would be reported. The NUMBER ONE complaint of those who have suffered such an event is the fact that the treating physician DENIES that it could possibly be the result of fluoroquinolone therapy. Any number of the tens of thousands of such victims I have discussed this issue with have reported that their physician REFUSED to make such a report, REFUSED to review the citations brought to them by their patients, and instructed their patients to stay off the internet. Even when such documentation was presented to the drug reps via pharmacafe those posting such information were ridiculed and harassed. This is not a situation I find condusive to accurate reporting of such events. It is a situation that results in false and misleading information being available to both the patient and the physician, while the true state of affairs is swept under the carpet.

Result number: 77

Message Number 184951

Re: antibiotic (quinolone) and tendons View Thread
Posted by Scott R on 10/16/05 at 10:43

Patients are 4 times more like to get tendon rupture when taking quinolone. They are 28 times more likely for it to happen if they are > 60 years old and taking ofloxacin. I think anyone taking quinolone and beginning an aggressive stretching program for plantar fasciitis should be very concerned about getting at least achilles tendonitis. Stretching the calf muscles is very unusual behavior for the general population, maybe only 1 in 20 people do it at the level that is generally recommended for plantar fasciitis. Night splints make the situation even worse. So for patients stretching for plantar fasciitis and taking quinolone, they might be 4x20=80 times more likely to have tendon rupture. The incidence of achilles tendon rupture in the general population is 0.33% of those showing up at a doctor's office. So 80x0.0033 = 0.26 which means there's a 26% chance a patient doing aggressive stretching and taking this pill will pay a return visit to the doctor for achilles tendon rupture. So I wouldn't be surprised if it's a sure bet that a patient taking this pill and stretching should count on getting simple achilles tendonitis.


Here's the reference:

Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids.

van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HM, Rowlands S, Stricker BH.

Pharmacoepidemiology Unit, Department of Epidemiology & Biostatistics and Internal Medicine, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands.

BACKGROUND: In several case reports, the occurrence of Achilles tendon rupture has been attributed to the use of quinolones, but the epidemiologic evidence for this association is scanty. METHODS: We conducted a population-based case-control study in the General Practice Research Database in the United Kingdom during the period 1988 through 1998. Cases were defined as all persons who had a first-time recording of an Achilles tendon rupture, and who had at least 18 months of valid history before the index date. As a control group, we randomly sampled 50 000 patients with at least 18 months of valid history who were assigned a random date as index date. RESULTS: We identified 1367 cases that met the inclusion criteria. The adjusted odds ratio (OR) for Achilles tendon rupture was 4.3 (95% confidence interval [CI], 2.4-7.8) for current exposure to quinolones, 2.4 (95% CI, 1.5-3.7) for recent exposure, and 1.4 (95% CI, 0.9-2.1) for past exposure. The OR of Achilles tendon rupture was 6.4 (95% CI, 3.0-13.7) in patients aged 60 to 79 years and 20.4 (95% CI, 4.6-90.1) in patients aged 80 years or older. In persons aged 60 years and older, the OR was 28.4 (95% CI, 7.0-115.3) for current exposure to ofloxacin, while the ORs were 3.6 (95% CI, 1.4-9.1) and 14.2 (95% CI, 1.6-128.6) for ciprofloxacin and norfloxacin, respectively. Approximately 2% to 6% of all Achilles tendon ruptures in people older than 60 years can be attributed to quinolones. CONCLUSIONS: Current exposure to quinolones increased the risk of Achilles tendon rupture. The risk is highest among elderly patients who were concomitantly treated with corticosteroids.

Result number: 78

Message Number 184818

Re: to Dr. Goldstein View Thread
Posted by Dr. David S. Wander on 10/14/05 at 19:39

Dr. Goldstein,
There's no reason to become so defensive when confronted with legitimate questions. You are not a "pioneer" of crysurgery in this country. Do a search on the web and you'll find many doctors claiming to be the "only doctor" in their geographic area performing cryosurgery. It is a promising new therapy, just as ESWT and EPF were when first introduced. Every procedure has it's indication. And unfortunately, for a true blinded study to be legitimate, some patients will have to have a "sham" procedure performed, just as some patients are given a placebo. No one is proposing that you perform that study. However, there is no procedure that will withstand critics without SOME form of study. When the EPF procedure was introduced everyone jumped on it as being the new cure for heel pain, then ESWT came along and now we're seeing that although ESWT is a great non invasive modality, it's not the cure all. Cryosurgery certainly is also an excellent procedure to add to our armamentarium, but first I believe we all need to learn a little more about it's long term results. You've come onto this website, solicited patients to your website, made very strong claims of success, so are you surprised that some of us are asking questions??? Don't be so defensive, just be professional.

Result number: 79

Message Number 184793

Re: to Dr. Goldstein View Thread
Posted by Dr. David S. Wander on 10/14/05 at 16:13

I agree with Dr. Davis 100%. Many of these cases may have been mis-diagnosed in the first place. The success rates that Dr. Goldstein reports are very high. 97% success rates are a very high number. After visiting Dr. Goldstein's website I see that he has written a few papers regarding cryotherapy. Writing papers and publishing studies are quite different. Reporting results of success rates of 97% versus published blinded studies of results may vary. I would be very interested to see published data of blinded studies regarding cryotherapy and it's use on neuroma's, plantar fasciitis, etc. I sincerely believe that this is a valuable modality, and would like to see statistics that are scientifically validated, not simply reported.

Result number: 80

Message Number 183334

Re: Bi-lateral Tarsal Tunnel Symdrome View Thread
Posted by brenda s on 9/22/05 at 04:20

As the saying goes "Don't complain until you have walked in my shoes". Anyone with TTS knows how what that means. IT HURTS NO MATTER WHAT YOU DO!! I am thankful for this website and all the different information I am reading. Thanks to all for info and for listening to me complain. I know what worse could be. I have a sister who is totally bedridden from a brain tumor and disease called von Hippel Lindeau. She can only move her left arm and head. Her husband waits on her hand and foot. She cannot talk any longer or hear good. Her eyesight is going. She has the faith of the grain of a mustard seed and always is smiling. She has been sick since 1971. I always think about her when I get to crying with my feet hurting and burning so bad. Then I cry about her. Oh well. God bless.

Result number: 81
Searching file 17

Message Number 178888

Re: ESWT after procdure pain/recovery timeline View Thread
Posted by Dr. Z on 7/22/05 at 20:42

Foot and Ankle

The Safety and Efficacy of High Energy Extracorporeal Shock Wave Therapy in Active, Moderately Active, and Sedentary Patients

By John P. Furia, MD
ORTHOPEDICS 2005; 28:685

July 2005

Extracorporeal shock wave therapy was investigated in patients with chronic plantar fasciitis. Fifty-three patients (60 heels) were treated with a single session of shock wave therapy. Sixteen patients (19 heels) were active, 21 (22 heels) were moderately active, and 16 (19 heels) were sedentary. Twelve weeks post-treatment, mean visual analog scores improved from 9.2 to 2.4 (P<.05), RAND-Physical Functioning score improved from 40.4 to 91.5 (P<.05), and RAND-Pain score improved from 33.3 to 90 (P<.05). Fifty heels (83.3%) were assigned an excellent or good result. Extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis.

Plantar fasciitis is the most common cause of inferior heel pain. It is estimated that plantar fasciitis occurs in approximately two million Americans per year,1 and it is the most common foot condition seen by most foot and ankle surgeons.2 The disorder frequently occurs in athletes3-5 but also afflicts sedentary individuals, particularly middle-aged women.6-8 Men and women are affected equally.7,8 Symptoms are bilateral in .10% of cases.2 The exact etiology is unknown.

Plantar fasciitis is characterized by pain on the bottom of the heel, particularly with the first steps in the morning and when weight bearing is resumed after sitting.9-12 The pain usually persists and often becomes worse with activities of daily living. Physical examination almost always reveals tenderness over the fascia. Pain is aggravated by dorsiflexion of the toes.

Radiographs frequently reveal a heel spur on the inferior surface of the calcaneus.10,11 The heel spur may be an incidental finding as heel spurs also have been noted in 10% to 27% of asymptomatic individuals.2,13

Most physicians agree that acute plantar fasciitis often will respond to traditional nonoperative measures6,8,14-16; however, approximately 20%-30% of those patients treated with traditional measures progress to a chronic condition.17 Martin et al17 reviewed a large number of reports of nonoperative treatment of plantar fasciitis and showed a wide range of acceptable outcomes ranging from 44% to 82% of patients who obtained complete pain relief.

There is no consensus as to the best method of treatment.8,15,16,18 Traditional measures include relative rest, ice, massage, stretching of the plantar fascia and Achilles tendon, anti-inflammatory medications, taping, shoe modification, orthotics, and night splints.

Steroid injections into the painful fascia may be helpful but are not without risk. Steroid injections often are associated with recurrence of symptoms, and the effect usually is temporary.19,20 Steroid injections may cause infection, fat pad atrophy, and complete plantar fascia rupture.19,20

Surgical treatment of chronic plantar fasciitis with either open or endoscopic partial plantar fascia release is an option for those who fail to respond to nonoperative measures.8,21-23 Surgical intervention is invasive, has inherent morbidity, and can produce inconsistent results.8,22

Extracorporeal shock wave therapy is a byproduct of renal lithotripter technology. Extracorporeal shock wave therapy has been used in Europe since the 1980s to treat a litany of orthopedic conditions including lateral epicondylitis, shoulder calcific tendinitis, Achilles tendinitis, and nonunion of fractures of long bones.24-32

In 1996 Rompe et al10 reported on their favorable experience using shock wave therapy to treat chronic plantar fasciitis. Since that time many investigators have substantiated these results.5,11,33-42

Extracorporeal shock wave therapy is approved by the United States Food and Drug Administration (FDA) for the treatment of chronic plantar fasciitis and chronic lateral epicondylitis. A meta-analysis of the current published literature on the relationship between shock wave therapy and chronic plantar fasciitis revealed that the application of shock wave therapy to the enthesis of the plantar fascia is a safe and effective method to treat chronic plantar fasciitis.43 The authors suggested that shock wave therapy should be considered prior to surgical intervention.43 Several recent studies, however, have questioned the efficacy of shock wave therapy for the treatment of chronic tendinopathies.44-46

This study examined the effects of extracorporeal shock wave therapy on patients with chronic plantar fasciitis treated by the same investigator (J.P.F.) in a rural, community setting to determine if there was a difference in outcome between active, moderately active, and sedentary individuals. The hypothesis was that extracorporeal shock wave therapy would be an effective treatment for each patient.

Materials and Methods
From June 2002 to June 2003 all patients treated by the primary investigator for chronic plantar fasciitis were considered for evaluation. Inclusion criteria included patients with an established diagnosis of chronic plantar fasciitis for at least six months prior to treatment who had failed at least three forms of traditional nonoperative treatment. For this study, chronic fasciitis was defined as symptoms of moderate to severe heel pain in the involved foot at the origin of the proximal plantar fascia on the medial calcaneal tuberosity. Traditional nonoperative treatments consisted of rest, anti-inflammatory medications, heel cups, orthotics, stretching, night splints, physical therapy, and steroid injections.

Exclusion criteria included rheumatoid arthritis, generalized polyarthritis, Reiter’s syndrome, local infection, pregnancy, patients with bleeding disorders, patients with tumors, patients aged <18 years, patients with severe endocrine disease, and patients with advanced peripheral vascular disease. Patients with a history of spontaneous or steroid-induced plantar fascia rupture and patients with a history of previous plantar fascial surgery also were excluded.

For the purposes of this study "active" lifestyle was defined as one in which the patient regularly participated in some form of aerobic fitness activity approximately three hours per week. Patients were assigned an "active" designation if their work required extensive physical activity such as manual labor or heavy factory work

A "moderately active" lifestyle was defined as one in which the patient exercised <3 hours per week. Patients also were assigned a "moderately active" designation if their work required regular, moderate physical activity such as nursing or restaurant work. A "sedentary" lifestyle was defined as one in which the patient did not exercise or worked in a sedentary profession.

All patients signed an informed consent form. The details of the procedure and potential risks were discussed fully before treatment. The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 1983.

All treatments were performed on an outpatient basis. Patients were anesthetized in a pre-treatment holding room using a combined tibial and sural nerve block with 1% lidocaine. A blood pressure cuff was applied to their right arm. They were positioned in the lateral decubitus position with a pillow between their knees and with their affected foot resting on the target head. A coupling gel was applied to their heel, and the ultrasound was used to focus on the area of intended treatment. The patient's vital signs and local discomfort were monitored by a registered nurse throughout the procedure.

The extracorporeal shock wave therapy was applied using the Dornier Epos lithotripter (Dornier MedTech Inc, Kennesaw, Ga) by following the protocol used in the FDA clinical trials.33,45 The Dornier Epos uses an electromagnetic coil to generate shock waves47 and the shock waves are focused using a lens. Shock wave application was applied to the area of maximal tenderness as based on the physical examination, and guided using ultrasound.

A standard protocol was used for application of shock waves. Each patient received a single treatment using a total of 3800 shocks for a total energy flux density of 1300 mJ/mm2. Fifty shocks were given at each power level from one through six for a total of 300 shocks. The final 3500 shocks were given at power level seven (0.36 mJ/mm2), which makes this a high-energy treatment. Frequency of shock wave application was increased from 60 shocks/minute at power level one to 240 shocks/minute at power level seven.

Upon completion of the procedure the treated heel was assessed for hematoma, bruising, and swelling. The patients were discharged from the same day holding area with instructions to ice and stretch their heels. No patient received narcotics or other forms of prescription medications. No other co-interventions were used, but patients were told to continue using their orthotics if they had used them regularly prior to treatment.

The follow-up examinations were scheduled at 4 and 12 weeks post-treatment. All patients were contacted via a telephone survey. Outcome measures included visual analog scores, RAND-Physical Functioning scores, RAND-Pain scores, Roles and Maudsley scores, and a subjective assessment of overall satisfaction with the procedure.

Visual analog scores were collected pre-treatment, 4 weeks post-treatment, and 12 weeks post-treatment. On the visual analog scale 10 points indicated severe pain and zero points indicated no pain. The values of the scores pre-treatment and at 4 and 12 weeks post-treatment were compared statistically using a paired t test with a statistical significance at P<.05.

The RAND-36 -Item Health Survey scores (Physical Functioning and Pain) were collected pre-treatment, 4 weeks post-treatment, and 12 weeks post-treatment. The RAND-36-Item Health Survey score is a validated instrument for the assessment of health concepts.48 The RAND-Physical Functioning score ranges from 100, indicating perfect physical functioning, to zero, indicating severe loss of physical functioning.48 The RAND-Pain score ranges from 100, indicating absence of pain, to zero, indicating severe pain.48 The values of the scores pre-treatment and at 4 and 12 weeks post-treatment were compared statistically using a paired t test with a statistical significance at P<.05.

The Roles and Maudsley scale49 is a subjective four-point rating scale that has been used by many investigators when reporting results of shock wave therapy.5,11,36 On the scale, one point was defined as an excellent result with the patient having no symptoms. Two points was defined as a good result with the patient significantly improved from the pre-treatment condition and satisfied with their result. Three points was defined as a fair result with the patient somewhat improved from their pre-treatment condition and partially satisfied with their treatment outcome. Four points indicated a poor outcome with symptoms identical or worse than their pre-treatment condition and with dissatisfaction with the treatment result.

At 12 weeks post-treatment patients were asked if they were pleased with their overall result, and, if they had the condition again, would they elect to undergo the procedure. The results of both questions were recorded as yes or no.

Statistical analysis was performed using the paired student t test for comparison of the outcome variables. The significance level was <.05.

Results
A total of 56 patients (65 heels) were treated during the study. All but three patients were assessed by the primary investigator after treatment, and all patients were contacted by telephone three months after treatment. One patient did not return for follow-up. The other two patients were unable to return for a follow-up evaluation. Both of these patients had a bilateral procedure. Thus, after three months, 53 (34 women and 19 men) patients representing 60 heels were available for analysis. The average patient age was 47.7 years (range: 31-71 years). Seven patients underwent bilateral treatments. The average duration of the condition was 22 months (range: 9-120 months) for the entire group.

Visual Analog Scale
The mean pre-treatment visual analog score for the entire group was 9.2±0.7. Four weeks after treatment the VAS score decreased to 3.4±1.9. This difference was statistically significant (P<.05) (Figure 1).


Figure 1: The difference in mean visual analog score pre-treatment and four weeks post-treatment was statistically significant (P<.05).


Twelve weeks after treatment the VAS score decreased to 2.4±1.8. The difference between pre-treatment and 12 week post-treatment VAS scores was statistically significant (P<.05) (Figure 2).


Figure 2: The difference in mean visual analog score pre-treatment and 12 weeks post-treatment was statistically significant (P<.05).


RAND Score-Physical Functioning
The mean pre-treatment RAND-Physical Functioning score for the entire group was 40.4±1.3. Four weeks after treatment the RAND-Physical Functioning score increased to 91.5±11.5. This difference was statistically significant (P<.05).

Twelve weeks after treatment the RAND-Physical Functioning score was 91.5±10.6. The difference between pre-treatment and 12 week post-treatment RAND-Physical Functioning scores also was statistically significant (P<.05).

RAND Score-Pain
The mean pre-treatment RAND-Pain score for the entire group was 33.3±11. Four weeks after treatment the RAND-Pain score increased to 88.6±16. This difference was statistically significant (P<.05).

Twelve weeks after treatment the RAND-Pain score increased to 90±11.6. The difference between pre-treatment and 12 week post-treatment RAND-Pain scores also was statistically significant (P<.05).

Roles and Maudsley Score
Pre-treatment all patients rated the condition of the affected heel as “4” (poor) in the subjective four point Roles and Maudsley scale. Four week post-treatment, 34 (56.7%) heels were rated as “1” (excellent), 15 (25%) heels were rated as “2” (good), and 7 (11.6 %) heels were rated as “3” (fair), and 4 (6.7%) heels rated as “4” (poor or unchanged).

Twelve week post-treatment 36 (60%) heels were rated as “1” (excellent), 14 (23.3%) heels were rated as “2” (good), and 6 (10%) heels were rated as “3” (fair). There were 4 (6.7%) heels rated as “4” (poor or unchanged) (Table 1). No patient reported a worsening of symptoms compared to pre-treatment.

Table 1
Patients With Excellent, Good, Fair, and Poor Results 4 and 12 Weeks Post-Treatment*
No. (%)
--------------------------------------------------------------------------------

4 Weeks Post-Treatment 12 Weeks Post-Treatment

Excellent 34 (56.7) 36 (60)
Good 15 (25) 14 (23.3)
Fair 7 (11.6) 6 (10)
Poor 4 (6.7) 4 (6.7)

*Roles and Maudsley Scores, N=60 heels.


Patient Satisfaction
Four weeks post-treatment, 49 (82%) patients reported that they were satisfied with their procedure and all 49 patients reported that they would undergo the procedure again. Twelve weeks post-treatment the same 49 (82%) patients reported that they were satisfied with their procedure and all 49 patients reported that they would undergo the procedure again.

Subgroups
There were 16 patients who were designated as having an “active” lifestyle. Mean VAS, RAND-Physical Functioning, and RAND-Pain scores 12 weeks post-treatment were 2.7±1.6, 90±11.3, and 87.6±11.2 respectively (Table 2). There were 21 patients who were designated as having a "moderately active" lifestyle. Mean VAS, RAND-Physical Functioning, and RAND-Pain scores 12 weeks post-treatment were 2.3±1.8, 92.3±10.4, and 91±11 respectively (Table 2).

Table 1
Mean VAS, RAND-Physical Functioning, and RAND-Pain Scores 12 Weeks Post-treatment
Scores
--------------------------------------------------------------------------------

Visual Analog RAND-Physical Activity RAND-Pain

Active 2.7±1.6 90.0±11.3 87.6±11.2
Moderately active 2.3±1.8 92.3±10.4 91.0±11.0
Sedentary 2.2±1.5 92.5±10.5 91.7±13.4
Total group 2.4±1.6 91.5±10.6 90.0±11.6



There were 16 patients who were designated as having a "sedentary" lifestyle. Mean VAS, RAND-Physical Functioning, and RAND-Pain scores 12 weeks post-treatment were 2.2±1.5, 92.5±10.5, and 91.7±13.4 respectively (Table 2). Although the values of the VAS, RAND-Physical Functioning, and RAND-Pain scores for "active," "moderately active," and "sedentary" patients were similar, there were not enough patients in each subgroup to make statistically significant comparisons between the three subgroups.

A few minor complications were noted, all of which were temporary and that resolved spontaneously with minimal treatment. Two patients had pain for approximately one week after the treatment. The pain subsequently resolved without the use of prescription medication. One patient had pain during treatment that prolonged the procedure by approximately 15 minutes. One patient developed mild bruising at the site of the local injection. The bruising resolved without treatment 48 hours after the procedure.

Discussion
The plantar fascia is a broad, thick structure that originates from the medial calcaneal tuberosity and inserts on the plantar plates of the metatarsalphalangeal joints and proximal phalanges.50,51 The plantar fascia supports the medial longitudinal arch of the foot.50,51

Although the exact pathogenesis of plantar fasciitis remains unclear, it has been hypothesized that excessive stress on the plantar fascia can result in microtears at its origin.52 An inflammatory reaction is incited that then leads to a degenerative process.44,52 Biopsies of diseased plantar fascia reveal fibroblastic proliferation and chronic granulomatous tissue.52 The diseased fascia becomes thickened, from a normal 3.0-mm thickness to as much as 15.0-mm of thickness.52 Decreased vascularity, loss of normal elasticity, and alterations of nociceptor function may all contribute to the onset and persistence of this condition.3,4

Prior to 1996, failure of nonoperative treatment often led to surgical intervention. Some investigators have reported favorable results with plantar fasciitis surgery23; however, several recent studies have demonstrated that, despite improvement in symptoms, a prolonged recovery time and persistent pain were not uncommon.53-58 Davies et al53 reported that <50% of patients treated with chronic heel pain were completely satisfied with the results of surgery.

Several lithotripsy devices have been approved by the FDA for the treatment of various musculoskeletal conditions. Two of the devices, including the Dornier Epos used in this study, generate the shock waves using electromagnetic energy; one device uses electrohydraulic energy.12 Comparison studies of devices used for musculoskeletal lithotripsy have not been performed.

Extracorporeal shock wave therapy is an emerging technology and protocols vary from trial to trial. The different delivery modes of shock waves—single treatment versus multiple treatments, low energy shock waves (often defined as energy levels between 0.05-0.10 mJ/mm2) versus high energy shock waves, electrohydraulic versus electromagnetic methods of generating the shock waves—all can influence the outcome of therapy. For this reason, the results reported in a study are only valid for the parameters applied in that study.

In a prospective single-blinded pilot study, Rompe et al10 in 1996 reported a significant alleviation of pain and improved function in 30 patients treated with low-energy shock wave therapy for chronic plantar fasciitis. Follow-up was 24 weeks. Maier et al36 reported 75% good or excellent results in 48 heels 29 months after shock wave therapy. These investigators noted that clinical outcome was not influenced by length of follow-up.

Ogden et al39 used a very rigid success criteria to determine efficacy of shock wave therapy for patients with chronic plantar fasciitis. Patients were assigned a success or failure status according to four criteria: a minimum of 50% improvement in investigator assessment of pain, a minimum of 50% improvement in a patient’s self-assessment of pain, an improvement of a patient’s assessment of physical activity, and lack of use of pain medication between 10 and 12 weeks after treatment.39 Each patient had to meet all four outcome criteria to be considered a success. Twelve weeks after treatment 47% of treated patients met all four success criteria compared to only 30% of patients who received sham treatment.39 This difference was statistically significant. Approximately 76% of treated patients were satisfied with their outcome, even when pain relief was not complete.39

Buch et al33 reported the results of another multicenter prospective randomized double blind placebo controlled trial. These investigators followed the identical protocol used in the present study. After 12 weeks 61% of the treated patients met all success criteria compared to 40% of the placebo group.33

Chen et al16 reported on 80 patients treated with high-energy shock wave therapy for chronic plantar fasciitis. At 24 week follow-up, 86% were either symptomatic or significantly improved. Hammer et al35 reported on their experience using high-energy shock wave therapy to treat 47 patients (49 heels) with chronic plantar fasciitis. Approximately 80% of patients experienced complete or nearly complete pain relief at six months post-treatment.35

Wang et al41 demonstrated 80% satisfactory results in their cohort of patients with chronic plantar fasciitis treated with shock wave therapy. These investigators noted a positive cumulative effect from 6 to 12 weeks post-treatment.41 In a second study with longer follow-up, these same investigators noted that shockwave therapy for patients with chronic plantar fasciitis provided 94% complete or nearly complete resolution of pain.34

Rompe et al5 demonstrated similar findings. In their cohort of 45 running athletes with chronic plantar fasciitis treated with low-energy shock wave therapy, visual analog scores decreased from an average of 6.9 to 2.1 24 weeks after treatment and from 6.9 to 1.5 one year after treatment.

In another report with longer follow-up, Rompe et al11 noted that patients with chronic plantar fasciitis treated with shock wave therapy had progressive diminution of pain on manual pressure over a five-year period. The mean score for pain on manual pressure gradually decreased from 77 points (before treatment) to 19 points (at six months post-treatment) to 9 points (at five years post-treatment).11 In controls, the mean scores were 79 points before treatment, 77 points at six months, and 29 points at five years post-treatment.11

The results from this study add to the growing number of favorable reports that substantiate the efficacy of extracorporeal shock wave therapy as an effective treatment for chronic plantar fasciitis. Mean VAS, RAND-physical functioning, and RAND-pain scores were statistically improved at one and three months following treatment. The percentage of excellent or good results using the Roles and Maudsley score at 12 weeks post-treatment was 83.3%. There were no significant complications and no patient required additional shock wave treatment. Subjectively, patients were very satisfied with the procedure.

Two patient cohorts seem to have a particularly high incidence of plantar fasciitis: obese middle-aged women and young athletic men.8,36,39 This is the first report that examined the relationship between activity level and outcome after extracorporeal shock wave therapy. Although the outcome parameters among “active,” “moderately active,” and “sedentary” patients were similar, the relatively small number of patients prevented meaningful comparisons among the subgroups. Larger prospective studies are necessary to better define the role of extracorporeal shock wave therapy in these groups of patients.

Recent reports have shown that extracorporeal shock wave therapy was ineffective in the treatment of chronic plantar fasciitis. In a double-blind, randomized study from Australia, Buchbinder et al44 reported no statistically significant difference in the degree of improvement between the extracorporeal shock wave therapy treated group and a placebo group. In a German trial, Haake et al45 also reported no difference between the extracorporeal shock wave therapy treated group and a placebo group. Speed et al46 reported that a moderate dose of shock wave therapy (1500 impulses of 0.12 mJ/mm2, given monthly for three months) resulted in a 37% improvement in the extracorporeal shock wave therapy group and 24% improvement in the sham group with respect to pain.

There were some important differences between these negative studies and the present study. In the Buchbinder et al study,44 shock wave therapy was given in smaller doses, weekly, for three weeks.44 In the Haake et al study,45 shock wave therapy was applied every 2 weeks ±2 days (3 doses of 4000 impulses). In the Speed study,46 shock wave therapy was given each month for three months. In this study, shock wave therapy was given in a single, larger dose.

In the Buchbinder study,44 the total calculated dose of shock waves administered to each treated patient was different. In this study, each patient received the same dose.

In regards to inclusion criteria, patients were enrolled in the Buchbinder et al study if they were symptomatic for at least six weeks.44 Patients were enrolled in the Speed et al study46 if they were symptomatic for three months. In this study, patients were only treated with shock wave therapy if they were symptomatic for a minimum of six months. In this author’s experience, those patients with less chronic symptoms (<6 months) are likely to improve whether or not they have extracorporeal shock wave therapy.

The treatment parameters in the Speed et al46 study (1500 pulses of 0.12 mJ/mm2, given in several doses over a period of several months) are very different from the treatment parameters used in this study. The protocol in the Speed et al study used a “moderate-energy” dose of shock waves whereas a “high-energy” dose was used in this study.

We believe that the results of extracorporeal shock wave therapy are only valid for the therapeutic parameters applied. Patient selection and treatment technique (adequate number of shocks, adequate total dose) are critical. Differences in results between different trials may be related to heterogeneity of treatment parameters (total dose, interval of time between doses, number of sessions, etc), study populations (rural versus university), and perhaps machine design. Further work is needed to clarify these issues.

This study is retrospective and as such has some inherent weaknesses. This series represents a relatively large number of patients considering that patients were derived from a rural, community setting. However, when considering the number of patients in each subgroup, the absolute numbers are relatively small. The length of follow-up was only three months, however, a positive effect was already evident at this time. Other larger studies have used a similar length of follow-up.39,41,44 Finally, this study did not use a control group.

Nonetheless, this series contributes valuable information. The data from this study demonstrates that extracorporeal shock wave therapy is a safe and effective procedure that can be used to treat patients with chronic plantar fasciitis. The procedure is reliable and enjoys a high rate of patient satisfaction.

Conclusion
The results of the current study revealed beneficial effects of extracorporeal shock wave therapy in patients with chronic plantar fasciitis. Unlike surgery for plantar fasciitis, which bears a higher risk of complications, recovery from shock wave therapy generally occurs without significant morbidity. Our results show that this procedure can be an excellent treatment option. Further prospective work is underway to better define this emerging technology.

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Authors
Dr Furia is from SUN Orthopedics and Sports Medicine, Lewisburg, Pa.

Reprint requests: John P. Furia, MD, SUN Orthopedics and Sports Medicine, 900 Buffalo Rd, Lewisburg, PA 17837.




· Experts discuss what to expect after ankle surgery (Jul. 2005)
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· How top surgeons treat arthritis (May. 2005)

Result number: 82

Message Number 178274

Re: Complete list of ESWT research- the rest View Thread
Posted by Ed Davis, DPM on 7/12/05 at 20:45

List of publications from ismst.com website, July, 2005
Author Title Year Publisher
Ackaert KS, Schröder FH Effects of extracorporeal shock wave lithotripsy (ESWL) on renal tissue. 1989 Urological Research, 17: 3-7
Alvarez R. Preliminary results on the safety and efficacy of the OssaTron for treatment of plantar fasciitis. 2002 Foot Ankle Int 2002;23:197-203
Amelio E, Cugola L Acute and chronic tendon pathology in athlete 2000 3rd Congress of the ISMST - Naples, Abstracts:81
Amini A, Hafez M, Zhou S, Garcia E, Coombs R Shockwave Treatment for Chronic Non-union 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 159-164
Ammendolia A, Perticone L, Milano C Chronic shoulder articular pain: treatment by extracorporeal shockwaves 2000 3rd Congress of the ISMST - Naples, Abstracts:19
Ape A, Bosco V, Buselli P, Coco V, Gerardi A, Saggini R A retrospective, multi-centre experience report of shock wave therapy on epicondylitis 2000 3rd Congress of the ISMST - Naples, Abstracts:35-36
Apfel RE Acoustic cavitation. 1981 Methods of experimental physics, vol. 19, P. Edmonds ed., Academic Press New York: 355-411
Arbeitsgruppe "Orthopädische Stosswellenbehandlungen" Standortbestimmung 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 137-142
Arbeitsgruppe "Technische Entwicklungen" Standortbestimmung 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 15-20
Assenza, Buselli P, Chiacchio C, Pozzolini M, Scrocca M, Saggini R A retrospective, multi-centre experience report of shock wave therapy on rotator cuff tendonitis with calcific deposit 2000 3rd Congress of the ISMST - Naples, Abstracts:25
Auersperg V, Labek G, Böhler N Correlations Between Length of History and Outcome 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 37-42
Augat P, Claes L, Suger G In vivo effects of shock waves on the healing of fractured bone. 1995 Clin. Biomechan., 10: 374-378
Baloglu I, Aydinok H, Lök V Our results of the ossatherapy for treatment of pseudoathrosis 2000 3rd Congress of the ISMST - Naples, Abstracts:56
Baloglu I, Lök V Shockwave Therapy for Plantar Fasciitis 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 51-52
Bao S, Thrall BD, Miller DL Transfection of a reporter plasmid into cultured cells by sonoporation in vitro. 1997 Ultrasound in Medicine & Biology, 23: 953-959
Baumann J, Baumann J Treatment of neuromuscular dysfunction in children with spastic cerebral palsy by extracorporeal unfocused shock waves. 1997 Siebert W, Buch M (Hrsg), Extracorporal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 231-239
Beg M, Melikyan E, Yang X, Bainbridge L Shockwave Treatment for Intractable Tennis Elbow 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 81-90
Begg C, Cho M, Eastwood S Improving the quality of reporting of randomized controlled trials: the CONSORT statement. 1996 JAMA 1996; 276:637-639
Benson K, Hartz AJ A comparison of observational studies and randomized, controlled trials. 2000 N Engl J Med 2000; 342: 1878-1886
Betz U, Heine J, Riedel C, Rompe J D, Schöllner C The value of Cervical Spinal Manipulative Therapy Combined with Low Energy Shockwaves for Chronic Tennis Elbow 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 123-130
Boxberg W, Perlick L, Giebel G Stosswellenbehandlung bei therapieresistenten Weichteilschmerzen. 1996 Chirurg, 67: 1174-1178
Boyer MI, Hastings H Lateral tennis elbow: Is there any science out there? 1999 J Shoulder Elbow Surg 1999; 8:481-491
Braun W, Claes L, Rüter A, Paschke D Untersuchung zur Wirksamkeit von Stosswellen auf die Festigkeit des Verbundes von Knochen und Polymethylmetacrylat. 1991 Experimentelle Orthopädie, 130: 236
Braun W, Claes L, Rüter A, Paschke D Effects of extracorporeal shock waves on the stability of the interface between bone and polymethylmethacrylate: an in vitro study on human femoral segments. 1992 Clin. Biomechan., 7: 47-54
Braun W, Rüter A Frakturheilung: Morphologische und physiologische Gesichtspunkte. 1996 Unfallchirurg, 99: 59-67
Brendel W, Delius M, Goetz A Effect of shock waves on the microvasculature. 1987 Prog. Appl. Microcirculation, 12: 41-50
Brocai DRC, Lukoschek M, Hartmann M, Loew M Biometrische Planung klinisch-orthopadischer Studien. Der optimale Stichprobenumfang. 1998 Orthopäde 1998; 27:301-304
Brunner W, Thüringer R, Ascher G, Maluche C, Kellner F, Neuking A, Solleder A, Schmidt-Hoensdorf F, Vetter K High energy shock waves for pain management in orthopedics - a two year foolow-up in 899 cases 2000 3rd Congress of the ISMST - Naples, Abstracts:75
Brunner W, Thüringer R, Ascher G, Neuking A, Flesch A, Solleder A, Schmidt-Höhnsdorff F, Bärtel B Die extrakorporelle Stosswellentherapie in der Orthopädie - Drei-Monats-Ergebnisse in 443 Fällen. 1997 Orthopädische Praxis, 7: 461-464
Brümmer F, Brenner J, Bräuner T, Hülser D Effect of shock waves on suspended and immobilized L1210 cells. 1989 Ultrasound in Medicine & Biology, 15: 229-239
Brümmer F, Bräuner T, Hülser D Biological effects of shock waves. 1990 World Journal of Urology, 8: 224-232
Brümmer F, Suhr D, Hülser D Sensitivity of normal and malignant cells to shock waves. 1992 Stone Disease, 4: 243-248
Bräuner T, Brümmer F, Hülser DF Histopathology of shock wave treated tumor cells suspensions and multicell tumor spheroids. 1989 Ultrasound in Medicine & Biology, 15: 451-460
Buch M Shock wave therapy of heel spur. 1997 Orthopaedic Product News, July/Aug./Sep.: 28-30
Buch M Prospektiver Vergleich der hochenergetischen Stoßwellentherapie sowie des Needling bei der Tendinosis calcarea der Schulter 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 127-136
Buch M, Fleming L, Theodore G, Amendola A, Bachmann C, Zingas C. Resultate einer prospektiven placebokontrollierten randomisierten doppelblinden Multicenterstudie zur Evaluation der Effektivität und Sicherheit der Stoßwellentherapie bei plantarer Fasciitis. 2001 Vortrag, Symposium Muskuloskeletale Stoßwellentherapie, Mainz
Buch M, Knorr U, Fleming L, Theodore G, Amendola A, Bachmann C et al Extracorporeal shock wave therapy in plantar fasciitis: a review. 2002 Orthopaede 2002;31:637-644
Buch M, Knorr U, Siebert W E Chronic plantar fasciitis treated by ESWT 2000 Minimally Invasive Therapy & Allied Technologies, Isis Medical Media, Volume 9, Number 3/4 August 2000: 310 (Abstract 7)
Buch M, Schlangmann B, Träger D, Siebert W Prospektiver Vergleich der niedrig- und hochenergetischen Stosswellentherapie und Needling bei der Behandlung der Tendinosis calcarea der Schulter. 1997 45. Jahrestagung der Vereinigung Süddeutscher Orthopäden, Abstractband: 101-102
Buch M, Siebert W Shockwave Treatment for Heel Pain Syndrome - a Prospective Investigation 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 73-77
Burger C, Tsironis K, Helling HJ, Prokop A, Rehm KE Die extrakorporale Stosswellentherapie bei Ansatztendopathien der Schulter, des Ellenbogens und der Ferse - vorläufige Ergebnisse einer prospektiven Kölner Studie. 1996 45. Jahrestagung der Deutschen Orthopädenvereinigung e.V. User Meeting Ossatron, Wiesbaden
Buselli P, Saggini R ESWT in ossificans myositis 2000 3rd Congress of the ISMST - Naples, Abstracts:83
Bürger R, Witzsch U, Haist J, Grebe P, Hohenfellner R Die extrakorporale Stosswellentherapie (ESWT) - eine neue Möglichkeit der Behandlung von Pseudarthrosen. 1993 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Stosswellenlithotripsie - Aspekte und Prognosen, Attempto Verlag, Tübingen: 127-130
Bürger R, Witzsch U, Haist J, Karnofsky V Extrakorporale Stosswellenbehandlung bei Pseudarthrose und aseptischer Knochennekrose. 1991 Urologe A, 30: 48
Bürger R, Witzsch U, Haist J, Karnofsky V, Hohenfellner R Extracorporeal shock wave therapy of pseudo-arthrosis and aseptic osteonecrosis. 1991 Endourology, 5, Suppl. 1: 48
Bürger R, Witzsch U, Haist J, Karnovsky V, Ahlers J, Hohenfellner R Extracorporeal shock wave therapy of pseudo-arthrosis. 1992 Urology, 147: 48 ff
Bödekker I, Haake M Die extrakorporale Stosswellentherapie zur Behandlung der Epicondylitis humeri radialis. Ein aktueller Überblick. 2000 Orthopäde 2000; 29:463-469
Bödekker R, Schafer H, Haake M Extracorporeal shock wave therapy in the treatment of plantar fasciitis – a biometrical review. 2001 Clin Rheumatol 2001; 20:324-330
Chaussy C, Eisenberger F, Wanner K, Forssmann F, Hepp W, Schmiedt E, Brendel W The use of shock waves for the destruction of renal calculi without direct contact. 1976 Urol Res 1976; 4:181-188
Chen H, Chen L, Huang T Treatment of painfull heel syndrome with shock waves 2001 Clinical Orthopaedics and Related Research, 387: 41-46
Chen H, Chen L, Huang T Treatment of painful heel syndrome with shock waves 2001 Clin Orthop 2001; 387: 41-46
Child SZ, Hartman C, Schery LA, Carstensen EL Lung damage from exposure to pulsed ultrasound. 1990 Ultrasound in Medicine & Biology, 16: 817-825
Church C A theoretical study of cavitation generated by an extracorporeal shock wave lithotripter. 1989 Acoustic Society of America, 86: 215-227
Coleman AJ, Saunders JE A review of the physical properties and biological effects of the high amplitude acoustic fields usedr in extracorporeal lithotripsy. 1993 Ultrasonics, 31: 75-89
Coleman AJ, Saunders JE A survey of the acoustic output of commercial extracorporeal shock wave lithotripters. 1989 Ultrasound in Medicine & Biology, 15: 213-227
Coleman AJ, Saunders JE, Crum LA, Dyson M Acoustic cavitation generated by an extracorporeal shock wave lithotripter. 1987 Ultrasound in Medicine & Biology, 13: 69 ff
Concato J, Shah N, Jorwitz RI Randomized, controlled trials, observational studies, and the hierarchy of research. 2000 N Engl J Med 2000; 342: 1887-189
Corrado B, Russo S, Gigliotti S, De Durante C, Canero R Shockwave Treatment for Non-unions of the Carpal Scaphoid 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 187-194
Cosentino R, de Stefano R, Frati E, Manca S, Tofi C, Falsetti P, Linari S, Morfini M, Rossi-Ferrini P, Marcolongo R Safety and efficacy of extracorporeal shock wave therapy in the treatment of painful non articular rheumatism of patients with hemophilia 2000 3rd Congress of the ISMST - Naples, Abstracts:86
Cozzolino F, Corrado B, Izzo M, Borrelli M, Russo S, Gigliotti S, de Durante C Axial external fixation plus high energy shock waves in the treatment of unstable leg non union 2000 3rd Congress of the ISMST - Naples, Abstracts:61
Crawford F, Atkins D, Edward J Interventions for treating plantar heel pain (Cochrane Review) 2000 Cochrane Library, Issue 3. Oxford: Update Software, 2000
Crowther M. A prospective randomised study comparing shockwave therapy and steroid injection in the treatment of 'tennis elbow' 2000 3rd Congress of the ISMST - Naples, Abstracts:34
Crum L Tensile strength of water. 1979 Nature, 278: 148-149
Crum L Acoustic cavitation. 1982 Proceedings of the 1982 IEEE ultrasonics Symposium, IEEE, New York: 1-11
Cugola L, Amelio E Long bone non-union: treatment by extracorporeal shock wave (ESW) 2000 3rd Congress of the ISMST - Naples, Abstracts:59Dahm K Stosswellentherapie bei schmerzhaftem Fersensporn: Nachuntersuchungen bei 362 Patienten. 1997 2. Radevormwalder ESWT-Symosium, Radevormwald: 8-9
Dahmen GP, Franke R, Gonchars V, Poppe K, Lentrodt S, Lichtenberger S, Jost S, Montigel J, Nam VC, Dahmen G Die Behandlung knochennaher Weichteilschmerzen mit extrakorporaler Stosswellentherapie (ESWT) - Indikation, Technik und bisherige Ergebnisse. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 175-186
Dahmen GP, Meiss L, Nam VC, Skruodies B Extrakorporale Stoßwellentherapie (ESWT) im knochennahen Weichteilbereich an der Schulter 1992 Extracta Orthopaedica 1992; 15:25-28
Dahmen GP, Nam VC, Meiss L Extrakorporale Stosswellentherapie zur Behandlung von knochennahen Weichteilschmerzen: Indikation, Technik und vorläufige Ergebnisse. 1993 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Stosswellenlithotripsie - Aspekte und Prognosen, Attempto Verlag, Tübingen: 143-148
Davis PF, Severud E, Baxter DE Painful heel syndrome: results of nonoperative treatment. 1994 Foot Ankle Int 1994;15:531-5
de Durante C, Russo S, Gigliotti S, Corrado B The Treatment of Shoulder Periarticular Calcification 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 143-144
de Durante C, Russo S, Gigliotti S, Pecoraro C The treatment of shoulder periarticular calcifications by shock waves 2000 3rd Congress of the ISMST - Naples, Abstracts:23
de Maio M, Paine R, Mangine RE, Drez D Plantar fasciitis. 1993 Orthopedics 1993;16: 1153-63
de Oya R, Sanchez Benitez Soto J, Garcia Munilla M Extracorporeal shock waves in the treatment of tendinitis of shoulder 2000 3rd Congress of the ISMST - Naples, Abstracts:13
de Pretto M, Dalla Valle I, Ferrari G, Pacetti A Follow-up and evaluation of heterotopic ossifications treated with shockwave therapy 2000 3rd Congress of the ISMST - Naples, Abstracts:85
de Pretto M, Guerra L, Pozzolini M, Zucchetti R, Saggini R A retrospective multi-centre experience report of shock wave therapy on achilles tendonitis 2000 3rd Congress of the ISMST - Naples, Abstracts:45-46
Delius M Minimal static excess pressure minimizes the effect of extracorporeal shock waves on cells and reduces it on gallstones. 1997 Ultrasound in Medicine & Biology, 23: 611-617
Delius M Experimentelle Stosswellenlithotripsie - aktuelle Entwicklungen. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 3-9
Delius M Biologische Wirkung von Stosswellen - mehr als "nur" Steinzertrümmerung? 1995 Zentralblatt Chirurgie, 120: 259-273
Delius M Medical applications and bioeffects of extracorporal shock waves. 1994 Shock waves, 4: 55-72
Delius M Bioeffects of shock waves: in vivo and in vitro actions 2000 3rd Congress of the ISMST - Naples, Abstracts:9
Delius M, Denk R, Berding C, Liebich H, Jordan M, Brendel W Biological effects of shock waves: cavitation by shock waves in piglet liver. 1990 Ultrasound in Medicine & Biology, 16: 467-472
Delius M, Draenert K Einfluß hochenergetischer Stosswellen auf Knochen, Wirkung von Stosswellen auf Knochen. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 10-11
Delius M, Draenert K, Al Diek Y, Draenert Y Biological effect of shock waves: in vivo effect of high energy pulses on rabbit bone. 1995 Ultrasound in Medicine & Biology, 21: 1219-1225
Delius M, Draenert K, Draenert Y, Börner M Effects of extracorporeal shock waves on bone: a review of shock wave expiriments and the mechanism of shock wave action. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 91-107
Delius M, Enders G, Heine G, Stark J, Remberger K, Brendel W Biological effects of shock waves: lung hemorrhage by shock waves in dogs - pressure dependence. 1987 Ultrasound in Medicine & Biology, 13: 61-67
Delius M, Enders G, Xuan Z, Liebich H, Brendel B Biological effects of shock waves: kidney damage by shock waves in dogs - dose dependence. 1988 Ultrasound in Medicine & Biology, 14: 117-122
Delius M, Hoffmann E, Steinbeck G, Conzen P Biological effects of shock waves: induction of arrhythmia in piglet hearts. 1994 Ultrasound in Medicine & Biology, 20: 279-285
Delius M, Jordan M, Eizenhoefer H, Marlinghaus E, Heine G, Liebich H, Brendel W Biological effects of shock waves: kidney hemorrhage by shock waves in dogs - administration rate dependence. 1988 Ultrasound in Medicine & Biology, 14: 689-694
Delius M, Jordan M, Liebich H, Brendel W Biological effects of shock waves: effect of shock waves on the liver and gallbladder wall of dogs - administration rate dependence. 1990 Ultrasound in Medicine & Biology, 16: 459-466
Delius M, Weiss N, Gambihler S, Goetz A, Brendel W Tumor therapy with shock waves requires modified lithotripter shock waves 1989 Naturwissenschaften, 76: 573-574
Delius M, Überle F, Eisenmenger W Extracorporeal shock waves act by shock wave gas bubble interaction. 1998 Ultrasound in Medicine & Biology, 24: 1055-1059
Dellian M, Walenta S, Gamarra F, Kuhnle G, Mueller-Klieser W, Goetz A Ischemia and loss of ATP in tumors following treatment with focused high energy shock waves. 1993 British Journal of Cancer, 68: 26-31
di Silverio F, Galluci M, Gambardella P, Alp G, Benedetti R, La Mancusa R, Pulcinelli FM, Romiti R, Gazzangia PP Blood cellolar and biochemical changes after extracorporeal shock wave in lithotripsy. 1990 Urological Research, 18: 49 ff
Dieppe P, Chard J, Tallon D, Egger M Funding clinical research. 1999 Lancet 1999; 353:1626-1629
Diesch R, Haupt G Anwendung der hochenergetischen extrakorporalen Stosswellentherapie bei Pseudarthrosen. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 63-64
Diesch R, Haupt G Use of extracorporeal shock waves in the treatment of pseudarthrosis. 1991 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), High energey shock waves in medicine, Thieme Verlag, Stuttgart: 136-139
Diesch R, Haupt G Extracorporeal shock wave treatment of pseudarthrosis, tendinosis calcarea of the shoulder and calcaneal spur. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 131-135
Diesch R, Straub T, Penninger E, Frolich T, Scholl J Conventional Versus Ballistic Shockwave Treatment for Calcaneal Spur 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 71-72
Duarte LR The stimulation of bone growth by ultrasound. 1983 Archives of Orthopaedic and Trauma Surgery, 101: 153 ff
Dyson M, Brookes M Stimulation of bone repair by ultrasound. 1983 Ultrasound in Medicine & Biology, Suppl 2: 61 ff
Eichenblat M Experience with two different types of shockwave therapy for chronic calcifying tendinitis of the shoulder and chronic heel syndrome 2000 3rd Congress of the ISMST - Naples, Abstracts:71
Eisenmenger W Experimentelle Bestimmung der Stossfrontdicke aus dem akustischen Frequenzspektrum elektromagnetisch erzeugter Stosswellen in Flüssigkeiten bei einem Stossdruckbereich von 10 atm bis 10 atm. 1964 Acustica, 14: 188-204
Ekkernkamp A Extrakorporale Stosswellen. 1998 Deutsches Ärzteblatt, 95: B-1403
Ekkernkamp A Die Wirkung extrakorporaler Stosswellen auf die Frakturheilung. 1992 Habilitationsschrift, Ruhr-Universität, Bochum
Ekkernkamp A, Bosse A, Haupt G, Pommer A Der Einfluß der extrakorporalen Stosswellen auf die standardisierte Tibiafraktur am Schaf. 1992 Ittel TH, Sieberth HG, Matthiaß HH (Hrsg), Aktuelle Aspekte der Osteologie, Springer Verlag, Berlin Heidelberg New York: 307-310
Ekkernkamp A, Haupt G, Knopf HJ, Püllenberg P, Muhr, Senge T Effects of extracorporeal shock waves on standardized fractures in sheeps. 1991 Urology, 145: 257 ff
Feigl T, Schneider T, Riedlinger R, Löhr M, Hahn EG, Ell C Beschallung von humanen Pankreaskarzinomzellen mit hochenergetischem gepulsten Ultraschall. 1992 Med. Tech., 3: 139-143
Ferrari G, lo Prete F, de Pretto M, Pacetti A Use of imaging for heterotopic ossifications evaluation 2000 3rd Congress of the ISMST - Naples, Abstracts:84
Folberth W, Krause H, Reuner T Stosswellenmesstechnik in der Lithotripsie: Historie und Ausblick. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 45-50
Forriol F, Solchaga L, Moreno JL, Canadell J The effects os shock waves on mature and healing cortical bone. 1994 International Orthopaedics, 18: 325-329
Fritze J Extrakorporale Stoßwellentherapie in orthopädischer Indikation: Eine ausgewählte Übersicht. 1998 Versicherungsmedizin 1998; 50: 180-183
Fukada E, Yasuda I On the piezoelectric effect of bone. 1957 Phys. Soc. Japan, 12: 1158-1162
Fuson RL, Sherman M, Van Fleet J, Wendt, T The conduct of orthopaedic clinical trials. 1997 J Bone Joint Surg 1997; 79-A: 1089-1098



Feigl T, Schneider T, Riedlinger R, Löhr M, Hahn EG, Ell C Beschallung von humanen Pankreaskarzinomzellen mit hochenergetischem gepulsten Ultraschall. 1992 Med. Tech., 3: 139-143
Ferrari G, lo Prete F, de Pretto M, Pacetti A Use of imaging for heterotopic ossifications evaluation 2000 3rd Congress of the ISMST - Naples, Abstracts:84
Folberth W, Krause H, Reuner T Stosswellenmesstechnik in der Lithotripsie: Historie und Ausblick. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 45-50
Forriol F, Solchaga L, Moreno JL, Canadell J The effects os shock waves on mature and healing cortical bone. 1994 International Orthopaedics, 18: 325-329
Fritze J Extrakorporale Stoßwellentherapie in orthopädischer Indikation: Eine ausgewählte Übersicht. 1998 Versicherungsmedizin 1998; 50: 180-183
Fukada E, Yasuda I On the piezoelectric effect of bone. 1957 Phys. Soc. Japan, 12: 1158-1162
Fuson RL, Sherman M, Van Fleet J, Wendt, T The conduct of orthopaedic clinical trials. 1997 J Bone Joint Surg 1997; 79-A: 1089-1098


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Galasso O, de Durante C, Russo S, Gigliotti S, Corrado B Chronic achilloynia. Treatment with extracorporeal shock waves 2000 3rd Congress of the ISMST - Naples, Abstracts:43
Gambihler S, Delius M In vitro interaction of lithotripter shock waves and cytotoxic drugs. 1992 British Journal of Cancer, 66: 69-73
Gambihler S, Delius M, Ellwart JW Permeabilization of the plasma membrane of L1210 mouse leukemia cells using lithotripter shock waves. 1994 Membr. Biol., 141: 267-275
Gambihler S, Delius M, Ellwart JW Transient increase in membrane permeability of L1210 cells upon exposure to lithotripter shock waves in vitro. 1992 Naturwissenschaften, 79: 328-329
Gebhart C, Widhalm R The Biological Effects of Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 11-12
Gerdesmeyer L ESWT bei Tendinosis calcarea – Ergebnisse der prospektiven placebokontrollierten Multicenterstudie der DGOOC. 2001 Vortrag, Arbeitskreis Stoßwellentherapie, Berlin, 2001
Gerdesmeyer L, Bachfischer K, Hauschild M Overview of Calcifying Tendonitis of the Shoulder Treated with Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 151-156
Gerdesmeyer L, Hasse A, Engel A, Bachfischer K, Rechl H Der Einfluß extrakorporaler Stoßwellen auf die Osteoinduktion nach Radiatio 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 13-22
Gerdesmeyer L, Hauschild M, Bachfischer K The change of clinical outcome of tendinitis calcarea after ESWT in course of time 2000 3rd Congress of the ISMST - Naples, Abstracts:28
Gerdesmeyer L, Russlies M, Peters P, Gradinger R Die hochenergetische ESWT zur Behandlung der Tendinosis calcarea. 1997 46. Jahrestagung Norddeutsche Orthopädenvereinigung, Kurzreferate: 14
Galasso O, de Durante C, Russo S, Gigliotti S, Corrado B Chronic achilloynia. Treatment with extracorporeal shock waves 2000 3rd Congress of the ISMST - Naples, Abstracts:43
Gambihler S, Delius M In vitro interaction of lithotripter shock waves and cytotoxic drugs. 1992 British Journal of Cancer, 66: 69-73
Gambihler S, Delius M, Ellwart JW Permeabilization of the plasma membrane of L1210 mouse leukemia cells using lithotripter shock waves. 1994 Membr. Biol., 141: 267-275
Gambihler S, Delius M, Ellwart JW Transient increase in membrane permeability of L1210 cells upon exposure to lithotripter shock waves in vitro. 1992 Naturwissenschaften, 79: 328-329
Gebhart C, Widhalm R The Biological Effects of Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 11-12
Gerdesmeyer L ESWT bei Tendinosis calcarea – Ergebnisse der prospektiven placebokontrollierten Multicenterstudie der DGOOC. 2001 Vortrag, Arbeitskreis Stoßwellentherapie, Berlin, 2001
Gerdesmeyer L, Bachfischer K, Hauschild M Overview of Calcifying Tendonitis of the Shoulder Treated with Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 151-156
Gerdesmeyer L, Hasse A, Engel A, Bachfischer K, Rechl H Der Einfluß extrakorporaler Stoßwellen auf die Osteoinduktion nach Radiatio 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 13-22
Gerdesmeyer L, Hauschild M, Bachfischer K The change of clinical outcome of tendinitis calcarea after ESWT in course of time 2000 3rd Congress of the ISMST - Naples, Abstracts:28
Gerdesmeyer L, Russlies M, Peters P, Gradinger R Die hochenergetische ESWT zur Behandlung der Tendinosis calcarea. 1997 46. Jahrestagung Norddeutsche Orthopädenvereinigung, Kurzreferate: 14
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Haake M, Böddeker IR, Decker T, Buch M, Vogel M, Labek G, Maier M, Loew M, Maier-Boerries O, Fischer J, Betthäuser A, Rehack HC, Kanovsky W, Müller I, Gerdesmeyer L, Rompe JD Efficacy of Extracorporal Shockwave Therapy (ESWT) in patients with lateral epicondylitis - A placebo controlled multicenter trial. 2001 4th International Congress of the ISMST, Berlin, 2001
Haake M, Böddeker IR, Decker T, Buch M, Vogel M, Labek G, Maier M, Loew M, Maier-Boerries OM, Fischer J, Betthäuser A, Rehack HC, Kanovsky W, Müller I, Gerdesmeyer L, Rompe JD Side effects of Extracorporeal Shock Wave Therapy (ESWT) in the treatment of tennis elbow. 2002 Arch Orthop Traum Surg 2002
Haake M, Deike B, Thon A, Schmitt J Exact focusing of extracorporeal Shock Wave Therapy for calcifying tendinopathy. 2002 Clin Orthop 2002
Haake M, Deike B, Thon A, Schmitt J. Importance of accurately focussing of extracorporeal shock waves (ESWT) in the treatment of calcifying tendinitis - A prospective randomised study. 2001 Biomed Tech 2001; 45: 69-74
Haake M, Jensen K, Prinz H, Willenberg T Design einer Multizenterstudie zum Wirksamkeitsnachweis der Extrakorporalen Stosswellentherapie (ESTW) bei Epicondylitis humeri radialis. 2000 Z Orthop Ihre Grenzgeb 2000; 138:99-103
Haake M, Rautmann M, Griss P Therapieergebnisse und Kostenanalyse der Extrakorporalen Stoßwellentherapie bei Tendinitis calcarea und Supraspinatussehnensyndrom. 1998 Orthop Praxis 1998;34: 110-113
Haake M, Rautmann M, Wirth T Assessment of treatment costs of Extracorporeal Shock Wave Therapy (ESWT) - Comparison of ESWT and surgical treatment in shoulder diseases 2001 Int J Tech Ass Health Care 2001; 17: 612-617
Haake M, Rautmann M, Wirth T Extracorporeal Shock Wave Therapy versus surgical treatment in calcifying ttttrendinitis and non calcifying tendinitis of the supraspinatus muscle. 2001 Eur J Orthop Surg Traumatol 2001; 11: 21-24
Haake M, Sattler A, Gross MW, Schmitt J, Hildebrandt R, Müller HH Vergleich der Extrakorporalen Stoßwellentherapie mit der Röntgenreizbestrahlung beim Supraspinatussehnensyndrom – ein prospektiver randomisierter einfachblinder Parallelgruppenvergleich 2001 Z Orthop Ihre Grenzgeb 2001; 139: 397-402
Haist J Die Osteorestauration via Stosswellen-Anwendung. Eine neue Möglichkeit zur Therapie der gestörten knöchernen Konsolidierung. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 157-161 Haist J Osteorestoration via shock wave application. A new possibility of treating disturbed bone union. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 119-129
Haist J Einsatzmöglichkeiten der analgetisch wirksamen extrakorporalen Stosswellentherapie an der Schulter. 1995 Orthopädische Praxis, 9: 591-593
Haist J Shockwave Treatment for Radial and Ulnar Epicondylitis 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 115-113
Haist J Shockwave Therapy for Pseudarthroses 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 195-196
Haist J Shockwave Treatment of Dupuytren's Contracture and Ledderhose's Contraction 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 253-254
Haist J, Reichel W, Bürger R, Witzsch U Einsatz der extrakorporalen Stosswelle bei der osteosynthetisch versorgten Pseudarthrose - eine experimentelle Studie. 1993 Orthopädische Praxis, 5: 345-346
Haist J, Reichel W, Witzsch U, Bürger R Die extrakorporale Stosswellenbehandlung der gestörten Frakturheilung - eine Alternative zu operativen Verfahren ? 1993 Orthopädische Praxis, 29: 842-844
Haist J, Steeger von Keitz D Die Stosswellentherapie (ESWT) der Epicondylopathia radialis et ulnaris. Ein neues Behandlungskonzept knochennaher Weichteilschmerzen. 1994 Orthopädie Mitteilungen, 173
Haist J, Steeger von Keitz D Stosswellentherapie knochennaher Weichteilschmerzen - ein neues Behandlungskonzept. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 162-165
Haist J, Steeger von Keitz D, Mohr G, Schulze G, Weber F The orthopaedic shock wave therapy in the treatment of chronic insertion tendopathy and tendinosis calcarea. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 159-163
Haist J, Steeger von Keitz D, Witzsch U, Bürger R, Haist U The extracorporeal shockwave therapy in the treatment of disturbed bone union. 1992 7th International Conference on Biomedical Engineering, December 2.- 4.1992, Singapore: 222-224
Haist J, Steeger von Keitzr D Shock wave therapy in the treatment of near to bone soft tissue pain in sportsmen. 1996 International Journal of Sports Medicine, 17: 79-81
Hammer DS, Rupp S, Ensslin S, Kohn D, Seil R Extracorporal shock wave therapy in patients with tennis elbow and painful heel. 2000 Arch Orthop Trauma Surg 2000; 120:304-7
Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. 2002 Foot Ankle Int 2002;23:309-13
Hasegawa S, Kato K, Takashi M, Zhu Y, Obata K, Miyake K S100a0 protein as a marker for tissue damage related to extracorporeal shock wave lithotripsy. 1993 Eur. Urology, 24: 393-396
Haupt G Stosswellen in der Orthopädie. 1997 Urologe A, 36, Nr.3: 233-238
Haupt G Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendopathy and other orthopaedic diseases. 1997 Urology, 158: 4-11
Haupt G, Diesch R, Straub T, Penninger E, Fröhlich T, Scholl J, Löhrer H, Senge T Ballistic Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 271-272
Haupt G, Ekkernkamp A, Püllenberg A, Senge T Einfluß extrakorporal erzeugter Stosswellen auf standardisierte Tibiafrakturen im Schafmodell. 1992 Urologe A, 31: A 43ff
Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M Influence of shock waves on fracture healing. 1992 Urology, 39: 529-532
Haist J, Steeger von Keitz D, Witzsch U, Bürger R, Haist U The extracorporeal shockwave therapy in the treatment of disturbed bone union. 1992 7th International Conference on Biomedical Engineering, December 2.- 4.1992, Singapore: 222-224
Haist J, Steeger von Keitzr D Shock wave therapy in the treatment of near to bone soft tissue pain in sportsmen. 1996 International Journal of Sports Medicine, 17: 79-81
Hammer DS, Rupp S, Ensslin S, Kohn D, Seil R Extracorporal shock wave therapy in patients with tennis elbow and painful heel. 2000 Arch Orthop Trauma Surg 2000; 120:304-7
Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. 2002 Foot Ankle Int 2002;23:309-13
Hasegawa S, Kato K, Takashi M, Zhu Y, Obata K, Miyake K S100a0 protein as a marker for tissue damage related to extracorporeal shock wave lithotripsy. 1993 Eur. Urology, 24: 393-396
Haupt G Stosswellen in der Orthopädie. 1997 Urologe A, 36, Nr.3: 233-238
Haupt G Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendopathy and other orthopaedic diseases. 1997 Urology, 158: 4-11
Haupt G, Diesch R, Straub T, Penninger E, Fröhlich T, Scholl J, Löhrer H, Senge T Ballistic Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 271-272
Haupt G, Ekkernkamp A, Püllenberg A, Senge T Einfluß extrakorporal erzeugter Stosswellen auf standardisierte Tibiafrakturen im Schafmodell. 1992 Urologe A, 31: A 43ff
Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M Influence of shock waves on fracture healing. 1992 Urology, 39: 529-532
Haupt G, Haupt A, Gerety B, Chvapil M Enhancement of fracture healing with extracorporeal shock waves. 1990 AUA Annual Meeting, New Orleans 1990
Haupt G, Haupt A, Senge T Die Behandlung von Knochen mit extrakorporalen Stosswellen - Entwicklung einer neuen Therapie. 1993 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Stosswellenlithotripsie - Aspekte und Prognosen, Attempto Verlag, Tübingen: 120-126
Haupt G, Katzmeier P Anwendung der hochenergetischen Stosswellen-therapie bei Pseudarthrosen, Tendinosis calcarea der Schulter und Ansatztendinosen (Fersensporn, Epiconylitis). 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 143-146
Hearnden A, Flannary MC A prospective, blinded randomised control trial assessing the use of different energy extracorporeal shock wave therapy for calcifying tendonitis 2000 3rd Congress of the ISMST - Naples, Abstracts:16
Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF Accleration of tibial fracture-healing by non-invasive low-intensity pulsed ultrasound. 1994 Bone Joint Surgery (Am), 76: 26-34
Heidersdorf S, Lauber S, Lauber H, Hötzinger H, Ludwig J, Dreisliker U Rädel R Osteochondritis Dissecans 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 255-264
Heinrichs W, Witzsch U, Bürger R Extrakorporale Stosswellentherapie (ESWT) von Pseudarthrosen. 1993 Anaesthesist, 42: 361-364
Helbig K, Herbert C, Schostok T, Brown M, Thiele R Correlations between the duration of pain and the success of shock wave therapy 2001 Clinical Orthopaedics and Related Research, 387: 68-71
Helbig K, Schostok T, Brown M, Herbert C, Thiele R Correlations Between Duration of Pain and Success 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 43-48
Heller KD, Niethard FU Der Einsatz der extrakorporalen Stoßwellentherapie in der Orthopädie – eine Metaanalyse 1998 Orthop Ihre Grenzgeb 1998; 136:390-401
Herbert C, Thiele R, Hartmann T, Helbig K Musculoskeletal shock wave therapy for the treatment of tendinosis calcarea, follow-up of 1483 patients between 1995 and 1998 (4 years) 2000 Minimally Invasive Therapy & Allied Technologies, Isis Medical Media, Volume 9, Number 3/4 August 2000: 322 (Abstract 28)
Herbert C, Thiele R, Helbig K, Hartmann T, Mälzer H Pseudarthrosentherapie mit der Stosswelle in der Praxis. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg:
Herken K, Bernhardt F, Lenz G Die extracorporale Stosswellenbehandlung bei der chronischen, therapieresistenten Tendinosis calcarea der Schulter. 1996 45. Jahrestagung Norddeutsche Orthopädenvereinigung e.V.: 124-125
Holmes RP, Yeaman LD, Taylor RG, McCullough DL Altered neutrophil permeability following shock wave exposure in vitro. 1992 Urology, 147: 733-737
Hötzinger H, Rädel R, Lauber S, Lauber H, Platzek P, Ludwig J MRI-Guided Shockwaves for Multiple Stress Fractures of the Tibia 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 165-168
Jakobeit C, Welp L, Winiarski B, Schuhmacher R, Osenberg T, Splittgerber T, Spelsberg G, Buntrock W, Missulis U, Kroll U, Schmeiser A, Beer M, Watzlawik A, Olschner G, Winarski B Ultrasound-guided extracorporeal shock wave therapy of tendinosis calcarea of the shoulder, of symptomatic plantar calcaneal spur (heel spur) and of epicondylopathia radialis and ulnaris. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 165-180
Johannes EJ, Sukul Kaulesar DMKS, Mature E, Schutte HE High energy shock waves for the treatment of nonunions - experiments in dog. 1994 Surg. Research, 57: 246-252
Jurgowski W, Loew M, Cotta H, Staehler G Extracorporeal shock wave treatment of calcareous tendinitis of the shoulder. 1993 Endourology, 7, Suppl. 1: 193
Karlsen JS, Smevik B, Hovig T Acute morphological changes in canine kidneys following exposure to extracorporeal shock waves. 1991 Urological Research, 19: 105-115
Karpman R, Magee F, Gruen T, Mobley M The Lithotriptor and its potential use in the revision of total hip arthroplasty 2001 Clinical Orthopaedics and Related Research, 387: 4-7
Kawahara K, Koba M The effect of extracorporeal shock wave therapy (ESWT) for carpal tunnel syndrome (CTS) in chronic hemodialysis patients 2000 3rd Congress of the ISMST - Naples, Abstracts:93
Ko J, Chen H, Chen L Treatment of lateral epicondylitis of the elbow with shock waves 2001 Clinical Orthopaedics and Related Research, 387: 60-67
Koeweiden E, Chin A Paw E Promising results of ESWT for tennis elbow 2000 3rd Congress of the ISMST - Naples, Abstracts:33
Kolsky H Stress waves in solids. 1963 Dover, New York: 186
Krause H Physik und Technik medizinischer Stosswellensysteme. 1997 Rompe JD (Hrsg), Extrakorporale Stosswellentherapie - Grundlagen, Indikation, Anwendung, Chapman & Hall GmbH, London Glasgow Weinheim New York Tokio Melbourne Madras
Krischek O, Hopf C, Nafe B, Rompe JD Shock-wave therapy for tennis and golfer`s elbow. 1999 Arch Orthop Trauma Surg 1999; 119: 62-66
Krischek O, Rompe JD, Herbsthofer B, Nafe B Symptomatische niedrig-energetische Stosswellentherapie bei Fersenschmerzen und radiologisch nachweisbarem plantarem Fersensporn. 1998 Orthopädie, 136: 169-174
Krischek O, Rompe JD, Hopf C, Stratmann M, Vogel J, Nafe B Ist die extrakorporelle Stosswellentherapie bei Epicondylitis humeri ulnaris indiziert? Kurzfristige Ergebnisse einer vergleichenden, prospektiven Studie. 1997 Orthopädische Praxis, 7: 465-469
Krischek O, Rompe JD, Zöllner J Extrakorporale Stoßwellentherapie bei der Tendinosis calcarea der Schulter – eine kritische Bestandsaufnahme nach einem Jahr. 1997 Phys Rehab Kur Med 1997; 7:272-277
Kuderna H, Schaden W, Sailler A, Fischer A, Kölpl C, Hagmüller V Comparison of 30 tibial non-unions: costs of surgical treatment versus costs of extracorporeal shockwave therapy 2000 3rd Congress of the ISMST - Naples, Abstracts:65-66
Kuhns JC Changes in elastic adipose tissue. 1949 Bone Joint Surg Am 1949;31:541-8
Kuner EH, Berwarth H, Lücke SV Behandlungsprinzipien bei aseptischen Pseudarthrosen. 1996 Orthopäde, 25: 394-404
Kusnierczak D, Brocai DRC, Vettel U, Loew M The influence of extrycorporeal shock wave application (ESWA) on the biological behaviour of bone cells in vitro 2000 3rd Congress of the ISMST - Naples, Abstracts:100
Kusnierczak D, Loew M Einfluß von Stosswellen auf das Wachstums- und Expressionsverhalten von Knochenzellkulturen - eine Pilotstudie. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 12-13
Kusnierczak D, Loew M, Nitschmann C Studie ESWA (extrakorporale Stosswellen-anwendung) bei schmerzhaftem Fersensporn. 1997 46. Jahrestagung Norddeutsche Orthopädenvereinigung, Kurzreferate: 156
Kuwahara M, Ioritani N, Kambe K, Shirai S, Taguchi K, Saitoh T, Orikasa S, Takayama K, Aida S, Iwama N Hyperechoic region induced by focused shock waves in vitro and in vivo: possibility of acoustic cavitation bubbles. 1989 Lithotripsy Stone Disease, 1: 282-288
la Bruna SC, Tedeschi C, Camurri GB Shock waves therapy for a rehablitation program 2000 3rd Congress of the ISMST - Naples, Abstracts:74
Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard CH Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow: an attempted metaanalysis 1992 J Bone Joint Surg 1992 ; 74-B:646-651
Larini P, Marcato C, Ugolotti U, Meneghetti S, Paroli C, Mazzucchi A, Cavatorta S Extracorporeal shock wave therapy in paraosteoarthropathy (POA). Preliminary results 2000 3rd Congress of the ISMST - Naples, Abstracts:76
Lauber S, Lauber HJ, Ludwig J, Hötzinger H, Rädel R, Dreisilker U MRI controlled results of extracorporeal shockwave therapy in adult osteonecrosis of the femoral head 2000 3rd Congress of the ISMST - Naples, Abstracts:91
Lauber S, Ludwig J, Hötzinger H, Dreisilker U, Rädel R, Platzek P MRI after Shockwave Treatment for Osteonecrosis of the Femoral Head 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 241-247
Lauber S, Ludwig J, Lauber H, Hötzinger B, Dreisilker U, Rädel R Die ESWT-Behandlung der Hüftkopfnekrose und der Osteochondrosis dissecans 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 161-192
Lauer U, Bürgelt E, Squire Z, Messmer K, Hofschneider PH, Gregor M, Delius M Shock wave permeabilization as new gene transfer method. 1997 Gene Therapy, 4: 710-715
Lehmkühler K, Köhnke W, Wrede A Focus Positioning 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 33-34
Levitt R, Alvarez R, Ogden JA The FDA Studies of Musculoskeletal Shockwave Therapy for Lateral Epicondylitis and Heel Pain Syndrome 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 107-110
Levitt R, Ogden JA, Selesnick H FDA study for chronic lateral epicondylitis 2000 3rd Congress of the ISMST - Naples, Abstracts:39
Loew M Stosswellenbehandlung bei Erkrankungen an Schulter und Ellenbogen - Mythen und Wirklichkeit. 1997 Mitteilungsblatt DVSE Juni 1997: 5-7
Loew M Die Wirkung extrakorporal erzeugter hoch-energetischer Stosswellen auf den klinischen, röntgenologischen und histologischen Verlauf der Tendinosis calcarea der Schulter - eine klinische und experimentelle Studie. 1994 Habilitationsschrift, Ruprecht-Karls-Universität Heidelberg
Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck V Extracorporal shock wave application – an effective treatment for patients with chronic and therapy-resistant calcifying tendinitis? 1999 Bone Joint Surg 1999 ; 81-B:863-867
Loew M, Jurgowski W Erste Erfahrungen mit der extrakorporalen Stosswellen-Lithotripsie in der Behandlung der Tendinosis calcarea der Schulter. 1993 Orthopädie, 131: 470-473
Loew M, Jurgowski W Erste Erfahrungen mit der Extrakorporalen Stosswellen-Lithotripsie (ESWL) in der Behandlung der Tendinosis calcarea der Schulter. 1993 Orthop Ihre Grenzgeb 1993; 131:470-473
Loew M, Jurgowski W, Mau HC, Perlick L, Kuszniercak D Die Wirkung extrakorporal erzeugter hochenergetischer Stosswellen auf den klinischen, röntgenologischen und histologischen Verlauf der Tendinosis calcarea der Schulter - eine prospektive Studie. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 153-156
Loew M, Jurgowski W, Mau HC, Thomsen M Treatment of calcifying tendinitis of rotator cuff by extracorporeal shock waves: a preliminary report. 1995 Shoulder Elbow Surg 1995; 4:101-106
Loew M, Jurgowski W, Thomsen M Die Wirkung extrakorporaler Stosswellen auf die Tendinosis calcarea der Schulter. 1995 Urologe A, 34: 49-53
Loew M, Jurgowski W, Thomsen M, Cotta H Extracorporale Stosswellenbehandlung bei chronischer Tendinitis calcarea der Schulter 1994 Orthopädie Mitteilungen
Loew M, Nitschmann R Shock wave application in heel spur syndrome. 1995 3. Münchener Symposium für Fußchirurgie, München


Loew M, Rompe JD Stosswellenbehandlung bei orthopädischen Erkrankungen. 1998 Grifka J (Hrsg), Bücherei des Orthopäden, Band 71, Enke, Stuttgart
Lohse-Busch H, Kraemer M, Reime U The use of extracorporeal shock wave fronts for treatment of muscle dysfunction of various etiologies: an overview of first results. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 215-230
Lohse-Busch H, Kraemer M, Reime U Pilotuntersuchung zur Wirkung von niederenergetischen, extrakorporalen Stosswellen auf Muskelfunktionsstörungen bei spastischen Bewegungsstörungen von Kindern. 1997 Schmerz, 11, Nr. 2: 108-112
Ludwig J, Hötzinger H, Lauber S, Trenkel I Pre- and post shockwave therapy (SWT) MRI evaluation of artificial calcifications of the supraspinate tendon in pig shoulders 2000 3rd Congress of the ISMST - Naples, Abstracts:94
Ludwig J, Lauber S, Lauber H, Dreisilker U, Rädel R, Hötzinger H High-energy shock wave treatment of femoral head necrosis in adults 2001 Clinical Orthopaedics and Related Research, 387: 119-126
Lüssenhop S, Hahn M, Seemann S, Meiss L Einfluß der Stosswelle auf Epiphysenfugen. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 12-13
Lüssenhop S, Seemann D, Hahn M, Meiss L The influence of shock waves on epiphysal growth plates: first results of an in-vivo study with rabbits. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 109-118
Lök V, Baloglu I, Aydinok H Experience of Shockwaves for Non-unions in Izmir 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 185-186


Maier M Gibt es magnetresonanztomographische Veränderungen nach Stosswellenbehandlung bei Tendinitis calcarea ? 1997 Orthopädie, 2: 20-21
Maier M, Dürr HR, Kohler S, Staupendahl D, Pfahler M, Refior HJ, Meier M Analgetische Wirkung niederenergetischer extrakorporaler Stosswellen bei Tendinosis calcarea, Epikondylitis humeri radialis und Plantarfasziitis. 2000 Orthop Ihre Grenzgeb 2000; 138:34-8
Maier M, Dürr HR, Staupendahl D, Refior HJ Einfluß des Koppelmediums auf den Applikationsschmerz bei der ESWT des Stütz- und Bewegungsapparates 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 227-234
Maier M, Schnarkowski P, Pfahler M, Refior H Kernspintomographische Veränderungen der Schulterregion nach Stosswellentherapie bei Tendinosis calcarea. 1997 45. Jahrestagung der Vereinigung Süddeutscher Orthopäden, Abstractband: 101
Maier M, Stabler A, Lienemann A, Kohler S, Feitenhansl A, Dürr HR, Pfahler M, Refior HJ Shockwave application in calcifying tendinitis of the shoulder - prediction of outcome by imaging. 2000 Arch Orthop Trauma Surg 2000; 120:493-8
Maier M, Steinborn M, Staebler A, Koehler S, Pfahler M, Dürr HR, Refior HJ Extracorporeal shock wave application for chronic plantar fasciitis – prediction of outcome by imaging? 2000 Rheumatol 2000; 27:2455-246
Marchetti I, Carnevali R, Russo N Our experience with ESW: first review of the cases 2000 3rd Congress of the ISMST - Naples, Abstracts:73
May TC, Krause WR, Preslar AJ, Smith MJV, Beaudoin AJ Use of high energy shock waves for bone cement removal. 1990 Arthroplasty, 01: 19-27
McCullough DL, Yeaman LD, Bo WJ, Assimos DG, Kroovant RL, Griffin AS, Furr EG Effects of shock waves on the rat ovary. 1989 Urology, 141: 666-669
Melegati G, Tornese D, Bandi M, Cappadonia C L'utilizzo della terapia con onde d'urto extracorporee nella sindrome da conflitto acromion-omerale: studio prospettico controllato 2000 3rd Congress of the ISMST - Naples, Abstracts:17-18
Neuland HG The treatment of complaints caused py playing golf using ESWT 2000 3rd Congress of the ISMST - Naples, Abstracts:78
Niethard FU Wissenschaftlichkeit und Wirtschaftlichkeit in Orthopädie und Physiotherapie - Editorial. 1997 Orthopädie, 135:1-2
Niethard FU Qualitätssicherung - Editorial 1997 Orthopädie, 135: 93-94
Nigrisoli M, Bosco V Non-unions-treatment and results 2000 3rd Congress of the ISMST - Naples, Abstracts:57
Nigrisoli M, Bosco V, Sisca G Shockwave Treatment for Knee and Achilles Tendinopathies 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 249-251
O'Brien WD, Zachary JF Rabbit and pig lung damage comparison from exposure to continuous wave 30 kHz ultrasound. 1996 Ultrasound in Medicine & Biology, 22: 345-354
Ogden JA, Alvarez R, Levitt R, Cross GL Chronic heel pain: results of FDA shockwave study 2000 3rd Congress of the ISMST - Naples, Abstracts:51
Ogden JA, Alvarez R, Levitt R, Cross GL, Marlow M Shock wave therapy for chronic proximal plantar fasciitis 2001 Clinical Orthopaedics and Related Research, 387: 47-59
Ogden JA, Alvarez R, Levitt R, Marlow M Shock Wave Therapy (Orthotripsy®) in Musculoskeletal Disorders 2001 Clinical Orthopaedics and Related Research, 387: 22-40
Ogden JA, Tóth-Kischkat A, Schultheiss R Principles of Shock Wave Therapy 2001 Clinical Orthopaedics and Related Research, 387: 8-17
Oosterhof G, Cornel EB, Smits GA, Debruyne F, Schalken J The influence of high energy shock waves on the development of metastases. 1996 Ultrasound in Medicine & Biology, 22: 339-344
Oosterhof G, Smits G, de Ruyter A, Schalken J, Debruyne F Effects of high energy shock waves combined with biological response modifiers in different human kidney cancer xenografts. 1991 Ultrasound in Medicine & Biology, 17: 391-399


Peers K, Onkelinx L, Brys P, Lysens R ESWT for calcific tendinopathy of the rotator cuff: one year foolow-up and outcome comparison with surgery 2000 3rd Congress of the ISMST - Naples, Abstracts:15
Peers K, van den Eeede E, Brys P, Bellemans J, Lysens R Cross sectional functional outcome comparison of ESWT versus surgery for chronic patellar tendinopathy 2000 3rd Congress of the ISMST - Naples, Abstracts:42
Perlick L, Boxberg W, Giebel G Hochenergetische Stosswellenbehandlung des schmerzhaften Fersensporns. 1998 Unfallchirurg 1998; 101:914-918
Perlick L, Gassel F, Zander D, Schmitt O, Wallny T. Vergleich der Ergebnisse der mittelenergetischen ESWT und der operativen Therapie in der Technik nach Mittelmeier bei der therapieresistenten Epicondylitis humeri radialis 1999 Orthop Ihre Grenzgeb 1999; 137: 316-321
Perlick L, Wallny T Die ESWT der Tendinosis calcarea. Untersuchungen zur Desintegrationswirkung von Stoßwellen auf ein standardisiertes Kalkdepot im Tiermodell 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 149-160
Perren SM Aktivierung der Knochenbildung durch Stosswellentherapie in der Frakturbehandlung. 1993 AO Forschungsinstitut, Davos
Philipp A, Delius M, Scheffzyk C, Vogel A, Lauterborn W Interaction of lithotripter-generated shock waves with air bubbles. 1993 Acoustic Society of America, 93: 2496-2509
Pigozzi F, Giombini A, Parisis A, Casciello G, Di Salvo V, Santori N, Mariani PP The application of shock wave therapy in the treatment of resistant chronic painful shoulder. 2000 Sports Med Phys Fitness 2000; 40:356-361
Polak HJ Ergebnis der Literaturrecherche der MDK-Gemeinschaft zur ESWT mit orthopädischen Indikationen. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 66-68
Prat F, Sibille A, Luccioni C, Pansu D, Chapelon J, Beaumatin J, Ponchon T, Cathignol D Increased chemocytotoxicity to colon cancer cells by shock wave induced cavitation. 1994 Gastroenterology, 106: 937-944


Randazzo RF, Chaussy C, Fuchs GJ, Lovrekovich H, de Kernion JB The in vitro and in vivo effects of extracorporeal shock waves on malignant cells. 1988 Urological Research, 16: 419-426
Richter D, Ekkernkamp A Klinischer Einsatz der Stosswellentherapie in der Unfallchirurgie. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 12-13
Richter D, Ekkernkamp A, Muhr G Die extrakorporale Stosswellentherapie - ein alternatives Konzept zur Behandlung der Epicondylitis humeri radialis ? 1995 Orthopäde, 24: 303-306
Rodríguez de Oya R, Sánchez Benitez de Soto J, Garcia Munilla M Shockwave Treatment for Chronic Non-unions 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 169-172
Roles NC, Maudsley RH Radial tunnel syndrome: resistant tennis elbow as a nerve entrapment. 1972 Bone Joint Surg [Br] 1972;54:499-508
Rompe JD Tierexperimentelle und klinische Ergebnisse der Stosswellentherapie am Knochen. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 38-39
Rompe JD Extrakorporale Stosswellentherapie - Grundlagen, Indikation, Anwendung. 1997 Chapman & Hall GmbH, London Glasgow Weinheim New York Tokio Melbourne Madras
Rompe JD Stosswellentherapie: therapeutische Wirkung bei spekulativem Mechanismus. 1996 Orthopädie, 134: 13-19
Rompe JD Die Auswirkung extrakorporaler Stosswellen unterschiedlicher Energiedichten auf knochennahes Sehnengewebe - tierexperimentelle und klinische Studien. 1996 Habilitationsschrift, Johannes Gutenberg-Universität Mainz
Rompe JD Overview of Tennis Elbow Treated with Shockwaves 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 131-135


Rompe JD, Bohl J, Riehle HM, Schwitalle M, Krischek O Überprüfung der Läsionsgefahr des Nervus ischiadicus des Kaninchens durch die Applikation niedrig- und mittelenergetischer extrakorporaler Stosswellen. 1998 Zeitschrift für Orthopädie, 136: 407-411
Rompe JD, Burger R, Hopf C, Eysel P. Shoulder function after extracorporeal shock wave therapy for calcific tendinitis. 1998 Shoulder Elbow Surg 1998; 7: 505-509
Rompe JD, Decking J, Schoellner C, Nafe B Shock wave application for chronic plantar fasciitis in running athletes – a prospective, randomized, placebo-controlled trial. 2001 Persönliche Mitteilung, 2001
Rompe JD, Eysel P, Hopf C, Vogel J, Küllmer K Extrakorporale Stosswellenapplikation bei gestörter Knochenheilung - eine kritische Bestandsaufnahme. 1997 Unfallchirurg, 100: 845-849
Rompe JD, Eysel P, Küllmer K, Vogel J, Kirkpatrick CJ, Bürger R, Nafe B, Heine J Extrakorporale Stosswellentherapie in der Orthopädie - aktueller Stand. 1996 Orthopädische Praxis, 8: 558-561
Rompe JD, Hopf C, Eysel P, Heine J, Witzsch U, Nafe B Extrakorporale Stosswellentherapie des therapieresistenten Tennisellenbogens - erste Ergebnisse von 150 Patienten. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 147-152
Rompe JD, Hopf C, Küllmer K, Heine J, Bürger R Analgesic effect of extracorporeal shock-wave therapy on chronic tennis elbow. 1996 Bone Joint Surgery, 78 B: 233-237
Rompe JD, Hopf C, Küllmer K, Heine J, Bürger R, Nafe B Low-energy extracorporeal shock wave therapy for persistent tennis elbow. 1996 International Orthopaedics, 20: 23-27
Rompe JD, Hopf C, Küllmer K, Witzsch U, Nafe B Extrakorporale Stosswellentherapie der Epicondylopathia humeri radialis - ein alternatives Behandlungskonzept. 1996 Orthopädie, 134: 63-66
Rompe JD, Hopf C, Nafe B, Bürger R Low-energy extracorporeal shock wave therapy for painfull heel: a prospektiv controled single-blind study. 1996 Archives of Orthopaedic and Trauma Surgery, 115: 75-79


Rompe JD, Hopf C, Rumler F 2 Jahre extrakorporelle Stosswellentherapie (ESWT) in der Orthopädie - Indikationen und Resultate ? 1994 Orthopädie Mitteilungen, 173
Rompe JD, Kirkpatrick CJ, Küllmer K, Schwitalle M, Krischek O Dose-related effects of shock waves on rabbit tendo Achillis. 1998 Bone Joint Surgery 80 B: 546-552
Rompe JD, Küllmer K, Eysel P, Riehle HM, Bürger R, Nafe B Niedrigenergetische extrakorporale Stosswellentherapie beim plantaren Fersensporn. 1996 Orthopädische Praxis, 4: 271-275
Rompe JD, Küllmer K, Riehle HM, Herbsthofer B, Eckardt A, Bürger R, Nafe B, Eysel P Effektiveness of low-energy extracorporeal shock waves for chronic plantar fasciitis. 1996 Foot Ankle Surgery, 2 : 215-221
Rompe JD, Küllmer K, Vogel J, Eckardt A, Wahlmann U, Eysel P, Hopf C, Kirkpatrick CJ, Bürger R, Nafe B Extrakorporale Stosswellentherapie - experimentelle Grundlagen, klinischer Einsatz. 1997 Orthopäde, 26: 215-228
Rompe JD, Riedel C, Betz U, Fink C Chronic lateral epicondylitis of the elbow (tennis elbow) – Prospective comparison of low-energy shock wave therapy with low-energy shock wave therapy plus manual therapy of the cervical spine. 2001 Arch Phys Med Rehabil 2001; 82: 578-582
Rompe JD, Rosendahl T, Schöllner C, Theis C High-energy extracorporeal shock wave treatment of nonunions 2001 Clinical Orthopaedics and Related Research, 387: 102-111
Rompe JD, Rumler F, Hopf C, Eysler P Shoulder function after extracorporeal shock wave therapy (ESWT) for calcifying tendinitis. 1997 Shoulder and Elbow Surgery
Rompe JD, Rumler F, Hopf C, Nafe B, Heine J Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. 1995 Clinical Orthopaedics and Related Research, 321: 196-201
Rompe JD, Schoellner C, Nafe B Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis 2002 Bone Joint Surg [Am] 2002;84:335-41

Result number: 83

Message Number 177900

Re: ESWT View Thread
Posted by Ed Davis, DPM on 7/06/05 at 01:01

Here is a partial list of research -- the www.asmst.org site is still under construction (by the way United may be hiring techs and sales reps).
ps. I have only gotten up to "k" on the researchers list:


Author Title Year Publisher
Ackaert KS, Schröder FH Effects of extracorporeal shock wave lithotripsy (ESWL) on renal tissue. 1989 Urological Research, 17: 3-7
Alvarez R. Preliminary results on the safety and efficacy of the OssaTron for treatment of plantar fasciitis. 2002 Foot Ankle Int 2002;23:197-203
Amelio E, Cugola L Acute and chronic tendon pathology in athlete 2000 3rd Congress of the ISMST - Naples, Abstracts:81
Amini A, Hafez M, Zhou S, Garcia E, Coombs R Shockwave Treatment for Chronic Non-union 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 159-164
Ammendolia A, Perticone L, Milano C Chronic shoulder articular pain: treatment by extracorporeal shockwaves 2000 3rd Congress of the ISMST - Naples, Abstracts:19
Ape A, Bosco V, Buselli P, Coco V, Gerardi A, Saggini R A retrospective, multi-centre experience report of shock wave therapy on epicondylitis 2000 3rd Congress of the ISMST - Naples, Abstracts:35-36
Apfel RE Acoustic cavitation. 1981 Methods of experimental physics, vol. 19, P. Edmonds ed., Academic Press New York: 355-411
Arbeitsgruppe "Orthopädische Stosswellenbehandlungen" Standortbestimmung 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 137-142
Arbeitsgruppe "Technische Entwicklungen" Standortbestimmung 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 15-20
Assenza, Buselli P, Chiacchio C, Pozzolini M, Scrocca M, Saggini R A retrospective, multi-centre experience report of shock wave therapy on rotator cuff tendonitis with calcific deposit 2000 3rd Congress of the ISMST - Naples, Abstracts:25
Auersperg V, Labek G, Böhler N Correlations Between Length of History and Outcome 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 37-42
Augat P, Claes L, Suger G In vivo effects of shock waves on the healing of fractured bone. 1995 Clin. Biomechan., 10: 374-378
Baloglu I, Aydinok H, Lök V Our results of the ossatherapy for treatment of pseudoathrosis 2000 3rd Congress of the ISMST - Naples, Abstracts:56
Baloglu I, Lök V Shockwave Therapy for Plantar Fasciitis 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 51-52
Bao S, Thrall BD, Miller DL Transfection of a reporter plasmid into cultured cells by sonoporation in vitro. 1997 Ultrasound in Medicine & Biology, 23: 953-959
Baumann J, Baumann J Treatment of neuromuscular dysfunction in children with spastic cerebral palsy by extracorporeal unfocused shock waves. 1997 Siebert W, Buch M (Hrsg), Extracorporal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 231-239
Beg M, Melikyan E, Yang X, Bainbridge L Shockwave Treatment for Intractable Tennis Elbow 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 81-90
Begg C, Cho M, Eastwood S Improving the quality of reporting of randomized controlled trials: the CONSORT statement. 1996 JAMA 1996; 276:637-639
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Brunner W, Thüringer R, Ascher G, Maluche C, Kellner F, Neuking A, Solleder A, Schmidt-Hoensdorf F, Vetter K High energy shock waves for pain management in orthopedics - a two year foolow-up in 899 cases 2000 3rd Congress of the ISMST - Naples, Abstracts:75
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Buch M, Fleming L, Theodore G, Amendola A, Bachmann C, Zingas C. Resultate einer prospektiven placebokontrollierten randomisierten doppelblinden Multicenterstudie zur Evaluation der Effektivität und Sicherheit der Stoßwellentherapie bei plantarer Fasciitis. 2001 Vortrag, Symposium Muskuloskeletale Stoßwellentherapie, Mainz
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Buch M, Siebert W Shockwave Treatment for Heel Pain Syndrome - a Prospective Investigation 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 73-77
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Buselli P, Saggini R ESWT in ossificans myositis 2000 3rd Congress of the ISMST - Naples, Abstracts:83
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Bödekker R, Schafer H, Haake M Extracorporeal shock wave therapy in the treatment of plantar fasciitis – a biometrical review. 2001 Clin Rheumatol 2001; 20:324-330
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Chen H, Chen L, Huang T Treatment of painfull heel syndrome with shock waves 2001 Clinical Orthopaedics and Related Research, 387: 41-46
Chen H, Chen L, Huang T Treatment of painful heel syndrome with shock waves 2001 Clin Orthop 2001; 387: 41-46
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Coleman AJ, Saunders JE A review of the physical properties and biological effects of the high amplitude acoustic fields usedr in extracorporeal lithotripsy. 1993 Ultrasonics, 31: 75-89
Coleman AJ, Saunders JE A survey of the acoustic output of commercial extracorporeal shock wave lithotripters. 1989 Ultrasound in Medicine & Biology, 15: 213-227
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Corrado B, Russo S, Gigliotti S, De Durante C, Canero R Shockwave Treatment for Non-unions of the Carpal Scaphoid 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 187-194
Cosentino R, de Stefano R, Frati E, Manca S, Tofi C, Falsetti P, Linari S, Morfini M, Rossi-Ferrini P, Marcolongo R Safety and efficacy of extracorporeal shock wave therapy in the treatment of painful non articular rheumatism of patients with hemophilia 2000 3rd Congress of the ISMST - Naples, Abstracts:86
Cozzolino F, Corrado B, Izzo M, Borrelli M, Russo S, Gigliotti S, de Durante C Axial external fixation plus high energy shock waves in the treatment of unstable leg non union 2000 3rd Congress of the ISMST - Naples, Abstracts:61
Crawford F, Atkins D, Edward J Interventions for treating plantar heel pain (Cochrane Review) 2000 Cochrane Library, Issue 3. Oxford: Update Software, 2000
Crowther M. A prospective randomised study comparing shockwave therapy and steroid injection in the treatment of 'tennis elbow' 2000 3rd Congress of the ISMST - Naples, Abstracts:34
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Cugola L, Amelio E Long bone non-union: treatment by extracorporeal shock wave (ESW) 2000 3rd Congress of the ISMST - Naples, Abstracts:59Dahm K Stosswellentherapie bei schmerzhaftem Fersensporn: Nachuntersuchungen bei 362 Patienten. 1997 2. Radevormwalder ESWT-Symosium, Radevormwald: 8-9
Dahmen GP, Franke R, Gonchars V, Poppe K, Lentrodt S, Lichtenberger S, Jost S, Montigel J, Nam VC, Dahmen G Die Behandlung knochennaher Weichteilschmerzen mit extrakorporaler Stosswellentherapie (ESWT) - Indikation, Technik und bisherige Ergebnisse. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 175-186
Dahmen GP, Meiss L, Nam VC, Skruodies B Extrakorporale Stoßwellentherapie (ESWT) im knochennahen Weichteilbereich an der Schulter 1992 Extracta Orthopaedica 1992; 15:25-28
Dahmen GP, Nam VC, Meiss L Extrakorporale Stosswellentherapie zur Behandlung von knochennahen Weichteilschmerzen: Indikation, Technik und vorläufige Ergebnisse. 1993 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Stosswellenlithotripsie - Aspekte und Prognosen, Attempto Verlag, Tübingen: 143-148
Davis PF, Severud E, Baxter DE Painful heel syndrome: results of nonoperative treatment. 1994 Foot Ankle Int 1994;15:531-5
de Durante C, Russo S, Gigliotti S, Corrado B The Treatment of Shoulder Periarticular Calcification 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 143-144
de Durante C, Russo S, Gigliotti S, Pecoraro C The treatment of shoulder periarticular calcifications by shock waves 2000 3rd Congress of the ISMST - Naples, Abstracts:23
de Maio M, Paine R, Mangine RE, Drez D Plantar fasciitis. 1993 Orthopedics 1993;16: 1153-63
de Oya R, Sanchez Benitez Soto J, Garcia Munilla M Extracorporeal shock waves in the treatment of tendinitis of shoulder 2000 3rd Congress of the ISMST - Naples, Abstracts:13
de Pretto M, Dalla Valle I, Ferrari G, Pacetti A Follow-up and evaluation of heterotopic ossifications treated with shockwave therapy 2000 3rd Congress of the ISMST - Naples, Abstracts:85
de Pretto M, Guerra L, Pozzolini M, Zucchetti R, Saggini R A retrospective multi-centre experience report of shock wave therapy on achilles tendonitis 2000 3rd Congress of the ISMST - Naples, Abstracts:45-46
Delius M Minimal static excess pressure minimizes the effect of extracorporeal shock waves on cells and reduces it on gallstones. 1997 Ultrasound in Medicine & Biology, 23: 611-617
Delius M Experimentelle Stosswellenlithotripsie - aktuelle Entwicklungen. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 3-9
Delius M Biologische Wirkung von Stosswellen - mehr als "nur" Steinzertrümmerung? 1995 Zentralblatt Chirurgie, 120: 259-273
Delius M Medical applications and bioeffects of extracorporal shock waves. 1994 Shock waves, 4: 55-72
Delius M Bioeffects of shock waves: in vivo and in vitro actions 2000 3rd Congress of the ISMST - Naples, Abstracts:9
Delius M, Denk R, Berding C, Liebich H, Jordan M, Brendel W Biological effects of shock waves: cavitation by shock waves in piglet liver. 1990 Ultrasound in Medicine & Biology, 16: 467-472
Delius M, Draenert K Einfluß hochenergetischer Stosswellen auf Knochen, Wirkung von Stosswellen auf Knochen. 1997 Siebert W, Buch M (Hrsg), Stosswellenanwendung am Knochen - Klinische und experimentelle Erfahrungen, Dr. Kovac, Hamburg: 10-11
Delius M, Draenert K, Al Diek Y, Draenert Y Biological effect of shock waves: in vivo effect of high energy pulses on rabbit bone. 1995 Ultrasound in Medicine & Biology, 21: 1219-1225
Delius M, Draenert K, Draenert Y, Börner M Effects of extracorporeal shock waves on bone: a review of shock wave expiriments and the mechanism of shock wave action. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 91-107
Delius M, Enders G, Heine G, Stark J, Remberger K, Brendel W Biological effects of shock waves: lung hemorrhage by shock waves in dogs - pressure dependence. 1987 Ultrasound in Medicine & Biology, 13: 61-67
Delius M, Enders G, Xuan Z, Liebich H, Brendel B Biological effects of shock waves: kidney damage by shock waves in dogs - dose dependence. 1988 Ultrasound in Medicine & Biology, 14: 117-122
Delius M, Hoffmann E, Steinbeck G, Conzen P Biological effects of shock waves: induction of arrhythmia in piglet hearts. 1994 Ultrasound in Medicine & Biology, 20: 279-285
Delius M, Jordan M, Eizenhoefer H, Marlinghaus E, Heine G, Liebich H, Brendel W Biological effects of shock waves: kidney hemorrhage by shock waves in dogs - administration rate dependence. 1988 Ultrasound in Medicine & Biology, 14: 689-694
Delius M, Jordan M, Liebich H, Brendel W Biological effects of shock waves: effect of shock waves on the liver and gallbladder wall of dogs - administration rate dependence. 1990 Ultrasound in Medicine & Biology, 16: 459-466
Delius M, Weiss N, Gambihler S, Goetz A, Brendel W Tumor therapy with shock waves requires modified lithotripter shock waves 1989 Naturwissenschaften, 76: 573-574
Delius M, Überle F, Eisenmenger W Extracorporeal shock waves act by shock wave gas bubble interaction. 1998 Ultrasound in Medicine & Biology, 24: 1055-1059
Dellian M, Walenta S, Gamarra F, Kuhnle G, Mueller-Klieser W, Goetz A Ischemia and loss of ATP in tumors following treatment with focused high energy shock waves. 1993 British Journal of Cancer, 68: 26-31
di Silverio F, Galluci M, Gambardella P, Alp G, Benedetti R, La Mancusa R, Pulcinelli FM, Romiti R, Gazzangia PP Blood cellolar and biochemical changes after extracorporeal shock wave in lithotripsy. 1990 Urological Research, 18: 49 ff
Dieppe P, Chard J, Tallon D, Egger M Funding clinical research. 1999 Lancet 1999; 353:1626-1629
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Diesch R, Haupt G Use of extracorporeal shock waves in the treatment of pseudarthrosis. 1991 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), High energey shock waves in medicine, Thieme Verlag, Stuttgart: 136-139
Diesch R, Haupt G Extracorporeal shock wave treatment of pseudarthrosis, tendinosis calcarea of the shoulder and calcaneal spur. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 131-135
Diesch R, Straub T, Penninger E, Frolich T, Scholl J Conventional Versus Ballistic Shockwave Treatment for Calcaneal Spur 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 71-72
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Dyson M, Brookes M Stimulation of bone repair by ultrasound. 1983 Ultrasound in Medicine & Biology, Suppl 2: 61 ff
Eichenblat M Experience with two different types of shockwave therapy for chronic calcifying tendinitis of the shoulder and chronic heel syndrome 2000 3rd Congress of the ISMST - Naples, Abstracts:71
Eisenmenger W Experimentelle Bestimmung der Stossfrontdicke aus dem akustischen Frequenzspektrum elektromagnetisch erzeugter Stosswellen in Flüssigkeiten bei einem Stossdruckbereich von 10 atm bis 10 atm. 1964 Acustica, 14: 188-204
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Ekkernkamp A Die Wirkung extrakorporaler Stosswellen auf die Frakturheilung. 1992 Habilitationsschrift, Ruhr-Universität, Bochum
Ekkernkamp A, Bosse A, Haupt G, Pommer A Der Einfluß der extrakorporalen Stosswellen auf die standardisierte Tibiafraktur am Schaf. 1992 Ittel TH, Sieberth HG, Matthiaß HH (Hrsg), Aktuelle Aspekte der Osteologie, Springer Verlag, Berlin Heidelberg New York: 307-310
Ekkernkamp A, Haupt G, Knopf HJ, Püllenberg P, Muhr, Senge T Effects of extracorporeal shock waves on standardized fractures in sheeps. 1991 Urology, 145: 257 ff
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Ferrari G, lo Prete F, de Pretto M, Pacetti A Use of imaging for heterotopic ossifications evaluation 2000 3rd Congress of the ISMST - Naples, Abstracts:84
Folberth W, Krause H, Reuner T Stosswellenmesstechnik in der Lithotripsie: Historie und Ausblick. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 45-50
Forriol F, Solchaga L, Moreno JL, Canadell J The effects os shock waves on mature and healing cortical bone. 1994 International Orthopaedics, 18: 325-329
Fritze J Extrakorporale Stoßwellentherapie in orthopädischer Indikation: Eine ausgewählte Übersicht. 1998 Versicherungsmedizin 1998; 50: 180-183
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Fuson RL, Sherman M, Van Fleet J, Wendt, T The conduct of orthopaedic clinical trials. 1997 J Bone Joint Surg 1997; 79-A: 1089-1098



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Feigl T, Schneider T, Riedlinger R, Löhr M, Hahn EG, Ell C Beschallung von humanen Pankreaskarzinomzellen mit hochenergetischem gepulsten Ultraschall. 1992 Med. Tech., 3: 139-143
Ferrari G, lo Prete F, de Pretto M, Pacetti A Use of imaging for heterotopic ossifications evaluation 2000 3rd Congress of the ISMST - Naples, Abstracts:84
Folberth W, Krause H, Reuner T Stosswellenmesstechnik in der Lithotripsie: Historie und Ausblick. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 45-50
Forriol F, Solchaga L, Moreno JL, Canadell J The effects os shock waves on mature and healing cortical bone. 1994 International Orthopaedics, 18: 325-329
Fritze J Extrakorporale Stoßwellentherapie in orthopädischer Indikation: Eine ausgewählte Übersicht. 1998 Versicherungsmedizin 1998; 50: 180-183
Fukada E, Yasuda I On the piezoelectric effect of bone. 1957 Phys. Soc. Japan, 12: 1158-1162
Fuson RL, Sherman M, Van Fleet J, Wendt, T The conduct of orthopaedic clinical trials. 1997 J Bone Joint Surg 1997; 79-A: 1089-1098



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Galasso O, de Durante C, Russo S, Gigliotti S, Corrado B Chronic achilloynia. Treatment with extracorporeal shock waves 2000 3rd Congress of the ISMST - Naples, Abstracts:43
Gambihler S, Delius M In vitro interaction of lithotripter shock waves and cytotoxic drugs. 1992 British Journal of Cancer, 66: 69-73
Gambihler S, Delius M, Ellwart JW Permeabilization of the plasma membrane of L1210 mouse leukemia cells using lithotripter shock waves. 1994 Membr. Biol., 141: 267-275
Gambihler S, Delius M, Ellwart JW Transient increase in membrane permeability of L1210 cells upon exposure to lithotripter shock waves in vitro. 1992 Naturwissenschaften, 79: 328-329
Gebhart C, Widhalm R The Biological Effects of Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 11-12
Gerdesmeyer L ESWT bei Tendinosis calcarea – Ergebnisse der prospektiven placebokontrollierten Multicenterstudie der DGOOC. 2001 Vortrag, Arbeitskreis Stoßwellentherapie, Berlin, 2001
Gerdesmeyer L, Bachfischer K, Hauschild M Overview of Calcifying Tendonitis of the Shoulder Treated with Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 151-156
Gerdesmeyer L, Hasse A, Engel A, Bachfischer K, Rechl H Der Einfluß extrakorporaler Stoßwellen auf die Osteoinduktion nach Radiatio 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 13-22
Gerdesmeyer L, Hauschild M, Bachfischer K The change of clinical outcome of tendinitis calcarea after ESWT in course of time 2000 3rd Congress of the ISMST - Naples, Abstracts:28
Gerdesmeyer L, Russlies M, Peters P, Gradinger R Die hochenergetische ESWT zur Behandlung der Tendinosis calcarea. 1997 46. Jahrestagung Norddeutsche Orthopädenvereinigung, Kurzreferate: 14
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Galasso O, de Durante C, Russo S, Gigliotti S, Corrado B Chronic achilloynia. Treatment with extracorporeal shock waves 2000 3rd Congress of the ISMST - Naples, Abstracts:43
Gambihler S, Delius M In vitro interaction of lithotripter shock waves and cytotoxic drugs. 1992 British Journal of Cancer, 66: 69-73
Gambihler S, Delius M, Ellwart JW Permeabilization of the plasma membrane of L1210 mouse leukemia cells using lithotripter shock waves. 1994 Membr. Biol., 141: 267-275
Gambihler S, Delius M, Ellwart JW Transient increase in membrane permeability of L1210 cells upon exposure to lithotripter shock waves in vitro. 1992 Naturwissenschaften, 79: 328-329
Gebhart C, Widhalm R The Biological Effects of Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 11-12
Gerdesmeyer L ESWT bei Tendinosis calcarea – Ergebnisse der prospektiven placebokontrollierten Multicenterstudie der DGOOC. 2001 Vortrag, Arbeitskreis Stoßwellentherapie, Berlin, 2001
Gerdesmeyer L, Bachfischer K, Hauschild M Overview of Calcifying Tendonitis of the Shoulder Treated with Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 151-156
Gerdesmeyer L, Hasse A, Engel A, Bachfischer K, Rechl H Der Einfluß extrakorporaler Stoßwellen auf die Osteoinduktion nach Radiatio 2001 Siebert W, Buch M (Hrsg), Extrakorporale Stoßwellentherapie in der Orthopädie - Grundlagen und Anwendung, Ecomed Verlagsgesellschaft, Germany: 13-22
Gerdesmeyer L, Hauschild M, Bachfischer K The change of clinical outcome of tendinitis calcarea after ESWT in course of time 2000 3rd Congress of the ISMST - Naples, Abstracts:28
Gerdesmeyer L, Russlies M, Peters P, Gradinger R Die hochenergetische ESWT zur Behandlung der Tendinosis calcarea. 1997 46. Jahrestagung Norddeutsche Orthopädenvereinigung, Kurzreferate: 14
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Haake M, Böddeker IR, Decker T, Buch M, Vogel M, Labek G, Maier M, Loew M, Maier-Boerries O, Fischer J, Betthäuser A, Rehack HC, Kanovsky W, Müller I, Gerdesmeyer L, Rompe JD Efficacy of Extracorporal Shockwave Therapy (ESWT) in patients with lateral epicondylitis - A placebo controlled multicenter trial. 2001 4th International Congress of the ISMST, Berlin, 2001
Haake M, Böddeker IR, Decker T, Buch M, Vogel M, Labek G, Maier M, Loew M, Maier-Boerries OM, Fischer J, Betthäuser A, Rehack HC, Kanovsky W, Müller I, Gerdesmeyer L, Rompe JD Side effects of Extracorporeal Shock Wave Therapy (ESWT) in the treatment of tennis elbow. 2002 Arch Orthop Traum Surg 2002
Haake M, Deike B, Thon A, Schmitt J Exact focusing of extracorporeal Shock Wave Therapy for calcifying tendinopathy. 2002 Clin Orthop 2002
Haake M, Deike B, Thon A, Schmitt J. Importance of accurately focussing of extracorporeal shock waves (ESWT) in the treatment of calcifying tendinitis - A prospective randomised study. 2001 Biomed Tech 2001; 45: 69-74
Haake M, Jensen K, Prinz H, Willenberg T Design einer Multizenterstudie zum Wirksamkeitsnachweis der Extrakorporalen Stosswellentherapie (ESTW) bei Epicondylitis humeri radialis. 2000 Z Orthop Ihre Grenzgeb 2000; 138:99-103
Haake M, Rautmann M, Griss P Therapieergebnisse und Kostenanalyse der Extrakorporalen Stoßwellentherapie bei Tendinitis calcarea und Supraspinatussehnensyndrom. 1998 Orthop Praxis 1998;34: 110-113
Haake M, Rautmann M, Wirth T Assessment of treatment costs of Extracorporeal Shock Wave Therapy (ESWT) - Comparison of ESWT and surgical treatment in shoulder diseases 2001 Int J Tech Ass Health Care 2001; 17: 612-617
Haake M, Rautmann M, Wirth T Extracorporeal Shock Wave Therapy versus surgical treatment in calcifying ttttrendinitis and non calcifying tendinitis of the supraspinatus muscle. 2001 Eur J Orthop Surg Traumatol 2001; 11: 21-24
Haake M, Sattler A, Gross MW, Schmitt J, Hildebrandt R, Müller HH Vergleich der Extrakorporalen Stoßwellentherapie mit der Röntgenreizbestrahlung beim Supraspinatussehnensyndrom – ein prospektiver randomisierter einfachblinder Parallelgruppenvergleich 2001 Z Orthop Ihre Grenzgeb 2001; 139: 397-402
Haist J Die Osteorestauration via Stosswellen-Anwendung. Eine neue Möglichkeit zur Therapie der gestörten knöchernen Konsolidierung. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 157-161 Haist J Osteorestoration via shock wave application. A new possibility of treating disturbed bone union. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 119-129
Haist J Einsatzmöglichkeiten der analgetisch wirksamen extrakorporalen Stosswellentherapie an der Schulter. 1995 Orthopädische Praxis, 9: 591-593
Haist J Shockwave Treatment for Radial and Ulnar Epicondylitis 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 115-113
Haist J Shockwave Therapy for Pseudarthroses 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 195-196
Haist J Shockwave Treatment of Dupuytren's Contracture and Ledderhose's Contraction 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 253-254
Haist J, Reichel W, Bürger R, Witzsch U Einsatz der extrakorporalen Stosswelle bei der osteosynthetisch versorgten Pseudarthrose - eine experimentelle Studie. 1993 Orthopädische Praxis, 5: 345-346
Haist J, Reichel W, Witzsch U, Bürger R Die extrakorporale Stosswellenbehandlung der gestörten Frakturheilung - eine Alternative zu operativen Verfahren ? 1993 Orthopädische Praxis, 29: 842-844
Haist J, Steeger von Keitz D Die Stosswellentherapie (ESWT) der Epicondylopathia radialis et ulnaris. Ein neues Behandlungskonzept knochennaher Weichteilschmerzen. 1994 Orthopädie Mitteilungen, 173
Haist J, Steeger von Keitz D Stosswellentherapie knochennaher Weichteilschmerzen - ein neues Behandlungskonzept. 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 162-165
Haist J, Steeger von Keitz D, Mohr G, Schulze G, Weber F The orthopaedic shock wave therapy in the treatment of chronic insertion tendopathy and tendinosis calcarea. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 159-163
Haist J, Steeger von Keitz D, Witzsch U, Bürger R, Haist U The extracorporeal shockwave therapy in the treatment of disturbed bone union. 1992 7th International Conference on Biomedical Engineering, December 2.- 4.1992, Singapore: 222-224
Haist J, Steeger von Keitzr D Shock wave therapy in the treatment of near to bone soft tissue pain in sportsmen. 1996 International Journal of Sports Medicine, 17: 79-81
Hammer DS, Rupp S, Ensslin S, Kohn D, Seil R Extracorporal shock wave therapy in patients with tennis elbow and painful heel. 2000 Arch Orthop Trauma Surg 2000; 120:304-7
Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. 2002 Foot Ankle Int 2002;23:309-13
Hasegawa S, Kato K, Takashi M, Zhu Y, Obata K, Miyake K S100a0 protein as a marker for tissue damage related to extracorporeal shock wave lithotripsy. 1993 Eur. Urology, 24: 393-396
Haupt G Stosswellen in der Orthopädie. 1997 Urologe A, 36, Nr.3: 233-238
Haupt G Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendopathy and other orthopaedic diseases. 1997 Urology, 158: 4-11
Haupt G, Diesch R, Straub T, Penninger E, Fröhlich T, Scholl J, Löhrer H, Senge T Ballistic Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 271-272
Haupt G, Ekkernkamp A, Püllenberg A, Senge T Einfluß extrakorporal erzeugter Stosswellen auf standardisierte Tibiafrakturen im Schafmodell. 1992 Urologe A, 31: A 43ff
Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M Influence of shock waves on fracture healing. 1992 Urology, 39: 529-532
Haist J, Steeger von Keitz D, Witzsch U, Bürger R, Haist U The extracorporeal shockwave therapy in the treatment of disturbed bone union. 1992 7th International Conference on Biomedical Engineering, December 2.- 4.1992, Singapore: 222-224
Haist J, Steeger von Keitzr D Shock wave therapy in the treatment of near to bone soft tissue pain in sportsmen. 1996 International Journal of Sports Medicine, 17: 79-81
Hammer DS, Rupp S, Ensslin S, Kohn D, Seil R Extracorporal shock wave therapy in patients with tennis elbow and painful heel. 2000 Arch Orthop Trauma Surg 2000; 120:304-7
Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. 2002 Foot Ankle Int 2002;23:309-13
Hasegawa S, Kato K, Takashi M, Zhu Y, Obata K, Miyake K S100a0 protein as a marker for tissue damage related to extracorporeal shock wave lithotripsy. 1993 Eur. Urology, 24: 393-396
Haupt G Stosswellen in der Orthopädie. 1997 Urologe A, 36, Nr.3: 233-238
Haupt G Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendopathy and other orthopaedic diseases. 1997 Urology, 158: 4-11
Haupt G, Diesch R, Straub T, Penninger E, Fröhlich T, Scholl J, Löhrer H, Senge T Ballistic Shockwave Treatment 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 271-272
Haupt G, Ekkernkamp A, Püllenberg A, Senge T Einfluß extrakorporal erzeugter Stosswellen auf standardisierte Tibiafrakturen im Schafmodell. 1992 Urologe A, 31: A 43ff
Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M Influence of shock waves on fracture healing. 1992 Urology, 39: 529-532
Haupt G, Haupt A, Gerety B, Chvapil M Enhancement of fracture healing with extracorporeal shock waves. 1990 AUA Annual Meeting, New Orleans 1990
Haupt G, Haupt A, Senge T Die Behandlung von Knochen mit extrakorporalen Stosswellen - Entwicklung einer neuen Therapie. 1993 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Stosswellenlithotripsie - Aspekte und Prognosen, Attempto Verlag, Tübingen: 120-126
Haupt G, Katzmeier P Anwendung der hochenergetischen Stosswellen-therapie bei Pseudarthrosen, Tendinosis calcarea der Schulter und Ansatztendinosen (Fersensporn, Epiconylitis). 1995 Chaussy C, Eisenberger F, Jocham D, Wilbert D (Hrsg), Die Stosswelle - Forschung und Klinik, Attempto Verlag, Tübingen: 143-146
Hearnden A, Flannary MC A prospective, blinded randomised control trial assessing the use of different energy extracorporeal shock wave therapy for calcifying tendonitis 2000 3rd Congress of the ISMST - Naples, Abstracts:16
Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF Accleration of tibial fracture-healing by non-invasive low-intensity pulsed ultrasound. 1994 Bone Joint Surgery (Am), 76: 26-34
Heidersdorf S, Lauber S, Lauber H, Hötzinger H, Ludwig J, Dreisliker U Rädel R Osteochondritis Dissecans 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 255-264
Heinrichs W, Witzsch U, Bürger R Extrakorporale Stosswellentherapie (ESWT) von Pseudarthrosen. 1993 Anaesthesist, 42: 361-364
Helbig K, Herbert C, Schostok T, Brown M, Thiele R Correlations between the duration of pain and the success of shock wave therapy 2001 Clinical Orthopaedics and Related Research, 387: 68-71
Helbig K, Schostok T, Brown M, Herbert C, Thiele R Correlations Between Duration of Pain and Success 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 43-48
Heller KD, Niethard FU Der Einsatz der extrakorporalen Stoßwellentherapie in der Orthopädie – eine Metaanalyse 1998 Orthop Ihre Grenzgeb 1998; 136:390-401
Herbert C, Thiele R, Hartmann T, Helbig K Musculoskeletal shock wave therapy for the treatment of tendinosis calcarea, follow-up of 1483 patients between 1995 and 1998 (4 years) 2000 Minimally Invasive Therapy & Allied Technologies, Isis Medical Media, Volume 9, Number 3/4 August 2000: 322 (Abstract 28)
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Herken K, Bernhardt F, Lenz G Die extracorporale Stosswellenbehandlung bei der chronischen, therapieresistenten Tendinosis calcarea der Schulter. 1996 45. Jahrestagung Norddeutsche Orthopädenvereinigung e.V.: 124-125
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Hötzinger H, Rädel R, Lauber S, Lauber H, Platzek P, Ludwig J MRI-Guided Shockwaves for Multiple Stress Fractures of the Tibia 2000 Coombs R, Schaden W, Zhou S (eds), Musculoskeletal Shockwave Therapy, Greenwich Medical Media Ltd, London: 165-168
Jakobeit C, Welp L, Winiarski B, Schuhmacher R, Osenberg T, Splittgerber T, Spelsberg G, Buntrock W, Missulis U, Kroll U, Schmeiser A, Beer M, Watzlawik A, Olschner G, Winarski B Ultrasound-guided extracorporeal shock wave therapy of tendinosis calcarea of the shoulder, of symptomatic plantar calcaneal spur (heel spur) and of epicondylopathia radialis and ulnaris. 1997 Siebert W, Buch M (Hrsg), Extracorporeal shock waves in orthopaedics, Springer Verlag, Berlin Heidelberg New York: 165-180
Johannes EJ, Sukul Kaulesar DMKS, Mature E, Schutte HE High energy shock waves for the treatment of nonunions - experiments in dog. 1994 Surg. Research, 57: 246-252
Jurgowski W, Loew M, Cotta H, Staehler G Extracorporeal shock wave treatment of calcareous tendinitis of the shoulder. 1993 Endourology, 7, Suppl. 1: 193
Karlsen JS, Smevik B, Hovig T Acute morphological changes in canine kidneys following exposure to extracorporeal shock waves. 1991 Urological Research, 19: 105-115
Karpman R, Magee F, Gruen T, Mobley M The Lithotriptor and its potential use in the revision of total hip arthroplasty 2001 Clinical Orthopaedics and Related Research, 387: 4-7
Kawahara K, Koba M The effect of extracorporeal shock wave therapy (ESWT) for carpal tunnel syndrome (CTS) in chronic hemodialysis patients 2000 3rd Congress of the ISMST - Naples, Abstracts:93
Ko J, Chen H, Chen L Treatment of lateral epicondylitis of the elbow with shock waves 2001 Clinical Orthopaedics and Related Research, 387: 60-67
Koeweiden E, Chin A Paw E Promising results of ESWT for tennis elbow 2000 3rd Congress of the ISMST - Naples, Abstracts:33
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Krause H Physik und Technik medizinischer Stosswellensysteme. 1997 Rompe JD (Hrsg), Extrakorporale Stosswellentherapie - Grundlagen, Indikation, Anwendung, Chapman & Hall GmbH, London Glasgow Weinheim New York Tokio Melbourne Madras
Krischek O, Hopf C, Nafe B, Rompe JD Shock-wave therapy for tennis and golfer`s elbow. 1999 Arch Orthop Trauma Surg 1999; 119: 62-66
Krischek O, Rompe JD, Herbsthofer B, Nafe B Symptomatische niedrig-energetische Stosswellentherapie bei Fersenschmerzen und radiologisch nachweisbarem plantarem Fersensporn. 1998 Orthopädie, 136: 169-174
Krischek O, Rompe JD, Hopf C, Stratmann M, Vogel J, Nafe B Ist die extrakorporelle Stosswellentherapie bei Epicondylitis humeri ulnaris indiziert? Kurzfristige Ergebnisse einer vergleichenden, prospektiven Studie. 1997 Orthopädische Praxis, 7: 465-469

Result number: 84

Message Number 177829

Supply all sorts of herb extracts View Thread
Posted by Anthony Tian on 7/05/05 at 02:39

Acanthopanax 4:1 五加皮提取物 92.00 Achyranthes 10% olc Achyranthes bidentata 牛膝 USD36.00/kg aconite Aconite 4:1 Aconitum carnichaeli 附子 USD37.00/kg Actinidia P.E. 25:1 猕猴桃 Adenophora 10:1 Phospholipids 南沙参 290 FOB GZ by Air Adenophora P. E. 7:1 Phospholipids 南沙参 Adonophora 8:1* Phospholipids 南沙参 200.00 Adsuki Bean 4:1* 绿豆皮 115.00 Adsuki Bean P.E. 15:1 绿豆 148 Agnus Castus Kaempferol Vitex agnus castus 穗花牡荆 USD46.00/kg Agrimony Agrimonia pilosa 仙鹤草 USD35.00/kg Agrimory 12:1 Agrimonins 仙鹤草 190 Agrimory P. E. 4:1 Agrimonins 仙鹤草 Agrimory Powder Agrimonins 仙鹤草生粉 Aiye Leaf 4:1 艾叶 100 Aiye Leaf Powder 艾叶生粉 Akebia Caulis 10:1 木通 248 Alfalfa Powder Medicago sativa 紫花苜蓿 16 Alfalfa 5% Total Flavonoids (HPLC) Medicago sativa 紫花苜蓿 230 Alfalfa 2:1 Medicago sativa 紫花苜蓿 45 Alfalfa 4:1* Medicago sativa 紫苜蓿提取物 45.00 Alfalfa 5:1 Medicago sativa 紫花苜蓿 100 Alfalfa 7:1 Medicago sativa 紫苜蓿 88.00 Alfalfa 8:1 Medicago sativa 紫苜蓿 90.00 Alfalfa 8:1* Medicago sativa 紫苜蓿 125.00 Alfalfa Dicoumarol & 10:1 Medicago sativa 紫花苜蓿 USD38.00/kg Alfalfa P. E. 6:1 Medicago sativa 苜蓿 Alisma Alisma orientali 泽泻生粉 12.00 Alisma 4:1 Alisma orientali 泽泻 95 Alisma 10:1 Alisma orientalis 泽泻 USD38.00/kg Alisma 20:1 Alisma orientali 泽泻 245 Alisma P. E. 1.5% Alisma orientali 泽泻 All Heal 10:1 Prunella vulgaris 夏枯草 USD43.00/kg Almond 4:1 杏仁 180 Almond 15:1 杏仁 350.00 Almond Powder 杏仁生粉 Aloe 2:1 芦荟 Aloe A Vera 4:1 芦荟 130.00 Althaea Rosae Root 4:1 蜀葵 82.00 Althaea Rosae Root 7:1 蜀葵 210.00 270 Amla 30% Tannins 酸藤子 / Amomum 4:1 Amomum villosum 砂仁 USD83.00/kg Amomum P.E. 50:1 沙仁 Amomum P.E. 20:1 砂仁 Amomum Powder 砂仁生粉 Amur Corktree Bark 12:1 黄柏 An leaf summer Podwer 一叶秋 An leaf summer 10:1 一叶秋 Andrographis paniculata P. E. 3% Andrographolide 穿心莲 Andrographis paniculata powder Andrographolide 穿心莲生粉 Andrographis Paniculate 4% Andrographolide 穿心莲 180 Andrographis Paniculate 50% Andrographolide 穿心莲 1800 Andrographis Paniculate 5% Andrographolide 穿心莲 200 Andrographis Paniculate 10% Andrographolide 穿心莲 350 Andrographis Paniculate 95% Andrographolide 穿心莲 3900 Andrographis Paniculate P.E. 7:1 Andrographolide 穿心莲 Andrographis Paniculate P.E. 10:1 Andrographolide 穿心莲 Andrographolide Andrographis paniculata Chuan Xin Lian穿心莲内酯 USD530.00/kg Anemarhenae Asphodeliodes 4:1 知母 145 Anemarhenae sphodeliodes P. E. 3% 知母 Anemarhenae sphodeliodes P. E. 5% 知母 Anemarhenae sphodeliodes P. E. 50% 知母 Anemarhenae sphodeliodes P. E. 95% 知母 Anemarhenae sphodeliodes P. E. 6:1 知母 Angelica/Dong Quai 1%x (HPLC - USA Methods ) Ligustilides 当归 225 (Amax: 177) Angelica/Dong Quai 4:1 当归Just for Amax: 78.00 85 Angelica/Dong Quai 7:1 当归Just for Amax: 85.00 125 Angelicae (Dangguai) Powder 当归生粉 Annual artemisia 8:1* 黄花蒿 112.00 Antifebrile dichroa Dichroine & 10:1 Dichroa febrifuga Chang Shan常山 USD42.00 Apricot 10:1 Prunus armeniaca Ku Xing Ren苦杏仁 USD44.00/kg Aristolochia 7:1 Aristolochia contororta Ma Dou Ling马兜铃 USD33.00/kg Armillarella mrllea 蜜环菌粉 Arnebia (Shikonin) Arnebia euchroma Zi Cao紫草 USD2450.00/kg Asari/Wild Ginger 4:1 Asarum heterotropoides 细辛 136.00 195 Asari/Wild Ginger 10:1(Essential Oils) Asarum heterotropoides 细辛 370 Asari/WildGinger 10:1 细辛 Asari/WildGinger Powder 细辛生粉 Ashwagandha (Zui Qie) 1.5% /1.7% Alkaloids/ Withanolides 南非醉茄 Asparagus Root 4% (HPLC) Asparagosides 天门冬 200 Asparagus Root 10% Asparagosides 天门冬 360 Asparagus Root 4:1 Asparagosides 天门冬 145 Asparagus Root P.E. 18:1 Asparagosides 天门冬 Asparpgua Root 10:1 天门冬提取物 250.00 Asparpgua Root 20:1* 天门冬提取物 440.00 Aster 10:1 Aster tataricus Zi Wan紫菀 USD39.00/kg Astragalus 5:1 Astragalus Membranaceus Huang Qi黄芪 USD42.00/kgUSD27.00/kg Astragalus / Bay Chi 16% (UV-VIS) Polysacchrides 黄芪 150 Astragalus / Bay Chi 70% (UV-VIS) Polysacchrides 黄芪 350 Astragalus / Bay Chi 0.2%/16% Flavone &/ Polysacchrides 黄芪 155 Astragalus / Bay Chi 0.4%/16% Flavone &/ Polysacchrides 黄芪 240 Astragalus / Bay Chi 4:1 Flavone &/ Polysacchrides 黄芪 75 Astragalus / Bay Chi 10:1 Flavone &/ Polysacchrides 黄芪 150 Astraglus Powder Flavone &/ Polysacchrides 黄芪生粉 Atractyhodes 4:1 苍术 94.00 Atractyhodes 15:1 苍术 175.00 Baijiang 4:1 Scabiosides 败酱草 65.00 Baijiang P.E. 12:1 Scabiosides 败酱草 Baijiang Powder Scabiosides 败酱草生粉 Bamboo shavings Powder 竹茹生粉 Barley Grass Juice 16% 麦苗精 Barley Grass Juice 70% 麦苗精 Barley Grass Juice 0.2% 麦苗精 Barley Grass Juice 0.4% 麦苗精 Barley Grass Juice 4:1 麦苗精 Barley Grass Juice 8:1 麦苗精 Barley Grass Juice 20:1 麦苗精 220 Barley Grass Juice Powder 麦苗精生粉 Basil Herb 10:1 Ocimum basilicum Luo Le罗勒 USD48.00/kg Basket fern 10:1 Dryoathyrium crostichoides Guan Zhong贯众 USD38.00/kg Bayberry Root Bark 30:1 Myrica cerifera Yang Mei杨梅 USD62.00/kg Be Mu 4:1 贝母 Bee Pollen Apis mellifica Feng Hua Fen蜂花粉 USD6.80/kg Bee Propolis Apis mellifica Feng Jiao蜂胶   Belamcanda 10:1 Belamcanda chinensis She Gan射干 USD44.00/kg Beta Vulgars P. E. 10:1 恭菜根 Bian Hao 12:1 扁蒿 Bilberry 10%, 25% Athocyanidins Vaccinium Myrtillus Yue Ju越桔 USD290.00/kg Bilberry 10% 越橘 1450 Bilberry 15% 越橘 1900 Bilberry 25% (UV-VIS) Anthocyanidins 越橘 3000 Bilberry 4:1 越橘 120 Bilberry 5:1 越橘 130 Bilberry 12:1 越橘 200.00 230 Bilberry 20:1 越橘 500 Bilberry P. E. 32% 越橘 Bilberry P. E. 10:1 越橘 Bistort 10:1 Polygonum bistorta Quan Shen拳参 USD49.00/kg Bitter cardamon 10:1 Alpinia Oxyphylla Yi Zhi Ren益智仁 USD94.00/kg Bitter Melon 30:1 苦瓜 210 Bitter Melon 25:1 苦瓜提取物 110.00 Bitter Melon 20:1 HPLC Charantin 苦瓜 155 Bitter Melon P. E. 10% Charantin 苦瓜 Bitter Melon P. E. 25% Charantin 苦瓜 Bitter Melon P. E. 12:1 Charantin 苦瓜 Bitter Sophora Root 20% Matrines & Oxymatrine 苦参 220 Bitter Sophora Root 90% Matrines & Oxymatrine 苦参 650 Bitter Sophora Root 4:1* Matrines & Oxymatrine 苦参提取物 40.00 Bitter Sophora Root 5:1 Matrines & Oxymatrine 苦参 100 Bitter Sophora Root 8:1 Matrines & Oxymatrine 苦参 Bitter Sophora Root 20:1 Matrines & Oxymatrine 苦参 Bitter Sophora Root Powde Matrines & Oxymatrine 苦参生粉 Black Bean 15:1 Isoflavones 黑豆 200 Black Bean P. E. 20% Isoflavones 黑豆 Black Bean P. E. 90% Isoflavones 黑豆 Black Bean P. E. 4:1 Isoflavones 黑豆/柿子蒂 158 Black Bean P. E. 5:1 Isoflavones 黑豆 Black Bean P. E. 8:1 Isoflavones 黑豆 Black Bean P. E. 15:1 Isoflavones 黑豆 Black Bean Powder Isoflavones 黑豆生粉 Black Cohosh 1.5% Triterpenes 黑升麻 150 Black Cohosh 2.5% (HPLC) Triterpenes 黑升麻 240 Black Cohosh (7:1 & 4:1) Cimicifuga racemosa Sheng Ma黑升麻 USD35.00/kgUSD21.00/kg Black Cohosh 4:1* Triterpenes 黑升麻 108.00 110 Black Cohosh 4:1 Triterpenes 黑升麻提取物 65.00 Black Cohosh 15:1 Triterpenes 黑升麻 292.00 Black Cohosh P. E. 2:1 Triterpenes 黑升麻 Black Cohosh P. E. 15:1 Triterpenes 黑升麻 Black Cohosh Powder Triterpenes 黑升麻生粉 Black Elder 10:1 Sambucus nigra Jie Gu Mu接骨木 USD52.00/kg Black Seumum 25:1* 黑芝麻 350.00 Black Tea 30%~40% (China UV-VIS) polyphenols 红茶 90 Black Tea P. E. 30% Polyphenols 红茶/功夫茶 Black Tea P. E. 50% Polyphenols 红茶 Black Tea P. E. 15% Polyphenols 红茶(麦芽) Black Tea P. E. 2.5% Polyphenols 红茶 Black Tea P. E. 4:1 Polyphenols 红茶 Black Tea P. E. 10:1 Polyphenols 红茶 Black Tea P. E. 15:1 Polyphenols 红茶 Black Walnut Null 4:1* 核桃提取物 96.00 BlackTea Pohyphenols 90% 红茶多酚 Bladderwrack 10:1 Fucus versiculosus Hai Zao海藻 USD37.00/kg Bletilla Tuber 4:1 白芨 Bletilla tuber 10:1 白芨 Bletilla Tuber Powder 白芨生粉 Blue Flag 10:1 Iris versicolor (tectorum) Yuan Wei鸢尾 USD58.00/kg Boewellia Sorrata 65% Boewellie Acids 乳香树 200 Boneset, Herb 10:1 Eupatorium perfoliatum Pei Lan佩兰 USD38.00/kg Boewellia Serrata 60% Boewellie Acids 乳香提取物 126.00 Broom cypress 10:1 Kochia scoparia Di Fu Zi地肤子 USD38.00/kg Buchu Leaf 4:1 / BuffaloHorn P.E 10:1 水牛角 BuffaloHorn P.E 20:1 水牛角 Bupleurum 5% (UV-VIS) Bupleurum falcatum 柴胡 300 Bupleurum 5:1 Bupleurum falcatum 柴胡 138.00 180 Bupleurum 12:1* Bupleurum falcatum 柴胡 260.00 Bupleurum P. E. 30% Bupleurum falcatum 柴胡 Bupleurum P. E. 10:1 Bupleurum falcatum 柴胡 Bupleurum Powder Bupleurum falcatum 柴胡生粉 Burdock Root 4:1* 牛蒡根提取物 65.00 150 Burdock Root 4:1 Arctiin & Arctigenin 牛蒡子 105.00 Burdock Root 10:1 牛蒡根 135.00 Burdock Root P. E. 5% 牛蒡根 Burdock root P. E. 10:1 Arctium lappa Niu Bang Gen牛蒡根 USD45.00/kg Burdock Root Powder 牛蒡根生粉 Burdock Seed 40% Arctiin & Arctigenin 牛蒡籽 280 Burdock Seed 4:1 牛蒡籽 140 Butcher's Broom Root 2.5% Ruscus aculeata Jia Ye Shu假叶树   Caffeine 30% 咖啡因 Caffeine 40% 咖啡因 Caffeine 70% 咖啡因 Caffeine 80% 咖啡因 Calendula Flower 10:1 Calendula officinalis Jin Zhan Hua金盏花 USD88.00/kg Camellia Oleifera 7:1* 油茶树 65.00 Camphor 8:1 樟芽 Camptothecine 90%, 98% Xi Shu Jian喜树碱 USD15500/kg Capillaris 20:1* 因陈蒿 120.00 Capillary wormwood 10:1 Artemisia scoparia Yin Chen茵陈 USD38.00/kg Carrot Juice 20:1 Carrotenoids 胡萝卜汁 140 Carrot Juice Powder 25:1* Carrotenoids 胡罗卜 72.00 Carrot Juice Powder Carrotenoids 胡萝卜汁粉 Carrot Juice Powder 40% Carrotenoids 胡萝卜精 Carrot Juice Powder 4:1 Carrotenoids 胡萝卜精 Carthamus 10:1* 红花 290.00 Cascara Sagrada Bark Cascara Sagrada Shu Li鼠李 USD48.00/kg Cassia Fistula 1.5% Anthraquinones 婆罗门皂荚 240 Cassia Seed 5% Cassia tora 决明子 Cassia Seed 15:1* Cassia tora 决明子 150.00 Cassia Tora / Juemingzi 10:1 Cassia tora 决明子 160 Cat Nut 7% 荆芥 70.00 Cat Nut 4:1 荆芥 130 Cat Nut 8:1 荆芥 Cat Nut P. E. 20:1 荆芥 Cat Nut Powder 荆芥生粉 Cat’s Claw 4% Alkaloids 钩藤 260 Cat’s Claw 4:1 钩藤 110 Catnip 10:1 Nepeta cataria Jing Jie心叶荆芥 USD42.00/kg Cat's Claw 猫爪草 Cat's Claw 4:1,& 3% Alk. Uncaria rhynchphilla 钩藤/猫爪草 USD39.00/kg Cayenne P. E. 辣椒 Cayenne P. E. 12:1 辣椒 Celandine 2% Chelldonine 白屈菜 170 Celandine 4:1 Chelldonine 白屈菜 85.00 Celandine 12:1* Chelldonine 白屈菜 180.00 Celandine P. E. 2% Chelldonine 白屈菜 Celandine P. E. 8:1 Chelldonine 白屈菜 Celery Seed P. E. 欧芹籽 Centipede Powder 蜈蚣生粉 Chaenomeles 8:1 木瓜 115.00 Chain fern 10:1 Cibotium barometz Gou Ji狗脊 USD38.00/kg Chamomile 1.2%/0.5% HPLC Apigenin/ Essential Oil 母菊 260 Chamomile 4:1 母菊 150 Chasteberry 5% (HPLC) Vitexin 蔓荆子 420 Chasteberry 4:1 Vitexin 蔓荆子 200 Chasteberry 10:1 Vitexin 蔓荆子 390 Chastetree fruit 5:1 Vitex trifolia L. Man Jing Zi蔓荆子 USD62.00/kg Cherokee rose fruit 10:1 Rosa laevigata Michx Jing Ying Zi金樱子 USD34.00/kg Chickweed Herb 10:1 Stellaria media Fan Lv繁缕 USD39.00/kg Chicory Inulin: 90% Cichorium iintybus Ju Ju菊苣 USD77.00/kg Chinese Anemone 12:1* 白头翁提取物 180.00 ChineseAnemone Powder 白头翁生粉 Chinese Mosla Herb 10:1 香芋草 Chondroitin Sulfate (Bovine) 90% Chondroitin Sulfate 硫酸软骨素(牛骨) / Chondroitin Sulfate (Bovine) 95% Chondroitin Sulfate 硫酸软骨素(牛骨) / Chondroitin Sulfate (Bovine) 98% Chondroitin Sulfate 硫酸软骨素(牛骨) / Chrysanthemum 12:1 Parthenolide 菊花 270.00 300 Chrysanthemum P. E. 2% Parthenolide 菊花 Chrysanthemum P. E. 4:1 Parthenolide 菊花 Chrysanthemum Powder Parthenolide 菊花生粉 Cinnamon 15:1* 肉桂 280.00 Cinnamon Bark 20:1 桂皮 300 Cinnamon Bark P. E. 4:1 桂皮 Cinnamon Bark P. E. 12:1 桂皮 Cinnamon Bark Powder 肉桂生粉 Cinnamon P. E. 40:1 Cinnamaldehyde 肉桂 Cistanche, 5% alk. & 5:1 Cistanche deserticola Rou Cong Rong肉苁蓉 USD68.00/kg Citrus Aurantinum 4% (HPLC) Synepherin 枳实 130 Citrus Aurantinum 30% Synepherin 枳实 1300 Citrus Aurantinum 6% Synepherin 枳实 175 Citrus Aurantinum 8% Synepherin 枳实 220 Citrus Aurantinum 10% Synepherin 枳实 315 Citrus Aurantinum 20% Synepherin 枳实 800 Citrus Aurantinum 30:1 Synepherin 枳实 Citrus Aurantinum Powder 枳实生粉 Classial Cassia 4:1 草决明 Cleaver Herb 10:1 Galium aparine Zhu Yang Yang猪殃殃 USD37.00/kg Clematis root Clematis chinensis Wei Ling Xian威灵仙 USD42.00/kg Cloves 4:1 丁香 150.00 200 Cloves P. E. 4% 丁香 Cloves P. E. 6% 丁香 Cloves P. E. 8% 丁香 Cloves P. E. 20:1 丁香 Cloves Powder 丁香生粉 Club Moss P. E. Huperzine A 千层塔 Club Moss P. E. 4:1 Huperzine A 千层塔 115.00 Club Moss P. E. 10:1 Huperzine A 千层塔 210.00 Cnidium fruit 10:1 Cnidium monieri She Chuang Zi蛇床子 USD38.00/kg Cochinchina momordica 10:1 木鳖子 Codonopsis 10:1 Codonopsis Pilosula Dang Shen党参 USD49.00/kg Codonopsis Root 4:1 Codonopsis Pilosula 党参 190 Codonopsis Root P. E. 20:1 Codonopsis Pilosula 党参 Codonopsis Root Powder Codonopsis Pilosula 党参根生粉 Coix Seed 薏苡仁生粉 Coloed mistletoe herb 2:1 槲寄生 Coltsfoot, leaf 10:1 Tussilago farfara Kuan Dong Hua款冬花 USD46.00/kg Combined Spicebush Root 20% 乌药 Combined Spicebush Root 8:1* 乌药 132.00 Commen Hong Fennel Root 前胡 Common Curcaligo Rhizome 4:1 仙茅 100.00 Common Lophatherum Herb 12:1 淡竹叶 Cooked Rehmannia P.E. 6:1 熟地 Cooked Rehmannia Powder 熟地生粉 Coptis Root 10% Berberine Copitids Chinensis 黄连根 560 Coptis Root 8:1* Copitids Chinensis 黄连提取物 300.00 Coptis Root 98% Berberine & 10:1 Copitids Chinensis Huang Lian黄连 USD148.00/kg Coptis Root 10:1 Copitids Chinensis 黄连根 800 Coptis Root P. E. 10% Copitids Chinensis 黄连 Coptis Root P. E. 3:1 Copitids Chinensis 黄连 Coptis Root P. E. 4:1 Copitids Chinensis 黄连 Coptis Root Powder Copitids Chinensis 黄连生粉 Cordyceps Sinensis 冬虫夏草菌 Cordyceps Sinensis 4:1 冬虫夏草菌丝体 510.00 Cordycops 4:1 兔丝子提取物 120.00 Cordycops 16:1 兔丝子 294.00 Cordycops 20:1 兔丝子 535.00 Cordycops 20:1* 兔丝子 570.00 Coriolus Mushroom 20% Polysaccharides 云芝 360 Coriolus Mushroom 10:1 Polysaccharides 云芝提取物 140.00 Coriolus Mushroom 12:1 Polysaccharides 云芝 200.00 Coriolus Mushroom 20:1 Polysaccharides 云芝 260.00 320 Coriolus ushroom (Yunzhi) 4:1 Polysaccharides 云芝 Coriolus ushroom (Yunzhi) 10:1 Polysaccharides 云芝 Coriolus Versicolor Polysaccharides 云芝菌粉 Corn Silk 15% Zea mays Yu Mi Xu玉米须 USD37.00/kg Cornsilk 4:1 玉米须 140 Cornsilk P. E. 20:1 玉米须 Cornsilk Powder 玉米须生粉 Corus OfficinalisP. E. 3% 茱萸 Corus OfficinalisP. E. 4:1 茱萸 150.00 200 Corus Officinalis Powder 山茱萸生粉 Corus Officinals 5:1 山茱萸 340.00 Corydaila 25:1 Bio-Akloids 延胡索 540.00 Corydaila Powder 延胡索生粉 Corydalis Rhizome 5:1 Corydalis decumbens Xia Tian Wu夏天无 USD52.00/kg Corydalis Yanhusuo W. T. Wang 80% (HPLC) Total Alkaloids 延胡索 6400 Corydalis Yanhusuo W. T. Wang 25:1 Total Alkaloids 延胡索 750 Corydalis, 5% alk.& 10:1 Cordalis bungeana Ku Di Ding苦地丁 USD38.00/kg Costustoot 8:1 8:1 木香 Cranberry 10:1 蔓越桔 200 Cranesbill 4:1 Geranium maculatum 老鹤草 90 Cranesbill 10:1 Geranium maculatum Lao Guan Cao老鹳草 USD38.00/kg Cranesbill P. E. 25:1 Geranium maculatum 老鹤草 Cranesbill Powder Geranium maculatum 老鹤草生粉 Creeper 7:1 Quisqualis indica Shi Jun Zi使君子 USD39.00/kg Cubeb Berry 10:1 Piper cubeba Bi Cheng Qie荜澄茄 USD68.00/kg Curculigo 5:1 Curculigo orchioides Xian Mao仙茅 USD38.00/kg Curcumae 2:1 Curcujinoids 姜黄/郁金 158.00 Curcumae 12:1 Curcujinoids 姜黄/郁金 220 Curcumae Powder Curcujinoids 郁金生粉 Curcumin 95% x Curcuminoids 姜黄素 1350 Cushaw seed 4:1 南瓜子 Cyathula Root 4:1 川牛膝 115.00 Cyperus tuber 10:1 Cyperus rotundus Xiang Fu香附 USD40.00/kg Dahurian Angelica Root 4:1 白芷 Dahurian Angelica Root 12:1 白芷 Dahurian Rhododenron Leaf 50% Proanthocyanidins 映山红 650 Dahurian Rhodoendron Leaf 70% Proanthocyanidins 满山红 850 Damiana Leaf 4:1 Proanthocyanidins 满山红 48.00 / Dandelion 3% (HPLC) Flavonoids 蒲公英 150 Dandelion 2:1* Flavonoids 蒲公英提取物 38.00 Dandelion 4:1 Flavonoids 蒲公英 75 Dandelion 7:1* Flavonoids 蒲公英提取物 65.00 Dandelion 8:1 Flavonoids 蒲公英 120 Dandelion 14:1 Flavonoids 蒲公英根 155.00 Dandelion Herb P. E. 10:1 Flavonoids 蒲公英 Dandelion Powder Flavonoids 蒲公英生粉 Dark Plumfruit 4:1 乌梅 Dark Plumfruit 8:1 乌梅 158.00 Decumbent Corydalis Tuber 20:1 夏天无 Devil’s Claw Root 3% (HPLC) Harpagosides 钩果草 300 Devil’s Claw Root 4:1 钩果草 170 Devil's Club, root bark 1.5-5% Harpagosides Ci Shen刺参   Diospyros kaki P.E. 4:1 柿子蒂 60 Diospyros kaki Powder 柿子蒂生粉 Dipscus 5% alk & 10:1 Dipsacus asperoides Xu Duan续断 USD42.00 Dogbane powder 西番莲 Dogwood Fruit, 20% cornin & 7:1 Cornus officinals Shan Zhu Yu山茱萸 USD460.00/kg Angelica/Dong Kuai 1% & 7:1 Ligustilide Dang Gui当归 USD28.00/KG Dong Ling 5:1 冬凌草 Angelica/Dong Kuai 2:1 当归提取物 5.00 Angelica/Dong Kuai 1% Ligustilide 当归 Angelica/Dong Kuai 0.1% Ligustilide 当归 Angelica/Dong Kuai 4:1 Ligustilide 当归 Angelica/Dong Kuai 7:1 Ligustilide 当归 Angelica/Dong Kuai 12:1 Ligustilide 当归 Dragon Blood 4:1 血竭 92.00 Drug solomonseal 10:1 Polygonatum oddratum Yu Zhu玉竹 USD45.00/kg Drynaria 10:1 Drynaria fortunei Gu Sui Bu骨碎补 USD38.00/kg Drynaria Root 4:1 Drynaria fortunei 骨碎补 95.00 Drynaria Root 15:1 Drynaria fortunei 骨碎补 140.00 Dryopteris 15:1 贯众 200 Dryopteris P. E 3% 贯众 Dryopteris Powder 贯众生粉 Dwarf lilyturf tuber 10:1 麦冬 Dwarf lilyturf tuber 20:1 麦冬 East Asian Tree Ferm Rhizome 4:1 狗脊 East Asian Tree Ferm Rhizome 12:1 狗脊 Echinacea P.E. 4:1 hinacea angustifolia 紫锥菊 175 Echinacea Purpurea Herb 4% Phenolic Compounds 紫锥菊 200 Eclipta 10% Eclipta prostrata Han Lian Cao旱莲草 USD46.00/kg Elderberry 5% (UV-VIS) Anthocyanidins 蒴藋 700 Elderberry 5:1 Anthocyanidins 蒴藋 160 Elderberry P. E. 10:1 Anthocyanidins 蒴瞿 Elderberry P. E. 15:1 Anthocyanidins 蒴瞿 Elderberry Powder Anthocyanidins 蒴瞿生粉 Elecampane 7:1 Inula helenium Tu Mu Xiang土木香 USD38.00/kg Elecampane Flower 10% 旋复花 Elecampane Flower 40% 旋复花 Elecampane Flower 5% 旋复花 Elecampane Flower 2:1* 旋复花 38.00 Elecampane Flower 4:1 旋复花 140 Elecampane Flower 5:1 旋复花 Elecampane Powder 旋复花生粉 Emblic Leafflower Fruit 佘甘子 Eordythia P. E. 10:1 连翘 Eordythia P. E. 20:1 连翘 Eordythia Powder 连翘生粉 Ephedra 6% Ephedra Sinica Stapf Ma Huang麻黄   Ephedra P.E. 20% Ephedrines 麻黄 Epigeal srephaia root 80% 地不容 Epigeal srephaia root 4:1 地不容 Epimedium 5% Flavonoids 淫羊藿 200 Epimedium 8% 淫羊藿 250 Epimedium 1:1 淫羊藿生粉 10.00 Epimedium 10:1 淫羊藿 108.00 Epimedium 20:1 淫羊藿提取物 170.00 Epimedium P.E. 3% Epimedioside 淫羊藿 Eucommia Bark 10:1 Eucommia ulmoides Du Zhong杜仲 USD58.00/kg Eucommia Bark 20:1 杜仲皮 500 Eucommia Bark P. E. 4:1 杜仲皮 Eucommia Leaf Powder 杜仲叶生粉 Eucommia Leaves 2:1 杜仲叶 45.00 Eucommia Leaves 7:1 杜仲叶 120 Europe Chrysanthemum 0.1% 欧小菊 European Verbena 4:1 马鞭草 100.00 European Verbena 5:1 马鞭草 110.00 Evening-Primrose Oil(EPO) 10% Oenothera biennis Yue Jian Cao月见草油 USD5.20/KG Evodia 20:1 吴茱萸 800 Evodia fruit 4:1 Evodia lepta Wu Zhu Yu吴茱萸 USD53.00/kg Evodia P.E. 20:1 Bio-akloids 吴茱萸 Evodia Powder 吴茱萸生粉 Eyebright Herb 4:1 Euphrasia officinalis 小米草 200 Fannel Foeniculum vulgare Xiao Hui Xiang小茴香   Fennel Seed Powder 小茴香 32 Fennel Seed 4:1 小茴香 115 Fennel Seed 12:1* 小茴香 130.00 Fennel Seed 15:1 小茴香 158.00 240 Fennel Seed P. E. 7:1 小茴香 Fenugreek 25:1 葫芦巴 255 Fenugreek 4:1 葫芦巴 115 Fenugreek 10:1 葫芦巴提取物 150.00 Fenuguek 20:1 葫芦芭 Feverfew 欧菊花 Feverfew 0.1% (HPLC) Parthenolide 欧甘菊 Feverfew 0.8% 欧甘菊 / Feverfew 4:1 欧甘菊 Feverfew P.E. 0.1% Parthenolide 菊花 Fevervine Herb 18:1 鸡血藤 Fig, fruit 7:1 Ficus carica Wu Hua Guo无花果 USD43.00/kg Figwort root 玄参 Figwort root 5% 玄参 Figwort root 6:1 玄参 Figwort root 10:1 玄参 Figwortflower Picrohiza Rhizom 3:1 胡黄连 172.00 Figwortflower Picrohiza Rhizom 4:1* 胡黄连 220.00 Figwortflower Picrohiza Rhizom 5:1 胡黄莲 Figwortflower Picrohiza Rhizom 8:1* 胡黄连 410.00 Finger citron 4:1 Citrus medica sarcodactylis Fo Shou佛手 USD87.00/kg Flammulina Velutipes 金针菇菌粉 Fo Ti P.E 2:1 何首乌提取物 42.00 Fo Ti P.E 8:1 何首乌提取物 116.00 Fo Ti P.E 10:1 何首乌提取物 116.00 Fo Ti P.E 14:1 何首乌提取物 210.00 Fo Ti Powder Phosphatide 何首乌生粉 Fo Ti / Ho Shou Wu 2% Phosphatide 何首乌 165 Fo Ti / Ho Shou Wu 4:1 何首乌 80 Fo Ti / Ho Shou Wu 12:1 Phosphatide 何首乌 160 Fragrant Solomonseal Rhizome 4:1 玉竹 Frankincense 三代 乳香 Frankincense 60% 乳香 Fu Ling 40% Poris Cocos Fu Ling茯苓 USD35.00/kg Fufang1302 复方1302 Fufang-4 10:1 复方4 Fufang-A 复方A Fufang-kangbing 抗病毒复方 Fumitory 10:1 Fumaria officinalis Zi Jin紫堇 USD44.00/kg Galangal 10:1 Alpinia officinarum Gao Liang Jiang高良姜 USD28.00/kg Galange resurrectionlily 5:1 Kaempferia galanga Shan Nai山奈 USD36.00/kg Gan Lan 4:1 甘蓝 Ganoderma Lucidum 灵芝菌粉 Ganoderma Lucidum Karst 60% Polyose 赤芝 3800 Garcinia (potassiun) 10% 麻黄 Garcinia (potassiun) 6% 麻黄 Garcinia (potassiun) 8% 麻黄 Garcinia Cambogia Fruit/ Gamboge 65% Garcinia hanburgy Teng Huang藤黄   Garcinia Cambogia Fruit/ Gamboge 50% Hydroxycitric Acid 藤黄 / Garden Euphorbia Herb 4:1 大飞扬草 Gardenia 10:1 Gardenia Jasminoides Zhi Zi栀子 USD35.00/kg Gardenia Fruit P. E. 8:1 栀子 Garlic 2% Allicin 大蒜 / Garlic 1% (HPLC) Allicin 大蒜 120 Garlic 4:1 Allicin 大蒜 80.00 Garlic P. E. 25:1 Allicin 大蒜 Gastrodia Rhizoma 4:1 天麻 350.00 Gastrodia Rhizoma 20:1 天麻 2,100.00 2000 Gastrodia Rhizoma Powder 天麻生粉 Gastrodia Tuber 5:1 Gastrodia eleta Tian Ma天麻 USD128.00/kg Gecko P.E. 10:1 壁虎 Gecko Powder 壁虎生粉 Gentain 龙胆草生粉 38.00 Gentian P. E. 5:1 Gentianine 龙胆草 Gentian Root 5% Gentiopicroside 龙胆草 180 Gentian Root 10% 龙胆草 280 Gentian Root 4:1 龙胆草 150 Giant Knotweed P. E. 50% 虎杖 Giant Knotweed P. E. 15% 虎杖 Giant Knotweed P. E. 20% 虎杖 Giant Knotweed P. E. 4% 虎杖 Giant Knotweed P. E. 20:1 虎杖 Giant Knotweed P.E. 80% 虎杖 254 Giant Knotweed Powder 虎杖生粉 Ginger 4:1 Gingerols 生姜 105.00 Ginger 5:1 Gingerols 生姜 120.00 Ginger P. E. 2% Gingerols 生姜 Ginger P. E. 5% Gingerols 生姜 250 Ginger P. E. 8:1 Gingerols 生姜 200 Ginger P. E. 12:1 Gingerols 生姜 Ginger Powder 生姜生粉 Gingko Biloba 24% 6% Gingko Biloba Ying Xing银杏 USD92.00/kg Ginkgo Biloba Leaf 24% (HPLC)6% (HPLC) Ginkgoflavoglycosides/ Terpene Lactories 银杏叶 320 Ginkgo Biloba Leaf 1:1 银杏叶生粉 8.50 Ginkgo Biloba Leaf 4:1 银杏叶 90.00 Ginkgo Biloba Leaf 7:1 银杏叶 90.00 Ginkgo Biloba Leaf, <5 ppm 24% (HPLC)6% (HPLC) Ginkgoflavoglycosides/Terpene Lactories/<5ppm 银杏叶 600 Ginnamon Bark 4:1* 桂皮 62.00 Ginseng C.A. 80% Saponin 人参 680 Ginseng Leaf P. E. 20% 人参叶 Ginseng Leaf P. E. 7:1 人参叶 Ginseng Leaf Powder 人参叶生粉 Ginseng Root 10%(UV-VIS) Ginsenosides 人参 260 Ginseng Root 20% 人参 500 Ginseng Root 30% 人参 650 Ginseng Root 80% 人参 900 Ginseng Root ( American ) 25%(UV-VIS) Ginsenosides 人参 / Ginseng Root P. E. 15% 人参 Ginseng Root P. E. 90% 人参 Glehnia Root 7:1 Glehnia littoralis Bei Sha Shen北沙参 USD31.00/kg Globethistle root 10:1 Rhaponticum uniflourum Lou Lu漏芦 USD39.00/kg Glucosamine HCL 90% Glucosamine 葡萄糖 / Golden Rod 5% (HPLC) Flavonoids 一支黄花 210 Golden Rod 一枝黄花生粉 9.50 Golden Rod 4:1 一枝黄花 90.00 Golden rod 6:1 Solidago virgaurea Yi Zhi Huang Hua一枝黄花 USD27.00/kg Golden Rod P. E. 5% 一枝黄花 Golden Rod P. E. 8:1 一枝黄花 Golden Rod P. E. 10:1 一枝黄花 Golden Seal Root 5% Total Akloids 北美黄连提取物 270.00 380 Golden Seal Root P. E. 10% 北美黄连 Golden Seal Root P. E. 35% Hydrastis canadensis 北美黄连 Golden Seal Root P. E. 4:1 北美黄连 Golden Seal Root P. E. 8:1 北美黄连 Gordon euryale seed 5:1 Euryale ferox Qian Shi芡实 USD32.00/kg Gotu Kola 10:1 积雪草 135.00 Gotu Kola Herb 10% Triterpenes (HPLC) 积雪草 230 Gotu Kola Herb 20% 积雪草 450 Gotu Kola Herb 4:1 积雪草 120 Gotu Kola Herb 8:1 积雪草 200 Gotu Kola P. E. 90% Centella asiatica 积雪草 Gotu Kola P. E. 7:1 积雪草 Gotu Kola P.E. 80% Triterpenes 积雪草 Gotu Kola Powder 积雪草生粉 Grape leaf P.E. 葡萄叶 Grape Seed 95% (UV-VIS) Proantocyanidins 葡萄籽 1250 Grape Seed P. E. 20:1 葡萄籽 Grape Seed Powder 葡萄籽生粉 Grape Skim Extract 20:1 葡萄皮提取物 225.00 Grape Skin 20% (UV-VIS) Polyphenols 葡萄皮 200 Grape Skin 30% 葡萄皮 270 Grape Skin P. E. 20% Proanthocyanidins 葡萄皮 Grape Skin Powder 葡萄皮生粉 Grassleaf Sweetflag ASarone & 10:1 Acorus gramineus Shi Chang Pu石菖蒲 USD42.00/kg Grassy Privet 20% trit. & 10:1 Ligustrum lucidum Nv Zhen Zi女贞子 USD42.00/kg Gravel Root 10:1 Eupatorium purpureum Pei Lan佩兰 USD38.00/kg Green Tea 绿茶 Green Tea Caffeine 30% 儿茶素 115 Green Tea Caffeine 40% 儿茶素 250 Green Tea Caffeine 50% 儿茶素 350 Green Tea Caffeine 60% 儿茶素 450 Green Tea Caffeine 70% 儿茶素 550 Green Tea Caffeine 80% 儿茶素 700 Green Tea Caffeine 10% 茶天然咖啡因 100 Green Tea Caffeine 20% 茶天然咖啡因 160 Green Tea Caffeine 40% 茶天然咖啡因 280 Green Tea Caffeine 50% Green Tea (HPLC) Natural Caffeine 茶天然咖啡因 380 Green Tea Caffeine 30% / <0.5% 儿茶素 200 Green Tea Caffeine 50% / <0.5% 儿茶素 450 Green Tea Caffeine 60% / <0.5% 儿茶素 550 Green Tea Caffeine 70% / <0.5% 儿茶素 650 Green Tea Caffeine 80% / <0.5% 儿茶素 900 Green Tea Caffeine 85% / <0.5% 儿茶素 950 Green Tea Catechins 20% (HPLC) Catechins / Caffeine 儿茶素 75 Green Tea EGCg 10% (HPLC) EGCg 儿茶素EGCg 100 Green Tea EGCg 60% EGCg 儿茶素EGCg 1000 Green Tea EGCg 95% EGCg 儿茶素EGCg 1200/g Green Tea EGCg 20% EGCg 儿茶素EGCg 300 Green Tea EGCg 30% EGCg 儿茶素EGCg 500 Green Tea EGCg 97% Polyphenols / 65%Catechins / 38%EGCg / <4% Caffeine EGCg 儿茶素EGCg 550 Green Tea EGCg 50% EGCg 儿茶素EGCg 900 Green Tea EGCg 97% / 65% /38% /<0.5% EGCg 儿茶素EGCg 600 Green Tea Polyphenols 50% 茶多酚 100 Green Tea Polyphenols 60% 茶多酚 200 Green Tea Polyphenols 70% 茶多酚 300 Green Tea Polyphenols 80% 茶多酚 400 Green Tea Polyphenols 90% 茶多酚 500 Green Tea Polyphenols 98% 茶多酚 650 Green Tea Polyphenols 40% 茶多酚 90 Green Tea Polyphenols 50% / <0.5% 茶多酚 250 Green Tea Polyphenols 98% / 80% / 45% EGCg / <0.5% 茶多酚 Green Tea Polyphenols 98% / 80% / <1.0% 茶多酚 Green Tea Polyphenols 30% / 20% /<1.0% 茶多酚 Green Tea Polyphenols 40% / 25-30% / <1.0% 茶多酚 Green Tea Polyphenols 50% / 35-40% / <1.0% 茶多酚 Green Tea Polyphenols 60% / 45% / <1.0% 茶多酚 Green Tea Polyphenols 70% / 50-55% / <1.0% 茶多酚 Green Tea Polyphenols 80% / 60% / <1.0% 茶多酚 Green Tea Polyphenols 90% / 70% / <1.0% 茶多酚 Green Tea Polyphenols 95% / 75-80% / <1.0% 茶多酚 Green Tea Polyphenols 40% / 25-30% /7-10% 茶多酚 Green Tea Polyphenols 50% / 35-40% / 7-10% 茶多酚 Green Tea Polyphenols 60% / 45% / 7-10% 茶多酚 Green Tea Polyphenols 70% / 50-55% /7-10% 茶多酚 Green Tea Polyphenols 80% / 60% / 7-10% 茶多酚 Green Tea Polyphenols 90% / 70% / 7-10% 茶多酚 Green Tea Polyphenols 95% / 75-80% / 7-10% 茶多酚 Greenbrier 10% Z & E Sterones & 10:1 Smilax glabra Tu Fu Ling土茯苓 USD40.00/kg Griffonia Seed 99% 1-5- Hydroxyiryninphan 5-HTP Grosvener siraitia 罗汉果 Grosvener siraitia 4:1 罗汉果 Guarana Seed 10% Caffeine / Guarana Seed 22% / Guggul 4% / Guggul 2.5% Guggulsterones / Gunostemma 7:1;20% 绞股兰 95.00 Gymnema 25% Gymnemic Acids 武靴藤 310 Gymnema flower 4:1 武靴藤 Gymnema flower 5:1 武靴藤 Gymnema flower 8:1 武靴藤 Gymnema flower 18:1 武靴藤 Gynostemma 20% (HPLC) Gypenosides 绞股蓝 240 Gynostemma 40% 绞股蓝 400 Gynostemma 80% 绞股蓝 700 Gynostemma 90% 绞股蓝 800 Gynostemma P. E. 7:1 绞股兰 Gynostemma P.E. 95% Gypenosides 绞股兰 Gynostemma Powder 绞股兰生粉 Hairy Antler Powder 鹿茸生粉 Hawthorn Berry 2% Vitexins (HPLC) Cretaegus Laevigata 山楂果 / Hawthorn Berry 4% Cretaegus Laevigata 山楂果 / Hawthorn Berry 4:1 Cretaegus Laevigata 山楂果 75 Hawthorn Berry 7:1 Cretaegus Laevigata 山楂果 110 Hawthorn Berry P. E. 5% Cretaegus Laevigata 山楂 Hawthorn Berry P. E. 10:1 Cretaegus Laevigata 山楂 Hawthorn Leaves 2% Hyperosides (HPLC) 山楂叶 240 Hawthorn Leaves P. E 山楂生粉 8.50 Hedyotis diffusa 12:1 白花舌蛇草 300 Hedyotis P. E 12:1 牛白藤. Heitao 4:1 核桃 Hemidesmus indicus 20% Saponins / Henbane 10:1 & Hyoscyamine Hyoscyamus niger Tian Xian Zi天仙子 USD69.00/kg Hericium Hericium erinaceus Hou Tou Mo猴头蘑 USD35.00/kg Hericium Caputmedusas 猴头菌粉 Herrate Clubomoss 1% & 5% Huper Cinum-A Huperezia Serrata Qian Cheng Ta千层塔 1%:USD1320.00/KG5%:USD2780.00/KG Hibiscus Flower 1% (UV-VIS) Anthocyanidins 木芙蓉花/玫瑰茄 185 Hibiscus Flower 玫瑰茄/玫瑰茄生粉 36.00 Hibiscus Flower P. E. 4:1 木芙蓉花/玫瑰茄 Honey Suckle Flower 4:1 金银花 Honey Suckle Flower 7:1 金银花 200 Honey Suckle Flower Powde 金银花生粉 Honey Suckle Stem 10:1 忍冬藤 120 Honey suckle Stem Powder 忍冬藤生粉 Hops Girardinia cuspidata She Ma Cao蛇麻草 Hops Flower 0.35% (HPLC) Flavonoids as Rutosid 啤酒花 220 Hops Flower 4:1 啤酒花 68.00 Hops Flower P. E. 0.35% 啤酒花 Horehound Marrubium vulgare Xia Zhi Cao夏至草 Horse Chest Nut 20% Aesbin (UV-VIS) 娑罗子 315 Horse Chest Nut P. E. 12:1 娑罗子 Horse Chest Nut Powder 娑罗子生粉 Horse Ohestt Nut 18:1 娑罗子 540.00 Horsetail Organic Silica:7%, 10% Equiseti Arvensis Wen Jing问荆 7%:USD18.00/KG;10%: USD27.00/KG Horsetail 2% Silica (Atomic Absorption) Silica 问荆 120 Horsetail 7% Silica 问荆 160 Horsetail 4:1 Silica 问荆 68.00 Horsetail 4:1* Silica 问荆 102.00 Horsetail 7:1 Silica 问荆 85.00 Horsetail 10:1 Silica 问荆提取物 77.00 Horsetail 12:1* Silica 问荆提取物 85.00 Horsetail Powder 问荆生粉 Houttuynia 10:1 鱼腥草 150 Houttuynia Powder 鱼腥草生粉 Huperzia Serrata 1% Huperzine A (HPLC) 石杉碱 11000 Huperzia Serrata 99% 石杉碱 3300/g Huperzia Serrata 5% 石杉碱 55000 Hydrangea Root 4:1 常山 74.00 130 Hydrangeu Root 15:1 土常山 150.00 Hypoglauca yam 10:1 Dioscorea gracillima Bi Xie萆解 USD39.00/kg Indigowoad Leaf 2:1 大青叶 28.00 Indigowoad Leaf 5:1 大青叶 Indigowoad Leaf 7:1 大青叶 78.00 Indigowoad Leaf 7:1* 大青叶 112.00 Inkberry, root 10:1 Phytolacca americana Shang Lu商陆 USD42.00/kg Inmortal, root 5:1 Asclepias asperula Xu Chang Qing徐长卿 USD43.00/kg Inula Helehium 4:1 土木香 80.00 Inula Helehium 8:1 土木香 120.00 Inula racemosa 0.2% Alkaloids 土木香 200 Isatis indigotica fort 60% Indirum 板蓝根 8000 Isatis indigotica fort 7:1 板蓝根 Isatis indigotica fort 12:1 板蓝根 Isatis Root 10:1* 板兰根 100.00 Island Moss 依兰苔 Jackbean Flower 20:1 豆蔻/瞿麦 Jackbean flower Powder 豆蔻生粉 Jasmine Tea 40% Plyphenols (UV-VIS) 茉莉花茶 130 Jasmine tea 4:1 茉莉花 Java brucea, fruit 10:1 Brucea javanica Ya Dan Zi鸦胆子 USD42.00/kg Ji Long Corydalis P.E. 25:1 夏天无 Ji Long Corydalis Powder 夏天无生粉 Juniper Berries 7:1 Juniperus communis Ci Bai刺柏 USD46.00/kg Kamboo Leaf 2:1 淡竹叶 120.00 Kansui root 5:1 Euphorbia kansui Gan Sui甘遂 USD72.00/kg Karela 3% Bitters / Kava Kava 30% (HPLC) Kavalactones 卡瓦根 750 Kelp P.E. 50:1 海带 340.00 Kelp P.E. 50:1* 海带 380.00 Kelp P.E. 1:1* 海带生粉 12.00 Kelp P.E. 20:1 海带 185.00 Kiwi Mogrosides 80%, 90% Siraitia grosvenoril Luo Han Guo罗汉果 Knotweed Herb 8:1 火炭母 Kola Nut 10% Caffeine 可可 / Kola Nut 12% 可可 / Kola Nut 20% 可可 / Korean Ginseng 高丽参 Kudzu Root 4:1* 葛根 42.00 Kudzu Root (Puerara) P. E 40% 葛根 Kudzu Root (Puerara) P. E 60% 葛根 Kudzu Root (Puerara) P. E 10:1 葛根 L-5HTP 99% L-5- Hydroxytryptophan Largeleaf Gentian Root 12:1 秦艽 Lemop Balm 4:1* 滇荆芥 65.00 Lentinus Edodes 香菇菌粉 Licorice P. E. 26% 甘草 Licorice P. E. 4:1 甘草 96.00 Licorice P. E. 10:1 甘草 Licorice P. E. 12:1 甘草 Licorice P.E. 12% Glycyrrhizic Acid 甘草 Licorice Powder 甘草生粉 Licorice Root 20% 甘草 100 Licorice Root 10% (HPLC, 100% Natual Extract) Glycyrrhizic Acid 甘草 85 Liferoot 10:1 Senecio aureus Qian Li Guang千里光 USD46.00/kg Ligusticum 5:1* 蒿本 180.00 Ligusticum 10:1 篙本 170 Ligusticum P. E. 4:1 藁本 Ligusticum P.E. 7:1 蒿本 Ligustrum 4:1 Triterpenes 女贞子 56.00 Ligustrum 10:1 Triterpenes 女贞子 138.00 200 Ligustrum 12:1 Triterpenes 女贞子 120.00 Ligustrum P. E. 50% Triterpenes 女贞子 Ligustrum Powder Triterpenes 女贞子生粉 Lindera aggregata 10:1 Lindera aggregata Wu Yao乌药 USD38.00/kg Lobelia Intiata 4:1 半边莲 180 Lobelia Intlata Powder 半边莲生粉 Long Pepper Piper longum Bi Ba荜茇 USD38.00/kg Longan Aril 4:1 龙眼 435 Longan Aril P. E. 4:1 龙眼肉 390 Longan Aril Powder 龙眼肉生粉 Lonicera P.E. 7:1 Chlirogenic acid 金银花 Loquat Leaves 4:1 枇杷叶 120 Loquat Leaves P. E. 8:1 枇杷叶 Loquat Leaves Powder 枇杷叶生粉 Lotus Leaf Powder 荷叶生粉 Lous Leaf 20:1 荷叶提取物 158.00 Lovage 15:1 川芎 320 Lovage P. E. 10:1 川芎 Lovage Powder 川芎生粉 Luffa Luffa 10:1 Luffa cylindrica Si Gua Luo丝瓜络 USD39.00/kg Lurmeria 10:1 Curcuma longa Jiang Huang姜黄 USD32.00/kg Luttuce 4:1* 野莴茞 75.00 Lycium 1:1 枸杞生粉 25.00 Lycium 8:1 枸杞子 150 Lycium P. E. 2:1 枸杞子 Lycium P. E. 3:1 枸杞子 Lycium P. E. 4:1 枸杞子 Lycium Powder 枸杞生粉 Lycium Powder 6:1 枸杞 Lycoris radiata Herb 80% Alkaloids 石蒜 1300 Lysimachia 10:1 Lysimachia christinae Jin Qian Cao金钱草 USD36.00/kg Ma Huang 6% Total Alkaloids 麻黄草 / Ma Huang 8% Total Alkaloids 麻黄草 52.0 / Ma Huang 10% Total Alkaloids 麻黄草 92.0 / Ma Huang 4:1* 麻黄 Madder root 10:1 Rubia cordifolia QIan Cao茜草 USD36.00/kg Magnolia Bark Magnoliae Offcinalis Hou Pu厚朴 USD47.00/kg Magnolia Bark 30:1 厚朴提取物 360.00 Magnolia Bark P.E. 10:1 Magnolol 厚朴 Magnolia Bark Powder 厚朴生粉 Magnolia Bark Powder 4:1 厚朴 Maiitake Mushroom P.E. 20% Polysaccharides 灰树花 Maitake Mushroom 15% (UV-VIS) Polysaccharides 灰树花 1700 Maitake Mushroom 20% Polysaccharides 灰树花 1900 Maitake Mushroom 7:1 灰树花提取物 650.00 Mallow Blossom 钱葵 Malva Verticillata 4:1 冬葵子 175 Malva Verticillata Powder 冬葵子生粉 Marsh Mallow 药葵 Marshmallow Althaea officinalis Shu Kui蜀葵 USD52.00/kg Medicago 10% Coumestrol 苜蓿 280 Melatonin 99% N-Acetyl-5-Methoxy-Tryptamine 褪黑激素 / Melia Toosendan 4:1 川楝皮提取物 58.00 Melia Toosendan P.E. 10:1 Toosendanin 苦楝皮 Melia Toosendan Powder 苦楝皮生粉 Menganthus Tritoliata 4:1* 睡菜提取物 95.00 Milk Thistle 80% (HPLC) Silymarin 水飞蓟 285 Milk Thistle 85% Silymarin 水飞蓟 290 Milk Thistle 15:1 Silymarin 水飞蓟 280.00 Milk Thistle P. E. 70% Silymarin 水飞蓟 Momordica, 10% Charantin & 1% esc. Momordica charantia Ku Gua苦瓜 USD45.00/kg Monkshood 7:1 Aconitum carmichaeli Chuan Wu川乌 USD31.00/kg Morinda Radix Powder 巴戟天生粉 Morinda Root 4:1 Polysaccharides 巴戟天 152.00 210 Morinda Root 5:1 Polysaccharides 巴戟天 200.00 Morinda Root 7:1 柏子仁 158.00 Morinda, 2% mer. & 4:1 Morinda officinalis Ba Ji Tian巴戟天 USD45.00/kg Motherwort 2:1 益母草提取物 35.00 Motherwort 4:1 益母草提取物 54.00 Motherwort 5:1 益母草 85 Motherwort 8:1 益母草 120 Motherwort 20% alk. & 10:1 Leonurus sibiricus Yi Mu Cao益母草 USD39.00/kg Motherwort Powder 益母草生粉 Moutan Baek 14:1 Paeonol 丹皮 280.00 Moutan Baek P. E. 4:1 Paeonol 丹皮 Moutan Black 20:1 Paeonol 丹皮 520 Moutan Powder Paeonol 丹皮生粉 Mucuna 10% L-Dopa 油麻藤 240 Mucuna 15% 油麻藤 320 Mugwort 10:1 Artemisia vulgaris Ai Ye艾叶 USD38.00/kg Mulberry 4:1 桑椹 80.0 110 Mulberry Bark 5:1 桑树皮 75.00 Mulberry Leaf 4:1 桑叶 48.00 Mulberry Mistletoe P. E. 12:1 桑寄生 110 Mulberry Mistletoe Powder 桑寄生生粉 Mulberry Mistletos 4:1 桑寄生 65.00 Mulberry Mistletos 4:1* 桑寄生 95.00 Mulberry Mistletos 8:1 桑椹子 120.00 Mulberry Mistletos 10:1 桑寄生 115.00 Mulberry Mistletos 10:1* 桑寄生 150.00 Mustard Seed 5% 白芥子 200 Mustard Seed 4:1 白芥子 70.00 Mustard Seed 4:1* 白芥子 110.00 Mustard Seed 14:1 白芥子 200.00 Mustard Seed 20:1 白芥子 330 Mustard Seed P. E. 20:1 白芥子 Myrrha P.E. 4:1 没药 Nardostachytis 12:1 甘松 240 Nardostachytis P. E. 10:1 甘松 Nardostachytis Powder 甘松生粉 Nasturtium Officinale 4:1 水田芥 Netoginseng Flower Powder 田七花生粉 Netoginseng Flower Powder 4:1 田三七 420.00 Netoginseng Leaf Powder 田七叶生粉 Nettle Leaf / Root 1% 寻麻 Nettle Leaf / Root 1.5% 寻麻 Nettle Leaf / Root 10:1 荨麻 150.00 Nettle Powder 荨麻生粉 Nettle Root / Leaf 4:1 寻麻 95 Nippon yam rhizome 16% 穿地龙 Nippon yam rhizome 4:1 穿地龙 No.16 Compound 10:1 16号复方 Notoginsemg Root 10% Panax notoginseng 三七根 Notoginseng Flower Powder Panax notoginseng 三七花生粉 Notoginseng Flower. 4:1 Panax notoginseng 三七花 620 Notoginseng Leaf P. E. 7:1 Netoginsenosides 三七叶 105.00 Notoginseng Root 10% (HPLC) Notoginsenosides 三七根 560 Notoginseng Root 4:1 三七根 480 Notopterygium Root 4:1 羌活 108.00 Notopterygium Root 4:1* 羌活 148.00 Notopterygium root 7:1 Notopterygium incisum Qing Huo羌活 USD39.00/kg Notopterygium Root 10:1* 羌活 220.00 Notopterygium Root 12:1 羌活 330 Notopterygium Root P.E. 13:1 羌活 332 Notopterygium Root Powder 羌活生粉 Nuphar Pumilum Root 12:1 萍蓬草 210 Nutgrass 4:1 香附 105 Nutgrass Powder 香附生粉 Nutmeg 2:1 肉豆蔻 Nutmeg 4:1 肉丛蓉 198.00 Nutmeg, 60% Myristica fragans Rou Dou Kou肉豆蔻 USD120.00/kg Oat Straw 4:1* 野燕麦 70.00 Oat Straw 10:1 燕麦草 150 Oat Straw 12:1* 燕麦草 132.00 Oat Straw P. E. 燕麦草生粉 Ocimum sanctum 0.2% (HPLC) Alkaloids 罗勒 200 Oldenlandia P. E. 12:1 白花蛇舌草 Oldenlandia Powder 白花蛇舌草 Olive Leaf P.E. 20% 橄榄叶 Olive Leaf P.E. 6% 橄榄叶 Olive Leaf Powder 橄榄叶生粉 Olive Powder 20% 橄榄 Oolong Tea 30% (UV-VIS) Polyphenols 乌龙茶 140 Ophipogon Root. 7:1 Opehiopogon japonicus Mai Dong麦冬 USD39.00/kg Orthosiphi Herb 4:1* 猫须草 80.00 Osha Root 10:1 Ligusticum sinense Gao Ben藁本 USD39.00/kg Ovate 20:1 梓白皮 330 Ovate Atractyodes Root 5:1 Atractylodes macrocephala Bai Zhu白术 USD32.00/kg Oxytropis Psammocharis Hance 4:1 沙棘汁 Pacliaxel Zi Shan Chun紫杉醇 98% :USD220.00/G99%: USD235.00/G Paeonia Lactiflora 10:1 Paeonia Lactiflora Bai Shao白芍 USD38.00/kg Paeonia lactiflora Pall 80% Glycoside 芍药(白芍) Palygala Root 4:1 Polygala tenuifolia Yuan Zhi远志 USD52.00/kg Parley (Celery Juice) 20:1* 芹菜(鲜品) 95.00 Passion Flower 4% Passiflora coerulea Xi Pan Lian西番莲 USD35.00/kg Passion Flower 4:1 西番莲 200 Peony Root 10:1 Paenia obovata Chi Shao赤芍 USD42.00/kg Pepper P.E. 80:1 Piperine 胡椒 Pepper P.E. 20:1 Piperine 胡椒 Pepper Powder 胡椒生粉 Peppergrass Lepidium apetalum Ting Li Zi葶苈子 USD38.00/kg Peppermint 4:1 薄荷叶 55.00 Peppermint 7:1 薄荷叶 70.00 Peppermint 8:1 薄荷 160 Peppermint Powder 薄荷生粉 Perilla Leaf P.E. 7:1 紫苏叶 70.00 Perilla Seed P.E. 4:1 紫苏子 65.00 Perilla Seed P.E. 4:1* 紫苏子 100.00 Phaseolas Vulgaris L. 4:1 白饭豆 65.00 Phaseolas Vulgaris L. 7:1 白饭豆 80.00 Phaseolas Vulgaris L. 10:1 白饭豆 Phelloden Dron 12:1* 黄柏 158.00 Phoenix Tree 8:1 草梧桐 Phyllanthus niruri 3% Bitters 珍珠草 280 Picrorhiza Rhizome 7% 黄莲 Picrorhiza Rhizome 5:1 黄莲 Picrorhiza Rhizome 8:1 黄莲 Pig extract 猪胰复方 Pimellia Tuber 7:1 半夏 Pine Bark OPC 95% Pinus massoniana Song Shu Pi松树皮 USD225.00/KG Pine Bark 95% (UV-VIS) Proanthocyanidins 松树皮 1200 Pine Bark P. E. 4:1 松树皮 Pine Rhizoma 4:1 油麻藤 Pine Root 10:1 松树根 Pinellia 5:1 Pinellia ternata Han Ban Xia旱半夏 USD46.00/kg Pipe Fish P.E. 12:1 海龙 Pipe Fish P.E. 15:1* 海龙 4,200.00 Piper nigrum 10% Piperine 胡椒 290 Plantago Herb 4:1 车前草 120 Plantago Herb 8:1 车前草 80.00 Plantago Herb P. E. 9:1 车前草 Plantago Herb P. E. 15:1 车前草 Plantago Powder 车前子生粉 Plantago Seed 4:1 Aucubin 车前子 200.00 260 Plantago Seed 15:1 Aucubin 车前子 320.00 Plantago Seed P. E. 5:1 Aucubin 车前子 Plantago Seed P. E. 12:1 Aucubin 车前子 Platycladi Seed 7:1 柏子仁 Pleasealus Vulgaris 4:1 白饭豆提取物 82.00 Pohygonati 10:1 Polygonatum sibiricum Huang Jing黄精 USD39.00/kg Pomeg Bark 4:1 石榴皮 78.00 Pomeg Bark 12:1 石榴皮 135.00 Pomeg Rinate 10:1* 石榴 150.00 Pomeg Rinate 10:1 石榴子 115.00 Pomegranate seed P.E. 4:1 石榴籽 Poncirus 10:1 枸桔 170 Poncirus P.E. 4:1 枸橘 Poria 12:1 Pachyman 茯苓提取物 132.00 Poria Cocos 6:1 Pachyman 茯苓 140 Poria P. E. 2% Pachyman 茯苓 Poria P. E. 20:1 茯苓 Poria Powder 茯苓生粉 Pricklyash peel P.E. 花椒生粉 19.00 Pricklyash peel P.E. 1:1 花椒枝叶 300.00 Pricklyash peel P.E. 7:1 花椒枝叶 Propolis P.E. 60% 蜂胶粉 Psoralea fruit Psoralea corylifolia Bu Gu Zhi补骨脂 USD42.00/kg Pu Er Tea P.E. 5:1 普洱茶 Pu Er Tea P.E. 10:1 普洱茶 Pu Erh Tea 30% 普洱茶 155 Pu Erh Tea 15% (UV-VIS) Polyphenols 普洱茶 85 Puerara P.E. 10:1 Puerarin 葛根 Puerara Powder 葛根生粉 Pueraria/Kudzu 40% Isoflavones (HPLC) 葛根 335 Pueraria/Kudzu 60% 葛根 450 Pueraria/Kudzu 80% 葛根 550 Pueraria/Kudzu 95% 葛根 700 Pumpkin Seed 4:1 南瓜子 76.00 115 Pumpkin Seed 5:1 南瓜子 145 Pumpkin seed 10:1 & 25:1   Nan Gua Zi南瓜子 USD42.00/kg Purple willow bark 20:1 紫柳皮 Purslane 10:1 Portulaca oleracea 马齿苋提取物 126.00 Purslane Powder 马齿苋生粉 Pygeum Africanum 25% Phytosterols / Pyrola herb P.E. 12:1 鹿衔草 Qiao Mai 10:1 荞麦 Rabdosia 2.5% & 99% Rubescenin A & B Rabdosia rubescens Dong Ling Cao冬凌草 USD120.00/kg Rabdosia japonica Hara 60% Diterpene 香茶菜 2400 Raphanus Sativus 莱菔子生粉 18.00 Raphanus Sativus 4:1* 莱菔子 65.00 Raphanus Sativus 15:1 莱菔子 158.00 Raspberry 10:1 Rubus idaeus Fu Pen Zi覆盆子 USD52.00/kg Raspberry 12:1 Anthocyanidin 覆盆子 550 Raspberry 14:1 Anthocyanidin 复盆子 470.00 Raspberry P. E. 4:1 Anthocyanidin 复盆子 Raspberry Powder 复盆子生 Rauwolfia serpentina 4:1 萝芙木 150 Red Clover 20% (HPLC) Isoflavones 红车轴草 1000 Red Clover 1% & B (HPLC) Biochanin A 红车轴草 155 Red Clover 40% (HPLC) 红车轴草 2000 Red Clover 8% (HPLC) Isoflavones 红车轴草 650 Red Clover 8% Biochanin A & B 红车轴草 750 Red Clover 4:1 Flavonoids 红车轴草 150 Red clover 8.0% ISOFLAVONES Trifolium pratense Hong Che Zhou Cao红车轴草 USD88.00/kg Red Clover 14:1* 红车轴草提取物 215.00 Red Clover Powder 红车轴生粉 Red Gensing P.E. 红参生粉 Red Peony 12:1 赤勺 205 Red Peony P. E. 20% 赤芍 Red Peony P. E. 4:1 赤芍 Red Poony 14:1 赤芍 210.00 Red Rice Yeast 红曲生粉 Red Rice Yeast 0.5% (HPLC) Lovastatin 红曲 215 Red Rice Yeast 4:1 红曲 145 Red Rice Yeast 11:1 红曲 205.00 Red Rice Yeast 16:1 红曲 205.00 Red Williow Bark 20:1 红柳皮 Red-Rooted Salia Tanshinone 10% & 10:1 Salvia Miltiorrhiza Dan Shen丹参 USD54.00/kg Rehmannia 10% ico Rehmannia glutinosa Sheng Di生地 USD37.00/kg Rehmannia (Cooked) P. E. 6:1 熟地 Rehmannia(Cooked) 6:1 熟地黄 115 Reishi Mushroom 10% & 25% Lucid Polysaccharide. Ganoderma Lucidum Ling Zhi灵芝 USD210.00/kg Reishi Mushroom 60% Polysacchrides 灵芝 3200 Reishi Mushroom 10% /4% Polysacchrides/Triterpenoids 灵芝 680 Reishi Mushroom 4:1 灵芝提取物 95.00 Reishi Mushroom P. E. 4% 灵芝 Reishi Mushroom P. E. 40% 灵芝 Reishi Mushroom P. E. 8:1 灵芝 Reishi Mushroom P. E. 12:1 灵芝 Reishi Mushroom P. E. 16:1 灵芝 Reishi Mushroom P.E. 10% 灵芝 Rhadiola 2% sali. Rhadiola rosea Hong Jing Tian红景天 USD72.00/kg Rhadiola 3% sali. Rhadiola rosea Hong Jing Tian红景天 USD72.00/kg Rhadiola 4% sali. Rhadiola rosea Hong Jing Tian红景天 USD72.00/kg Rhadiola 1% sali. Rhadiola rosea Hong Jing Tian红景天 USD72.00/kg Rhizoma Drynaria 10:1 槲蕨 140 Rhodiola 40%, 1% Polyphenols/ Salisorosides 红景天 300 Rhodiola 12:1 红景天提取物 225.00 Rhodiola P. E. 40% 红景天 Rhodiola P. E. 8:1 红景天 Rhodiola P. E. 10:1 红景天 Rhubarb Rhaponticin & 10:1 Rheum officinale Da Huang大黄 USD41.00/kg Rhubarb Root 4:1 大黄提取物 75.00 Rhubarb Powder 大黄生粉 Rhubarb Root 9% Anthaquivone 大黄 240 Rhubarb Root 10:1 大黄 200 Ribwort 蓖大叶子 Rosehips 5% Ascorbic Acid 金樱子 200 Rosehips 4:1 金樱子 105 Rosehips 5:1 金樱子 120 Rosehips P. E. 8:1 金樱子 Rosehips P. E. 15:1 金樱子 Rosehips Powder 金樱子生粉 Rosemary 3% Rosmaricine. Rosmarinus officinalis Mi Die Xiang迷迭香 Rosemary Herb 4:1 迷迭香 / Rosemary Herb 5:1 迷迭香 / Royal Jelly P.E. 皇浆粉 Royal Jelly Powder ( F/D ) 6% 10-HDA 蜂王浆干粉 420 Rue Rutamarin Ruta graveolens Yun Xiang芸香 Rydrangea Root P. E. 4:1 常山 Rydrangea Root P. E. 20:1 常山 Rydrangea Root Powder 常山生粉 Safflower 10% saf. & 10:1 Carthamus tinctorius Hong Hua红花 USD67.00/kg Safflower P.E. 5:1 红花 Sage 洋苏草 Sanquisorba root 10:1 sanguisorba officinalis Di Yu地榆 USD38.00/kg Sanssurea 4:1 木香 80.00 Saponion 80% 薯蓣皂甙 Saposhnikovia 10:1 Saposhnikovia divaricata Fang Feng防风 USD84.00/kg Sarrsaparilla Diosgenin 1:1 菝葜生粉 10.00 Sarrsaparilla Diosgenin 20:1 菝葜 180.00 Sarsaparilla Root 4:1 菝契 130 Saullea Vaginate 5% Triterpene Glycosides 丹参 / Saullea Vaginate 2.5% Triterpene Glycosides 丹参 / Saw Palmetto Berry 25% Fatty Acids & Sterols 锯齿棕榈 220 Saw Palmetto Berry 90% Fatty Acids & Sterols 锯齿棕榈 800 Saw Palmetto Berry 4:1 Fatty Acids & Sterols 锯齿棕榈 200 Saw Palmetto Fruit P. E. 欧蒲葵 Schisandra 8:1 Schsandrines 五味子 110.00 Schisandra Berry 2% (HPLC) Schsandrines 五味子 190 Schisandra Berry 5% Schsandrines 五味子 330 Schisandra Berry 9% Schsandrines 五味子 800 Schisandra Berry 4:1 Schsandrines 五味子 52.00 110 Schisandra Berry 10:1 Schsandrines 五味子 114.00 190 Schisandra Powder 五味子生粉 Scubellaria 4:1 半枝连 90.00 Scubellaria P. E. 8:1 半枝莲 Scubellaria Powder 半枝莲生粉 Scullcap 98% Baicalin & 10:1 Scutellaria baicalensis Huang Qin黄芩 USD57.00/kg Sculltellarla Root P.E. 8:1 黄芩 135 Sculltellarla Root Powder 黄芩生粉 Scultellaria Root 4:1 黄芩 90.00 Scultellaria Root P. E. 2:1 黄芩 Scutellaria baicalensis Grorgi. 80% Flavonoids 黄芩 400 Sdomon'sseal 15:1 玉竹 410.00 Seaweed 4:1 海藻 Seaweed 12:1 海澡 Semen Coicis 4:1 薏苡仁提取物 95.00 Semen Coicis P. E. 13:1 薏苡仁 Semen Coicis P. E. 15:1 薏苡仁 Semen Coicis Powder 薏苡仁生粉 Semen Nelumbinis P.E. 4:1 莲子 Semiaquilegia root 5:1 Semiaquilegia adoxoides Tian Kui Zi天葵子 USD44.00/kg Senna Leaf 4% Sennosides 番泻叶 200 Senna Leaf 8% 番泻叶 300 Senna Leaf 4:1 番泻叶 130 Senna Leaf 4:1 番泻叶 82.00 Senna Leaf 8:1 番泻叶 180.00 Senna Leaf (5% Sennosides) & 10:1 Cassia senna &Cassiaangustifolia Pan Xie Ye蕃泻叶 USD35.00/kg Senna Leaf P. E. 5:1 潘泻叶 Senna Leaf P. E. 7:1 潘泻叶 Senna Leaf Powder 番泻叶生粉 Shave Grass Powder 木贼生粉 Shavegrass 2% Silica 木贼 155 Shiitake Mushroom 8% Polysaccriarides (UV-VIS) Polysaccharides 香菇 600 Shilake Mushroom 3:1 香菇提取物 120.00 Shilake Mushroom 4:1 香菇提取物 95.00 Shilake Mushroom 6:1 Polysaccharides 香菇提取物 128.00 Shilake Mushroom 20:1 香菇提取物 500.00 Shitake Mushroom P. E. 6% Polysaccharides 香菇 Shitake Mushroom Powder 香菇生粉 Siberian caklour fruit 4:1 苍耳子 Siberian Ginseng 1% Eleutherosides B + E (HPLC) 刺五加 130 Siberian Ginseng 50~60% 刺五加浸膏 52.00 Siberian Ginseng 0.8% / 28:1 刺五加 120 Siberian Ginseng Eleutheroside B&E: 0.8% , 1.0% Eleutherococcus senticose Ci Wu Jia刺五加 USD16.00/kg Siberian Ginseng 1:1 刺五加生粉 12.00 Siberian Ginseng P. E. 8:1 刺五加 Siberian Ginseng Powder 刺五加生粉 Siberian Milkwort 4:1 远志 170 Siberian Milkwort P. E 5% 远志 Siberian Milkwort Powder 远志生粉 Siberian Solomonsel 10:1 黄精 140.00 Siberian Solomonsel Powde 黄精生粉 Sida cordifolia 1.7% Alkaloids 心叶黄花捻 195 Siler 4:1 防风 190 Siler 12:1 防风 300 Siler Powder 防风生粉 Silktree Albizzia Bark 10:1 合欢皮 115.00 Silktree Albizzia Bark 15:1 合欢皮 Silktree albizzia Flower 4:1 合欢花 Snake Shere Glass Powder 蛇舌草生粉 Snake Shere Glass Powder 20:1 蛇舌草 Snakegourd Root 7:1 Trichosanthes kirilowii Tian Hua Fen天花粉 USD33.00/kg Sorophulariae Nigpoensis 4:1 玄参 102.00 Sorophulariae Nigpoensis 12:1 玄参提取物 170.00 Soybean 3% Soy Isoflavones 大豆蛋白 Soybean 20% Soy Isoflavones 大豆异黄酮 1200 Soybean 40% Soy Isoflavones 大豆异黄酮 2400 Soybean 10% (HPLC) Soy Isoflavones 大豆异黄酮 600 Srvertia Psedochinensis 8:1 獐牙菜 125.00 St. John s Wort 贯叶连翘生粉 17.20 St. John’s Wort 0.3% Hypericins (UV-VIS) 贯叶连翘 110 St. John’s Wort 0.3% Hypericins (HPLC) 贯叶连翘 150 St. John's Wort P. E. 0.1% 贯叶连翘 St. John's Wort P. E. 0.5% 贯叶连翘 St.John's Wort 贯叶莲翘切 Star Anis 东洋茴香 Stenona root 10:1 Stemona sessilifolia &Stemona japonica Bai Bu百部 USD34.00/kg Stephania cepharantha Hayata 80% Total Alkaloids 白药子 2600 Stevia 85% 甜菊甙 125 Stevia 95% 甜菊甙 135 Stevia 80% Steviosides (No Bitter Taste) 甜菊甙 195 Stevia P. E. 90% 甜菊糖 Sui Lian 4:1 睡莲 Suicao 4:1 睡草 Suizaojiao 10:1 水皂角 Summa Root 4:1 / Sunflower 5:1 (100% Water Soluble) 向日葵 100 Swordlink atractylodes rhizome 4:1 苍术 Szechwan lovage 10:1 Ligusticum chuanxiong Chuan Xiong川芎 USD64.00/kg Tangerine Peel 陈皮生粉 8.50 Tangerine Peel 4:1 陈皮提取物 46.00 Tangerine Peel 10:1 Pericarpim Citri Reticulatae Chen Pi陈皮 USD38.00/kg Tangerine peel 12:1 陈皮 Tatarian Aster Root 10:1 紫苑 Tea EGCG 茶皂素 Teasel Root 8:1 续断 155 Teasel root 10:1 Dipsacus asperoides Xu Duan续断 USD38.00/kg Teasel Root P. E. 4:1 续断 Teasel Root P. E. 12:1 续断 Teasel Root Powder 续断生粉 Terminalia bellerica 60% Tannins 毛诃子 150 Terminalia chebula 40% Tannins 诃子 130 Termiralia Cheloulda Fruit 4:1 诃子提取物 60.00 Thunbery Fritillary Bulb 4:1 浙贝 Thunbery Fritillary Bulb 20:1 浙贝 400.00 Thyme 4:1 麝香草 98.00 125 Thyme 4:1* 麝香草 130.00 Tokay Powder 蛤蚧生粉 750.00 Tokay Powder 4:1 蛤蚧 2,340.00 Tomato 30:1* 西红柿(鲜品) 126.00 Tonkin sophora Root 10:1 Sophorae Tonkinensis Shan Dou Gen山豆根 USD38.00/kg Toosendan fruit 10:1 Melia toosendan Chuan Lian Zi川楝子 USD38.00/kg Tremella Fuciformis Powder 2:1 白木耳 70.00 Tribulus Ferrertris P. E. 12:1 Protodioscin 白蒺藜 Tribulus Ferrertris Powde 白蒺藜生粉 Tribulus Ferretris Fruit 20:1 白蒺藜 225.00 Tribulus Ferretris Fruit P. E. 45% 白蒺藜 Tribulus Terrestris 20% (HPLC & UV) Tribulus Saponins 白蒺藜 160 Tribulus Terrestris 40% Tribulus Saponins 白蒺藜 270 Trichosanthes Kirilow 5:1* 栝蒌提取物 165.00 Triperygium wilfordii Alkaloids: 4% & 10% Triperygium wilfordii  Lei Gong Teng雷公藤 USD52.00/kg Triphala 40% Tannins / Tsaoko 5:1 Amomum tsao-ko Cao Guo草果 USD46.00/kg Tu shi Zhi 4:1 菟丝子 Tu Shi Zhi 20:1 菟丝子 Tuber Fleeceflower Stem 10:1 夜交藤 Tuber Onion Powder 韭菜生粉 Tuniu Xi P. E. 12:1 土牛膝 180 Tuniu Xi Powder 土牛膝生粉 Turmeric 10:1 姜黄提取物 180.00 Turmeric P.E. 12:1 Curcumin 姜黄 Turmeric Powder 姜黄生粉 Turmeric Root 95% Curcuminoids 姜黄/郁金 1350 Turmeric Root 3% Curcuminoids 姜黄/郁金 165 Uva Ursi Leaf (Xiong Guo) 20% Arbutine 熊果 / Uva Ursi Leaf (Xiong Guo) 4:1 熊果 / Valerian Root 缬草生粉 12.00 Valerian Root 0.8% Valerianic Acid 缬草根 / Valerian Root 4:1 缬草提取物 60.00 Valerian Root 5:1 缬草根 120 Valerian Root 10:1 (Grain Powder, Deodorized) 缬草根 260 Valerian Root P. E. 0.5% 缬草 Valerian Root Powder 缬草生粉 Viola 10:1 Viola philippica 紫花地丁 USD53.00/kg Virgate Wormwood Herb 20:1 菌陈蒿 Vitex (Chasteberry) 2:1 蔓荆提取物 60.00 Vitex (Chasteberry) 4:1 蔓荆提取物 98.00 Vitex (Chasteberry) 4:1* 蔓荆提取物 138.00 Vitex (Chasteberry) 5:1 蔓荆提取物 150.00 Vitex (Chasteberry) 12:1 蔓荆提取物 280.00 Vitex/Chasteberry 5% Vitexin (HPLC) 蔓荆子 / Vitex/Chasteberry 10:1 蔓荆子 420 Wateroress 4:1* 水田芥提取物 60.00 Wheat Grass 4:1 小麦草 140 White Atractrylodes 4:1 白术提取物 76.00 White Atractrylodes 15:1 白术 175.00 230 White Atractrylodes P. E. 6:1 白术 White Atractrylodes P. E. 10:1 白术 White Atractrylodes P. E. 15:1 白术 White Atractrylodes Powde 白术生粉 White Peony 80% (HPLC) Glycosides 白芍 1250 White Peony 1.5% (HPLC) Albasides 白芍 280 White Peony 4:1 Albasides 白芍 95.00 White Peony 4:1* Albasides 白芍 135.00 White Peony 12:1* Albasides 白芍提取物颗粒 170.00 White Peony P. E. 20% Albasides 白芍 White Peony P. E. 10:1 Albasides 白芍 White Peony Powder 白芍生粉 White swallowwort 10:1 Cynanchum stauntonii Bai Qian白前 USD30.00/kg White Willow Bark 12% (HPLC) Sallcin 白柳皮 330 White Willow Bark 15% 白柳皮 390 White Willow Bark 4:1 白柳皮 100 White willow bark 15:1 白柳皮 235.00 White willow bark 20:1 白柳皮 Wild Jujube 2% juj. & 20:1 Zizyphi Spinosae Suan Zao Ren酸枣仁 USD105.00/kg Wild Yam Powder 山药 13 Wild Yam 8% Saponin on Diosgenin (HPLC) 山药 170 Wild Yam 16% 山药 230 Wild Yam 4:1 山药 58.00 Wild Yam 10:1 山药 150 Wild Yam P. E. 6% 山药 Wild Yam P. E. 20:1 山药 Wildcelery Herb P.E. 10:1 芹菜 Williams Eider Twig 20:1 接骨木 Wolfberry Fruit 15% bet. & 10:1 Lycium Barbarum & Lycium chinensis Gou Qi枸杞 USD46.00/kg Wolfberry Root-bark 12:1 地骨皮 Woolly Grass-white Powder 白茅 Wormrwood 4:1 青蒿提取物 65.00 Wormrwood 8:1 青蒿提取物 70.00 Wormwood 7:1 青篙 160 Wormwood P. 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Result number: 85

Message Number 177661

To Elyse View Thread
Posted by Ralph on 7/01/05 at 14:43

Good for you Elyse by now you recognize the fork in the path and which one not to go down.

I'm not an expert in ESWT but it's my understanding that the only machine FDA approved to treat Chronic Lateral Epicondylatis, which is commonly called tennis elbow, is the Ossation Machine.

Here is an article that states this. I just surfed the web and found it.

HealthTronics OssaTron Receives FDA Approval to Treat Chronic Lateral Epicondylitis - Tennis
2003-03-18 HealthTronics Surgical Services, Inc. announced that the US Food and Drug Administration has approved its high energy OssaTron(R) orthopaedic shock wave device for the treatment of chronic lateral epicondylitis (also known as tennis elbow).

The OssaTron is the only high-energy orthopaedic shock wave device approved for one time treatment of epicondylitis. The OssaTron already is approved for treatment of plantar fasciitis (heel pain) and now becomes the only such device approved for multiple indications.

The FDA approved the device based on the results of a 225 patient multi-center, randomized, placebo-controlled, double-blinded study. The comparison of results between active treatment patients and placebo-treated patients was highly significant according to the statistical analyses. In fact, 90% of treated patients received a benefit from the treatment and 64% had an excellent or good outcome.

Epicondylitis is most often associated with overuse of the arm in a wide variety of activities associated with work and play. Traditionally, the only alternative for patients who did not respond to conservative non-surgical treatment was an invasive surgical procedure. These procedures typically have extended recovery times and may be associated with significant complications and poor outcomes.

Now my interpetation(guess) of how a Podiatrist could provide treatment for this condition. Under current law in the U.S. I don't think that they can provide treatment unless under the supervision of an M.D. or D.O. who is licensed to treatment that part of the skelton. In addition they must be trained and certified to do so, but picture this. Say the Podiatrist is also a certified ESWT Tech. He/she is wearing two hats and working two jobs , one of a Podiatrist, the other of a certified ESWT Tech or simply a Pod that was trained in how to do ESWT on the Ossatron and happens to be an ESWT tech at the surgical center when he has time. I don't know of many Pods that have spare time, but picture that. Any Podiatrist certified to use the Ossatron would be considered a certified ESWT Tech.

Situation at hand, Ortho Doc. A has a patient with tennis elbow and wants that patient to have ESWT. Ortho Doc. A has two choices. He can send his patient to the Outpatient Surgical Center that has the Ossatron and he and the tech work together along with an anaestheologist if one is required provide the patients treatment, or if that center accepts the fact that the ESWT tech they employ has the necessary training to do the entire procedure themselves Ortho Doc A's patient could be treated at the center by the Tech alone with of course the anaestheologist if needed for this procedure.

My guess and it's strickly a guess is that Ortho Doc A is going to be on the scene for the treatment. At the cost of malpractice insurance I bet he shows up at the surgical center. Heck he want to be paid even if the tech administers the treatment.

Now imagine the Tech at that OutPatient Surgical Center just happens to be a Podiatrist. Bingo one could say that a Podiatrist is treating the elbow, but in reality that isn't how it would be seen. The tech who happens to also be a Pod in this case I think would more than likely be under the supervision of the attending Ortho Doc just an any other tech would be. I think how the treatment is delivered depends on the Ortho Doc, the Surgical Center's requirements and the certification of the tech and of course the help of anaesthologist if one is required.

I think what Dr. Zuckerman is imagineing for the future are centers where the more portable Dornier machines are set up or even the use of mobile units like his and Ortho doctors send their patients to these sites for their treatment or the mobile unit rolls up to the Orthos office. The ortho does the diagnosis and the "ESWT center's tech" provides the treatment using the Dornier machine in "off label usage".

Doctors are permitted to use the machine to provide treatment that they think is beneficial to other areas of the body even though the machine may not have been FDA approved to treat that area. Pods must stick to treating the area of the body they are licensed by their state to treat. Right now I don't think they can legally treat an elbow or shoulder in any state in off label usage unless under the supervision of an Ortho, but I'm not certain. You'd have to check with the state. An Ortho on the other hand could use the machine off label to treat any part of the skeleton. They are not restricted to ankles and feet.

With law restrictions I think you'll find docs don't take chances when providing treatments. No one wants to risk their licenses.

Personally I think Doc's just want to treat patients. They want to make their pains go away. Each tries his/her best to do so with the training, medicine and machines available.

I think it's best to live in the present, not worry about the past, plan for the future, but don't fixate on problems that haven't happen yet.

Result number: 86

Message Number 177055

Re: DR Z Your radio ad View Thread
Posted by Dr. Z on 6/18/05 at 09:37

Vince,
Not sure what you are talking about with " MY AD" . I am not aware of any advertizement in New York . Here is what may or may not be what the 94% is about from the one year FDA follow up.



. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment


1: Foot Ankle Int. 2004 May;25(5):290-7. Related Articles, Links


Extracorporeal shock wave therapy for the treatment of plantar fasciitis.

Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C.

Foot and Ankle Surgery, Massachusetts General Hospital, Boston, MA 02114, USA. GTheodore@Partners.org

One hundred fifty patients were enrolled in a multicenter, randomized, placebo-controlled, prospective, double-blind study to assess the clinical safety and effectiveness of extracorporeal shock wave therapy (ESWT) using the Dornier Epos Ultra for the treatment of plantar fasciitis. The Active Group was treated with electromagnetically generated shocks using ultrasound guidance during a single therapy session. The Control Group received a sham treatment under similar clinical conditions. The groups were demographically similar with respect to age, height, and weight. The average duration of symptoms was nearly 2 years in both groups. All patients were evaluated by the visual analog scale for pain, American Orthopaedic Foot and Ankle Society scores, Roles and Maudsley Score, SF-12 health status questionnaire, and physical examination. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment. The Control Group reported 47% success at 3 months posttreatment. Twelve-month data were not collected for the Control Group as they were unblinded at 3 months and offered treatment. ESWT represents a safe treatment option for chronic proximal plantar fasciitis.

Publication Types:
Clinical Trial
Multicenter Study
Randomized Controlled Trial

PMID: 15134608 [PubMed - indexed for MEDLINE]

Result number: 87

Message Number 176564

To Kathy G. - the saga continues View Thread
Posted by Tina H on 6/11/05 at 21:25

Hi Kathy-
Saw your message below. Hope all was well with your colonoscopy, fun right! Now the router, that sounds more interesting. What are you doing with that? Not the colonoscopy I hope :) ha

I just had to tell you the latest about my daughter, boy how could I have been so stupid!! A little history, the first time I took her to the foot orthopedist who was supposed to be the best in Pittsburgh, yeah right, he said she didn't have pf due to a flexibility issue. "Kids don't get pf for these reasons it's the pes cavus foot bla bla bla. Don't bother with stretching, physical therapy or night splints won't work." I believed him which in hindsight how would he have known if she was flexible or not when he didn't even check that.

Well after the fiasco with the cast and tape, I decided not only to dump that dr but to take her for physical therapy anyway to someone who helped me with my pf. After an hour long evaluation he said in his humble opinion, that my daughter has pf because of a flexibility issue. She only had 5 degree range of movement instead of the 15-20 that's normal in both of her feet. He said the plaster cast was about the worse thing the doctor could have done because her feet were screaming for more flexibilty not less and it made a bad problem much worse. So now she is having physical therapy. At least there is hope! He is a good physical therapist and he feels confident her can cure her pf. He agreed that she has very high arches, but he said if high arches were so bad they would have been selected out of the population thousands of years ago. He has her doing 4 different stretchs 3X/day, plus manual stretches he does, deep tissue massage and ultrasound. It's too early to say if it will work but it's the best advice we've had since this nightmare started last Novemeber. So far so good. Just thought I'd share that with you. I consider myself to be relatively informed when it comes to pf but boy I had my blinders on with this doctor. Thanks for your support. Tina H

Result number: 88

Message Number 174337

Double blinded peer reviewed studies View Thread
Posted by Ed Davis, DPM on 5/05/05 at 19:17

If we subjected the entire body of medical knowledge top double blinded peer reviewed studies we could toss out about 3/4 of what docs do. The FDA has a legitimate function but it cannot even come close to determining efficacy of the vast majority of medical treatment. Considering the limited resources of the FDA, their dollars would be most efficiently spent on issues of safety (drug or device) and ensuring potency and putety of drugs, neutriceuticals (an 80 billion dollar industry).

One day, if the "first world' countries can get their "act" together, the duties that the FDA is literally nibbling at could be assigned and apportioned to similar agencies throughout those countries.
Ed

Result number: 89

Message Number 174241

Cortisone better and less expensive than ESWT View Thread
Posted by Jan R. on 5/04/05 at 13:53

I found this abstract in pubmed:

Porter MD, Shadbolt B.

Intralesional Corticosteroid Injection Versus Extracorporeal Shock Wave Therapy for Plantar Fasciopathy.

Clin J Sport Med. 2005; 15:119-124.


From the *Orthopaedic Department, Ipswich Hospital, Ipswich, QLD 4305, Australia; and the daggerDepartment of Epidemiology, Canberra Hospital, Garran, Australia.

OBJECTIVE: To compare the efficacy of low-energy extracorporeal shock wave therapy (ESWT) and intralesional corticosteroid injection (CSI) for the treatment of plantar fasciopathy present for at least 6 weeks. DESIGN:: A prospective, randomized, controlled, observer-blinded study over a period of 12 months.

SETTING: Primary care and hospital setting.

PATIENTS: A total of 132 patients were enrolled in the study, and 125 completed the study. Nineteen nonrandomized patients acted as a surrogate control group.

INTERVENTIONS: All patients performed a standardized Achilles tendon and plantar fascia stretching program. The patients were randomly allocated to either treatment group A or B. Group A received a single CSI, while group B were referred for a course of low-dose ESWT comprising 3 treatments over a period of 3 weeks. Group C consisted of 19 nonrandomized patients who performed the standardized stretching program only.

MAIN OUTCOME MEASUREMENTS: The worst daily pain recorded on a visual analogue scale (VAS), and the tenderness at the plantar fascia insertion as determined by an algometer. These measures were recorded immediately prior to the commencement of treatment and 3 months and 12 months posttreatment.

RESULTS: With regard to VAS pain scores, values for the CSI (1.48; 0-7) were significantly lower than both ESWT (3.69; 0-8), and controls (3.58; 2-5) at 3 months. At 12 months, VAS scores for CSI (0.84; 0-7) and ESWT (0.84; 0-4) were both significantly lower than controls (2.42; 1-4). The tenderness values at 3 months were significantly higher for CSI (9.42; 7-11) than both ESWT (6.72; 4-11) and controls (7.63; 6-9). P < 0.05 was used throughout.

CONCLUSIONS: Corticosteroid injection is more efficacious and multiple times more cost-effective than ESWT in the treatment of plantar fasciopathy that has been symptomatic for more than 6 weeks.

What is your experience with local cortisone injection?

Result number: 90

Message Number 173868

New article from Austria View Thread
Posted by Jan R. on 4/28/05 at 09:44

Influence of Local Anesthesia and Energy Level on the Clinical Outcome of Extracorporeal Shock Wave-Treatment of Chronic Plantar Fasciitis.

Z Orthop Ihre Grenzgeb. 2005 Jan;143:240-246

Labek G, Auersperg V, Ziernhold M, Poulios N, Bohler N.

e-mail: gerold.labek@akh.linz.at

BACKGROUND: The efficacy of low energy extracorporeal shock wave treatment (ESWT) for chronic plantar fasciitis is discussed controversially. It is unclear whether the simultaneous application of local anesthesia (LA) interferes with clinical outcome.

METHODS: 60 patients with a chronic plantar fasciitis were enrolled in a triple-arm (20 patients per group), prospective randomized and observer-blinded pilot trial. The patients were randomly assigned to receive either active ESWT without LA (;3 x 1 500 shocks, total energy flux density [EFD] per shock 0.09 mJ/mm(2) [Group A]), ESWT with LA (3 x 1 500 shocks, EFD 0.18 mJ/mm(2) per shock [Group B]) or ESWT with LA (3 x 1 500 shocks, EFD 0.09 mJ/mm(2) [Group C]). Main outcome measures were: pain during first stepps in the morning (measured on a 0-10 point visual analogue scale) and number of patients with > 50 % reduction of pain and no further therapy needed, measured at 6 weeks after the last ESWT.

RESULTS: Group A improved in the VAS from 6.4 (SD: 1.7) to 2.2 (SD: 2.6) points, group B from 6.7 (SD: 1.5) to 4.1 (SD: 2.4) points, group C from 6.2 (SD: 1.6) to 3.8 (SD: 2.5) points. A reduction of pain of at least 50 % was achieved in 60 % of group A, in 36 % of group B and in 30 % of group C. Group A without LA showed a significantly higher improvement in the VAS and subjective evaluation than groups B (p = 0.007) and C (p = 0.016).

CONCLUSION: At 6 weeks success rates after low-energy ESWT with local anesthesia were significantly lower than after identical low-energy ESWT without local anesthesia. Higher energy levels could not balance the disadvantage of this effect. LA significantly influenced the clinical results after low energy ESWT in a negative way. Blinding patients by LA in ESWT studies must therefore be considered a systematic error in study design.

Result number: 91

Message Number 173718

Re: Thank you Dr. SanFilippo View Thread
Posted by Ed Davis, DPM on 4/25/05 at 18:29

Ralph:
It is part of our "job" to ask the technical questions. Doctors are trained to be professional skeptics. We are given the responsibility to find out how things work, what they do, what the limits are and to separate the facts from the non-facts. Type in "heel pain" in any search engine and you will get enough potions, gadgets, etc. to make your head spin (mine sure does).

Luckily, we finally have a doctor who provides ART and can answer the questions. Also, our new doctor sounds like he really is knowledgeable about biomechanics which is one of the harder things to explain.

Keep in mind that you will find healthy skepticism and questioning and that which is not. For example, it would probably not be reasonable to ask for a "double blinded peer reviewed study" before accepting the information. Some will demand it because they will not consider empiric evidence or experiential evidence. Those individuals probably will not get such a study for quite a while unless one has been launched which I do not know about. Interestingly, a lot of medicine being practiced today has never really gone through that process being demanded of newer modalities.
Ed

Result number: 92

Message Number 171579

Here is part of the FDA study for Radial Shockwave View Thread
Posted by Dr. Z on 3/19/05 at 13:40




Login Logout Search HMPCME Health Pro Connect Health Job Connect Discussion Board Related Links Home Current Issue Archives Subscribe Industry News New Products News and Trends Events and Symposia Educational Tools Classifieds E-News Email Directory About Us Specifications for Advertisers
Welcome Zuckerman


















Continuing Education:
What You Should Know About Shockwave Therapy
- By Lowell Scott Weil, Jr., DPM, MBA

--------------------------------------------------------------------------------

In order to provide clarity to a controversial and confusing subject, this author discusses different forms of shockwave therapy and offers a closer look at recent literature on the subject.


--------------------------------------------------------------------------------

Continuing Education Course #125 — November 2004
-

I am very pleased to introduce the latest article, “What You Should Know About Shockwave Therapy,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Extracorporeal shockwave therapy (ESWT) has been a subject of controversy as various experts have debated its efficacy in treating chronic plantar fasciitis. With this in mind, Lowell Scott Weil Jr., DPM, explores the various types of shockwave therapy and provides a thorough analysis of the literature on ESWT.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Editor-In-Chief
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 61 and successfully answering the questions on pg. 66. Use the enclosed card provided to submit your answers or fax the form to the NACCME at (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by the NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Weil has disclosed that he has received grant and/or research support from Healthtronics, EMS DolorClast, UMS Wolf and Orthometrix.
This article contains discussion of published and/or investigational uses of agents that are not indicated by the FDA. Neither NACCME nor HMP Communications recommends the use of any agent or device outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings.
GRADING: Answers to the CE exam will be graded by the NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: November 2004.
EXPIRATION DATE: November 30, 2005.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the different types of technology used to create medical shockwave;
• cite the potential benefits of ESWT for patients with chronic plantar fasciitis; and
• discuss the recent literature on electrohydraulic, piezoelectric and radial shockwave therapy.
Sponsored by the North American Center for Continuing Medical Education.



Last year, I wrote “Extracorporeal shockwave therapy (ESWT) has a long way to go to prove it has overwhelming medical benefits that are claimed by the manufacturers, but it is still in the early stages of its evolution. With time, it will be necessary to prove these claims through prospective studies.” (See “Extracorporeal Shockwave Therapy: Hope Or Hype?,” page 46, November 2003 issue.)
While this article is not intended to prove beyond a statistical doubt that ESWT works, emerging research via prospective placebo-controlled, double-blind studies shows that ESWT is effective and should be considered a proven technology.
Employing ESWT for the treatment of musculoskeletal (MSK) disorders evolved in Europe in the early 1990s. ESWT is a derivative of lithotripsy, the mechanical breaking up of renal stones with sound waves. ESWT has been considered valuable in treating many different MSK disorders including plantar fasciitis, epicondylitis, tendinitis and non-unions of bone. In all situations, it is considered the non-invasive alternative to surgery.
Clinicians should only consider ESWT for treating a pathology after more common, accepted and proven non-invasive treatments have failed.
In the United States, ESWT received its first FDA-approved indication for the treatment of plantar fasciitis. Up to 15 percent of podiatric visits result from painful plantar fasciitis. Given the prevalence of plantar fasciitis in the U.S., with over 1 million people suffering from it annually, it has become the epicenter of debate about ESWT.
What One Randomized Study Revealed About Electrohydraulic Shockwave




Numerous studies have proven that 80 to 90 percent of people suffering with plantar fasciitis will be treated successfully with conservative treatment over a six-month period of time. There is little debate over the most effective conservative management options for plantar fasciitis although the only randomized, proven method is the use of night splints in the chronic cases.
However, continued controversy abounds regarding the proper method of treating the 10 to 20 percent of plantar fasciitis sufferers who do not respond to conservative care in a timely fashion.
Over the years, many different procedures have been described for treating chronic heel pain. These procedures include: large incisional sectioning of the plantar fascia with removal of bone spur; only sectioning the plantar fascia; decompressing a branch of the lateral calcaneal nerve with partial sectioning of the plantar fascia; minimally invasive techniques with or without an endoscope; in-step fasciotomies; and more recently, injections of different chemical agents, either Botox or alcohol. For the past four years, ESWT has been on the list of available treatments in the U.S.

Understanding The Different Shockwave Technolologies
Electrohydraulic, electromagnetic, piezoelectric and radial are four different technologies that are currently utilized to create medical shockwave.
The electrohydraulic system is also known as spark gap technology and was employed with the first generation of shockwave machines. A spark plug is used to generate heat and a sonic pulse, resulting in cavitation. Eisenmenger first described the electromagnetic principle in 1962. This involves the passing of an electrical current through a coil, which produces a strong magnetic field. The subsequent compression of the fluid creates a shockwave.
The piezoelectric principle employs a high voltage current, which is applied to a substantial number of piezo crystals mounted on the inside of a sphere. The piezoelectric effect causes deformation of the crystals, inducing a shockwave. The focal point or area of maximal therapeutics is at some fixed distance away from the shock wave generator in the electrohydraulic, electromagnetic and piezoelectric machines.
The radial principle has a focal point that differs from the other three technologies. The focal point of the radial principle is directly at the device-skin interface and is dispersed in a megaphone fashion from the head of the radial device.
There have been several proposed theories when it comes to the mechanism of action of shockwave. Research by Wang described the mechanism of MSK-ESWT as multiple microtraumas that promote neovascularization to the tissue that one is treating. Others have compared the process to that of tenderizing meat whereby repeated pounding on the meat will break up the interstitial fascia or scar tissue, and make the meat more pliable.
In a study of the Achilles tendons of mongrel dogs versus a placebo, Wang showed that shockwave not only promotes neovascularizaton but also facilitates the release of growth factors PCNA, VEGF and eNOS. Shockwave treatments have been employed for several different MSK applications including the treatment of tendonitis, calcifying tendonitis, periarticular shoulder calcification, plantar fasciitis, medial and lateral epicondylitis, osseous non-unions and avascular necrosis.
Currently, there is no consensus on the use of low-energy shockwaves, which do not require local anesthesia, and high-energy shockwaves, which require local or regional anesthesia for the treatment of chronic plantar fasciitis. There is no consensus for differentiating between low-energy and high-energy shockwaves as multiple physical parameters are involved.
While the clinical effect of both protocols appears to be comparable, there is clear evidence of increasing side effects as the energy level increases. Although these side effects do not appear to be significant from a macroscopic view, local tissue and nerve tissue may be affected. No local anesthesia is required for low-energy shockwaves so related side effects are lacking.
The only “disadvantage” of low-energy shockwaves is that one has to provide a repeat application. A comparison of the effectiveness of low-energy and high-energy shockwaves has not been studied.

Shockwave Therapy Or Surgery For Chronic Plantar Fasciitis?
Why have surgeons continued to change their procedure of choice over the years despite citing literature with good to excellent early results? It is probably the same reason why there are over 100 bunion operations. They are searching for the procedure that is predictable over the long term with the least amount of complications and disability for the patient.
What One Randomized Study Revealed About Piezoelectric Shockwave




We have certainly heard surgeons proclaim minimally invasive surgery as being 95 percent successful with immediate weightbearing and no complications. Certainly, those statistics are far from reality. Whenever one performs invasive surgery, there are risks. It is not uncommon to hear of the patient who underwent an endoscopic plantar fasciotomy (EPF) and wound up having severe nerve injury to branches of the plantar nerve.
We have also encountered the patient who had open sectioning of the plantar fascia and removal of the bone spur only to wind up in severe pain for months, unable to work or pursue normal activities over that time frame. While these scenarios may be unusual, they are certainly more common than we would like.
ESWT has emerged as a noninvasive, minimal risk procedure for chronic conditions such as plantar fasciitis. ESWT allows patients to return to activities of daily life within one or two days with immediate return to most jobs and normal daily shoegear. Complications of ESWT for plantar fasciitis have been virtually non-existent.
In 2002, we published a paper in JFAS showing 82 percent success with ESWT. This success rate was comparable to our success rate with the minimally invasive plantar fasciotomy (83 percent), which we published in JFAS in 1994. This pilot study was a retrospective study and we are certainly aware that only a randomized, prospective, placebo-controlled study can provide evidenced based medicine.
However, this is true of all the studies on surgical outcomes for plantar fasciitis as these studies are similarly designed as retrospective without the control of a placebo group. Therefore, our study shows that outcomes with ESWT are comparable to surgical outcomes without the risks, complications and disability inherent to surgery.
Without a doubt, the literature is controversial when it comes to the relative benefit of ESWT. Opponents of ESWT point to literature that shows its ineffectiveness when it is compared to placebo. One can selectively quote literature to support a stance on ESWT either way.
However, some of the oft-discussed papers against ESWT have been scientifically flawed. The paper most often cited by the opponents of ESWT is by Buchbinder out of Australia. This study included patients who had heel pain for as little as six weeks and ESWT energy levels were given to each patient’s tolerance rather than having a uniform standard application throughout the study. Furthermore, the energy levels used were far less than those recommended in the U.S.
Additionally, the placebo group was administered a small dose of ESWT that could have theoretically been therapeutic. Lastly, the study was performed by a non-clinician who worked for the government of a national health care system. The motives of the study were skewed from the beginning.
Critics will also point out that ESWT is extremely expensive. However, the cost of new technologies is often high as it is with new pharmaceuticals. The benefits of ESWT in terms of social costs are immeasurable. Patients are able to return to activities of daily life and work immediately. There are no costs of lost work to either the patient or employer. There are virtually no risks or complications with ESWT whereas postoperative nerve injuries and infections can require intense medical care that can run into tens of thousands of dollars. These are just some of the examples of the overall cost benefit of ESWT over surgical options.

What Studies Say About Electrohydraulic, Piezoelectric And Radial Devices
Over the past two years, the Weil Foot and Ankle Institute has been fortunate to be involved with five different randomized, double-blind, placebo-controlled studies on the effectiveness of shockwave. Three of the studies were multicenter, pivotal studies for the purpose of securing a PMA from the FDA. The other two were single site studies.
Two of the multicenter FDA studies utilized sedation. One study involved the electrohydraulic device whereas the other study involved the piezoelectric device. Both studies had a rigorous exclusion criteria with qualified patients having pain for greater than six months and medical treatment for at least four months that included at least four of the following: arch support (custom or OTC), antiinflammatory medication for at least four weeks, cortisone injection, physical therapy, night splints, stretching exercises and/or shoe modifications.
Patients were given sedation and the appropriate heel was anesthetized with 6 to 10 cc of 0.5% Marcaine plain. Computer randomization then determined whether the patient would receive active treatment or a sham treatment (no treatment). These patients were then followed for three months by a podiatric physician, who was not aware of the treatment that was provided to these patients.
What One Randomized Study Revealed About Radial Shockwave




The electrohydraulic device showed that 60 percent of the active group improved by more than 50 percent while only 38 percent of the sham group improved by more than 50 percent. This compares favorably to the Ossatron FDA study results.
The piezoelectric study showed that 48 percent of the active group had an improvement of greater than 50 percent while 50 percent of the sham group had more than 50 percent improvement.
However, there was a greater improvement in the Roles and Maudsley criteria for the active treatment group than the sham treatment group, and the active failures had more improvement than the sham failures. Composite scores from all sites are still undergoing statistical analysis.
A third randomized, double-blind, placebo-controlled multicenter study used radial shockwave therapy. Although local anesthetic was available for patients who had severe pain during treatment, no one required the injections.
The study had a rigorous inclusion criteria similar to the aforementioned studies. Computer randomization determined whether patients were treated with an active handpiece or a sham handpiece every two weeks for three treatments. A blinded physician then followed these patients for three months.
For this study of 242 randomized patients, 125 received active treatment while 118 received the sham treatment. The active group improved their visual analog scale (VAS) of pain from a baseline of 7.1 to 3.6 three months after the treatment. The sham group improved from 6.7 to 5.9 at three months.
The active group significantly outperformed the sham group using the Roles and Maudsley criteria. Fifty-seven percent of the active group achieved successful alleviation of their morning pain while only 40 percent of the sham treatment group had this success. Fifty percent of the active group had success treating their activity pain while only 33 percent of the sham group succeeded with treatment of their activity pain.

Using ESWT To Treat Bilateral Heel Pain And Painful Morton’s Neuroma
A single center study focused on the use of ESWT for treating bilateral heel pain. Patients were only eligible for the study if they had been unsuccessfully treated for bilateral heel pain for greater than six months, they had a visual analog pain scale > 6, and systemic causes of the heel pain had been ruled out. Researchers sedated the patients and both heels received 6 to 10 cc of 0.5% Marcaine plain. Computer randomization determined which foot was to be treated.
Researchers used an electrohydraulic ESWT device at a level of 19 Kv and applied 2,000 pulses on the treated foot. The sham foot received no treatment. The patients then followed up with a blinded physician for three months.
This study showed that 70 percent of the active treatment group improved and 52 percent of the sham treatment group improved. Sixty-five percent of the active group improved by more than 50 percent while only 47 percent of the sham treatment group improved by more than 50 percent. Sixty-five percent of the active treatment group achieved a VAS of less than 3 while only 39 percent of the sham treatment group had a VAS less than 3.
According to the study, 4 percent of participants had no improvement in either foot while 39 percent of the participants had improvement in both feet.
A single center study focused on the use of ESWT for treating painful Morton’s neuroma. Patients were only included in the study if they had been unsuccessfully treated for Morton’s neuroma pain for greater than six months, they had a visual analog pain scale > 6, and they had been offered surgical treatment as an option to EWST.
Researchers sedated the patients and injected the third interspace with 3 to 5 cc of 0.5% Marcaine plain. Computer randomization determined whether the patients received active treatment or sham treatment.
Researchers utilized an electrohydraulic ESWT device at a level of 21 Kv and applied 2,000 pulses to the treated foot. The sham foot received no treatment. The patients then followed up with a blinded physician for three months.
The study revealed that 83 percent of the active treatment group improved by more than 50 percent while only 25 percent of the sham treatment group improved by 50 percent. Seventy-five percent of the active treatment group had a VAS of less than 3 three months following the procedure while only 25 percent of the sham treatment group had the same findings. Eight percent of the active treatment group had no improvement while 50 percent of the sham treatment group had no improvement three months following the procedure.
No surgical procedure for heel pain, epicondylitis, calcific shoulder tendinitis, Achilles pathology or Morton’s neuroma has ever been subject to the rigors of a prospective, placebo-controlled, double-blind study the way ESWT has.

Final Notes
At the Weil Foot and Ankle Institute, we treat plantar fasciitis for at least four months with a strict conservative protocol that has been detailed in multiple publications. A vast majority of patients will respond to that conservative approach in that time frame.
After thoroughly ruling out other etiologies, we present patients with the option of ESWT or surgery to relieve their chronic heel pain.
Financial concern is the only issue that keeps patients from choosing the surgery option. In some cases, we provide the treatment pro bono to those who would be best served but just cannot afford the treatment.
At this time, one should consider ESWT a proven treatment for plantar fasciitis and part of any care pathway for physicians who treat the foot. In the future, research may reveal it appropriate to move to ESWT earlier in the treatment pathway if certain diagnostic criteria are met and show that ESWT is more likely to help than other conservative options.
Additionally, it is possible that ESWT will actually reduce overall costs if less money is spent on non-productive conservative care and physician visits, and if there is less chance of lost productivity and days off work from pain, physician visits and surgical recovery. Employers and patients alike may be crying out for ESWT to be utilized and the health insurance companies will have to listen.

Dr. Weil is the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons.

CE Exam 125

Choose the single best response to each question listed below.

1. Numerous studies have proven that between ___ to ____ percent of people with plantar fasciitis will be treated successfully with conservative treatment over a six-month period of time.
a) 50 to 60
b) 90 to 100
c) 80 to 90
d) 60 to 70
e) 70 to 80

2. Which of the following musculoskeletal disorders has extracorporeal shockwave therapy (ESWT) been considered valuable in treatment?
a) epicondylitis
b) plantar fasciitis
c) osseous non-unions
d) tendonitis
e) all of the above

3. The electromagnetic principle of shockwave therapy …
a) is also known as spark gap technology.
b) was employed with the first generation of shockwave machines.
c) involves the passing of an electrical current through a coil, which produces a strong magnetic field.
d) employs a high voltage current which is applied to a substantial number of piezo crystals mounted on the inside of a sphere.
e) a and b

4. The piezoelectric principle of shockwave therapy …
a) is also known as spark gap technology.
b) was employed with the first generation of shockwave machines.
c) involves the passing of an electrical current through a coil, which produces a strong magnetic field.
d) employs a high voltage current which is applied to a substantial number of piezo crystals mounted on the inside of a sphere.
e) a and b

5. The focal point or area of maximum therapeutics is at some fixed distance away from the shock generator in all currently available shockwave devices except those with _______ technology.
a) radial
b) electrohydraulic
c) piezoelectric
d) electromagnetic
e) a and b

6. One multicenter FDA study that involved using an electrohydraulic shockwave device to treat chronic plantar fasciitis found that _____ percent of the active treatment group improved by more than 50 percent.
a) 50
b) 60
c) 70
d) 80
e) 90

7. Another multicenter FDA study that involved using a piezoelectric
shockwave device to treat chronic plantar fasciitis found that _____ percent of the active treatment group improved by more than 50 percent.
a) 38
b) 58
c) 78
d) 28
e) 48

8. A randomized, double-blind, placebo-controlled multicenter study of radial shockwave therapy for chronic plantar fasciitis found that _____ percent of the active treatment group had successful alleviation of their morning pain three months after treatment.
a) 57
b) 47
c) 67
d) 87
e) 77

9. Three months after treatment, a single center study of ESWT for bilateral heel pain revealed …
a) 70 percent improvement for the active treatment group.
b) 50 percent improvement for the active treatment group.
c) 40 percent improvement for the active treatment group.
d) 60 percent improvement for the active treatment group.
e) 80 percent improvement for the active treatment group.

Instructions for Submitting Exams

Fill out the enclosed card that appears on the following page or fax the form to the NACCME at (610) 560-0502. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date.



--------------------------------------------------------------------------------

References

1. Tomczak RL, Haverstock BD. A Retrospective Comparison of Endoscopic Plantar Fasciotomy to Open Plantar Fasciotomy with Heel Spur Resection for Chronic Plantar Fasciitis/Heel Spur Syndrome. J. Foot Ankle Surg. 34(3): 305-311, 1995.

2. Gill L, Kiebzak G. Outcome of Non-surgical Treatment for Plantar Fasciitis. Foot Ankle Int. 1996; 17: 527-532.

3. Weil LS, Golding PB, Nutbrown NJ. Heel Spur Syndrome. A Retrospective Study of 250 Patients Undergoing a Standardized Method of Treatment. J. Foot Ankle Surg. 4: 69-78, 1994.

4. Benton-Weil, Borelli AB, Weil Jr. LS, Weil Sr. LS. Percutaneous Plantar Fasciiotomy: A Minimally Invasive Procedure for Recalcitrant Plantar Fasciitis. J. Foot Ankle Surg. 37(4): 269-272, 1998.

5. Jerosch JU. Endoscopic Release of Plantar Fasciitis - A Benign Procedure? Foot Ankle, 21: 511-513, 2000.

6. Alvarez R. Preliminary Results on the Safety and Efficacy of the Ossatron for Treatment of Plantar Fasciitiis. Foot Ankle Int. 2002; 23: 197-203.

7. Weil Jr. LS, et al. Extracorporeal Shock Wave Therapy for the Treatment of Chronic Plantar Fasciitis: Indications, Protocol, Intermediate Results, and a Comparison of Results to Fasciotomy. JFAS 41(3), 2002.

8. Chen HS, et al. Shockwave Therapy for Patients with Plantar Fasciitis: A One-Year Follow-Up Study. Clinical Orthopedics and Related Research 387: 41-46, 2001.

9. Wang CJ, et al. Shockwave Therapy for Patients with Plantar Fasciitis: A One-Year Follow-up Study. Foot and Ankle International, 23(3), 2002.

10. Ogden JA, et al. Shockwave Therapy for Chronic Proximal Plantar Fasciitis: A Meta-Analysis. Foot and Ankle International 23(4), 2002.

11. Hammer DS, et al. Extracorporeal Shockwave Therapy (ESWT) in Patients with Chronic Proximal Plantar Fasciitis. Foot and Ankle International 23(4), 2002.

12. Buchbinder R, et. al. Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis: A Randomized Controlled Trial. JAMA 288(11), 2002.

13. Rompe JD, et. al. Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes: A Prospective, Randomized, Placebo-Controlled Trial. The American Journal of Sports Medicine 31(2), 2003.

14. Dalay PJ, et al. Plantar Fasciotomy for Intractable Plantar Fasciitis: Clinical Results and Biomechanical Evaluation. Foot and Ankle, 13(41), 1992.

15. Vohra PK, et al. Long-term Follow-up of Heel Spur Surgery: A 10-Year Retrospective Study. JAPMA, 89(2), 1999.

16. Lundeen RO, et al. Endoscopic Plantar Fasciotomy: A Retrospective Analysis of Results in 53 Patients. JFAS, 39(4), 2000.

Podiatry Today - ISSN: 1045-7860 - Volume 17 - Issue 11 - November 2004 - Pages: 60 - 66






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Result number: 93

Message Number 171301

an alternative view of ESWT View Thread
Posted by elliott on 3/16/05 at 10:37


For the most part, the dominant view we see on this board is that expressed by ESWT providers--not casual providers, but those concentrating on it and earning a good bulk or even all of their income from it. They have left enough of an impression on all the boards here that the prevailing thinking and advice offered by posters is that every PF pain sufferer who has tried some conservative measures and not had success within 6 months should strongly consider ESWT (price no object). Since it gets virtually no airtime around here, I think it's worth at least mentioning that there is an alternative but still respectable view (I don't mean my own), namely that ESWT does not really work or if so only marginally. Please read carefully Blue Cross Blue Shield's updated (Dec 04) Tec Assessment on ESWT for plantar fasciitis, whose conclusion is to reject coverage of ESWT:

http://www.bcbs.com/tec/tecinpress/02.html

Yes, BCBS might be viewed as slanted against new treatments it'll have to pay for (as if ESWT providers are not automatically slanted for it). But that does not mean its reasoning and conclusions are invalid. It should also be remembered that covering ESWT does not automatically mean a loss for BCBS; what it certainly would mean is hefty premium and/or out-of-pocket increases for those with BCBS coverage, especially if PF really is an epidemic as many claim.

In previous versions of this report, BCBS basically lumped together the results of all studies it considered to be of sufficient quality, e.g., including Buchbinder's low-energy Dornier study on patients with shorter-term symptoms, using the rationale that no clear evidence has been offered as to ideal protocol of machine settings and patients. But this time around, they also offer separate combined statistics for just the high-energy studies, generally perceived as being of higher quality. What they conclude is that there is a small bias in favor of ESWT for first-step-in-the-morning pain, but that this does not translate into improved function, and that overall, ESWT has not been shown to improve health outcomes.

The report discusses the Roles & Maudsley scoring. For the two high-energy trials, the number needed to treat (i.e., to declare a single success actually attributable to the machine based on the test measure) was a dismal 6.

--

While on this topic, there is a feeling out there that the Dornier Epos is sort of the gold standard in ESWT machines. Not enough has been talked about the *complete* Dornier FDA results. Here is a list of ALL the tests in the Dornier FDA study, and the outcomes as compared to the control group at 3 months (at which time the control group was unblinded):

PRIMARY:

1) VAS improvement from baseline in first few minutes of walking in the morning: *just barely* statistically significant.

2) At least 60% improvement in pain while walking the first few minutes in the morning: *not* statistically significant.

SECONDARY:

1) AOFAS Ankle-Hindfoot Scale: *not* statistically significant
2) 4-point R&M: *yes* statistically significant
3) SF-12 health status questionnaire: *not* statistically significant
4) Heel pressure test: *not* statistically significant
5) ROM assessment: *not* statistically significant

In summation, of all the tests, the only one that had clear statistical significance was 4-point R&M. The other test results, so conveniently ignored, should at least give pause before any sweeping conclusions as to efficacy should be made. At the least, given Dornier’s pre-testing expectations as to success based on its own selected test measures, one could say the results were downright disappointing. That does *not* mean that FDA approval wasn't warranted. But if Dornier approval were not granted, I don't think that would have been an irrational decision either.

Result number: 94

Message Number 170951

Re: Haake View Thread
Posted by elliott on 3/11/05 at 12:28


Elvis:

What I found most interesting about the Haake study is that it is the only one at least that I know of where the placebos were kept blinded for a full year. The placebos had a very respectable 76% success rate at one year based exclusively on the same 4-point Roles & Maudsley test being quoted so often. This highlights the dangers of making too much out of a single 12-month success measure for an ESWT treatment group in isolation.

Haake did come up with an interesting and ethical way to keep his subjects blinded for so long. He allowed all patients, both placebo and control, to seek any other conservative treatment within the year. Perhaps the 76% figure would have been lower in a more controlled setting, but one could argue that this setup of allowing other treatments after ESWT is actually more like what goes on in real life. The power of (real-life) ESWT treatment at one year would then be more like the difference between the real-life success rates of the two groups, maybe something on the order of 20%, or 1 in 5 (I think the technical jargon would be that the Number Needed to Treat, or NNT, is 5).

Result number: 95

Message Number 170914

Re: To Moderator View Thread
Posted by Dr. Z on 3/10/05 at 20:18


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1: Foot Ankle Int. 2004 May;25(5):290-7. Related Articles, Links


Extracorporeal shock wave therapy for the treatment of plantar fasciitis.

Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C.

Foot and Ankle Surgery, Massachusetts General Hospital, Boston, MA 02114, USA. GTheodore@Partners.org

One hundred fifty patients were enrolled in a multicenter, randomized, placebo-controlled, prospective, double-blind study to assess the clinical safety and effectiveness of extracorporeal shock wave therapy (ESWT) using the Dornier Epos Ultra for the treatment of plantar fasciitis. The Active Group was treated with electromagnetically generated shocks using ultrasound guidance during a single therapy session. The Control Group received a sham treatment under similar clinical conditions. The groups were demographically similar with respect to age, height, and weight. The average duration of symptoms was nearly 2 years in both groups. All patients were evaluated by the visual analog scale for pain, American Orthopaedic Foot and Ankle Society scores, Roles and Maudsley Score, SF-12 health status questionnaire, and physical examination. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment. The Control Group reported 47% success at 3 months posttreatment. Twelve-month data were not collected for the Control Group as they were unblinded at 3 months and offered treatment. ESWT represents a safe treatment option for chronic proximal plantar fasciitis.

Result number: 96

Message Number 170744

Re: Dr. Zuckerman was the following Australian Study Incorrect??? View Thread
Posted by Rob M on 3/08/05 at 18:07

Dear Fed Up Also

I certainly don't speak for Dr. Z. There were a few important notes presented in the commentary to this study (by Buchbinder et al)

First, the results don't speak directly of improvement but of statistical differences in outcome between treated and placebo groups. Both groups of patients got better. (on some measures)

Second, patients with PF as young as 6 weeks were included. We know that in the majority of cases, PF will clear itself, and many never seek help for the problem. So if many of members of either group would have gotten better anyway, then it will serve to minimize the effect of treatment.

Third, targeting the thickest part of the plantar fascia (versus the insertion point) is not typical, at least at our clinc. The results are not surprising to me since sound waves have little effect on tissue with a high water content, and have greater effect the more dense the tissue is. As an experiment, administer a few shocks, at low level to a muscle, or fleshy part of the body. You will probably feel nothing. Now do the same to a dense part, like a bone. You will jump. Accurate targeting of the correct location is critical in treatment with ESWT because the beam is very narrow. Being off by only a few mm can make a difference. (I have had ESWT in several locations, several quite uncommon)

Fourth, I take issue with the definition of placebo. They delivered a very small dose of ESWT, NOT nothing. Making a placebo is a very very difficult thing to do with ESWT because it must be indistinguishable to both the patient and researcher from real treatment. The therapist had to have realized that this was a placebo patient because they only gave them 100 shocks at low level. The patient might also have realized it if they know anything about ESWT and knew that they should have received more. At low dose, the patient would have felt little or nothing and may have suspected they were part of the placebo group.
Other studies have tried to mask the effect of the shockwave by putting a thin metal foil inside (or outside) the shock head rubber membrane. This is probably a better method. However the technician delivering treatment would still know the difference from patient feedback or from ultrasound monitor. (The creation of cavitation bubble artifacts for instance)

Fifth, patients were allowed to continue taking Acetominophen. Compare this to the Rompe et al study (seminal European low energy study) where no other treatments after ESWT were allowed. The Rompe study also required 6 months of pain AT THE INSERTION of the plantar tendon and that patients had failed conservative treatments for at least 6 months. Heelspur present on X-ray, no connective tissue disease, or arthritis. (Why did the Buchbinder group choose a less specific set of entry criteria, and more lax post treatment controls?)

It is very unfortunate that the Buchbinder study was then used by BC/BS in their followup technical assessment of ESWT (2003) in combination with the Dornier and Healthtronics studies because it contradicts many of the earlier low energy trials (which showed benefit vs. placebo). Technical Assessments may be used by some BC/BS members to determine coverage.

The BC/BS assessment saw that in double blinded studies, 34%-47% of the placebo cohort showed improvement, whereas in the earlier, European single blinded trials, only 0%-4% of the placebo group saw improvement. They concluded that the single blind studies must be wrong, not because of the study data, but (the authors assert) because in studies of pain, double blinding is better than single blinding based on Turner et al 1994 . Yet if you accept the criticisms leveled in response to the Buchbinder study, another interpretation is that poor selection criteria or treatment location may be a more reasonable answer. (eg. allowing too many young injuries that would have improved anyway, not treating the insertion point) I found the BC/BS TE arbitrary in the acceptance of double vs. single blinding as the only possible explanation for the significant differences between placebo outcome between Rompe et al (and other European studies) and Buchbinder et al.

Reading the abstract of a study can be misleading. Often it is more important to read the whole study, compared to prior literature, and to understand what differences in approach might be significant.

I think that my points above also shed some light on why 'XX% of patients get better' is posted on some website while YY% is claimed by another. No two groups of patients in a study are identical, (they are all individuals) and inclusion criteria are often different in important ways, as are treatment protocols, therapist skill and experience.

So in brief answer to your question, the Buchbinder study is not incorrect. The results are correct for the group of 166 treated. Trying to extrapolate from these results to the population in general (or to the individual heelspur sufferer) is less clear.
.
Robert Mitchell
PainFree ESWT
1 866 444 3798

Result number: 97

Message Number 170730

Re: Posted figures maybe for advertising purpose ok by me. View Thread
Posted by elliott on 3/08/05 at 14:56


Dr. Z, you said:

"If you use the FDA Dornier study 62% reported an Excellence or Good result at the 12 week mark. All had at least 50% reduction in VAS. These patients were satisfied with their ESWT treatment."

Are you proposing that as your new language? It does specify that it's including Good with Excellence, er, Excellent, a positive step. It might be nice to say that this was based on the R & M measure of success. But it still has problems. You probably should say that this 62% was from the blinded treatment group. Are you also going to reveal that the blinded control group's R & M success rate was a still respectable 40%? Or that this was a secondary measure of success in the FDA study and that other important measures of success came out not that significant at 12 weeks? Furthermore, you then say "All had at least 50% reduction in pain." Unlcear. By "All" do you mean everyone in the treatment group? This would be false. There was a MEAN improvement of 56.5%, but the RANGE was given as 4.1 +/- 3.1, so some had a final pain score as high as 7.2 at 3 months, not much improved from the starting average of 7.7, and certainly not a 50% reduction in pain. If you mean that all those who were labeled a success (E or G) under R & M also had a 50% improvement in pain, I don't see that anywhere in the FDA report. The wording should be clear and accurate.

Result number: 98

Message Number 170726

Dr. Zuckerman was the following Australian Study Incorrect??? View Thread
Posted by Fed Up Also on 3/08/05 at 14:37

Synopsis
Summary of Buchbinder R, Ptasznik R, Gordon J, Buchanan J, Prabaharan V and Forbes A (2002): Ultrasound-guided extracorporeal shock wave therapy
for plantar fasciitis. A randomised controlled trial.
JAMA 288: 1364-1372. [Prepared by Chris Maher, Editorial Board member.]
Question: Does ultrasound-guided extracorporeal shock wave therapy (ESWT) improve, pain function or quality of life in patients with plantar fasciitis? Design: Randomised placebo-controlled trial. Setting: Melbourne (Australia) radiology clinic. Patients: Of 178 patients referred to the clinic, 169 were eligible for inclusion and 166 consented and were randomised. Criteria for inclusion included: older than 18 years, presence of plantar heel pain for at least six weeks and ultrasound confirmed lesion. Exclusion criteria included: inflammatory arthritis, previous surgery to heel and previous ESWT to any site. Interventions: Eighty-one patients were allocated to the active ESWT group and 85 to placebo ESWT. Both groups received 3-weekly treatments.
In the ESWT group, patients received either 2000 or 2500 shock waves per treatment of energy levels varying between 0.02 mJ/mm2 and 0.33 mJ/mm2, pulse frequency gradually increased to 240 per minute, a minimum total
dose of 1000 mJ/mm2 being the treatment goal. In the placebo group, treatment consisted of 100 shock waves per treatment, energy level of 0.02 mJ/mm2, frequency 60 per minute, total dose 6.0 mJ/mm2. Outcomes: Overall, morning and activity pain were measured with 100 mm visual analogue scales, reported walking tolerance was measured on a 6-point ordinal scale, disability was measured with the Maryland Foot Score (range 0-100) and a patient-specific measure (the Problem Elicitation
Technique), quality of life was measured with the SF-36 (eight sub-scales each scored 0-100). Outcomes were assessed at six and 12 weeks by a blinded assessor and analysed according to the intention-to-treat principle.
Result: There were no clinically significant differences between groups at baseline. In general, there were no statistically significant between-group differences for any outcome (two sub-scales of the SF-36 were marginally significant at six weeks, p = 0.03 and 0.05, and favoured placebo). For example, at 12 weeks the between-group difference (95% CI) for change in overall pain was 0.6 (- 10.3; 11.5), morning pain 0.2 (-12.7; 13.1), Maryland Foot Score 1.2 (-7.6; 5.3), SF-36 Physical Function score -2.3 (- 9.9; 5.3). Conclusion: In patients with plantar fasciitis,
ESWT is not effective in improving pain, function or quality
of life.
Commentary
A Cochrane review and three systematic reviews have provided conflicting conclusions on the efficacy of ESWT. Heller and Niethard’s (1998) meta-analysis of 24 RCTs (1585 patients) concluded that ESWT was of clinical
benefit. Bodekker et al (2001) reviewed 21 RCTs specific to plantar fasciopathy and determined that none of the trials satisfied all their criteria and that further RCTs were needed. Crawford et al (2002) concluded that limited evidence existed supporting the effectiveness of low energy ESWT. Ogden et al (2002), in a meta-analysis of eight RCTs (840 patients), concluded that ESWT directed at the enthesis of the plantarfascia on the inferior calcaneus is a “safe and effective non-surgical method of treating chronic, recalcitrant heel pain syndrome that has been refractory to other commonly used non-operative procedures.”
There are a number of possible reasons for the Buchbinder et al result. Firstly this study included subjects with a relatively short symptom duration (from eight weeks with median duration 36 weeks) whereas previous studies have not included subjects of less than 24 weeks duration, which may be prior to the processes of the inflammatory response
having stabilised and prior to maturation of scarring within the fascia. Secondly, the authors describe the ESWT focus targeting criteria as being within the thickest area of the plantar fascia. This may differ from results obtained in studies that have targeted, under imaging guidance, the symptomatic region at the enthesis and obtained a treatment effect.
This study does not support the use of ESWT in subjects who have a symptom pattern of less than 24 weeks. Gordon Waddington The University of Sydney References Boddeker R et al (2001): Clinical Rheumatology 20: 324-330.
Crawford F et al (2002): The Cochrane Library. Oxford: Update
Software.
Helbig K et al (2001): Clinical Orthopedics 387: 68-71.
Heller K and Niethard F (1998): Zeitschrift Für Orthopadie Und Ihre
Grenzgebiete 136: 390-401.
Ogden J et al (2002): Foot and Ankle International 23: 301-308
Critically Appraised Papers
Extracorporeal

Result number: 99

Message Number 170617

Re: Gas Prices View Thread
Posted by Richard, C.Ped on 3/07/05 at 13:17

I sure do love my little Nissan 4 cylinder truck and my wifes 4 cylinder Camry.

Result number: 100
Searching file 16

Message Number 168455

low energy ESWT for athletes View Thread
Posted by Ed Davis, DPM on 2/03/05 at 22:36

advantages of low energy ESWT in athletes
Posted by Ed Davis, DPM on 2/03/05 at 22:06 View Thread
Patients who are serious runners in my practice tend to wish to avoid treatments that will interfere with their training schedules so the application of low energy ESWT has been ideal as supported by this paper:
Ed Davis, DPM

JBJS Archive Help Proceedings Subscriptions Courses & Meetings
Journal of Bone and Joint Surgery - British Volume, Orthopaedic Proceedings
Vol 86-B, Issue SUPP III, 365.
Copyright © 2004 by British Editorial Society of Bone and Joint Surgery

European Federation of National Associations of Orthopaedics and Traumatology (EFORT): Oral Presentations: ESWT
Helsinki – 4–10 June, 2003

President – Professor Dr. Nikolaus Böhler

O3304 SHOCK WAVE APPLICATION FOR CHRONIC PLANTAR FASCIITIS IN RUNNING ATHLETES – A PROSPECTIVE, RANDOMIZED, PLACEBO-CONTROLLED TRIAL
J.D. Rompe, J. Decking, J. Schoellner, B. Nafe and J. Heine

Dept. of Orthopedic Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany

Aims: To assess the efþcacy of repeated low-energy extracorporeal shock wave application (ESWA) for chronic plantar fasciitis in runners. Methods: 45 running athletes with intractable plantar heel pain were enrolled in a randomized single-blind trial with a parallel-group design and blinded independent observer, to evaluate the efþcacy of three applications of 2100 impulses of ESWA (Group I) compared with sham treatment (Group II). Follow-up examinations were done at six months, and at one year after ESWA. The primary efþcacy endpoint was reduction of subjectsÕ self-assessment of pain on þrst walking in the morning on a visual analog scale (range, 0 Ð 10 points) at six months after shock wave application. Results: After six months self-assessment of pain on þrst walking in the morning as primary efþcacy endpoint showed a signiþcant reduction from an average 6.9 to 2.1 points in Group I, and from an average 6.9 to 4.7 points in Group II on the visual analog scale. The mean difference between both groups was 2.6 points (p= 0.0004; 95% CI: 1.3 Ð 3.9; power = 0.9). After twelve months pain on þrst walking in the morning showed a further reduction in both groups, to an average 1.5 points in Group I, and to 4.4 points in Group II (p < 0.0001). Conclusion: The current study showed that three treatments with 2100 impulses of low-energy ESWA were a safe and effective non-surgical method for treating chronic plantar fasciitis compared with sham therapy.

Theses abstracts were prepared by Professor Dr. Frantz Langlais. Correspondence should be addressed to him at EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.








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Posted in Category: Social / Support . . View All Heel Pain Categories

Result number: 101

Message Number 168452

advantages of low energy ESWT in athletes View Thread
Posted by Ed Davis, DPM on 2/03/05 at 22:06

Patients who are serious runners in my practice tend to wish to avoid treatments that will interfere with their training schedules so the application of low energy ESWT has been ideal as supported by this paper:
Ed Davis, DPM

JBJS Archive Help Proceedings Subscriptions Courses & Meetings
Journal of Bone and Joint Surgery - British Volume, Orthopaedic Proceedings
Vol 86-B, Issue SUPP III, 365.
Copyright © 2004 by British Editorial Society of Bone and Joint Surgery

European Federation of National Associations of Orthopaedics and Traumatology (EFORT): Oral Presentations: ESWT
Helsinki – 4–10 June, 2003

President – Professor Dr. Nikolaus Böhler

O3304 SHOCK WAVE APPLICATION FOR CHRONIC PLANTAR FASCIITIS IN RUNNING ATHLETES – A PROSPECTIVE, RANDOMIZED, PLACEBO-CONTROLLED TRIAL
J.D. Rompe, J. Decking, J. Schoellner, B. Nafe and J. Heine

Dept. of Orthopedic Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany

Aims: To assess the efþcacy of repeated low-energy extracorporeal shock wave application (ESWA) for chronic plantar fasciitis in runners. Methods: 45 running athletes with intractable plantar heel pain were enrolled in a randomized single-blind trial with a parallel-group design and blinded independent observer, to evaluate the efþcacy of three applications of 2100 impulses of ESWA (Group I) compared with sham treatment (Group II). Follow-up examinations were done at six months, and at one year after ESWA. The primary efþcacy endpoint was reduction of subjectsÕ self-assessment of pain on þrst walking in the morning on a visual analog scale (range, 0 Ð 10 points) at six months after shock wave application. Results: After six months self-assessment of pain on þrst walking in the morning as primary efþcacy endpoint showed a signiþcant reduction from an average 6.9 to 2.1 points in Group I, and from an average 6.9 to 4.7 points in Group II on the visual analog scale. The mean difference between both groups was 2.6 points (p= 0.0004; 95% CI: 1.3 Ð 3.9; power = 0.9). After twelve months pain on þrst walking in the morning showed a further reduction in both groups, to an average 1.5 points in Group I, and to 4.4 points in Group II (p < 0.0001). Conclusion: The current study showed that three treatments with 2100 impulses of low-energy ESWA were a safe and effective non-surgical method for treating chronic plantar fasciitis compared with sham therapy.

Theses abstracts were prepared by Professor Dr. Frantz Langlais. Correspondence should be addressed to him at EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.








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Result number: 102

Message Number 167608

Ongoing controversy on Ogden&#180;s article in JBJS View Thread
Posted by Jan R. on 1/20/05 at 11:14

What is your opinion regarding Ogden´s article:
Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis. J Bone Joint Surg Am. 2004 Oct;86-A(10):2216-28


STEP #1:

On November 1, 2004 I had written the following letter to the Editor of the Journal of Bone and Joint Surgery

James D. Heckman
Journal of Bone and Joint Surgery
AMERICAN OFFICE
20 Pickering Street
Needham, MA 02492-3157
USA

Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis. J Bone Joint Surg Am. 2004 Oct;86-A(10):2216-28


Sir:
Richard Brand, Editor-in-Chief, CORR, advised me today to write to you again regarding the above mentioned article. He also feels that the sequence of events is indeed disturbing and requires investigation.

In my Letter to you (which you published as an e-letter on http://www.ejbjs.org/cgi/eletters/86/10/2216) I had made clear that very similar data had been published previously by Dr. Ogden and that the statistical analysis of these data had not shown a significant difference.
Now, in the publication in the current American issue of the Journal of Bone and Joint Surgery, very similar data are reported by Dr. Ogden now showing a statistical difference:
...
I wonder why Ogden, who quoted the Buchbinder paper in his article, did not specifically respond to these objections. How is it possible that suddenly significant differences are calculated at 3-month follow-up while in the original FDA paper,(4) no statistically significant difference had been observed at the same follow-up?…
...

Sir, I had contacted Professor Rachel Buchbinder in Australia, a world-renowned expert in evidence-based medicine, and I had asked her for her opinion on this article (she had vigorously condemned a very similar paper published by Ogden in CORR 2001 in her JAMA publication from 2002).
...

Professor Buchbinder then did submit the following Letter to your office:

“To the Editor:
Dr Ogden and colleagues recently reported the results of a trial of shock-wave treatment for chronic plantar fasciitis1. We seek clarification on whether this is a reanalysis of a previously published trial2, and if so, why the sample sizes are significantly different. While the results appear similar, the authors now claim a significant difference in the mean score of subject self-assessment of pain at 12 weeks favouring the active treatment group (p=0.014). While this cannot be verified from the data presented, as no measures of variance are provided, independent t-test comparison of mean scores for subject self-assessment of pain at 12 weeks using data published in the original trial report submitted to the US Food and Drug Administration found no statistically significant difference between groups (mean (SD) scores: 3.48 (3.11) and 4.18 (3.04) in 115 and 114 patients in the active- and placebo-treated groups respectively; mean difference = 0.7 (95% CI -0.1 to 1.5), P = 0.08).

Rachelle Buchbinder MBBS (Hons), FRACP, MSc
...

Sir, I support Professor Buchbinder in her opinion, that the data presented are probably a reanalysis of previous data. Like her I don´t think it is adequate scientific behaviour to reanalyse data so long until you can calculate a statistical difference.

To my knowledge Dr. Ogden has not responded to my e-letter which you published. I therefore wonder whether the letter had been forwarded to Dr. Ogden and whether he had an opportunity to respond and chose not to do so.

Sincerely yours,

Jan D. Rompe
...


STEP #2:

On January 4, 2005 I received the following response from Dr. Heckman:

Dear professor Rompe:
At last I am able to respond to the concerns that you raised in your letter to us on November 1, 2004 regarding the article "Electrohydraulic high energy shock wave treatment for chronic plantar fasciitis" (JBJS 2004; 86-A:2216-2228 by Dr. Ogden et al.).

As I am sure you are aware we had a great deal of difficulty receiving response to the letters from you and Dr. Buchbinder from Dr. Ogden.
The response finally arrived in our office during the last week of December.
By now you will probably have read the response in the electronic version of The Journal.

Because of the seriousness of the concerns that you raised, we are going to publish your letter, Dr. Buchbinder´s letter and Dr. ogden´s response in the March issue of The Journal as well.

Sincerely yours,

James D. Heckman, MD
Editor-in-Chief


STEP #3:

On January 11, 2005 Dr. Ogden´s response was published in the electronic version of The Journal:

To the Editor:

...
The previous article that we published involved preliminary data assessed at three months following shock-wave treatment(4).

Our recent study included the complete patient cohort in phases 1 and 2. This involved a larger number of randomized patients as well as nonrandomized patients.
Furthermore, all treated patients were assessed with a different outcomes analysis, in which we used the criteria described by Roles and Maudsley (which were used in many European studies of extracorporeal shock-wave therapy). These different patient numbers and assessments led to different p values.

The data submitted to the FDA were derived with multiple different statistical analyses, and we chose to report a limited number of them.

The data were critically reviewed by an independent statistician, by the FDA statistician, by the orthopaedic FDA panel statistician, and by the JBJS reviewer.
...

John A. Ogden, MD Richard G. Alvarez, MD Richard L. Levitt, MD



STEP #4:

On January 12, 2005 I sent the following reply to Dr. Heckman:


James D. Heckman
Journal of Bone and Joint Surgery
AMERICAN OFFICE
20 Pickering Street
Needham, MA 02492-3157
USA


Electrohydraulic High-Energy Shock-Wave Treatment for Chronic Plantar Fasciitis Ogden et al. (1 October 2004)
Here: Dr. Ogden and colleagues reply to Drs. Rompe and Buchbinder
John A. Ogden M.D., et al. (11 January 2005)


Dear Professor Heckman:

...
Together with Dr. Brand, Editor of CORR, and with Dr. Buchbinder I have read the complete response from Dr. Ogden.

In his response Dr. Ogden claims that his "previous article ... involved preliminary data assessed at three months following shock-wave treatment."
However, when reading the original paper (Clin Orthop 2001; 387:47-59) the study was designed as a randomized, placebo-controlled double-blinded trial to determine the safety and effectiveness of ESWT for the treatment of chronic plantar fasciitis. Clearly, this publication was not preliminary!

Dr. Ogden also wrote “Our recent study included the complete patient cohort in phases 1 and 2. This involved a larger number of randomized patients as well as nonrandomized patients. Furthermore, all treated patients were assessed with a different outcomes analysis, in which we used the criteria described by Roles and Maudsley. These different patient numbers and assessments led to different p values.”

What I can understand is adding more patients, but I cannot understand changing the methods of assessments.

I therefore fully support Dr. Buchbinder´s comments regarding appropriate reporting and reanalysis using different numbers for the randomised patients. Like her I am convinced that publishing some data and then add some more numbers and change the reported outcome measures etc. does not represent correct scientific behaviour.

I hope the readers of The Journal will decide for themselves. Basically, it comes down to valid reporting of trial results based upon the a priori research questions and in this case things have been not made clear at all.

Dr. Brand wrote to me he found Dr. Ogden’s response “at best confusing, and at worst misleading. Scientifically it is unethical to change outcome assessments and then report different results unless those changes are explicitly justified on strong scientific grounds.”
...

Sincerely yours,

Jan D. Rompe

Result number: 103

Message Number 164547

Re: john View Thread
Posted by Ed Davis, DPM on 11/22/04 at 13:45

john:
There are good theories as to why ESWT works and we have good experiential
results with it. I think that the only arrogance comes from those who insist that anything less than a double blinded peer reviewed study plus FDA acceptance is needed to validate a treatment. Those out "in the field" have patients to treat and are obligated to do the best based on a combination of medical knowledge, cumulative experiential data and experimental methods.
Ed

Result number: 104

Message Number 163911

Re: John -- please answer the question! View Thread
Posted by Ed Davis. DPM on 11/14/04 at 18:54

Vince:

So you work for Ossatron and are in their favor. I will compliment you for revealing that since it is only fair that readers know where we stand and what our biases are.

I truly wish their were studies out there fro everything we do in health care, but lets face it, only a small percentage of what we practice is backed by the kind of studies we are talking about. Many jestingly mention that aspirin, due to all of its potential side effects could never make it through the FDA today. We know for a fact that, for most people, if you have a headache, taking two aspirin will make it better. Sorry but there are no double blinded studies to that effect and probably never will be. Much of what we do in healthcare is based on experiences from our personal practice and by comparing notes with hundreds of other practitioners, now thousands due to the internet. The bottom line is, studies or not, when thousands are being cured with low energy ESWT it is very hard to attribute that to placebo effect. Yes, I would love to see more studies, but experiential evidence dwarfs the numbers looked at it the studies.
Ed

Result number: 105

Message Number 163664

Re: Okay, that's it - no more trying to be healthy! View Thread
Posted by Ed Davis, DPM on 11/12/04 at 01:11

Dorothy:

Johnathan Wright is well respected but keep in mind that as a practitioner of "alternative" medicine, he has his share of detractors simply becasue he goes against "mainstream" thinking. I don't know him well personally but have heard him speak at lectures. He had gotten the attention of the mainstream media a few years ago when FDA agents armed with automatic assault rifles raided his office, making his patients lay spread eagle on the floor while they confiscated his supply of an herb that he was not supposed to have.

Bastyr is regarded as probably as one of the top schools of naturopathic medicine. Dr. Joseph Pizzorno, a naturopath and former dean of the school wrote an encyclopedic work that many MDs bought copies of a few years back.

Again, one of the dilemnas faced in naturopathic medicine is having to work hard to get the right information. Commission E from Germany is one source. We just don't devote enough research to the area so it is easy to criticize those praciticing alternative medicine for not having enough "double blinded" studies. That criticism is often a lame excuse since if one has a good understanding of physiology then one can come to conclusions empirically that don't always require extensive studies. Certainly, if many of us had our way, a lot more resources would be devoted to the preventative medicine advocated by the naturopathic profession and those practicing alternative or integrative (mixing traditonal with alternative) medicine. So many studies in preventative medicine are not led by the "right" people, that is, individuals with an agenda designed to prove those advocating supplements wrong. I think that some of the prior studies that used dl-Alpha tocopherol are prime examples of this as such studies are basically "doomed" from the start to yield poor results as a basic understanding of the physiology of the synthetic form of vitamin E allows us to realize that if you crowd out the natural form of vitamin E with the synthetic which has significantly lower antioxidant power, a bad result will occur. That is is study basically designed to fail. Too few have the guts to admit that Rachel Buchbinder's ESWT study was designed to fail becasue 50% of the patients had acute PF (not affected by ESWT) -- Rompe, as a scientist is much more diplomatic than me in his criticisms.
Ed

Result number: 106

Message Number 163645

A reminder.... View Thread
Posted by Ed Davis, DPM on 11/11/04 at 22:35



PubMed

PubMed Citation
Articles by Rompe, J. D.
Articles by Nafe, B.

Related Collections

Track and field

The American Journal of Sports Medicine 31:268-275 (2003)
© 2003 American Orthopaedic Society for Sports Medicine

Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes
A Prospective, Randomized, Placebo-Controlled Trial
Jan D. Rompe, MD*, Jens Decking, MD, Carsten Schoellner, MD and Bernhard Nafe, MD
From the Department of Orthopaedics, Johannes Gutenberg University School of Medicine, Mainz, Germany

* Address correspondence and reprint requests to Jan D. Rompe, MD, Department of Orthopaedics, Johannes Gutenberg University School of Medicine, Langenbeckstrasse 1, D-55131 Mainz, Germany


Background: Recent articles have reported success with repeated low-energy shock wave application for treatment of chronic plantar fasciitis in runners.

Hypothesis: Shock wave treatment for chronic plantar fasciitis is safe and effective.

Study Design: Prospective, randomized, placebo-controlled trial.

Methods: Forty-five running athletes with intractable plantar heel pain for more than 12 months were enrolled; half were assigned to a treatment group that received three applications of 2100 impulses of low-energy shock waves, and half received sham treatment. Follow-up examinations were performed at 6 months and at 1 year by a blinded observer.

Results: After 6 months, self-assessment of pain on first walking in the morning was significantly reduced from an average of 6.9 to 2.1 points on a visual analog scale in the treatment group and from an average of 7.0 to 4.7 points in the sham group. The mean difference between groups was 2.6 points. After 12 months, there was a further reduction of pain in both groups, to an average 1.5 points in the treatment group, and to 4.4 points in the sham group.

Conclusion: Three treatments with 2100 impulses of low-energy shock waves were a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

Result number: 107

Message Number 161880

Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial View Thread
Posted by Mark Evans on 10/21/04 at 08:14


Objective To determine the effectiveness of extracorporeal shock wave therapy compared with placebo in the treatment of chronic plantar fasciitis.

Design Randomised, blinded, multicentre trial with parallel group design.

Setting Nine hospitals and one outpatient clinic in Germany.

Participants 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo.

Main outcome measures Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention.

Results The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group (95% confidence interval - 8.0% to 15.1%). No difference was found in the secondary end points. Few side effects were reported.

Conclusions Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis.

---------------------------------------------------------------------------

The full article can be seen at:

http://bmj.bmjjournals.com/cgi/gca?...06%2F75&allchb=

Result number: 108

Message Number 161823

Effect of local anesthesia on clinical outcome after repetitve low-energy ESWT View Thread
Posted by Jan R. on 10/20/04 at 02:40

Recently repetitive low-energy extracorporeal shock wave treatment (ESWT) has been widely used to treat a number of musculoskeletal conditions, including insertional disorders such as plantar fasciitis.

In clinical practice, the application of a local anesthesia prior to low-energy ESWT became subject to criticism therefore calling in question the negative results of a multicenter trial on ESWT in patients suffering from chronic plantar fasciitis. In this trial local anesthesia had been applied for reason of blinding.

Labek et al.(1) reported they had enrolled 60 patients with a chronic plantar fasciitis in a triple-arm (20 patients per group), prospective randomized and observer-blinded pilot trial. Patients were randomly assigned to receive either active ESWT without local anesthesia, given daily for three days (Group I, 3 x 1500 pulses, total energy flux density per shock 0.09 mJ/mm²), or ESWT with local anesthesia (Group II, 3 x 1500 pulses, total energy flux density per shock 0.18 mJ/mm²) or ESWT with local anesthesia (Group III, 3 x 1500 pulses, total energy flux density per shock 0.09 mJ/mm²). Main outcome measures were: Pain during first step in the morning (measured on a 0-10 point visual analog scale) and number of patients with >50% reduction of pain and no further therapy needed, measured at six weeks after the last ESWT. At six weeks, there was significant improvement in pain during first steps in the morning in all groups, by 4.2 points in Group I, by 2.6 points in Group II, and by 2.4 points in Group III. The mean between-group difference of improvement was statistically significant, between Group I and Group II, and between Group I and Group III. A reduction of pain of at least 50% was achieved in 60% of patients of Group I, in 36% of patients of Group II, and in 29% of patients of Group III. In conclusion, at six weeks success rates after low-energy ESWT with local anesthesia were significantly lower than after identical low-energy ESWT without local anesthesia.

Our confirmatory randomized-controlled study(2)on 86 patients confirmed their observation. The average pain score for patients who received ESWT without local anesthesia (Group I) was 6.9 points at baseline, and 2.2 points at 3 months. The average pain score for patients who received ESWT with local anesthesia (Group II) was 6.7 points at baseline, and 4.1 points at 3 months. At 3 months in Group I 67% of patients achieved at least a 50% reduction of pain, compared with 29% of patients in Group II. At 3 months in Group I 67% of patients achieved an excellent or good result, compared with 24% patients in Group II. Not all patients were satisfied, of course, in Group I. But with two third of them presenting with either no pain, full movement, and full activity, or with only occasional discomfort, full movement, and full activity, the results were not only statistically impressing. The results were clinically significant as well.

Obviously, accurate targeting of the pathology at the spot of maximal point tenderness, as described to the examiner by the patient, is crucial for optimal application of low-energy shock waves.

We conclude that there is a positive treatment effect of repetitive low-energy ESWT as applied at 3-month follow-up in subjects with chronic plantar fasciitis. This positive treatment effect may be reduced by application of a local anesthetic to the painful area prior to low-energy ESWT. Until further experimental and clinical research has developed evidence for this effect, a local anesthetic should not be used for blinding in randomized-controlled trials evaluating the clinical efficacy of repetitive low-energy ESWT for musculoskeletal disorders.

(1)Labek et al., Z Orthop Ihre Grenzgeb, in press
(2)Rompe et al., J Orthop Res, in press

Result number: 109

Message Number 161580

Re: ESWT - trials cast doubt on efficacy View Thread
Posted by Ed Davis, DPM on 10/15/04 at 11:04

Mark:
There mmy not be a formal organization doing what you ask. Certainly, not all of what you do in your practice nor I in my practice is backed up with multiple double blinded studies and approved by the FDA. I don't know much about your practice but show me the studies that matricectomies work, the at orhtotics work and so on.
Ed

Result number: 110

Message Number 161135

Ogden JA: J Bone Joint Surg Am. 2004 ; 86-A:2216-2228 View Thread
Posted by Jan R. on 10/08/04 at 06:16

There is an updated version available of the data originally published in Clinical Orthopaedics and Related Research in 2001:


Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis.

Ogden JA, Alvarez RG, Levitt RL, Johnson JE, Marlow ME.

Skeletal Educational Association, 3435 Habersham Road N.W., Atlanta, GA 30305. orthozap@aol.com.

BACKGROUND: Plantar fasciitis is a common foot disorder that may be resistant to nonoperative treatment. This study evaluated the use of electrohydraulic high-energy shock waves in patients who failed to respond to a minimum of six months of antecedent nonoperative treatment.

METHODS: A randomized, placebo-controlled, multiply blinded, crossover study was conducted. Phase 1 consisted of twenty patients who were nonrandomized to treatment with extracorporeal shock waves to assess the phase-2 study protocol. In phase 2, 293 patients were randomized and an additional seventy-one patients were nonrandomized. Following ankle-block anesthesia, each patient received 100 graded shocks starting at 0.12 to 0.22 mJ/mm(2), followed by 1400 shocks at 0.22 mJ/mm(2) with use of a high-energy electrohydraulic shock-wave device. Patients in the placebo group received minimal subcutaneous anesthetic injections and nontransmitted shock waves by the same protocol. Three months later, patients were given the opportunity to continue without further treatment or have an additional treatment. This allowed a patient in the active treatment arm to receive a second treatment and a patient who received the placebo to cross over to the active treatment arm. Patients were followed at least one year after the final treatment.

RESULTS: Treatment was successful in seventeen of the twenty phase-1 patients at three months. This improved to nineteen (95%) of twenty patients at one year and was maintained at five years. In phase 2, three months after treatment, sixty-seven (47%) of the 144 actively treated patients had a completely successful result compared with forty-two (30%) of the 141 placebo-treated patients (p = 0.008). At one year, sixty-five of the sixty-seven actively treated, randomized patients maintained a successful result. Thirty-six (71%) of the remaining fifty-one nonrandomized patients had a successful result at three months. For all 289 patients who had one or more actual treatments, 222 (76.8%) had a good or excellent result. No patient was made worse by the procedure.

CONCLUSIONS: The application of electrohydraulic high-energy shock waves to the heel is a safe and effective noninvasive method to treat chronic plantar fasciitis, lasting up to and beyond one year.

Result number: 111
Searching file 15

Message Number 159448

Full report View Thread
Posted by Ed Davis,DPM on 9/06/04 at 20:00


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PubMed Citation
Articles by Ward, E. D.
Articles by Phillips, R. D.

Journal of the American Podiatric Medical Association
Volume 93 Number 6 429-442 2003
Copyright © 2003 American Podiatric Medical Association

In Vivo Forces in the Plantar Fascia During the Stance Phase of Gait
Sequential Release of the Plantar Fascia
Erin D. Ward, DPM *, Kevin M. Smith, DPM , Jay R. Cocheba, DPM , Patrick E. Patterson, PhD and Robert D. Phillips, DPM (PIPE)(PIPE)
* Central Iowa Foot Clinic, PC, Perry.
Department of Podiatric Medicine, College of Podiatric Medicine, Des Moines University, Des Moines, IA.
Broadlawns Medical Center, Des Moines, IA.
Department of Industrial and Biomedical Engineering, Black Engineering, Iowa State University, Ames.
(PIPE)(PIPE) Podiatry Section, Veterans Affairs Medical Center, Coatesville, PA.

Corresponding author: Erin D. Ward, DPM, Central Iowa Foot Clinic, PC, 1302 Warford St, Perry, IA 50220.

Abstract

Plantar fasciotomies have become commonplace in podiatric and orthopedic medicine for the treatment of plantar fasciitis. However, several complications have been associated with plantar fascial release. It has been speculated that the cause of these complications is excessive release of the plantar fascia. The aim of this project was to determine whether the amount of fascia released, from medial to lateral, causes a significant increase in force in the remaining fascia. A dynamic loading system was developed that allowed a cadaveric specimen to replicate the stance phase of gait. The system was capable of applying appropriate muscle forces to the extrinsic tendons on the foot and replicating the in vivo timing of the muscle activity while applying force to the tibia and fibula from heel strike to toe-off. As the plantar fascia was sequentially released from medial to lateral, from intact to 33% released to 66% released, the real-time force and the duration of force in the remaining fascia increased significantly, and the force was shifted later in propulsion. In addition, the subtalar joint was unable to resupinate as the amount of fascia release increased, indicating a direct relationship between the medial band of the plantar fascia and resupination of the subtalar joint during late midstance and propulsion. (J Am Podiatr Med Assoc 93(6): 429-442, 2003)



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Background
Anatomy

The plantar surface of the calcaneus is triangular, with its most posterior aspect containing two ridges beside a depression. These two ridges have become known as the medial and lateral tubercles. The lateral tubercle is smaller than the medial tubercle, and it allows for partial attachment of the abductor digiti minimi and the long plantar ligament. The larger and broader medial calcaneal tubercle allows for attachment of the abductor hallucis, the flexor digitorum brevis, the medial head of the quadratus plantae, and the abductor digiti minimi muscles, along with the long plantar ligament. Cancellous bone sectioning and neutron diffraction studies indicate that the calcaneus contains both compression and tension lamellae.1 Compression lamellae surround the articular surfaces and the posterior plantar aspect of the calcaneus. Tension lamellae are observed at the attachment of the Achilles tendon and the plantar fascia, indicating that the plantar fascia produces a significant amount of tension on the plantar calcaneus.2, 3

The plantar fascia is composed of three strong bands (medial, central, and lateral) formed by collagen fiber matrices.4 The medial calcaneal tubercle functions as a partial attachment site for the medial and lateral bands and as a total attachment site for the central band. Barrett et al5 found the mean width of the medial band to be 13.48 mm, the central band to be 4.54 mm, and the lateral band to be 10.77 mm, for a total mean width of 28.78 mm. They found the mean thickness of the medial band to be 4.45 mm, the central band to be 1.57 mm, and the lateral band to be 2.54 mm. Hawkins et al6 conducted a cadaveric study of plantar fascial release in which the average width and thickness of the fascia were 17.4 mm and 3.5 mm, respectively; the average percentage of fascia cut was 82%. These three bands divide into five bands as they proceed distally. At the metatarsal heads, the five bands attach to the metatarsals via the superficial transverse metatarsal ligament. Smaller slips of plantar fascia cross the metatarsophalangeal joints and attach to the proximal phalanges, allowing the "windlass effect" described by Hicks7 to occur when the metatarsophalangeal joints are extended.

Plantar Fascia Biomechanics

Plantar fascial function and its relationship to the function of the foot has been a point of investigation for many years. In 1943, Lapidus8 concluded that the foot could not be considered an arch, or at least not an arch in architectural terms, because the bones of the foot cannot stand alone without soft-tissue structures. He believed the foot to be a truss, with the bones of the foot being in compression and the plantar fascia being in tension. Twenty years later, in 1963, Lapidus9 published a second article concerning whether the foot is an arch or a truss. He again concluded that the foot should be considered a truss, with the bones of the foot being in compression and, this time, not only the plantar fascia but also the plantar ligaments being in tension.

Hicks7 was the first to publish data on the mechanics of the plantar fascia. He noted that upon extension of the metatarsophalangeal joints, the height of the longitudinal arch of the foot increased. He went on to hypothesize that the plantar fascia must increase in tension for the windlass effect to occur during propulsion. Hicks10 proposed a formula by which the tension in the plantar fascia can be determined. Wright and Rennels11 revised Hicks’ equation and applied it to lateral foot radiographs. With their equation, Wright and Rennels indicated that the tension on the fascia should be approximately 47% of the tibial load. However, neither equation accounts for the three-dimensionality of the plantar fascia or for the three separate fascial bands. MacConaill12 and Sarrafian,13 on the other hand, view the foot as a twisted plate. As a twisted plate, the plantar fascia is tensed when the talotibial complex is internally rotated, the rearfoot and midfoot are pronated, and the forefoot is supinated.

The integrity of the plantar fascia has become synonymous with proper foot function. Therefore, the material properties of the plantar fascia are important in determining the role that the plantar fascia plays in the integrity of the foot during stance as well as propulsion. Wright and Rennels11 noted that the modulus of elasticity of the plantar fascia increased as the load on the fascia increased, reaching a maximum of 0.12 x 106 pounds per square inch. A load of 2,500 pounds was placed on the plantar fascia, at which time the plantar fascia underwent elastic deformation, followed by elastic recovery when unloaded. Wright and Rennels surmised that at 200 pounds of tibial load, the plantar fascia underwent elongation of only 1.68%. A more recent study conducted by Kitaoka et al14 determined that the mean ± SD force at which the plantar fascia ruptured was 1,540 ± 246 N in men and 1,002 ± 101 N in women.

Ker et al15 and McMahon16 established that upon flattening of the arch, the foot stored the energy produced by the compression and then released the stored energy in the form of elastic recoil. Ker et al believed the energy to be stored in both the plantar fascia and the plantar ligaments. Simkin and Leichter17 constructed a formula that they believed correlated the calcaneal inclination angle with the amount of energy created when the medial longitudinal arch flattened. Kitaoka et al14 determined the failure rate of the plantar fascia to be 111.2 N/sec. At 11.1 N/sec, they found the mean ± SD stiffness of the plantar fascia to be 203.7 ± 50.5 N/mm and the average force at which failure occurred to be 1,189 N. Kim and Voloshin18 created a mathematical model of the foot for determining the role of the plantar fascia in the integrity of the foot. Their data indicated that the fascia carried approximately 14% of the total load applied to the foot. They also found that the fascia was important for shock absorption. A biomechanical model created by Arangio et al19 demonstrated a significant increase in vertical displacement and horizontal length of the model with the plantar fascia released.

Cadaveric Plantar Fascia Research

With the increasing acceptance that the inferior calcaneal exostosis is not involved in plantar fasciitis, plantar fascial release alone has become the primary target of surgical relief of plantar fasciitis. This concept was first introduced by Spitzy20 in 1937. However, several studies indicate that the plantar fascia is an integral component of foot function, especially the stability of the longitudinal arch and midtarsal joint. Huang et al21 examined longitudinal arch stability through serial sectioning of the plantar fascia and the long plantar, short plantar, and spring ligaments. This study indicated that the plantar fascia was the structure most important to the integrity of the medial longitudinal arch. Kitaoka et al22 noted that with the application of increasing loads to the tibia, the height of the medial longitudinal arch decreased.

Thordarson et al23 evaluated the role of the plantar fascia in foot function through serial sectioning of one-quarter, one-half, three-quarters, and full release of the fascia. They noted a decrease in arch height and an increase in foot length once half of the fascia was sectioned. A cadaveric study conducted by Kitaoka et al24 in 1997 demonstrated a significant decrease in sagittal plane height of the talotibial joint, the talometatarsal joint, and the talocalcaneal joint upon complete plantar fascial release. In a study conducted by Murphy et al,25 an equinus rotation of the calcaneus and a drop in the cuboid occurred when the entire plantar fascia was cut, but this was not observed when only one-third of the fascia was transected.

Thordarson et al26 found the plantar fascia to be significantly involved in the development of flatfoot deformity. Cadaveric studies undertaken by Sharkey et al27, 28 indicate that plantar fascial release disrupts the configuration of the medial longitudinal arch and significantly decreases the transfer of load to the forefoot during propulsion. Carlson et al29 found a direct relationship among the increasing force in the Achilles tendon, the increasing dorsiflexion of the metatarsophalangeal joint, and the increasing tension in the plantar fascia. A study conducted by Anderson et al30 indicated that as the plantar fascia is sequentially released, the inferior sinus tarsi joint space increases, the lateral band of the plantar fascia length increases, and the medial longitudinal arch height decreases. Hamel et al31 discovered that when the plantar fascia was totally released, the contact pressure under the digits decreased, the pressure under the metatarsal heads increased, and the forefoot pressure underwent a posterolateral shift during simulated propulsion.

In Vivo Plantar Fascia Research

Several postoperative studies have been undertaken to assess complications following plantar fasciotomy. Daly et al32 investigated the biomechanical significance of dividing the central band of the plantar fascia. They found a significant decrease in arch height postoperatively. The study also indicated that fasciotomy patients proceeded through the stance phase more rapidly and applied much less vertical force than controls, and thus had a less efficient gait. Gormley and Kuwada33 noted that of nine patients in whom 0.5 cm of plantar fascia was resected, all experienced complete relief of their symptoms. Barrett and Day,34 in an initial study of endoscopic plantar fascial releases, noted the occurrence rate of midtarsal pain postoperatively to be 9.6%. White35 noted that upon release of the plantar fascia and plantar musculature at the area of the medial calcaneal exostosis in 30 feet, 27 feet exhibited metatarsalgia or lateral column pain at a minimum of 4 weeks. A more recent analysis of endoscopic plantar fascial release by Barrett et al36 indicated that lateral column pathology, similar in clinical presentation to cuboid syndrome, occurred at a rate of at least 4.25%. In a follow-up study of 652 plantar fasciotomies, Barrett et al37 found 62 complications postoperatively. Of the 62 complications, 25 were associated with the calcaneocuboid joint. They believed this to be due to disproportionate excision of the medial and central bands of the plantar fascia, causing an increase in tension in the lateral fascial band and a change in force at the calcaneocuboid joint. In a follow-up study of endoscopic plantar fasciotomies, Stone and Davies38 found a significant decrease in calcaneocuboid pain when a cast was applied postoperatively.

Materials and Methods

A specially designed dynamic gait–replicating loading system known as the Dynamic Gait Replicator was developed for this study. The Dynamic Gait Replicator is composed of a platform on a rail, with a variable motor and cable attached to the platform capable of pulling the platform linearly (Fig. 1). Nine motors with controllers and gear reducers are attached to the platform, with an encased cable attached to each gear reducer. Each of these cables extends from the platform and is attached to a strain gauge. A pneumatic cylinder capable of applying 1,112.5 N of force is also attached to the platform. A manufactured functional knee joint is attached to the cylinder ram. Four fresh-frozen specimens that were severed 11 cm proximal to the tibial plafond were obtained for this study. Skin and subcutaneous tissue were removed to 5 cm proximal to the tibial plafond to show the individual extrinsic muscles of the foot and yet leave the retinacula intact. Two Kirschner wires with markers were driven into the posterior tibia, and two were driven into the posterior calcaneus of each specimen for obtaining kinematic data (Fig. 2). Each extrinsic tendon was transected at its musculotendinous junction. A braided line capable of withstanding 667.5 N of force was knotted to each tendon. A steel rod was driven into the intermedullary canal of the tibia of each specimen, with a second rod fixed to the fibula, and both were attached to the distal portion of the manufactured knee joint. Each braided line from the individual extrinsic tendons was then attached to the opposite end of the strain gauge from the encased cable (Fig. 3).





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Figure 1. Top view of platform. 1, Pneumatic cylinder; 2, motor controller; 3, motor; 4, gear reducer.







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Figure 2. Rearfoot, with arrows indicating markers on the posterior leg and calcaneus.







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Figure 3. Medial aspect of specimen. 1, Tibial rod; 2, cable from motor; 3, strain gauge; 4, braided line.




A controller board (Fig. 4), created from electromyographic data, was placed below the platform so that as the platform moved over the controller board, each motor (ie, muscle) was triggered to activate and release as in vivo. The force applied by each motor from heel strike to toe-off was derived from feedback through each strain gauge using LabVIEW software (National Instruments Corp, Austin, Texas), and the force was adjusted using the motor controller to replicate theoretical in vivo muscle forces as indicated by Dul et al,39 Brand et al,40 and Perry41 (Fig. 5). A 2-cm incision was made on the medial aspect of the foot to visualize and measure the medial band of the plantar fascia, and a 2-cm incision was made on the lateral aspect of the foot to visualize and measure the lateral band of the plantar fascia. A microstrain gauge (MicroStrain, Inc, Williston, Vermont) was implanted in the medial band of the plantar fascia, and a microstrain gauge was implanted in the lateral band of the plantar fascia (Fig. 6). The real-time forces being applied to each microstrain gauge were read using LabVIEW throughout the stance phase of gait.




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Figure 4. Muscle activity controller board.







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Figure 5. LabVIEW screen, with each curve demonstrating muscle activity for each extrinsic tendon.







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Figure 6. Microstrain gauge.




Each foot was then walked from heel strike to toe-off for three trials with the plantar fascia intact (Fig. 7). The muscle forces and timing as well as the forces in the plantar fascia were collected from LabVIEW for each trial. The plantar fascia was then released sequentially, from medial to lateral, 33%, then 66%, and finally 100%, with data collected at each stage. The maximal force and the impulse (area under the force–time curve) within the medial and lateral bands of the plantar fascia were ascertained using ImageJ (National Institutes of Health, Bethesda, Maryland). A digital camera was placed behind the specimen, and each trial was videotaped to capture movements of markers for frontal plane subtalar motion. Each video was segmented frame by frame and each marker was hand-digitized using VirtualDub (National Institutes of Health). Angular changes between the markers were measured using Scion (National Institutes of Health) at heel strike, forefoot loading, and heel-off and just before toe-off.




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Figure 7. Specimen walking in real time from heel strike to just before toe-off. The images should be viewed from top to bottom, column by column.




Results
Validation of Dynamic System

To validate the plantar fascia force data, we determined that the cadaveric specimen had to replicate the in vivo foot mechanically during the stance phase of gait in real time. Two systems were used: first was plantar force data from heel strike to just before toe-off using the F-Scan force-measuring system (Tekscan, Boston, Massachusetts) (Fig. 8) and the second was rearfoot kinematics throughout stance (Fig. 9). Data from kinematics as well as plantar pressures were found to be essentially identical to in vivo data, indicating that the Dynamic Gait Replicator did indeed produce cadaveric dynamic gait similar to in vivo gait.





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Figure 8. F-Scan data from heel strike to just before toe-off with the plantar fascia intact.







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Figure 9. Frontal plane subtalar joint motion with the plantar fascia intact from heel strike to just before toe-off. HS, Heel strike; FFL, forefoot loading; HO, heel-off; Pre-TO, before toe-off.




Plantar Fascia Force Data with Sequential Release of the Plantar Fascia
This study demonstrated that real-time forces in the cadaveric plantar fascia could be obtained in a dynamic cadaveric scenario (Table 1). With the entire fascia intact, the force in the medial band began just after heel strike and had two peaks: a lower first peak during midstance and a second larger peak during early propulsion. Force in the lateral band of the plantar fascia also began just after heel strike and peaked at early midstance and then peaked a second time during early propulsion. Unlike in the medial band, the second lateral band peak is smaller than the first (Fig. 10).




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Table 1. Impulse in the Lateral Band of the Plantar Fascia in a Dynamic Cadaveric Scenario







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Figure 10. A, Impulse in the medial and lateral bands of the plantar fascia with the entire fascia intact; B, impulse in the lateral band of the plantar fascia with 33% of the plantar fascia released; C, impulse in the lateral band of the plantar fascia with 66% of the plantar fascia released.




The impulse in the lateral band of the plantar fascia increased significantly throughout stance in all specimens tested from intact to 33% of the plantar fascia released. When 66% of the fascia was released, the impulse in the lateral band also increased significantly from that observed with 33% released in all but one specimen (Fig. 11). This increased force also occurred earlier in stance and peaked during propulsion (Fig. 12).




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Figure 11. Impulse in the lateral band of the plantar fascia of all four specimens during the stance phase of gait with the plantar fascia intact, 33% released, and 66% released.







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Figure 12. Impulse in the lateral band of the plantar fascia throughout the stance phase of gait during plantar fascial release in Specimen 10602 (A), Specimen 11202 (B), Specimen 12002 (C), and Specimen 12702 (D). HS, Heel strike; FFL, forefoot loading; HO, heel-off; Pre-TO, before toe-off.




Rearfoot Kinematic Data with Sequential Release of the Plantar Fascia
With the plantar fascia intact, the subtalar joint was noted to be supinated prior to heel strike and to progressively pronate until midstance, at which time the subtalar joint began to resupinate. Supination continued until heel-off, at which time the subtalar joint returned to neutral and continued to supinate. When 33% of the plantar fascia was released, there was not a significant increase in subtalar joint pronation during contact and early midstance. During the latter half of midstance, the subtalar joint began to resupinate, but it was unable to continue resupinating after heel-off. When 66% of the plantar fascia was released, the subtalar joint pronated normally in contact; however, it remained pronated and was unable to resupinate to neutral before heel-off. When the plantar fascia was completely released, the results were similar to when 66% of the fascia was released: the subtalar joint remained pronated from just after heel strike throughout the remainder of stance and was unable to resupinate before heel-off. Interestingly, in two specimens, the subtalar joint resupinated more when the plantar fascia was completely released than when only 66% of the fascia was released (Fig. 13). Also, a direct relationship was found between the increasing force in the lateral band of the plantar fascia from intact to 33% and 66% released and increased subtalar pronation (Figs. 14 –17).





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Figure 13. Frontal plane subtalar joint motion with the plantar fascia intact, 33% released, 66% released, and 100% released in Specimen 10602 (A), Specimen 11202 (B), Specimen 12002 (C), and Specimen 12702 (D). HS, Heel strike; FFL, forefoot loading; HO, heel-off; Pre-TO, before toe-off.







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Figure 14. Impulse in the lateral band of the plantar fascia compared with frontal plane subtalar joint motion with the plantar fascia intact (A), 33% released (B), and 66% released (C) in Specimen 10602. HS, Heel strike; FFL, forefoot loading; HO, heel-off; Pre-TO, before toe-off.







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Figure 15. Impulse in the lateral band of the plantar fascia compared with frontal plane subtalar joint motion with the plantar fascia intact (A), 33% released (B), and 66% released (C) in Specimen 11202. HS, Heel strike; FFL, forefoot loading; HO, heel-off; Pre-TO, before toe-off.







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Figure 16. Impulse in the lateral band of the plantar fascia compared with frontal plane subtalar joint motion with the plantar fascia intact (A), 33% released (B), and 66% released (C) in Specimen 12002. HS, Heel strike; FFL, forefoot loading; HO, heel-off; Pre-TO, before toe-off.







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Figure 17. Impulse in the lateral band of the plantar fascia compared with frontal plane subtalar joint motion with the plantar fascia intact (A), 33% released (B), and 66% released (C) in Specimen 12702. HS, Heel strike; FFL, forefoot loading; HO, heel-off; Pre-TO, before toe-off.




Discussion
The etiology of plantar fasciitis and the etiology of complications associated with partial and complete release of the plantar fascia have spawned many investigations. Although they added some insight into the potential causes of these phenomena, the previous studies have been constrained either by mathematical modeling or by static or quasi-dynamic cadaveric modeling.

We believe that the system we developed overcomes most of these constraints by providing a model capable of replicating gait. The model was validated through the use of kinematics and ground reaction force data. Heel strike to just before toe-off occurred in approximately 0.6 to 0.8 sec for each specimen, with muscle force curves read by LabVIEW in close agreement with attenuation and length of activity with electromyographic data presented by Perry.41 We realize that the model did not apply force to any of the intrinsic musculature of the foot that may also play a role in stabilizing the foot during gait. We believe that the strain gauges implanted in the plantar fascia provided the closest determination of real-time forces in the medial and lateral bands throughout the stance phase of gait.

As the plantar fascia was transected from medial to lateral at 33% and 66%, the impulse significantly increased in the lateral band of the fascia. The observed loss of resupination of the subtalar joint when the medial band of the plantar fascia was released seems to be a significant finding, as no other changes were made in the foot structure or function except release of the medial band of the plantar fascia. It seems that the extrinsic supinatory muscles were adequate to provide enough force to keep the initial subtalar joint velocity under control and prevent the subtalar joint from pronating excessively during the contact period. However, it seems that tension in the medial band of the plantar fascia provided the necessary force on the subtalar joint during late midstance and propulsion to create resupination of the subtalar joint. This may explain the postoperative foot instability observed in 4.25% to 9.6% of plantar fasciotomy patients and may be one of the etiologic factors involved in plantar fasciitis. Therefore, any device that would assist in resupinating the subtalar joint from its normal pronation during contact would alleviate the pain associated with plantar fasciitis. We realize that it can be argued that as the released plantar fascia in vivo heals, the fascia may become reattached to the calcaneus through fibrous tissue. However, whether the healed plantar fascia will be able to produce resupination of the subtalar joint has not been studied.

Conclusion

Although plantar fasciotomies continue to be used to relieve the heel pain associated with plantar fasciitis, there are no criteria as to the amount of fascia release required to relieve symptoms while maintaining the integrity of foot function. This study demonstrated that it is conceivable for a device to be fabricated to allow the cadaveric foot to replicate the in vivo foot during the stance phase of gait. The study demonstrated that partially releasing the plantar fascia imparts forces to the remaining fascia that are not usually observed with the fascia intact. Not only did the impulse increase, but a shift was noted in where the maximal force occurred during gait. When the plantar fascia was released, the subtalar joint was unable to resupinate in late midstance and propulsion, and there seems to be a direct correlation between the amount of fascia transected and the subtalar joint’s inability to resupinate. Although the exact nature of this relationship was not ascertained from the study, resection of the medial band of the plantar fascia was the only variable changed with the lack of resupination. More research is needed to determine more precisely the amount of plantar fascia that can be released before significant increases in forces in the remaining fascia are observed and before loss of the subtalar joint’s ability to resupinate during late stance and propulsion. From this initial study, it seems that less than 66% of the fascia should be released to maintain foot stability, which is in agreement with in vivo research on lateral column symptoms following plantar fascial release.42



















Acknowledgments

The Iowa Osteopathic Education Foundation and the Central Iowa Foot Clinic, PC, for funding this project; the University of California, San Diego, for specimens; the IE 386 class at Iowa State University and Greg Leuke, PhD, of Iowa State University for aiding in development of the loading system; MicroStrain, Inc, for supplying the microstrain gauges and the amplifier for determining the forces in the plantar fascia; and Kevin A. Kirby, DPM, and Christopher J. Nester, PhD, for technical assistance with validating the loading system.

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STONE PA, DAVIES JL: Retrospective review of endoscopic plantar fasciotomy: 1992 through 1994. JAPMA 86: 414, 1996.[Abstract]

DUL J, SHIAVI R, GREEN NE: Simulation of tendon transfer surgery. Eng Med 14: 31, 1985.[Medline]

BRAND RA, PEDERSEN DR, FRIEDRICH JA: The sensitivity of muscle force predictions to changes in physiological cross-sectional area. J Biomech 19: 589, 1986.[Medline]

PERRY J: "Ankle Foot Complex," in Gait Analysis: Normal and Pathological Function, p 51, McGraw-Hill, New York, 1992.

BRUGH AM, FALLAT LM, SAVOY-MOORE RT: Lateral column symptomatology following plantar fascial release: a prospective study. J Foot Ankle Surg 41: 365, 2002.[Medline]





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Result number: 112

Message Number 154942

Attention science geeks....the future of Nanotechnology View Thread
Posted by marie on 7/09/04 at 11:53

http://share.shutterfly.com/osi.jsp?i=EeAMmjZu2bOGjGsg

This is a photo through an electron microscope of some nano wires that my son grew for his research this summer. I am including some information on the field of Nanotechnology. This research will have a huge impact on the medical and pharmaceutical industry in the future. His research is being sponsored by BSAF.

Boston Globe
By Robert Gavin, Globe Staff, 3/6/2004

Nanotechnology creates devices smaller than a human hair, and it might just be the next big thing in Massachusetts.

A new study by the Massachusetts Technology Collaborative and Cambridge-based Nano Science and Technology Institute says the state's universities, entrepreneurial networks, and diversified technology base make it well-positioned to cash in on this emerging field, which the federal government projects could create a $1 trillion worldwide market by 2015. Scientists see the technology, which builds structures about one-thousandth the width of a human hair, leading to an array of new materials and products, from longer-lasting batteries to more powerful computers to ''smart pills" that deliver the right dose of drugs at the right time.

The study, released in conjunction with a national nanotechnology conference that opens in Boston tomorrow, finds that Massachusetts has already grabbed a lead in the field, much of it based on the strength of its research universities. To maintain the lead, the state must support university research efforts, and bring together academia and industry to commercialize discoveries, the study said. ''We have to continue to win on research," said Thomas Hubbard, vice president for technology development at the Massachusetts Technology Collaborative, a state economic development agency. ''And we have to exploit the burgeoning amount of intellectual property that's coming out of our universities." Massachusetts is already home to two federally funded nanotechnology research centers: Harvard University's Center for the Science of Nanoscale Systems and Their Device Applications, and the Institute for Soldier Nanotechnologies at the Massachusetts Institute of Technology. In addition, the state's universities boast top-ranked programs in a variety of disciplines critical to nanotechnology, including physics, chemistry, materials science, and biomedical engineering the study said.

The entrepreneurial culture and well-established venture capital sector in the state also provide key components to move products from the lab to the marketplace, the study said. A number of start-ups are already at work, using nanotechnology to build lighter and cheaper solar cells, improve computer memory, and enhance drug discovery. Massachusetts has at least 100 firms developing nanoscale products and processes, the study estimated.

Ultimately, the study said, nanotechnology's greatest impact is likely to come from its application across many industries, and Massachusetts has a mix that is likely to benefit most from nanotechnology, including electronics, medical devices, biotechnology and advanced materials.

Story location: www.boston.com/business/technology/...

http://www.innovations-report.com/html/reports/physics_astronomy/report-30981.html

Turning Science Fiction Into Fact



In the future, our computers no longer crash as we try and download pictures that are too heavy in memory, our cars no longer pollute the atmosphere and cancer could be dealt with by a visit to the GP. Some of it, at least, will happen thanks to cutting edge research happening now at the University of Leicester Department of Physics and Astronomy.

Here scientists are among a handful across the world helping to turn science fiction into a fact of the future through the science of nanotechnology.

Their work relates to the miniscule -smaller than a grain of talcum powder - in the realms of one thousand millionth of a metre in size. At the other end of the spectrum they are concerned with computer memories thousands of times more powerful than they are now; potential new ways of targeting cancer cells too small or fragmented to be identified with current technology; hugely enhanced mobile phone batteries; and safe, effective ways of storing fuel for hydrogen cars.

This is all in the realms of the future, but when, one day, it ceases to be the stuff of science fiction and becomes scientific fact, then that will be because of research in just a handful of laboratories worldwide, one of which is at the University of Leicester.

Chris Binns, Professor of Nanoscience at the University, explained some of the projects he and his research team are working on:

“Our main current research is the properties of nano-particles of 10-1000 atoms, just one or two nanometres across. What is interesting about them is that they show us how matter is developed, how properties change as a result of the number of atoms in a cluster. Clusters of atoms have characteristics that are different from the atoms themselves, and they become giant artificial atoms whose properties you can change.

Recently Professor Binns has been looking at ways of making materials out of these clusters. “We start with designer atoms and build materials out of them. Taking them in gas form, we can make clusters and coat surfaces. The material they make is very different because the clusters retain a memory of their novel properties in the gas phase.

With major funding from the magnetic recording industry, in particular Seagate, Leicester researchers are working on the production of a material that is more magnetic than anything available at the moment. “The most magnetic material today has been around for about a century, Chris Binns said. “We think the clusters we are working on may produce something that is far more magnetic. The thing that limits magnetic recording is the write head. The effectiveness of this is constrained by the degree of magnetism between the write head and the surface it links to. If we can come up with much higher magnetism then computer disks could become much more powerful.

As far as breaking the record for the most magnetic material is concerned this is the only game in town.

Looking to the future, the Leicester research team, in collaboration with Dr Ellis and Dr Wheeler in the Chemistry department, has recently applied for funding to develop even more sophisticated clusters. In what Professor Binns calls “nanocluster onions , they will produce a core containing tens to hundreds of atoms, around which they will grow sophisticated shells that would not occur in nature.

The applications for this branch of nanotechnology are enormous. “If we can achieve this, it will allow us to produce particles using nanotechnology for cancer diagnosis. We could attach antibodies for tumours to the clusters and inject them into the body, and they would find the tumour and kill the tumour cells. This is very exciting stuff. The clusters would be able to detect tumours too small to see, including tumours that have dispersed.

“Potentially you could go to your GP, be injected with these clusters and then walk through something like an airport security arch, and any cancer cells in your body could be located and dealt with.

In three or four years Professor Binns hopes they will be able to get suspensions of the clusters in solution. Then they have to attach biological particles to the clusters. He is, however, optimistic about this stage. “This has already been done. The problems will come in the medical field. How would it work in the body? What side effects might there be?

Core-Shell cluster technology also has applications for the mobile phone battery, as well as for magnetic recording of the future. Computer memory that currently requires a surface of 100 x 100 nanometres could, using shell technology, be stored on a single particle of 2 x 2 nanometres, multiplying the total memory by a factor of 1000.

It may also change motoring of the future. The move is increasing to get away from petrol-fuelled cars. Hydrogen is a clean, non-polluting fuel, which can be obtained from anything as simple as sea water. The problem is in storing it. In gas form it would have to be stored in huge cylinders too heavy for a car to tow. In liquid form it is too dangerous for general consumption. Using nanotechnology, you could store enough hydrogen as a gas in a “metal sponge weighing a few kilogrammes to power a car over the same distance as a conventional petrol tank.

“These are all real possibilities for the future, Professor Binns said, “though for some of them we are looking decades ahead.

There is, however, no harm in dreaming of such a future, when our computers no longer crash as we try and download pictures that are too heavy in memory, when our cars no longer pollute the atmosphere and when cancer can be dealt with by a visit to the GP. Some of it, at least, will happen.

Result number: 113

Message Number 154449

Re: ESWT and Insurance View Thread
Posted by Ed Davis, DPM on 7/03/04 at 11:02

Pauline:
Better than 90% of the material on this site does not have the type of studies you are looking for, so if you are serious, then you may be hanging around the wrong place. Most of the material on Scott's Heel Pain Book is valuable material based on a fairly substantial knowledge base but you won't see double blinded peer reviewed studies to back it up as you won't see for better than 90% of surgery practiced today and the majority of medicine.
Ed

Result number: 114

Message Number 153510

Re: To: Scott D 92% success View Thread
Posted by Ed Davis,DPM on 6/19/04 at 15:10

Mark:
It is likely that Dr. Z is performing ESWT in conjunction with whatever other modalities are needed for PF and the 92% rate may reflect that. This is a very different scenario than an experimental scenario in which one group gets nothing done and a second group has ESWT performed in isolation. My numbers, in my experience would corroborate that of Dr. Z, but, again, my patients are usually getting "the works" as opposed to ESWT in isolation. This is where it is tricky comparing our experience to double blinded studies...
Ed

Result number: 115

Message Number 153509

Re: To: Scott D 92% success View Thread
Posted by Ed Davis,DPM on 6/19/04 at 15:10

Mark:
It is likely that Dr. Z is performing ESWT in conjunction with whatever other modalities are needed for PF and the 92% rate may reflect that. This is a very different scenario than an experimental scenario in which one group gets nothing done and a second group has ESWT performed in isolation. My numbers, in my experience would corroborate that of Dr. Z, but, again, my patients are usually getting "the works" as opposed to ESWT in isolation. This is where it is tricky comparing our experience to double blinded studies...
Ed

Result number: 116

Message Number 153508

Re: To: Scott D 92% success View Thread
Posted by Ed Davis,DPM on 6/19/04 at 15:09

Mark:
It is likely that Dr. Z is performing ESWT in conjunction with whatever other modalities are needed for PF and the 92% rate may reflect that. This is a very different scenario than an experimental scenario in which one group gets nothing done and a second group has ESWT performed in isolation. My numbers, in my experience would corroborate that of Dr. Z, but, again, my patients are usually getting "the works" as opposed to ESWT in isolation. This is where it is tricky comparing our experience to double blinded studies...
Ed

Result number: 117

Message Number 152134

for Scottr or Scott R - I'll remember which one one of these days -- an interesting product... View Thread
Posted by Ed Davis, DPM on 6/05/04 at 21:02

http://www.deroyal.com/sportsmedicine/default.asp

See the foot control strap to control plantar fascial tension. I recetnly saw a full page add for it. They claim that it simultaneously inverts the subtalar joint while stabilizing the midtarsal joint. Note how it has a portion that pulls down on the big toe -- it is thus trying to releive tension from the distal portion of the fascia. They go on to state that it can be worn with orthotics and shoes.

This thing actually looks like it has the potential to work, particularly if it will stay in place without having to put too much tension on it.
The website states they only sell to medical professionals. I will order a few (my staff won't be happy campers -- I've got too much stuff and not enough space). If you are interested there may be a way to get them to you as I know you are looking for something to sell online. Let me try it for a while as I want to be convinced that it is effective. (No I don't need a double blinded peer reviewed study Elliott -- I can figure it out...)
Ed

Result number: 118

Message Number 152077

Re: 94% = 25%, revisited View Thread
Posted by Bill jr on 6/05/04 at 07:27

Elliott,

I understand your concern about the control group being unblinded at 3 months . However it is not reasonable to expect study participants to remain blinded for one year. Remember study participants were restricted from all conservative therapies for the length of the study. This means that all of the study's participants where prohibited from taking pain medicine, orthotics, message, etc... until the study ended. I doubt that anyone would live with PF pain for one year, untreated, for the sake of science. Call me crazy, but I just don't see it happening.

Result number: 119

Message Number 152020

Re: 94% = 25%, revisited View Thread
Posted by elliott on 6/04/04 at 13:19


Bill:

You'll have to ask Dr. Z and others that question. In fairness to Dornier, if someone goes from wheelchair to walking with moderate pain, that's a miracle but would not be included in success using your definition. Another reason may be that 66% doesn't sound impressive enough. Of course, I'd say it's too generous, because it includes the placebo effect and natural healing. I might add that all one-year figures should be viewed cautiously, since there are no comparable figures for the control group, which was unblinded at 3 months.

Don't work for Dornier. OK, then. Can you tell us anything else about why you're here? I gather you're not just a PF sufferer who wandered onto the site.

Result number: 120

Message Number 151992

94% = 25%, revisited View Thread
Posted by elliott on 6/04/04 at 08:07


In the past, my view that Dornier's one-year 94% success rate translates into more like a 1-in-4 chance that the Machine Actually Cures (MAC) you has been subject to some ridicule on these boards. Perhaps my previous attempts to elucidate fell short. Let me try again with a very simple explanation:

At 3 months, the control group exhibited a "success" rate in the 40-percent range. Even if that rate would remain unchanged by one year, that would mean that the MAC rate would be around one in two (94%-40% = 54%). Suppose the control group were kept blinded until one year, and continued to improve so that at one year their success rate was 69%, a figure conveniently selected after the fact but eminently reasonable based on other data. Then at one year, the MAC rate is 94 - 69 = 25%, or one in four, as claimed.

It is a fact and not Dornier's fault that in PF studies, many will get better due to placebo effect and natural course of healing. At the same time, it is unrealistic to say that the machine is curing 94% of the people who get treatment. If you are one of those who are less likely to fall for placebo (e.g., you're in a wheelchair and can't walk) and are less likely to heal in the next few months or year (e.g., you've had it for many years without any signs of improvement), then the MAC rate, i.e., the odds of the machine curing you, may be more like 25%. Which I think is still pretty good--a lot better than nothing--but then you can see that price does matter. This reasoning may also explain why the experience on this board has fallen far short of expectations.

Result number: 121

Message Number 151429

ScottR -- I hope this is okay with you, placing the article here... View Thread
Posted by Ed Davis, DPM on 5/27/04 at 21:16




Previous Volume 350:2159-2166 May 20, 2004 Number 21
Next



Plantar Fasciitis

Rachelle Buchbinder, M.B., B.S., F.R.A.C.P.





This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 55-year-old overweight woman presents with a three-month history of pain in her right inferior heel. The pain is worse on taking her first steps in the morning. The physical examination is normal except for nonspecific tenderness in the region of the medial calcaneal tubercle. How should the patient be evaluated and treated?

The Clinical Problem

Epidemiologic Features

Plantar fasciitis, reportedly the most common cause of pain in the inferior heel, is estimated to account for 11 to 15 percent of all foot symptoms requiring professional care among adults.1,2 Reliable population-based incidence data are lacking, although plantar fasciitis has been reported to account for about 10 percent of injuries that occur in connection with running3,4,5 and is common among military personnel.6 The incidence reportedly peaks in people between the ages of 40 and 60 years in the general population and in younger people among runners.7,8,9 The predominance of the condition according to sex varies from one study to another.5,8,10 The condition is bilateral in up to a third of cases.6,7,8,10

Pathological Features

The site of abnormality is typically near the site of origin of the plantar fascia at the medial tuberosity of the calcaneus (Figure 1). Histologic examination of biopsy specimens from patients undergoing plantar fascia–release surgery for chronic symptoms has shown degenerative changes in the plantar fascia, with or without fibroblastic proliferation, and chronic inflammatory changes.11,12,13


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Figure 1. Plantar and Medial Views of the Foot Demonstrating the Origin and Insertion of the Plantar Fascia and the Location of Nerves in Proximity to the Heel.
The windlass mechanism, or bowstring effect, of the plantar fascia refers to its function in raising the arch of the foot during the push-off phase of walking.




Risk Factors

The cause of plantar fasciitis is poorly understood and is probably multifactorial. Limited data from case–control studies have identified such risk factors as obesity, occupations that require prolonged standing, pes planus (excessive pronation of the foot), reduced ankle dorsiflexion, and inferior calcaneal exostoses (or heel spurs).6,9,14,15,16,17,18

Because of its high incidence among runners, plantar fasciitis is commonly assumed to be caused by repetitive microtrauma.3 Proposed risk factors include running excessively (or suddenly increasing the distance run), wearing faulty running shoes, running on unyielding surfaces, and having a cavus (high-arched) foot or a shortened Achilles tendon, but evidence for most of these factors is limited or absent.19

Clinical Course

On the basis of long-term follow-up data in large case series that predominantly involved patients seen in orthopedic practices, the clinical course for most patients with plantar fasciitis is favorable, with resolution of symptoms in more than 80 percent of patients within 12 months.8,20,21,22 Up to 5 percent of patients in reported case series are treated surgically,3,7,8,22 although reliable data on surgical rates in unselected patients are lacking.

Strategies and Evidence

Clinical Diagnosis

The diagnosis of plantar fasciitis can be made with reasonable certainty on the basis of clinical assessment alone. Patients typically report a gradual onset of pain in the inferior heel that is usually worse with their first steps in the morning or after a period of inactivity. Patients may describe limping with the heel off the ground. The pain tends to lessen with gradually increased activity but worsens toward the end of the day with increased duration of weight-bearing activity. Associated paresthesias are uncommon. Patients may report that before the onset of their symptoms, they increased the amount or intensity of their regular walking or running regimen, changed footwear, or exercised on a different surface. There is often a localized area of maximal tenderness over the anteromedial aspect of the inferior heel. Limitation of ankle dorsiflexion due to tightness of the Achilles tendon may be present. Other causes of pain in the inferior heel are usually distinguishable on the basis of history and physical examination (Table 1).23,24

View this table:
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Table 1. Differential Diagnosis of Pain in the Inferior Heel.



Imaging

Imaging plays a limited role in routine clinical practice, although it may be useful in selected cases to rule out other causes of heel pain or to establish the diagnosis of plantar fasciitis when it is in doubt. Occasionally, it may be difficult to differentiate plantar fasciitis from calcaneal stress fracture on clinical grounds. Plain radiographs may rule out calcaneal stress fracture and other rare bony lesions. Although the detection of heel spurs is of no value in either confirming the diagnosis of plantar fasciitis or ruling it out, a "fluffy periostitis" with ill-defined borders may suggest an underlying spondyloarthropathy.

When plain radiographs are normal, bone scans are useful for distinguishing plantar fasciitis from calcaneal stress fracture. Positive findings on bone scanning for plantar fasciitis have been reported in 60 to 98 percent of cases,25 although the false positive rate is unknown. Typical findings in the early images include increased blood flow and blood pooling; in the delayed images, findings often include a focal increase in activity at the plantar fascial insertion site in the calcaneus. By contrast, a linear fracture line or more diffuse calcaneal uptake on delayed images is consistent with calcaneal stress fractures.

Ultrasonography may be diagnostically useful, although, like other imaging techniques, it is not routinely used. The plantar fascia can be easily distinguished from the hyperechoic superficial heel pad of fat and the underlying calcaneus and is normally 2 to 4 mm thick.26 Many studies have found a marked increase in the thickness of the plantar fascia in plantar fasciitis (to a total of approximately 5 to 7 mm) and have variably demonstrated local or diffuse hypoechogenicity at the calcaneal insertion of the plantar fascia, loss of definition at the interface between the plantar fascia and the surrounding tissue, and peri-insertion edema.25,26

Magnetic resonance imaging can also be used to visualize the plantar fascia, with sagittal and coronal images.27 Normally, the plantar fascia is characterized by homogeneous low signal intensity on all pulse sequences. In plantar fasciitis, a marked increase in plantar fascial thickness can be detected, together with variable features of moderately increased signal density in the substance of the fascia on T2-weighted and short tau inversion-recovery pulse sequences (consistent with edema and intrasubstance microtears) and abnormally increased signal intensity in adjacent subcutaneous tissue and in the calcaneus at the plantar fascial insertion site. Markedly increased signal intensity in the calcaneus may be suggestive of plantar fasciitis associated with an underlying spondyloarthropathy.28

Treatment

A variety of therapies are used for plantar fasciitis; however, there are few data from high-quality, randomized, controlled trials that support the efficacy of these therapies.29 Initiation of conservative treatment within six weeks after the onset of symptoms is commonly believed to hasten recovery from plantar fasciitis,23,24 but this is also unproved. The role of various management strategies should be considered in the light of the self-limiting nature of the condition.

Physical Therapy

Many types of physical therapy have been proposed as treatments for plantar fasciitis.24 Support for the use of ice, heat, and massage and for strengthening of the intrinsic muscles of the foot comes predominantly from anecdotal data. Stretching of the calf muscles and plantar fascia and taping or strapping of the foot are commonly recommended, but these therapies have generally been assessed in combination with other interventions, making it difficult to interpret the results of any individual intervention. A recent trial involving 101 participants showed that heel pain was either eliminated or much improved at eight weeks in 24 of 46 patients (52 percent) who were treated with an exercise program to stretch the plantar fascia, as compared with 8 of 36 patients (22 percent) who reported such results after participating in a program to stretch the Achilles tendon.30 However, the study was not blinded, there was a large difference in the dropout rate between the groups (28 percent in the group in which patients stretched the Achilles tendon and 10 percent in the group in which patients stretched the plantar fascia), and only those who completed the trial were included in the analysis. Two randomized, placebo-controlled trials31,32 did not demonstrate a benefit of using magnetic insoles, and small randomized, placebo-controlled trials29 found no significant benefit of ultrasonography, laser treatment, iontophoresis, or exposure to an electron-generating device.

Orthotic Devices

A wide variety of prefabricated and custom-made orthoses, including heel pads and cups that are variously designed to elevate and cushion the heel, provide medial arch support, or both, are used to treat plantar fasciitis. There are no data on the efficacy of these devices as compared with placebo or no treatment, and the available data on their efficacy in comparison with that of other interventions are conflicting or limited. One study, involving 103 patients, compared mechanical treatment (taping and orthoses) with the use of a heel cup or antiinflammatory treatment (three corticosteroid injections administered at weekly intervals, plus nonsteroidal therapy). Among the 77 patients who completed the trial, mechanical treatment was more effective in achieving an outcome rated as "excellent" or "fair" at three months (reported for 19 of 27 patients, or 70 percent) than was use of the heel cup (7 of 23 patients, or 30 percent) or antiinflammatory treatment (9 of 27 patients, or 33 percent).33 In a trial involving 236 participants, prefabricated shoe inserts (a silicone cone, felt pad, or rubber heel cup) were found to be superior both to using custom-made orthotic devices and to stretching alone. (The percentages of patients whose condition had improved at eight weeks were 95 percent for a silicone-cone insert, 88 percent for a felt pad, 81 percent for a rubber heel cup, 68 percent for custom-made orthotic devices, and 72 percent for stretching alone.2 )

Splinting and Walking Casts

The use of night splints, designed to keep the ankle in a neutral position with or without dorsiflexion of the metatarsophalangeal joints during sleep, has been evaluated in two randomized, controlled trials, with conflicting results.34,35 One trial involving 116 participants showed no benefit of a night splint worn for three months as compared with no treatment.35 In contrast, a crossover trial involving 37 participants suggested a benefit of a night splint worn for one month as compared with no treatment.34 However, a crossover design may not be a valid method for studying interventions for treatment of a self-limiting condition. A third trial involving 255 participants showed no benefit of a posterior tension splint used at night as compared with either custom-made orthoses or over-the-counter arch supports.36 There are no published data from controlled trials of immobilization with casts or other devices. A retrospective review reported a recurrence of pain, usually within a month after cessation of the use of a plaster cast, in 11 of 24 patients (46 percent) for whom follow-up data were available.37

Antiinflammatory Agents

Nonsteroidal antiinflammatory drugs are often used in practice, but randomized trials have not been conducted to assess their benefit. The injection of corticosteroids, usually mixed with local anesthetic and injected with the use of a medial approach, is another common treatment for heel pain.29 Limited data suggest that this treatment provides only short-term pain relief. One trial, involving 91 participants, showed that 1 ml of prednisolone acetate (25 mg) with 1 ml of local anesthetic, injected with the use of a medial approach, resulted in significantly greater improvement in pain at one month than did injection of local anesthetic alone; the mean (±SD) changes in the pain score, measured on a 10-cm visual-analogue scale, were 2.0±2.9 and 0.06±3.0, respectively.29 At three and six months, there were no differences between the groups in pain measures, but a high rate of loss to follow-up precluded the drawing of conclusions. A tibial-nerve block given before injection did not appear to reduce the discomfort of the injection. One concern is that corticosteroid injections may be associated with an increased risk of rupture of the plantar fascia,38,39 although data to support this association are limited and inconclusive.13,38

Extracorporeal Shock-Wave Therapy

Extracorporeal shock-wave therapy has been proposed as an alternative approach on the grounds that it may stimulate healing of soft tissue and inhibit pain receptors.40 However, the available data do not provide substantive support for its use. Of six randomized, double-blind, placebo-controlled trials assessing the efficacy of extracorporeal shock-wave therapy,40,41,42,43,44,45 three studies (involving 166, 272, and 88 participants) showed no benefit,40,43,44 and two studies (involving 150 and 302 participants) reported small benefits that were of questionable clinical importance.41,42 A sixth trial, involving 45 runners, showed that extracorporeal shock-wave therapy, as compared with placebo, resulted in a significant reduction in the score for pain on first walking in the morning (a mean reduction of 2.6 on a 10-cm visual-analogue scale) at six months.45

Surgery

Surgery may be considered for a small subgroup of carefully selected patients who have persistent, severe symptoms despite nonsurgical intervention for at least 6 to 12 months. The surgical procedures used for plantar fasciitis include variations of open or closed partial or complete plantar fascia release with or without calcaneal spur resection, excision of abnormal tissue, and nerve decompression.46,47 In case series, favorable outcomes were reported in more than 75 percent of patients who underwent surgery, although the recovery times varied and were sometimes months,48 and persistent pain occurred in up to a quarter of patients who were followed for an average of two or more years.48,49 Potential complications include transient swelling of the heel pad, calcaneal fracture, injury of the posterior tibial nerve or its branches, and flattening of the longitudinal arch with resultant midtarsal pain. As compared with open release surgery, closed procedures may allow for more rapid recovery and resumption of usual activities,47,50 although the risk of nerve injury may be higher with endoscopic release and other closed procedures than with other approaches.51 Controlled trials are required to verify these findings.

Prevention

The efficacy of preventive strategies such as stretching exercises and control of the intensity of running (e.g., limiting distance, frequency, and duration) is not known.52 A randomized trial that involved 390 male infantry recruits showed that improved shock absorption, obtained with the use of basketball shoes rather than standard infantry boots, during 14 weeks of training resulted in a significantly lower incidence of foot-overuse injuries (including heel pain, arch pain, and metatarsalgia but not metatarsal stress fracture). Overuse injuries occurred in 15.5 percent of the men who wore basketball shoes, as compared with 29.1 percent of those who wore standard infantry boots (relative risk, 0.53; 95 percent confidence interval, 0.36 to 0.80).53

Areas of Uncertainty

The cause or causes of plantar fasciitis remain uncertain. The potential role, if any, of imaging studies in guiding treatment, monitoring the course of the disorder, or both has yet to be clarified; currently, imaging techniques have little role in routine clinical practice. One study showed that ultrasound-guided corticosteroid injections had the same outcome as injections administered without such guidance.54 Randomized clinical trials are needed to assess whether the commonly used treatments are beneficial in modifying the natural history of plantar fasciitis.

Guidelines

The American College of Foot and Ankle Surgeons issued a practice guideline in 2001 that is based on expert opinion.55 The recommendations generally reflect current clinical practice, but most of them are of unproven benefit. Initial treatment options include administering nonsteroidal antiinflammatory drugs, padding and strapping the foot, injecting corticosteroids, regularly stretching the calf muscles, avoiding the use of flat shoes and walking barefoot, applying ice to the affected area, using over-the-counter arch supports and heel cushions, and limiting activities. Second-line options for those patients who have not had any improvement after six weeks include the use of custom orthotic devices, night splints, and immobilization of the foot with casts and other devices during activity for four to six weeks. Plantar fasciotomy is reserved for patients in whom conservative measures have failed; removal of the plantar spur is not believed to add to the success of surgery.

A position statement regarding endoscopic and open heel surgery that was issued by the American Orthopaedic Foot and Ankle Society recommends that endoscopic plantar fascia release not be performed if there is nerve compression.51 This recommendation is based on suggestions that the risk of nerve injury may be higher with endoscopic procedures than with open procedures.

Conclusions and Recommendations

Patients, such as the woman in the introductory vignette, who have symptoms and signs consistent with plantar fasciitis — including heel pain that worsens on first walking in the morning and tenderness over the anteromedial aspect of the inferior heel — should be informed that the condition is self-limiting and that in more than 80 percent of patients, the symptoms will resolve within a year, regardless of therapy. Since there is limited evidence about the value of treatments for plantar fasciitis, a reasonable approach to intervention is to start with patient-directed, low-risk, minimal-cost interventions, such as regularly stretching the calf muscles and the plantar fascia, avoiding flat shoes and walking barefoot, using over-the-counter arch supports and heel cushions, and limiting extended physical activities. A trial of nonsteroidal antiinflammatory drugs may be reasonable. Corticosteroid injections may provide a short-term benefit.

More costly treatments — such as the use of custom-made orthotic devices, night splints, and immobilization with casts or other devices — may be options for patients in whom the condition does not improve, although the value of these treatments is currently uncertain. Surgery should be reserved for those patients whom conservative therapy has not helped after 6 to 12 months. In the absence of data to guide the surgical approach, referral to a surgeon with expertise in treating patients with plantar fasciitis is recommended.




I am indebted to Daniel Riddle, Stephen Hall, and Peter Lowthian for their insightful comments.


Source Information

From the Department of Clinical Epidemiology, Cabrini Hospital; and the Department of Epidemiology and Preventive Medicine, Monash University — both in Melbourne, Vic., Australia.

Address reprint requests to Dr. Buchbinder at Cabrini Medical Centre, Suite 41, 183 Wattletree Rd., Malvern, VIC 3144, Australia, or at rachelle.buchbinder@med.monash.edu.au.

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The diagnosis and treatment of heel pain. J Foot Ankle Surg 2001;40:329-340.[Medline]





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Result number: 122

Message Number 150741

Re: Getting a cast? View Thread
Posted by MARK L on 5/18/04 at 06:18

If you fit the FDA protcall and have a confirmed diagnosais of Insertional Plantar Fasciitis then you should avail yourself of ESWT done with either of the 2 FDA approved machines- Dornier or Ossatron. The latest double blinded study shows an effectiveness as high as 94%. You have nothing to lose and the expense to you, if your insurance company does not cover it, could be only the fee you negotiate with your doctor. A major ESWT service company, using FDA approved ESWT, currently has a policy of not charging for their technical fee if the patients insurance company does not cover the therapy. If you want more info e-mail me @

Result number: 123

Message Number 150176

Re: Survey on the price of gasoline- not political and please keep it that way! View Thread
Posted by Richard, C.Ped on 5/07/04 at 08:32

Well, my wife and I both drive a four cylinder. They both get wonderful gas mileage, unless you turn on the air conditioner. Its going to be 93 today. haha.

Our prices are around $1.75 for regular. I think it is crazy. I have spoken to others who said that its just capitalism and they can charge what they want. I am trying to convince a local owner to reduce his price by five to ten cents. Think of all the business he would get. Selling gas, and having customers come in for sodas and other groceries. I don't think he will do it. haha I think I would.

Result number: 124
Searching file 14

Message Number 149862

Re: New Surgical Approach, Part II View Thread
Posted by Ed Davis, DPM on 4/30/04 at 19:42

No mention of ESWT in the discussion. It is amazing that no one is questioning a "new" approach, demanding a double blinded peer reviewed study, FDA approval, etc. Insurers have no problem considering payment for this, I would assume, but giving ESWT the "third degree." Does this not lead one to beleive that there is a problem inherent with our "system."
Ed

Result number: 125

Message Number 148023

Re: 65% = 0% View Thread
Posted by elliott on 3/28/04 at 21:02


Dr. Jan R:

Thank you for your comments. Yes, I am aware both groups in Haake's lateral epicondylitis study were not kept blinded, just as they were not in Haake's PF study. My point was that, as with the PF study, it is interesting to see where the *control* group is holding a year later since they never got ESWT. If a year later a large percentage of the control group is considered to have met the criteria for "success", we must be careful as to the significance of the ESWT treatment group a year later as well, even in other studies.

Do you have any explanation as to why, at the 3-month mark, even the ESWT group did so poorly in the Haake study? (It is hard to accept Dr. Z's claim that local anesthesia inflated the success rates when those success rates were so low at 3 months.)

Can you also please respond to the questions I asked you in a recent post? Here is a link to it:

bbv.cgi?n=147739

In particular, the BCBS paper had some comments as to why they did not consider some of your studies to offer presuasive evidence as to ESWT efficacy. Even I would doubt that all of the reasoning in that paper is completely sound, so I was wondering how you would respond to their claims. Thanks.

Result number: 126

Message Number 147091

Re: Pressing on the bottom of the heel- what does this mean View Thread
Posted by Ed Davis, DPM on 3/15/04 at 21:24

Elliott:
One needs to look at the aggregate of provider experience, studies which are not double blinded, studies which are. The aggregate suggests a relatively high success rate for ESWT.
Ed

Result number: 127

Message Number 146930

Re: Pressing on the bottom of the heel- what does this mean View Thread
Posted by elliott on 3/14/04 at 09:29


Dr. Z, here are my observations (which don't need FDA approval to be valid) on 4-point R/M as a sole measure of success as you have been using it on these boards:

1. At the 3-month mark, while the Dornier treatment group scored better in the "Good" category than the placebo group, it did no better in "Excellent".

2. At the 3-month mark, many of the other endpoints showed no difference between treatment and placebo groups. If 4-point R/M in isolation is such a good indicator of overall improvement, one would expect the other endpoints to have been generally more positive.

3. Beyond the 3-month mark there is no placebo group to compare to, so boasting of a one-year 94% success rate in isolation gives a false impression as to the Dornier's power. Why stpo there? Use a 3-year endpoint; that should push it even closer to 100%, and with no control group to dispel the accomplishment. It would be nice also to see at the one-year mark how many of those were E and how many were G. If a big chunk were G, that puts more of a qualification on what "success" means.

4. There was a study that kept the placebos (who had rather similar inclusion criteria as in the FDA study) blinded for a full year, the Haake study. At the 1-year mark they had a 76% success rate based on the exact same R/M criterion you use, even more impressive given one of the criticisms of the study was that it did not continue an adequate level of conservative treatment throughout. If you ask me, this puts a damper on your 94% figure. Your answer to this was that they must not have had adequate blocking of the waves. The burden of proof is on *you* that the FDA study's "thin air cushion...placed on the therapy head" was far better than the Haake study's "polyethylene foil filled with air...fixed with ultrasound gel in front of the coupling cushion", and in a study that had a lower level of energy than the FDA's.

I'm not saying ESWT is totally worthless. I've consistently thought it has a PF success rate of somewhere between 0 and 30%, and because I have an open mind when I look at the evidence, I consider the lower limit still a distinct possibility. And then we have to define "success", which, the more I read, the weaker it seems to become. I feel you have given the readers on this site the impression for a long time that they have a 94% chance of being completely healed one year after getting blasted by the Epos. Sorry if they now think otherwise.

[]

Result number: 128

Message Number 146473

Re: For the Doctors View Thread
Posted by BrianJ on 3/08/04 at 16:35

Dr. Wander --

The article I'm referring to is titled "Topical Nitric Oxide Application in the Treatment of Chronic Extensor Tendinosis at the Elbow: A Randomized, Double-Blinded, Placebo-controlled Clinical Trial." It's in the American Journal of Sports Medicine, Nov.-Dec., 2003, by Justin Paoloni. I would value your thoughts on the subject. Thanks.

Result number: 129

Message Number 146105

Re: Response to Dr. Ed's ESWT posts View Thread
Posted by Dr. Z on 3/05/04 at 13:13

Elliott,
This is sooo obvious maybe to you. Here we have a case where all I asked you was to answer one question and you come back with a study ( one year follow up which was blinded) and this study didn't have the same energy treatment as the Dornier FDA study used.
The problem is that you are a stat man and I am doctor.

Result number: 130

Message Number 146093

Re: Response to Dr. Ed's ESWT posts View Thread
Posted by elliott on 3/05/04 at 10:38


Dr. Z, here is the answer to your question:

Maybe that patient got better just from the passage of time (which with PF is what eventually happens to the vast majority) rather than due to the machine. The way to minimize this effect in studies is to use a shorter time interval such as 3 months (which for PF most experts in the field agree to be about right), measure its effect and compare it to placebo. While the one-year mark is useful too, by itself it paints too rosy a picture of things. In my O vs. D part 2 post, I pointed out that there was a study that kept the placebos blinded for a year, and in that study the placebo group achieved a one-year success rate of 76% using the exact same R & M measure that produced the D study's 94% success rate on the treatment group. Here a straight subtraction is appropriate. Based on those two studies, it tells me that at the one-year mark, around 18% (give or take a little due to study differences) of patients treated actually get better due to the machine. And then we still haven't defined "better". Success determining the 94% figure was not defined as running or shop till you drop. It was defined as moving up from "fair" or "poor" to at least "good".

I've grown tired and weary of repeating the obvious over and over; maybe I was a fool for trying. The boards are in general shambles too. It's time to let this drop. Have a great day.

Result number: 131

Message Number 145431

Ossatron vs. Dornier, part 2 View Thread
Posted by elliott on 2/26/04 at 12:40


Now for the 12-month results. The Dornier part is easy:

http://www.ismst.com/congresses/2002_winterthur_abstracts%20-%202.htm

(After clicking, just do a find on "94%".) The R&M at the 1-year mark indicated a success rate of 94%, as did the VAS. Note also the lower VAS score for the crossover group as compared to the R&M. It would be interesting to see what the Dornier success rate would be if both criteria had to be satisfied, with and without crossovers; the Dornier researchers probably have that data.

Before getting to the Ossatron, at this time it is worth mentioning that we have to be especially careful with the significance of 12-month data, lest one conclude, say, that a machine is "curing" 94% or whatever of the people it treats. Since both FDA studies unblinded the participants at 3 months, it is not possible for either study to compare their one-year results to placebo. There was a separate study that did in fact keep the placebo group blinded for a full year, the Haake study:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=164919

This study did get its share of criticism, but not so the handling of the placebo group. In that study, the placebos had a one-year success rate of 76% based solely on the 4-point R&M.

Now for the Ossatron. The logical starting place is the Healthtronics site:

http://www.healthtronics.com/ftp/LEWhitePaper.pdf

Page down a bit and the first thing you notice is Table 1, and we see the 81%. A quick glance at the table is all it takes to see that 81% success was defined as meeting at least 2 out of 4 criteria, which should be an immediate tipoff that it was not produced from a single R&M score. Let's leave this site for now and look at this one:

http://www.hmt-ag.ch/shared/data/pdf/studien/zus__fda_ferse_osa.pdf

I urge you to print out this 3-page paper. It appears to be the official document submitted to the FDA and includes 12-month data. I believe HMT is Healthtronics' Swiss partner (but it still comes up in a web search!). Look at the last page. It seems that when considering a later endpoint, the definition of success has been watered down from that of the 3-month study (why?). Now one needs to meet only 2 out of 4 criteria to achieve success. It is a little unclear to me as to what endpoints in time apply to what criteria of success rates. I take the single-treatment 76% success rate to be for a one-year endpoint. The sentence above the table starts, "The overall results of all subjects which received a single ESWT (active, non-randomized, change)". [Note: "change" means crossover.] Based on the clause preceding the parentheses and the punctuation in the parentheses, I take it that it these are three separate groups. Regardless, why are the non-randomized being lumped together with the randomized? Is the 88% at 6 months also at least 2/4 or is it now 4/4? Regardless, it is illustrative that the individual criteria making up the 88% were individually so high (94%, 100%, 97%, and 97%). We also see an 81%: it is the success rate based solely on investigator assessment (pressure test) for those getting a repeat treatment following failed treatment! If this is the 81% we seek (I do not think it is), it surely is not comparable to Dornier's figure. Here are some more relevant links:

http://www.hmt-ag.ch/ww/en/pub/medicalinformation/clinicalstudies/orthopaedics.htm

http://www.hmt-ag.ch/ww/en/pub/news/statement_of_hmt_to_article_.htm

The language in all of them is not sufficiently clear (for example, one link refers to one type of 81% in the text right above the table and throws in "investigator assessment", as if a reader reading without the context of the success criteria will know that means the first criterion only (pressure) and not just some blathering generality automatically ignored, and then the table apparently refers to a different 81%, as if a casual reader will figure that out too). I admit to spending hours--something one shouldn't have to do--to sort it out. It seems to me that coincidentally there are two 81%s: one is for the repeats described above, and the other is an overall ESWT success rate based on satisfying 2 out of 4 criteria. Notice also that the overall 81% and its breakdown is not given at all in the FDA report (why?). The Healthtronics link also is hard to fathom, especially in how it jibes with the others. It is the only one of these links that states explicitly in the passage right above the table, Table 1, that 81% is for a single treatment, and presumably that statement applies to the table. The table sub-heading says, "Results of all Patients Treated (at One Year)". But then how does that differ from the 76%? Do I take the semicolon in the asterisked footnote (Active treatment, Non-randomized; Treatment after placebo) literally so as to imply the first two are one group (or perhaps even that they then morph into the third?) Again, why are non-randomized included? To distinguish from the 76%, I would have liked to say that the overall 81% is for the randomized actives only (i.e., excluding crossovers and non-randomized), but it doesn't say that. In fact, I am still not sure what exactly this 81% is and am tired of thinking about it. (Is it too much to ask for clear and accurate writing in an important paper, especially concerning its main point--the overall success rate?) Don't hesitate to offer your own interpretation.

Anyway, whatever this 81% is, it results from at least 2 out of 4 criteria. Ironically, it comes out that every combination contributing towards success either excludes the R&M measure altogether or includes at least one other with it!!

BOTTOM LINE: Dornier's one-year 94% came from just a 4-point R&M selected after the fact. Ossatron's one-year 81% apparently comes from satisfying at least 2 out of 4 criteria, but regardless, certainly was not produced from anything even resembling 4-point R&M. Furthermore, as stated previously, the initial inclusion criteria and different R&M scales between the two studies do not allow a direct comparison of 4-point R&M between the two machines.

Here on heelspurs, the 94% to 81% comparison typically was made without qualification. On the doctor's web site, which devotes a separate page just to the Dornier-Ossatron comparison,

http://www.eswtusa.com/comparison/index.html

the chart at the bottom is very specific in calling it a Roles-Maudsley comparison. BTW, even if you accept the numbers in the comparison, the "13% higher" in the text, apparently derived from a straight subtraction (94%-81%), is incorrect: correct would be either "13 percentage points higher" or "16% higher" [or possibly even 17%, depending on rounding] produced from .94/.81 – 1. Rather than say this R-M comparison is outright wrong, one could make an interesting argument (although I have not heard anyone make it yet, including the doctor) that the person responsible for putting together the material in this link never intended a comparison of the original 4-point R&M criteria (i.e., as used by investigators in studies) between the two machines. Rather, maybe he meant this: Since each machine's performance is now broken down into the four general categories Excellent, Good, Fair, Poor, they're now both 4-point R&M! Get it? Of course, the corresponding categories are not really comparable; they just coincidentally are called the same thing. IMO that link should be pulled or modified.

CONCLUSION: Reasonable people would conclude that a straight comparison of Dornier's 94% to Ossatron's 81% is not valid and should be laid to rest.

[]

Result number: 132

Message Number 145163

Re: Queston for Dr. Rompf View Thread
Posted by Jan R. on 2/24/04 at 03:48

Sir:

You could do me great favor if you spellt my name in a correct way.


I have no clear answer to your problem. But I am convinced there is a biological limitation to the energy flux density that can be applied.

From >0.2 mJ/mm² per shock you must be aware of - reversible? - damage to tendinous tissue.

So, instead of applying 3x 2000 shocks of 0.09 mJ/mm² in weekly intervals (= 540 mJ/mm²), I would not apply 500 impulses of 1.08 mJ/mm² once, or 1000 impulses of 0.54 mJ/mm².

You risk detrimental effects (rupture, inflammation) at an already damaged tendon.


See:

The effects of extracorporeal shock waves on the rat Achilles tendon: is there a critical dose for tissue injury?

Zafer Orhan

Arch Orthop Trauma Surg 2004, in press


Introduction: Extracorporeal shock waves (ESW) have been extensively studied in the field of orthopedics. Experimental and focused, well-designed clinical studies have suggested the clinical utilisation of ESW in several pathologies including delayed bone union, tennis elbow, and plantar fasciitis. However, the unwanted detrimental effects of ESW on various tissues have been questioned by some authors. In this experimental study, the effects of ESW were investigated at different intensity applications on the Achilles tendons of rat.
Materials and methods: A total of 32 adult Wistar albino rats was divided into four groups. The first three groups received 1000 impulses of 0.15 mJ/mm2, 1500 impulses of 0.15 mJ/mm2, and 2000 impulses of 0.20 mJ/mm2, respectively. The last group was kept as the control group. Subsequently, Achilles tendons were harvested for histological studies from all rats at the 3rd week after a single application of ESW.
Results: There were no histological abnormalities observed in the Achilles tendons of the first two groups compared with the control group. No alteration in the histological configuration was observed, and consequently the pathologist who had been blinded could not differentiate these rats from the control group by light microscopy. However, in the high intensity group (2000 impulses of 0.20 mJ/mm2), grade II and III disorganisation of collagen fibers was noticed in 7 out of 8 rats, which was not detected in any of the rats from the first two groups (p<0.05). Consequently, the pathologist could distinguish the majority of the rats (7 out of 8) of this group from the remaining ones. Meanwhile, grade I lymphocyte infiltration was observed in some sections of the rats receiving the highest ESW dose.
Conclusion: This study confirms that ESW application at high intensity is associated with detrimental tissue effects. Additionally, it was suggested that the extent of tissue injury caused by ESW is dose-related.

Result number: 133

Message Number 144878

Jan R, Elliott, and Dr Z posts View Thread
Posted by Scott R on 2/20/04 at 22:45

Dr Z, someone complained and i looked at the files that were deleted and i don't see where they should be deleted, especially all of them. So I'm reposting the ones that don't mention Dr Z (i assume those are the ones you objected to).

Here they are:
=================
Jan R posted:

The strength of a study is defined by its statistical power. If you see a high between-group difference with low standard deviation, you may have a high power though your sample size may be quite low.

Calculation of a sample size also depends on the variable you declare as your main outcome measure.

As you deny adequate treatment to 50% of your patients in a placebo-controlled trial I find it questionable from an ethical standpoint to expand patient enrollment over the absolutely necessary minimum (statistically seen).

What clearly is favourable is a multi-center design!

Of course, the more patients you enroll per group, the better. But you have to weigh advantages and disadvantages. If you have a clear result in 50 patients, you don´t have to examine 500 patients.

It would be more favourable in my opinion to repeat the exact treatment design at a second, independent location.


=================
elliott posted:

Dr. Jan R:

I understand what you're saying, as well as the ethical and practical considerations. But with new treatments one usually doesn't know what the standard deviation is until after conducting the study. What I'm saying is, if one year later the treatment group success rate is, say, 85%, and the placebo group success rate is 75%, then 85% of 25 is 21 (rounded) people, and 75% of 25 is 19 (rounded) people. Sure, the binomial distribution has quite a small standard deviation, and the difference between 75% and 85% can be statistically significant, but I just wouldn't want to be making any sweeping statements as to ESWT efficacy based on a difference of 2 people between the groups.


======================
Jan R posted:

I agree.

This is why one should define which between-group difference at which point of follow-up is considered statistically significant (before the trial starts).

If you then find a difference you have to determine whether this difference is clinically relevant at all.

Usually only differences of at least 20% are considered both significant and relevant (Should be defined before the trial starts).

Regarding standard deviations: That is why you perform a pilot study. It is this pilot study with its results (mean and SD) that then enables you to calculate sample size sufficient for a power of more than 80%.

Look at the Haake trial (BMJ 2003): No pilot trial before, sample size calculation pure speculation. 100s of patients enrolled in a protocol that would have shown in less than 50 patients to be ineffective.

Regarding FU of one year: As to plantar fasciitis I am not aware of any controlled trial focusing on 12-month follow-up as main follow-up interval. With tendinopathies and their great tendency for self-healing, between-group differences at much shorter notice have been chosen for main outcome measure.So, we cannot provide evidence on 12 months after treatment.
======================
Elliott:

Dr. Jan R, good points. I think this discussion is very helpful.

Concerning the Haake trial, inefficiencies and all, what I found most interesting was that it is perhaps the only (large) study that kept the control group blinded for an entire year, and (ethical issues aside) the one-year success rate for this group was an impressive 75% (this even though a main criticism of the study was that not enough appropriate conservative care was continued throughout). So in my mind, ceteris paribus (as if this were so, because it's not), a study claiming, say, a one-year success rate of 81% may not have achieved all that much over placebo.

Concerning your first and last points, namely

"one should define which between-group difference at which point of follow-up is considered statistically significant (before the trial starts)"

and

"Regarding FU of one year: As to plantar fasciitis I am not aware of any controlled trial focusing on 12-month follow-up as main follow-up interval. With tendinopathies and their great tendency for self-healing, between-group differences at much shorter notice have been chosen for main outcome measure. So, we cannot provide evidence on 12 months after treatment",

very well said indeed. These two basic points seem to be either violated or ignored in much of the discussion on heelspurs. Both here and on a popular ESWT web site (the one that always shows up first in any web search), it is repeatedly pointed out (at least with full disclosure, unlike many annoying anonymous or semi-anonymous posts on this board claiming all kinds of things) that the one-year FDA Dornier Epos results showed a 94% success rate. Ignoring that the FDA officially only followed the study for 3 months (and so a more accurate wording would be "one-year followup on the FDA study"), this violates both of your points at once: it emphasizes a one-year period (without a control group to compare it with, I may add), and also conveniently selects after the fact what was just ONE of the SECONDARY endpoints, the Roles and Maudsley pain score. A justification might be that the R & M pain score has become a standard endpoint in ESWT studies for PF, but this does not change the fact that it violates your first point. It also happens to be true that the Ossatron to which it is often compared had a far more selective criterion for success and, to its credit, stuck with it at the end, even on their web site. So it could be that if you compare apples to apples, Ossatron might come out the more impressive machine.

=========================
There is one other aspect of the FDA trials that has bothered me for some time. When they chose the patients for the ESWT trials, they chose patients who were most likely to be able to heal themselves, by other methods (such as stretching, rest, ice, etc). The patients only had to have PF for one year. Why didn't they pick some people who had PF for 10 years? They also would not take anyone who had any surgery. Yet, we continoulsly hear that ESWT will cure patients that have had surgery. In fact, it has been said on these pages that patients who have had surgery are some of the easiest to cure! Sorry, I don't see it happening on this message board. I think the FDA did everyone a great disservice, by not taking patients who represented the majority of people who have PF. I personally think they (FDA) should look at their original criteria, and then conduct a second group of trials for both the Ossatron, and the Dornier, with patients that represent a majority of PF sufferers.

Am I off base here?
BrianG
================
elliott:

BrianG, sorry, I'm going to have to disgree somewhat. The problem is not with the FDA study, but rather with the marketing and advertising that take place afterward, leading many to believe their chances are much higher than the evidence dictates. But if I were going to do an initial FDA study on PF, I'd start with similar criteria as the FDA did. You first want to see what ESWT can accomplish with "pure" PF, and then and only then you start to expand the horizons by including or excluding groups, e.g., long-term and post-surg patients. I'm with you that the more studies of this sort, the better, and hopefully we'll see them in time. Keep in mind also that this issue is complicated by the fact that a large percentage get better with time anyway, so peeling away the amount attributable to ESWT is problematic.

BTW, FYI: the minimum was 6 months [conservative care], not 1 year, and both FDA studies *did* include people who had symptoms for 10 years and longer; check the links. Regarding duration, a new study has found little difference in success rates between those under and those over the 2-year limit:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14733347&dopt=Abstract

See, they're working on it!
=============
Hi Elliot,

As I read it, you are correct. I know it was a few years ago, and I was just going by memory. Something I probably shouldn't do! ) I really did think that the majority of the patients only had PF for 1 year. I still don't see the healing rates on this forum, any where near what the FDA would lead us to believe.

Thanks
BrianG

Result number: 134

Message Number 144710

Re: question for Dr. J. Rompe View Thread
Posted by elliott on 2/19/04 at 12:43


Dr. Jan R, good points. I think this discussion is very helpful.

Concerning the Haake trial, inefficiencies and all, what I found most interesting was that it is perhaps the only (large) study that kept the control group blinded for an entire year, and (ethical issues aside) the one-year success rate for this group was an impressive 75% (this even though a main criticism of the study was that not enough appropriate conservative care was continued throughout). So in my mind, ceteris paribus (as if this were so, because it's not), a study claiming, say, a one-year success rate of 81% may not have achieved all that much over placebo.

Concerning your first and last points, namely

"one should define which between-group difference at which point of follow-up is considered statistically significant (before the trial starts)"

and

"Regarding FU of one year: As to plantar fasciitis I am not aware of any controlled trial focusing on 12-month follow-up as main follow-up interval. With tendinopathies and their great tendency for self-healing, between-group differences at much shorter notice have been chosen for main outcome measure. So, we cannot provide evidence on 12 months after treatment",

very well said indeed. These two basic points seem to be either violated or ignored in much of the discussion on heelspurs. Both here and on a popular ESWT web site (the one that always shows up first in any web search), it is repeatedly pointed out (at least with full disclosure, unlike many annoying anonymous or semi-anonymous posts on this board claiming all kinds of things) that the one-year FDA Dornier Epos results showed a 94% success rate. Ignoring that the FDA officially only followed the study for 3 months (and so a more accurate wording would be "one-year followup on the FDA study"), this violates both of your points at once: it emphasizes a one-year period (without a control group to compare it with, I may add), and also conveniently selects after the fact what was just ONE of the SECONDARY endpoints, the Roles and Maudsley pain score. A justification might be that the R & M pain score has become a standard endpoint in ESWT studies for PF, but this does not change the fact that it violates your first point. It also happens to be true that the Ossatron to which it is often compared had a far more selective criterion for success and, to its credit, stuck with it at the end, even on their web site. So it could be that if you compare apples to apples, Ossatron might come out the more impressive machine.

[]

Result number: 135

Message Number 144682

Re: Low vs High Energy? View Thread
Posted by Jan R. on 2/19/04 at 05:31

Regarding side effects:

The effects of extracorporeal shock waves on the rat Achilles tendon: is there a critical dose for tissue injury?

Zafer Orhan

Arch Orthop Trauma Surg, in press


Introduction: Extracorporeal shock waves (ESW) have been extensively studied in the field of orthopedics. Experimental and focused, well-designed clinical studies have suggested the clinical utilisation of ESW in several pathologies including delayed bone union, tennis elbow, and plantar fasciitis. However, the unwanted detrimental effects of ESW on various tissues have been questioned by some authors. In this experimental study, the effects of ESW were investigated at different intensity applications on the Achilles tendons of rat.
Materials and methods: A total of 32 adult Wistar albino rats was divided into four groups. The first three groups received 1000 impulses of 0.15 mJ/mm2, 1500 impulses of 0.15 mJ/mm2, and 2000 impulses of 0.20 mJ/mm2, respectively. The last group was kept as the control group. Subsequently, Achilles tendons were harvested for histological studies from all rats at the 3rd week after a single application of ESW.
Results: There were no histological abnormalities observed in the Achilles tendons of the first two groups compared with the control group. No alteration in the histological configuration was observed, and consequently the pathologist who had been blinded could not differentiate these rats from the control group by light microscopy. However, in the high intensity group (2000 impulses of 0.20 mJ/mm2), grade II and III disorganisation of collagen fibers was noticed in 7 out of 8 rats, which was not detected in any of the rats from the first two groups (p<0.05). Consequently, the pathologist could distinguish the majority of the rats (7 out of 8) of this group from the remaining ones. Meanwhile, grade I lymphocyte infiltration was observed in some sections of the rats receiving the highest ESW dose.
Conclusion: This study confirms that ESW application at high intensity is associated with detrimental tissue effects. Additionally, it was suggested that the extent of tissue injury caused by ESW is dose-related.

Result number: 136

Message Number 144221

Re: Water exercises for pf? and a question about cost View Thread
Posted by Dorothy on 2/12/04 at 23:54

Kathy G.~ This stuff (PF, arthtitis, Achilles Tend....all of it) IS discouraging - but, as you already indicate that you know full well, being discouraged will be temporary. You will find your courage and keep on trying and looking for new ways and new information...
A few days ago, "rsk" posted here about a product called Lyprinol; he/she had not heard of it before and neither had I. I didn't look it up at the time, but today, while looking for some other information, I came across this word again - so I began doing some reading. I have cut and pasted one article I read about it to share with you. Although it has been used in various forms for about 25 years, apparently it is only within more recent time that the researchers have developed a form and way of delivery that seems to make it effective for osteoarthritis (and also asthma, they think). I don't know if OA is your form of arthritis or if you have another kind, but maybe this is something that holds some hope for you. I am interested in it for its possible asthma benefit. It is expensive, but maybe it will come down in price as it becomes more widely available. SAM-E started out very expensive but came down fairly quickly.
Anyway, here is a website address and then the pasted article. You have my best wishes for a fresh feeling for a fresh start in the morning.
www.lyprinolusa.com is the website.
Placebo Trial Results Lyprinol in Osteoarthritis
Wednesday, 14 January 2004, 10:52 am
Press Release: Lindenberg and Partners


Results of a placebo-controlled Hong Kong University study confirm the clinical efficacy of Lyprinol® in patients with Osteoarthritis
Auckland –The results of a new study conducted under rigorous standards confirm the clinical activity and safety of a natural New Zealand marine lipid extract called Lyprinol® in patients with osteoarthritis (OA) and other chronic inflammatory diseases.

Arthritis affects one in three adults and is the greatest single cause of disability in New Zealand. Osteoarthritis is the most common form of arthritis, with half of all New Zealanders over the age of 60 and almost everyone over the age of 80 suffering from the condition.

The latest study validates the findings of over 25 years of pioneering Australian research into this natural extract, and shows Lyprinol® is a safe and effective addition to the therapeutic arsenal. Its composition is a unique combination of polyunsaturated fatty acids that had been investigated by leading Australian research institutes including The Royal Melbourne Institute of Technology (RMIT), The Queen Elizabeth Hospital in Adelaide and The University of Queensland.

Lyprinol® is the unique oil of Perna canaliculus, the green-lipped mussel of New Zealand. A large number of laboratory and clinical studies have confirmed its unique anti-inflammatory activity and safety.

The first double-blind placebo-controlled study with Lyprinol® in patients with osteoarthritis was conducted from 2001-2003 at the Queen Mary Hospital of the University of Hong Kong, an internationally respected institution. The principal investigator was Professor C.S. Lau, MD, Professor of Medicine. The results of the study confirm that Lyprinol® is statistically significantly effective against pain and in the global assessment score.

Treatment of osteoarthritis includes pain control and improvement of patients' function and quality of life. While conventional treatment such as non-steroidal anti-inflammatory drugs and simple analgesics may achieve these goals, their long-term use is associated with serious side effects.

Design of the latest study Eighty patients with knee OA were randomized to receive either Lyprinol® or placebo for six months. All were allowed paracetamol/acetaminophen rescue treatment during the study and were reviewed at week 0, 2, 4, 8, 12, 18 and 24 for arthritis assessment and safety evaluation. Assessment of the patients' arthritis included the use of a 100 mm visual analog scale (VAS) for pain, patient's and physician's global assessment of arthritis, a validated Chinese version of the Oxford Knee Score (COKS), a validated Chinese version of the Arthritis Impact Measurement Scale 2-short form (CAIMS2-SF), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

Clinical trial results There was a greater improvement in the perception of pain as measured by the VAS, and patients' global assessment of arthritis in those who took Lyprinol® when compared with controls from week 4 following adjustment for the change in the amount of paracetamol/acetaminophen used between study visits. Patients who took Lyprinol® but not placebo also had improved scores in the CAIMS2-SF physical function and psychological status domains from week 4.

When used over six months, Lyprinol® was safe and well tolerated with no serious side effects reported. Further, there were no significant differences in the overall incidence of adverse reactions or withdrawal from study as a result of trial drug toxicity between Lyprinol® and placebo-treated patients.
Researchers’ conclusion Prof. C.S. Lau concludes that Lyprinol®, the unique lipid extract of the green-lipped mussel, may be considered a safe option in the treatment of OA. The study is being published in the first 2004 issue of the journal Progress in Nutrition (Mattioli 1885 Publ.).

Lyprinol® is also active in asthmatics, as demonstrated by Professor Aleksander Emelyanov et al in a double-blind placebo-controlled study published in the European Respiratory Journal 2002;20:596-600. Since experimental studies had shown that Lyprinol® was effective in inhibiting -5-lipoxygenase and cyclo-oxygenase pathways responsible for production of eicosanoids, including leukotrienes and prostaglandins, the aim of that study was to assess its effect on symptoms, peak expiratory flow (PEF) and hydrogen peroxide (H2O2) in expired breath condensate as a marker of airway inflammation in patients with steroid-naive atopic asthma in a double-blind randomized, placebo-controlled clinical trial. Forty-six patients with atopic asthma received two capsules of Lyprinol® or placebo b.i.d for 8 weeks. There was a significant decrease in daytime wheeze, the concentration of exhaled H2O2 and an increase in morning PEF in the Lyprinol group compared to the placebo group. There were no significant side effects. The authors concluded that Lyprinol® had beneficial effect in patients with atopic asthma.

Further clinical trials of Lyprinol® are planned for asthma and also psoriasis.

For further information on arthritis in New Zealand, go to the Arthritis New Zealand website at http://www.arthritis.org.nz.


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Result number: 137

Message Number 143592

APMA and ACFAS Joint Policy Statement View Thread
Posted by Ed Davis,DPM on 2/03/04 at 22:24

APMA and ACFAS
Joint Policy Statement on
Extracorporeal Shock Wave Therapy
December 2003

STATEMENT

The American Podiatric Medical Association and the American College of Foot and Ankle Surgeons acknowledge that extracorporeal shock wave therapy is one of many surgical procedures that foot and ankle surgeons utilize to treat plantar fasciitis. As with any surgical procedure for chronic plantar fasciitis, it is recommended that conservative therapy be delivered for a minimum of six months prior to surgery, and that patients consult with their foot and ankle surgeon regarding the potential risks of surgery and which procedure is best suited for them.

Description of Chronic Proximal Plantar Fasciitis
Chronic proximal plantar fasciitis is a debilitating condition characterized by pain on the inferior surface of the heel. It is a common problem that afflicts up to 15% of the population presenting to foot and ankle specialists.1 First-step pain (post-static dyskinesia) is the hallmark of the malady.2 Plantar fasciitis occurs most often in middle-aged women.3, 4 The etiology of plantar fasciitis is, in all likelihood, multifactorial. Biomechanical abnormalities5, obesity 3,4,6 and repetitive microtrauma from prolonged standing and walking have all been cited as causative conditions.7

Plantar fasciitis can be managed conservatively with strappings and paddings, exercises, supportive shoe gear, anti-inflammatory medications, physical therapy, foot orthoses, night splints and corticosteroid injections. These treatment measures are effective in 85-90% of the patients with plantar fasciitis.8,9 In patients unresponsive to conservative forms of treatment, surgical intervention is the last treatment option. Surgical intervention is very effective in resolving recalcitrant plantar fasciitis. Traditional heel surgery often requires 4-6 weeks of recovery time that includes short-term disability from work. Complications with traditional heel surgery have been reported in 15-20% of the cases.10

Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy (ESWT) has been used since the early 1990s as an alternative to traditional heel surgery in chronic cases of painful proximal plantar faciitis.11 Patients who have failed at least four conservative modalities and have had pain for at least six months can be considered for ESWT. Some studies have shown that patients who have had a steroid injection within four weeks of proposed treatment, calcaneal fracture, malignancy or osteomyelitis, history or documented evidence of autoimmune disease, inflammatory arthropathies, circulatory or bleeding problems, an open wound over the site to be treated or infection in the area to be treated, or pregnancy should not receive ESWT.12

OssaTronTM
A number of different ESWT machines are available for clinical use. The OssatronTM by HealthTronics is a high-energy device utilized to treat chronic plantar fasciitis. It was the first machine approved by the FDA for the treatment of chronic proximal plantar fasciitis in October of 2000. It utilizes electrohydraulic “spark gap technology to generate the shock wave. Typically, 1500 shocks are delivered at 18 kV. The treatment setting and the type of anesthesia are determined by the physician rendering the service. In all cases, anesthesia is required. The physician performs the procedure with the assistance of a technician.

EposTM Ultra
The EposTM Ultra by Dornier was the second device approved by the FDA for the treatment of chronic proximal plantar fasciitis in February of 2002. It is a high-energy device utilized to treat chronic plantar fasciitis. An electromagnetic emitter generates the shock wave. An ultrasound unit is attached to the EposTM Ultra to evaluate the plantar heel and guide the treatment. The amount of energy used in a treatment can be variable but the typical number of shocks generated is 3800 for a total energy of 1300 mJ/mm2. The treatment setting and the type of anesthesia are determined by the physician rendering the service. In all cases, anesthesia is required. The physician performs the procedure with the assistance of a technician.

SonorexTM
The SonorexTM by Siemens is a low energy device that has not been approved by the FDA for the treatment of chronic plantar fasciitis. It is, however, approved by the FDA for the treatment of chronic lateral epicondylitis. SonorexTM utilizes an electromagnetic shock wave emitter. In the FDA studies, 2000 shocks were generated for a total energy of 360 mJ/mm2. The procedure is typically performed by a technician in an office setting and anesthesia of any kind is not required.

Clinical Trials for FDA Approval
Several clinical trials have been published which support the efficacy of ESWT for chronic plantar fasciitis.16,28,31, The study used for FDA approval of the OssatronTM was a multicenter, randomized, sham-controlled clinical trial.16,31 According to the summary of safety and effectiveness data, a total of 350 subjects were enrolled in the study, including 300 subjects randomized to either active ESW treatment or sham treatment with the OssaTronTM and 50 nonrandomized subjects to allow each investigator to complete training requirements for performing the OssaTronTM procedure. A minimum of two investigators participated in the study at each site so that one investigator could serve as the blinded evaluator for baseline and post treatment follow up visits. The non-blinded investigator performed the study procedures as follows: Each study subject received a local anesthetic or an ankle block prior to the study procedure. The affected leg was then draped from the view of the study subject. Each subject assigned to the active treatment group received 1500 shocks delivered at a power setting of 18kV. For subjects assigned to sham treatment, a Styrofoam block was placed against the coupling membrane of the shock head to absorb the shock waves. A fluid-filled IV bag was then placed between the Styrofoam block and the subject’s heel to mimic the feel of the coupling membrane, and 1500 shocks were then delivered at 18 kV.

Follow-up visits were done at four, eight, and twelve weeks after the treatment. Primary effectiveness measurements were determined at the twelve-week follow-up visit. Four criteria were utilized to establish the success of the treatment: (1) Investigator’s assessment of heel pain: A minimum 50% improvement over baseline, and a score no greater than 4.0 on a Visual Analog Scale (VAS);16,18,33 (2) Subject’s self-assessment of pain upon first few minutes of walking in the morning: A minimum 50% improvement over baseline with a score no greater than 4.0 on VAS was required for a status of “success to be assigned for this parameter; (3) Subject’s self-assessment of activity level, measured by the distance and time the subject is able to walk without heel pain: The subject must demonstrate an improvement of 1 point on a 5 point scale OR maintain a baseline score of 0 or 1 (no limitation/minor limitation) at the 12 week follow up for a status of “success to be assigned for this parameter; (4) Use of pain medications: The subject must not be taking any pain medications for heel pain at the 12 week follow up for a status of “success to be assigned for this parameter.

Upon completion of the study, 62.2% of the active treatment subjects met the first success criteria; 59.7% met the second success criteria; 71.42% met the third success criteria; and 69.7% met the fourth success criteria. 47.1% of the ESWT subjects met all four success criteria compared to 30.2% for the placebo group. This difference was statistically significant.

The study used for FDA approval of the Dornier EposTM Ultra was a multicenter, randomized, placebo-controlled, prospective, double masked clinical study of patients with plantar fasciitis with at least moderate pain for at least six months and a history of prior conservative therapy with two groups: a group receiving ESWT with the EposTM Ultra and a control group receiving a sham treatment.30 A total of 150 patients were enrolled at six clinical centers. The procedure for active and sham treatments was performed identically except that for patients randomized to sham, a thin air cushion was placed on the therapy head prior to the patients arrival to the treatment room. The treatment was administered by a physician who did not perform follow-up evaluations. All patients received an injection of 5ml of 1% Xylocaine into the medial calcaneal branch of the tibial nerve. Eleven percent of patients in the Active group and 4.1% of patients in the Sham group received additional anesthesia during treatment. A total of 3800 shock waves were generated to reach an approximate total energy delivery of 1300mJ/mm2. Follow-up visits were performed at three to five days, six weeks, three months, six months, and twelve months after treatment.

The primary efficacy endpoint was the difference between the active EposTM Ultra treatment and the sham EposTM Ultra treatment at 3 months post-treatment in the improvement from baseline in the VAS score for pain while walking for the first few minutes in the morning using a repeated measures analysis with covariates. In addition to evaluating the actual changes in pain score, the proportion of patients achieving at least 60% improvement in pain while walking for the first few minutes in the morning was compared between groups at 3 months.

The secondary efficacy endpoints were the difference between groups in the improvement from baseline at 3 months post-treatment of the pain evaluation from the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale Score, the Roles and Maudsley Score32, the SF-12 health status questionnaire, pain measurement on palpation with a pressure threshold meter, and the ROM Assessment from the AOFAS Ankle-Hindfoot Scale Score. Safety was assessed as the number of adverse events and severity of complications that were related to extracorporeal shock wave therapy.

In the active treatment group, the primary efficacy endpoint showed a mean improvement of 56.5% while the sham group showed a 46.6% improvement. The change from baseline due to treatment was statistically significant.

The secondary efficacy endpoints as evidenced by the Roles and Maudsley pain score was found to be statistically significant between the groups with 61.6% of active subjects having good to excellent results, compared to only 39.7% of sham subjects. The AOFAS Ankle-Hindfoot Scale and the SF-12 health status questionnaire did not show significant change between the active and sham groups. In other studies, success rates using differing endpoints were achieved.12,13,16,17,18

Other Clinical Studies
Alvarez Study
In a study performed by Alvarez, which focused on high-energy shockwave treatment using the OssaTronTM, 20 patients received a heel block of approximately 20 cc of .5% marcaine and 1% lidocaine 50/50 mixture. Initially, 10 shocks with the settings at 14 kV and frequency of .5 hertz was used. As the patient tolerated, the settings were advanced every 10 shocks to a maximum of 16 kV at a frequency of 2 hertz. A total of 1,000 shocks were delivered. Subjects returned for follow-up within 72 hours, at six weeks, three months, six months and one year. The mean individual improvement in pain score by investigator’s assessment (VAS) (described above) at three months post treatment was 85.7% and at 12 months, the VAS scores improved to a mean of 95.8%. At three months post treatment, 70% of patients met the success criterion for patient self-assessment (described above) and at 12 months, 85% of patients satisfied this criterion. Alvarez concluded that the OssaTronTM with high-energy shockwave is a safe and effective tool to treat heel pain syndrome.

Weil Study
In a study performed by Weil et.al., 94 patients underwent ESWT. All procedures were performed under intravenous sedation combined with a local infiltration of 6 cc of 0.5% bupivicaine. ESWT was applied using an electrohydraulic shock wave generator. The mean percentage of improvement for the satisfied group was 81.2% and 25.0% for the dissatisfied group. The authors concluded that ESWT is an attractive alternative for the treatment of chronic plantar fasciitis recalcitrant to nonoperative treatments.

It is important to note that there are two studies from Europe and Australia that do not support the efficacy of low energy ESWT for plantar fasciitis.19,29

Buchbinder Study
Buchbinder et.al. evaluated 166 patients in a randomized, double blind, placebo controlled, low energy study performed by a technician without anesthesia. Three separate treatments were given at weekly intervals. The minimum duration of symptoms was six weeks with a median duration of 36 and 43 weeks in the ESWT and placebo groups respectively. A total mean dose of 1406.73 mJ/mm2 was given but the calculated dose of each participant was different and the pre-treatment energy level varied between 0.02 mJ/mm2 and 0.33 mJ/mm2 depending on patient tolerance. The primary endpoint for determination of efficacy was overall pain at 12 weeks. The authors concluded that ESWT, as applied in this study, was no better than placebo in the treatment of plantar fasciitis.

Discussion on Buchbinder Study
The design of this study varies significantly from the studies used for FDA approval of the OssatronTM and Dornier EposTM Ultra. First, the Buchbinder study uses low energy ESWT. While total energy dosages compare to those in other trials, the authors make the assumption that the effect of ESWT is cumulative over time. The duration of symptoms was in some cases as low as six weeks. The current standard for ESWT treatment in the United States includes recalcitrant symptoms of at least six months duration. As with other low-energy studies, no anesthesia was used in this study. Often, this may result in a failure to complete the treatment. Most high-energy studies include, at a minimum, a local or regional block and in most procedures, the use of intravenous sedation as well. Titration of shock-wave amplitude to decrease painful symptoms elicited during the procedure may limit the effectiveness of ESWT, as a lower energy will likely result. The authors acknowledge that their results are inconsistent with the findings of other placebo-controlled trials.11,16,21,27,28

Haake Study
Haake et.al. evaluated 272 patients in a randomized, blinded, multicenter trial with a two sample parallel group design, low energy study performed with local anesthesia. Therapy was applied every two weeks plus or minus two days. Enrolled subjects had chronic plantar fasciitis recalcitrant to conservative therapy for at least six months. A total mean dose of 960 mJ/mm2 was administered over the course of three treatments. The required number of pulses and energy level for treatment was reached in all cases. The primary endpoint was the success rate after 12 weeks and success was defined by a Roles and Maudsley score of 1 or 2 and if the patient received no additional treatment. The authors concluded that ESWT, as applied in this study, is ineffective in the treatment of chronic plantar fasciitis.

Rompe Study
A recently published study evaluating low-energy ESWT for the management of plantar fasciitis revealed markedly different results.20 Rompe et.al. evaluated 45 long-distance runners in a prospective, randomized, placebo-controlled trial without anesthesia. Each study subject assigned to active treatment underwent low energy shock wave application for a total of 6300 shocks in three treatment sessions, with a 1-week interval in between, at an energy flux density of 0.16 mJ/mm2 and at a frequency of 4 Hz. This study revealed statistically significant improvement from baseline at 6 and 12-month follow-up, and a statistically significant difference between treatment and placebo groups at both intervals. The authors specifically critique the findings of the Buchbinder study in their discussion section, addressing many of the concerns presented above. The authors concluded that ESWT, as applied in this study, is a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

Martini Study
In attempt to understand the biological mechanisms of extracorporeal shock wave therapy, these authors evaluated the effects of shock wave therapy on human osteoblastlike cells at three energy levels.34 The control group received no energy while groups A (14kV, 0.15 mJ/mm2), B (21kV, 0.31 mJ/mm2) and C (28 kV, 0.40mJ/mm2) received two total impulses 500 and 1000 for each level. Group A and B demonstrated ostoeblast differentiation after the first 24 hours and an increase in C-terminal procollagen Type 1 production and bone matrix deposition after an additional 24 hours. The study demonstrated that shock waves have a dose-dependent effect upon cells.

Ogden Study
This study followed patients who had received ESWT for a five year period of time. All patients received a single treatment using an electrohydraulic shock wave device.35 The article addresses four studies that were performed, Study A-D. Studies B, C and D, assessed clinical outcome efficacy and patient satisfaction. In Study A, a randomized, double blind placebo controlled crossover study was performed. An 85% success rate was noted three months after treatment. This improved to a 95% success rate after 1 year and was noted to be durable with a 95% success rate after 5 years of treatment.

Surgical Treatment vs. ESWT
A review of the literature to compare surgical treatment of plantar fasciitis via either an open approach or an endoscopic plantar fasciotomy (EPF) against ESWT was performed. No studies presently exist that randomize patients between surgical and ESWT treatments; therefore, direct comparisons between these types of treatment cannot be made. However, the literature demonstrates that success rates for surgical treatment, either via an open approach or an EPF, are between 60-90%.1,22,23,24,25,26 According to the literature, the complication rate associated with surgical procedures is higher than that associated with ESWT.1, 12,13,14,15,16,21,22.23,24,25,26 Complications for open procedures can be as high as 15-20%. In one study, patients undergoing surgical treatment via percutaneous plantar fasciotomy experienced a 17% complication rate. In general, complications with EPF are lower. Studies demonstrate that complications associated with ESWT are minimal. In one study, of 302 patients treated, 13 related complications occurred. Complications identified in the surgical treatment of plantar fasciitis include, among others, infection, neuritis, scar problems and lateral column instability.1,22,23,24,25,26 The primary complication associated with ESWT is bruising, although other adverse events are possible.12,13,14,15,16,21

In terms of recovery, there is a substantially shorter recovery time with ESWT as compared to traditional heel surgery.1,13,22,23,26 In most cases, patients are able to immediately return to work following ESWT and typically resume full activities within 2-3 weeks of treatment. Open surgical treatment typically requires a more prolonged recovery, including 2-6 weeks of non-weight bearing, followed by partial to full weight bearing. In most cases, treatment with ESWT allows patients to get better quicker with fewer complications.

Payment Issues
Consistent with the studies used for FDA approval, ESWT is an anesthesia requiring, physician-administered service that involves a professional and technical component. As such, payment for this service should be established in a manner that is consistent with the establishment of payment for other physician services. Failure to recognize ESWT as a physician-administered service will cause an erroneous valuation and inadequate reimbursement. As such, access to this emerging technology could be impeded. Additionally, ESWT involves equipment of significant expense that must be appropriately recognized. At the appropriate time, ESWT must be evaluated through the American Medical Association/Specialty Society Current Procedural Terminology (CPT) and Relative Value Update Committee (RUC) processes so that an appropriate Category I code can be established and valued.

Costs for the procedure extend beyond physician payment and should be fairly reimbursed. Medicare reimbursements are established by the Centers for Medicare and Medicaid Services and its Carriers and will not vary significantly. Charges submitted by ESWT companies to payers other than Medicare should be developed fairly and in a manner consistent with charges submitted for other surgical services.

Coding
In terms of coding, Category III CPT Code 0020T is the accepted code at the present time for reporting ESWT services. Lithotripsy code 50590 should not be used to report ESWT for plantar fasciitis.

Coverage
Coverage of ESWT for plantar fasciitis by Medicare and private payers is variable.

Conclusions
Throughout history, there have been numerous examples of improvements in medical care as a result of new technology. In fact, before the 1990s traditional surgery for heel pain required a more prolonged recovery that usually resulted in 2-6 weeks of non-weight bearing, followed by partial to full weight bearing. With traditional heel surgery, 15-20 % of the cases can result in complications, such as nerve entrapments, continued pain, or lateral column syndromes, which may lead to chronic pain. This prolonged recovery and potential for complications led to the need for an improved surgical technique. In the early 1990s the endoscopic plantar fasciotomy came into vogue. It was a much easier procedure to perform with fewer complications than traditional heel surgery. In October of 2000 the first device became available for extracorporeal shock wave therapy. This new technology is revolutionizing the treatment of chronic heel pain, much the same way the lithotriptor did for kidney stones in 1984. The ESWT procedure has few, if any, complications that are minor in comparison to previous types of heel surgeries.

The number of shock wave procedures being performed has greatly increased in the past year, primarily due to the effectiveness of the treatment, fewer complications, and the increase in availability of the technology. Based on a thorough review of the literature, ESWT appears to be an efficacious, FDA-approved non-surgical option in the treatment of chronic proximal plantar fasciitis.

REFERENCES
1. Tomczak, R.L., Haverstock, B.D. A Retrospective Comparison of Endoscopic Plantar Fasciotomy to Open Plantar Fasciotomy with Heel Spur Resection for Chronic Plantar Fasciitis/Heel Spur Syndrome. J. Foot Ankle Surg. 34(3): 305-311, 1995.

2. Strash, W.W., Perez R.R., Extracorporeal Shockwave Therapy for Chronic Plantar Fasciitis. Clin. Podiatric Med. Surg. 19 (2002) 467-476.

3. Steinbach, P., et al. In vitro Investigations on Cellular Damage Induced by High Energy Shockwaves. Ultrasound, Med. Biol. 18: 691-699, 1992.

4. McCarthy, D., Gorecki, G. The anatomical Basis of Inferior Calcaneal Lesions: A Cryomicrotomy Study. J. Am. Podiatr. Assoc. 69: 527-536, 1979.

5. Kibler, W. B., Goldberg C., Chandler, T.J. Functional Biomechanical Deficit in Running Athletes with Plantar Fasciitis. Am. J. Sports Med. 1991; 19: 66-71.

6. Gill, L., Kiebzak, G. Outcome of Non-surgical Treatment for Plantar Fasciitis. Foot Ankle Int. 1996; 17: 527-532.

7. Schepsis, A.A., Leach, R.E., Gorzyca, J. Plantar Fasciitis. Etiology, Treatment, Surgical Results, and Review of the Literature. Clin. Orthop. 266: 185-196, 1991.

8. Weil, L.S., Gouldwing, P.B., Nutbrown, N.J. Heel Spur Syndrome. A Retrospective Study of 250 Patients Undergoing a Standardized Method of Treatment. J. Foot Ankle Surg. 4: 69-78, 1994.

9. Benton-Weil, W., Borelli, A.H., Neil, Jr., L.S., Weil, Sr., L.S. Percutaneous Plantar Fasciiotomy: A Minimally Invasive Procedure for Recalcitrant Plantar Fasciitis. J. Foot Ankle Surg. 37(4): 269-272, 1998.

10. Jerosch, JU.: Endoscopic Release of Plantar Fasciitis - A Benign Procedure? Foot Ankle, 21: 511-513, 2000.

11. Rompe, J.D., Hopf, C., Nafe, B., Burger, R.: Low Energy Extracorporeal Shockwave Therapy for Painful Heel: A Prospective Controlled Single-blind Study. Arch. Orthop. Trauma Surg., 115: 75-79, 1996.

Alvarez, R. Preliminary Results on the Safety and Efficacy of the
Ossatron for Treatment of Plantar Fasciitiis. Foot Ankle Int. 2002; 23: 197-203.

13. Weil, Jr., L.S., et al.: Extracorporeal Shock Wave Therapy for the Treatment of Chronic Plantar Fasciitis: Indications, Protocol, Intermediate Results, and a Comparison of Results to Fasciotomy. JFAS 41(3), 2002.

14. Chen, H.S., et al: Shockwave Therapy for Patients with Plantar Fasciitis: A One-Year Follow-Up Study. Clinical Orthopedics and Related Research 387: 41-46, 2001.

15. Wang, C.J., et al: Shockwave Therapy for Patients with Plantar Fasciitis: A One-Year Follow-up Study. Foot and Ankle International, 23(3), 2002.

16. Ogden, J.A., et al.: Shockwave Therapy for Chronic Proximal Plantar Fasciitis. Clinical Orthopaedics and Related Research, 387: 47-59, June 2001.

17. Ogden, J.A., et al: Shockwave Therapy for Chronic Proximal Plantar
Fasciitis: A Meta-Analysis. Foot & Ankle International 23(4), 2002.

Hammer, D.S., et al: Extracorporeal Shockwave Therapy (ESWT) in
Patients with Chronic Proximal Plantar Fasciitis. Foot & Ankle International 23(4), 2002.

19. Buchbinder, R., et al.: Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis: A Randomized Controlled Trial. JAMA 288(11), 2002.

20. Rompe, J.D., et al.: Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes: A Prospective, Randomized, Placebo-Controlled Trial. The American Journal of Sports Medicine 31(2), 2003.

21. Costentino, R., et al.: Efficacy of Extracorporeal Shock Wave Treatment in Calcaneal Enthesophytosis. Ann Rheum Dis. 60: 1064-1067, 2001.

22. Kinley, S., et al.: Endoscopic Plantar Fasciotomy versus Traditional Heel Spur Surgery: A Prospective Study. JFAS, 32(6), 1993.

23. Brekke, M.K., et al.: Endoscopic Plantar Fasciotomy versus Traditional Heel Spur Surgery: A Prospective Study. JAPMA, 88(2), 1998.

24. Dalay, P.J., et al.: Plantar Fasciotomy for Intractable Plantar Fasciitis: Clinical Results and Biomechanical Evaluation. Foot and Ankle, 13(41), 1992.

25. Vohra, P.K., et al.: Long-term Follow-up of Heel Spur Surgery: A 10-Year Retrospective Study. JAPMA, 89(2), 1999.

26. Lundeen, R.O., et al.: Endoscopic Plantar Fasciotomy: A Retrospective Analysis of Results in 53 Patients. JFAS, 39(4), 2000.

27. Rompe, J.D., et al: Effectiveness of Low Energy Extracorporeal Shock Waves for Chronic Plantar Fasciitis. Foot & Ankle Surgery, 1996;2:215-221.

28. Dornier MedTech Inc., Dornier EposTM Ultra: Summary of Safety and Effectiveness Data. Kennesaw, GA: Dornier MedTech Inc: 2002.

Haake, M., et al: Extracorporeal Shock Wave Therapy for Plantar Fasciitis: Randomized Controlled Multicentre Trial. British Medical Journal, Vol. 327, July 2003.

Dornier Epos™ Ultra - P000048 FDA Approval Related Information available at: http://www.fda.gov/cdrh/pdf/p000048.html
HealthTronics OssatronTM – P990086 FDA Approval Related Information available at: http://www.fda.gov/cdrh/pdf/p990086.html
Roles, NC, Maudsley, RH. Radial Tunnel Syndrome: Resistant Tennis Elbow as a Nerve Entrapment. J Bone Joint Surg (Br) 1972;54:499-508.
Chapman, CR, Case, KL, Dubner, R. Pain Measurement: An Overview. Pain 22:1-31, 1985.
Martini, L, Giavaresi, G, Fini, M, et al.: Effect of Extracorporeal Shock Wave Therapy on Osteoblastlike Cells. Clinical Orthopaedics and Related Research 413:269-280, 2003.
Ogden, JA, Alvarez RG, Levitt RL et al: Electrohydraulic High-Energy Shock Wave Treatment (Orthotripsy TM) for Chronic Plantar Fasciitis. Manuscript Under Review by the Journal of Bone and Joint Surgery.








Result number: 138

Message Number 143445

Re: To Mark Just had first round of Sonocur ESWT - great results so far View Thread
Posted by Karen on 2/01/04 at 21:08

Mark,
Are you saying Dr. Rompe's lying in his findings???

Shock wave application for chronic plantar fasciitis in running athletes View Thread
Posted by Jan Rompe on 3/19/03 at 06:32

Dear colleagues:

Our latest study has just been published in:


Am J Sports Med 2003 Mar-Apr;31(2):268-75

Shock wave application for chronic plantar fasciitis in running athletes: a prospective, randomized, placebo-controlled trial.

Rompe JD, Decking J, Schoellner C, Nafe B.

Department of Orthopaedics, Johannes Gutenberg University School of Medicine, Mainz, Germany.

BACKGROUND: Recent articles have reported success with repeated low-energy shock wave application for treatment of chronic plantar fasciitis in runners. HYPOTHESIS: Shock wave treatment for chronic plantar fasciitis is safe and effective. STUDY DESIGN: Prospective, randomized, placebo-controlled trial. METHODS: Forty-five running athletes with intractable plantar heel pain for more than 12 months were enrolled; half were assigned to a treatment group that received three applications of 2100 impulses of low-energy shock waves, and half received sham treatment. Follow-up examinations were performed at 6 months and at 1 year by a blinded observer. RESULTS: After 6 months, self-assessment of pain on first walking in the morning was significantly reduced from an average of 6.9 to 2.1 points on a visual analog scale in the treatment group and from an average of 7.0 to 4.7 points in the sham group. The mean difference between groups was 2.6 points. After 12 months, there was a further reduction of pain in both groups, to an average 1.5 points in the treatment group, and to 4.4 points in the sham group. CONCLUSION: Three treatments with 2100 impulses of low-energy shock waves were a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

Any PROFESSIONAL comments are welcome to:

Jan D. Rompe
Professor
Dept. of Orthopaedic Surgery
Johannes gutenberg University
School of Medicine
Langenbeckstr. 1
D-55131 Mainz
Germany

e-mail: rompe@mail.uni-mainz.de

Result number: 139

Message Number 143013

Re: Help with Diagnosis! Part II View Thread
Posted by Debbie G. on 1/27/04 at 23:27

Dear Dr. Wander, I ran out of room on my previous e-mail. I hope you get this half. To finish the story, my daughter also had bloodwork for lyme, gout, diabetes, arthritis, etc. All was normal. New Ortho. in Linden NJ, goes with the TTS theory and wants to do surgical release ASAP since she is in so much pain. He feels it's not RSD because only the TTS area is swollen and painful. It does get cold and discolored occasionally, but he says that's normal for an "angry nerve". She was doing PT but it was too painful. Is on low dose of Elavil. Tried Neurontin for three weeks(900 mg.)to no avail. Your thoughts? Should we come to see you or the other doc on this site, or do you feel we've done enough? Please share your expertise. It is greatly appreciated. My daughter, Erica, is still on crutches. Thank you, Debbie G.

Result number: 140

Message Number 142273

New Study on ESWT on patellar tendinitis (Jumper's Knee) View Thread
Posted by David L on 1/17/04 at 11:52

http://www.bcma.org/public/bc_medical_journal/BCMJ/december_2003/shock_wave_therapy.asp

BC Medical Journal Volume 45, Number 10, December 2003, page 500 - 507


Treatment of patellar tendinopathy with extracorporeal shock wave therapy

Subjects in this evaluation of a new treatment for activity-related anterior knee pain demonstrated significant improvement.



K.M. Taunton, BSc, J.E. Taunton, MD, K.M. Khan, MD, PhD

Ms Taunton is a research associate at the Allan McGavin Sports Medicine Centre and a graduate in Kinesiology from the University of Victoria. Dr Taunton is a primary care physician at the Allan McGavin Sports Medicine Centre and a professor in the School of Human Kinetics, UBC. Dr Khan is a primary care physician at the Allan McGavin Sports Medicine Centre and a professor in the department of Human Kinetics, UBC.



Contents:

Abstract
Objective
Method
Evaluation
Statistical analysis
Results
Veritcal jump score
VISA score
Other data
Discussion
Pathology of jumper's knee
Mechanism of ESWT
Other ESWT studies
Indicators of success
Conclusion
Competing interests
Acknowledgments
References



Abstract

Objective: To determine the effectiveness of extracorporeal shock wave therapy (ESWT) on patellar tendinopathy.
Method: This was a single-centre, randomized controlled trial, with 20 male and female subjects ranging from age 23 to 52. Treatment subjects received three to five sessions of ESWT and the control subjects received three to five sessions with the use of an energy-absorbing pad. The effects of the shock wave therapy were measured using the Victorian Institute of Sport Assessment (VISA) test and a vertical jump test. Pretreatment ultrasound was used to determine which subjects had neovascularization in the area of the patellar tendon.
Results: ESWT resulted in a significant improvement in the VISA score for questions 1, 3, and 6; for the VISA total score; and for the vertical jump score. Additionally, anecdotal evidence suggested an overall decrease in pain and an increase in function.
Conclusions: Extracorporeal shock wave therapy appears to be a useful adjunct to the eccentric drop-squat strength protocol in the treatment of chronic patellar tendinopathy. Future studies need to include a larger subject pool, a long-term follow-up, and a reliable objective measure of the microscopic and macroscopic improvement of the patellar tendon.



Patellar tendinopathy refers to a clinical condition of activity-related anterior knee pain assessed with tenderness at the inferior pole of the patella at the patellar tendon attachment. It is an overuse injury caused by repeated mechanical stress on the patellar tendon. Repetitive movement of the extensor mechanism of the knee overloads and damages the tendon. This injury is especially prevalent in running and in sports involving a large amount of running and jumping, such as basketball, volleyball, and soccer.[1]

Numerous conservative treatments (ice, rest, heat, massage, nonsteroidal anti-inflammatory medication, physical therapy modalities, corticosteroid injections, strengthening, stretching, bracing, taping, and orthotics) and surgical treatments have been recommended for patellar tendinopathy.[2-4] The most effective of these treatments to date is a strengthening program with eccentric drop-squat exercises.[5] While most cases can be treated conservatively, surgical treatment may be required when noninvasive therapy has not been effective or if there is a complete rupture of the patellar tendon.[2,3]



Objective

Overall, the conservative and surgical treatments for patellar tendinopathy have not proven to be highly successful in relieving symptoms to such a degree that athletes can continue to participate in their sport at their full potential. Although many methods of treatment permit athletes to return to activity, a form of therapy that eliminates the pain, resolves the symptoms, treats the patellar tendon itself, and makes surgical intervention unnecessary is required. Extracorporeal shock wave therapy (ESWT) may be such an effective treatment and therefore needs to be evaluated.

Extracorporeal shock wave therapy, or lithotripsy, was initially used to treat kidney stones, and then to treat stones at other sites, such as the gallbladder, bile duct, and pancreas. By the mid-1980s, Valchanou and Michailov were using ESWT to stimulate healing with bone fractures.[6] Since the early 1990s, shock wave therapy has been shown to be effective in treating chronic tendinopathies of the elbow, shoulder, and heel regions,[7-10] and chronic calcific tendinitis of the shoulder.[11-15]

A substantial amount of research has involved the use of shock wave therapy on calcific shoulder tendinitis,[7,11-14,16] lateral epicondylitis,[9,10,12,13,17] and calcaneal spurs,[8,13,15] but little research has involved patellar tendinopathy.

The purpose of this study was to evaluate the effectiveness of ESWT on patellar tendinopathy, as the current forms of therapy for this condition are not adequate, especially for elite athletes. The hypothesis was that ESWT would reduce pain and improve function in athletes with chronic patellar tendinopathy.

[Contents]

Method

This study was a single-centre, randomized controlled trial. Twenty individuals, who participated regularly in running and/or jumping sports and were diagnosed with patellar tendinopathy, were recruited as subjects (10 males and 10 females, ranging from age 23 to 52). One of the subjects was removed from the control group before the study ended and his data were not utilized in any of the results.

The criteria used to make the diagnosis of patellar tendinopathy were:

• Pain at the inferior pole of the knee with training.
• Tenderness at the inferior pole of the patella with palpation.
• Absence of other knee disorders, such as patellofemoral stress syndrome.
Each potential study subject was screened to meet the following inclusion criteria:
• Diagnosis of patellar tendinopathy as described above.
• History of patellar tendinopathy for at least 3 months.
• Pain that was non-responsive to nonsteroidal anti-inflammatory medication.
Each potential study subject was also screened to meet the following exclusion criteria:
• Younger than 18 years of age.
• Receiving physiotherapy (eccentric loading/stretching, etc.) within 4 weeks of randomization visit.
• Receiving NSAIDs or acetaminophen for any chronic condition within 1 week of randomization visit.
• History or physical findings of lumbar disc disease, compression syndrome, local arthrosis, or neurological abnormality.
• Previous surgery for patellar tendinopathy.
• Thrombopathy, infection, tumor, or other severe systemic disease.
• Receiving systemic therapeutic anticoagulation.
• Pregnancy.
• Previous ESWT treatment.

All subjects who were selected provided written informed consent before entering the study.

Subjects were randomly assigned to two groups: the treatment group, designated TG (five males and five females), who received active treatment, and the control group, designated CG (five males and five females), who received placebo treatment. The TG received three to five treatment sessions of 2000 shocks each at maximum energy level 4 (0.17 mJ/mm2). The CG received three to five treatment sessions of 2000 shocks each at energy level 4, but with the use of an energy-absorbing pad. A maximum of two specific points of tenderness were treated at each treatment session. In both the treatment and control groups, the first three treatments were administered weekly.

The Siemens Sonocur machine was used for all treatments in this study. This machine is a low-energy device with medium footprint and accurate focusing, and is used without imaging. The machine generates shock waves using an electromagnetic acoustic source. The patient receives neither sedation nor anesthesia. The area to be treated is confirmed by palpation. A coupling gel is applied and the shock module coupling bellows are placed in contact with the painful site.

The method used to determine which subjects received a fourth and fifth treatment involved the subjects’ subjective measure of their degree of improvement. The final two treatments were given no earlier than 3 weeks after the third treatment session. The fourth and fifth treatments were given 1 week apart.

The researchers and the subjects were not aware which subjects were assigned to the treatment group. The technician who administered the treatment randomly assigned the subjects to either the placebo or active treatment group, keeping this information encoded.

[Contents]

Evaluation

The age, activity level, frequency and type of training, presence of anterior knee pains, and history of injury of the subjects were evaluated with a questionnaire (Figure 1). [Requires Adobe Acrobat]

Real-time spatial compound imaging was done before treatment to aid the diagnosis of patellar tendinopathy and determine the severity.

Other methods of evaluation used were a vertical jump test and the Victorian Institute of Sport Assessment (VISA) test (Figure 2). [Requires Adobe Acrobat] Both of these assessments were done before, during, and after the treatment sessions. The vertical jump score was used to analyze the functional impairment of the tendinopathy and the VISA score was used to assess the degree of pain as well as the functional impairment. The VISA has proven to be a reliable method of assessing the severity of tendinosis based on symptoms and function.[18] The test has been particularly useful given that patellar tendinopathy does not have any pathognomic symptoms other than tenderness with palpation, and its diagnosis often relies on patients’ ratings of pain.[2,3]

Statistical analysis

This study is a pretest, midtest, and posttest randomized controlled study. Between-group differences on the VISA score and the vertical jump score were analyzed using analysis of variance with a statistical significance set at P < .05. The primary endpoint was the status of the patient on the VISA score at 12 weeks after the final ESWT treatment. Subject data were collected before treatment, 3 to 4 weeks after the third treatment, 3 to 4 weeks after the fifth treatment, when applicable, and at 12 weeks after the last treatment session. The subjects were not aware of their assignment to a particular group at the pretreatment and midtreatment point, and at 3 to 4 weeks posttreatment. However, they were aware of their assignments at 12 weeks when the final data were collected.

Results

The results of the study are based on the vertical jump scores, the VISA scores, anecdotal reports, and neovascularization as shown by ultrasound images. There were no significant differences between the groups at the start of the study.

Vertical jump score

The group change in vertical jump scores showed significance (P < .05). The mean change in vertical jump results for the control group was 0.0 inches and the mean change for the treatment group was 1.5 inches.

VISA score

Significant results were seen in the total VISA score versus group and time effects (P < .05). The mean VISA score for the control group was 49.9 pretreatment, 54.3 posttreatment at 5 weeks, and 53.2 at 12 weeks. The mean VISA score for the treatment group was 54.4 pretreatment, 65.6 posttreatment at 5 weeks, and 61.4 at 12 weeks.

Further analysis of the VISA score questions revealed VISA question 3 results to be significant (P < .05). The mean change for the control group was 0.85 and for the treatment group was 2.3.

The absolute group value for VISA question 6 was also significant (P < .05). The mean scores for the control group were 3.9 pretreatment, 4.2 posttreatment at 5 weeks, and 5.3 at 12 weeks, compared with 4.8 pretreatment, 7.3 posttreatment at 5 weeks, and 5.7 at 12 weeks for the treatment group.

Significant group effects were seen in VISA question 1 absolute group values (P < .05). The mean control group values were 6.3 pretreatment, 6.0 posttreatment at 5 weeks, and 6.6 at 12 weeks, compared with 8.1 pretreatment, 8.8 posttreatment at 5 weeks, and 7.4 at 12 weeks for the treatment group.

[Contents]

Other data

The pretreatment ultrasound results of 13 subjects were evaluated. These results showed that 6 of the 13 subjects had neovascularization in the area of the patellar tendon.

After treatment, anecdotal reports from the treatment group revealed five out of nine subjects had decreased pain and increased function; two subjects still experienced pain with stairs but felt they had improved overall, and two subjects reported still feeling pain with activity.

In the control group, six of seven subjects reported no improvement or change. One of the control subjects experienced some pain relief after the five treatment sessions, but this subject also reported decreased frequency of activity during the study.

Discussion

The primary etiologic factors for patellar tendinopathy include fatigue and overuse of the extensor mechanism, which together result in microtrauma to the patellar tendon.[2] Without proper rest and repair, collagen and matrix production is reduced and the tendon becomes more vulnerable to injury—a situation than can ultimately lead to a complete rupture of the tendon.[3] Furthermore, the intensity and the frequency of training are factors in the development of patellar tendinopathy, as are specific sport skills involving rapid acceleration, deceleration, jumping, and cutting (changing direction).[3]

Ferretti[1] found that extrinsic factors such as the intensity, frequency, and duration of training as well as training surface were more consequential than intrinsic factors. Anatomical and biomechanical abnormalities that were assessed included high Q-angle (quadriceps angle from anterior inferior iliac spine to centre of patella to tibial tubercle), limb length discrepancy, pelvic asymmetry, patellar squinting (inward pointing patella from femoral neck anteversion), genu varum and genu valgum, femoral anteversion, and foot abnormalities. None of these abnormalities were significantly correlated with patellar tendinopathy; however, muscle and gait imbalances were related.[19]

[Contents]

Pathology of jumper’s knee

Patellar tendinopathy, otherwise known as jumper’s knee, has often been referred to as patellar tendinitis. The macroscopic pathology of patellar tendinitis is degeneration of the tendon with an inflammatory response, while the pathology of jumper’s knee is noninflammatory degeneration, which requires replacing the term patellar “tendinitis with patellar “tendinosis. [3]

Mucoid degeneration occurs in the patellar tendon of patients with patellar tendinosis. Macroscopically, the tendon’s tissue is soft, yellow-brown, and disorganized. Microscopically, the tendon has increased ground substance, abnormal collagen, tenocytes, and vasculature, fibrocartilagenous metaplasia, fibroblast proliferation, capillary ingrowth, and fibrinoid necrosis.[2,3]

Recently, H. Alfredson of Sweden used perfusion microdialysis to investigate 20 patients with chronic Achilles tendinopathy. On the fluid analysis over a 2-hour period, there was a lack of E2 prostaglandin (indicating an absence of inflammation), increased ischemia with high lactate levels, and, for the first time, elevated levels of glutamate, a potent pain neurotransmitter.[20] This was followed by a biopsy that identified the glutamate receptor NMDAR1. Furthermore, Alfredson has used ultrasound color Doppler to identify neovascularization with vascular ingrowth in the area of nodular tendinosis in 28 of 28 patients with chronic tendinopathy. In a recent pilot study of 10 subjects, Ohberg and Alfredson reported elimination of pain in these patients for up to 6 months with sclerosing these new vessels with polidocanol as used in sclerosing varicose veins.[21]

Mechanism of ESWT

Several different theories attempt to explain how extracorporeal shock wave therapy works. Haist and von Keitz-Steeger have three hypotheses to explain the mechanism involved with shock wave therapy:

• “Shock waves damage cell membranes and therefore nociceptors cannot build up a potential to transmit pain signals.
• “Nociceptors which are stimulated by shock waves send a high frequency of impulses which are suppressed by a gate-control mechanism.
• “Shock wave-induced pericellular free radicals change the chemical milieu and pain-suppressing substances are released. [22]

Rompe and others suggest another hypothesis regarding the mechanism of ESWT in which the shock wave therapy alleviates pain by hyperstimulation analgesia.[9] According to this mechanism, intense stimulation controls pain via brain-stem mechanisms that exert descending inhibitory control over neural transmission through the dorsal horns and at higher levels in the somatic projection system.[9] As a result, no additional transmission of nociceptor information occurs.[12]

[Contents]

Other ESWT studies

The effects of ESWT on calcific rotator cuff tendinitis,[7,11-14,16] calcaneal spurs,[8,13,15] lateral epicondylitis,[9,10,12,13,17] Achilles tendinitis,[23] plantar fasciitis,[24] and pseudarthrosis,[6,12,13,25] have been studied and ESWT has been found to have a success rate of approximately 80%.[13] However, the effects of shock wave therapy on patellar tendinopathy have been researched at only a preliminary level.[8,9,11,13,24-26]

The single previous study involving shock wave therapy specifically for the treatment of patellar tendinopathy was done by Lohrer and colleagues at the Institute of Sports Medicine in Germany. When the effectiveness of extracorporeal shock wave therapy was evaluated in 35 subjects with jumper’s knee, ESWT was found to be an effective noninvasive method of treating patellar tendinopathy.[27]

Unfortunately, a comparison of the study described in this article with other studies is difficult for a number of reasons:

• Lack of research involving the effect of shock waves on patellar tendinopathy.
• Current research on other forms of tendinopathy uses different numbers of impulses and different shock waves (with the majority of studies using high-energy density shock waves that require the use of anesthetic).
• Some studies do not include a control group and are not blinded.[7,16]
• Follow-up times differ from study to study.

However, a comparison of results achieved with the higher shock wave frequency (0.28 mJ/mm2–0.8 mJ/mm2) used in most other studies and the results achieved in this study with a low frequency (0.17 mJ/mm2) may suggest that lower shock wave frequency provides more effective long-term results for decreasing pain and increasing function. [7,12,14,16]

Indicators of success

In this study, significant results were shown on analysis of VISA question 3 (pain with non-weight-bearing knee extension), question 6 (pain with 10 single-leg hops), and question 1 (number of minutes of pain-free sitting). The greatest improvements in subjects occurred at 3 weeks to 4 weeks after the five treatment sessions. This differs from other research on ESWT, which finds the most significant improvements at least 12 weeks after five treatment sessions.[12,15] This may suggest that more than five treatments should be administered and that a strength training program should be used in addition to ESWT to maintain the benefits of the shock wave therapy. Furthermore, subjects may have decreased their activity during the treatment period but then felt their improvements allowed them to increase their activity, meaning that at 12 weeks posttreatment they were stressing the knee to a greater extent.

Along with the VISA scores, the vertical jump test results and the anecdotal results suggest an increase in power and function in subjects due to a decrease in pain and, possibly, stimulation of fibroblastic activity, which strengthens the tendon. The ultrasound results support Alfredson’s research, which showed evidence of neovascularization at the tendon as well as decreased levels of glutamate receptors.[19] Perhaps the improvement with ESWT is a result of the disruption of the new vessels and/or pain receptors.

There has only been one report of side effects with ESWT in this study. One subject reported that the intensity of knee pain increased during the 3 weeks of treatment. However, upon evaluation 4 weeks after the first three treatment sessions, the subject’s pain had subsided.

There are potential sources of error that could account for unexpected results according to the hypothesis. The VISA score may not adequately reflect the improvement or lack of improvement in pain and functional impairment. One of the treatment group subjects did not show an improvement in VISA score; in fact the subject’s score decreased. However, the subject also reported anecdotally that pain had decreased from a rating of 9 out of 10 (where 10 is the most pain) pretreatment to 1 out of 10 posttreatment. Furthermore, the subject reported that time to onset of pain during activity had significantly increased.

The most useful indicator in this study may be question 8 on the VISA, which refers to the time to onset of pain and the degree of pain experienced while undertaking sport. However, this question still raises some issues: it accounts for 30 out of a total 100 points and therefore heavily penalizes subjects who experience any pain with activity. Many athletes possess the ability to play through pain, and although the pain may be sufficient to cause some people to stop training or competing, these athletes continue. Thus, there may not be a true reflection of the degree and the consequences of this pain in the subject’s response. In retrospect, adding a subjective visual analog scale question may have provided a useful indicator of pain relief and, therefore, improvement.

[Contents]

Conclusion

Although extracorporeal shockwave therapy appears to be a useful adjunct to the eccentric drop-squat strength protocol in the treatment of chronic patellar tendinopathy, further research is needed to determine the most efficient ESWT energy density, the ideal number of impulses, and the ideal follow-up time. In addition, more research is needed to determine the mechanism of pain relief of shock wave therapy on patellar tendinopathy. The next study should include a larger subject pool, a long-term follow-up, as well as a follow-up of successfully treated subjects to determine, using a color Doppler ultrasound, whether there is an elimination of the areas of neovascularization. Finally, a reliable objective measure of the microscopic and macroscopic improvement of the patellar tendon itself would be useful in evaluating the effects of shock waves on patellar tendinopathy.

Competing interests
Dr Taunton has a nominal investment in the local Sonocur machine.

Acknowledgments
The authors would like to acknowledge the support of the Nike Research Foundation, BC Sports Medicine Research Foundation, Siemens AG, and Sonorex.

References

1. Ferretti A. Epidemiology of jumper’s knee. Sports Med 1986;3:289-295.

2. Ban, JW. Patellar tendinopathy: Determinants of clinical and ultrasonographic abnormalities in elite male basketball players [master’s thesis]. Vancouver: University of British Columbia, 1999.

3. Khan KM, Maffulli N, Coleman BD, et al. Patellar tendinopathy: Some aspects of basic science and clinical management. Br J Sports Med 1998;32:346-355. PubMed Citation Full Text

4. Cook JL, Khan KM, Harcourt PR, et al. A cross sectional study of 100 athletes with jumper’s knee managed conservatively and surgically. Br J Sports Med 1997;332-336. PubMed Abstract

5. Cannell LJ, Taunton JE, Clement DB, et al. A randomized clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes. Br J Sports Med 2001;35:60-64. PubMed Abstract Full Text

6. Valchanou VD, Michailov P. High-energy shock waves in the treatment of delayed and non-union fractures. Int Orthop 1991;15:181-184. PubMed Abstract

7. Rompe JD, Rumler F, Hopf C, et al. Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. Clin Orthop 1995;321:196-201. PubMed Abstract

8. Rompe JD, Hopf C, Nafe B, et al. Low-energy extracorporeal shock wave therapy for painful heel: A prospective controlled single-blind study. Arch Orthop Trauma Surg 1996;115:75-79. PubMed Abstract

9. Rompe JD, Hopf C, Kullmer K, et al. Analgesic effect of extracorporeal shock-wave on chronic tennis elbow. J Bone Joint Surg Br 1996;78:233-237. PubMed Abstract Full Text

10. Rompe JD, Hopf C, Kullmer K, et al. Low-energy extracorporeal shock wave therapy (ESWT) for persistent elbow epicondylitis. Int Orthop 1996;20:23-27.

11. Loew M, Jurgowski W, Mau HC, et al. Treatment of calcifying tendinitis of rotator cuff by extracorporeal shock waves: A preliminary report. J Shoulder Elbow Surg 1995;4:101-106. PubMed Abstract

12. Rompe JD. Efficient use of extracorporeal shock waves in tendinopathies. Electromedica 1997;65:20-25.

13. Haupt G. Use of extracorporeal shock waves in the treatment of pseudathrosis, tendinopathy and other orthopedic diseases. J Urol 1997;158:4-11. PubMed Abstract

14. Loew M, Daecke W, Kusnierczak D, et al. Shock wave therapy is effective for chronic calcifying tendonitis of the shoulder. J Bone Joint Surg Br 1999:81:863-867. PubMed Abstract Full Text

15. Wang C, Chen H, Chen W, et al. Treatment of painful heels using extracorporeal shock wave. J Formos Med Assoc 2000:99:580-583. PubMed Abstract

16. Rompe J, Burger R, Hopf C, Eysel P. Shoulder function after extracorporeal shock wave therapy for calcific tendonitis. J Shoulder Elbow Surg 1998:7:505-509. PubMed Abstract

17. Pettrone F, Lefton CS, Romness DW, et al. Evaluation of extracorporeal shock wave therapy for chronic lateral epicondylitis. AAOS, Paper 271, 2002.

18. Visentini PJ, Khan KM, Cook JL, et al. The VISA score: An index of the severity of jumper’s knee (patellar tendinosis). Victorian Institute of Sport Tendon Study Group. J Sci Med Sport 1998;1:22-28. PubMed Abstract

19. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36:95-101. PubMed Abstract Full Text

20. Alfredson H, Thorsen K, Lorentzon R. In situ microdialysis in tendon tissue: High levels of glutamate but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surg Sports Traumatol Arthrosc 1999;7:378-381. PubMed Abstract Full Text

21. Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessel in painful chronic Achilles tendinosis: Pilot study of a new treatment. Br J Sports Med 2002;36:173-175. PubMed Abstract Full Text

22. Haist J, von Keitz-Steeger D. In: Haupt G. Use of extracorporeal shock waves in the treatment of pseudoarthrosis, tendinopathy and other orthopedic diseases. J Urol 1997:158:4-11. PubMed Abstract

23. Rompe J, Kirkpatrick C, Kullmer K, et al. Dose-related effects of shockwaves on rabbit tendo Achilles. A sonographic and historical study. J Bone Joint Surg Br 1998:546-552. PubMed Abstract Full Text

24. Rompe J, Kullmer K, Riehle H, et al. Effectiveness of low-energy extracorporeal shock waves for chronic plantar fasciitis. Foot Ankle Surg 1996;2:215-221.

25. Vogel J, Eysel P, Hopf C, Rompe JD. Lithotripsy in non-unions of the lower extremities: An alternative to surgery? In: Chaussy C, Eisenberger F, Jocham D, et al. (eds). High Energy Shock Waves in Medicine. New York: Georg Tieme Verlag, 1997:129-135.

26. Walter N, Seal S. Extracorporeal shock wave therapy: A review of the literature and analysis in treatment of chronic tendinopathy [directed study paper]. Vancouver: University of British Columbia, 1999.

27. Lohrer H, Scholl J, Arentz S. Pilot study: Radial shock wave therapy for the treatment of "jumper's knee" and Achilles tendonitis. Proceedings Canadian Academy Sports Medicine Annual Meeting, Calgary, AB, 4-7 July 2001.

Result number: 141
Searching file 13

Message Number 135994

Re: English podiatists not amused by ESWT.. View Thread
Posted by Jan R. on 10/30/03 at 07:14

This is my comment on the study published by Speed and co-workers:

Prof. J.A. Buckwalter, MD
Editor
The Journal of Orthopaedic Research
Department of Orthopaedic Surgery
The University of Iowa Hospitals and Clinics
200 Hawkins Drive
Iowa City, IA 52242-1088
USA

August 13, 2003

Letter to the Editor:
“Extracorporeal shock wave therapy for plantar fasciitis – a double blind randomised controlled trial” by C.A. Speed et al., J Orthop Res 2003; 21:937-940

Sir,

I read with interest the article in the Journal of Orthopaedic Research entitled “Extracorporeal shock wave therapy for plantar fasciitis – a double blind randomised controlled trial” by C.A. Speed et al.(1)

I congratulate them for the well-conducted randomised controlled trial, the negative results of which contrast with our and others recently published experience (2,6) and confirm data of the Australian multi-center study (3) and of the German multi-center study.(4)

All four randomised controlled trials (2,3,4,6) were not included in the discussion of their article.

In the trial from our department (2) forty-five running athletes with intractable plantar heel pain were enrolled in a randomized single-blind trial with a parallel-group design and blinded independent observer, to evaluate the efficacy of three applications of 2000 impulses of low-energy shock waves (Group I) compared with sham treatment (Group II). Followup examinations were done at six months, and at one year after extracorporeal shock wave application. Symptoms had been present from one year to six years. The primary efficacy endpoint was reduction of subjects´s self-assessment of pain on first walking in the morning on a visual analog scale (range, 0 - 10 points) at six months after shock wave application. After six months self-assessment of pain on first walking in the morning as primary efficacy endpoint showed a significant reduction from an average 6.9 to 2.1 points in Group I, and from an average 7.0 to 4.7 points in Group II on the visual analog scale. The mean difference between both groups was 2.6 points. After twelve months pain on first walking in the morning showed a further reduction in both groups, to an average 1.5 points in Group I, and to 4.4 points in Group II . In conclusion, this study showed that three treatments with 2100 impulses of low-energy shock waves were a safe and effective non-surgical method for treating chronic plantar fasciitis in long-distance runners after a followup of six months.

This study sharply contrasted with the Australian multi-center trial published by Buchbinder et al. in JAMA 2002.(3) They enclosed 166 patients in a double-blind, randomized, placebo-controlled trial. Patients were randomly assigned to receive either ultrasound-guided ESWT given weekls for 3 weeks to a total dose of at least 1J/mm² or identical placebo to a total dose of 0.006 /mm². After significant improvements in both groups, the between- group difference of improvement was only 0.6 on a 100 mm visual analog scale. There was no evidence of ESWT over placebo. The study of Buchbinder was of excellent quality but there were clear differences regarding our trial. First, patients in the active group did not receive identical treatment (either 2000 or 2500 shock waves per treatment of energy levels varying between 0.02 mJ/mm² and 0.33 mJ/mm²) contrary to the current study.4 Second, the mean dose in the active group was 1407 mJ/mm², 500mJ/mm² more than in the current study. In the experience of the author of the current study patients will not tolerate such a high dose unless the treatment area of maximal pain is missed. Accordingly, third, Buchbinder did not focus on the area of maximal pain like in the current study, but on the area of maximal thickness of the plantar fascia. Fourth, a potent analgetic drug was allowed for the duration of the study. Fifth, patients were enrolled with a pain history as short as 6 weeks, contrary to 12 months in the current study. Sixth, there was no real placebo group, but sham therapy consisted of application of 100 shock waves of 0.02 mJ/mm².

With regard to the German multicenter trial published by Haake et al.(4) in the BMJ the study design is excellent. It was a randomised, blinded, multicenter trial with parallel group design. 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months were enrolled: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo. Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention. The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group. No difference was found in the secondary end points. Few side effects were reported. In conclusion, extracorporeal shock wave therapy was ineffective in the treatment of chronic plantar fasciitis. However, Haakes´s treatment regimen is clearly different from the regimen applied in our trial (2) regarding shock wave device, number of shock waves, energy flux density, technique of focussing, period between application, permission of additional pain medication, simultaneous application of local anesthesia.

A possible influence of simultaneous local anesthesia has been discussed particularly. Auersperg et al.(5) reported they had enrolled fifty-one patients with a chronic plantar fasciitis in a randomized controlled observer-blinded trial. Patients were randomly assigned to receive either active ESWT without local anesthesia, given daily for 3 days (Group I, n=25; 3 x 1500 pulses, total energy flux density 0.04 mJ/mm2) or identical ESWT with local anesthesia (Group II, n=26). Main outcome measures were: Pain during first step in the morning (measured on a 0-10 point visual analog scale), and no further therapy needed, measured at six weeks after the last ESWT. At six weeks, there was significant improvement in pain during first steps in the morning in both groups, by 4.4 points in Group I, and by 2.6 points in Group II. The mean between-group difference of improvement was statistically significant. In Group I 19/25 (76%) patients didn´t need any further therapy compared with 9/26 (35%) patients in Group II. In conclusion, at six weeks success rates after low-energy ESWT with local anesthesia were significantly lower than after identical low-energy ESWT without local anesthesia.

Buch et al.(6)presented results of a US-based prospective randomised placebo-controlled double-blind multicenter trial. 150 patients with persistent heel pain were enrolled. 76 patients received a single active treatment (3800 pulses, 0.36 mJ/mm², local anesthesia of the posterior tibial nerve), 74 received a single sham treatment. A reduction of heel pain at first step in the morning was observed in both groups at 3-month follow-up, by 4.4 points in the active group, and by 3.6 points in the placebo group. The between-group difference was significant. The Roles and Maudsley score also showed a significant difference between the groups, with 61.6% good or excellent results in the active group, and 39.7% in the placebo group. The data presented in this study led to FDA approval of the shock wave device in January 2002.

Now, Speed et al.(1) present another treatment concept. They performed a double blind randomised trial of moderate shock wave therapy in plantar fasciitis of at least 3-month duration. 88 patients either received active treatment (1500 pulses of 0.12 mJ/mm², given 3x in monthly intervals) or placebo treatment. At three months from baseline, that is at one month after completion of treatment, 37% of the subjects in the ESWT group, and 24% in the sham group showed a >50% improvement from baseline with respect of pain. In conclusion, there appeared to be no treatment effect of moderate dose ESWT. Clearly, Speed´s treatment regimen is different from the regimen applied in our trial (2) regarding number of shock waves (3x 1500 vs. 3x 2000), energy flux density (0.12 mJ/mm² vs. 0.18 mJ/mm²), period between application (1 month vs. 1 week), and time of follow-up (1 month after completion of treatment vs. 6 months). The technique of focusing was similar to ours, and they did not use a local anesthesia.

Some questions remain to be answered by Dr. Speed and his co-authors:

·88 patients were in the study. Was it a pilot study? Was there any sample size calculation prior to starting the trial. If so, which data were the basis of this calculation? Or was selection of treatment parameters just empirical, with emphasis on a feasible regime?

·The primary endpoint relied on assessment of heel pain during the day. It remains unclear how patients rate a pain over a 24-hour period. Concerning difference between groups: What was the statistical power of the analysis?

·As I read there was no statistically significant difference between both groups concerning the visual analog pain scores one month after treatment. What was the statistical power of the analysis? Maybe the power was too small to detect a clinically relevant difference between the groups?

All authors made clear in the discussion of their papers (1,2,3,4,6) that "the results were only valid for the therapeutic variables applied". Therefore I fully agree with Dr. Speed that differences between different studies may be related to differences in study populations, heterogeneity of treatment parameters, different placebos and different machine designs.

So, many questions still remain to be answered by future prospective randomized controlled trials:

·What roles do treatment intervals and follow-up periods play?

·Has a local anesthetic an adverse effect on the clinical outcome after repetitive low-energy ESWT? What about performing the treatment under regional anesthesia?

·Is there an adverse effect of additional pain medication on the clinical outcome after repetitive low-energy ESWT? If so, why and to which extent?

·Is clinical outcome after repetitive low-energy ESWT comparable with results after high-energy ESWT performed under regional anesthesia?

·What clinical results are observed when exactly repeating treatment protocols which have reportedly been successful?

All these issues warrant further research in order to develop evidence-based recommendations for the use of ESWT in musculoskeletal disorders. I strongly disagree with Haake (4) in whose opinion the diverging results of the existing RCTs justify a ban on further research. On the contrary, these diverging data are a magnificent basis for future trials according GCP and ICH criteria.

Sincerely yours,

Jan R.


References

1.Speed CA, et al. Extracorporeal shock wave therapy for plantar fasciitis – a double blind randomised controlled trial. J Orthop Res 21:937-940, 2003
2.Rompe JD, et al. Shock wave application for chronic plantar fasciitis in running athletes – a prospective, randomized, placebo- controlled trial. Am J Sports Med 31:268-275, 2003
3.Buchbinder R, et al. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis. JAMA 288: 1364-1372, 2002
4.Haake M, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ 327:75-79, 2003
5.Auersperg V, et al. Influence of simultaneous local anesthesia on the outcome of repetitive low-energy shock wave therapy for chronic plantar fasciitis. Presentation at the 3rd Tri-National Meeting of the Austrian, Swiss, and German Societies for ESWT, Munich 2003
6.Buch M, et al. Extracorporeal shockwave therapy in symptomatic heel spurs. Orthopäde 31:637-644, 2002

Result number: 142

Message Number 133450

Re: Changing the constitution View Thread
Posted by john h on 10/10/03 at 14:13

Rick: name recogniton is everything in an election. Ike, Regan, Grant, etc. In the most recent poll on name recognition I was supprised to see that Clark only had about a 5% name recognition. If you do not get it then there is no way you can get elected. I am blinded here in Arkansas as he is from Little Rock and we all have known him forever so we forget in the rest of the country he is probably better known as a talking head during the Iraq War. He really did not get that much recognition as NATO Commander.

Do you think we are better served by a career politican as President? In recent years most of our Presidents have been Governors. I think a man or woman who has the wisdom to surround themselves with good and experienced people, can communicate his/her message to the people and Congress, has a wide range of experience in many fields such as business, politics but not really a requirement in my mind, and most importantly seeks the position to help his country and not because of a thirst for power to be some of the qualities I look for in a President. I think to many of our politicans are on a power trip. Bill Clinton was driven to be a politican since he was a teenager. He even said when he was at the Governor's school for teens many years ago he was going to be President. Why do we see so many sons of politicans become politicans. Name recognition sure helps.Al Gore a good example. Here in Arkansas former Senator Pryor's son recently elected to the Senate. Pure name recognition. George Bush's son. Anyone named Roosevelt. Anyone named Kennedy. I think if you have the name recogniton an idiot might get elected. Do you think Hillary Clinton would have ever been elected to the Senate from New York without her name recognition? Jesse Ventura? He was no genius but a lot of people knew him.

Result number: 143

Message Number 131709

Re: healthronics getting sued View Thread
Posted by Jan R. on 9/30/03 at 07:06

I do not want to comment on the legal aspects of this conflict.

However, there are obvious discrepancies between scientific results and those results made available to the public by HealthTronics.

For example, only a few moths ago, HeathTronics received FDA approval for ESWT to treat tennis elbow (http://www.fda.gov/cdrh/pdf/p990086s003.html)

Let´s have a look at their "Effectiveness Analysis":

“a. Investigator Assessment:

The subjects randomized to active ESW treatment improved from a mean baseline VAS score Forty-three of the 82 subjects (52.4%) randomized to active ESW treatment met the success criteria for this parameter. Twenty-six of the 83 subjects (31.3%) randomized to placebo ESW treatment met the success criteria (minimum 50% improvement and VAS score of 4.0 or less) for this parameter. The difference between the active treatment and placebo group was statistically significant.

b. Subject Self-Assessment of Pain:

Forty-eight of the 82 subjects (58.6%) randomized to active ESW treatment met the success criteria (minimum 50% improvement and VAS score of 4.0 or less) for this parameter. Thirty-six of the 83 subjects (43.4%) randomized to placebo ESW treatment met the success criteria (minimum 50% improvement and VAS score of 4.0 or less) for this parameter. The difference between the active treatment and placebo group was not statistically significant.

c. Use of Pain Medications:

Seventy-one of 82 subjects followed to 8 weeks (86.6%) randomized to active ESW treatment met the success criteria for this parameter. Sixty-one of 83 subjects followed to 8 weeks (73.5%) randomized to placebo ESW treatment met the success criteria for this parameter. The difference between the active treatment and placebo group was not statistically significant.

d. Overall Success/Fail Status:

Of the 82 subjects followed to 8 weeks after an active OssaTron ESW treatment, 33 (40%) met all 3 success criteria, compared to 20 of 83 placebo treated subjects (24 %) who met all 3 criteria. The difference between the active treatment and placebo group was statistically significant.

The majority of the treatment effect was observed in the blinded evaluator’s assessment of elbow pain. The subjects’ self-assessments of pain with activity did not indicate large treatment differences through 8 weeks, and were not statistically different. The active treatment subjects showed greater improvement use of pain medications and in SF-36 scores than did placebo subjects. However, none of the primary or secondary outcome measurements demonstrated statistically significant treatment differences.”



Now, what do we read when clicking at “NOW FDA APPOVED TO TREAT TENNIS ELBOW (http://www.healthtronics.com/ossatron/le_index.html)?

“What Are The Expected Results?

90% of patients receiving Orthotripsy® with the OssaTron® received a benefit with only one treatment. Some patients have reported immediate pain relief after treatment, although it can take up to four weeks for pain relief to begin.”

And

“The OssaTron® has a proven success rate that is equal to or greater than surgery, usually with just one treatment and without the risks, complications, and lengthy recovery time of invasive surgery. The OssaTron® treatment procedure requires a minimal amount of time and patients can go home the same day the OssaTron® procedure is performed. Patients can return to normal activity within a few days of the procedure.”


In my opinion, data provided on this website do not agree with the data provided in the FDA trial. The information on this website mislead the public.

Result number: 144
Searching file 12

Message Number 129772

Re: Brian here is the informaton about the one year follow-up View Thread
Posted by Dr. Z on 9/12/03 at 17:52

Shockwave Therapy for Plantar Fasciitis of the Eposcorporus Dornier
Authors: Christopher Zingas, David Collon, Kyle Anderson
Institution: Henry Ford Health System William Clay Ford Center for Athletic Medicine
The study is designed to assess the safety and efficacy of musculoskeletal shock wave therapy in the treatment of chronic plantar fasciitis. The authors hypothesize that shock wave therapy will be useful in the treatment of chronic plantar fasciitis which has failed conventional conservative methods.
Preliminary twelve month results indicate that shock wave therapy may provide an effective alternative treatment for chronic plantar fasciitis with minor transient adverse effects.
One hundred and fifty patients with chronic plantar fasciitis were enrolled in a randomized, 1:1 allocated, placebo-controlled, prospective, double blind clinical study with two groups: one receiving Extracorporeal Shock Wave Therapy (ESWT) with Dornier Epos Ultra and the other receiving sham treatment. All 150 patients had failed at least six months of physician supervised conventional conservative methods and would have been considered surgical candidates by guidelines set forth by the AOFAS. All patients were greater than 18 years of age with unilateral single site plantar medial heel pain, and had a visual analog score of >5 (scale 1-10) for the first few minutes of morning walking. There were 119 women and 31 men enrolled. The mean age was 50 years (26-69) for the active group and 53 years (31-72) for the sham group. Each active treatment patient was subjected to a single 20 minute ESWT session which delivered approximately 1300mJ/mm2 to the treatment area. The control group patients went through the identical treatment procedure without shock wave penetration. All patients were evaluated 3-5 days, 6 weeks, 3 months, 6 months, and 1 year post-treatment. Patients were assessed using the Visual Analog Score (VAS) during the first few minutes of walking and the Roles and Maudley score. The participants were unblinded at 3 months post-treatment. Patients in the sham treatment group who did not improve at 3 months were offered active ESWT and were considered the 'Crossover Group'.
The VAS for the first few minutes of walking at 3 months post-treatment showed a 45% success rate in the sham treatment group and 56% success in the active group. The Roles and Maudsley scoring showed a 40% success rate in the sham group and 62% success rate in the active group at 3 months. The VAS for the first few minutes of walking at 12 months post-treatment showed a 94% success rate in the active group. The Roles and Maudsley scoring showed also 94% success rate in the active group at 12 months. The crossover group at 12 months had a VAS score 63% success and Roles and Maudsley scoring of 93% success.
There were 17 active, 19 sham, 11 crossover mild transient complications seen. These included ecchymosis, edema, hypesthesia, paresthesia, petechiae, rash, neuralgia, injections site hemorrhage, nonpalpable pulse (sham treatment), and infection. These all resolved within a few days post-treatment. There was 1 permanent minor complication of paresthesia. No

Result number: 145

Message Number 129674

Brian maybe you were correct in your thinking View Thread
Posted by Pauline on 9/11/03 at 22:18

Enough studies to keep your head spinning. Here is another one. Was this one posted before?

Copyright © 2003, BMJ Publishing Group Ltd.
BMJ. 2003 July 12; 327 (7406): 75


Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial
Michael Haake, associate assistant professor,1 Mathias Buch, assistant medical director,2 Carsten Schoellner, senior resident,3 Felix Goebel, senior resident,4 Martin Vogel, senior resident,5 Ingo Mueller, senior resident,6 Jörg Hausdorf, senior registrar,7 Karin Zamzow, data manager,8 Carmen Schade-Brittinger, head of coordinating centre for clinical trials,9 Hans-Helge Mueller, senior biostatistician10


1 Orthopädische Klinik, Universität Regensburg, 93077 Bad Abbach, Germany 2 Orthopädische Klinik Kassel, 43131 Kassel, Germany 3 Orthopädische Klinik, Johannes Gutenberg Universität Mainz, 55131 Mainz, Germany 4 Klinik für Orthopädie, Martin Luther Universität Halle, 06097 Halle, Germany 5 Rehbergklinik St Andreasberg, 37444 St Andreasberg, Germany 6 Orthopädische Klinik, Christian-Albrechts-Universität Kiel, 24105 Kiel, Germany 7 Orthopädische Klinik, Ludwig Maximilians Universität München, 81377 München, Germany 8 Medizinische Biometrie und Epidemiologie, Philipps-Universität Marburg, 35033 Marburg, Germany 9 Koordinierungszentrum Klinische Studien, Philipps-Universität Marburg 10 Medizinische Biometrie und Epidemiologie, Philipps-Universität Marburg


Correspondence to: M Haake m.haake@rheumaortho-zentrum.de


Accepted April 15, 2003.

Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
Abstract

Objective To determine the effectiveness of extracorporeal shock wave therapy compared with placebo in the treatment of chronic plantar fasciitis.

Design Randomised, blinded, multicentre trial with parallel group design.

Setting Nine hospitals and one outpatient clinic in Germany.

Participants 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo.

Main outcome measures Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention.

Results The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group (95% confidence interval - 8.0% to 15.1%). No difference was found in the secondary end points. Few side effects were reported.

Conclusions Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis.



Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
Introduction

Plantar fasciitis is a common cause of heel pain, affecting 10% of the general population.1 It may be due to injury at the origin of the plantar fascia or to biomechanical abnormalities of the foot.2 3 A heel spur may be present, but has also been reported in up to 27% of patients without symptoms.1

Standard treatment for plantar fasciitis is conservative, but about 10% of patients fail to respond.4 Surgery is recommended eventually, but is unsuccessful in 2% to 35% of patients.5 For both conservative and surgical methods there is only limited evidence for a short term reduction of pain from local treatment with corticosteroids.6

Extracorporeal shock wave therapy is well established for the treatment of urolithiasis.7 It was introduced in the early 1990s for the treatment of insertion tendinopathies.8 Extracorporeal shock wave therapy for orthopaedic diseases is thought to provide long lasting analgesia and stimulate the healing process. It has been recommended as treatment for chronic plantar fasciitis in patients unresponsive to conservative treatment.9–13 Two shock wave devices are currently approved by the Food and Drug Administration.12 13

The efficacy of extracorporeal shock wave therapy in plantar fasciitis cannot be ascertained owing to the poor quality of methods in previous studies.14 We aimed to determine its effectiveness in chronic plantar fasciitis.



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Abstract
Introduction
Materials and methods
Results
Discussion
References
Materials and methods

Our study was a randomised, blinded, multicentre trial with a two sample parallel group design. Central randomisation and independent monitoring was conducted according to the Committee for Proprietary Medicinal Products and International Conference on Harmonisation guidelines for good clinical practice and statistical principles in clinical trials.

Patients were recruited in seven university hospitals, two clinics, and one practice in Germany (see bmj.com for inclusion and exclusion criteria). In cases where the clinical diagnosis was uncertain, the centres were advised to perform additional diagnostic tests, such as electromyography. Signed informed consent was obtained from all patients before randomisation.

Patients were randomised to receive either extracorporeal shock wave therapy (135 patients) or placebo (137 patients). The study doctor was told by telephone what treatment had been allocated to his or her patient when the patient turned up for the first intervention. Random permuted blocks of sizes six and four were used to provide each centre with a separate computer generated list of random treatment assignments.

Intervention
Extracorporeal shock wave therapy was provided by a Dornier Epos Ultra lithotripter (Dornier Medizintechnik, Wessling, Germany) equipped with an outline 7.5 MHz linear array ultrasound positioning system. Before recruitment of patients, the study doctors were given training in the diagnosis of plantar fasciitis and treatment with extracorporeal shock wave therapy or placebo.

Extracorporeal shock wave therapy comprised 4000 impulses of a positive energy flux density (0.08 mJ/mm2) under local anaesthesia with 2 ml mepi-vacaine 1%. Therapy was applied every two weeks plus or minus two days (3 × 4000 impulses). The head of the lithotripter was docked medially to the heel, and the ultrasound transducer from plantar to the insertion of the fascia. A cross hair on the monitor of the ultrasound guidance system constantly indicated the focus of the shock wave at the heel spur at the insertion of the fascia. The parameter positive energy flux density (ED+) is generally assumed to be the primary variable for physical and biological effects, and it was chosen to assure uniform treatment.15 The total positive dose was 0.96 J/mm2, the energy flux density was 0.22 mJ/mm2, and the positive pressure was 13.7 MPa. The appropriate execution of the intervention was controlled for each centre.

Patients in the control group received the same regimen of placebo therapy under local anaesthesia. A polyethylene foil filled with air was fixed with ultrasound gel in front of the coupling cushion to reflect the shock waves. The set up in both groups was identical, and the sound created by the lithotripters was similar.

Blinding
Patients were blinded to their particular treatment allocation, and only the caregiver performing the intervention knew the treatment. Study doctors were not informed until assessment of the primary end point. The caregiver was not involved in follow up and was not allowed to decide about further treatment.

The clinical outcome was assessed by observers blinded to treatment allocation. The extent to which patients' remained blinded was assessed after the last intervention. Unblinding was possible after the assessment of the primary end point and only if the patient required further therapy.

End points and side effects
Follow up examinations were carried out at six and 12 weeks and at one year after the last intervention. The primary end point was the success rate after 12 weeks; success was defined by a Roles and Maudsley score of 1 or 2 and if the patient received no additional treatment. Additional treatment was allowed after assessment of the primary end point, and the amount was recorded. The modified Roles and Maudsley score is a patient administered scoring system (see table A on bmj.com).16 We used the German version, which is clinically relevant in plantar fasciitis and has been applied in major studies on extracorporeal shock wave therapy.9 10

Secondary end points encompassed the Roles and Maudsley score and pain intensities (pain at rest, pain at night, pain at pressure, morning pain) on visual numeric rating scales (0 for no pain to 10 for unbearable pain), walking ability, and the need for additional treatments for one year after the last intervention. Side effects were noted.

Statistics
We carried out a two sided Fisher's exact test to compare the success rates at an overall significance level of 5%. Patients were included according to the intention to treat principle. Absolute differences were calculated for the success rates, odds ratios, and exact 95% confidence intervals. In addition we performed a stratified analysis by centre for verification of robustness of results. The secondary end points were analysed descriptively. An interim analysis was performed at α=0.005 after examination of half the patients. The final analysis was performed at α=0.048. The sample size of 272 patients was calculated with the aim of detecting a minimal clinically relevant difference of 20% in the success rates (placebo: 35%; extracorporeal shock wave therapy: 55%) with a power of 80%, allowing for a dropout rate of 20%. Analyses were conducted with the validated programs SAS 8.2 and StatXact 5.0.



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Abstract
Introduction
Materials and methods
Results
Discussion
References
Results

Overall, 272 patients were randomised between March 1999 and February 2001 (figure). Personal characteristics were similar in both groups (table 1).

The required number of pulses and energy level for treatment was reached in all cases. Three patients in the placebo group accidentally received three sessions of extracorporeal shock wave therapy, and one patient in the therapy group received placebo. In the therapy group, one patient received no treatment because of a dorsal heel spur, one patient turned up for the first session only, and one patient missed the last session. One patient in the placebo group received no further intervention after the first session because of a deep vein thrombosis.

Blinding of the patients was successful: 95 (74%) patients in the therapy group and 89 (69%) patients in the placebo group thought they had been treated with extracorporeal shock wave therapy, the difference being less than 6%.

End points
The primary end point could be assessed in 94% of the patients (table 2). The difference in success rates was 3.6% (- 8.0% to 15.1%; P=0.5927) and the odds ratio was 1.18 (0.675 to 2.07). Despite two centres recruiting only nine and seven patients, none of the observed differences reached the minimal clinically relevant difference of 20%. The odds ratio remained robust when data were stratified by centre (1.20, 0.674 to 2.13).

At the one year follow up, 91 of 113 (81%) patients in the therapy group and 87 of 115 (76%) in the placebo group had a Roles and Maudsley score of 1 or 2 (table 3). Additional treatment was sought by 41 (36%) patients in the therapy group and 64 (56%) patients in the placebo group. The number of conservative treatments was comparable between the groups except for the use of extracorporeal shock wave therapy (13 (12%) patients in therapy group, 44 (38%) patients in placebo group). One in each group had undergone surgery (see table B on bmj.com).

Side effects
Few side effects occurred during and after the treatment. More side effects were reported by the therapy group than by the placebo group (24 (18%) v 12 (9%)). Side effects were skin reddening (16 (12%) in therapy group; 5 (4%) in placebo group), pain (7 (5%) in therapy group; 2 (2%) in placebo group), and local swelling (3 (2%) in therapy group; 0 (0%) in placebo group). Less often reported were haematoma, nausea, dizziness, hair loss, and sleep disturbance. These were valued as non-serious effects, which in no case resulted in discontinuation of treatment. We expected a higher risk for side effects in the therapy group than in the placebo group (odds ratio 2.26, 1.02 to 5.18). We considered the case of deep vein thrombosis in the placebo group as not related to the treatment.



Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
Discussion

We found no meaningful improvement of clinical outcome in patients treated with extracorporeal shock wave therapy for chronic plantar fasciitis compared with placebo, unlike previous studies. Although the success rates in patients with excellent or good results for the Roles and Maudsley score three months (45.7%) and one year (80.5%) after intervention were comparable to former trials, similar results could be achieved with placebo.10 12 17

About three quarters of the patients in both groups had a good outcome one year after intervention. Reasons for the observed improvement could have been a spontaneous remission of plantar fasciitis, additional conservative treatment, or a sustained placebo effect. Despite this, we found no evidence of additional benefits from extracorporeal shock wave therapy.

Most of the newly reported trials on extracorporeal shock wave therapy for plantar fasciitis that were not included in a former systematic review14 also show deficiencies in the quality of the methods (for example, lack of a control group,18 19 small sample size,18 20 unblinded design17 20 21). Therefore these trials only provide limited evidence for the effectiveness of extracorporeal shock wave therapy.

We are aware of only three published randomised, blinded, placebo controlled trials. Two of them show benefits from extracorporeal shock wave therapy for plantar fasciitis.12 13 However, the absolute difference of 17% in the first trial was not statistically significant and would not have met our definition of a clinically relevant result.12 The authors did not, however, report the method of randomisation. Different types of anaesthesia were used (foot block for extracorporeal shock wave therapy versus subcutaneous injection for placebo). Problems in the analysis and presentation of the data of this study have been published.22 These factors may have influenced the results.

One study reported the alleviation of pain in the morning,13 but according to the Roles and Maudsely score, the American Orthopaedic Foot and Ankle Society score, and pain scores, the findings were negative and comparable to our results. We do not believe that the only positive variable in that trial is a clinically relevant finding.

The negative findings of our study support the conclusion of the recently published third trial, although the treatment protocols of the studies differ slightly (mean total dose 1.4 J/mm2).23 In contrast to our study the authors applied a minimal shock wave dose without anaesthesia (3 × 100 impulses; 0.02 mJ/mm2) instead of a sham therapy in the control group. This may have minimised a clinically relevant effect between both treatment groups.

Our results are only valid for therapeutic variables applied. This might not be a limitation, as the variables we tested reflect the true setting of extracorporeal shock wave therapy. The total energy of shock waves was higher in our trial than in most of the previous studies.9 10 17 Despite this, the use of different treatment variables might lead to different overall results, but the evidence for this could only be obtained from clinical trials with adequate study designs. We cannot recommend specific applications of extracorporeal shock wave therapy to be tested in further clinical studies because all major trials, using different shockwave variables and types of lithotripters, showed negative results.



What is already known on this topic

Observational trials recommend extracorporeal shock wave therapy as treatment for recalcitrant chronic plantar fasciitis

No evidence exists of its efficacy from well designed randomised clinical trials

What this study adds

Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis

No clinically relevant difference was found in success rates between therapy and placebo after 12 weeks and a year

Three quarters of patients improved 12 months after intervention, irrespective of treatment






Footnotes

Tables and criteria for inclusion or exclusion of patients appear on bmj.com

We thank I R König, H Wolf, C Wöhner, O Maier-Boerries, and C Riemert who helped with the conduct of the trial or recruited patients, our colleagues in the participating centres without whom this study could not have been carried out, and the participants.

Contributors: MH was the principal investigator and will act as guarantor for the paper. MB, MH, and HHM designed the study. HHM was the biostatistician. CSB coordinated the study. HHM and KZ analysed the data. MH, HHM, CSB, and KZ prepared and finalised the paper. All authors interpreted the results, commented on the first draft, and approved the final version.

Funding: This trial was supported by the Deutsche Forschungsgemeinschaft (grant No 1079/2-1), the German Association for Orthopaedics and Orthopaedic Surgery, and the Association for Promoting Science and Research at the Rehberg Clinic, Germany. Dornier Medizintechnik Germany provided us with the shock wave equipment. They had no involvement in, or control over, the conduct of the study or the content of this paper.

Competing interests: None declared.

Ethical approval: The study protocol was approved by the local ethics committees of the principal investigator (approval No 83/98) and the participating centres.



Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
References

De Maio M, Paine R, Mangine RE, Drez D. Plantar fasciitis. Orthopedics 1993;16: 1153-63. [PubMed]

Kuhns JC. Changes in elastic adipose tissue. J Bone Joint Surg (Am) 1949;31: 541-8.

Gill LH. Plantar fasciitis: diagnosis and conservative management. J Am Acad Orthop Surg 1997;5: 109-17. [PubMed]

Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of non-operative treatment. Foot Ankle Int 1994;15: 531-5. [PubMed]

Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. Etiology, treatment, surgical results, and review of the literature. Clin Orthop 1991;266: 185-96. [PubMed]

Crawford F, Atkins D, Edwards J. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2000;3: CD000416.

Chaussy C, Eisenberger F, Wanner K. The use of shock waves for the destruction of renal calculi without direct contact. Urol Res 1976;181: 352-7.

Dahmen GP, Meiss L, Nam VC, Skruodies B. Extrakorporale Stosswellentherapie (ESWT) im knochennahen Weichteilbereich an der Schulter. Extracta Orthopaedica 1992;11: 25-7.

Rompe JD, Hopf C, Nafe B, Bürger R. Low-energy extracorporeal shock wave therapy for painful heel: a prospective controlled single-blind study. Arch Orthop Trauma Surg 1996;115: 75-9. [PubMed]

Rompe JD, Küllmer K, Riehle MH, Herbsthofer B, Eckardt A, Bürger R, et al. Effectiveness of low energy extracorporeal shock waves for chronic plantar fasciitis. Foot Ankle Surg 1996;2: 215-21.

Krischek O, Rompe JD, Herbsthofer B, Nafe B. Symptomatic low-energy shockwave therapy in heel pain and radiologically detected plantar heel spur. Z Orthop Ihre Grenzgeb 1998;136: 169-74. [PubMed]

Ogden JA, Alvarez R, Levitt R, Cross GL, Marlow M. Shock wave therapy for chronic proximal plantar fasciitis. Clin Orthop 2001;387: 47-59. [PubMed][Full Text]

Buch M, Knorr U, Fleming L, Theodore G, Amendola A, Bachmann C, et al. Extracorporeal shock wave therapy in plantar fasciitis: a review. Orthopäde 2002;31: 637-44.

Böddeker IR, Schäfer H, Haake M. Extracorporeal shock-wave therapy (ESWT) in the treatment of plantar fasciitis—a biometrical review. Clin Rheumatol 2001;20: 324-30. [PubMed][Full Text]

Granz B, Kohler G. What makes a shock wave efficient in lithotripsy? J Stone Dis 1992;4: 123-8. [PubMed]

Roles NC, Maudsley RH. Radial tunnel syndrome: resistant tennis elbow as a nerve entrapment. J Bone Joint Surg [Br] 1972;54: 499-508.

Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg [Am] 2002;84: 335-41.

Alvarez R. Preliminary results on the safety and efficacy of the OssaTron for treatment of plantar fasciitis. Foot Ankle Int 2002;23: 197-203. [PubMed]

Wang CJ, Chen HS, Chen WS, Chen LM. Treatment of painful heels using extracorporeal shock wave. J Formos Med Assoc 2000;99: 580-3. [PubMed]

Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R. Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. Foot Ankle Int 2002;23: 309-13. [PubMed]

Weil LS Jr, Roukis TS, Weil LS, Borrelli AH. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy. J Foot Ankle Surg 2002;41: 166-72. [PubMed]

Beckman KD, Letter to the editor. Clin Orthop 2002;398: 267-8. [PubMed][Full Text]

Buchbinder R, Ptasznik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA 2002;288: 1364-72. [PubMed][Full Text]




Figures and Tables



Figure 1. Flow of patients through trial


Table 1. Characteristics of patients randomised to receive either extracorporeal shock wave therapy or placebo for chronic plantar fasciitis. Values are numbers (percentages) of patients unless stated otherwise


Table 2. Success rate of treatment for chronic plantar fasciitis six and 12 weeks and one year after extracorporeal shock wave therapy or placebo. Values are numbers (percentages) of patients unless stated otherwise


Table 3. Intensity of pain from chronic plantar fasciitis six and 12 weeks and one year after extracorporeal shock wave therapy or placebo

Result number: 146

Message Number 129664

Cure/no cure???? View Thread
Posted by Pauline on 9/11/03 at 21:41

What does all this mean and where to the Roles and Maudsley percentages come from???? No one seems to agree on the figures or the cure. I guess you just pick the numbers that meet your needs. Doctors pick one set/ insurance companies use another.

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications

Assessment Program
Volume 18, No. 5
August 2003

Executive Summary
This Assessment evaluates whether extracorporeal shock wave treatment (ESWT) improves health outcomes for patients with musculoskeletal conditions that are unresponsive to conservative treatment.

Chronic musculoskeletal conditions include a wide range of inflammatory and degenerative conditions of the musculoskeletal system. These disorders sometimes respond poorly to conservative treatments such as rest, medications, physical therapy, and/or corticosteroid injections. Surgery is an option, but involves recovery time and possible morbidity. ESWT may be an alternative for musculoskeletal conditions that are not responsive to conservative measures.

ESWT delivers shock waves via a device that is similar to that used for renal lithotripsy. The mechanism of action of ESWT for musculoskeletal conditions is not well understood. The shock waves generated by ESWT may disrupt calcific deposits, increase the diffusion of cytokines across vessel walls, stimulate angiogenesis, and/or promote new bone formation. One or more of these mechanisms may operate to aid in the healing process.

ESWT can theoretically be applied to a large number of musculoskeletal conditions. A broad literature search was performed to capture all potential indications. Published prospective trials comparing ESWT to placebo or an alternative treatment were selected for inclusion in this review of evidence. Studies meeting the selection criteria have been published for only 3 indications: plantar fasciitis (with or without a heel spur), tendinitis of the shoulder, and tendinitis of the elbow.

The main outcomes evaluated in the treatment of chronic musculoskeletal conditions are improvements in pain and function (e.g., activity). These outcomes are influenced by nonspecific effects (e.g., placebo response, natural history, regression to the mean). Pain and functional outcomes should be evaluated in randomized, controlled trials that maintain adequate blinding of treatment assignment. The purpose of blinding is to prevent knowledge of which treatment is given from influencing the assessment of the success of the treatment. The gold standard is double-blinding, which means that
neither the patient nor the physician examining the patient knows which treatment was given.

This Assessment updates the December 2001 TEC Assessment, which concluded that ESWT met the TEC criteria for treatment of chronic plantar fasciitis. At that time, the published evidence consisted of 3 randomized, controlled trials, only 1 of which was double-blinded. There are now 2 additional randomized, double-blind trials, one of which found that ESWT was no more effective than placebo for plantar fasciitis.1 The purpose of this Assessment is to reassess the evidence on ESWT for plantar fasciitis and to update the evidence on ESWT for other musculoskeletal indications.

Based on the available evidence, the Blue Cross and Blue Shield Medical Advisory Panel made the following judgments about whether ESWT meets the Blue Cross and Blue Shield Association Technology Evaluation Center (TEC) criteria for musculoskeletal indications.

1. The technology must have final approval from the appropriate governmental
regulatory bodies.

There are currently 3 ESWT devices approved by the U.S. Food and Drug Administration (FDA). The Ossatron® device (HealthTronics, Marietta, GA.), an electrohydraulic delivery system, was approved by the FDA on July 20, 2000, for patients with chronic proximal plantar fasciitis that has failed to respond to conservative management. The Epos™ Ultra (Dornier, Germering, Germany), an electromagnetic delivery system, was approved on January 15, 2002, for similar indications. The SONOCUR® Basic (Siemens, Erlangen, Germany) also uses an electromagnetic delivery system and was approved for tendinitis of the elbow (lateral epicondylitis) on July 19, 2002.

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.

Plantar Fasciitis. The scientific evidence does not permit conclusions concerning the effect of the technology on health outcomes of plantar fasciitis. The literature on ESWT for plantar fasciitis is the most robust body of evidence of any of the indications considered in this Assessment. There are 3 randomized double-blind, placebo-controlled trials that together include over 600 patients. Two of these trials (HealthTronics, Dornier) report a statistically significant improvement in pain measures, but the improvement is small and not generally accompanied by improvement in activity or use of pain medication. The third trial (Buchbinder) reported that ESWT was no better than placebo.

Overall, the results of the trials are inconclusive. If ESWT provided a clinically significant
improvement in plantar fasciitis, one would expect consistent improvement across multiple ways of measuring pain and function (e.g., morning pain, use of pain medications, ability to walk without pain). But the results of various measures within studies and across studies do not give a consistent picture.

The HealthTronics trial (n=293) found improvement in pain on first walking in the morning as reported by the patient. There was also improvement in the investigator assessment of pain caused by applying pressure to the heel. But there was no difference between ESWT and placebo in the patients’ self-assessment of the distance and time they were able to walk without heel pain. There was also no difference between ESWT and placebo in the proportion of patients who reported talking no pain medication.
The Dornier trial (n=150) reported that ESWT improved the mean pain on first walking compared to placebo; however, there was no difference in proportion of patients achieving at least a 60% improvement in pain. The difference between ESWT and placebo was statistically significant on the Roles and Maudsley Scale, but not on the AOFAS Ankle-Hindfoot Score or SF-12 health status questionnaire.
The Buchbinder trial (n=166) found no difference between ESWT and placebo in any outcome measure: self-reported pain (overall pain, morning pain, pain with activity); self-reported walking time; Maryland Foot Score; Problem Elicitation Technique; SF-36 health status questionnaire.
Because the above conclusion is a reversal of the 2001 TEC Assessment on ESWT for plantar fasciitis, the evidence bases for the 2001 and 2003 Assessments are compared in the following paragraphs.

2001 Evidence Base

The evidence for the 2001 TEC Assessment consisted of the HealthTronics trial and 2 smaller randomized, controlled trials that were single-blinded (n=96). Median duration of plantar fasciitis was 18 months in the HealthTronics trial and 8.4 and 9 months in the smaller trials. The HealthTronics trial used high-energy shock waves given in one session, while the 2 smaller studies used lower-energy shock waves given in multiple sessions.

The main outcome reported in the HealthTronics trial was a composite measure derived from 4 individual pain and activity scales measured at 12 weeks’ follow-up. Treatment success was defined as meeting all 4 of these criteria: 1) improvement in investigator assessment of pain caused by applying pressure to the heel; 2) improvement in pain on first walking in the morning as reported by the patient; 3) improvement in the patients’ self-assessment of the distance and time they were able to walk without heel pain; and 4) no pain medication for the past 2 weeks.

This composite measure was difficult to interpret because the difference between ESWT and placebo was statistically significant even though 2 of the 4 component measures were not. However, the result of the composite measure was accepted for two reasons. First, HealthTronics explained that the measure had been defined a priori and was intended as a conservative measure. This allayed concerns that the composite measure might have been chosen after the investigators knew that half the outcome measures were not statistically significant. Second, the 2 smaller trials reported results of various pain and activity measures that were highly statistically significant. Although single-blind trials are known to somewhat overestimate outcome compared to double-blind trials, the results of the 2 smaller trials appeared to substantiate that ESWT resulted in clinically significant improvements in patients who have chronic plantar fasciitis.

2003 Evidence Base

Two additional randomized double-blind trials (Dornier, Buchbinder) are now available. Although all 5 trials used a placebo control, there was a remarkable difference in percent improvement reported for the control arm in the 3 double-blind trials compared to the 2 single-blinded trials: 34–46% vs. 0 and 4%. The nonspecific or placebo effect is so large that single-blind trials cannot be considered reliable for assessing this technology. Moreover, it was difficult to compare results among the double-blind trials using the composite measure reported in the HealthTronics trial, so the component measures were analyzed separately.

As in the HealthTronics trial, the Dornier trial (n=150) used high-energy shock waves delivered in a single session. The study population had plantar fasciitis for a median duration of 15 months. In contrast, the Buchbinder trial (n=166) used low-energy shock waves delivered in several sessions in a population with median duration of plantar fasciitis of 8.8 months.

It has been suggested that the Buchbinder trial is flawed because it used low-dose shock wave therapy and that its inclusion in the present Assessment is not consistent. However, the proposition that low-dose therapy is ineffective is a hypothesis. There are no controlled clinical trials that test the relative efficacy of various techniques for shock wave dosage and delivery. A second objection is that the Buchbinder trial was not adequately blinded because anesthetic was not used during the procedure. However, inadequate blinding would favor the ESWT group, as is shown by the single-blind trials. In any event, the researchers evaluated the quality of blinding and showed that it was adequate. A third objection is that the trial did not select a population with chronic plantar fasciitis, as the minimum duration for entry was 6 weeks. However, the patients actually enrolled in a trial had a median duration of 8.8 months. Whether this trial represents a
different population from that in HealthTronics or Dornier is a hypothesis that has not been tested in a controlled trial.

Finally, the 2 single-blinded trials also used low-dose, multi-session therapy and have a population with a similar median duration of plantar fasciitis as in the Buchbinder trial. In the 2001 Assessment, these trials were viewed as substantiating the pain and functional outcomes reported in the largest trial. Thus, the 2001 and 2003 TEC Assessments are consistent in utilizing data on both high-energy and low-energy ESWT.

In summary, the available evidence consists largely of good quality studies; there are 3 doubleblind, randomized controlled trials that included over 600 patients. Overall, the results of the trials are inconclusive. If ESWT provided a clinically significant improvement in plantar fasciitis, one would expect consistent improvement across multiple ways of measuring pain and function (e.g., morning pain, use of pain medications, ability to walk without pain). However, the results of various measures within studies and across studies do not give a consistent picture concerning the effect of ESWT on health outcomes for plantar fasciitis.

Other Indications

Tendinitis of the Shoulder. There is not sufficient evidence to permit conclusions on whether ESWT improves outcomes for patients with tendinitis of the shoulder. The highest quality evidence, 2 randomized, placebo-controlled (n=114 total) trials including one that was doubleblinded found no significant differences between treatment and control groups. Outcomes measured were shoulder pain and disability index, Constant and Murley score for functional assessment of the shoulder, pain at rest and pain with activity.

Two other studies (n=159 total) were nonrandomized and uncontrolled, including one that compared ESWT with surgery. These studies reported significant results favoring ESWT, but represent a poor quality of trial design.

Tendinitis of the Elbow. There are 2 trials that evaluated ESWT for tendinitis of the elbow. Both were randomized, double-blind, placebo-controlled trials. The first (n=114) reported statistically significant improvement in pain on resisted extension and the upper extremity function score. The second (n=75) reported no group differences on elbow pain during the day or at night. This study appeared to have some group differences at baseline, although none was reported as statistically significant. Thus, the existing evidence from randomized, controlled trials does not permit conclusions on the effect of ESWT for tendinitis of the elbow.

3. The technology must improve the net health outcome.

The evidence is not sufficient to permit conclusions on the health outcome effects of ESWT for any of the musculoskeletal indications evaluated; therefore it is not possible to conclude whether overall health outcomes are improved.

4. The technology must be as beneficial as any established alternatives.

The evidence is not sufficient to permit conclusions on the health outcome effects of ESWT for any of the musculoskeletal indications evaluated; therefore, it is not possible to conclude whether the technology is as beneficial as alternatives.

5. The improvement must be attainable outside the investigational settings.

Whether extracorporeal shock wave treatment for musculoskeletal indications improves health outcomes has not been demonstrated in the investigational setting.

Therefore, based on the above, extracorporeal shock wave treatment for musculoskeletal
indications does not meet the TEC criteria.

1. As this Assessment went to press, an additional randomized, double-blind trial was published; however, this publication does not affect the Assessment conclusions.



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Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications

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Result number: 147

Message Number 127624

Re: Another RCT - Dr. Rompe....your comments? View Thread
Posted by Jan D. Rompe on 8/22/03 at 03:05

Sir:

I read with interest the article in the Journal of Orthopaedic Research entitled “Extracorporeal shock wave therapy for plantar fasciitis – a double blind randomised controlled trial” by C.A. Speed et al.(1)

I congratulate them for the well-conducted randomised controlled trial, the negative results of which contrast with our and others recently published experience (2,6) and confirm data of the Australian multi-center study (3) and of the German multi-center study.(4)

All four randomised controlled trials (2,3,4,6) were not included in the discussion of their article.

In the trial from our department (2) forty-five running athletes with intractable plantar heel pain were enrolled in a randomized single-blind trial with a parallel-group design and blinded independent observer, to evaluate the efficacy of three applications of 2000 impulses of low-energy shock waves (Group I) compared with sham treatment (Group II). Followup examinations were done at six months, and at one year after extracorporeal shock wave application. Symptoms had been present from one year to six years. The primary efficacy endpoint was reduction of subjects´s self-assessment of pain on first walking in the morning on a visual analog scale (range, 0 - 10 points) at six months after shock wave application. After six months self-assessment of pain on first walking in the morning as primary efficacy endpoint showed a significant reduction from an average 6.9 to 2.1 points in Group I, and from an average 7.0 to 4.7 points in Group II on the visual analog scale. The mean difference between both groups was 2.6 points. After twelve months pain on first walking in the morning showed a further reduction in both groups, to an average 1.5 points in Group I, and to 4.4 points in Group II . In conclusion, this study showed that three treatments with 2100 impulses of low-energy shock waves were a safe and effective non-surgical method for treating chronic plantar fasciitis in long-distance runners after a followup of six months.


This study sharply contrasted with the Australian multi-center trial published by Buchbinder et al. in JAMA 2002.(3) They enclosed 166 patients in a double-blind, randomized, placebo-controlled trial. Patients were randomly assigned to receive either ultrasound-guided ESWT given weekls for 3 weeks to a total dose of at least 1J/mm² or identical placebo to a total dose of 0.006 /mm². After significant improvements in both groups, the between- group difference of improvement was only 0.6 on a 100 mm visual analog scale. There was no evidence of ESWT over placebo. The study of Buchbinder was of excellent quality but there were clear differences regarding our trial. First, patients in the active group did not receive identical treatment (either 2000 or 2500 shock waves per treatment of energy levels varying between 0.02 mJ/mm² and 0.33 mJ/mm²) contrary to the current study.4 Second, the mean dose in the active group was 1407 mJ/mm², 500mJ/mm² more than in the current study. In the experience of the author of the current study patients will not tolerate such a high dose unless the treatment area of maximal pain is missed. Accordingly, third, Buchbinder did not focus on the area of maximal pain like in the current study, but on the area of maximal thickness of the plantar fascia. Fourth, a potent analgetic drug was allowed for the duration of the study. Fifth, patients were enrolled with a pain history as short as 6 weeks, contrary to 12 months in the current study. Sixth, there was no real placebo group, but sham therapy consisted of application of 100 shock waves of 0.02 mJ/mm².


With regard to the German multicenter trial published by Haake et al.(4) in the BMJ the study design is excellent. It was a randomised, blinded, multicenter trial with parallel group design. 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months were enrolled: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo. Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention. The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group. No difference was found in the secondary end points. Few side effects were reported. In conclusion, extracorporeal shock wave therapy was ineffective in the treatment of chronic plantar fasciitis. However, Haakes´s treatment regimen is clearly different from the regimen applied in our trial2 regarding shock wave device, number of shock waves, energy flux density, technique of focussing, period between application, permission of additional pain medication, simultaneous application of local anesthesia.


A possible influence of simultaneous local anesthesia has been discussed particularly. Auersperg et al.(5) reported they had enrolled fifty-one patients with a chronic plantar fasciitis in a randomized controlled observer-blinded trial. Patients were randomly assigned to receive either active ESWT without local anesthesia, given daily for 3 days (Group I, n=25; 3 x 1500 pulses, total energy flux density 0.04 mJ/mm2) or identical ESWT with local anesthesia (Group II, n=26). Main outcome measures were: Pain during first step in the morning (measured on a 0-10 point visual analog scale), and no further therapy needed, measured at six weeks after the last ESWT. At six weeks, there was significant improvement in pain during first steps in the morning in both groups, by 4.4 points in Group I, and by 2.6 points in Group II. The mean between-group difference of improvement was statistically significant. In Group I 19/25 (76%) patients didn´t need any further therapy compared with 9/26 (35%) patients in Group II. In conclusion, at six weeks success rates after low-energy ESWT with local anesthesia were significantly lower than after identical low-energy ESWT without local anesthesia.


Buch et al.(6) presented results of a US-based prospective randomised placebo-controlled double-blind multicenter trial. 150 patients with persistent heel pain were enrolled. 76 patients received a single active treatment (3800 pulses, 0.36 mJ/mm², local anesthesia of the posterior tibial nerve), 74 received a single sham treatment. A reduction of heel pain at first step in the morning was observed in both groups at 3-month follow-up, by 4.4 points in the active group, and by 3.6 points in the placebo group. The between-group difference was significant. The Roles and Maudsley score also showed a significant difference between the groups, with 61.6% good or excellent results in the active group, and 39.7% in the placebo group. The data presented in this study led to FDA approval of the shock wave device in January 2002.


Now, Speed et al.(1) present another treatment concept. They performed a double blind randomised trial of moderate shock wave therapy in plantar fasciitis of at least 3-month duration. 88 patients either received active treatment (1500 pulses of 0.012 mJ/mm², given 3x in monthly intervals) or placebo treatment. At three months from baseline, that is at one month after completion of treatment, 37% of the subjects in the ESWT group, and 24% in the sham group showed a >50% improvement from baseline with respect of pain. In conclusion, there appeared to be no treatment effect of moderate dose ESWT. Clearly, Speed´s treatment regimen is different from the regimen applied in our trial2 regarding number of shock waves (3x 1500 vs. 3x 2000), energy flux density (0.12 mJ/mm² vs. 0.18 mJ/mm²), period between application (1 month vs. 1 week), and time of follow-up (1 month after completion of treatment vs. 6 months). The technique of focusing was similar to ours, and they did not use a local anesthesia.

Some questions remain to be answered by Dr. Speed and his co-authors:

1. 88 patients were in the study. Was it a pilot study? Was there any sample size calculation prior to starting the trial. If so, which data were the basis of this calculation? Or was selection of treatment parameters just empirical, with emphasis on a feasible regime?

2. The primary endpoint relied on assessment of heel pain during the day. It remains unclear how patients rate a pain over a 24-hour period. Concerning difference between groups: What was the statistical power of the analysis?

3. As I read there was no statistically significant difference between both groups concerning the visual analog pain scores one month after treatment. What was the statistical power of the analysis? Maybe the power was too small to detect a clinically relevant difference between the groups?


All authors made clear in the discussion of their papers (1,2,3,4,6) that "the results were only valid for the therapeutic variables applied". Therefore I fully agree with Dr. Speed that differences between different studies may be related to differences in study populations, heterogeneity of treatment parameters, different placebos and different machine designs.


So, many questions still remain to be answered by future prospective randomized controlled trials:

1. What roles do treatment intervals and follow-up periods play?

2. Has a local anesthetic an adverse effect on the clinical outcome after repetitive low-energy ESWT? What about performing the treatment under regional anesthesia?

3. Is there an adverse effect of additional pain medication on the clinical outcome after repetitive low-energy ESWT? If so, why and to which extent?

4. Is clinical outcome after repetitive low-energy ESWT comparable with results after high-energy ESWT performed under regional anesthesia?

5. What clinical results are observed when exactly repeating treatment protocols which have reportedly been successful?


All these issues warrant further research in order to develop evidence-based recommendations for the use of ESWT in musculoskeletal disorders. I strongly disagree with Haake (4) in whose opinion the diverging results of the existing RCTs justify a ban on further research. On the contrary, these diverging data are a magnificent basis for future trials according GCP and ICH criteria.


References
1.Speed CA, et al. Extracorporeal shock wave therapy for plantar fasciitis – a double blind randomised controlled trial. J Orthop Res 21:937-940, 2003
2.Rompe JD, et al. Shock wave application for chronic plantar fasciitis in running athletes – a prospective, randomized, placebo- controlled trial. Am J Sports Med 31:268-275, 2003
3.Buchbinder R, et al. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis. JAMA 288: 1364-1372, 2002
4.Haake M, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ 327:75-79, 2003
5.Auersperg V, et al. Influence of simultaneous local anesthesia on the outcome of repetitive low-energy shock wave therapy for chronic plantar fasciitis. Presentation at the 3rd Tri-National Meeting of the Austrian, Swiss, and German Societies for ESWT, Munich 2003
6.Buch M, et al. Extracorporeal shockwave therapy in symptomatic heel spurs. Orthopäde 31:637-644, 2002

Result number: 148

Message Number 125832

Re: Relief at last. Hope this message will help other people View Thread
Posted by DrMan on 7/31/03 at 22:27

Cynthia, I'm very glad you are still doing so well. Continue Stretching. Don't forget, tightness is a major factor in the cause of proximal plantar fasciitis (actually it's plantar fasciopathy, because there is minimal to no inflammation in chronic heel pain. The ESWT instigates an new inflammatory reaction, promoting healing and new elasticity of the fascia). Good Luck.

DrZ, Cynthia was in the FDA Double-Blinded Placebo Study with the Orthometrix ESWT Device. She obviously did receive the actual ESWT treatment and is now 7 1/2 months post treatment. She started out with a VAS pain scale index of 8.6 and completed the three months follow-up with a 1.1 index on the VAS pain scale. She still feels some tightness, yet no pain. I don't know if I could accept all those compliments, but, I'm sure you would agree that experience does matter. Those of us that have been doing ESWT for a long time could appreciate some of the finer details in the treatment process.
We are still recruiting patients into the FDA Study using this ESWT device. As you know this High-Energy Device is very successful with favorable results ranging 80-85%.

Result number: 149

Message Number 125543

ESWT Trials in NYC ending soon View Thread
Posted by Aly on 7/29/03 at 10:24


For those of you in the tri-state area, there are still clinical trials going on in NYC for ESWT that you may be able to join. Even if you weren't in the 50% who receive the actual ESWT treatment, at least you'd be part of the efforts to find a cure for PF.

I checked in with Dr. Mancuso, a podiatrist down in NYC who mentioned ESWT trials in a post back in Feb or March. I emailed him yesterday and received the follwing response:

*********************************************************************
We are still conducting an FDA approved clinical trial on a new office based version of a high energy Extracorporeal Shock Wave Therapy device. This study has been ongoing since August of 2002. This is a Double-Blinded Placebo Study, meaning, by entering the study you receive the treatment at no cost to you, however, you may or may not actually receive the ESWT treatment. You would have a 50% of receiving the actual ESWT treatment and a 50% chance of receiving the placebo (fake) treatment. You are Blinded (meaning you do not know which treatment you received) for 12 weeks. At the end point (12 weeks) you will be unblinded and be informed as to which treatment you actually received. Follow up visits to the office would be at 4 weeks, 8 weeks, and 12 weeks. This clinical study will be coming to an end soon, so if you are interested feel free to contact me. You can call my NYC office at (212) 759-9090.
*********************************************************************

I called an was able to set up an evaluation for next Thursday. Wish me luck!

Aly

Result number: 150

Message Number 124718

Re: to : Jan Rhompe Re: Is ESWT ineffective for plantar fasciitis? View Thread
Posted by David on 7/18/03 at 10:49

One should examine the differences in protocol and ask the question of Haake et al why Dr. Rompe's study, published earlier this year, shows positive results in the treatment of pf

Am J Sports Med. 2003 Mar-Apr;31(2):268-75. Related Articles, Links


Shock wave application for chronic plantar fasciitis in running athletes: a prospective, randomized, placebo-controlled trial.

Rompe JD, Decking J, Schoellner C, Nafe B.

Department of Orthopaedics, Johannes Gutenberg University School of Medicine, Mainz, Germany.

BACKGROUND: Recent articles have reported success with repeated low-energy shock wave application for treatment of chronic plantar fasciitis in runners. HYPOTHESIS: Shock wave treatment for chronic plantar fasciitis is safe and effective. STUDY DESIGN: Prospective, randomized, placebo-controlled trial. METHODS: Forty-five running athletes with intractable plantar heel pain for more than 12 months were enrolled; half were assigned to a treatment group that received three applications of 2100 impulses of low-energy shock waves, and half received sham treatment. Follow-up examinations were performed at 6 months and at 1 year by a blinded observer. RESULTS: After 6 months, self-assessment of pain on first walking in the morning was significantly reduced from an average of 6.9 to 2.1 points on a visual analog scale in the treatment group and from an average of 7.0 to 4.7 points in the sham group. The mean difference between groups was 2.6 points. After 12 months, there was a further reduction of pain in both groups, to an average 1.5 points in the treatment group, and to 4.4 points in the sham group. CONCLUSION: Three treatments with 2100 impulses of low-energy shock waves were a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

PMID: 12642264 [PubMed - in process]

Result number: 151

Message Number 124693

Is ESWT ineffective for plantar fasciitis? View Thread
Posted by Jan Rompe on 7/18/03 at 02:32

The full text of the following abstract is available at http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12855524

or at http://bmj.com/cgi/content/full/327/7406/75.


BMJ. 2003 Jul 12;327(7406):75.

Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial.

Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, Hausdorf J, Zamzow K, Schade-Brittinger C, Mueller HH.

Orthopadische Klinik, Universitat Regensburg, 93077 Bad Abbach, Germany. m.haake@rheumaortho-zentrum.de

OBJECTIVE: To determine the effectiveness of extracorporeal shock wave therapy compared with placebo in the treatment of chronic plantar fasciitis. DESIGN: Randomised, blinded, multicentre trial with parallel group design. SETTING: Nine hospitals and one outpatient clinic in Germany. PARTICIPANTS: 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo. MAIN OUTCOME MEASURES: Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention. RESULTS: The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group (95% confidence interval - 8.0% to 15.1%). No difference was found in the secondary end points. Few side effects were reported. CONCLUSIONS: Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis.

Result number: 152

Message Number 124033

Re: Aly...a note for your boss View Thread
Posted by michael j on 7/10/03 at 23:14

thank you very much fdor letting me thank you ivehad towork very hard on thisjob just to keep it.after working on this job 20 years kiking 2 200pound argon and other cylinders around all day its nice of you to just let me find out a little about my problem no one else will listen thankyouvery much.michael j

Result number: 153

Message Number 120919

ome light reading for you Elliot View Thread
Posted by Scott D. on 6/04/03 at 13:08


Part 3. ESWT for the Treatment of Lateral Epicondylitis
The etiologic origin on lateral epicondylitis includes injury, mechanical imbalance, aging, and
chemical, vascular, hormonal, and hereditary factors. Wang cites a Nirschl study of 1,213
patients with lateral epicondylitis, which found that 7.3% required surgery after failing
conservative therapy. (Wang 2002)
I. FDA Status
In July 2002, the FDA granted Pre-Market Approval to Siemens for its SONOCUR Basic device.
The device provides treatment for patients with symptoms of chronic lateral epicondylitis lasting
more than 6 months and unresponsive to conservative treatment. The low-energy, electromagnetic
Sonocur treatment does not require anesthesia and can be administered in an office
setting.
II. Evidence
The majority of the studies excluded subjects due to infection, pregnancy, arthritis, cardiac
arrhythmia, neurological abnormality, or malignancy.
A. Case Series Studies of ESWT on Lateral Epicondylitis
1. Maier examined in a prospective case series whether magnetic resonance imaging
(MRI) acted as a predictive parameter for clinical outcome. Patients with chronic
lateral tennis elbow underwent MRI before ESWT. A 100-point VAS measured
patient pain. Researchers compared data from the clinical exam before ESWT to data
gathered at average 19-month follow-up. (Maier 2001)
MRI determined the presence or absence of signal intensity changes or contrast
enhancement of the common extensor tendon.
The study used the Minilith SL1, Compact S, or the Epos Ultra to provide ESWT.
Subjects underwent 3 or 5 single treatment sessions at weekly intervals. They
received 2000 pulses with a frequency of 2 Hz for an EFD of .15 mJ/mm.
The Roles and Maudsley score categorized ESWT performance.
Grade 1: excellent – no pain, full movement and activity
Grade 2: good – occasional pain, full movement and activity
Grade 3: acceptable – some discomfort after prolonged activity
Grade 4: poor – pain limiting activity
Study Population: The study included 42 subjects with chronic lateral tennis elbow of
more than 6 months and unsuccessful conservative therapy. Patients were excluded if
they presented with radial tunnel syndrome, elbow instability, local bursitis, gout,
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 22
dysfunction of the ipsilateral shoulder joint, trauma, surgery, previous ESWT, metal
implants, or injections into the elbow within 12 weeks before ESWT.
Results: The mean VAS score for female patients significantly decreased from 68.9
to 34.1. The mean VAS score for male patients significantly decreased from 66 to
17.6. Researchers detected significant differences between post-treatment scores for
females compared to males.
Researchers also found a significant difference between female and male patients on
T1-CM and T2. T1-CM and T2 showed significant differences when examining
patients with Roles and Maudsley Scores of 1 or 2 compared to patients scoring 3 or
4. Researchers did not detect this difference in male subjects.
Using T2, the diagnosis area of increased signal intensity with tendon thickening of
common extensor tendon had a positive predictive value of .6, a sensitivity of 1, and
specificity of .42. using T1-CM, the diagnosis ‘area of increased signal intensity with
tendon thickening of common extensor tendon’ had a positive predictive value of
0.67, a sensitivity of 1.00, and a specificity of 0.5.
Principal findings: At 19-month follow-up, 52% of female and 84% of male patients
with lateral tennis elbow showed better clinical performance after ESWT than before
treatment.
Males and females differed in signal intensity of common extension tendon crosssection
and tendon thickening in T1 and T2 MRI scans of lateral tennis elbow. The
study suggests that T2 and T1-CM MRI may predict satisfactory clinical outcome of
ESWT for female patients.
2. Wang reported an update on a case series study examining the effect of ESWT on
lateral epicondylitis.4 (Wang 2002)
4 Ko published in 2001 the results of short-term results from the case series.
Number of Subjects and Average Assessment Scores at Follow-up
Before
Treatment
6-week 12-week 6 months
Number of Patients 53 47 35 25
Pain Score 16.7 25.3 30.1 34
Function Score 14.5 20.8 24.5 26.4
Elbow Motion Score 9.7 9.9 10 10
Total Score 41 64.4 77.6 87.8
Number (%) of patients rated as:
Excellent 1 (2%) 5 (13.2%) 8 (30.8%)
Good 16 (34.7%) 16 (44.7%) 10 (42.3%)
Number (%) of patients with 50% improvement 26 (53.1%) 23 (60.5%) 18 (73.1%)
Researchers found statistically significant improvement in function and pain when comparing 6 and 12-week results
as well as when comparing 6-week and 6-month results. However, the early period from 6 weeks to 3 months
showed a more dramatic magnitude of improvement. The researchers conclude that low-energy ESWT seems to be
effective for lateral epicondylitis of the elbow in selected patients. (Ko 2001)
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 23
The researchers evaluated patients using a 100-point system that designated 40 points
for pain, 30 points for function, 20 points for strength, and 10 points for range of
motion. A 10-point VAS measured pain intensity with 0 set as severe pain.
Researchers defined an excellent result as no pain, full motion and activity. Subjects
received good ratings if they experienced occasional soreness, good motion and
activity. The average length of follow-up for the group was 17.4 months
The OssaTron orthotriptor provided 1000 impulses of shockwaves at 14 kV (EFD
0.18 mJ/mm2).
Study Population: The study included subjects with lateral epicondylitis that did not
respond to at least 6 months of conservative treatment. All patients discontinued
other treatments, including non-steroidal anti-inflammatory drugs for 2 weeks before
treatment.
Researchers treated 58 elbows with refractory lateral epicondylitis in 57 patients.
Patient age averaged 46 years and the duration of their conditions averaged 11
months.
Nine subjects received a second treatment 30 to 60 days after their first treatment.
Results:
Evaluation Scores before and after Treatment in Patients Who Received
One or Two Shockwave Treatments
One Treatment Two Treatment
Before After Before After
Pain Score 15.6 36.8 21.4 37.3
Function Score 13.6 28.2 18.4 28.1
Strength Score 9.9 18.3 12.6 17.6
Elbow Motion Score 9.6 10.0 10.0 10.0
Total Score 39.9 93.0 50.0 90.0
Conclusion: The researchers conclude that low energy shockwave treatment seems to
be effective for lateral epicondylitis of the elbow in selected patients.
B. Randomized Controlled Trials of ESWT for Lateral Epicondylitis
1. Rompe conducted a randomized, controlled trial to examine the effect of ESWT on
chronic tennis elbow. Researchers used the Siemens Osteostar to administer 3
episodes of treatment at a frequency of 3 Hz. Subjects received treatment one time
per week for 20 to 30 minutes. (Rompe 1996)
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 24
The active treatment group received 1000 impulses at .08 mJ/mm2, and the control
group received 10 impulses at .08 mJ/mm2. Shockwaves were directed at the anterior
aspect of the lateral epicondyle and at 3 points around the site at a radius of 1.5 to 2
cm.
Researchers evaluated patient pain induced by palpating, resisting wrist extension,
resisting finger extension, and lifting a chair. A 100-point VAS determined the extent
of the pain, grip strength, and pain at night and at rest. Follow-up occurred at 3, 6,
and 24 weeks after treatment.
Study Population: Subjects were included in the study if they had pain in the lateral
epicondyle for more than 12 months. Subjects must have attempted and failed
conservative therapy in the previous 6 months. The study excluded subjects if they
experienced shoulder, neck, or thoracic dysfunction, radial nerve entrapment, or
reduced range of movement at the elbow. Researchers also prohibited subjects from
seeking treatment for the 6 weeks prior to or during ESWT.
The 50 subjects of the treatment group had an average age of 43.9 years and a mean
duration of pain of 24.8 months. The 50 placebo subjects had an average age of 41.9
years and a mean duration of pain of 21.9 months.
Results: The treatment group showed significant decreases in pain and increases in
grip strength compared to the placebo group at each follow-up.
Number of Subjects by Outcome at 24-week Follow-up
Active Treatment Group Placebo Group
Excellent and Good Results 24 3
Treatment Failure 5 35
2. Using the Storz Minilith, Crowther’s prospective, randomized study compared ESWT
to steroid injections for patients with tennis elbow. Subjects received 2000
shockwaves for a maximum EFD of 0.1 mJ/mm2. Follow-up occurred at 6 weeks
and 3 months. (Crowther 2002)
Study Population: Patients were included in the study if they had a history of tennis
elbow for longer than 4 months and had not undergone surgical intervention or
injection in the previous year. Subjects must also have experienced tenderness over
the lateral epicondyle of the humerus and reproducible pain with resisted finger and
wrist extension. Subjects were excluded if they experienced shoulder, neck, or
thoracic dysfunction, nerve entrapment, a clotting disorder, or anticoagulant therapy.
After 3 subjects withdrew, 48 subjects remained in the ESWT group. Of the 42
subjects randomized to receive injections, 17 refused resulting in 25 subjects in the
injection group. The mean age for all subjects was 49 years (range 27 to 69 years).
Results:
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 25
Average VAS scores by Therapy Group at Follow-up
Therapy Group Pre-Treatment 6 weeks 3 months
Injection Group 67 21 12
ESWT Group 61 35 31
Twenty-one subjects (84%) in the injection group had a reduction of pain of 50% or
more compared with 29 (60%) ESWT subjects.
At 3 months, 10 of the 19 ESWT failures and 2 of the 4 injection failures were
referred for surgical release.
Conclusion: The authors conclude that although injections and ESWT relieve
symptoms, steroid injections and local anesthetic more effectively treat lateral
epicondylitis compared to ESWT.
3. Speed conducted a double-blind randomized controlled trial examining the effect of
ESWT on lateral epicondylitis. (Speed 2002)
Subjects received either active ESWT with 1500 pulses at 0.18 mJ/mm2 or sham
treatment with the Siemens Sonocur device. The placebo group received 0.04
mJ/mm2, but the technician avoided the region of interest. Treatments were
administered at monthly intervals.
Researchers defined a positive response as 50% improvement from baseline at 3-
month follow-up.
Study Population: The researchers included subjects with lateral epicondylitis for at
least 3 months. Subjects had tenderness at the common extensor tendon insertions at
the lateral epicondyle and pain with resisted extension of the middle finger. The
study excluded patients due to anticoagulant therapy, treatment to the area in the
previous 6 weeks, or diabetes.
The 40 subjects in the active treatment group had an average age of 46.5 years and an
average duration of symptoms of 15.9 months. The 35 subjects in the placebo group
had an average age of 48.2 years and an average duration of symptoms of 12 months.
Results: At 3 months, 14 (35%) subjects of the active group and 12 (34%) placebo
subjects showed a positive response. No significant differences existed in the degree
of change in pain scores.
Average VAS Pain Scores by Treatment Group and Follow-up
Baseline One Month Two Months Three Months
ESWT 73.4 65.9 54.7 47.9
Placebo 67.2 61.1 54.3 51.5
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 26
Conclusion: The researchers state that a significant placebo effect occurs in subjects
with lateral epicondylitis after moderate doses of ESWT. They continue by stating
that “there is no evidence of added benefit of treatment when compared to sham
therapy.”
4. Haake studied the effect of ESWT or placebo on lateral epicondylitis in a doubleblind,
randomized, placebo-controlled study.5 (Haake 2002a)
Researchers used low-energy lithotripters to administer the shockwaves. Subjects in
the active therapy group received 3 sessions of low-energy ESWT. Researchers
applied 2000 pulses using an EFD between 0.07 and 0.09 mJ/mm2.
The primary end-point examined success rate at 12-week follow-up. A Roles and
Maudsley Pain Score of 1 or 2 defined success. In addition, a successful patient did
not receive additional treatment during follow-up.
Study Population: The study included patients with epicondylitis of the radial
humerus unresponsive to 6 months of conservative therapy. The subjects failed at
least three local injections, at least 10 individual treatments with physiotherapy, and
at least 10 individual treatments of physical therapy. Two weeks must have elapsed
since the last conservative therapy session. Subjects were excluded due to elbow
surgery, thrombopathy, anticoagulant therapy, or hyperthyroidosis.
The active ESWT treatment group included 135 subjects with an average age of 46.9
years. Their symptoms lasted an average of 27.6 months, and they attempted
conservative treatment for an average of 22.3 months. The placebo group included
137 subjects with an average age of 46.3 years. The placebo group’s symptoms
lasted an average of 22.8 months, and they attempted conservative treatment for an
average of 20.2 months.
Results: Researchers withdrew 11 subjects from the active group and 15 subjects
from the placebo group due to missing data.
Number of Subjects by Outcome and Treatment Group at 12-Week Follow-up
ESWT Placebo
Success 32 (25.8%) 31 (25.4%)
Failure
5 Haake used the same study to report the side effects and complications from ESWT or placebo in a separate
publication. The ESWT group had a higher likelihood of experiencing side effects compared to the placebo group
(OR = 4.3, CI = 2.9 - 6.3). The most frequently reported side effects included reddening of the skin, pain,
petecchiae, bleeding, and hematoma. Patients who underwent treatment with the Storz Minilith experienced
reddening of the skin more frequently than other devices. The Dornier products caused more swelling, petecchiae,
bleeding, and hematomas. Four patients experienced migraines after treatment with the Siemens Sonocur. (Haake
2002b)
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 27
Total
92 (74.2%) 91 (74.6%)
Due to additional treatment
10 (8.1%) 10 (8.2%)
Due to Roles and Maudsley score of 3 or 4 53 (42.7%) 44 (36.1%)
Due to additional treatment and Roles and
Maudsley score of 3 or 4
29 (23.4%) 37 (30.3%
Total 124 (100%) 122 (100%)
Conclusion: The authors conclude that ESWT in the study was ineffective in the
treatment of lateral epicondylitis. They do not recommend that ESWT be used to
treat patients with chronic lateral epicondylitis, except in controlled clinical trials.
C. Meta-Evaluations of ESWT for Lateral Epicondylitis.
1. Two independent reviewers assessed randomized and pseudo-randomized trials that
compared the use of ESWT as a treatment strategy for individuals with lateral elbow
pain. (Buchbinder 2002)
Buchbinder’s review included trials that did not conceal treatment or control group
allocation from the outcome assessor. A sensitivity analysis including and excluding
blinded trials was conducted to test the effect of inclusion of these trials. Studies in
all languages were translated into English and considered for inclusion in the review.
A sensitivity analysis including and excluding foreign language trials was conducted
to test the effect of inclusion of these trials.
The review included two trials that compared ESWT to placebo. The frequency of
ESWT application, dosage, and technique were similar in both studies. Both trials
also included similar adult study populations with chronic symptoms who had failed
conservative treatment.
Results: The first trial conducted by Rompe demonstrated highly significant
differences in favor of ESWT whereas the second trial conducted by Haake found no
benefits of ESWT over placebo.
After pooling the data from the two trials, the benefits observed in the first trial no
longer reached statistical significance. The relative risk for treatment failure (defined
as Roles-Maudsley score of 4) of ESWT over placebo was .40 at 6-weeks and .44 at
1-year. After 6 weeks, there was no statistically significant improvement in pain at
rest, pain with resisted wrist extension, or pain with resisted middle finger extension.
Results after 12 or 24 weeks were similar.
Conclusion: The authors state that they cannot draw definite conclusions about the
value of ESWT for chronic lateral elbow pain due to the small number of trials and
the trials’ conflicting results.
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 28
III. Costs
An orthopedic clinic in Seattle, WA intends to charge $900 per low-energy treatment session.
Each treatment requires use of a treatment room for one and a half hours including preparation
and clean-up.
Crowther reports that one course of ESWT costs about 300 pounds and the components of an
injection amount to 3 pounds. (Crowther 2002)
IV. Department Issues
In 2002, the Department of Labor and Industries accepted 2,494 claims under the International
Classification of Diseases code 726.32, lateral epicondylitis.
Top 18 Treatments for Lateral Epicondylitis Claims Paid by LNI, 2002
Number of
Paid Requests
CPT or HCPCS Code
Therapy
98 24356 fasciotomy, lateral or medial
198 20550 injection, tendon sheath, ligament
203 J8499 oral prescription drug, NOS
251 97112 neuromuscular reeducation of movement, balance, coordination…
328 73070, 73080 radiologic exam
335 97535, 97537 self-care/home management, community/work reintegration
353 20605 arthrocentesis, aspiration and/or injection, intermediate joint or bursa
354 97124 massage
408 97003, 97004 occupational therapy
427 97022 whirlpool
638 97001, 97002 physical therapy
682 L3700, L3999, L3908 upper limb, elbow, wrist orthosis
703
J2000, J3301, J1030,
J1040, J0702
injection (lidocaine, triamcinolone acetonide, methylprednisolone
acetate, methylprednisolone acetate, or betamethasone acetate and
betamethasone sodium phosphate)
1768
97530
therapeutic activities, use of dynamic activities to improve functional
performance
2975 97014, 27032 electrical stimulation
3772 97035 ultrasound stimulation
5668
97140
manual therapy techniques (mobilization, manipulation, manual
traction)
6481
97110
therapeutic procedures to develop strength and endurance, ROM,
flexibility
Part 3. ESWT for the Treatment of Lateral Epicondylitis
Page 29
References
Buchbinder, R, et al. “Shock Wave Therapy for Lateral Elbow Pain.” The Cochrane Library.
2002; Issue 4. Oxford: Updated Software.
Crowther, MAA, et al. “A Prospective, Randomised Study to Compare Extracorporeal Shock-
Wave Therapy and Injection of Steroid for the Treatment of Tennis Elbow.” J Bone Joint
Surg (Br). 2002 July; 84(B5): 678-679.
Food and Drug Administration (FDA). “Summary of Safety and Effectiveness Data.” 2002
July; Available at http://www.fda.gov/cdrh/pdf/P010039b.pdf. Last accessed on
January 21, 2003.
Haake, M, et al. “Extracorporeal Shock Wave Therapy in the Treatment of Lateral
Epicondylitis.” Journal of Bone and Joint Surgery. 2002a November; 84A(11): 1982-
1991.
Haake, M, et al. “Side-Effects of Extracorporeal Shock Wave Therapy (ESWT) in the Treatment
of Tennis Elbow.” Arch Orthop Trauma Surg. 2002b May; 122(4): 222-228.
Ko, JY, et al. “Treatment of Lateral Epicondylitis of the Elbow with Shock Waves.” Clin
Orthop. 2001 Jun; 387: 60-67.
Maier, M, et al. “Extracorporeal Shock-wave Therapy for Chronic Lateral Tennis Elbow –
Prediction of Outcome by Imaging.” Arch Ortho Trauma Surg. 2001; 121: 379-384.
Rompe, J, et al. “Analgesic Effect of Extracorporeal Shock-Wave Therapy on Chronic Tennis
Elbow.” Journal of Bone and Joint Surgery (Br). 1996 Mar; 78(B2): 233-237.
Speed, CA, et al. “Extracorporeal shock wave therapy for lateral epicondylitis – a double blind
randomized controlled trial.” Journal of Orthopaedic Research. 2002 September; 20:
895-898.
Wang, CJ, et al. “Shock Wave Therapy for Patients with Lateral Epicondylitis of the Elbow: A
One- to Two-Year Follow-up Study.” American Journal of Sports Medicine. 2002 May-
June; 30(3): 422-425.

Result number: 154

Message Number 120672

Re: To Harry tennis elbow View Thread
Posted by Pauline on 6/01/03 at 20:29

Harry,
Here is Ossatron's press release. If you read through it you'll find their web site listed where patients can also secure physician find information. Sometime those big terms chronic epicondylitis (tennis elbow) are a bit confusing.


Press Release Source: HealthTronics Surgical Services, Inc.


HealthTronics OssaTron Receives FDA Approval to Treat Chronic Lateral Epicondylitis - Tennis Elbow
Monday March 17, 10:13 am ET


MARIETTA, Ga.--(BUSINESS WIRE)--March 17, 2003--HealthTronics Surgical Services, Inc. (Nasdaq: HTRN - News), a leading provider of minimally invasive urologic and orthopaedic services, today announced that the US Food and Drug Administration has approved its high energy OssaTron® orthopaedic shock wave device for the treatment of chronic lateral epicondylitis (also known as tennis elbow).
ADVERTISEMENT


The OssaTron is the only high-energy orthopaedic shock wave device approved for one time treatment of epicondylitis. The OssaTron already is approved for treatment of plantar fasciitis (heel pain) and now becomes the only such device approved for multiple indications.

The FDA approved the device based on the results of a 225 patient multi-center, randomized, placebo-controlled, double-blinded study. The comparison of results between active treatment patients and placebo-treated patients was highly significant according to the statistical analyses. In fact, 90% of treated patients received a benefit from the treatment and 64% had an excellent or good outcome.

Epicondylitis is most often associated with overuse of the arm in a wide variety of activities associated with work and play. Traditionally, the only alternative for patients who did not respond to conservative non-surgical treatment was an invasive surgical procedure. These procedures typically have extended recovery times and may be associated with significant complications and poor outcomes.

Argil Wheelock, MD, the company's Chairman and Chief Executive Officer commented, "This approval is a major step forward in our goal to establish the OssaTron as the most effective choice for the treatment of a wide variety of chronic orthopaedic conditions. Indeed, we believe that eventually patients will opt for the OssaTron treatment before subjecting themselves to traditional surgical techniques. With over 10,000 successful treatments of plantar fasciitis, the OssaTron has proven its safety and effectiveness."

Dr. Jim Andrews, renowned sports medicine authority and member of HealthTronics' Board of Directors commented, "There is significant anticipation among the orthopaedic community for a high energy, single treatment shock wave device like the OssaTron®. Acceptance of the OssaTron® could create a paradigm shift in how doctors treat their patients that may otherwise have had to undergo more invasive surgical procedures."

HealthTronics orthopaedic procedures are offered in more than 300 healthcare facilities nationwide. Insurers have begun to recognize the OssaTron® as a viable and cost-effective alternative to surgery. This is evidenced by the fact that the number of directly contracted covered lives grew from less than 2 million at the beginning of 2002 to approximately 36 million by the year end.

About HealthTronics Surgical Services, Inc.

HealthTronics Surgical Services, Inc. is one of the nation's leading providers of non-invasive and minimally invasive surgical services for certain urologic and orthopaedic conditions. The Company provides technical and administrative services to physicians, hospitals and ambulatory surgery centers using extracorporeal shock wave devices. The two primary services offered by the Company are lithotripsy extracorporeal shock wave treatment, which is a procedure for treating kidney stones in a non-invasive manner, and Orthotripsy® extracorporeal shock wave treatment, which is a procedure for treating orthopaedic soft tissue disorders in a non-invasive manner. The Company has operations in approximately 40 states in the U.S. More information about HealthTronics Surgical Services can be found at the Company's website, www.healthtronics.com.

This press release may contain "forward-looking statements" within the meaning of the Private Securities Litigation Reform Act of 1995. Such forward-looking statements involve known and unknown risks, uncertainties or other factors which may cause actual results, performance or achievements of HealthTronics Surgical Services to be materially different from any future results, performance or achievements express or implied by such forward-looking statements. Factors that might cause such a difference, include, but are not limited to those discussed in the Management's Discussion and Analysis of Financial Condition and Results of Operations in the Company's Annual Report on Form 10-KSB for the year ended December 31, 2001, and in subsequent documents filed by HealthTronics Surgical Services with the Securities and Exchange Commission.



--------------------------------------------------------------------------------
Contact:
HealthTronics Surgical Services, Inc., Marietta
Investor Relations Contact
Martin J. McGahan, 800/464-3795
www.healthtronics.com
or
Manning, Selvage & Lee
News Media Contact
Shani St. John, 404/875-1444 ext.6830
shani.stjohn@mslpr.com

Result number: 155
Searching file 11

Message Number 118811

Re: Report on life memories (no politics) View Thread
Posted by Richard, C.Ped on 5/15/03 at 08:03

I think I can only remember back to around four or five years old. What stands out to me is "cutting" class in kindergarten. My friend at the time and I stayed outside after recess hidden in a large concrete cylinder. When we finally decided to go inside...the rest of the class was having their snack. For punishment, our teacher would not let us have our cookies and grape juice. I remember that like it was yesterday. haha
Richard

Result number: 156

Message Number 116589

Re: John... View Thread
Posted by john h on 4/19/03 at 18:09

You guys are bringing back some of my childhood toys which really did help you become some what creative. Today they would be considered dangerous or silly. 1. Erector Set - some with a wind up motor. you could build anything you could imagine. 2. Chemistry Set - with instructions on how to make a stink bomb. I do not even remember what all chemicals were in those. 3. Tinker Toys -Do they still make these? 4. Lead moulding set. You could melt lead and mould all sorts of things including army solders and tanks. I burned many a hole in our rugs. 5. Electric train - my first one was a Lionel of course and you wound it up but eventually I got one with a transformer. How many hours a day did we roller skate. How many pairs of soles did I ruing by tighten down with a key the holders that clipped to yur shoes. We did not have skate boards but we did attach the ball bearing wheels from old roller skates to boards and go flying down steep paved hills lying on our stomach. I must have built 1000 model airplanes out of those little balsa wood strips and had glue all over the house. Do they still make scooters? Probably Ralph Nader would outlaw them. Seems we even had the famous Ouji Board way back then. By the time you were a teenager you should have liitle problem fixing almost any inline engine six cylinder as there weas not much to fix. Where did the manual choke disappear to? Running boards were cool and if you never made out in a rumble seat you have not lived.

Result number: 157

Message Number 113676

ESWT for tennis elbow, the OssaTron View Thread
Posted by BrianG on 3/20/03 at 19:42

I know this is not heels, but it's some good reading. I'm sure more machines will be getting approved as soon as the trials are done.

BrianG

BW5585 MAR 17,2003 7:13 PACIFIC 10:13 EASTERN
( BW)(GA-HEALTHTRONICS)(HTRN) HealthTronics OssaTron Receives FDA Approval to Treat Chronic Lateral Epicondylitis - Tennis Elbow
    Health/Medical Writers
    MARIETTA, Ga.--(BUSINESS WIRE)--March 17, 2003--HealthTronics Surgical Services, Inc. (Nasdaq: HTRN), a leading provider of minimally invasive urologic and orthopaedic services, today announced that the US Food and Drug Administration has approved its high energy OssaTron(R) orthopaedic shock wave device for the treatment of chronic lateral epicondylitis (also known as tennis elbow).
    The OssaTron is the only high-energy orthopaedic shock wave device approved for one time treatment of epicondylitis. The OssaTron already is approved for treatment of plantar fasciitis (heel pain) and now becomes the only such device approved for multiple indications.
    The FDA approved the device based on the results of a 225 patient multi-center, randomized, placebo-controlled, double-blinded study. The comparison of results between active treatment patients and placebo-treated patients was highly significant according to the statistical analyses. In fact, 90% of treated patients received a benefit from the treatment and 64% had an excellent or good outcome.
    Epicondylitis is most often associated with overuse of the arm in a wide variety of activities associated with work and play. Traditionally, the only alternative for patients who did not respond to conservative non-surgical treatment was an invasive surgical procedure. These procedures typically have extended recovery times and may be associated with significant complications and poor outcomes.
    Argil Wheelock, MD, the company's Chairman and Chief Executive Officer commented, "This approval is a major step forward in our goal to establish the OssaTron as the most effective choice for the treatment of a wide variety of chronic orthopaedic conditions. Indeed, we believe that eventually patients will opt for the OssaTron treatment before subjecting themselves to traditional surgical techniques. With over 10,000 successful treatments of plantar fasciitis, the OssaTron has proven its safety and effectiveness."
    Dr. Jim Andrews, renowned sports medicine authority and member of HealthTronics' Board of Directors commented, "There is significant anticipation among the orthopaedic community for a high energy, single treatment shock wave device like the OssaTron(R). Acceptance of the OssaTron(R) could create a paradigm shift in how doctors treat their patients that may otherwise have had to undergo more invasive surgical procedures."
    HealthTronics orthopaedic procedures are offered in more than 300 healthcare facilities nationwide. Insurers have begun to recognize the OssaTron(R) as a viable and cost-effective alternative to surgery. This is evidenced by the fact that the number of directly contracted covered lives grew from less than 2 million at the beginning of 2002 to approximately 36 million by the year end.
    About HealthTronics Surgical Services, Inc.
    HealthTronics Surgical Services, Inc. is one of the nation's leading providers of non-invasive and minimally invasive surgical services for certain urologic and orthopaedic conditions. The Company provides technical and administrative services to physicians, hospitals and ambulatory surgery centers using extracorporeal shock wave devices. The two primary services offered by the Company are lithotripsy extracorporeal shock wave treatment, which is a procedure for treating kidney stones in a non-invasive manner, and Orthotripsy(R) extracorporeal shock wave treatment, which is a procedure for treating orthopaedic soft tissue disorders in a non-invasive manner. The Company has operations in approximately 40 states in the U.S. More information about HealthTronics Surgical Services can be found at the Company's website, www.healthtronics.com.

Result number: 158

Message Number 113434

Shock wave application for chronic plantar fasciitis in running athletes View Thread
Posted by Jan Rompe on 3/19/03 at 06:32

Dear colleagues:

Our latest study has just been published in:


Am J Sports Med 2003 Mar-Apr;31(2):268-75

Shock wave application for chronic plantar fasciitis in running athletes: a prospective, randomized, placebo-controlled trial.

Rompe JD, Decking J, Schoellner C, Nafe B.

Department of Orthopaedics, Johannes Gutenberg University School of Medicine, Mainz, Germany.

BACKGROUND: Recent articles have reported success with repeated low-energy shock wave application for treatment of chronic plantar fasciitis in runners. HYPOTHESIS: Shock wave treatment for chronic plantar fasciitis is safe and effective. STUDY DESIGN: Prospective, randomized, placebo-controlled trial. METHODS: Forty-five running athletes with intractable plantar heel pain for more than 12 months were enrolled; half were assigned to a treatment group that received three applications of 2100 impulses of low-energy shock waves, and half received sham treatment. Follow-up examinations were performed at 6 months and at 1 year by a blinded observer. RESULTS: After 6 months, self-assessment of pain on first walking in the morning was significantly reduced from an average of 6.9 to 2.1 points on a visual analog scale in the treatment group and from an average of 7.0 to 4.7 points in the sham group. The mean difference between groups was 2.6 points. After 12 months, there was a further reduction of pain in both groups, to an average 1.5 points in the treatment group, and to 4.4 points in the sham group. CONCLUSION: Three treatments with 2100 impulses of low-energy shock waves were a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

Any PROFESSIONAL comments are welcome to:

Jan D. Rompe
Professor
Dept. of Orthopaedic Surgery
Johannes gutenberg University
School of Medicine
Langenbeckstr. 1
D-55131 Mainz
Germany

e-mail: rompe@mail.uni-mainz.de

Result number: 159

Message Number 113123

Re: "They Drew Fire" View Thread
Posted by john h on 3/16/03 at 11:30

I really love all history but most of my college work was in Civil War History. I love to go to the National Park Battle Fields but have yet to make it to Gettysburg. One of the fine military museums if you like aircraft is the Air Force Museum in Dayton, Ohio. I have been fortunate to vist the Louve, the Prado in Madrid, the ancient ruins in Athens and Rome,and Kyoto one of the ancient capitals in Japan. Today President Bush is in conference in the Azores and the meetings will be conducted at the Air Force Offer's Club. On my numerous flights back from Europe when taking the southern route we always stopped in the Azores for fuel and food. I still remember the steak and eggs at this officers club which sat high on a mountain overlooking the small islands an ocean. The club which was on tv yesterday looks just like it did when I was traveling there in the late 50's. During this period not to far from the Azores a volcanic island arose out of the ocean. Flying over it monthly we got to see it grow from just 100 feet or so wide to a good size island. When I was fling a DC-6 the flight time to Bermuda from the Azores was between 10-11 hours. Now days with jets it is 4 hours. Sitting in the cockpit going due west when the sun begin to hit your face for 5-6 hours you really got a bit sun blinded even with strong sun glasses. I have some very beautiful lace hand made table clothes from the Azores (Portugese)...

Result number: 160

Message Number 112677

Re: ESWT at Bayshore in Toronto View Thread
Posted by DrMan on 3/12/03 at 16:13

It is very, very rare for a patient to be worse after ESWT, either high power or low power, however, there have been reports of a select few experiencing this unfortunate incident. Keep in mind, ESWT is a medical treatment that should be utilized by a physician, either orthoped..ic or podiatric. There are always risks, however, my experience, those of doctors I know and those of the International Society of Musculoskeletal Shock Wave Therapy would be that the risk is very, very slight. Keep in mind that the diagnosis must be correct in order to utilize this technology within its scope. The doctor must also have experience with the application of this technology.

As for an ESWT doctor near you, I'm sure there must be someone nearby. You could search this site or contact the International Society of Musculoskeletal Shock Wave Therapy or American Society of Musculoskeletal Shock Wave Therapy websites. We are in New York City, and have access to HIgh power and low power devices. WE are also conducting an approved FDA study on a newer HIgh Power ESWT device. If money is an issue you may consider participating in this study. It is a prospective, double-blinded , placebo study with follow up for 12 weeks. We actually have had a patient come from Texas for the study because her insurance did not cover ESWT. Feel free to contact me if you have any questions: DrMan86@aol.com

Result number: 161

Message Number 112204

Re: variations on a theme View Thread
Posted by Ed Davis, DPM on 3/07/03 at 20:26



New cost-effective treatment for calcaneal spur and tennis elbow

G. Haupt, R. Diesch, T. Straub, E. Penninger, T. Frölich, J. Schöll, H. Lohrer, T. Senge

Department of Urology, Ruhr-Universität Bochum, Germany and Multicenter Ballistic Shock Wave Therapy Study Group

Introduction: Extracorporeal Shockwaves are used for various tendopathies including so-called tennis elbow and calcaneal spur. Although as efficient as open surgery, the availability and cost of extracorporeal shock wave machines has been a drawback to this treatment. We have developed a new device for treatment using ballistic shock waves.

Material and methods: In a prospective, randomised, multi-centre and blinded trial the new treatment was performed on patients with tennis elbow or calcaneal spur. 100 patients with tennis elbow and 100 patients with calcaneal spur were randomized to either treatment or sham treatment groups. The study was approved by the ethics committee of the university. Only patients with a minimum history of 6 months, at least two different unsuccessful conservative treatment approaches and a definite indication for open surgery were included. Informed consent was obtained from each patient. History and physical examinations including more than 20 parameters were recorded. One to three treatments were performed with or without local anaesthesia. Re-examinations were scheduled after 1, 4 and 12 weeks, respectively, with detailed physical examination and subjective scaling of pain. Crossover from sham to active treatment was allowed after a minimum of 4 weeks.

Results: To date more than 90 % of the patients have been after 12 weeks. Complete analysis will be presented in detail. Summarised results are listed in the table.

Good and intermediate (%)
Tennis elbow
Calcaneal spur


verum
sham
verum
sham

1 week
50
40
74
44

4 weeks
86
46
88
36

12 weeks
100
44
82
38


Conclusions: In a placebo controlled, randomized, prospective and multicentre study ballistic shock wave therapy is a successful treatment for calcaneal spur as well as tennis elbow. This new therapy has even greater potential since treatment parameters can be further optimised and have to be included in further studies. Since the new device is far cheaper than conventional extracorporeal devices it reduces costs while maintaining efficacy and is therefore very competitive.





ESWT in the treatment of Induratio penis plastica

Result number: 162

Message Number 111499

Re: Need a New York doctor to do ESWT View Thread
Posted by DrMan on 3/02/03 at 19:58

Hi Krsitie R

I am in NYC with an associate on Long Island. We are conducting an FDA study on a newer High Power Electro-Hydrolic ESWT device. If you have had your heel pain for at least six months and failed conservative care under a doctors management you may qualify for the study. This is a double-blinded placebo study. If you get the ESWT treatment there will be absolutely no charge to you. If you get the placebo you may be eligable for the treatment after the study is finished. Either way there will be minimal if any expense to you. If you do not wish to participate in this study or do not qualify for the study, we could perform the ESWT procedure with a different device. With this senerio, however, there would be insurance and financial considerations. If I could be of any further assistance to you either now or in the future please feel free to contact me at: DrMan86@aol.com

Result number: 163

Message Number 111498

Re: Need a New York doctor to do ESWT View Thread
Posted by DrMan on 3/02/03 at 19:58

Hi Krsitie R

I am in NYC with an associate on Long Island. We are conducting an FDA study on a newer High Power Electro-Hydrolic ESWT device. If you have had your heel pain for at least six months and failed conservative care under a doctors management you may qualify for the study. This is a double-blinded placebo study. If you get the ESWT treatment there will be absolutely no charge to you. If you get the placebo you may be eligable for the treatment after the study is finished. Either way there will be minimal if any expense to you. If you do not wish to participate in this study or do not qualify for the study, we could perform the ESWT procedure with a different device. With this senerio, however, there would be insurance and financial considerations. If I could be of any further assistance to you either now or in the future please feel free to contact me at: DrMan86@aol.com

Result number: 164

Message Number 111071

how to find old comments View Thread
Posted by Scott R on 2/27/03 at 19:50

I had sought comments when the study came out. You can do a search on the message board for the word "JAMA" to see a lot of stuff from many. I believe Dr Ed, Dr Z, Sunny Jacobs with bayshore, rob a, David Lowry with sonorex, and then "non-professionals" had some good comments, myself and elliott to name two who had some things to say. Below are links to some of the threads during that time period. And below is the letter response frmo healthtronics that JAMA printed. Also below is the press release they did. (i'll be out of town for a while starting tonight)

Responses to the JAMA article:
http://heelspurs.com/m/09/61/t28.html David Lowry
bbv.cgi?n=92281 Elliot
The above are just 2 threads out of many that were posted.

Other Message Board Threads on the Study:
bbt.cgi?n=95976
bbt.cgi?n=96117
bbt.cgi?n=95607

To the Editor: Dr Buchbinder and colleagues1 report that low-energy extracorporeal shock wave therapy (ESWT) for plantar fasciitis offered no measurable benefit. Plantar fasciitis is characterized by poor healing and the formation of scar tissue after an acute or overuse injury. The scar tissue has extremely poor blood supply that inhibits the entry of tissue healing cells (fibroblasts and osteoblasts) into the pathologic site. The delivery of shock waves to this scar tissue is thought to cause microscopic injury with associated deposit of endothelial cells, resulting in re-engineering of the scar tissues.

For this process to occur, we believe that sufficient energy must be delivered to cause the necessary controlled tissue damage. It appears that the use of low-energy devices without anesthesia, such as used by Buchbinder et al, does not create the magnitude of tissue damage necessary to trigger the neovascularization process. We also believe that treatments should be performed by a qualified surgeon who is intimately familiar with the technology and the patient being treated, not by a disengaged technician as in the Buchbinder study. One could say that the expression "no pain, no gain" certainly applies in this situation.

To be properly regarded, research on this technology should take differences in high-power (electrohydraulic) and low-power (electromagnetic) devices into account.

Argil J. Wheelock, MD
HealthTronics Surgical Services
Marietta, Ga
=============
"We at HealthTronics Surgical Services commend JAMA on publishing the Buchbinder et al article (JAMA Vol. 288, No. 11, 2002) that reports the use of low energy extracorporeal (electromagnetic) shock wave therapy for plantar fasciitis offers no sustainable beneficial effect. This is a finding that HealthTronics has been espousing for nearly two years since our high energy (electrohydraulic) orthopedic shock wave device, the OssaTron(R), was approved by the FDA. Unfortunately, the Buchbinder article has generally been presented in the lay media as a condemnation of all orthopedic shock wave therapy. This misunderstanding has the potential to undermine the very significant clinical benefits to patients suffering from a wide variety of chronic orthopedic conditions that have been shown to respond to high energy extracorporeal shock wave therapy. These conditions include a wide variety of tendonopathies and bone pathologies that severely restrict the ability of many hundreds of thousands of Americans from performing normal day to day work and recreational activities, negatively impacting the quality of life of these people. The purpose of this letter is to differentiate between high energy and low energy treatments and to detail our clinical experience using the OssaTron(R) high energy shock wave device to treat plantar fasciitis.

"In order to appreciate the difference between low and high energy devices, one must first understand the widely accepted theory as to why extracorporeal shock waves promote healing of the targeted pathology. The chronic orthopedic conditions now being treated with shock waves are characterized by poor healing and the formation of scar tissue after an acute or overuse injury to fascia, tendon or bone. The scar tissue is characterized by extremely poor blood supply which inhibits the entry of tissue healing cells (fibroblasts and osteoblasts) into the pathologic site. The delivery of shock waves to this scar tissue causes microscopic injury with associated deposit of endothelial cells into the scar tissue. The endothelial cells then form new blood vessels (a process called neovascularization) which allow the tissue healing cells to penetrate the area of scarring and promote re-engineering of the tissues. For this process to occur, sufficient energy must be delivered to the scar tissue to cause the necessary controlled tissue damage. It appears that the use of low energy devices without anesthesia does not create the magnitude of tissue damage necessary to trigger the neovascularization process. Furthermore, it does not appear that repeat treatments, as in the Buchbinder study, compensate for this deficiency. We also believe that treatments should be performed by a qualified surgeon who is intimately familiar with the technology and the patient being treated, not by a disengaged technician as in the Buchbinder study. In summary, it should not be a surprise to anyone that patients failed to show a long term benefit from such treatment as rendered in the Buchbinder study. One could say that the expression 'no pain, no gain' certainly applies in this situation.

"The United States experience with the HealthTronics OssaTron confirms that the delivery of high energy shock waves under anesthesia by a qualified surgeon results in a significant clinical benefit to patients suffering from chronic plantar fasciitis. Some of this experience was obtained within the constraints of a randomized, double-blind, placebo-controlled study which became the basis of the approval of the OssaTron by the FDA. In that study, 47.1% of patients were considered a success only if they had an excellent clinical outcome. Such an outcome was achieved only if the patient significantly improved according to four different criteria. This was statistically significant (p=.008) to the 30.2% successful outcome in the placebo group. It is important to note that patients who may have improved on two or three of the criteria for success were considered failures.

"Additional review of the data from this study showed that 81% of patients treated had an excellent or good outcome (improvement in at least two of the four criteria). Long term follow-up of these patients showed that over 90% of those who had shown good or excellent results maintained their success to one year from treatment. In contrast, only 14% of the placebo patients who chose no subsequent treatment had a good or successful result at twelve months. In a survey of 449 patients treated with the OssaTron subsequent to its FDA approval, 83% of patients who had not had prior surgical treatment had a good or excellent outcome. This survey is consistent with and reinforces our patient results reported to the FDA. A detailed analysis of the cumulative experience in treating plantar fasciitis with the OssaTron is being submitted for publication in a peer reviewed journal.

"HealthTronics has also completed a study on the treatment of lateral epicondylitis (tennis elbow) with the OssaTron. The data from that study, which shows results that are comparable to our chronic proximal plantar fasciitis study, is currently being reviewed by the FDA. Our two randomized, double-blinded, placebo controlled studies validate the vast experience with the OssaTron in the rest of the world. It has been well documented that high energy extracorporeal shock wave therapy has enhanced the quality of life of patients suffering from numerous chronic orthopedic conditions.

"We at HealthTronics believe strongly that high energy orthopedic wave treatments will provide a non-invasive surgical solution to properly selected patients who may otherwise have to resort to traditional surgical procedures that have less satisfactory outcomes with much greater morbidity. It will be a disservice to many if this highly effective new technology is improperly regarded due to a lack of understanding about the differences in high power (electrohydraulic) and low power (electromagnetic) machines."

Result number: 165

Message Number 110129

Re: Ed View Thread
Posted by john h on 2/20/03 at 19:01

We really have the capability to cut back greatly on our use of oil Ed. The price of gas in Europe has always been several times higher than ours which discourages the use of gas. We are really bad about running gas guzzlers and always have been. $3 per gallon gas is probably not uncommon in Europe. Julie can probably tell us but when I was there small cars and diseles were the order of the day. The biggest selling vehicle in my state and I think Texas also is the pickup truck. Certainly farmers need these but a lot of my friends do not know what a farm looks like and drive 8 cylinder gas guzzler trucks and have a Lexus sitting in the driveway.. Our GM SUV's are as big as a small bus. I like the Presidents ideas on starting now with alternative fuels. It will take some years to develop but you have to start somewhere. Fossile fuel as we all know will eventually run out. I see gas prices have reached $2.00 a gallon at some places in CA. When you fill up that 35 gallon tank now a days the price makes you think. I remember buying gas in Wichita in the 60's for $.15 a gallon during the gas wars. In the 70's diesel could be bought for $.03 a gallon. A big rig tractor trailer typically carries either 300 gallons or 230 gallons and probably are getting on the order of 7 mpg. This now brings back the war years when gas was rationed. Seems like the typical family got about 20 gallons a month. Hey tires and butter were also rationed come to think of it. Can you imagine telling our public now they can only have 20 gallons per month per family. You would see some real demonstrations..

Result number: 166
Searching file 10

Message Number 109924

Re: ESWT is Unnecessary and Explorartory View Thread
Posted by DrMan on 2/19/03 at 21:03

Elaine, I'm in NYC. We are one of three groups in the country conducting an FDA study on a new ESWT device. This is an electrohydrolic, spark-gap, high power ESWT device. This is similar to the OssaTron yet slightly different than the Dornier units. This device has been used in clinical practice for over three years and is now undergoing final FDA clinical trials. This is a double-blinded, placebo study. The patient must have proximal plantar fasciitis for at lease six months and failed conservative care consisting of at least three modalities. The patient must be in good health. Follow-up is for 12 weeks. This is not a crossover study, however. This means you would have a 50% chance of receiving the ESWT and a 50% chance of receiving the placebo. If, after 12 weeks, you find out you received the placebo, the study is finished, you will not automatically receive the actual ESWT. This is different than the study you referenced in your post. If you did receive the actual ESWT there would be no financial obligation to you. If you are interested or have questions E-Mail Dr. John E. Mancuso: DrMan86@aol.com

Result number: 167

Message Number 107437

Re: Who should I believe???? View Thread
Posted by Lara T on 1/30/03 at 22:15

Even the most competent, knowledgeable doctor comes with limitations - their own biases, training, and experiences. It could be noted these limitations may also be the doctor's strength - their own biases, training and experiences.

Certainly there are some doctors we can decide are not that useful for our purposes. Either they admit they don't have the experience, or they aren't someone who's style meshes sufficiently with ours, or any number of reasons, only some of which may be related to competence. So I think seeking a 2nd, 3rd & 4th opinion makes sense - and doing research, so that you can see how their recommendation fits in to the scheme or things.

I saw two podiatrists who gave me bad advice until I found a 3rd podiatrist who was able to recognize the TTS. He recommended surgery, so I then got a 2d opinion from an orthopedic surgeon. I decided to hold off after this. IN the meantime, my neighbor who works in the medical field learned of a guy locally who is doing surgery and research in TTS so I decided to get a 3rd opinion from him. Several months later I was referred to a different orthopedic surgeon for a knee problem totally unrelated to my escapades with TTS. While there a problem had arisen with my feet and I thought maybe I could ask if they knew something since I was already there. Turns out they did know tarsal tunnel syndrome and gave me a fourth opinion (2 for surgery, 2 against surgery, 1 for diabetes and 1 for going home and stop worrying myself so much). My podiatrist has turned his practice over to a new podiatrist who also seems very knowledgeable about TTS. So now I have a fifth opinion (breaking the tie - it's now 3 against, 2 for surgery).

I don't know how doctors or insurance companies would look at seeking out
so many "2nd" opinions. I didn't get 7 opinions by design. However, by continuing to research, become knowledgeable, and keeping my ears open, I have collected more information. I can say with the exception of the doctor that diagnosed it as the beginning of diabetes (despite negative blood tests) and one that said it was in my head, all of the opinions have been helpful to me in understanding the options and the fuller picture - even though they didn't all agree. More helpful than their recommendation was their thoughts on what might have happened, and why they recommended the way they did. I would be sure to ask those questions.

Most doctors have had enough training with colds and flu, mumps, meningitis, etc that you can figure their knowledge is based on the accumulated wisdom of years of understanding passed down through generations of medical professionals. That can't be said for TTS. About 3 years ago I went to the local Med School Bookstore and went to the section on orthopedics. I found the text on Foot & Ankles, and looked up Tarsal Tunnel in the index. In this book that could probably be weighed in pounds, was at least 8-1/2" x 11", and over an inch thick, there was less than two pages on Tarsal Tunnel. It's just not been recognized long enough for standard protocols and treatments to have been passed along to the next generation of doctors.

The doctor that was doing research in surgery & TTS was perhaps the most biased and blinded by his training and experience - he seemed to me to have tunnel vision. If I was going to have surgery, he would probably have been the best, but he wasn't the best for looking at other options for treatment.

Unfortunately, it's hard to know who to believe. I was fortunate that my feet calmed down enough after getting compression socks that I had some time. I don't know if you have the same luxury. I wish it were easier - it's bad enough to have to deal with the pain of TTS.

I guess in the end, if you don't have the luxury of time, I would listen to their reasoning for their recommendation, and see how it fits with your understanding of your feet and what you learn here (or elsewhere).

Result number: 168

Message Number 106893

Participate in an FDA clinical study with ESWT, at no cost to you, in NYC View Thread
Posted by DrMan on 1/26/03 at 16:14

We are seeking patients to participate in an approved FDA clinical study on the use of a new to the market Extracorporeal Shock Wave Therapy device. Orthometrix, the manufacturer of a new office based ESWT unit, is conducting a Double-Blinded Placebo Study for final FDA approval. Inclusion criteria consists of at least six months failed conservative treatment under a doctor's care and must be in good health. This is not a clinic setting. Treatment and follow-up will be at the private office of Dr. John E. Mancuso in midtown Manhattan in New York City. In addition to the treatment visit, follow-up visits will be at 4,8 and 12 weeks. Arrangments could be made for patients from out-of-state or out of the country. This study has been ongoing since september 2002. For additional information contact John E. Mancuso, DPM at his New York City office (212) 759-9090 or E-Mail: DrMan86@aol.com . Located at: 133 East 54 Street (@ Park Avenue), New York, New York 10022.

Result number: 169

Message Number 105039

Re: Printed Peer Review Articles View Thread
Posted by BrianG on 1/07/03 at 16:43

Do you think this might help? It was presented at an International ESWT conferance by Dr. Rompe, ESWT guru.

BrianG


Shockwave Application for Chronic Plantar Fasciitis in Running Athletes – a Prospective, Randomised, Placebo-Controlled, Double-Blinded Trial
Authors: Jan D. Rompe, Jens Decking, Carsten Schöllner, Bernhard Nafe
Institution: Department of Orthopaedic Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany
AIM:
To assess the efficacy of repeated low-energy shock wave application for chronic fasciitis in runners.
MATERIALS AND METHODS:
Forty-five running athletes with intractable plantar heel pain were enrolled in a randomized single-blind trial with a parallel-group design and blinded independent observer, to evaluate the efficacy of three applications of 2100 impulses of low-energy shock waves (Group I) compared with placebo treatment (Group II). Followup examinations were done at six months, and at one year after extracorporeal shock wave application. Symptoms had been present from one year to six years. Each patient satisfied numerous inclusion and exclusion criteria before he or she was accepted into this study. The primary efficacy endpoint was reduction of subjects´s self-assessment of pain on first walking in the morning on a visual analog scale (range, 0 - 10 points) at six months after shock wave application.
RESULTS:
After six months self-assessment of pain on first walking in the morning showed a significant reduction from an average seven to 2.1 points in Group I, and from an average seven to 4.7 points in Group II on the visual analog scale. The difference of 2.6 points between both groups was significant six months after the intervention (p= 0.0004, 95% CI: 1.9 - 3.3 points; power > 0.9). Twelve of nineteen patients (63%) of the treatment group versus six of twenty patients (30%) of the sham group reported a >50% improvement. After twelve months 81% of the patients of the treatment group versus 37% of the patients of the placebo group rated accordingly. Co-interventions remained on a comparable, low level in both groups.
CONCLUSION:
The current study showed that three treatments with 2100 impulses of low-energy shock waves were a safe and effective nonsurgical method for treating chronic plantar fasciitis in runners.

Result number: 170

Message Number 104440

Re: Progress is good ! View Thread
Posted by john h on 1/01/03 at 09:16

And Dr. Z it may be Judy and Brian are just girly girl and girly man. Judy still whines about her ESWT even with the shot. When Brian had his shot did you have that blinder up so he could not see what you were up to. Maybe he just thought you gave him a shot. I need to be there to hold his hand next time. That bottle of wine we all had after the round of treatmens a couple of years ago eased all pain.Comon Brian there are only a couple of us manly men on this board do not show fear or these women will attack just like a pack of hungary wolves.

Result number: 171

Message Number 103661

Re: Re: Food for thought View Thread
Posted by john h on 12/20/02 at 18:45

Leon: Just an old inline 6 cylinder with a single carb. No PS,PB,PW,blah blah blah. We could all get those babies going. Get two or three of us behind it and we could push start it.

Result number: 172

Message Number 102352

Still seeking patients for NYC Clinical Trial on ESWT View Thread
Posted by Dr.Man on 12/09/02 at 12:20

We are three months into our FDA approved clinical study on the use of the Orbasone Pain Management System for proximal plantar fasciitis (Heel Pain Syndrome).This is the newest version of Extracorporeal Shock Wave Therapy devices.Since this is a clinical study certain criteria must be met along with "Inclusion and Exclusion Criteria".Briefly, the patient must have failed at least six months of conservative care for proximal plantar fasciitis.Must have received at least four types of modalities such as cortisone injections, oral madications, orthotics, stretching, physical therapy ect..Exclusion criteria would be if both heels hurt, if it is a diagnosis other than proximal plantar fasciitis, previous heel surgery or if the patient has a diagnosis of diabetes or other systemic disorder.This is a "Double-Blinded Plecebo Study". This means the patient may or may not receive the actual treatment.The end-point of the study is twelve weeks.There will be no cost to patients accepted into the study, however the facility will accept whatever fees are reimbursed by insurance. Dr.Mancuso, 133 E 54 St, NYC. (212)759-9090, E-Mail: DrMan86@AOL.com

Result number: 173

Message Number 101961

an ESWT study on runners!! View Thread
Posted by elliott on 12/06/02 at 10:15


Several here have expressed curiosity in what such a study will show. Below is an abstract from that same German site I dug the other study from. Of note is that, among other selection criteria, it had a one-year minimum. The study still showed decent results at the 12-month mark, albeit lower than that for the Dornier FDA study. Of disapointment is that it doesn't say whether they were allowed to run during their recovery, and if so, how much they did.

-----

Shockwave Application for Chronic Plantar Fasciitis in Running Athletes – a Prospective, Randomised, Placebo-Controlled, Double-Blinded Trial

Authors: Jan D. Rompe, Jens Decking, Carsten Schöllner, Bernhard Nafe

Institution: Department of Orthopaedic Surgery, Johannes Gutenberg University School of Medicine, Mainz, Germany

AIM:

To assess the efficacy of repeated low-energy shock wave application for chronic fasciitis in runners.

MATERIALS AND METHODS:

Forty-five running athletes with intractable plantar heel pain were enrolled in a randomized single-blind trial with a parallel-group design and blinded independent observer, to evaluate the efficacy of three applications of 2100 impulses of low-energy shock waves (Group I) compared with placebo treatment (Group II). Followup examinations were done at six months, and at one year after extracorporeal shock wave application. Symptoms had been present from one year to six years. Each patient satisfied numerous inclusion and exclusion criteria before he or she was accepted into this study. The primary efficacy endpoint was reduction of subjects´s self-assessment of pain on first walking in the morning on a visual analog scale (range, 0 - 10 points) at six months after shock wave application.

RESULTS:

After six months self-assessment of pain on first walking in the morning showed a significant reduction from an average seven to 2.1 points in Group I, and from an average seven to 4.7 points in Group II on the visual analog scale. The difference of 2.6 points between both groups was significant six months after the intervention (p= 0.0004, 95% CI: 1.9 - 3.3 points; power > 0.9). Twelve of nineteen patients (63%) of the treatment group versus six of twenty patients (30%) of the sham group reported a >50% improvement. After twelve months 81% of the patients of the treatment group versus 37% of the patients of the placebo group rated accordingly. Co-interventions remained on a comparable, low level in both groups.

CONCLUSION:

The current study showed that three treatments with 2100 impulses of low-energy shock waves were a safe and effective nonsurgical method for treating chronic plantar fasciitis in runners.

[]

Result number: 174

Message Number 101848

I think this is a report on the Dornier FDA study at the 1-year mark! View Thread
Posted by elliott on 12/05/02 at 10:24


I dug this off a German site giving abstracts of its organization's latest ESWT conference:

----------

Shockwave Therapy for Plantar Fasciitis of the Eposcorporus Dornier

Authors: Christopher Zingas, David Collon, Kyle Anderson

Institution: Henry Ford Health System William Clay Ford Center for Athletic Medicine

The study is designed to assess the safety and efficacy of musculoskeletal shock wave therapy in the treatment of chronic plantar fasciitis. The authors hypothesize that shock wave therapy will be useful in the treatment of chronic plantar fasciitis which has failed conventional conservative methods.

Preliminary twelve month results indicate that shock wave therapy may provide an effective alternative treatment for chronic plantar fasciitis with minor transient adverse effects.

One hundred and fifty patients with chronic plantar fasciitis were enrolled in a randomized, 1:1 allocated, placebo-controlled, prospective, double blind clinical study with two groups: one receiving Extracorporeal Shock Wave Therapy (ESWT) with Dornier Epos Ultra and the other receiving sham treatment. All 150 patients had failed at least six months of physician supervised conventional conservative methods and would have been considered surgical candidates by guidelines set forth by the AOFAS. All patients were greater than 18 years of age with unilateral single site plantar medial heel pain, and had a visual analog score of >5 (scale 1-10) for the first few minutes of morning walking. There were 119 women and 31 men enrolled. The mean age was 50 years (26-69) for the active group and 53 years (31-72) for the sham group. Each active treatment patient was subjected to a single 20 minute ESWT session which delivered approximately 1300mJ/mm2 to the treatment area. The control group patients went through the identical treatment procedure without shock wave penetration. All patients were evaluated 3-5 days, 6 weeks, 3 months, 6 months, and 1 year post-treatment. Patients were assessed using the Visual Analog Score (VAS) during the first few minutes of walking and the Roles and Maudley score. The participants were unblinded at 3 months post-treatment. Patients in the sham treatment group who did not improve at 3 months were offered active ESWT and were considered the 'Crossover Group'.

The VAS for the first few minutes of walking at 3 months post-treatment showed a 45% success rate in the sham treatment group and 56% success in the active group. The Roles and Maudsley scoring showed a 40% success rate in the sham group and 62% success rate in the active group at 3 months. The VAS for the first few minutes of walking at 12 months post-treatment showed a 94% success rate in the active group. The Roles and Maudsley scoring showed also 94% success rate in the active group at 12 months. The crossover group at 12 months had a VAS score 63% success and Roles and Maudsley scoring of 93% success.

There were 17 active, 19 sham, 11 crossover mild transient complications seen. These included ecchymosis, edema, hypesthesia, paresthesia, petechiae, rash, neuralgia, injections site hemorrhage, nonpalpable pulse (sham treatment), and infection. These all resolved within a few days post-treatment. There was 1 permanent minor complication of paresthesia. No major transient or permanent complications were noted.

--------------

Result number: 175

Message Number 101046

Re: Time off work after endoscopic surgery? View Thread
Posted by Trudy on 11/24/02 at 14:48

You are right, I am sure the bed of roses Doctor would be doing more surgeries.Alot of people would be walking into it with blinders on.My employer will allow up to 26 weeks of short term disability(which I have paid extra for ,for over 22 years).If he had told me the truth(He was going to take me off for 4 weeks instead of 12 like he said),I would not have had the surgery.I just would like to have my foot healed as well as possible before I go beating it into the ground again.It just wasn't honest.But, that's life,either he will have to make it longer or I will have to go hunting for a different job!

Result number: 176
Searching file 9

Message Number 99728

orthotics not FDA approved View Thread
Posted by Mike on 11/10/02 at 16:19

Orthotics have never been approved by the FDA as safe and effective for PF.
A separate message board exists on this site for orthotics. Scott must cease and desist from any attempts to market orthotic devices. No double blinded studies published in peer reviewed journals have been performed in the US showing the efficacy of orthotics for plantar fasciitis.
Mike

Result number: 177

Message Number 98354

Free? 0rbasone FDA trial in NY View Thread
Posted by scott r on 10/25/02 at 21:57

We are conducting an FDA clinical trial on the 0rbasone Pain Relief System
(ESWT). This is an office based unit being studied for the treatment of
proximal plantar fasciitis. STudy design is Double-blinded placebo format
with an end point at 12 weeks. We are utilizing 2000 pulses at 21kv to the target area. There are certain FDA authorized inclusion and exclusion
criteria that must be met for participation into this study. We are actively seeking patients for this study. We are located in midtown Manhattan at: 133 East 54 Street, NY,NY 10022. Tel. # (212) 759-9090. It would be most helpful if you could post this info on your website.

Thank you,

John E. Mancuso, DPM

Result number: 178

Message Number 98211

I think I got it yet! View Thread
Posted by elliott on 10/24/02 at 07:56

JAMA
Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis

A Randomized Controlled Trial

Rachelle Buchbinder, MBBS, MSc; Ronnie Ptasznik, MBBS, FRANZCR; Jeanine Gordon, BAppSci; Joylene Buchanan, DipAppSci; Vasuki Prabaharan, BSc, MAppSci; Andrew Forbes, PhD


Context Extracorporeal shock wave therapy (ESWT) is increasingly used for plantar fasciitis, but limited evidence supports its use.

Objective To determine whether ultrasound-guided ESWT reduces pain and improves function in patients with plantar fasciitis.

Design Double-blind, randomized, placebo-controlled trial conducted between April 1999 and June 2001.

Setting Participants were recruited from the community-based referring physicians (primary care physicians, rheumatologists, orthopedic surgeons, and sports physicians) of a radiology group in Melbourne, Australia.

Participants We screened 178 patients and enrolled 166; 160 completed the 15-week protocol. Entry criteria included age at least 18 years with plantar fasciitis, defined as heel pain maximal over the plantar aspect of the foot of at least 6 weeks' duration, and an ultrasound-confirmed lesion, defined as thickening of the origin of the plantar fascia of at least 4 mm, hypoechogenicity, and alterations in the normal fibrillary pattern.

Interventions Patients were randomly assigned to receive either ultrasound-guided ESWT given weekly for 3 weeks to a total dose of at least 1000 mJ/mm2 (n = 81), or identical placebo to a total dose of 6.0 mJ/mm2 (n = 85).

Main Outcome Measures Overall, morning, and activity pain, measured on a visual analog scale; Maryland Foot Score; walking ability; Short-Form–36 Health Survey (SF-36) score; and Problem Elicitation Technique score, measured at 6 and 12 weeks after treatment completion.

Results At 6 and 12 weeks, there were significant improvements in overall pain in both the active group and placebo group (mean [SD] improvement, 18.1 [30.6] and 19.8 [33.7] at 6 weeks [P = .74 for between-group difference], and 26.3 [34.8] and 25.7 [34.9] at 12 weeks [P = .99], respectively). Similar improvements in both groups were also observed for morning and activity pain, walking ability, Maryland Foot Score, Problem Elicitation Technique, and SF-36. There were no statistically significant differences in the degree of improvement between treatment groups for any measured outcomes.

Conclusion We found no evidence to support a beneficial effect on pain, function, and quality of life of ultrasound-guided ESWT over placebo in patients with ultrasound-proven plantar fasciitis 6 and 12 weeks following treatment.

JAMA. 2002;288:1364-1372



Plantar fasciitis, or painful heel, is a common musculoskeletal problem estimated to affect 10% of runners at some time and to occur in a similar proportion of the general population in their lifetime.1 It denotes a clinical condition of pain in the plantar aspect of the heel, characteristically worse on arising in the morning and after periods of prolonged sitting.2 There is maximal tenderness at the plantar fascial origin on the medial process of the calcaneal tuberosity, and pain increases with passive stretching of the plantar fascia. The etiology of plantar fasciitis is unknown and probably multifactorial. Excessive loading may result in inflammation, degeneration, microtears, and/or fibrosis at the plantar fascia origin. A calcaneal spur may be present in 50% of patients with painful heel,3 but has been reported in 10% to 27% of asymptomatic patients.3, 4 Plantar fasciitis is most commonly a disorder of middle age3, 5 and men and women are affected equally. Other risk factors include obesity3, 5-8 and spending prolonged periods standing or walking,3, 5 particularly on hard floors.5 Symptoms may be bilateral in over 10% of cases.3 Plantar heel pain is generally a self-limiting condition, and more than 80% of those who present for medical attention have resolution of the problem within 12 months of onset of symptoms.9, 10

Treatments advocated for plantar fasciitis have included rest, ice, stretches, nonsteroidal anti-inflammatory drugs,2, 10 corticosteroid injection,2, 6 iontophoresis of dexamethasone,11 various orthotics including heel cushions, low-profile plastic heel cups,5, 12 Tuli heel cups,13 night splints,8 heat, ultrasound,14 below-the-knee non–weight-bearing casts,5 and short-leg walking casts.15 A small number of patients undergo surgery, including spur resection and release of all or part of the fascial band.16 However, evidence of the effectiveness of all these treatment modalities is limited due to the lack of well-designed and conducted comparative studies, as documented in a Cochrane systematic review performed by Atkins et al.17, 18

Recently, extracorporeal shock wave therapy (ESWT) has been advocated for treatment of this condition.18-28 Since 1976, ESWT in the form of lithotripsy has been used to disintegrate renal and biliary calculi.29 Shock waves are single-pulse acoustic waves (sound waves) that propagate rapidly in 3-dimensional space and cause a sudden rise in pressure at the wave front.30, 31 They dissipate mechanical energy at the interface of 2 substances with differing acoustic impedance, resulting in disintegration of calculi. From the early 1990s there have been published descriptions of its use in Germany in a variety of musculoskeletal disorders including pseudoarthroses, calcific tendinitis of the shoulder, lateral and medial epicondylitis, and painful heel.19, 21, 32, 33

Medical shock waves are usually generated through a fluid medium (eg, water) and a coupling gel to facilitate transmission into biological tissues.31 There are 3 main techniques for generating shock waveselectrohydraulic, electromagnetic, and piezoelectric31and all 3 have been used to treat plantar fasciitis. The first generation of orthopedic shock wave machines used a spark plug to generate the shock wave (electrohydraulic technique).31 In October 2000 the US Food and Drug Administration (FDA) approved an electrohydraulic device for use in the treatment of chronic proximal plantar fasciitis (heel spurs) in the United States.34 Subsequently, an electromagnetic device, which generates the shock wave by passing an electric current through a coil to produce a strong magnetic field, has also been approved.35 Piezoelectrically generated shock waves are produced by piezocrystals that are mounted on the inside of a sphere. These receive a rapid electrical discharge, resulting in deformation of the crystals to induce the shock wave.31

While all 5 placebo-controlled trials of ESWT in chronic plantar fasciitis have reported benefit of variable magnitude,19, 20, 22, 23, 35 methodological limitations may have influenced their outcome. Participants were unblinded in 3 trials,19, 20, 23 and none of the 5 trials described their method of randomization, allocation concealment, or sample size calculation. One double-blind trial, performed by Ogden et al,22 evaluated success of therapy by combining 4 outcomes into a composite outcome. While the overall proportion of participants who met the predetermined criterion of success at 12 weeks was significantly higher in the actively treated group (47.1% vs 30.2%; P = .008), the superiority of the active treatment compared with placebo treatment was only statistically significant for investigator assessment of heel pain (62.2% of the active group vs 44% of the placebo group met success criteria; P = .005).36 The second double-blind trial found a small but statistically significant difference favoring the active group in their primary end point (difference in improvement in morning pain between the active and placebo groups measured at 12 weeks posttreatment: 0.7 cm on a 10-cm visual analog scale [VAS]; P = .01).35 The determination of the presence of plantar fasciitis was made solely on clinical grounds in both double-blind trials.

To further clarify the value of ESWT for this condition we performed a double-blind, randomized, placebo-controlled trial in patients with ultrasound-proven plantar fasciitis. The aim of our study was to determine whether ultrasound-guided ESWT, given weekly for 3 weeks, reduces pain and improves function at 6 and 12 weeks after completion of treatment.




METHODS



Study Design

A double-blind, randomized, placebo-controlled trial was conducted between April 1999 and June 2001. Patients who fulfilled inclusion criteria and provided written informed consent were randomized and stratified by treatment center (3 treatment sites) in blocks of 4 to receive either active treatment or placebo regimens according to a computer-generated random-numbers list created by the study biostatistician. Both the patients and a single outcome assessor were blinded to the therapy received.

Patients

Patients were recruited from the community-based referring physicians (primary care physicians, rheumatologists, orthopedic surgeons, and sports physicians) of Mayne Health Diagnostic Imaging (formerly Melbourne Diagnostic Imaging Group) in Melbourne, Australia. Radiologists evaluated all referred patients to ascertain eligibility criteria. The radiologists who ascertained eligibility had no other involvement in the study. Patients were included if they were 18 years or older, described heel pain felt maximally over the plantar aspect for at least 6 weeks, and had an ultrasound-confirmed lesion. The latter was defined as thickening of the origin of the plantar fascia (greater than or equal to 4 mm) as well as hypoechogenicity and alterations in the normal fibrillary pattern. When symptoms were bilateral, the more symptomatic side was studied. Patients were excluded if any of the following were present: generalized inflammatory arthritis, including ankylosing spondylitis, Reiter syndrome, rheumatoid arthritis, or psoriatic arthritis; any wound or skin lesion; pregnancy; severe infection; known malignancy; bleeding disorder; pacemaker; previous surgery to the heel; previous ESWT to any site (because of the risk of unblinding); oral and/or topical nonsteroidal anti-inflammatory medication in the previous 2 weeks; local corticosteroid injection in the previous month; oral glucocorticosteroids within the previous 6 weeks; lack of informed consent; or any other reason thought likely to result in inability to complete the trial, such as uncertainty about being able to attend for follow-up assessment and poor English skills thought likely to affect ability to complete outcome assessment.

Description of Interventions

All treatments were given by a single extracorporeal shock wave (ESW) therapist who was informed of treatment allocation (by central telephone) just prior to commencement of treatment according to the participant's identification number. An ESW therapist is a qualified health professional who has undergone training in the delivery of ESWT. The ESW therapist was not involved in any other part of the study and interacted with study participants in a standardized way irrespective of treatment allocation. Care was taken to ensure that study participants did not meet, and individual study participants were asked to wait in separate waiting areas.

All treatments were given according to a standardized protocol using the Dornier MedTech EPOS (Extracorporeal Pain therapy and Orthopaedic System) Ultra (Dornier MedTech America Inc, Kennesaw, Ga).35 All patients were positioned sitting in a chair with the affected foot resting on a foam support and footstool. Ultrasound gel was placed on a water cushion and the ultrasound transducer. The water cushion and transducer were placed over the heel and positioned so that the origin of the plantar fascia adjacent to the calcaneum was visible. The cross hair, which is used to indicate the position of the shock wave focus, was positioned within the plantar fascia adjacent to the calcaneum, in the thickest portion of the plantar fascia.

Each patient in both the placebo and experimental groups received a total of 3 treatments given at weekly intervals. For the placebo group this consisted of 100 shock waves per treatment, of energy 0.02 mJ/mm2 (energy level 1). The frequency of these pulses was set at 60 per minute. The total dose received by the placebo group was 6.0 mJ/mm2. The experimental group received either 2000 or 2500 shock waves per treatment of energy levels varying between 0.02 mJ/mm2 and 0.33 mJ/mm2 (ie, within levels 1-9). The frequency of these pulses was gradually increased to 240 per minute. Treatment began on level 1 and was gradually increased through to the highest tolerable level of pain for each participant. Thus the total calculated dose for each participant was different. In general, a total dose of 1000 mJ/mm2 or more was the treatment goal. The mean (SD) dose of ESWT in the experimental group was 1406.73 (390.58) mJ/mm2.

Participants were able to continue to wear orthotics/splints as prescribed, but no new orthopedic devices were allowed. Apart from paracetamol, no other therapies (including massage, chiropractic, laser, night splints, acupuncture, or oral, topical, or locally injected corticosteroids) were allowed for the duration of the study.

Ethical approval was obtained from the Epworth Hospital Ethics Committee.

Baseline and Outcome Assessment

Baseline variables that were recorded included date of birth, sex, weight, height, years of formal education, marital status, duration of symptoms, history of trauma, previous episodes, medication, previous treatments including orthotics, results of radiological investigations, any coexisting condition(s), approximate hours of weight bearing per day, and the type of flooring used for the majority of the day.

The presence or absence of a heel spur on plain anteroposterior/lateral radiograph if already obtained was noted, but plain radiographs were not performed routinely. All participants had a diagnostic ultrasound.

Follow-up evaluations were performed at 6 and 12 weeks following completion of the 3-week course of treatment. Seven outcomes were measured: (1) Overall, morning, and activity pain were each measured on a vertical 100-mm VAS with descriptors at either end of 0 (no pain) to 100 (maximal pain). Overall pain at 12 weeks was the primary end point of the study for the determination of efficacy and sample size. (2) Walking ability without need for a rest to relieve painful heel,19 measured using a 6-point rating scale (0 = <5 minutes, 1 = 5-14 minutes, 2 = 15-29 minutes, 3 = 30-44 minutes, 4 = 45-59 minutes, and 5 = 60 minutes). (3) The Maryland Foot Score37 is a disability index that derives a score from 0 to 100 points, taking into account pain and function of the foot. Interpretation of the score has been suggested as 100 graded as normal, 90 to 100 as excellent, 75 through 89 as good, 60 through 74 as fair, and less than 60 as poor. While its clinimetric properties have not been formally studied, it has been shown to correlate with the severity of foot injuries37 and has also been used in a clinical trial of plantar fasciitis in which it appeared to be responsive to change.11(4) The Problem Elicitation Technique38 is an interviewer-administered patient-preference disability measure in which the individual is asked to identify his/her own problems related to the condition under study that he/she would most like to see improve as a result of therapy. The importance and magnitude of each identified problem are elicited by Likert scales (importance: 0 ["not at all important"] to 10 ["most important"]; magnitude: 0 ["without any difficulty"] to 7 ["unable to do"]). The score for each problem is obtained by multiplying the importance of the problem by the magnitude of the problem (level of difficulty, frequency, or degree of severity). A higher score indicates a higher degree of perceived disability and/or importance. The Problem Elicitation Technique score is obtained by adding the scores for all volunteered problems. (5) The Short-Form–36 Health Survey (SF-36)39 is a self-administered 36-item generic indicator of health status that consists of 8 subscales representing 8 dimensions of quality of life: physical function, role limitations due to physical health problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and general mental health. Each of the 8 subscales is rescaled from 0 to 100; higher scores represent better health. (6) All reported adverse effects were recorded. (7) Success of blinding was assessed at the conclusion of the study by asking participants to indicate which treatment they believed they had received.

Sample Size

The sample-size calculation was based on the comparison of ESWT and placebo groups with respect to the principal outcome measure of pain (on a 0- to 100-mm VAS scale) at the 12-week follow-up assessment. Pilot data collected in 121 participants indicated that the between-subject SD was approximately 25 mm and the baseline/6-week correlation was approximately 0.5. The baseline/12-week correlation can be extrapolated from this value to be 0.25. Using these parameters, a sample size of 60 patients per group would have 80% power (P = .05, 2-sided) to detect a difference of 13 mm in mean pain level between the groups at 12-week follow-up using an analysis of covariance adjusting for baseline pain level.

Data Analysis

All analyses were planned on an intention-to-treat principle using all randomized patients who provided any postbaseline data. Demographic characteristics of the ESWT and placebo groups were summarized by descriptive statistics. Changes from baseline to 6 and 12 weeks for outcomes measured using essentially continuous scales (pain, Problem Elicitation Technique, Maryland Foot Score, and SF-36 components) were compared between ESWT and placebo groups using t tests, or Mann-Whitney U tests where required. Additional supportive analyses using adjustment for baseline values of the outcome variables and characteristics exhibiting at least slight imbalance at baseline were performed using multiple linear regression. The estimates of between-group differences in means with and without such adjustments exhibited only minor differences, and therefore only the unadjusted between-group differences are presented, together with 95% confidence intervals (CIs). For simplicity of presentation, all results are presented as improvements from baseline (for example, reduction of 20 units on a VAS scale is represented by an improvement of 20 units). Consistency of results across a priori–specified subgroups (thickness of lesion and unilateral vs bilateral symptoms) was assessed including relevant interaction terms in regression models. In addition, consistency of results across total doses of ESWT (as greater or less than 1000 mJ/mm2) was also assessed by multiple regression.

Walking ability was measured on an ordinal scale and was compared between groups at 6 and 12 weeks using an ordinal logistic regression model. This regression produces odds ratios (ORs) comparing the likelihood of higher scores on the scale for ESWT compared with placebo. For example, an OR of 0.80 indicates that the odds