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Abstract presented at ISMST Congress in Orlando, Florida on February 11, 2003

Dr. Cosentino of Sienna
ESWT IN THE TREATMENT OF INFERIOR CALCANEAL ENTHESOPHYTOSIS: PREDICTION OF OUTCOME BY FAN-BEAM DUAL-X-RAY ABSORPTIOMETRY (D.X.A.).

The purpose of our study has been to evaluate variation in the density of enthesophytosis associated with the clinical outcome after ESWT.

Painful heel is a common syndrome with evidence of an inferior calcaneal enthesophytosis in about 50% of cases. The patients feel severe pain in the inferior aspect of the heel, especially in the morning and after a period of rest. The condition is slowly progressive to the extent that the patient may become disabled.

The cause of this clinical entity remains enigmatic and is not clear. However, numerous factors have been claimed: functional overuse, degenerative diseases, inflammatory diseases and metabolic diseases.

The conservative methods of treatment usually adopted included: insole supports, injections of local anesthesia and corticoids, antiphlogistic medication.

20 patients (14 females and 6 males) were examined aged between 40 and 70 years, with a mean age of 53 years, showing talalgia associated with enthesophytosis of the plantar fascia.

Inclusion criteria were: pain over the radiologically examined heel spur and unsuccessful conservative therapy (insole supports, injections of local anesthesia and corticoids, analgesics and non steroidal anti-inflammatory drugs) during the 6 months before referral to our hospital.

The exclusion criteria were: arthritis (rheumatoid arthritis, spondylartritis, crystal induced artropaty), neurologic abnormalities, nerve entrapment syndrome, pregnancy, age under 18 years, infectious or tumorous diseases, ulcerations, bursitis.

No other treatment or drug was used during the 4 weeks before the trials began or during the study period. During the periods of treatment and follow-up only the use of insole supports were permitted. All patients were informed of and consented to the treatment methods.

A ESWT system was utilized Orthima by Direx Medical Systems Ltd. That is characterized by an electrohydraulic shock wave source assembled on a mobile arm with full possibility of movement. It is also equipped with a sonographic system with Linear Array and 7.5 MHz probe.

The therapy comprised 5 treatment (1 every 7 days), each treatment consisting of 1200 shocks with a frequency of 120 shocks per minute, the energy density utilized varied from 0.03 mj/mm to 0.4 mj/mm.

Since pain could use high energy mostly during the first treatment, all patients during the first treatment, were treated with an energy density of 0.03 mj/mm for the first five minutes, which was the progressive increasing of up to0.28 mj/mm. During the second treatment, all patients were treated with an energy density of 0.28 mj/mm for the first five minutes, which was the progressive increasing of up to 0.4 mj/mm. During the other treatments the energy density was 0.4 mj/mm.

The shocks were aimed at the enthesophytosis that was identified during sonographic examination. Local anesthetics were not used during the procedure.

Pain level were evaluated by Visual analog Scale (VAS), ranging from 0-no pain to 10-maximum pain, at rest, following walking and after normal daily activity. Such assessment was made before, at the end of the therapy, after 3 months and after 6 months.

Variations in the density of enthesophytosis were evaluated by dual-x-ray absorptiometry (DXA) at baseline and after 1 month from the end of therapy. Bone Mineral Density (BMD) and Bone Expert version 1.72; in each patient was created a region of interest (R.O.I.) to include the enthesophytosis and to exclude the os-calcis cortex. This R.O.I. remained unchanged for lateral controls.

The non parametric Wilcoxon-test for dependent samples was applied to compare means of VAS, the paired Student T-test was applied to compare changes in BMD and BMC.

A significant decrease of VAS (P<0.0001) was observed just after the treatment and after 3 and after 6 months at the three reference points of at rest, following walking on awakening and after normal daily activity.

Densitometric analysis of enthesophytosis showed a significant decrease of bone mineral content (BMC) (P<0.001) and a significant increase of bone mineral density (BMD) (P<0.0001) after 1 month from the end of the therapy.

In this study we did not observe side effect of ESWT< such as consecutive bleeding, superficial or deep hematoma, or clinical signs of nerve lesion. A temporary, slight redness of the skin and a transient increase in pain levels are within the norm.


Our results showed that ESWT has a safe and efficacious effect on the painful symptomatology and that the improvement in painful symptomatology can be correlated with a decrease of BMC of the enthesophytosis.

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