Happy Feet: New Techniques, Materials Advance Foot/Ankle Care

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"To him whose feet hurt, everything hurts." Socrates

You don't have to be an ancient Greek philosopher to agree with Socrates. Anyone who has suffered from serious foot pain knows how physically limiting and mentally and emotionally distracting it can be. The human foot is highly complex: about 25 percent of the bones in the human body are in the feet; each foot and ankle contains 26 bones, 33 joints, more than 100 muscles, tendons, and ligaments, and a network of blood vessels, nerves, skin, and soft tissue. Our feet absorb one and one-half times to twice our body weight during normal walking and up to four times our body weight when we are jogging, notes the Australasian Podiatric Council ( www.feet.org.au ). And throughout an average lifetime, our feet will carry us a distance equivalent to walking around the entire earth three timesabout 75,000 miles!

Feet grow the fastest during childhood, and if you think your teenage son has big feet, consider Matthew McGrory, an actor who was seven feet, six inches tall and wore size 29 shoes! Until his death in 2005, McGrory held the Guinness Book of World Records title of the world's largest feet for a person not suffering from elephantiasis.

On the downside, the Australasian Podiatric Council notes that by the time the average person reaches the age of 50, his or her natural foot pad will have lost up to half of its shock-absorbing capacity. Considering factors such as an aging population with age-related health issues and the surge in diabetes and obesity, both of which have been labeled "epidemics," the stage is set for an increasing number of persons needing treatment from pedorthists, podiatrists, and orthotists, as well as orthopedic and podiatric surgeons.

Janisse
Janisse

The numbers are already high. According to the American Academy of Orthopaedic Surgeons (AAOS) ( www.aaos.org), one in six persons in the United States has foot problems, a total of 43.1 million people. Thirty-six percent of those regard their foot problems as serious enough to warrant medical attention. One obstacle to providing that care issurprise!reimbursement issues. Dennis Janisse, CPed, president and CEO of National Pedorthic Services, Milwaukee, Wisconsin, and a former president of the Pedorthic Footwear Association (PFA), says, "With the current insurance reimbursement structure, I don't think we have as much freedom as we did in the past to provide the kind of patient care we would like. And people often are reluctant to pay expenses out of pocket, or else they just don't have the resources to do so."

Despite reimbursement obstacles, advances in materials and techniques continue to emerge, enabling foot care professionals not only to achieve better patient outcomes, but also to increase patient satisfaction. "We have a much better selection now in hosiery; a lot more attention is being paid to hosiery to create a better environment in the shoe," Janisse says. New products that reduce shear forces inside the shoe also help, he notes. Janisse sees more use of natural fibers and materials, including materials incorporating copper and silver, which have natural antimicrobial and antifungal properties. "These materials are not...always cost effective," he observes, "but I think they will become more affordable in the future." In fact, copper as a medicinal agent is a good example of something old that is now new again. "The ancient Egyptians used it to prevent infection and disease," Janisse notes.

Weil
Weil

When more conservative, traditional methods fail, new technologies are coming to the rescue. Two of these involve extracorporeal shockwave therapy (ESWT) and a new, metal-free, total-ankle-replacement technology.

Extracorporeal Shockwave Therapy

Extracorporeal shockwave therapy (ESWT) is a derivative of lithotripsy, the mechanical breaking of kidney stones with sound waves. Use of ESWT to treat musculoskeletal disorders began in Europe in the early 1990s and has been used for treating various disorders, including plantar fasciitis, epicondylitis, tendinitis, and osseous non-unions. The U.S. Food and Drug Administration (FDA) approved ESWT in October 2000 for treatment of plantar fasciitis and in March 2003 for lateral epicondylitis (tennis elbow). The treatment has been considered a noninvasive alternative to surgery for cases not responding to more conservative treatment.

"I suggest using [ESWT] when standard, more conservative treatment fails, but to consider it before surgery," says Lowell Weil Jr., DPM, MBA, FACFAS, fellowship director, Weil Foot & Ankle Institute, Chicago, Illinois, and team podiatrist for the Chicago White Sox. Besides other research, Weil has authored a paper on the efficacy of ESWT for Mortons neuroma, slated to be published before the end of the year in the Journal of the American Podiatric Medicine Association (JAPMA).

An Internet search reveals that the treatment is growing in popularity among podiatric and orthopedic professionals. Kirk Woelffer, DPM, Raleigh Foot and Ankle Center, Raleigh, North Carolina, is one such proponent. "This is a one-time procedure to stimulate healing using high-energy sound waves that are projected into the foot following local anesthesia to the area," he says. "The most common condition that this technology is used for is proximal plantar fasciitis.... It is a low-risk, high-reward procedure, with high success rates and low complication rates. It is reserved for patients who do not get better following several months of traditional treatments. It is a great alternative to surgery."

Woelffer
Woelffer

Just how shockwave therapy acts to treat musculoskeletal pathologies is not known. It is theorized that the waves cause microtraumas, which promote neovascularization of the tissue being treated. A study of shockwave versus a placebo on the Achilles tendons of mongrel dogs showed that shockwave not only promotes neovascularization but also facilitates the release of the growth factors proliferating cell nuclear antigen (PCNA), vascular endothelial growth factor (VEGF), and endothelial nitric oxide synthase (eNOS), Weil notes in the article, "What You Should Know about Shockwave Therapy," Podiatry Today, November 2004.

High-energy ESWT involves only one treatment, but local anesthesia generally is required, and other types of anesthesia may be used. Low-energy ESWT involves more treatments but generally requires no anesthetic, especially when biofeedback is incorporated, according to Weil. "In situations when the treatment includes biofeedback, no local or sedative anesthetic whatsoever is required," Weil notes in "Emerging Concepts in Shockwave Therapy," Podiatry Today, June 2008. "It is critical that the patient feels the full effects of the treatment and that the physician accurately directs that treatment. The treatment typically includes a low intensity initially to target the critical areas of treatment accurately and to get the patient acclimated to the slight discomfort. As the treatment proceeds, patients will find the higher energy levels increasingly more tolerable and energy levels increase throughout the procedure."

Weil notes that the low-energy radial ESWT (rESWT) is more cost-effective than high-energy ESWT and surgery.

Advantages of ESWT over surgery include faster return to work and normal daily activities, Weil wrote in the "Shockwave Therapy" article. "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."

Persons with pacemakers or pregnant women are not appropriate candidates for ESWT. Side effects can include minor pain or discomfort during and after treatment and minor skin bruising or reddening or swelling of the treated area, but such effects usually resolve within a few days, according to various sources.

Kirk Woelffer, DPM, performs the shockwave procedure on a patient who has plantar fasciitis.					Photograph courtesy of Raleigh Foot and Ankle Center.
Kirk Woelffer, DPM, performs the shockwave procedure on a patient who has plantar fasciitis. Photograph courtesy of Raleigh Foot and Ankle Center.

Although a number of studies support the efficacy of ESWT in treating various musculoskeletal disorders, the treatment is controversial, and many insurance companies do not cover it. However, Medicare does cover high-energy ESWT, according to Weil.

Total Ankle Replacementwithout Metal

Patients suffering from painful, disabling arthritis of the ankle can now have total ankle replacement without permanent metal implants, thanks to a new technique developed by Daniel K. Lee, DPM, FACFAS, director of podiatric surgery at the University of California, San Diego Medical Center, and assistant clinical professor in the department of orthopedic surgery at the University of California, San Diego. The technique provides increased mobility and pain relief without the failures and complications often caused by metal implants. The damaged cartilage is removed around the ankle joint through a four-centimeter incision, and then a proprietary, FDA-approved biologic material, similar to collagen found in cartilage, is molded into the joint. The minimally invasive surgery takes about two hours.

The material adapts to the contour of the patient's ankle. "Unlike a metal device, the advantage to this material is that the implant can be customized in size and contour for every patient's individual need," Lee is quoted as saying in a university press release. "No matter how the patient's ankle is shaped, the collagen is a perfect fit."

Daniel K. Lee, DPM, FACFAS.					Photograph courtesy of the University of California, San Diego.
Daniel K. Lee, DPM, FACFAS. Photograph courtesy of the University of California, San Diego.

The biologic material, processed from either human or animal collagen sources, has been used for more than ten years in various surgical procedures, the university notes, adding, "Since it is non-allergenic and sterile in nature, there is no risk of rejection or need for the patient to take immunosuppressors."

To allow the material to fully integrate with the ankle joint, a temporary external device, attached by small pins, is used to stabilize the joint area, keeping it distracted for a period of four to six weeks. The cylinder-shaped device keeps the joint free from friction and movement until healing is complete; it is then removed. The device follows the principles of the Ilizarov Technique, but is much less invasive and painful, Lee says. Since the technique is new, it is not yet known how long the replacement will last.

The new technique and results of a study will be described in late 2008 in the Journal of Foot & Ankle Surgery.

"I think the future for the technique is bright," says Lee. "Advances come from collaboration between basic science and clinical science. We have better cartilage replacement materials now than we had before, and scientists can help us by developing even better materials."

And, thanks to advances in materials, technology, and treatment modalities, the future looks brighter for the millions of persons suffering from painful foot disorders.

Miki Fairley is a contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mailat miki.fairley@gmail.com

Learn More about ESWTM

A radial ESWT device is being used to treat plantar fasciitis.					Photograph courtesy of Well Foot & Ankle Institute					.
A radial ESWT device is being used to treat plantar fasciitis. Photograph courtesy of Well Foot & Ankle Institute .

Here is a partial list of relevant "pro and con" research studies, articles, and expert discussions.

  • "Extracorporeal Shockwave Therapy: Hope or Hype?" Podiatry Today, November 2003 ( www.podiatrytoday.com/article/2137).
  • Letters to the editor published in the Journal of Bone and Joint Surgery 2004 ( www.ejbjs.org/cgi/eletters/86/10/2216). The letters were in response to: "Electrohydraulic High-Energy Shock-Wave Treatment for Chronic Plantar Fasciitis," John A. Ogden, Richard G. Alvarez, Richard L. Levitt, Jeffrey E. Johnson, and Marie E. Marlow, Journal of Bone and Joint Surgery October 2004.
  • "Long-Term Results of Extracorporeal Shockwave Treatment for Plantar Fasciitis," C.J. Wang, F. S. Wang, K.D. Yang, et al., American Journal of Sports Medicine, April 2006.
  • "Radial Extracorporeal Shock Wave Therapy Is Safe and Effective in the Treatment of Chronic Recalcitrant Plantar Fasciitis: Results of a Confirmatory Randomized Placebo-Controlled Multicenter Study," Ludger Gerdesmeyer, Carol Frey, Johannes Vester, Markus Maier, Lowell Weil Jr., Lowell Weil Sr., et al., American Journal of Sports Medicine, October 2008.
  • "Radial Shock Wave Therapy (RESWT) in Chronic Plantar Heel Pain: A Prospective Randomized Placebo Controlled Trial," L. Gerdesmeyer, M. Henne, and J. Vesters, Journal of Bone and Joint Surgery-British Volume 2006,Vol. 88-B, Issue SUPPJ, 21; ( http://proceedings.jbjs.org.uk/cgi/content/abstract/88-B/SUPP_I/21-b).
  • "Shock Wave-Enhanced Neovascularization at the Tendon-Bone Junction: An Experiment in Dogs," C. J. Wang, H.Y. Huang, C.H. Pai, Journal of Foot & Ankle Surgery, January-February 2002.
  • "Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis: A Randomized Controlled Trial," by Buchbinder, et al. Journal of the American Medical Association, September 18, 2002, ( http://jama.ama-assn.org/cgi/content/full/288/11/1364).
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