Is Radiofrequency Ablation Effective For Achilles Tendinosis?
A recent study shows good results for endoscopy-assisted radiofrequency ablation for patients with insertional Achilles tendinosis in combination with synovectomy and tendon debridement.
The study, published online in the Journal of the American Podiatric Medical Association, included 78 patients with unilateral insertional Achilles tendinosis. Patients had either endoscopy-assisted radiofrequency ablation, extracorporeal shockwave therapy (ESWT) or eccentric calf muscle exercises. For patients who had radiofrequency ablation, Visual Analogue Scale (VAS) scores, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot score, and the Victorian Institute of Sports Assessment-Achilles (VISA-A) scale score were significantly better than those in the ESWT and eccentric exercise groups after 18 months of treatment, according to the study.
Radiofrequency offers a minimally invasive approach to treat recalcitrant Achilles tendinosis, notes Patrick DeHeer, DPM, FACFAS. He says one should consider radiofrequency when a “robust attempt” at conservative therapy has failed. Bob Baravarian, DPM, FACFAS, concurs, noting that podiatrists should use radiofrequency ablation for chronic Achilles tendinosis that has not responded to any forms of conservative care.
Radiofrequency breaks up chronic scar tissue and allows neovascularization, according to Dr. Baravarian, the Chief of Podiatric Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and the Director of the University Foot and Ankle Institute in Los Angeles. He says the therapy also allows for some small fiber nerve ablation. Dr. Baravarian cites a disadvantage of radiofrequency ablation in that the small fiber nerve ablation does not protect the area and can also cause some fibrosis in comparison to other treatments.
As equinus is often the underlying etiology to Achilles tendinosis, Dr. DeHeer says one should treat equinus conservatively as well. However, if surgery is an option, one may attempt surgical treatment of the equinus deformity either prior to or in conjunction with radiofrequency, according to Dr. DeHeer, a Diplomate of the American Board of Podiatric Surgery, who is in private practice with various offices in Indianapolis.
Dr. DeHeer uses a comprehensive conservative approach for Achilles tendinosis, including equinus management, inflammation reduction and eccentric exercises. For non-responsive cases, he prefers a Baumann gastrocnemius recession. Additionally, Dr. DeHeer has found the injection of amniotic products to the Achilles to be beneficial and also does this intraoperatively when performing a gastrocnemius recession.
For the Achilles, Dr. Baravarian says platelet rich plasma (PRP) and amniotic stem cell injections have been about 70 percent successful in his practice while Topaz (Arthrocare) is about 80 percent successful. If none of those treatments works, he will perform debridement with a possible flexor tendon transfer.
For a related article, see “A Closer Look At New Developments In Treating Achilles Tendon Ruptures” on page 68 in this month’s issue.
Study: Forefoot Cushioning More Effective Than Metatarsal Pads For Reducing Plantar Pressure In Runners
By Brian McCurdy, Managing Editor
An orthosis with forefoot cushioning can reduce plantar pressure in runners more than metatarsal pads, according to a new study in the Journal of Foot and Ankle Research.
The study focused on 23 asymptomatic patients who ran on a treadmill for two minutes wearing either a metatarsal pad, forefoot cushioning or control footwear. Researchers found peak pressure in the forefoot was significantly lower when patients wore an orthosis with forefoot cushioning in comparison to control footwear or a metatarsal pad. They also noted no difference in peak pressures between control footwear and a metatarsal pad.
For runners with a lot of plantar metatarsal pressure, Richard Blake, DPM, says one option for reducing pressure is a zero drop shoe with less heel elevation, such as the Altra line of shoes. He notes other options include placing metatarsal pads just behind the weightbearing surface of the metatarsals to spread out the weight better; making full-length orthotic devices without as much drop between the heel and forefoot; trying a non-rearfoot posted orthotic device; or attempting to have runners change their gait to spread their weight evenly on the foot, going away from forefoot landing or even heel striking.
The advantage to metatarsal padding is that it can capture the bony structure of the metatarsal shafts really well, notes Dr. Blake, the Past President of the American Academy of Podiatric Sports Medicine, who is in private practice in San Francisco. However, he says the difficulty with using metatarsal pads is that labs that bury the pads under the topcover make the pads difficult to adjust. Dr. Blake emphasizes that the doctor and patient should place the pads, and experiment with their size.
“Forefoot cushioning sounds great but it can disrupt shoe fit if there is too much cushioning, or float the foot, leading to instabilities if cushioning is too soft,” says Dr. Blake.
Dr. Blake prefers a forefoot cushion like Spenco, which is not too hard and not too soft. He likes to bevel the toe area to avoid dealing with ingrown nails. Dr. Blake will use forefoot cushioning to full length to control propulsion by adding varus wedging, valgus wedging, Morton’s extension or dancer’s padding (reverse Morton’s extension). He notes one can add sweet spot accommodations to the forefoot padding to assist in offloading.
Are Close Contact Casts As Effective As Surgery For Unstable Ankle Fractures?
By Brian McCurdy, Managing Editor
Close contact casting may be as effective as surgery in older patients with unstable ankle fractures, according to a new study in the Journal of the American Medical Association.
The study focused on 620 adults over the age 60 with acute, overtly unstable ankle fractures. Three hundred and nine patients had surgery while 311 had casting with a six-month follow-up. The study found that close casting had functional outcomes that were similar to surgery with no significant differences in secondary outcomes such as quality of life, pain, ankle motion, mobility and patient satisfaction.
Ted C. Lai, DPM, notes the most effective treatment protocol for an unstable ankle fracture is first obtaining proper anatomical closed reduction, splintage with posterior and sugar tong splints to stabilize the unstable fracture, and allowing soft tissue swelling to subside. Once the soft tissue swelling has resolved, he says open reduction internal fixation (ORIF) is required. Although external fixation and casting are treatment options for ankle fractures, the stability these two methods afford is significantly less, especially with casting, according to Dr. Lai, a Fellow at the Orthopedic Group in Pittsburgh.
In contrast to the study, Dr. Lai has found that contact casting is not as effective as surgery/ORIF for an unstable ankle fracture in terms of stability. With fracture healing/stabilization, he notes primary bone healing is necessary, entailing rigid internal fixation with minimal interfragmentary strain. Dr. Lai says fixation creates compression of the fracture and ultimately decreases any micromotion, which also decreases the risk of non-union.
With contact casting, Dr. Lai notes fractures heal by secondary bone healing, there is no rigid stabilization and micromotion is present at the fracture site. If there is excessive micromotion, which is easily evident with casting, he says nonunion may occur.
With unstable ankle fractures, Dr. Lai notes the fibula is usually shortened and due to the fact it is unstable, the syndesmosis or deltoid may also be disrupted.
“If all these factors are not appropriately addressed, most of which have to be addressed by surgical means, then the ankle mortise will not be intact and you will have incongruity of the ankle joint, which may eventually develop post-traumatic arthritis,” explains Dr. Lai.
