Okay, all right everybody, we're gonna get started. So thank you all for coming today. So our topic today is going to be innovations for management of foot and ankle conditions. So really excited to introduce our panel today. So I said we're waiting on one more speaker just to drop in today, but we're gonna begin with Dr. Benjamin Washburn, who comes to us from the University of Missouri in Columbia, where he's an assistant professor working in sports and spine medicine, is a head team physician for the US men's beach soccer team, as well as some of the other extended national teams. I'll be after that as well, and so my name is Ross Malek. I'm from Spalding over in Boston, where I also work with the US men's youth soccer teams as well. Next, coming to us from Tennessee at the Campbell Clinic, we have Dr. Christina Carrico, where she really specializes in performance arts, dance medicine as well. And then last for us today, we'll be having Dr. Adam Tenforty, who is the director of running and shockwave medicine at Spalding Rehabilitation Hospital and the National Spalding Running Center. So today our main objectives that we're gonna really touch on is fairly straightforward. We're gonna first start off with some anatomy and pathology of the foot and ankle, just to make sure everybody's on the same page, before really introducing some updates with regards to conservative treatments for foot and ankle injuries and exercise therapies, before we dive right into more regenerative medicine-based treatments. So certainly shockwave therapy, platelet-rich plasma injections, as well as discussing some of the ins and outs of bone stress injuries as well. Okay, so I'll hand it off to Dr. Washburn here. Thanks for the intro, Ross. Thanks everybody for being here. So yeah, I'm Ben Washburn. I don't have any relevant financial disclosures related to this talk. What I'm gonna try to do today is gonna briefly set the stage for my colleagues to talk about the kind of interesting things that they're going to be covering, and really just review some of the common foot and ankle related injuries and pathologies you may come across in clinic or on the sideline if you're doing sports medicine coverage. Some kind of pearls for evaluating and diagnosing these conditions, as well as not just the common things, but some less common conditions that can mimic them, and some specific diagnoses that you certainly don't want to miss. So, you know, in my personal experience, as well as in the literature, these are some of the common reasons that people will present to you in a clinical setting for kind of foot or ankle pain. And so certainly osteoarthritis, very common, you know, can affect multiple regions obviously, but, you know, the ankle joint, different regions of the midfoot or the first MTP joint are certainly among the more common. Ankle sprains, which we'll talk about in a little bit more detail in a minute, but are again very common reasons for someone to come see you in clinic. Tendinopathies, so certainly Achilles, peroneal, you know, posterior tib, among some of the common larger tendinopathies. Heel pain, as a common reason for presentation, certain plantar fascia is among the most common, but there's others we'll talk about you should be aware of. And then Morton's neuroma, bone stress injuries, which we'll talk about in more detail a little bit later, but just to kind of briefly review some of those, and then certainly a wide range of fractures. There's a bit of overlap on the sideline, but also some specific things. So certainly ankle sprain, very common in a lot of sporting settings. Contusions, certainly covering soccer. I see quite a bit of this, especially my beach soccer athletes who are playing barefoot, you know, toe, foot, shin, all sorts of different areas for contusion. Sprains, particularly the first MTP, so the turf toe type injury. Midfoot sprains, again a wide range of potential fractures, but the metacarpal, or sorry, metatarsal fracture being the most common there. And then plantar fascia, so not just, you know, maybe managing chronic condition, but, you know, acute injuries on the sideline. And then a little beyond the scope of this talk, but you know, a lot of other possible injuries or severities there as well. Some kind of pearls and things to think about in terms of evaluating these injuries on the sideline. I mean, one of the key things is you may not have access to imaging, x-ray, ultrasound, those sorts of things, and so relying on your mechanism of injury, the history, your physical exam, those things are gonna be very key for making decisions on the sideline, return to play, you know, imaging decisions, those sorts of things. In terms of your physical exam, some obvious things, right? Open fracture, dislocation, neurovascular compromise, certainly very clear that those would require, you know, kind of more urgent further evaluation and management. But also things like, you know, bode uniformity, crepitus, point tenderness, any gross instability, those would be things to think about when evaluating foot and injury, foot and ankle injuries on the sideline. Your auto-ankle rules, which we'll review in a second, but are very well validated for when you should consider x-ray of foot and ankle injuries. And then your functional assessment, right? So things like pain, swelling, range of motion, strength, but also sport-specific testing. So whatever your athlete is doing, whatever sport, whatever position they have, making sure that they can do those things on the sideline before you put them back in play. And then also important, both in kind of the immediate sideline return, but also longer term, is that athlete's perception and readiness to go back in. I mean, I've certainly covered high school games where there's an injury, it's probably safe to return. The athlete is not really sure they want to, and so making sure that you kind of have that discussion or evaluation as well. I mentioned the auto-ankle rules, I'm sure we're all familiar, but just to review because these are very important, very well validated in a number of studies. So anyone after a foot or ankle injury who can't bear weight for four steps, either immediately after or in their initial evaluation, bony tenderness of the distal fibula, tibia, medial lateral malleolus, base of the fifth metatarsal, or the navicular, these would be reasons to consider x-ray or further imaging before return to play due to the risk of possible fracture. So to cover a couple of these common things that we talked about that you will see in clinic and on the sideline, most definitely if you do this long enough, ankle sprain. And so, you know, most commonly this will be an inversion sprain, the ATFL ligament most likely involved with that, but also certainly other ligaments, you know, your CFL, your PTFL, sometimes the peroneal tendons, especially if you get into higher severity of these inversion sprains, as well as, you know, deltoid ligament in the medial structures if you have an inversion sprain. It's very important to keep in mind to distinguish between this and a high ankle sprain for a couple reasons. You know, high ankle sprains are less common, but they have typically a much longer recovery time, higher risk of requiring surgical intervention, and so definitely be on the lookout for these and consideration of like a syndesmosis or AITFL ligament involvement. In terms of managing this diagnostically, you know, x-ray to rule out a fracture if you're concerned. Look at the ankle mortis, you know, the joint space widening. These can give you clues about, you know, high grade ligamentous disruption or syndesmosis injury. Oftentimes with these ankle sprains, you may notice really small, minimally, or non-displaced avulsion fractures at the ligament origin or insertions. In most cases, those can be treated, you know, kind of the same way you would treat an ankle sprain, but keep in mind that those will often show up on x-ray. Usually this won't need an MRI unless you're suspecting a really high grade injury, a lot of instability on your exam, weakness. Again, if the x-ray shows concern for like, you know, ligamentous disruption with ankle mortis widening or syndesmosis injury, certainly those would be indications to think about MR. You know, or if someone's not getting better, right? If you've treated them appropriately, it's been several weeks and they're still struggling, maybe just consider to make sure you're not missing something. I won't get too much into rehab because we're going to talk about that in a bit, but certainly keeping in mind that for these ankle sprains, early rehab, range of motion strengthening, definitely with progression to functional rehab considerations does improve outcomes in return to support those sorts of things. Achilles tendinopathy, very common in athletes, but also in the general population. You know, in terms of things patients will complain of, localized pain to the tendon, sometimes focal swelling either at the mid portion or at the insertion. Loss of function, you know, they can't do the things they used to be able to do. They have stiffness when they first get out of bed or really stiff or painful after they've been sitting for a while. Sometimes movement will make it feel a little bit better, but then too much tendon loaning hurts as well. This would be kind of the common history you'll hear from these folks. You know, in terms of some patient-specific risk factors to keep in mind, some of these being modifiable, you know, individual physical biomechanical conditions like range of motion limitations, you know, strength, neuromuscular control, but also, you know, extrinsically. And a lot of times there's associations with Achilles tendinopathy of training error, right? Overuse, overloading, not enough recovery, those sorts of things. You know, also like medications, right? Again, this is pretty much a clinical diagnosis. If you do get an x-ray, you may see some intertendinous calcifications. You may see, like, cortical irregularity at the insertion. Sometimes a Hagelin deformity at the calcaneus at the insertion, which is kind of an associated but slightly different condition, but can certainly cause kind of that distal achilles, some insertional pain. MRI ultrasound, usually not necessary. I mean, if you have access to a bedside ultrasound, by all means, kind of put it on, take a look at the tendon. A lot of times it can help confirm your diagnosis. Um, plantar fascia, um, you know, I notice, or I label this plantar fasciopathy or plantar fasciosis. And, you know, a lot of times we term this plantar fasciitis still, implying this as, you know, inflammatory. This is typically more of a degenerative, mechanical, kind of repetitive overload type condition of the plantar fascia. One of the most common causes for heel pain, um, very classically first step pain. So in the morning or after prolonged inactivity, um, significant worsening of that heel pain. Um, you know, some factors to think about in terms of, um, you know, risk factors or things we can modify, um, limited ankle range, you know, BMI or obesity, um, activities, you know, occupational or athletic activities that involve a lot of prolonged weight bearing or a lot of high impact, um, again, especially if there's kind of a, um, a loading mismatch or kind of rapid increase in kind of the strain through those areas. Um, that can sometimes be associated with, you know, foot and ankle weakness or deconditioning certainly, um, and then age, you know, related factors. Um, again, typically you don't need imaging, uh, for your initial diagnosis and management of this. People will have, you know, the classic, uh, historical findings we're, we're discussing, you know, tenderness of the heel or kind of the medial calcaneal, um, uh, insertion there. Um, but certainly if people are not getting better, um, and they've tried all the appropriate things, um, it may be reasonable to get some imaging, uh, particularly to rule out some of these other kind of less common, um, uh, causes of heel pain. Um, you know, calcaneal stress fractures, Baxter's neuritis, Tarsal Tunnel Syndrome, all much less common than, uh, plantar fasciopathy, but certainly should be on your differential or in the back of your mind if someone's not getting better with kind of appropriate management of that condition. Um, Morton's neuroma, this will be a really common reason people see, um, you know, we'll see kind of clinical evaluation and oftentimes they'll come in complaining of even paresthesia in the toes or it feels like I'm walking on a pebble. There's like a rock in my shoe, that sort of thing. Um, and so this is, uh, kind of inflammation of the inter, interdigital nerve, um, as it passes between the metatarsals and the metatarsal head. Um, and, uh, typically you can distinguish this from like just a metatarsalgia. between the metatarsals. If you have access to an ultrasound and kind of have the skills to do that, you can certainly see the focal thickening. I'll touch a bit on bone stress injuries, again we'll talk about this in more detail, but I just wanted to mention this to be on your radar in terms of kind of high versus low risk bone stress injuries of the lower extremity of the foot and ankle. And the reason being that lower risk fractures typically respond very well to rest, you know, modified activity, gradual return to weight bearing, and have a really good prognosis with kind of appropriate management conservatively. Whereas high risk fractures, you really have to be on the lookout for these because you typically want to be a lot more aggressive initially with your management, much longer sometimes prolonged weight bearing or non-weight bearing, or even surgical intervention. And so some regions to be aware of high risk fractures would include your navicular, your medial malleolus, the proximal metatarsal, talus, or the great toe sesamoids. Whereas, you know, calcaneal or kind of mid shaft metatarsal are some lower risk areas for bone stress injury. And then, a little bit beyond the scope of this talk, but just some things to put on your radar to be aware of where, you know, you may want to talk to your surgical colleagues a little bit sooner rather than later, you know, distal fibula fractures at or above or proximal to the syndesmosis, so kind of your Weber C or B fractures. Certainly fracture dislocations, unstable fractures, trimalleolar fractures, or possibly, you know, Jones fracture at the base of the fifth met due to kind of risk for nonunion. Any sort of dislodged or unstable OCD lesions, you know, ankle joint dislocations with your high ankle sprains if there's syndesmosis, you know, significant disruption or widening of the joint. Acute tendon tears, not always, you know, Achilles don't, you know, we don't always have to operate on these, but at least to have the discussion or have that awareness in certain populations of primary surgical repair, and then, you know, kind of acute unstable ligament tears. So a couple of things to take home, one, foot and ankle pathologies, very common complaints in musculoskeletal clinics, on the sideline, a lot of your initial diagnosis and evaluation is going to be based on your clinical history and your exam. Keep in mind that a lot of these common pathologies do have some mimicking, less common conditions that can be overlooked or cause people to have delayed diagnosis. And that in general, conservative treatment does pretty well for a lot of these, but there are certainly things you want to be aware of that may require more early surgical intervention. So here's a couple of my pages for references, and I'll pass it off to Dr. Mihalik. Thank you. Okay, thank you so much, Dr. Washburn, for the great introduction to some of the pathologies that we're going to be seeing a little bit more frequently. And so I know many of you are already familiar with a lot of the conservative treatments, the exercise therapies that go along with some of these pathologies, but the goal today is really to hopefully expand on some of these and see if there's been any new updates with these. So I don't have anything to disclose, and some of you may say, so what's so special about the foot and ankle? It's a lot of small joints and bones, so why is it that important? And I think it's really said well by U.S. men's national team soccer star Weston McKinney when he was highlighting a conversation he had with one of his former teammates and global superstar Cristiano Ronaldo. One story with Ronaldo, he was getting a massage and I was walking by, I said, oh my gosh, your feet look terrible, terrible, he said, my friend, these feet are worth 1 billion euros. So the point really is, right, if we take care of our feet, hopefully maybe one day our feet can also be worth 1 billion euros. But with this, there's a lot of different pathologies as we already highlighted, so I tried to pick a couple that are going to be very well representative of the foot and ankle in general, and some of these treatment plans can also overlap with other pathologies as well. So we'll start with the lateral ankle sprain, then going into Achilles tenopathy, plantar fasciopathy, as well as progressive collapsing foot deformity. So with the lateral ankle sprains, certainly many of you, again, are familiar with this, and so we're kind of elaborating a little bit here, but this was a diagram taken from a clinical guidelines piece from 2021, which really highlights a couple of different things. In the first two columns on the left, this is very much about prophylactic treatments for initial ankle sprains as well as recurrent ankle sprains. And really from these two columns, the takeaway is just that prophylactic bracing can be quite helpful, there's evidence there, but really prophylactic exercise didn't really show to be that helpful for these groups. But in the third column, where we talk about acute lateral ankle sprains, that's where we really shift, and it really is all about early and often weight-bearing as well as range of motion exercise, as Dr. Washburn really alluded to. It's kind of the opposite of, I feel like, when I was first learning, where it was all about resting, kind of letting the knees back in and things. We want to try and get them moving as soon as possible. Additionally, using some manual therapies as well, focusing mostly on joint mobilization, which we'll touch on a little bit later too. The last column is what they call tertiary prevention here, but this is more chronic ankle instability. We've all met these patients as well, and we'll talk about this a little more in the next slide, but I wanted to highlight here that a lot of the literature really shows that for our lateral ankle sprains, up to about a third, even a half of these patients are really still experiencing chronic ankle instability and recurrent ankle sprains, certainly chronic pain in that ankle as well. So when we address chronic ankle instability, some of the takeaways that I noted in the literature was that bracing really wasn't that useful in sort of limiting and improving the function in this group, but therapeutic exercise, again, was really the hallmark here. So focusing on proprioceptive as well as neuromuscular exercises to improve that dynamic stability in the joint. Additionally, I think one of the things I always tell our patients is that it's not just about the foot and ankle here. So interestingly enough, focusing on that proximal lower extremity stabilization, so hip strength, glute strength, core strength, can also be really helpful for improving that static as well as dynamic balance. Additionally, manual therapy can be a helpful adjunct here, so addressing joint mobilizations, especially ankle dorsiflexion, trying to improve that range of motion is quite helpful here. And then one that was new for me, at least, was dry needling of the fibularis muscle group was also shown to have some therapeutic benefit here as well. Now when we address proximal lower extremity stabilization, I lean a little bit on one of our great physical therapists at Mass General, David Nolen, who highlighted a couple exercises for me especially, but a lot of it is side-lying exercises. So certainly side-lying plank holds, side-lying bridges, side-lying hip abduction, as well as addressing single leg stance exercises, single leg stance squats is quite helpful. You can do this both on a flat surface as well as on a medicine ball seen here in the photo. Now we're moving into our next pathology with Achilles teninopathy. So really the first thing is you want to address is it insertional Achilles teninopathy or mid-bellies Achilles teninopathy? A lot of these principles are still going to be the same, but there are going to be some subtle variations with each of these protocols depending on where the teninopathy is. But in general, there's going to be three sort of main protocols here. There's going to be the classic eccentric strengthening protocol made famous by Alfredson's group, concentric and eccentric strengthening, and then a variation of this called heavy slow resistance as well. But in general, most people kind of progress from a manual resistance strengthening program to using resistance bands, and then finally more weight-bearing based exercises. So when talking about Achilles teninopathy, I think it's important first to take one step back and just sort of understand that there's constant remodeling in fairly most tissues, but especially with a tendon injury, and Achilles tendon is no exception to that. But with that, that's a normal physiologic process. But to be able to address Achilles teninopathy where there's been sort of this pathologic healing going on with that and there's chronic repetitive damage, when we're addressing and developing an exercise plan, we need to modify that and really meet the specific characterizations of that patient and their specific limitations so that we're not loading the tendon too much and too early for them. So for example, if someone has severe pathology, we certainly don't want to start off very aggressively. We want to start with fairly low-grade exercises. And this sounds very simple, but this pain diagram I took from this paper here on the right just really helps to give you a visual. And that 0 to 2 mild pain, it's okay to live in that range certainly where we're loading the tendon, but even moderate pain is okay. Again, we're adequately stressing that tendon, but we don't want to push through that going into that more severe pain, that 5 to 10 range. That means we're overdoing it for these patients and could potentially cause more harm. So this first paper I highlighted here really takes the gold standard eccentric strengthening protocol and compares it to concentric and eccentric strengthening. And this was really a 12-week exercise program for both of these, and it really highlighted that both groups did quite well from a pain and functional standpoint. There really was not any significant difference. So both groups did well at up to one year here. With that, there's a couple of exercises that I kind of highlighted here as well, but really the main progression here is that they started them with basically just doing exercises on a flat surface before progressing to using a step, using a step with weights, then progressing to quick rebound heel raises, and then finally into sport-specific plyometric exercises. Now just to give an example of one subtle variation here is that if you do have insertional Achilles tendinopathy, you need to be very careful about implementing a step into your exercises because we really don't want them to push past neutral with regards to ankle dorsiflexion because that can put undue stress on that insertion point of the Achilles. So with our plyometric progression exercises here, again, leaning on our physical therapist David Nolan, there's a couple exercises I just wanted to highlight to give you an idea. But certainly you can start with two-legged press exercises before progressing into single-leg presses, and then going into agility ladder plyometric exercises and sort of dynamic resistance-based movements. Now another comparison study here, we have again the classic eccentric strengthening protocol from Alfredson, and then comparing it against heavy-slow resistance, which we kind of highlighted as well. So that's sort of a variation of the concentric and eccentric strengthening protocols. Again, both groups did very, very well. They followed them for about 52 weeks. So at 12 weeks and 52 weeks, both groups did very well and had significant improvements with both pain and function. They also noted that there was significant reduction in the tendon thickness, as well as the neovascularization of the Achilles tendon. But really the main difference here that I thought was interesting, and you may already be familiar with this, is that with the heavy-slow resistance, there was actually greater patient satisfaction and compliance compared to the traditional eccentric strengthening. So certainly if you're trying to get patients to do the same exercises and complete your protocol that you have in mind, it may be an option to switch over to the heavy-slow resistance. Now kind of tying all the Achilles tenopathy we've been discussing so far, this is a clinical guidelines paper from 2018, which again highlights that the heavy-slow resistance, eccentric strengthening protocols both have good evidence for them. Knight splints were shown not to be as helpful in this group as well. But again, kind of what we talked about for the ankle sprains, activity modification and kind of getting them back early if we can and keeping them moving is going to be more helpful than just the classic rest and not using that area. Stretching the posterior chain, so certainly plantar flexors as well as the hamstring can also be really helpful in this group as well. Now as Dr. Washburn alluded to, this is very commonly known as plantar fasciitis, but again I want to highlight again, this is really a more accurately termed plantar fasciopathy, right, because this is a chronic degenerative pathology. And from this clinical guidelines paper, again we're really taking a big picture and that's what I really want to drive home. We get so focused on the plantar fascia, but really it's important to adjust the entire kinetic chain here. So certainly I always describe a little bit of the posterior chain, so going from the hamstrings down to the gastroxilius complex and into the plantar fascia and Achilles as well is important to address that. So really focusing on improving lower extremity flexibility, stretching of the gastroxilius complex as well as the plantar fascia can be quite helpful for both long-term and short-term pain and functional improvements. Taping did have some benefit in this group and we've all seen people that come in that have been prescribed very fancy shoe orthotics, but really what they highlighted from this piece was that just in isolation, shoe orthotics didn't have any benefit when used as an adjunct to some of these treatments. So it could still be useful, but it's important to keep them moving and doing exercises, which we'll highlight a little bit here. But they also mentioned night splints are helpful up to about three months or so. But again, the exercise therapy is really what helps to get these patients back to where they need to be, focusing mostly on resistance strength training, neurodynamic interventions as well, and then focusing also on foot intrinsic muscle core strengthening exercises. So certainly like foot yoga type exercises, but again, I don't want you to lose track of that kinetic chain that we're talking about. So certainly addressing any flexibility issues in the hamstring is going to be important as well as addressing any hip or glute strengthening can be imperative here. Dry kneading was shown to be a helpful adjunct as well, again, focusing on that posterior chain, so that gastroc soleus complex, as well as plantar muscles. Now our last pathology here is a little bit different one. So this is progressive collapsing foot deformity, or I guess many people will know this as posterior tibial tendon dysfunction. And I highlight this here because it has undergone a little bit of a name change here. And the new name really highlights the fact that there is noticeable joint destruction that can occur with these in the foot and ankle, as well as arch destruction. So it really just highlights that the posterior tibial tendon really has a lot of important functions in this area of the body. So with that being said, bracing can be helpful up until about seven years or so in terms of limiting this joint destruction. With that, strengthening as well as stretching is really important here. So even though the posterior tibial tendon is not one we classically think about strengthening, Kulig et al. really highlighted that a 10-week eccentric strengthening protocol for this did have significant improvements in this group, as well as also tying in foot core strengthening, core strengthening exercises as well. So we kind of rapid fired through a couple of different things through here. But really what I want you to take home from this is that for lateral ankle sprains, again, we got to get them moving early and often, right? So we want to get them doing whatever they can early. We're also tying in that proximal lower extremity stabilization. So that hip and glute strengthening is going to be important. For Achilles tendinopathy, right off the bat, we have to distinguish is it insertional Achilles tendinopathy or mid-belly Achilles tendinopathy before then progressing into the classic either eccentric strengthening or heavy slow resistance strengthening. For plantar fasciopathy, again, we got to think big picture here. We have to also address the entire posterior chain here, as well as also addressing that intrinsic foot muscle strengthening. As for the progressive collapsing foot deformity, again, eccentric strengthening protocols. For the posterior tibial tendon, we've got to focus on that first before also trying to limit that classic degeneration that can happen in the foot and ankle joint, as well as the arch. So bracing can be helpful for that as well. And with that, I will turn it over to Dr. Karoliko. So I'm going to talk to you guys about some of the regenerative medicine techniques for foot and ankle injuries that we had previously discussed. I'm primarily going to focus on shockwave and PRP because that's what most of the literature, which is not a lot of it, but that's what most of the literature kind of covers. I don't have any disclosures. So first off, what is a shock wave? Shock wave is a sound wave. It's actually found in the atmosphere. It's an abrupt change in pressure, but you can use it clinically, and we call it extracorporeal shock wave therapy. And that shock wave can propagate the energy to evoke some interstitial and extracellular responses. So how is it different from ultrasound, also a sound wave? It's 1,000 times stronger, and also the waves are different. So you can kind of see in that top chart, that's what an ultrasound wave looks like. It's sinusoidal, whereas the bottom chart shows what a shock wave looks like. There's a positive deflection and a negative deflection. The positive is kind of that direct mechanical force in the sound that you hear, and the negative produces something called cavitation. So cavitation is a descriptor for that impulse that goes through the cells, basically bursts them, causes some micro-bleeding, and that would then cause a signaling cascade to happen in the body. Very similar to PRP in terms of trying to stimulate some healing there. Now there's two types of shock wave that you'll hear about in the literature. One type is called focused shock wave, and that's represented by A, B, and C on those charts there. So it's electrohydraulic, electromagnetic, and piezoelectric ways to generate the shock waves. And then that last picture on that bottom right in D, that's representative of what's called a radial pressure wave. It used to be called radial shock wave, but we're trying to move away from that nomenclature and call it a radial pressure wave, because it is slightly different from focused shock wave. And in that chart on that bottom right, we'll kind of show you kind of where the treatment zones are. So radial pressure waves, which is represented by that blue line, it has more of an effect just below the surface of the skin. And then as the waves propagate deeper, they become a little bit weaker. Whereas with focused shock wave devices, you can actually change the depth of where the treatment zone is based on the standoff at the end of the probe. And I'll go into that in a little bit. In terms of mechanism of action, honestly it's not entirely known. However, there are different proposed mechanisms. One is neovascularization in the degenerative tissue. At high energy levels, you can actually have destruction of calcifications. There's also some increased collagen synthesis and tissue remodeling that can happen. And at the same time, it also helps reduce pain. And they hypothesize that this could be because of stimulation of nociceptive C fibers and an increase in local pain inhibiting substances. Now in the literature, there's a lot of parameters that they'll describe. And so I just wanted to quickly go over them. EFD is energy flux density. So when people talk about high energy, low energy, that's kind of what they mean. Typically for soft tissue conditions like tendinopathies, plantar fasciopathy, in general you'll see in the literature you want to stay in the medium intensity range, which is about 0.08 or 0.10 millijoules per millimeter squared to 0.25 approximately. You can also change the settings on your machine, not just for the energy level, but the amount of pulses you do, the hertz, which is the frequency. In terms of number of treatment sessions, it's going to vary. All these parameters are actually going to vary depending on what condition you're treating. And I'm going to go into it a little bit once we delve into the literature. But generally in terms of how often this is done, in the literature it cites approximately every one to two weeks you'll do a session. However many treatment sessions you do is still not well defined. And anecdotally I've found that it varies based on how long the patient's been in pain, how high is their level of pain, and what the condition actually is that you're treating. Clinical focusing tends to be fine, meaning that as you're doing the treatment the patient feels it and it kind of hurts when you go over the area that's painful. And so I'm in constant dialogue with the patient saying like, oh, does it hurt here? And then they're like, yes. And once it starts to feel better I'll say, okay, let me know so I can move and find another area that's painful so I can treat that too. And for that reason it's actually been found in the literature that we want to avoid using local anesthetic because of that. I think that it prevents you from having that biofeedback with the patient. Using ultrasound gel is optimal so that way it's easier for the transmission of those shock waves into the tissue and honestly it makes it easier to actually glide and move the probe around. In terms of side effects, most of it's local and temporary. So they'll have pain at the application site. I always tell patients usually the first session is the worst and then as you get better it's more tolerable. And so I start off at a lower energy level and I gradually increase it, sometimes within the same session, you know, as the patients are able to tolerate it better. But certainly it's fine to like very slowly increase it in subsequent sessions as well. If they have sensitive skin they might get some petechiae, some redness, some erythema in the skin. If they're on blood thinners they could potentially get some hematomas or bruising. If you're over a nerve, this is where anatomy comes into play, they could potentially develop paresthesias or even nerve-like pain. I had one patient who I was treating the plantar fascia but then he called me later and he goes, I'm having all this crazy pain that's going up my Achilles and you didn't even treat there. You probably didn't tell me when I was kind of over like a branch of like this oral nerve. So next time tell me and then I'll just move away from it. So I usually tell patients if you feel pain shooting to a different part of the foot or going up the ankle that's different from where I'm holding the probe, let me know because that means I'm holding it over a nerve and I just need to move it. So I was curious to see how long it was because the guy was very stoic. He didn't say a word to me the entire session for like 10 minutes. I was curious as to how long that nerve pain would last for. It lasted for a week and then it went away. So just to kind of give you guys a thought. There are two case reports in literature of Achilles tendon ruptures. So this is extremely rare and when you delve and read a little bit more into those two case reports, the women were in their 70s. So it's possible that because of the natural history of their Achilles tendinopathy, they might have ruptured anyway without the help of the shock wave. So just something to keep in mind. In terms of the systemic effects, the most common one is headache, you know, and that's really the only one. It's very temporary. Now I'm just going to pivot a little bit. In the interest of time, I only wanted to focus on PRP. There's limited studies on the use of bone marrow aspirate or microfragmented adipose tissue as injectables in the foot and ankle. So I'm not going to touch on those. So we're just going to focus on PRP. So I know we've had a lot of lectures over the conference on PRP, so I'm not going to dwell too much on it, but basically it's a higher concentration of platelets than the circulating plasma and it can stimulate healing response. PRP is variable. There was actually a study done that showed that the platelet concentration can vary in an individual even throughout the day. So that's why the literature is often a lot kind of all over the place because it is so variable and we don't really know what the ideal protocol is per condition and all that. Now you might have heard about leukocyte-rich, leukocyte-poor and how leukocytes could potentially be harmful for chondrocytes, but they do help stimulate the repair process. There was a study done that showed that there's no differences between leukocyte-rich and leukocyte-poor when it comes to mediators of nociceptive pain, which I thought was interesting. And now we're finding that it might be the ratio of platelets to leukocytes that actually may be more important as opposed to the traditional leukocyte-rich, leukocyte-poor. In terms of potential risks and adverse effects for PRP, pain at the injection site, potential bleeding, potential infection because you are putting a needle in, superficial hematoma formation, potentially nerve damage if you're by a nerve. For this reason, you know, we use ultrasound guidance. That's preferred. It could potentially have scar formation. And then tendon rupture is extremely rare. Usually just as a precautionary measure, I will... If I'm injecting a PRP and needling a tendon, I'll have them non-weight-bearing and then gradually progress to partial weight-bearing and full weight-bearing over the course of a week. And that's been fine for me so far, knock on wood. Haven't had any tendon ruptures from doing that protocol, but everybody's protocol is kind of different. Now unfortunately, neither of these treatments are covered by insurance. The radial shockwave devices are FDA approved for... and focus shockwave devices as well, particularly for plantar fasciopathy and for lateral epicondylopathy, but insurances are still not covering it despite that. They still consider them investigational and so it's not covered by Medicare, Medicaid, or commercial insurances. I can tell you I've had had some success with workers' comp. So if you do have a workers' comp case and you want to think about doing this, I would say why don't you try submitting it because I have had it covered for a couple of my patients, several of my patients actually. For billing purposes, just for your billing department so they know what procedure code it is, that's what those procedure codes are for shockwave and for PRP. For two sites of treatment for shockwave, I use 0101T2X for like two sites. And now just delving a little bit into the literature, I separated it by condition to make it a little bit easier, but first focusing on shockwave therapy in the foot and ankle. Plantar fasciitis or plantar fasciopathy has by far the most literature out there supporting its use. Most recent meta-analysis that was done was in 2024 and they looked at 16 randomized controlled trials that used this and they found that shockwave improved pain and function better than steroid injections. And then there's actually been several studies even beyond that that found that shockwave resulted in a quicker return to running compared to placebo. They were able to return to running about four to five weeks sooner compared to controls, which I think is pretty significant. When it comes to Achilles tendinopathy, there were two meta-analyses that were done in 2020 and 22 and they found that shockwave improved pain and function better than placebo or with physical therapy alone. For medial tibial stress syndrome, there's limited evidence regarding this, but they found that the shockwave combined with physical therapy can actually accelerate recovery in military cadets and runners with medial tibial stress syndrome. When you look a little bit closer in the literature, there is a major limitation that all these studies were not placebo controlled unfortunately, but they did find that the return to running was about 30 days quicker in the shockwave group compared to the physical therapy group. For metatarsal stress fractures, also limited evidence, and it shows that there are equivocal clinical, radiological, and functional outcomes in shockwave groups compared to surgical treatment actually in acute, delayed, and non-units of the fifth metatarsal stress fracture, which I thought was great. There was about a 70% success rate with shockwave by three months, 90% success rate by 12 months for the delayed, which they described as 10 weeks of not having had any healing, or non-unions, which they described as more than 24 weeks of not showing any healing in the bone. One study actually was done where they reported a full return to...a return to full competition in about 10 to 24 weeks after treatment with shockwave of a delayed union and non-union with only three to four sessions of focused shockwave, which I found was incredible. So definitely something to keep in mind, something to offer to your patients. When it comes to Morton's neuroma, there's even less evidence of supporting its use. However, there were two case reports, two studies that I found that showed that shockwave improved the VA scores and the function up to four weeks. Now how about PRP in foot and ankle? So going back again to plantar fasciopathy, there were more...most studies, you know, supporting its use for that. There were nine randomized controlled trials that I found that compared PRP to steroid injection, and they found that there was greater improvement in pain and functional outcomes in the PRP groups up to 12 months. At the one-month mark, there were no differences between the two, but then after two months the PRP was actually found to be superior. For Achilles tendinopathy, most of the studies showed no difference between placebo and PRP groups for the mid-portion, which I found was interesting. But there were two studies, one that was done in 2019 and another that was done in 2017 that actually found that they were superior to placebo for insertional Achilles tendinopathy. For ankle sprains, insufficient evidence, there was only one small randomized controlled trial that found that PRP to the AITFL resulted in a shorter duration of pain and a quicker return to play compared to the controls. It was about 20 days shorter duration. For osteochondral lesions of the talus, there is limited evidence supporting its use. There was like no evidence for its use as an injectable, but there was use of it helping perioperatively if they used the PRP when they were doing surgery for it. Hallux rigidus, also insufficient evidence for this. There was one study that found that there was improvement in range of motion function up to 24 months, but again, they reused it as part of their surgery. There's interestingly no studies out there for its use, or at least no randomized controlled trials supporting its use as an injectable. And then for ankle arthritis, there was one study that was done that found that there was no difference between PRP and saline injections. And I was curious if they did under ultrasound guidance. They did. So I was like, oh, that's sad. But hopefully somebody can repeat it and hopefully show the opposite. So how about, when do you choose shockwave and when do you choose PRP? I was curious about that. So I looked into that. Really not a lot in the literature. There were only these two conditions that I found that there were any studies that compared them directly. Two meta-analyses in 2024 actually found that PRP was more effective than shockwave, steroid, and placebo in reducing pain for plantar fasciopathy. And it was actually found to be more effective than shockwave in reducing plantar fascia thickness, but there was no differences between them in improving function. There is this one group in Italy that actually found that there was an equivalent reduction in pain for both the PRP and the shockwave groups. However, the PRP group had a faster return to sport and that was about 20 days. For Achilles tendinopathy, there was only one study that compared the two and they found that the outcomes were equivalent in terms of the VISA-A and the VAS scores for insertional Achilles tendinopathy. And they used focused shockwave. Now how about combination treatments? There's even less studies on that, which needs to be done because anecdotally I found that combination really works well for these athletes to get them back sooner. But these were the only studies that I found and they're just case reports, so they're not even robust studies. So for plantar fasciopathy, there was a case report of two runners and they found that they had tried shockwave first to incomplete relief, and then it was followed by a single PRP injection, followed by two more shockwave treatments, and then they were able to return back to running. for treatment of plantar fasciopathy. According to the literature, PRP's slightly more effective. There's limited evidence that shockwave and PRP. Limited evidence that shockwave can treat medial tibial stress syndrome or acute delayed or non-unative metatarsal fractures. Personally I choose shockwave if a patient is averse to injections, can't be off their blood thinners, if their treatment needs to cover multiple sites or a large area, or if they can't have any downtime at all. I'll choose PRP if a patient is traveling from far, you know, it's not... or beyond. take out the variability, the variables. So again, this is a big takeaway. why terminology like stress reaction is so confusing to the athlete because you can have an injury that's just short of developing a stress fracture, but a grade three injury is... We also need to recognize that the Again, with the high-risk locations, we've talked about this. The big takeaway from this is that if you use the triad coalition statement, if you have one high-risk or two high-risk, and you have one high-risk, and you have one high-risk or two high-risk, and you have one high-risk, and you have one high-risk, and you have women if at all possible. For Teo. bone stress injury, and those are probably the medications we would think about, but the downside with them is that they're daily injectable medications. MSRP for Forteo is about $5,500. We have to think about physical therapy for all these athletes. We're going to question and answer. Great. Thank you for all the great talks to our panel. I just wanted to open this up and make this more of an interactive session if anybody has any questions for any of our members up here today. Yeah, so in this case the neovascularization is going to be more an indicator for pathologic tendinopathy. So certainly that neovascularization is the kind of same sort of way I would think of it a little bit, not to the same degree as like cancer neovascularization, but it is sort of like a form of pathologic blood vessels that are growing in that area. And so that's one of the reasons why sometimes you'll hear about like hydro dissection, especially with the Achilles tendon, where certainly we want to avoid putting steroids in this area as well. So there is an idea that you can basically use normal saline to basically dissect off that neovascularization, kind of break those blood vessels up a little bit, if you will, and separate them from the tendon so that we're not continuing to cause that pathologic hypertrophy in the tendon, which can in turn lead to poor functional outcomes. So it's also a thought that you get along with the neovascularization, the neonerves, Well, and not to exactly sound like a, you guys can hear me, right? All right, so not to sound like a. Great questions everybody. I think in the interest of time, I'll let everybody go today, but we'll be up here if anybody has any more questions. Thank you all.

foot and ankle conditions

conservative treatments

exercise therapies

regenerative medicine

sports medicine

physical exams

rehabilitation strategies

shockwave therapy

platelet-rich plasma

Achilles tendinopathy

neovascularization