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La s er Therapy : App l ic a tion s for F oot and Ank le P a tholog y
•K erry Zang, DPM•Fellow American College of Foot & Ankle Surgeons
•Diplomate American B oard of Podiatric Surgery
Arizona Ins ti tu te of F ootc a re P hy s ic ia n s1620 S. Sta p ley Dr. , Ste . 132 ◘ Mes a , AZ 85204
480-834-8804 ◘ www.a z feet. c om
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Introduction
• Differentiate between Inflammatory & Degenerative Processes in Tendons, Capsules & Fascia
• Non-invasive Therapy for Tendons, Capsules & Fascia
• Diagnosis of Inflammatory vs Degenerative Process
• Current Foot & Ankle Applications for Low Level Laser Therapy
• Hypothesis
• Summary & Conclusions
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Tendonosis~Capsulosis~Fasciosis
• Not tendonitis, capsulitis or fasciitis: acute reactions with inflammatory cells present
• Not an inflammatory process~ a degenerative process
• Characterized by collagen degeneration and hypovascularity
• Lack of inflammatory cells
• No new advances in treatment in US until recently
• New Treatment Option: Erchonia FX 635 or PL Touch Low Level Laser Therapy
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Current Foot & Ankle Applications for LLLT
• Reverse tendonopathy: Achilles, Posterior & Anterior tibial, Peroneal (brevis & longus) and ELH tendons
• Reverse plantar fasciosis
• Reverse plantar plate derangement, a degenerative capsulopathy
• NON-INVASIVE treatment of chronic tendonoapthy, capsulopathy & fasciopathy
• Enhance angiogenic response in repair of compromised and degenerative tissues
• Pain control
• Restoration of function
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Characteristics of
Low Level Laser Therapy
• Accelerates cell growth & tissue repair
• Accelerates fibroblast & collagen production for faster wound healing
• Reduces inflammation
• Reduces scar tissue formation
• Reduction of pain & acts as an analgesic
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Characteristics of
Low Level Laser Therapy
• Reduction of pain & acts as an analgesic
• Induces angiogenesis
• Induces neurogenesis
• Stimulates an increase in intracellular energy
• Stimulates a cascade of physiologic effects to promote repair, regeneration & restoration of function
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Overall Effects of
Photo-Biostimulation
• Shortens the inflammatory phase
• Accelerates the repair process
• Stimulates tissue regeneration after injury
• Additionally increases plasma concentrations of prostaglandins, enkephalins and endorphins all playing a role in pain management
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The Erchonia Laser Difference• Quick, simple NON-INVASIVE procedure
• Un-manned or handheld options so suitable for all budgets
• Uses low level laser technology, so delivers coherent, collimated energy optimising energy delivery
• Designed to specifically address the problem
• Stimulates a healing response
• No Adverse Affects or Complications Reported
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Photobiomodulation
Mitochondria and Cell Membrane
ATP
Singlet Oxygen Production
Change in Membrane Potential
Membrane Permeability
DNAtranscription
Photons
Physiologic Changes
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Studied Effects on Cells and Tissue
• Promotion Angiogenesis
• Increase proliferation of endothelial cells
• Increased osteoblastic activity and neobone formation
• Increased bone mineralization
• Increased expression of collagen and elastin
• Decreased inflammation
• Decreased pain
• Accelerated nerve regeneration
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Lower Extremity Indications
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Case 1: Achilles Tendinitis6mm
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Laser Therapy for Tendinitis
• Reduce inflammation
• Promote formation of collagen and elastin fibers
• Stimulate growth factor release from fibroblasts during early phase wound healing
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Plan
Multiple diode laser posterior heel
10 minute duration
Every other day
Total of 6 treatments
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BEFORE LASER AFTER LASER
1st
2nd
3rd
Note the increase in vascularity after treatment
4th
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Case 2: Achilles tendinosis
• 67 year old Female
• Bilateral Posterior Heel Pain
• 6 month duration, getting worse
POP Achilles Tendon insertion
Palpable exostosis calcaneus
Mild/Moderate thickening of the tendon
Muscle strength testing normal and pain-free
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Treatment
4 treatments to bilateral achilles insertion
10 minutes duration
Every other day
No augmenting treatment
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Imaging12mm
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1st
2nd
3rd
4th
BEFORE LASER AFTER LASER
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Case 3: plantar fasciitis
• 64 year old female
• Tried and failed orthotic therapy, topical analgesic, oral anti-inflammatory, stretching exercises
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Doppler Enhancement
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Case 4: plantar plate derrangement
• 54 year old female
• Pain at 2nd MTPJ
• MRI showed degenerative changes but no rupture
PLAN
Course of 6 laser treatments
10 minutes, 3 times weekly
Ultrasound before and after treatment
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2nd MTPJ before Laser 2nd MTPJ after Laser
• Relates 80% improvement
• Able to resume running
• No pain on physical examination
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Peripheral Neuropathy
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Clinical Presentation:
small fiber neuropathy
• Stocking and glove distribution
• Early hyperesthesia and pain, late hypoesthesia and numbness
• Pain is burning, superficial
• Impaired thermal and pain thresholds
• Decreased sweating
• Normal strength, reflexes and EMG
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Diagnosis:
Epidermal Nerve Density
• Small C-fibers and A-delta fibers
• Established normative value based on body site
• Objective way to quantify and monitor neuropathy
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Case 5: small fiber neuropathy
• 65 year old male
• 2 year history of numbness bottom of feet, alternating burning and cold sensations both feet and legs
• No DM, metabolic syndrome.
PLAN: biopsy
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• Site Result Value Abnormal Low Normal
• Rt Foot 1.16 < 3.113.11 – 4.5
• Lt Foot 1.33
• Rt Calf 3.62 < 5.4 5.4 – 5.7
• Lt Calf 2.88
NORMALSMALL FIBER
NEUROPATHY
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• PLAN:
- 15 laser treatments
- 10 minutes per leg
- Three times weekly
- Multi-diode laser centered over:
• - common peroneal
• - posterior tibial
• - superficial peroneal
• - plantar foot
• - Repeat Biopsy
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Before LaserLeft Calf: 2.88
After Laser:Left Calf: 6.71
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Before Laser:Right Calf: 3.62
After Laser:Left Calf: 6.57
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Before Laser:Left Foot: 1.33
After Laser:Left Foot: 4.37
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Before Laser:Right Foot: 1.16
After Laser:Right Foot: 4.91
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PF Protocol
1. Full history of activity
2. Current medical history including medication
3. Physical examination of the lower limb, gastrocnemius, soleus and plantaris giving
attention to the tendo achilles.
4. Physical examination of the foot, plantar apronus, tibialis anterior, extensor digitorum
brevis, peroneus brevis
5. Physical examination whilst standing giving attention to the arches of the foot.
6. Patient exercise routine that MUST be complete BEFORE the patient gets out of bed.
Plantar fasciitis stretch (X10) to BOTH feet. (see attached download)
7. Five to eight treatments as prompted by the results.
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The XLR8 PL Touch
Touchscreen
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Diode Placement Example - Handhelds
Position the laser over the dorsum pointed towards the mid tarsus, the tibialis
anterior tendon and the joint insertion of the EDB and PB tendons
Helpful hints
- Plantar Fasciitis is a very debilitating pain and is the result of a
repetitive strain injury of the Plantar Apronus.
- Plantar Fasciitis is difficult to resolve without some form of
intervention; orthotics, exercise, injections
- Plantar Fasciitis almost always comes back if it is not managed
correctly
*More than 8 treatments should not be needed, even with the most
uncooperative complaint
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EXERCISES TO HELP
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• Emerging new treatment modality in Europe, with over 16,000 lasers
on the market in North America!
• The most studied laser on the market
• Quick return on investment
• Expand your scope of practice
• Optimise your efficacy levels compared to standard treatment
options
• Offer your patients leading edge investment
• Applications for multiple foot and ankle conditions
In Conc lu s ion