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

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

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

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

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

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

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

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

Photobiomodulation

Mitochondria and Cell Membrane

ATP

Singlet Oxygen Production

Change in Membrane Potential

Membrane Permeability

DNAtranscription

Photons

Physiologic Changes

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

Lower Extremity Indications

Case 1: Achilles Tendinitis6mm

Laser Therapy for Tendinitis

• Reduce inflammation

• Promote formation of collagen and elastin fibers

• Stimulate growth factor release from fibroblasts during early phase wound healing

Plan

Multiple diode laser posterior heel

10 minute duration

Every other day

Total of 6 treatments

BEFORE LASER AFTER LASER

1st

2nd

3rd

Note the increase in vascularity after treatment

4th

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

Treatment

4 treatments to bilateral achilles insertion

10 minutes duration

Every other day

No augmenting treatment

Imaging12mm

1st

2nd

3rd

4th

BEFORE LASER AFTER LASER

Case 3: plantar fasciitis

• 64 year old female

• Tried and failed orthotic therapy, topical analgesic, oral anti-inflammatory, stretching exercises

Doppler Enhancement

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

2nd MTPJ before Laser 2nd MTPJ after Laser

• Relates 80% improvement

• Able to resume running

• No pain on physical examination

Peripheral Neuropathy

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

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

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

• 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

• 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

Before LaserLeft Calf: 2.88

After Laser:Left Calf: 6.71

Before Laser:Right Calf: 3.62

After Laser:Left Calf: 6.57

Before Laser:Left Foot: 1.33

After Laser:Left Foot: 4.37

Before Laser:Right Foot: 1.16

After Laser:Right Foot: 4.91

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.

The XLR8 PL Touch

Touchscreen

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

EXERCISES TO HELP

• 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