xtra-print Medical Sports Network

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medicalsports
network
Prevention, Diagnostic, Therapy,
Rehabilitation & Medical Technology
Interview with the professional
football players Okazaki and Koo
from FSV Mainz 05 about conservative
therapy in football on page 6.
> ALL ABOUT
SHOCKWAVE THERAPY IN SPORTS MEDICINE 2015
©Titelbild: 1. FSV Mainz 05
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02 therapy
ACUTE-PHASE RSWT
DR. CHRISTOPH SCHMITZ MD
05 application
SHOCK WAVES TREATMENT
BOTAFOGO
06 treatment
CONSERVATIVE TREATMENT
INTERVIEW
08 case series
CASE STUDIES FOR ACUTE-PHASE RSWT
PROF. CHRISTOPH SCHMITZ MD,
STEFAN MATTYASOVSZKY MD,
STEFFEN TRÖSTER
10 treatment
MYOFASCIAL TRIGGER POINTS
ANDREAS KREUTZ MD
15 treatment rugby
MUSCLE INJURIES
JEAN- BAPTISTE GRISOLI MD
16 interview
TOGETHER WITHOUT
IFS AND BUTS!
>
KURT MOSETTER MD
RSWT® in theory and practice
20 treatment
GET ACCESS TO TRAININGS FROM
THE INVENTOR OF THE RADIAL
SHOCK WAVE THERAPY }
ESWT CASE STUDY
RENÉ TOUSSAINT MD
Editor
E.M.S. Electro Medical Systems S.A.
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1260, Nyon
Switzerland
www.ems-company.com
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Special Edition 2015 and Reprint medicalsportsnetwork
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editorial
PRACTICE AND EVIDENCE
24 pages of shock wave treatment
Dear valued reader,
it is my pleasure to introduce the
present collection of reprints of
articles published in “medicalsports network” during the last
years, together with very recent
information and updates about the
same topic: shock wave therapy in
high-end sports medicine.
Together with many partners worldwide we
have developed the Swiss DolorClast method
during the last 20 years into a unique combination of cutting-edge medical device technology,
globally recognized clinical science according
to the highest standards of evidence based
medicine, and profound education of users via
our Swiss DolorClast Academy. Pioneers like
Prof. Dr. Christoph Schmitz (Munich, Germany) have supported us with basic and clinical
science from the very beginning. As one result
of all these activities, we are today collaborating
with many partners, supporters & authors in
the field of high-end sports medicine like
Dr. Stefan Mattyasovszky and Mr. Steffen
Tröster (FSV Mainz 05, German Football
Bundesliga), Dr. Paolo Manetti and Dr. Jacopo
Giuliattini (AC Fiorentina, Italian Football
Seria A), Dr. Andreas Kreutz (Herzogenaurach, Germany), Dr. Kurt Mosetter (team doctor
US Soccer national team), Dr René Toussaint
(Brühl, Germany) and all others who have
contributed case reports and articles to the
present collection of publications. All the
initiatives and applications of the authors
helped us to gain more and more knowledge
from the field of high-end sports medicine and
bring it back to the patient.
I would like to express my sincere thanks to
all who have contributed, and wish you fun
while reading and doing sports for your health
or personal benefit. As you may know investing
in your health is the best investment you can do.
Paolo Zanetti, CEO, EMS Medical
Disclaimer:
The information and views set out in these
articles are those of the author(s) and do not
necessarily reflect the official opinion of
EMS. EMS expressly disclaims any liability for any damage or loss that may arise
from relying upon or using information
contained in this collection of publications.
Information regarding the medical device’s
intended purpose and proper use and any
precautions to be taken are provided in the
instructions for use.
medicalsportsnetwork
1
therapy
ACUTE-PHASE RSWT
Acute-Phase Radial Shock Wave Therapy –
New Concepts and Possibilities for Professional Footballers
Dr. Christoph Schmitz MD,Department of Neuroanatomy,
Ludwig-Maximilians University, Munich, Germany
Acute-phase RSWT is also
used for players at
ACF Fiorentina.
The medical and physiotherapeutic care of professional footballers during the season is an enormous
challenge for all involved. Most players want to be fit and well enough to play as soon as possible after an
injury because they want to keep their place in the squad. But it is also important to return players to full
fitness as quickly as possible even during a match, e.g. in the half-time break. Treatment with Radial Shock
Wave Therapy (acute-phase RSWT) is an attractive and innovative method to help achieve this goal.
This article is an introduction to this new concept.
2
medicalsports network
Being a “trained” (i. e. habilitated) anatomist
and a licensed medical doctor, I had been
interested in extracorporeal shock waves as my
scientific hobby for many years. It became my
day job when I worked as International Business
Development Manager Orthopaedics at EMS
from 2008 to 2009. While at EMS, I worked
with clinicians and physiotherapists at professional football clubs on developing new approaches to using Radial Shock Wave Therapy
(RSWT) for the treatment of players during
the season, which differ significantly from the
“normal” RSWT treatment concepts published
in the orthopaedic literature, e.g. for heel pain
or tennis elbow. Key elements of this “acutephase RSWT” are daily treatment with RSWT,
a primary focus on (legal) enhancement of the
player’s performance and freedom from pain
without aiming for a speedy recovery, as well as
the use of RSWT within days, or even hours,
following an injury. These new concepts are being
used with great success by top-level clubs in the
United States, Brazil, Ecuador, England, Italy
and Norway, and most recently the German
Bundesliga.
N.B. The aim of this concept is not
a speedy recovery but to keep the
player in action, ideally without
any downtime at all. For this reason,
acute-phase RSWT is applied during
the match, at half-time and immediately
after the match as well as during daily
training sessions.
The following does not describe any specific
treatment, but rather the important aspects of
creating the right conditions for using acutephase RSWT with professional footballers.
1. Build Trust
The first step is always a personal discussion to
overcome a lot of justified doubt and mistrust.
The usual questions are: “Does this really
work?”, “Isn't this doping in disguise?”, “Does
the treatment pose any unintended risk to the
player?”, “How do I explain to the player that
some RSWT treatments need to be uncomfortable in order to be effective?”, “What kind of
therapies could be usefully combined with the
treatment?” and “Where are its limits?”. The
answers to all these questions are based mostly
on our current knowledge of the molecular and
cellular mechanisms of action of shock waves
on the musculoskeletal system (see below).
2. Establish Infrastructure
When we started using acute-phase RSWT at
the Italian Series A team ACF Fiorentina about
a year ago, the question of the necessity for
medical imaging was raised. My experiences at
the Olympic Games in Athens 2004, Beijing
2008 (see also Henne M, Schmitz C. Stoßwellentherapie – Mythos oder Evidenz? medicalsportsnetwork, Volume 05.11) and particularly
London 2012 taught me just how important a
clear diagnosis is, especially for elite athletes,
and that the greatest caution must be taken
with partial ruptures of tendons and ligaments
in particular. Almost every application of RSWT
in the treatment room at ACF Fiorentina is
therefore preceded by an ultrasound scan. Of
course, this does not replace the use of magnetic
resonance imaging (MRI), other imaging
techniques or further diagnostic procedures
when indicated.
Steffen Tröster, physiotherapist at the
German Bundesliga club FSV Mainz 05,
treating players with acute-phase RSWT.
3. Gain Experience
Once confidence in the possibilities of acutephase RSWT has been established, the most
important aspects explained and a diagnostic
ultrasound unit and shock wave therapy device
installed, the team physicians and physiotherapists need to gradually gain experience and
build up their expertise. During this time, I am
always available via email, phone, SMS or
WhatsApp to answer any questions immediately, for instance during the half-time. This is
probably the most important phase when implementing acute-phase RSWT and it is impossible to make any generalisations about it.
Each club has developed its own medical/physiotherapeutic infrastructure, each clinician
and physiotherapist has his/her own background, experience and preferences. Accordingly, any club that uses acute-phase RSWT
will have created its very own, highly individual
approach.

State-Certified Physiotherapist since 2007
(Praehagruppe Kerpern/Horrem)

2011, Diploma in Sports Science
(Training & Performance,
German Sport University, Cologne)

2014, Osteopath BAO –
Institute for Applied Osteopathy

2011-2012, Medical Department,
Junior Squad FC Bayern Munich

2012 to date, Medical Department
FSV Mainz 05
3
therapy
Christoph Schmitz
4. Think Mechanisms of Action
Usually many questions arise during the
“gaining experience” phase with regard to
treatment modus and duration. There are rarely
straight answers to these questions, due to the
practical impossibility of a scientific validation
of acute-phase RSWT in accordance with the
criteria of evidence-based medicine (see information box). But many hypotheses can be
based on our current knowledge of the molecular and cellular mechanisms of action of shock
waves on the musculoskeletal system and I like
to refer to that. Courses run by the Swiss
DolorClast Academy (www.swissdolorclastacademy.com) are a reliable source of current
thinking and knowledge and are open to all
interested parties. All trainers at the Academy
have received extensive training themselves.

Holder of the chair for neuroanatomy
at LMU Munich, Germany

2008 to 2011, International Business
Manager Orthopaedics and Medical Scientific
Officer at EMS Electro Medical Systems S.A.

Main areas of research include the molecular
and cellular mechanisms of
action of extracorporeal shock waves
on the musculoskeletal system
[email protected]
The “normal” treatment concepts of RSWT for
the musculoskeletal system have been documented in a variety of scientific publications.
If you would like to pick a selection of the best
and most meaningful clinical studies by a
truly independent body (comparable to a
consumer advice organisation) from this
plethora of publications, it is worth having a
look at the PEDro database of the Centre for
Evidence Based Physiotherapy of the George
Institute for Global Health at the University
of Sydney, Australia (www.pedro.org.au). By
the time this article went to print, the PEDro
database contained a total of 20 publications
about RSWT. Fifteen of these studies were
conducted with the Swiss DolorClast device
by Electro Medical Systems, Nyon, Switzerland. (A compilation of the PEDro content is
4
5. Establish and Develop Concepts
Certain conditions and injuries that are particularly common in footballers can be treated
quickly and effectively with acute-phase
RSWT, and even prevented altogether in many
cases. It is fascinating to see players for whom
the season should have been over due to chronic
achillodynia or patellar tendinopathy continue
playing until the end of the season, thanks to
available from the author.) Many of these 15
publications come courtesy of the colleagues
Dr Jan-Dirk Rompe (now Alzey/Germany),
Dr Ludger Gerdesmeyer (now Kiel/Germany)
and Dr Markus Maier (now Starnberg/Germany).
The author was involved with two of these 15
studies. The publications have the following
underlying treatment concepts in common:
(i) a randomized controlled approach, i. e.
comparison to an alternative therapy or
placebo treatment, (ii) the use of RSWT only
after a waiting period of several weeks or
months of unsuccessful classic conservative
therapy, (iii) dispensing with a systematic
use of imaging techniques such as ultrasound
and MRI before treatment with RSWT, (iv)
applying RSWT three times at weekly intervals, (v) dispensing for the most part with any
acute-phase RSWT. The initial investment in
acute-phase RSWT pays off many times over
for the clubs, even if they can reduce their
squad by just one player, simply because of faster
rehabilitation after and better prevention of
injuries.
Conclusion
Acute-phase RSWT opens up entirely new
perspectives for the treatment of professional
footballers, both for rehabilitation after and
prevention of injuries, benefiting all stakeholders, i.e. players, managers and clubs. The
therapeutic approach of acute-phase RSWT
differs quite considerably from the “normal”
treatment concepts of RSWT, which are
primarily concerned with a speedy recovery,
whereas the primary focus of acute-phase
RSWT is enhancing players' performance and
keeping them free from pain.
Pictures: © www.violachannel.tv | © Steffen Tröster
published in medicalsportsnetwork 02.15 p.26-29
other types of treatment in addition to RSWT
and (vi) resting the patient during the treatment period.
In practice, such a treatment concept is out
of the question for professional footballers
during an ongoing season. Numerous discussions with clinicians and physiotherapists at
professional football clubs have shown that
conducting randomized controlled studies
for new treatment approaches are virtually
impossible in the professional game. This is
also the reason why these new concepts do
unfortunately find it difficult ever to be
added to excellence databases such as PEDro.
Moreover, rarely is only one single type of
therapy used when treating injuries in football
professionals.
application
SHOCK WAVES TREATMENT
Innovative care with promising results
The Botafogo football club continues to develop
innovative care to prevent and heal lesions
amongst its players. Faced with an increasingly
busy sporting calendar, the “Black and Whites”
medical department’s medical coordinator,
Rodrigo Kaz, proposes an innovative and
modern therapy based on shock waves.
This therapy is used to treat tendonitis, groin strains, plantar fasciitis and
muscular pains. The technique practiced by the club’s professionals has
been adopted by the players and has produced some conclusive results.
The pain, inflammations and injuries that the players often suffer from
can impact their performance on the field, not to mention the time spent
receiving medical treatment or resting. And the players face an increasingly busy schedule, with intensive training sessions and a testing
competitive calendar. All these factors have prompted the club‘s medical
staff to prefer shock wave treatment, which is non-invasive, can be administered within the club and lasts 30 minutes per session on average.
The medical staff at Botafogo has been using modern shock wave
therapy to improve its athletes’ performance for 2 years. It is particularly
efficient for the treatment of tendonitis of the patellar tendon, the
Achilles’ heel, plantar fasciitis and groin strains, which are very painful
and represent a serious handicap. Now that the technique has proven its
worth, Dr. Rodrigo Kaz explains its advantages. “I started using shock
wave therapy in 2007 on Olympic athletes and runners with great
success. It has already achieved excellent results at Botafogo, by reducing
the length of time for which players are unavailable. And they quickly
accepted the treatment too,” explains the orthopedic specialist and
medical coordinator Rodrigo Kaz.
Example Emerson
The case of the striker Emerson Sheik illustrates one of the most recent
successes scored by this technique. Suffering from a chronic and painful
inflammation in his foot, his condition has been significantly improved
by shock wave therapy. When Botafogo played against Ceará to qualify
for the Brazilian National Cup, Emerson was able to stay on the field of
play for the full 90 minutes. Other athletes, including Marcelo Mattos,
André Bahia, Edílson and Bolívar, have also benefited from the
treatment. “In 2014, we consolidated our partnership with Ecomed, the
national importer of Swiss DolorClast equipment, which is used all over
the world. Clubs like FC Barcelona, AC Milan and Liverpool have
already been using this treatment for several years. We are pioneers in
our country, because we are the first Brazilian club to use this Swiss
medical device on our own premises. As well as avoiding pointless trips
to clinics or hospitals, the sessions are delivered by the club’s own
doctors, who have been trained in this method and are familiar with each
player’s particular characteristics”, emphasizes Rodrigo Kaz.
www.botafogo.com
Pictures: Copyright Botafogo
published in medicalsportsnetwork 01.15 p.48
5
treatment
CONSERVATIVE TREATMENT
Acute-Phase RSWT in Elite Football
Conservative therapy options are
becoming more and more popular
among both therapists and
athletes. In elite football,
alternatives in therapy, and also
prevention, may lead to great
improvements for players and
clubs – on both a purely physical
and also an economic level.
One good example of positive conservative treatment can be found at the German Bundesliga
club FSV Mainz 05, where shock wave therapy
has been applied since November 2014. The whole medical team of Mainz 05 (see information
box) is involved, which is of crucial importance for
the successful application of the method. Only
complete cooperation between the medical
team and the players can ensure optimal treat-
ment. Masiar Sabok Sir, Robert Erbeldinger
and Nils Schulz talked about the subject with
the Mainz physiotherapy team (Steffen Tröster,
Christopher Rohrbeck, Stefan Stüwe) and five
of the club's professionals: Johannes Geis, Jonas
Hofmann, Koo Ja-Cheol, Park Joo-ho and
Shinji Okazaki, all of whom have received
shock wave therapy.
The players' viewpoint
Jonas Hofmann, on loan from Borussia Dortmund for the season, speaks very positively
about shock wave therapy. "Steffen Tröster got
everybody to give it a try. What made me feel
positive about this method was his clear
message that the treatment was going to help
us", says Hofmann. "It reduces pain very
quickly, even if it hurts a bit at the beginning.
FSV Mainz 05 players receiving shock wave therapy (EMS, Swiss DolorClast + PiezoClast).
From left: Okazaki, Koo, Park
6
But you feel quite soon how this eases and that
there is a marked reduction of pain afterwards.
Of course, that gives you enormous confidence
in the therapy." The player could be restored
quickly to the performance level he would like
to achieve. Furthermore, shock wave therapy is
an efficient and fast method of treatment. This
means that the players' patience is not unnecessarily tested. This, in turn, has a positive effect
on their mental state.
In Asia, shock wave therapy has been used
successfully for quite some time. And the
players Koo, Park and Okazaki have already
experienced the method when playing for their
national teams (South Korea and Japan). "At
home in South Korea you might find several
machines being used in a team, and I can only
speak positively about it. That's why I'm really
pleased that it is now also used at Mainz 05, my
current club", reports Koo. His team mates
Park and Okazaki agree. They talk about the
method being used around the ankle as well as
on muscles.
Practical application
All Mainz players accepted shock wave therapy
very quickly. The principal areas of application
are the ankle, as well as all football-specific
muscles (active locomotor system muscles,
tendons and ligaments). Shock wave therapy
was used mainly after training or a match for up
to 2 to 3 times per week, primarily for regene-
MEDICAL TEAM FSV MAINZ 05
Cardiologists/Internists
Kathrin Stelzer MD
Felix Post MD
Karsten Keller MD
Orthopaedic Specialists
Stefan Mattyasovszky MD
Patrick Ingelfinger MD
External Osteopath
Dietmar Hellmich MD
Dentist:
Christopher Köttgen DDSc
Athletic Fitness Coach:
Jonas Grünewald
Axel Busenkell
Physiotherapists
Steffen Tröster (Dip. Sport Sciences,
Osteopath BAO)
Christopher Rohrbeck (Osteopath, Naturopath)
Stefan Stüwe (Naturopath, Acupuncturist)
ration but also for rehabilitation if there were
symptoms, especially pain. The management of
pain plays a prominent role for all players.
"Shock wave therapy takes the pain away very
quickly. This is very helpful and we are very
grateful for that", says Koo. The method is also
used after matches as a preventive measure. But
what kind of role do the doctor and therapist
play? Here, too, the players are in agreement: A
very important one. "We trust our therapists
and team doctors blindly. Steffen Tröster has
extensive knowledge of shock wave therapy and
has been trained intensively at the Swiss
DolorClast Academy and by Prof. Christoph
Schmitz (LMU Munich). He is the driving
force behind the therapy method here at the
club. I can speak for everybody and say that our
confidence in him and the cooperation with the
team doctors is absolute", reports Johannes
Geis. He has been treated with shock wave
therapy for a hardened muscle in the thigh, for
instance, and for small, everyday injuries. "I am
very inquisitive and open to new things, and
have no problem with trying out new therapies,
especially when there is evidence that I will
benefit from it", adds Hofmann. The FSV
Mainz 05 players have been fully informed and
educated about the therapy by the club's medical
team, which has had an extremely positive effect.
A final statement, with which all players agree,
comes from Johannes Geis: "I regenerate a lot
quicker with this treatment." Quite an important
point in modern high performance sports.
FSV Mainz 05 players receiving shock wave therapy
(EMS, Swiss DolorClast + PiezoClast). From left: Hofmann, Geis
Picture: Polaroid Hintergrund © istockphoto.com| t_kimura
Steffen Tröster, for which indications
would shock wave therapy be used?
Firstly, there are the classic indications to name, such as the tendinopathies, for example
patellofemoral pain syndrome or achillodynia.
Calcaneal spurs have also been treated successfully. In our view, acute shock wave therapy,
both radial and focused, opens up new treatment options. Some examples are: hardened or
strained muscles, acute trigger point therapy,
acute ligament injuries, bone healing disorders,
like pseudarthrosis, and acute muscle contusions. Our experience has also shown that shock
wave therapy helps to reabsorb oedemas following sports injuries more rapidly. Modern acute-phase shock wave therapy, both radial and
focused, is a great addition to other proven therapeutic options, such as manual therapy, osteopathy or sports physiotherapy, for the type of
musculoskeletal injuries I mentioned above. We
also use shock waves in the area of prevention,
especially for muscle care.
7
case series
CASE STUDIES
FOR ACUTE-PHASE RSWT
Treatment of professional footballers at FSV Mainz 05
Stefan Mattyasovszky MD1, Steffen Tröster2, Prof. Christoph Schmitz MD3
1 Orthopaedic Clinic at University Medical Center Mainz, Team Physician FSV Mainz 05, 2 Physiotherapist FSV Mainz 05,
3 Shock Wave Research Laboratory, Anatomical Institute, Ludwig-Maximilians University, Munich, Germany
Following the presentation of acute-phase RSWT in professional football (MSN 02.15) and the experiences of
several FSV Mainz 05 players reported in this issue, we would like to present a few short case studies about the
specific use of acute-phase RSWT with FSV Mainz 05 professionals and discuss them in a scientific context.
These may or may not be related to the interviews with the players above. The case studies
are taken from a systematic observation study
on the use of acute-phase RSWT with players
at FSV Mainz 05, ACF Fiorentina (Italy) and
Botafogo (Rio de Janeiro/Brazil; see MSN
01.15). All the treatments described were carried
out with a Swiss DolorClast device (EMS,
Nyon, Switzerland) and an EvoBlue applicator.
The specific data (working pressure, pulse frequency) cannot be transferred to radial shock
wave therapy devices by other manufacturers,
since the particular applicator used in the described cases produces higher energies at high
frequencies than can be achieved with other
devices (Császár et al., submitted for publication).
An important element of acute-phase RSWT is
the individual adjustment of working pressure
and pulse frequency, based on biofeedback from
the player. Use of pre-set default settings (common in currently available radial shock wave
therapy devices) should be categorically avoided.
a Bundesliga match (36 - mm applicator,
3,000 impulses at a working pressure of
2.4 bar and a pulse frequency of 14 Hz).
Outcome: Pain reduction to VAS = 0
at the start of the match. The player was
able to play through the entire match.
There were no complications either during
or after the match and the treated muscle
remained pain free.
This is a typical example for the successful application of acute-phase RSWT. To date, there is
only a rudimentary scientific understanding of
the acute effects of shock waves on muscles. It is
very likely that at least three mechanisms work
together synergistically: (1) mechanical muscle
relaxation; (2) pain relief through the removal of
substance P from C pain fibres and myofascial
trigger points (Mayer et al., 2003; Shah et al.,
2008), and (3) temporary paralysis of (over)contracted muscle fibres (cf. Angstman et al., 2015).
within two days post-injury. The player was
able to complete both sessions on the first
training day of the week without experiencing any pain.
"Thigh knock" is a classic injury in professional
football, in many cases caused by a disguised
foul. Often, it remains unclear what exactly
triggers the frequently prolonged pain, which
can have a great negative impact on the player.
The most obvious reason might possibly be an
irritation of the trochanter major periosteum.
The good results of the acute-phase RSWT in
thigh knock injuries are comparable to those for
RSWT in chronic greater trochanteric pain
syndrome (Furia et al., 2009; Rompe et al., 2009).
Case 2

Case 1

8
History and diagnosis: Fatigue-induced
hardening of right m. biceps femoris. Pain
intensity before treatment according to
Visual Analog Scale (VAS score) = 6.
Treatment: RSWT on the day preceding

History and diagnosis: Thigh knock injury
of let hip in the area of m. tensor fasciae
latae during a Bundesliga match; VAS = 8.
Treatment: RSWT on Day 1 post-match in
the area of m. tensor fasciae latae (36 - mm
applicator, 5,000 impulses, 2.5 bar, 14 Hz).
Outcome: Pain reduction to VAS = 1
Case 3

History and diagnosis: Re-fracture of right
5th proximal metatarsal shaft. Initial
fracture treatment: consecutive screw
osteosynthesis; subsequent pseudoarthrosis.
Treatment: RSWT over the course of
ten weeks with an average of six applications
per week (a total of 49 treatments)
(36 - mm applicator, 2,000 impulses each,
2.0 bar, 20 Hz).
Outcome: Osseous restoration of
pseudarthrosis at the end
of the treatment period.
Stefan Mattyasovszky
Steffen Tröster
Christoph Schmitz

Studied medicine at Friedrich-AlexanderUniversity Erlangen-Nuremberg, Germany

State-certified physiotherapist, Diploma in
Sports Science and osteopath BAO

Holder of the chair for neuroanatomy at
LMU Munich, Germany

Senior Surgeon, Orthopaedic Clinic,
University Hospital Mainz - Centre for Orthopaedics and Trauma Surgery

2011 - 2012, Medical Department Junior Squad FC Bayern Munich

Team physician, FSV Mainz 05
2012 to date, Medical Department FSV
Mainz 05
2008 to 2011, International Business
Manager Orthopaedics and Medical Scientific
Officer at EMS Electro Medical Systems S.A.

Main areas of research include:
molecular and cellular mechanisms of
the action of extracorporeal shock waves
on the musculoskeletal system
This case is interesting in several respects: (1)
Contrary to some literature, the treatment of
pseudarthrosis in superficial bones does not
require high-energy focused shock wave therapy. (2) The case presented here corresponds
with reports of successful treatment of superficial pseudarthroses with RSWT described in
the literature (Silk et al., 2012). (3) Even multiple repeat treatments of the pseudarthrosis, as
described here, did not cause any loosening of
the osteosynthesis in situ. (4) We cannot say for
certain whether 49 applications of RSWT were
really necessary. However, considering that
each individual treatment lasted less than two
minutes and that the players have daily contact
with the medical team, this does not seem to be
excessive.
Case 4

History and diagnosis:
Right medial collateral ligament sprain
with mild oedema in the attachment area
of the ligament; VAS = 6-7.
Treatment: RSWT, one treatment per day,
first application on day 1 post-injury, four
applications in total (36 - mm applicator,
2,000 impulses, 1.7 bar, 20 Hz).
Outcome: complete freedom from pain
(VAS = 0), even before the last treatment,
and complete elimination of the oedema.
This case is an impressive example of how
effective RSWT can be in supporting a more
rapid resorption of oedema. The underlying
mechanisms are still unknown. However, there
may be a possible association with a suppression
of C pain fibres by the shock wave therapy
(cf. Campos und Calixtos, 2000).

Case 5

History and diagnosis: Strain of left ischiocrural muscles; VAS = 6; VAS with SLR
(straight leg raise) = 4.
Treatment: Combined radial (RSWT) and
focused (fESWT) shock wave therapy, one
application of RSWT and one of fESWT
per day, first treatment on Day 2 post-injury
on a total of four treatment days (RWST:
36-mm applicator, 2,000 impulses spread
over the entire muscle belly, 2.0 bar, 20 Hz;
fESWT: Swiss PiezoClast [EMS], 35 - mm
gel pad [i.e. focal point approx. 15 mm below the skin surface], 2,000 impulses each
at the point of pain on setting 12 [positive
energy flux density 0.173 mJ/mm 2], 8.0 Hz).
Outcome: Pain reduced to VAS = 1 even
before the second application. VAS with
SLR = 0 before the fourth treatment. Pain
free when running and able to train normally after the fourth application.
This case fits in well with our previous results
of treating athletes with acute muscle problems
during the Olympic Games 2004 and 2008, as
well as the rapid healing process of Aksel Lund
Svindal before the Winter Olympics 2010 (see
Henne and Schmitz msn 5/2011). The mechanisms are complex and are likely to include the
activation of muscle stem cells.

Conclusion
In summary we can say that acute-phase
RSWT opens up a most interesting new prospect in accelerated rehabilitation, not just for
professional footballers. The success of acutephase RSWT depends to a considerable degree
on the expertise and experience, as well as the
interaction with each other, of the individual
medical team members.
Literature and x-rays (Case 3) available from the authors.
9
treatment
MYOFASCIAL
TRIGGER POINTS
More method than goal in the treatment of locomotor illnesses
Andreas Kreutz MD,
Medical Director of the Dr. Kreutz Competence Center in Herzogenaurach, Germany
The treatment of myofascial trigger points (MTPs) in pain therapy for athletes and non-athletes
has long since become part of the clinical routine. However, if MTPs are considered only as a source of pain,
this does not even come close to recognizing their far-reaching medical significance.
MTPs do not occur by themselves; a source of
disturbance is required. This is hypothesized to
be an energy crisis [1] in which acute or chronic
overstressing of the muscle leads to localized
ischemia (strain/excessive demand). The accompanying energy (ATP) deficit results in the
contractile elements (actin and myosin) being
unable to separate again in the affected muscle
cells. Localized, nodule-like muscular rigidity
occurs, which in turn promotes regional ischemia and apparently also leads to accompanying
inflammatory reactions with an increase in
phosphorus. Thus at the beginning of the
MTP, there is a local overstressing load which
puts the muscle into a biochemically and morphologically pathological situation at particular
preferred sites. The muscle cannot correct this
itself, even if sometimes there is a different
impression clinically from the reduction of
symptoms over time.
The muscle quickly learns to switch off the
region of the MTP and excluded from active
work. Intramuscular processes, even entire
sequences of movement are restructured accordingly. Consequences of this include muscular
10
imbalances which, contrary to the usual accepted practice, cannot be treated by conventional
strategies of strengthening therapy [2 – 4].
We've already reported on this and further
obstacles for successful medical training
therapy [5]. Most patients only show symptoms
after the increasing number and concentration
of MTPs cause the remaining musculature to
be unable to meet the demands placed on it
without “switching on” the portions affected by
MTPs. Conversely, this also explains why the
symptoms can also improve soon with therapy
even though numerous MTPs can still be found
in the musculature and the neuromuscular
patterns of movement have still not normalized.
If the athlete resumes the accustomed training
load in this condition, relapse is inevitable
Case study 1
Treatment of the right
M. infraspinatus of a
competitive equestrienne
About seven months previously there was an
unexpected excentric force applied (the horse
pulled on the halter), with initial symptoms of
a strain. The progression particularly included
the occurrence of nocturnal pain while resting
on the shoulder as well as movement pain during stabilization and stationary tasks, particularly during riding. This was accompanied by
typical symptoms of pain transfer to the long
biceps tendon region and radial forearm. The
patient’s symptoms were resolved after a single
treatment The subsequent mobilization of the
posterior shoulder joint capsule prevented relapse as did the training therapy that followed
for initiation of the caudalizing muscle groups
centered on the humeral head. Prior to the start
of treatment, following questions must be answered:
1. Is the dysfunction or trauma which caused
to the problem still present?
2. Is the disturbance intrinsic to the patient's
motor system or external (incorrect sitting
position on the bicycle, incorrectly assembled
roller skis, etc.)
Only in the rare case that the causative disturbance is no longer present will the currently
Andreas Kreutz

Medical Director of the Dr. Kreutz Competence Center in Herzogenaurach, Germany

Specialist in orthopaedics and
trauma surgery

Lecturer for manual medicine at the
University of Erlangen
Network

President of the Deutsch-Österreichischen
Gesellschaft für stabilisierende Verfahren
am Bewegungsorgan (www.dsvb.org)
[the German-Austrian Association for
Stabilising Locomotor Procedures]

Team doctor for the Abu Dhabi triathlon
team since its establishment in 2009

Team doctor for the US biathlon team
from 2007 – 2009

Founder of “Medical Fitting” for
locomotor performance diagnostics and
improvement
11
treatment
popular method of “triggering away” solve the
(pain) problem, because then only the painful
residual effects must be dealt with. However,
normalization of the original patent movement
is still necessary in this case.
Trigger points lead
to new diagnostic strategies
Trigger points as a source of pain leading increasingly to diagnostic consideration of musculature is a pain source rather than structural
lesions. Knowledge of the technical pain transfer zones [2] is a valuable protection against
incorrect interpretations of results from morphological imaging and local indications of
pain by patients. The list of possible diagnostic
errors covers the entire locomotor system here.
Without the examination for corresponding
MTPs, it is easy for a misdiagnosis to occur, for
example of a femoral acetabular impingement
(MTPs in the M. iliacus or M. pectineus), tennis
elbow (M. supinator / extensor group), meniscopathy (M. sartorius/M. vastus medialis), tendini-
tis of the long biceps tendon (M. infraspinatus)
or radiculopathy (M. gluteus minimus/medius;
M. tensor fasciae latae). There is considerable
risk of an incorrect conclusion drawn of a
relationship between structural damage observed in morphological imaging and pain felt
by the patient leading to operative consequences
without knowledge of the possibility of pain
transfer phenomenon developing due to MTPs
(see case study 2).
Case study 2
Five months prior to the Olympic Summer
games in 2012, Max Müller (captain of the
German national field hockey team at the time)
was given the external diagnosis of femoral
acetabular impingement of the right hip with
an indication of arthroscopic decompression.
However, with the application of radial shock
waves in the area of the Mm. iliacus, psoas and
pectineus, all clinical symptoms of the athlete
were able to be reproduced. Satellite points
were found in the Mm. quadratus lumborum left,
tibialis posterior right, gluteus minimus and medial head of the gastrocnemicus, right. The
cause of all the symptoms was a Cyriax capsular
pattern II with a lack of internal rotation and
reduced extension of the right hip. This led to a
deviation of the neutral position of the right hip
toward outer rotation and thus to valgisation
stress on the knee joint with increased pronation positioning of the right foot. In the course of
a total of eight therapy sessions, along with accompanying measures, particularly using radial
ESWT, freedom from pain was achieved and
with manual capsule techniques from K. Sell
[6], improvement of the internal rotation from
0° to 40° and free hip extension were achieved
with unrestricted, pain-free flexion. The femoral acetabular impingement previously diagnosed had no clinical cause. The athlete was able
to perform in London to the full extent of his
capacity in the role of captain for the German
national field hockey team and won his second
Olympic gold medal.
Case study 1: Treatment of the right M. infraspinatus of a competitive equestrienne.
12
Cause or consequence?
Particularly with degenerative changes and
chronic progressions, structural diagnoses provide little information with regard to the following questions.
1. What is the source of the damage or which
dysfunctional influences are present?
2. How important are the harmful effects
which can cause further damage to the
locomotor system?
What happens to the spinal column segment
after the herniated disc is removed in the cause
of the damage is not taking care of? There are
similar questions prior to numerous further
operative measures performed, of which there
are a great number of cases each year, from
subacromeal/femoral “decompression” and
“meniscus smoothing” to reinforcement of “soft
bands” or surgical procedures in dentistry with
pain transmitted from the region of the masticatory musculature. Structural damage shown
in morphological imaging is ultimately just a
snapshot of the progressive damage to the segment of the motor system resulting from an
unusual load. Thus the sole approach of conservative or operative therapy to the joint frequently has no influence on the underlying
cause of the problem and thus no influence on
the long-term course of the damage. If one asks
what difference in this motor segment or sequence of movement might have been needed
so that this damage would not occur, an entirely new perspective for consideration is revealed, not only for treating existing symptoms,
but particularly for new strategies of early diagnosis and prevention. We have already described
our conclusions for high-performance sports [7].
Trigger point therapy
is much more than pain therapy
MTPs are reflection of the specific pattern of
pathological load in the musculoskeletal system. Whereas earlier a working hypothesis was
proposed based on available clinical findings or
morphological imaging, which can only be
shown to be true or false after a longer period
of treatment (if at all), using the pattern of
trigger points, working hypothesis can be tested to a great extent prior to actual treatment.
The following questions are answered directly:
1. Do the pain transfer zones of the MTPs
completely or only partially account for the
patient’s symptoms?

2. Which muscles are host to primary MTPs
and which to satellite points, and does this
account for the findings of the clinical motion
analysis of the sequence of movement?

After therapy corresponding to the working
hypothesis and its influence on the symptoms
of the patient has begun, these questions are
answered:
1. How great is the possible influence of any
existing structural damage on the patient's
symptoms?
2. Have the treatment measures show sufficient influence on the cause of the pathological
stress?
Here the assessment is essentially not of the
dimension of clinical symptoms and Robin the
therapeutic effect on key parameters for the
undue musculoskeletal stresses such as the
1. functional axis of movement,
2. local pressure conditions
(Cyriax capsular pattern),
3. the balance of muscles and ligaments,
4. local trophism and
5. the continuance or new formation of MTPs
in the area subject to symptoms.
Treatment of trigger points with the sole objective of relieving pain is insufficient, particularly in top-class sports. Pain represents neither in
early warning system nor a sufficient progression parameter in achieving system normalization. Even latent MTPs (those not routinely
noticeable) disrupt the essential parameters for
performance capacity and sports, such as proprioception and patterns of muscular activity.
Moreover, they need to muscular weakness
without atrophy not only for the muscle affected but for entire functional chains as well. Test
subjects with MTPs in the hand flexors or extensors require 50 % more time than those without MTPs 450 quick flexion/extension movements in the wrist [8].

inter- and intramuscular coordination)
muscular weakness (strength endurance
and maximum force)
limitation of joint mobility (as a reaction to
pain and structurally due to changes in the
collagen support tissue and intra- and extramuscular fasciae)
vegetative trophic dysfunction
(activation of the sympathetic nervous system)
articular dysfunction
(greater wear)
peripheral nerve compression syndromes
(scalenus group/M. pect. minor/M. piriformis)
Please note: All direct and indirect locomotor
disruptions caused by MTPs are referred to as
myofascial pain and dysfunction syndrome
(MFPDS) [9] today.
Pain stimuli from a wide range of sources,
including those from ligaments, fasciae and
internal organs can result in activation of the
motor system with secondary formation of pain
stimuli produced in the muscles, for example by
MTPs. The principle of convergence and additive stimuli essentially govern the occurrence,
extent and spread of musculature dysfunction
[9]. There is no linear correlation between the
quality, extent, intensity or manifestation of the
symptom with regard to the occurrence of pain,
pain transfer or the processing of pain, nor with
regard to its perception. Moreover, if one considers that the distribution of pain receptors in
different types of tissue varies considerably, our
perception of pain is sometimes to a large extent not related to the principle of cause and
Case study 2:
Max Müller (captain of
the German national field
hockey team at the time)
during radial extracorporeal shockwave treatment
(ESWT) of satellite trigger
points.
Secondary dysfunctions caused by MTPs include:
sensomotor dysfunction (disturbance of the
13
treatment
effect Thus ultimately at no level of consideration is the absence of pain the same as the
absence of a problem. If MTPs remain undiscovered and the original factors which led to
the MTPs remain unresolved, there is considerable potential for relapse with the initial
symptoms and an obstacle for normalizing or
optimizing patterns of movement previously
demonstrated, i.e. the technical abilities of the
athletes. Expressed in positive terms, there is
often considerable remaining potential in
reserve for the athletes in these cases On the
negative side, this unresolved condition
comprises an increased risk of further symptoms and continued pathological stress on the
structures of muscles and joints – a risk which
ranges from repeated muscle fibre rupture to
premature wearing of the joints.
Capable of full performance or
just free of pain?
In professional sports particularly, the absence
of pain is routinely the sole criterion for returning to competition and not infrequently the
direct path to permanent injury. If only the
points of pain are routinely “triggered away” is
possible that the locomotor system is deprived
of the only sensor available, albeit a rather
nonspecific one, for identifying locomotor dysfunctions before structural damage occurs. As
is known, menisci, joint cartilage and also important parts of our intervertebral disks have no
pain receptors worth mentioning, similar to
dental enamel, with the trivial consequence
that pain only occurs once there is a hole through it. Knowledge of the importance of MTPs together with corresponding inferences of
function for the muscle groups involved constitutes an indispensable means of verifying the
working hypothesis. Though the therapeutic
and diagnostic treatment of MTPs is only one
aspect of many on the path to restoring full
locomotor performance capacity, it is an extremely valuable one.
Conclusion
Myofascial trigger points (MTPs) are primarily
not the cause of locomotor dysfunction but
rather the consequence of a disturbance. The
treatment of MTPs is an important aspect of
14
advertorial
diagnosing causes as well as an effective
treatment for pain.
CLOSE TO SPORTS
Diagnostic information from the treatment of
MTPs includes:
EMS is proud to announce that the partnership with FSI – Italian Winter Sports Federation – continues in 2015.

reproduction of the pain transfer
representation of the problem sequence
checking of the working hypothesis by
the success of treatment
distinguishing between functional and
structural sources of symptoms
The treatment should also take into account
latent and satellite trigger points. Trigger point
therapy is only an accompanying element for
the treatment of causative dysfunctions.
Strength training to treat muscular imbalances
caused by MTPs is not only ineffective but also
bears the risk of symptoms assuming a further
chronic character. Freedom from pain is not the
same as resolution of the problem The decisive
question and challenge for treating the causes
of locomotor dysfunction is:
What difference would be necessary
so that this damage would not have occurred?
Full capacity to perform and full achievement
of an athlete's potential can only be expected if
the sources of dysfunction and their consequential components are treated successfully at all
levels of the locomotor system.
EMS Italy was present as a partner at the
world ski championships in Schladming last
February, providing the FISI medical team
with the Swiss Dolorclast Smart for onsite
treatments.
Shown in the photo are Dr. Filippo
Balestrieri, Chief Doctor of the medical
team, Dr. Andrea Panzeri and Dr. Marco
Freschi during a treatment of an athlete.
They confirmed the efficacy and great overall
results obtained with the Swiss Dolorclast®
Smart, which is recognized worldwide.
“Thanks to he collaboration between EMS and
the FISI, our National Team achieved great
results in every discipline this year“, said Dr.
Andrea Panzeri and Dr. Marco Freschi.
Confirming the importance of the contribution of our devices, EMS was also present
in March at the Nordic Ski World Championship in Val di Fiemme, supporting the
FISI and its team of Italian athletes. On this
occasion, “the use of the Swiss Dolorclast Smart
has proven to be essential in obtaining positive
results“, says Dr. Filippo Balestrieri.
Bibliography:
[1] Gautschi, R. (2nd ed. 2013). Manuelle Triggerpunkt-Therapie.
Myofasziale Schmerzen und Funktionsstörungen erkennen, verstehen
und behandeln
[2] Travell, J. G., & Simons, D. G. (April 1998). Travell & Simons‘
Myofascial Pain and Dysfunction: The Trigger Point Manual, (Vol. 1)
[3] Travell, G., & Simons, D. G. (2002). Handbuch der Muskel-Triggerpunkte: Obere Extremität, Kopf und Rumpf. (2nd ed., Vol. 1)
[4] Simons, D. G. (April 2002). Understanding effective treatments of
myofascial trigger points. (Elsevier, Hrsg.) Journal of Bodywork and
Movement Therapies, 81 – 88.
[5] Kreutz, A. K. (April 2012). Medical Training. medicalsportsnetwork,
p 4 – 9.
[6] Bischoff, H. P., & Moll, H. (2011). Lehrbuch der Manuellen Medizin
(6 ed.)
[7] Kreutz, A. K. (May 2009). medical fitting. medicalsportsnetwork, 47.
[8] Lucas, K. R., Polus, B., & Rich, P. (August 2004). Latent myofascial
trigger points: their effects on muscle activation and movement
efficiency. J Bodyw Mov Ther, p. 160 – 166.
[9] Böhni, U. W., Lauper, M., & Locher, H. A. (2014). Manuelle Medizin
(Vol. 1). publ. Thieme Verlag.
treatment rugby
advertorial
MUSCLE INJURIES
sport traumatology - treatment of professional rugby players
Jean- Baptiste Grisoli MD, Chief Medic for the French national rugby team and Toulon Rugby Club
I first discovered shockwaves in sports
medicine around the turn of the century
when I was the team doctor for the Olympic
Marseille football team. It just so happened
that I was lent a Swiss DolorClast® unit by
EMS, the company who had just invented
radial shockwave technology. This was back
in 1999. I wanted to try it out, it appeared
to be a promising treatment method and I
was intrigued. Not long afterwards and
quickly convinced, I bought my own unit
for my sports medicine practice.
Having acquired this technology so soon
after its invention made me one of the first
radial shockwave practioners in France. I now
have more than 15 years’ experience. This has
convinced me that there should be radial shockwave technology available in every sport traumatology treatment centre today.
The busy schedule of a professional rugby
player’s demanding physical conditioning and
excessive training can often result in chronic
associated conditions such as tendonitis or
plantar fasciitis etc. The Swiss DolorClast®
Method complements the physiotherapy by
allowing the most efficient treatment of the
condition while also permitting the athlete to
continue playing professionally.
Rugby is a contact sport and as a result, muscle
trauma is common. These contusion injuries
tend to leave fibrous scar tissue, which in the
course of time will inhibit the player’s performance. Given the huge muscle mass of professional rugby players today, it is difficult to treat
conditions with classical physiotherapy alone.
By using the Swiss DolorClast® Method we
allow muscle conditions to be treated with a
considerable amount of force or pressure
although in fact, it is done quite effortlessly.
Drawing on my experience, I would like
to give new Swiss DolorClast® users
some helpful advice. Firstly, do not use
shockwave treatment in association with
nonsteroidal anti-inflammatory drugs
(NSAIDs). NSAIDs actually cancel out
the neovascularisation reaction and reduce the quality of scar tissue formation
which would work against these processes the shockwaves produce. Secondly,
the patient should find shockwave treatment uncomfortable but not painful.
Even my strongest players get emotional about the Swiss DolorClast®
sessions although they are always in
approval of them, which just goes to
show the very good results achieved
with this method.
Pictures: © Jean- Baptiste Grisoli MD
15
interview
advertorial
TOGETHER WITHOUT IFS AND BUTS!
The Role of Conservative Therapy in Modern Sports Medicine
Dr. Kurt Mosetter and Jürgen Klinsmann have worked together on
the US national soccer team since September 2011. During a test
match of the US versus Germany and Cologne (on 5 June 2015),
Robert Erbeldinger spoke with an extremely motivated team
doctor for the US soccer team about the relationship of soccer
and sports medicine, discussing the role and importance of
modern physiotherapy unit and conservative orthopaedic
treatment methods.
16
Tell me, Kurt, what is your daily
routine like as team doctor for the
US national team? Other problems,
for example because compared to
team doctors for a club, there is
relatively little time spent with
the players?
First of all, I have to say that working with such
an extraordinary person and innovative trainer
like Jürgen Klinsmann is easy. In the short time
we have together the work is always a very particular challenge, but of course we work closely
with the entire team throughout the year. The
US Medical Soccer Team consists of the doctor
and emergency medical specialist George Chiampas, physiotherapists Sue Falsone and Jeremy Hassler, athletic trainer Masa Sakihana,
and the myo squad with the very experienced,
myo and sports physiotherapist Niklas Albers.
Niklas is at all the camps, all games and all
competitions. He is a key interface in the integration of various parts of the medical team and
the trainers. Niklas is a good friend of our
co-trainer Andy Herzog, and he has the complete trust of Jürgen Klinsmann. And he is
perfectly placed as a strategic bridge to support
the professionals playing in Europe, even outside of the national team. We were also pleased
to welcome Oliver Schmidtlein, who visited us
while we were in Düsseldorf. He also has professional expertise in sports physiotherapy,
myoreflex therapy and athletic training. Here
you really have a case of friends working together. Even in the short time available, many
things can be managed well, primarily muscular synchronization, the analysis of weak points,
muscle/fasciae length training, elimination of
areas of disturbance, mental cooperation with
the team, analysis of micronutrients and individual plans for treatment and training. Here it is
particularly important that everything be organized together in the team and that everyone is
involved. Everyone – the trainer, medical team,
even a special team cook who prepares meals
according to our metabolic learning plan, the
“Glycoplan”. This uses healthy sugars such as
galactose and ribose in the food and sports beverages. Recipes for cooking are sent to the players
and their clubs, and every aspect of the necessity
for dietary supplements is explained time and
again. These individual components and the way
they are communicated by the “team behind the
team” could be understood as instructions and
an inspiration for more personal responsibility
and personal development. We have the impression that all those responsible and the players
have actually understood Jürgen’s concept.
Soccer and sports medicine. Can you
explain to us the roles of trainer,
doctor and therapist?
Possible reasons for the many injured players in
the German National League are currently
being discussed. Just take the last season with
Bayern Munich and Dortmund. For example,
Bayern Munich invested many millions of
euros in comprehensive medical measures for
the new season, with detailed, routine blood
analyses. Jürgen Klinsmann introduced to these
far-sighted, holistic medical ideas intended for
prevention to the US national team when he
began the job in September 2011. Some key
elements here include myoreflex therapy, Kid
exercises, comprehensive athletics, nutrition
management, high-tech laboratory and micronutrient analyses through the competence network of Prof. Dr. Elmar Wienecke and selective nutritional supplements. The decisive point
is surely that everyone works closely together as
a team. Therapists, doctors and sports scientists
must pass everything on to the trainer in perfect coordination and keep his back covered.
Trust plays a big role, also in working with the
players. After all, prevention and therapy too
begin with trust. Without it, nothing is possible.
Let's talk about treatment. What role
does myoreflex therapy (MRT) play
for you and your work? You have used
shock wave therapy since 2015.
What can you tell us about that?
Myoreflex therapy plays a key role in my work
as one of the team doctors As of September, I
offered it to all US national team players, and
everyone is using it, without exception, even in
their free time. Players from the German National League in particular come regularly and
take advantage of it. Since January 2015, I have
expanded my work with shock wave therapy
thanks to the collaboration with the Swiss manufacturer Electro Medical Systems (EMS).
I'm very pleased about that. Is the perfect com-
plement to our work in regeneration, rehabilitation and prevention (particularly for muscular
issues). I have had very good experience with
the Swiss DolorClast® equipment for radial
shock wave treatment. We are pleased to take
advantage of its quality for treating fasciae on
the Tractus iliotibialis or on the heavy fascial
layers over the lumbar spine. It enables me to
work individually with various frequency
strengths and specifically adapted depths of
penetration. At the start of treatment, weak
stimuli can open up the paths to healing. At
some deep, concealed points, short strong
pulses can facilitate important solutions and via
some superficial fasciae we can even apply training stimuli and eliminate weak points in
combination with our active Kid stretching
exercises. The focused shock wave device, the
Swiss Piezoclast, is ideal for avoiding needle
injections, particularly with places deep down
which are hard to access. This provides noninvasive, gentle treatment. Basically, I see physical or equipment-supported conservative therapy, with shockwave treatment as an example, is
an ideal support, extension and facilitation of
the work for doctors focused on noninvasive,
conservative work, as well as physiotherapists
and myo practitioners. Of course it depends on
how familiar or well-trained the therapists are
with this treatment method. Like many other
therapists in the German National League, we
were trained by the Swiss Dolorclast Academy.
Of course this is not the only measure; in fact it
is good if various measures complement each
other or are able to provide alternatives for their
tasks. The dual treatment of neuromuscular
myoreflex stimulation and this advanced
medical technology with shock waves is
outstanding and is accepted very gratefully by
our clients. At the centre of our clinical practice
network, at the Center for Interdisciplinary
Therapies in Konstanz (ZiT), this combination
is working so well that our teams in Gutach,
Herrenberg and Cologne would also like to be
“upgraded”.
Many thanks
for the interesting discussion!
Picture: © Markus Gillliar / GES-Sportfoto
17
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THE SWISS DOLORCLAST® METHOD
treatment
advertorial
ESWT CASE STUDY
Treating a Partial Rupture of the Plantar Fascia for a Handball Player
René Toussaint MD, Medical office for orthopedics and sports medicine on Brühl
Case study 1:

20
27-year-old female, first National Handball League,
more than 10 years of experience in competitive sports
Acute injury of the left foot (impact trauma of the heel with
Distorsion of the foot) on 29 th 2004 second injury incidence
on 1st May 2005
Diagnosis: Partial rupture of the plantar fascia, left (MRT diagnosis)
Treatment: Injections (local anaesthetic with added cortison, rest,
analgesics, physiotherapy with physical therapy / ultrasound)
Initial contact by Dr. Toussaint in September 2005.
Clinical assessment: treatment-resistant plantar fasciitis, left
Persistent pain on weight-bearing, long races are not possible and
handball-specific stress on the left foot possible
2 x 5 sessions of extracorporeal shock wave therapy/ ESWT
(equipment: Swiss DolorClast® from EMS in Switzerland)
in October and November 2005
Treatment parameters: 2000 pulses, 10 Hz, 1.5-2 bar,
Other accompanying treatments:
Kinesiotaping of the foot and calf, left
Physiotherapy for the lower limb
Accompanying self-treatment (including stretching
of the thigh and lower leg musculature, excentric
training, rolling on the sole of the foot with a tennis
ball and golf ball according to instructions,
alternating hot and cold foot baths)
Conditioning of the upper arm with an ergometer,
crosstrainer, strong pain indicated with the bike
ergometer
Insole discussed, but not provided
(note: sensomotor insole), no relevant foot deformity
Two weeks after the last series of ESWT treatments: symptomoriented increased weight-bearing, rehabilitation training (with
focus on the sensomotoric function and to reduce dysbalances),
jogging possible, symptoms almost completely resolved prior to
the Christmas break in December 2005, afterwards returning to
handball-specific trainings was planned.
Premature competition stress from 28th December 2005 and in
January 2006. Strong exacerbation of symptoms once again, with
limitations of the handball performance and clinical presentation
of a plantar fasciitis.
Renewed ESWT in a third series (Parameters see above),

sport-specific reduction of stress (for handball), personal measures
in combination with rehabilitation training (see above)
At the end of March 2006, completely able to compete after
increased weight-bearing four weeks after the last ESWT session;
follow-up examination in August 2006 showed no symptoms even
with high stress during handball
Case study 2:

Male, 38 years old, professional equestrian
Approximately 2.5 years prior to ESWT after a trauma, tear of
the adductor tendon diagnosed, left (low level of symptoms,
sensitive to cold, pulling pain, occasional stabbing pain,
improvement with stretching)
June 2003: minor accident during sports, pain exacerbation
of the groin, left
Treatment: Injections, compression stockings, rest, analgesics,
medical gymnastics
CT: (January 2004) calcified insertion tendinitis of the adductors, left
2 x 3 ESWT treatments in January and February 2004
(2000, 6 Hz, 2 bar)
After ESWT: manual therapy, kinesiotaping, almost symptom-free
Participation in the 2004 Olympics in Athens ensured
[email protected]
René Toussaint

Medical specialist for orthopaedics, sports medicine,
manual medicine, physical therapy and social medicine

Praxis für Orthopädie und Sportmedizin am Brühl

Primary focus: Diagnostics, treatment, prevention and rehabilitation of
locomotor illnesses and dysfunctions (spinal column, joints, musculature, tendons and ligaments), goal-oriented individual treatment of pain
and sports medicine management for injuries, pathological stress and
overload as well as performance diagnostics and support for competition.
Network

More than 20 years of continuous activity providing care for athletes
(in individual and team sports, including handball, tennis and triathlon).

Current activities include the position of the team doctor for the men's
handball team SC DHfK (first German national league) and tournament
doctor for the Leipzig Open.
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For more information: [email protected]