Low-dose X-ray treatment is being used for arthritis, plantar fasciitis and other benign conditions

Washington Post

2 days ago

In March 2024, radiation oncologist Sanjay Mehta had been dealing with painful Achilles tendinitis on his left ankle for over a year. He'd tried steroid injections and PRP (platelet-rich plasma) injections, which Mehta said eventually did the trick.
But when his right Achilles started hurting three months later, he opted for a different approach. He had recently started offering low-dose radiation therapy to treat some patients suffering from inflammatory conditions and thought: Why not try it himself? After six self-administered low-dose X-rays, covered by insurance, he found he was pain-free — and he began offering the therapy to more patients with similar noncancerous conditions.
'The main surprise was … why didn't I think of this earlier?' he said.
Mehta is part of a growing trend among U.S. radiation specialists, who have begun offering low-dose X-ray therapy for benign conditions such as arthritis, plantar fasciitis, Peyronie's disease and thick raised scars, or keloids.
After the American Society for Radiation Oncology discussed the use of low-dose radiation therapy for nonmalignant conditions in its spring 2024 quarterly newsletter, its use began to pick up steam, Mehta said. Unlike radiation therapy for cancer, LDRT, as its name suggests, uses low doses to suppress inflammatory cells. Mehta said six LDRT treatments expose the patient to about the same amount of radiation as in one cancer treatment or what someone might get from 'a few' CT scans.
Low-dose radiation treatments almost date back to when X-rays were first discovered in 1895, Mehta said. They eventually fell out of favor in part due to new treatment options, such as nonsteroidal anti-inflammatory drugs, but also because of radiation fears, he said.
Gopal Bajaj, the musculoskeletal lead for the American Society for Radiation Oncology task force on non-oncologic disease, said LDRT remained popular in Europe. The German Society for Radiation Oncology published national guidelines for its use in nonmalignant diseases in 2000. In the United States, 'it's within the last decade or so that there's been a slow reemergence of interest into exploring radiotherapy for conditions other than cancer,' Bajaj said.
Bajaj first encountered it as a therapy about a decade ago when an interested patient with Dupuytren's contracture — a condition that involves thickening of the skin on the palm of the hand, often causing fingers to curl under — asked for it. He started delving into the scientific literature, which was primarily German, and decided it was worth a try. It worked, halting the progression of her condition, which Bajaj said is the goal of the treatment. Since then, Bajaj has seen around 800 people with the disease who fly in from all over the country.
'Most patients we see with Dupuytren's are actively progressing when they begin treatment, and after radiation therapy, fewer than 5 to 8 percent continue to worsen,' Bajaj said. When it comes to inflammatory conditions like osteoarthritis, tendinopathy or plantar fasciitis, Bajaj said, 60 to 80 percent of his patients report some symptom improvement.
A Department of Veterans Affairs survey last year of 48 studies on the effectiveness of LDRT for a variety of conditions, some several decades old, found mixed evidence to make conclusions about its effectiveness, but it said there was no reason not to try it 'after conventional therapy fails.' Bajaj and Mehta said they believe the research is still catching up to what doctors are seeing in the clinical setting.
Whenever there's trauma (from a surgery or an injury), macrophages, white blood cells that modulate inflammation, begin to secrete chemicals that promote inflammation. The X-rays suppress the macrophages, which 'stops this inflammatory cascade from taking hold and, therefore, the pain and the swelling goes away,' Mehta said.
LDRT can work for injuries or conditions where there's inflammation, Mehta said, such as tendinitis, osteoarthritis and plantar fasciitis.
In some cases, LDRT seems to provide immediate relief, while others can take longer. In Mehta's case, it took six to eight weeks before his Achilles felt better. A cortisone shot may work faster, he said, but judging from his and his patients' experiences, the LDRT results seem to last longer. He said it may also be more beneficial to the long-term health of the joints because cortisone shots can weaken the tendon and the fibers of the connective tissue, which can up the risk for tendon ruptures with repeated injections.
There is a 'sweet spot' for LDRT, Bajaj said. If a patient's condition is too advanced, such as if their arthritis has led to a bone-on-bone (without cartilage or fluid to pad it) situation, or there's an autoimmune component to it, such as with ankylosing spondylitis, it probably won't work, he said.
Not all radiation specialists are on board with low-dose X-ray treatment for benign conditions. At Moffitt Cancer Center in Florida, for instance, when Jose Penagaricano, a radiation oncologist who has been treating patients with malignant conditions for six years, started treating osteoarthritis and Dupuytren contracture about a year ago, he got some pushback from colleagues worried that LDRT would take machine time away from ill cancer patients, he said. By limiting consultations for LDRT cases, though, he said the impact has been minimal.
The bigger concern that those using LDRT have heard from colleagues and patients is radiation exposure. Even low-dose exposure over a lifetime has the potential to cause a small increase in the risk of cancer, according to the Environmental Protection Agency.
David Brenner, director of the Center for Radiological Research at the Columbia University Vagelos College of Physicians and Surgeons, said that, in general, the long-term health concerns related to radiation exposure are specific to organs that 'have a lot of dividing cells,' such as the gastrointestinal system. Hands, feet and knees — frequent sites for LDRT — would be of less concern, he said.
A 2015 study in the British Journal of Radiology suggests that the risks of cancer following low-dose radiation therapy for benign disease tend to be small, especially in older patients. But because 'exposure to radiation has the potential to cause a radiation-induced cancer many years after treatment,' it may be an issue for younger adults, adolescents and children, the study said. Concerns about lifetime accumulation of radiation is why radiation doctors typically use this treatment only on patients over 40, Mehta said.
'The major thing people are worried about with radiation is radiation itself causing cancer, [but] it takes, even in higher-dose cancer patients, literally decades for a second cancer to develop,' he said. 'With these low doses of radiation that we use for arthritis and tendinitis, there's been nothing described in the literature for over a hundred years.'