Extracorporeal Shock Wave Therapy

[Dieter Fellner]

Extra Corporal Shock Wave Therapy: This treatment does not appear to have gained favour in the UK. I have spent the last year in the US, where the treatment often now preceeds surgical intervention.

I am interested to hear from any practitioners willing to share their experience of using ESWT in the treatment of heel pain/achilles tendon pathology.

Apologies to Podiatry Forum visitors.

[davidh]

Extra Corporal Shock Wave Therapy: This treatment does not appear to have gained favour in the UK. I have spent the last year in the US, where the treatment often now preceeds surgical intervention.

I am interested to hear from any practitioners willing to share their experience of using ESWT in the treatment of heel pain / achilles tendon pathology.

Apologies to Podiatry Forum visitors.

I dont have any practical experience with this modality, and thus cannot quote you personal empirical evidence, but you may like to look at a paper published in the BMJ in July 2003.

http://bmj.bmjjournals.com/cgi/gca?allch=&SEARCHID=1098343993338_35185&FULLTEXT=ESWT+and+plantar+fasciitis&FIRSTINDEX=0&hits=10&RESULTFORMAT=&gca=bmj%3B327%2F7406%2F75&allchb=

I did a lit search on ESWT a while ago, and couldn't find any robust evidence of it's effectiveness, although I am aware that it has been around in various forms for a few years for use with musculoskeletal problems.
Regards,
David

[Dieter Fellner]

David

Thanks for that reference. A multi-centre RCT with similar patient numbers was performed in the US using the same equipment demonstrating the treatment to be effective and subsequently gaining FDA approval. This was a multi-million dollar initiative, apparently.

Does it work or doesn't it? Puzzling ....... :confused:

[nicpod1]

Dieter,

There's a Rheumatologist named Cathy Speed, who works at Addenbrookes Hospital in Cambridge who uses this regularly, also on plantar fasciitis. She is also biomechanically aware with respect to the foot and, I think, also treats sports injuries.

She also works privately at BUPA Cambridge Lea Hospital. A Podiatrist by the name of Sophie Cox also works there, so, if you get hold of her details, she may also do a joint clinic with her? Sophie, as you may know, works with Simon Costain.

They may give you more info on successes (or otherwise). Anyway, I thought they were all for this 'cryogun' therapy for plantar fasciitis now in Pod in Lincs SW PCT?

The number for Addenbrookes is (01223) 245151.

This info is probably useless - but maybe not!

[Dieter Fellner]

Thanks for the information. When I get back to England I will check it out.

Cryogun..... is that for VP's on heels? ;)

[nicpod1]

No........for plantar fasciitis :eek: - I'll let you do the leg-work! :D

[Dieter Fellner]

my legs are way too old to work..... any young legs for hire? Anyone???? :p

[toemeister]

You have to stop NSAID's during healing so it's tender. I have treated two people with 0 % success, however, others in the community claim 50-80% success.

[Craig Payne]

I have had access to ESWT for a while now - have not had to need to use it, except for 2 recalcitrant cases (both then failed to espond to the ESWT) ... I just think we have got better at determining the orthoses design parameters for foot types that develop plantar fasciitis, that we just don't have as many failures to orthoses therapy that we used to.

[podrick]

in the us there is no greater authority on it than lowel scot weil,d.p.m. he has done extensive,published studies on it.i will tell you that it is effective in true cases of plantar fasciatus.however,current research as published by weil,you may check it out on his website states that it is contraindicated in tendo achilles pathologies.both the orthopedic and podiatric communities seem to agree on this.
however,here is a thought.if you consider the mechanism by which eswt works.you are actually causing micro trauma to the affect fascia.the actual healing process is what givesthe patient relief,via the generation of healthy new micro-fibers.this isn't much different than what has been achieved(although through mainly anecdotal research) through prolotherapy and at much less cost.the cost of an eswt unit is astronomical.i have a neurologist in my area which has been treating plantar fasciatus with prolotherapy for years with very good results.
i would appreciate any comments anyone may have with regards to prolotherapy.

rick

[Michael G. Warshaw]

I would very much like to hear from patients that have undergone shockwave therapy for plantar fasciitis and have less than desirable results.

[podrick]

I Do Agree With Something Craig Stated,with Regrds To Its Efficacy.like Any Treatment Modality,one Size Doesn't Fit All.it Most Definitely Does Not Alleviate All Case Of Plantar Fasciatus.however,in The States(due To Big Money Interest) It Is Billed This Way.
I Would Like To Hear Any Commentary On My Original Point Regarding Prolotherapy.

Rick

[pgcarter]

I worked with a pod who spent some years in Asia, she said some TCM practitioners will wack the medial tubercle area with a hammer.....stimulates a healing response for very little capital investment.
Regards Phill Carter

[podrick]

man,that was hilarious.what a witty contribution to this forum.

[Admin]

Cutting-edge without the scalpel (http://www.herald-mail.com/?module=displaystory&story_id=93720&format=html)

John Hoffman was in for shocks when he sought treatment for chronic heel pain.
Hoffman recently received a series of shock waves....
more... (http://www.herald-mail.com/?module=displaystory&story_id=93720&format=html)

<ADDED> The free access period to this news story has ended

[pgcarter]

Dear Podrick,
It was not intended to be funny...it is true....and I thought some of the people reading this may not be aware of this historically developed perspective on this condition, which is still used in Asia with some anecdotaly reported success. As much support as many things done in western health care.
Regards Phill Carter

[podrick]

dear phil,

my apologies.i did not know this,fascinating.

rick

[Craig Payne]

From latest Podiatry Today:
What You Should Know About Shockwave Therapy (http://www.podiatrytoday.com/podtd/displayArticleaa.cfm?articleID=article3165)
- By Lowell Scott Weil, Jr., DPM,

[Don ESWT]

Hello everyone,
ESWT has been in Australia since 1998. The first unit was in Melbourne, There are now about 12 Dornier EPOS Ultra machines nation wide. I know of at least 3 Podiatrists in Australia doing either ESWT or RSWT (R=Radial). I, have the Dornier set up in Macquarie Street, Sydney.
I have been doing ESWT for 2 years. So far I have had good to excellent results with the patients treated.
ESWT machine are expensive varying from $50,000.00 to $350,000.00 there are not in private practices yet.

Donald Iain Scott
Podiatrist
Wollongong/Sydney

[Dieter Fellner]

Admin,

Thanks for the link but it is necessary to subscribe to the Herald to access this story...are you on cyberspace comission???

more... (http://www.herald-mail.com/?module=displaystory&story_id=93720&format=html)

<ADMIN ADDED> The news story was free, but access to archives needs a subscription. The free period has passed - sorry.

[Dieter Fellner]

From latest Podiatry Today:
What You Should Know About Shockwave Therapy (http://www.podiatrytoday.com/podtd/displayArticleaa.cfm?articleID=article3165)
- By Lowell Scott Weil, Jr., DPM,

This is as an excellent review article. Thanks for the link and, (Admin please note ) nothing to pay! :rolleyes:

[Admin]

From the latest issue of Radology (http://radiology.rsnajnls.org/cgi/content/abstract/2341031653v1)Chronic Plantar Fasciitis: Acute Changes in the Heel after Extracorporeal High-Energy Shock Wave Therapy—Observations at MR Imaging

PURPOSE: To prospectively evaluate with magnetic resonance (MR) imaging the acute changes in the heel associated with extracorporeal shock wave therapy (ESWT).

MATERIALS AND METHODS: Institutional clinical study review board approved the study, and informed consent was obtained. MR imaging was performed within 24 hours before and after ESWT on 18 feet of 12 patients (eight women and four men; age range, 33–63 years; average, 49.9 years) with chronic plantar fasciitis. ESWT was applied to the most painful point on the plantar surface of the heel, with a total of 1500 shocks at 18 kV. The MR imaging protocol consisted of sagittal and coronal T1- and T2-weighted images with and without fat saturation. The images were reviewed to assess the post-ESWT changes in soft-tissue and bone marrow edema, the thickness of the proximal plantar fascia, and the presence of a heel spur. Paired t test was used for the statistical analysis.

RESULTS: Soft-tissue edema, which was present in 16 (89%) of 18 heels before ESWT, had increased in severity in 12 (75%) heels after ESWT. Calcaneus bone marrow edema at the insertion site was observed in eight heels before ESWT. After ESWT, the extant of bone marrow edema had increased in one heel and had newly developed in another heel. The heel spur seen in nine (50%) feet was not affected by ESWT. In 17 (94%) heels, the proximal plantar fascia was abnormally thick, with thickness not significantly changed with use of ESWT (P > .05).

CONCLUSION: Increase in soft-tissue edema is the most common acute response associated with ESWT

[Atlas]

I worked with a pod who spent some years in Asia, she said some TCM practitioners will wack the medial tubercle area with a hammer.....stimulates a healing response for very little capital investment.
Regards Phill Carter


I think Kathy Bates was trying to help that fellow (who was tied to the bed) and his stubborn chronic knee pain. :rolleyes:


Anyway, my motto is, (bio)mechanical problems have (bio)mechanical solutions. It is a bit like going to the hardware shop and asking for the strongest plaster to fill a crack, when all along one stump is rotted.


A clinician's brain is much more potent than electotherapy IMO.

[Admin]

The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis
Colin E Thomson, Fay Crawford and Gordon D Murray

BMC Musculoskeletal Disorders 2005, 6:19 (http://www.biomedcentral.com/1471-2474/6/19/abstract)

Background

There is considerable controversy regarding the effectiveness of extracorporeal shock wave therapy in the management of plantar heel pain. Our aim was to conduct a systematic review of randomised controlled trials to investigate the effectiveness of extracorporeal shock wave therapy and to produce a precise estimate of the likely benefits of this therapy.

Methods

We conducted a systematic review of all randomised controlled trials (RCTs) identified from the Cochrane Controlled trials register, MEDLINE, EMBASE and CINAHL from 1966 until September 2004. We included randomised trials which evaluated extracorporeal shock wave therapy used to treat plantar heel pain. Trials comparing extra corporeal shock wave therapy with placebo or different doses of extra corporeal shock wave therapy were considered for inclusion in the review. We independently applied the inclusion and exclusion criteria to each identified randomised controlled trial, extracted data and assessed the methodological quality of each trial.

Results

Six RCTs (n = 897) permitted a pooled estimate of effectiveness based on pain scores collected using 10 cm visual analogue scales for morning pain. The estimated weighted mean difference was 0.42 (95% confidence interval 0.02 to 0.83) representing less than 0.5 cm on a visual analogue scale. There was no evidence of heterogeneity and a fixed effects model was used.

Conclusion

A meta-analysis of data from six randomised-controlled trials that included a total of 897 patients was statistically significant in favour of extracorporeal shock wave therapy for the treatment of plantar heel pain but the effect size was very small. A sensitivity analysis including only high quality trials did not detect a statistically significant effect.

[Craig Payne]

I will bump this old thread with this story from Podiatry Online (http://www.podiatryonline.com/main.cfm?pg=how_to&fn=ESTW4PF):
Australian Researchers Purport Value of Corticosteroid Injections over ESWT for Plantar Fasciitis



By Joene Hendry



Studies increasingly assert that extracorporeal shock wave therapy (ESWT) is an effective, non-invasive therapy for plantar fasciitis.



Researchers from Australia now question the use of low-dose ESWT in light of their findings that intralesional corticosteroid injections (CSI), which cost significantly less than ESWT, are more effective in reducing pain and tenderness at three months and equally effective as ESWT at 12 months post-treatment.



Mark D. Porter, FACSP, DSc, Orthopaedic Department at Ipswich Hospital in Ipswich and Bruce Shadbolt, PhD, Department of Epidemiology at Canberra Hospital in Garran, assessed patient accounts of pain on a visual analog scale and algometer-measured tenderness following CSI or low-energy ESWT compared with standardized stretching in otherwise healthy adult patients with unilateral proximal plantar fasciopathy for at least six weeks and no prior treatment.



All patients were instructed in a standardized stretching program, but 19 patients declined the other interventions and continued with stretching only. Sixty-four patients received an injection of 1 mL betamethasone (5.7 mg) combined with 2 mL lignocaine (1 percent) at the site of maximal tenderness, followed by avoidance of running or impact activities for at least 10 days. Another 61 patients received three low-dose (1,000 pulses of 0.08 square mm flux density) ESWT weekly for three weeks, without local anesthesia or sedation.



Three-month post-treatment assessments revealed significantly lower levels of pain and higher tenderness thresholds in the CSI-treated patients compared with the ESWT and the stretching-only group. By 12 months, however, the CSI and ESWT groups reported similar, low-end of the scale levels of pain, while the stretching group reported higher levels of pain. All three treatment groups had high tenderness thresholds at 12 months.



While all patients in the CSI group reported injection pain, only eight required analgesia and/or ice for a mean duration of seven days, and no patient experienced infection or rupture of the plantar fascia. Of the patients treated with ESWT, six reported throbbing pain and erythema, and four reported severe headache or migraine.



Writing in the May 2005 Clinical Journal of Sport Medicine [Vol. 15, No. 3, Pgs. 119-124], the authors concluded, “Once plantar fasciopathy has persisted for more than six weeks, intralesional corticosteroid injection is more effective than ESWT within the first three months with regard to pain and tenderness.” They suggested that “Careful injection technique and appropriate advice to the patient may minimize the risk of side effects associated with CSI.”



“At 12 months, CSI and ESWT were equally effective,” Porter told Podiatry Online, “but CSI was approximately 10 times more cost effective.” The authors noted that intralesional CSI treatment costs from $60 to $70, while ESWT costs from $600 to $800 Australian.

[podrick]

craig,

excellent article.i think that eswt is overutilized in the states due to the investment the physician has in it.i can tell you that many of my colleagues resort to it as a first line of treatment.
the study i think brings to light something that was touched upon by one of the contributors.heel spur syndrome/plantar fasciatus are biomechanical pathologies.thus they must be treated first with a comprehensive conservative regimen,consisting of pt,injection therapy,nsaids,stretching and orthosis.there are a lot of practitioners who will do one but not the other of all of these.thus not giving conservative treatment a true chance.
incidentally,we are currently trying a plantar approach after a pt block when injecting difficult to relieve patients which has worked fairly well (anecdotal).the idea is that by using a 20 gauge needle we are able to open an aperture in the fascia while depositing the cocktail and allow for some additional stretching.it is being used by some local orthopods in my area.and it too is less expensive than eswt.

[Ron Lucerne]

Craig, Podric,
What are your opinions on treating Plantar fasciitis using Cryosurgery for long term pain relief? When should a patient consider this type of treatment?
Ron Lucerne (lucerner@att.net)

[Craig Payne]

There is even less evidence for that than there is for the shock therapy.

At the end of the day, plantar fasciitis is due to a mechanical overload in the tissues (we could argue how that overload got there) - all these modalities are doing is providing symptomatic relief - in some people that is all thats needed provided they modifiy activity levels. .... but in most something needs to be done to reduce the load in the tissues (we could argue over the best way to do that)

I will post soon the results of our RCT in those with failed orthoses treatment for plantar fasciitis ---- BUT, they do get better if you get the orthotics right.

[Ron Lucerne]

Craig,
Thanks for your reply. What does it take to get the Orthotics right other than a custom fit from a casting of the patient's foot by a board certified podiatrist? How is the Podiatrist able to determine that the finished Orthotic provided from the lab is correct for that individual patient?
Ron Lucerne

[Don ESWT]

Excuse me.

If you are not treating patients with ESWT or Cryrotherapy how can you make such a flippent remark.
ESWT has excellent results for PF, Golfers and Tennis Elbow, Peryonis Disease, Non Union Fractures, Achilles Tendonitis, Haglunds' Deformity, Rotator Cuff Tears, Hips, Knees, and the latest Diabetic wound healing and Myocardial disease.
Years of solid research in Europe and Japan have the results (News-Medical.Net 31/5/2005)
Studies from Monash University in 2001 have be debunked by the broader ESWT community/researchers.
Poor Q form and patients involved.
No Podiatrist on hand for biomechanical assessment.
No ESWT Therapist present at trial.
Trail carried out by students.
No Xray or Ultrasound to confirm PF or tendon thickness

ESWT works, it just take time for the individuals body to react to the treatment. There is also a patient compliance component with the treatment. Do exactly what the practitioner recommends.

Orthotics work ESWT works and Cryotherapy works.


Donald Iain Scott
Podiatrist
ESWT Therapist

[Craig Payne]

Studies from Monash University in 2001 have be debunked by the broader ESWT community/researchers.
No even close to be true - those with a vested interest seems to have tried to pick holes in it and other studies, but conviently ignored the bigger holes in the studies that they claim support ESWT!!! From a methodological standpoint, it is probably the most rigourously conducted - most of the critics conviently ignored the research question from that study - they answered it.

ESWT was an overused fad that is now being put in its appropriate place as a useful modality and not the "end all and be all" - its just those that have invested financially so heavily in the equipment have to justify what they have done.

We have done 3 RCT's on plantar fasciitis, one of which was on those with failed orthoses -- we just do not see the need to use ESWT anymore --- we just don't see patients that need it as we got better fixing them with foot orthoses.

I am not aware of one single RCT that shows cryotherapy works in plantar fasciitis, so its easy to make the claim about lack of evidence (that does not mean it does not work).

[Don ESWT]

So, your saying orthotics are the only answer to Plantar Fasciitis

[Don ESWT]

Graig,
ESWT started in Europe not Australia or America, why do you not acknowledge their initial work and their recent breakthroughs

Don Scott

[Craig Payne]

ESWT started in Europe not Australia or America, why do you not acknowledge their initial work and their recent breakthroughs
I have copies of it all - they just do not stand up to any methodological scrutiny. The recent prospective RCTs that are rigourously done are just not supporting the less rigourous studies previously done. I have nothing against or for ESWT therapy - I have no vested interest in it either way - I have referred patients for it - some got better - some did not. Those with vested interests are someone selective in their critiques of methodological issues in studies that do and do not support its use.
So your saying orthotics are the only answer to Plantar Fasciitis Never said that. What I am saying is that EWST is probably only ever needed in a few isolated cases. Now that we are getting better outcomes with foot orthoses, I have just not had to send anyone off for EWST for over a year now.

I just object to the almost "religious fanaticism" amoung some in the ESWT that is harming it for all --- see the similarities to the threads we have had on manipulation, barefoot running and minimum incision surgery :)

I recall when that Monash paper came out, a message posted in PM News from a DPM who had purchased an EWST machine, demanding that the American Podiatric Medical Association do everything it can to totally discredit the study ---- certainly smacks of a credibility issue that the owner of a machine with a vested financial interest would demand such scrutiny, without demanding that the studies that have tended to support EWST not be put under the same such scrutiny :confused:

[Don ESWT]

Craig,
Scrutiny is important, I am sure you would not let something be published unless someone proofed it for you.

Yes I have a vested interest in the success of ESWT as I have a machine but the Monash results are now 5 year out of date.

Yes the manufacturers and there are about 10 world wide, have a vested interest in the success ESWT, as they have outlaid millions of EUROS. Dornier the company which loaned the machine to Monash University were upset that they were not involved throughout the process, but that is past history.

I remember reading that the Prof. Rachel Buchbinder study, was taken up by US Health Funds they used it to refuse patients a rebate for treatment, yet the FDA approves ESWT go figure!

There are arguement for and against ESWT and I don't they will be settled easily.

I have been involved with ESWT since September 1998. I was able to purchase a machine in 2002. I will keep trying to help my patient with their pain management.

On another point Functional Orthotics have been around over 50 years, surely as Podiatrists we should have it right by now, but we still have not come to an agreement as to the style of orthotic to cure PF.

I gave a pair of Functional Orthotics to the Sydney College in the mid 80's that my father made in 1951 along with his Anaesthetic Injection Kit and Ross Fraser Brace Kit.

Donald Iain Scott

Podiatrist
Extracorporeal Shock Wave Therapist
Wollongong
New South Wales
Australia

[R.S.Steinberg]

In the USA, the criteria for using High Energy Dornier EPOS Ultra ESWT for plantar fasciitis is six months of failed conservative therapy having utilized at least three of the following: NSAIDs, cortisone injection, ultrasound, massage, stretching, over-the-counter arch supports, or prescription orthotics. Then, and only then, is it time to try ESWT. (According to the US Federal Drug Administration)

And, without a doubt, ESWT should be tried before any surgical release of the medial portion of the plantar fascia. I would call it malpractice if it weren't! With that said, in my 28 years of practice I have found that at least 70% of my patients with plantar fasciitis respond well to the conservative therapies I listed above. At this point in my career, I shudder when I even think about a surgical release because of the damming affect it has on the biomechanics of foot function. In reviewing the literature, I found that most of the study findings are suspect because legitimate protocols were not followed. Injections can and do work so it is no surprise that they were shown to be "as effective" as ESWT. But injections, and all the other conservative therapies do not always work. We all know this, don't we?

I have been certified on ESWT for over 6 years now; first on the clumsy Ossatron, and now on the Dornier EPOS Ultra. Both devices work, but the EPOS Ultra produces consistently better results. I think this is mainly due to its real-time ultrasound imaging capabilities that allow for extremely accurate aiming throughout the procedure. You can believe me or not, but I am seeing an 80%+ cure rate. I have had three cases where I felt it necessary to re-do the procedure.

I believe that ESWT will become the gold standard of care for chronic plantar fasciitis in the not too distant future. It is non-invasive, effective, and has a low risk of negative side effects.

Robert Scott Steinberg, DPM, DACCPPS (BP)
Hoffman Estates, IL USA
Doc@FootSportsDoc.com

[podrick]

i think don misses one vital point in his argument.there are many treatment modalities which may relieve a condition without ever having addressed its cause and thus risk long term damage or even offer short term results.
i can site steroid injections for the knee.they may resolve the pain while they actually crystalize and create further damage to the tissue,particularly when over used.
in the U.S. eswt is marketed for conditions ranging from plantar fasciatus to tendo achilles tendinitis( a condition which its own research has indicated it is not indicated for).so i do believe there is cause for questioning long term results.
then there is the question of the price of the modality.it may very well be a very expensive solution to a problem which may be treated with more conservative economical means.particularly in the states,at a time with limited insurance coverage and resources, for healthcare.price cost does matter.
i am not closing the door on it.i just have read all the available research on it and think more is needed,before we touted as a "cure-all," to our patients.

[podrick]

Craig, Podric,
What are your opinions on treating Plantar fasciitis using Cryosurgery for long term pain relief? When should a patient consider this type of treatment?
Ron Lucerne (lucerner@att.net)
ron,
i think with cryosurgery you have an even bigger dilemma then with eswt.if you read their own research and spend time in a demonstration.you walk away with more questions then answers.
they simply don't have a real answer as to why it works and for how long will it work.
as to how they get fda approval in the states now a days.i just don't know may be they got some advice from the vioxx makers.

[R.S.Steinberg]

Podrick,

Where did you go to school? When did you graduate? Will you post your full name?

I am not sure where you get your information. And, every bit of medicine is marketed. Hanging your shingle is marketing. So, what is your point?

In the USA, ESWT is marketed, promoted, pushed, etc., as a treatment for chronic plantar fasciitis, and off lable for chronic Achilles tendonitis. It is currently under review by the FDA for approved use.

It goes without saying that doctors always, or at least should be, looking for cause and effect, as well as the effect any certainj treatment has long term. Sx of the PF produces a permanant change in foot structure and function. There are no reports of any long term negative effects of ESWT, and ESWT has been used in Europe for over 12 years.

ESWT is far less costly in terms of missed work and recovery then SX. Period. And since it is not supposed to tried until conservative therapy has failed, where is the problem, or better yet, where is your problem.

Podrick, how many high-energy ESWT procedures (following all protocals) have you performed?

Oh, and lets not forget that our patients are demanding relief from their pain.

Robert Scott Steinberg, DPM
Hoffman Estates, IL
Doc@FootSportsDoc.com

[Craig Payne]

The Cochrane Collaboration conclusion on ESWT was:

A meta-analysis of data from six randomised-controlled trials that included a total of 897 patients was statistically significant in favour of extracorporeal shock wave therapy for the treatment of plantar heel pain but the effect size was very small. A sensitivity analysis including only high quality trials did not detect a statistically significant effect.

It will never become a "gold standard"

[podrick]

Podrick,

Where did you go to school? When did you graduate? Will you post your full name?

I am not sure where you get your information. And, every bit of medicine is marketed. Hanging your shingle is marketing. So, what is your point?

In the USA, ESWT is marketed, promoted, pushed, etc., as a treatment for chronic plantar fasciitis, and off lable for chronic Achilles tendonitis. It is currently under review by the FDA for approved use.

It goes without saying that doctors always, or at least should be, looking for cause and effect, as well as the effect any certainj treatment has long term. Sx of the PF produces a permanant change in foot structure and function. There are no reports of any long term negative effects of ESWT, and ESWT has been used in Europe for over 12 years.

ESWT is far less costly in terms of missed work and recovery then SX. Period. And since it is not supposed to tried until conservative therapy has failed, where is the problem, or better yet, where is your problem.

Podrick, how many high-energy ESWT procedures (following all protocals) have you performed?

Oh, and lets not forget that our patients are demanding relief from their pain.

Robert Scott Steinberg, DPM
Hoffman Estates, IL
Doc@FootSportsDoc.com
robert,
my name is rick reyes,d.p.m. graduated from barry university school pod med,psr24,adjunct clinical instructor,i own two practices in the south florida area,feel free to look me up.what are you going to do beat me up in the playground.
i get my information from the same articles that our administrator and craig payne do.read those articles and you will see something lacking in the original research presented on eswt,large sample patient population and long term follow up.
in terms of fda standards for approving a modality's indications,give me a freaking brake.this is the same fda that approved cold laser therapy for everything from neuropathy to tennis elbow,without significant research.considering recent scandals,such as the ones with vioxx.this doesn't strenghthen your argument much.
i am not saying that it doesn't have its place in terms of treating painful conditions.but it shouldn't take the place of good diagnosis and conservative care.the reality is that this is very unlikely if you are leasing one of these babies.there is too much of a financial stake involved.

later bobby,
don't forget to look me up

[R.S.Steinberg]

Rick,

I am not leasing one of those "Babies". I wanted to know about you so that I could better understand your experience, and where you might be coming from. I am not looking for a playground fight, but I guess I know where to find you if I was. (Just kidding!) I have been in practice since 1976. I have been a surgical instructor for some 18 years. Until this past January, I was Podiatry Section Chief for 4 years at Norwegian American Hospital, Chicago, where I continue as a surgical instructor and Director of the Residents' Foot & Ankle Clinic.

You did not answer my question: How many high-energy ESWTs have you done? Many times, I am not a patient's first treating DPM. Some come to me with one, two & 3-year histories of recalcitrant plantar fasciitis. Post high-energy ESWT on these patients is remarkable. This class of patients is my single largest source for new patients needing heel pain treatment. You can argue with me if you want, but the proof is in. High-energy ESWT just plain works. If you want, I can arrange for you to be certified to perform the procedure.

Craig,

Would you be so kind as to e-mail me a copy, or a link to the Cochrane collaboration? If you do not mind, I would like to see the methodology and then draw my own conclusions.

As I said, 70% of my patients respond very well to conservative therapy. Each patient gets a gait cycle analysis and biomechanical exam. I review their lifestyle and their shoes choices. ESWT is for that 10-30% who are very frustrated by the lack of relief provided by the multiple conservative modalities applied multiple times over a 6-month period. If I, a foot and ankle expert, cannot offer anything further except surgery, then I have failed my patient.

None of you has talked about just how bad a release of the medial portion of the plantar fascia is. Is this because you do not view this surgery as being bad?

Robert Scott Steinberg, DPM, DACCPPS (BP)
Hoffman Estates, IL USA
Doc@FootSportsDoc.com

[Don ESWT]

Rick,
ESWT is used as a last resort prior to surgery. A lot of people who post are also missing that ESWT is about to evolve again with the treatment of heart damage and ulcer repair.
Since the mid 70's when Dornier used it for Metalergical application (Wing strength), 80's Kidney and Gall Stone (ESWL) and 90's ESWT tendon repair,
Yes as one postee stated hit "it with a hammer", pretty close to the truth.

ESWT is for some and not for others.
With over 50million treatments under theri belts the European ESWT community is happy.

On another happy note at least 250 Million people have read the Harry Potter series at least once.

Donald Iain Scott

[Don ESWT]

Craig,
Sorry to put you on the spot, but what is the "Gold Standard" for the treatment of Plantar Fasciitis.

Hands on ground feet in air (Could get Carpal Tunnel Syndrome)
Don't wear Footwear (Too much broken Glass and syringes)
Stay in bed all day (Watch TV and eat Chocolate "ummm chocolate" and reruns of the Simpsons)
My wife says amputation. A bit drastic, but she has the MRI and the screws in her right foot (Triple Arthro) and no PF in her Left foot after ESWT.



There is really no such thing as a "Gold Standard", as what may work for one may not work for another. All we can do is our best with the resources available.

Donald Iain Scott

[podrick]

Rick,
ESWT is used as a last resort prior to surgery. A lot of people who post are also missing that ESWT is about to evolve again with the treatment of heart damage and ulcer repair.
Since the mid 70's when Dornier used it for Metalergical application (Wing strength), 80's Kidney and Gall Stone (ESWL) and 90's ESWT tendon repair,
Yes as one postee stated hit "it with a hammer", pretty close to the truth.

ESWT is for some and not for others.
With over 50million treatments under theri belts the European ESWT community is happy.

On another happy note at least 250 Million people have read the Harry Potter series at least once.

Donald Iain Scott
ron,

you seem like a reputable practitioner and i have no problem even referring a recalcitrant case of plantar fasciatus to you.however,at least in south florida where i practice.there are practices that touted it,as a first line treatment for every heel or arch pain that walks through the door.this i feel is strictly due to the financial stakes in such an expensive modality.

you asked me how many i have done the answer is directly none.when i was doing my fellowship,eswt was becoming popular and i participated in a few cases.i can only tell you the same thing craig stated.in some cases it worked very well and in others it didn't ,not that much different than other methods.

i did do a bunch of endoscopy procedures when i was in training and agree with your views of it.yet with endoscopy the motivating factor was economical as well.you had a huge investment in a system and (at least in florida) mega medicare reimbursements.it was basically a fad, bolstered by ample research sponsored by the system's manufacturer.

we owe it to our patients to offer diagnosis and choices,not a one size fits all modality.i am not saying you do this.but unfortunately a good percentage of practitioners using this modality are doing this.

best regards,

rick

[Admin]

but what is the "Gold Standard" for the treatment of Plantar Fasciitis. The 2003 conclusion from the Cochrane collaboration was:
Although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in randomised controlled trials. At the moment there is limited evidence upon which to base clinical practice. Treatments that are used to reduce heel pain seem to bring only marginal gains over no treatment and control therapies such as stretching exercises. Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. Orthoses should be cautiously prescribed for those patients who stand for long periods; there is limited evidence that stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than eight hours per day. Well designed and conducted randomised trials are required. This analysis was done prior to several of the recent most major RCT's in plantar fasciitis (the most significant of which is still 'in press').

Their conclusion on EWST was posted above, with the meta analyis showing small effect sizes. Now that there are sufficiant RCTs on foot orthoses in pantar fasciitis (not all yet published), there is now sufficent for a meta analysis to show the effect sizes with foot orthoses.

The only the study published since the above Cochrane reviewvthat would have been worthy of inclusion is one that showed strecthing is effective.

But given that the natural history of plantar fasciitis is to get better without treatment (ie look at the placebo groups in the longer term RCT's) I am not sure that we can have 'gold standard'.

[R.S.Steinberg]

Ok Everyone,

The Cochrane Collaboration has been quoted and re-quoted, yet no one is willing to provide a copy of the study. Is it because it cannot stand the "light of day"? I would like to review the methodology for my self.

Funny thing about treatments, ever notice you get better at them with time? I have seen less then successful post ESWTs and have discussed this with others. Most often it is a failure of technique, not equipment, When the Ossatron was first introduced, I heard of a number of failures. Maybe this was because you cannot visualize the abnormal area of the plantar fascia with this device. I remember the first time the Dornier EPOS Ultra was demonstrated. Identifying the abnormally thickened plantar fascia and measuring it – alone its entire length of the abnormal thickness -- allowed precise targeting, but further, it also allowed me to modify the procedure isf the length of the abnormal plantar fascia was 20 mm or more. This came from using the device and getting better at it.

So, for someone to weight in on the efficacy of any treatment and not ever really used it is, is, is, well, ................. Oh someone think of a good word, please!!!

Robert Scott Steinberg, DPM, DACCPPS, (BP)
Doc@FootSportsDoc.com

[Admin]

The Cochrane Collaboration has been quoted and re-quoted, yet no one is willing to provide a copy of the study. Is it because it cannot stand the "light of day"? I would like to review the methodology for my self. The Cochrone Collaboration is NOT a study - its a very highly respected international non-profit unbiased clearing house for meta analyses of RCT's done by others. Its was established by the "founding father" for evidence based practice (Archie Cochrane):
http://www.cochrane.org

Only studies of the highest quality are incorproted into the meta-analyses and all meta-analyses are subjected to the highest standard of peer review.

[Don ESWT]

To All,
To Me Chochrane is, excuse the word "Bull***t". Meta analysis the same. It is assumption that the other researshers work is accurate or complete.
I looked up Chrochane and type in ESWT, only 2 studies in there. Both are on elbow papers (NOT ACTUAL WORK) done by Buchbinder in 2005. She uses Jan Romps paper and another from 2001 and 2003 and says ESWT does not work.
Without a machine to do her own research how can we rely on impartiality, and you can look up www.monash.med.edu.au "They are compiling data" "BUT WHOS"
She is gleening data from sources. It is not true research.

I am about to contact Jan Romp and see if he you care to comment.

Donald Iain Scott.

[Craig Payne]

I have made a mistake above (more on that in a moment)

BUT, you really showing your lack of understanding of what a meta analysis is and how powerful they are with evidence. Ony two studies may have been included in the elbow meta analyses, but that is because only two were of good enough or high enough standard to be included! A RCT is a powerful form of evidence, but the meta analysis is even more powerful (as it combnes the data of several studies) - it may not be true research to you (all researchers consider it real research), but it the best kind of evidence!!! (you really need to go an look up epidemiology 101 before making the claims you do). Meta analyses rank at the top of the hierarchy on the quality of evidence they provide.

The mistake I made was that I did not notice that the meta analsyses on EWST in heel pain was not part of he Cochrane Collab ---- but its conclusons on the small effect size of EWST still stands. This is what I was refering to:
http://www.biomedcentral.com/1471-2474/6/19/abstract

Those who do the Conchrane collab reports and those authors of the meta-analysis on EWST and heel pain have no bias, no conflicts of interest and no vested interests.

[DrPod]

I'm with Craig on this one. EWST was an overhyped fad, that is still useful in some limited cases. Fortunately in my area it is now being used more sensibly. I was less than impressed wth the success rates on patients I sent off for it when the hype started. It only helped a couple of the dozen or so I refered. They were all chronic and nothing else seems to want to work. What is really needed is some better guidance so I could better pick the 2/12 that it helped, rather than just send off so many for it (it hurts, it costs and it has inconviences).

[Don ESWT]

craig,
Did Buchbinder do the work herself or was it her lackies
Don

[Craig Payne]

Did Buchbinder do the work herself or was it her lackies
I have no idea. Why is it important?

I have research assistants and research students do the bulk of the data collection on my projects.... its the usual way. Why is it a problem, just because you do not like the results of a particular study?

All I know is Buchbinder is part of a radiology group that owns some ESWT machines (the ones we also happen to refer to), so she has a vested financial interest in showing they work. Its commendable that they rose above that....

[Don ESWT]

Craig,
When she compiled her data, did she take into consideration what machine were being used there could be as many as 10 manufactures out there.
To DrPod, Ask the 5million kidney stone free patient if they unhappy since ESWL same process different letters

Don

[podrick]

Rick,
ESWT is used as a last resort prior to surgery. A lot of people who post are also missing that ESWT is about to evolve again with the treatment of heart damage and ulcer repair.
Since the mid 70's when Dornier used it for Metalergical application (Wing strength), 80's Kidney and Gall Stone (ESWL) and 90's ESWT tendon repair,
Yes as one postee stated hit "it with a hammer", pretty close to the truth.

ESWT is for some and not for others.
With over 50million treatments under theri belts the European ESWT community is happy.

On another happy note at least 250 Million people have read the Harry Potter series at least once.

Donald Iain Scott
don,

the problem is that in the states,it is being touted as a first line treatment.many times by-passing the biomechanical work up necessary to treat the majority of plantar fasciatus cases.

the reason here being the money invested in it.you simply are not going to invest $100,000 in a devise to use it as a last resort on less than 5% of the cases you see.

you forget my freind,sadly american medicine is very much profit driven.craig is correct when he states that the original studies don't stand up to any real scrutiny( small group of patients,very subjective grading system and very little long term follow up).in the states,most of the research is sponsored either directly or indirectly by the system's manufacturer.

i am not saying it can't work.however,it isn't this silver bullet their marketing states.

regards

[DrPod]

To DrPod, Ask the 5million kidney stone free patient if they unhappy since ESWL same process different letters
Whats that got to do with it? Kidney stones are very different pathological process to the degenerative changes of plantar fasciitis. I have no idea of the evidence on kidney stones and ESWL, but assume its good. From what I read above the evidence for its use in plantar fasciitis is very weak.

[Don ESWT]

Craig,

Monash University does not have an ESWT machine so there is no vested interest. They have been anit ESWT from the start.

I do not have the facilites or staff to carry out mass research that you can accomplish.

Have a good weekend

Don

[Don ESWT]

DrPod,
The application for ESWL and ESWT are many and varied.
Since the mid 80's the Dornier machines have been treating Kidney and Gall Stones.
Since the mid 90's treatments on Plantar Fasciitis, Achilles Tendonitis, Haglunds' Deformity, Knees, Hips, Elbows, Shoulders and Non Union fractures.
2000 to present treatment of Diabetic ulcers and more recently Myocardial tissue repair.
ESWT is also used in the horse racing industry.

There are thousands of entries on Google relating to ESWT world wide.
The best site for ESWT is www.ismst.com, of which I am a member, therfore a discosed interest.

My opinions are at conflict with yours as I will defend the treatment for chronic suffers, So, lets just leave it at that.

Have a good weekend

Don Scott

[R.S.Steinberg]

DrPod,

You should have sent your patients to me for ESWT I guess. :) One thing is obvious, though, you do not perform the procedure yourself, and since you don't, we really cannot get into whether the technique was at fault, can we????? Your comments are about as valid - scientifically - as the Cochrane "Analysis" of someone else's maybe good, maybe not so good "study". You know, medicine is more then this type of Voodo "analysis".

Robert Scott Steinberg, DPM,DACCPPS, (BP)
Doc@FootSportsDoc.com

[podrick]

cochrane's group are the father's of evidence based research.i would suggest you check out the latest issue of podiatry management magazine.it features a panel discussion on the subject.the collaborators include weil and markinson,not exactly lightweights in our profession.this is certainly not b***S***.
it is considered the most accurate means in which to measure true medical efficacy.it has been embraced by the ama,well before we heard of it.
sometimes true scrutiny may not give us the answer we are wishing for and we tend to lash out.but this is science,not opinions.

regards

[podrick]

craig,

i commend you on some excellent points with regards to this issue.the fact that a therapy has been used to treat kidney stones is completely unrelated.the reality of the matter is that when it came to shock therapy in kidney stones,it was rigorously tried and tested in different medical schools.
i know this because one of the first centers,was in my neck of the woods,university of florida.i am sure these studies were published and reviewed.otherwise,major medical schools around the world would not have adopted it and most importantly,insurance wouldn't have covered it.
keep in mind that in the states,a good litmus of a modality's efficacy is if medicare covers it.i know a lot of my colleagues wont agree with this but it has proven very true over time.
by the way i read you will be one of the lecturers for the upcoming canadian seminar.i will attend as a guest of a canadian colleague.i look forward to hearing you and saying hi.

regards

[R.S.Steinberg]

Rick,

Still, you expect me to accept the "findings" of the Cochrane group because they were published in PM. Really? Other people have certain vested interests in studies and are supported by manufacturers. No possibility of any bias there, so I should accept - without question - their opinions as well.

Cochrane's reporting is on "old science", and does not take into account up to date studies. It can't. That's the problem with studies done on emerging technology. Things develop way too fast for "mega analysis" to tell us anything worthwhile. We are not talking about the 15 year use of some heart medication where studies abound, are we?

Oh, and BTW, Buchbinder has recanted. Another example of not just "bad science”, but more to no science at all. The study used a machine that was designed for high-energy ESWT and used it at low energy. Dahhhhhhhhh, it doesn't work. Yea, so how does that equate to its use - as allowed by the USFDA - as a high-energy treatment? Maybe I am missing something here, but Buchbinder obviously forgot to read the instructions. I hope the ESWT devices that were used in the "study" were plugged in !!!

It is obvious that you do not like the procedure. What I feel is not fair is that you do not do the procedure and attempt to speak with some authority on ESWT. As well trained as you are, are you not open to advances in procedures, techniques, or other treatment modalities? If Lowell Scott Weil, DPM had your attitude (since you mentioned him), our profession would have missed out on a number of significant advances. Podiatry's biggest problem is that we do not have enough visionaries. We definitely have way too many people with their heads-in-the-sand.

Robert Scott Steinberg, DPM, DACCPPS (BP)
Doc@FootSportsDoc.com

[R.S.Steinberg]

Dr. Payne,

Since you took the job of being a moderator on the forum, you should know that that requires you to be non-biased. Still it is nice to see you and Rick glad-handing and slapping each other on the back.

Seriously, comments like yours and Rick's do more harm then good. Neither of you have any real expertise in using high-energy ESWT and only make your arguments based on someone else’s "weird science". That is not allopathic science. It's voodoo.

It is correct that ESWT of kidney stones has nothing to do with treating PF. Not sure how that came up. Podiatry has always suffered from a lack of research. Our profession is small, and we are routinely ignored for grants to do the kind of studies like ESWT for stones. There isn't enough money in it for drug or equipment companies. So what do you say we should do? Maybe we should all revert back to chiropodists?

Robert Scott Steinberg, DPM, DACCPPS, (BP)
Doc@FootSportsDoc.com

[Craig Payne]

Seriously, comments like yours and Rick's do more harm then good. Neither of you have any real expertise in using high-energy ESWT and only make your arguments based on someone else’s "weird science". That is not allopathic science. It's voodoo.
I would suggest the opposite is the case. Its Podiatry's track record in understanding evidence based practice and what good evidence is, is the problem...

I just find it paradoxical that suppporters of ESWT will go to no ends to discredit and find flaws in studies that do not show ESWT to be useful, but are unwilling to put studies that support it under the same scrutiny (and launch personal attacks on the authors of the "anti" studies, but not the "pro" studies).... don't figure! ... the meta analysis do this in an unbiased way ..... and look at what happens.

I have nothing to loose or nothing to gain with rgards to ESWT. I have read all the literature and research and have referred patients for it (and have a responsibility to teach it in an unbiased way ---- students get taught to read the literature in such a way that they can make their own minds up) ... my expereince in the early days with those we referred for ESWT was that it was not very successful. Now we just do not see as many chronic plantar fasciitis cases as we use to. We have done 3 RCT's on plantar fasciitis in the last 12 months (who said there is a lack of research in podiatry?) - so we seen a lot of cases this year --- in all that I have only sent one of for ESWT (and it woked).

[eddavisdpm]

Extra Corporal Shock Wave Therapy: This treatment does not appear to have gained favour in the UK. I have spent the last year in the US, where the treatment often now preceeds surgical intervention.

I am interested to hear from any practitioners willing to share their experience of using ESWT in the treatment of heel pain/achilles tendon pathology.

Apologies to Podiatry Forum visitors.
We have recently formed the American Society of Musculoskelatal Shockwave Therapy (www.asmst.org) and invite anyone interested to join.

I took an active role in forming the society at my own expense, building a homemade website, drawing a logo and getting paying to get it registered. After performing several hundred ESWT via the US and via my proximity to Vancouver, BC, being in the Seatlle area of the US, there is no qustion in my mind that ESWT is the treatment of choice for enthesopathies and tendinopathies. I would perform ESWT on my own mother or myself long before considering surgical treatment. IT WORKS! Opposition to it has been politically motivated by very well financed surgical societies and surgery equipment manufactureres, not to mention the powerful hospital lobby in the USA.

Eddie Davis, DPM
eddavis@webmail.us

[eddavisdpm]

No even close to be true - those with a vested interest seems to have tried to pick holes in it and other studies, but conviently ignored the bigger holes in the studies that they claim support ESWT!!! From a methodological standpoint, it is probably the most rigourously conducted - most of the critics conviently ignored the research question from that study - they answered it.

ESWT was an overused fad that is now being put in its appropriate place as a useful modality and not the "end all and be all" - its just those that have invested financially so heavily in the equipment have to justify what they have done.

We have done 3 RCT's on plantar fasciitis, one of which was on those with failed orthoses -- we just do not see the need to use ESWT anymore --- we just don't see patients that need it as we got better fixing them with foot orthoses.

I am not aware of one single RCT that shows cryotherapy works in plantar fasciitis, so its easy to make the claim about lack of evidence (that does not mean it does not work).

Craig:
There is a "treatment triad" in plantar fasciitis. Early on, we are dealing with a perdominance of inflammation: later, if pain persists, biomechanics plays are role. when we fix the biomechanics, we often allow the third "leg" of the problem to resolve and that is a breakdown in tissue quality. ESWT directly addresses tissue quality. This is proven in literally scores of papers on the www.asmst.org and www.ismst.com websites. Rompe's research used sonography to show an undisputable difference in tissue quality of the fascia 20 weeks after application.
Regards.
Eddie Davis, DPM
edavis@webmail.us

[eddavisdpm]

I have copies of it all - they just do not stand up to any methodological scrutiny. The recent prospective RCTs that are rigourously done are just not supporting the less rigourous studies previously done. I have nothing against or for ESWT therapy - I have no vested interest in it either way - I have referred patients for it - some got better - some did not. Those with vested interests are someone selective in their critiques of methodological issues in studies that do and do not support its use.
Never said that. What I am saying is that EWST is probably only ever needed in a few isolated cases. Now that we are getting better outcomes with foot orthoses, I have just not had to send anyone off for EWST for over a year now.

I just object to the almost "religious fanaticism" amoung some in the ESWT that is harming it for all --- see the similarities to the threads we have had on manipulation, barefoot running and minimum incision surgery :)

I recall when that Monash paper came out, a message posted in PM News from a DPM who had purchased an EWST machine, demanding that the American Podiatric Medical Association do everything it can to totally discredit the study ---- certainly smacks of a credibility issue that the owner of a machine with a vested financial interest would demand such scrutiny, without demanding that the studies that have tended to support EWST not be put under the same such scrutiny :confused:

The Buchbinder study, as shown by Rompe, already broke every rule necessary to prove/disprove ESWT. Buchbinder used a sublcinical dose of shockwave energy on a population of which 50% would not even qualify for ESWT by not having pathologic fascia, defined, ultimately by sonography but, proximally by having had plantar fasciitis for at least 6 months.
Eddie Davis, DPM
eddavis@webmail.us

Note that very few American podiatrists purchased ESWT machines. They use machines owned by kithotripsy companies, and often perform the service without getting paid. As far as you "insult" of fanatacism among ESWT proponents, please levy that insult to the hundreds of researchers published at www.ismst.com and see what their response is.
Eddie Davis, DPM

[Craig Payne]

The Buchbinder study, as shown by Rompe, already broke every rule necessary to prove/disprove ESWT
Thats exactly my point - the lengths that biased people will go to to discredit papers that do not support ESWT and not put papers that support ESWT under the same methodological scrutiny. The unbiased meta-analysis mentioned above that only included those that stood up to methodological scrutiny showed that ESWT worked but the effect size were small --- thats good enough for me.

[Don ESWT]

Ed,
I was unable to contact Dr. Rompe for his comments I only have is old email can you help get him online.

Don Scott

[eddavisdpm]

Thats exactly my point - the lengths that biased people will go to to discredit papers that do not support ESWT and not put papers that support ESWT under the same methodological scrutiny. The unbiased meta-analysis mentioned above that only included those that stood up to methodological scrutiny showed that ESWT worked but the effect size were small --- thats good enough for me.

So, you are satisfied to ignore the hundreds of competent research papers on www.ismst.com in favor of a long discredited study by Buchbinder? That says very little for your objectivity. Let the readers here read the two hundred plus abstracts on www.ismst.com and make there own decision.
Ed Davis, DPM

[eddavisdpm]

So, you are satisfied to ignore the hundreds of competent research papers on www.ismst.com in favor of a long discredited study by Buchbinder? That says very little for your objectivity. Let the readers here read the two hundred plus abstracts on www.ismst.com and make there own decision.
Ed Davis, DPM

Ps. Almost all readers familiar with the Buchbinder study realized that she applied a subclinical dose of ESWT on a population, 50% of which did not meet the basic criteria for intractable plantar fasciitis which is a minimimum of 6 months of PF unaffected by standard treatment means. A minimum of 1300 mj/mm squared must be applied to show a tissue effect.
Ed Davis, DPM

[Craig Payne]

Almost all readers familiar with the Buchbinder study realized that she applied a subclinical dose of ESWT on a population, 50% of which did not meet the basic criteria for intractable plantar fasciitis which is a minimimum of 6 months of PF unaffected by standard treatment means I agree totally...BUT thats exactly what the set out to do. Their research question was to test if a lower dose worked on shorter duration plantar fascitis - they found it didn't. The research design and methodology was set up to test that hypothesis. Of all the ESWT studies, their research desgin was the soundest.
So, you are satisfied to ignore the hundreds of competent research papers on www.ismst.com (http://www.ismst.com) in favor of a long discredited study by Buchbinder? That says very little for your objectivity. Let the readers here read the two hundred plus abstracts on www.ismst.com (http://www.ismst.com) and make there own decision. All but a couple of those hundred are easier to dismiss than Buchbinder - did you not notice that almost all of them did not have sound enough methodology to be included in the unbiased meta-analysis mentioned above. Thats just not my objectivity - that a lot of others objectivty as well who have no vested interest in the outcome. Why do you not put them under the same scrutiny as Buchbinder's? Why just post the abstracts on the website, so readers can not see all the shortcomings in the methods?

I will be the first to change my mind as soon as the evidence from methdologically sound studies that are properly controlled, blinded, with adequate statistical power and with the use of validated outcome meaures are available.This level of evidence for EWST for heel pain just does not yet exist. In the mean time I will not be taken in by marketing hype and the outcome of poorly controlled, unblinded studies, underpowered with unvalidated outcome measures.

[eddavisdpm]

Craig:
Stop making orhtotics immediately because I know of no study that holds up to the level of methodology proving that orthotics work at the level you hold the Buchbinder study.

I am missing the point of creating a study for the express intent to lead to treatment failure by applying a subclinical ESWT dose as does Buchbinder. What does that show.

We now have 12 years of European experience, 7 years of Canadian experience, 5 years of US experience in which ESWT has worked on thousands of patients to whom surgery was recommended as a last resort. That coupled with hundreds of papers that show its efficacy not only on the gross level, but more importantly AT THE TISSUE LEVEL simply makes the evidence overwhelmingly favorable. A paper was presented last year at ISMST by Norris, Werber, et. al. that comes very close to the methodology and research quality of Buchbinder.

Craig; please tell me-- how many of the papers and abstracts on the www.ismst.com website have you actually read?
Fraternally,
Ed Davis, DPM

[Craig Payne]

Stop making orhtotics immediately because I know of no study that holds up to the level of methodology proving that orthotics work at the level you hold the Buchbinder study.
There is evidence of that level of quality. .... its just the data on which type of ot orthoses is lacking.
how many of the papers and abstracts on the www.ismst.com website have you actually read?
Probably most of them - I have a huge file of papers on ESWT.

[eddavisdpm]

Craig:

I could use the paper or abstract you mention on foot orthotics very much as this is a big battle ground with regards to third party reimbursement in the US.
We also have a proliferation of minimally trained individuals creating various "customized" insoles and calling them orthotics in the US. As far as ESWT we just will have to respect our mutual opinions and let others study the same evidence that is out there. Keep in mind that private practitioners do place considerable weight to experiential evidence especially when their experience or the experience of their colleagues has been extensive. The agency responsible for health research in the US, the FDA or Food and Drug Administration is known to be heavily politicized by a number of big money interests and has lost much respect.
Regards,
Ed

[Peter]

http://www.nice.org.uk/pdf/ip/IPG139guidance.pdf

Nice have published guidelines on the use of ECSWT. The above is the web address.

[eddavisdpm]

The "official" governnment propaganda is duly noted. Unfortunately, it appears not based on the factual evidence but politics as usual...
Ed Davis, DPM

[Peter]

With respect, this is not a government paper. NICE is the UK NHS National Institute for Clinical Effectiveness. OK you don't like the reading, but it cannot be classed as Propaganda.

I think this paper will put ECSWT to bed in the UK NHS, for now....

[Craig Payne]

I can't see anything in the document that is not based on factual evidence.

[eddavisdpm]

Unfortunately, the use of only a small portion of the available studies to reach a conclusion while simultaneously ignoring the larger body of studies available that contradict the conclusions of the statement demonstrates a bias inconsistent with the level of objectivity expected.
Ed Davis, dPM

[NewsBot]

Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: A North American confirmatory study.

J Orthop Res. 2005 Nov 18;24(2):115-123 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=16435344&dopt=Abstract)
Despite numerous publications and clinical trials, the results of treatment of recalcitrant chronic plantar fasciitis with extracorporeal shockwave therapy (ESWT) still remain equivocal as to whether or not this treatment provides relief from the pain associated with this condition. The objective of this study was to determine whether extracorporeal shock wave therapy can safely and effectively relieve the pain associated with chronic plantar fasciitis compared to placebo treatment, as demonstrated by pain with walking in the morning. This was set in a multicenter, randomized, placebo-controlled, double-blind, confirmatory clinical study undertaken in four outpatient orthopedic clinics. The patients, 114 adult subjects with chronic plantar fasciitis, recalcitrant to conservative therapies for at least 6 months, were randomized to two groups. Treatment consisted of approximately 3,800 total shock waves (+/-10) reaching an approximated total energy delivery of 1,300 mJ/mm(2) (ED+) in a single session versus placebo treatment. This study demonstrated a statistically significant difference between treatment groups in the change from baseline to 3 months in the primary efficacy outcome of pain during the first few minutes of walking measured by a visual analog scale. There was also a statistically significant difference between treatments in the number of participants whose changes in Visual Analog Scale scores met the study definition of success at both 6 weeks and 3 months posttreatment; and between treatment groups in the change from baseline to 3 months posttreatment in the Roles and Maudsley Score. The results of this study confirm that ESWT administered with the Dornier Epos Ultra is a safe and effective treatment for recalcitrant plantar fasciitis. (c) 2005 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

[eddavisdpm]

A more recent article in the Nov/Dec ed. of the Journal of the American Podiatric Medical Association by Norris, et. all had a large sample size and supported efficacy of ESWT for plantar fasciitis:

"Effectiveness of Extracorporeal Shockwave Treatment in 353 Patients with Chronic Plantar Fasciitis (http://www.japmaonline.org/cgi/content/abstract/95/6/517)," Donald M. Norris, MD, Kimberly M. Eickmeier, DPM and Bruce R. Werber, DPM JAPMA, Vol. 95, No.6, November/December 2005.

Ed Davis, DPM

[DrPod]

A more recent article in the Nov/Dec ed. of the Journal of the American Podiatric Medical Association by Norris, et. all had a large sample size and supported efficacy of ESWT for plantar fasciitis: "Effectiveness of Extracorporeal Shockwave Treatment in 353 Patients with Chronic Plantar Fasciitis," Donald M. Norris, MD, Kimberly M. Eickmeier, DPM and Bruce R. Werber, DPM JAPMA, Vol. 95, No.6, November/December 2005.
Which is realy easy to dismiss as it was uncontrolled. JAPMA also did a nose dive in credibility over this article by not printing a disclaimer such as one of the authors having a "proprietary and commercial interests" in ESWT !!! Another article in that edition of JAPMA on a different commercial product did disclose the authors commercial interests in a disclaimer.

I am with something Craig said earlier in the thread about the lengths that supporters of ESWT will go to when it comes to discrediting studies that do not support ESWT, yet are not prepared to put the studies that do support it under the same methodological scrutiny.

I have no vested interest either way (I do not own a machine or have shares in a company), so like to think I am not blinded by this interest and my reading of the literature has me unconvinced either way as to its effectiveness.

[eddavisdpm]

Only Dr. Norris has a "proprietary" interest. It is very common for manufacturers to fund studies. Dr. Werber, was the primary researcher in the study as far as I know. I will look at the Journal again to see what disclosures Dr. Norris provides but I have noted him to be an individual with impeccable ethics. The primary fault would rest with JAPMA for failing to provide full disclousre but would not use that as a major factor to discredit Dr. Werber's work nor the JAPMA itself. JAPMA has few studies of this sample size and most of the papers presented in JAPMA, have smaller sample sizes or are case reports. JAPMA typcially contains few if any double blinded peer reviewed studies. I would certainly consider this to be one of the better articles in JAPMA. United Shockwave is not a manufacturer but a distributor and in all likelihood did not have the funds to commit to a double blinded peer reviewed study as a large manufacturer or drug company could accomplish.The experimental design did not have obvious flaws such as in the Buchbinder study which a sublcinical does of shock wave energy was applied and about 50% of the patients in the study did not meet the basic criteria for the diagnosis of chronic plantar fasciitis. Refer to the comments of Dr. Jan Rompe of the University of Mainz on websites such as www.heelspurs.com. Additionally, the study supports the vast body of experiential evidence already in place.

Experience based medicine is an important and accepted part of the healing art and we are at the point where the successful experience with ESWT in the US, Canada and Europe is considerable. Certainly, we would not ask for a double blinded peer reviewed study for aspirin (there is none that I know of) due to the vast body of experience with the effects of that drug. We also would not ask that to be performed on foot orthotics. Would you stop utilizing foot orthotics becasue no study that meets such criteria exists?

Ultimately, studies based on the VAS score which is subjective are not as accurate as tissue level studies. Refer to the www.ismst.com website for Rompe's studies which demonstrate decresase in plantar fascial thickness 20 weeks after application of ESWT to a population. I would hope that more such studies are performed and could accept the paucity of such studies as an argument against ESWT. The numerous studies on www.ismst.com demonstrate when looked at collectively, that when ESWT is applied to tissue at adequate levels, there is a beneficial tissue effect. That is an effect not just limited to the plantar fascia. Much of the literature on the www.ismst.com site has progressed well beyond the plantar fascia to utilzation in various tendinopathies, enthesopathies and even non-unions.

Understandably, much of the literature on the www.ismst.com site does not meet the criterion of the double blinded peer reviewed study which is what is often being asked for. That may be a valid criticism. Nonetheless, considering the mass of literature demonstrating a tissue effect coupled with the mass of experiential evidence is quite compelling.
Regards,
Ed Davis, DPM

[eddavisdpm]

I loooked at the article in JAPMA again this morning and note that Dr. Norris is clearly listed on the bottom of the first page as being associated with United Shockwave Therapy. JAPMA is not culpable of hiding that affiliation.
Ed Davis, DPM so, considering the fair disclosure and relative research quality of the paper and I could not conisder its publishing to be a "new low" for JAPMA.
Ed Davis DPM

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Second Application of Low-energy Shock Waves Has a Cumulative Effect on Free Nerve Endings.
Clin Orthop Relat Res. 2006 Feb;443:315-319 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=16462457&dopt=Abstract)
Some physicians recommend treating tendinopathies with multiple sessions of shock waves. Some evidence, however, suggests shock wave application can induce nerve fiber degeneration. We questioned whether repeated shock wave application provides a cumulative effect on nerve fibers compared with the effect of one application. One thousand shock wave impulses of an energy flux density of 0.08 mJ/mm were applied to the foot pad of 32 rats. After 14 days, 16 rats received a second application. The foot pads were resected on Days 7, 14, 28, and 42. Sections were processed immunohistochemically using antibodies for sensory nerve. We compared the number of epidermal nerve fibers in rats that received one application of shock waves with the fibers in rats that received two applications. During the first 4 weeks, there was nearly complete degeneration of epidermal nerve fibers in both groups. By the end of 6 weeks, reinnervation of the epidermis began in the single-treatment group. Reinnervation occurred slower in the repeated-treatment group. These data show that a second application has a cumulative effect on nerve fibers. Our data suggest multiple applications of low-energy shock waves might a provide longer-lasting antinociceptive effect.

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Long-term Results of Extracorporeal Shockwave Treatment for Plantar Fasciitis
The American Journal of Sports Medicine 34:592-596 (2006) (http://ajs.sagepub.com/cgi/content/abstract/34/4/592)
Background: Extracorporeal shockwave treatment has shown mixed short-term results for plantar fasciitis. However, the long-term results are not available.

Hypothesis: Long-term results of shockwave treatment are comparable with short-term results.

Study Design: Randomized controlled clinical trial; Level of evidence, 1.

Methods: This prospective study consisted of 149 patients (168 heels) with an established diagnosis of chronic plantar fasciitis, including 79 patients (85 heels) in the shockwave treatment group and 70 patients (83 heels) in the control group. In the shockwave group, patients received 1500 impulses of shockwaves at 16 kV to the affected heel in a single session. Patients in the control group received conservative treatment consisting of nonsteroidal anti-inflammatory drugs, orthotics, physical therapy, an exercise program, and/or a local cortisone injection. Patients were evaluated at 60 to 72 months (shockwave group) or 34 to 64 months (control group) with a 100-point scoring system including 70 points for pain and 30 points for function. The clinical outcomes were rated as excellent, good, fair, or poor.

Results: Before treatment, the groups showed no significant differences in the scores for pain and function. After treatment, the shockwave group showed significantly better pain and function scores as compared with the control group. The overall results were 69.1% excellent, 13.6% good, 6.2% fair, and 11.1% poor for the shockwave group; and 0% excellent, 55% good, 36% fair, and 9% poor for the control group (P < .001). The recurrence rate was 11% (9/81 heels) for the shockwave group versus 55% (43/78 heels) for the control group (P < .001). There were no systemic or local complications or device-related problems.

Conclusion: Extracorporeal shockwave treatment is effective and safe for patients with plantar fasciitis, with good long-term results.

[NewsBot]

Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study.
J Orthop Res. 2006 Feb;24(2):115-23 (http://www3.interscience.wiley.com/cgi-bin/abstract/112147917/ABSTRACT?CRETRY=1&SRETRY=0)
Despite numerous publications and clinical trials, the results of treatment of recalcitrant chronic plantar fasciitis with extracorporeal shockwave therapy (ESWT) still remain equivocal as to whether or not this treatment provides relief from the pain associated with this condition. The objective of this study was to determine whether extracorporeal shock wave therapy can safely and effectively relieve the pain associated with chronic plantar fasciitis compared to placebo treatment, as demonstrated by pain with walking in the morning. This was set in a multicenter, randomized, placebo-controlled, double-blind, confirmatory clinical study undertaken in four outpatient orthopedic clinics. The patients, 114 adult subjects with chronic plantar fasciitis, recalcitrant to conservative therapies for at least 6 months, were randomized to two groups. Treatment consisted of approximately 3,800 total shock waves (+/-10) reaching an approximated total energy delivery of 1,300 mJ/mm(2) (ED+) in a single session versus placebo treatment. This study demonstrated a statistically significant difference between treatment groups in the change from baseline to 3 months in the primary efficacy outcome of pain during the first few minutes of walking measured by a visual analog scale. There was also a statistically significant difference between treatments in the number of participants whose changes in Visual Analog Scale scores met the study definition of success at both 6 weeks and 3 months posttreatment; and between treatment groups in the change from baseline to 3 months posttreatment in the Roles and Maudsley Score. The results of this study confirm that ESWT administered with the Dornier Epos Ultra is a safe and effective treatment for recalcitrant plantar fasciitis.

[Don ESWT]

So, what I have been saying since 1998 is now valid and that ESWT works for most patients. ESWT is the last line before surgery and all avenue's should be exhausted before ESWT
1. Anti inflams
2. Measure feet compare with footwear
3. X-Ray and Ultrasound
4. Orthotics
5.Footwear
6.ESWT
7.Surgery

No to cortisone injections
Good evening to all

Don Scott
Wollongong

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Extracorporeal shock wave therapy in the treatment of chronic tendinopathies.
J Am Acad Orthop Surg. 2006 Apr;14(4):195-204 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=16585361&dopt=Abstract)Many clinical trials have evaluated the use of extracorporeal shock wave therapy for treating patients with chronic tendinosis of the supraspinatus, lateral epicondylitis, and plantar fasciitis. Although extracorporeal shock wave therapy has been reported to be effective in some trials, in others it was no more effective than placebo. The multiple variables associated with this therapy, such as the amount of energy delivered, the method of focusing the shock waves, frequency and timing of delivery, and whether or not anesthetics are used, makes comparing clinical trials difficult. Calcific tendinosis of the supraspinatus and plantar fasciitis have been successfully managed with extracorporeal shock wave therapy when nonsurgical management has failed. Results have been mixed in the management of lateral epicondylitis, however, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. Extracorporeal shock wave therapy has consistently been more effective with patient feedback, which enables directing the shock waves to the most painful area (clinical focusing), rather than with anatomic or image-guided focusing, which are used to direct the shock wave to an anatomic landmark or structure.

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High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Insertional Achilles Tendinopathy
The American Journal of Sports Medicine 34:733-740 (2006) (http://ajs.sagepub.com/cgi/content/abstract/34/5/733)
Background: Results of high-energy extracorporeal shock wave therapy for the treatment of insertional Achilles tendinopathy are not determined. It is unclear how local anesthesia alters the outcome of this procedure.

Hypothesis: Extracorporeal shock wave therapy is an effective treatment for insertional Achilles tendinopathy. Local anesthesia field block adversely affects outcome.

Study Design: Case control study; Level of evidence, 3.

Methods: Thirty-five patients with chronic insertional Achilles tendinopathy were treated with 1 dose of high-energy extracorporeal shock wave therapy (ESWT group; 3000 shocks; 0.21 mJ/mm2; total energy flux density, 604 mJ/mm2), and 33 were treated with nonoperative therapy (control group). All extracorporeal shock wave therapy procedures were performed using a local anesthesia field block (LA subgroup, 12 patients) or a nonlocal anesthesia (NLA subgroup, 23 patients). Evaluation was by visual analog score and by Roles and Maudsley score.

Results: One month, 3 months, and 12 months after treatment, the mean visual analog score for the control and ESWT groups were 8.2 and 4.2 (P < .001), 7.2 and 2.9 (P < .001), and 7.0 and 2.8 (P < .001), respectively. Twelve months after treatment, the number of patients with successful Roles and Maudsley scores was statistically greater in the ESWT group compared with the control group (P > .0002), with 83% of ESWT group patients having a successful result, and the mean improvement in visual analog score for the LA subgroup was significantly less than that in the NLA subgroup (F = 16.77 vs F = 53.95, P < .001). The percentage of patients with successful Roles and Maudsley scores did not differ among the LA and NLA subgroups.

Conclusion: Extracorporeal shock wave therapy is an effective treatment for chronic insertional Achilles tendinopathy. Local field block anesthesia may decrease the effectiveness of this procedure.

[Admin2]

Extracorporeal Shockwave Therapy Versus Placebo for the Treatment of Chronic Proximal Plantar Fasciitis: Results of a Randomized, Placebo-Controlled, Double-Blinded, Multicenter Intervention Trial.
J Foot Ankle Surg. 2006 July - August;45(4):196-210 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=16818146&dopt=Abstract)
Extracorporeal shockwave therapy (ESWT) has demonstrated efficacy in the treatment of recalcitrant proximal plantar fasciitis. The objective of this investigation was to compare the outcomes of participants treated with a new ESWT device with those treated with placebo. A total of 172 volunteer participants were randomized in a 2:1 active-to-placebo ratio in this prospective, double-blind, multicenter trial conducted between October 2003 and December 2004. ESWT (n = 115) or placebo control (n = 57) was administered on a single occasion without local or systemic anesthesia or sedation, after which follow-up was undertaken. The primary outcomes were the blind assessor's objective, and the participant's subjective assessments of heel pain during the first 3 months of follow-up. Participants were also followed up to 1 year to identify any adverse outcomes that may have been related to the shockwave device. On the visual analog scale, the blind assessor's objective assessment of heel pain displayed a mean reduction of 2.51 in the shockwave group and 1.57 in the placebo group; this difference was statistically significant (P = .045). On the visual analog scale, the participant's self-assessment of heel pain displayed a mean reduction of 3.39 in the shockwave group and 1.78 in the placebo group; this difference was statistically significant (P < .001). No serious adverse events were observed at any time. It was concluded that ESWT was both efficacious and safe for participants with chronic proximal plantar fasciitis that had been unresponsive to exhaustive conservative treatment.

[NewsBot]

Extracorporeal shock wave therapy for tendinopathies.
Expert Rev Med Devices. 2006 Jul;3(4):463-470 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=16866643&dopt=Abstract)
Shock waves, as applied in urology and gastroenterology, were introduced in the middle of the last decade in Germany to treat different pathologies of the musculoskeletal system, including epicondylitis of the elbow, plantar fasciitis, and calcifying and noncalcifying tendinitis of the rotator cuff. With the noninvasive nature of these waves and their seemingly low complication rate, extracorporeal shock wave therapy (ESWT) seemed a promising alternative to the established conservative and surgical options in the treatment of patients with chronically painful conditions. However, the apparent advantages of the method led to a rapid diffusion and even inflationary use of ESWT; prospective, randomized studies on the mechanisms and effects of shock waves on musculoskeletal tissues were urgently needed to define more accurate indications and optimize therapeutic outcome. This review covers recent international research in the field and presents actual indications and results in therapy of musculoskeletal conditions with ESWT.

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Extracorporeal shockwaves induce the expression of ATF3 and GAP-43 in rat dorsal root ganglion neurons.
Auton Neurosci. 2006 Jul 30;128(1-2):96-100 (http://www.journals.elsevierhealth.com/periodicals/autneu/article/PIIS1566070206001068/abstract)
Murata R, Ohtori S, Ochiai N, Takahashi N, Saisu T, Moriya H, Takahashi K, Wada Y
Although extracorporeal shockwave has been applied in the treatment of various diseases, the biological basis for its analgesic effect remains unclear. Therefore, we investigated the dorsal root ganglion neurons of rats following shockwave exposure to the footpad to elucidate its effect on the peripheral nervous system. We used activating transcription factor 3 (ATF3) and growth-associated phosphoprotein (GAP-43) as markers for nerve injury and axonal regeneration, respectively. The average number of neurons immunoreactive for ATF3 increased significantly in the treated rats at all experimental time points, with 78.3% of those neurons also exhibiting immunoreactivity for GAP-43. Shockwave exposure induced injury of the sensory nerve fibers within the exposed area. This phenomenon may be linked to the desensitization of the exposure area, not the cause of pain, considering clinical research with a particular absence of painful adverse effect. Subsequent active axonal regeneration may account for the reinnervation of exposed area and the amelioration of the desensitization.

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Location modalities for focused extracorporeal shock wave application in the treatment of chronic plantar fasciitis.
Foot Ankle Int. 2006 Nov;27(11):943-7 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=17144957&dopt=Abstract)
Dorotka R, Sabeti M, Jimenez-Boj E, Goll A, Schubert S, Trieb K
BACKGROUND: Focused extracorporeal shock waves (ESWT) has been used in the treatment of plantar fasciitis with heel spurs. The optimal location for administering treatment, however, has not been determined. The purpose of this study was to determine whether fluoroscopy-guided location of a heel spur or patient location of the maximal point of tenderness is more effective in administering ESWT.

METHODS: In a prospective, examiner-blinded trial, 41 patients were randomized into two groups for treatment by ESWT: group 1, location of the heel spur for ESWT by fluoroscopy, and group 2, patient location for ESWT by maximal point of tenderness. Each group had three session of ESWT at 1-week intervals. The success rates between the two groups were assessed at 6 and 12 weeks.

RESULTS: No significant differences were noted between the groups.

CONCLUSIONS: Despite the small number of patients in the study, patient location for positioning the focus in ESWT in treatment of plantar fasciitis with a heel spur is recommended.

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Comparison of different energy densities of extracorporeal shock wave therapy (ESWT) for the management of chronic heel pain.
Chow IH, Cheing GL.
Clin Rehabil. 2007 Feb;21(2):131-41 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=17264107&dopt=Abstract)
OBJECTIVE: To compare the effectiveness of different energy densities of extracorporeal shock wave therapy (ESWT) for managing chronic heel pain.

DESIGN: A randomized clinical trial. SETTING: Hospital-based practice. SUBJECTS: Fifty-seven patients with chronic heel pain were recruited; eight patients withdrew from the study. INTERVENTIONS: Subjects were randomized into three groups receiving: (1) a 'fixed' energy density, (2) 'maximum tolerable' energy density, or (3) control treatment once a week for three weeks.

OUTCOME MEASURES: Pain on palpation, pain on tension, maximum tolerable walking/standing duration and Foot Function Index were assessed before treatment in each treatment session and at the three-week follow-up.

RESULTS: By week 3, the 'maximum tolerable' energy density group experienced a 66% cumulative reduction in pain from tension, a 65% reduction on palpation and a 112% cumulative increase in maximum tolerable walking/standing duration. The 'fixed' energy density group experienced a 45% cumulative reduction in pain from tension, a 32% reduction in pain on palpation, and a 45% increase in walking/standing tolerance. The 'maximum tolerable' energy density group also showed a significantly greater reduction in Foot Function Index scores than the other two groups. Therapeutic effects were maintained at least up to the three-week follow-up period. The control group had no significant changes in any outcome measures across time periods.

CONCLUSION: The delivery of ESWT with a maximum tolerable energy density is a more effective treatment protocol than a fixed energy density in terms of relieving pain and restoring the functional activity of people suffering from chronic heel pain. The analgesic effects were maintained at least up to the three-week follow-up.

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Extracorporeal shock wave treatment for chronic plantar fasciitis (heel pain).
Issues Emerg Health Technol. 2007 Jan;(96 (part 1)):1-4 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=17302019&dopt=Abstract)
Ho C
(1) Electrohydraulic, electromagnetic, or piezoelectric devices are used to translate energy into acoustic waves during extracorporeal shock wave treatment (ESWT) for chronic plantar fasciitis (or heel pain). These waves may help to accelerate the healing process via an unknown mechanism. (2) ESWT, which is performed as an outpatient procedure, is intended to alleviate the pain due to chronic plantar fasciitis. (3) Results from randomized controlled trials have been conflicting. Six trials reported data that favour ESWT over placebo or conservative treatment for efficacy outcomes, while three trials showed no significant difference between the ESWT group and the placebo group. (4) The lack of convergent findings from randomized trials of ESWT for chronic plantar fasciitis suggests uncertainty about its effectiveness. The evidence reviewed in this bulletin does not support the use of this technology for this condition.

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Thinner Plantar Fascia Predicts Decreased Pain After Extracorporeal Shock Wave Therapy.
Clin Orthop Relat Res. 2007 Mar 8; (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=17353798&dopt=Abstract)
Liang HW, Wang TG, Chen WS, Hou SM
Increased plantar fascia thickness is common with chronic plantar fasciitis, and reduction of the thickness after extracorporeal shock wave therapy or steroid injection has been reported. We hypothesized a decrease of plantar fascia thickness was associated with pain reduction after extracorporeal shock wave therapy. Fifty-three eligible patients with 78 symptomatic feet were randomly treated with piezoelectric-type extracorporeal shock wave therapy of two intensity levels (0.12 and 0.56 mJ/mm). Two thousand shock waves for three consecutive sessions were applied at weekly intervals. A visual analog scale for pain, the Foot Function Index, the Short Form-36 Health Survey, and ultrasonographic measurement of plantar fascia thickness were evaluated at baseline and 3 and 6 months after treatment. We analyzed the association between pain level and plantar fascia thickness with generalized estimating equation analysis and adjusted for demographic and treatment-related variables. Patients with thinner plantar fascia experienced less pain after treatment; high-intensity treatment and regular exercise were associated with lower pain level. The overall success rates were 63% and 60% at the 3- and 6-month followups. High- and low-intensity treatments were associated with similar improvements in pain and function. Receiving high-intensity treatment, although associated with less pain at followup, did not provide a higher success rate.

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Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device.
Gollwitzer H, Diehl P, von Korff A, Rahlfs VW, Gerdesmeyer L.
J Foot Ankle Surg. 2007 Sep-Oct;46(5):348-57. (http://www.ncbi.nlm.nih.gov/sites/entrez?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=17761319&dopt=AbstractPlus)
Published data describing the efficacy of extracorporeal shock wave therapy for the treatment of plantar heel pain provide conflicting results, and optimal treatment guidelines are yet to be determined. To assess the efficacy and safety of extracorporeal shockwave therapy compared with placebo in the treatment of chronic painful heel syndrome with a new electromagnetic device, we undertook a prospective, double-blind, randomized, placebo-controlled trial conducted among 40 participants who were randomly allocated to either active, focused extracorporeal shockwave therapy (0.25 mJ/mm(2)) or sham shockwave therapy. Both groups received 3 applications of 2000 shockwave impulses, each session 1 week apart. The primary outcome was the change in composite heel pain (morning pain, pain with activities of daily living, and pain upon application of pressure with a focal force meter) as quantified using a visual analog pain scale at 12 weeks after completion of the interventions compared with baseline. Secondary endpoints included changes in morning pain, pain with activities of daily living, and pain upon application of pressure with a focal force meter, as measured on a visual analog pain scale, as well as the change in the Roles and Maudsley score, at 12 weeks after the baseline measurement. Active extracorporeal shockwave therapy resulted in a 73.2% reduction in composite heel pain, and this was a 32.7% greater reduction than that achieved with placebo. The difference was not statistically significant (1-tailed Wilcoxon Mann-Whitney U test, P =.0302), but reached clinical relevance (Mann-Whitney effect size = 0.6737). In regard to the secondary outcomes, active extracorporeal shockwave therapy displayed relative superiority in comparison with the sham intervention. No relevant adverse events occurred in either intervention group. The results of the present study support the use of electromagnetically generated extracorporeal shockwave therapy for the treatment of refractory plantar heel pain.

[NewsBot]

High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Noninsertional Achilles Tendinopathy
John P. Furia,
American Journal of Sports Medicine 2007, doi:10.1177/0363546507309674) (http://ajs.sagepub.com/cgi/content/abstract/0363546507309674v1)
Background: High-energy extracorporeal shock wave therapy has been shown to be an effective treatment for chronic insertional Achilles tendinopathy. The results of high-energy shock wave therapy for chronic noninsertional Achilles tendinopathy have not been determined.

Hypothesis: Shock wave therapy is an effective treatment for noninsertional Achilles tendinopathy.

Study Design: Case control study; Level of evidence, 3.

Methods: Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated with a single dose of high-energy shock wave therapy (shock wave therapy group; 3000 shocks; 0.21 mJ/mm2; total energy flux density, 604 mJ/mm2). Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated not with shock wave therapy but with additional forms of nonoperative therapy (control group). All shock wave therapy procedures were performed using regional anesthesia. Evaluation was by change in visual analog score and by Roles and Maudsley score.

Results: One month, 3 months, and 12 months after treatment, the mean visual analog scores for the control and shock wave therapy groups were 8.4 and 4.4 (P< .001), 6.5 and 2.9 (P< .001), and 5.6 and 2.2 (P< .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 12 and 0 (P< .001), 17 and 9 (P< .001), 5 and 17 (P< .001), and 0 and 8 (P< .001), respectively. A 2 analysis revealed that the percentage of patients with excellent ("1") or good ("2") Roles and Maudsley scores, that is, successful results, 12 months after treatment was statistically greater in the shock wave therapy group than in the control group (P< .001).

Conclusion: Shock wave therapy is an effective treatment for chronic noninsertional Achilles tendinopathy.

[NewsBot]

The Electrophysiological and Functional Effect of Shock Wave on Peripheral Nerves.
Wu YH, Lun JJ, Chen WS, Chong FC.
Conf Proc IEEE Eng Med Biol Soc. 2007;1:2369-2372. (http://www.ncbi.nlm.nih.gov/sites/entrez?tmpl=NoSidebarfile&db=PubMed&cmd=Retrieve&list_uids=18002469&dopt=AbstractPlus)
Recently, extracorporeal shock wave therapy (ESWT) is found to be effective for musculoskeletal disorders, such as calcific tendonitis, epicondylitis, and plantar fasciitis. Until now, there is no study on the influence of ESWT on motor nerve and the underlying mechanism of ESWT on musculoskeletal disorders remains unclear. This study evaluated the effects of shock wave of different intensity on peripheral nerves and the tracking of long term observation on induced injury. Shock wave treatments of different intensity were applied on the sciatic nerve of rat and electrophysiological changes were recorded. Besides, the functional activities were estimated with sciatic functional index (SFI). The results showed a decrease of motor nerve conduction velocity (MNCV) after shock wave treatment, but recovery was observed within 14 days. When the intensity of shock wave was higher, the decrease of MNCV sustained longer. There was no significant change in functional assessment. It is suggested that ESWT may be harmless to peripheral nerves and can be used in the treatment of musculoskeletal disorders.

[Admin]

High-Energy Extracorporeal Shock Wave Therapy as a Treatment for Chronic Noninsertional Achilles Tendinopathy
John P. Furia,
American Journal of Sports Medicine 2007, doi:10.1177/0363546507309674) (http://ajs.sagepub.com/cgi/content/abstract/0363546507309674v1)

This odd. I do not understand. An embargo has been placed on this paper, even though the abstract is still accessible via the above link. Check here (http://ajs.sagepub.com/cgi/content/abstract/0363546507309674v2).

[NewsBot]

Preliminary Experience of a Single Session of Low-energy Extracorporeal Shock Wave Treatment for Chronic Plantar Fasciitis.
Höfling I, Joukainen A, Venesmaa P, Kröger H.
Foot Ankle Int. 2008 Feb;29(2):150-4. (http://www.ncbi.nlm.nih.gov/pubmed/18315969?dopt=Abstract)
BACKGROUND: The purpose of the present study was to evaluate the effect of a single session of ultrasound- and biofeedback-assisted extracorporeal shock wave treatment (ESWT) in patients with chronic plantar fasciitis.

MATERIALS AND METHODS: 20 patients (22 heels) with symptomatic plantar fasciitis that did not respond to conservative treatment for at least 6 months were studied. Patients received a single session of low-energy, ultrasound- and patient feedback-guided ESWT. Visual analog scale (VAS) was used to compare pain intensity before treatment and at followup (72 +/- 15 days after treatment).

RESULTS: There was a significant decrease in overall pain (VAS 5.5 +/- 1.8 vs. 3.3 +/- 2.7, p = 0.001), maximum pain (7.7 +/- 2.1 vs. 4.0 +/- 3.9, p = 0.008) and pain at activities of daily living (5.3 +/- 2.1 vs. 2.5 +/- 2.6, p = 0.018). Night pain decreased to a lesser extent (2.4 +/- 2.5 vs. 1.3 +/- 2.1, p = 0.317). ESWT improved symptoms in 16 heels, of which six were completely symptom-free at followup 2.4 months after treatment. Six patients experienced no change. Fourteen patients with pain localized to the heel and all male patients benefited from ESWT. No difference was noted for age, body mass index, duration, and severity of symptoms or previous treatment.

CONCLUSION: Low-energy ESWT proved to be an effective treatment option for the majority of patients with chronic plantar fasciitis that failed to respond to conservative treatment. Predictive parameters for successful outcome are male gender and an easily detectable pain center at the heel.

[DaVinci]

Preliminary Experience of a Single Session of Low-energy Extracorporeal Shock Wave Treatment for Chronic Plantar Fasciitis.
Höfling I, Joukainen A, Venesmaa P, Kröger H.
Foot Ankle Int. 2008 Feb;29(2):150-4. (http://www.ncbi.nlm.nih.gov/pubmed/18315969?dopt=Abstract)

Control group? duh? :pigs: :deadhorse:

[NewsBot]

Extracorporeal shockwave application to the distal femur of rabbits diminishes the number of neurons immunoreactive for substance P in dorsal root ganglia L5.
Hausdorf J, Lemmens MA, Kaplan S, Marangoz C, Milz S, Odaci E, Korr H, Schmitz C, Maier M.
Brain Res. 2008 Mar 25 [Epub ahead of print] (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6SYR-4RVVHMF-8&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c079ed86b24aabed7ffc181687cf6509)
Application of extracorporeal shockwaves to the musculoskeletal system can induce long-term analgesia in the treatment of chronic painful diseases such as calcifying tendonitis of the shoulder, tennis elbow and chronic plantar fasciitis. However, the molecular and cellular mechanisms underlying this phenomenon are largely unknown. Recently it was shown that application of extracorporeal shockwaves to the distal femur of rabbits can lead to reduced concentration of substance P in the shockwaves' focal zone. In the present study we investigated the impact of extracorporeal shockwaves on the production of substance P within dorsal root ganglia in vivo. High-energy shockwaves were applied to the ventral side of the right distal femur of rabbits. After six weeks, the dorsal root ganglia L5 to L7 were investigated with high-precision design-based stereology. The application of extracorporeal shockwaves caused a statistically significant decrease in the mean number of neurons immunoreactive for substance P within the dorsal root ganglion L5 of the treated side compared with the untreated side, without affecting the total number of neurons within this dorsal root ganglion. No effect was observed in the dorsal root ganglia L6 and L7, respectively. These data might further contribute to our understanding of the molecular and cellular mechanisms in the induction of long-term analgesia by extracorporeal shockwave application to the musculoskeletal system.

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Extracorporeal shock-wave therapy (ESWT) with a new-generation pneumatic device in the treatment of heel pain. A double blind randomised controlled trial.
Marks W, Jackiewicz A, Witkowski Z, Kot J, Deja W, Lasek J.
Acta Orthop Belg. 2008 Feb;74(1):98-101. (http://www.ncbi.nlm.nih.gov/pubmed/18411608?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_RVDocSum)
Although low-energy extracorporeal shock wave therapy (ESWT) is widely used to treat a variety of soft tissue disorders, no precise algorithm has been accepted in clinical management. Furthermore, the clinical use of a new generation pneumatic device has not yet been evaluated. We performed a double blind randomised controlled trial on a group of 25 patients with heel pain from chronic plantar fasciitis, to assess the efficacy of ESWT. The main outcome measure was the patients' subjective assessment of pain by means of a Visual Analog Scale (VAS) and the Roles and Maudsley Score before ESWT, early after treatment and six months later. There appeared to be a significant placebo effect with low-energy ESWT in patients with heel pain, and there was also lack of evidence for the efficacy of ESWT when compared to sham therapy.

[drsarbes]

Hi Don:
ESWT does work (most of the times) as well as cryo or orthotics or surgical procedures.
The question is, if we are performing all these different therapies for the same diagnosis, why doesn't ONE of them work ALL THE TIME?

I think numerous previous discussions here on the underlying etiologies for heel pain should be taken seriously. Whether spurs, periostitis, fasciitis, fascioses, neuritis, tarsal tunnel, mechanical irritation, bursitis, etc......... is causing the heel pain, one size fits all treatment doesn't make it in the real world.

Patients expect results. If they don't get it they will go somewhere else.

I think the key to treating heel pain successfully is first and foremost a proper diagnosis. I always view outcome studies on heel pain treatments with a grain of salt mainly because we really aren't sure what the patients in the study ACTUALLY had - do we?

Isn't it logical to assume that if the failure rate of ESWT for chronic fasciitis is 22% then perhaps those 22% had something other than fasciitis causing their symptoms?

Steve

[drsarbes]

Hi Don:
ESWT does work (most of the times) as well as cryo or orthotics or surgical procedures.
The question is, if we are performing all these different therapies for the same diagnosis, why doesn't ONE of them work ALL THE TIME?

I think numerous previous discussions here on the underlying etiologies for heel pain should be taken seriously. Whether spurs, periostitis, fasciitis, fascioses, neuritis, tarsal tunnel, mechanical irritation, bursitis, etc......... is causing the heel pain, one size fits all treatment doesn't make it in the real world.


I think the key to treating heel pain successfully is first and foremost a proper diagnosis. I always view outcome studies on heel pain treatments with a grain of salt mainly because we really aren't sure what the patients in the study ACTUALLY had - do we?

Isn't it logical to assume that if the failure rate of ESWT for chronic fasciitis is 22% then perhaps those 22% had something other than fasciitis causing their symptoms?

Steve

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Selective loss of unmyelinated nerve fibers after extracorporeal shockwave application to the musculoskeletal system.
Hausdorf J, Lemmens MA, Heck KD, Grolms N, Korr H, Kertschanska S, Steinbusch HW, Schmitz C, Maier M.
Neuroscience. 2008 Apr 7. [Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/18579315?dopt=Abstract)
Application of extracorporeal shockwaves (ESW) to the musculoskeletal system may induce long-term analgesia in the treatment of chronic tendinopathies of the shoulder, heel and elbow. However, the molecular and cellular mechanisms behind this phenomenon are largely unknown. Here we tested the hypothesis that long-term analgesia caused by ESW is due to selective loss of nerve fibers in peripheral nerves. To test this hypothesis in vivo, high-energy ESW were applied to the ventral side of the right distal femur of rabbits. After 6 weeks, the femoral and sciatic nerves were investigated at the light and electron microscopic level. Application of ESW resulted in a selective, substantial loss of unmyelinated nerve fibers within the femoral nerve of the treated hind limb, whereas the sciatic nerve of the treated hind limb remained unaffected. These data might indicate that alleviation of chronic pain by selective partial denervation may play an important role in the effects of clinical ESW application to the musculoskeletal system.

[Secret Squirrel]

These data might indicate that alleviation of chronic pain by selective partial denervation may play an important role in the effects of clinical ESW application to the musculoskeletal system. Is that a good thing? Get rid of the chronic pain by denervation? What about the pathological process that is still going on?

[Dieter Fellner]

While there have been controversies and shifts in the prevailing thinking on extracorporeal shockwave therapy (ESWT) in recent years, this author says emerging data on efficacy and cost-effectiveness warrant a closer look at the potential of low-energy radial ESWT.

- By Lowell Weil, Jr., DPM, MBA

http://www.podiatrytoday.com/article/8785

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4gxNXesNxJk

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The Use of Low-Energy Radial Shockwave in the Treatment of Entrapment Neuropathy of the Medial Calcaneal Nerve: A Pilot Study
Stephen L. Barrett
Foot & Ankle Specialist, Vol. 1, No. 4, 231-242 (2008) (http://fas.sagepub.com/cgi/content/abstract/1/4/231)
Medial calcaneal nerve entrapment is a well-recognized cause of heel pain. In addition, the development of an amputation neuroma of the medial calcaneal nerve from prior heel surgery via an open incision on the medial aspect of the heel is a serious common postoperative complication and can be extremely difficult to treat. This preliminary pilot study demonstrates that the use of low-energy extracorporeal shockwave is safe and efficacious in the treatment of this disorder without the morbidity associated with denervation surgery, which would be one of the most common methods to treat this complicated situation. Four patients, 2 with bilateral affectation, for a total of 6 medial calcaneal nerves, had a series of treatments with low-energy radial shockwave with the Swiss DolorClast machine. All 4 patients had improvement in their pain scores, to the point that none elected surgical treatment, and there were no complications.

[DaVinci]

These data might indicate that alleviation of chronic pain by selective partial denervation may play an important role in the effects of clinical ESW application to the musculoskeletal system.
Is that a good thing? Get rid of the chronic pain by denervation? What about the pathological process that is still going on?The Use of Low-Energy Radial Shockwave in the Treatment of Entrapment Neuropathy of the Medial Calcaneal Nerve: A Pilot Study .............All 4 patients had improvement in their pain scores
Interesting observations...

BUT, Four patients, 2 with bilateral affectation, for a total of 6 medial calcaneal nervesWe have no idea if that is any better than a placebo; they did not use any controls.

[NewsBot]

Comparison of two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur. A randomized controlled study.
Tornese D, Mattei E, Lucchesi G, Bandi M, Ricci G, Melegati G.
Clin Rehabil. 2008 Sep;22(9):780-7. (http://www.ncbi.nlm.nih.gov/pubmed/18728131?dopt=Abstract)
Objective: To describe and compare two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur.

Design: Random assignment to two groups of treatment with two and eight months follow-up.

Setting: The data were collected in outpatients.Subjects: Forty-five subjects with a history of at least six months of heel pain were studied.Interventions: Each subject received a three-session ultrasound-guided extracorporeal shock wave therapy (performed weekly). Perpendicular technique was used in group A (n=22, mean age 59.3 +/- 12 years) and tangential technique was used in group B (n= 23, mean age 58.8 +/- 12.3 years).

Main outcome measures: Mayo Clinical Scoring System was used to evaluate each subject before the treatment and at two and eight months follow-up.

Results: Mayo Clinical Scoring System pretreatment scores were homogeneous between the groups (group A 55.2 +/-18.7; group B 53.5 +/- 20; P>0.05). In both groups there was a significant (P<0.05) increase in the Mayo Clinical Scoring System score at two months (group A 83.9 +/- 13.7; group B 80 +/- 15,8) and eight months (group A 90 +/- 10.5; group B 90.2 +/-8.7) follow-up. No significant differences were obtained comparing the Mayo Clinical Scoring System scores of the two groups at two and eight months follow-up.

Conclusions: There was no difference between the two techniques of using extracorporeal shock wave therapy. The tangential technique was found to be better tolerated as regards treatment-induced pain, allowing higher energy dosages to be used.

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Radial Extracorporeal Shock Wave Therapy Is Safe and Effective in the Treatment of Chronic Recalcitrant Plantar Fasciitis: Results of a Confirmatory Randomized Placebo-Controlled Multicenter Study
Ludger Gerdesmeyer, Carol Frey, Johannes Vester, Markus Maier, Lowell Weil Jr, Lowell Weil Sr, Martin Russlies, John Stienstra, Barry Scurran, Keith Fedder, Peter Diehl, Heinz Lohrer, Mark Henne, Hans Gollwitzer
American Journal of Sports Medicine (First published on October 1, 2008) (http://ajs.sagepub.com/cgi/content/abstract/0363546508324176v1)
Background: Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials.

Hypothesis: There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis.

Study Design: Randomized, controlled trial; Level of evidence, 1.

Methods: Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm2; 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks’ follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients’ and investigators’ global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy.

Results: Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1sided). No relevant side effects were observed.

Conclusion: Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.

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Extracorporeal Shockwave Therapy for the Treatment of Achilles Tendinopathies
A Prospective Study
Robert Fridman, Jarrett D. Cain, Lowell Weil, Jr., and Lowell Weil
Journal of the American Podiatric Medical Association; Volume 98 Number 6 466-468 2008 (http://www.japmaonline.org/cgi/content/abstract/98/6/466)
Background: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders.

Methods: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score > 5. The mean follow-up was 20 months (range, 4–35 months).

Results: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1.

Conclusion: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy

[DaVinci]

and it has a role in the treatment of chronic Achilles tendinopathy How can they make that claim in the absence of a control group? How do we know that the natural history of the condition did not change during the study?

I wonder how those who support EWST would react to the small sample size and lack of a control group if the study had the opposite result?

[Don ESWT]

Here we go again!
We live in the real world where we have to make a living and don't have the time or money to do studies. We can only give you data arising from patients we treat.
Not all work can be done under uni study grants etc. Yes I own a machine and I have been told I have a vested interest in the outcome of any study which is beneficial and makes me money.
This all got out of hand back in 2001 and it still has not been resolved by the same mob who did a study on elbow treatments, where they are still compiling the data. (look up Monash uni Rachel Buchbinder)

Where is there conclusive data that double blinded tests are accurate. Because after a time the people who were part of the sham group will demand a real treatment for their compliant, negating the control of the study.

The moment a patient leaves your paractice after any treatment what is the time factor when he/she trips on a crack in the sidewalk and undoes the work carried out to repair them.

DO A CONTROL STUDY ON THAT

[NewsBot]

Comparison of two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur. A randomized controlled study.
Tornese D, Mattei E, Lucchesi G, Bandi M, Ricci G, Melegati G.
Clin Rehabil. 2008 Sep;22(9):780-7. (http://cre.sagepub.com/cgi/content/abstract/22/9/780)

OBJECTIVE: To describe and compare two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur.Design: Random assignment to two groups of treatment with two and eight months follow-up.

SETTING: The data were collected in outpatients. SUBJECTS: Forty-five subjects with a history of at least six months of heel pain were studied. INTERVENTIONS: Each subject received a three-session ultrasound-guided extracorporeal shock wave therapy (performed weekly). Perpendicular technique was used in group A (n=22, mean age 59.3 +/- 12 years) and tangential technique was used in group B (n= 23, mean age 58.8 +/- 12.3 years).Main outcome measures: Mayo Clinical Scoring System was used to evaluate each subject before the treatment and at two and eight months follow-up.

RESULTS: Mayo Clinical Scoring System pretreatment scores were homogeneous between the groups (group A 55.2 +/-18.7; group B 53.5 +/- 20; P>0.05). In both groups there was a significant (P<0.05) increase in the Mayo Clinical Scoring System score at two months (group A 83.9 +/- 13.7; group B 80 +/- 15,8) and eight months (group A 90 +/- 10.5; group B 90.2 +/-8.7) follow-up. No significant differences were obtained comparing the Mayo Clinical Scoring System scores of the two groups at two and eight months follow-up.

CONCLUSIONS: There was no difference between the two techniques of using extracorporeal shock wave therapy. The tangential technique was found to be better tolerated as regards treatment-induced pain, allowing higher energy dosages to be used.

[Paul Bowles]

ESWT works, it just take time for the individuals body to react to the treatment.

Several studies also show doing nothing also works if you leave it long enough. So I could add to your statement Don by saying that if you do nothing and leave the patients alone you will have spontaneous resolution on its own accord. So does the ESWT really work or is the "time" you are giving for the individuals body to react just spontaneous resolution or natural "disease" process taking its course?

I had an old English professor who used to say to me:

"I drink Scotch and water and I get drunk, I drink Gin and water and I get drunk, I drink Vodka and water I get drunk - maybe I should stop drinking water because it is making me drunk!"

Food for thought?

[NewsBot]

Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis.
Greve JM, Grecco MV, Santos-Silva PR.
Clinics. 2009;64(2):97-103. (http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200006&lng=en&nrm=iso&tlng=en)
OBJECTIVE: To compare radial shockwave treatment and conventional physiotherapy for plantar fasciitis.

MATERIALS AND METHODS: Thirty-two patients with plantar fasciitis were included in this study. They were randomly divided into two groups. Group 1 was composed of 16 patients who underwent 10 physiotherapy sessions each, consisting of ultrasound, kinesiotherapy and instruction for stretching exercises at home. Group 2 was composed of 16 patients who underwent three applications of radial shockwaves (once a week) and received instruction for stretching exercises at home. Pain and ability to function were evaluated before treatment, immediately afterwards, and three months later. The mean age of the patients was 47.3 +/- 10.3 years (range 25-68); 81% were female, 87% were overweight, 56% had bilateral impairment, and 75% used analgesics regularly.

RESULTS: Both treatments were effective for pain reduction and for improving the functional abilities of patients with plantar fasciitis. The effect of the shockwaves was apparent sooner than physiotherapy after the onset of treatment.

CONCLUSION: Shockwave treatment was no more effective than conventional physiotherapy treatment when evaluated three months after the end of treatment.

[NewsBot]

Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors.
Chuckpaiwong B, Berkson EM, Theodore GH.
J Foot Ankle Surg. 2009 Mar-Apr;48(2):148-55. (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B75DJ-4VBC5V3-6&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=317a1cc2370503e68aa9708a8dfa7bd5)

Plantar fasciitis can be a chronic and disabling cause of foot pain in the adult population. For refractory cases, extracorporeal shock wave therapy (ESWT) has been proposed as therapeutic option to avoid the morbidity of surgery. We hypothesized that the success of extracorporeal shock wave therapy in patients with chronic plantar fasciitis is affected by patient-related factors. A retrospective review of 225 patients (246 feet) who underwent consecutive ESWT treatment by a single physician at our institution between July 2002 and July 2004 was performed. Subjects were included only if they had plantar fasciitis for more than 6 months and failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Follow-up was 30.2 +/- 8.7 months post procedure. Multivariable analysis was performed to assess factors leading to successful outcomes. Success rates of 70.7% at 3 months and 77.2% at 12 months were noted in this population. Previous cortisone injections, body mass index, duration of symptoms, presence of bilateral symptoms, and plantar fascia thickness did not influence the outcome of ESWT. The presence of diabetes mellitus, psychological issues, and older age were found to negatively influence ESWT outcome. Whereas many factors have been implicated in the development of plantar fasciitis, only diabetes mellitus, psychological issues, and age were found to negatively influence ESWT outcome

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Extracorporeal Shock Wave Therapy in Inflammatory Diseases: Molecular Mechanism that Triggers Anti-Inflammatory Action.
Mariotto S, de Prati AC, Cavalieri E, Amelio E, Marlinghaus E, Suzuki H.
Curr Med Chem. 2009;16(19):2366-72.
(http://www.ncbi.nlm.nih.gov/pubmed/19601786?dopt=Abstract)Shock waves (SW), defined as a sequence of single sonic pulses characterised by high peak pressure (100 MPa), a fast rise in pressure (< 10 ns) and a short lifecycle (10 micros), are conveyed by an appropriate generator to a specific target area at an energy density ranging from 0.03 to 0.11 mJ/mm(2). Extracorporeal SW (ESW) therapy was first used on patients in 1980 to break up kidney stones. During the last ten years, this technique has been successfully employed in orthopaedic diseases such as pseudoarthosis, tendinitis, calcarea of the shoulder, epicondylitis, plantar fasciitis and several inflammatory tendon diseases. In particular, treatment of the tendon and muscle tissues was found to induce a long-time tissue regeneration effect in addition to having a more immediate anthalgic and anti-inflammatory outcome. In keeping with this, an increase in neoangiogenesis in the tendons of dogs was observed after 4-8 weeks of ESW treatment. Furthermore, clinical observations indicate an immediate increase in blood flow around the treated area. Nevertheless, the biochemical mechanisms underlying these effects have yet to be fully elucidated. In the present review, we briefly detail the physical properties of ESW and clinical cases treated with this therapy. We then go on to describe the possible molecular mechanism that triggers the anti-inflammatory action of ESW, focusing on the possibility that ESW may modulate endogenous nitric oxide (NO) production either under normal or inflammatory conditions. Data on the rapid enhancement of endothelial NO synthase (eNOS) activity in ESW-treated cells suggest that increased NO levels and the subsequent suppression of NF-kappaB activation may account, at least in part, for the clinically beneficial action on tissue inflammation