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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.
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.
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
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.
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?
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.
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.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
Last edited by Craig Payne : 26th October 2004 at 12:06 AM.
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.
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.
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
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
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
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.
Chronic Plantar Fasciitis: Acute Changes in the Heel after Extracorporeal High-Energy Shock Wave Therapy—Observations at MR Imaging
Quote:
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
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.
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.
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
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.
I will bump this old thread with this story from Podiatry Online:
Quote:
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.
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.
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)
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.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
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
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.
Extracorporeal Shock Wave Therapy
- I'll let you do the leg-work! 
Eswt
Shock Wave Therapy
hammer comedian
Craig...
heel pain
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