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Post ESWT 2 days

Posted by John M on 1/30/02 at 12:04 (071937)

I live in Albuquerque. I just had Ossatron on both feet here on Monday. I was surprised that they put you out for a little while under general anethstesia. I was in at 12 and out by 2:30 the actual procedure took about 20 minutes. It takes a while to come out of the drugs but there was no nausea

I am feeling some discomfort but not real pain. Aleve takes care of it. My Doc was telling me now that they have done a bunch of these there is a body of evidence that the heel spurs actually breaks up in a lot of cases.

They gave me some dorky looking post op shoes to wear but they kept falling off so I am using my rockports with orthotics. I only missed a half a day of work. I am staying off my feet at much as possible.

I can already notice the difference especially in the AM when I get up. The Doc says maximum effect is in 4 weeks.

FYI my doc is Dr. Phillip Bartel

Re: Post ESWT 2 days

DR Zuckerman on 1/30/02 at 14:55 (071960)

Good luck . Sounds like you are on your way. I know A Philip Bartel. I though he was from Cinn, Ohio How old of a man is he.?

Re: Post ESWT 2 days

Dr. Marlene Reid on 1/31/02 at 00:21 (072034)

I have to comment. I don't agree with a few things you were told, but the one that you must've for sure misunderstood is that it takes 4 months, not 4 weeks for the maximum benefit. In fact, Healthtronics just changed there info to reflect that, they used to say 12 weeks and now they say 16 weeks.

Re: Post ESWT 2 days

John M on 1/31/02 at 09:04 (072053)

I think what I meant was noticeable improvement rather than maximum. As far as the heelspur thing I am just repeating what the Doc and the Ossatron Tech told me. I know I wasn't dreaming because he wants to take xrays to see if it happened.

Re: Post ESWT 2 days

Jen R on 1/31/02 at 09:44 (072063)

I might be confused...and maybe Dr. Z or another doctor can answer this...but what would an x-ray show as far as ESWT improvement (or lack thereof) goes???

Re: Post ESWT 2 days

John M on 1/31/02 at 12:38 (072080)

They are checking to see if the spur was broken up. I am having it today I'll post the results later

Re: Insurance ??

BrianG on 1/31/02 at 18:48 (072123)

Hi JohnM,

Just wondering, did you have any insurance coverage? Good luck in your healing. Your fortunate to have a desk job.

BCG

Re: Post ESWT 2 days

DR Zuckerman on 1/31/02 at 19:35 (072136)

Nothing. But in this case the doctor feels that the heel spur is going to dissolve. I am aware of any ESWT treatment doing this at the energy levels that are approved by the FDA

Re: Post ESWT 2 days

Jen R on 2/01/02 at 05:52 (072170)

Dr. Z,

Did you mean you are NOT aware....?

And...an x-ray would show a spur? I didn't know that...I thought an x-ray was strictly a picture of bones. Hmmmmmm...learning something new everyday.

As always, thanks for the info.

Jen R

Re: Post ESWT 2 days

DR Zuckerman on 2/01/02 at 17:55 (072233)

Not aware of ESWT at the energy levels we use dissolving heel spurs

Re: Post ESWT 2 days

John M on 2/01/02 at 18:14 (072239)

That's him. He bought a practice out here about 3 years ago. He likes the weather here better (except it is snowing today) I am the first of his patients to receive the procedure and the first one that principal agreed to pay for.

Re: Post ESWT 2 days

John M on 2/01/02 at 18:15 (072240)

Actually, it was the Ossotron tech who first mentioned it and they only noticed by accident at the clinic in Santa Fe. Dissolve isnt a good word. Maybe weaken would be better. Im not a doc so its hard for me to discribe.. anyway I saw Dr. Bartel and mentioned your name to him and he was stunned and pleased to hear your name again. He said on was going to get on the website and contact you.. He can teel you more about the spur thing

Re: Insurance ??

John M on 2/01/02 at 18:17 (072242)

Yes, I have a PPO wtih Principal. Ossotron charges 9k for both feet. Principal said they would pay 5500. Ossatron said okay. Since it is a PPO i am only on the hook for my $10 co pay.

Re: Insurance ??

JudyS on 2/01/02 at 19:18 (072251)

John M - Please, tell us more! You have no idea how welcome your insurance information is given that many folks here are beyond desperate.
Can you get any paperwork from your insurance carrier as to the codes they use for ESWT and their written justification for being willing to cover it?
Where are you located?

Re: Post ESWT 2 days

DR Zuckerman on 2/01/02 at 19:33 (072255)

Dr. Bartel may be thinking of my father. Dr. Bartel is very well known and respeced in the field of miminial incision foot surgery. I believe he wrote many articles on the subject. Anyway I would be happy to here from him.

Re: Insurance ??

John M on 2/01/02 at 23:37 (072279)

Judy,

I am with Principal. It is a group PPO. The approval letter had no codes but I will ask the Doc on Monday and see if he has any info. I am guessing he should. It took 4 months to get approval. On the bright side they never really turned it down they just kept reviewing it.

Feet are sore but not the shooting ice pick pain. I hope I am not being over optimistic but i think if this didn't cure it it at least improved it quite a bit

Re: Insurance ??

John M on 2/01/02 at 23:38 (072280)

ps I am in Albuquerque. My plan is administerd at Principal HQ in IA

Re: Insurance ??

BarbB on 2/03/02 at 18:46 (072479)

MY INSURANCE CO. (PPO) HAS DENIED MY HOSPITAL CLAIM AS EXPERIMENTAL.ONE AND A HALF YEARS AGO I FELL FROM A LATTER AT MY VOLUNTEER JOB. IBROKE MY HEEL IN FIVE PLACES, DEVELOPED CALCIUM DEPOSITS AND A STIFF ACHILLES TENDON. I AM MUCH IMPROVED BECAUSE OF THIS TREATMENT BUT NOW MUST FIGHT WITH MY INSURANCE CO. BECAUSE THEY SAY IT IS EXPERIMENTAL ANY SUGESTIONS !

Re: Heel Spurs

Allan.G on 2/10/02 at 23:02 (073323)

Hi again to all
I am a qualified Radiographer and Ultrasonographer. The XRay of the Calcaneum in the lateral projection can show a spur. However, you can have a heel spur and NO PAIN at all. This is because it is the Plantar Fascia which is inflamed and causes the pain. The Ultrasound is the quickest , easiest and cheapest way of showing you plantar fascia attachment na d whether it is thickened.
The spur itself usually forms as a body response to try and heel the inflamation. This is because the inflammation occurs close to where the tendon attaches to the bone and usually causes some bony cortical inflammation as well. The body lays down new bone in this region as a healing response. In most cases this actually fixes the problem. However , in others , the tendon is so inflamed that the 'process' continues onto a chronic stage.
An example of the spurs is a Radiographer at a clinic I worked at had very bad heel pain. We XRayed her and her foot was totally normal. I Ultrasounded her and she had a marked thickening of her plantar attachment. She had a course of anti inflammatories and after a while her pain subsided. We XRayed her 2 months later when she was pain free and she had a SPUR !!!
Regards again
Allan Gottliebsen

Re: Heel Spurs

Julie on 2/11/02 at 03:22 (073331)

Allan, thanks for this. Dr Z gave us this explanation of heel spurs some time ago, and it made perfect sense to me. Your clarification will be greatly helpful to people who have come to heelspurs.com more recently.

Re: Heel Spurs

john h on 2/11/02 at 10:37 (073343)

well put alan. if i read you correctly if you have pain and no spur you probably have an inflamed fascia. If this is the case and you put a person on anti inflamatories and at the same time cast the foot or put him/her on crutches for a month, why would not even chronic inflamation respond? we have so many people who have done this and got no response or even became worse. I do know from practical experience that injuries to the large tendons are very slow to heal. would it not be a wonderful experience to send someone with PF on a space mission where one would be weightless for 3 months and have absolutely no weight on the fascia to see what happens. that would seem to answer a lot of questions that seem unaswerable on earth. it would seem to also answer some question concerning disc compression problems.

Re: Heel Spurs

Allan.G on 2/12/02 at 04:25 (073405)

The problem with tendons , especially where they attach, is that they are not as vascular as other regions of the body , so the healing response can be slow. Also , all tissues rely on their permeability for the flow of cells , ions , etc to pass through and in and out.. With a chronic tendinitis , due to oedema the tendon membranes and fibres can become impermeable and therefore the 'anti inflammatories' (including cortisone injections) cannot get in and dp their job. Therefore we end up with this chronic condition which just won't respond to anything.
The Hypothesis of ESWT is that the shockwaves create stress in the fibres and cause the membranes to allow molecular transfer between layers again by opening up the permeability pathways.
It has also been shown that there is an increase in Macrophagic activity. ( the body's 'PACMAN' that goes round removing old tissues). There also is an increase in the blood flow to the region which brings all the body's natural healing processes to the area.
We have also shown , and one site in Australia is recommending, that patients who have failed ESWT Should have one more low level treatment and a Cortison injection straight after, are having Excellent recovery then.
Their may be a time in the future where we just administer a single treatment PLUS cortisone !!!

Regards again
Allan G

Re: Heel Spurs

john h on 2/12/02 at 12:28 (073447)

Allan what you state is very informative as usual and makes good sense. I think one of the FDA protocols for not doing ESWT is having had a cortisone injection within a few weeks (? cannot remember exact number) of ESWT. The more I think about your hypothesis the more sense it makes for people who suffer from chronic PF. Anti inflamatories seldom work and cortisone is short lived if it works at all. I cannot wrap my brain around why multiple doses of low energy ESWT is better than the big dose of Ossatron although I am now reading that the success with Ossatron jumps significantly with a second treatment. Problem here is the first treatment with Ossatron is so expensive that a second one with hospital and all you will have to mortgage your house.My other question about Dornier is if you are shooting the energy laterially across the fascia how do you focus to a spot perhaps the size of a dime since the fascia laterially is probably several inches wide wheras coming from the bottom you are only dealing with millimeters of thickness to focus on?Also if you focas to a point say 1' acoss the fascia will you lose much energy at the focal point as the shockwave travels across the fascia laterially? Would or does it make sense to shock the entire fasca all the way across at the insertion point to be sure you are hitting the desired area?

Re: Heel Spurs

Glennx on 2/12/02 at 13:33 (073453)

Allan, I too appreciate your thoughts about Dornier treatments. They have been illuminating and most helpful. I'll talk to my doc about the cortizone partnering. Is that done same day?

I had Sonocur treatment 7 weeks ago. It too is low energy and I had three treatments within a period of 10 days total. (treatment center is in Canada). I haven't realized much benefit as yet and will almost certainly go for a second round, but will wait until 9 weeks in to decide.

How long after the first regimen of Dornier treatments would you typically recommend a second battery, if needed?

Also, Sonocur is aimed at the bottom of the foot rather than coming in from the side. I found this approach easy to help the technician aim at the sweet spot. Might be similarly easy with Dornier. (I'm not sure though how wide the impact zone is with Sonocur). Since it (and Dornier) are low energy, would there be any real concern with pulsing the calcaneum as a spillover consequence of treating the fascia?

Re: Heel Spurs

Allan.G on 2/17/02 at 01:42 (073968)

Phew John , what an epic.
The reason people who had taken cortisone up to 2 weeks prior to the FDA trial were excluded was to prove it was the ESWT getting them better and not the Cortisone.
We DON'T point directly at the heel ( from underneath ) as we would then transmit a lot of the focal energy onto the bone itself . That causes a lot more pain. We shoot across the heel because the focal spot is only 4mm wide (1/6th inch) and because we monitor the region with Ultrasound we can make sure we don't hit the bone.
Our aim is to create a metabolic reaction in the whole region , not just the small area we hit with the focal spot area. Our maximum energy is in the focal spot but we still have smaller intensities outside this area.
Some people actually move their treatment around the region while they are treating , so they cover a larger region anyway , but still keeping away from the bone.
We do not lose energy by shooting across the heel.
Happy to be of help
Regards again
Allan G

Re: Heel Spurs

Allan.G on 2/17/02 at 01:50 (073969)

Hi Glenn
We give 3 treatments , 1 week apart. We re assess the patient 6 weeks after the first treatment and then 12 weeks after the first treatment.
We have found that some recovery can be slow or fast depending on the age of the patient , and the extent of the condition itself.
Normally at the 6 week check up we have a good idea how things have gone , however we have found some patients who are on 50% better at 6 weeks are pain free at 12 weeks.
We would not offer re treatments until after the 12 week follow up. They have 1 treatment and then cortisome in the following day or 2.
We DO NOT teat directly at the heel because we would hit the calcaneum. We shoot across under Ultrasound guidance so we don'thit the bone. We can find the 'sweet' spot very well because we can see it !!!
The others have to shoot from under the foot as they would not know at what depth to treat from the side of the foot because they have NO imaging for guidance.
Hop this helps
Regards Allan G

Re: Heel Spurs

Glennx on 2/17/02 at 09:25 (073975)

Allan: Most helpful! Thanks for getting back.

I saw an Ossatron being used on the local news the other day. Under IV sedation, the technician moved the bottom of the foot around the head of the pulsing machine. Looked like they were covering an area roughly 1 inch in diameter. I would think with imaging, the Dornier treatment would be more pointed. The Sonocur was fairly stationary, though I moved my foot 1/4 to a 1/2 inch to find the tenderest spot before the intensity of rhe shockwaves were cranked up. .

Re: Heel Spurs

Dr. Zuckerman on 2/17/02 at 09:39 (073977)

I got to see and operate the epos . It is a honey !!! Sweet. smooth and great range of energy for treatment. .

Re: Pioneering

Glennx on 2/17/02 at 12:27 (073999)

The Dornier sure does sound like a sweet direction. Exciting to imagine where this will all be a few short years from now when equipment is widely distributed and used, all insurances acknowledge that it works -- and cover it, technique is finely tuned, adjunct treatment is more fully understood and complementary, and heelspurs is shut down for lack of need (but Scott has an envious legacy and continues to prosper).

Your enthusiasm and pioneering are truly admirable Dr. Z.

Re: Allan/Dr Z Dornier

John h on 2/17/02 at 13:06 (074004)

allan: am i reading you correctly in that you give a cortisone treatment on the day after or second day after your firt ESWT session?

Dr. Z. is that part of the FDA protocol or would their be any reason not to do this under FDA guidlines?

Allan if you do give the cortisone after treatment do you have any data of people who received cortisone vs those who have not?

Allan do you offer treatment on both feet on the same day? Obviously if someone is traveling a great distance travel expense becomes a factor. Is one week between treatments a hard and fast rule. It seems to me that the Sonnocur people told me in Canada they can do four treatments in 4 days (i may be wrong as it has been a while since i talked to them.) That is a low energy machine.

Re: Allan/Dr Z Dornier

Dr. Zuckerman on 2/17/02 at 13:35 (074007)

John

I just a steriod injection on a patient six weeks after ESWT number two treatment. Just wasn't getting any great relief some but nothing to write home about. Injected her with local steriod she is feeling great . Playing tennis, have fun, She is post steriod about eight weeks. I hope this is helpful for you.

Re: Allan/Dr Z Dornier

John h on 2/17/02 at 14:03 (074011)

Dr Z: Allans post last week about giving a cortisone treatment soon (?) after ESWT made sense. He said the solution of steriod is more likely to absorb into the chronic fascia soon after ESWT. He explained the science behind this. I have no training in molecular science (other than H-Bomb) so I really do not know but Allan seems wise,well trained or both.

Re: Allan/Dr Z Dornier

Glennx on 2/17/02 at 14:08 (074012)

John: When I underwent Sonocur I did Thursday, Tuesday, Thursday, which makes it seven days between first and third. That was to accomodate a 300 mile distance. They would have done Mon, Wed, Fri -- and perhaps even three days in a row. Who really knows? Maybe 6,000 hits at one time can be as effective as 2,000 spread out three times.

Having seen a video of the Ossatron, it seemed to be a 'shotgun' directed at a larger area of the heel as the technician moved the foot around the chamber head. The Sonocur was more like a rifle shot, and there wasn't much foot movement once a real sore spot was discovered. I sort of think, with a real chronic condition, more of the fascia is dysfunctional (impermeable as Dr. Z described in a recent post) and perhaps benefits from more widespread 'trauma,' whether that's from repeated rifle hits or from a more dispersed blast.

I appreciate your good questions about all this. Lots yet to learn.

Re: Allan/Dr Z Dornier

John h on 2/17/02 at 16:38 (074018)

Glenn: I know Dr. Z shoot for a primary spot but will move it to some adjacent area if he thinks it necessary. One very different thing that has grabbed my attention is Alans post that they sometimes (or all the time I am not sure) give a steriod shot after the ESWT as the inflamed area can now be pentetrated by the steriod whereas before ESWT it could not. Dr Z now mentions that with one of his patients he gave a steriod shot to a patient who after one ESWT treatment was not responding so after second ESWT he gave her the shot and now she is back to her normal activities. This just might be the breakthough some people need to solve this problem.

Re: Allan/Dr Z Dornier

DR Zuckerman on 2/17/02 at 16:43 (074021)

This is a very important break thought in my opinion. Alan also pointed out that this works with patients that have had no relief with a local steriod injection even before the ESWT treatment

Re: Heel Spurs

john h on 2/18/02 at 11:31 (074155)

Allan: thanks again for the enlightening information. I am still very much intrigued by the cortisone shot 1-2 days after treatment. With your information about the inflamed area not being able to absorb the cortisone prior to an ESWT treatment it makes much sense. I would certainly try it if it were available to me. Since some of the warnings (there are zillions on everything to cover possible law suits) for ESWT and for cortisone shots are possible rupture of the fascia it is easy to under stand why here in the states you would have a hard time getting the FDA to make this part of the ESWT protocol. Of course there is nothing to prevent a patient to get a cortisone injection a few days after ESWT at his/her own risk.Is an inflamed fascia hard to spot on your ultrasound? How big would the typical area of an inflamed fascia be? Between you and the good doctors on this board there is a wealth of information on ESWT that I have not been able to acquire from studies,books,reports, etc. You guys/ladies are dealing with patients on a daily basis and your information is current and not influenced by political or manufactures pressure.

Re: Heel Spurs

Glennx on 2/18/02 at 12:20 (074170)

John/Allan: Yet another little piece to factor in here is fascia thickness. I would assume the Dornier aiming ultrasound can spot that and treatment can be customized acordingly. I wonder if the cortisone would work as well with more fascial volume to treat. But then, I have no idea how cortisone does its work.

Re: Allan/Dr Z Dornier

Allan.G on 2/19/02 at 03:10 (074269)

Hi John
We do our treatments one week apart ....STANDARD. We just have found that this gives us the best results for our protocols.
The cortisone is only given (offered) to patients who have failed the first lot of 3 treatments after their 12 week follow up.We have found that they recover better with a second 'top up' of ESWT PLUS cortisone , better than just another ESWT session.
We will treat both feet but start one foot first week , week 2 we do the 2nd treatment on the first foot and the first treatment on the other etc.
This means we finish both feet over 4 weeks instead of 3. The reason we don't do both straight away as we initially cause an exacerbartion of symptoms before the patient starts to get some relief and we would rather have the patient hopping on one sore foot than crawling on their hands and knees because both feet are a little worse !!!
Allan

Re: Heel Spurs

Allan.G on 2/19/02 at 03:26 (074271)

Glenn
On Ultrasound , we usually see that with Plantar fasciitis the tendon is either very thick ( 2 to 3 times normal thickness) or quite normal ( approx. 3mm in thickness)There doesn't seem to be many 'half ways' with this chronic tendon condition.
Allan

Re: Allan/Dr Z Dornier

john h on 2/19/02 at 12:11 (074309)

Allan: I never had sore feet once after treatment with the Orby and I assume it is delivering more power. Of course the Orby is coming from the bottom and your machine from the side which could account for a sore foot.

Re: Allan/Dr Z Dornier

Allan.G on 2/20/02 at 01:34 (074371)

John
Try and find out what energy levels they are using .
Allan

Re: Allan/Dr Z Dornier

john h on 2/20/02 at 10:14 (074396)

Allan: I know Dr. Z with his orby uses 16KV but do not know what that translates into at the focal point. I bet Dr. Z knows what the setting is for the Dornier for the FDA protocol. As a matter of fact I think I saw the setting on the FDA website and will go back and check it now.

Re: Post ESWT 2 days

Linda A on 3/18/02 at 18:01 (076767)

John, I live in Tijeras, NM and am also having problems with a heel spur. Please keep me informed of your progress. Thanks!

Re: Post ESWT 2 days

DR Zuckerman on 1/30/02 at 14:55 (071960)

Good luck . Sounds like you are on your way. I know A Philip Bartel. I though he was from Cinn, Ohio How old of a man is he.?

Re: Post ESWT 2 days

Dr. Marlene Reid on 1/31/02 at 00:21 (072034)

I have to comment. I don't agree with a few things you were told, but the one that you must've for sure misunderstood is that it takes 4 months, not 4 weeks for the maximum benefit. In fact, Healthtronics just changed there info to reflect that, they used to say 12 weeks and now they say 16 weeks.

Re: Post ESWT 2 days

John M on 1/31/02 at 09:04 (072053)

I think what I meant was noticeable improvement rather than maximum. As far as the heelspur thing I am just repeating what the Doc and the Ossatron Tech told me. I know I wasn't dreaming because he wants to take xrays to see if it happened.

Re: Post ESWT 2 days

Jen R on 1/31/02 at 09:44 (072063)

I might be confused...and maybe Dr. Z or another doctor can answer this...but what would an x-ray show as far as ESWT improvement (or lack thereof) goes???

Re: Post ESWT 2 days

John M on 1/31/02 at 12:38 (072080)

They are checking to see if the spur was broken up. I am having it today I'll post the results later

Re: Insurance ??

BrianG on 1/31/02 at 18:48 (072123)

Hi JohnM,

Just wondering, did you have any insurance coverage? Good luck in your healing. Your fortunate to have a desk job.

BCG

Re: Post ESWT 2 days

DR Zuckerman on 1/31/02 at 19:35 (072136)

Nothing. But in this case the doctor feels that the heel spur is going to dissolve. I am aware of any ESWT treatment doing this at the energy levels that are approved by the FDA

Re: Post ESWT 2 days

Jen R on 2/01/02 at 05:52 (072170)

Dr. Z,

Did you mean you are NOT aware....?

And...an x-ray would show a spur? I didn't know that...I thought an x-ray was strictly a picture of bones. Hmmmmmm...learning something new everyday.

As always, thanks for the info.

Jen R

Re: Post ESWT 2 days

DR Zuckerman on 2/01/02 at 17:55 (072233)

Not aware of ESWT at the energy levels we use dissolving heel spurs

Re: Post ESWT 2 days

John M on 2/01/02 at 18:14 (072239)

That's him. He bought a practice out here about 3 years ago. He likes the weather here better (except it is snowing today) I am the first of his patients to receive the procedure and the first one that principal agreed to pay for.

Re: Post ESWT 2 days

John M on 2/01/02 at 18:15 (072240)

Actually, it was the Ossotron tech who first mentioned it and they only noticed by accident at the clinic in Santa Fe. Dissolve isnt a good word. Maybe weaken would be better. Im not a doc so its hard for me to discribe.. anyway I saw Dr. Bartel and mentioned your name to him and he was stunned and pleased to hear your name again. He said on was going to get on the website and contact you.. He can teel you more about the spur thing

Re: Insurance ??

John M on 2/01/02 at 18:17 (072242)

Yes, I have a PPO wtih Principal. Ossotron charges 9k for both feet. Principal said they would pay 5500. Ossatron said okay. Since it is a PPO i am only on the hook for my $10 co pay.

Re: Insurance ??

JudyS on 2/01/02 at 19:18 (072251)

John M - Please, tell us more! You have no idea how welcome your insurance information is given that many folks here are beyond desperate.
Can you get any paperwork from your insurance carrier as to the codes they use for ESWT and their written justification for being willing to cover it?
Where are you located?

Re: Post ESWT 2 days

DR Zuckerman on 2/01/02 at 19:33 (072255)

Dr. Bartel may be thinking of my father. Dr. Bartel is very well known and respeced in the field of miminial incision foot surgery. I believe he wrote many articles on the subject. Anyway I would be happy to here from him.

Re: Insurance ??

John M on 2/01/02 at 23:37 (072279)

Judy,

I am with Principal. It is a group PPO. The approval letter had no codes but I will ask the Doc on Monday and see if he has any info. I am guessing he should. It took 4 months to get approval. On the bright side they never really turned it down they just kept reviewing it.

Feet are sore but not the shooting ice pick pain. I hope I am not being over optimistic but i think if this didn't cure it it at least improved it quite a bit

Re: Insurance ??

John M on 2/01/02 at 23:38 (072280)

ps I am in Albuquerque. My plan is administerd at Principal HQ in IA

Re: Insurance ??

BarbB on 2/03/02 at 18:46 (072479)

MY INSURANCE CO. (PPO) HAS DENIED MY HOSPITAL CLAIM AS EXPERIMENTAL.ONE AND A HALF YEARS AGO I FELL FROM A LATTER AT MY VOLUNTEER JOB. IBROKE MY HEEL IN FIVE PLACES, DEVELOPED CALCIUM DEPOSITS AND A STIFF ACHILLES TENDON. I AM MUCH IMPROVED BECAUSE OF THIS TREATMENT BUT NOW MUST FIGHT WITH MY INSURANCE CO. BECAUSE THEY SAY IT IS EXPERIMENTAL ANY SUGESTIONS !

Re: Heel Spurs

Allan.G on 2/10/02 at 23:02 (073323)

Hi again to all
I am a qualified Radiographer and Ultrasonographer. The XRay of the Calcaneum in the lateral projection can show a spur. However, you can have a heel spur and NO PAIN at all. This is because it is the Plantar Fascia which is inflamed and causes the pain. The Ultrasound is the quickest , easiest and cheapest way of showing you plantar fascia attachment na d whether it is thickened.
The spur itself usually forms as a body response to try and heel the inflamation. This is because the inflammation occurs close to where the tendon attaches to the bone and usually causes some bony cortical inflammation as well. The body lays down new bone in this region as a healing response. In most cases this actually fixes the problem. However , in others , the tendon is so inflamed that the 'process' continues onto a chronic stage.
An example of the spurs is a Radiographer at a clinic I worked at had very bad heel pain. We XRayed her and her foot was totally normal. I Ultrasounded her and she had a marked thickening of her plantar attachment. She had a course of anti inflammatories and after a while her pain subsided. We XRayed her 2 months later when she was pain free and she had a SPUR !!!
Regards again
Allan Gottliebsen

Re: Heel Spurs

Julie on 2/11/02 at 03:22 (073331)

Allan, thanks for this. Dr Z gave us this explanation of heel spurs some time ago, and it made perfect sense to me. Your clarification will be greatly helpful to people who have come to heelspurs.com more recently.

Re: Heel Spurs

john h on 2/11/02 at 10:37 (073343)

well put alan. if i read you correctly if you have pain and no spur you probably have an inflamed fascia. If this is the case and you put a person on anti inflamatories and at the same time cast the foot or put him/her on crutches for a month, why would not even chronic inflamation respond? we have so many people who have done this and got no response or even became worse. I do know from practical experience that injuries to the large tendons are very slow to heal. would it not be a wonderful experience to send someone with PF on a space mission where one would be weightless for 3 months and have absolutely no weight on the fascia to see what happens. that would seem to answer a lot of questions that seem unaswerable on earth. it would seem to also answer some question concerning disc compression problems.

Re: Heel Spurs

Allan.G on 2/12/02 at 04:25 (073405)

The problem with tendons , especially where they attach, is that they are not as vascular as other regions of the body , so the healing response can be slow. Also , all tissues rely on their permeability for the flow of cells , ions , etc to pass through and in and out.. With a chronic tendinitis , due to oedema the tendon membranes and fibres can become impermeable and therefore the 'anti inflammatories' (including cortisone injections) cannot get in and dp their job. Therefore we end up with this chronic condition which just won't respond to anything.
The Hypothesis of ESWT is that the shockwaves create stress in the fibres and cause the membranes to allow molecular transfer between layers again by opening up the permeability pathways.
It has also been shown that there is an increase in Macrophagic activity. ( the body's 'PACMAN' that goes round removing old tissues). There also is an increase in the blood flow to the region which brings all the body's natural healing processes to the area.
We have also shown , and one site in Australia is recommending, that patients who have failed ESWT Should have one more low level treatment and a Cortison injection straight after, are having Excellent recovery then.
Their may be a time in the future where we just administer a single treatment PLUS cortisone !!!

Regards again
Allan G

Re: Heel Spurs

john h on 2/12/02 at 12:28 (073447)

Allan what you state is very informative as usual and makes good sense. I think one of the FDA protocols for not doing ESWT is having had a cortisone injection within a few weeks (? cannot remember exact number) of ESWT. The more I think about your hypothesis the more sense it makes for people who suffer from chronic PF. Anti inflamatories seldom work and cortisone is short lived if it works at all. I cannot wrap my brain around why multiple doses of low energy ESWT is better than the big dose of Ossatron although I am now reading that the success with Ossatron jumps significantly with a second treatment. Problem here is the first treatment with Ossatron is so expensive that a second one with hospital and all you will have to mortgage your house.My other question about Dornier is if you are shooting the energy laterially across the fascia how do you focus to a spot perhaps the size of a dime since the fascia laterially is probably several inches wide wheras coming from the bottom you are only dealing with millimeters of thickness to focus on?Also if you focas to a point say 1' acoss the fascia will you lose much energy at the focal point as the shockwave travels across the fascia laterially? Would or does it make sense to shock the entire fasca all the way across at the insertion point to be sure you are hitting the desired area?

Re: Heel Spurs

Glennx on 2/12/02 at 13:33 (073453)

Allan, I too appreciate your thoughts about Dornier treatments. They have been illuminating and most helpful. I'll talk to my doc about the cortizone partnering. Is that done same day?

I had Sonocur treatment 7 weeks ago. It too is low energy and I had three treatments within a period of 10 days total. (treatment center is in Canada). I haven't realized much benefit as yet and will almost certainly go for a second round, but will wait until 9 weeks in to decide.

How long after the first regimen of Dornier treatments would you typically recommend a second battery, if needed?

Also, Sonocur is aimed at the bottom of the foot rather than coming in from the side. I found this approach easy to help the technician aim at the sweet spot. Might be similarly easy with Dornier. (I'm not sure though how wide the impact zone is with Sonocur). Since it (and Dornier) are low energy, would there be any real concern with pulsing the calcaneum as a spillover consequence of treating the fascia?

Re: Heel Spurs

Allan.G on 2/17/02 at 01:42 (073968)

Phew John , what an epic.
The reason people who had taken cortisone up to 2 weeks prior to the FDA trial were excluded was to prove it was the ESWT getting them better and not the Cortisone.
We DON'T point directly at the heel ( from underneath ) as we would then transmit a lot of the focal energy onto the bone itself . That causes a lot more pain. We shoot across the heel because the focal spot is only 4mm wide (1/6th inch) and because we monitor the region with Ultrasound we can make sure we don't hit the bone.
Our aim is to create a metabolic reaction in the whole region , not just the small area we hit with the focal spot area. Our maximum energy is in the focal spot but we still have smaller intensities outside this area.
Some people actually move their treatment around the region while they are treating , so they cover a larger region anyway , but still keeping away from the bone.
We do not lose energy by shooting across the heel.
Happy to be of help
Regards again
Allan G

Re: Heel Spurs

Allan.G on 2/17/02 at 01:50 (073969)

Hi Glenn
We give 3 treatments , 1 week apart. We re assess the patient 6 weeks after the first treatment and then 12 weeks after the first treatment.
We have found that some recovery can be slow or fast depending on the age of the patient , and the extent of the condition itself.
Normally at the 6 week check up we have a good idea how things have gone , however we have found some patients who are on 50% better at 6 weeks are pain free at 12 weeks.
We would not offer re treatments until after the 12 week follow up. They have 1 treatment and then cortisome in the following day or 2.
We DO NOT teat directly at the heel because we would hit the calcaneum. We shoot across under Ultrasound guidance so we don'thit the bone. We can find the 'sweet' spot very well because we can see it !!!
The others have to shoot from under the foot as they would not know at what depth to treat from the side of the foot because they have NO imaging for guidance.
Hop this helps
Regards Allan G

Re: Heel Spurs

Glennx on 2/17/02 at 09:25 (073975)

Allan: Most helpful! Thanks for getting back.

I saw an Ossatron being used on the local news the other day. Under IV sedation, the technician moved the bottom of the foot around the head of the pulsing machine. Looked like they were covering an area roughly 1 inch in diameter. I would think with imaging, the Dornier treatment would be more pointed. The Sonocur was fairly stationary, though I moved my foot 1/4 to a 1/2 inch to find the tenderest spot before the intensity of rhe shockwaves were cranked up. .

Re: Heel Spurs

Dr. Zuckerman on 2/17/02 at 09:39 (073977)

I got to see and operate the epos . It is a honey !!! Sweet. smooth and great range of energy for treatment. .

Re: Pioneering

Glennx on 2/17/02 at 12:27 (073999)

The Dornier sure does sound like a sweet direction. Exciting to imagine where this will all be a few short years from now when equipment is widely distributed and used, all insurances acknowledge that it works -- and cover it, technique is finely tuned, adjunct treatment is more fully understood and complementary, and heelspurs is shut down for lack of need (but Scott has an envious legacy and continues to prosper).

Your enthusiasm and pioneering are truly admirable Dr. Z.

Re: Allan/Dr Z Dornier

John h on 2/17/02 at 13:06 (074004)

allan: am i reading you correctly in that you give a cortisone treatment on the day after or second day after your firt ESWT session?

Dr. Z. is that part of the FDA protocol or would their be any reason not to do this under FDA guidlines?

Allan if you do give the cortisone after treatment do you have any data of people who received cortisone vs those who have not?

Allan do you offer treatment on both feet on the same day? Obviously if someone is traveling a great distance travel expense becomes a factor. Is one week between treatments a hard and fast rule. It seems to me that the Sonnocur people told me in Canada they can do four treatments in 4 days (i may be wrong as it has been a while since i talked to them.) That is a low energy machine.

Re: Allan/Dr Z Dornier

Dr. Zuckerman on 2/17/02 at 13:35 (074007)

John

I just a steriod injection on a patient six weeks after ESWT number two treatment. Just wasn't getting any great relief some but nothing to write home about. Injected her with local steriod she is feeling great . Playing tennis, have fun, She is post steriod about eight weeks. I hope this is helpful for you.

Re: Allan/Dr Z Dornier

John h on 2/17/02 at 14:03 (074011)

Dr Z: Allans post last week about giving a cortisone treatment soon (?) after ESWT made sense. He said the solution of steriod is more likely to absorb into the chronic fascia soon after ESWT. He explained the science behind this. I have no training in molecular science (other than H-Bomb) so I really do not know but Allan seems wise,well trained or both.

Re: Allan/Dr Z Dornier

Glennx on 2/17/02 at 14:08 (074012)

John: When I underwent Sonocur I did Thursday, Tuesday, Thursday, which makes it seven days between first and third. That was to accomodate a 300 mile distance. They would have done Mon, Wed, Fri -- and perhaps even three days in a row. Who really knows? Maybe 6,000 hits at one time can be as effective as 2,000 spread out three times.

Having seen a video of the Ossatron, it seemed to be a 'shotgun' directed at a larger area of the heel as the technician moved the foot around the chamber head. The Sonocur was more like a rifle shot, and there wasn't much foot movement once a real sore spot was discovered. I sort of think, with a real chronic condition, more of the fascia is dysfunctional (impermeable as Dr. Z described in a recent post) and perhaps benefits from more widespread 'trauma,' whether that's from repeated rifle hits or from a more dispersed blast.

I appreciate your good questions about all this. Lots yet to learn.

Re: Allan/Dr Z Dornier

John h on 2/17/02 at 16:38 (074018)

Glenn: I know Dr. Z shoot for a primary spot but will move it to some adjacent area if he thinks it necessary. One very different thing that has grabbed my attention is Alans post that they sometimes (or all the time I am not sure) give a steriod shot after the ESWT as the inflamed area can now be pentetrated by the steriod whereas before ESWT it could not. Dr Z now mentions that with one of his patients he gave a steriod shot to a patient who after one ESWT treatment was not responding so after second ESWT he gave her the shot and now she is back to her normal activities. This just might be the breakthough some people need to solve this problem.

Re: Allan/Dr Z Dornier

DR Zuckerman on 2/17/02 at 16:43 (074021)

This is a very important break thought in my opinion. Alan also pointed out that this works with patients that have had no relief with a local steriod injection even before the ESWT treatment

Re: Heel Spurs

john h on 2/18/02 at 11:31 (074155)

Allan: thanks again for the enlightening information. I am still very much intrigued by the cortisone shot 1-2 days after treatment. With your information about the inflamed area not being able to absorb the cortisone prior to an ESWT treatment it makes much sense. I would certainly try it if it were available to me. Since some of the warnings (there are zillions on everything to cover possible law suits) for ESWT and for cortisone shots are possible rupture of the fascia it is easy to under stand why here in the states you would have a hard time getting the FDA to make this part of the ESWT protocol. Of course there is nothing to prevent a patient to get a cortisone injection a few days after ESWT at his/her own risk.Is an inflamed fascia hard to spot on your ultrasound? How big would the typical area of an inflamed fascia be? Between you and the good doctors on this board there is a wealth of information on ESWT that I have not been able to acquire from studies,books,reports, etc. You guys/ladies are dealing with patients on a daily basis and your information is current and not influenced by political or manufactures pressure.

Re: Heel Spurs

Glennx on 2/18/02 at 12:20 (074170)

John/Allan: Yet another little piece to factor in here is fascia thickness. I would assume the Dornier aiming ultrasound can spot that and treatment can be customized acordingly. I wonder if the cortisone would work as well with more fascial volume to treat. But then, I have no idea how cortisone does its work.

Re: Allan/Dr Z Dornier

Allan.G on 2/19/02 at 03:10 (074269)

Hi John
We do our treatments one week apart ....STANDARD. We just have found that this gives us the best results for our protocols.
The cortisone is only given (offered) to patients who have failed the first lot of 3 treatments after their 12 week follow up.We have found that they recover better with a second 'top up' of ESWT PLUS cortisone , better than just another ESWT session.
We will treat both feet but start one foot first week , week 2 we do the 2nd treatment on the first foot and the first treatment on the other etc.
This means we finish both feet over 4 weeks instead of 3. The reason we don't do both straight away as we initially cause an exacerbartion of symptoms before the patient starts to get some relief and we would rather have the patient hopping on one sore foot than crawling on their hands and knees because both feet are a little worse !!!
Allan

Re: Heel Spurs

Allan.G on 2/19/02 at 03:26 (074271)

Glenn
On Ultrasound , we usually see that with Plantar fasciitis the tendon is either very thick ( 2 to 3 times normal thickness) or quite normal ( approx. 3mm in thickness)There doesn't seem to be many 'half ways' with this chronic tendon condition.
Allan

Re: Allan/Dr Z Dornier

john h on 2/19/02 at 12:11 (074309)

Allan: I never had sore feet once after treatment with the Orby and I assume it is delivering more power. Of course the Orby is coming from the bottom and your machine from the side which could account for a sore foot.

Re: Allan/Dr Z Dornier

Allan.G on 2/20/02 at 01:34 (074371)

John
Try and find out what energy levels they are using .
Allan

Re: Allan/Dr Z Dornier

john h on 2/20/02 at 10:14 (074396)

Allan: I know Dr. Z with his orby uses 16KV but do not know what that translates into at the focal point. I bet Dr. Z knows what the setting is for the Dornier for the FDA protocol. As a matter of fact I think I saw the setting on the FDA website and will go back and check it now.

Re: Post ESWT 2 days

Linda A on 3/18/02 at 18:01 (076767)

John, I live in Tijeras, NM and am also having problems with a heel spur. Please keep me informed of your progress. Thanks!