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ESWT on the West Coast Los Angeles Area

Posted by David L on 7/17/02 at 10:43 (089868)

I just received Scott's emailing regarding an update on ESWT treatments and much of what he said is accurate. I am a podiatric surgeon in Orange County California (Southern Calif) and my company So. Cal ESWT LLC is currently operating the first Epos Ultra in the Greater Los Angeles Area. So we've found that the billing for insurances in California has been a difficult process, but reimbursements are coming through, although slowly. The two largest payors, Blue Cross and Blue Shield are just beginning at the corporate level to understand the ESWT efficacy and shortly , if not already, will be publishing 'White' letters acknowledging the coverage of this treatment. Currently we have received authorization from about 8 companies including workman's compensation. We've found that outside of California there are more insurance companies willing to pay for ESWT.

It is anticipated that Medicare will soon authorize its acceptance of ESWT and this should cause most insurance companies to view this treatment as a 'Standard of Care' in the near future.

The biggest problem with cash pricing in the U.S. compared to the european or Canadian sites is the large initial cost of the device itself and the limited indications in the U.S. making it very hard to offer the treatment without financial detriment to the provider itself. Additionally because this device in the U.S. must be used in an Ambulatory Surgical Center or Outpatient Surgery Center/Hospital, the total cost of treatment dramatically rises. So. Cal. ESWT has developed a cash pricing of $2500 for the treatment in our best effort to offer this treatment to those patients needing this method of treatment.

Despite these issues the Dornier EPOS ultra has been a wonderful blessing and is still one of the most cost effective treatment at this price when you calculate the cost of 8-12 months of traditional remedies, loss of work, cost of invasive surgery and, most importantly, loss of lifestyle.

Our surgeons are currently experiencing approximately an >85% success rate (patient high level of satisfaction) on severe recalcitrant chronic heel pain. For experiemental use on the achilles tendonitis we are experiencing even more dramatic results. As the surgeon of ten years I am profoundly excited for my patients!

Kindest Regards,

David Lee DPM
http://www.leepodiatry.com

Re: West coast results vs. East coast results ?

BrianG on 7/17/02 at 20:28 (089914)

Hi Dr. Lee,

Welcome to Heelspurs.com. I'm happy to hear that you are working with the insurance companies, especially Medicare, to ensure they will begin covering the expense of ESWT. Everyone, regardless of income, should have the chance for ESWT treatment, before surgery.

I do have one question for you. You say that your group has an 85% success rate. I have been watching the postings from the people here, (Heelspurs.com) that have had the Dornier treatment in the NJ area, myself included. The are a few patients that are claiming to be much better, but most are not. Many have little, if no improvement, and a few are reporting more pain, than before their ESWT treatment. Can you please explain the difference in your healing rates, as opposed to the east coast results? About how many ESWT treatments for PF, has your group performed.

Regards
BrianG

Re: West coast results vs. East coast results ?

Dr David Lee on 7/18/02 at 01:35 (089931)

Dear Brian,

The healing rates are for my specific practice and are actually conservative
only because I have not put all the numbers together for my study. In
actuality the studies from our whole LLC which includes over 300 patients
from the Midwest (at 10 sites) are close to 90% patient satisfaction level
since last mid year, 2002. It is my belief that there are several reasons
why my patients are doing so well:

1. I have a very strict post operative regimen that you can read on my
website, http://www.leepodiatry.com .
2. I have all my patients completely abstain from any anti-inflammatory
medicines for12 weeks. (Dornier's standard does not mention prohibition of
NSAIDs.)
3. I often combine a calcaneal fenestration procedure with ESWT if the
patient has a suspected stress fracture of the calcaneus in addition to
plantar fasciitis.
4. I strictly adhere to the indication of ESWT for patients who have tried
at least 3 forms of conservative therapy and have had heel pain greater than
6 months.
5. My follow up on patients is weekly and involves constant monitoring of an
achilles stretching technique (a very specific type) for which they are
required to stretch a minimum of 4 times each day for 1 minute intervals per
leg.
6. My orthotics are very aggressive and extremely form fitted.
7. I do not use any cortisone injections and will not perform ESWT if a
person has had one within 4 weeks.

The reason why I am so strict about this is because ESWT merely accelerates
the body's natural healing potential by causing a rapid inflammatory
response from the bruising effect of ESWT. Inflammation is a required stage
of the soft tissue or bone tissue healing process. Without this stage
complete healing cannot occur by physiologic definition. Anything that
would inhibit this process over a 12 week period will easily counteract the
positive effect of ESWT. Additionally, ESWT is not a substitute for
treatment of the underlying cause of plantarfasciitis. Often times PF is a
symptom or result of such conditions as posterior tibial tendon
dysfunction, hypermobility of the lower ankle joint, in-toed position of the
feet, primary injury to the achilles tendon or a tight achilles tendon.
These condition must be resolved prior to effective ESWT treatment. For
those patient which have failed, I have found that there is often either an
oversight on the actual underlying diagnosis or a portion of the
post-opertive regimen that was not applied correctly.

The last thing that I believe is important is patient expectation and time
frame.

Hope this helps, and please let me know if you would like clarification on
this brief reply.

Sincerely,

David Lee DPM
Diplomate, American Board of Podiatric Surgery

Re: West coast results vs. East coast results ?

john h on 7/18/02 at 09:31 (089957)

Brian when I first had ESWT about three years ago my feet were terrible as was my hope. I ended up with 4 ESWT treatments in New Jersey over about two years. I have had bi-laterial Pf for about 8 years or more now. For the past 4-5 months my feet have been the best they have ever been. I cannot run but I do not think about my feet all day, work in the yard, shop and live a reasonable normal life except for an occasional flareup. I cannot say that ESWT is what got me to this point but I do think it played an important part in it. I know shoe wear is important because there are just some shoes that will aggrevate my feet. Birks are still my Gold Standard with Mesphito sandals right there with them. I also wear Rockport Pro Walkers to work with a semi-rigid foot orthotic. I have tried almost everything ever mentioned on this board and spent a lot of money on questionable remedies. I do not consider this a waste as I eliminated them as remedies. For the past month I have not even iced or taped. I have come a long way over the past 8 years so I say to you all never give up hope. Be wary of surgery of any kind unless it is the court of last resort and then get at least three opinions. Do not look for a miracle in a bottle. Know that some orthotics can make your feet worse if you do not need them or have an improper fitting. Lastly people with PF who have had it many many years can and do get better.

Re: West coast results vs. East coast results ?

BrianG on 7/18/02 at 20:41 (090015)

Thanks for the reply, Dr Lee. I see a couple of things jump right out at me. The first is that you discourge NSAIDS for the 1st 12 weeks. It's the first I have read about that. Are the new generations like Vioxx and Celebrex included also?

The 2nd is the aggressive and extremely form fitted orthotics. Does your office make them, and do you have your patients in them, before or after, the ESWT treatment.
I am familia with the FDA protocol and their success rate from when they had their trials. Your numbers are certainly much higher than any ohers I've seen yet. I really hope this is the future of PF healing. I'll feel better about it (the numbers) when some long term studies have been completed in this country. Thanks again

BrianG

PS JohnH, I do believe ESWT is the answer, it's just not happening quick enough for my particular case. I'll take another look at a 2nd treatment, at the 6 month mark.

Re: West coast results vs. East coast results ?

Dr David Lee on 7/18/02 at 23:32 (090048)

Dear Brian,

Stopping of NSAIDs includes Vioxx and Celebrex (cox2 inhibitors).

The orthotics I cast myself and sent out for manufacture with a reputable orthotics firms. The important aspect to making a good orthotic is not the type of materials but rather how you capture the foot with plaster impressions in a 'face down' position and then how you order modifications to the orthotics manufacturing company. Patients are required to have my orthotics prior to starting the ESWT protocol. What I have found that many of my patients who have gone to several doctors may have several pairs, but their are not contoured well enough to the arch. It's unfortunate that they spent all that money, but I still required good fitting orthosis in order to prevent re-injury in the post-operative period.

Yes, the results are better than the FDA trails which only showed about a 65% improvement overall. However, if you read the Journal of Bone and Joint Surgery, March 2002 and the latest Journal of Foot and Ankle, May , 2002, you will see roughly 82% success rates.

You can obtain a a reprint if you send me your direct email.

I believe that the difference in results is because the technique and the protocols have been honed a bit more and the follow up process in my office has evolved provide higher compliance with the patient. If your trace the effectiveness of lithotripsy from the inital FDA trials to today's efficacy you will also find the same situation. As practititioners get more experience with the device, success levels dramatically increase.

Additionally, as said before, diagnosing the true cause of the plantar fasciitis is key. Today I saw a lovely mom who had pain for 5 years and hasn't had any success in either of her feet even after 2 pairs of orthotics, night splints, 6 injections in one foot and finally Endoscopic surgery in her left foot. After spending 45 minutes gathering her background information I discovered that she has primary posterior tibial dysfunction. That's why her previous treatment failed! She may not even require any other procedures if I can conservatively heal the tendon which will allow the PF to heal.

Best,

David Lee, DPM

Re: West coast results vs. East coast results ?

Dr David Lee on 7/18/02 at 23:35 (090050)

Brian,

I do agree that you should have patience in letting your body heal. However, before attempting another ESWT treatment please confirm that your PF is not a secondary condition cause by an underlying problem such as posterior tibial dysfunction,tarsal tunnel,nerve impingment,achille equinus, etc.

ESWT is not treatment for any of those conditions. These primary conditions must be satisfied before ESWT will heal your PF.

Re: what is resp the cause and the effect ?

Niels on 7/19/02 at 06:01 (090072)

Dr Lee, couldnt it be the other way round, meaning that it is the pf which has triggered tts, achilles tendonitis etc ? Or even hallux limitus (which i also suffer from) ?

If this is a possiblity, couldnt it be so that curing the pf (by way of ESWT) would result in healing of the disfunctions of the feet ?

My doc advised me to get EWST based on the above points of view, though he did hardly bother to examine my feet prior to the ESWT. I have had the ESWT treatments, so now i am just waiting and hoping.

Re: West coast results vs. East coast results ?

BrianG on 7/19/02 at 07:54 (090081)

I'm quite sure that I have only a simple case of PF (hahaha, that's an understatement!) Early on I could not believe that all this pain could be from PF only. I saw numerous Pod & Md's. I had 2 EMG's, a bone scan, and finally forced them to give my an MRI. I had to go to their board of appeals for that one. I do have a comfertble pair of custom orthitics, cast by SporThotics, by Langer. They have not helped, but they are comfertable to wear.

Thanks
BrianG

Re: West coast results vs. East coast results ?

Ed Davis, DPM on 7/19/02 at 15:20 (090140)

David:

Your success rates are related to patient selection and protocols used.
Basically, you are doing everything else 'right' before moving forward with ESWT. I have proposed a 'treatment triad' on this site which lists 3 areas that need to be dealt with in the succesful treatment of PF: biomechanics, inflammatory process and tissue quality. ESWT is the first modality that deals directly with tissue quality -- you have already dealt with the first two areas.

Unfortunately, I would suspect that there is and will be increasing usage of ESWT as a perceived 'magic bullet' for PF where the biomechanics will not be adequately addressed. Success rates will be lower in such scenarios.

Regards,
Ed

Re: West coast results vs. East coast results ?

Ed Davis, DPM on 7/19/02 at 15:25 (090141)

Brian:

See my post below. ESWT is one leg of a 'treatment triad.' It may or may not be a 'stand alone' treatment. Success rates will be drastically affected by what is being done for the other two 'legs.' Dr. Lee appears to be paying strict attention to the entire treatment protocol before moving forward with ESWT and that is why I believe he can list such high percentages.
Ed

Re: what is resp the cause and the effect ?

Dr. David Lee on 7/20/02 at 18:09 (090228)

I find that very rarely is the PF ever just the only problem. Unless there was a direct trauma to the arch or PF itself there is a primary condition that caused the PF to injure (something causing the collapse or the arch- i.e. post tib dysfunction,) or one could have heel pain due to another condition (tarsal tunnel, neuritis to the lateral plantar nerve). Understand that the PF is a static entity unlike a muscle or joint. All the PF does is contribute to the suport of the arch of the foot. It reacts to things not creates things.

My primary point is that a practitioner should always look for underlying conditions to the cause of plantar fasciitis to verify that the ESWT will indeed cure the ligament and wont return.

Re: West coast results vs. East coast results ?

Dr. David Lee on 7/20/02 at 18:24 (090232)

Ed,

You are correct. the proper dx and selection is necessary and should be not different than with any form of treatment. I do also believe the post op regimen should be very strict and enforce to give a realistic recovery from the use of EWST.

ESWT is a great modalit and by no means a 'magic Bullet' in the wrong indications and hands.

Best,

Dave

Re: what is resp the cause and the effect ?

john h on 7/20/02 at 19:27 (090241)

Dr. Lee: Why do you think there are so many cases of bi-laterial PF that begin almost at the same time. It is unlikely you would injure both feet at the same time.

Re: what is resp the cause and the effect ?

Dr David Lee on 7/20/02 at 23:01 (090250)

Actually, most of the time the heel pain starts with one foot and rarely at the same unless there was a concurrent injury. This is usually due to a painful heel on one side then the other foot compensates by supporting the body leading to injury of the other heel.

Contralateral heel pain is seen very often but usually not at the exact same moment. When I refer to 'injury' I am meaning not necessarily a known traumatic incident but rather the act of inflammation or 'injury' to the tissues in the body. There are 'chronic' or slower levels of injury and 'acute' or rapid injurous events.

Re: what is resp the cause and the effect ?

Dr David Lee on 7/20/02 at 23:10 (090252)

Let me clarify one point: Primary Plantarfasciitis does occur without any other major medical obvious problem like complete posterior tibial tendon dysfunction, however, primary plantarfasciitis is related to an underlying failure of the arch to sustain itself properly. This could be caused by a little bit of the following: gradual weakening of the intrinsic muscles, tibial muscles, ligamentous laxity, etc. It's just that you may not be able to clinically find a complete failure of any individual area. PF'itis is a complex and multifaceted injury as any practitioner will atest.

Re: what is resp the cause and the effect ?

john h on 7/21/02 at 08:47 (090269)

Dr Lee: Another strange phonomena is that if one foot gets better so does the other. I thought I was a head case until one day when I was getting a steriod shot in the foot I asked the doctor why he was only doing it in one foot and he said very ofter for reasons unkonwn to him if the shot helped the one foot the pain in the other foot would often lessen and so it did! I know steriods can enter the blood stream but I have my doubts that is the causative factor. How many bi-laterial PF folks out there have noticed if one foot gets better or worse the other seems to follow?

Re: what is resp the cause and the effect ?

DR Zuckerman on 7/21/02 at 10:31 (090278)

Hi

This is either from the local steriod injection getting into the blood stream or one foot no pain so you are now walking correctly and there is no compensatin. Or it could be a mircle. Whatever very common response

Re: what is resp the cause and the effect ?

john h on 7/21/02 at 19:49 (090308)

Dr. Z: Not only with steriod injections does this occur but when I have a setback or an improvement it is always in both feet. One of the local Podiatrist says he sees this all the time. I have had surgeons tell me they never like to operate on both feet at the same time not only for the obvious reasons but they have in fact seen patients with bilateral PF who experienced relief in both feet when they only operated on one foot. I am not a mystic and very much a believer in science I can understand but this I do not understand.

Re: West coast results vs. East coast results ?

BrianG on 7/17/02 at 20:28 (089914)

Hi Dr. Lee,

Welcome to Heelspurs.com. I'm happy to hear that you are working with the insurance companies, especially Medicare, to ensure they will begin covering the expense of ESWT. Everyone, regardless of income, should have the chance for ESWT treatment, before surgery.

I do have one question for you. You say that your group has an 85% success rate. I have been watching the postings from the people here, (Heelspurs.com) that have had the Dornier treatment in the NJ area, myself included. The are a few patients that are claiming to be much better, but most are not. Many have little, if no improvement, and a few are reporting more pain, than before their ESWT treatment. Can you please explain the difference in your healing rates, as opposed to the east coast results? About how many ESWT treatments for PF, has your group performed.

Regards
BrianG

Re: West coast results vs. East coast results ?

Dr David Lee on 7/18/02 at 01:35 (089931)

Dear Brian,

The healing rates are for my specific practice and are actually conservative
only because I have not put all the numbers together for my study. In
actuality the studies from our whole LLC which includes over 300 patients
from the Midwest (at 10 sites) are close to 90% patient satisfaction level
since last mid year, 2002. It is my belief that there are several reasons
why my patients are doing so well:

1. I have a very strict post operative regimen that you can read on my
website, http://www.leepodiatry.com .
2. I have all my patients completely abstain from any anti-inflammatory
medicines for12 weeks. (Dornier's standard does not mention prohibition of
NSAIDs.)
3. I often combine a calcaneal fenestration procedure with ESWT if the
patient has a suspected stress fracture of the calcaneus in addition to
plantar fasciitis.
4. I strictly adhere to the indication of ESWT for patients who have tried
at least 3 forms of conservative therapy and have had heel pain greater than
6 months.
5. My follow up on patients is weekly and involves constant monitoring of an
achilles stretching technique (a very specific type) for which they are
required to stretch a minimum of 4 times each day for 1 minute intervals per
leg.
6. My orthotics are very aggressive and extremely form fitted.
7. I do not use any cortisone injections and will not perform ESWT if a
person has had one within 4 weeks.

The reason why I am so strict about this is because ESWT merely accelerates
the body's natural healing potential by causing a rapid inflammatory
response from the bruising effect of ESWT. Inflammation is a required stage
of the soft tissue or bone tissue healing process. Without this stage
complete healing cannot occur by physiologic definition. Anything that
would inhibit this process over a 12 week period will easily counteract the
positive effect of ESWT. Additionally, ESWT is not a substitute for
treatment of the underlying cause of plantarfasciitis. Often times PF is a
symptom or result of such conditions as posterior tibial tendon
dysfunction, hypermobility of the lower ankle joint, in-toed position of the
feet, primary injury to the achilles tendon or a tight achilles tendon.
These condition must be resolved prior to effective ESWT treatment. For
those patient which have failed, I have found that there is often either an
oversight on the actual underlying diagnosis or a portion of the
post-opertive regimen that was not applied correctly.

The last thing that I believe is important is patient expectation and time
frame.

Hope this helps, and please let me know if you would like clarification on
this brief reply.

Sincerely,

David Lee DPM
Diplomate, American Board of Podiatric Surgery

Re: West coast results vs. East coast results ?

john h on 7/18/02 at 09:31 (089957)

Brian when I first had ESWT about three years ago my feet were terrible as was my hope. I ended up with 4 ESWT treatments in New Jersey over about two years. I have had bi-laterial Pf for about 8 years or more now. For the past 4-5 months my feet have been the best they have ever been. I cannot run but I do not think about my feet all day, work in the yard, shop and live a reasonable normal life except for an occasional flareup. I cannot say that ESWT is what got me to this point but I do think it played an important part in it. I know shoe wear is important because there are just some shoes that will aggrevate my feet. Birks are still my Gold Standard with Mesphito sandals right there with them. I also wear Rockport Pro Walkers to work with a semi-rigid foot orthotic. I have tried almost everything ever mentioned on this board and spent a lot of money on questionable remedies. I do not consider this a waste as I eliminated them as remedies. For the past month I have not even iced or taped. I have come a long way over the past 8 years so I say to you all never give up hope. Be wary of surgery of any kind unless it is the court of last resort and then get at least three opinions. Do not look for a miracle in a bottle. Know that some orthotics can make your feet worse if you do not need them or have an improper fitting. Lastly people with PF who have had it many many years can and do get better.

Re: West coast results vs. East coast results ?

BrianG on 7/18/02 at 20:41 (090015)

Thanks for the reply, Dr Lee. I see a couple of things jump right out at me. The first is that you discourge NSAIDS for the 1st 12 weeks. It's the first I have read about that. Are the new generations like Vioxx and Celebrex included also?

The 2nd is the aggressive and extremely form fitted orthotics. Does your office make them, and do you have your patients in them, before or after, the ESWT treatment.
I am familia with the FDA protocol and their success rate from when they had their trials. Your numbers are certainly much higher than any ohers I've seen yet. I really hope this is the future of PF healing. I'll feel better about it (the numbers) when some long term studies have been completed in this country. Thanks again

BrianG

PS JohnH, I do believe ESWT is the answer, it's just not happening quick enough for my particular case. I'll take another look at a 2nd treatment, at the 6 month mark.

Re: West coast results vs. East coast results ?

Dr David Lee on 7/18/02 at 23:32 (090048)

Dear Brian,

Stopping of NSAIDs includes Vioxx and Celebrex (cox2 inhibitors).

The orthotics I cast myself and sent out for manufacture with a reputable orthotics firms. The important aspect to making a good orthotic is not the type of materials but rather how you capture the foot with plaster impressions in a 'face down' position and then how you order modifications to the orthotics manufacturing company. Patients are required to have my orthotics prior to starting the ESWT protocol. What I have found that many of my patients who have gone to several doctors may have several pairs, but their are not contoured well enough to the arch. It's unfortunate that they spent all that money, but I still required good fitting orthosis in order to prevent re-injury in the post-operative period.

Yes, the results are better than the FDA trails which only showed about a 65% improvement overall. However, if you read the Journal of Bone and Joint Surgery, March 2002 and the latest Journal of Foot and Ankle, May , 2002, you will see roughly 82% success rates.

You can obtain a a reprint if you send me your direct email.

I believe that the difference in results is because the technique and the protocols have been honed a bit more and the follow up process in my office has evolved provide higher compliance with the patient. If your trace the effectiveness of lithotripsy from the inital FDA trials to today's efficacy you will also find the same situation. As practititioners get more experience with the device, success levels dramatically increase.

Additionally, as said before, diagnosing the true cause of the plantar fasciitis is key. Today I saw a lovely mom who had pain for 5 years and hasn't had any success in either of her feet even after 2 pairs of orthotics, night splints, 6 injections in one foot and finally Endoscopic surgery in her left foot. After spending 45 minutes gathering her background information I discovered that she has primary posterior tibial dysfunction. That's why her previous treatment failed! She may not even require any other procedures if I can conservatively heal the tendon which will allow the PF to heal.

Best,

David Lee, DPM

Re: West coast results vs. East coast results ?

Dr David Lee on 7/18/02 at 23:35 (090050)

Brian,

I do agree that you should have patience in letting your body heal. However, before attempting another ESWT treatment please confirm that your PF is not a secondary condition cause by an underlying problem such as posterior tibial dysfunction,tarsal tunnel,nerve impingment,achille equinus, etc.

ESWT is not treatment for any of those conditions. These primary conditions must be satisfied before ESWT will heal your PF.

Re: what is resp the cause and the effect ?

Niels on 7/19/02 at 06:01 (090072)

Dr Lee, couldnt it be the other way round, meaning that it is the pf which has triggered tts, achilles tendonitis etc ? Or even hallux limitus (which i also suffer from) ?

If this is a possiblity, couldnt it be so that curing the pf (by way of ESWT) would result in healing of the disfunctions of the feet ?

My doc advised me to get EWST based on the above points of view, though he did hardly bother to examine my feet prior to the ESWT. I have had the ESWT treatments, so now i am just waiting and hoping.

Re: West coast results vs. East coast results ?

BrianG on 7/19/02 at 07:54 (090081)

I'm quite sure that I have only a simple case of PF (hahaha, that's an understatement!) Early on I could not believe that all this pain could be from PF only. I saw numerous Pod & Md's. I had 2 EMG's, a bone scan, and finally forced them to give my an MRI. I had to go to their board of appeals for that one. I do have a comfertble pair of custom orthitics, cast by SporThotics, by Langer. They have not helped, but they are comfertable to wear.

Thanks
BrianG

Re: West coast results vs. East coast results ?

Ed Davis, DPM on 7/19/02 at 15:20 (090140)

David:

Your success rates are related to patient selection and protocols used.
Basically, you are doing everything else 'right' before moving forward with ESWT. I have proposed a 'treatment triad' on this site which lists 3 areas that need to be dealt with in the succesful treatment of PF: biomechanics, inflammatory process and tissue quality. ESWT is the first modality that deals directly with tissue quality -- you have already dealt with the first two areas.

Unfortunately, I would suspect that there is and will be increasing usage of ESWT as a perceived 'magic bullet' for PF where the biomechanics will not be adequately addressed. Success rates will be lower in such scenarios.

Regards,
Ed

Re: West coast results vs. East coast results ?

Ed Davis, DPM on 7/19/02 at 15:25 (090141)

Brian:

See my post below. ESWT is one leg of a 'treatment triad.' It may or may not be a 'stand alone' treatment. Success rates will be drastically affected by what is being done for the other two 'legs.' Dr. Lee appears to be paying strict attention to the entire treatment protocol before moving forward with ESWT and that is why I believe he can list such high percentages.
Ed

Re: what is resp the cause and the effect ?

Dr. David Lee on 7/20/02 at 18:09 (090228)

I find that very rarely is the PF ever just the only problem. Unless there was a direct trauma to the arch or PF itself there is a primary condition that caused the PF to injure (something causing the collapse or the arch- i.e. post tib dysfunction,) or one could have heel pain due to another condition (tarsal tunnel, neuritis to the lateral plantar nerve). Understand that the PF is a static entity unlike a muscle or joint. All the PF does is contribute to the suport of the arch of the foot. It reacts to things not creates things.

My primary point is that a practitioner should always look for underlying conditions to the cause of plantar fasciitis to verify that the ESWT will indeed cure the ligament and wont return.

Re: West coast results vs. East coast results ?

Dr. David Lee on 7/20/02 at 18:24 (090232)

Ed,

You are correct. the proper dx and selection is necessary and should be not different than with any form of treatment. I do also believe the post op regimen should be very strict and enforce to give a realistic recovery from the use of EWST.

ESWT is a great modalit and by no means a 'magic Bullet' in the wrong indications and hands.

Best,

Dave

Re: what is resp the cause and the effect ?

john h on 7/20/02 at 19:27 (090241)

Dr. Lee: Why do you think there are so many cases of bi-laterial PF that begin almost at the same time. It is unlikely you would injure both feet at the same time.

Re: what is resp the cause and the effect ?

Dr David Lee on 7/20/02 at 23:01 (090250)

Actually, most of the time the heel pain starts with one foot and rarely at the same unless there was a concurrent injury. This is usually due to a painful heel on one side then the other foot compensates by supporting the body leading to injury of the other heel.

Contralateral heel pain is seen very often but usually not at the exact same moment. When I refer to 'injury' I am meaning not necessarily a known traumatic incident but rather the act of inflammation or 'injury' to the tissues in the body. There are 'chronic' or slower levels of injury and 'acute' or rapid injurous events.

Re: what is resp the cause and the effect ?

Dr David Lee on 7/20/02 at 23:10 (090252)

Let me clarify one point: Primary Plantarfasciitis does occur without any other major medical obvious problem like complete posterior tibial tendon dysfunction, however, primary plantarfasciitis is related to an underlying failure of the arch to sustain itself properly. This could be caused by a little bit of the following: gradual weakening of the intrinsic muscles, tibial muscles, ligamentous laxity, etc. It's just that you may not be able to clinically find a complete failure of any individual area. PF'itis is a complex and multifaceted injury as any practitioner will atest.

Re: what is resp the cause and the effect ?

john h on 7/21/02 at 08:47 (090269)

Dr Lee: Another strange phonomena is that if one foot gets better so does the other. I thought I was a head case until one day when I was getting a steriod shot in the foot I asked the doctor why he was only doing it in one foot and he said very ofter for reasons unkonwn to him if the shot helped the one foot the pain in the other foot would often lessen and so it did! I know steriods can enter the blood stream but I have my doubts that is the causative factor. How many bi-laterial PF folks out there have noticed if one foot gets better or worse the other seems to follow?

Re: what is resp the cause and the effect ?

DR Zuckerman on 7/21/02 at 10:31 (090278)

Hi

This is either from the local steriod injection getting into the blood stream or one foot no pain so you are now walking correctly and there is no compensatin. Or it could be a mircle. Whatever very common response

Re: what is resp the cause and the effect ?

john h on 7/21/02 at 19:49 (090308)

Dr. Z: Not only with steriod injections does this occur but when I have a setback or an improvement it is always in both feet. One of the local Podiatrist says he sees this all the time. I have had surgeons tell me they never like to operate on both feet at the same time not only for the obvious reasons but they have in fact seen patients with bilateral PF who experienced relief in both feet when they only operated on one foot. I am not a mystic and very much a believer in science I can understand but this I do not understand.