Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

ultrasound normal

Posted by Peter F on 11/13/02 at 11:14 (100021)

Dear Docs -I have definite PF (2 years) but completely normal US performed by a consultant radiologist-my question is :

Does ESWT help when normal US-I only ask this because I have read that you use US to locate the area to 'hit'

Thanks

Re: ultrasound normal

Ed Davis, DPM on 11/13/02 at 14:47 (100053)

Peter:

Excellent question. Please ask the radiologist what the thickeness of the fascia is at its origin. We believe that the thickest part of the fascia is the most diseased portion but this has not been firmly established.
Dornier uses ultrasound for aiming but not the protocol used by Ossatron nor Sonorex. Note that Siemans does make a machine with diagnostic ultrasound called the Sonocur Plus as opposed to the Sonocur Basic which is marketed via Sonorex.

Have you had all of the other conservative modalities (use Scott's Heel Pain Book as a guide)?
Ed

Re: ultrasound normal

Steve on 11/13/02 at 19:21 (100074)

Ultrasound does not allow one to 'see' pain as is evidenced in your case. ESW treatment is focused on the point of maximum tenderness which is located by the doctor via palpation. Focal area is the working area of the focused shock wave. Electrohydraulic ESW such as that generated by the OssaTron produces a large focal area and allows the doctor to treat the entire are of chronic inflamation. The ultrasound imaging on lower energy devices is required due to the small focal area generated by the electromagnetic mechanism. This small focal area is also why Dornier treatments are administered from the side (less PF area to treat) of the foot, as the focal area is not large enough to practically treat from the bottom of the heel. In short you treat the pain, not the picture.

Re: Just not true

Dr. Z on 11/13/02 at 19:31 (100078)

This isn't true. The treating doctor palpates the area of max tenderness.
He or she then marks the areas. The transductor is then placed on the marked areas. The treating doctor is able to evaluate the area of max tenderness but most important he is able to keep the focus area in contact with the shockwave at all times. There aren't any studies except the Roles Maundsley study one year post dornier and one year post ossatron that compares the dornier high energy treatment with the ossatron high treatment. The dornier results were much higher then the ossatron and there were no pf tears that were experienced with the ossatron. Whether condensed focal points are better then wider focal point is yet to be determined but common sense and the one study I mentioned tells you your answer. Coming from the side of the foot is done so that you can use an outline ultrasound .

Re: ultrasound normal

Dr. Z on 11/13/02 at 19:33 (100080)

palpation is a very important part of the dornier protocol. Ultrasound is using or aiming and keeping the area of pathology within the focal point at all times. The foot movement during treatment and the ultrasound keeps track of this movement

Re: Just not true

Steve on 11/13/02 at 20:04 (100082)

Please point me to this study comparison information that you reference.

Re: Specifically, what item(s) are you saying is(are) not true?

Steve on 11/13/02 at 20:07 (100083)

Specifically, what item(s) are you saying is not true?

Re: ultrasound normal

Peter F on 11/14/02 at 05:02 (100113)

Dear Ed,

Apparently 4mm at it's thickest

Yes I am mainly stretching icing and resting with inserts

Thanks

Re: Just not true

Dr. Z on 11/14/02 at 21:33 (100184)

The 81% sucess rate with some poor results after a one year follow for the ossatron comes from healthronics, They did the study. It is a one year follow up from the 12 week FDA study. The dornier is the same thing with a 94% sucess rate. Both Companies did a one year follow up. So call the companies. IF you give me your company name and address I have them . Just e-mail Dr. Z at (email removed).

Re: Specifically, what item(s) are you saying is(are) not true?

Dr. Z on 11/14/02 at 21:39 (100186)

The statement that because the focal point is small you need ultrasound imaging. Statement about why the shockwave is approached from the side and not th bottom with the dornier. The reason is you have too because the transductor is on the bottom and the shockwave have to be 90 degree to the plantar fascia.

The ossatron doesn't cover the entire area inflammation. It's width is about 7-8 mms. This is why they rotate the head so as to increase the area of treatment. In addition when treating the lateral band of the pf you have to re-position the head. The areas of focused shockwave aren't that different between the dornier and the ossatron. .

Re: Specifically, what item(s) are you saying is(are) not true?

Steve on 11/14/02 at 21:54 (100190)

My statement about the OssaTron is that it can treat the entire area of inflamation during one 1500 shock session. As for the treating from the side, your answer confirms my statement. The imaging is required to line up the focal area with the plantar fascia.

Re: Specifically, what item(s) are you saying is(are) not true?

Dr. Zuckerman on 11/15/02 at 11:34 (100273)

I guess this is the problem with e-mail it can be confusing to read.

Re: ultrasound normal

Ed Davis, DPM on 11/15/02 at 17:18 (100312)

Peter:

Again, while we don't have good stats as to what thickness should be considered pathologic, I would not consider 4 mm to be abnormal.

Considering that finding, it may be worth another opinon as to the origin of your pain.
Ed

Re: Specifically, what item(s) are you saying is(are) not true?

Bill on 11/16/02 at 07:02 (100361)

Steve,

Imaging is used to make sure that the high intensity shock waves only hit the fascia and not the surrounding bones. The Ossatron sends a significant amount of high energy shock waves into the bones of the foot. I have always been concerned about what this energy does to the bones. After all, the Ossatron's is used for non-union fractures where is causes bone growth through the use
of shockwaves.

Do you believe that a machine should be evaluated on the amount of energy that is delivered to the fascia or the amount of energy delivered to the foot? Please note that the Ossatron and Epos deliver about the same amount of energy to the fascia. If you think that the fascia is causing the pain then why would you send high energy shock waves to surrounding tissue?

Re: Specifically, what item(s) are you saying is(are) not true?

Steve on 11/17/02 at 00:15 (100461)

Per the FDA Summaries of Safety and Effectiveness:

0% of OssaTron patients reported that they experienced pain during the treatment.
3.7% of OssaTron patients reported pain after the treatment.

72.3% of Epos Ultra patients reported that they experienced pain during the treatment.
40.8% of Epos Ultra patients reported pain after the treatment.

Many dotors are using IV sedation for patient safety and comfort in the controlled environment of an ASC.

Re: Specifically, what item(s) are you saying is(are) not true?

Bill on 11/17/02 at 08:27 (100465)

Steve,

I don't understand your statement on treatment pain because the Healthtronics PMA states that the 'adverse effects observed during ESW treatment with the OssaTron include: (1) Pain during the ESW treatment; (2) Localize numbness, tingling or decreased sensation in the foot or at the site of shock wave delivery; (3) Local subcutaneous hematoma, bruising, or petechial bleeding in the foot or at the treatment site; and (4) Rupture of plantar fascia.'

It is on page 3 of the PMA at the FDA site. I guess that there was pain during treatment.

Likewise, how does IV sedation lead to patient safety? I thought that there are increased risks associated with anestesia.

Re: Specifically, what item(s) are you saying is(are) not true?

Bill on 11/17/02 at 08:37 (100466)

Steve,

You need to question the pain reporting in the Dornier PMA since they found that 17 out of 74 patients in the sham group reported pain during treatment. It is remarkable that 23% of the patients who did not receive treatment reported pain on treatment. These patients did not receive
any shock waves. I would not place too much stock in the statistics you reported.

Maybe Dr. Z. could comment on his patient's experience with pain?

Re: Specifically, what item(s) are you saying is(are) not true?

john h on 11/17/02 at 11:00 (100504)

Having had 3 or maybe it was 4 Orby treatments I certainly can comment on pain. I had treatments on both feet on each occasion and I think at least 1500 shocks (or was it 3000 Dr. Z) at the Orby setting of 18. The first treatment I received an ankle block. No pain during or after. Remainder of treatments were with no block or med of any sort. The first 10 shock waves produced moderate pain but after that the foot became more or less numb and was basically pain free. Every once in a while the machine would seem to give an extra strong jolt which I would feel but those were very few. If the Epos power is on the same level as the Orby I would really wonder why even get a shot unless you are very adverse to any kind of pain.

Re: ultrasound normal

john h on 11/18/02 at 10:21 (100560)

Dr. Ed: Does the fascia increase or decrease in thickness with age? Does the thickness of the fascia vary with the size of the individual. Would a marathon runner or someone else who was on their feet all day long every day tend to have a thicker fascia? Can you just be a person with a thick fascia for no reason other than you were born that way?

Re: Specifically, what item(s) are you saying is(are) not true?

Dr. Zuckerman on 11/19/02 at 14:19 (100652)

Here is what I have found with pain during the treatment . I use a complete block for dornier epos treatments. This reduces the pain level during treatment to almost zero. What I mean by this is that 48 out of 50 have no pain. The block that was used during the FDA trial is totally lacking for profound anesthesia.

Patients can and do have pain after ESWT. with the dornier. That isn't typial . Most patients never take a narcotic drug for pain post ESWT

Re: ultrasound normal

Ed Davis, DPM on 11/13/02 at 14:47 (100053)

Peter:

Excellent question. Please ask the radiologist what the thickeness of the fascia is at its origin. We believe that the thickest part of the fascia is the most diseased portion but this has not been firmly established.
Dornier uses ultrasound for aiming but not the protocol used by Ossatron nor Sonorex. Note that Siemans does make a machine with diagnostic ultrasound called the Sonocur Plus as opposed to the Sonocur Basic which is marketed via Sonorex.

Have you had all of the other conservative modalities (use Scott's Heel Pain Book as a guide)?
Ed

Re: ultrasound normal

Steve on 11/13/02 at 19:21 (100074)

Ultrasound does not allow one to 'see' pain as is evidenced in your case. ESW treatment is focused on the point of maximum tenderness which is located by the doctor via palpation. Focal area is the working area of the focused shock wave. Electrohydraulic ESW such as that generated by the OssaTron produces a large focal area and allows the doctor to treat the entire are of chronic inflamation. The ultrasound imaging on lower energy devices is required due to the small focal area generated by the electromagnetic mechanism. This small focal area is also why Dornier treatments are administered from the side (less PF area to treat) of the foot, as the focal area is not large enough to practically treat from the bottom of the heel. In short you treat the pain, not the picture.

Re: Just not true

Dr. Z on 11/13/02 at 19:31 (100078)

This isn't true. The treating doctor palpates the area of max tenderness.
He or she then marks the areas. The transductor is then placed on the marked areas. The treating doctor is able to evaluate the area of max tenderness but most important he is able to keep the focus area in contact with the shockwave at all times. There aren't any studies except the Roles Maundsley study one year post dornier and one year post ossatron that compares the dornier high energy treatment with the ossatron high treatment. The dornier results were much higher then the ossatron and there were no pf tears that were experienced with the ossatron. Whether condensed focal points are better then wider focal point is yet to be determined but common sense and the one study I mentioned tells you your answer. Coming from the side of the foot is done so that you can use an outline ultrasound .

Re: ultrasound normal

Dr. Z on 11/13/02 at 19:33 (100080)

palpation is a very important part of the dornier protocol. Ultrasound is using or aiming and keeping the area of pathology within the focal point at all times. The foot movement during treatment and the ultrasound keeps track of this movement

Re: Just not true

Steve on 11/13/02 at 20:04 (100082)

Please point me to this study comparison information that you reference.

Re: Specifically, what item(s) are you saying is(are) not true?

Steve on 11/13/02 at 20:07 (100083)

Specifically, what item(s) are you saying is not true?

Re: ultrasound normal

Peter F on 11/14/02 at 05:02 (100113)

Dear Ed,

Apparently 4mm at it's thickest

Yes I am mainly stretching icing and resting with inserts

Thanks

Re: Just not true

Dr. Z on 11/14/02 at 21:33 (100184)

The 81% sucess rate with some poor results after a one year follow for the ossatron comes from healthronics, They did the study. It is a one year follow up from the 12 week FDA study. The dornier is the same thing with a 94% sucess rate. Both Companies did a one year follow up. So call the companies. IF you give me your company name and address I have them . Just e-mail Dr. Z at (email removed).

Re: Specifically, what item(s) are you saying is(are) not true?

Dr. Z on 11/14/02 at 21:39 (100186)

The statement that because the focal point is small you need ultrasound imaging. Statement about why the shockwave is approached from the side and not th bottom with the dornier. The reason is you have too because the transductor is on the bottom and the shockwave have to be 90 degree to the plantar fascia.

The ossatron doesn't cover the entire area inflammation. It's width is about 7-8 mms. This is why they rotate the head so as to increase the area of treatment. In addition when treating the lateral band of the pf you have to re-position the head. The areas of focused shockwave aren't that different between the dornier and the ossatron. .

Re: Specifically, what item(s) are you saying is(are) not true?

Steve on 11/14/02 at 21:54 (100190)

My statement about the OssaTron is that it can treat the entire area of inflamation during one 1500 shock session. As for the treating from the side, your answer confirms my statement. The imaging is required to line up the focal area with the plantar fascia.

Re: Specifically, what item(s) are you saying is(are) not true?

Dr. Zuckerman on 11/15/02 at 11:34 (100273)

I guess this is the problem with e-mail it can be confusing to read.

Re: ultrasound normal

Ed Davis, DPM on 11/15/02 at 17:18 (100312)

Peter:

Again, while we don't have good stats as to what thickness should be considered pathologic, I would not consider 4 mm to be abnormal.

Considering that finding, it may be worth another opinon as to the origin of your pain.
Ed

Re: Specifically, what item(s) are you saying is(are) not true?

Bill on 11/16/02 at 07:02 (100361)

Steve,

Imaging is used to make sure that the high intensity shock waves only hit the fascia and not the surrounding bones. The Ossatron sends a significant amount of high energy shock waves into the bones of the foot. I have always been concerned about what this energy does to the bones. After all, the Ossatron's is used for non-union fractures where is causes bone growth through the use
of shockwaves.

Do you believe that a machine should be evaluated on the amount of energy that is delivered to the fascia or the amount of energy delivered to the foot? Please note that the Ossatron and Epos deliver about the same amount of energy to the fascia. If you think that the fascia is causing the pain then why would you send high energy shock waves to surrounding tissue?

Re: Specifically, what item(s) are you saying is(are) not true?

Steve on 11/17/02 at 00:15 (100461)

Per the FDA Summaries of Safety and Effectiveness:

0% of OssaTron patients reported that they experienced pain during the treatment.
3.7% of OssaTron patients reported pain after the treatment.

72.3% of Epos Ultra patients reported that they experienced pain during the treatment.
40.8% of Epos Ultra patients reported pain after the treatment.

Many dotors are using IV sedation for patient safety and comfort in the controlled environment of an ASC.

Re: Specifically, what item(s) are you saying is(are) not true?

Bill on 11/17/02 at 08:27 (100465)

Steve,

I don't understand your statement on treatment pain because the Healthtronics PMA states that the 'adverse effects observed during ESW treatment with the OssaTron include: (1) Pain during the ESW treatment; (2) Localize numbness, tingling or decreased sensation in the foot or at the site of shock wave delivery; (3) Local subcutaneous hematoma, bruising, or petechial bleeding in the foot or at the treatment site; and (4) Rupture of plantar fascia.'

It is on page 3 of the PMA at the FDA site. I guess that there was pain during treatment.

Likewise, how does IV sedation lead to patient safety? I thought that there are increased risks associated with anestesia.

Re: Specifically, what item(s) are you saying is(are) not true?

Bill on 11/17/02 at 08:37 (100466)

Steve,

You need to question the pain reporting in the Dornier PMA since they found that 17 out of 74 patients in the sham group reported pain during treatment. It is remarkable that 23% of the patients who did not receive treatment reported pain on treatment. These patients did not receive
any shock waves. I would not place too much stock in the statistics you reported.

Maybe Dr. Z. could comment on his patient's experience with pain?

Re: Specifically, what item(s) are you saying is(are) not true?

john h on 11/17/02 at 11:00 (100504)

Having had 3 or maybe it was 4 Orby treatments I certainly can comment on pain. I had treatments on both feet on each occasion and I think at least 1500 shocks (or was it 3000 Dr. Z) at the Orby setting of 18. The first treatment I received an ankle block. No pain during or after. Remainder of treatments were with no block or med of any sort. The first 10 shock waves produced moderate pain but after that the foot became more or less numb and was basically pain free. Every once in a while the machine would seem to give an extra strong jolt which I would feel but those were very few. If the Epos power is on the same level as the Orby I would really wonder why even get a shot unless you are very adverse to any kind of pain.

Re: ultrasound normal

john h on 11/18/02 at 10:21 (100560)

Dr. Ed: Does the fascia increase or decrease in thickness with age? Does the thickness of the fascia vary with the size of the individual. Would a marathon runner or someone else who was on their feet all day long every day tend to have a thicker fascia? Can you just be a person with a thick fascia for no reason other than you were born that way?

Re: Specifically, what item(s) are you saying is(are) not true?

Dr. Zuckerman on 11/19/02 at 14:19 (100652)

Here is what I have found with pain during the treatment . I use a complete block for dornier epos treatments. This reduces the pain level during treatment to almost zero. What I mean by this is that 48 out of 50 have no pain. The block that was used during the FDA trial is totally lacking for profound anesthesia.

Patients can and do have pain after ESWT. with the dornier. That isn't typial . Most patients never take a narcotic drug for pain post ESWT