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ESWT for insertional AT

Posted by Alex on 2/17/03 at 13:45 (109495)

Does anyone have any experience with ESWT for achilles tendonitis with a bone spur? I had surgery that detached my achilles, sawed off the spur, and then reattached... I have a couple of screws in there - can ESWT be done if you have screws in your heel?

Basically the surgery neither hurt nor helped (although the recovery time was brutal and long) - I think it was a mistake as the pain I have is still the same kind as before the surgery. I was a competitive runner and would like something that could get me back on the roads.

Re: ESWT for insertional AT

Ed Davis, DPM on 2/17/03 at 14:08 (109500)

Alex:

There are several issues to consider.

1) ESWT appears to work for achilles tendinitis. It is an 'off label' use so insurance reimbursement may be difficult to obtain for that. Dr. Z has more experience in that area and may join in soon.

2) Pain at the attachment of the achilles to the back of the heel bone is generally caused by too much side to side motion at the bone-tendon interface.
a) The manner in which the achilles is re-attached can be a factor.
b) An orthotic with a rearfoot post may be needed to decrease side to side motion.
c) a tight gastrosoleus achilles complex can be a problem -- has that been looked at or dealt with?
Ed

Re: ESWT for insertional AT

Dr. Z on 2/17/03 at 14:10 (109501)

I have alot of experience with ESWT for insertional Achilles tendonitis. It is a very effective procedure. I have many patients that have avoided the type of achilles tendon surgery that you have gone thru. We use the dornier epos. If you want additional information about our ESWT program just e-mail Dr. Z at (email removed)

Re: ESWT for insertional AT

Dr. Z on 2/17/03 at 14:11 (109502)

good points to consider Dr. Ed

Re: ESWT for insertional AT

Alex on 2/17/03 at 16:52 (109534)

Thanks for the replies, Dr. Ed and Dr. Z!

Do you know if ESWT is possible w/ the screws in or do I need those removed first?

I'm not concerned about the insurance reimbursement as healing is more important than the cost for me.

I've been a runner my whole life and was able to tolerate quite a bit of running at one point with no memorable pains at all (in the 60-80 miles/week range).

Tried before surgery:
1. Physical Therapy (gastroc/soleus stretching, balance work, general strengthening/stretching)
2. Time off/reduced mileage.
3. Orthotics, heel lifts, etc.
4. Every type of desperate attempt to keep running (i.e. glucosamine, massage, rolfing, etc.)

The surgeon said that I had more build up than he thought pre surgery. He didn't think he'd have to detach it fully, but ended up needing to because I had such a sizable spur. I was in a cast for six weeks (4-5 with no weight bearing at all), and then very, very slowly getting back into stuff. He thought I'd be able to run at three months, but I felt a little discomfort, so I chose to not really go back to running yet.

At about 5 months out, I tried running about once a week with moderate discomfort. Now I'm about 8 months out and can still only really run once or twice a week with moderate discomfort.

Basically, I want to be able to start running using any rehab possible to get back quicker. I'm definitely no pro-athlete, but running was a huge part of my athletic life and I would devote insane amounts of resources/time to get back to it... But I don't want to run a lot again until I can do it without damaging myself, so if ESWT gives me a shot of getting that tendon a little bit stronger, I would love to give it a shot.

How off-base are my hopes? I've pretty much faced the music that my tendon performance may never be normal again, but does ESWT offer some true healing as opposed to just pain reduction? The pain is not a daily problem if I don't run, but the tightness/pain come with increase in activity.

Thanks in advance for your advice :o)

Re: ESWT for insertional AT

Dr. Z on 2/17/03 at 18:08 (109545)

Eight months and running twice each week is not bad at this stage of healing. It can take a very long time for surgery on the achilles tendon,sometimes up to one year.to finally heal. ESWT will stimulate healing if in fact it has stopped. An ultrasound and or mri would be helpful. Screw are fine and don't need removal
ESWt will heal insertional achilles tendon in a patient that has not healed at the insertion. We need to determine if that is your problem.
So on a scale of one to ten how is your pain level?

Re: ESWT for insertional AT

Alex on 2/17/03 at 18:25 (109549)

Hi Dr. Z,

Running is about the only thing I do that causes a decent amount of AT pain at this point... I can still work out a good amount (an hour+/day) and find no AT pain from either the bike or rowing machine and low-moderate pain from an elliptical trainer.

From running, I feel far more tightness than pain. I would have an obvious limp if I either ran hard or ran two days in a row. The evening after a run I can't walk easily without shoes (i.e. a lift on me heel). Same is true for the next two or so mornings...

But, to be honest, I purposefully make it so the pain is not very high. The function is low (tightness), and the pain would get very high if I tried to do any of the workouts I miss so much (intervals/hills/tempo runs) but I've been avoiding any additional stresses on it.

So, to answer your question: pain a couple hours after a run: 4-5. Pain without having run for 2-3 days: 2... Pain after not having run for 7-10 days: 0.

As you can see, I can do most things and a lot of people would count their blessings for the activity level I can do... However, if you think ESWT would speed things along at all, I would want to do it just to get out there quicker. I'm also I guess just a bit worried about my recovery because the pain/tightness I do feel is so similar to the pain/tightness I had before the surgery.

Thanks again for your interest and responses!!

Re: ESWT for insertional AT

Dr. Z on 2/17/03 at 18:31 (109552)

Here is how i would evaluate this. It there is pain on palpation at the center of the insertion of the achilles tendon and the ulrasound was postive for thickness, and fluid then I would recommend ESWT for you. I am also assuming that there is no ankle arthritis restricting motion. I doubt this, due to your other levels of activity

Re: ESWT for insertional AT

steveb on 2/18/03 at 17:22 (109721)

alex,

i too have AT. i had eswt in vancouver, canada last june. 3 treatments on a sonocur (us$600). i've also been using a night splint (nice'n stretch). i still have pain in my heel, but i guess it's less than before. i'm able to run for about an hour with only minimal pain, but it starts to act up after that. i could probably use more treatments, and may do so later this spring (after the soccer season is over, they recommend 6 weeks of only mild activity after the treatment). the night splint has relieved the morning pain, but, after wearing every night for 5 months, it's getting a bit annoying.

after all that, i guess i would recommend it. it's doesn't hurt (maybe a little during the treatment), and it's relatively inexpensive.

Re: ESWT for insertional AT

Dr. Z on 2/18/03 at 17:43 (109723)

It is a great procedure. We use high energy at the insertion. Have had very good results for the past three years.