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Posted by tammy s on 5/08/03 at 00:43 (118075)

Can you tell me how necessary and ultrasound is in diagnosis, and what I could expect to learn from having one ? Tammy

Re: ultasound

Phil S on 5/08/03 at 06:39 (118076)

With ultrasound the doctor can measure your plantar fascii and determine if it is thickened to the point where it is considered pathological for PF pain. The only therapy device that utilizes it is the Dornier Epos and using it gives the doctor a clear picture of exactly where to apply the therapy for maximum effect.

Re: ultasound

john h on 5/08/03 at 09:45 (118088)

Tammy the Doctors can better address this than me but I looked at the ultrasound as the Doctor was performing ESWT with the EPOS. You could clearly see the fascia but I did not see anything unusual about the fascia in any particular area nor do I think the Doctor saw anything. It was effective in keeping the beam focused in the area where I described the pain as being located. Some Doctors such as Baxter think PF pain in many cases is caused by the fascia pressing on the underlying Baxter nerve. It seems to me ultrasounds main benefit is to direct the shockwave to a specific spot. As to being a diagnostic tool it may be of some benefit but there is a lot more to it than that. Not all Doctors agree on what the pain generator is in PF.

Re: ultasound

Sunny Jacob on 5/09/03 at 05:46 (118158)

You are absolutely right. From our experience and the experience of many in Europe, continuous ultrasound imaging during treatment is of great importance. Only in this way, can the focal point of the shockwave be focused on the pain trigger point within a hairline cross that is continuously visible on the screen during treatment. This exact positioning of the shockwave application can be achieved only by using an in-line ultrasound.
Phil is misinformed. Dornier Epos is NOT the ONLY device that uses ultrasound. There are several other equipments that have ultrasound. The ultrasound of Dornier Epos is not an in-line ultrasound. Sonocur Plus by Siemens provides an in-line ultrasound for imaging during treatment.

Re: ultasound

Scott D. on 5/09/03 at 08:27 (118164)


There is no doubt that the use of ultrasound as a targeting tool during ESWT is an advantage! Not only does it allow you to place the precise area to be treated at F2, but it immediately gives feedback of small movements of the patient's foot once the treatment has been started.

I am very curious however, why you say that 'only' in-line US can do this. From your post, 'This exact positioning of the shockwave application can be achieved only by using an in-line ultrasound.' Have you ever used out-line US? We use in-line US on our kidney lithotripter, and out-line on our EPOS. The structures we are visualizing during US imaging for ESWT are quite clearly identified with out-line ESWT.

I wonder if you can elaborate on your comment for us please?

Re: ultasound

Sunny Jacob on 5/09/03 at 20:13 (118206)

Since you have brought up the subject of lithotriptor and in-line ultrasound, I think it is obvious that for lithotripsy treatment the use of an in-line ultrasound, and not an out-line ultrasound, is advantageous. If initially only an x-ray or even an out-line ultrasound is used to focus on the kidney stone, I am certain that the number of required repeat treatments will increase. This has been proven in some North American centers and a few other countries where in-line ultrasound is not used for lithotripsy.

I am making the same point with my argument about the advantage of ESWT with in-line ultrasound. Yet, to date, the only statistical proof I have is from our own clinic where we use in-line ultrasound for ESWT treatment and, as a result, the number of repeat cases has been kept at a minimum. From the several hundred treatments we did over the past few years we only had one or two repeat cases, whereby one was due to other complications.

In conclusion, it is my opinion that ESWT treatment without any type of ultrasound imaging is like trying to find a needle in a haystack. An out-line ultrasound imaging should be the minimum for performing ESWT. The best option, based on our experience, is still in-line ultrasound. For this reason we use Sonocur Plus which has an in-line ultrasound. The equipment also has an outline ultrasound, but we use this component only for initial assessment. As you have stated, Epos has only an out-line ultrasound.

Re: ultasound

john h on 5/10/03 at 08:06 (118226)

Sunny: My question is what you see with any ultrasound the pain generator? The problem it seems to me is knowing exactly where the pain is coming from and why. Yes, you can focus on what you see but what are you seeing?

Re: ultasound

Ed Davis, DPM on 5/10/03 at 15:15 (118242)


Excellent question!

I have enormous respect for Sunny and would certainly trust him to do ESWT on my foot. Sunny's use of low energy with targeting places his treatment on the leading edge of ESWT for North America. Nevertheless, I must respectfully disagree with his opinions concerning targeting.

There are differing philosophies on the targeting issue and not much solid evidence to show that one means of targeting is superior to others. The origin of the plantar fascia is far from the 'needle in a haystack' that Sunny describes. One either blankets the entire origin of the plantar facia with shock waves (Ossatron method), directs shockwaves to the thickest part of the fascia via ultrasound guidance (Dornier, Sonocur Plus) or direct shockwaves to the most tender part of the fascial origin (Sonocur Basic).

Unquestionably, targeting via inline ultrasound is the most elegant and sophisticated means and, intuitively, sounds the best. There are areas of the body where the target is much smaller so I can see a distinct advantage to inline ultrasound for targeting. On a practical basis there just has not been enough information to convince me of the advantage of one means of targeting over another.

Re: ultasound

Dr. Z on 5/10/03 at 16:33 (118250)

We do all three when we use the dornier. Palpation determines the areas to be treated or confirms the area needed to be treated . The ultrasound allows the doctor to keep the focus of treatment at all times in the area that is most tender.
I find you should use all three methods
Patient feedback
Ultrasound confirmation in addition to keep the target area at all times in the field of treatment

Re: ultasound

Paula A on 5/10/03 at 18:32 (118259)

In your message you mention the Ossatron, Dornier and the Sonocur Plus.
I had an Ossatron treatment done in Dec. which failed. I was hoping to have a Dornier treatment soon but negotiations about the fee schedule
at my surgi-center has stalled. You mentioned the Sonocur Plus. My administrator has been unable to locate a Seimens Sonocur Plus website and neither have I. I don't even know if it even available in Pa. Could you help? Also, what are you post treatment dischage instructions? My orthopod
basically followed what the tech with the Ossatron advised which was say off the NSAID's and I could go back to work the next day. I stand 8-10
hours a day.

Re: ultasound

Dr. Z on 5/10/03 at 18:49 (118261)


This is Dr. Z . The problem with locating a Soncur Plus is that it is only in Canada. There are Soncur treatment sites in the USA. Dr. Ed being one of them . The Soncur isn't FDA approved for Plantar Fasciitis in the USA.

Where in Pa do you live? We are across the border in New Jersey and we use the Dornier Epos Ultras. There is no reason to have a Dornier Treatment in a Surgical Center. We have done well over five hundred in our mobile treatment site and in physician offices.

Re: ultasound

Dr. Z on 5/10/03 at 18:52 (118262)

Try use a seach for Soncur or Sonnex for information about the soncur. I will try to find it for you.

Re: ultasound

rob a on 5/11/03 at 07:29 (118280)

I have used both in-line and out-line ultrasound in lithotripsy and have found that they both work equally well in targeting kidney stones. I would think that it is probably the same with ESWT. The main difference is the person using the equipment. Some people would want you to believe that there is a difference but no one can give you any clinical studies that compare the two methods so it is a difficult statement to back up. Overall, having the ability to image is a good thing because you are working in a small area. If the patient moves at all, you have the means to know where to reposition exactly where you were before.

Re: ultasound

Dr. Z on 5/11/03 at 08:33 (118285)

I agree. Patients do move and the best way to discover this is via the ultrasound viewing. So if you do have the opportunity to use an ultrasound you use. The only study that I can compare with and without ultrasound is the FDA one year follow-up study which showed the dornier had a 94% success rate compared to the ossatron having 81% success. There were poor results with the ossaton with two pf tears reports months down the road. There were no poor results with the dornier with this study. The definition of success was defined as excellent or very good pain relief. Excellent meant no good with any activity . Very good was defined as very little discomfort in any activity. This is called the Roles Maundsly scoring

Re: ultasound

Sunny Jacob on 5/11/03 at 09:43 (118296)

I do not think it is appropriate for us to take the valuable space on this message board to debate about lithotripsy and outcomes using in-line/outline ultrasound, X-ray imaging, etc. If you are interested, please send me your email address. I can send you references on this subject published by internationally recognized scientist.

Re: ultasound

Sunny Jacob on 5/11/03 at 09:45 (118297)

Thank you for Ed's message and John's question.
Ed, I equally respect your opinion and contribution to this message board. You are right; some of your and my ESWT philosophies may differ, specifically with regard to the large and small focal area.
Please note that when I write on this message board about ESWT it applies to all types of joint tendonitis, including PF. I am a firm believer of directly treating the most tender area (pain trigger point) in multiple sessions, rather than using equipment with a large focal area.

John, such tender areas or pain points cannot be initially seen on an imaging equipment or measured with an electronic device. It requires an experienced therapist with a lot of patience. First, ESWT test shocks are applied and with the patient's help the tender point (or points) are identified. This point is marked on the skin. Then the shockwave head is aligned to this point (in our case with an in-line ultrasound imaging).

If we identify two separate tender points on a tendon or fascia, each point receives the shock application separately. This requires double the treatment time. Since both are on the same joint, we do not bill this as two treatments.

Re: ultasound= Sunny

Dr. Z on 5/11/03 at 11:03 (118304)

I have a question and something I will like to try. How about starting with low energy with the ultrasound in place. You determine the patient feed back areas and then MARK the ultrasound picture and use that area to concentrate on treatment. I haven't try this yet but my feeling is that the ultrasound marking and the skin marking should work out the same for positioning purposes. What is your take on this one.

Re: ultasound

john h on 5/11/03 at 11:36 (118320)

Sunny: You provided me with info I had never heard. That you apply several shocks initially to help identify the tender area and then use this as a basis for aligning the ultra sound. This makes sense to me. Dr. Z when using the Orby used thumb pressure to identify the tender area but did not have the luxury of ultra sound to keep the Orby aligned on the spot. Thanks.

Re: ultasound

Paula A on 5/11/03 at 19:23 (118352)


I'm located southeast of Pittsburgh. The surgi-center is the only place on this side of the state that offers eswt treatments. Also what post treatment activity/therapy/pain med/foot exercise do you recommend. Somehow the suggestion it was ok to go back to work the next day wasn't very prudent advice. Maybe that was a contributing factor to my failure.
The next time I have this treatment I want to have as much knowledge as possible to make my outcome a success. I fear the thought of having an EPF.
I find it very interesting that you have done over 500 cases from a mobile
unit. I'm sure you have done outcome studies on these cases. It would be interesting to know the results. Just like to mention this side of the
state is an open market.

Re: ultasound

Dr. Z on 5/11/03 at 20:07 (118359)

Did you have any improvement with your first ESWT treatment. Sometimes you need a 2nd treatment. Activity levels post ESWT treatment will vary. Most patients can return to work. I can understand wanting to know as much as possible but the fact is that some will need a 2nd ESWT treatment.
Some patients won't get better. The outcome FDA results were better with the dornier.

Re: ultasound= Sunny

Sunny Jacob on 5/11/03 at 20:20 (118361)

I don't see any reason why it shouldn't work. One can do the test shocks with low energy and, using the patient's feed back, concentrate on the tender spot. We find that test shocks are an ideal way to identify pain trigger point/s.
From our experience, one cannot depend on the manufacturer alone to obtain all the nuances of the treatment protocol. Their interest is getting approval from the health authorities and sell. As you might have seen from your experience, one has to come up with one's own refined methods through years of clinical experience and exchanging ideas.

Re: ultasound

Scott D. on 5/12/03 at 08:26 (118387)


Actually 85% of our ESWL cases are done exlusively with x-ray imaging (which is FAR superior to US in that modality). While this is not the forum to discuss ESWL, my point was in referencing the targeting systems of in-line vs. out-line US and it's applications to ESWT. For anyone familiar with viewing US images, the out-line US on the EPOS is MORE than adequate for presise targeting. Could the in-line be better? I'm sure that is possible, but I am also sure that it isn't necessary for the task at hand. A scientific analogy.. If I wanted to look at the cellular structure of onion skin I could see all I needed to with a $50 microscope and some stain. While it would be pretty cool do do it with an electron microscope, it just wouldn't give me any more information. Out-line US imaging for ESWT gives a clear visualization of the structures we are looking for. That is all it needs to do.

Re: ultasound

Ed Davis, DPM on 5/12/03 at 14:15 (118430)

One must go to Canada for the Sonocur Plus. The Sonocur Basic, which is one of the machines I use is available tin the US.

Re: ultasound= Sunny

Ed Davis, DPM on 5/12/03 at 14:20 (118431)

Dr. Z:
I have had a few patients who had difficulty tolerating even the low energy Sonocur. This is uncommon though.

I have had to deliver a medial calcaneal block, wait about 5 minutes, then start the Sonocur treatment. The patient is still sensate after 5 minutes so we can still locate the area of maximum tenderness. Once located, we keep our aim, then can increase energy levels as the anesthesia gradually sets in.

Re: www.sonorex.com

Ed Davis, DPM on 5/12/03 at 14:23 (118432)

Check out http://www.sonorex.com

When you are on the site, you may click on the section for Canadian residents since official FDA approval for PF marketing does not exist in the US yet.

Re: www.sonorex.com

Ed Davis, DPM on 5/12/03 at 14:26 (118434)

By the way, it still rankles me that a government agency can limit freedom of speech -- an entity gauranteed by our constitution. One should not have to click on 'non-US' citizen to be allowed to read the facts.

Re: ultasound= Sunny

Dr. Z on 5/12/03 at 15:20 (118446)

Boy are you correct.

I have found with almost any procedure that I have learned I had to adopt
and adjust and refine these procedures so that they worked in my hands

Re: ultasound

Paula A on 5/13/03 at 19:35 (118616)

I had bilat ESWT. My left foot is 100% cured. My right foot 0%
For about 9 days my right foot was decreased in pain level from
7 pre-op to a 3. Then it all returned and then some. Multiple stretches and ice during the day is no longer helping me get through a work day.
Even after morning stretches I still stumble with severe heelpad pain.
I walk with a limp and now have ankle and calf pain. Then to boot I received my insurance statement. My company paid Ossatron @100% per foot.
This doesnot include the facility fee, Anesthesia fee and the orthopod's fee that was already paid. Never the less I feel I need another treatment.
What can I do in the meantine until the facility resolves their reinbursment issues.

Re: ultasound

Dr. Z on 5/13/03 at 20:24 (118622)

This is a very common problem with the ossatron model of treatment. I will have a frank decussion with your orthopedic doctor. Maybe the doctor, and the company will either drop or reduce their fee. What is the problem with the facility fee?

Re: ultasound

Paula A on 5/14/03 at 18:06 (118762)

Ossatron does their own billing to which they in turn pay the facility
a set fee. This is where the hold up is. Reinbursment is better if the company does the billing then the facility. There is a remarkable difference. Once again insurance companies are getting in the way of heathcare.