OsatronPosted by Lori W. on 7/12/03 at 14:19 (124229)
Two years after diagnosis and trying just about everything; orthotics, stretches, anti-inflammatories, icing, night splint, 3 cortizone shots, my pod is down to another cortizone shot or Ossatron (which my insurance hasn't approved, by the way). I don't like either of these options. But after reading, I am wondering about the difference between ESWT and Ossatron. He says it is a higher level and requires only 1 treatment as opposed to several. He also says he has about an 80% effective rate. Can anyone help me with this information?
Re: OsatronDr. Z on 7/12/03 at 14:34 (124234)
The ossatron is the name of the machine that is used to perform ESWT. There are two FDA high energy ESWT machine approved in the USA . The dornier and the ossatron. There is alot of information on this site about ESWT. We have used ESWT for over four years with very effective pain resolution using the dornier epos ultra. This is the only ESWT machine with ultra-sound that actually sees the fascia as the shockwaves are introduced into the damaged non healing fascia insertion.
Feel free to ask any questions that you may have about ESWT and I will be very happy to guild you to a decision that is best for you. On another
note too many local steriod injection can rupture the plantar fascia. There is an article on this site . Look in the journal section
Re: OsatronPeter R on 7/12/03 at 18:03 (124263)
Select treatment with the Dornier Epos Ultra. With he Ossatron you will usually need IV sedation and will have no ultrsound imaging. Would you let a blind surgeon operate on you??
Re: Osatronjohn h on 7/12/03 at 18:08 (124264)
Actually when a Doctor cuts your fasica he is operating 'blind': most of the time as he generally does it by feel if Dr. Z is telling me the straight skinny.
You can see the fasica with the ultrasound but what you see is not necessarily where the pain is coming from. Many people's fasica will appear perfectly normal. You can keep the beam focused on what ever spot you select but the quest dear Watson is which spot?..
Re: OsatronLori W. on 7/13/03 at 00:23 (124289)
Thanks for the input. I will definitely do some more reading on the subject and come back with questions.
Re: OsatronPeter R on 7/13/03 at 09:11 (124298)
If the plantar fascii appears normal, 3-3.5 mm, then the patients does not totaly fit the protocall for treating insertion chronic PF with ESWT. These patients, in my opinion, will not respond as well and the effectivness of the modality will be compromised. This will result in more insurance companies having an excuse not to cover the treatment. ESWT is a wonderful modaility but it will not resolve every pain in someones foot.
Re: OsatronDr. Z on 7/13/03 at 10:08 (124300)
When the surgeon is using the minimial incision technique he is cuttting the fascia by feel not by sight. As for ultrasound guildance eswt. Besides seeing the fascia you can tell if the patient has moved away from the area you want to treat. So you visualize the area that you have the shockwaves
placed. With the ossatron you treat both normal and abnormal areas.
Re: OsatronPeter R on 7/13/03 at 13:32 (124318)
I'll repeat what has been ignored- Without Ultrsound or MRI Imaging you have absolutly no idea if the Plantar Fascii thickness is pathological for Plantar Fasciitis. You are simply treating a pain. ESWT without Ultrasound or radiological imaging should never have received FDA approval. As far as doing minimal incision surgery without imaging- would anyone here let an orthopod due a lateral release or ACL repair without a scope. Or how about some spinal surgery without any imaging- who's up for that technique.
Re: OsatronDr. Z on 7/13/03 at 14:25 (124325)
Good point about making sure there is pathology with the plantar fascia before ESWT is performed.
Re: OsatronLori W. on 7/14/03 at 13:10 (124396)
OK then, well, here's my question. How do you find a Dr. that does this? My Dr. did use an ultrasound to administer my last shot, but said nothing about measurements, only that there was a lot of inflammation. He's light years ahead of my last Dr. who told me he would give me 3 shots and then cut it. But at the same time, I live in an area where there is not a great pool of expertise to draw from. So either I need to find a new Dr. and barring that, is the Ossitron better than nothing (assuming the protocal is met)?
Re: TO Lori W :Re: OsatronPeter R on 7/14/03 at 13:37 (124403)
If you post your e-mail I'll get you to a very competant DPM who has access to the latest technology. I prefer not to do this in this forum.
Re: OsatronDr. Z on 7/14/03 at 14:01 (124407)
If your doctor has an ultrasound machine I am sure he has determined that you have plantar fasciitis. I can't give you personal experience with the ossatron however that it is has been used for some time and has completed FDA approval for Chronic insertional plantar fasciitis. ESWT is a much better choice then any type of foot surgery. Discuss your plantar fascia findings with your doctor. Feel free to ask any questions you may have about ESWT, ossatron, and or the dornier.
Re: Osatronjohn h on 7/14/03 at 15:16 (124415)
Does the thickness of the fascia vary with age? Does the thikness of the fasica vary with the size of the individual? Would the thickness of the fasica vary between a profession athlete such as a runner, power lifter, or basketball player and an office worker? Does the thinkness of the fascia rule in or rule out patients in the treatment of PF based on FDA rules. Does an inflamed fascia necessarily have to be thick? Who sets the standard for what the norm is for the thickness of the fascia. We have many people with PF pain and no heelspurs and many people with heelspurs and no pain. With all Doctors not even agreeing on the the cause of heelspur pain it would seem arbitrary to rule out all people for treatment with ESWT who do not have a fascia of a certain thickness. No one can say with scientific certainity what the pain generator is in PF pain for a specific individual. Could it be the Baxter Nerve as suggested by the highly regarded Dr. Baxter. Could it be an anxiety problem as suggested by Dr. Sarno? Could it be an inlfamed fascia which is the commonly accepted theory? Could it be TTS? The primary question remains to this day and that is what is the Pain Generator for people who are diagnosed with PF? You anwer that question with scientific certainity and a cure is in sight.I still suggest that saying you have Plantar Fasciatits or Heel Spur Syndrome is like saying you have Cancer.Many kinds with many different treatments and many different outcomes. From reading this board almost from the begining you get a sense that people who seemed to have found a cure have found it in many different ways. I do not see a predominant common thread among the many who have posted that they finally were cured. Many may have just got well over time while others have offered their many different reasons for getting well.
Re: OsatronEd Davis, DPM on 7/14/03 at 21:21 (124435)
Unfortunately there is no definitive information correlating plantar fascial thickness and pathology. There is a supposition that plantar fascial thickness correlates to poor tissue quality although the data is far from complete and there may be other measures of poor tissue quality.
There are numerous procedures performed without complete or with partial visualization of structures.
Re: controversiesEd Davis, DPM on 7/14/03 at 21:34 (124437)
Take some time to peruse this board and go back in history here for a while, possibly doing search. There are a number of controversies in the ESWT area: ultrasound imaging vs. no imaging, the importance of plantar fascial thickness, high vs. low energy....
Keep in mind that none of these issues has been resolved. As such I have taken a position to support all of the technologies out there until there has been enough evidence to show the superiority of one over the other. The current situation is that the availability of ESWT is very small compared to the need so it is not time yet to start avoiding certain machines or technologies until substantially more information is out there.
Re: OsatronDorothy on 7/14/03 at 22:17 (124442)
Well said, John H. I agree with you completely.
Re: controversiesDr. Z on 7/14/03 at 22:41 (124445)
I do think we can all agree that if there is a choice between ESWT and plantar fascia release that ESWT should be the treatment of first choice
Re: controversiesEd Davis, DPM on 7/15/03 at 00:25 (124453)
You, I , most readers on the board, but only a few health insurance companies to date. It is just a matter of time. It is interesting to talk to some of the people who pioneered renal lithotripsy as they ran into similar resistance. It was, in part, the legal system that was influential in that arena. The morbidity rate for surgical excision of kidney stones was quire high. When a number of patients with complications found out they could have had lithotripsy instead the lawsuits started flying.
Re: controversiesPeter R on 7/15/03 at 06:26 (124455)
Unfortunatly for those who suffer from PF the insurance bandits will never provide any significant coverage for ESWT. While it is a viable alternative for surgery they see it costing them more because many more patients will opt for ESWT over surgery. The situation is different than with ESWL because there are no cases of people having anywhere near the complications from PF and surgery vs having kidney stones and surgery to remove them. I believe it will classified as an elective procedure. Just take a look at how much they have reduced what they are paying for the surgery and you'll see the future for ESWT coverage.
Re: controversiesEd Davis, DPM on 7/15/03 at 10:09 (124460)
Good points, although once ESWT has been firmly established as the 'standard of care,' insurers will have a harder time denying such treatment. Insurers do pay for elective procedures that are 'medcally necessary.' Unfortunately, we let the insurance companies determine what is 'medically necessary' and that really needs to change.
Another scenario is that coverage is extended by insurers but at a rate that discourages use of the modality. That, at times, can be worse than no coverage at all. A good example of this is my local Blue Shield carrier, Regence. They provisionally covered ESWT as of about Nov. 2002 but then retroactively insisted that all the procedures needed to be performed by the Ossatron, the most expensive technology. They reimbursed the procedure at below the cost of the procedure so the Ossatron owners refused to allow their machine to be used for Regence patients as of Dec. 2002. Providers, by contract, could not charge the balance and,as such, the procedure could not be done.
Re: See my post below ... "why did my doctor not tell me about...Ed Davis, DPM on 7/15/03 at 10:42 (124467)
Peter, Dr. Z and everyone else:
I am surprised that I got no repsonse to the post on doctors revealing treatment options below. I feel that that is the crux of what is happening with ESWT at this point. Providers, at times, chose to take the 'path of least resistance' and that means going with what a patient's insurer covers...
Re: See my post below ... "why did my doctor not tell me about...Dr. Z on 7/15/03 at 11:21 (124472)
I didn't know what to say. It is true that some insurance companies are falsely stating that they cover ESWT when in fact they pay below cost and make it impossible for equipment vendors to supply the equipment.
Re: controversiesDr. Z on 7/15/03 at 13:26 (124483)
I have talked to some of the ESWL centers who started ESWL in 1985. Medicare started paying from day one. Dornier had everything in place. They were paid somewhere in the five thousand dollar range. As medicare covered this procedure so did the rest of the major insurance groups. ESWL had a much easier beginning then ESWT has had.
Re: controversiesEd Davis, DPM on 7/15/03 at 14:24 (124487)
Interesting. Much of what I had said came from my conversations with the people at United Shockwave, since they were involved in both areas.
I do like their gung ho attitude. We just did ESWT on a worker's comp. patient where our state carrier refused payment. They have the ability to absorb some losses that we, as individuals would have a hard time doing.
They have machines in states which are getting well reimbursed to counter the more difficult states. Lots of regional variability -- good ESWT coverage in Rhode Island, for example. Werber, one of the authors of the upcoming study I mentioned previously practices there.
Re: controversiesScott D. on 7/15/03 at 16:27 (124493)
Not sure who you talked with on that one but it is totally offbase. ESWL has never been covered by Medicare to any provider other than a hospital! Still isn't to this day, although there is hope of that changing sometime soon.
Re: controversiesDr. Z on 7/15/03 at 16:38 (124494)
I got my information from the stone center in New Jersey. They received the first ESWL machine in New Jersey from Dornier back in 1985 I though that Werber used AKMS-orth. I guess he switched. I am really getting some great results. Yesterday all six of my cases are pain-free today and back at work.
We have no problems with work compensation, United Healthcare and unions. It is Horizon Blue Shield that is difficult. I may be able to resolve the Horizon problem in the near future.
Re: controversiesScott D. on 7/15/03 at 16:58 (124499)
The Stone Center is a great facility and they were a huge help to us when we opened in 1989! They are also, as you know, part of UMDNJ and that is how they get reimbursed from Medicare. There is no coverage for free-standing facilities under Medicare.
Re: controversiesjohn h on 7/15/03 at 17:26 (124504)
Having had a kidney stone and ESWL and PF and ESWT I would opt for ESWL everytime. I can think of no pain to compare with a kidney stone. If some person in a 3rd world country had a kidney stone and could not pass it I would think he would die from the pain. Probably not a lot of decison makers have had PF so do not really understand how it effects people. After all how bad can a sore foot be???????? Some of those people in the FDA or Congress may have had a kidney stone and will not likely forget it in a lifetime. Of course the outcome of ESWL is very measurable not only by the lack of pain but with x-ray or mri as the stone is gone in short order. ESWL was one great invention and is better than sex or a dry martini.
Re: controversiesLori W. on 7/15/03 at 18:23 (124507)
Better than sex? Sign me up! You make a good point about decision makers. I think many podiatrists don't even understand the pain involved.
Re: controversiesEd Davis, DPM on 7/15/03 at 19:53 (124513)
That is an interesting fact. There have always been a number of procedures (although not ESWL) that could have been office based but were taken to hospitals because Medicare would not cover costs if done in the office. Some of the financial problems of Medicare are related to politically based decision making.
Re: controversiesDr. Z on 7/15/03 at 20:19 (124516)
That is very interesting. I had no idea. I was really impressed with the quick medicare coverage that they talked about one day when I was negiotating ESWT with them
Re: controversiesScott D. on 7/15/03 at 20:58 (124520)
The history on this is that Medicare proposed a rate years back for ESWL to be done in ambulatory settings. The American Lithotripsy Society (ALS) challenged the rate because HCFA had not done the appropriate number crunching to arrive at the rate. In doing such they did a cost analysis themselves of all of the lithotripsy centers in the country and presented the data in court. The bottom line is that the ALS sued HCFA and won! Not once, but twice (they also successfully challenged inclusion in Stark II when Pete Stark had specifically excluded lithotripsy on the floor of Congress).. HCFA, still holding a grudge, has refused to allow ESWL to be reimbursed by Medicare outside of a hospital setting.
Re: controversiesjohn h on 7/16/03 at 08:40 (124530)
Scott: When I had a kidney stone and was rolled into the lithotripsy room at the hospital the urologist was on hand to first make an attempt to see if he could grab the stone out of the ureter with his scope. that failed so he pushed the stone back into the kidney and the radiologist I assume proceeded with the lithotripsy.. Would all this be appropriate out of a hospital setting? I have not idea just inquiring. It seems for this procedure you need a radiologist, anathesiologist, and a urologist and a nurse so I assume you need a good sized clinic at the minimum to offer this out of a hospital setting..
Re: controversiesScott D. on 7/16/03 at 09:36 (124531)
Very true! There is substantial equipment and staff needed, though not all ESWL Centers offer cystoscopy and/or ureteroscopy.
Re: controversiesjohn h on 7/16/03 at 10:39 (124537)
Scott: Just for information purposes I think the actual billing for the hospital,urologist,radiologist and emergeny room was on the order of $12,000. Medicare of course cut that in half as I recall. Is there some reason that kidney stones occur after midnight of Friday when all the regular staff and Doctors have disappeared????????? As you know when you go to an emergency room now they really check you out before they will prescribe drugs. My daughter works in the emergency room and says the drug addicts have the symptoms down pat for kidney stones in an attempt to get drugs.
Re: controversiesScott D. on 7/16/03 at 10:55 (124538)
It does seem that way sometimes.. and while they may have the symptoms down pat often the drug of choice for the docs is torodol, which is a non-narcotic. Terribly disappointing for those feigning a stone attack to get drugs I'm afraid.
Re: controversiesjohn h on 7/16/03 at 11:55 (124546)
They ended up putting me on a morophine drip which stopped the pain.Looking back I think this just relaxed me and allowed the ureter to stop the spasams. As the Doctor later explained my pain was coming from the ureter being in spasm. I had thought the pain was caused by the barbed stone. You will enjoy this. I had never had a kidney stone but had read enough to know that my pain had to be from a stone. It was midnight Friday. I tried the strongest drugs I had in the house which did nothing and then made the fatal error of trying a TENS unit. I placed the pad over the kidney area and with a ureter in spasam an electrical impulse just upped the pain level. Bad bad move.I lasted about 2 hours and then told my wife it is emergency room time while I was still conciouus.
Re: controversiesScott D. on 7/16/03 at 12:33 (124548)
Sorry to hear of your troubles with your stone. They have proven to be a terrible experience for many people. Luckily it is usually over and done with in a relatively short period of time unlike PF. Speaking of which, we had better get back to ESWT before we get scolded! If you want to talk more on this though, feel free to email me!
Re: controversiesDr. Z on 7/16/03 at 13:38 (124553)
I still remember my first stone. Thanks for the IV drug Dilaudid. All I remember is telling the doctors I have a stone. I am dying please get some Dilaudid in me. I am dying. Well after all kinds of tests. They finally give me my dilaudid. The worse pain I ever had except for the time, my wife hit me for being late for an anniversity diner.
Re: controversiesEd Davis, DPM on 7/16/03 at 14:17 (124559)
Thank you. More interesting history. Pete Stark pretends to be the 'champion' of the patient -- I wonder where he was coming from on that one?
Re: controversiesBrianG on 7/16/03 at 17:10 (124569)
John, putting that tens unit right over the stone sounds kind of kinky to me. What other S&M stuff are you into? :*)
Re: controversiesjohn h on 7/16/03 at 17:45 (124572)
Brian if that is what S & M is all about then I know why I never engaged. I do not like to admit this Brian but the pain was really bad and I was trying anything I could think of. I could not stand still and at midnight I was walking around in circles in my back yard. Finally I resorted to standing on my head in the living room thinking that might dislodge the stone. I wish I had a video of the events of that night. It is funny now but sure not funny then. I read about people who develop hundreds of kidney stones. I know that all stones do not cause the pain I experienced but how does one survive hundreds of stones. You sure would not want to be a pilot in a fighter and have one of these babies activate on you. I think I would put the aircraft in a dive and make a 10 G pullout which is about all the body can take. This might actually work. ummmm! new form of treatment.If a pilot develops a kidney stone in the military your flying days are over. You are permenently grounded.
Re: controversiesSummerA on 7/17/03 at 07:42 (124611)
I have had multiple orthotics, cortisone injections, tapings, anti-inflammatories, and bilateral plantar fascia release. The release was done 2 years ago and I am having as much pain as before the procedure. I am thinking of trying ESWT as a last resort. Would its effects be lost if the release had already been completed?
Re: controversiesjohn h on 7/17/03 at 10:10 (124620)
Summer: i had a PF release on one foot and posed that question to Dr. Gordon in Canada. He is a very experienced surgeon who performs a lot of ESWT using various machines. He recommeded the Ossatron for a person who had previous PF surgery. He told me that because of scar tissue he thought this machine would be more effective. He also uses the low power machine for ESWT for somone who has not had sugery.
Re: controversiesSummerA on 7/17/03 at 10:29 (124625)
John: Where does Dr. Gordon work? I was thinking of trying Painfree ESWT in Toronto, but I am not sure they use the Ossatron? So have you had the Ossatron done?
Re: controversiesjohn h on 7/17/03 at 12:28 (124636)
Summer. I think he has a private practice in Toranto. He was a consultant to Bayshore in Toronto and may be affiliated with Pain Free. Sunny who frequents this board should have his phone number. I may still have it. Do a search on this board under 'Dr. Gordon'. He did a number of ESWT for people on this board before it was FDA approved in the U.S. and has presented papers to ESWT conventions in Europe. He is an Orthopedic Surgeon so should be easy to find.
Re: controversiesEd Davis, DPM on 7/17/03 at 14:05 (124643)
A number of practitioners including Dr. Z have used ESWT after failed plantar fascial release surgery.
Re: controversiesDr. Z on 7/17/03 at 15:03 (124648)
Hi Summer A
We have used ESWT with very effective pain resolution. The key is make sure that we are still treating insertional plantar fascia and not some other problem such as nerve damage. Be happy to have you speak with some of our patients that we have cured after failed insertional plantar fasciitis surgery
Re: controversiesSunny Jacob on 7/19/03 at 10:25 (124783)
Dr. Gordon can be reached at (email removed)
Re: controversiesjohn h on 7/19/03 at 11:31 (124791)
Thanks Sunny. Where does he practice his ESWT now?
Re: controversiesSunny Jacob on 7/20/03 at 08:46 (124824)
To the best of my knowledge, Dr. Gordon presently works as an orthopedic surgeon at the Osler Health Centre, Etobicoke (Ontario) hospital campus. My last information is that he schedules patients a couple of times a month in his private practice (outside the hospital) for ESWT with Ossatron. However, to confirm the latest information please contact him directly via the email address provided.
Re: controversiesSunny Jacob on 7/20/03 at 08:49 (124825)
P.S.: Please also see the information in the treatment location listing on this website, location ID # 13.
Re: controversiesSummerA on 8/06/03 at 12:01 (126394)
Thanks for that information. I just saw the doctor that did my surgery and he was very disappointed with the results of the release. It was done two years ago.