ESWT instead of injectionsPosted by Toni on 8/13/03 at 20:43 (126894)
I am due to see an orthopedic doc. tomorrow for my right knee and right foot which I think may have plantar fascitis. After reading all about injections and how horrific they are it is the LAST thing I want done. Do doc's ever go to ESWT without trying the injections, especially if you have tried all the various other treatments?
Re: ESWT instead of injectionsDr. Z on 8/13/03 at 21:06 (126897)
Yes you can skip the local injection treatment and go to ESWT. Local steriod can be very helpful in alot of patients however they do have side effects including pain during and after. If isn't unreasonble to want ESWT done
Re: ESWT instead of injectionsToni on 8/13/03 at 21:35 (126902)
Well especially too, (pain during insertion aside), after reading through this website and the controversey over the amount of fascia rupture that occurs with steroid injections and susequent sequalae from it, I really don't want it done, but wonder how many insurance companies would require it first before they would okay ESWT.
Re: ESWT instead of injectionsDavid on 8/13/03 at 23:39 (126913)
The insurance companies/medicare states that cover ESWT generally want a number of conservative measures tried first before a patient has ESWT. It would then be approved after failure of usually 3 of the following: rest, ice, orthotics, NSAIDS, steroid injections.
As an example, see the Blue Cross/Blue Shield of North Carolina policy at
Re: ESWT instead of injectionsDr. Z on 8/14/03 at 15:07 (126946)
But a steriod injection isn't a requirement
Re: ESWT instead of injectionsEd Davis, DPM on 8/14/03 at 16:55 (126958)
There is a time and a place for all treatments. There are times when injections are very helpful. They certainly are not horrific. Unfortunately there are doctors with poor injection technique who give painful shots. Such injections do not need to be painful and are not if done with care.
Re: ESWT instead of injectionsDr. Z on 8/14/03 at 20:05 (126974)
Still there is no reason why a patient can't have ESWT without ever having a local steriod injection There is no standard that I am aware of that states you must undergo steriod injections. Is there any standard. Especially if we are talking about a fasciosis and not fasciitis
Re: ESWT instead of injectionsEd Davis, DPM on 8/14/03 at 20:43 (126981)
I would defer to my description of the 3 'legs' or components of PF. If a patient is relatively early in the process and there is a significant inflammatory component, then the injections may be very helpful. If a patient is later in the process and the tissue quality 'leg' predominates and a small inflammatory component exist, I would skip the shot and go directly to ESWT. The downside to injections is small considering the relative safety, low cost and what should be, limited discomfort involved.
Re: ESWT instead of injectionsDr. Z on 8/14/03 at 21:02 (126983)
I was answering Toni's question where she talks about after trying all types of treatment . I agree early inflamatory stages of pf can respond to local steriod injections. I have observed severe complications with local steriod injections and their use should be carefully evaluated. IT can damage tissue quality and cause pf rupture. Whether orthopedic surgeons understand this I have no idea.
Re: ESWT instead of injectionsEd Davis, DPM on 8/15/03 at 10:59 (127027)
It is also important to advise patients on the difference between proper use and improper use of such injections. We would hope that the improper use would only be in the province of professional sports. Unfortunately, this board has shown us too many examples of misuse.
I would not be overly concerned about damage to tissue quality or rupture with the proper use of one or two shots provided under the proper circumstances and with proper dosing of the medications. Repeated or excessive injections and use of injections when other modalities should have been applied are often the problems we have encountered here.
Re: ESWT instead of injectionsjohn h on 8/15/03 at 12:03 (127043)
Dr Ed you comments make complete sense to me.
Re: ESWT instead of injectionsjohn h on 8/15/03 at 12:06 (127045)
Having had 3 injections over about a 5 year period I would never describe them as horrific. For me tha pain lasted about 3 seconds and I would describe as moderate. My broke toe hurt one heck of a lot more. Most of us can survice 3 seconds of pain.
Re: ESWT instead of injectionsDr. Z on 8/15/03 at 17:11 (127063)
What about the article on this web site that talks about pf rupture with just an average of two injections. The rate of rupture was close to 10%
Please comment Ed Thanks
Re: ESWT instead of injectionsEd Davis, DPM on 8/15/03 at 18:20 (127068)
What was used in the injections? Too much repository steroid could certainly be the culprit.
Also -- what were the circumstances surrounding the rupture? If, for example, a shot is provided to a runner planning on running a marathon in a few days, that can be a recipe for a rupture. Injections, provided without consideration and treatment of the associated biomechanical issues can be a problem. For example, I may combine taping with an injection to protect the fascia.
Re: ESWT instead of injectionsDr. Z on 8/16/03 at 08:41 (127109)
I agree that they you need to either tape or support the fascia after any type of local plantar fascia injection to make the injection more effective and to protect it.
One of the misconceptions in our field that I always hear is that well if you rupture the fascia you just did a pf release surgery and it will cure your problem. That is another problem that just isn't true. Rupture as well as pf release can and does lead to permanment foot pain. The rate of this complication I am not sure of but it does occur.
Proper injection with proper injection can and does lead to plantar rupture. I have seen it with just one injection with a patient that had injections with taping.
The key is probaby to only give a local steriod injection when it is fasciitis and not fasciosis.
Re: ESWT instead of injectionsEd Davis, DPM on 8/16/03 at 14:32 (127133)
It is unlikely that use of a non-repository steroid can lead to a rupture. I have not seen a single rupture after a steroid injection I have provided in about 21 years of practice.
The distinction between fasciitis and fasciosis, I agree, is a key consideration. It is important in many respects, including the need for ESWT. I would encourage you and others, in future posts here, to keep repeating that concept and terminology. As mentioned on a number of occasions, I believe that we both consider the 6 months wait period to be arbitrary -- the 6 month period is an unsophisticated means to determine the presence of poor fascial tissue quality. That waiting period is, essentially, diagnosis by process of elimination: if nothing works then it must indeed be fasciosis or a tissue quality problem.
Re: ESWT instead of injectionsDr. Z on 8/16/03 at 15:12 (127135)
I haven't seen a rupture from any local non-repository injections that I have given either during the past twenty four years either. I have over the past few years seen this with other patients from other podiatrists.
What type of injection was the patient given I am not sure. I do know that these patients left their podiatrists and came to me due to ESWT. I consider alot of these podiatrists very competent physicians. This has led me to re-evaluate the use of local steriod injections and how they may or may not cause a pf rupture.
The rupture occurs months after the injection in the cases I have seen.
not immediately. Patients leave previous doctors without telling the doctor why. I believe that I probaby have caused a rupture in patients without the patients and or the doctor knowing it due to the patient never returning to the previous .to me when it happens.
In the past patients would go to the big named city clinics when they
they develop pf problems.from surgery and or injections. Since ESWT patients in alot of situations come to me and this has allowed me to see alot more complicatoins then I have ever seen before ESWT
Before ESWT if you would have mentioned pf rupture with a local steriod injection I would have just pass it off as what are you talking about.
As more and more physicians, pateints learn about you and ESWT you will see more and more of the compications from injections,and surgery which come to your office in hopes you can help them
Just yesterday a woman came into my office with post Pf release. DVT develped in addition to chronic pain developed. My evaluation was severe lateral band plantar fasciitis second to complete medial column insufficiency form pf medial band release.
This would have been a rare patient visit in my years practice now it is a weekly occurence. Its the price you pay for concentrationing your practice on heel pain problems
Re: ESWT instead of injectionsEd Davis, DPM on 8/16/03 at 18:44 (127146)
Many patient with chronic PF may have excessive plantar fascial tension plus poor tissue quality. Both factors can predispose to a rupture of the plantar fascia so it is not clear that injections to the fascia were the culprit especially if a substantial amount of time had passed in betwen the injection and the tear. A subtantial number of patients in my area are enrolled in a big group model HMO that does litle more for PF than advise stretching and shots. I have seen a patient who had 15 shots -- he was in bad shape.
A number of such patients may have had multiple injections, use of long term repository steroids such as triamcinolone acetonide and a lack of attention to the problem biomechanics behind the PF.
Re: ESWT instead of injectionsjohn h on 8/17/03 at 10:01 (127183)
One of the pro football players strained his plantar fascia tendon in a game yesterday and they announced he was out for the season??? Carson Palmer the #1 pick this year also sprained his fascia tendon a week ago but he played well this week.
Re: ESWT instead of injectionsDr. Z on 8/17/03 at 11:49 (127187)
There is also a major player who has chronic insertional achilles tendonitis that is probaby undergoing foot surgery very soon. I contacted his orthopedic surgeon about ESWT. The reponse was basically we have it under control.and don't need your services. Go figure the ego's . I even offered to allow to give him all of the credit. Didn't want to discuss the condition with Dr. Z. I hope that that all works out with this player cause the famous doctor placed his opinion in writing to Dr. Z. Ok let just stick witht he real everyday people out there
Re: MarketingEd Davis, DPM on 8/18/03 at 10:06 (127210)
There are a number of different marketing strategies for docs. One of the 'hottest' strategies in orthopedics is to be named as a team doc or consulting doc for a pro team. Some pro teams have great docs, others have docs who are politically well placed and are, at best, average practitioners in terms of skills.
Insertional achilles tendinopathy and its surgical treatment are areas of interest to me. It is an area in which the orthopedic literature is weak -- there is often a failure to differentiate insertional problems from Haglund's and an incomplete understanding of the biomechanics of the insertion. Unquestionably, ESWT plus biomechanical modification should be the gold standard in professional sports. If the player you mention is not having attention in that area then he is not getting the quality treatment he deserves.
Re: Joan Benoit SamuelsonAlex on 8/18/03 at 10:39 (127215)
Joan Benoit Samuelson (winner of the first Olympic Marathon) has had Achilles problems for almost her whole career. This time, she opted for ESWT over surgery. She's either having or just had the procedure done somewhere in Mass., I think... So at least some professional athletes receive good enough advice to try ESWT before surgery. I have a friend who knows her pretty well, so I'll post back the results of her ESWT when I find out.
Re: Joan Benoit SamuelsonEd Davis, DPM on 8/18/03 at 10:48 (127217)
Looking forward to see the results. I was pleasantly surprised to see the list of pro athletes that hasd ESWT, the first time I visited the Sonocur Treatment Center in Vancouver, BC, Canada a couple of years ago.
The beauty of the low energy treatments is that the athletes treated had to lose almost no playing time.
Re: Joan Benoit SamuelsonDr. Z on 8/18/03 at 19:20 (127256)
The professional star I ever treated with ESWT was a 1965 runner back for the Philadelphia Eagles. I cured his pf a few years ago. There was also a New York Giant Quarterback that I refused because I hate the NY Giant. Just joking.
Re: ESWT instead of injectionsWill B on 8/25/03 at 05:42 (127884)
If you have had full blown PF like me, and many others here. By full blown i mean disabled, and tears in your eyes because you can barely walk. The shot is nothing. It 'can' be well worht the temporary relief of the symptoms.