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A debate without end in sight

Posted by Sunny Jacob on 10/27/03 at 16:40 (135779)

During the last few days I was catching up on the comments on this website in September and early October. During that time I was in Asia and Europe in preparation to establish ESWT clinics for the treatment o PF, joint tendonitis and Peyronie's disease. As these clinic will be in partnership with hospitals and specialists, a certain uniformity is required such as
1. Clear established criteria for partners' qualifications and a common philosophy in their commitments. This will allow the clinic to treat patients with the best available expertise and technology at any give time, for the most reasonable cost.
2. No endorsement to specific manufacturers because R&D and also availability of useful features for medical equipment are cyclical.
3. Centralized clinical data base for clinical studies that also ensures patient confidentiality.
This brings me to some of the recent heelspurs.com comments:
Dr.Z. whom I respect and who is also a great help to many patients seeking his advice. He does not hide his unquestionable preference for Dornier. If used properly, it can be a great tool to treat PF with ultrasound imaging and I am certain he does because of many positive comments written by his patients.
However, the following contradictory comments can only confuse patients:
Dr. Z. on October 23: 'low energy can be painful due to the fact that no local anesthesia is used.'
Dr. Ed's quote: 'Pain from low energy is rare during treatment.'
From my involvement with low energy and high energy ESWT clinics in Europe and Canada since the mid-90s, I fully agree with Dr. Ed.
Three sessions of low energy ESWT treatment (without local anesthesia) at 2000 pulses per session is the recommended and most commonly used treatment procedure with low energy.

My second point is in reference to David L.'s comments.
'.. the fact that they use ultrasound, in my view (we have done 7,000 treatments) and the view of some Australian researchers in Australia …….. is unnecessary.'
This is a statement of opinion vs. established procedure that has been used in hundreds of thousands of treatments elsewhere; an accepted norm for a good treatment outcome.
Perhaps one should compare the numerous ESWT studies where ultrasound imaging was used, instead of taking the opinion of one provider such as ‘Sonorex' and an Australian study, as well as the business political interest behind it.
Perhaps also find out the opinion of ISMST and many ESWT researchers in Europe who are part of a teaching hospital, with regard to in-line ultrasound imaging during ESWT treatment, including the equipment manufacturers who provide the inline ultrasound.

On October 24, David L. commented: 'Pain must be well localized. It can hurt all over but there have to be one or two particular spots that are very tender to touch. Every area of PF is different, but having the point of tenderness is the key to success with ESWT.'
I agree with the above quote except that it requires some clarification:
a) In some cases there can be more than two pain trigger points.
b) The pain trigger points are the size of a grain of rice. One has to aim the shockwave focal point directly to that point for the best effect during treatment. Each individual point has to be treated separately for the best result, using test shocks to identify the pain trigger points, i.e. not with touch and feel.
It is beyond my comprehension how one can achieve this 100% effect if an ESWT equipment without inline ultrasound is used.

Most of these points have been raised and debated many times on this message board I am not certain why they come up again once in a while by the same individuals, including me. The reason I am responding again is that I find it necessary to correct the contradictory comments which may lead to confuse the patients. Patients, I am certain, can gather readily available information here and elsewhere and make their own decisions.

Re: A debate without end in sight

Pauline on 10/27/03 at 19:19 (135795)

Nice to have you posting again. I think the reason these points come up so often is because of competition, cost, and the fact that the Sonocur medical device must be used off label for P.F. treatment in the U.S.

Re: A debate without end in sight

Dr. Z on 10/27/03 at 20:22 (135797)


The reason these points come up is because posters bring these points up and ask questions.
There is going to be different experiences with different machines. This is even going to be different physician experiences with the same machine.
By the way Sonny point is that you MUST use ultrasound guilded ESWT treatment with the sonocur. As you know there isn't one Soncur eswt machine in the USA that has ultrasound. So now we have difference in opinion with the same machine
Medicine is both an ART and an Science that is what this all about

Re: A debate without end in sight

Pauline on 10/27/03 at 20:57 (135804)

Dr. Z,
Most new people come to the board and simply tell us they are going to have ESWT. They don't know what machine, how many Zaps, whether it has ultrasound, how much experience the doctor has or sometimes not even how much it's going to cost them when all is said and done.

It isn't until they ask 'Will it Help' that they are thrown all the details with a certain amount of good salesmanship thrown in depending on who is providing the answers.

Nothing wrong with this, but each ESWT provider does have biased opinions
based on the machine they are using. If the are marketing any treatment for profit I believe biased opinions will always be part of the equation.

Re: A debate without end in sight

Dr. Z on 10/27/03 at 21:44 (135815)

and the way you make a profit is to provide the most accurate information that you can from your own experience. I see nothing wrong with the for profit medicine that exists in the USA.

Re: A debate without end in sight

Sunny Jacob on 10/29/03 at 07:31 (135923)

Dr.Z.: Just a correction
My opinion is that ultrasound guidance and imaging option should be a feature for all ESWT equipment, which includes Sonocur.
It is my recollection that, after acquiring the Dornier Epos, Dr. Z. also stated the advantage of ultrasound imaging.
I do agree that medicine is a combination of art and science. Therefore, experience of the provider and the treatment protocol play an equally important role for a good treatment outcome.
I also believe that there is nothing wrong with ‘for profit' medicine. We all benefit from the numerous advances in medicine because of it. At the same time, patients deserve the best ESWT treatment for a reasonable fee. In a competitive world, the current huge variation in fees will settle itself to a reasonable level.

Re: A debate without end in sight

Dr. Z on 10/29/03 at 12:55 (135949)


We are both on the same page. I beleive that ultrsound for ALL eswt equipment is very important and plays a very important role in improved outcomes.

Re: A debate without end in sight

mitch b on 10/29/03 at 14:19 (135957)

well dr Z you have convinced me that if given a choice i ought to opt for
treatment with ultrasound.i have been debating between toronto or vancouver with the latter being an easier trip but i will now opt for
thanks to all who contribute to this mesaage board

Re: A debate without end in sight

Paula A. on 11/01/03 at 21:05 (136163)

You can debate the technical differences between the different companies and the different machines all you want and yes cost is also big factor. All I can tell you is I hope my experience can help someone decide not to give up on ESWT and opt for surgery. I had Healthtronics Ossatron ESWT for my first treatment with little success. It was because of this message board that I persuaded my reluctant orthopod to let me have a second treatment but this time with a Donier epos. 3 months out of my second treatment I can happily say I doing very well. The improvement was slow at the beginning but around weeks 9 & 10 I noticed my most improvement occured. I'm not a 100% but I'm so happy to be 80% better. So whoever is reading this message board don't be hesitant to have a retreatment. I've had both machines often describe on this board the Donier epos helped me the most.

Re: A debate without end in sight

Dr. Z on 11/01/03 at 22:27 (136174)

Hi Paula ,

Glad you are doing very well. I have always felt and practiced that no matter what result with the first ESWT treatment, a second treatment can do alot so long as the correct diagnosis called insertional plantar fascitis is correct.
I don't understand why your doctor was so hesitate to do a second treatment