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APMA and ACFAS Joint Policy Statement

Posted by Ed Davis,DPM on 2/03/04 at 22:24 (143592)

Joint Policy Statement on
Extracorporeal Shock Wave Therapy
December 2003


The American Podiatric Medical Association and the American College of Foot and Ankle Surgeons acknowledge that extracorporeal shock wave therapy is one of many surgical procedures that foot and ankle surgeons utilize to treat plantar fasciitis. As with any surgical procedure for chronic plantar fasciitis, it is recommended that conservative therapy be delivered for a minimum of six months prior to surgery, and that patients consult with their foot and ankle surgeon regarding the potential risks of surgery and which procedure is best suited for them.

Description of Chronic Proximal Plantar Fasciitis
Chronic proximal plantar fasciitis is a debilitating condition characterized by pain on the inferior surface of the heel. It is a common problem that afflicts up to 15% of the population presenting to foot and ankle specialists.1 First-step pain (post-static dyskinesia) is the hallmark of the malady.2 Plantar fasciitis occurs most often in middle-aged women.3, 4 The etiology of plantar fasciitis is, in all likelihood, multifactorial. Biomechanical abnormalities5, obesity 3,4,6 and repetitive microtrauma from prolonged standing and walking have all been cited as causative conditions.7

Plantar fasciitis can be managed conservatively with strappings and paddings, exercises, supportive shoe gear, anti-inflammatory medications, physical therapy, foot orthoses, night splints and corticosteroid injections. These treatment measures are effective in 85-90% of the patients with plantar fasciitis.8,9 In patients unresponsive to conservative forms of treatment, surgical intervention is the last treatment option. Surgical intervention is very effective in resolving recalcitrant plantar fasciitis. Traditional heel surgery often requires 4-6 weeks of recovery time that includes short-term disability from work. Complications with traditional heel surgery have been reported in 15-20% of the cases.10

Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy (ESWT) has been used since the early 1990s as an alternative to traditional heel surgery in chronic cases of painful proximal plantar faciitis.11 Patients who have failed at least four conservative modalities and have had pain for at least six months can be considered for ESWT. Some studies have shown that patients who have had a steroid injection within four weeks of proposed treatment, calcaneal fracture, malignancy or osteomyelitis, history or documented evidence of autoimmune disease, inflammatory arthropathies, circulatory or bleeding problems, an open wound over the site to be treated or infection in the area to be treated, or pregnancy should not receive ESWT.12

A number of different ESWT machines are available for clinical use. The OssatronTM by HealthTronics is a high-energy device utilized to treat chronic plantar fasciitis. It was the first machine approved by the FDA for the treatment of chronic proximal plantar fasciitis in October of 2000. It utilizes electrohydraulic 'spark gap technology to generate the shock wave. Typically, 1500 shocks are delivered at 18 kV. The treatment setting and the type of anesthesia are determined by the physician rendering the service. In all cases, anesthesia is required. The physician performs the procedure with the assistance of a technician.

EposTM Ultra
The EposTM Ultra by Dornier was the second device approved by the FDA for the treatment of chronic proximal plantar fasciitis in February of 2002. It is a high-energy device utilized to treat chronic plantar fasciitis. An electromagnetic emitter generates the shock wave. An ultrasound unit is attached to the EposTM Ultra to evaluate the plantar heel and guide the treatment. The amount of energy used in a treatment can be variable but the typical number of shocks generated is 3800 for a total energy of 1300 mJ/mm2. The treatment setting and the type of anesthesia are determined by the physician rendering the service. In all cases, anesthesia is required. The physician performs the procedure with the assistance of a technician.

The SonorexTM by Siemens is a low energy device that has not been approved by the FDA for the treatment of chronic plantar fasciitis. It is, however, approved by the FDA for the treatment of chronic lateral epicondylitis. SonorexTM utilizes an electromagnetic shock wave emitter. In the FDA studies, 2000 shocks were generated for a total energy of 360 mJ/mm2. The procedure is typically performed by a technician in an office setting and anesthesia of any kind is not required.

Clinical Trials for FDA Approval
Several clinical trials have been published which support the efficacy of ESWT for chronic plantar fasciitis.16,28,31, The study used for FDA approval of the OssatronTM was a multicenter, randomized, sham-controlled clinical trial.16,31 According to the summary of safety and effectiveness data, a total of 350 subjects were enrolled in the study, including 300 subjects randomized to either active ESW treatment or sham treatment with the OssaTronTM and 50 nonrandomized subjects to allow each investigator to complete training requirements for performing the OssaTronTM procedure. A minimum of two investigators participated in the study at each site so that one investigator could serve as the blinded evaluator for baseline and post treatment follow up visits. The non-blinded investigator performed the study procedures as follows: Each study subject received a local anesthetic or an ankle block prior to the study procedure. The affected leg was then draped from the view of the study subject. Each subject assigned to the active treatment group received 1500 shocks delivered at a power setting of 18kV. For subjects assigned to sham treatment, a Styrofoam block was placed against the coupling membrane of the shock head to absorb the shock waves. A fluid-filled IV bag was then placed between the Styrofoam block and the subject's heel to mimic the feel of the coupling membrane, and 1500 shocks were then delivered at 18 kV.

Follow-up visits were done at four, eight, and twelve weeks after the treatment. Primary effectiveness measurements were determined at the twelve-week follow-up visit. Four criteria were utilized to establish the success of the treatment: (1) Investigator's assessment of heel pain: A minimum 50% improvement over baseline, and a score no greater than 4.0 on a Visual Analog Scale (VAS);16,18,33 (2) Subject's self-assessment of pain upon first few minutes of walking in the morning: A minimum 50% improvement over baseline with a score no greater than 4.0 on VAS was required for a status of 'success to be assigned for this parameter; (3) Subject's self-assessment of activity level, measured by the distance and time the subject is able to walk without heel pain: The subject must demonstrate an improvement of 1 point on a 5 point scale OR maintain a baseline score of 0 or 1 (no limitation/minor limitation) at the 12 week follow up for a status of 'success to be assigned for this parameter; (4) Use of pain medications: The subject must not be taking any pain medications for heel pain at the 12 week follow up for a status of 'success to be assigned for this parameter.

Upon completion of the study, 62.2% of the active treatment subjects met the first success criteria; 59.7% met the second success criteria; 71.42% met the third success criteria; and 69.7% met the fourth success criteria. 47.1% of the ESWT subjects met all four success criteria compared to 30.2% for the placebo group. This difference was statistically significant.

The study used for FDA approval of the Dornier EposTM Ultra was a multicenter, randomized, placebo-controlled, prospective, double masked clinical study of patients with plantar fasciitis with at least moderate pain for at least six months and a history of prior conservative therapy with two groups: a group receiving ESWT with the EposTM Ultra and a control group receiving a sham treatment.30 A total of 150 patients were enrolled at six clinical centers. The procedure for active and sham treatments was performed identically except that for patients randomized to sham, a thin air cushion was placed on the therapy head prior to the patients arrival to the treatment room. The treatment was administered by a physician who did not perform follow-up evaluations. All patients received an injection of 5ml of 1% Xylocaine into the medial calcaneal branch of the tibial nerve. Eleven percent of patients in the Active group and 4.1% of patients in the Sham group received additional anesthesia during treatment. A total of 3800 shock waves were generated to reach an approximate total energy delivery of 1300mJ/mm2. Follow-up visits were performed at three to five days, six weeks, three months, six months, and twelve months after treatment.

The primary efficacy endpoint was the difference between the active EposTM Ultra treatment and the sham EposTM Ultra treatment at 3 months post-treatment in the improvement from baseline in the VAS score for pain while walking for the first few minutes in the morning using a repeated measures analysis with covariates. In addition to evaluating the actual changes in pain score, the proportion of patients achieving at least 60% improvement in pain while walking for the first few minutes in the morning was compared between groups at 3 months.

The secondary efficacy endpoints were the difference between groups in the improvement from baseline at 3 months post-treatment of the pain evaluation from the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale Score, the Roles and Maudsley Score32, the SF-12 health status questionnaire, pain measurement on palpation with a pressure threshold meter, and the ROM Assessment from the AOFAS Ankle-Hindfoot Scale Score. Safety was assessed as the number of adverse events and severity of complications that were related to extracorporeal shock wave therapy.

In the active treatment group, the primary efficacy endpoint showed a mean improvement of 56.5% while the sham group showed a 46.6% improvement. The change from baseline due to treatment was statistically significant.

The secondary efficacy endpoints as evidenced by the Roles and Maudsley pain score was found to be statistically significant between the groups with 61.6% of active subjects having good to excellent results, compared to only 39.7% of sham subjects. The AOFAS Ankle-Hindfoot Scale and the SF-12 health status questionnaire did not show significant change between the active and sham groups. In other studies, success rates using differing endpoints were achieved.12,13,16,17,18

Other Clinical Studies
Alvarez Study
In a study performed by Alvarez, which focused on high-energy shockwave treatment using the OssaTronTM, 20 patients received a heel block of approximately 20 cc of .5% marcaine and 1% lidocaine 50/50 mixture. Initially, 10 shocks with the settings at 14 kV and frequency of .5 hertz was used. As the patient tolerated, the settings were advanced every 10 shocks to a maximum of 16 kV at a frequency of 2 hertz. A total of 1,000 shocks were delivered. Subjects returned for follow-up within 72 hours, at six weeks, three months, six months and one year. The mean individual improvement in pain score by investigator's assessment (VAS) (described above) at three months post treatment was 85.7% and at 12 months, the VAS scores improved to a mean of 95.8%. At three months post treatment, 70% of patients met the success criterion for patient self-assessment (described above) and at 12 months, 85% of patients satisfied this criterion. Alvarez concluded that the OssaTronTM with high-energy shockwave is a safe and effective tool to treat heel pain syndrome.

Weil Study
In a study performed by Weil et.al., 94 patients underwent ESWT. All procedures were performed under intravenous sedation combined with a local infiltration of 6 cc of 0.5% bupivicaine. ESWT was applied using an electrohydraulic shock wave generator. The mean percentage of improvement for the satisfied group was 81.2% and 25.0% for the dissatisfied group. The authors concluded that ESWT is an attractive alternative for the treatment of chronic plantar fasciitis recalcitrant to nonoperative treatments.

It is important to note that there are two studies from Europe and Australia that do not support the efficacy of low energy ESWT for plantar fasciitis.19,29

Buchbinder Study
Buchbinder et.al. evaluated 166 patients in a randomized, double blind, placebo controlled, low energy study performed by a technician without anesthesia. Three separate treatments were given at weekly intervals. The minimum duration of symptoms was six weeks with a median duration of 36 and 43 weeks in the ESWT and placebo groups respectively. A total mean dose of 1406.73 mJ/mm2 was given but the calculated dose of each participant was different and the pre-treatment energy level varied between 0.02 mJ/mm2 and 0.33 mJ/mm2 depending on patient tolerance. The primary endpoint for determination of efficacy was overall pain at 12 weeks. The authors concluded that ESWT, as applied in this study, was no better than placebo in the treatment of plantar fasciitis.

Discussion on Buchbinder Study
The design of this study varies significantly from the studies used for FDA approval of the OssatronTM and Dornier EposTM Ultra. First, the Buchbinder study uses low energy ESWT. While total energy dosages compare to those in other trials, the authors make the assumption that the effect of ESWT is cumulative over time. The duration of symptoms was in some cases as low as six weeks. The current standard for ESWT treatment in the United States includes recalcitrant symptoms of at least six months duration. As with other low-energy studies, no anesthesia was used in this study. Often, this may result in a failure to complete the treatment. Most high-energy studies include, at a minimum, a local or regional block and in most procedures, the use of intravenous sedation as well. Titration of shock-wave amplitude to decrease painful symptoms elicited during the procedure may limit the effectiveness of ESWT, as a lower energy will likely result. The authors acknowledge that their results are inconsistent with the findings of other placebo-controlled trials.11,16,21,27,28

Haake Study
Haake et.al. evaluated 272 patients in a randomized, blinded, multicenter trial with a two sample parallel group design, low energy study performed with local anesthesia. Therapy was applied every two weeks plus or minus two days. Enrolled subjects had chronic plantar fasciitis recalcitrant to conservative therapy for at least six months. A total mean dose of 960 mJ/mm2 was administered over the course of three treatments. The required number of pulses and energy level for treatment was reached in all cases. The primary endpoint was the success rate after 12 weeks and success was defined by a Roles and Maudsley score of 1 or 2 and if the patient received no additional treatment. The authors concluded that ESWT, as applied in this study, is ineffective in the treatment of chronic plantar fasciitis.

Rompe Study
A recently published study evaluating low-energy ESWT for the management of plantar fasciitis revealed markedly different results.20 Rompe et.al. evaluated 45 long-distance runners in a prospective, randomized, placebo-controlled trial without anesthesia. Each study subject assigned to active treatment underwent low energy shock wave application for a total of 6300 shocks in three treatment sessions, with a 1-week interval in between, at an energy flux density of 0.16 mJ/mm2 and at a frequency of 4 Hz. This study revealed statistically significant improvement from baseline at 6 and 12-month follow-up, and a statistically significant difference between treatment and placebo groups at both intervals. The authors specifically critique the findings of the Buchbinder study in their discussion section, addressing many of the concerns presented above. The authors concluded that ESWT, as applied in this study, is a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

Martini Study
In attempt to understand the biological mechanisms of extracorporeal shock wave therapy, these authors evaluated the effects of shock wave therapy on human osteoblastlike cells at three energy levels.34 The control group received no energy while groups A (14kV, 0.15 mJ/mm2), B (21kV, 0.31 mJ/mm2) and C (28 kV, 0.40mJ/mm2) received two total impulses 500 and 1000 for each level. Group A and B demonstrated ostoeblast differentiation after the first 24 hours and an increase in C-terminal procollagen Type 1 production and bone matrix deposition after an additional 24 hours. The study demonstrated that shock waves have a dose-dependent effect upon cells.

Ogden Study
This study followed patients who had received ESWT for a five year period of time. All patients received a single treatment using an electrohydraulic shock wave device.35 The article addresses four studies that were performed, Study A-D. Studies B, C and D, assessed clinical outcome efficacy and patient satisfaction. In Study A, a randomized, double blind placebo controlled crossover study was performed. An 85% success rate was noted three months after treatment. This improved to a 95% success rate after 1 year and was noted to be durable with a 95% success rate after 5 years of treatment.

Surgical Treatment vs. ESWT
A review of the literature to compare surgical treatment of plantar fasciitis via either an open approach or an endoscopic plantar fasciotomy (EPF) against ESWT was performed. No studies presently exist that randomize patients between surgical and ESWT treatments; therefore, direct comparisons between these types of treatment cannot be made. However, the literature demonstrates that success rates for surgical treatment, either via an open approach or an EPF, are between 60-90%.1,22,23,24,25,26 According to the literature, the complication rate associated with surgical procedures is higher than that associated with ESWT.1, 12,13,14,15,16,21,22.23,24,25,26 Complications for open procedures can be as high as 15-20%. In one study, patients undergoing surgical treatment via percutaneous plantar fasciotomy experienced a 17% complication rate. In general, complications with EPF are lower. Studies demonstrate that complications associated with ESWT are minimal. In one study, of 302 patients treated, 13 related complications occurred. Complications identified in the surgical treatment of plantar fasciitis include, among others, infection, neuritis, scar problems and lateral column instability.1,22,23,24,25,26 The primary complication associated with ESWT is bruising, although other adverse events are possible.12,13,14,15,16,21

In terms of recovery, there is a substantially shorter recovery time with ESWT as compared to traditional heel surgery.1,13,22,23,26 In most cases, patients are able to immediately return to work following ESWT and typically resume full activities within 2-3 weeks of treatment. Open surgical treatment typically requires a more prolonged recovery, including 2-6 weeks of non-weight bearing, followed by partial to full weight bearing. In most cases, treatment with ESWT allows patients to get better quicker with fewer complications.

Payment Issues
Consistent with the studies used for FDA approval, ESWT is an anesthesia requiring, physician-administered service that involves a professional and technical component. As such, payment for this service should be established in a manner that is consistent with the establishment of payment for other physician services. Failure to recognize ESWT as a physician-administered service will cause an erroneous valuation and inadequate reimbursement. As such, access to this emerging technology could be impeded. Additionally, ESWT involves equipment of significant expense that must be appropriately recognized. At the appropriate time, ESWT must be evaluated through the American Medical Association/Specialty Society Current Procedural Terminology (CPT) and Relative Value Update Committee (RUC) processes so that an appropriate Category I code can be established and valued.

Costs for the procedure extend beyond physician payment and should be fairly reimbursed. Medicare reimbursements are established by the Centers for Medicare and Medicaid Services and its Carriers and will not vary significantly. Charges submitted by ESWT companies to payers other than Medicare should be developed fairly and in a manner consistent with charges submitted for other surgical services.

In terms of coding, Category III CPT Code 0020T is the accepted code at the present time for reporting ESWT services. Lithotripsy code 50590 should not be used to report ESWT for plantar fasciitis.

Coverage of ESWT for plantar fasciitis by Medicare and private payers is variable.

Throughout history, there have been numerous examples of improvements in medical care as a result of new technology. In fact, before the 1990s traditional surgery for heel pain required a more prolonged recovery that usually resulted in 2-6 weeks of non-weight bearing, followed by partial to full weight bearing. With traditional heel surgery, 15-20 % of the cases can result in complications, such as nerve entrapments, continued pain, or lateral column syndromes, which may lead to chronic pain. This prolonged recovery and potential for complications led to the need for an improved surgical technique. In the early 1990s the endoscopic plantar fasciotomy came into vogue. It was a much easier procedure to perform with fewer complications than traditional heel surgery. In October of 2000 the first device became available for extracorporeal shock wave therapy. This new technology is revolutionizing the treatment of chronic heel pain, much the same way the lithotriptor did for kidney stones in 1984. The ESWT procedure has few, if any, complications that are minor in comparison to previous types of heel surgeries.

The number of shock wave procedures being performed has greatly increased in the past year, primarily due to the effectiveness of the treatment, fewer complications, and the increase in availability of the technology. Based on a thorough review of the literature, ESWT appears to be an efficacious, FDA-approved non-surgical option in the treatment of chronic proximal plantar fasciitis.

1. Tomczak, R.L., Haverstock, B.D. A Retrospective Comparison of Endoscopic Plantar Fasciotomy to Open Plantar Fasciotomy with Heel Spur Resection for Chronic Plantar Fasciitis/Heel Spur Syndrome. J. Foot Ankle Surg. 34(3): 305-311, 1995.

2. Strash, W.W., Perez R.R., Extracorporeal Shockwave Therapy for Chronic Plantar Fasciitis. Clin. Podiatric Med. Surg. 19 (2002) 467-476.

3. Steinbach, P., et al. In vitro Investigations on Cellular Damage Induced by High Energy Shockwaves. Ultrasound, Med. Biol. 18: 691-699, 1992.

4. McCarthy, D., Gorecki, G. The anatomical Basis of Inferior Calcaneal Lesions: A Cryomicrotomy Study. J. Am. Podiatr. Assoc. 69: 527-536, 1979.

5. Kibler, W. B., Goldberg C., Chandler, T.J. Functional Biomechanical Deficit in Running Athletes with Plantar Fasciitis. Am. J. Sports Med. 1991; 19: 66-71.

6. Gill, L., Kiebzak, G. Outcome of Non-surgical Treatment for Plantar Fasciitis. Foot Ankle Int. 1996; 17: 527-532.

7. Schepsis, A.A., Leach, R.E., Gorzyca, J. Plantar Fasciitis. Etiology, Treatment, Surgical Results, and Review of the Literature. Clin. Orthop. 266: 185-196, 1991.

8. Weil, L.S., Gouldwing, P.B., Nutbrown, N.J. Heel Spur Syndrome. A Retrospective Study of 250 Patients Undergoing a Standardized Method of Treatment. J. Foot Ankle Surg. 4: 69-78, 1994.

9. Benton-Weil, W., Borelli, A.H., Neil, Jr., L.S., Weil, Sr., L.S. Percutaneous Plantar Fasciiotomy: A Minimally Invasive Procedure for Recalcitrant Plantar Fasciitis. J. Foot Ankle Surg. 37(4): 269-272, 1998.

10. Jerosch, JU.: Endoscopic Release of Plantar Fasciitis - A Benign Procedure? Foot Ankle, 21: 511-513, 2000.

11. Rompe, J.D., Hopf, C., Nafe, B., Burger, R.: Low Energy Extracorporeal Shockwave Therapy for Painful Heel: A Prospective Controlled Single-blind Study. Arch. Orthop. Trauma Surg., 115: 75-79, 1996.

Alvarez, R. Preliminary Results on the Safety and Efficacy of the
Ossatron for Treatment of Plantar Fasciitiis. Foot Ankle Int. 2002; 23: 197-203.

13. Weil, Jr., L.S., et al.: Extracorporeal Shock Wave Therapy for the Treatment of Chronic Plantar Fasciitis: Indications, Protocol, Intermediate Results, and a Comparison of Results to Fasciotomy. JFAS 41(3), 2002.

14. Chen, H.S., et al: Shockwave Therapy for Patients with Plantar Fasciitis: A One-Year Follow-Up Study. Clinical Orthopedics and Related Research 387: 41-46, 2001.

15. Wang, C.J., et al: Shockwave Therapy for Patients with Plantar Fasciitis: A One-Year Follow-up Study. Foot and Ankle International, 23(3), 2002.

16. Ogden, J.A., et al.: Shockwave Therapy for Chronic Proximal Plantar Fasciitis. Clinical Orthopaedics and Related Research, 387: 47-59, June 2001.

17. Ogden, J.A., et al: Shockwave Therapy for Chronic Proximal Plantar
Fasciitis: A Meta-Analysis. Foot & Ankle International 23(4), 2002.

Hammer, D.S., et al: Extracorporeal Shockwave Therapy (ESWT) in
Patients with Chronic Proximal Plantar Fasciitis. Foot & Ankle International 23(4), 2002.

19. Buchbinder, R., et al.: Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis: A Randomized Controlled Trial. JAMA 288(11), 2002.

20. Rompe, J.D., et al.: Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes: A Prospective, Randomized, Placebo-Controlled Trial. The American Journal of Sports Medicine 31(2), 2003.

21. Costentino, R., et al.: Efficacy of Extracorporeal Shock Wave Treatment in Calcaneal Enthesophytosis. Ann Rheum Dis. 60: 1064-1067, 2001.

22. Kinley, S., et al.: Endoscopic Plantar Fasciotomy versus Traditional Heel Spur Surgery: A Prospective Study. JFAS, 32(6), 1993.

23. Brekke, M.K., et al.: Endoscopic Plantar Fasciotomy versus Traditional Heel Spur Surgery: A Prospective Study. JAPMA, 88(2), 1998.

24. Dalay, P.J., et al.: Plantar Fasciotomy for Intractable Plantar Fasciitis: Clinical Results and Biomechanical Evaluation. Foot and Ankle, 13(41), 1992.

25. Vohra, P.K., et al.: Long-term Follow-up of Heel Spur Surgery: A 10-Year Retrospective Study. JAPMA, 89(2), 1999.

26. Lundeen, R.O., et al.: Endoscopic Plantar Fasciotomy: A Retrospective Analysis of Results in 53 Patients. JFAS, 39(4), 2000.

27. Rompe, J.D., et al: Effectiveness of Low Energy Extracorporeal Shock Waves for Chronic Plantar Fasciitis. Foot & Ankle Surgery, 1996;2:215-221.

28. Dornier MedTech Inc., Dornier EposTM Ultra: Summary of Safety and Effectiveness Data. Kennesaw, GA: Dornier MedTech Inc: 2002.

Haake, M., et al: Extracorporeal Shock Wave Therapy for Plantar Fasciitis: Randomized Controlled Multicentre Trial. British Medical Journal, Vol. 327, July 2003.

Dornier Epos™ Ultra - P000048 FDA Approval Related Information available at: http://www.fda.gov/cdrh/pdf/p000048.html
HealthTronics OssatronTM – P990086 FDA Approval Related Information available at: http://www.fda.gov/cdrh/pdf/p990086.html
Roles, NC, Maudsley, RH. Radial Tunnel Syndrome: Resistant Tennis Elbow as a Nerve Entrapment. J Bone Joint Surg (Br) 1972;54:499-508.
Chapman, CR, Case, KL, Dubner, R. Pain Measurement: An Overview. Pain 22:1-31, 1985.
Martini, L, Giavaresi, G, Fini, M, et al.: Effect of Extracorporeal Shock Wave Therapy on Osteoblastlike Cells. Clinical Orthopaedics and Related Research 413:269-280, 2003.
Ogden, JA, Alvarez RG, Levitt RL et al: Electrohydraulic High-Energy Shock Wave Treatment (Orthotripsy TM) for Chronic Plantar Fasciitis. Manuscript Under Review by the Journal of Bone and Joint Surgery.

Re: APMA and ACFAS Joint Policy Statement

Jan R. on 2/04/04 at 02:52 (143599)

This is a very differentiated statement clearly showing limitations and chances of ESWT for plantar fasciitis.

Thank you for making this public.

Re: APMA and ACFAS Joint Policy Statement

Dr. Z on 2/04/04 at 20:43 (143646)

Please explain

Re: APMA and ACFAS Joint Policy Statement

Ed Davis, DPM on 2/04/04 at 22:35 (143649)

Dr. Z:
Take a look at the first paragraph in which ESWT is being referred to as a 'surgical' option -- that is not really the case. There is a faction within ACFAS(the American College of Foot and Ankle Surgeons) that is not enthusiastic about this as a 'non-surgical' entity. I think that the only consideration should be what is best for the patient. I don't know if Jan has 'read into' or 'read between the lines on this' but should let him explain.