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ESWT after cortisone?

Posted by Kim on 3/20/04 at 09:59 (147388)

It's been recommended that I have ESWT. It's about 18 months since have cortisone injections that worked really well for about a year.

In reading up on studies using ESWT, it's not clear how effective it is if the patient has previously had cortisone injections.

So, I'm interested in knowing if anyone has received the treatment after having the injections.

If so, how much time elapsed between cortisone and ESWT?
Was there improvement?
How much improvement?
How fast was improvement?
What was the amount of your treatment (doses)?
If no improvement, how much time elapsed between cortisone and ESWT?
Is there some other possible explanation for no improvement besides having the cortisone?

Thanks for taking to time to respond thoughtfully.
Kim

Re: ESWT after cortisone?

Steve G on 3/20/04 at 11:13 (147393)

For many people, ESWT is the next step after cortizone. If you have not had a shot in a year and a half. There is no reason you can't have ESWT. I had the treatment about 4 months after cortizone. You can tell, with cortizone, whether you are going to get much benefit right away. I noticed some improvement for about a week.

I not sure I understand the rest of your questions - are you talking about improvement after ESWT?? At any rate, don't worry about the fact that you had cortizone a year and a half ago. The drug has been out of your system for ages. What other treatment are you using - night splints, orthodics, stretching, etc. Have you read the heel pain book on this site??

Re: ESWT after cortisone?

alan on 3/21/04 at 19:06 (147487)

I had 5 cortisone shots in each foot in 2003 and 4 of those were between Sept and Dec. Had ESWT in Jan 2004 for both feet. No response so far. In fact, probably a little worse now than ever. Before ESWT I could walk with both feet heavily taped without a cane. Now I cannot take one step without a cane. And the cortisone shots? All they did was cause my feet to swell up for a couple days. Last visit to PODS office (two weeks ago) he wanted more cortisone shots. I fired him!

Re: ESWT after cortisone?

Jan R. on 3/24/04 at 05:34 (147655)

Please read:

Plantar fasciitis: a degenerative process (fasciosis) without inflammation.

by Lemont H, Ammirati KM, Usen N.

J Am Podiatr Med Assoc. 2003; 93(3):234-7.

The authors review histologic findings from 50 cases of heel spur surgery for chronic plantar fasciitis. Findings include myxoid degeneration with fragmentation and degeneration of the plantar fascia and bone marrow vascular ectasia. Histologic findings are presented to support the thesis that 'plantar fasciitis' is a degenerative fasciosis without inflammation, not a fasciitis.

These findings suggest that treatment regimens such as serial corticosteroid injections into the plantar fascia should be reevaluated in the absence of inflammation and in light of their potential to induce plantar fascial rupture.

My personal view: There is no scientific basis for repetitive cortisone shots in the treatment of plantar fasciitis. If you had cortisone injection in the heel have you fascia evaluated by MRI before agreeing to potentially hazardous high-energy ESWT.

Re: ESWT after cortisone?

Pauline on 3/25/04 at 09:53 (147743)

Thank you for pointing out the importance of an MRI prior to ESWT if one has had cortisone injections.

This sounds like it should be made a permanent part of the ESWT protocol just prior to treatment.

Re: ESWT after cortisone?

elliott on 3/25/04 at 09:58 (147744)

The problem with quoting an article is that often a contrary article can also be found, e.g.,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9481460

That's why, as with ESWT, a totality of evidence from numerous articles coming to the same conclusion is favorable. Of course, all the title of this ones says is that it's safe, not that it's effective. :-) And there's loads of articles saying it's not so safe either. Anyway, we've already had a few long discussions on these boards on the fasciitis vs. fasciosis article you quote, including some comments from our resident docs as to why that article may not be entirely definitive against the use of even repeated cortisone shots:

bbt.cgi?n=119503

bbt.cgi?n=119898

[]

Re: ESWT after cortisone?

Dr. Z on 3/25/04 at 10:00 (147745)

I am curiouus as to why diagnostic ultrasound wasn't used instead of mri. Diagnostic ultrasound is very effective in determining inflamation and or rupture of tendons.

Re: ESWT after cortisone?

elliott on 3/25/04 at 10:23 (147748)

Pauline:

If everyone with PF who has had a cortisone shot should have an MRI prior to ESWT, that sure does increase health care expenses associated with ESWT. In any case, you may have missed a subtle point made by Dr. J. He didn't say that anyone who has had a cortisone shot should have an MRI prior to ESWT. He said that anyone who has had a cortisone shot should have an MRI prior to potentially hazardous *HIGH-ENERGY* ESWT--you know, the kind Dr. Z administers. OTOH, low-energy ESWT as used by Dr. J, well, you can have your cortisone shot and eat repeated low-energy treatments too! Assuming high-energy risk following cortisone, given that many PF sufferers try cortisone shots beforehand, this admittedly would be a plus in favor of low-energy ESWT.

PS-Pauline, you feeling all right lately? You're starting to sound a bit too accommodating with regards to ESWT. I hope the almost knee-jerk pro-ESWT mindset that has taken over this board lately has not infected you too. :-)

Re: ESWT after cortisone?

Dr. Z on 3/25/04 at 12:06 (147757)

All patients that have any kind of ESWT the treating physician needs to make sure that they have the correct diagnosis. This is why Dr. J used MRI's to make sure he was in fact dealing with pf and not some other cause such as nerve entrapement. Whether you are treating with low and or high energy you must also rule out rupture and or partial tear.
Ultrasound is an excellenct cost effective diagnostic modality that will confirm tendonitis and or fasciitis.
The dornier is the only FDA approved high energy machine in the USA ( the kind that Dr.Z Administers ) that has built in ultrasound that confirms pathology before treatment. One of the major advantages
PS: DR. J just wrote another article in the AMA journal showing the significant benefits of high energy treatment for califying tendonitis of the rotator cuff. In this article there were no HAZARDOUS effects clinically for the tendon, ligaments and or joint.

PSS: I didn't know that the kind of high energy I use is specific to just Dr. Z. Wow maybe they will name High energy eswt after me. HA HA

Re: ESWT after cortisone?

elliott on 3/25/04 at 14:45 (147775)

Dr. Z, the kind of high energy you use is indeed named after you: Z is for zap. Get zapped and get better; it's that simple. Thanks to you, more is talked here about the kind of high energy Dr. Z administers than any other type of high energy. Yours is clearly superior: 94% to 81%. Open and shut case.

Re: ESWT after cortisone?

Dr. Z on 3/25/04 at 15:20 (147778)

I love your sense of humor. Seriously I would love to have other doctors come on board that are using the ossatron and discuss their experience with this unit. All we get is dornier epos providers and sonocur providers.
So all of you ossatron providers out there please come to this site. Elliott would love to interview you.

Re: To Elliott ESWT after cortisone?

Pauline on 3/25/04 at 16:33 (147785)

Elliott,
To be honest, I have developed a recent health problem. I'm just trying to figure out who put the pin in their voodoo doll. That should take this discussion in a different direction:*

I have to agree with you about additional cost of providing treatment if MRI is included. BTW I didn't miss the term 'high energy' just left it out of my post assuming that anyone who read the beginning post in this thread knew we were only talking about high energy ESWT.

What a coincidence while you were thinking of me, I was worried about you too. I thought you might be ill when you didn't join the long running two sided ESWT conversation that went nowhere. I could tell you were smiling though.

Honestly, I appreciate your concern, thanks.