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ESWT - trials cast doubt on efficacy

Posted by Mark Evans on 10/06/04 at 15:39 (161061)

I was sent the following information by a colleague - I do not have library access at this time so I cannot read the articles for critical appraisal. If any of the professionals on this site have seen the information, I will be interested to know your comments

In a very nice recent review of the literature pertaining to plantar
>fasciitis, Buchbinder (2004) said the following regarding extracorporeal
>shock-wave therapy:
>'...the available data do not provide substantive support for its use. Of
>six randomized, double-blind, placebo-controlled trials assessing the
>efficacy of extracorporeal shock-wave therapy, three studies (involving
>272 and 88 participants) showed no benefit, and two studies (involving 150
>participants and 302 participants) reported small benefits that were of
>questionable clinical importance. A sixth trial, involving 45 runners,
>showed that extracorporeal shock-wave therapy, as compared with placebo,
>resulted in a significant reduction in the score for pain on first walking
>in the morning (a mean reduction of 2.6 on a 10cm visual-analogue scale) at
>six months.'
>There was also a letter of correspondence from Rompe (an author of a number
>ESWT trials) with a reply from Buchbinder several issues later for those
>I'm inclined to agree and say that there is no real evidence to support its

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/06/04 at 20:40 (161076)

This study has been discussed several times on this site. Type 'Buchbinder' into the search feature.

Rachel Buchbinder is an epidemiologist (in other words, never treated a case of plantar fasciitis in her life). The population used in the study included 50% whom had PF less than 6 months, ie. not meeting the minimum duration for inclusion in most PF studies. Also, technique was questionable in that a subtherapeutic dose of shockwave was delivered.

Re: ESWT - trials cast doubt on efficacy

Angie on 10/06/04 at 22:29 (161086)

While the Buchbinder study may be flawed, it is apparently the one my insurance company has sited to deny EWST treatment. Being a lay person, I have no way of fighting them on this issue, and therefore must have an endoscopic release to relieve my pf, which they have approved as effective. It would be nice if the doctors, who have the best arguments against this type of study, would do the appeals of these insurance company decisions on behalf of their patients instead of leaving us to fight with no ammunition.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/07/04 at 07:51 (161093)

Ed, thanks for the tip. Should have thought of it myself! Clearly a nasty can of worms. Of course empirical evidence is important. I have to agree it is odd that an epidemiologist would focus on this topic totally out of the blue. Feet rarely attract such interest- does anyone know the impetus for this study? Ultimately the only viable defense is to produce further evidence. I guess time and money will sort this one out.

The role of the HMO's and insurance companies, and punishing professional indemity insurance in the US is a principal reason why I am returning to the UK. Whilst its no cherry picking there either and we have our own unpalatable problems, at least I continue to enjoy the clinical freedom to offer the best available treatments (for now) - and assuming of course our beleaguered NHS can afford it!

Re: ESWT - trials cast doubt on efficacy

Jan R. on 10/07/04 at 10:30 (161096)

My reply to the Buchbinder article was:

In 'conclusions and recommendation' Buchbinder favored surgery in chronic cases of plantar fasciitis. Keeping to the standards of evidence based medicine, it is undue to recommend 'in the absence of data' referral to a surgeon. Obviously, the recommendations made by Buchbinder are biased towards surgical treatment.

It is difficult to understand why the authors did not consider extracorporeal shock wave therapy (ESWT) advisable when dealing with this small subgroup of carefully selected chronic patients: Several placebo-controlled trials have shown a benefit of ESWT, even in the longer run.

Contrary to Buchbinder, Speed and others made clear that currently there is evidence of benefit from some regimes of ESWT for chronic plantar fasciitis. ESWT - producing virtually no complications, allowing immediate full weight bearing without splints - should therefore be given priority before surgery.

There is a need for further research for both interventions, for ESWT and particularly for surgery: into the local and central effects, and into the optimal regime in this specific condition.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/07/04 at 12:16 (161101)

JanR - this topic is wide open and there is much controversy among professionals. Absolutely there is need for more research.

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/07/04 at 18:24 (161116)

There should be no controversy over what procedure is in the best interests of the patient. Is it ESWT or is it pf release. From my experience ESWT is a better choice for the doctor when treating his patients

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/07/04 at 18:27 (161118)

The problem is the insurance companies only listen to you the subcriber. Your doctor should take an active role in explaining and guilding you thru this process.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/07/04 at 20:17 (161120)

Sure Doc, I don't disagree but the way I see it the problem is this. Doctors who administer treatments, and that includes me, are not necessarily the best people to audit their outcomes. We have a vested interest and desire in getting good results for our patients. Patients, not wishing to offend their doctor, do not always relate their experiences accurately directly to their doctor. There are numerous variables at play - the randomised controlled double blind trial overcomes many of these criticisms and remains the hallmark in research. And this work needs to be done by those with no obvious vested interest in the outcome. Because of the number of variables- e.g. Dr. Ed already drew attention to the weaknesses of the Buchbinder study- the research absolutely has to be repeated by others also to verify the findings and reduce the risk of chance observation still further - even when statistical analysis is correctly applied, this remains as a potential error. Also such studies will help identify the optimum treatment protocol, or can be used to further identify subgroups of patients who may benefit the most from this therapy. It is clear even from entries on this website that not everyone benefits from the treatment - it would be remarkable and atypical if this were true.

Re: ESWT - trials cast doubt on efficacy

Elizabeth Y. on 10/07/04 at 22:18 (161123)

Angie and Dr. Z.:

My insurance company listened to my husband and me advocate for ESWT until we were bluer in the face than the insurance company's logo. We were told by the appeals board that our chances would improve for ESWT treatment coverage if my orthopaedic surgeon would advocate for us. While she exhausted all modalities of treatment, she refused to call the insurance company--fearful of being eliminated as a preferred provider....it is all, unfortunately, about the needs of the provider far outweighing the needs of the patient.

Re: ESWT - trials cast doubt on efficacy

Elizabeth Y. on 10/07/04 at 22:28 (161124)

I have had ESWT treatments as a victim of recalcitrant chronic plantar fasciitis (2+ years). There was absolutely no 'immediate full weight bearing capability', but am still hopefull after two months for some improvement. Any improvement will be heaven sent.

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/07/04 at 23:00 (161126)


If your orthopedic surgeon hsd read the AMA code of ethics then he or she would have known that it is their obligation to advocate the proper treatment in writing to your insurance company. I have no idea what your insurance company is but if its Aetna US Healthcare then I agree that advocating is a waste of time but a small claim legal action may work. I have many times advocated how to win.

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/07/04 at 23:06 (161127)

Isn't this why we have FDA double blind, randonized, multicenter studies to start with?
It is funny how we do surgical procedures such as a bunionectomy without this type of review, or to be more specific plantar fasciotomies.
Go to http://www . ismst.com and then make your own determination whether you should apply ESWT therapy to your patients.

Re: ESWT - trials cast doubt on efficacy

Lori S. on 10/08/04 at 00:36 (161129)

Angie... you should look into ESTW a little bit more. The big $$$ for this treatment scare most people. But I searched, and through the help of some people here got information to help me find a way to get ESTW done, tho my insurance wouldnt pay. Even if they do/or did pay, I would have easily had to paid more than I recieved this treatment for with insurance(my 20% would have been more than I paid). Search around a little. I myself, started calling docs. I had to drive 5 hours one way, but I will tell you, I have had a signifigant reduction in pain since having this done. I am currently post ESTW 8 days. I didnt want anyone cutting my feet up. I hope you find help....

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/08/04 at 08:58 (161142)

Dr.Z. - I have reviewed some of the data on the website. I agree it makes for interesting reading, though I would prefer to see the original articles. This will have to wait until I have library access. The website summaries do not provide enough information to rate the quality of the research. In their presented format, the studies lack a consistant approach in terms of outcome variables, patient groups, previous treatments etc. FDA studies also is not a measure of absolute quality - there have been many drugs FDA approved susbsequently found to cause injury to patients. The stud also has numerous weaknesses - not least the multi-center approach with the problem of inter/intra -observer variances. The recent Vioxx debacle is a good example. A professional meta-analysis is called for. Any takers?

By the way, I seem to have little luck in arousing the interest of the reps handling this equipment. Business must be good if they can afford to ignore a potential customer.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/08/04 at 09:08 (161145)


Dr. Ed critizised Buchbinder for the fact that she has never treated a patient. As far as I know she never claimed she had. She is an epidemiologist who carried out a meta-analysis drawing on her prfoessional expertise - and that is what she is best trained to do. Although I have not seen the articles alluded to by Buchbinder the following is a daming statement : -

Of six randomized, double-blind, placebo-controlled trials assessing the
efficacy of extracorporeal shock-wave therapy, three studies (involving
166,272 and 88 participants) showed no benefit, and two studies (involving 150 participants and 302 participants) reported small benefits that were of
questionable clinical importance.

The question, gentlemen, is how do we reconcile these very significant variances in findings. Even if if assume there is a conspiracy and Buchbinder was specifically tasked to disprove the efficacy of ESWT, which is doubtful, she did not carry out the research, but merely reported on outcomes.

If anyone out there has access to the original research papers, perhaps you can review the methodology.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/08/04 at 09:14 (161147)

and there is more: I relayed Dr.Ed's remarks to a colleague who sent me this repsonse:
I am afraid I believe your colleague is confusing publications. I quoted
from a Buchbinder 'review' article, I think his arguments are aimed at an
ESWT trial that Buchbinder published in the Journal of the American Medical
Association (2002).

My quote was regarding the six randomized, double-blind, placebo-controlled
trials that have been published evaluating this intervention. These trials
are the highest quality of evidence available and should be the research
that we hang our hats on, not anecdotal evidence coming from clinical
experience. Five of these trials showed either very small or no benefit.
Only one, the smallest trial, reported a large reduction in pain.

Five out of six trials with similar results is enough to convince me and I'd be interested to know if your colleague believes a subtherapeutic dose of shockwave was used in every trial.

Less than 6 months duration is not a necessary requirement for participants
in plantar fasciitis trials. Four weeks is commonly used as inclusion
criteria in such trials.

And for what it counts, Rachelle Buchbinder is a rheumatologist as well as a clinical epidemiologist. And as seronegative arthropathies may present with heel pain, I believe she would be very aware of plantar fasciitis as a
differential diagnosis and have seen a case or two in her time. More info
available on her here:


Her article on plantar fasciitis that I quoted from used research to back up every statement and is possibly the best review article I have seen on
plantar fasciitis. And as it is in the New England Journal of Medicine
should be readily available at almost at every large hospital in the world.
I urge all interested to find a copy of it.

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/08/04 at 10:01 (161154)

The FDA study isn't the end all report, however it sure is better then having a doctor report back from his own experience. There is a new report out called the Aeguis study that really is a great piece of research review

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/08/04 at 10:33 (161157)

I agree with you . My question is who set up the parameters for the study and who determined the treatment protocol.
What Dr. Ed is talking about is WE don't use the buchbinder protocol and or the group standards. In fact her selection of patients and treatment protocol is below the ESWT standards of care and below the FDA accepted protocol. The question why would a USA journal accept this without doing any background check on what are the treatment standards in the USA and more importantly the plantar fascia treatment protocols.

Re: ESWT - trials cast doubt on efficacy

Ellie P. on 10/08/04 at 13:59 (161166)

I am not a doctor. I am a patient. I had shock wave therapy 2 1/2 years ago. I had already tried every other possible remedy. Pain was so bad it was making it difficult to walk. I had been under treatment for over 2 years. Had the shock wave treatment. Some immediate relief. It took several months for all the pain to go away. I have had no foot pain since. So I don't know what their tests show but my personal test says this procedure worked.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/08/04 at 14:04 (161168)

Dr.Z - I think we are talking about 2 different articles carrying the name of Buchbinder, as my colleague pointed out.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/08/04 at 14:16 (161172)

EllieP - I am glad you have found relief from your pain. Unfortunately anectodal evidence, as interesting as it is, it is not scientific evidence.
A patient of mine once swore that kissing a toad cured his warts - worked for him!

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/08/04 at 15:08 (161178)

To all:
The docs have done a LOT to argue with insurers over this. The people with the greatest influence over the insurers is...'he who writes the check' to the insurance company which in the US, is very often, the employer. Going to ones human resources department to complain and to the State Insurance Commissioner are still the two strongest avenues of appeal.

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/08/04 at 15:11 (161179)

Dr. Z:
Yes; I cannot and probably will never see how the burden of proof for performing ESWT should be greater than performing surgery for PF. The track record for surgery really should place surgical payment in question unless used as a true last resort.

Re: ESWT - trials cast doubt on efficacy

John on 10/09/04 at 07:40 (161192)


Your colleague should note that Buchbinder was the lead author on the 2002 JAMA article, a negative ESWT article that has received significant critism. Buchbinder's NEJM literature review could be tainted by her desire to support her original negative study. I would have liked to see a non-biased author perform a literature review. What we have are pro-ESWT authors producing positive literature and anti-ESWT authors producing negative literature.

Finally, there is a growing body of evidence that ESWT is indicated as a treatment of last resort. The inclusion of study participants should be restricted to those who failed conservative therapy and have had PF for 6 months. ESWT does not appear to work any better than placebo for patients with less than 6 months of symptoms. Pro-ESWT authors realize this distinction while anti-eswt authors ignore it. Buchbinder seems to ignore the length of symptoms as she included in her review all articles, regardless of duration of symptoms of the study participants.

Please ask your colleague about my comment on let us know his response. It is obvious that he has considerable experience in evidence based medicine.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/09/04 at 20:39 (161229)


I am not sure why you feel Buchbinder set out to produce a negative review. In her review she collated the best available data setting specific criteria for study inclusion i.e. the randomised controlled trials . This would be in keeping with good epidimiological meta-analysis protocol. I don't want to over-state the case because, as I have said before, I have not had an opportunity to read the original articles. Far too many of the 'positive' studies I have seen mentioned here are inherently weak and would be excluded because of this. Buchbinder has no known links with any groups and was not paid by any group with a vested interest to produce this work.

I will relate your comments and post back.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/10/04 at 08:31 (161232)

I have received this reponse from my colleague about the Buchbinder criticisms (my reply to him is pasted below):
I think you should get your american colleague to read this article and actually come back and tell us what was wrong with the research methodology? Why slander the author like that? As for 'has received significant critism' - only from those who just plain do not like the outcome -- I have yet to find anyone who has come to a valid criticism of the methodology.

This was a soundly designed study. The research question was about the effectvieness of ESWT on shorter duration symptoms. The methodlogy was set up to determine that. They found it didn't. Perhaps someone could explain to me, what is actualy wrong with that??? Why bag it just becasue you do not like the results.

>I would have liked to see a non-
>biased author perform a literature review.

Thats rubbish - they are not anti-ESWT (I know the authors and they use ESWT a lot for plantar fasciitis).... why slander them? The NEJM has a peer review process ...

> ESWT does not appear to work any better than placebo for patients
> with less than 6 months of symptoms.

Which is exactly the hypothesis that they set out to test. I ask what is actually wrong with the methodology of the original study? ---apart from the fact that some just don't like the outcome???


The Americans are upset because although the treatment has been FDA validated, the insurance companies will not in many, if not all cases, accept claims for ESWT, apparently quoting the Buchbinder work as evidence, and as a valid reason not to do so. But the patient group investigated in the FDA study were the long term cases i.e. 6 months or more, and resistant to treatment, not the short term cases. It is accepted that 85% or more of new PF cases improve via conservative means, so this is not the patient group the treatment is aimed at.

ESWT is deployed by a growing number of US Podiatrist in treating the long term, chronic cases, recalcitrant to conventional treatments. And the outcomes appear quite favourable. The dilemma is that HMO's and the like are pretty much dictating doctors on what treatments they can offer their patients. The doctors judgment is severly undermined. A patient can therefore have PF surgery under insurance cover, but not the less damaging ESWT, which appears to produce outcomes at least comparable to surgical intervention. This is frustrating the hell out of a lot of doctors as well as patients in the US, and some patients opt to travel to Canada for access to the treatment. As the doctors can make equal money on either option I don't think this reflects a financial bias for using the treatment, but a heart-felt opinion that surgery can and does at times damage the patient, and it is an unethical choice when there is a viable alternative.

This is not so much an attack on Buchbinder, although the undercurrent seems to be that she is somehow 'working for' or in collusion with the insurance companies. I believe this is merely displaced frustration, as the insurance companies do not seem to want to consider the evidence for treating the chronic cases.

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/10/04 at 10:14 (161236)


My critism and most of the people that I know including Dr.George is that using the Buchbinder report to invalidate ESWT as used in the USA/FDA protocol is ridiculous. Like it has been stated her protocol and study group are just two different studies.
Why a study of this type was ever used is very strange. Why the Blue TECH report uses this is offensive. To make sure it is understood. It is the report and how it is being used that is bringing critism.
It is has been some time since I have read the article and I will go back to review if this was the hypothesis as stated. For posters reading this a good example of what we are talking about would be this Lets say that there is an FDA approval for a drug called Penicillin and the dosage is 500mgs to be taken three times each day. Ok a study is published that states that PENICILLIN IS NOT EFFECTIVE FOR THE TREATMENT OF INFECTIONS. You read the study and find out that they used the drug only once each day and that the dosage was only 100mgs. It is published by the AMA journal and now the insurance companies aren't pay for the drug. We all know from experiene that Penicillin does work with infection and we have patients who need and are demanding treatment. This is exactly what the buchbinder report did when they studied a treament protocol that any physician knows isn't going to have a positive outcome before the study even started. On top of that it was so called peer reviewed by the AMA and accepted. WHy. No peer review would ever accept an article like this because the hypothesis is one that always has been shown and accepted that most plantar fasciitis will be cured with conservative treatment.
and isn't include for ESWT treatment.

Re: ESWT - trials cast doubt on efficacy

john on 10/10/04 at 14:27 (161245)


I feel that Buchbinder set out to produce a negative review because her conclusions far exceeded the results of the study. She made statements about the effectiveness of high intensity ESWT and duration of symptoms even though the statements were not tested in her study.

In terms of her NEJM article, Dr. Buchbinder recommended surgery even though she admitted that the evidence was weak. Dr. Rompe provided a nice rebuttal to the NEJM article.

I think that there is a dose effect with ESWT and the recent JAMA article on rotator cuff demonstrates a dosing effect. Buchbinder and others do not recognize the difference between high intensity and low intensity ESWT, preferring instead, to group all protocols into one.

Buchbinder's original JAMA article was conducted properly and was high quality research. My complaint is that it did not study the protocol approved by the FDA so it's results cannot be used to make conclusions about the FDA approved protocol. In the US, ESWT is reserved as a treatment of last result after all other methods fail and before surgery. It would be improper to take a patient with 6 weeks of symptoms and treat them with ESWT. Evidently, in Australia, it may be acceptable to use ESWT as a first line treatment.

Hope this helps to clarify the concerns over Buchbinder and her two articles.

Re: ESWT - trials cast doubt on efficacy

john on 10/10/04 at 14:36 (161246)


I have read both articles and am disappointed that your colleague did not understand my concern. In the US, ESWT has been shown to be safe and effective in treating patients with 6 months or more of heel pain that fails to respond to conservative therapies. There were two high quality, double blind, placebo controlled studies that proved this point.

In this regards, Buchbinder's recommendations on ESWT should be qualified by her results on treating patients will short duration symptoms. Buchbinder does not acknowledge the validity of the results of these studies or their one year follow ups. Her claim that the results are not clinically significant flies in the face of the fact that they were statistically significant at 3 months and clinically significant at one year.

There is nothing wrong with Buchbinder's methodology, except for concerns about the uniformity of treatment energy. The problem with her study is that her conclusions reach beyond her study design and condemn ESWT as a whole.

In terms of anit-ESWT, I believe that she is anit-ESWT because her recommendation against ESWT in favor of surgery even though she found no properly controlled studies showing surgery works. Please read this again, she did not find one double blind, placebo controlled study that show that surgery works!

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/10/04 at 14:36 (161247)

The Buchbinder protocol doesn't even take into account international standards for using ESWT.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/11/04 at 08:50 (161271)


The response about the Buchbinder review was from another colleague, not the colleague who first responded. The latter clearly feels passionately about the Buchbinder work.

I have to repeat one point here. 'B' carried out a review of 6! RCT's which mostly failed to support the view that ESWT works consistently.

John, have you persoanlly read all 6 cited reports ? If so, are ALL of the studies using substandard treatment protocols?

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/11/04 at 09:01 (161272)


1. What is the BlueTech report?

2. Why are patients travelling to Canada for ESWT treatment

3. What the heck is 'ballistic' ESWT

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/11/04 at 09:03 (161273)


you said: There were two high quality, double blind, placebo controlled studies that proved this point.

Can you provide the references?

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/11/04 at 11:21 (161282)

I am talking about the Blue Shield Tech report. This was a negative report based on the Buchbinder article published in the AMA journal . You can find it on googles search engine

Re: ESWT - trials cast doubt on efficacy

john on 10/11/04 at 20:19 (161307)


Most of the studies that 'B' reviewed were low intentisy ESWT, a modality that is not FDA approved. Please keep in mind that there appears to be a difference between high intensity and low intensity ESWT. Please look at the rotator cuff article in the November 19, 2003 issue of JAMA.

Mark, the reports were not using 'substandard' research protocols. The reports proved that low intensity ESWT fails to work consistently. They are not applicable to high intensity ESWT. I believe that there is a clinical difference between high intensity and low intensity ESWT.

Furthermore, 'B' did not find any RCT's to support surgery but she recommended surgery. Do you find it odd that surgery was recommended without any RCT's?

Re: ESWT - trials cast doubt on efficacy

john on 10/11/04 at 20:42 (161310)


The two high quality studies are the FDA studies by Dornier and Healthtronics. These studies were multi-center, placebo controlled studies conducted by leading orthopedic surgeons at leading medical research institutions, including Harvard. The FDA panel that reviewed the studies was composed of leading orthoepdic surgeons.

The Dornier study was recently published in the Foot & Ankle International, 2004, title: 'Extracorporeal Shock Wave Therapy for the Treatment of Plantar Fasciitis', Theodore, et. al., Vol 25, No 5, May 2004, pp 290-297.

I think that the Healthtronics study was referred to in your previous email and was co-authored by Odgen.

Buchbinder criticizes these studies. She states that while the Dornier study showed statistical significance, it failed to show clinical significance. She also had problems with the Healthtronics study. These studies were reviewed by a distinguished FDA panel of orthopods and researchers who found the studies demonstrated the effectiveness of high intensity ESWT.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/12/04 at 09:25 (161329)


I will have mentioned before that any studies paid for by the equipment manufacturers will always be viewed with suspicion. Way too much bias. Way too much history. We need independently conducted RCT's.

A claim there is statistical significance can be misleading in the real clinical world. Clinical significance is way more important to the real world clinician. Also, such researchers are under pressure ... negative outcomes are often not reported. You also to have respect the fact the New England Journal is peer reviewed, Buchbinder is a Rheumatologist, she uses ESWT herself for heel pain patients, and no-one can claim bias, because she carried out the work independently.

And guys, I am still waiting to hear why the 6 RCT's Buchbinder refers to are allegedly invalid or failing to meet standards?

Buchbinder's work is published already. If there are serious errors in her research methodology this can be incorporated in future research. The best defense right now is to seek out equally solid unbiased research vindicating ESWT.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/12/04 at 09:37 (161334)


Having just re-read your earlier posting, I can accept your comment B. focused on low intensity ESWT. Low intensity ESWT is promoted by some clinics as a valid effective alternative obviating the need for anaesthesia. If this is so, her analysis has been profoundly useful, and for this, she should be commended, except of course by those who have invested in the useless, expensive treatment technology.

Consider this ... as a clinician I am evaluating ESWT as a treatment option. I am looking at the researchers for evidence to guide my judgment. I have no way to know if one or the other are better. Anaesthesia free ESWT on the face of it is a much better option - a lot of patients DO NOT enjoy local anaesthesia. Without this evidence I too might have opted to spend a lot of money on a treatment which does not benefit my patients.

If B. recommends surgery I guess that is because it is the accepted standard, rightly or wrongly. Until there are RCT studies demonstrating surgery is harmful I guess it will remain the standard. And to re-iterte an earlier point. There are no RCT's indicating that properly conducted skillful surgery deploying good technique is harmful.

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/12/04 at 15:22 (161347)

As you know I own Dornier Epos's. One advantage of this equipment is the ability to use it for low, medium and high energy procedures. This would be an important criteria when evaluating any type of ESWT equipment whether its a dornier or some other device.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/12/04 at 16:26 (161356)


Actually no, that somewhow escaped my attention. I was under the impression you are part of a consortium of doctors using the equipment. I have to say, I have been arguing in favour of ESWT on the UK forum but some people are determined that ESWT does not have a sufficiently robust evidence base (yet) to be an acceptable treatment alternative to surgery....I guess that controversy will rage on for a while yet. Unfortunately until I have access to reserach papers my ability to counter the arguments is limited to the information I can obtain from the internet.

BTW - I saw your entry on the new Podiatry Forum on MIS ? Ah the wonders of technology. I seem to remember that someonce also once ridiculed the idea of the 'internet' as implausible.

Re: To Dr. Z

Pauline on 10/12/04 at 19:56 (161372)

Dr. Z,
Speaking about Podiatry forums, why are their so many Pods who post complaining about income, their degree vs M.D. and their profession in general.

Here is one example. Isn't anyone happy? With posts like this, in a forum
where other colleagues join the conversation I can see the need for anonymity. What's up with all the negativeity and who is feeding this fire? Surely these people looked before they leaped.

What's your take on these people that are crying after the fact? The way I see it they still have choices so why complain just do something else.

by Dr. A (no login)

I did my research before i joined podiatry

Podiatrist 25th%ile Median 75th%ile
The United States $83,224 $115,338 $154,787
Employment of podiatrists is expected to grow about as fast as the average for all occupations through 2012.


I did two year residency...and work as a podiatrist for 10 year. I want out. It suck BIG TIME. Look at the new york times job section....every other medical profession are needed except our. I would have had a better life if i was a dentist, or lawyer. I was trick in podiatry because I wanted to be a doctor...well being a podiatrist suck. Everyone in my family is a doctor...a M.D. and i was stupid enough to go to podiatry. They make so much more money than me and respected more. The truth is out profession is full of just cutting corn and callus..that is our bread and butter. I was sucker.There is nothing you can do with your degree except podiatry.....

I feel like i ****ed my life over.. I am totally screwed because of this. Stuck in a job that suck......GOD HELP ME PLEASE. I wake up wishing this was a dream and it is not.

Posted on Jul 19, 2004, 5:51 PM

Re: Pauline...

Mark Evans on 10/12/04 at 21:40 (161374)

unbelievable ... WHAT is your problem ?

Re: To Dr. Z

Dr. Z on 10/12/04 at 21:41 (161375)


I guess you are always going to have complaining. I will agree that the cost of a podiatry education is very expensive and without surgical training you are in for alot of debt.
This particular post is a podiatrist with a two year surgical training. I have no idea why he can't make a good living with this kind of training.
As you stated there are choices and you make these choices. Change is hard but it can be done.

Re: ESWT - trials cast doubt on efficacy

john on 10/13/04 at 06:16 (161392)


I don't beleive that researchers at Harvard would bias the results for Dornier! There is not enough money in it to risk your reputation.

As you know, most clinical research in the US is sponsorer by manufacturers. The research process is designed to catch cheaters.

As the devils advocate, you continue to ignore my explaination on the 6 RCT's. Those studies either treat patients with low intensity ESWT or take patients with less than 6 months of symptoms. These are the reasons that the studies do not apply to treatments performed in the USA.

I doubt that Buchbinder uses ESWT since she has stated in the JAMA and NEJM that it doesn't work. If she did, I would question her integrity!

As I said, as Rompe has said, and others have said, Buchbinder's research moethodology does not have serious errors. The problem with her study is that is asks the wrong questions and therefore its conclusions do not allpy to FDA approved ESWT!

Finally, with doctors being squeezed by insurance companies, it is doubtful that any doctor will conduct a RCT without financial support. Who do you suggest would support your proposed 'unbiased' research vindicating ESWT?

Re: ESWT - trials cast doubt on efficacy

john on 10/13/04 at 06:20 (161393)


The problem with surgery is that there may be a placebo effect. We recently saw a study that showed a placebo effect for a commonly accepted orthoepdic surgery. It is not acceptable to recommend surgery just because it is commonly performed. You need studies to show that it works, remember for evidence based medicine you mist show that a procedure works not that it causes not harm. Buchbinder believes in the power of the placebo effect and she should have discounted surgery.

Re: To Dr. Z

john on 10/13/04 at 06:27 (161394)


Please resist the urge to post off topic posts. First, it takes this forum off track. Second, it is offensive. Finally, it undermines your creditability. A new visitor to this forum would quickly figure out that your posts are all over the board and generally negative and stop giving them merit.

Please, Pauline, vent your frustration on another board and keep your posts here about ESWT!

Re: ESWT - trials cast doubt on efficacy

john on 10/13/04 at 06:35 (161395)


I understand your frustration with the research and the ability to argue to your colleagues. However, ESWT is like all other new procedures. There are the early adopters who are using the technology to treat their patients and there are the late adopters who are waiting for more studies.

It might be interesting to poll your US colleagues and see how many have stopped using ESWT because of poor results. This would be the same question that would be asked if a podiatrist was using a new surgical technique and you wanted to know if it worked. In fact, based on the experience of Dr. Z. you might be willing to try several patients and evaluate the results yourself. If the results were positive, you would probably continue to use ESWT for the difficult to treat patients.

Re: To Dr. Z

Pauline on 10/13/04 at 08:21 (161400)

Dr. Z,
I think you're right. These people can make changes in their situations if they so desire and they probably should put more effort into doing this instead of posting their anger and negative views on the Podiatry Forums.

Re: To Dr. Z

Ed Davis, DPM on 10/13/04 at 11:01 (161412)

All forums have their 'dirty laundry.' You seem intent on finding that in my profession. One big problem in may profession, if you consider it as such, is that we, as podiatrists are, for the most part, self employed. The occupation is almost purely 'entrepreneurial' in nature. Those who enter the profession looking for a 'job' will have limited availability. The schools, in my opinion, could do a significantly better job letting prospective applicants know about this simple fact.

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/13/04 at 11:07 (161414)

I think that things go a bit deeper than that. It was certainly my expetation that ESWT, the proof of efficacy is scores of times greater than that of surgery would have good acceptance by now. No one, in their wildest dreams, could imagine the degree of insurance company politics this modality would get mired with. Mark, as others, are astounded and frustrated by this as it had been the expectation that the US system is the 'freest' but when it comes to healthcare, it is not.

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/13/04 at 11:30 (161415)

Such arguments against ESWT are not logical as ESWT has scores of times more evidence in its favor than surgical treatment.

Re: ESWT - trials cast doubt on efficacy

Lynn F. on 10/13/04 at 22:44 (161467)

Ellie - thanks for posting what I feel, is the only worthy read in this long (winded) thread! Being less than 2 weeks post ESTW (and still in considerable pain) your experience and positive outcome gives me a great deal of hope.

Thank You!

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/14/04 at 11:18 (161493)


- An unbiased study such as this can be performed but probably needs to come from a country with a different (health) economic system, such as the UK. I will be happy to do this if I can get my hands on the equipment. I doubt individual doctors in the US could ever perform this type of research. As has been rightly pointed out in the US doctors are also business people. How can you persuade a paying customer to participate in a study when they may or may not receive treatment?

- when money is involved there is always the risk, (What safeguards?) of 'error' in reporting findings objectively and accurately. I did not in fact know that ALL research in the US has backing from manufacturer's. I accept your constraints about professional life in the US. Here is the issue - if I invest tens of thousands of dollars in this equipment, what incentive is there for me to find out if the treatment 'really' works? Especially if I get reports from patients to say it works. BUT !!! is this placebo ? Of course surgery can also have a placebo effect. Anything can have a placebo effect. Thats why we need the research. It has been my observation that when patients pay for their treatment out of their own pocket, somehow it often seems so much more effective..... motivation ?

- what is the incentive of the manufacturer's in detailing such RCT's? If the outcome is negative do you REALLY think clinicians would get to hear about? This is an industry worth many millions. The mighty dollar rules. Here and elsewhere. I have faith in the integrity of participating professionals (well, mostly). I have less faith the data won't get manipulated along the way.... doesn't happen? Sure it does .....

- why am I sceptical : I have to tell you, and it won't be popular, but research in the US, in the field of Podiatry, is sometimes regarded as skewed in Europe. There have been numerous occasions when US reported findings have not been duplicated when repeated elsewhere.

- Please read again my earlier response. I have acknowledged your comments about the 6 RCT's . What I am unclear about is are you stating that ALL 6 RCT's used low energy ESWT on patients with symptoms of 6 months or less? I have also posted this on the UK site and I am awaiting a response.

- accumulated evidence : I agree there is SOME evidence, but once the search is narrowed down the information on heel pain gets to be more sparse, and no evidence that I can find meeting strict criteria i.e. not linked directly to the manufacturer (i.e. unbiased- and I mean by this in the scientific sense), randomised, controlled, prospective, double-blind. There is not one such study. This is a global enterprise. Why is this?

- I WANT this technology to work, but I will need to be convinced thoroughly before I spend a small fortune on the equipment. At this time my opinion is that it CAN be useful for some, not all patients, and that right now perhaps, just perhaps, ESWT is being oversold. Every new technology/treatment suffers this to an extent until it can find its own level naturally.

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/14/04 at 22:01 (161554)


When it comes to PF release, that surgery CAN take so long to heal we may not know if the healing occurred due to the surgery itself, or, at times, due to the prolonged rest it may require.

There is often a belief system that surgery is somewhat more definitive and thus carries with it a fairly strong potential for a placebo effect.
That view of surgery as a definitive entity relates to the concept that if surgery fails then there was fault with the surgery, professional liability. We often lose sight of the fact that surgery indeed is a treatment like all others with its success and failure rates. Surgery, is unquestionably the most expensive option as it involves the surgeon, anesthesilogist, hospital/surgicenter and last but not least, the considerable expense of lost productivity of a worker due to time loss or loss of function during recovery. When looking at medical expenses, insurance companies are not looking at the productivity/time loss issue and benefits managers have difficulty factoring that in as a medical expense. Loss of productivity can be an enormous healthcare expense that MAY NOT be characterized, from an accounting point of view as a heathcare expense. This can be where the cost comparison between plantar fascial release surgery and ESWT can break down...

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/14/04 at 22:04 (161556)

The cumulative experience of thousands of practitioners treating thousand of patients always carries a lot of weight with me.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/15/04 at 09:24 (161573)


who collects, analyses and publishes this evidence? Thousands of practitioners using ESWT....really?

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/15/04 at 10:27 (161577)

I collect and give it out as needed. Just joking. I believe what Dr. Ed is talking about is that there is alot of clinical success stories every day that has been going on for years in both the USA, Europe, and Canada by thousounds of physicain in addition to the publishing of data increasing more and more. There has been over 10,000 cases reported by Healthtronics.
I will tell you if we had to use the same criteria for ESWT as for PF surgery, there would be no insurance coverage in fact there would be alot of surgery denied insurance coverage in all fields of medicine. The reason ESWT is having difficulty with insurance coverage is that is it still considered elective and costs more then then pf surgery.

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/15/04 at 11:04 (161580)

There mmy not be a formal organization doing what you ask. Certainly, not all of what you do in your practice nor I in my practice is backed up with multiple double blinded studies and approved by the FDA. I don't know much about your practice but show me the studies that matricectomies work, the at orhtotics work and so on.

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/15/04 at 15:50 (161597)


I agree there isn't the high level of evidence supporting all of our interventions. This applies to much of medicine and surgery. Right now, that's not my focus. As far as I am concerned, if ESWT doesn't work the worst outcome is the patient is no better....(or if the patient resides in the US the worst outcome is they are no better, and a little poorer...ah hem!)

I am required to spin an argument to persuade senior NHS managers to invest tens of thousands of dollars in providing a 'new' treatment. You have to understand NHS managers are accustomed to pressure from clinicians from all disciplines who want to get their hands on public funds for the 'latest' toy.

As a public service the NHS is accountable for how the tax money is spent. I have stated before, investing in this equipment would mean allocating about 1/4 of my annual budget. For me personally, right now, the issue is can I trust the information to buy the equipment out of my own pocket, or even to recommend the NHS to purchase the equipment? Is the evidence base strong enough? I am not sure, but unlesss I can make a strong case and back this up with sufficiently robust research findings, I am sure the NHS will not release public funds for this.

Dr.Z. believes in high energy ESWT... others believe in low energy ESWT. There is no consensus right now. So the evidence base isn't strong enough to decide absolutely and with confidence. The Europeans are years ahead in the game yet still the definitive evidence isn't out there. Why? Heel pain is ubiquitous and there is ample opportunity to investigate approproiately and settle the argument. It seems we are still waiting.

I am not sure we can make a statement about surgical outcomes - to re-iterate, there has been no RCT's investigating the alleged harmful effects of the right surgery in the right hands on the right patient, so your assumption doubting the value of e.g. controlled surgical lengthening of the PF must remain hypothetical. Perhaps the surgery is extremely effective in the right hands....perhaps not.

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/15/04 at 16:50 (161599)

You are going to have to make the business determination as to either purchase, lease or rent ESWT equipment. What is the cost of the Dornier Epos Ultra in Europe

Re: ESWT - trials cast doubt on efficacy

Mark Evans on 10/15/04 at 20:14 (161621)


You know what? I wanted to know the costs also. I contacted the disributors of your favoured device. In their response the UK representative told me he will be happy to meet me when I am back in the UK, in post. Until then I am left to twiddle my thumbs... how's that for customer service?

Re: ESWT - trials cast doubt on efficacy

Dr. Z on 10/15/04 at 21:00 (161624)

Not good. IF you are sincerly interested call Mike Boss at Dornier USA and he can help you. Go to their web site for the telephone number. There are other companies in Europe that you can also contact. Storz ,Wolf, HTM etc

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/16/04 at 00:51 (161631)

Have you been to http://www.ismst.com website yet?
It is the website of the International College of Musculskeletal Shockwave Therapy and has quite the collection of professional presentations and data. Try to get a hold of Dr. Rompe at the University of Mainz in Germany -- you will be happy that you did. Did you get my recent email?

Re: ESWT - trials cast doubt on efficacy

Ed Davis, DPM on 10/16/04 at 00:59 (161632)

ps Be sure to talk to David Lowy at the Sonorex Treatment Center in Vancouver, B.C.: I have a couple of different numbers:
604-714-0542 and 604-684-3035 : not sure which one is the most recent.
David directs the Sonorex Treatment Center in Vancouver, BC, has a wealth of information and experience. His center was treating American pro-basketball players long before most US citizens, ;let alone doctors knew what ESWT was!