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Debating Surgery or ESWT for PF

Posted by Joe W on 11/16/04 at 20:52 (164122)

I have tried conventional method for relief of PF on left foot. Orthotics, night splint, custom birks, Physical Therapy without relief for two years. A new Physical Therapist advised I try a Heel Pain clinic in St Louis, and/or a Dr. Kosova in
Westmont, Illinois. I called the Dr office in Illinois they wanted $5000. for a 20 minute high energy one stop procedure, discouraging! On top of that they want to do an evaluation on me first which would require another visit, I live in Kalamazoo, Mi. 3 hours from Chicago.

On this web site I found the Toronto site Scott recommended they charge only $1050. but you need to stay for 4 days and have 3 'low energy' treatments.
My podiatrist tells me that ESWT doesn't work and I may need to go the surgery route. I am confused! Help! Anybody have any experince with this procedure in Detroit or Michigan area they could recommend. I an tired of limping!

Re: Debating Surgery or ESWT for PF

Connie Moody on 11/16/04 at 21:04 (164124)

I did the three treatments in Toronto..with VERY good succes the first 4 weeks..then gradually got worse until I was recommended (from this site) heat (lots of it) and the Foot Trainer exercises...now I am improving again. I have had PF for well over 10 years and understand we 'chronics' are harder to treat. I would say, that the treatments were successful. Just wish I had started the heat and exercises at about the 4th week instead of the 9th! (I was using ice and NO exercise prior to that). I have been graciously given the opportunity for two repeat treatments; but will decline due to holidays and illness in my family. However, I am hearing from some not to call the final call until 16 weeks...(I am at the 11th week today). I found the technician who did my treatments very informative and allowed me to challenge myself as far as I could with the treatments. I would do it again, for a booster, if the timing were different. Let me know if I might answer any other questions patient to patient on the Toronto experience.
Connie Moody

Re: Debating Surgery or ESWT for PF

Connie Moody on 11/16/04 at 21:08 (164125)

BTW I had the surgery 4 years ago with NO success! But that was just me as I know some have had success!
Connie Moody

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/16/04 at 21:21 (164127)

Hi Joe,

Our group Excellence Shockwave Therapy has been using ESWT for chronic pf for over five years. We have Dr. Zingas, one of the FDA investigator in Michigan. He is excellent. IF you would like our informational packet just me Dr. Z at (email removed). One of our coordinator will be happy to talk to you and or send you our informatonal ESWT packet.

Re: Debating Surgery or ESWT for PF

Tina H on 11/17/04 at 06:38 (164145)

Joe- There are lots of good doctors offering high Energy ESWT these days. You can certainly do better than 5M$ especially since you are close to a metropolitan area. Check to see if your insurance will cover this. Several of us who visit this board (no insurance) have had this treatment for a faction of the price you've been quoted. A pre-visit would be very appropriate and necessary. They have to determine if you would be a good candidate for ESWT. That should be standard anywhere and is for your own safety. While this is not an invasive procedure, no knife etc., it still causes trauma to the fascia. Good Luck, Tina

Re: Debating Surgery or ESWT for PF

Jan R. on 11/17/04 at 10:38 (164164)

Following Buchbinder (2004), surgery may be considered for a small subgroup of carefully selected patients who have persistent, severe symptoms despite nonsurgical intervention for at least 6 to 12 months.

The surgical procedures used for plantar fasciitis include variations of open or closed partial or complete plantar fascia release with or without calcaneal spur resection, excision of abnormal tissue, and nerve decompression. In case series, favorable outcomes were reported in more than 75 percent of patients who underwent surgery, although the recovery times varied and were sometimes months, and persistent pain occurred in up to a
quarter of patients who were followed for an average of two or more years.

Potential complications include transient swelling of the heel pad, calcaneal fracture, injury of the posterior tibial nerve or its branches, and flattening of the longitudinal arch with resultant midtarsal pain. As compared with open release surgery, closed procedures may allow for more rapid recovery and resumption of usual activities, although the risk of nerve injury may be higher with endoscopic release and other closed procedures than with other approaches.

Controlled trials are required to verify these findings.

Together, surgery should be reserved for those patients whom conservative therapy has not helped after 6 to 12 months. In the absence of data to guide the surgical approach, referral to a surgeon with expertise in treating patients with plantar fasciitis is recommended.


Re: Debating Surgery or ESWT for PF

Joe W on 11/17/04 at 13:21 (164174)

Thanks Connie for the response, was this the 4 day low energy version? I heard of a Dr. Jeff Klien in Detroit that is offering $699 for the high energy one treatment method.

Re: Debating Surgery or ESWT for PF

vince on 11/17/04 at 14:09 (164178)

Dr. Davis- and what do you have to say about the long term destuctive unbalance to the structure of the foot that PF release causes?

Re: Debating Surgery or ESWT for PF

Pat on 11/17/04 at 14:17 (164180)

I had the surgery because, basically, my insurance company wouldn't pay for ESWT and I didn't know what the heck to do. I had the surgery on my left foot 10 years ago and it was the surgery from hell - everything that could possibly go wrong DID! I was in so much pain for so long but today I'm pain free in my left foot. The surgery on the right was on 11/3/2004 - I'm one of the 10% of the people that nothing else would help but I think part of the problem was because I have alot of neurological stuff going on (to much to explain here) I couldn't fully stretch. Here it is two weeks post surgery and I'm in pain but nothing like I thought I would be. I know it's a long road and I know it doesn't work on everyone so it's a hard decision to make. Did you check with your insurance company? Whether they pay or not may help you decide but the thing that would bother me is the one shot treatment for $5,000 - what if one shot doesn't work (and from these boards it sounds like it doesn't always work the first time).

Re: Debating Surgery or ESWT for PF

Ed Davis, DPM on 11/17/04 at 14:35 (164182)


I think that the answer to that question depends on whether the plantar fascia which is cut regrows. Ideally, the tissue regrows in an elongated position which is not painful. If the tissue regrows, then no long term damage should occur.

When the fascia is cut, there is a loss of a primary support mechanism in the foot -- see Scott's Heel Pain Book as he shows diagramatically how tension is ditributed along the fascia. Often, patients who have had plantar fascial release surgery sexperience either lateral column (calcaneo-cuboid) pain or midfoot pain. In other words the joints that make up the arch now have significantly more stress on them since the plantar fascia that strings across the bottom of the foot like a guy wire is not there.

Looking carefully at the plantar fascia diagramatically you can also see how the fascia acts as a spring like mechanism aiding in propulsion -- as the arch flattens to absorb shock the fascia is stretched (stores potential energy) and as the heel comes off the ground the stretch/tension is released as an aid to propuslion (potential energy converted to kinetic energy). So if the fascia is cut, some of the force of propulsion is decreased meaning that the calf muscle needs to work harder to allow us to push off or propel forward.

Re: Debating Surgery or ESWT for PF

Ed Davis, DPM on 11/17/04 at 14:42 (164184)

One need shop around as there are much better deals on ESWT to be had.

Re: Debating Surgery or ESWT for PF

Connie Moody on 11/17/04 at 17:40 (164196)

Yes, this was the 4 day (3 treatment) low energy version. You also have to consider the cost of plane fare and motel room.

Re: Debating Surgery or ESWT for PF

J. P. (Sunny) Jacob on 11/18/04 at 17:50 (164283)

Hello Connie Moody,
From you description it appears that you were treated at the PainFree ESWT clinic, Toronto. Were you also treated with low intensity laser as part of the 3-session ESWT treatment protocol of the clinic?
If it is acceptable to you, can you quote the total amount you spent in $US, i.e. treatment, plus airfare and hotel?

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/18/04 at 18:00 (164285)

There is something else that is very important . The doctor. There is a story that I want to tell you that I just read. I hope that it makes my point. Morton's Salt ( the blue box ) is alot more money then any other salt product. Salt is Salt but distributor's buy the product and pay alot more, because of the customer service, quality control, and all other aspects of what makes a company, doctor, stand out and make the difference between a good result and a fair result. You are a prime example of where my advice made a difference in your after care. Your should to come to heelspurs.com for advice. It should be given to you where you had the serice performed.
There is no price that you can place on quality of service ( post-op ESWT care). Placing just a dollar amount on the product is just not going to get you the best doctor, service and expert advice that is needed for ESWT treatment.
So to quote prices well its a starting point but first look for the doctor who is the best and has the track record to match it.

Re: Debating Surgery or ESWT for PF

Connie Moody on 11/18/04 at 20:01 (164307)

Yes it was. I was pleased. Total cost (treatments, airfare, hotel & cabs was $3020.00) Both feet by the way!

Re: Debating Surgery or ESWT for PF

Connie Moody on 11/18/04 at 20:04 (164308)

Sure did not mean to offend.
I will leave heelspurs.com at this point as I have certainly not meant to cause issues and have appreciated your advice, Dr. Z. but I must have a misunderstanding of what this site is all about.
Signing out and wishing all well.

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/18/04 at 20:45 (164310)

Hey Connie,
I looked back over this thread. I have no idea why I addressed my post to you. I wanted to add it to the thread to complete this discuss on costs. I used your example how you improved with information from myself and this site after ESWT. It is my feeling that what information you received from this site should have been provided to you from your provider. Again this was not meant to insult you but to educate other posters. I am sorry to I offended you.

Re: Debating Surgery or ESWT for PF

J. P. (Sunny) Jacob on 11/18/04 at 22:24 (164316)

Dr. Z,
It is a sad day for this message board that a patient turns away because of specific statements on this site. Your quote 'Your should to come to heelspurs.com for advice. It should be given to you where you had the serice performed.' - although it is somewhat incomprehensible, - may not have been directed at the patient, - but the damage has been done.
At the same time you are setting a certain monetary value for advice given by you on this board. I believe this is not in the interest of patients or other providers.
In case you were referring to PainFree clinic in Toronto, I am certain the clinic is quite capable of providing treatment and post treatment advice to all patients without your direct interference.

Re: Debating Surgery or ESWT for PF

Just An Observer on 11/18/04 at 22:31 (164317)

Talk about pouring salt in the wound... yikes!!

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/19/04 at 06:07 (164328)

Either you understood what I was trying to explain or you don't and lets just move on. There was never any inteniton to insult or hurt anyone but to help add something to the definition of cost and its true meaning

Re: Debating Surgery or ESWT for PF

Ed Davis, DPM on 11/19/04 at 10:53 (164351)

Dr. Z and Sunny:
I don't think that Dr. Z had any intention of scaring anyone away, in all fairness. Dr. Z may be a little testy since he misses Pauline... (what happened to the emoticons?)
I think that the atmosphere here in general may be a bit confusing to patients particularly with the 'infighting' between providers, manufacturers with the biggest blame going to the anonymous manufacturers reps who may not realize that in critiquing the 'competition' in ESWT, they may be hurting their own cause. I just want to let patients know that ESWT WORKS and that the arguments over equipment and techniques should not divert patients from needed treatment.

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/19/04 at 16:44 (164377)

Seriously my intention was for patients to try to understand that ESWT isn't a product. It is a service and to try to compare apples to apple is tough.
Some times it is after the ESWT treatment that patient who have had the treatment begin to realize how important advice, follow up care with a physician and the rest of what goes into excellent post eswt care. This is a service that going to the cheapest place may not be the best idea. We sometimes forget on this board

Re: Debating Surgery or ESWT for PF

Ed Davis, DPM on 11/20/04 at 12:50 (164429)

Dr. Z:
Certainly that goes back to the old maxim of shopping for value vs. cheapness. Looking for value is more important. I do think that most of the 'regulars' here including Sunny Jacob are quite experienced with ESWT and provide a good value.

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/20/04 at 13:37 (164435)

Dr. Ed,

The ability to provide aftercare advice and if necessary see the patient is also important. I am not sure about Canada by as you know in the USA a liscenced doctor must be involved in the care of the patient before, after and during.

Re: Debating Surgery or ESWT for PF

Ed Davis, DPM on 11/20/04 at 16:28 (164444)

Dr. Z:
The patients I had referred to Sonorex in Vancouver were followed by me before and after.

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/20/04 at 17:25 (164447)

I know they are thanks, but what about the others.

Re: Debating Surgery or ESWT for PF

J. P. (Sunny) Jacob on 11/21/04 at 11:27 (164483)

Without having sufficient information, the recent finger pointing, unfortunately, was merely one provider accusing another and all later attempts to justify the statements were pathetic. Let the readers make their own judgment regarding the agenda behind it.

The patients who visit PainFree clinic are diagnosed by their family physician, orthopedic surgeon, podiatrists, etc., and in the case of Peyronie's, their urologist. Of course, they also go back to these providers for their continuum of care as they choose. Some of the patients also need additional care and consultation by physiotherapists or dietitians. We are not a one-stop solution and have never made such a claim.
PainFree Clinic in Toronto provides continuous ESWT advice and follow-ups for each and every patient treated at the clinic. The ESWT clinic provides a service very similar to MRI or lithotripsy, but still provides all necessary advice before, during and after treatment (12 weeks and beyond).

ESWT is not a procedure for the exclusive domain of podiatrists and was never meant to be. In Europe, except for Great Britain, podiatry is hardly known as a profession. Our patient population is from Canada, USA, Europe and South America.
I think we should put this subject to rest and let the patients speak.

Based on recent statements about 'authority' I would like to ask the following:
On what basis may a podiatrist in USA provide 'off label' ESWT treatment for tennis elbow or shoulder tendonitis, including the before and after consultation?

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/21/04 at 11:55 (164484)

I asked an excellent and very important question: Is there follow- up care post eswt with patient having ESWT in Canada. This is another piece of the fee comparison puzzle. All ESWT provided by Excellence Shockwave Therapy is a global fee. For patients that don't understand this it means that the after care post ESWT is included in the fee that you were quoted.
If is my opinion that post eswt care is very important and can and does contribute to the final result. This was my example with Connie. Here we had a patient that considered her ESWT a failure until she received post -eswt care advice. I will repeat so there is no mistake about this and we don't think it was directed toward anyone. The point is post-op eswt is important. I have no idea what the follow up is with Pain free and you have pointed to out in your post that you do have a follow up program. This is why I asked the question.
Have no idea why you think that ESWT is the exclusive domain of just podiatry. Podiatry does treat alot of plantar fasciitis. Excellence Shockwave Therapy has podiatrists orthopedic surgeons which specialize in the foot, elbow and shoulder pathology
I am confused about this statment. I know of no podiatrist who is treating elbows and shoulders in the USA, Canada and or Europe. If you are referring to me, you may be confused I am the ESWT director for Excellence Shockwave Therapy and have taught ESWT to many orthpedic surgeons who use ESWT very succesfully for elbows, shoulders. All patients that have ESWT with Excellence Shockwave Therapy Group are evaluated and treated by an orthopedic surgeon who is present at the time of the treatment and follow up after the treatment. I hope this clears up anything. I agree lets move to another topic.

Re: Debating Surgery or ESWT for PF

Lynn F. on 11/21/04 at 14:34 (164492)

I have to agree with Dr. Z. My aftercare from ESWT has been practically non-existent. My dr. sent me home with a sheet of paper (exercises that made me worse off) and has only had me back once, at 2 weeks, when I was in agony. He taped it, (reluctantly) gave me a prescription for Tylenol #3 and sent me off without a word about seeing me again. He has excellent credentials, and is used by many local sports, ballet companies, etc. He seems very knowledable, but is non-communicative to the point that I don't feel comfortable. When I ask questions, he gives me a 'deer in the headlights' look. He was the only pod in my area who does ESWT. He is also the 3rd one I've been to. I keep thinking if he gets me better, his personality (or lack of) won't matter. But I've decided if I don't see improvement after the normal post-treament period, I will have to change pod's... again. I don't know what's considered normal dr. fee in this case, but in hindsight, I would have paid more for better care.

Thanks for letting me vent. =:0

Re: Debating Surgery or ESWT for PF

Dr. Z on 11/21/04 at 16:12 (164497)


Your after care was included or should be included. In the USA the CPT code if your had insurance includes the aftercare. IF you paid for it I still believe its included and you should be seen as many times as needed to satisfy your care requirement.
I think I hit a nerve with this subject because alot of places are able to give you a lower fee because of lack of physician supervision or just plain lack of follow up care.

My originaql post only had the purpose of pointing this out when doing a fee comparison. ESWT is a service not a product

Re: Debating Surgery or ESWT for PF

Lynn F. on 11/21/04 at 22:30 (164521)

My insurance did not cover ESWT. My dr's fee was $500. He owns the Dornier equipment and supervised the procedure. My follow-up visits are being billed to my insurance co. and I make a $25 co-payment each time I go. I never asked if the $500 fee included post treatment visits.. but clearly it does not.