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Stress fractures caused by ESWT?

Posted by Bob C on 2/03/05 at 16:29 (168429)

My wife had ESWT on both feet in March 2004 after several years of conservative treatments including PT, night splints, exersizes, cortisone shots, orthotics, and lots of Tylenol. For two days she was very excited because the pain had subsided considerably and the podiatrist had told her it would only get better over an 8 to 12 week period. On the third day, after very little activity of any kind over the weekend, she started complaining of sharp pain again, only a little different than the previous pain. She just couldn't explain how it was 'different'. The pod. again told her it should improve over a longer period. She saw him twice more (a total of 3 times) over the next 10 weeks. He finally told her there wasn't anything more he could do and suggested she see someone else. It took 2 weeks to get into an orthopedic surgeon but took him only 5 minutes to diagnose the problem as stress fractures - in both feet! He ordered a bone scan to confirm the diagnosis and it was confirmed. That was in July. She is still in an air cast that she can remove at night but her left foot is having problems healing.
To make a long question shorter, could ESWT be the cause of the stress fractures? After the ESWT there was no activity other than walking in the house for almost 3 days. The treatment was done on a Friday at noon and she didn't do a thing until Monday morning. The only thing the Orthopedic Dr. will say was that it could only be caused by 'some trauma'. We are trying to figure out what that could have been. Any answers, comments or ideas would be appreciated.

Re: Stress fractures caused by ESWT?

Dr. Zuckerman on 2/03/05 at 20:13 (168443)

Hi
I don't know of any documented ESWT cases whereby a stress fracture developed. Which machine did your wife have treatment with the Dornier or ossatron.? It is very possible that there were stress fractures present along with plantar fasciosis all along. A bone scan doesn't confirm stress fractures. An MRI can confirm a stress fracture. Physical examination can diagnosis stress fractures. Stress fractures are due to a fatigue in the bone, due to repetitive stress such as walking, standing, climbing, excercise, trend mill.

How is she doing? What is going on with the left foot. I wish I can give you additional information but without an examination tough to say. If there wasn't an MRI done if may be needed for the left foot at this time

Re: Stress fractures caused by ESWT?

Ed Davis, DPM on 2/04/05 at 14:48 (168488)

Dr. Z:
I beleive that there was only one documented case, years ago, in an elderly patient with osteoporosis.
Ed

Re: Stress fractures caused by ESWT?

Dr. David S. Wander on 2/04/05 at 17:25 (168513)

Bone scans are sensitive, but not specific for stress fractures of the calcaneus. MRI's can certainly diagnosis a stress fracture of the calcaneus, though a CT scan is still the gold standard for a suspected fracture. I do not agree that a stress fracture can be diagnosed by physical examination. Compressing the calcaneus from side to side is often painful when there is a stress fracture, but certainly is not an accurate method of diagnosing a stress fracture. It is useful in the overall examination, but I would not state that a stress fracture can be accurately diagnosed with a physical examination.

Re: Stress fractures caused by ESWT?

Dr. Z on 2/04/05 at 18:40 (168519)

Dr. Wander,

You can correct I left out a history AND a physical examination can be used to diagnosis a stress fracture but you need an MRI for confirmation . Please show me in the literature where a CT scan is the gold standard for a suspected stress fracture. My point is that a bone scan isn't a very accurate confirmation for a stress fracture. I would like to see where it states in the podiatric literature where a CT is the gold standard for stress fracture confirmation.

Re: Stress fractures caused by ESWT?

Ed Davis, DPM on 2/04/05 at 20:25 (168523)

Dr. Z:
I think we have all been 'victims' of bone scans of the heel being misread. If a radiologist renders a diagnosis of a calcaneal stress fracture, I will ask for a copy of the films to make sure he is is not misreading the often copious periostitis that goes along with insertional plantar fasciitis. I will go for a third option, MRI. Nevertheless, I happen to be close to a facility with a very good short bore scanner with exceptional resolution on small body parts.
Ed

Re: Stress fractures caused by ESWT?

Dr. Z on 2/04/05 at 20:34 (168525)

ED

Are you aware of CT for Calcaneus stress fracture confirmation being the gold standard. ???

Re: Stress fractures caused by ESWT?

Dr. David S. Wander on 2/04/05 at 21:05 (168530)

CT scan is really the gold standard for bone pathology. MRI is useful when looking for pathology in addition to bone pathology, such as soft tissue components to injuries. That is why CT scans are used for calcaneal fractures, tarsal coalitions, etc. MRI's are useful for stress fractures and will show bone marrow edema, but CT scans show greater bone detail, but unfortunately do not show the soft tissue detail that is often useful in an MRI. If you would like literature to support the CT scan vs. MRI for fracture assessment, I will be happy to provide you with that literature.

Re: Stress fractures caused by ESWT?

Dr. David S. Wander on 2/04/05 at 21:17 (168531)

Dr. Z,

Just to set the record straight, if I have a patient that is not responding to conservative care for heel pain, and I suspect a stress fracture, I usually order an MRI, not a CT scan. This is because the MRI will show evidence of a stress fracture via bone marrow edema and some periosteal changes, and will also show any possible tearing or thickening of the plantar fascia or intrinsic muscles. Therefore, I find the MRI very useful since it covers several different possible pathologies. I published an article with the foot & ankle orthopedists from Hahneman University Medical Center in Philadelphia and the Radiology Department from Jefferson Medical School/Hospital in Philadelphia regarding this topic. However, from a 'purist' standpoint, if speaking of a test to look strictly for a stress fracture, a CT scan shows finer bone details than an MRI and is much more specific than a bone scan. The use of MRI is often more practical since it allows for the visualization of soft tissue structures and does not expose the patient to any radiation. Hopefully this makes my point a little more understandable.

Re: Stress fractures caused by ESWT?

Dr. Z on 2/04/05 at 21:45 (168532)

David
I am completely aware of the difference between MRI And CT and what they show. I just never heard any podiatrist state that CT is the gold standard for stress fracture confirmation
Are you saying that you order a CT instead of an MRI study when a patient presents for chronic plantar fasciosis and your history with physical examination indicates that a stress fracture may be present.
MRI resolution is so clear with the above clinical presentation.

I will order a CT for tarsal coalition, fractures, chronic bone injections and trauma.

Re: Stress fractures caused by ESWT?

Dr. Z on 2/04/05 at 21:49 (168533)

David
It makes it much more clear. I only asked about this because I didn't want posters runnning back to their doctors stating that CT is the gold standard and they must have a CT scan.
Would you please send me your article. I would like to read it.
Thanks

Re: Stress fractures caused by ESWT?

Dr. David S. Wander on 2/04/05 at 22:07 (168537)

Dave,

Hopefully my explanation above clears it up. I almost always order an MRI, since I'm usually looking for a stress fracture in addition to a possible tear or thickening of the fascia. A CT is the 'gold' standard when you are only concerned with bone pathology, since the bone architecture is visualized so well on CT scan. But once again, this is really from a purist position, since heel pain presents with pain from bone and soft tissue. The bottom line is that in the case presented, it is most likely that her stress fractures existed prior to her ESWT as you suspected, and the ESWT simply aggravated the pre-existing stress fracture. That's why it is certainly prudent to have a patient have an MRI prior to ESWT if there is pain with compression with the calcaneus to rule out a pre-existing stress/occult fracture of the calcaneus. In the paper we wrote, the outcomes didn't differ greatly in patients that had bone marrow edema, thickening of the fascia, etc., but it would be nice to know if a patient had a stress fracture prior to performing ESWT.

I believe that Denise has a copy of the article I wrote in my file at Excellence 'headquarters'. If not, let me know and I'll drop a copy at your house. It'll cost you a beer or a vodka.....your choice.

Re: Stress fractures caused by ESWT?

Bob C on 2/09/05 at 17:09 (168820)

Doctors - I appreciate all of your input concerning the stress fractures. I feel better knowing that the stress fractures were probably present prior to the ESWT. My wife insists that after the OS 'suspected' stress fractures it was a bone scan, not MRI or CT, that he used to determine that fractures were present.
My wife says she is getting better and is going about 6 hours each day without her air cast, but as I massage her feet each night I suspect that the pain is still there and she may just be trying to 'will' her recovery into being. She begins physical therapy tomorrow, although she began daily exercises after her initial evaluation last week. Hopefully this round of PT will be more beneficial than the last two. All we can do is cross our fingers and hope the nightmare ends sooner rather than later.

Re: Stress fractures caused by ESWT?

Dr. Z on 2/09/05 at 17:16 (168821)

If they think she has a stress fracture there should be no physical therapy to the heel ie ultrasound