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question regarding appropriateness of ESWT

Posted by elliott on 2/23/05 at 23:58 (169767)

A secretary in my office has had PF since November 04. She's gone thru numerous treatment protocols (NSAIDs, icing, stretching, shoe change, OTC inserts, custom orthotics, one cortisone shot) in that short period of time. (Two interesting tidbits: 1) her stretching, as recommended by her pod, includes the standing wall stretch; 2) she claims it was the OTC inserts that gave her the most relief, and that no additional relief was provided by the customs.) Her first-step-in-the-morning pain is gone, she is now 75% better, but the improvement has noticeably leveled off, and she wants to get rid of that final 25%. Her pod is already talking about possibly trying ESWT.

My question is, even if they wait till the 6-month minimum recommended for ESWT, do you think she is an appropriate ESWT candidate at that point? Or would you say, she's had tremendous relief in such a short period of time, the pain is bearable, continue with the inserts, just wait up to say a year or so and it likely will heal naturally by itself, just as it does with so many other people?

elliott

Re: question regarding appropriateness of ESWT

Dr. Z on 2/24/05 at 00:51 (169769)

What is her VAS. How much pain does she have with clinical palpation. Is United in her state. Common sense in her doctor head ? I have a better question your secretary is in severe pain has tried casting, orthosis , local steriod injection,nsaid, VAS 10/10 Duration of treatment three months. Would your physician try ESWT.?

Re: question regarding appropriateness of ESWT

elliott on 2/24/05 at 10:09 (169786)

Well, even if her VAS was 10 to start with (which I doubt), since she is now 75% better, now it's no more than a 2 or 3. It all seems so rushed to me, including the cortisone shot. So many get better with the passage of several months that it just seems premature to rush things like that.

Regarding your scenario of maximum pain, 10/10, for 3 months, if it's likely she'll get better in the next few months, one could still make the argument to wait, especially since ESWT does not necessarily offer instantaneous relief either. Regardless, I believe there is some literature claiming ESWT is less effective for PF of such short duration. Perhaps all the above are reasons for the 6-month guidelines.

Re: question regarding appropriateness of ESWT

Dr. Zuckerman on 2/24/05 at 12:23 (169796)

Elliott,
It sounds like she is almost 100% and that quick effective treatment by her podiatrist has reduced her heel pain to 75% reduction in pain. Why do you think she is so rushed her conservative treatment is helping her alot

Re: question regarding appropriateness of ESWT

elliott on 2/24/05 at 12:29 (169797)

I think it is rushed because

a) her pod wants to do yet another cortisone shot, let alone the first

b) he is already talking about ESWT at 3 months, after 75% improvement.

elliott

Re: question regarding appropriateness of ESWT

Dr. Zuckerman on 2/24/05 at 12:38 (169800)

I will sometimes educate patient about ESWT now so that down the road they won't feel that this is the end with conservative treatment or that surgery is something that is the only solution. In fact it is a very good idea to provide a complete plan of action at the beginning and why you do every treatment at each step

The use of cortisone should be used early if at all. You want to reduce inflamation as soon as possible

Very hard to judge the doctor's treatment without an examination but getting the pain down to 75% reduction should make this person happy. The real question is the very subjective 75%.
Tell your friend about the plantar fascia stretch and wrap her foot with flexbile coban it could make the difference

Re: question regarding appropriateness of ESWT

elliott on 2/24/05 at 17:49 (169824)

Dr. Z, I find very interesting your recommendation to use cortisone early. I presume you are assuming PF is initially a fasciitis (with inflammation) and only afterward a fasciosis. I'm not saying you're wrong or that what you're saying doesn't have merit, but I'm not sure that opinion is universally accepted, and even if true in some cases whether universally true. Regardless, there is already a decent amount of literature about whether to try cortisone or ESWT first, suggesting cortisone comes much later in the process. My own reservation is that with PF rupture resulting in around 6-10% of cases depending on who is doing the shooting, it makes sense to try other conservative measures (including just waiting it out for a while) before taking on such risk.

Re: question regarding appropriateness of ESWT

vince on 2/24/05 at 17:52 (169825)

In what study(s) did you find the info that ESWT causes PF rupture in 6-10% of cases?

Re: question regarding appropriateness of ESWT

elliott on 2/24/05 at 18:39 (169835)

Vince:

Not ESWT. Cortisone.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9498581

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Re: question regarding appropriateness of ESWT

Dr. Z on 2/24/05 at 20:08 (169841)

Elliott,
Cortisone is used in the acute phase of a fasciitis or tendonitis. It is pretty standard practice to try a local steriod early on in the treat plan as opposed to later. Trying a local steriod injection in the chronic phase may be one of the reason why there is a rupture. Using additional local steriod injections is another issue. The 6-10 rupture rate was with an average of two local steriod injections. Also note that you don't use steriods are a single treatment but in conjunction with other treatments, taping, orthosis, stretching etc.
Waiting it out when the pain is high only causes only lower extremity compensation pain.

Re: question regarding appropriateness of ESWT

Ed Davis, DPM on 2/24/05 at 20:18 (169842)

Elliott:

I think you have presented a case illustrative of the coverage dilemna for ESWT at times. While it is true that ESWT is less costly than surgery, because the downside to the patient is so minimal, the potential for this to be a high demand procedure certainly exists. There is no easy answer to your question in that we are asking basically how far one should go in treatment. Bill Fallon, MD, the 'father' of ESWT in WA stated in a lecture that if he got someone down to VAS 4, he was satisfied and 'declared' a cure. Many, at level 4 would state that that is enough to get through the day but not enough to allow a game of tennis after a day standing at work. Until we place the decision making more heavily into the hands of the patient, it is difficult to have criterion that is cost effective as a third party payor.

If it was my foot, I would probably opt for ESWT but I would do it with low energy, very economically, but that is a whole other 'bag of worms.'
Ed

Re: question regarding appropriateness of ESWT

elvis on 2/24/05 at 22:27 (169851)

Dr. Davis.......why would you opt for low energy ESWT first? From what I've read it doesn't appear to be very effective. The sports chiropractor I go to in Encinitas, CA has had 3 people try the Sonorex treatments here in San Diego. It helped none of them in any way, shape or form. I know 3 strikes and you're out in baseball but what if anything should I take away from my chiropractor's 'experience' with Sonoroex? I'm opting for the Dornier protocol.

Re: question regarding appropriateness of ESWT

Rob M on 2/24/05 at 23:48 (169852)

Dear Elvis

Sorry for jumping in, but was Ultrasound used for guidance with the Sonorex treatments? Was anesthetic used?

Rob Mitchell
PainFree ESWT
1 866 444 3798

Re: question regarding appropriateness of ESWT

elvis on 2/25/05 at 01:44 (169857)

I didn't have ESWT. I was just asking Dr. Davis why he would opt for low energy ESWT for a first course of treatment.

Re: question regarding appropriateness of ESWT

elliott on 2/25/05 at 11:02 (169873)

Dr. Ed, thanks for your insightful comments. I can't help but get the feeling that docs making some of their livelihood off of ESWT would be inclined to use ESWT earlier than someone else in more objective circumstances. Most PF patients are not at a level 10 pain, and many are not in pain all the time (e.g., while sitting). They are just annoyed with the whole thing and that it takes a while to get better. But most do get better in time. So let them heal if they will, especially someone making progress. The average time it takes for ESWT to work anyway, the money involved (to both the insurance companies and to the premium-payers they pass the expense on to), and yes, even the ESWT success rates when you minus out those who would have got better anyway in an cceptable amount of time, are relevant. I know about 20 people personally who had PF and they all got better in time. It took a couple of them (both runners) with severe cases several years, but the rest got over it within, say, a year or less.

Re: question regarding appropriateness of ESWT

elvis on 2/25/05 at 12:57 (169882)

Elliott......I just turned 51. My midlife crisis was running marathons. I started in Dec 2001 and ran 8 marathons ending in Dec 2003. While I had little bouts of pf it always went away with ice, 2 days rest and some ibuprofen. After my last marathon it got progressively worse slwoly but surely. In Jan 2004 I reduced my mileage. In Feb 2004 I stopped running and went on the usual conservative treatments,ie, rest, stretching, taping, Medrol Doespak, night splint, cortisone inj #1, cast (a total disaster), chirpractor (deep tissue massage, electric stim, ultrasound, etc) accunpuncture, 2 more cortisone inj, more stretching, rest, blah, blah, blah. I am now redy for ESWT and wish I looked into this about May of 2004.

Re: question regarding appropriateness of ESWT

Ed Davis, DPM on 2/25/05 at 13:28 (169885)

elvis:
Keep in mind that Canada and Europe migrated to low energy years ago because they found it to be effective and cost effective. High energy ESWT is a fairly large cost item so the dollars involved in marketing high energy (criticizing low energy) has, for the time being, won the day in the US.
Ed

Re: question regarding appropriateness of ESWT

Ed Davis, DPM on 2/25/05 at 13:31 (169886)

elliott:
Thank you. I think that there are definitely several variations on a theme. Those with acute PF basically may have a strain on the plantar fascia which will self resolve like a sprain.

Can people with chronic PF go on to resolution. Yes, if the plantar fascia has sufficient elasticity to allow a modest lengthening of the ligament (a lot comes back to tissue quality).
Ed

Re: question regarding appropriateness of ESWT

Dr. Z on 2/25/05 at 18:30 (169917)

There are many patients that gets a decrease in pain within one week following ESWT. There is a protocol for ESWT that is used by insurance companies in order for payment to occur so your feelings about over use can't happen. Letting it heal is a good idea in some cases and in some cases it a very very bad idea. ESWT is just like any other treatment its use is very benefical when used properly by a skilled physician. Pain is so subjective and no one can really appreciate levels of pain except the patient so trying to tell a patient to wait a few years is something most patients wouldn't be very happy to hear.

Re: question regarding appropriateness of ESWT

Dr. Z on 2/25/05 at 18:31 (169918)

Ed,
I though that ESWT in Europe and Canada started with low energy for tendopathies. The only reason high energy is expensive is due to the use of an ASC

Re: question regarding appropriateness of ESWT

PodinFla on 2/27/05 at 21:01 (170093)

I see a ton of classic PF as does 99% of all practicing podiatrists. In my office, if your receptionist is stating that she is 75% better. Her morning pain is essentially gone and the prefab orthotics are really helping, then I would have her continue with the current therapy. In addition, Dr. Z is right about educating patients about treatment modalities. It is our duty to discuss all treatment options with every patient that walks in the door. I have several patients who come into my office every week that ask about so and so treatment be it ESWT, Sclerosing Injections, the Wound Vac etc.... I don't believe the guy was trying to push ESWT or another injection or whatever. He is probably just discussing other options if the condition doesn't get better. The ones you have to be afraid of are those who discuss surgery initially without any recommendations of conservative care. This goes for all podiatric conditions that we see on a daily basis. I practice in a large orthopedic surgery group that is associated with a hospital. Typically the only patients I will discuss immediate surgery to are those who are referred to me by vascular surgeons for amputation of a toe or a portion of their foot due to gangrene or a limb / life threatening infection. Anyway, I've been a lurker on this board for a while. I enjoy the dialogue. This is a very useful site and I do send my patients to it. Hopefully, their supporting the site by buying the Powerstep orthotics that are advertised on here.

Re: question regarding appropriateness of ESWT

Dr. Z on 2/27/05 at 21:17 (170094)

Hi

Feel free to join in at any time !!!!!

Re: question regarding appropriateness of ESWT

Ed Davis, DPM on 3/07/05 at 14:19 (170624)

Elliott:
Techincal difficulties pervent us from doing so but a more logical crtierion for when to use ESWT should be based on tissue quality. The only measuring device that gives us a fair picture is sonography -- looking at plantar fascial thickness. Nevertheless, I feel that after a few years I can take a fairly educated guess, looking at sonograms on those people who have a tissue quality problem. Sonograms are cost effect enough to be the right tool but the learning curve (to really glean all relevant information) is a bit steep. I look at plantar fascial thickness but also at fiber orientation (normallly aligned vs. random) and look at things like hypoechogenicity, a sign of tissue breakdown often associated with lack of parallel fiber orientation. Perhaps a small 'corps' of musculoskeletal ultrasasound specialists could be trained but that may be prevented by turf battles.
Ed
Ed