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Cortisone better and less expensive than ESWT

Posted by Jan R. on 5/04/05 at 13:53 (174241)

I found this abstract in pubmed:

Porter MD, Shadbolt B.

Intralesional Corticosteroid Injection Versus Extracorporeal Shock Wave Therapy for Plantar Fasciopathy.

Clin J Sport Med. 2005; 15:119-124.

From the *Orthopaedic Department, Ipswich Hospital, Ipswich, QLD 4305, Australia; and the daggerDepartment of Epidemiology, Canberra Hospital, Garran, Australia.

OBJECTIVE: To compare the efficacy of low-energy extracorporeal shock wave therapy (ESWT) and intralesional corticosteroid injection (CSI) for the treatment of plantar fasciopathy present for at least 6 weeks. DESIGN:: A prospective, randomized, controlled, observer-blinded study over a period of 12 months.

SETTING: Primary care and hospital setting.

PATIENTS: A total of 132 patients were enrolled in the study, and 125 completed the study. Nineteen nonrandomized patients acted as a surrogate control group.

INTERVENTIONS: All patients performed a standardized Achilles tendon and plantar fascia stretching program. The patients were randomly allocated to either treatment group A or B. Group A received a single CSI, while group B were referred for a course of low-dose ESWT comprising 3 treatments over a period of 3 weeks. Group C consisted of 19 nonrandomized patients who performed the standardized stretching program only.

MAIN OUTCOME MEASUREMENTS: The worst daily pain recorded on a visual analogue scale (VAS), and the tenderness at the plantar fascia insertion as determined by an algometer. These measures were recorded immediately prior to the commencement of treatment and 3 months and 12 months posttreatment.

RESULTS: With regard to VAS pain scores, values for the CSI (1.48; 0-7) were significantly lower than both ESWT (3.69; 0-8), and controls (3.58; 2-5) at 3 months. At 12 months, VAS scores for CSI (0.84; 0-7) and ESWT (0.84; 0-4) were both significantly lower than controls (2.42; 1-4). The tenderness values at 3 months were significantly higher for CSI (9.42; 7-11) than both ESWT (6.72; 4-11) and controls (7.63; 6-9). P < 0.05 was used throughout.

CONCLUSIONS: Corticosteroid injection is more efficacious and multiple times more cost-effective than ESWT in the treatment of plantar fasciopathy that has been symptomatic for more than 6 weeks.

What is your experience with local cortisone injection?

Re: Cortisone better and less expensive than ESWT

Dr. Z on 5/04/05 at 14:26 (174244)

My experience is that local steriod injections are effective in the treatment of plantar fasciitis in combination with other treatments such as taping, orthosis nsaid. stretching, heat, ice etc.
Local steriod injection can and do cause increase pain, fat atropy, plantar fascia tear and or rupture.
I find this study not very practical since most of my patients have had local steriod injections by myself or from other treating physicians and have failed to achieve any temporary or lasting pain reduction.
So in my practice we don't typical have the clinical picture that was tested in this study, that being a choice between local steriod injections and ESWT. Our ESWT patients typical have had failure to achieve pain reduction with a course of local steriod injections and are in the need of either other treatment such as ESWT

Re: Cortisone better and less expensive than ESWT

elliott on 5/04/05 at 14:53 (174246)

Dr. Jan R,

If doctors consider cortisone injections to be so effective for PF, then perhaps it should be standard protocol, even mandatory (barring other preventative factors), to apply cortisone before administering ESWT. OTOH, cortisone might negatively affect the outcome of ESWT results, at least for low energy:



Re: Cortisone better and less expensive than ESWT

Dr. Z on 5/04/05 at 15:07 (174253)

How can you make patients undergone a specific treatment such as a local steriod ? Patients do have choices. Just as every patient isn't a candidate for ESWT such is the cases when deciding on injection therapy with a local steriod. Some patients just don't want a local steriod injection for many reasons

Re: Cortisone better and less expensive than ESWT

john on 5/04/05 at 22:14 (174273)


Please be careful. The Porter study gives another reason to stay away from low energy ESWT. It would be great if the researchers in Australia stopped studying failed protocols and started looking at FDA approved protocols. Buchbinder's JAMA study provided demonstrated that low energy ESWT does not work for plantar fasciitis. I, for one, do not see the need for further studies of low energy ESWT.

You might want to qualify your prescription to insist on cortisone injections before administering low energy ESWT since we do not know if the study's conclusion applies to high energy ESWT!

Re: Cortisone better and less expensive than ESWT

Dr. Z on 5/04/05 at 22:22 (174274)


I do want to add that low energy is very effective for non-insertional achilles tendonitis that fails to respond to conservative therapy. In fact you DON'T want to use high energy for this specific tendonitis
The most recent new FDA machine called the orthospec makes it very clear in their study that low energy doesn't seem to help plantar fasciitis . This may be the first head to head comparison between HIGH energy vs LOW energy with results, in this specific study, showing that LOW energy doesn't work as well as HIGH energy when treating plantar fasciitis

Re: Cortisone better and less expensive than ESWT

elliott on 5/04/05 at 22:58 (174278)

John, what's with all the dramatics? You obviously have an interest in backing high-energy ESWT, but that doesn't mean everyone here has to agree with you that high energy is so superior to low energy, or even that high energy works all that well for PF. I think the jury's still out, and that's after carefully reading the actual FDA reports and followups.

No, Buchbinder's JAMA study did not demonstrate that low-energy ESWT does not work for plantar fasciitis. It demonstrated that the Dornier device set on low energy used on patients with duration of symptoms as low as 6 weeks did not work. I wonder if Jan R, who published studies on low-energy ESWT, or Dr. Ed, who uses low-energy machines too, would agree with your sweeping statements as to the worthlessness of low-energy ESWT.

Re: Cortisone better and less expensive than ESWT

elvis on 5/05/05 at 01:10 (174283)

I had 3 cortisone injections (April, Sept. Oct 2004). The first one gave me complete releife for only 2 days. The second on I got partial relief for a day or 2. the 3rd one was hardly effective at all. So much for cortisone. It was worth a try though.

Re: Cortisone better and less expensive than ESWT

elvis on 5/05/05 at 01:13 (174284)

Eliot....dude, you want to make WHAT mandatory? Another Communist health care Nazi. Get a life!

Re: Cortisone better and less expensive than ESWT

john on 5/05/05 at 06:25 (174295)


I am tried of all of the research articles on low energy ESWT because insurance companies are using them to deny coverage for high energy ESWT. I would like to see studies using the FDA approved protocols from someone other than the manufacturer.

Don't miss the point of my post. I don't give much credit to another study showing low energy ESWT is no better than other techniques. There are enough negative studies on low energy ESWT. There are few high energy studies and all of them have flaws. It is time for the research community to explore high energy and settle whether the results of the FDA studies are valid.

Finally, your comment about the Dornier system is the first time that I have heard anyone state that the success of ESWT depends on the manufacturer and not the energy level. I do not know of one properly controlled studies comparing the results from two differnt macines and concluding that one machine out performs another. You are a man of facts. If you know of a study comparing machines, please give me the reference so I can read it.

Re: Cortisone better and less expensive than ESWT

Dr Ben Pearl on 5/05/05 at 07:10 (174297)

what was the average length of time the patients had p.f. before the study? How many shots?
It would also be interesting to see how high energy treatments fared and results after 1 year.

Re: Cortisone better and less expensive than ESWT

Jan R. on 5/05/05 at 09:13 (174301)

You should be ashamed.

Re: Cortisone better and less expensive than ESWT

Dr. Z on 5/05/05 at 09:30 (174302)

This is called heelspurs.com. USA, hyperspace, anything and everything is talked about. There are a mixture of doctors, posters etc. I see nothing for anyone to be ashamed about so long as they aren't doing this to hurt patients.
There maybe mistakes, misconceptions etc but discussions are always important. Ashamed is maybe not the best word. How about being Stupid about something that may fit better. I think that might be the word you were looking for.

Re: Cortisone better and less expensive than ESWT

Dr. Z on 5/05/05 at 09:36 (174304)

I just realized why the statement you should be ashamed. Believe it or not it is a term used very loosely by generations that are two generations post WW 11 in the USA. Sorry you are 100% Correct. We tend to use terms without realizing what they really mean. Stupid is still a good word.

Re: Cortisone better and less expensive than ESWT

Julie on 5/05/05 at 11:46 (174308)

Yes, a good word. Many, if not most, Europeans would respond as Dr Rompe has.

Re: Cortisone better and less expensive than ESWT

Dr. Zuckerman on 5/05/05 at 15:01 (174313)

I agree with you Julie. These are words not to be taken lightly

Re: Cortisone better and less expensive than ESWT

elliott on 5/05/05 at 15:23 (174314)

Dr. Z, I agree. That many Americans may use it loosely doesn't make it right or acceptable.

One thing I'm curious about. For your first post, before you checked, did you think Dr. J was addressing someone else for his comments on low energy, or did you think he was addressing me for suggesting cortisone be mandatory before ESWT? Gotta know. It was just an idea, a suggestion, I didn't mean no harm, honest, so sorry, humble apologies...


Re: Cortisone better and less expensive than ESWT

Dr. Zuckerman on 5/05/05 at 15:59 (174315)

I though it was the ENITRE discussion about low energy, steriods etc. The entire thread.

Re: Cortisone better and less expensive than ESWT

Ed Davis, DPM on 5/05/05 at 19:09 (174334)

We have been struggling with the concepts of protocols and treatment flow sheets for years.

First of all the term 'cortisone' should be avoided becasue it refers to a broad range of substances under the heading of catabolic steroids (as opposed to anabolic steroids used to build muscle tissue).

Dexamethasone phosphate is an example of a short acting steroid. It has powerful but shorting acting anti-inflammatory and anti-allergy properties.

Triamcinolone acetonide is an example of a long acting steroid. It has powerful atrophying properties (helps atrophy scar tissue and all tissues it touches), is quite catabolic but is only weekly anti-inflammatory.

Celestone soluspan is a combination of short acting betamethasone phophate and intermediate acting betamethasone acetate.

We cannot even begin this discussion until we can discusss a specific substance or perhaps, a combination of substances.

One virtue of a powerful anti-inflammatory is to allow one to resume normal gait as gait alteration may lead to further injury.

One virtue of a long acting steroid is the ability to 'thin out' scar tissue.

Typically, neither type of 'cortisone' leads to a long term cure of chronic plantar fasciitis but can 'cure' acute plantar fasciitis.

Often, one may look at these substances as treatment adjuncts in chronic plantar fasciitis, not primary treatments.

As always, never focus on one modality or substance as a solitary cure.

Re: Double blinded peer reviewed studies

Ed Davis, DPM on 5/05/05 at 19:17 (174337)

If we subjected the entire body of medical knowledge top double blinded peer reviewed studies we could toss out about 3/4 of what docs do. The FDA has a legitimate function but it cannot even come close to determining efficacy of the vast majority of medical treatment. Considering the limited resources of the FDA, their dollars would be most efficiently spent on issues of safety (drug or device) and ensuring potency and putety of drugs, neutriceuticals (an 80 billion dollar industry).

One day, if the 'first world' countries can get their 'act' together, the duties that the FDA is literally nibbling at could be assigned and apportioned to similar agencies throughout those countries.

Re: Cortisone better and less expensive than ESWT

elvis on 5/06/05 at 20:40 (174416)

Well I am not ashamed and maybe you should be ashamed. I don't know where you're from but calling someone a healthcare Nazi has nothing whatsoever to do with Hitler and WWII. In America any radical group forcing their ways on the masses is called a 'blank-Nazi'. Case in point some radicals want to force people to eat or not eat certain things. They are the 'food Nazis' and some of these folks want to tax or completely prohibit certain foods and beverages. Some people want to ban certain words from being spoken or printed. They are the 'word-Nazis'. So you see it has nothing to do with the abomination - Hitler. And if you;re from Euorpe I thank you in advance for the help America gave to its allies in WWII. The reason I called Eliott what I did is because he came up with a preposterous suggestion that cortisone shots should be mandatory in the treatment of ESWT or at least before ESWT. Elliott of all people who nitpicks others' words should be ashamed of his 'proposal' as Dr Z said was stupid. I agree with Dr Z that the whole thread was stupid including my post. My country is based on liberty and personal freedoms. Apparently yours is not. The price we pay for liberty sometimes comes at a cost. Heated debate is not bad. I understand you didn't like what I said however you took it completely out of context in addditoion to not understanding a word of what I said. That's OK with me but I am cetainly not ashamed of what I said. I totally expect to hear more whining but that's OK too. You have a right to whine.

G'Day to you.

Re: The power of words

Julie on 5/07/05 at 01:43 (174425)


There are some words that, if used thoughtlessly and without recognition of their original meaning and context, and of the punch that they still pack for anyone who experienced, or remembers, or even just knows and cares about what happened during the Second World War. One of them is 'Nazi'. (Another is 'holocaust'.) The fact that these words are commonly used as thoughtlessly as you describe doesn't make them less offensive.

I don't question your right to use the term if that's what you want to do, but maybe you should be a little more aware of how it strikes other people when you do, and a little more considerate.

As for heated debate, no, it's not bad, but mud-slinging insults (like 'My country is based on liberty and personal freedoms, apparently yours is not') don't really qualify as 'debate'.

Re: The power of words

elvis on 5/07/05 at 23:43 (174460)

I'll tell you what........I'll be sure not use the 'N' word again on this website so I don't offend any sensitive readers. OK? From now on I will substitute 'police' for you know what word!! Healthcare Police! Food Police! Word Police!




Re: The power of words

Ralph on 5/08/05 at 09:55 (174478)

If you just can't help yourself then I guess you'll just have to use the word police. Many of us appreciate and understand the fact that people have no control over their fingers:* Flash and before you know it the word is typed.

Re: Cortisone better and less expensive than ESWT

VINCK on 8/22/06 at 04:35 (208106)

I agree about high energy being effective. I have treated over 75 PF cases and a 18 month follow-up show <75% still having good results.