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recent meta-analysis on ESWT

Posted by elliott on 5/16/05 at 16:23 (175142)

An article doing a meta-analysis on ESWT studies to date to determine effectiveness was published a few weeks ago. The entire article, including a pdf version with built-in charts, is available on-line:


Any comments?


Re: recent meta-analysis on ESWT

Dr. Zuckerman on 5/16/05 at 17:32 (175147)

Systematic review of the management of heel pain has highlighted the paucity of evidence for managing the condition. The review concluded that treatments used to reduce heel pain, including steroid injections, NSAIDs, night splints, orthoses and stretching regimes, seem to bring only marginal gains ?

Seems to bring only marginal gains.? I don't understand what this statment means. Does it mean that conservative treatment doesn't work

Re: recent meta-analysis on ESWT

Ralph on 5/16/05 at 18:46 (175149)

I don't know how you do it but you certainly find some really good but technical articles. I read the post through only one time and will go back and reread it again.

I didn't really get all the charts, but do I understand the conclusion that ESWT is NOT effective or did I misread this article.

In the past you did an excellent job taking articles that you found and put them into very simple terms. If you have the time maybe you'd be willing to go through some of this post with me especially if I'm not reading it corrrectly.

Re: recent meta-analysis on ESWT

Dr Ben Pearl on 5/16/05 at 19:52 (175151)

The studies in the meta-anaysis are all over the board in terms of design, machine, doage.
I don't think this snapshot tells us what we are looking for, we need consistency amongst the studies in order to draw a rationale conclusion.

Re: recent meta-analysis on ESWT

john on 5/16/05 at 21:16 (175156)


The article you referenced makes the classic mistake of treating all ESWT the same, ignoring differences between high energy and low energy and between inclusion criterion. It also makes the mistake of treating all articles with equal weight, regardless of their authors. As a result, the study's conclusions are suspect.

I find it troubling that the authors give so little weight to FDA studies conducted by orthopedic surgeons from leading US medical institutions like Harvard.

I was recently looking at credentials of the authors for some of the ESWT articles used in the Meta analysis. I find it interesting that articles ignored author credentials in analyzing the results.

For example, Dr. Theodore is an orthopedic surgeon who lead the FDA study on the Dornier machine. He is the head of foot and ankle surgery at Mass General, a Harvard teaching institution. Harvard is one of the leading medical institutions in America and in the world!

On the other hand, Rachael Buchbinder is an epidemiologist at Monash University. Monash University ranks 46 among Asian universities.

How can a negative article by Dr. Buchbinder be given the same crediability as a positive article by Dr. Theodore?

In my honest opinion, I give higher crediability to articles written by professors from Harvard over articles written by professors from Monash University. Rankings matter! It is hard to imaging how a 46th ranked Asian univeristy would rank in the US but I would guess that Monash would be at the level of a good community college in the US!

Finally, it takes a very smart person to get a teaching position at Harvard and such a person must have integrity. I find it unbelievable that the meta analysis suggested that the Harvard FDA study was less than honest because it was sponsored by Dornier.

Just my thoughts on the article you posted.

Re: harvard medical school

Scott R on 5/16/05 at 22:10 (175158)

I don't disagree with john's post, but if you've ever read literature coming out of harvard, it's easy to see they're completely controlled by pharmaceuticals and would not advise you to take a nutritional supplement if your life depended on it.....and it does. I've seen them explain 2 huge studies on selenium and how it reduces all forms of cancer by 50% with no significant drawbacks and yet by some twisted logic they advise against taking it.

Re: recent meta-analysis on ESWT

elliott on 5/16/05 at 22:24 (175159)

Dr. Z, good question (when citing passages, if you could use quotation marks, that would make your point easier to grasp). By doing an internet search, I found the abstract of the reference cited, which makes things somewhat more clear:



Re: recent meta-analysis on ESWT

Dr. Z on 5/16/05 at 22:35 (175162)

Here is my concern with this article. I see a battle of what is called evidence based medicine vs experience based medicine vs what our eyes, ears tells us over the many years what really works and what doesn't. I do feel evidence based medicine is what we should work toward but in reality alot of good medical procedures are going to be avoided and the patient will suffer in the end. You can quote me someday if you want too!!

Re: harvard medical school

Dr. Z on 5/16/05 at 22:37 (175163)

Just my point. We can't leave out of the poor suffering patient who means pain relief.

Re: recent meta-analysis on ESWT

elliott on 5/16/05 at 22:39 (175164)

Dr. Pearl:

Just about any meta-analysis is all over the board, as there are always great differences in methodologies between studies and at least minor flaws in some. That's why the authors make decisions as to which studies to include and which not, and one can then agree or not agree. Rather than be perfect, the meta-analysis is meant to give a feel as to whether the treatment is effective in an overall sense. In the case of ESWT, one rationale for including a broad range of studies is that there still is not much evidence as to what is or is not the ideal protocol. Yes, an argument could be made that e.g. high-energy studies should be kept separate from low-energy studies. At the same time, those who believe firmly in the validity of low energy might disagree. See my other posts in this thread.

Re: recent meta-analysis on ESWT

elliott on 5/16/05 at 23:58 (175165)


Decisions must go into every meta-analysis. You disagree with some of them, and that's fine. Whether that negates the overall conclusion is another thing. Not sure why negative outcome per se should be weighed less than positive outcome as you seem to suggest.

I for one am not at all comfortable with a company sponsoring its own study, no matter who the researchers are (and this can be even worse when the financial arrangements are not spelled out to the public). Bias has been shown to occur way too often with such setups. Think about it: on the one side, a negative result and that leading researcher or institution is forever shunned from gaining (sometimes free) use of the technology and sharing in the potential profits; on the other side, give it your blessing and take your cut. As an example, one of the main researchers for the Dornier FDA study, well-respected, is now a consultant for a major ESWT provider. I am not questioning his character or motives. I am just saying that in an ideal world, avoiding this possibility would give more confidence in the study.

Addressing your very point about separating high and low energy studies, the 2005 BCBS TEC report on ESWT (which includes a similar meta-analysis with a similar conclusion) also gives separate statistics for just the two high-energy studies, just as you ask, and the results are still unimpressive. Could you and Ralph and any others who might be interested read this new BCBS report and give your comments? Even if you assume BCBS to biased against treatment, statistics derived fairly should not lie. If there are weaknesses in their argument, perhaps you could point them out. Here's the link:



Re: recent meta-analysis on ESWT

Dr. Z on 5/17/05 at 07:04 (175169)

The same can be stated about the Blue Shield Tech report. Who pays for the doctor-member?

My question and I haven't research this yet is what new techincal procedure has the Blue Shield Tech committee approved at all in the last two years. I know that the new disc implant and ESWT for everything hasn't made the grade with them
We all know someone or some family member that has been denied healthcare benefits due to money. I would be very careful accepting anything that any Blue Shield report produces. There is just too much finanical risk for any report to have a postive outcome.
I see the war between clinical experience and so called evidence based medicine being the next HMO phase is the war to seek more insurance profit and less patient care.
I go back to my unquoted statement about conservative treatment for heel pain. If this piece of literature was used by a Blue Shield Tech report the use of almost any type of conservative therapy except sit home on your A wouldn't make the grade and there would be no Insurance payments. So my point was we all know someone who has benefited from the conservative treatment of heel pain and that the most individual studies show a very postive use of conservative therapy so how come some meta- study is now useing this piece of literature at all. Very interesting.
Sometimes there are report that come to the conclusiont first and then dig up the literature to support their conclusion. Just something to think about.

Re: recent meta-analysis on ESWT

john on 5/17/05 at 07:46 (175170)


In an ideal world there would be no bias. From my perspective, there is bias and just as you have problems with company sponsored studies, I have problems with insurance industry sponsored analysis. Insurance companies have an incentive to keep their money and not pay for new technology so they are much more likely to hold a new technology to an unrealistically high standard.

I'll look at the new TEC report but I remember that in the past the TEC criticized the FDA studies because there was not a dramatic effect on function from ESWT. However, it is my understanding that plantar fasciitis patients do not suffer significant decreased function as a result of their pain so how could the TEC expect ESWT to improve function. I also question why they do not give more weight to Theodore's one year follow up study. The statistics in that study look very good.

I am critical of including high energy and low energy because there are conflicting low energy studies. These conflicts lead me to believe a uniformly successful low energy protocol does not exist.

The fact that a researcher becomes a consultant for an ESWT provider supports the argument that these providers need all of the help they can get in dealing with insurance companies. I would be more worried if the research became a consultant with a manufacturer. It is ridiculous to suggest that the research was tainted because a research is now affiliated with an ESWT provider because the ESWT provider did not even exist during the FDA trials so there is no possibility that the potential consulting job tainted the research!

Just my two cents, ESWT seems to work for many people. Regardless of any additional studies, insurance companies can continue to deny coverage based on European studies. It bothers me that insurance companies can base their denials on studies using non-FDA approved protocols. It seems like and an 'apples-to-oranges' comparison and it is unfair to patients who might benefit from ESWT using FDA protocols.

Re: recent meta-analysis on ESWT

Ralph on 5/17/05 at 08:21 (175172)

Front page Wall Street Journal Tue. May 10, 2005
' New Protocol
Worrisome Ailment in Medicine:
Misleading Journal Articles'
By Anna Wilde Mathews

'Doctors and patients who rely on articles in prestigious medical journals for information about drugs have a problem: The articles don't always tell the full story.

Some omit key findings of trials about a drug's safety and efficacy or inconvenient details about how the trial's design changed partway through.

A study published in the Journal of the American Medical Association last year reviewed 122 medical-journal articles and found that 65% of findings on harmful effects weren't completely reported. It also found gaps in half the findings on how well treatments worked.'

The article goes on for 2 pages. If you haven't seen the article it may be of interest to you. Here is another qote from it.

The JAMA study last year said articles often cherry-picked strong results to report, even if those results were in a different area than the study was designed to test. Typically scientist set up clinical trials to answer one or two primary questions. (examples provided in the paper). These are called primary outcomes. The JAMA study found that 64% of trials had at least one primary outcome that was changed, added or omitted'.

The article was speaking to recent drug recalls relating bias or 'cherry picking' of outcomes when studies are sponsored by the manufacturer.

Re: recent meta-analysis on ESWT

Dr. Zuckerman on 5/17/05 at 08:44 (175175)

I find that alot of patients that have plantar fasciitis suffer from dramatic reduction in function. Due to the severe first step morning pain or pain after sitting for any lenght of time they realize that there is a direct relationship with increase activity causing increase first step morning pain and reduce their daily acativity. In addition there are alot of patients that suffer compensatory pain in the foot, ankle, knee and other lower extremity joints
I would like to see one of the end point whether primary or secondary to be what activities have you not beable to do and now can do after ESWT treatment. This to me would be an indication of function

Re: recent meta-analysis on ESWT

elliott on 5/17/05 at 10:02 (175178)


I do not accept your reasoning regarding researcher bias. Even if there is no hidden arrangement or offer, if a researcher concludes to throw the device in the garbage, he is cutting himself off from potential future profits. If he gives the thumbs up, he is at the forefront of it all and a logical choice to be given a position offering compensation, as indeed it has turned out with some of them. In short, there is an incentive to give a favorable review.

Please read the BCBS report, and in particular the stats for the high-energy studies, which is exactly what you requested. Again, even if BCBS is biased--and I can agree with Dr. Z's statement that BCBS in general would be reluctant to approve treatment (but will also point out that it is we who pay for health care that are absorbing the costs of new treatments, not the evil BCBS), if the stats were produced in an objective, fair, and appropriately applicable way, they should still be illuminating.

Since you want to focus just on the FDA studies (would you care to disclose your own interest?), perhaps you'd care to comment on my own reservations about them. As long as we're having a discussion on meta-analyses and the like, I take it you're at least receptive to such a discussion. Hopefully, you can offer a response better than the tiring 'how dare you challenge FDA approval?' (How dare a researcher publish a meta-analysis on FDA-approved studies! How dare the journal publish it!) I am not challenging FDA approval. There is no contradiction between FDA approval and results less than stellar.

Here are some of the problems I have with the FDA studies:

1) There was a long list of carefully selected tests for the Dornier. Here are the tests and their 3-month results.


1) VAS improvement from baseline in first few minutes of walking in the morning: MARGINALLY statistically significant.

2) At least 60% improvement in pain while walking the first few minutes in the morning: NOT statistically significant.


1) AOFAS Ankle-Hindfoot Scale: NOT statistically significant
2) 4-point R&M: YES statistically significant
3) SF-12 health status questionnaire: NOT statistically significant
4) Heel pressure test: NOT statistically significant
5) ROM assessment: NOT statistically significant

Even the pre-selected primary outcomes were disappointing to say the least. Basically, the only really convincing test was 4-point R&M. An objective observer could just as well say that in totality, the evidence is not all that convincing. The published journal study attempts to offer some after-the-fact rationalization as to why some of the other tests came out negative, but one could just as well if not easier defend the opposite view.

2) I even find the 4-point R&M results somewhat disappointing. First of all, the treatment group did no better (in fact worse) at 3 months in the Excellent category than the placebo group, so this whole result is based on more active patients reaching the 'Good' category. No one is saying that everyone is completely 'cured' at 3 months, but I still find this result surprising- after all, 3 months is the end of the blinding period and a decent interval that you'd think at least a number (more than random) would be totally cured by then, as many providers' web sites suggest. Another mitigating factor is that more of the placebos started in Poor (the lowest category) than did the actives. Yet another is that this was just one among many tests (making it easier to pass at least something). Yet another is that this test was then highlighted after the fact mostly to the exclusion of the others. I just don't find all this that inspiring.

3) Now to the Ossatron. While its initial study design was impressive and made in good faith, it turned out that 3 out of 4 of their test results (all primary) were not all that impressive either. Complicating matters is their inexcusable lack of clarity in their published reports.

4) I have a major reservation regarding Ossatron vs. Dornier. The one test Ossatron claimed was most important (and they gave reasons why, e.g., less patient bias, although counter-arguments can be made) was of course the one that scored by far the best. By contrast, Dornier's heel pressure test was not significant at all -basically identical numbers to the random group. You can't have it both ways: is the heel pressure test an important measure or not? If yes, Ossatron scores points and Dornier looks very weak; if no, Ossatron is basically out the window. (This highlights the danger in getting carried away over one test and which one it is.) If this sways things, one of the two primary outcome measures of the newly FDA-approved Orthospec was the heel pressure test (page down in the link below):


Please address my four specific reservations. Thanks.

I do not have a problem if ESWT is proven effective. I have no financial interest in or any other connection with ESWT--I ended up here due to major foot troubles. Aside from wishing there was a bit more balance and accuracy on this board, I just honestly feel that ESWT is nowhere near as impressive as being made out, that a rather small number of people are being helped, that moving from say an 8 to a 3 on a 0-10 VAS as compared to moving from an 8 to a 4 or whatever for the placebo group is just not what either expert or layman would call that impressive.


Re: recent meta-analysis on ESWT

Dr. Zuckerman on 5/17/05 at 10:45 (175179)

This discussion could go on and on. The real discussion should be between actual doctors with clinical experience. Doctors who see results with ESWT and see complications with foot surgery.
I do have one very important issue with your statement that ' I do not have a problem if ESWT is proven effective' ESWT has already been proven effective when they received FDA approval

' Aside from wishing there was a bit more balance and accuracy on this board, I just honestly feel that ESWT is nowhere near as impressive as being made out, that a rather small number of people are being helped, that moving from say an 8 to a 3 on a 0-10 VAS as compared to moving from an 8 to a 4 or whatever for the placebo group is just not what either expert or layman would call that impressive '

The problem with your view point is you have no experience with the treatment of chronic plantar fasciitis or how difficult and painful it is to see patients every day in pain So the bias you have is your background in numbers is being used to review ESWT treatment studies. If you saw the type of complications that we as doctors see from plantar fasciitis treatments and the chronic pain that has been resolved with ESWT you view point may be different.

Re: recent meta-analysis on ESWT

elliott on 5/17/05 at 11:22 (175182)

Dr. Z,

Other than occasional interjections by me and a few others, you basically already have what you want here: an ESWT discussion among wildly pro-ESWT doctors and other financially affiliated parties, which hopefully for you will translate into more patients coming your way. Just send them a packet. Newspaper articles have quoted you as saying 90% percent of your business is in ESWT. You're the objective voice we should trust? The typical pod I've seen is seeing patients three days a week, is in surgery the other two, and has no time--during the day, no less--to post on boards like these. Even among pods I've seen who provide or can arrange for ESWT, they are nowhere near as pushy or gung-ho about it as you are. And leaving it up to you the doctor with clinical experience has not exactly equated with accuracy, even with the basic facts.

The purpose of clinical trials is to try and give a dispassionate, objective view of efficacy, a worthy cause, your appeal to sentimentality aside. You seem to go back and forth, using controlled trials as evidence when convenient, and discounting controlled trials as evidence when convenient. Like I said, you can't seem to accept that meta-analyses are even taking place let alone a discussion on them given lofty FDA approval. Maybe John can.


Re: recent meta-analysis on ESWT

Dr. Zuckerman on 5/17/05 at 11:52 (175183)

I must be good. I see 20-25 new patients per week, ESWT medical director for Excellence Shockwave Therapy. Teach three- four times per month. You have no idea how many hours I practice. I also do surgery almost every day of the week. Superpod !. At one time they called me the Wizard of this board but that before Metafoolish studies were introduced. Come on a study is very simple. Here is the Dr. Z primary endpoints
1. List what you can't do now
2. List what you can do now post four months after treatment
3. Would you recommend this treatment to other patients
4. Do you feel that your money was well spent
5. Do you know Elliott ( I want to make sure that you don't have plants in my study)
6. Rate you results are Excellent, Good, Fair , Poor. We would have a definition for the patient to use.
I am not asking you to trust me I could leave this board today and it would have no finanical effect on myself period. Pushy ? You bet I am when there is a decision between having ESWT and Plantar Fascia Surgery.
When you have seen the horrific complications that Plantar Fascia Surgery can cause you would be as you call it pushy.
You missed my point. The dicussion should be between doctors and not stat people or people that are working for insurance companies. Our guardian of healthcare is the FDA and that test whether you agre or not has been PASSED

Re: recent meta-analysis on ESWT

Ralph on 5/17/05 at 14:04 (175189)

Dr. Zuckerman,
My question is a simple one based on what doctors like yourself have seen and experienced. If indeed Podiatric Medicine is seeing horrific complications regularily due to Plantar Fascia Surgery why do Podiatrist still continue to do them?

'Do no harm' is the doctors creed yet Podiatric Medicine apparently is very willing to turn a blind eye to this procedure and instead willing to continue seeing horrific results happen to their patients by their own hands. They just can't say NO.

I can't remember which Podiatrist posting here said they make far more income doing a surgery than performing ESWT, but ME thinks in the long run the added income from in office ESWT or traveling ESWT is a pretty good size income carrot waved before doctors when companies like the one recently cited by the FDA asks them to joint a group. The amount posted on their website as added yearly income if I remember correctly was six figures. I can't remember if that was for treating one patient per week or per month but it wasn't pocket change. Added or even replacement income generated by using ESWT without the time involve with doing a surgery could free up a lot of the doctor time without any loss of income and perhaps even a gain at the end of the year.

The Wall Street Journal article I posted earlier about goes on to say 'The problem (false reporting) calls into question whether journals can play the role of gatekeeper in an era when articles are increasingly used as MARKETING TOOLS. Editors have 'found themselves playing a game of research hide-and-seek,' says Jeffrey Drazen, editor in chief of the New England Journal of Medicine. They have 'had experiences' where authors tried to pitch it, where they were telling you the good news and not the bad news.'

It's also possible I think to relate this statement to the people doing the most marketing of ESWT and as a whole Podiatrist seem to be the largest group marketing ESWT today. I think we have to ask ourselves how much of that carrot that was promised plays a part in their marketing of ESWT.

Re: recent meta-analysis on ESWT

Ralph on 5/17/05 at 14:56 (175192)

Rapid Recovery Health Services prediction.
OTC:RPRV Estimates there is a Market Demand for over 15 Million ESWT Treatments Per Year

Re: recent meta-analysis on ESWT

Dr. Zuckerman on 5/17/05 at 14:59 (175193)

I am not seeing horrific results every day but I see enough of them to have wanted to listen and seek out other treatments such as ESWT which have none of the complications that Foot surgery has. I have known about ESWT since 1996. Podiatry has always tried to improve foot surgery and foot care to reduce complications. ESWT is just one of the advance in this goal of reducing complication.
I have also seen lost of legs from total knee implants. These are known complications that patients are willing to risk.
What are doctors doing about this. I can tell you what I am doing about this. I explain and talk about ESWT to patients, our profession,orthopedic profession. . When I first started out there were very few ESWT procedures being performed now I am told there are in the thousands being done .
There is a standard of care and protocol so there really can't be any fooling around or too many being ESWT procedures being done.

I think there is alot of marketing in almost every procedure today including hospital. Just turn on the TV and watch plastic surgeons change your life.
The only reason Podiatry is doing most of the marketing and I have no idea if this is true is because podiatry sees the majority of plantar fasciitis. In my area the orthopedic surgeons refer to podiatry for this foot complaint.

Re: recent meta-analysis on ESWT

Ralph on 5/17/05 at 15:39 (175196)

Dr. Zuckerman,
I think in one of your posts you indicated that ESWT now has a permanent billing code. If it's use off label to treat a neuruoma or achilles problem is it coded the same for insurance billing or do off label uses have different codes?

Re: recent meta-analysis on ESWT

Dr. Zuckerman on 5/17/05 at 15:49 (175198)

There are different codings used for different parts of the body. The permenant coding is for Plantar fasciitis/ ESWT Work compensation is tyically the only insurance that covers off label ESWT. I am not aware of any companies payiny for the use of ESWT for neuroma's

Re: recent meta-analysis on ESWT

Dr. Zuckerman on 5/17/05 at 16:14 (175203)

Is this online. ?

Re: recent meta-analysis on ESWT

Ed Davis, DPM on 5/17/05 at 23:12 (175225)


I think that the focus of research has not been going in the right direction. I would like to see more research that looks at the tissue effect of ESWT. Rompe's before and after measurments of plantar fascial thickness, I believe are more relevant because the impotant thing to verify is the tissue level effect of ESWT. this type of reaearch has less variables. is more objective and gets to the key issue in ESWT.

Re: recent meta-analysis on ESWT

Donald Iain Scott on 5/18/05 at 05:30 (175226)

I have a real problem with meta analysis. How can it be deemed accurate.
Example 1
You could input data from 4 studies - 1 favourable - 2 not favourable 1 neurtal . Analysis output becomes an unfavourable study
Example 2
4 studies - 1 favourable 1 not favourable 2 neutral = result neutral to possibly unfavourable
You can see where this is going.
The results can be skewed in favour to the way the company or rival wants the results to go.
In some ways I think meta analysis is a type of plagariarism using other peoples work and not their own

Re: recent meta-analysis on ESWT

Ron on 5/18/05 at 21:33 (175297)

From the reference in the article:

Interventions for treating plantar heel pain (Cochrane Review)
Crawford F, Thomson C



Re: recent meta-analysis on ESWT

Dr. Z on 5/18/05 at 21:40 (175299)

I just cancelled all of my heel pain patients. There is no treatment that helps.

Re: recent meta-analysis on ESWT

Ron on 5/18/05 at 21:46 (175300)

Here's the article:


Re: recent meta-analysis on ESWT

elliott on 5/19/05 at 12:44 (175322)

Dr. Scott,

Can I take it the problems you have with meta-analyses and your opinion that they cannot be deemed accurate apply to Dr. Rompe's latest meta-analysis as well?



Re: recent meta-analysis on ESWT

Ed Davis, DPM on 5/20/05 at 12:46 (175362)

Fine discussion but this type of research, outcomes research, has too many variables subject to the treatment triad. ESWT either has the desired tissue effect or it does not -- we need to focus on ONE parameter which is the one that REALLY COUNTS.

Re: recent meta-analysis on ESWT

elliott on 5/20/05 at 16:08 (175385)

Dr. Ed,

You keep posting that the only parameter that really counts is whether ESWT has the desired tissue effect or not. Well, what if it does have the desired tissue effect but does not improve the patient's PF? What if it doesn't have the desired tissue effect (e.g., low-energy ESWT) but it does improve the patient's PF?


Re: recent meta-analysis on ESWT

Dr Ben Pearl on 5/21/05 at 07:41 (175409)

I agree with Scott's comment about influences of study results by design. I would consider a tighter group of research parameters useful and think are statistician colleagues deserverve their due but like the old computerstudent saying goes garbage in = garbage out.

Re: recent meta-analysis on ESWT

Dr Ben Pearl on 5/21/05 at 07:47 (175411)

I agree with the conclusions of that Wall street article because I have seen this in cases of how some drugs and technologies have been taken to market.

Re: recent meta-analysis on ESWT

Ed Davis, DPM on 5/21/05 at 14:52 (175425)

First, we have to take ESWT for what it is: a tool to improve the quality of damaged or diseased tendons and ligaments, nothing more, nothing less. Most plantar fasciitis is cured by other conservative means and it appears that the only reason that a small percentage do not heal (provided that appropriate treatment was provided which is too often not the case) is that the tissue qulaity of the fascia is too poor to be healed by 'conventional' conservative means so we either go in an cut the fascia off the heel bone or use a modality that can basically induce a change in the tissue. We are, basically, already accepting the hypothesis that tissue quality is the issue when we do surgery. We are using a different approach to the tissue quality issue in ESWT.

So it really boils down to testing the hypothesis: is tissue quality the reason PF become recalcitrant? I believe that sonography gives us the best look as virtually every patient who has had recalitrant PF and go on to surgery or ESWT has had pathologic appearing fascia.

Unfortunately, sonography, is a bit underutilized with respect to what we are looking for. Personally, I feel that I can use sonography, based on 5 years of experience with it, to predict whether 'conventional' conservative treatment will work or not based on how bad the fascia looks.

If the answer is that the issue with recalcitrant PF is tissue quality, then we have to ask what is the most cost effective means of addressing that. Surgery probably is not. ESWT looks like a good option. Some support ART as a means of affecting the tissue quality. Scott beleives that a form of phototherapy that he is working on can influence tissue quality.

Re: recent meta-analysis on ESWT

Dr. Z on 5/21/05 at 15:11 (175428)

Ultrasound has really help to diagnosis plantar fasciitis and plantar fasciosis. There is going to be a lecture in Vienna next week which is going to address a two year follow of post ESWT ultrasound. I don't know if you saw my post about color doppler and viewing the degree of vascularity in the pain epicenter. This is something I now doing with all of my ultrasound evaluation. My conclusions are too early to make any type of statment.

Re: recent meta-analysis on ESWT

Ed Davis, DPM on 5/21/05 at 15:31 (175431)

I think that the absence of good imaging of the plantar fascia, performed regularly has been a 'handicap' in our ability to do a good meta-analysis on changes in tissue quality. Many are still doing x-rays for patients with plantar fasciitis which is okay to rule out other problems but tells you little if anything about the fascia which is soft tissue.

The imaging situation is rapidly changing for the better so that 'handicap' will disappear.

Re: recent meta-analysis on ESWT

Ralph on 5/21/05 at 16:05 (175433)

If you go back and read the posts from people who were asking questions on this site, most of them say they had an MRI. If ultra sound is superior in finding out the quality of tissue why don't we see folks here saying their Pod did an ultra sound instead of reading 'I had an MRI'?

Certainly ultra sound is cheaper than having an MRI, but looking back you hardly find any posts that say their doctor did an ultra sound. The MRI was ordered.

It's not a new device so why does it seem like only our two residents Pods, Dr. Ed and Dr. Z know the benefits of using it. If you can see blood flow as Dr. Z said it seems like the perfect choice to help with diagnosis. Why are the others sending people for MRI's.

Re: recent meta-analysis on ESWT

Ed Davis. DPM on 5/22/05 at 19:43 (175505)


An MRI is an $800 to $1500 test so most of the MRIs that are being ordered are done so for difficult cases. Keep in mind that the majority of posters on this site have difficult cases.

Sonography is an $80 to $150 test and is not just done for difficult cases but can be done on the first visit to determine whether the case will be difficult or not, how easy or difficult it will be to cure the patient.

While it is true that Dr. Z and I mention this modality on this site, songraphy is rapidly becoming the standard of care. It is just that Dr. Z and I are the two doctors discussing ESWT and the tissue quality issue the most on this site and that a number of posters on this site are here because they recieved substandard care allowing their plantar fasciitis to get bad.

Re: recent meta-analysis on ESWT

Dr. Z on 5/22/05 at 20:00 (175506)

There are alot of doctors who use ultrasound for plantar fascia evaluation. Does everyone have a unit in their office. No. Does every center have ultrasound no.

Re: recent meta-analysis on ESWT

Ralph on 5/23/05 at 07:15 (175518)

Dr. Zuckerman,
Most hospitals I think have ultrasound available. If a doctor is sending a patient for an MRI they could just as easily send them to a hospital lab for an ultrasound.

Although it would be nice if they actually had one in their office I don't think there would be a major problem to get one done.

MRI's are sure plentiful if you read some of the posts here. Much more so than ultrasound.

Re: recent meta-analysis on ESWT

Dr. Z on 5/23/05 at 08:29 (175523)

You are correct, but we are talking about MS ultrasound, not for kidneys, liver babies.

Re: recent meta-analysis on ESWT

Jan R. on 5/28/05 at 10:35 (175839)

First, the authors included our research in their review, but then excluded the papers from their meta-analysis.

Second, if you compare apples (disorder of various intensity of various duration) to oranges (various ESWT regimens regarding number of sessions, number of shocks applied per session, various energy flux density per shock, various periods between applications) to peaches (various outcome measures, various periods of follow-up) is it not clear that you will find inconclusive evidence?

Third, speaking of evidence, do you know of any treatment regimen for plantar fasciosis that fulfills the criteria for conclusive evidence?

Fourth, and if this is that way, what practical worth can such an assessment have for the treating physician when apples are compared to oranges to peaches?