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San Diego Update

Posted by elvis on 8/03/05 at 13:22 (179857)

I went to the podiatrist this morning. My heel has been hurting less and less and the top and lateral side of my foot below the ankle and radiating across the front of my foot have been hurting more and more. The other pains from my new rigid orthotics subsided completely with my last orthotic adjustment 3 weeks ago.

The doc probed my foot quite a bit and found 2 hot spots. One is the 3rd metatarsal joint on the top of my foot. He was reluctant to adjust my orthotic at this point. His reason was that the 3rd metatarsal is right in the middle of the foot and it probably won't respond well to an orthotic adjustment either way (more pronation or more supination). In my case he was thinking about adjusting the orthotic to make me pronate less (said another way supinate more, i guess). Anyway he wanted to wait to how that area progresses.

The other area where he found acute pain was in the sinus tarsi area. WE talked about options and decided to go with a cortisone shot. He injected some cortisone into this area. I didn't watch but he said he probably put the needle in about 1 1/4 inches into my foot. I told him he should be glad I didn't watch because I probably would have kicked him in the face with my good foot! :-) Anyway he froze the area with ethyl chloride and I didn't feel anything. Completley pain free unlike the metatarsal shots that hurt like a SOB. He said that this (sius tarsi) is the only area of the foot where there appears to be no downside of tissue degeneration from cortisone.

I asked him about the incidence of PF rupture with cortisone injections. He said that he has given well over a thousand cortisone shots and never to his knowledge caused a PF rupture. He has seen 2 patients that got cortisone shots from other doctors. One clearly had a PF rupture. The other was a 'probable' partial tear but he did not see them before the shots. He said he only gives 20mg of triamcinalone for PF while he knows some doctors give 40mg. He said that will matter. My read on cortisone shots is that it is a reasonable thing to do as one progresses on treating PF. My first orthopedic has also never personally caused a PF rupture with a cortisone shot.

A few weeks ago someone here asked about the risk of getting cortisone in the metatarsal area. He said that all cortisone injections in the foot have the risk of causing tissue regeneration (tendon, cartlidge, pf etc) except for the sinus tarsi area.

He also showed me an interesting article comparing the energy of Sonocure, Dornier and Ossatron ESWT machines. He pointed to the focal point as an area of distinction. At highe energy settings the Ossatron has a quite large focal point of energy delivery, the Dornier has a rather small focal point and the the Sonocur is in the middle. The bigger the focal point the more tissue that is treated. He said that he thought that this was maybe a cause for some differences in outcome between the 3 machines.

Anyway, it's baby steps to pain free running. I'm gonna start adding in a little bit of jogging during my walks this weekend.

Re: San Diego Update

Dr. Z on 8/03/05 at 13:45 (179862)

Here is my take on local steriod injections. I never have never seen a rupture by an injection given by Dr. Z because most of the time the patient will have this down the road and go to the ER, another doctor or back to me where I never realized what it was, but treated it the same way.
As for size of local point the ossatron is the largest, not sure what the sonocur is and then the dornier. This is why it is important to use ultrasound because you need to move ALL 3 ESWT machines during the treatment and the dornier is the only one where there is a picture showing where you are and where you are going. It is interesting how the sonocur has ultrasound in Canada and not in USA. Good luck it sounds like you are moving forward but with baby steps. Not is the reason for the metatarsal pain. It could be the sinus tarsi

Re: San Diego Update

elvis on 8/03/05 at 14:07 (179865)

Thanx for the information. This doc used to teach the Ossatron techniques for the company that makes Ossatron. He now uses the Sonocure with an off label protocol that I have mentioned before. He did talk about the ultrasound imaging to direct the Dornier but he still thought the small focal point could be an issue. He said that they mark the sensitive areas before the Ossatron and because of the large focal area he thought that the correct tissue will be treated. He made an analogy to a shotgun for the Dornier because fo the small focal point. He said 'dotting' the area may not give complete delivery of the shock waves. Of course he said expertise at administering the Dornier will improve treatment but on the otherhand he thought that that was why there has been some variability on its effectiveness recently. He now uses the Sonocure whihc I would say has focal point right in the middle between Ossatron and dornier. Because he doesn't use any anesthsia at all he treats the sensitive tissues based on biofeedback from the patient as the procedure is being done.

He said in the last 2-3 years he suspects that only about 1% of his patients progress to ESWT.

Re: San Diego Update

Dr. Z on 8/03/05 at 15:27 (179875)

Here is what I know. The ossatron focal point is 5-6 mm. the dornier is 3mm . I am not sure what the sonocur is but if he is correct it would be between 4-5mm. They are all very very small.
The effectiveness of the Dornier was again shown to be 83% excellent or good at 12 week with the most recent article by Dr. Furia, Bucknell medical school.
I have no doubt that you can get good results from the sonocur if you know how to use the machine. You do have to do alot of procedures to be good at any procedure. So if you see 500 pf cases per year that would be five cases per year. That not enough to know anything about ESWT treatments and how to use the sonocur.

Re: San Diego Update

Ralph on 8/03/05 at 16:21 (179885)

Sounds like your doctor takes a lot of time to explain things to you which is something that's sometimes hard to find. Glad you finally found a good doc and are getting some relief and improvement already. Like you said 'baby steps' but you sound a lot more positive now.

Re: San Diego Update

elvis on 8/03/05 at 16:50 (179890)

Ralph........he likes talking to me because I can understand much of what he says. I have a Pharmcay degree but am not a practicing pharmacist. The last time when he whipped out his prescription pad to write me a prescription for naproxyn (Naprosyn, Alleve) I said I have a big bottle form costco and I take 2 tablets twice a day. He said what's the dose? I said 444mg BID whihc is close enough to 500mg BID at least according to govt standards! LOL Anyway, that's why he probably pulled out the paper showing the different focal points between the different machines.

Dr Z...he wasn't slamming the Dornier. He was just pointing out the differenet focal points and the fact that you have to take that into consideration in administering the ESWT. My recollection is that the focal point for the Ossatron was much bigger than the others. I believe he said there was a direct relationship between the focal point and the energy of the Ossatron (as energy increases focal point increases) and an inverse relationship between the focal point and the energy with the Dornier (as the energy increases the focal point decreases). This was very evident from looking at the graphics presented in the paper. The focal point of the Sonocur got smaller as energy increased but at a much slower rate than the Dornier. There was a nice graphic in this paper that tracke the various focal points at 3 or 4 energy levels so you can see the differences in the focal points as the energy was gradually increased and most importantly at the high energy levels.

I thanked him for lableing me with a syndrome (sinus tarsi syndrome) without having to go to a shrink!! LOL He thought that was pretty funny!

Re: San Diego Update

Ralph on 8/03/05 at 17:05 (179893)

I was trying to find out where the sinus tarsi was located before I asked you. The article I read said in the ankle so I hope that's correct.

Re: San Diego Update

elvis on 8/03/05 at 17:49 (179898)

Thanx for looking up that info! :-)

The needle went in just in front of the side of the ankle near that little fatty circular piece of tissue. The needle went in an inch and a quarter so I guess it's at the base of the ankle/calcaneous/talus bones?


Re: San Diego Update

Dr. Z on 8/03/05 at 17:51 (179899)

IF this relieves alot of your pain which this could be the cause of alot of your pain then cyotherapy, local alcohol injections can give you longer lasting relief. The local steriod injection might just do the trick itself.

Re: San Diego Update

Ralph on 8/03/05 at 18:48 (179908)

Your article was a better one than I found. The pictures really show it's location well. Thanks.