Cath Lab Digest

Does Diabetes Thwart The Impact Of ESWT For Plantar Fasciitis?

By Brian McCurdy, Senior Editor

   In a recent retrospective study of extracorporeal shockwave therapy (ESWT), researchers found a greater than 70 percent success rate in treating plantar fasciitis at three months and 12 months after treatment. The study authors also found that the presence of diabetes or psychological issues may have a negative impact upon ESWT results.

   The study, which was recently published in the Journal of Foot and Ankle Surgery (JFAS), offered a retrospective review of 246 feet that underwent ESWT treatment between July 2002 and July 2004. Patients who were treated with ESWT had plantar fasciitis for more than six months and had not responded to at least five conservative modalities, according to the study. The follow-up was an average of 30.2 months post-procedure.

   Researchers found that ESWT had a success rate of 70.7 percent at three months and 77.2 percent at 12 months. David Zuckerman, DPM, says the 12-month results are a “very respectable outcome.” He also notes that the current literature suggests that additional high-energy treatment after four months can relieve initial heel pain even when there is a poor initial outcome with the first ESWT treatment.

   However, in the JFAS study, researchers noted that the presence of diabetes and psychological issues negatively affects ESWT results.

   Lowell Scott Weil Jr., DPM, says his research has never stratified variables such as diabetes and psychological issues in ESWT treatment. In three different FDA approval studies on ESWT studies in which he participated, patients with diabetes were excluded from the studies. While Dr. Weil does not think that shockwave will not work on patients with diabetes and psychological issues, he notes there are multiple variables affecting those patient populations and their pain is more difficult to define as “plantar fasciitis.”

    “Heel pain can have many different etiologies and in my experience, these types of patients can be affected by neurologic issues (local nerve entrapment, radiculopathy, neuropathy) not to mention medications to treat their problems that can have neurologic side effects,” says Dr. Weil, the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill.

   Dr. Zuckerman, who has performed over 8,000 ESWT procedures for plantar fasciosis, Achilles tendinosis and patellar tendinosis, does not agree with the study’s conclusion about the impact of diabetes on ESWT results. However, Dr. Zuckerman concurs with Dr. Weil that neuropathy and poor vascularity in patients with diabetes can affect outcomes with the use of ESWT for plantar fasciitis.

Other Pertinent Insights On Patient Selection

   In regard to proper patient selection for ESWT, Dr. Zuckerman, the ESWT Medical Director of Excellence Shock Wave Therapy in Woodstown, N.J., says patients must have: plantar fasciitis pain for at least six months; a Visual Analogue Scale score of greater than 5; pain at or near the origin of the plantar fascia; and at least three failed conservative treatments.

   Dr. Weil says patients with absolute “plantar fasciitis” or “plantar fasciosis” do the best with ESWT. In his research, Dr. Weil has noted a reduced success rate for ESWT when patients have had heel pain for more than two years.

   While the JFAS study noted that plantar fascia thickness had no impact on ESWT results, Dr. Weil has found in his experience that patients with thicker than normal plantar fascia (as shown on MRI or ultrasound) do better than people who have normal thickness.

Podiatry Today Poll: ACFAS Conference Offers Most Clinical Value

By Brian McCurdy, Senior Editor

   The Annual Scientific Conference of the American College of Foot and Ankle Surgeons (ACFAS) offers the most clinical value, according to a recent online survey by Podiatry Today.