Extracorporeal Shockwave Therapy: Hope Or Hype?

By Lowell Scott Weil, Jr., DPM, MBA; By Patrick A. DeHeer, DPM, with Stephen M. Offutt, DPM, Gary A. Trent, DPM, and Michael J. Baker, DPM

Hope. Lowell Scott Weil Jr., DPM, says ESWT is a non-invasive alternative with minimal risk for patients who have failed conservative treatment for plantar fasciitis. Medical devices and technology are constantly changing and evolving with the “newest and best” treatments being constantly promoted. Whenever new treatments emerge, they must be looked at carefully and critically to assess their efficacy and safety. They must also be compared to the currently accepted treatments and their benefits over those modalities. Extracorporeal shockwave therapy (ESWT) for the treatment of musculoskeletal (MSK) disorders evolved in Europe in the early 1990s. ESWT is a derivative of lithotripsy, the mechanical breaking up of renal stones with sound waves. ESWT has been considered valuable in treating many different MSK disorders including plantar fasciitis, epicondylitis, tendinitis and non-unions of bone. In all situations, it is considered the non-invasive alternative to surgery. Regardless of the pathology that ESWT is used for, one should only consider it after more common, accepted and proven noninvasive treatments have failed. Plantar fasciitis is the first pathology that was FDA approved for ESWT treatment in the United States. Up to 15 percent of podiatric visits result from painful plantar fasciitis. Given the prevalence of plantar fasciitis in the U.S. (with over 1 million people suffering from it annually), it has become the epicenter of debate about ESWT. However, numerous studies have proven that 80 to 90 percent of people suffering with plantar fasciitis will be successfully treated conservatively over a six-month period of time. There is little debate over the most effective conservative management options for plantar fasciitis, with the only randomized proven method being night splints in the chronic cases. Yet controversy is never far from a discussion about the proper method of treating the 10 to 20 percent of plantar fasciitis sufferers who do not respond to conservative care in a timely fashion. Pointing Out The Potential Shortcomings Of Surgical Options Over the years, many different procedures have been described for treatment of chronic heel pain. They have included: large incisional sectioning of the plantar fascia with removal of bone spur to only sectioning the plantar fascia; decompression of a branch of the lateral calcaneal nerve with partial sectioning of the plantar fascia; minimally invasive techniques with or without an endoscope; in-step fasciotomies; and, more recently, injections of different chemical agents (either Botox or alcohol). In the past three years, ESWT has been added to the list of available treatments in the U.S.. Why have surgeons continued to change their procedure of choice over the years despite citing literature with good to excellent early results? It is probably the same reason why there are over 100 bunion operations. They are searching for the procedure that is predictable over the long term with the least amount of complications and headaches for both the patient and surgeon. We have certainly heard surgeons proclaim minimally invasive surgery as being approximately 95 percent successful with no complications and immediate full weightbearing. Certainly, those statistics are far from reality. Any time one performs invasive surgery, there are risks involved. It is not uncommon to hear of the patient who had an endoscopic plantar fasciotomy (EPF) performed that resulted in severe nerve injury to branches of the plantar nerve. We also encounter the patient who has had open sectioning of the plantar fascia and removal of the bone spur only to be in severe pain for months with an inability to return to work or pursue normal activities over that timeframe. While these scenarios may be unusual, they are certainly more common than we would like. A Closer Look At The Literature On ESWT ESWT has emerged as a noninvasive, minimally risky procedure for chronic conditions such as plantar fasciitis. ESWT allows patients to return to activities of daily life within one or two days with an immediate return to most occupations and normal daily shoegear. While complications have been described, they are more corporate disclaimers than actual pathologic entities. Opponents of ESWT point to literature that shows its ineffectiveness and its high cost. Without doubt, the literature is clouded as to the relative benefit of ESWT. There is literature on both sides of the debate.

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