Extracorporeal Shockwave Therapy: Hope Or Hype?
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. One can selectively quote literature to support a stance on ESWT either way.
Some of the more discussed papers against ESWT have been scientifically flawed. The paper most often cited by the opponents of ESWT is by Buchbinder out of Australia. This study included patients who had heel pain for as little as six weeks and the authors used ESWT energy levels that were far less than those recommended in the U.S. Additionally, the authors of the study administered a small but nevertheless present dose of ESWT to the placebo group. Lastly, the study was performed by a non-clinician who worked for the government of a national health care system. The motives of the study were skewed from the beginning.
We published a paper in the Journal of Foot And Ankle Surgery (JFAS) that showed an 82 percent success rate with ESWT, which was comparable to our study of minimally invasive plantar fasciotomy (83 percent success) in JFAS. Critics of our ESWT paper will correctly point out that it is a retrospective study and that only a randomized, prospective, placebo-controlled study can accurately show the true value of a procedure. This is true. However, all of the studies on surgical outcomes for plantar fasciitis are similarly designed as retrospective without the control of a placebo group. Therefore, our study shows that outcomes with ESWT are comparable to surgical outcomes without the risks and complications inherent to surgery.
Assessing The Cost Benefit Of ESWT
Critics will also point out that ESWT is extremely expensive. Without doubt, the cost of ESWT is high. However, the cost of new technologies, as with new pharmaceuticals, is often high.
The benefits of ESWT in terms of social costs are immeasurable. Patients are able to return to activities of daily life and work immediately. There are no costs of lost work to either the patient or employer. There are no risks such as infection. Postoperative infections require intense medical care that can run into tens of thousands of dollars. These are just some of the examples of the overall cost benefit of ESWT over surgical options.
ESWT has a long way to go in proving the overwhelming medical benefits that are claimed by the manufacturers, but it is still in the early stages of its evolution. With time, it will be necessary to prove these claims through prospective studies. Additionally, a scientific explanation as to the mechanism of action and physiologic effects of shockwave therapy is necessary to further understand the medical applications.
Ultimately, I have to ask you the question: If you had painful plantar fascitis that failed to respond to conservative care over six months, what would you choose? Surgery or ESWT?
Dr. Weil is the Fellowship Director of the Weil Foot And Ankle Institute in Des Plaines, Ill., and is a Fellow of the American College of Foot and Ankle Surgeons.
1. Tomczak RL, Haverstock BD. A Retrospective Comparison of Endoscopic Plantar Fasciotomy to Open Plantar Fasciotomy with Heel Spur Resection for Chronic Plantar Fasciitis/Heel Spur Syndrome. J. Foot Ankle Surg. 34(3): 305-311, 1995.
2. Gill L, Kiebzak G. Outcome of Non-surgical Treatment for Plantar Fasciitis. Foot Ankle Int 1996; 17: 527-532.
3. Weil LS, Gouldwing PB, Nutbrown NJ. Heel Spur Syndrome. A Retrospective Study of 250 Patients Undergoing a Standardized Method of Treatment. J. Foot Ankle Surg. 4: 69-78, 1994.
4. Benton-Weil W, Borelli AH, Weil Jr. LS, Weil Sr. LS. Percutaneous Plantar Fasciiotomy: A Minimally Invasive Procedure for Recalcitrant Plantar Fasciitis. J. Foot Ankle Surg. 37(4): 269-272, 1998.