Extracorporeal Shockwave Therapy: Hope Or Hype?
- Volume 16 - Issue 11 - November 2003
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Avoiding The Bandwagon Mentality With New Procedures
The next point I would like to present is that of the “new” procedure mentality and the need to be first one on the block to perform it. For example, prior to the EPF procedure, I had reasonably good success rates with an in-step plantar fasciotomy. However, with a new technique at my disposal, I performed the EPF for approximately five years. My success rate with EPF was definitely less than my success rate with the in-step procedure, with the primary complication being recurrence of heel pain. I subsequently returned to my tried and true procedure and have been doing it ever since.
From this experience, I learned that I don’t need to be the first to jump on the bandwagon of a new procedure and that it is probably best to wait and see if research shows a definitive lean one way or the other.
When One Considers The Common Etiology Of Most Chronic Heel Pain Cases
Another critical aspect in the decision process for ESWT is accurate diagnosis of the etiology of chronic heel pain. I feel strongly that much of chronic heel pain is, in fact, due to an entrapment of the first branch of the lateral plantar nerve (Baxter’s neuritis), and, according to the literature, ESWT is then contraindicated.
In their 1984 article, Baxter and Thigpen attributed 20 percent of all chronic heel pain to entrapment of the first branch of the lateral plantar nerve. After several years of experience with this diagnosis clinically, I think that the percentage is actually higher. Initially, I was skeptical about this diagnosis and the resulting treatment, but I started to check for it regularly on my heel pain exam and documented its presence. If a patient was not responsive to conservative care, I would confirm the diagnosis of nerve entrapment with an injection. To my surprise, many of my chronic heel pain patients did in fact have entrapment. (When this condition does not respond to conservative treatment, my procedure of choice is a release of the first branch of the lateral plantar nerve with a partial plantar fasciectomy).