Extracorporeal Shockwave Therapy: Hope Or Hype?
Foot and Ankle International, 23(3), 2002. 10. Ogden JA, et al: Shockwave Therapy for Chronic Proximal Plantar Fasciitis: A Meta-Analysis. Foot & Ankle International 23(4), 2002. 11. Hammer DS, et al: Extracorporeal Shockwave Therapy (ESWT) in Patients with Chronic Proximal Plantar Fasciitis. Foot & Ankle International 23(4), 2002. 12. Buchbinder R, et al.: Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis: A Randomized Controlled Trial. JAMA 288(11), 2002. 13. Rompe JD, et al.: Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes: A Prospective, Randomized, Placebo-Controlled Trial. The American Journal of Sports Medicine 31(2), 2003. 14. Dalay PJ, et al.: Plantar Fasciotomy for Intractable Plantar Fasciitis: Clinical Results and Biomechanical Evaluation. Foot and Ankle, 13(41), 1992. 15. Vohra PK, et al.: Long-term Follow-up of Heel Spur Surgery: A 10-Year Retrospective Study. JAPMA, 89(2), 1999. 16. Lundeen RO, et al.: Endoscopic Plantar Fasciotomy: A Retrospective Analysis of Results in 53 Patients. JFAS, 39(4), 2000. Hype. Patrick A. DeHeer, DPM, Stephen M. Offutt, DPM, Gary A. Trent, DPM, and Michael J. Baker, DPM, cite the limited indications of the modality and the lack of a clear and standard procedural protocol for its use. Extracorporeal shockwave therapy (ESWT) is becoming increasingly popular for the treatment of chronic plantar fasciitis despite much controversy over its efficacy. (See a recent headline from USA Today: “Study treads on ‘shockwave’ heel therapy; controversial report finds no evidence that treatment cuts pain.”) As with any controversial topic, there is a pro and con argument. There are some key points to consider on the con side of the ledger. They are as follows: ESWT and its role in the overall treatment algorithm of heel spur syndrome; the prevalence of a neurological etiology for heel pain; the current literature confusion over efficacy and treatment protocols; and, finally, potential complications (primarily recurrence of heel pain). Please understand that while Healthtronics certified me in ESWT approximately two years ago, I have yet to perform ESWT on a single patient. I have several reasons for avoiding the procedure. First and foremost is the lack of insurance coverage for ESWT in the state in which I practice. This lack of coverage seems to stem from some of the current negative literature. My patients have chosen more invasive procedures based upon insurance coverage. Before starting to make my case against ESWT, I have always been intrigued by the strong opinions generated from the surgical treatment of heel spur syndrome. Do bunion surgeries cause such lines in the sand? I don’t think so. Procedures for heel spur syndrome seem to be inherently controversial and it appears that much of the furor stems from the fact that adequate (the important word here) conservative treatment will successfully treat this condition as much as 90 percent of the time. When the endoscopic plantar fasciotomy (EPF) was first introduced, a major concern was that some might employ the procedure as a first line of treatment. Well, standard of care dictates otherwise and, for the most part, the anticipated abuse never took place. Similar to the EPF procedure, ESWT should be well down the treatment algorithm. As with any other invasive plantar heel surgery, adequate conservative treatment should be rendered for six months prior to treatment with ESWT. 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.