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
I understand how orthotics and stretching provide long-term success rates for plantar fasciitis, but I am simply not sure how ESWT will prevent the re-straining of the plantar fascia if the patient is overweight, has poor foot mechanics, selects inappropriate shoe gear, has an excessively high activity level or works standing for long periods of time on hard surfaces. Only properly conducted patient trials over a longer period of time can answer these questions. One should consider the possibility of recurrence and discuss it with the patient during the consent process. Although the literature has reported few complications, periosteum detachments, small fractures of the inner surface of the cortex, neurologic symptoms, plantar fascial rupture when done following multiple cortisone injections, lateral column and peroneal tendon pain have been reported in the literature for high-energy treatment. While high-energy treatment seems to be more efficacious than low-energy treatment, it apparently is associated with more potential complications, leading to still more questions on the standard of therapy. The potential to cause compartment syndrome would also seem to be a valid concern when evaluating potential complications, though it is not specifically mentioned in the literature. Final Notes So what is the bottom line with ESWT? If I had chronic, unresponsive heel pain and I chose ESWT, several conditions would have to be met prior to my consent to having the procedure. First, I would have had to undergone adequate conservative treatment for at least six months. Second, Baxter’s neuritis would have to have been ruled out. Third, I would have to accept the fact that no one knows how or why the procedure works and what the long-term success and recurrence rates are. Finally, I would have to have a clear understanding that this is not an entirely benign procedure without potential complications. My patients deserve the same consideration that I would warrant and so should yours. Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons and is a Diplomate of the American Board of Podiatric Surgery. He is also the team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. Offutt is a second-year resident at Winona Memorial Hospital in Indianapolis, Ind. Dr. Baker works out of the Wound Care Center at the aforementioned institution and is also in private practice in Indianapolis, Ind. Dr. Trent is in private practice in Park Ridge, Ill. References 1. Baxter DE, Thigpen CM. Heel pain-operative results. Foot and Ankle. 5: 16-25, 1984. 2. Boddeker IR, Schafer H, Haake M. Extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis - A Biomaterial Review. Clin Rhem. 20: 324-330, 2001. 3. Buchbinder R, Ptasznik R, Gordon J, Buchanaan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis. JAMA 288(11): 1364- 1372, 2002. 4. Chen HS, Chen,LM, Huang TW. Treatment of painful heel syndrome with shock waves. Clin Ortho Related Research. 387: 41-46, 2001. 5. Cosentino, R, Falsetti P, Manca S, De Stefano R, Frati E, Frediana B, Baldi F, Selvi E, Marcolongo R. Efficacy of extracorporeal shock wave treatment in Calcaneal enthesophytosis. Ann Rheum Dis. 60: 1064-1067, 2001. 6. Maier M, Steinborn M, Schmitz C, Stabler A, Kohler S, Pfahler M, Durr HR, Refior HJ. Extracorporeal shock wave application for chronic plantar fasciitis associated with heel spurs: prediction of outcome by magnetic resonance imaging. J Rheumatol. 27: 2455-2462, 2000. 7. Ogden JA, Alvarez R, Levitt R, Cross GL, Marlow M. Shock wave therapy for chronic proximal plantar fasciitis. Clin Ortho Related Research. 387: 47-57, 2001. 8. Ogden JA, Alvarez RG, Marlow M. Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis. Foot & Ankle. 23(4): 301-307, 2002. 9. Peterson KS: Study treads on “shock wave” heel therapy; Controversial report finds no evidence treatment cuts pain. USA Today, p. D8, Sept. 18, 2002. 10. Rajkurmar P, Schmitgen GF. Shock waves do more than just crush stones: extracorporeal shock wave therapy in plantar fasciitis. Int J Clin Pract 56(10): 735-737, 2002. 11. Rompe JD, Schoellner MD, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. JBJS. 84A(3): 335-341, 2002.

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