First, I’d like to say that the article on adult-acquired flatfoot (AAF) was insightful and thorough (see the cover story “A New Approach To Adult-Acquired Flatfoot,” pg. 32, May issue). It is now my reference on AAF. However, I found that the heel pain article left questions unanswered (see “Conquering Conservative Care For Heel Pain,” pg. 48, May issue). I wonder why James Losito, DPM, offered his comments on Extracorporeal Shockwave Therapy (ESWT) while having very limited knowledge of ESWT.

Out of the three methods of generating shockwave, Dr. Losito only describes one. By his own admission, he is only familiar with the electrohydraulic method offered by the Ossatron device (Healthtronics). He makes sort of a leap of faith when he suggests that because the Ossatron was the first FDA approved device and is the most powerful, it is better than the other FDA approved device, the newer and more advanced Dornier Epos Ultra.
Further, the cautions he lists are actually contraindications. He also fails to include bleeding disorders, the presence of metal for implants, as well as patients on chemotherapy as additional contraindications, just to name a few.
Dr. Losito also should have mentioned that due to the intense pain produced by the Ossatron’s shockwave being aimed through the plantar aspect of the foot directly into the calcaneus, most patients require IV sedation prior to complete foot and ankle block. All people in the treatment room must also wear hearing protection.
His failure to mention the Dornier Epos Ultra’s precise aiming capabilities (from the inclusion in design of real-time ultrasound imaging), and the fact that the Epos Ultra requires only a simple ankle block, suggests that maybe an unintentional bias exists.
Enough controversy exists about the efficacy of ESWT. This controversy is stretched and expressed mostly by the medical directors of insurance plans who do not want to pay for the procedure. Those of us who have experience with ESWT for plantar fasciitis know that ESWT is now the gold standard for the treatment of chronic plantar fasciitis. It is important to our patients that the podiatry profession does not unnecessarily create controversy over which of the two FDA-approved devices is the most effective. I have seen remarkable results with both devices six months after patients have had the procedure.
I have been certified on the Ossatron for nearly three years and on the Epos Ultra device for two years. I have at my disposal the ability to use either device, but I have found the Epos Ultra easier to use. Additionally, since the Epos Ultra is aimed from medial to lateral through the plantar fascia, and not directly at the calcaneus, there is less immediate post-procedure discomfort for patients.

— Robert S. Steinberg, DPM
Section Chief-Podiatric Surgery,
Department of Surgery
Norwegian American Hospital
Chicago

Responding To Questions On ESWT
James Losito, DPM, responds: Dr. Steinberg, thank you for your comments. Quite obviously, I shared my comments on ESWT because it should be included in any discussion on the conservative care of heel pain. I in no way stated or implied that because the Ossatron was the first FDA-approved device that it is superior to other devices such as the Dornier Epos Ultra. This is simply not true.
I did not list all of the potential complications with the Ossatron because the article was not designed to discuss ESWT in any depth. In addition, I agree completely with the potential for problems in patients with bleeding disorders or on chemotherapy. However, I disagree in the case of patients with metallic implants and I challenge you to produce literature proving otherwise.
Finally, I have done at least 50 Ossatron procedures with only local anesthetic blockades and my patients were in most cases comfortable during the procedure. I have also performed many Ossatron procedures with IV sedation and I will agree that this is preferred. However, your assertion that all those in the room must wear hearing protection is also your opinion and I would welcome any documentation supporting this claim.
I welcome your comments regarding your experiences with the Dornier and Healthtronics devices, and you are certainly qualified to compare the two. As I mentioned earlier, the discussion of ESWT was only part of this article and it was not possible for me to elaborate further on this technology. It is true that I have no hands-on experience with the Dornier device, but I hardly believe that this disqualifies me from sharing my knowledge and experience on ESWT or its place in the management of heel pain.

Editor’s Note: Dr. Losito is a Professor at the Barry University School of Graduate Medical Sciences. He is the President of the American Academy of Podiatric Sports Medicine and is the Team Podiatrist for the Miami Heat.

A Cautionary Tale Of Lung Cancer
I am a 45-year-old podiatrist and I have been in practice since 1986. In March, I was diagnosed with non-small cell carcinoma of the lung. I am a non-smoker and, to my knowledge, have not been exposed to radon.
However, as podiatrists, we are all exposed to potentially carcinogenic materials (i.e. phenol). Breathing nail dust and smoke from hypercating warts cannot be healthy even when one wears a mask and uses vac systems.
My oncologist has said that environmental exposure is the best guess as to why I contracted this disease, and the things that I mentioned certainly are possible.
If anyone has information or is aware of anyone else in our profession who has this or a similar disease, and is a non-smoker, please let me know. Thank you.

— Jeffrey Marks, DPM
Naples, Fla.
jamnaples@comcast.net