ESWT For Plantar Fasciitis: What Do The Long-Term Results Reveal?

Lowell Weil, Jr., DPM, MBA

Offering a closer look at the role of extracorporeal shockwave therapy (ESWT) in the armamentarium for chronic plantar fasciitis, this author reviews long-term research from randomized controlled trials, offers a compelling case study and assesses the cost-effectiveness of ESWT in comparison to surgical alternatives.

   Heel pain is the number one reason why patients seek medical attention from a foot and ankle specialist. Conservative care alternatives and successes are well known if not well validated in the literature. It is commonly accepted that between 70 and 90 percent of patients will undergo successful treatment via those conservative measures.
However, no study has looked at the timeframe necessary for those conservative alternatives to be successful or the cost involved with those measures. Additionally, 20 to 30 percent of those patients will progress to a chronic condition for which response to conservative treatment becomes less predictable, more costly and has a higher rate of recurrence.

   Tong and Furia looked at the total cost for treating heel pain/plantar fasciitis in their 2010 study.1 They found that at any given time, 5 million Americans were undergoing treatment for heel pain/plantar fasciitis. The 2007 national economic burden of plantar fasciitis was an estimated $284 million annually (a range of $192 million to $376 million) with 80 percent of those costs associated with medications and 14 percent to office visits (physician or physical therapist).

   This economic calculation did not incorporate lost work, lost wages, societal burden and personal psychological burden.1 In fact, no study has looked at those indirect effects of plantar fasciitis as they pertain to patient outcomes and economics. It stands to reason that any therapy that returns patients back to a normal daily lifestyle quickly and in a cost-effective manner should be attractive.

   In 2000, extracorporeal shockwave therapy (ESWT) entered the United States medical landscape as an alternative for treating chronic plantar fasciitis, trailing Europe by at least a decade. There was a great deal of controversy and posturing between manufacturers of ESWT technologies. Each company was determined to create an exclusive market at the expense of their competition. One of the most common targets for criticism was the level of energy of shockwave technology. In my own experience, high-energy ESWT is the most effective modality for the musculoskeletal system and one should consider those devices that fail to reach high energy to be inferior.

   Interestingly, there was no standard by which energy levels were measured so comparisons were not valid. When physicists who were experts in ESWT were questioned as to which modalities were high energy and which modalities were low energy, they usually were unable to answer the question because of the lack of standardization.

A Closer Look At The Research

Many different studies in peer-reviewed journals were published on the success or failure of ESWT. Nearly every study that involved a retrospective analysis of ESWT on plantar fasciitis found success in the 80 to 88 percent range in substantially reducing heel pain.2,3 These statistics were nearly identical to those of retrospective studies on surgical procedures for plantar fasciitis.

   My colleagues and I published a study comparing surgical success with that of ESWT and found the success rates of both treatments to be equivalent.4 The study consisted of 40 feet treated with ESWT. We used electrohydraulic shockwave with a mean of 20.6 kV in combination with a mean of 2,506 pulses.



You discuss high vs. low energy shockwave. How do you define it? How do energy levels compare with the various systems available (i.e., mJ/mm vs. barr vs. kV?


Richard Bouche, DPM, FACFAS

Can you give any advice on which high-energy ESWT device your group prefers to use?


Rich Bouche, DPM, brings up a point that the industry needs to better address: a more uniform manner to describe energy delivery to tissue.

I use the Swiss Dolorclast based on your recommendation. The results are very good and I want to thank you for the good advice.

The machine, using radial shockwave type technology, uses the "bar" for measurement which is a unit of pressure as opposed to energy delivery which is often measured in mj/mm sq. Energy delivery measures the end effect and is referred to in the literature. Rompe endeavored to establish the minimum energy delivery required to achieve a therapeutic effect. That was an important endeavor as we later saw the critical Buchbinder study, in which subtherapeutic energy levels were delivered and concluded that ESWT was ineffective based on such flawed experimental design.

The distinction between low" and "high" energy appears to have been de-emphasized in recent years as energy or pressure levels delivered are a continuum and what really counts is the total energy delivered to the tissue. The original US model was to use fewer shocks by utilization of more expensive machines capable of more intense energy delivery, which required anesthesia.

Our medical-political system took that artificial distinction and over-emphasized the distinction for insurance coding and reimbursement services. The low vs. high energy debate really was a non-issue in Europe and Canada.



San Antonio, Texas

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