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

Author(s): 
Lowell Weil, Jr., DPM, MBA

   We reviewed outcomes after a mean follow-up time of 8.4 months and compared the results to those of patients who had a percutaneous plantar fasciotomy. Eighty-two percent of the patients treated with ESWT were successfully treated in comparison to 83 percent with a percutaneous plantar fasciotomy. On the Visual Analogue Scale (VAS) of 0 to 10, the mean score for satisfied patients in the ESWT group was 7.9 preoperatively and 2.95 within seven days postoperatively. After three months, the mean VAS in the ESWT group was 4.2 or 50 percent of the preoperative value after a mean of 8.4 months following treatment. The VAS improvement of the surgical group we had previously studied was identical. However, our study noted that the ESWT group returned to work and activities of daily life nearly immediately following the procedures without complications. This was much different than the surgical group.

   There have been other prospective randomized placebo controlled trials (RCTs) on ESWT. Some showed good results and others did not show a difference between the treatment and the placebo groups. Some studies showed no difference between treated and non-treated groups. These studies received more attention from the media, insurance companies and public (physicians included).

   Rarely does anyone point out that no surgical procedure is under the same scientific scrutiny as ESWT as placebo controlled studies would be unethical in a surgical setting. Therefore, ESWT has always been held to a higher scientific burden than surgical procedures that have equivalent retrospective success. There are far more studies published on the successes of shockwave than on its lack of success and now it is commonly accepted as an appropriate and evidenced-based alternative for the treatment of chronic plantar fasciitis.

   In an attempt to quantify the long-term success of ESWT, we recently performed a study looking at the patients who underwent ESWT at the Weil Foot and Ankle Institute from 2000 to 2002.5 We presented our results at the 2010 International Society for Medical Shockwave Treatment Annual Congress and at the 2010 American College of Foot and Ankle Surgeons Annual Scientific Congress. My colleagues and I have also submitted the study results for publication in a peer-reviewed journal.

   The study included 75 patients and 87.5 percent of the patients were either satisfied or very satisfied with their ESWT experience at an average of nine years after treatment with a mean pain score of 1.2 on the VAS scale of 0 to 10. Twenty-four percent of patients were able to discontinue all aspects of maintenance treatment including orthotics, medications, supportive devices or shoes and physical therapy type activities. In addition, 24 percent of patients maintained 95.8 percent improvement with a pain rating of 0.67. The remaining 76 percent of patients continued their heel pain maintenance treatment(s)and had a 79.9 percent improvement with an average pain score of 2.07.

Case Study: Achieving Results For A Patient Who Had Three Years Of Unilateral Heel Pain

As a good example of the early and long-term success of ESWT, consider a 48-year-old woman who presented to my clinic in October of 2000. At the time, she had suffered with unilateral heel pain for nearly three years. She was a primary school teacher who was finding it difficult to complete her normal day of work due to the pain she was suffering. Very typically, she had pain when getting out of bed in the morning. Her drive to work took approximately 45 minutes and getting out of the car was very painful. Additionally, every time she rose from her seat in the classroom, the pain stopped her and she felt the pain was affecting her classroom behavior. Furthermore, because of her heel pain, she had been unable to exercise to her desires and had gained 40 pounds during that three-year span.

   The patient previously had seen three different podiatrists for treatment. She received three different pairs of orthotics, shoe gear changes, a reduction in physical activities, five cortisone injections, a variety of over the counter and prescription anti-inflammatory medications, several rounds of physical therapy, immobilization with a walking boot and cast, and a night splint. Her VAS pain at the time of initial presentation was 8 out of 10 at its worst on a daily basis.

Comments

Lowell,

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?

Thanks,

Richard Bouche, DPM, FACFAS

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

Lowell,

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.

Regards,

Ed

Ed Davis, DPM, FACFAS
San Antonio, Texas

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