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

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

   Two weeks after her initial consultation, she was treated with high-energy ESWT under sedation. At her first follow-up visit two weeks after her procedure, she noted a 50 percent reduction in pain. At her visit three months after the ESWT procedure, she felt that 90 percent of her symptoms were resolved and was anxious to return to all activities including the use of a treadmill.

   When we called patients back for our long-term study, she was insistent about having a long conversation with me. She wanted to help the study in any way she could because she felt that ESWT had “given her life back.” She related that her current condition was terrific. She has had no heel pain since six months following the original ESWT procedure. She had returned to all aspects of life including exercise and stated that not only had she lost the 40 pounds that she had gained during the plantar fascia problem but lost an additional 10 pounds. She told me she was running regularly and had completed two marathons in the previous five years. Her story, more detailed than most, was very common during our long-term study evaluations.

How Does ESWT Compare With Other Treatments In Cost And Efficacy?

The alternative to ESWT for chronic plantar fasciitis (plantar fasciosis) is often surgical intervention and more recently platelet rich plasma (PRP). Platelet-rich plasma is the use of autologous blood products to stimulate healing of bone, tendons, ligaments and cartilage. At this moment, there are no published prospective RCTs on PRP for plantar fasciitis or any other pathology that PRP treats in an ambulatory, injectable, soft tissue healing situation. There are several anecdotal reports on success but they are only that.

   Furthermore, PRP is constantly evolving, much in the same way the way that ESWT did in the early 2000s with different companies jockeying for positioning and stating their system is superior to others. The cost of PRP may be higher than ESWT and ranges from $500 to $1,500 per treatment with some advocating two or three treatments for a given condition.6

   Comparing the costs of surgical intervention (open, percutaneous or endoscopic) to ESWT will significantly favor ESWT. According to Tong and Furia, the median cost of surgical procedures for plantar fasciitis in 2008 was $1,347 for surgeon reimbursement and ranged from $4,352 to $9,500 for hospital or surgery center reimbursement.1

   The indirect costs associated with surgical intervention include the chance of significant complications requiring some intervention (2 to 5 percent) and the resultant expense of care needed for those complications. Other indirect costs associated with open surgery include lost time from work and changes in activities of daily living. It is not uncommon for postoperative plantar fasciitis patients to miss work for two to six weeks due to immobilization and partial weightbearing. It is difficult to accurately determine the overall cost of someone being away from work as this is different from person to person based on the job. It is even more difficult to put a number on the cost of interference in activities of daily life. Without doubt, there are tangible dollars and social costs that are significant with both.

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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