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

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

   With low-energy ESWT, the typical costs range from $900 to $1,500 total for three treatments, based on my experience and talking to people around the country, and recognizing what insurance covers when ESWT is covered. There is no facility fee or anesthesia fee. There are no complications associated with low-energy ESWT that would create any additional expenses. There is virtually no loss of work with the exception of the time spent to have the procedure performed. Social costs are also reduced as patients can return to almost all activities of daily life without restrictions.

   High-energy shockwave does have higher costs associated with it in comparison to low-energy ESWT and can range from $1,000 to $3,000 total. However, treatment with high-energy ESWT does have the advantage of one-time treatment.

   Extracorporeal shockwave therapy, high energy or low energy, exhibits strong cost benefits in both absolute dollars and less tangible but equally important work and social costs. The Journal of Bone and Joint Surgery states that long-term studies must be those that have been performed at least five years following the original study. We initially reported our early results in 2002 in the Journal of Foot and Ankle Surgery and now have reported our long-term results, which, as far as we know, is the only long-term study on ESWT and plantar fasciitis.4,5

Final Notes

Extracorporeal shockwave therapy has gone through the trials and tribulations of being a new and expensive technology. These include inconsistent information to consumers, conflicting results of research on the efficacy of the technology and the relative inaccessibility to physicians and patients. However, years of clinical success and proper research have proved the validity of ESWT.

   Plantar fasciitis continues to be a burden on our healthcare system, economy and society. It is incumbent on all medical providers to find the most proven and cost-effective treatments for their patients to return to life and work. While there are many treatments employed for plantar fasciitis, most have not been proven and we have pointed out their costs. Others have been studied but their costs are quite substantial and their complications are notable.

   Extracorporeal shockwave therapy has proven to be a cost effective treatment for plantar fasciitis while showing long-term success that other treatments cannot boast. Not only should one consider ESWT a mainstay of treatment for more chronic cases of plantar fasciitis, it should now be an option earlier in the treatment regimen and possibly supplant other treatments that have not been validated. The future may show that combining treatments such as ESWT and PRP will provide the fastest and safest recovery but until PRP is better studied, it will still take a back seat to ESWT.

   Dr. Weil is the Research and Fellowship Director for the Weil Foot and Ankle Institute, which has various office locations in Illinois. He is the Editor of Foot and Ankle Specialist, and is a Past President of the International Society for Medical Shockwave Treatment.

References

1. Tong KB, Furia J. Economic burden of plantar fasciitis treatment in the United States. Am J Orthop. 2010; 39(5):227-31.
2. Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R. Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. Foot Ankle Int. 2002; 23(4):309-13.
3. Ogden JA, Alvarez RG, Marlow M. Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis. Foot Ankle Int. 2002; 23(4):301-8.
4. Weil LS Jr., Roukis TS, Weil LS Sr., Borrelli AH. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy, J Foot Ankle Surg. 2002 May-Jun;41(3):166-72.
5. Weil L Jr., et al. Long-term results of extracorporeal shockwave treatment for chronic plantar fasciitis. Presented at the International Society for Medical Shockwave Treatment Annual Meeting, Chicago, June 2010.
6. Taylor DW, Petrera M, Hendry M, Theodoropoulos JS. A systematic review of the use of platelet-rich plasma in sports medicine as a new treatment for tendon and ligament injuries. Clin J Sport Med. 2011; 21(4):344-52.

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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