ESWT

ESWT known as Extracorporeal Shock Wave Therapy is used in the foot primarily to treat chronic recalcitrant heel pain. This type of therapy became popular a number of years ago to treat kidney stones.

The procedure is also used to treat Achilles tendonitis, tennis elbow, frozen shoulder, golf elbow, jumpers knee, non-union of bone in bone fractures and shoulder calcification. Note that not all indications for shock wave therapy are FDA approved at this time. Presently it is only indicated for heel pain and lateral epicondylitis or tennis elbow. Click here for more information on heel pain.

The FDA has set a protocol for use of shock wave therapy for the treatment of heel pain. Basically a patient has had to have heel pain for at least six months, which has been unresponsive to at least three forms of therapy. These therapies include, but are not limited to:

• physical therapy
• night splints
• orthotics
• cortisone injections
• oral anti-inflammatory medication
• stretching exercises

There are a couple of theories as to how ESWT works. It is thought that the shock wave takes a chronic problem and turns it back into an acute problem thus creating an increased flow of blood to the area (increased inflammation) in an effort to heal the affected area. (The idea here is that once plantar fasciitis becomes a chronic problem, the "brain" can no longer read the pain and because of this cannot work to heal the area.)

As the treatment relates to the foot there are certain contraindications for ESWT. These include:

• neurological disease in the foot
• vascular disease in the foot
• history of rupture of the plantarfascial ligament
• any open bone growth plates
• pregnancy
• any medications that interfere with blood clotting (people on prophylactic aspirin therapy, or coumadin)
• a history of bleeding disorders and any implanted metal within the treatment area.

There are two types of shock wave therapy being performed. One is low intensity and the other is high intensity. Low intensity shock wave is usually performed in the doctor's office, and as the name implies is a lower intensity application that does not require anesthesia.

The problem here is that because it is of a low intensity, the procedure needs to be performed on a repeated schedule, usually three to five visits, in order to achieve the desired results. The other advantage here besides the fact that no anesthesia is required, is that since it is performed in the doctor's office, there is no expense associated with going to a hospital or surgery center.

High intensity shock wave is a one visit procedure and for most will require a hospital or surgery center visit along with anesthesia.

Prior to the procedure a patient will have to stop taking all anti-coagulant medication including aspirin, along with anti-inflammatory medication (Advil, Aleve, Motrin, etc.)

The procedure itself is done in an out patient setting. The procedure does require local anesthesia. Some doctors prefer to do the procedure in an operating room where the patient can then be sedated. The procedure itself takes about 30 minutes, generally there is no pain, but occasionally patients will comment on a feeling of “thumping” on their heel.

Since there is no incision there are no bandages afterwards. Patients are able to leave the office under their own power, although someone should drive them home.

Post treatment instructions are simple. No ice or anti-inflammatory medication for three weeks, the reason being is that ESWT has just re-created inflammation and ice and medication will reduce that inflammation which is not what we want. If there is pain afterwards we generally give Tylenol or Tylenol with codeine.

The patient may return to normal activities within 24 hours with the exception of exercise or heavy lifting, which should be avoided for about one month. The patient should continue with other conservative treatments such as orthotics, night splints, stretching, etc.

What can you expect in regards to pain relief? Keep in mind that this procedure is only done in patients that have tried everything else short of surgery. Having said that the results run in the 80 percent range meaning that 8 out of ten people are vastly improved as a result of the procedure. (If this procedure were done on everyone who suffers from heel pain we would probably be in the 95 percent range) This does not mean that 80 percent of the improved group is totally pain free. It means that in studies approximately 80 percent of those who have had the procedure are satisfied with the results, ranging all the way from complete resolution of the problem down to greatly improved.

It is also important to note that it can take up to six months after the procedure to notice the improvement.

In a recent study (2009) it was noted that diabetics and people with psychological problems tend to fare poorer with ESWT than the population at large. There was no reason given for these findings nor did they define "psychological problems".

REFERENCES

Mayo Clinic

National Institutes of Health

Journal of Bone and Joint Surgery

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