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Extracorporeal Shock Wave Therapy

Discussion in 'General Issues and Discussion Forum' started by Dieter Fellner, Oct 20, 2004.

  1. Dieter Fellner

    Dieter Fellner Well-Known Member

    Members do not see these Ads. Sign Up.
    Extra Corporal Shock Wave Therapy: This treatment does not appear to have gained favour in the UK. I have spent the last year in the US, where the treatment often now preceeds surgical intervention.

    I am interested to hear from any practitioners willing to share their experience of using ESWT in the treatment of heel pain/achilles tendon pathology.

    Apologies to Podiatry Forum visitors.
    Last edited by a moderator: May 12, 2005
  2. davidh

    davidh Podiatry Arena Veteran

    I dont have any practical experience with this modality, and thus cannot quote you personal empirical evidence, but you may like to look at a paper published in the BMJ in July 2003.


    I did a lit search on ESWT a while ago, and couldn't find any robust evidence of it's effectiveness, although I am aware that it has been around in various forms for a few years for use with musculoskeletal problems.
  3. Dieter Fellner

    Dieter Fellner Well-Known Member

    FDA approval


    Thanks for that reference. A multi-centre RCT with similar patient numbers was performed in the US using the same equipment demonstrating the treatment to be effective and subsequently gaining FDA approval. This was a multi-million dollar initiative, apparently.

    Does it work or doesn't it? Puzzling ....... :confused:
  4. nicpod1

    nicpod1 Active Member



    There's a Rheumatologist named Cathy Speed, who works at Addenbrookes Hospital in Cambridge who uses this regularly, also on plantar fasciitis. She is also biomechanically aware with respect to the foot and, I think, also treats sports injuries.

    She also works privately at BUPA Cambridge Lea Hospital. A Podiatrist by the name of Sophie Cox also works there, so, if you get hold of her details, she may also do a joint clinic with her? Sophie, as you may know, works with Simon Costain.

    They may give you more info on successes (or otherwise). Anyway, I thought they were all for this 'cryogun' therapy for plantar fasciitis now in Pod in Lincs SW PCT?

    The number for Addenbrookes is (01223) 245151.

    This info is probably useless - but maybe not!
  5. Dieter Fellner

    Dieter Fellner Well-Known Member


    Thanks for the information. When I get back to England I will check it out.

    Cryogun..... is that for VP's on heels? ;)
  6. nicpod1

    nicpod1 Active Member


    No........for plantar fasciitis :eek: - I'll let you do the leg-work! :D
  7. Dieter Fellner

    Dieter Fellner Well-Known Member


    my legs are way too old to work..... any young legs for hire? Anyone???? :p
  8. toemeister

    toemeister Member


    You have to stop NSAID's during healing so it's tender. I have treated two people with 0 % success, however, others in the community claim 50-80% success.
  9. Craig Payne

    Craig Payne Moderator

    I have had access to ESWT for a while now - have not had to need to use it, except for 2 recalcitrant cases (both then failed to espond to the ESWT) ... I just think we have got better at determining the orthoses design parameters for foot types that develop plantar fasciitis, that we just don't have as many failures to orthoses therapy that we used to.
    Last edited: Oct 26, 2004
  10. podrick

    podrick Active Member


    in the us there is no greater authority on it than lowel scot weil,d.p.m. he has done extensive,published studies on it.i will tell you that it is effective in true cases of plantar fasciatus.however,current research as published by weil,you may check it out on his website states that it is contraindicated in tendo achilles pathologies.both the orthopedic and podiatric communities seem to agree on this.
    however,here is a thought.if you consider the mechanism by which eswt works.you are actually causing micro trauma to the affect fascia.the actual healing process is what givesthe patient relief,via the generation of healthy new micro-fibers.this isn't much different than what has been achieved(although through mainly anecdotal research) through prolotherapy and at much less cost.the cost of an eswt unit is astronomical.i have a neurologist in my area which has been treating plantar fasciatus with prolotherapy for years with very good results.
    i would appreciate any comments anyone may have with regards to prolotherapy.

  11. Michael G. Warshaw

    Michael G. Warshaw Welcome New Poster

    Re: Extracorporeal shockwave therapy

    I would very much like to hear from patients that have undergone shockwave therapy for plantar fasciitis and have less than desirable results.
  12. podrick

    podrick Active Member

    Shock Wave Therapy

    I Do Agree With Something Craig Stated,with Regrds To Its Efficacy.like Any Treatment Modality,one Size Doesn't Fit All.it Most Definitely Does Not Alleviate All Case Of Plantar Fasciatus.however,in The States(due To Big Money Interest) It Is Billed This Way.
    I Would Like To Hear Any Commentary On My Original Point Regarding Prolotherapy.

  13. pgcarter

    pgcarter Well-Known Member

    I worked with a pod who spent some years in Asia, she said some TCM practitioners will wack the medial tubercle area with a hammer.....stimulates a healing response for very little capital investment.
    Regards Phill Carter
  14. podrick

    podrick Active Member

    hammer comedian

    man,that was hilarious.what a witty contribution to this forum.
  15. admin

    admin Administrator Staff Member

    Cutting-edge without the scalpel


    <ADDED> The free access period to this news story has ended
    Last edited: Nov 20, 2004
  16. pgcarter

    pgcarter Well-Known Member

    Dear Podrick,
    It was not intended to be funny...it is true....and I thought some of the people reading this may not be aware of this historically developed perspective on this condition, which is still used in Asia with some anecdotaly reported success. As much support as many things done in western health care.
    Regards Phill Carter
  17. podrick

    podrick Active Member

    shock therapy

    dear phil,

    my apologies.i did not know this,fascinating.

  18. Craig Payne

    Craig Payne Moderator

  19. Don ESWT

    Don ESWT Active Member

    Extracorporeal Shock Wave Therapy In Australia

    Hello everyone,
    ESWT has been in Australia since 1998. The first unit was in Melbourne, There are now about 12 Dornier EPOS Ultra machines nation wide. I know of at least 3 Podiatrists in Australia doing either ESWT or RSWT (R=Radial). I, have the Dornier set up in Macquarie Street, Sydney.
    I have been doing ESWT for 2 years. So far I have had good to excellent results with the patients treated.
    ESWT machine are expensive varying from $50,000.00 to $350,000.00 there are not in private practices yet.

    Donald Iain Scott
  20. Dieter Fellner

    Dieter Fellner Well-Known Member

    Need to subscribe


    Thanks for the link but it is necessary to subscribe to the Herald to access this story...are you on cyberspace comission???

    <ADMIN ADDED> The news story was free, but access to archives needs a subscription. The free period has passed - sorry.
    Last edited by a moderator: Nov 20, 2004
  21. Dieter Fellner

    Dieter Fellner Well-Known Member


    This is as an excellent review article. Thanks for the link and, (Admin please note ) nothing to pay! :rolleyes:
  22. admin

    admin Administrator Staff Member

    From the latest issue of Radology
  23. Atlas

    Atlas Well-Known Member

    I think Kathy Bates was trying to help that fellow (who was tied to the bed) and his stubborn chronic knee pain. :rolleyes:

    Anyway, my motto is, (bio)mechanical problems have (bio)mechanical solutions. It is a bit like going to the hardware shop and asking for the strongest plaster to fill a crack, when all along one stump is rotted.

    A clinician's brain is much more potent than electotherapy IMO.
  24. admin

    admin Administrator Staff Member

    The latest

    The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis
    Colin E Thomson, Fay Crawford and Gordon D Murray

    BMC Musculoskeletal Disorders 2005, 6:19

  25. Craig Payne

    Craig Payne Moderator

    I will bump this old thread with this story from Podiatry Online:
  26. podrick

    podrick Active Member

    heel pain


    excellent article.i think that eswt is overutilized in the states due to the investment the physician has in it.i can tell you that many of my colleagues resort to it as a first line of treatment.
    the study i think brings to light something that was touched upon by one of the contributors.heel spur syndrome/plantar fasciatus are biomechanical pathologies.thus they must be treated first with a comprehensive conservative regimen,consisting of pt,injection therapy,nsaids,stretching and orthosis.there are a lot of practitioners who will do one but not the other of all of these.thus not giving conservative treatment a true chance.
    incidentally,we are currently trying a plantar approach after a pt block when injecting difficult to relieve patients which has worked fairly well (anecdotal).the idea is that by using a 20 gauge needle we are able to open an aperture in the fascia while depositing the cocktail and allow for some additional stretching.it is being used by some local orthopods in my area.and it too is less expensive than eswt.
  27. Ron Lucerne

    Ron Lucerne Welcome New Poster

    Craig, Podric,
    What are your opinions on treating Plantar fasciitis using Cryosurgery for long term pain relief? When should a patient consider this type of treatment?
    Ron Lucerne (lucerner@att.net)
  28. Craig Payne

    Craig Payne Moderator

    There is even less evidence for that than there is for the shock therapy.

    At the end of the day, plantar fasciitis is due to a mechanical overload in the tissues (we could argue how that overload got there) - all these modalities are doing is providing symptomatic relief - in some people that is all thats needed provided they modifiy activity levels. .... but in most something needs to be done to reduce the load in the tissues (we could argue over the best way to do that)

    I will post soon the results of our RCT in those with failed orthoses treatment for plantar fasciitis ---- BUT, they do get better if you get the orthotics right.
  29. Ron Lucerne

    Ron Lucerne Welcome New Poster

    Thanks for your reply. What does it take to get the Orthotics right other than a custom fit from a casting of the patient's foot by a board certified podiatrist? How is the Podiatrist able to determine that the finished Orthotic provided from the lab is correct for that individual patient?
    Ron Lucerne
  30. Don ESWT

    Don ESWT Active Member

    Excuse me.

    If you are not treating patients with ESWT or Cryrotherapy how can you make such a flippent remark.
    ESWT has excellent results for PF, Golfers and Tennis Elbow, Peryonis Disease, Non Union Fractures, Achilles Tendonitis, Haglunds' Deformity, Rotator Cuff Tears, Hips, Knees, and the latest Diabetic wound healing and Myocardial disease.
    Years of solid research in Europe and Japan have the results (News-Medical.Net 31/5/2005)
    Studies from Monash University in 2001 have be debunked by the broader ESWT community/researchers.
    Poor Q form and patients involved.
    No Podiatrist on hand for biomechanical assessment.
    No ESWT Therapist present at trial.
    Trail carried out by students.
    No Xray or Ultrasound to confirm PF or tendon thickness

    ESWT works, it just take time for the individuals body to react to the treatment. There is also a patient compliance component with the treatment. Do exactly what the practitioner recommends.

    Orthotics work ESWT works and Cryotherapy works.

    Donald Iain Scott
    ESWT Therapist
  31. Craig Payne

    Craig Payne Moderator

    No even close to be true - those with a vested interest seems to have tried to pick holes in it and other studies, but conviently ignored the bigger holes in the studies that they claim support ESWT!!! From a methodological standpoint, it is probably the most rigourously conducted - most of the critics conviently ignored the research question from that study - they answered it.

    ESWT was an overused fad that is now being put in its appropriate place as a useful modality and not the "end all and be all" - its just those that have invested financially so heavily in the equipment have to justify what they have done.

    We have done 3 RCT's on plantar fasciitis, one of which was on those with failed orthoses -- we just do not see the need to use ESWT anymore --- we just don't see patients that need it as we got better fixing them with foot orthoses.

    I am not aware of one single RCT that shows cryotherapy works in plantar fasciitis, so its easy to make the claim about lack of evidence (that does not mean it does not work).
  32. Don ESWT

    Don ESWT Active Member

    So, your saying orthotics are the only answer to Plantar Fasciitis
  33. Don ESWT

    Don ESWT Active Member

    ESWT started in Europe not Australia or America, why do you not acknowledge their initial work and their recent breakthroughs

    Don Scott
  34. Craig Payne

    Craig Payne Moderator

    I have copies of it all - they just do not stand up to any methodological scrutiny. The recent prospective RCTs that are rigourously done are just not supporting the less rigourous studies previously done. I have nothing against or for ESWT therapy - I have no vested interest in it either way - I have referred patients for it - some got better - some did not. Those with vested interests are someone selective in their critiques of methodological issues in studies that do and do not support its use.
    Never said that. What I am saying is that EWST is probably only ever needed in a few isolated cases. Now that we are getting better outcomes with foot orthoses, I have just not had to send anyone off for EWST for over a year now.

    I just object to the almost "religious fanaticism" amoung some in the ESWT that is harming it for all --- see the similarities to the threads we have had on manipulation, barefoot running and minimum incision surgery :)

    I recall when that Monash paper came out, a message posted in PM News from a DPM who had purchased an EWST machine, demanding that the American Podiatric Medical Association do everything it can to totally discredit the study ---- certainly smacks of a credibility issue that the owner of a machine with a vested financial interest would demand such scrutiny, without demanding that the studies that have tended to support EWST not be put under the same such scrutiny :confused:
    Last edited by a moderator: Jul 29, 2005
  35. Don ESWT

    Don ESWT Active Member

    Scrutiny is important, I am sure you would not let something be published unless someone proofed it for you.

    Yes I have a vested interest in the success of ESWT as I have a machine but the Monash results are now 5 year out of date.

    Yes the manufacturers and there are about 10 world wide, have a vested interest in the success ESWT, as they have outlaid millions of EUROS. Dornier the company which loaned the machine to Monash University were upset that they were not involved throughout the process, but that is past history.

    I remember reading that the Prof. Rachel Buchbinder study, was taken up by US Health Funds they used it to refuse patients a rebate for treatment, yet the FDA approves ESWT go figure!

    There are arguement for and against ESWT and I don't they will be settled easily.

    I have been involved with ESWT since September 1998. I was able to purchase a machine in 2002. I will keep trying to help my patient with their pain management.

    On another point Functional Orthotics have been around over 50 years, surely as Podiatrists we should have it right by now, but we still have not come to an agreement as to the style of orthotic to cure PF.

    I gave a pair of Functional Orthotics to the Sydney College in the mid 80's that my father made in 1951 along with his Anaesthetic Injection Kit and Ross Fraser Brace Kit.

    Donald Iain Scott

    Extracorporeal Shock Wave Therapist
    New South Wales
  36. R.S.Steinberg

    R.S.Steinberg Member

    ESWT - From Experience

    In the USA, the criteria for using High Energy Dornier EPOS Ultra ESWT for plantar fasciitis is six months of failed conservative therapy having utilized at least three of the following: NSAIDs, cortisone injection, ultrasound, massage, stretching, over-the-counter arch supports, or prescription orthotics. Then, and only then, is it time to try ESWT. (According to the US Federal Drug Administration)

    And, without a doubt, ESWT should be tried before any surgical release of the medial portion of the plantar fascia. I would call it malpractice if it weren't! With that said, in my 28 years of practice I have found that at least 70% of my patients with plantar fasciitis respond well to the conservative therapies I listed above. At this point in my career, I shudder when I even think about a surgical release because of the damming affect it has on the biomechanics of foot function. In reviewing the literature, I found that most of the study findings are suspect because legitimate protocols were not followed. Injections can and do work so it is no surprise that they were shown to be "as effective" as ESWT. But injections, and all the other conservative therapies do not always work. We all know this, don't we?

    I have been certified on ESWT for over 6 years now; first on the clumsy Ossatron, and now on the Dornier EPOS Ultra. Both devices work, but the EPOS Ultra produces consistently better results. I think this is mainly due to its real-time ultrasound imaging capabilities that allow for extremely accurate aiming throughout the procedure. You can believe me or not, but I am seeing an 80%+ cure rate. I have had three cases where I felt it necessary to re-do the procedure.

    I believe that ESWT will become the gold standard of care for chronic plantar fasciitis in the not too distant future. It is non-invasive, effective, and has a low risk of negative side effects.

    Robert Scott Steinberg, DPM, DACCPPS (BP)
    Hoffman Estates, IL USA
  37. podrick

    podrick Active Member


    i think don misses one vital point in his argument.there are many treatment modalities which may relieve a condition without ever having addressed its cause and thus risk long term damage or even offer short term results.
    i can site steroid injections for the knee.they may resolve the pain while they actually crystalize and create further damage to the tissue,particularly when over used.
    in the U.S. eswt is marketed for conditions ranging from plantar fasciatus to tendo achilles tendinitis( a condition which its own research has indicated it is not indicated for).so i do believe there is cause for questioning long term results.
    then there is the question of the price of the modality.it may very well be a very expensive solution to a problem which may be treated with more conservative economical means.particularly in the states,at a time with limited insurance coverage and resources, for healthcare.price cost does matter.
    i am not closing the door on it.i just have read all the available research on it and think more is needed,before we touted as a "cure-all," to our patients.
  38. podrick

    podrick Active Member


    i think with cryosurgery you have an even bigger dilemma then with eswt.if you read their own research and spend time in a demonstration.you walk away with more questions then answers.
    they simply don't have a real answer as to why it works and for how long will it work.
    as to how they get fda approval in the states now a days.i just don't know may be they got some advice from the vioxx makers.
  39. R.S.Steinberg

    R.S.Steinberg Member

    ESWT - From Experience


    Where did you go to school? When did you graduate? Will you post your full name?

    I am not sure where you get your information. And, every bit of medicine is marketed. Hanging your shingle is marketing. So, what is your point?

    In the USA, ESWT is marketed, promoted, pushed, etc., as a treatment for chronic plantar fasciitis, and off lable for chronic Achilles tendonitis. It is currently under review by the FDA for approved use.

    It goes without saying that doctors always, or at least should be, looking for cause and effect, as well as the effect any certainj treatment has long term. Sx of the PF produces a permanant change in foot structure and function. There are no reports of any long term negative effects of ESWT, and ESWT has been used in Europe for over 12 years.

    ESWT is far less costly in terms of missed work and recovery then SX. Period. And since it is not supposed to tried until conservative therapy has failed, where is the problem, or better yet, where is your problem.

    Podrick, how many high-energy ESWT procedures (following all protocals) have you performed?

    Oh, and lets not forget that our patients are demanding relief from their pain.

    Robert Scott Steinberg, DPM
    Hoffman Estates, IL
  40. Craig Payne

    Craig Payne Moderator

    The Cochrane Collaboration conclusion on ESWT was:

    It will never become a "gold standard"

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