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Dr. Barbara Rien, DPM, PA
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Shockwave Therapy for Heel Pain

Extracorporeal shockwave treatment, also known as ESWT, is a non-invasive, non-surgical treatment option for the intense, persistent heel pain associated with chronic plantar fasciitis and achilles tendonitis. "Extracorporeal" means "outside the body". Shockwaves, also known as pressure or sound waves, are generated from a special ESWT device and focused onto the targeted tissue. The shockwaves are delivered outside the body to trigger an individual's own repair mechanisms. The concept behind shockwave therapy in orthopedic disorders is that the shockwave stimulates and reactivates healing to encourage revascularization and other elements necessary to advance normal tissue healing. Additionally, shockwaves help to over-stimulate pain transmission nerves, which can lead to a reduction in sensitivity and pain.

What is plantar fasciitis?

The plantar fascia is a band of connective tissue on the plantar surface of the heel that plays a large role in maintaining the normal architecture of one's foot. Plantar fasciitis is a common clinical condition caused by overuse or injury of the plantar fascia and is defined as traction degeneration of the plantar fascial band at its origin on the medial tubercle of the calcaneus. Inflammation, fibrosis, and decreased vascularization of the fascia occur, causing symptoms of heel pain. Other symptoms that may occur include burning in the sole of the foot, recurring foot pain that is especially aching in the morning or after sitting, or heel pain after beginning a new exercise routine.

What causes plantar fasciitis?

There are a number of predisposing factors, including foot pronation, obesity, poor fitting shoes, minor trauma, occupational risks and change in exercise program. Although everyone is at risk, plantar fasciitis is most commonly found in athletes, runners, overweight individuals, or those who are required to stand on hard surfaces for prolonged periods of time. Although approximately 2,000,000 Americans suffer from plantar fasciitis ESWT is an appropriate treatment option in approximately 5 to 10% of those cases, as the remainder of the cases can be adequately addressed with more conservative therapies.

Who should receive ESWT for plantar fasciitis?

Prior to undergoing ESWT treatment, the patient must have been diagnosed with chronic plantar fasciitis for at least six months. Only after the patient's symptoms fail to respond to three conservative treatments should ESWT be administered. Conservative treatments include rest, physical therapy, heel cushions, non-steroidal anti-inflammatory drugs (ibuprofen, acetaminophen, etc), cortisone injections, taping, orthotics, shoe modifications, night splinting and casting. In years past, surgical intervention for chronic plantar fasciitis was required when these other treatments had failed. Today, ESWT is available as an alternative, non-invasive treatment option.

Who should not receive ESWT treatment for plantar fasciitis?

Your health history should be reviewed with your doctor to see if this treatment is appropriate for you. ESWT is not recommended for patients with certain conditions. Patients with pacemakers and patients taking medications that may prolong or interfere with blood clotting (coumadin) are not candidates for ESWT. Also, children or pregnant women are not considered appropriate candidates for ESWT. ESWT is not appropriate for individuals suffering from acute plantar fasciitis.

What are the side effects of ESWT?

Compared to surgery, ESWT has fewer side effects and a much shorter recovery time. The most common patient complaint is some minor pain or discomfort during and after treatment. Other side effects might include minor skin bruising, reddening, or swelling of the treated area. However, these possible occurrences usually resolve within a few days. The risks associated with surgery and general anesthesia are eliminated.

Is ESWT covered by insurance?

Unfortunately, ESWT is not covered by any insurance company. Despite numerous favorable articles about the positives of ESWT for chronic musculoskeletal pain problems this remains an uncovered service.

What should I expect before, during, after ESWT treatment?

An initial consultation to rule out other causes of your Heel or Achilles pain will be done. During the visit a digital x-ray series is taken to ensure that are no other problems are causing your pain such as a stress fracture, fracture, bone tumors, etc. At times a soft tissue ultrasound will be done to assess the exact location and measure the extent of inflammation and possible tears.

During the procedure:

  1. Low energy ESWT: expect to spend about 10 minutes getting the treatment, no anesthesia is required but for some patients the initial treatment can be uncomfortable. Local anesthesia can be administered in such cases, but only 1% of our patients requires such. If you are in the 1% usually by the third treatment your condition (Plantar Fasciitis or Achilles Tendonitis) would have improved enough to not require anymore anesthesia. The low ESWT procedure causes anesthesia via negative feedback and desensitize the treated area. Remember that 5 treatments are required for the low energy at 4-7 days apart.

  2. High energy ESWT: a local / regional anesthesia will be administered then after 5 minutes the procedure is started. Expect 15-20 minutes for treatment but you will be totally anesthetized. Usually one treatment is all that is needed, but on a rare occasion a second application would be required at 6 months.

After the procedure, you are allowed to continue your activity with light aerobic activities such as walking, even jogging, this will be the limitation for 6 weeks. During this recovery time no NSAIDS such as aleve, naproxen, celebrex, motrin, etc are allowed unless you are taking 81 mg Aspirin or 325 mg Aspirin for your cardiac health. Instead Tylenol should be used as needed. Rarely narcotics are prescribed. You should feel 90% - 100% resolution by 5 months.

For Achilles tendonosis / tendonitis we have been able to avoid surgery on a majority of our patients even those with large heel spurs! The spurs remains but the pain is gone, thus, no further intervention is required. We have had patients that were scheduled for surgery at another facility but after ESWT the pain fully resolved.

For Plantar Fasciitis / Fasciosis: in case of a tight plantar fascia that just won't give up, a simple medial plantar fascia lengthening can be done in the office via our minimally invasive technique. Remember, it is not the spur that is causing your pain it is the inflammation of the tissue that is causing your pain.




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Dr. Barbara Rien, DPM, PA
9980 Central Park Blvd., Suite 120
Boca Raton, Fl 33428

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