Extracorporeal Shock Wave Therapy For Plantar Fasciitis and Achilles Tendonitis
Extracorporeal Shock Wave Therapy or ESWT, was initially used in the treatment of urinary, kidney, and salivary stones. ESWT has been used since the late 1980s for the treatment of various musculoskeletal disorders, including:
- plantar fasciosis/ plantar fasciitis
- Achilles tendinosis/ Achilles tendonitis
- stress fractures
- fresh fractures of bones
- delayed union of fractures
- nonunion of fractures
- wound healing
Currently, we use the treatment for mainly plantar fascitis/fasciosis and for Achilles tendonitis/tendinosis conditions. Although we have used it for would healing, we have found better options for these other conditions.
ESWT is not limited to the foot and ankle problems, as it has also been shown to help:
- patellar tendinopathy (jumper’s knee)
- lateral epicondylitis (tennis elbow)
- medial epicondylitis (golfer’s elbow)
- shoulder calcific tendinitis
Types of ESWT
ESWT has been FDA approved and used in the United States since 2000. ESWT is a non-invas ive treatment that involves the delivery of low- or high-energy shock waves to a specific site to the body. Low-energy shock waves require a series of treatments and do not typically require anesthesia or injections. High-energy shock wave treatment is done in one session and usually requires general or regional anesthesia. Currently, more physicians are using low-energy shock waves without any anesthesia. A recent 86 patient study by Rompe et al. showed that using local anesthesia before shock wave treatments actually reduced the efficacy of ESWT. In another recent study by Klonschinski et al., local anesthetic was found to inhibit and alter the effects of ESWT.
We have used both low energy and high energy shockwave therapy options. With high energy, due to the need to get a good treatment with one shockwave session and the overall cost of multiple sessions, we have found that in certain cases there is an over treatment which may result in stress reactions or bruising of the heel. Furthermore, the treatment is very aggressive and may be overkill. On the contrary, stress fracture or delayed bone healing cases seem to do better with high energy treatment.
Low energy cases seem to be a little less stressful to the foot and do not cause deep bone bruising. Low energy shockwave does require 3 treatments on average, however the treatments can be more catered to the patient’s needs and symptoms.
Mechanism of ESWT
ESWT is thought to work on areas where the body has stopped responding to the area of concern due to the chronicity of the problem. Multiple studies have shown that over time, there is a reduction in the amount of blood flow to a region of damage. This blood flow is essential for healing of damaged tissue. Without blood flow, there is an increase in chronic scar tissue resulting in chronic pain. ESWT increases trauma to the area causing the return of blood supply which helps with healing. The shock waves travel through fluid and soft tissue and their effect occurs at sites where there is a change in impedance (ie -bone/soft tissue interface). This creates an expansion and compression within the area being treated. The expansion and compression of the soft tissue causes microscopic levels of trauma to the area of concern, stimulating inflammation to the area, thereby promoting blood flow and nutrients to reach the problem area and stimulate healing of the area. It is also thought that ESWT may reduce the transmission of pain signals from the sensory nerves, reducing sensitivity and pain to the foot. It is important that no anti-inflammatory medications are taken after ESWT as it would counteract its purpose.
When do we consider shockwave?
ESWT is considered when patients fail approximately 6 months of conservative therapy. At this point, musculoskeletal problems are generally chronic and require acute inflammatory tissue to resolve the issue. Conservative therapy for musculoskeletal problems often involve:
- physical therapy
- custom or over-the counter orthotics
- activity modification
- shoe modification
What is the visit like?
Low-energy ESWT is performed in the office over a period of 3 visits, each spaced about one week apart. Thousands of shock waves are directed at the area of concern without local anesthesia and are custom catered to the patient’s needs. Patients will typically feel mild improvement after the visit, significant improvement after the second treatment and often
are able to return to work and activities of daily life after the third treatment. Patients may be put in a walking boot for comfort or kept in a stiff soled shoe. Some patients may experience bruising, reddening, or swelling of the treated area. The patient should refrain from taking any anti-inflammatory medication so that the effects of the shock wave can be realized without inhibition. Overall, shockwave is a very safe treatment option but there are a few contraindications to shockwave, including bleeding disorders, and pregnancy.
ESWT is similar to treatments such as Platelet-Rich-Plasma, and Topaz ablation therapy in that they turn a chronic, or non-inflammatory, process into an acute, or inflammatory, process, leading to increased blood flow and healing to the area. However, ESWT is the least invasive of the three as it can be done in the office and does not require any needles or opening of the skin. ESWT is becoming one of the mainstays of treatment for many chronic musculoskeletal problems as there is an increasing body of evidence supporting the use of ESWT for various musculoskeletal areas of the body.