Joel,


Thanks for our comments - I will (once again) relay this information. The
information I have about it suggests the Buchbinder trials looked at low
intensity ESWT focusing on patients with heel pain of 6 months or less.

The American Podiatrists, I am in communication with, use high intensity
ESWT on chronic heel pain cases i.e. 6 months or more.This is comparing
apples and oranges.

My guess is the correspondents do have a vested interest. They may have
invested in expensive equipment to provide this treatment. But also they
have many years experience of treating patients with ESWT, and relate good
outcomes. So they have a vested interest in getting patients better. Also,
it should be added doctors are buying this equipment in the full knowledge
that insurance companies will not cover payment for the treatments.

But, at the risk of overstating the point, the US Issurance companies
decline payments on ALL ESWT quoting the Buchbinder study. So the
criticisms are aimed at the Insurance companies, more than Buchbinder. US
patients already pay HUGE health insurance premiums, so, when the insurance
companies decline the treatment, patients are rail roaded into accepting
surgery. This is in spite of the recommendation of their foot doctor.

I have read here the doctors should beable determine the treatment for
their patients. Unfortunately, increasingly doctors in hte US are
disempowered in that respect. This is "managed health care" designed to
help reduce insurance premiums. You can guess it is not very popular with
doctos and the patients, who get caught in the middle.

Regarding surgery. Whilst I am also not aware of RCT there are certainly
studies, boh cadaveric and follow-up studies, drawing attention to the
harmful effects of severing the fascia leading to a loss of support to the
foot structure resulting in lateral column syndrome.

A lack of evidence from RCT's vindicating (or otherwise) surgical
intervention cannot be used as an arguement in favour of surgery.

I am led to believe there are other studies about to be published
vindicating the contribution of high intensity ESWT in managing chronic
heel pain.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Electrohydraulic High-Energy Shock-Wave Treatment for Chronic Plantar
Fasciitis

John A. Ogden, MD1, Richard G. Alvarez, MD2, Richard L. Levitt, MD3,
Jeffrey E. Johnson, MD4 and Marie E. Marlow, RN5
1 Skeletal Educational Association, 3435 Habersham Road N.W., Atlanta, GA
30305. E-mail address: [log in to unmask]
2 725 Glenwood Drive, Suite E-884, Chattanooga, TN 37404
3 1150 Campo Sano Avenue, Suite 301, Coral Gables, FL 33146
4 Department of Orthopaedics, Washington University School of Medicine, 660
South Euclid, Box 8233, St. Louis, MO 63110
5 719 A Street N.E., Washington, DC 20002

Background: Plantar fasciitis is a common foot disorder that may be
resistant to nonoperative treatment. This study evaluated the use of
electrohydraulic high-energy shock waves in patients who failed to respond
to a minimum of six months of antecedent nonoperative treatment.
Methods: A randomized, placebo-controlled, multiply blinded, crossover
study was conducted. Phase 1 consisted of twenty patients who were
nonrandomized to treatment with extracorporeal shock waves to assess the
phase-2 study protocol. In phase 2, 293 patients were randomized and an
additional seventy-one patients were nonrandomized. Following ankle-block
anesthesia, each patient received 100 graded shocks starting at 0.12 to
0.22 mJ/mm2, followed by 1400 shocks at 0.22 mJ/mm2 with use of a high-
energy electrohydraulic shock-wave device. Patients in the placebo group
received minimal subcutaneous anesthetic injections and nontransmitted
shock waves by the same protocol. Three months later, patients were given
the opportunity to continue without further treatment or have an additional
treatment. This allowed a patient in the active treatment arm to receive a
second treatment and a patient who received the placebo to cross over to
the active treatment arm. Patients were followed at least one year after
the final treatment.

Results: Treatment was successful in seventeen of the twenty phase-1
patients at three months. This improved to nineteen (95%) of twenty
patients at one year and was maintained at five years. In phase 2, three
months after treatment, sixty-seven (47%) of the 144 actively treated
patients had a completely successful result compared with forty-two (30%)
of the 141 placebo-treated patients (p = 0.008). At one year, sixty-five of
the sixty-seven actively treated, randomized patients maintained a
successful result. Thirty-six (71%) of the remaining fifty-one
nonrandomized patients had a successful result at three months. For all 289
patients who had one or more actual treatments, 222 (76.8%) had a good or
excellent result. No patient was made worse by the procedure.

Conclusions: The application of electrohydraulic high-energy shock waves to
the heel is a safe and effective noninvasive method to treat chronic
plantar fasciitis, lasting up to and beyond one year.

Level of Evidence: Therapeutic study, Level I-1a (randomized controlled
trial [significant difference]). See Instructions to Authors for a complete
description of levels of evidence.

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