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Extracorporeal Shockwave Therapy for Plantar Fasciitis and Achilles Tendonitis

What is ESWT?

Extracorporeal shockwave therapy (ESWT) is an effective new technology used to treat chronic plantar fasciitis and Achilles tendinopathy. ESWT uses shockwaves to break up scar tissue and allow healing of the inflamed fascia or tendon. The studies have reported 57-80% good or excellent results. Studies have also shown complete or near complete relief of pain with 1-3 sessions of ESWT.

Currently, ESWT is used to treat various musculoskeletal pathologies. Shockwave therapy stimulates the healing process in tendons and bones by stimulating vascular growth in these tissues. These tissues then release local growth factors and naturally occurring stem cells to allow more normal tissue healing. ESWT exerts a deep tissue effect that causes healing of chronically damaged deep soft tissue. The new blood flow stimulated by the therapy helps the tissue regenerate by increasing the break down and removal of chronic scar tissue that gets in the way of healing.

When is it used?

Current indications for ESWT include proximal plantar heel pain (pain close to the heel) that has lasted longer than 3 months and has been recalcitrant to at least three conservative therapies, such as cortisone injections, strapping, custom orthotics, Achilles tendon stretching, NSAIDS, and/or physical therapy.

What are the contradictions with this procedure?

contradictions to ESWT quoted in the literature include pregnancy, coagulopathies(bleeding disorders such as hemophilia), bone tumors, bone infection, and skeletal immaturity.

How do I prepare for the procedure?

You will need to plan for your care and recovery after the procedure. Allow for time to rest, and try to find people to help you with your heavy housework or yard work. You should arrange for someone to drive you home after the procedure if the right foot is treated.

Follow your healthcare provider's instructions about not smoking before and after the procedure. Smokers heal more slowly. For the same reason, if you are a smoker, you should quit at least 2 weeks before the procedure. It is best to quit 6-8 weeks before the procedure.

If you need a minor pain reliever in the week before the procedure, choose acetaminophen rather than aspirin, ibuprofen, or naproxen. This helps to avoid extra bleeding. If you are taking daily aspirin for a medical condition, ask your provider if you need to stop taking it before your procedure. If you are taking a blood thinner, such as warfarin (Coumadin), your physician will tell you when you need to stop taking it before the procedure.

What happens during the procedure?

You will be given a local anesthetic injection behind the ankle to anesthetize the treatment area. Next, a gel solution will be applied to the skin over the area of chief complaint (maximal pain). The ESWT machine creates shockwaves by converting electrical energy into mechanical energy. The resultant shockwave is sound impulse created in a water medium, which spreads through the tissue without losing substantial energy. The patient rests on a treatment table with the ESWT machine pointing at the area of pain. Ear plugs can be used for comfort.

What happens after the procedure?

You may experience some pain or discomfort in the shockwave treated area after the numbing medication from local anesthesia subsides. You may also experience some pain for the next 1-2 weeks. In some cases, the patient experiences little or no pain for the first 1-3 weeks, then pain may return to the pretreatment level, which improves as the tissue heals. Pain is manageable with over-the-counter pain medication, such as Tylenol. For 4 weeks following shockwave treatment, do not treat the affected area with heat or ice, and do not take any anti-inflammatory medications such as Motrin, Advil, etc., unless advised differently by your physician. Do not participate in any stressful activities involving the affected area for 4 weeks. Stressful activities may include running, jogging, doing heavy housework, yard work, or participating in exercise or sports. Heel pain patients should avoid completely flat shoes such as sandals (flip-flops), loafers, moccasins or house slippers. If you have orthotics, please continue to use them. If your current treatment plan involves Cam Walker immobilization, please continue to wear the device as directed by your physician.

Simple, gentle Achilles tendon stretching exercises must be performed several times per day and prior to any exercise or sports activity. Heel pain patients should continue Achilles tendon stretching exercises as directed.

It is important to remember that the reduction in pain is due to increased blood flow from the formation of the blood vessels in the foot. This process takes time, and you likely experience pain for 8-12 weeks. Keep in mind that this is normal, so do not get discouraged if relief does not occur sooner.

What are the benefits?

You may eliminate your heel pain and the problems it causes without surgery. ESWT is a safe, effective, and non-operative treatment for plantar fasciitis and Achilles tendinopathy. Boot bracing, in addition to ESWT, should be offered to all patients prior to surgery because this treatment has minimal side effects. Depending on the severity of the patient's condition, your physician might allow for a more aggressive post-ESWT rehabilitation protocol.

What are the risks associated with this procedure?

Mild bruising and local swelling has been reported.

When should I call my healthcare provider?

Call your provider right away if:
  • You develop a fever.
  • You have increasing pain.
Call during office hours if:
  • You have questions about the procedure or its result.
  • You want to make another appointment.