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Friday, August 17, 2012

Recalcitrant Plantar Fasciitis and Extracorporeal Shockwave Therapy (ESWT)

According to some experts wearing high heels can put up to 26% more stress on the knee joints and that a three-inch heel can add 76% more stress to the feet. Plantar fasciitis is a common problem that causes pain under the heel bone and in the arch of the foot. Plantar fasciitis is an irritation to the tough, fibrous tissue that forms the arch of the foot. Most patients with plantar fasciitis are effectively treated with some simple measures. Common treatments include anti-inflammatory medications, ice applications, shoe inserts, and stretching exercises. In some situations patients do not find relief from their symptoms and require more aggressive treatment. Surgical intervention has been the last resort for patients when other treatments of plantar fasciitis do not work. The problem is that the success rate of surgery is not excellent, and surgery has potentially complicating side-effects.

Extracorporeal shock wave therapy (ESWT), has emerged as a possible treatment option for patients with chronic plantar fasciitis. ESWT delivers focused shock waves to the body. There is both a high-energy and low-energy form of ESWT; and both forms of shock wave therapy can be used in the treatment of plantar fasciitis. Low-energy shock wave treatments are given as a series of three or more treatments. The low-energy shock waves are not painful, or mildly painful. On the other hand, the high-energy shock wave treatments are given at one session. High-energy shock wave treatments are quite painful, and some type of anesthesia is needed. Either a regional block or general anesthesia can be administered for the high-energy treatments.

Shock wave therapy is thought to work by inducing microtrauma to the tissue that is affected by plantar fasciitis. This microtrauma initiates a healing response by the body. This healing response causes blood vessel formation and increased delivery of nutrients to the affected area. The microtrauma is thought to stimulate a repair process and relieve the symptoms of plantar fasciitis. The medical value of extracorporeal shockwave therapy is however disputed. A number of both favorable and unfavorable studies exist, some utilizing deficient research practices. For treatment of heel pain the FDA study criteria are quite specific. A person has to have experienced heel pain for at least six months and had at least three other types of treatments (cortisone injections, oral anti-inflammatory medication, orthotics, physical therapy, etc.) without relief. In the US the technology is approved by the Food and Drug Administration (FDA) for treatment of plantar fasciitis and tennis elbow. However there is a FDA study to treat recalcitrant diabetic wounds.

Improved technology means ESWT can be done without anesthesia in the physician's office in less than 10 minutes. Research indicates that there is significant reduction in intensity of application pain with the use of castor oil rather than ultrasound jelly. The positive effect of castor oil can be explained by its cavitations-free quality. The patient is afterwards able to walk out but may experience feeling on the heel. Because the treatment has reintroduced an inflammatory response then anti-inflammatory medication or ice are contraindicated. Experts believe people with neurological and vascular disease of the foot, or prior history of rupture of the plantar fascial ligament, open bone growth plates, pregnancy, implanted metal in the area (bone screws and pins) and people on medication that interferes with blood clotting such as coumadin and prophylactic aspirin should not undergo Extracorporeal Shockwave Therapy.

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