Thoughts on the Trajectory of ESWT in Podiatry
Extracorporeal shockwave therapy (ESWT) first emerged clinically in 1982.1 Evidence as a whole supports its potential benefits in treating symptoms related to conditions such as plantar fasciitis and Achilles tendinopathy with minimal side effects and a high safety profile.1,2 There are still some debates, though, about precise efficacy, and many continue to call for more randomized clinical trials to better evaluate this procedure.3 Nonetheless, there is wide discussion of the impact on the musculoskeletal system, positive results in pain relief and support of tissue healing.4
These different energy forms (focused versus radial) are still part of contemporary discussion and debate.4 Focused shockwave therapy first produces a wide pressure wave field that becomes more focused at a particular depth. The devices available commercially include piezoelectric, electromagnetic, and electrohydraulic.4 Radial shockwave, however, results in pressure waves at maximum pressure that attenuate as the waves travel more deeply. Radial shockwaves travel at comparatively lower speeds, and reach overall lower peak-pressures compared to focused therapy.4
Combining shockwave protocols with standard treatments such as calf stretching may also improve overall efficacy.5 Although typically an out-of-pocket cost, studies generally reveal high patient satisfaction and a low clinician learning curve.5
Lowell Weil Jr, DPM, FACFAS, Executive Chairman of Balance Health, was among the first in the field to perform ESWT in February 2000, adding that the original device was high-energy electrohydraulic, requiring sedation in an OR. Nonetheless, they saw an influx of patients from across the country at the time. He recalled high costs, due to the need for the surgical facility, anesthesiologist, and podiatrist.
“We published the first American peer-reviewed study6 on outcomes, which showed 82% success/complete resolution of symptoms,” he said. Dr. Weil went on to say that with time, the technology transitioned to primarily clinic use and more ballistic treatments. “The treatments are far more accessible with many people providing them and costs have come down tremendously. Outcomes have not come down though! For the right diagnosis and proper comprehensive approach, we are able to successfully treat patients over 90% of the time. I also had the exciting opportunity to use it on many professional and college athletes, allowing them to return to sport much more quickly than other alternatives. I served as President of the International Society for Medical Shock Wave in 2010, which was a very gratifying experience.”
He also points out additional benefits in practice management. “The best part is offering a well-studied, noninvasive option to patients,” he explained. “They really appreciate the approach. Treating people multiple times also allows you to get to know people and develop relationships that make a huge difference in them referring more patients to you.”
Priya Parthasarathy, DPM, DABPM, FASPS, President of the Maryland Podiatric Medical Association, agreed with the positive impact on practice management and has also noted an increase its use. “Anecdotally, just in my surrounding area there has been an increase in practices acquiring machines,” she said. “Personally, I have increased my usage tremendously over the last 5 years. I went from doing one every few months to doing multiple per week (8-10). From 2000 to present, studies on (this treatment) on plantar fasciitis have increased exponentially. It went from 1-5 per year in the early 2000s to well over 20 from 2020 to present. This is evidence that its popularity and acceptance as a normal treatment protocol has increased significantly.”
She also reflected on the impact this treatment has had on her practice. “I cannot remember the last time I have had to operate on a plantar fasciitis patient, and it has saved many patients from surgery for tendon tears and chronic tendinitis,” she said. “It has benefited my patients significantly, by reducing downtime, preventing time off of work for surgical procedures, and has provided long lasting relief.” When lecturing on regenerative medicine, Dr. Parthasarathy often hears that students and residents aren’t seeing their attendings performing these types of procedures. “I strongly encourage podiatrists to embrace more conservative treatments like shockwave therapy. We are a surgical profession, but regenerative medicine should also be emphasized in our training.”
References
1. Nazim B, Tengku Yusof T, Seow D, Vig KS. Extracorporeal shockwave therapy for foot and ankle disorders: A systematic review and meta-analysis. J Am Podiatr Med Assoc. 2022;112(3):18-191.
2. Parthasarathy P. Regenerative medicine in the foot and ankle. Podiatry Today. 2023;36(1).
3. Böddeker R, Schäfer H, Haake M. Extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis--a biometrical review. Clin Rheumatol. 2001;20(5):324-30.
4. Tenforde AS, Borgstrom HE, DeLuca S, et al. Best practices for extracorporeal shockwave therapy in musculoskeletal medicine: Clinical application and training consideration. PM R. 2022;14(5):611-619.
5. Abdelkader NA, Helmy MNK, Fayaz NA, Saweeres ESB. Short- and intermediate-term results of extracorporeal shockwave therapy for non-insertional Achilles tendinopathy. Foot Ankle Int. 2021; 42(6):788–97.
6. Weil LS Jr, Roukis TS, Weil LS Sr, Borelli AH. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy. J Foot Ankle Surg. 2002;41(3):166-172.
