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High Intensity Shockwave Therapy
For Resistant Heel Pain

Offering a New, State-of-the-Art, Solution to Unrelenting Heel Pain

If surgery has been recommended for your resistant heel pain or if you have had it for a long time without successful resolution of your pain, we have some exciting news for you! High Intensity Shockwave Therapy (also called Extra Corporeal Shockwave Therapy or ESWT) has proven to be an exciting and successful therapy for plantar fasciitis and heel spur pain. We are proud to announce that we are one of the first, if not the first, office in California to have a shockwave therapy machine full time right in the office. Note this is NOT done with a low-energy Radial Therapy device, but this is a true High Intensity Shockwave Therapy ultrasound machine usually reserved for hospitals or surgery centers.

HIST machine Certainly all podiatrists and orthopedic surgeons successfully treat plantar fasciitis and spur pain without surgery on a daily basis. Occasionally, however, a case defies all conservative measures and surgery is recommended. Now, there is an alternative that eliminates the need for surgery in most cases. That alternative consists of administering 2,800 high-intensity sound wave "shocks" to the heel. This technique uses a machine originally developed to non-surgically break up kidney stones and focuses it on the heel where the plantar fascia attaches. Our office has performed more than 200 shockwave procedures. We found that one third of the patients received complete or near complete reduction of their pain; one third had enough relief that surgery was not requested and, unfortunately, one third did not receive enough help to avoid surgery. In a scientific paper written by Dr. Hyen (see the end of this web page) he noted that patients had pain relief go from 8.71 to 3.54 (on a 10-point scale with 10 being the worst). In a study by Dr. Weil the pain levels decreased from 7.9 to only 2.95, on the average, in only 1 week.

How Is The Procedure Done?

The procedure is done in the office and it takes about 45 minutes. This is a High Intensity Shockwave Therapy machine and sometimes local anesthesia is needed, but not always. The machine has power settings that range from 3 to 7 in half unit increments. Above 5 is the range of high energy. We will slowly raise the intensity until we are in the therapeutic range: the higher the number the more effective is the treatment. If you cannot make level "5" without anesthesia, we are ready and willing to place enough anesthesias in and around your heel that the treatment can go forward.

One of our doctors just had the treatment performed on him without any anesthesia. He easily got to 6.5 without local anesthesia and could have done 7 if he "really needed to." He admits that he is certainly no hero and if he can reach a therapeutic level without local anesthesia, you probably can too.

Certainly there is no need to bring in an anesthesiologist or go to a hospital or surgery center for High Intensity Shockwave Therapy. For this reason the costs associated with shockwave therapy for heel pain, and other foot problems, is brought down to a very affordable level.

View a video of the procedure on Medispec

Note: the machine used in this video is brought to the offices of the doctors involved by a truck on a case-by-case basis. We HAVE the machine in our office full time so we can offer the procedure anytime it is needed (and save the cost of the middle-man).

What Is Involved?

All new patients are required to have an initial examination in one of our offices. Heel pain can be a complicated problem with many possible causes. It is important that our doctors confirm that you are an appropriate candidate for the shockwave procedure. The doctors will confirm your diagnosis and inform you of all the treatment options for your problem. Your initial visit will include the examination and tests. Tests may include xrays, blood work, ultrasound imaging, MRI, arterial circulation test, and nerve conduction study. The most common test performed is ultrasound imaging of the involved foot. This is done in the office and gives a good picture of the soft tissue and bone. It is rare to order the other tests for heel pain, but occasionally they are needed to help confirm a diagnosis.

Once your initial examination is complete, you will be informed of the treatment options for your condition. High Intensity Shockwave Therapy is not usually used as a first treatment for heel pain. If you have had other treatments which have failed, then you are likely a good candidate for High Intensity Shockwave Therapy. You may then schedule to have the procedure performed. If you are traveling from a long distance and are sure that you will need the shockwave treatment, then please inform our receptionists when you call to schedule. You will then need to schedule for the initial exam and for the shockwave procedure. Please be aware that there is always a slight possibility that you may not be a candidate for the procedure.

What Are The Fees?

Fees for High Intensity Shockwave Therapy can run as high as $3800 as is charged by the most common local supplier of the treatment, and much higher if you are forced to go to a surgery center and use an anesthesiologist and full-on anesthesia. Since we have the ability to perform the procedure in our office, we can pass on huge savings to you.

We do require an initial exam and tests before having the procedure. For your initial visit, you have two options. You may either use your health insurance or pay for the visit/tests yourself. We accept most PPO plans as well as medicare. If you do not have insurance or have an HMO that restricts which doctors you can see, then please inquire about special discount rates that may apply to you.

Once we agree that Shockwave Therapy is right for you we will have you scheduled for the procedure. The self-pay cost for the procedure is as follows:

If you decide to self-pay for the procedure, we will collect the fee at the time of service. You can pay for your treatment with a credit card, cash or check. You may also use your flexible spending account or health savings account. You can also apply for CareCredit, a healthcare specific credit agency. CareCredit offers two basic payment plans to meet an individual's financial needs:

You can apply on the CareCredit website.

Can I Use My Insurance For the Procedure?

Yes, but you may not want to. Most insurance companies refuse to pay for High Intensity Shockwave Therapy procedures. You are welcome to call your own insurance company and see if the procedure is covered. The code number used for High Intensity Shockwave Therapy is 28890. If you want to use your insurance to cover the procedure, we will bill them at our usual and customary fees (these are the standard rates for a specific procedure that is billed to the insurance company). This will include the doctor's procedure fee and a facility fee for use of the machine. Please keep in mind that you will be responsible for all copayments and deductibles, even if it is more than our discounted self-pay rate($1000 for one foot or $1600 for two feet). Prior to performing the procedure we will let you know exactly the fees for which you will be responsible. We will ask you to pay for your portion of your out of pocket expenses prior to the performance of the procedure. We accept all the same payment options as above.

High Intensity Shockwave Therapy is not considered by insurance companies to be a first-line treatment for plantar fasciitis or heel spurs. First line therapy for these conditions consists of the medical treatments of oral or injected anti-inflammatory or cortisone and the mechanical therapies of taping, orthotics, arch supports, night splints, cast immobilization, massage, stretching, manipulation and/or physical therapy. Our office has every option available to treat your foot and ankle problems, including our own physical therapist that specializes in foot and ankle therapy. If you have not been able to get rid of your heel pain, chances are we may have some options that other doctors do not have at their disposal.

Who Should Have High Intensity Shockwave Therapy?

Generally speaking High Intensity Shockwave Therapy is usually reserved for people who have had heel pain for more than six months and have tried at least three of the first-line treatments described in the previous paragraph.

If you have not had three treatments and pain of six months you can still have High Intensity Shockwave Therapy but insurance coverage is even rarer under these circumstances.

Note that one of the articles proved what we already know. The longer you have had plantar fasciitis the more effective the treatment is. Early onset plantar fasciitis is best treated with conventional treatments like strapping, orthotic, exercises and even a cortisone injection. The more resistant the plantar fasciitis is to conventional therapy and the longer you have had the condition the less it works. One study that failed to show efficacy of High Intensity Shockwave Therapy performed it on patients who had heel pain for less than three month, While the treatment is safe, it often is not effective on heel pain in such early stages.

What Are The Risks and Complications?

The beauty of High Intensity Shockwave Therapy is that, other than the anesthesia, there is no real risk of harm or complication. Either your body is "shocked" to making you better or it is not. In our experience no one has been made worse. This seems to be true with our colleagues across the countries that have used High Intensity Shockwave Therapy on their own patients.

Who Should Not Have High Intensity Shockwave Therapy?

High Intensity Shockwave Therapy is not advised for pregnant women, children, people with pacemakers, people on an anticoagulant like heparin or who have a history of bleeding problems problem.

How Is The Procedure Done?

At the end of your initial visit with one of our doctors we will make a mutual decision on whether or not High Intensity Shockwave Therapy is a reasonable choice for you. If that is the case an appointment will be made to perform the procedure. The shockwave machine is a strong ultrasound unit. It uses high intensity sound waves and sometimes requires that the heel or the foot be anesthetized. There have been many cases where the treatment has been successfully performed without local anesthesia (including one of our doctors – see the box above). Patients who have avoided anesthesia include the pain tolerant, certainly the ones who can have dental work done without anesthesia and many other "regular people" as well. If we raise the intensity slowly, the sound waves seem to produce a local anesthesia of their own. For most patients we will start trying to get to a therapeutic level without anesthesia but we will be prepared to administer local anesthesia if the need arises. If you do need a local anesthetic, our doctors are some of the best at minimizing the pain from a local anesthetic injection.

When you arrive at the office for High Intensity Shockwave Therapy you will be escorted to the procedure room and placed on a reclining examination chair. The head of the ESWT machine will be placed next to your heel and a conductive gel will seal the contact of the machine. The shockwaves will begin very small, and we will raise the intensity slowly so that we never exceed your pain tolerance. The administration of 2800 pulses takes about 45 minutes. You can then put your regular shoes back on and leave the office. If we use anesthesia on your right foot you will not be able to drive and will need to have transportation available. Please be prepared for this possibility on your procedure day.

How Does It Work?

The most accepted theory to explain why High Intensity Shockwave Therapy works is that the sound waves cause microtrauma and a controlled injury at the insertion site of the plantar fascia on the heel bone. This microtrauma occurs at a location that the body has hereto for refuse to heal. The new trauma causes the formation of new blood vessels and triggers the body's natural healing processes and repair mechanisms. In essence your body seems to have accepted your painful heel as some kind of natural state and the sound waves, in essence, "shock" your system into remembering how to heal this chronic painful condition.

Can Shockwave Therapy Be Used For Anything Else?

High Intensity Shockwave Therapy has been found useful for many foot complaints. It has been used successfully by our doctors for many of the following disorders:

We admit that the literature is lacking for the treatment of some of the conditions listed above but the frequency of success and the lack of negative side effects and the possibility of avoiding pain, immobilization and surgery make the attempt to treat these conditions worthwhile.

Medical Reports

Below is a selected group of scientific papers that used a variety of high energy shockwave machines to treat heel pain.

J Foot Ankle Surg. 2005 Mar-Apr;44(2):137-43.
Evaluation of ultrasound-guided extracorporeal shock wave therapy (ESWT) in the treatment of chronic plantar fasciitis.
Hyer CF, Vancourt R, Block A.
Orthopedic Foot and Ankle Surgery, Orthopedic Foot and Ankle Center, Columbus, Ohio, USA.
Thirty patients (39 heels) were evaluated to determine the success of ultrasound-guided ESWT for treatment of recalcitrant plantar fasciitis. All patients had been diagnosed and treated for plantar fasciitis for greater than 6 months and had failed at least 3 conservative treatment modalities. Each patient received 3800 shockwaves into the treated heel using the Dornier Epos Ultra ESWT machine. The average postoperative follow-up was 124 days (range, 33 to 255). Written subjective surveys evaluated pre- and post treatment pain levels using a visual analog scoring system. The mean pretreatment score was 8.51 (range, 5 to 10), which improved to a mean follow-up score of 3.75 (range, 0 to 10). This represents an improvement in the mean VAS of 4.76, which is statistically significant ( P = .0002). Twenty-five of 30 patients reported some degree of improvement, with 5 experiencing no change. These early results indicate ultrasound-guided ESWT may be a useful tool in the treatment armamentarium for chronic plantar fasciitis.

Clin Podiatr Med Surg. 2003 Apr;20(2):323-34.
Extracorporeal shock wave therapy for plantar fasciitis.
Perez M, Weiner R, Gilley JC.
Clintonville Foot and Ankle Group, Inc., 3695 N. High Street, Columbus, OH 43214, USA.
Shock wave therapy is quickly becoming a mainstay treatment for chronic recalcitrant plantar fasciitis, and many more applications for this therapy may exist. Many advances have been made in regard to this modality of treatment in just a few decades since it was first investigated in the 1950s. Much research has been conducted, revealing the physics and physiologic effect of shock wave therapy. Devices are now approved that produce shock waves for medicinal purposes by one of the three primary methods of shock wave generation. Studies and research are actively being reported and published that demonstrate shock wave therapy success rates comparable to those found in surgical intervention but without the risks inherent in surgery. In conclusion, ESWT has proved to be a viable treatment option for the intervention of chronic recalcitrant plantar fasciitis.

Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis.
Foot Ankle Int 2002 Apr;23(4):309-13
Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R.
Orthopaedic University Hospital, Homburg/Saar, Germany.
The aim of this study was to compare the effect of extracorporeal shockwave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, heel cup, orthoses and/or shoe modifications, local steroid injections and electrotherapy. Forty-seven patients (49 feet) with a previously unsuccessful conservative treatment of at least six months were randomized to two groups. Treatment of Group 1 (25 heels) started immediately with three sessions of ESWT (3000 shockwaves/session of 0.2 mJ/mm2) at weekly intervals. In the patients of Group 2 (24 heels) treatment was continued for 12 weeks. After this period they were treated using the protocol of Group 1. No significant difference of pain and walking time after further non-ESWT treatment (three months) was seen. Six months after ESWT pain decreased by 64% to 88% on the visual analog scale (VAS) and the comfortable walking time had increased significantly in both groups.

J Foot Ankle Surg 2002 May-Jun;41(3):166-72
Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy.
Weil LS Jr, Roukis TS, Weil LS, Borrelli AH.
Weil Foot & Ankle Institute, Des Plaines, IL 60016, USA.
A review of the history, mechanism of action, and application of extracorporeal shock wave therapy for chronic plantar fasciitis is presented. The results of 40 feet treated with this modality are reviewed after a mean follow-up time of 8.4 months. All procedures were performed under intravenous sedation and local infiltrative anesthesia. An electrohydraulic shock wave with a mean of 20.6 kV combined with a mean of 2,506 pulses was used. The results of a similar demographic class of patients having undergone a percutaneous plantar fasciotomy at our institution were compared to the results of this cohort of shock wave patients. Eighty-two percent of the patients treated with extracorporeal shock wave therapy were successfully treated as compared to 83% with a percutaneous plantar fasciotomy. The mean score on the 11-point visual analog scale for satisfied patients was 7.9 preoperatively and 2.95 within 7 days postoperatively. After 3 months, the mean visual analog score was 4.2 or 50% of the preoperative value after a mean of 8.4 months following treatment. Eighty-three percent of the patients treated stated that shock wave therapy improved their symptoms. There were no complications encountered in any patient in this study. Extracorporeal shock wave therapy is an effective treatment, which significantly reduces the symptoms associated with chronic plantar fasciitis and compares favorably to the results achieved with surgical intervention in the form of a percutaneous plantar

Foot Ankle Int 2002 Apr;23(4):301-8
Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis.
Ogden JA, Alvarez RG, Marlow M.
Skeletal Educational Association Atlanta, GA 30305, USA.
PURPOSE: Utilizing meta-analysis, the authors have reviewed the available literature to assess the biologic and therapeutic effects of shockwaves on patients with chronic plantar fasciitis and the credibility of these published studies. METHODS: Meta-analysis is a systematic method for statistical analysis that combines data from various independent studies, allowing the assessment of potential benefits of various treatments when conclusions based on individual studies may be difficult to evaluate. We hypothesized that extracorporeal shockwave therapy provided a reasonable nonoperative therapeutic alternative to surgical intervention in the treatment of chronic proximal plantar fasciitis. RESULTS: Eight of 20 published studies fulfilled our type A to C criteria for acceptable studies of sufficient duration (one year or more after treatment). These eight studies involved 840 patients, with success rates of as much as 88%. The other 12 studies had methodological variables or lack of appropriate follow-up data that would limit their validity, although the success rates were comparable to the A to C studies. CONCLUSIONS: This meta-analysis shows that the directed application of shockwaves to the enthesis of the plantar fascia at the inferior calcaneus is a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome that has been refractory to other commonly used nonoperative therapies. The results suggest that this therapeutic procedure should be considered before any surgical intervention, and may be preferable prior to cortisone injection, which has a recognized risk of rupture of the plantar fascia and a frequent recurrence of symptoms.PMID: 11991474

Foot Ankle Int 2002 Mar;23(3):197-203
Preliminary results on the safety and efficacy of the OssaTron for treatment of plantar fasciitis.
Alvarez R.
Southern Orthopaedic Foot and Ankle Center, Chattanooga, TN 37404, USA.
The OssaTron may be another alternative for management of plantar fasciitis (heel pain syndrome) after failure of non-operative management and prior to surgical management. This study evaluated primarily the safety and early preliminary efficacy of the OssaTron in treatment of patients with plantar fasciitis unresponsive to non-operative management. Twenty heels of 20 patients were treated with 1000 extracorporeal shockwaves from the OssaTron to the affected heel after administration of a heel block. The patients were followed for one year. Each patient was evaluated by roentgenogram, KinCom, range of motion and physical examination, including evaluation of point tenderness by means of a palpometer and according to a 10-cm visual analog scale. The control was the contralateral heel. Patients also performed self evaluation by means of patient activities of daily living questionnaire and pain reported by a 10-cm visual analog scale. There were no complications or adverse effects attributed to the procedure of orthotripsy. Of the 20 patients treated, 18 were improved or pain-free. Eighteen of the 20 subjects treated stated that they would undergo the procedure again instead of surgery. Based on these results, we concluded that orthotripsy is a safe and effective method of treating heel pain syndrome that has been unresponsive to nonoperative management. PMID: 11934060

Foot Ankle Int 2002 Mar;23(3):204-7
Shockwave therapy for patients with plantar fasciitis: a one-year follow-up study.
Wang CJ, Chen HS, Huang TW.
Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Kaohsiung, Taiwan.
The effect of shockwave therapy was investigated in 79 patients (85 heels) with plantar fasciitis with one-year follow-up. There were 59 women and 20 men with an average age of 47 (range, 15-75) years. Each patient was treated with 1000 impulses of shockwave at 14 kV to the affected heel. A 100-point scoring system was used for evaluation including 70 points for pain and 30 points for function. The intensity of pain was based on a visual analogue scale from 0 to 10. The overall results were 75.3% complaint-free, 18.8% significantly better, 5.9% slightly better and none unchanged or worse. The effect of shockwave therapy seemed cumulative and was time-dependent. The recurrence rate was 5%. There were no device-related problems, systemic or local complications. Shockwave therapy is a safe and effective modality in the treatment of patients with plantar fasciitis. PMID: 11934061

Clin Orthop 2001 Jun;(387):47-59
Shock wave therapy for chronic proximal plantar fasciitis.
Ogden JA, Alvarez R, Levitt R, Cross GL, Marlow M.
Atlanta Medical Center, GA, USA.
Three hundred two patients with chronic heel pain caused by proximal plantar fasciitis were enrolled in a study to assess the treatment effects consequent to administration of electrohydraulically-generated extracorporeal shock waves. Symptoms had been present from 6 months to 18 years. Each treated patient satisfied numerous inclusion and exclusion criteria before he or she was accepted into this study, which was approved by the Food and Drug Administration as a randomized, double-blind evaluation of the efficacy of shock wave therapy for this disorder. Overall, at the predetermined evaluation period 3 months after one treatment, 56% more of the treated patients had a successful result by all four of the evaluation criteria when compared with the patients treated with a placebo. This difference was significant and corroborated the fact that this difference in the results was specifically attributable to the shock wave treatment, rather than any natural improvement caused by the natural history of the condition. The current study showed that the directed application of electrohydraulic-generated shock waves to the insertion of the plantar fascia onto the calcaneus is a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome that has been present for at least 6 months and has been refractory to other commonly used nonoperative therapies. This technology, when delivered using the OssaTron (High Medical Technology, Kreuz-lingen, Switzerland), has been approved by the Food and Drug Administration specifically for the treatment of chronic proximal plantar fasciitis. The results suggest that this therapeutic modality should be considered before any surgical options, and even may be preferable to cortisone injection, which has a recognized risk of rupture of the plantar fascia and recurrence of symptoms. PMID: 11400894

Buch M, Knorr U, Fleming L, Theodore G, Amendola A, Bachmann C, Zingas C, Siebert WE.
Orthopade 2002 Jul;31(7):637-44
Orthopadische Klinik, Kassel.

Extracorporeal shock wave application (ESWA) has been successfully used for years in routine clinical management of plantar fasciitis. So far no clinical trails have shown the efficiency in placebo-controlled protocols. This paper presents an overview of conservative and operative treatment modalities with respect to their efficacy. Results of a prospective randomized placebo-controlled double-blind multicenter trial to show efficiency and safety of ESWT are presented. In patients treated conservatively without success, a single shock wave application can improve the condition significantly compared with placebo treatment (p = 0.0149). The Roles and Maudsley score also showed a significant improvement between the groups, with 61.6% good or excellent results in the verum group and 39.7% in the placebo group (p = 0.0128). Therapy-related side effects (local swelling, petechia) are rare. The data presented in this study led to FDA approval in January 2002 of the shock wave device used.PMID: 12219661

Below is a summary of the above information:

Country Machine Success Rate Number Patients Pulses Energy mJ/mm2 Average Number of Treatments
Spain Sonocur Plus 91% 18 1500 0.28 6
Austria Sonocur Plus 5.7 on 7 scale 39
Germany OssaTron 80% 60 800 0.08 3
Germany Sonocur 73% 47 1000 0.16 3
Taiwan OssaTron 80+% 66 1000 14KV 1.2

The doctors of the Agoura Los-Robles Podiatry Centers are looking forward to seeing you in one of our offices. We feel that we have the most comprehensive approach to treating your foot condition.

Take your first step towards treating your heel pain by calling us at 818-707-3668 to schedule your initial examination.

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