Welcome to the Website of

Dr. Michael Zapf, DPM, MPH, FACFAS

 Thank you for visiting my website. I have been placing information and articles on this site for many years and have received millions of  hits during that time (and not that many of them were mine). I have designed it for people who like to read about their foot and ankle problems. Since I started the web site, I have added two associates to my practice, Dr. Darren Payne and Dr. Stephen Benson.  Since my site is filled with just my thoughts and opinions they are not, necessarily, shared by my colleagues. To see our less controversial (and less windy) practice web site, I offer you: www.ConejoFeet.com, the practice site for The Agoura Los Robles Podiatry Centers (ALRPC). The ALRPC practice site has a lot of material about our office, many of our policies and the registration forms to be filled out before your visit. I suggest all prospective patients visit www.ConejoFeet.com.

 I made the web site to give my patients the extra depth information that I don’t always have time to cover in the office visit. Visitors who are not my patients are welcome to browse the information found here. My younger colleagues are both under 50 and they, like many their age, do not favor in depth reading. They prefer their information presented to them in a few short, crisp bullet points. I, being of the, ahem, older generation, like to read about my ailments in greater depth. Here, I present the greater depth. If you ask a question about heel pain or bunions that I have not answered in my two monographs, I will quickly add it so that it is as complete as I can make it. If you agree with this philosophy, welcome to my page. If you correspond with me please let me know if you like the in depth reporting.

 Remember, this site is in no way intended to tell you how your own ailment or problem should be treated, only the approach I use when confronted with certain situations. Your problem may well be different from what you think it is and should always be evaluated by the appropriate professional, whether podiatrist, orthopedist or other authority. Please understand that I, nor anyone else, can offer you a proper diagnosis or treatment plan without seeing and feeling the problem at hand (foot?).  Happy reading.

 Sincerely, Michael Zapf, DPM, MPH, FACFAS, FACFAOM

 P.S. All the information in this web site is © by me and it is mine alone. No picture or any of the articles cannot be used by anyone without permission from me, personally.

 


01/08/2012Home Shocking Patients $28K Heel Surgery? New Page 64News+FAQShock Wave

 

To Order Foot Supplies --> <-- click

            

 

 

I have tremendous heel pain but I do not want anybody (even you, Dr. Zapf ;-) ) cutting on my heel. What are my options? 

Great News! A Shocking New Way To Treat Heel Pain: ESWT

High Intensity Shockwave Therapy

For

Resistant Heel Pain

Offering a new, state-of-the-art, solution to unrelenting 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, offices 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 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. While we wish that all patients received surgery avoiding relief we are very proud that two thirds were able to avoid what would otherwise be a certain 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. If your right foot needs to be anesthetized with local anesthesia it is not safe for you to drive until your foot "wakes up."

Certainly there is no need to bring in an anesthesiologist or go to a 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.

For a Video of the procedure see the following web page:

http://www.medispec.com/ortho_video.html

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-men).

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.

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 sue an anesthesiologist and full-on anesthesia. We do not use any of these gimmicks and can offer the therapy at the lowest cost available.

In our office the cash fees for shockwave therapy are as follows:

Another gimmick we avoid in our office is the so-called free-visit come-on where you are "guilted" into accepting a treatment you do not really want. We charge a fair fee to evaluate your foot/feet and give you an honest opinion. We charge $100 for the initial visit which includes a complete examination with all necessary x-rays, an ultrasound examination and the development of a treatment plan. If you want, we will bill your insurance company for this visit at our usual and customary fees. While most companies will probably not cover the High Intensity Shockwave Therapy, they will usually cover the cost of the initial visit, x-rays and ultrasound.

Once we and you agree that Shockwave Therapy is right for you we will charge:

$1000 for the performance of a shockwave therapy session on 1 foot

$1600 for the performance of a shockwave therapy session on both feet

Can I Use My Insurance?

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. Please keep in mind that you will be responsible for all copayments and deductibles even if it more than $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.

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.

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 insurances 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.

How Is The Procedure Done?

At the end of your initial visit with one of our three doctors we will make a mutual decision that High Intensity Shockwave Therapy is a reasonable choice for you. If that is the case and appointment will be made to perform the procedure. Our machine uses high intensity sound waves and sometimes requires that the heel of 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). The 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.

When you arrive at the office for High Intensity Shockwave Therapy you will be escorted to the surgery suite and placed on a reclining examination table. 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 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.

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 drama 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 in the following disorders:

Achilles tendinitis

Achilles tendon insertional calcifications

Posterior tibial tendinitis

Peroneal tendinitis

Painful accessory navicular bones

Sesamoiditis

Neuromas

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.

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. dietrich.hammer@med-rz.uni.sb.de
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. orthozap@aol.com
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. DickAnkle@aol.com
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. w281211@adm.cgmh.org.tw
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. M.Buch@okkassel.de

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 an even rougher approximation of the above.
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
             

 

 

In February of 2001 Dr. Michael Zapf  was one of the first podiatrists (or doctors of any kind for that matter) certified to provide shock wave therapy for patients with heel pain. More recently Dr. Darren Payne attained certification and also offers this service to our patients. High power shock waves, produced by a 20,000-volt spark plug, or other sound generating mechanism, focused on the heel can result in significant pain relief even if all other treatments have failed. The treatment, called extra corporeal shockwave therapy (ESWT) has been available for in Europe since the mid 1990s and was approved in the United States in about 2000. The FDA approved the procedure in early 2001 for use on resistant heel pain. Our certification means that we are able to offer this unique service to our patients for relief of heel pain. The machine we use is brought to us by United Shockwave Therapy and it is an Ultrasound Guided for better accuracy.

A link to this ultrasound guided machine (with video) is found here: -->

Patients report on Shock Wave Treatment --->

Beware of the $56,000 dollar heel surgery ..>

Kay's Experience -->

As a recap to the foregoing monograph, heel pain is a common foot problem and is a frequent cause of visits to our office. The pain can range from the mild annoyance of a "stone bruise" to a cause of missing work, school or your turn on the field or court. Classically the pain is felt on the bottom of the heel with the first in the morning or after other periods of being off of the foot. In the first few months of heel pain the discomfort eases off after a few steps. In advanced cases the pain can persist throughout the day. Sometimes a heel spur can be seen on an x-ray. Heel pain with an actual spur on the x-ray is often more resistant to treatment.

We believe that the true cause of the pain is an abnormally strong pull of the plantar fascia on the heel bone. With our in-office ultrasound we can actually measure the thickness of the plantar fascia. The normal thickness of this fascia is about 2-4mm and symptomatic plantar fascia can get as large as 8 or 10mm or larger. For appointment purposes, we keep the ultrasound machine in our Agoura Hills office.

Most of the time the pain can be successfully treated by over the counter anti-inflammatory medications, heel lifts, stretching and shoes with some arch support. More resistant cases can be helped with prescription strength in-shoe arch supports called  orthotics. Sometimes a prescription anti-inflammatory medications or an injection of a cortisone medication are prescribed. Fortunately more than 90% of all heel pain patients are improved with these non-surgical therapies.

Unfortunately, non-surgical methods fail about 10 times out of a hundred. One or two of these people will choose to just live with their pain rather than face surgery. In the past the others had to choose from a variety of traditional surgeries. The surgery for heel pain involved cutting of the ligament involved, called the plantar fascia, removal of the heel spur or both. Finally, there is an alternative to traditional surgery: shock wave therapy.

Extra Corporeal Shock Wave is patterned after the shock wave therapy machines that have been used for 15 years to break up kidney stones. In the foot, ESWT is usually performed under only  local anesthesia. During the treatment the device is aimed at the heel and 3800 shocks are directed at the painful area. This takes about 18 minutes. Afterwards the heel is sore for a few days and occasionally the heel is "black and blue" for a few days more. In most studies a majority of patients are happy with the procedure and back to regular activates with less pain in 2 to 4 weeks. In one double blind study with patients at seven different medical centers, the most common side effect from the procedure was temporary pain and numbness occurring in 15 of 273 patients. Success was reported by 62% of the patients after one treatment. When the "failures" were subjected to a second treatment the success rate was an astounding 90.5%. The success of this study led to the FDA approval of this particular machine for heel pain.

ESWT is great news for anyone who has heel pain despite six months of conservative, non-surgical, care and for anyone who has heel pain despite having surgery. With this technique you may be able to finally [shock] "Wave Good-bye" to resistant heel pain.

February 27, 2007 - comments from Dr, Zapf - the number of ESWTs I do has dropped dramatically, I must have done more than 100 during my first 5 years of the procedure but I am seeing fewer resistant heel pain patients. I still do not shy away from the procedure. I find the statistics in my office are: 1/3 of patients find it a miracle therapy, 1/3 find it helps and 1/3 are not much helped. NO ONE HAS BEEN MADE WORSE.  Most insurance companies still do not cover the procedure and that is a mistake. If you have resistant heel pain that had not been helped with conventional therapy it is still worth a try. Call me if you want to explore this more.   MZ

 

A QUESTION I RECEIVED 5-5-2001

My wife has been suffering heel pain for the last 12 months due to a heel spur.  Though the severity has diminished since she has switched to wearing shoes with an elevated heel, she feels that she has come to a place where the condition is not improving and is considering a more aggressive treatment.

 
We would like you to evaluate her as a candidate for shock wave treatment. There are no podiatrist in our area that offer this treatment.
 
We live near Fort Bragg CA. and it will be quite a problem getting to your office.  However, if she is helped by this line of treatment ,it would be worth it.
 
Thanks
G& D
 

Dear G&D, 

Thank you for the vote of confidence. I understand how frustrating it can be to have heel pain that is not getting better. Before you make a trip to Agoura there are several things you need to think about. First, read the Patients Guide to Heel Pain elsewhere on this web site. You will find that most any garden variety podiatrist should be able to do an outstanding job evaluating and treating your wife's heel pain. You need to make sure you are not dealing with a stress fracture of the heel bone. Once you know it is mechanical heel pain please go through the gamut of heel pain therapy with your local podiatrist.  

I strongly believe in the value of treating the underlying mechanical problem with functional orthotics. I know that the mechanics of foot function  are important in your wife's case because you tell me that she feels better in an elevated heel. Please do not consider the surgery unless you have tried a good pair of orthotics. Once she has orthotics I would suggest a cortisone injection or two. If these are not helping enough, then consider adding a night splint to stretch the plantar fascia and the Achilles' tendon for several hours a night. If all these fail then she becomes a surgical candidate. 

I believe that the Epos Ultra,  OssaTron and other shockwave machines will someday become the first level of surgery when conservative therapy has failed. Unfortunately, it is early in the game (I write this on May 6, 2001) and insurance companies are still reluctant to authorize treatment. If your insurance company will not reimburse you for the surgery, the surgery center I am using is charging a flat cash fee of $3000 for use of the machine. This is in addition to my own modest fees. If you have tried conservative therapy to the extent you want and you are ready for surgery this is what you will have to pay. 

With this understanding, please give my office a call. You will need to make one trip down for my evaluation and we can do your surgery on the OssaTron the next day. Please call your insurance company first and ask of Extra Corporeal Sock Wave therapy is a covered service for long standing heel pain. See if they are calling it experimental or unproved or if they will pay for it.

I hope this helps.

 

Michael Zapf, D.P.M. 

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, these are the questions and answers where provided our front desk to answer the questions you have about shockwave therapy feel pain. Please feel free to e-mail me with any questions that are not answered here and I'll be happy to answer them for you on this page. My e-mail address is

zfootdoc (at) doctor (dot) com

Questions and Answers about Shockwave Therapy

Is this the office that does shockwave therapy?

Yes, we are one of the few, if not the only, office that offers high intensity shockwave therapy right in the office. Shockwave therapy is one of the many techniques that our doctors use to treat heel pain as well as many other conditions. We do not consider ourselves as just a shockwave office but we think of ourselves as a total center for heel pain treatment.

What is shockwave?

Extracorporeal Shockwave therapy (ESWT) uses highly focused sound waves to achieve healing for heel pain. Sound waves contain high amounts of energy as you can tell when the windows rattle during his stay shuttle landing. Our machines focus sound waves on heel about 1 inch deep where the plantar fascia attaches to the heel bone. In a 20 minute session 3800 high-intensity sound waves are directed at your heel.

How does it work?

Believe it or not there is still some debate as to how shockwaves actually work. The best theory is that it causes new blood vessels to grow in an area where the healing has stopped. With new blood vessels the area can go on to heel.

Is this technology new?

Far from new, shockwave therapy has been used for more than 20 years for breaking up kidney stones without surgery. About 10 years ago the lithotripsy machine, as the kidney shockwave therapy machine is called, was adapted for plantar fasciitis and the rest is history.

Have your doctors done this procedure before?

Our doctors have been performing shockwave therapy on patients for almost 10 years. During that time we have performed the procedure on more than 250 patients.

Is this used just for plantar fasciitis?

Absolutely not. Shockwave therapy has been used for tendinitis and capsulitis in almost every joint in the body. It is especially good for shoulder pain, tennis elbow, plantar fasciitis, Achilles tendinitis and for the bone spurs that develop where the Achilles tendon attaches to the heel bone. We have also used it successfully for sesamoiditis, which is an inflammation of little round bones by the big toe, and tendinitis of the peroneal and posterior tibial tendons. We have many examples of patients who have avoided traditional surgery by using shockwave therapy.

How fast does it work?

Many people report significant levels of pain relief in as few as three or four days after treatment. More commonly the treatment starts a healing process that can take one or two months to complete. In fact we do not call it a failure unless pain relief is not achieved after six months. Rarely would we ever repeat a treatment sooner than six months after treatment.

What are the benefits of shockwave therapy?

The high-intensity sound waves of the shockwave machine improved and accelerate healing in previously nonresponsive conditions that are usually slow to heal. Pain reduction is often dramatic without the use of pain medication.

How effective is it?

Depending on the study success rates vary from between 30% to 90%. On the average about 70% of patients received significant pain relief after one treatment. Of the 30% of patients who did not receive significant pain relief 70% of them (for a total of 92%) received significant pain relief after the second shockwave therapy session. These results are consistent with what we have seen in our office over the 10 years that we have been performing the procedure. We have done shockwave therapy on more than 250 patients.

You can see summaries of many of the studies done on shockwave therapy by visiting our website: www.ShockMyHeels.com.

Who should get shockwave therapy?

Shockwave therapy is the preferred treatment option for people who have had plantar fasciitis for six months or more and have not responded to conservative care.

Why should you wait six months?

Most heel pain, or plantar fasciitis, is a cutie in nature and responds readily to nonsurgical, conservative treatment methods like cortisone injections, functional orthotics, take strapping, anti-inflammatory medication, night splints, and physical therapy. Shockwave therapy is not very effective in the acute stage. Only about 10% of heel pain outlasts this six months time period. These are the people for whom shockwave therapy is the ideal treatment.

How much do you charge?

We are happy to bill your insurance for our usual and customary fees for shockwave therapy which average about $2300 per foot. Keep in mind that we do this treatment right in our office. There are no fees for a surgery center which saves about $3000 or more and there are no fees for an anesthesiologist which saves another $1500 or more.

Do insurance companies usually approve this procedure?

We will be happy to bill your insurance company for all of the costs involved in performing your shockwave therapy. Unfortunately most insurance companies, and virtually all HMOs, do not pay for shockwave therapy. Most people will be forced to pay cash for the procedure. Our cash fee is $1000 for 1 foot and $1600 for 2 feet. In addition we will charge for the initial office visit with x-rays and ultrasound. The cash fee for this visit is $125. Since most people will have to pay cash for this procedure the estimated cost is $1125 for 1 foot and $1725 for 2 feet.

If it is such a good procedure why don't insurance companies pay for it?

That is a good question and one we have been asking for 10 years. The results of shockwave therapy varied from study to study. Some show a high success rate in some a low success rate depending on a variety of parameters. It is our experience that insurance companies will pick the paper with the lowest result and use that as a basis to deny all shockwave therapy claims. The irony is that insurance companies will pay for surgery on your plantar fascia including the surgery center and anesthesiologist fees but not for the shockwave therapy session that can eliminate the need for surgery. We find the same issue with those insurance companies that will not pay for orthotics for heel pain. We strongly recommend that every patient have a series of conservative therapies for becoming a candidate for the shockwave.

 

What will you do during my office visit?

During your initial office visit we will take a detailed history on your heel pain. We will listen as you describe the various treatments or have tried so far. If you do not have recent x-rays or ultrasound of your feet we will take them during this visit. We will very clearly present to you your options for treating your heel pain. We offer many options for treating heel pain besides the shockwave therapy machine. If you would benefit from a cortisone injection, orthotics or physical therapy we can offer all of that to you as well. Most insurance companies will pay for this visit and we will be happy to bill them on your behalf. If you have an HMO or are they self-pay patient this visit will cost you $125.

Is this the same shockwave therapy offered by chiropractors and physical therapists?

Absolutely not. The shockwave therapy instruments used by chiropractors and physical therapists are low energy units that never require anesthesia. Their shockwave therapy treatment is usually sole as a package of 4 to 6 treatments for almost as much money as out high energy treatment.. Our shockwave therapy machine is one of only four or five to produce a high energy wave. Many times, but not always, local anesthesia of the heel is necessary.

Will I need local anesthesia?

For your shockwave therapy visit we will reserve enough time to perform a local anesthesia block on your foot or feet. The anesthesia is very profound and you will not be able to drive home if the procedure was done on your right foot. But before we inject you we will give you a chance to have the procedure performed without local anesthesia. Many people can reach a high energy level without local anesthesia and we will give you that opportunity before we inject you.

Why don't you offer a free initial consultation visit?

Our doctors believe there is no such thing as a free visit. Free visits invariably result in costly medical procedures or how else will the doctor pay for his time? We charge a fair fief for the initial visit which eliminates the need to pressure you for any treatment you do not need.

 

 

 

 

 

 

 

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Last modified: January 08, 2012