This article explains how Extracorporal Shock Wave Therapy (ESWT) is used to treat Achilles Tendonitis and Plantar Fasciitis. It contains the information given to patients who intend to attend for ESWT and includes a full discussion on the benefits and risks of ESWT, alternative treatment options, and what you can expect when you attend for treatment.
What is Achilles Tendinopathy?
Achilles Tendinopathy is pain, swelling, and stiffness in the Achilles tendon. The Achilles tendon attaches your calf muscles to your heel bone and is the wide tendon that runs at the back of your ankle. Achilles Tendinopathy is caused when the tendon is placed under excessive load, which may be caused by a rapid increase in walking and running activities, lifting heavy loads, a shift from a heeled to a flat shoe or barefoot walking (a common shift during lockdown), or by direct trauma, e.g., a kick to the tendon during sports.
What is Plantar Fasciitis?
The plantar fascia is a thick fibrous band of tissue that runs the full length of the sole of the foot from the heel to the toes. Normally, when the foot bears weight, the plantar fascia is placed under tension to support the arch of the foot. When the fascia is placed under too much strain, inflammation occurs at the attachment of the fascia on the heel bone. Plantar Fasciitis is characterized by pain on the inside of the sole of the heel, which may extend into the arch of the foot. Pain is often worse when rising from bed and with long periods of walking and standing.
What exactly is ESWT?
ESWT is a simple electro-therapy treatment procedure where a small amount of gel is placed onto the skin over the site of pain. A hand-piece (with a disposable silicone cap -- blue in the image below-- to avoid cross-contamination) held by the specialist is placed onto the site of pain and shock waves are passed through the skin to the injured Achilles tendon or plantar fascia. Extracorporeal means the impulses are generated outside of the body. The pulsations are produced mechanically, not electrically, inside the hand-piece. The impulses are audible (you will hear a 'click-click' sound during treatment), low-energy sound waves, which work by: 1) Acting on the nerve endings to reduce pain, 2) Increasing blood flow to the injured area to speed up healing, 3) Promoting the body's own healing mechanism, and 4) “Softening” scar tissue.
The treatment lasts for around 5-minutes, and you will usually require a course of three to six treatments at weekly intervals depending on the severity of the symptoms. ESWT for foot and ankle conditions will be given by Raymond Anthony, podiatrist.
What are the risks/side effects of ESWT?
You may experience some discomfort during the treatment session, which may continue after treatment. You may also see a little swelling with redness, and the area may be a little numb for a while, although these effects should resolve in a reasonably short period of time.
Who should NOT have ESWT?
You should not have ESWT if you:
· Are pregnant.
· Are taking anti-platelet medications such and Clopidogrel (Plavix), or anticoagulants (e.g., Warfarin or Rivaroxaban).
· Have a blood clotting disorder.
· Are under the age of 18.
· Have been diagnosed with bone cancer or are being treated for any active cancer.
· Have an infection in your foot.
· Have a history of Achilles tendon or plantar fascia rupture.
· Have had a steroid injection into the affected area in the previous 12-weeks.
It is important to let your specialist know if you have any of these contraindications. The risks will be discussed with you by your specialist when the treatment is offered.
Essential consultation process
If you are an established patient, you may be offered ESWT as part of your treatment programme for Achilles Tendinitis or Plantar Fasciitis, especially if the condition is long-standing and not responding to other treatments. If you have not seen Ray Anthony for your complaint, or you are a new patient not yet registered with Helix Healthcare, you must first attend an initial consultation with Ray Anthony - podiatrist, to confirm the diagnosis; to ensure you are a good candidate for ESWT, and to put together a comprehensive treatment plan for your particular complaint.
How do I prepare for ESWT?
You will need to be available for the full course of up to 6 treatments. You avoid taking any non-steroidal anti-inflammatory medications (NSAIDs), e.g., Ibuprofen (Advil) or Naproxen (Aleve) for two weeks before your first ESWT treatment session, nor throughout the course of your treatment. If you are unsure if any of your daily medicines are anti-inflammatory drugs, check with your doctor or pharmacist.
What should I expect during and after a ESWT session?
At your first session, you will be asked to sign a consent form, which confirms that you agree to the treatment and you understand what the therapy involves. If you would like more information about the consenting process, please speak to your specialist.
The specialist will apply ultrasound gel to the site of pain and then place the hand-piece of the device into the gel. The shock waves are delivered using the hand-piece, which delivers compressed air pulses through the ultrasound gel and into the skin. The application of ESWT will take approximately 5-minutes. Most patients do experience some discomfort during the treatment. You will be asked how much discomfort you are experiencing and the intensity of the pulses will be adjusted accordingly. After treatment, you will be able to bear-weight and walk immediately. If you do experience discomfort after the session, you can take headache doses of Acetaminophen (Tylenol, Panadol) as described on the product package, but do not take anti-inflammatory medication such as Advil or Aleve, nor use ice on the area as these can reduce the effectiveness of the therapy. You should be able to return to your usual activities, including work, immediately. However, you should not undertake any strenuous, pain-provoking activity, or high-impact exercise for 48-hours after a treatment session.
After you have completed the course of treatment, you should attend a follow-up consultation to review your response to ESWT.
The National Institute for Health and Care Excellence (NICE) in the UK has produced recommendations for patients having ESWT for Achilles Tendinopathy and Plantar Fasciitis. These documents can be accessed on the NICE website at www.nice.org.uk
Links to Published Research on ESWT for Achilles Tendinopathy and Plantar Fasciitis