Shock Wave Therapy for Heel Pain and Plantar Fasciitis

Do You Need Surgery for Meniscus Tears in Your Middle-Aged Knees?

Plantar fasciitis and other heel pain conditions can be persistent and debilitating, limiting your ability to perform normal daily activities. A big part of the problem is that most people do not have the luxury of staying off their feet long enough for healing to take place. In fact, for some patients, plantar fasciitis can persist for years.

Conventional treatment for plantar fasciitis and heel pain often involves orthotics, pain and anti-inflammatory medications, ice and rest. But those methods do not always work, and even when they do, recovery can take a long time.

Moreover, heel pain and plantar fasciitis are two distinct conditions, each with different causes that require completely different treatment approaches.

Plantar Fasciitis vs Heel Pain

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Because plantar fasciitis is a relatively common complaint, heel pain from other causes is often misdiagnosed as plantar fasciitis, resulting in costly, time-consuming and ineffective treatment.

Other common causes of heel pain include:

  • Heel spurs — bony growths on the calcaneus (heel bone) that sometimes coexist with plantar fasciitis
  • Achilles tendinopathy
  • Calcaneus fractures
  • Plantar nerve entrapment

By contrast, plantar fasciitis is damage to the plantar fascia itself, often manifesting as pain at its calcaneal (heel bone) insertion point. PF pain is thought to be caused by microtears to the thick fibrous band that spans the bottom of the foot from the heel to the toes. Accurate diagnosis is key to distinguishing plantar fasciitis from other causes of heel pain. High resolution diagnostic ultrasonography is an effective tool for differentiating between PF and other types of heel pain because it allows us to visualize neural bodies, tendon damage and soft tissue lesions in real time, with the patient in motion.

ESWT for Plantar Fasciitis and Heel Pain

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Extra corporeal shock wave therapy (ESWT) is a popular non-invasive tool used in sports medicine to treat musculoskeletal pain and injuries in athletes and non-athletes alike.

ESWT pulses rapid high-pressure sound waves to damaged tissues to promote neovascularization — the formation of new blood vessels — to enhance the delivery of oxygen and nutrients to the tissues for cellular repair.

ESWT is especially effective for tough connective tissues like the plantar fascia and Achilles tendon that naturally have a limited blood supply. Shock waves are also used to accelerate the healing of bone fractures, such as calcaneal fractures that cause heel pain.

Types of ESWT

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There are two basic types of ESWT: Radial (soft) and focused (hard).

  • Radial shock wave therapy is the most common form of ESWT, used for a larger treatment area at a more superficial level. Radial shock waves emit their greatest energy at the skin’s surface, and lose power as their energy penetrates deeper tissues. Radial shock waves are most often used for superficial tendinopathies and trigger points, myofascial pain, plantar fasciitis and hip pain at the greater trochanter.
  • Focused shock wave therapy uses a cylindrical coil to generate electromagnetic waves that penetrate deeper tissues. They cause tissue membranes to vibrate and create pressure waves in their surrounding fluids without losing energy. Focused shock waves target a smaller focal area. They are used to treat acute injuries, bone fractures, shin splints, groin pain, Achilles tendon injuries, tibial pain, ankle sprains and healing wounds.

Focused and radial shock waves are sometimes used in combination to treat plantar fasciitis and heel pain.

Ultrasound Guided ESWT

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ESWT performed with ultrasound guidance ensures that damaged tissues are being accurately targeted. Rather than directing shockwaves blindly at the general locus of pain, ultrasound imaging lets us visualize the tissues in real time, so we can accurately direct shock waves where they will be most effective.

It is often the case that the locus of pain is not where the actual damage originates. Because the myofascia of the lower leg and foot is a continuous sheet of tissue, tension in one area can generate pain, stiffness and lesions in another region.

Global vs Local Plantar Fasciitis Treatment

A recent study by Giordani et al. (2019) wanted to test the theory that plantar fasciitis pain and inflammation in the heel and bottom of the foot could actually be caused by tension elsewhere in the myofascial complex.

In the study, a 63-year-old male with severe PF pain was treated with shock waves directed at active myofascial trigger points in the leg, thigh and pelvis, with the goal of restoring balanced tension in the myofascial system of the entire leg. After only the second treatment session, he reported significant relief from PF pain, which was sustained at the third session, and confirmed at a one month followup.

Best Treatment for Heel Pain and Plantar Fasciitis in NYC

Accurate diagnosis is key to proper treatment and rapid recovery. At NYDNR, we take the guesswork out of musculoskeletal diagnosis with the highest available resolution ultrasound imaging, to visualize damaged tissues in real time. We then devise an individualized treatment plan based on the unique circumstances and diagnostic results of each patient.

For accurate diagnosis, effective personalized treatment and practitioners who really care about you as a patient, contact NYDNR today.

About the Author

Dr. Lev Kalika is clinical director of NYDNRehab, located in Manhattan. Lev Kalika is the author of multiple medical publications and research, and an international expert in the field of rehabilitative sonography, ultrasound guided dry needling and sports medicine Dr. Kalika works with athletes, runners, dancers and mainstream clients to relieve pain, rehabilitate injuries, enhance performance and minimize the risk of injuries. His clinic features some of the most technologically advanced equipment in the world, rarely found in a private clinic.

Resource:

Giordani, Federico, et al. “A global approach for plantar fasciitis with extracorporeal shockwaves treatment.” European journal of translational myology 29.3 (2019)

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

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Complete tear of rectus femoris
with large hematoma (blood)

image

Separation of muscle ends due to tear elicited
on dynamic sonography examination

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