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Shocking Relief: New Therapy Eases the Chronic Pain of Many Common Tendon Injuries

By Vicki Hyman
Tuesday, March 22, 2005
article from Newark Star-Ledger

Mary Jean Lange's first steps each morning were so excruciating that the Hackensack teacher resorted to crawling to the bathroom. Betty Davis, an Irvington nurse, felt like the soles of her feet had been branded. Jean Smitchger, a retired businesswoman from Cornwall, N.Y., dredged up only two little words to describe the pain: "all hell."

The three women suffered from plantar fasciitis, a swelling of the tough tissue on the bottom of the feet. Seen often among workers who have to stand on hard surfaces all day, it strikes about 2.5 million people a year. For most patients, rest, ice, stretching, special insoles or cortisone shots do the trick, but for these women, nothing short of surgery seemed to help.

Finally, their podiatrists recommended a new treatment for chronic heel pain called extracorporeal shock wave therapy. An ESWT machine sends acoustic waves into the foot, which bruises the already battered tissue. Doctors believe that these new microscopic tears promote the growth of new blood vessels, effectively jump-starting healing that had been stalled.

Davis just calls it "my miracle."

First used in the Europe to break up kidney stones, shock wave therapy jumped the pond in the 1980s and now is standard care for kidney stone sufferers. Since the Food and Drug Administration approved the first ESWT machine for treatment of plantar fasciitis in 2000, the therapy has taken off. Without the risk or complications of surgery, most patients are back on their feet within a day or so, some reporting immediate relief.

Now doctors use shock waves to repair many common tendon injuries, including tennis elbow, Achilles tendonitis, shoulder, knee and wrist tendonitis, and trigger finger, reporting success rates of about 80 percent.

Some major insurance companies, however, do not cover the treatment or cover it only for some tendon injuries. Aetna deems it "experimental" and will not pay for it. Horizon Blue Cross Blue Shield covers the therapy for plantar fasciitis only. The cost runs about $2,000 to $3,500.

But research in Europe and Japan shows shock wave therapy holds further promise. Doctors have been using it to heal diabetic ulcers and to fix bone fractures that have not healed properly, which alleviates the need for complicated and painful bone grafts, said podiatrist Kimberly Eickmeier, a spokeswoman for the American College of Foot and Ankle Surgeons and an adviser to the International Society for Musculoskeletal Shockwave Therapy.

A Japanese study published last year in the journal Circulation showed that shock waves repaired heart damage in pigs, suggesting that it could be used to help healing in humans after heart attacks.

The German firm Dornier developed medical shock wave technology after aircraft engineers noticed pitting in the aluminum of the stabilizer wings of airplanes breaking the sound barrier. Legend (among medical historians, at least) has it that one of the engineers mentioned the phenomenon to a surgeon over a beer, and they speculated that shock waves could be used to break up kidney stones.

Later, a patient in Europe who was to be treated with shock waves for his gallstones asked the surgeon to test the machine on his heel pain, and the doctor did, according to Eickmeier. (Picture that in America: "Dude, while you're fixing my eyes, how about zapping my hernia with that laser?") It worked, and word about the treatment spread quickly.

Doctors typically recommend the procedure if patients are still in pain after six months of conventional therapy. The outpatient procedure takes only 10 to 20 minutes, longer if the patient must be sedated first. The injured area is coated with gel and placed against the therapy head, a rubber dome filled with water. The machine generates sound waves that emanate through the membrane and into the injured area.

Two types of machines, the HealthTronics OssaTron and the Dornier EPOS Ultra, target the injured area with high energy sound waves. This can be painful, the feeling has been likened to getting hit with a baseball bat, so a nerve block is applied to the injured area. Many patients also undergo, "twilight sedation", in which patients remain conscious to avoid discomfort. The one-time treatment usually takes place in a hospital or surgery center.

Another machine, the Siemens Sonocur Basic, uses low-energy sound waves, so it can be performed without anesthesia in a doctor's office. It usually takes three visits to repair the damage.

The success rate compares with that of surgery, but it does not carry the risk of infection or require stitches. Patients typically get back to their normal routines much faster.

"The worst thing that happens here is it doesn't work," said Maplewood podiatrist Howard Hyman, as he watched technicians administer the treatment to a patient's right foot (the one with YES written on it) earlier this month at the Surgical Center at Millburn.

There's actually one thing that's worse: Paying out-of-pocket for the treatment and it doesn't work. Although proponents say they see shock wave therapy becoming standard care for tendon injuries, particularly among worker's compensation cases, many insurers will not cover the procedure.

Some patients who got their tennis elbow by actually playing tennis as opposed to working stiffs who got their injuries by cutting meat, fixing plumbing or painting houses, don't balk at paying for the treatment themselves.

After the pain in her foot pushed her into a wheelchair, Smitchger was more than willing to gamble $3,500. "I was at my wit's end," she said. "I'd try anything."

There is nothing about the treatment, however, that can prevent the patient from reinjuring the tendon. Doctors recommend ways to avoid reinjury, from losing weight for a heel pain sufferer to changing tennis rackets for a patient with tennis elbow. And some patients do not respond to the treatment at all.

Jeffrey Gross, a Manhattan doctor specializing in physical medicine and rehabilitation, served a number of patients who had been suffering from the same injury for years with little improvement. He followed the FDA approval process of the low-energy Sonocur machine closely, and within a month of its okay in 2002, he had one in his office.

He has since treated more than 900 patients with the device, including pro basketball, hockey and tennis players, and college and high school athletes.

"There are patients who will get better if you wave a wand over them because of the placebo effect," he said. "I am certain there is no placebo effect acting in these people. They get better."

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