What is the recommended shockwave (extracorporeal shock wave therapy (ESWT)) protocol for patients with heel spurs?

Extracorporeal Shock Wave Therapy Protocol for Heel Spurs

The recommended protocol for extracorporeal shock wave therapy (ESWT) in patients with heel spurs is 3 sessions at weekly intervals with 1000-2000 impulses per session at an energy level of 0.08-0.4 mJ/mm² to effectively reduce pain and improve function.

Mechanism and Rationale

ESWT works by delivering acoustic shock waves to the affected area, which may:

• Stimulate healing response in the plantar fascia
• Reduce inflammation at the insertion site
• Potentially alter pain receptors' sensitivity
• Improve local blood flow

Detailed Protocol Parameters

Session Frequency and Duration

• 3 treatment sessions 1
• Weekly intervals between treatments 1, 2
• Total treatment course: 3-5 weeks 3

Technical Parameters

• Energy flux density: Start at 0.05-0.08 mJ/mm² and gradually increase to 0.4 mJ/mm² 3
• Number of impulses per session: 1000-2000 impulses 1, 2
• Focused application around the heel spur and plantar fascia insertion 1

Localization Method

• Use of integrated fluoroscopy or ultrasound guidance for precise targeting 1
• Application around the calcaneal spur and plantar fascia insertion point

Expected Outcomes

Pain Reduction Timeline

• Initial improvement: Often noticeable within 1 week of beginning treatment 4
• Continued improvement: Between 6-12 weeks after treatment course 2
• Long-term results: Pain relief may continue to improve up to 12 months post-treatment 5

Functional Outcomes

• Increased pain-free walking ability (from minutes to hours) 5
• Reduced pain on manual pressure 5
• Improved daily function 1

Important Clinical Considerations

Patient Selection

• Best candidates: Patients with chronic heel pain (>6 months) who have failed conservative treatments 6
• X-ray confirmation of heel spur is recommended but not essential, as clinical symptoms may not correlate with radiographic findings 3

Contraindications

• Coagulation disorders
• Use of anticoagulants
• Pregnancy
• Local infection
• Malignancy in the treatment area

Adjunctive Treatments

• Continue with appropriate orthotic devices and stretching exercises 6
• Consider weight reduction if indicated 6
• Avoid barefoot walking during treatment course

Treatment Alternatives

If ESWT fails to provide adequate relief after a complete course:

1. Consider a second course of ESWT (shown to be beneficial in non-responders) 2
2. Consider other conservative measures like customized orthotic devices or night splinting 6
3. Consider corticosteroid injections (though not as a first-line approach) 6
4. Consider surgical intervention (plantar fasciotomy) only after failure of all conservative measures 6

Clinical Pearls and Pitfalls

• Important: Radiographic changes in the heel spur do not necessarily correlate with clinical improvement - focus on symptom relief rather than radiographic outcomes 3
• Local anesthesia may be used but might reduce treatment efficacy in some protocols
• Patients should be advised that maximum benefit may not be apparent until 12 weeks after completing the treatment course 2
• Higher impulse numbers (500 vs 100 per session) have shown significantly better outcomes 5

ESWT represents an effective non-surgical intervention for recalcitrant heel pain associated with heel spurs, with documented improvement in both pain levels and functional outcomes when properly administered according to the protocol outlined above.