Podiatry - Extracorporeal Shockwave Therapy (ESWT)

This leaflet explains the use of ESWT to treat lower limb tendon disorders or plantar heel pain (plantar fasciopathy).

It outlines the benefits, risks, and alternative treatments, as well as what to expect. If you have any questions, please speak to your podiatrist.

What is Tendinopathy or Plantar Fasciopathy?

Tendinopathy (tendon degeneration) causes localised tendon pain, swelling and stiffness, often worse on initiation of walking after rest. They are usually related to an inability of the tissue to tolerate load.

Plantar fasciopathy affects the band of tissue under the foot, causing heel pain and stiffness, particularly with weight-bearing after inactivity.

What is ESWT?

ESWT is a non-invasive treatment where acoustic shockwaves are delivered through the skin to the affected tissue.

The treatment is thought to work by:

• Stimulating local tissue activity
• Influencing pain pathways
• Encouraging changes within the affected tissue

The exact way it works is not fully understood. A course of treatment typically involves 3 weekly sessions, but this may vary depending on your condition and response to treatment.

Why have ESWT?

ESWT may be offered if:

• Your symptoms have been present for at least 6 months
• You have not improved with baseline appropriate measures such as:
  ○    Exercise therapy/rehabilitation
  ○    Activity modification
  ○    Footwear advice or use of orthoses

ESWT is used alongside an active rehabilitation programme, not as a replacement for it.

What are the risks or side effects?

It is normal to feel some discomfort during treatment.

After treatment you may experience:

• Increased pain (flare-up), which may last up to 72 hours
• Redness
• Bruising
• Swelling
• Less common risks include:
  ○    Temporary numbness
  ○    Rare soft tissue irritation
  ○    Very rare risk of tendon or tissue damage

When ESWT may not be suitable?

You should not have ESWT if you (absolute contraindications):

• Are under 18
• Are pregnant
• Have a cardiac pacemaker or an implanted defibrillator (ICD)
• Have an infection or tumour at the treatment site
• Have had a steroid injection in the same area within the last 6 - 8 weeks

ESWT may not be suitable or may require individual assessment if you:

• Use blood-thinning medication
• Have reduced sensation or neuropathy
• Have poorly controlled high blood pressure
• Have osteoporosis or bone fragility concerns
• Have metal implants in the treatment area

Your podiatrist will discuss these with you.

Are there any alternatives?

Alternatives may include:

• Continued rehabilitation/physiotherapy
• Podiatry management
• Injection therapy
• In some cases, surgery

How can I prepare for ESWT?

Your podiatrist will discuss your treatment plan with you.

You may be advised about medications such as anti-inflammatory drugs depending on your individual situation.

Please wear comfortable clothing suitable for examination and treatment.

Asking for your consent

It is important that you feel involved in decisions about your care.

Your podiatrist will:

• Explain the benefits and risks
• Answer any questions

Your consent will be obtained and recorded before treatment and confirmed at each session. You have the right to withdraw your consent at any time.

Who will perform the procedure?

ESWT will be carried out by a trained podiatrist.

What happens during ESWT?

• You will be positioned comfortably on a treatment couch
• Water-based gel will be applied to the skin
• A handheld device will deliver shockwaves to the area
• Treatment dose will be altered based on clinical judgement and your feedback

Treatment usually lasts around 5 minutes.

Will I feel pain?

Some discomfort is expected.

The intensity will be adjusted to a level that you can tolerate.

What happens after ESWT?

After treatment:

• You can walk immediately
• You may use simple pain relief such as paracetamol if needed
• Anti-inflammatory medication (e.g. ibuprofen, naproxen, diclofenac) is generally avoided as it may interfere with the treatment effect, unless you are taking it for another medical condition
• You should:
  ○    Modify activity- reduce high-impact activity but maintain light daily activity for 24 - 48 hours
  ○    Avoid strenuous or high-impact activity during this period
  ○    Continue your prescribed rehabilitation programme after 48 hours

What should I do when I get home?

• Gradually return to normal activity
• Continue with your exercises after 48 hours of relative rest
• Monitor your symptoms

Seek urgent advice from NCA Podiatry Department if:

• Pain becomes severe or unexpected
• You notice significant swelling or loss of function
• Call 0161 206 3842

Will I have a follow-up appointment?

• Follow-up will be arranged based on your treatment plan and response to therapy

Further sources of information

The National Institute for Health and Care Excellence (NICE) has produced recommendations for patients on ESWT for Achilles tendinopathy and plantar heel pain.

Please see the websites below for more information:

https://www.nice.org.uk/guidance/htg426

https://www.nice.org.uk/guidance/htg200