This leaflet explains the use of ESWT to treat lower limb tendon disorders or plantar heel pain, known as plantar fasciopathy.
It lists the benefits, risks, and alternative treatments, as well as what to expect when you come to clinic. If you have any further questions, please speak to the podiatrist caring for you.
What are Tendinopathies or plantar Fasciopathy?
Tendinopathies generally cause localised pain, swelling, stiffness, and impair function particularly after rest. The cause of tendinopathy is not completely understood however, they are known as overuse injuries and occur when the tendons are unable to adapt to loads placed upon them. This leads to microscopic changes within tendon fibres and as they heal, tendons become painful and thicker.
The Plantar Fascia is a long band of connective tissue from the base of the toes to underside of the heel. It is similar to a tendon but has some differences. Pain and stiffness are felt at the underneath and inside edge of the heel, where tissue becomes frayed or thickened. This is known as plantar Fasciopathy. Pain develops when the fascia is unable to tolerate excessive loads, for example, prolonged standing or increased exercise.
What is ESWT?
ESWT is a procedure where shockwaves are passed through the skin to the injured tissue. Extracorporeal means outside of the body. The shockwaves are mechanical and not electric. They are audible, low-energy sound waves, which work by increasing blood flow to the injured area, influencing inflammation and nerve fibres involved in pain. This helps with your body’s healing process. You will usually require three applications applied once weekly. This may be reviewed and repeated if appropriate.
Why should I have ESWT?
ESWT is offered to patients who have not responded effectively to other treatments, such as exercises, injections, foot orthoses (insoles), rest, ice therapy and pain relief. It is a minimally invasive treatment that is carried out on an outpatient basis, which means that you can go home following treatment. ESWT can offer relief from pain and other symptoms.
What are the risks or side effects?
You will experience some pain during the treatment, but most people cope well. Anaesthesia is not necessary.
Following the treatment, you may experience more pain, redness, bruising, swelling and numbness to the area at first. These side effects should resolve within 36 hours and before your next treatment. Studies have shown that 5-7 out of 10 patients have found it to be effective. There is a very small risk of tendon or ligament rupture, and damage to the soft tissue.
You must not have ESWT if you:
- Are pregnant
- Take anti-platelets (such as Clopidogrel) though 75mg aspirin is acceptable.
- Take anticoagulants (such as 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 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
These will be discussed with you by your podiatrist when the treatment is offered.
Your podiatrist will discuss the benefits and risks of the procedure with you in more detail – please let them know if you have any questions or would like any further information.
Are there any alternatives?
If ESWT does not help your pain, other options may include further physiotherapy, podiatry treatment or injection therapy. Sometimes an operation may be available depending upon your condition, although few patients go onto to have any surgical intervention. Your podiatrist can advise you on available options.
How can I prepare for ESWT?
You will need to be available for the full course of treatment which you podiatrist will discuss with you. You should not take any non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen, for two weeks before and throughout your treatment period. If you are unsure if any of your medicines contain NSAIDs then please check with your doctor, nurse or pharmacist. Wear comfortable clothing as you will be lying on your front for the treatment
Asking for your consent
It is important that you feel involved in decisions relating to your treatment. You will have spoken with a podiatrist about your treatment choices. If you wish to proceed with ESWT treatment, you will be asked to sign a consent form.
This confirms that you agree to have ESWT treatment and understand what it involves. If you would like more information about our consent process, please speak to your podiatrist
Who will perform the procedure?
Your ESWT will be carried out by a podiatrist, who has undertaken special training to carry out the procedure.
What happens during ESWT?
You will be asked to lie on your front with your legs supported by a pillow if treating Achilles or heel pain, however the position can be adapted if you find this uncomfortable. The podiatrist will put ultrasound gel over the area and place the device hand piece on the gel. ESWT is delivered using the hand piece – delivering compressed air pulses through the ultrasound gel. Each treatment takes approximately five minutes.
Will I feel any pain?
It is typical for patients to experience some pain or discomfort during the procedure. ESWT will be applied at a low level and slowly increased to a tolerance level.
You can inform us of your pain experience, and we will adjust treatment to allow you to manage more comfortably.
What happens after ESWT?
After treatment you may get up and walk straight away. If you do experience discomfort, following the shockwave treatment you can take over-the-counter pain relief (paracetamol) or use ice therapy but don’t take anti-inflammatory medication (such as ibuprofen) as these can interfere with the tissue healing process.
What do I need to do after I go home?
You may return to your usual activities, including work, straight away. However, we advise, for you not to undertake strenuous, pain-provoking activity or high-impact exercise for 48 hours after the procedure. If you experience sudden onset of pain to the area or any loss of function, please contact Podiatry, your GP or go to your nearest Emergency Department (A&E).
Will I have a follow-up appointment?
You will have a telephone follow-up appointment eight weeks after your final treatment.
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:
Date of Review: July 2023
Date of Next Review: July 2025
Ref No: PI_DS_1781 (Salford)