Podiatrist Toronto, ON Sheldon H. Nadal D.P.M.
586 Eglinton Avenue E. Suite 501 Toronto, Ontario M4P1P2
Local: 416-486-9917 Toll free: (877) 456-3338

Extracorporeal Shock Wave Therapy





Extracorporeal shock wave therapy or ESWT is the non invasive (non-surgical) therapeutic use of high intensity sound waves for the treatment of chronic orthopedic problems.

What problems can it treat?

1. Heel pain due to plantar fasciitis or heel spur syndrome
2. Achilles tendinitis
3. Non-healing fractures of the foot (and other parts of the body)
4. Jumpers knee (infrapatellar tendonitis)
5. Tennis elbow or golfer's elbow
6. Calcific tendonitis of the shoulder In this office we are concerned with the first three problems.

Can anyone with plantar fasciitis or heel spur pain be treated with ESWT?

This procedure is indicated in the treatment of chronic  Heel Spur Pain, and  Plantar Fasciitis. That is, people who have had heel pain for at least six months and have continued to have pain after conservative treatment. Before having ESWT, you should have been treated unsuccessfully with at least two or three of the following conservative modalities.

1. Non-steroidal anti-inflammatory pills (Aspirin, Naprosyn, Ibuprofen, etc.)
2. Supportive tapings or strappings
3. Orthotics
4. Cortisone injections
5. Physiotherapy
6. Below knee casting
7. Night splints If you have not had conservative treatment, we will be happy to discuss it with you and provide it for you

Who should not have ESWT?

People with:

1. Bleeding disorders
2. Local infections
3. Malignancies
4. Pregnant women
5. Children

Does ESWT hurt?

In our Toronto podiatry office we use local anaesthetic before treating a patient with ESWT so there is very little, if any, discomfort during the procedure. Afterward, some people may experience discomfort for several days. This will lessen over time. We will give you a prescription for an anti-inflammatory medication in case you need it. Please reduce your activities for a few days after treatment.

Are there potential complications with ESWT?

There are no known significant complications with ESWT. Some people may get localized bruising. Other people will feel discomfort for a period of time. In very rare cases, the local anaesthetic can cause allergic reactions, infection as well as temporary or prolonged nerve irritation. Compared to surgery, ESWT is a safer alternative and should be considered before having surgery.

What are the advantages of using local anaesthetic?

There is less discomfort during the procedure with local anaesthetic. Local anaesthetic allows the practitioner to increase the intensity of the shock wave therapy, which may hasten healing and reduce the number of treatments necessary.

What if I am feeling anxious before having the treatment?

We will give you something to relax you. You may take the pills one half hour to one hour before the procedure.

How soon will I notice improvement?

In most cases healing may take six weeks to three months. However, some people will notice an improvement within three weeks, others may take six months.

What is the success rate of ESWT?

According to one study ("Treatment of Painful heel syndrome with shock waves. Clinical Orthopedics and Related Research, Number 387, pp.41-46, June 2001) as many as eighty seven percent of patients with plantar fasciitis who were treated with shock wave therapy either had no complaints or were significantly better after six months.

How long has it been used?

Extracorporeal Orthopedic Shockwave Therapy has been available in Europe for approximately 20 years. Sheldon Nadal, Doctor of Podiatric Medicine has been using it in his Toronto podiatry office since 2003.

How many treatments will I need?

Most people will only need one treatment. Some people may benefit from a second treatment.

Is this procedure covered by O.H.I.P.?

Shock wave therapy is not covered by O.H.I.P. but it may be covered by some private medical, dental or drug plans.

What are shockwaves?

Shockwaves are acoustic or, sound waves.  Examples in the world around us include shockwaves produced by thunderstorms, explosives, and sonic booms which are produced when airplanes break the sound barrier. 

How does shockwave work?

According to Michael Thiel, shockwaves stimulate healing processes in tendons, bones and surrounding tissues.  This may involve micro damage to areas with poor circulation.  It is believed that the shockwaves stimulate re-vascularization, or the formation of new circulation.  It is also believed that shockwaves release local growth factors and have an effect on stem cells and, stimulates normal tissue healing.  The process is not completely understood. 

Shockwaves are known to have two effects.  The first effect is the direct effect which creates high pressure waves.  The second effect of shockwaves is indirect.  Shockwaves cause cavitation or bubbles which then collapse and cause additional shockwaves to be generated.

It is believed that kidney stones are disintegrated with the combination of the direct and indirect shockwaves effects.  It is not clear if orthopedic problems such as plantar fasciitis are improved by the direct effect or a combination of the two.   

Advantages of shockwaves

Studies have shown that shockwave treatment is at least as effective as surgical treatment and when performed properly, there are no complications, unlike surgery.  Shockwave treatment is also less expensive than surgery. 

History of shockwaves

During World War II, it was found that sailors that were exposed to depth charges which were used to destroy submarines, suffered lung tissue damage. In 1971, the first kidney stone disintegration was performed in a lab that was recorded by Haeusler and Kiefer.

The first time a patient was treated with shockwave for kidney stone was in 1980 in Munich, Germany.  The first patient to be treated for a gall bladder stone with shockwave was in 1985 also in Munich, Germany.

During kidney stone treatments it was found that the shockwaves did not damage hip bones and in fact stimulated bone fracture healing by activating osteoblasts which are the cells which help to build bones.

In 1988, the first fracture non -union was treated with shockwaves in Bochum, Germany by Haupt.

In 1993, the first shockwave device dedicated to orthopedics called the OssaTron became available. 

In the 1990’s, clinicians began to treat calcific tendonitis in the shoulder, epicondilitis, which is a tendonitis in the elbow and plantar fasciitis in the heel.

Other medical problems that are being treated with shockwaves include avascular necrosis of the head of the femur in the hip spasticity due to strokes and cerebral palsy, articular cartilage defects in joints as well as intracorporeal stimulation of ischemic heart tissue.  In addition, shockwaves are being used in plastic surgery to treat ulcers and burns.

Types of shockwave generators

There are three methods by which shockwaves can be generated.

 The first is electrohydraulic.  This uses an electrode similar to a sparkplug to generate the shock.

 The second type of shockwave generator is electromagnetic.  This uses an electromagnetic coil to generate a shockwave.

 The third type of shockwave generator is piezoelectric.  This type of generator uses piezoelectric crystals mounted on a spherical surface to create a shockwave. 

Several years ago I used a piezoelectric unit. It was quite effective but difficult to use because it had a very small focus.

The unit that I have be

Radial shockwen using for the last three or four years is electro hydraulic. I like it better because it is effective, like the piezoelectric unit, but has a bigger focus which makes it easier to use.

What is radial shockwave?

Radial shockwave is a  sound wave that is different  from extracorporeal shockwave. It can be generated pneumatically or electromagnetically. Although many practitioners promote it as extracorporeal shock wave, or call it a lower energy shockwave, it is actually a radial wave or pressure wave. It can also treat heel and arch pain due to plantar fasciitis as well as other enthesiopathies, but it is not the same as a shockwave.

In my Toronto foot clinic, I am fortunate to have an extracorporeal shockwave unit as well as a pneumatic radial wave unit and an electromagnetic pressure wave unit. I find that the radial wave or pressure wave units are effective for acute plantar fasciitis, acute Achilles tendinitis and other acute soft tissue problems, especially when I combine a Laser Pain Treatment with the sound wave treatment. (Acute means a condition that has been present for a relatively short period of time, such as days, weeks or a few months.) Most people will need three or four treatments. Anesthesia is not necessary.

For chronic Heel Spur Pain, due to Plantar Fasciitis (the condition has been present for several months or even years), I have personally found that extracorporeal shockwave is more effective. Usually one treatment is enough, and I usually perform it with a local anesthetic.

How can I get rid of  my heel pain, arch pain, Achilles tendinitis in Toronto?

Please call my Toronto podiatry office at 416-486-9917 to set up a private consultation. During your appointment, I will take a careful history, examine your feet, take X-Rays if necessary and explain the details of your problem to you and how best to treat it.


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