By Susan Burke March, MEd, RDN, LDN, CDE
My “routine surgery” had turned into a nightmare.
For three years prior to relocating to Cuenca in September 2014, I’d been plagued by a Morton’s neuroma in my right foot. Morton’s neuroma is a condition characterized by the development of fibrous tissues around a nerve, which subsequently gets inflamed, compressed and irritated. When this happens, the patient experiences severe pain usually on the balls of the foot and at the base of the toes.
Yes, that’s describes it. It feels as if you’re walking on marbles — or sometimes on razor blades (read more in PodiatryToday.com).
Morton’s neuroma mainly affects women (80%), and experts agree that women’s “slave to fashion” high-heeled shoes are the “podiatrist’s dream”. I plead guilty to wearing bad-fitting, high-heeled shoes — I looked great, in my own mind. Regrets, I have many.
My Florida podiatrist had followed established protocol: rest, ice, non-steroidal inflammatory drugs (NSAIDs), and custom shoe inserts (orthotics…expensive!). When none of these treatments helped, I tried a cortisone injection. No luck there either. Next, the doctor administered a series of alcohol injections — ouch! But they did alleviate the pain…for a while. But this past spring, walking, walking, walking in Cuenca, the pain returned worse than ever. I had been told that by protocol, the next step would be to have the neuroma surgically removed, so I scheduled with a local surgeon, who requested I have a sonogram to confirm the presence of the neuroma.
The neuroma was confirmed, and I was told the surgery would be a routine procedure, taking no more than about 30 minutes. No general anesthesia necessary, and so when I arrived for surgery I was relaxed, fully expecting to be up and about in just a few weeks. But, the surgery took 2 ½ hours and afterward the surgeon said that he’d discovered that my foot was already fibrotic, with a surprising amount of scar tissue surrounding the neuroma. It appears that although he successfully removed the neuroma, the unexpected length and involvement of the surgery led my foot to develop yet more scar tissue. A month later, although the scar was healed, my foot was still inflamed and painful. (Fibrosis is defined as an excess fibrous tissues or scar tissue, usually because of injury or long-term inflammation.)
What to do now? My surgeon prescribed physical therapy, which felt good while I was having it, but it wasn’t changing the amount of fibrosis — just making my foot feel better temporarily.
An acquaintance suggested that I see Dr. Luis Rojas, because she was told that he had success in treatment of injuries with a noninvasive therapy. I didn’t know what that was, but I knew of Dr. Rojas! Dr. Rojas had successfully repaired my husband’s torn meniscus two years ago. I’d come to wish that I’d consulted him before having my surgery, but as they say, you can’t look back, so we’re looking forward.
Bienestar Integral Ecuador
I visited Dr. Rojas in his office at his clinic Bienestar Integral, just a few blocks south of Hospital Santa Inéz. Upon examination, Dr. Rojas agreed that my foot indeed seemed fibrotic, but to confirm he wanted me to get an MRI of the foot. “When?” I asked. “Today”, he pronounced — and within just a minute he was on the phone, confirming an appointment for the MRI. “OK, you’re scheduled at Hospital del Rio. Have the MRI, then come upstairs to see me in my office on the third floor”, he said.
Before I knew it, I was in a cab on my way to the east side of town. Within just two hours I was up in Dr. Rojas’ Hospital del Rio office. He’d already consulted with the radiologist who had read the MRI, and greeted me by saying, “you didn’t tell me that you had a plastic joint in your foot”. Hmmm…with all the tumult of disappointing surgical results, and the unexpectedly rapid office visit and MRI, I had neglected to tell the doctor that I’d had a complete joint replacement of the big toe in that same foot…six years ago! The previous surgery was successful…I’d healed well and never even think of it. But now…complications from that darned neuroma!
Dr. Rojas said that it may have been to my advantage to have seen him first for the neuroma. He’d been working with Extracorporeal Shockwave Therapy (ESWT) for a number of conditions, and Morton’s Neuroma is just one with supporting studies showing that ESWT can be an effective alternative to surgery. And, in my case, he advised that ESWT could also be helpful in reducing pain and promoting healing following surgery.
“Shock therapy?” I asked. No, said Dr. Rojas patiently. Extracorporeal shockwave therapy or treatment.
Extracorporeal Shock Wave Therapy is a technology using shockwaves to treat chronic, painful tendon, joint, and muscle conditions, and has also been found effective in treating bone and wound healing. A shockwave is an intense but very short energy wave traveling faster than the speed of sound. The word “Extra-corporeal” means “outside the body” and refers to the fact that the shockwaves are generated outside the body.
The basic science behind ESWT is similar to lithotripsy, the technology that uses acoustic shockwaves to break up kidney stones without surgery. The technique of using shockwaves to break up kidney stones has been around for a nearly a quarter century now, and is the most common way of breaking up kidney stones in the USA. In the process of treating thousands of patients, it was found that many people undergoing the procedure had relief from pain from other injuries. It was at this point that scientists began to consider that shockwaves might have an effect to heal other sorts of tissues.
Specialized machines were then developed specifically with the idea of using these shockwaves on other parts of the body, and this is the origin of ESWT. Learn more about the physics of shockwave therapy here.
In the USA, the therapy is currently approved by the Food and Drug Administration (FDA) for tennis tendonitis (tennis elbow) and plantar fasciitis, and is under investigation for diabetic wound healing.
However, ESWT is in much wider use around the world, especially in Canada, Europe, Asia, and Latin America.
Besides the conditions mentioned above, ESWT has been successfully used to treat many additional sports injuries, joint injuries, connective tissue pain, stress fractures, non-healing bone (non-unions), slow-healing bone (delayed unions) — and Morton’s Neuromas. With ESWT, patients report faster healing – pain is reduced significantly, and there is no surgery or medications necessary.
|Prospective, randomized controlled trials have been conducted showing the efficacy of ESWT, and is currently also being used and studied for use for a wide variety of other conditions as disparate as skin ulcers and other chronic dermatological lesions, infections, angina, arthritis, reflex sympathetic dystrophy (RSD), and certain neurological conditions.
Dr. Rojas said that he uses ESWT for many of these conditions, as well as myofacial pain — trigger points — painful muscle knots. Think what happens when you’re working all day over a computer, and suddenly you have neck spasms that just won’t quit. Or you’ve been in an auto accident, and have suffered whiplash. Dr. Rojas noted that ESWT has been demonstrated as effective in diabetic patients suffering from foot ulcers. Diabetes is the number one cause of non-traumatic amputation, and ESWT is effective in promoting circulation and healing.
Dr. Rojas frequently treats patients for plantar fascitis — Dr. Rojas says that in fact, this condition is the most common cause of heel pain. The plantar fascia is the flat band of tissue, or ligament, connecting the heel bone to the toes, supporting the arch of your foot. Whether from overuse, or from age, the plantar fascia weakens, becomes irritated, swollen and inflamed, leading to pain under the heel bone and in the arch of the foot. Measures including ice, shoe inserts, stretching and anti-inflammatory medications may work temporarily, but many patients do not find relief.
In a review article in Podiatry Today, Dr. Lowell Weil, past president of the International Society of Medical Shockwave Treatment (ISMST), and a board-certified doctor of podiatry, reviewed long-term research from randomized controlled trials and concluded, “extracorporeal shockwave therapy has proven to be a cost effective treatment for plantar fasciitis while showing long-term success that other treatments cannot boast. Not only should one consider ESWT a mainstay of treatment for more chronic cases of plantar fasciitis, it should now be an option earlier in the treatment regimen and possibly supplant other treatments that have not been validated.”
Depending upon the level of pain the patient is already experiencing in the area, there may be some discomfort during each treatment. Dr. Rojas says that a skilled and trained practitioner will adjust the intensity of the treatment and allow for some pain relieving effect at the beginning of each session. Read more about the treatment from The American Orothpedic Foot & Ankle here. Most patients have pain relief with their first treatment, but for some, it may take 3–4 treatments. Full results require a complete course of therapy and can take up to several months to be completely realized as the body goes through a healing cycle. In my experience, after the first treatment the pain was lessened, and the goal is that with time the scar tissue will diminish, and there will be continued softening of the fibrosis, and more flexibility and healing.
Dr. Rojas utilizes two different machines to administer therapy: the Swiss PiezoClast® unit delivers focused shockwaves, and the Swiss DolorClast® delivers radial shockwaves. The technologies differ in the manner in which the shockwaves are produced, the ability of the shockwave to be controlled and focused, the depth to which the shockwaves can penetrate, the intensity of the shockwave being produced, the sorts of conditions they’re able to treat. When you consult with Dr. Rojas, he will discuss with you your best options for treatment and healing.
Dr. Rojas’ medical training is quite extensive, studying in Mexico, Paris, and Pamplona. As a trained surgeon in practice for more than 20 years, Dr. Rojas specializes in pediatric orthopedics, sports medicine, spine surgery, joint replacement, and trauma. He is a certified member of the International Society of Medical Shockwave Treatment (ISMST), and the Latin American Society for Musculoskeletal Shockwave Therapy (ONLAT) and has completed certification courses in Germany and Milan, and most recently in April 2015, in Argentina.
The effectiveness of extracorporeal shockwave therapy has been demonstrated — randomized controlled trials that show that ESWT works for:
- Eliminating pain
- Facilitating healing
- Improving local microcirculation, leading to improved tissue metabolism
- Increasing production of collagen
- Reducing local muscle tension
- Helping dissolve calcific fibroblasts
- Stimulating the elimination of Substance P (a pain producing chemical)
This is a non-invasive therapy to treat:
- Plantar fasciitis
- Heel spurs
- Hand pain (tendonitis)
- Hip bursitis
- Groin pain
- Jumper’s knee/patellar tendinitis
- Tennis/Golfer’s elbow
- Shoulder tendonitis
- Myofascial trigger points
- Acute muscle spasm/strain
- Diabetic foot
- Delay in healing
Contact the office for a consultation with Dr. Rojas. Dr. Rojas is fluent in Spanish and English, as well as proficient in French and Italian.
Location: Remigio Tamariz y Agustin Cueva, Edificio Santa Maria
Telephone: Local: 2810-854
Electro Medical Systems: Swiss DolorClast® , Swiss PiezoClast®
International Society for Musculoskeletal Shockwave Therapy (ISMST): http://www.shockwavetherapy.org/the-society/
Shockwave Therapy Canada: http://www.shockwavetherapy.ca/about_eswt.htm#How_do_the_physics_of_ESWT_promote_tissue_healing
The Latin American Federation of Associations and Shock Wave in Medicine (ONLAT): http://www.onlat.org/