PFE vs Shockwave Therapy (ESWT): Comparing Two Advanced Heel Pain Treatments
If you have been living with chronic heel pain for months — or even years — there is a good chance you have already tried the standard first-line treatments. Stretching exercises, custom orthotics, anti-inflammatory medications, physical therapy, and cortisone injections may have offered some temporary relief, but the pain keeps coming back. You are not imagining it, and you are certainly not alone. Many patients reach a point where the conventional playbook simply is not enough.
When conservative treatments fall short, your podiatrist or physician may suggest two advanced, non-surgical options: extracorporeal shockwave therapy (ESWT) and plantar fasciitis embolization (PFE). Both approaches go beyond basic pain management, and both aim to address the deeper mechanisms driving your heel pain. But they work in fundamentally different ways, target different aspects of the problem, and involve very different treatment experiences.
Understanding the differences between shockwave therapy and PFE can help you have a more informed conversation with your doctor and make a decision that aligns with your goals, your lifestyle, and how long you have been struggling. At Fox Vein & Vascular, Dr. David Fox, MD, FACS, RPVI — a board-certified vascular surgeon with more than 28 years of experience — helps patients evaluate their options and determine the most appropriate path forward.
- Minimally invasive treatments
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Understanding Why Chronic Heel Pain Persists
To understand why some treatments work and others do not, it helps to understand what is actually happening inside your heel when plantar fasciitis becomes chronic.
In the early stages, plantar fasciitis is an inflammatory condition — the thick band of tissue along the bottom of your foot becomes irritated and inflamed, usually at its attachment point near the heel bone. Rest, stretching, and anti-inflammatories can often resolve this acute inflammation. But when the condition persists beyond six months, something changes at a vascular level.
Your body responds to ongoing tissue damage by growing new, abnormal blood vessels into the injured area — a process called neovascularity. These tiny, disorganized vessels do not help the tissue heal. Instead, they bring with them a network of small nerve fibers that amplify pain signals and deliver a steady supply of inflammatory cells that perpetuate the cycle. This is why plantar fasciitis becomes chronic in so many patients: the very blood vessels your body creates to repair the damage end up sustaining the inflammation instead.
This distinction matters because it directly affects which treatments can help. Therapies that target the mechanical structure of the fascia — like stretching, orthotics, and shockwave — address one part of the equation. Treatments that target the abnormal vascular supply — like embolization — address the other.
- are not ready for knee replacement surgery
- have not responded well to physical therapy, injections, or medications
- want a non-surgical treatment option
- are trying to stay active while managing osteoarthritis symptoms
At Fox Vein & Vascular, Dr. David Fox performs GAE using real-time vascular imaging and minimally invasive catheter techniques developed through decades of vascular intervention experience.
What Is Shockwave Therapy (ESWT)?
Extracorporeal shockwave therapy is a non-invasive treatment that uses acoustic pressure waves — essentially sound energy — directed at the painful area of the heel. The technology was originally developed to break up kidney stones and has since been adapted for musculoskeletal conditions.
How Shockwave Therapy Works
During an ESWT session, a handheld device delivers focused or radial acoustic waves through the skin and into the plantar fascia. These waves create controlled micro-trauma in the tissue, which is intended to stimulate your body’s natural healing response. The mechanical disruption can help break up calcified deposits and scar tissue while encouraging increased blood flow to the treated area.
There are two main types of shockwave therapy:
- Focused ESWT: Delivers high-energy waves to a precise, targeted area deep within the tissue. Often requires local anesthesia due to discomfort during treatment.
- Radial ESWT: Distributes lower-energy waves over a broader area. Generally better tolerated but may be less effective for deep-seated chronic cases.
What to Expect with Shockwave Treatment
A typical shockwave treatment protocol involves 3 to 5 sessions, spaced one to two weeks apart. Each session lasts approximately 15 to 20 minutes. Pain during the procedure can range from moderate to significant, particularly with focused ESWT. Some patients describe the sensation as a deep, repetitive tapping or snapping against the heel.
Results from shockwave therapy are not immediate. Most patients begin to notice improvement several weeks after completing their full course of treatment. Clinical studies report success rates of approximately 74 to 76 percent for chronic plantar fasciitis cases, with results typically assessed at the three-month mark.
Insurance coverage for ESWT remains inconsistent. Some plans cover it as a medically necessary procedure, while others classify it as experimental or investigational and require out-of-pocket payment.
What Is Plantar Fasciitis Embolization?
Plantar fasciitis embolization takes a fundamentally different approach. Rather than mechanically stimulating the tissue to promote healing, PFE directly targets the abnormal blood vessels — the neovascularity — that are sustaining inflammation and pain in the plantar fascia.
How PFE Works
During PFE, Dr. Fox accesses the vascular system through a tiny puncture — typically at the ankle or top of the foot. Using real-time fluoroscopic imaging (live X-ray guidance), he navigates a microcatheter through the blood vessels to identify the specific abnormal vessels feeding the inflamed area of the plantar fascia. Once identified, microscopic embolic particles are delivered through the catheter to gently reduce blood flow through these problematic vessels.
By reducing the blood supply that sustains the inflammatory cycle, PFE allows the tissue to begin healing naturally. The procedure does not damage the plantar fascia itself or affect the healthy blood vessels that supply normal tissue.
What to Expect with PFE
PFE is a single, same-day procedure performed in approximately 45 to 90 minutes. It requires only local anesthesia, with sedation available if desired — no general anesthesia is needed. Patients return home the same day and can typically resume light activity within 24 to 48 hours.
Pain relief from PFE develops gradually. Most patients begin noticing improvement within 2 to 6 weeks, with significant relief by 2 to 3 months. Clinical studies show that 80 to 90 percent of patients report significant pain reduction following the procedure. You can learn more about what the research shows on our PFE success rates page.
Head-to-Head Comparison
The following table provides a direct comparison of the two treatments across the factors that matter most to patients:
| Factor | Shockwave Therapy (ESWT) | Plantar Fasciitis Embolization (PFE) |
|---|---|---|
| Mechanism | Acoustic waves create micro-trauma to stimulate healing | Targets and reduces abnormal blood vessels sustaining inflammation |
| Number of Sessions | 3–5 sessions over several weeks | Single procedure |
| Procedure Time (per session) | 15–20 minutes | 45–90 minutes |
| Pain During Treatment | Moderate to significant | Minimal |
| Anesthesia | Local anesthesia or none (radial) | Local anesthesia with optional sedation |
| Recovery | Minimal downtime per session; full protocol spans weeks | Same-day discharge; light activity in 24–48 hours |
| Success Rate | ~74–76% | ~80–90% |
| When Results Appear | Weeks to months after completing all sessions | Gradual improvement over 2–6 weeks; significant relief by 2–3 months |
| Insurance Coverage | Inconsistent; often classified as experimental | Varies; coverage determined on an individual basis |
| Invasiveness | Non-invasive (external) | Minimally invasive (tiny puncture, no incision) |
Both treatments are non-surgical and avoid the risks and lengthy recovery associated with plantar fascia release surgery. However, they differ significantly in how they work, how many visits are required, and the level of discomfort patients experience during treatment.
When Shockwave Might Be the Right First Step
Shockwave therapy has an established track record and may be a reasonable option for certain patients. It tends to work best in the following situations:
Earlier-stage chronic plantar fasciitis
If your symptoms have persisted beyond the initial acute phase but have not yet become deeply entrenched over many months or years, ESWT may provide the stimulus your tissue needs to heal.
When you prefer a completely non-invasive approach
Because shockwave is applied externally with no needle or puncture of any kind, some patients prefer trying it before considering a minimally invasive procedure
When PFE eligibility is uncertain
Not every patient is a candidate for embolization. If your diagnostic imaging does not clearly show the neovascularity that PFE targets, shockwave may be a more appropriate starting point.
As part of a multimodal plan:
Some podiatrists incorporate shockwave alongside continued physical therapy and orthotics as part of a comprehensive conservative approach.
When PFE May Be the Better Option
For many patients — particularly those who have been dealing with heel pain for an extended period and have exhausted other options — PFE offers distinct advantages:
- When shockwave therapy has already been tried: If you completed a full course of ESWT without lasting relief, PFE addresses a different underlying mechanism and may succeed where shockwave did not.
- Longer duration of symptoms: Patients who have been living with chronic plantar fasciitis for a year or more often have more established neovascularity, which is exactly what PFE is designed to treat.
- Preference for a single treatment: Rather than scheduling and attending 3 to 5 separate sessions, PFE is completed in one visit. For busy New Yorkers managing demanding schedules, this can be a meaningful practical advantage.
- Desire to minimize procedural discomfort: PFE is performed under local anesthesia with minimal discomfort during the procedure, while shockwave sessions can involve moderate to significant pain.
- When conservative treatments have failed: If you have already worked through the standard ladder of care — stretching, orthotics, physical therapy, cortisone injections, and possibly shockwave — PFE represents a logical next step before considering surgery.
Dr. Fox evaluates each patient individually, reviewing your imaging, treatment history, and symptom duration to determine whether PFE is appropriate for your specific situation. You can learn more about what makes someone a good candidate for PFE.
Can You Have Shockwave Before PFE?
Yes — and in fact, many patients who come to Fox Vein & Vascular for a PFE consultation have already tried shockwave therapy. This is perfectly fine and does not affect your eligibility for embolization.
Because shockwave and PFE target different aspects of the problem, they are not mutually exclusive. Shockwave works on the mechanical and structural level — stimulating tissue healing and breaking up scar tissue. PFE works on the vascular level — reducing the abnormal blood vessels that sustain chronic inflammation. Having tried one does not interfere with or diminish the potential effectiveness of the other.
In many cases, the fact that shockwave therapy did not provide lasting relief actually supports the case for PFE. If mechanical stimulation of the tissue was not enough to resolve your pain, it may be because the underlying vascular component — the neovascularity — is the primary driver of your ongoing symptoms. This is exactly what PFE is designed to address.
This collaborative approach reflects how Dr. Fox works alongside podiatrists in managing chronic plantar fasciitis. PFE is not a replacement for the care your podiatrist provides. It is the next step in the treatment pathway when conservative and non-invasive measures have not delivered the relief you need. Dr. Fox uses the same proven embolization technology that has shown success in genicular artery embolization for chronic knee pain, applying the same principles to the abnormal vessels in the heel.
David Fox, MD, FACS
- Double Board-Certified Vascular Surgeon
- Attending Vascular Surgeon, Lenox Hill Hospital
Dr. Fox has over two decades of experience diagnosing and treating venous and arterial conditions using the latest minimally invasive techniques. His approach is focused on precision, safety, and helping patients avoid major surgery whenever possible.
Schedule Your Consultation
If you have been living with chronic heel pain and are weighing your treatment options — whether you have already tried shockwave therapy or are exploring advanced solutions for the first time — Fox Vein & Vascular can help you understand which approach may be right for you.
Dr. Fox and his team will review your imaging, discuss your treatment history, and help you understand whether PFE could be the right next step toward lasting relief from plantar fasciitis.
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