[Influence of local anesthesia and energy level on the clinical outcome of extracorporeal shock wave-treatment of chronic plantar fasciitis]

Efficacy and safety of treating chronic nonspecific low back pain with radial extracorporeal shock wave therapy (rESWT), rESWT combined with celecoxib and eperisone (C + E) or C + E alone: a prospective, randomized trial

BACKGROUND

To investigate whether respectively radial extracoporeal shock wave therapy (rESWT) or a combination of rESWT, celecoxib and eperisone (rESWT + C + E) are superior in reducing pain in patients with chronic nonspecific low back pain (cnsLBP) compared to C + E alone (a standard treatment of this condition in China).

METHODS

140 patients with cnsLBP were randomly allocated to rESWT (n = 47), rESWT + C + E (n = 45) or C + E alone (n = 48) for four weeks between November 2017 and March 2019. Outcome was evaluated using the Pain Self-Efficacy Questionnaire (PSEQ), Numerical Rating Scale (NRS), Oswestry Low Back Pain Disability Questionnaire and Patient Health Questionnaire 9, collected at baseline as well as one week (W1), W2, W3, W4 and W12 after baseline.

RESULTS

All scores showed a statistically significant improvement over time. The PSEQ and NRS scores showed a significant Time × Treatment effect. Patients treated with rESWT had significantly lower mean NRS values than patients treated with rESWT + C + E at W1 and W3, as well as than patients treated with C + E alone at W3 and W4. No severe adverse events were observed.

CONCLUSIONS

rESWT may not be inferior to respectively rESWT + C + E or C + E alone in reducing pain in patients with cnsLBP.

LEVEL OF EVIDENCE

Level I, prospective, randomized, active-controlled trial.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT03337607. Registered November 09, 2017, https://www.clinicaltrials.gov/ct2/show/NCT03337607 .

LEVEL OF EVIDENCE

Level I; prospective, randomized, controlled trial.

Biologics in the Treatment of Plantar Fasciitis

Plantar fasciitis has been considered an acute inflammatory disorder. However, the local histologic findings represent a more chronic, degenerative state without inflammation. Patients may be stuck in a chronic state of cyclical inflammation leading to tissue degeneration, refractory symptoms, and disability. This idea process has influenced the treatment approach of some practitioners who have implemented the idea of regenerative medicine and use of biologic adjuvants in the treatment of plantar heel pain. Biologic therapies provide many different cellular components, growth factors, and proteins to restore normal tissue biology and are a useful adjunct in the treatment of recalcitrant plantar fasciitis.

Comparison of Radial Extracorporeal Shock Wave Therapy in Plantar Fasciitis Treatment Using Two Different Frequencies

Objective To compare results of two different frequencies and densities of radial extracorporeal shock wave therapy (rESWT) after 10 sessions. Methods A total of 41 patients with plantar fasciitis were included in this study. Patients were randomly divided into two groups. Both groups were administered 10 sessions of treatment consisting of 15 Hz frequency, 3.0 Bar density and 2000 impulses/ session for the 1^st group, and 10 Hz frequency, 2.0 Bar density and 2000 impulses/ session for the 2^nd group. Visual analog scale (VAS) and a modification of the clinical rating system of the American Orthopedic Foot and Ankle Society (AOFAS) were used for outcome measurement. The patients were assessed before treatment and followed up four weeks, and 12 weeks after end of treatment. Results Mean VAS scores were reduced after rESWT from 7.52 ± 2.34 (mean ± SEM) at baseline to 0.57 ± 0.68 at 12 weeks in the 1^st group and from 6.45 ± 2.04 at baseline to 0.40 ± 0.60 at 12 weeks in the 2^nd group. Similar changes were found for mean AOFAS scores from baseline after rESWT but were not observed significance between groups. Conclusion There is no significant different effect between the two treatment groups' results.

Efficacy of Different Energy Levels Used in Focused and Radial Extracorporeal Shockwave Therapy in the Treatment of Plantar Fasciitis: A Meta-Analysis of Randomized Placebo-Controlled Trials

The objective of this study was to assess the efficacy of different energy levels used in extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis using a systematic review and meta-analysis. We searched PubMed, Embase, and Cochrane library, from inception to March 2019 for randomized controlled trials that compared ESWT with placebo in patients with plantar fasciitis. The risk of bias for selected articles was assessed based on the Cochrane Handbook Systematic Review of Interventions. The pooled data were estimated by the mean difference or odds ratio. The meta-analysis showed that the high-energy ESWT group had a better success rate than the control group only at a three-month follow-up, but no significant difference between groups was observed for the other follow-up visits (1 and 12 months). In addition, no significant differences in visual analog scale (VAS) scores between groups were observed for all the follow-up visits (one-month and three-month). On the contrary, the medium-energy ESWT group had significantly better success rates than the control group for all the follow-up visits (3, 6, and 12 months). In addition, the medium-energy ESWT group had significant improvement in VAS scores compared with the control group for all the follow-up visits (1, 3, 6, and 12 months) after removing the extreme values. The low-energy ESWT group had significant improvement in VAS scores compared with the control group for all the follow-up visits (3 and 12 months). Otherwise, focused ESWT seems to be more effective than radial ESWT when compared with the control group. Use of local anesthesia can reduce the efficacy of low- and high-energy ESWTs. Our meta-analysis suggested that medium-energy ESWT in the treatment of plantar fasciitis was more effective than the control group. A limited number of trials related to low- and high-energy ESWTs were included in our meta-analysis. More research is required to confirm the efficacy of low- and high-energy ESWTs in future studies.

Long-term results of radial extracorporeal shock wave treatment for chronic plantar fasciopathy: A prospective, randomized, placebo-controlled trial with two years follow-up

Numerous randomized controlled trials (RCTs) demonstrated efficacy and safety of extracorporeal shock wave therapy (ESWT) for chronic plantar fasciopathy (cPF). However, only two such RCTs investigated a follow-up period of more than 1 year, both applying focused ESWT. Corresponding data for radial ESWT (rESWT) have not yet been reported. We therefore tested the hypothesis that rESWT is effective and safe for the management of cPF with long-term follow-up of 2 years. To this end n = 50 patients with cPF were randomly allocated to either two sessions of rESWT (one session per week; 2,000 shock waves with energy flux density of 0.16 mJ/mm² per session) (n = 25) or to placebo treatment (n = 25). Evaluation was by change in Visual Analog Scale (VAS) score and Roles and Maudsley (RM) score. Mean pretreatment VAS scores for the rESWT and placebo groups were 8.5 and 8.9, respectively. 1, 3, 6, 12, and 24 months after treatment, the mean VAS scores for the rESWT and placebo groups were 0.6, 1.1, 0.5, 2.3, and 1.4 and 7.6, 7.7, 7.4, 6.9, and 5.6 (p < 0.001), respectively. Differences in mean RM scores were statistically significant between groups at 1, 3, 6, 12, and 24 months post treatment, but not at baseline. There were no significant complications. These data indicate that rESWT is effective and safe for the management of cPF with long-term follow-up of 2 years. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1532-1538, 2017.

Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs

BACKGROUND

Plantar fasciitis (PF) is the most common reason for heel pain. The efficacy of extracorporeal shock wave therapy (ESWT) as an ideal alternative to conservative treatments and surgery is controversial, and almost all previous articles compared general ESWT with placebo without indicating the kind of shock wave. We undertook a meta-analysis to compare the efficacy of general ESWT, focused shock wave (FSW), and radial shock wave (RSW) with placebo, to assess their effectiveness in chronic PF.

METHODS

The PubMed, Medline, EmBase, Web of Science, and Cochrane library databases were searched for studies comparing FSW or RSW therapy with placebo in chronic PF. Clinical outcomes included the odds ratios (ORs) of pain relief, pain reduction, and complications. Relevant data were analyzed using RevMan v5.3.

RESULTS

Nine studies involving 935 patients were included. ESWT had higher improvement rates than the placebo group (OR 2.58, 95% confidence interval [CI] 1.97-3.39, P < .00001). ESWT had markedly lower standardized mean difference than placebo, with heterogeneity observed (standardized mean difference 1.01, 95% CI -0.01 to 2.03, P = .05, I = 96%, P < .00001). FSW and RSW therapies had greater therapeutic success in pain relief than the placebo group (OR 2.17, 95% CI 1.49-3.16, P < .0001; OR 4.63, 95% CI 1.30-16.46, P = .02), but significant heterogeneity was observed in RSW therapy versus placebo (I = 81%, P = .005).

CONCLUSION

This meta-analysis suggested that FSW therapy can relieve pain in chronic PF as an ideal alternative option; meanwhile, no firm conclusions of general ESWT and RSW effectiveness can be drawn. Due to variations in the included studies, additional trials are needed to validate these conclusions.

Radial extracorporeal shockwave therapy for the treatment of finger tenosynovitis (trigger digit)

Introduction

Stenosing tenosynovitis that is characterized by the inability to flex the digit smoothly, usually leads to prolonged rehabilitation or surgery.

Study design

This case series is a retrospective cohort study.

Purpose

The aim of this case series was to evaluate the effectiveness of radial extracorporeal shockwave therapy (rESWT) for the treatment of stenosing tenosynovitis of the digital flexor tendon (trigger digit).

Methods

A retrospective analysis of 44 patients (49 fingers) treated with an individually adapted rESWT protocol was conducted. Trigger digit pain and function were evaluated at baseline and 1-, 3-, and 12-months posttreatment. Recurrence and pretreatment symptom duration were analyzed.

Results

Significant reductions in pain scores and functional improvement were found between baseline and all follow-up assessments (P<0.001). Pretreatment symptom duration was significantly correlated with the number of rESWT sessions required (r=0.776, P<0.001) and 1-year posttreatment pain score (r=0.335, P=0.019).

Conclusion

This study provides initial evidence that rESWT is an effective treatment for trigger digit, but randomised controlled trials are required to provide further evidence of this effect.

Historical ESWT Paradigms Are Overcome: A Narrative Review

Extracorporeal Shock Wave Therapy (ESWT) is a conservative treatment modality with still growing interest in musculoskeletal disorders. This narrative review aims to present an overview covering 20-year development in the field of musculoskeletal ESWT. Eight historical paradigms have been identified and put under question from a current perspective: energy intensity, focus size, anesthesia, imaging, growth plates, acuteness, calcifications, and number of sessions. All paradigms as set in a historical consensus meeting in 1995 are to be revised. First, modern musculoskeletal ESWT is divided into focused and radial technology and the physical differences are about 100-fold with respect to the applied energy. Most lesions to be treated are easy to reach and clinical focusing plays a major role today. Lesion size is no longer a matter of concern. With the exception of nonunion fractures full, regional, or even local anesthesia is not helpful in musculoskeletal indications. Juvenile patients can also effectively be treated without risk of epiphyseal damage. Further research is needed to answer the question about if and which acute injuries can be managed effectively. Treatment parameters like the number of sessions are still relying on empirical data and have to be further elucidated.

Two emerging technologies for Achilles tendinopathy and plantar fasciopathy

Some common overuse injuries, such as Achilles tendinopathy and plantar fasciitis (or fasciopathy), can be refractory to treatment. When standard treatment options fail, operative intervention often becomes the treatment of last resort. Recently, newer technologies have been developed and refined, and can provide potential benefits for these conditions using noninvasive and minimally invasive approaches. Two technologies, extracorporeal shock wave therapy and ultrasound-guided percutaneous tenotomy/fasciotomy are discussed.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

ESWT for tendinopathy: technology and clinical implications

PURPOSE

The general consensus that tendinopathy, at least in the chronic stage, is mainly a degenerative condition and inflammation plays a minor role has led to a shift from treatments that target inflammation towards treatment options that promote regeneration. One of these treatments is extracorporeal shockwave therapy (ESWT), a physical therapy modality that uses pressure waves to treat tendinopathy. This review was undertaken to give an overview of the literature concerning this treatment, and special attention is given to the differences between focused and radial ESWT.

METHODS

A narrative description of wave characteristics, generation methods and in vitro effects of ESWT is given. The literature on ESWT as a treatment for one common tendinopathy, patellar tendinopathy, was systematically reviewed.

RESULTS

Waves that are generated for focused and radial ESWT have very different physical characteristics. It is unclear how these characteristics are related to clinical effectiveness. Studies into the biological effects of ESWT have mainly used focused shockwave therapy, showing a number of effects of shockwaves on biological tissue. The systematic review of studies into the clinical effects of ESWT for patellar tendinopathy showed conflicting evidence for its effectiveness.

CONCLUSION

Physical characteristics of focused and radial waves differ substantially, but effect on clinical effectiveness is unclear. Whereas in vitro studies often show the effects of ESWT on tendon tissue, results of clinical studies are inconsistent. Based on the review of the literature, suggestions are given for the use of ESWT in clinical practice regarding timing and treatment parameters.

Extracorporeal shockwave therapy for treatment of delayed tendon-bone insertion healing in a rabbit model: a dose-response study

BACKGROUND

Tendon-bone insertion (TBI) consists of both hard and soft tissues. TBI injury with delayed repair is not uncommon. High-dose extracorporeal shockwave (ESW) is effective for treating nonunion fracture, whereas low-dose ESW is used for tendinopathy therapy. The dosing effect of ESW on delayed TBI healing is lacking.

HYPOTHESIS

Low-dose ESW might have a healing enhancement effect comparable to that of high-dose ESW in treating delayed TBI healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Partial patellectomy was adopted to create a delayed TBI healing model by shielding the healing interface between tendon and bone. Ninety-six female New Zealand White rabbits with unilateral delayed TBI healing at the knee joint were divided into 3 groups: controls, low-dose ESW (LD-ESW; 0.06 mJ/mm(2), 4 Hz, 1500 impulses), and high-dose ESW (HD-ESW; 0.43 mJ/mm(2), 4 Hz, 1500 impulses). The TBI shielding was removed at week 4 after partial patellectomy, followed by treatment with control or ESW at week 6. The rabbits were euthanized at week 8 and week 12 for radiological, microarchitectural, histological, and mechanical assessments of healing tissues.

RESULTS

Radiologically, both the LD-ESW group and the HD-ESW group showed larger new bone area than the controls at week 8 and week 12. Microarchitectural measurements showed that the LD-ESW and HD-ESW groups had larger new bone volume than the controls at week 12. Histological assessments confirmed osteogenesis enhancement. Both the LD-ESW and HD-ESW groups showed significantly higher failure load at the TBI healing complex than the control group at week 12. No significant difference was detected between the 2 ESW treatment groups at week 8 or week 12.

CONCLUSION

Extracorporeal shockwave, a unique noninvasive physical modality, had similar effects between the low and high dose for treating delayed TBI healing.

CLINICAL RELEVANCE

Low-dose ESW for TBI delayed healing might be more desirable and have better compliance in clinical applications.

Tendinopathy treatment: where is the evidence?

Tendinopathy is a common and debilitating condition that results in significant deficits in performance and prolonged time away from activity. For this reason, much effort has been placed in defining beneficial and cost-effective treatments. This review has outlined the current literature on some of the most widely used therapies for cases of tendinopathy. As such, recommendations remain limited by the evidence available. The variability in both quantity and quality of research into tendinopathy treatments makes it difficult to make definitive treatment recommendations. In general, however, a reasonable first line of treatment for tendinopathy should include a course of NSAIDs and eccentric exercise-based physical therapy. Corticosteroid injections seem to offer excellent short-term pain relief but lack long term efficacy. Alternative injections, such as PRP, have shown short-term efficacy for tendinopathy sufferers; data are lacking to support sclerosing agents and proteinase inhibitors. Operative management seems to offer some benefit in symptomatic relief but carries a higher complication rate than other treatment options and should be reserved only for patients recalcitrant to other more conservative options. Although the inability to make definitive therapeutic recommendations in some instances is discouraging, it is important to note that a lack of high-quality evidence supporting specific treatments does not necessarily imply that they are inherently ineffective. Given the growing prevalence of tendinopathy and the impact it has on the general public, it is more important now than ever to continue the search for the most effective and accessible treatment modalities.

Extracorporeal shockwave therapy in musculoskeletal disorders

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

The TOPSHOCK study: effectiveness of radial shockwave therapy compared to focused shockwave therapy for treating patellar tendinopath - design of a randomised controlled trial

BACKGROUND

Patellar tendinopathy is a chronic overuse injury of the patellar tendon that is especially prevalent in people who are involved in jumping activities. Extracorporeal Shockwave Therapy is a relatively new treatment modality for tendinopathies. It seems to be a safe and promising part of the rehabilitation program for patellar tendinopathy. Extracorporeal Shockwave Therapy originally used focused shockwaves. Several years ago a new kind of shockwave therapy was introduced: radial shockwave therapy. Studies that investigate the effectiveness of radial shockwave therapy as treatment for patellar tendinopathy are scarce. Therefore the aim of this study is to compare the effectiveness of focussed shockwave therapy and radial shockwave therapy as treatments for patellar tendinopathy.

METHODS/DESIGN

The TOPSHOCK study (Tendinopathy Of Patella SHOCKwave) is a two-armed randomised controlled trial in which the effectiveness of focussed shockwave therapy and radial shockwave therapy are directly compared. Outcome assessors and patients are blinded as to which treatment is given. Patients undergo three sessions of either focused shockwave therapy or radial shockwave therapy at 1-week intervals, both in combination with eccentric decline squat training. Follow-up measurements are scheduled just before treatments 2 and 3, and 1, 4, 7 and 12 weeks after the final treatment. The main outcome measure is the Dutch VISA-P questionnaire, which asks for pain, function and sports participation in subjects with patellar tendinopathy. Secondary outcome measures are pain determined with a VAS during ADL, sports and decline squats, rating of subjective improvement and overall satisfaction with the treatment. Patients will also record their sports activities, pain during and after these activities, and concurrent medical treatment on a weekly basis in a web-based diary. Results will be analysed according to the intention-to-treat principle.

DISCUSSION

The TOPSHOCK study is the first randomised controlled trial that directly compares the effectiveness of focused shockwave therapy and radial shockwave therapy, both in combination with eccentric decline squat training, for treating patellar tendinopathy.

TRIAL REGISTRATION

Trial registration number NTR2774.

Shock wave therapy as a treatment of nonunions, avascular necrosis, and delayed healing of stress fractures

Shock wave therapy (SWT) stimulates angiogenesis and osteogenesis. SWT is commonly used to treat soft tissue musculoskeletal conditions such as fasciopathies and tendinopathies. Recent basic science and clinical data suggest that SWT can also be used to treat disorders of bone. Nonunions, avascular necrosis, and delayed healing of stress fractures have all been successfully treated with SWT. Success rates with SWT are equal to those with standard surgical treatment, but SWT has the advantage of decreased morbidity. The procedure is safe, well tolerated, yields few complications, and, typically, can be performed on an outpatient basis. SWT is a viable noninvasive alternative to stimulate healing of bone.

High-energy Extracorporeal Shock-Wave Therapy (ESWT) for the treatment of chronic plantar fasciitis

BACKGROUND

Few reports about the success of high-energy extracorporeal shock-wave therapy in cases of plantar fasciitis exist, even fewer about long-term results. This study investigated results of high-energy extracorporeal shock wave therapy applied to patients with recalcitrant plantar fasciitis.

MATERIALS AND METHODS

Ninety ESWT were applied to 63 patients (73 heels; 25 male and 38 female; average age 54 (29 to 77) years) from November 1999 to July 2003. All patients had plantar fasciitis for more than 6 months and failure of all non-surgical treatment for more than 3 months. A Dornier Lithotripter S, equipped with an electromagnetic shock-wave emitter was used. Routinely, 1000 shock wave impulses (frequency 2 per second, energy flux density (ED) 0.35 mJ/mm² at 10.5 kV, total dose 350 mJ/mm²) were applied per treatment. Followup was carried out 6 weeks after ESWT, then a second clinic evaluation and a final followup at an average of 73 months after ESWT by telephone.

RESULTS

The success of ESWT, defined as a 30% VAS reduction, was seen in 81% at 6-week followup, at 88% at last clinic followup and in 96% at final phone followup.

CONCLUSION

High-energy ESWT (0.35 mJ/mm²) was successful in the treatment of plantar fasciitis and the good short-term results seemed to be maintained over time.

Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors

Plantar fasciitis can be a chronic and disabling cause of foot pain in the adult population. For refractory cases, extracorporeal shock wave therapy (ESWT) has been proposed as therapeutic option to avoid the morbidity of surgery. We hypothesized that the success of extracorporeal shock wave therapy in patients with chronic plantar fasciitis is affected by patient-related factors. A retrospective review of 225 patients (246 feet) who underwent consecutive ESWT treatment by a single physician at our institution between July 2002 and July 2004 was performed. Subjects were included only if they had plantar fasciitis for more than 6 months and failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Follow-up was 30.2 +/- 8.7 months post procedure. Multivariable analysis was performed to assess factors leading to successful outcomes. Success rates of 70.7% at 3 months and 77.2% at 12 months were noted in this population. Previous cortisone injections, body mass index, duration of symptoms, presence of bilateral symptoms, and plantar fascia thickness did not influence the outcome of ESWT. The presence of diabetes mellitus, psychological issues, and older age were found to negatively influence ESWT outcome. Whereas many factors have been implicated in the development of plantar fasciitis, only diabetes mellitus, psychological issues, and age were found to negatively influence ESWT outcome.

LEVEL OF CLINICAL EVIDENCE

2.

Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study

BACKGROUND

Radial extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis that can be administered to outpatients without anesthesia but has not yet been evaluated in controlled trials.

HYPOTHESIS

There is no difference in effectiveness between radial extracorporeal shock wave therapy and placebo in the treatment of chronic plantar fasciitis.

STUDY DESIGN

Randomized, controlled trial; Level of evidence, 1.

METHODS

Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm(2); 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. Primary endpoints were changes in visual analog scale composite score from baseline to 12 weeks' follow-up, overall success rates, and success rates of the single visual analog scale scores (heel pain at first steps in the morning, during daily activities, during standardized pressure force). Secondary endpoints were single changes in visual analog scale scores, success rates, Roles and Maudsley score, SF-36, and patients' and investigators' global judgment of effectiveness 12 weeks and 12 months after extracorporeal shock wave therapy.

RESULTS

Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1-sided). No relevant side effects were observed.

CONCLUSION

Radial extracorporeal shock wave therapy significantly improves pain, function, and quality of life compared with placebo in patients with recalcitrant plantar fasciitis.

Preliminary experience of a single session of low-energy extracorporeal shock wave treatment for chronic plantar fasciitis

BACKGROUND

The purpose of the present study was to evaluate the effect of a single session of ultrasound- and biofeedback-assisted extracorporeal shock wave treatment (ESWT) in patients with chronic plantar fasciitis.

MATERIALS AND METHODS

20 patients (22 heels) with symptomatic plantar fasciitis that did not respond to conservative treatment for at least 6 months were studied. Patients received a single session of low-energy, ultrasound- and patient feedback-guided ESWT. Visual analog scale (VAS) was used to compare pain intensity before treatment and at followup (72 +/- 15 days after treatment).

RESULTS

There was a significant decrease in overall pain (VAS 5.5 +/- 1.8 vs. 3.3 +/- 2.7, p = 0.001), maximum pain (7.7 +/- 2.1 vs. 4.0 +/- 3.9, p = 0.008) and pain at activities of daily living (5.3 +/- 2.1 vs. 2.5 +/- 2.6, p = 0.018). Night pain decreased to a lesser extent (2.4 +/- 2.5 vs. 1.3 +/- 2.1, p = 0.317). ESWT improved symptoms in 16 heels, of which six were completely symptom-free at followup 2.4 months after treatment. Six patients experienced no change. Fourteen patients with pain localized to the heel and all male patients benefited from ESWT. No difference was noted for age, body mass index, duration, and severity of symptoms or previous treatment.

CONCLUSION

Low-energy ESWT proved to be an effective treatment option for the majority of patients with chronic plantar fasciitis that failed to respond to conservative treatment. Predictive parameters for successful outcome are male gender and an easily detectable pain center at the heel.