Shockwave for Plantar Fasciitis

Plantar Fasciitis or “joggers heel” is a disorder where the plantar fascia is irritated by repeated small injuries to it often via jogging or walking. The Plantar fascia is the connective tissue (aponeurosis) that supports the arch in your foot and helps connect your heel bone or calcaneus tuberosity to the heads of the metatarsal bones. This will cause pain when standing, walking or running and is often at its worst after periods of little or no weight bearing on the affected foot. There are a number of non operative procedures to help treat plantar fasciitis including heat, ice, calf strengthening exercises, weight reduction and non-steroidal anti-inflammatory drugs. More persistent issues are sometimes treated with corticosteroid injections; however, there are a number of risks that this treatment carries. There are also custom orthotic devices that can be used to help reduce pain. Although the last resort, surgery can produce good results and has few complications associated with it.

Extracorporeal shockwave therapy can provide another non surgical option to help treat plantar fasciitis. In terms of cost, it is a much cheaper option than surgery and has mounting evidence as to its efficacy, some of which is outlined below the video…

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Extracorporeal Shock Wave Therapy Is Effective In Treating Chronic Plantar Fasciitis: A Meta-analysis of RCTs
Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Clin Orthop Relat Res. 2013 Jun 28. [Epub ahead of print]

  • Overall improvement from baseline composite VAS (heel pain in the morning, doing daily activities, and application of dolorimeter)
  • Patients from the ESWT group had significantly better improvement of composite VAS scores compared with placebo.
  • Patients from the ESWT group had a significantly greater reduction in their absolute VAS scores compared with placebo.
  • Patients from the ESWT group had significantly greater success of improving heel pain by 60%when taking first steps and during daily activities.
  • Patients from the ESWT group had significantly better subjective measurement of pain using a pressure meter.
  • Significantly more patients in the ESWT group had a change to “excellent – good” Roles and Maudsley scores.
  • Improved pain scores with the use of ESWT were evident 12 weeks after treatment.
  • The evidence suggests this improvement is maintained for up to 12 months.

The authors conclude that ESWT is a safe and effective treatment of chronic plantar fasciitis refractory to nonoperative treatments. They recommend the use of ESWT for patients with substantial heel pain despite a minimum of 3 months of nonoperative treatment.

Comparative Effectiveness of Focused Shock Wave Therapy of Different Intensity Levels and Radial Shock Wave Therapy for Treating Plantar Fasciitis: a Systematic Review and Network Meta-analysis
Chang KV, Chen SY, Chen WS, Tu YK, Chien KL Arch Phys Med Rehabil. 93(7):1259-68.

  • Randomized control trials that compared shock wave and placebo therapy were included.
  • A total of 12 RCTs (n= 1431 participants) met the inclusion criteria and were enrolled into meta-analysis.
  • 1. Network meta-analysis revealed that: RSW had the highest effectiveness vs. placebo and also had the most significant pooled reduction in pain VAS.
  • The meta-regression indicated that the success rate of FSW wasn’t related to its intensity, but there was a dose-response relationship between pain reduction and energy flux density, whereas elevated energy efflux densities tended to relieve pain more.
  • Overall the network meta-analysis revealed that the probability of being the best therapy was the highest in RSW, followed by low, medium or high intensity FSW.

Setting the highest and mostly tolerable energy output within medium intensity ranges is the prior option when applying FSW on plantar fasciitis. RSW is considered as an appropriate alternative due to its lower price and probably better effectiveness. Its potential advantage over FSW comprises broader treatment area, less requirement of precisely focusing and free of adjunct local anesthesia.

Chronic Plantar Fasciitis Treated with Two Sessions of Radial Extracorporeal Shock Wave Therapy
Ibrahim MI, Donatelli RA, Schmitz C, Hellman MA, Buxbaum F. Foot Ankle Int. 2010 May;31(5):391-7.

  • a total of 50 subjects with unilateral, chronic PF
  • subjects were randomly assigned to either RSWT or placebo treatment (n = 25)
  • RSWT (n = 25) – applied in 2 weekly sessions (2,000 impulses with energy flux density = 0.16 mJ/mm² per session)
  • Placebo treatment (n = 25) was performed with a clasp on the heel.
  • The mean VAS scores were reduced after RSWT
  • The mean RM scores were changed after RSWT
  • These changes in mean VAS and RM scores were not observed after placebo treatment.

Statistical analysis demonstrated that RSWT resulted in significantly reduced mean VAS scores and mean RM scores at all followup intervals compared to placebo treatment (each with p < 0.001).  The authors conclude that RSWT was a safe, effective and easy treatment for patients with chronic PF and successful treatment can be achieved with only two sessions of RSWT which increases the attractiveness of this treatment method.  The authors recommend considering RSWT treatment for every patient with chronic plantar fasciitis who is irresponsive to conventional treatment.

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