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Jul 17, 2022

Shockwave (ESWT) for Plantar Fasciitis: What is the Evidence?

What is plantar fasciitis?

The plantar fascia is a tough band of fibrous tissue that runs across the bottom of your foot, connecting the heel bone to the toes. Plantar fasciitis is the most common cause of heel pain and accounts for approximately 11% to 15% of all foot symptoms requiring professional care in the adult. Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually the worst with the first few steps after awakening, although it can also be triggered by long periods of standing or when you get up from sitting.

How is plantar fasciitis treated?

Plantar fasciitis is typically treated conservatively first with a combination of shoe inserts, physical therapy/stretching, corticosteroid injections and shockwave therapy. When these conservative treatments fail, orthobiologic treatments can be considered such as platelet rich plasma (PRP), autologous stem cell therapy and ultrasound guided tenotomy.

What is Shockwave Therapy?

Extracorporeal shock wave therapy (ESWT) was originally developed for use as a non-invasive treatment for kidney, gallbladder or liver stones, but in the past 15 years has become a popular treatment for soft-tissue disorders. Although the biological mechanisms of the analgesic effect of ESWT are still controversial, beneficial effects have been proposed to be associated with accelerating micro-destruction and neovascularization of tissue (Wang, et. al., 2003).

How does Shockwave Therapy work?

The research suggests that ESWT stimulates of the wound healing cascade, allowing chronic damage to become acute damage and initiate the normal wound healing process by application of high intensity pressure waves into the body. It is also believed to induce microtrauma to the affected area by repeated shock waves, thereby stimulating neovascularization into the area, which promotes tissue healing. (Wang, et. al., 2003)

How often do I have Shockwave Therapy treatments?

The research suggests that performing the treatment once every 1-2 weeks for about 3-5 treatments applied to the greatest area of tenderness on the heel provides effective results. Each treatment should consist of 1500-2000 pulses or impacts, that are delivered at different intensity levels based on comfort and tolerance, gradually increasing intensity over treatments.

Advantages:


  • Non-invasive (no needles or surgery)
  • Treatments are quick (5-10 minutes)
  • No medications or chemicals
  • Low complication rate
  • High success rate

Disadvantages:


  • Not covered by insurance
  • Can be uncomfortable during the treatment
  • Not 100% effective in relieving pain in all cases

What does the evidence show?

DeLuca et al (2021)

In a retrospective cohort study, radial shockwave therapy was compared to radial and focused shockwave therapy. Both radial and combined groups received a similar number of treatments, and there was no difference in improved function between the groups suggesting both forms of shockwave therapy are affective.

Lai et al (2018)

In this retrospective study, shockwave therapy was compared to corticosteroid injections in 97 patients with chronic plantar fasciitis. Shockwave was more efficient than steroid injections in decreasing pain.

How does shockwave compare to PRP for plantar fasciitis?

Studies have consistently shown radial shockwave outperforms cortisone injections for plantar fasciitis (Lai et al; Eslamian et al).


Eslamian et al (2016)

In this randomized controlled trial radial shockwave therapy was compared to corticosteroid injections. 40 patients with chronic plantar fasciitis were enrolled. Patient received on average 5 sessions of shockwave therapy or a single steroid injection. More patients were satisfied with shockwave therapy. Good or excellent results were achieved in 55% of shockwave patients compared to only 30% of patients in the steroid group.

Gerdesmeyer et. al. (2008)

In this randomized controlled trial, 245 patients were treated with either 3 treatments of radial extracorporeal shockwave therapy (2000 pulses) or placebo treatment. The results showed significant findings that the radial shockwave treatments provided a 72.1% reduction of the VAS score compared with 44.7% in the placebo group at 12 weeks. Results were even more pronounced at the 12-month mark.

Hammer et. al. (2003)

This study looked at 22 patients with unilateral proximal plantar fasciitis, previously unsuccessful with at least 6 months of conservative treatments. They used Ultrasound to measure the thickness of the plantar fascia before and after ESWT treatments (3x at weekly intervals), using the contralateral side as the control. The results showed a statistically significant decrease in the thickness of the plantar fascia, as well as decreased pain and improved walking time.

REFERENCES

  1. DeLuca S, Robinson DM, Yun PH, Rosenberg C, Tan CO, Tenforde AS. Similar Functional Gains Using Radial Versus Combined Shockwave Therapy in Management of Plantar Fasciitis. J Foot Ankle Surg. 2021 Nov-Dec;60(6):1098-1102.
  2. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, Russlies M, Stienstra J, Scurran B, Fedder K, Diehl P, Lohrer H, Henne M, Gollwitzer H. 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. Am J Sports Med. 2008 Nov;36(11):2100-9.
  3. Gollwitzer H, Diehl P, von Korff A, Rahlfs VW, Gerdesmeyer L. Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg. 2007 Sep-Oct;46(5):348-57.
  4. Hammer DS, Adam F, Kreutz A, Rupp S, Kohn D, Seil R. Ultrasonographic evaluation at 6-month follow-up of plantar fasciitis after extracorporeal shock wave therapy. Arch Orthop Trauma Surg. 2005 Feb;125(1):6-9.
  5. Lai TW, Ma HL, Lee MS, Chen PM, Ku MC. Ultrasonography and clinical outcome comparison of extracorporeal shock wave therapy and corticosteroid injections for chronic plantar fasciitis: A randomized controlled trial. J Musculoskelet Neuronal Interact. 2018 Mar 1;18(1):47-54.
  6. Wang CJ, Wang FS, Yang KD, Weng LH, Hsu CC, Huang CS, Yang LC. Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits. J Orthop Res. 2003 Nov;21(6):984-9.
  7. Xiong Y, Wu Q, Mi B, Zhou W, Liu Y, Liu J, Xue H, Hu L, Panayi AC, Liu G. Comparison of efficacy of shock-wave therapy versus corticosteroids in plantar fasciitis: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg. 2019 Apr;139(4):529-536.

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