Thinner plantar fascia predicts decreased pain after extracorporeal shock wave therapy

Comparison of the Short-Term Effect between Iontophoresis and Radial Extracorporeal Shockwave Therapy in the Treatment of Plantar Fasciitis: A Randomized Controlled Trial

Conservative treatments for plantar fasciitis have different levels of effectiveness, so it is necessary to personalize the therapeutic modality that improves the patients' symptoms.

METHODS

A double-blinded randomized clinical trial was designed to evaluate the short-term efficacy of a physical treatment in chronic plantar fasciitis, namely iontophoresis, compared with radial shockwave therapy. Heel pain, health status using the EuroQol-5D questionnaire, and fascia thickness measured with ultrasound were evaluated. In total, 127 patients were randomly selected for group A and treated with iontophoresis therapy (lidocaine 0.4% and dexamethasone 0.5%), or for group B, in which they were treated with radial shockwave therapy (EWST). Measurements were taken at baseline and at follow-up during the 5 weeks of the study.

RESULTS

Statistically significant differences were observed to the shockwave therapy group in respect to the final fascia thickness, and the VAS scale (p = 0.001). The differences between groups A and B showed that the shockwave group follow-up after 3 weeks experienced complete pain remission (1.0 ± 0.9; 95%CI 0.8-1.2) and after the 6-week follow-up, complete pain remission of plantar fasciitis was observed for both therapies. Patients had a better perception of the use of EWST at the end of the treatment, although in both groups it was satisfactory (p = 0.001).

CONCLUSIONS

The results of this study showed a shorter-term effectiveness of shockwave treatment compared with the use of iontophoresis. However, both techniques were effective in satisfactorily reducing pain in this short period.

Platelet rich plasma therapy versus other modalities for treatment of plantar fasciitis: A systematic review and meta-analysis

INTRODUCTION

Plantar fasciitis (PF) is the most common cause of heel pain in adults. There are numerous non-operative treatments available including platelet rich plasma (PRP) injections. PPR has demonstrated effectiveness for a range of musculoskeletal conditions including plantar fasciitis.

PURPOSE/OBJECTIVE

To compare the effectiveness of PRP to other conservative treatment options for the management of PF.

METHODS

A systematic search of PubMed and Google Scholar was performed for randomized control trials (RCT) comparing PRP to other treatment modalities. Studies met inclusion criteria if mean and standard deviations for visual analog scale (VAS) pain scores, plantar fascia thickness (PFT), Foot Function Index (FFI), or American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were reported. Mean differences (MD) were used to compare VAS pain, PFT, FFI, and AOFAS between PRP and other treatments.

RESULTS

Twenty-one RCTs which altogether included 1356 patients were included in the meta-analysis. PRP demonstrated significantly greater improvements in VAS pain scores compared to extracorporeal shock wave therapy (ESWT) (SMD: 0.86; CI: [0.30, 1.41]; p = 0.002), corticosteroid injections (CSI) (SMD: 1.08; CI: [0.05, 2.11]; p = 0.04), and placebo (SMD: 3.42; CI: [2.53, 4.31]; p < 0.00001). In terms of FFI, no significant differences existed among PRP, ESWT, CSI, dextrose prolotherapy (DPT), and meridian trigger points (MTP) in enhancing foot functionality. However, PRP demonstrated a marked advantage over phonophoresis, showing a substantial improvement in FFI scores (SMD: 3.07, 95% CI: 2.34-3.81). PRP did not demonstrate superiority over ESWT, CSI, or MTP for improving PFT, but it was notably more effective than phonophoresis (SMD: 3.18, 95% CI: 2.43-3.94). PRP demonstrated significantly greater improvements in AOFAS scores over CSI (SMD: 3.31, CI: [1.35, 5.27], p = 0.0009) and placebo (SMD: 3.75; CI: [2.81, 4.70]; p < 0.00001).

CONCLUSION

PRP is more effective than CSI, ESWT, and placebo in reducing VAS and more effective than CSI and placebo in improving AOFAS. PRP did not demonstrate a consistent advantage across all outcome measures, such as PFT and FFI. These findings underscore the complexity of PF treatment and call for a more standardized approach to PRP preparation and outcome measurement.

LEVEL OF EVIDENCE

Level I Meta-Analysis.

Plantar Fasciitis: An Updated Review

Plantar fasciitis (PF) is a common musculoskeletal disease. Histologic findings of patients with PF showed mainly chronic degenerative processes rather than inflammation. In addition to mechanical factors, such as repetitive stress and reduced ankle dorsiflexion, PF is also linked to rheumatologic diseases and genetic factors. Ultrasound is becoming a standard imaging technique for assessing PF. Major sonographic findings included increased plantar fascia thickness and hypoechoic plantar fascia. In addition to traditional B-mode ultrasound, sonoelastography can also be utilized to diagnose PF. Ultrasound can also be used to guide therapeutic interventions. Over 80% of patients with PF improved under nonsurgical treatment. Treatment options for PF include physical therapy, modalities (laser, therapeutic ultrasound), extracorporeal shock wave therapy (ESWT), injections, transcatheter arterial embolization, and surgery. For injections, corticosteroid was mostly used in the past but has been replaced gradually by other techniques such as platelet-rich plasma or dextrose prolotherapy. There is also more and more evidence about ESWT in treating PF. Surgery serves as an option for recalcitrant PF cases, and endoscopic fasciotomy seemed to have good outcomes. Ultrasound plays an important role in diagnosing of PF and evaluating the treatment effect, and the use of sonoelastography in addition to traditional B-mode ultrasound may help in the early detection of PF and assessment of the treatment effect.

The Effects of Massage Guns on Performance and Recovery: A Systematic Review

The use of massage guns has become increasingly popular in recent years. Although their use is more and more common, both in a clinical and sports context, there is still little information to guide the practitioners. This systematic review aimed to determine the effects of massage guns in healthy and unhealthy populations as pre- and post-activity or part of a treatment. Data sources used were PubMed, PEDro, Scopus, SPORTDiscus, Web of Science and Google Scholar, and the study eligibility criteria were based on "healthy and unhealthy individuals", "massage guns", "pre-activity, post-activity or part of a treatment" and "randomized and non-randomized studies" (P.I.C.O.S.). Initially, 281 records were screened, but only 11 could be included. Ten had a moderate risk of bias and one a high risk of bias. Massage guns could be effective in improving iliopsoas, hamstrings, triceps suralis and the posterior chain muscles' flexibility. In strength, balance, acceleration, agility and explosive activities, it either did not have improvements or it even showed a decrease in performance. In the recovery-related outcomes, massage guns were shown to be cost-effective instruments for stiffness reduction, range of motion and strength improvements after a fatigue protocol. No differences were found in contraction time, rating of perceived exertion or lactate concentration. Massage guns can help to improve short-term range of motion, flexibility and recovery-related outcomes, but their use in strength, balance, acceleration, agility and explosive activities is not recommended.

The effects of a custom foot orthosis on dynamic plantar pressure in patients with chronic plantar fasciitis: A randomized controlled trial

BACKGROUND

Plantar fasciitis is one of the most common causes of heel pain. The plantar fascia supports the longitudinal arch and absorbs ground reaction forces during the static and dynamic phase(s) of weight-bearing. The purpose of this randomized controlled trial study was to determine the effects of CAD/CAM foot orthoses that were designed based on the dynamic plantar pressure in patients with plantar fasciitis.

METHODS

This study was performed on 34 patients with plantar fasciitis. Outcomes were compared based on plantar fascia thickness; peak pressure, mean pressure, and maximum force; and pain, activity of daily living, quality of life, and sports activity that were evaluated by ultrasound, plantar pressure platform, and the Foot and Ankle Outcome Score, respectively. The patients were randomly assigned into two groups: the experimental group (CAD/CAM orthoses and night splint) and the control group (night splint only). All data were recorded again after 4 weeks.

RESULTS

Pain ( P = 0.002) and plantar fascia thickness ( P = 0.001) decreased significantly after 1 month of intervention. Activity of daily living ( P = 0.044) and quality of life ( P = 0.001) showed a significant increase. There was a trend in increasing peak pressure in all masking regions in both groups. The maximum force remarkably reduced in the experimental group in all regions.

CONCLUSIONS

The results demonstrated that CAD/CAM foot orthoses designed based on dynamic plantar pressure with night splint can reduce the plantar fascia thickness and pain associated with plantar fasciitis and increase the activity of daily living, quality of life, and sports activity.

Effects of customized insoles with medial wedges on lower extremity kinematics and ultrasonographic findings in plantar fasciitis persons

The customized insole is widely recommended as an effective intervention for pain reduction and foot function improvement in plantar fasciitis persons. However, it is unclear whether the additional correction of medial wedges could change the kinematics from the only insole. The objectives of this study were thus to compare customized insoles with and without medial wedges on lower extremity kinematics during gait and to determine the short-term effects of the customized insole with medial wedges on pain intensity, foot function, and ultrasonographic findings in plantar fasciitis persons. A within-subject, randomized, crossover design within motion analysis research laboratory was conducted among 35 persons with plantar fasciitis. Main outcome measures included joint motions of the lower extremity and multi-segment foot, pain intensity, foot function, and ultrasonographic findings. The customized insole with medial wedges produced less knee motion in the transverse plane and hallux motion in all planes during the propulsive phase than that without medial wedges (all p < 0.05). After the 3-month follow-up, the insoles with medial wedges decreased pain intensity and increased foot function. Abnormal ultrasonographic findings also decreased significantly after the 3-month treatment of insoles with medial wedges. Customized insoles with medial wedges seem superior to those without medial wedges on both multi-segment foot motion and knee motion during propulsion. Positive outcomes from this study supported the use of customized insoles with medial wedges as an effective conservative treatment in patients with plantar fasciitis.Trial registration: TCTR20210928006 (28/09/2021).

Acute Effects of Percussive Massage Therapy on Thoracolumbar Fascia Thickness and Ultrasound Echo Intensity in Healthy Male Individuals: A Randomized Controlled Trial

Percussive massage therapy (PT) has been widely used by therapists and the fitness population to treat myofascial-related conditions. However, there is no evidence to confirm the effects of PT on the fascia. This study aimed to investigate the effects of PT on thoracolumbar fascia (TLF) morphology and other related outcomes.

METHODS

Sixty-six healthy males participated and were randomly allocated into a percussive massage group (PT group) and a control group. The PT group received 15 min of back percussion massage, while the control group rested prone lying in the same environment for 15 min. Thoracolumbar fascia (TLF) thickness and echo intensity, perceived stiffness, lumbar flexibility, and skin temperature were measured in both groups before and immediately after the intervention.

RESULT

TLF thickness and lumbar flexibility did not change when compared in the two groups. However, the echo intensity (left side, difference -3.36, 95% CI -5.1 to -1.6; right side, difference -4.39, 95% CI -6.1 to -2.7) and perceived stiffness (difference, -1.18, 95% CI -1.84 to -0.52) in the TLF region were significantly lower in the PT group than in the control group and were accompanied by increased skin temperature (difference 0.29, 95% CI 0.11 to 0.48).

CONCLUSION

We suggest that a 15 min PT with 30 Hz on the back region could reduce TLF echo intensity and perceived stiffness and increase skin temperature in healthy men individual.

Ground reaction force analysis for assessing the efficacy of focused and radial shockwaves in the treatment of symptomatic plantar heel spur

BACKGROUND

Extracorporeal shock wave therapy is among the conservative treatments for symptomatic heel spur.

OBJECTIVE

The purpose of this trial is to evaluate and compare the therapeutic effects of radial shock wave (RSWT) and focused shock wave (FSWT) applied in the treatment of symptomatic heel spur.

METHODS

Fifty-five participants were randomly divided into two comparative groups that were administered FSWT and RSWT, respectively. The severity of dysfunction (Foot Function Index, FFI), ground reaction forces (GRF) and walking temporal parameters were measured in all patients at baseline and at weeks 1, 3, 6, 12 and 24 after treatment.

RESULTS

In both groups, a gradual decrease in the FFI values occurred after treatment. The percentage reduction in the FFI was comparable for both groups. Statistically significant changes were only noted between some measurements of GRF and walking temporal parameters. The percentage changes in the values of the force and temporal parameters were similar between the groups.

CONCLUSIONS

Both FSWT and RSWT are efficacious in the treatment of symptomatic heel spur and their therapeutic effects are comparable. Objective data registered by force platforms during walking are not useful for tracing the progress of treatment applied to patients with symptomatic heel spur between consecutive procedures.

Clinical And Plantar Fascial Morphologic Changes After Proximal Medial Gastrocnemius Release Treatment of Recalcitrant Plantar Fasciitis

BACKGROUND

Magnetic resonance imaging (MRI) has been used as a diagnostic and prognostic instrument to evaluate the results of conservative treatment for plantar fasciitis. However, there are scarce data available relative to changes in the plantar fascia after operative treatment. The primary objective of this study is to evaluate the imaging changes in patients with recalcitrant plantar fasciitis treated operatively by means of proximal medial gastrocnemius release.

METHODS

Thirteen patients with recalcitrant plantar fasciitis were studied with MRI preoperatively and 1 year after operative treatment. Quantitative (plantar fascia thickness) and qualitative variables (hyperintensity in the plantar fascia, insertional calcaneus bone edema, a plantar fascia tear, and the presence of perifascial collections) were assessed by 2 musculoskeletal radiologists. Clinical results were also measured with American Orthopaedic Ankle & Society (AOFAS), visual analog scale (VAS) pain, and 36-Item Short Form Health Survey (SF-36) scales.

RESULTS

The mean plantar fascia thickness was 6.59 mm preoperatively and 6.37 mm postoperatively (P = .972). No statistically significant differences were found in any of the qualitative variables on comparing the pre- and postoperative periods. Patients reported clinical improvements in pain VAS, AOFAS measurement, and the physical subdomains of the SF-36 scale.

CONCLUSION

Quantitative and qualitative variables assessed for the plantar fascia on MRI did not show any significant change after medial gastrocnemius release despite clear clinical improvement.

LEVEL OF EVIDENCE

Level II, perspective cohort study.

The Impact of Extracorporeal Shock Wave Therapy and Dry Needling Combination on Pain and Functionality in the Patients Diagnosed with Plantar Fasciitis

This study aimed to evaluate the efficiency of extracorporeal shock wave therapy (ESWT) and dry needling (DN) combination on pain and functionality in plantar fasciitis. Forty patients who were clinically diagnosed with plantar fasciitis were included in the study. The patients were randomly divided into 2 groups. The ESWT-DN group was applied 3 sessions of ESWT to plantar fascia and DN to the trigger points in the gastrosoleus muscles. The ESWT group was applied only ESWT treatment to plantar fascia. We used visual analog scale (VAS) for pain and a pressure algometer for pressure pain threshold. The functionality of the patients was evaluated with Foot Function Index (FFI). Also, maximum painless standing time and maximum painless walking distance were recorded. All assessments were repeated twice; first, pretreatment and second 1 month after the treatment. In both groups, there were statistically significant improvements in VAS, pressure pain threshold, maximum painless standing time, maximum painless walking distance, and FFI's pain, disability, and activity limitation subscales scores (p ≤ .001). In intergroup comparison; it was showed that VAS scores, maximum painless standing time (p = .002), maximum painless walking distance (p ≤ .001), and FFI pain subscale scores (p = .034) were statistically superior in the ESWT-DN group. There was no statistically difference between the groups in pressure pain threshold (p = .132), FFI disability (p = .081), and FFI activity limitation subscale (p = .226) scores. ESWT and DN combination therapy in plantar fasciitis was seen to be superior in the pain scores. Further studies with larger patients' groups and longer term results of this combination are needed for a better comparison.

Comparison of Effectiveness of Density and Number of Sessions of Extracorporeal Shock Wave Therapy in Plantar Fasciitis Patients: A Double-Blind, Randomized-Controlled Study

This study aimed to investigate the effect of density and number of sessions extracorporeal shock wave therapy (ESWT) on pain, fatigue, disability, physical function, and quality of life in patients with plantar fasciitis (PF). Between September 2019 and December 2019, a total of 94 patients with the diagnosis of PF were included in the study. All patients were randomly divided into 3 groups. Group 1 (n = 33) received a total of 7 sessions of high-energy flux density (H-ESWT) (0.26 mJ/mm² ) , group 2 (n = 31) received a total of 3 sessions of H-ESWT (0.26 mJ/mm²), group 3 (n = 30) received total of 7 sessions of low-energy flux density (<0.08 mJ/mm²) with 3 days interval. At baseline and 1 month after the treatment, the Visual Analog Scale (VAS), Short Form-36, Foot Function Index (FFI), Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale, and Six-Minute Walking Test (6MWT) scores were compared among the groups. Of the patients, 69 were females and 25 were males with a mean age of 45.0 ± 8.43 (range, 25-67) years. There were no statistically significant differences in the age, sex, demographic characteristics, and baseline VAS, FFI, 6MWT, and FACIT scores between the groups (p > .05). However, there was a statistically significant decrease in the VAS, FACIT, and FFI scores in all groups after treatment compared to baseline, although only the 6MWT, and Short Form-36 subscale scores were statistically significantly higher (p < .05). There was also a statistically significant difference in the scale scores in Group 1 versus Group 2 and in Group 2 versus Group 3. Our study results suggest that H-ESWT for high number of sessions is more effective than LESWT for low number of sessions on pain, quality of life, physical function, fatigue, and disability in patients with PF.

Ultrasonography and erythrocyte distribution width in patients with plantar fasciitis

BACKGROUND

The measurement of plantar fascia thickness with ultrasonography can be used for both for diagnosis and as a response-to-treatment parameter in plantar fasciitis. Furthermore, with the recent studies, red cell distribution width may be used as an inflammatory marker. Aim of this study is to investigate the association of red cell distribution width and ultrasonography on diagnosis and monitoring of treatment in patients with plantar fasciitis.

METHODS

Clinically diagnosed 102 patients with plantar fasciitis between the dates January 2016 to July 2018 were analysed. Hemogram, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and plantar fascial ultrasonography were obtained on initial evaluation and in 1 month, 2 months and 3 months of the standard nonoperative treatment; American Orthopaedic Foot & Ankle Hindfoot Score (AOFAS) and Visual Analog Scale (VAS) scores were recorded. Posthoc and multivariate logistic regression analysis were used for statistical analysis on SPSS 21.0.

RESULTS

Red cell distribution width was correlated with plantar fascia thickness by the end of the 1 month (r=0.26, P=.013). Female sex, BMI over 30kg/m², higher red cell distribution width and higher plantar fascia thickness were associated with plantar fasciitis on initial evaluation. Higher red cell distribution width together with higher plantar fascia thickness were also found to be a risk factor for both on initial evaluation and 1 month after treatment in plantar fasciitis.

CONCLUSION

This study shows that association of red cell distribution width and plantar fascia thickness can be not only a diagnostic predictor but also an indicator of treatment response in plantar fasciitis.

LEVEL OF CLINICAL EVIDENCE

Level IV.

A novel closed technique for ultrasound-guided plantar fascia release with a needle: review of 107 cases with a minimum follow-up of 24 months

BACKGROUND

This study aims to analyze the clinical outcome of a new ultrasound-guided surgery for partial plantar fasciotomy performed with a needle for treatment of plantar fasciitis.

METHODS

We performed a retrospective review of 107 patients diagnosed with plantar fasciitis who underwent ultrasound-guided release of the plantar fascia. The series included 62 males (57.9%) and 45 females (42.1%) treated between April 2014 and February 2018, with a mean follow-up of 21.05 ± 10.96 months (7-66) and a minimum follow-up of 24 months. The mean age was 48.10 ± 10.27 years (27-72). Clinical assessments and ultrasound examination were carried out before treatment, after 1 week, and then after 1, 3, 12, and 24 months. The clinical assessment was based on a visual analog scale and the Foot and Ankle Disability Index.

RESULTS

Heel pain improved in 92.5% (99) of patients, but not in 7.4% (8 patients). In the group of patients whose heel pain improved, 9 experienced overload on the lateral column and dorsum of the foot, which improved with the use of plantar orthoses and a rehabilitation program. We recorded no nerve complications (e.g., paresthesia), vascular injuries, or wound-related problems.

CONCLUSION

Ultrasound-guided partial plantar fasciotomy with a needle is safe, since structures are under direct visualization of the surgeon and the risk of damage is minimal. Stitches are not necessary, and recovery is fast. Consequently, costs are low, and the patient can return to work quickly. This technique may represent a valid option for treatment of plantar fasciitis.

High-energy Flux Density Extracorporeal Shock-wave Therapy Versus Therapeutic Steroid Injection in Costochondritis: A Single-Blind, Randomised Controlled Study

Background This study aims to investigate the effects of extracorporeal shock-wave therapy (ESWT) and intra-articular steroid injection (IASI) on pain, depression, quality of life and pressure pain threshold (PPT) in patients with costochondritis.

Methods A total of 67 patients diagnosed with costochondritis were included. Patients were divided into 2 groups. Group 1 (n=34) received high-energy flux density (H-ESWT) (> 0.28 mJ/mm2) for a total of 7 sessions at 3-day intervals. Group 2 (n=33) received IASI twice at 2-week intervals. At baseline and one month after treatment, Visual Analog Scale (VAS), Short Form-36 (SF-36), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI) scores and PPT values were compared.

Results There was a statistically significant decrease in VAS scores after treatment compared with baseline scores in both groups. The PPT and SF-36 subscale scores were also statistically significantly higher (p<0.05). After treatment, VAS and PPT showed a significantly better improvement in Group 1 compared to Group 2. There was a significant correlation between VAS and SF-36 physical functioning as well as pain subscales in Group 1 and a significant correlation between VAS and SF-36 physical functioning in Group 2.

Conclusions Our data suggest that both treatments H-ESWT and IASI are effective in costochondritis patients. Of note, H-ESWT has a stronger effect on pain and PPT scores.

Assessment the reliability of ultrasonography in the imaging of the plantar fascia: a comparative study

BACKGROUND

Imaging methods for the plantar fascia have included radiography, ultrasound and magnetic resonance imaging (MRI), all of which have provided valuable information. This study assessed the reliability of ultrasonography examinations of the plantar fascia using a comparative study.

METHODS

Fifty healthy adult volunteers (25 males and 25 females, mean age 31.6 ± 3.5 years) were included in this study. Images of the plantar fascia from 100 ft were acquired with ultrasonography, CT and MRI. Ultrasound was used to measure the thickness of the plantar fascia. Imaging data from CT and MRI in a DICOM format were transformed into the Materialise Mimics Innovation Suite 16.0 software for digital analysis. SPSS software (SPSS, USA) was used for statistical analysis. The reliability was established by a t-test. Moreover, 42 patients with unilateral plantar fasciitis were examined by ultrasonography.

RESULTS

There were no significant differences between the three imaging modalities for patients of the same sex (P > 0.05). There were no statistically significant differences between the left and right sides for patients of the same sex (P > 0.05), but the difference between males and females was statistically significant (P < 0.01). There were no significant differences between US, CT and MRI in the normal group, but there were significant differences in the plantar fasciitis group evaluated with ultrasound. The plantar fascii of normal male subjects are significantly thicker than those of the normal female.

CONCLUSION

Ultrasonography can be a relatively simple and reliable method for the measurement of plantar fascia thickness.

High-Energy Flux Density Extracorporeal Shock Wave Therapy Versus Traditional Physical Therapy Modalities in Myofascial Pain Syndrome: A Randomized-controlled, Single-Blind Trial

Objectives

This study aims to investigate the effects of extracorporeal shock wave therapy (ESWT) on pain, sleep, fatigue, disability, depression, and quality of life (QoL) in patients with myofascial pain syndrome (MPS).

Patients and methods

Between March 2018 and September 2018, a total of 94 patients (16 males, 78 females; mean age 44.2±11.94 years; range, 19 to 74 years) with the diagnosis of MPS were included in the study. The patients were divided into two groups. The treatment group consisted of 49 patients and a total of seven sessions of high-energy flux density ESWT (H-ESWT) (0.26 mJ/mm2) were given with three days interval. The control group consisted of 45 patients and the treatment of hot pack, transcutaneous electrical nerve stimulation, and ultrasound was given for five days for two weeks. At baseline and one month after treatment, the visual analog scale (VAS), Short Form-36 (SF-36), Pittsburgh Sleep Quality Index (PSQI), Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale, Neck Disability Index (NDI), and Beck Depression Inventory (BDI) scores were compared between the groups.

Results

There were no statistically significant differences in the age, sex, demographic characteristics, and baseline VAS, SF-36, NDI, BDI, FACIT, and PSQI scores between the groups (p>0.05). In the ESWT group, there was a statistically significant decrease in the VAS, SF-36, NDI, BDI, FACIT, and PSQI scores after treatment compared to the baseline scores, while only the SF-36 subscale scores were statistically significantly higher (p<0.05). There was a statistically significant correlation between the VAS and SF-36 scores and the BDI, NDI, FACIT and PSQI scores after the treatment.

Conclusion

Our study results suggest that H-ESWT is more effective than traditional physical therapy methods on pain, QoL, sleep, fatigue, depression, and disability in patients with MPS.

Ultrasonographic assessment of patellar tendon thickness at 16 clinically relevant measurement sites - A study of intra- and interrater reliability

OBJECTIVES

To determine intra- and interrater reliability of ultrasonographic imaging (USI) measurements of patellar tendon (PT) thickness using 16 measurement sites covering the entire tendon.

DESIGN

Reliability study.

SETTING

Physiotherapy outpatient clinic.

PARTICIPANTS

Twenty healthy and physically active volunteers (9 women). Mean age: 24 years (SD ± 2.73). Mean body mass: 75.8 kg (SD ± 11.8).

MAIN OUTCOME MEASURES

Intraclass correlation coefficient (ICC) and 95% limits of agreement (LOA) in cm and in percentage relative to the mean PT thickness.

RESULTS

Intrarater reliability ranged from 0.59 to 0.87 and 0.59 to 0.93 for examiners I and II, respectively. Interrater reliability ranged from 0.37 to 0.89. Measurement precision for examiner I ranged from 0.05 to 0.09 cm (17.5%-26.7%) while ranging from 0.04 to 0.13 cm (13.3%-38.7%) for examiner II. Interrater measurement precision ranged from 0.07 to 0.15 cm (19.1%-42.5%).

CONCLUSION

In an attempt to replicate daily clinical USI practice, this was the first study extensively assessing reliability throughout the full range of the patellar tendon - revealing a considerable variation in intra- and interrater reliability as well as measurement precision throughout the 16 individual PT sites. In a clinical context, the low interrater reliability and precision found at the proximal tendon insertion site may have implications for USI of the symptomatic PT, as this is the site mainly associated with underlying pathologic changes. Further reliability studies are needed to clarify the region-specific reliability of the full length PT.

Piezoelectric focal waves application in the treatment of plantar fascitis

INTRODUCTION

Plantar fasciitis (PF) is one of the most frequent causes of thalalgia and disability. The effectiveness of extracorporeal shock wave therapy is an ideal alternative to conservative treatments.

OBJETIVE

To evaluate the effectiveness of the treatment with Piezoelectric Focal Shock Waves with echographic support and maintenance of the effect at 3 and 6 months.

MATERIALS AND METHODS

Causi-experimental, retrospective statistical study,June 2015 to June 2017, of 90 patients, 36.6% men and 63.3% women, with a mean age of 52 years, diagnosed with PF. Three sessions (one weekly for 3 weeks) of shock wave therapy (PiezoWave F10 G4 generator) were performed, with echographic support and weekly revision and at 3 and 6 months.

MAIN VARIABLES

pain,using Visual Analog Scale before and after each session and at 3 and 6 months and Roles and Maudsley Scale at the end of treatment and at 3 and 6 months.

RESULTS

2000 pulses per session were applied, medium energy intensity 0.45 mJ /mm2, median frequency 8 MHz and median depth of focus of 15 mm. Statistically significant improvement was observed in the Visual Analog Scale between the 3 treatment sessions and after 3 and 6 months posttreatment,obtaining a statistically significant improvement in all values (p <0.05).

CONCLUSION

Treatment with piezoelectric focal shock waves in PF may reduces pain from the first session and achieves a subjective perception of improvement, maintaining these results at 6 months post -treatment.

Thickness of plantar fascia is not predictive of functional outcome in plantar fasciitis treatment

OBJECTIVE

The aim of this study was to define a quantitative parameter to indicate which cases of plantar fasciitis will benefit from local corticosteroid injection or ESWT and to compare the efficacy of two different treatment modalities.

METHODS

Seventy patients (mean age: 49.10; range: 41-58) with chronic plantar fasciitis unresponsive to conservative treatment for 3 months were treated with either betamethasone injection or extracorporeal shock wave therapy (ESWT). Correlation between AOFAS scores, fascia thickness, duration of symptoms, age and calcaneal spur length were assessed.

RESULTS

Degree of fascial thickening (mean 4.6 mm for all patients) did not influence baseline AOFAS scores (r = -0.054). Plantar fascia thickness significantly decreased in both groups after treatment (1.2 mm for steroid, 1.2 mm for ESWT) (p < 0.01 for both groups). Percentage of change in AOFAS scores (68% for steroid and 79% for ESWT, p = 0.069) and fascial thickness (24% for steroid and 26% for ESWT, p = 0.344) were similar between two groups. Functional recovery was not correlated with baseline fascial thickness (r = 0.047) or degree of fascial thinning after treatment (r = -0.099). Percentage of change in AOFAS scores was correlated only with baseline AOFAS scores (r = -0.943).

CONCLUSIONS

Plantar fascia thickness increases significantly in plantar fasciitis and responds to treatment. Both ESWT and betamethasone injection are effective in alleviating symptoms and reducing plantar fascia thickness in chronic plantar fasciitis. However, the only predictive factor for functional recovery in terms of AOFAS scores is patients' functional status prior to treatment. Measuring of plantar fascia is not helpful as a diagnostic or prognostic tool and MRI imaging should be reserved for differential diagnosis.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Comparative effectiveness of extracorporeal shock wave, ultrasound, low-level laser therapy, noninvasive interactive neurostimulation, and pulsed radiofrequency treatment for treating plantar fasciitis: A systematic review and network meta-analysis

BACKGROUND

Plantar fasciitis is one of the most common causes of adult heel pain. The aim of this study is to comprehensively compare the effectiveness of various therapies for plantar fasciitis using network meta-analysis.

METHODS

Studies were comprehensively searched on Embase, MEDLINE via PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and the Physiotherapy Evidence Database (PEDro) up to December 4, 2017. Randomized controlled trials that used extracorporeal shock wave therapy, ultrasound, ultrasound-guided pulsed radiofrequency treatment (UG-PRF), intracorporeal pneumatic shock therapy (IPST), low-level laser therapy (LLLT), and noninvasive interactive neurostimulation (NIN) for the treatment of plantar fasciitis were included. The primary outcome is change in pain relief. Risk of bias was assessed using the Cochrane risk of bias tool. Quality assessment was performed using the GRADE system.

RESULTS

Nineteen trials with 1676 patients with plantar fasciitis plantar fasciitis were included. In the pair-wise meta-analysis, radial extracorporeal shock wave therapy (RSW), LLLT, and IPST showed a significant pooled reduction in the visual analogue scale (VAS) compared with placebo at 0 to 6 weeks [mean difference (MD) = 6.60, 95% confidence interval (CI): (6.04, -7.16); MD = 2.34, 95% CI: (1.60, 3.08); MD = 2.24, 95% CI: (1.44, 3.04), respectively]. Compared with placebo, UG-PRF [MD = 2.31, 95% CI: (1.26, 3.36)] and high-intensity focused extracorporeal shock wave (H-FSW) [MD = 0.82, 95% CI: (0.20, 1.45)] showed superior pain-relieving effects at 2 to 4 months; UG-PRF [MD = 1.11, 95% CI: (0.07, 2.15)] and IPST [MD = 4.92, 95% CI: (4.11, 5.73)] showed superior effects at 6 to 12 months. In the network meta-analysis, only RSW induced significant pain reduction compared with placebo at 0 to 6 weeks [MD = 3.67, 95% CI: (0.31, 6.9)]. No significant differences were found for the 2 to 4-month and 6 to 12-month periods because of the wide 95% CIs.

CONCLUSIONS

We recommend treating plantar fasciitis with RSW. The commonly used ultrasound and focused extracorporeal shock wave (FSW) therapies can be considered as alternative treatment candidates. IPST, NIN, and LLLT may potentially be better alternatives, although their superiority should be confirmed by additional comprehensive evidence.PROSPERO registration number: PROSPERO (CRD42015017353).

Relationship of Plantar Fascia Thickness and Preoperative Pain, Function, and Quality of Life in Recalcitrant Plantar Fasciitis

BACKGROUND

The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition.

METHODS

Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients.

RESULTS

In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36.

CONCLUSION

The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning.

LEVEL OF EVIDENCE

Level IV, case series.

High- versus low-energy extracorporeal shock-wave therapy for myofascial pain syndrome of upper trapezius: A prospective randomized single blinded pilot study

BACKGROUND

To compare the efficacy of high- and low-energy extracorporeal shock wave therapy (ESWT) for patients with myofascial pain syndrome (MPS) of the upper trapezius.

METHODS

Thirty patients (3 men, 27 women) were randomly assigned to receive either high-energy ESWT (0.210 mJ/mm) or low-energy ESWT (0.068 mJ/mm). Both groups received 1500 pulses of ESWT once a week, for 2 weeks. Outcome measurement was assessed by verbal numeric pain scale (VNS), neck disability index (NDI), neck range of motion (ROM) (flexion, extension, rotation, lateral bending), and pressure threshold (PT). Statistical analysis was performed with significance level of P < .05.

RESULTS

No statistically significant differences of demographic and clinical characteristics existed between the 2 groups. VNS, NDI, neck ROM (rotation to sound side, lateral bending to affected side, lateral bending to sound side), and PT were improved in both groups. In contrast, statistically significant improvements in neck flexion and neck extension were observed only in the high-energy group. We also found significant differences in post-treatment NDI (4.20 ± 1.78 vs 6.47 ± 2.48) and post-treatment neck flexion ROM (65.47 ± 10.09 vs 55.93 ± 11.07) between high-energy and low-energy group.

CONCLUSION

ESWT effectively improves VNS, NDI, neck ROM, and PT to patients with MPS of the upper trapezius. High-energy ESWT was more effective in improving NDI and neck flexion ROM compared to the low-energy ESWT, suggesting superiority in functional improvement. Further studies are required to specify the effect of ESWT by energy intensity.

Assessment of the Efficacy of Extracorporeal Shockwave Therapy for Plantar Fasciitis with Magnetic Resonance Imaging Findings

BACKGROUND

Extracorporeal shockwave therapy (ESWT) has recently been used as a new treatment modality for plantar fasciitis. We aimed to determine the efficacy of ESWT by magnetic resonance imaging (MRI) findings.

METHODS

Thirty patients with plantar fasciitis who had received no treatment for 6 months were included. Extracorporeal shockwave therapy was applied once a week for a total of three sessions (frequency of 12-15 Hz, 2-3 bars, and 2,500 pulses). All of the patients were assessed with the visual analog scale, a 6-point evaluation scale, the Foot and Ankle Outcome Score (FAOS), and MRI findings before and 3 months after ESWT. Visual analog scale scores were used in determining the pain level of patients in the morning, during activity, and at rest. Foot and ankle-related problems were evaluated with the FAOS.

RESULTS

The duration of painless walking according to the 6-point rating scale, the FAOS, and pain showed significant improvements after ESWT ( P < .05). Significant decreases in MRI findings, including thickening of the plantar fascia, soft-tissue edema, and bone marrow edema, were observed after treatment ( P < .05).

CONCLUSIONS

Extracorporeal shockwave therapy is a safe and effective treatment that yields favorable results in improvement of pain and function for plantar fasciitis. An MRI is useful for determining response to ESWT for these patients.

Clinical Utility of Ultrasound Measurements of Plantar Fascia Width and Cross-Sectional AreaA Novel Technique

BACKGROUND

We sought to develop a standardized protocol for ultrasound (US) measurements of plantar fascia (PF) width and cross-sectional area (CSA), which may serve as additional outcome variables during US examinations of both healthy asymptomatic PF and in plantar fasciopathy and determine its interrater and intrarater reliability.

METHODS

Ten healthy individuals (20 feet) were enrolled. Participants were assessed twice by two raters each to determine intrarater and interrater reliability. For each foot, three transverse scans of the central bundle of the PF were taken at its insertion at the medial calcaneal tubercle, identified in real time on the plantar surface of the foot, using a fine wire technique. Reliability was determined using intraclass correlation coefficients (ICC), standard errors of measurement (SEM), and limits of agreement (LOA) expressed as percentages of the mean. Reliability of PF width and CSA measurements was determined using PF width and CSA measurements from one sonogram measured once and the mean of three measurements from three sonograms each measured once.

RESULTS

Ultrasound measurements of PF width and CSA showed a mean of 18.6 ± 2.0 mm and 69.20 ± 13.6 mm² respectively. Intra-reliability within both raters showed an ICC > 0.84 for width and ICC > 0.92 for CSA as well as a SEM% and LOA% < 10% for both width and CSA. Inter-rater reliability showed an ICC of 0.82 for width and 0.87 for CSA as well as a SEM% and LOA% < 10% for width and a SEM% < 10% and LOA% < 20% for CSA. Relative and absolute reliability within and between raters were higher when using the mean of three sonographs compared to one sonograph.

CONCLUSIONS

Using this novel technique, PF CSA and width may be determined reliably using measurements from one sonogram or the mean of three sonograms. Measurement of PF CSA and width in addition to already established thickness and echogenicity measurements provides additional information on structural properties of the PF for clinicians and researchers in healthy and pathologic PF.

New and Accurate Predictive Model for the Efficacy of Extracorporeal Shock Wave Therapy in Managing Patients With Chronic Plantar Fasciitis

OBJECTIVE

To identify factors for the outcome of a minimum clinically successful therapy and to establish a predictive model of extracorporeal shock wave therapy (ESWT) in managing patients with chronic plantar fasciitis.

DESIGN

Randomized, controlled, prospective study.

SETTING

Outpatient of local medical center settings.

PARTICIPANTS

Patients treated for symptomatic chronic plantar fasciitis between 2014 and 2016 (N=278).

INTERVENTIONS

ESWT was performed by the principal authors to treat chronic plantar fasciitis. ESWT was administered in 3 sessions, with an interval of 2 weeks (±4d). In the low-, moderate-, and high-intensity groups, 2400 impulses total of ESWT with an energy flux density of 0.2, 0.4, and 0.6mJ/mm², respectively (a rate of 8 impulses per second), were applied.

MAIN OUTCOME MEASURES

The independent variables were patient age, sex, body mass index, affected side, duration of symptoms, Roles and Maudsley score, visual analog scale (VAS) score when taking first steps in the morning, edema, bone spurs, and intensity grade of ESWT. A minimal reduction of 50% in the VAS score was considered as minimum clinically successful therapy. The correlations between the achievement of minimum clinically successful therapy and independent variables were analyzed. The statistically significant factors identified were further analyzed by multivariate logistic regression, and the predictive model was established.

RESULTS

The success rate of ESWT was 66.9%. Univariate analysis found that VAS score when taking first steps in the morning, edema, and the presence of heel spur in radiograph significantly affected the outcome of the treatment. Logistic regression drew the equation: minimum clinically successful therapy=(1+e^{[.011+42.807×heel spur+.109×edema+5.395×VASscore]})^-1.The sensitivity of the predictive factors was 96.77%, 87.63%, and 86.02%, respectively. The specificity of the predictive factors was 45.65%, 42.39%, and 85.87%, respectively. The area under the curve of the predictive factors was .751, .650, and .859, respectively. The Youden index was .4243, .3003, and .7189, respectively. The Hosmer-Lemeshow test showed a good fitting of the predictive model, with an overall accuracy of 89.6%.

CONCLUSIONS

This study establishes a new and accurate predictive model for the efficacy of ESWT in managing patients with chronic plantar fasciitis. The use of these parameters, in the form of a predictive model for ESWT efficacy, has the potential to improve decision-making in the application of ESWT.

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.

Reliability of Various Measurement Stations for Determining Plantar Fascia Thickness and Echogenicity

This study aimed to determine the relative and absolute reliability of ultrasound (US) measurements of the thickness and echogenicity of the plantar fascia (PF) at different measurement stations along its length using a standardized protocol. Twelve healthy subjects (24 feet) were enrolled. The PF was imaged in the longitudinal plane. Subjects were assessed twice to evaluate the intra-rater reliability. A quantitative evaluation of the thickness and echogenicity of the plantar fascia was performed using Image J, a digital image analysis and viewer software. A sonography evaluation of the thickness and echogenicity of the PF showed a high relative reliability with an Intra class correlation coefficient of ≥0.88 at all measurement stations. However, the measurement stations for both the PF thickness and echogenicity which showed the highest intraclass correlation coefficient (ICCs) did not have the highest absolute reliability. Compared to other measurement stations, measuring the PF thickness at 3 cm distal and the echogenicity at a region of interest 1 cm to 2 cm distal from its insertion at the medial calcaneal tubercle showed the highest absolute reliability with the least systematic bias and random error. Also, the reliability was higher using a mean of three measurements compared to one measurement. To reduce discrepancies in the interpretation of the thickness and echogenicity measurements of the PF, the absolute reliability of the different measurement stations should be considered in clinical practice and research rather than the relative reliability with the ICC.

Prognostic Value of Diagnostic Sonography in Patients With Plantar Fasciitis

OBJECTIVES

The primary objective of this study was to determine whether the sonographic appearance of the plantar fascia is predictive of the treatment (ie, pain) response in patients receiving supportive therapy for proximal plantar fasciitis. This study was a secondary analysis of data obtained from a randomized controlled trial of ambulatory adults, which examined the efficacy of 3 different foot supports for plantar fasciitis.

METHODS

Participants underwent diagnostic sonographic examinations of their heel at baseline and again at 3 months by a single experienced foot and ankle surgeon. Quantitative (eg, thickness) and qualitative (eg, biconvexity) characteristics of the fascia were recorded according to a standard protocol. Logistic regression models were used to identify predictors of the pain response.

RESULTS

Seventy patients completed a baseline evaluation, and 63 patients completed a 3-month follow-up assessment. The pain response was not associated with the type of foot support (P> .05). The only significant indicator of an unfavorable response in the univariate and multivariate analyses was biconvexity of the plantar fascia on sonography at presentation (multivariate odds ratio, 4.76 [95% confidence interval, 1.16-19.5; P= .030). Furthermore, changes in self-reported pain over the 3-month study period were not accompanied by alterations in plantar fascia thickness over this time (r = .056; P = .671).

CONCLUSIONS

We conclude that patients who present with biconvexity of the plantar fascia may be less responsive to tier 1 treatment regimens that center around mechanical support of the plantar fascia. Furthermore, follow-up measurements of the fascia in this population should not weigh heavily in decisions such as return to play.

The effects of extracorporeal shock wave therapy on stroke patients with plantar fasciitis

[Purpose] The purpose of this research was to analyze the efficacy of extracorporeal shock wave therapy for the treatment of stroke patients with plantar fasciitis. [Subjects and Methods] This study included 10 stroke patients diagnosed with plantar fasciitis who were administered 3 sessions of extracorporeal shock wave therapy per week. After the last session, they performed stretching exercises for their Achilles tendon and plantar fascia for 30 min/day, 5 times a week for 6 months. The following parameters were measured and compared prior to therapy, 6 weeks after therapy, and 6 months after therapy: thickness of the plantar fascia, using an ultrasonic imaging system; degree of spasticity, using a muscle tension measuring instrument; degree of pain, using the visual analogue scale; and gait ability, using the Functional Gait Assessment. [Results] Decreased plantar fascia thickness, spasticity, and pain and increased gait ability were noted after therapy. These changes were significantly greater at 6 months after therapy than at 6 weeks after therapy. [Conclusion] These results indicated that extracorporeal shock wave therapy reduced tension in the plantar fascia, relieving pain and improving gait ability in stroke patients.

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.

Long-term outcome of low-energy extracorporeal shock wave therapy for plantar fasciitis: comparative analysis according to ultrasonographic findings

Objective

To investigate the long-term effect of low-energy extracorporeal shock wave therapy (ESWT) for plantar fasciitis (PF) according to ultrasonography (US) findings.

Methods

Thirty feet of 25 patients with clinical diagnosis of PF were enrolled and divided into two groups (Apparent-US and Uncertain-US) according to US findings, such as plantar fascia thickening or hypoechogenicity. Inclusion criteria were symptom duration >6 months and a fair or poor grade in Roles-Maudsley score (RMS). ESWT (0.10 mJ/mm², 600 shocks) was given once a week for 6 weeks. Numeric rating scale (NRS) and RMS were evaluated prior to each ESWT session, at short-term follow-up (one week after all ESWT sessions) and long-term follow-up telephone interview (mean 24 months after ESWT). Good and excellent grade in RMS were considered as treatment success.

Results

Repeated measure ANOVA demonstrated that NRS significantly decreased with time after ESWT up to the long-term follow-up (time effect, p<0.001) without group-time interaction (p=0.641), indicating that ESWT equally decreased pain in both groups. Overall success rate was 63.3% (short-term follow-up) and 80.0% (long-term follow-up). In comparative analysis between groups, success rate of Apparent-US and Uncertain-US at short-term follow-up was 61.9% and 66.7%, respectively, and 85.7% and 66.7%, respectively, at long-term follow-up.

Conclusion

If other causes of heel pain are ruled out through meticulous physical examination and ultrasonography, low-energy ESWT in PF seems to be beneficial regardless of US findings. In terms of success rate, however, long-term outcome of Apparent-US appears to be superior to Uncertain-US.

Outcomes of ultrasound-guided extracorporeal shock wave therapy for painful stump neuroma

OBJECTIVE

To investigate the effect of extracorporeal shock wave therapy (ESWT) on painful stump neuroma.

METHODS

Thirty patients with stump neuroma at the distal end of an amputation site were assigned randomly to the ESWT group (n=15) and the transcutaneous electrical nerve stimulation (TENS)+desensitization+pharmacological treatment group (n=15). For 3 weeks, the ESWT group received a weekly session involving 1,500 pulses at 0.10 mJ/mm(2), while the control group was treated 10 times each, 40 minutes per day with TENS and desensitization treatment, and daily medication for 3 weeks. ESWT stimulation was given by focusing on the area at the neuroma site clearly identified by ultrasound.

RESULTS

The changes in the McGill pain questionnaire were 38.8±9.0 prior to treatment and 11.8±3.1 following the treatment. The corresponding values for the control group were 37.2±7.7 and 28.5±10.3. The changes between groups were significantly different (p=0.035). The change in visual analog scale prior to and after treatment was 7.0±1.5 and 2.8±0.8 in the ESWT group, respectively, and 7.2±1.4 and 5.8±2.0 in the control group. These changes between the groups were also significantly different (p=0.010). The outcome in the pain rating scale also showed significant differences between groups (p<0.001). Changes in neuroma size and pain pressure threshold (lb/cm(2)) were not significantly different between groups (p>0.05).

CONCLUSION

The study findings imply that ESWT for stump neuroma is superior to conventional therapy.

Association between plantar fascia vascularity and morphology and foot dysfunction in individuals with chronic plantar fasciitis

STUDY DESIGN

Single-cohort laboratory-based study.

OBJECTIVES

To identify whether plantar fascia vascularity and thickness are associated with foot pain and dysfunction in individuals with chronic plantar fasciitis. Background Altered plantar fascia vascularity and thickening of the fascia have been identified in individuals with chronic plantar fasciitis.

METHODS

Thirty-eight patients with chronic unilateral plantar fasciitis and 21 controls participated in this study. Proximal plantar fascia vascularization and thickness were assessed using ultrasound imaging, and pain and foot dysfunction were quantified with a visual analog scale and the Chinese version of the Foot Function Index, respectively. Paired t tests were used to assess the side-to-side differences in fascia thickness and vascularity index (VI) in the control and patient groups, and an unpaired t test was used to make comparisons with the patient group. Multiple regression analysis was performed to identify whether the VI and fascia thickness were associated with pain and foot dysfunction.

RESULTS

There were significantly higher VI (mean ± SD, 2.4% ± 1.4%) and fascia thickness (5.0 ± 1.3 mm) values in the affected feet when compared with the unaffected feet in the patient group (VI, 1.4% ± 0.5%; fascia thickness, 3.3 ± 0.7 mm) and with the dominant side of the controls (VI, 1.6% ± 0.4%; fascia thickness, 2.9 ± 0.6 mm). After accounting for age, gender, body mass index, and duration of symptoms, the VI explained 13% and 33% of the variance in pain scores measured with a visual analog scale and the pain subscale of the Foot Function Index, respectively; the VI and fascia thickness explained 42% of the variance in the Foot Function Index.

CONCLUSIONS

Individuals with unilateral chronic plantar fasciitis demonstrated significantly greater vascularity and thickened fascia on the affected side compared to the unaffected side and also to healthy controls. Fascia vascularity was associated independently with self-perceived pain, and both fascia vascularity and thickness were associated with foot dysfunction in patients with chronic plantar fasciitis. Public trials registry: Current Controlled Trials, ISRCTN49594569.

Dose-related effect of extracorporeal shock wave therapy for plantar fasciitis

Objective

To examine the dose-related effect of extracorporeal shock wave therapy (ESWT) for plantar fasciitis.

Methods

Sixty patients with plantar fasciitis despite conservative treatment were enrolled. The patients were divided into a low-energy group (group L: n=30, 1,000 shocks/session, energy flux density [EFD] per shock 0.08 mJ/mm²) and a medium-energy group (group M: n=30, 1,000 shocks/session, EFD 0.16 mJ/mm²). The main outcome measures were visual analogue scale (VAS), Roles and Maudsley (RM) score, and thickness of plantar fascia (PF). To compare the effects between each group, follow-up was carried out 1 week after 3 and 6 sessions, and 1 and 3 months after ESWT.

Results

Significant VAS and RM score improvement, and PF thickness reduction were observed in both groups (p<0.01). After 3 sessions of ESWT, group M showed significant improvement in the VAS and RM score than group L, whereas after 3 additional sessions applied in group L, the main outcomes were no longer significantly different in both groups (p>0.05).

Conclusion

Therapeutic effect might disclose a dose-related relationship; therefore, EFD and the times of the session are considerable factors when treating with ESWT.

One-year treatment follow-up of plantar fasciitis: radial shockwaves vs. conventional physiotherapy

OBJECTIVE

To compare radial shockwave treatment with conventional physiotherapy for plantar fasciitis after 12 months of follow-up.

METHOD

This was a randomized, prospective, comparative clinical study. Forty patients with a diagnosis of plantar fasciitis were divided randomly into two treatment groups: group 1, with 20 patients who underwent ten physiotherapy sessions comprising ultrasound, kinesiotherapy and guidance for home-based stretching; and group 2, with 20 patients who underwent three applications of radial shockwaves, once a week, and guidance for home-based stretching. All patients were assessed regarding pain and functional abilities before treatment, immediately after and 12 months after treatment. The mean age was 49.6 ±11.8 years (range: 25-68 years), 85% were female, 88% were overweight, 63% were affected bilaterally, and 83% used analgesics regularly.

RESULTS

At the 12-month follow-up, both treatments were effective for improving pain and functional ability among the patients with plantar fasciitis. The improvement with shockwaves was faster.

CONCLUSION

Shockwave treatment was not more effective than conventional physiotherapy treatment 12 months after the end of the treatment.

Extracorporeal shock wave therapy in myofascial pain syndrome of upper trapezius

Objective

To evaluate the effect of extracorporeal shock wave therapy (ESWT) in myofascial pain syndrome of upper trapezius with visual analogue scale (VAS) and pressure threshold by digital algometer.

Method

Twenty-two patients diagnosed with myofascial pain syndrome in upper trapezius were selected. They were assigned to treatment and standard care (control) groups balanced by age and sex, with eleven subjects in each group. The treated group had done four sessions of ESWT (0.056 mJ/mm², 1,000 impulses, semiweekly) while the control group was treated by the same protocol but with different energy levels applied, 0.001 mJ/mm². The VAS and pressure threshold were measured twice: before and after last therapy. We evaluated VAS of patients and measured the pressure threshold by using algometer.

Results

There were two withdrawals and the remaining 20 patients were three men and 17 women. Age was distributed with 11 patients in their twenties and 9 over 30 years old. There was no significant difference of age, sex, pre-VAS and pre-pressure threshold between 2 groups (p>0.05) found. The VAS significantly decreased from 4.91±1.76 to 2.27±1.27 in the treated group (p<0.01). The control group did not show any significant changes of VAS score. The pressure threshold significantly increased from 40.4±9.94 N to 61.2±12.16 N in the treated group (p<0.05), but there was no significant change in the control group.

Conclusion

ESWT in myofascial pain syndrome of upper trapezius is effective to relieve pain after four times therapies in two weeks. But further study will be required with more patients, a broader age range and more males.

Clinical application of extracorporeal shock wave therapy in orthopedics: focused versus unfocused shock waves

For the past decade extracorporeal shock wave therapy has been applied to a wide range of musculoskeletal disorders. The many promising results and the introduction of shock wave generators that are less expensive and easier to handle has added to the growing interest. Based on their nature of propagation, shock waves can be divided into two types: focused and unfocused. Although several physical differences between these different types of shock waves have been described, very little is known about the clinical outcome using these different modalities. The aim of the present review is to investigate differences in outcome in select orthopaedic applications using focused and unfocused shock waves.

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

OBJECTIVES

To compare the effectiveness of focused shock wave (FSW) therapy of different intensity levels and a new alternative, radial shock wave (RSW) for managing plantar fasciitis.

DATA SOURCES

Electronic databases including MEDLINE and PubMed were searched from January 1996 to June 2011.

STUDY SELECTION

Randomized controlled trials comparing shock wave and placebo therapy were included. Two reviewers independently scrutinized eligible articles, and disagreement was resolved by discussion. Literature searching identified 93 nonduplicate citations, of which 12 trials comprising 1431 participants were included.

DATA EXTRACTION

Information, such as patient characteristics, shock wave intensity, and outcome measures, was extracted by 1 reviewer and checked by another. Both reviewers assessed the trials' quality by using the Jadad scale.

DATA SYNTHESIS

FSW therapy of different intensity ranges was treated as 3 subgroups, whereas studies using RSW therapy were regarded as a separate group. The success rates of treatment and pain reduction magnitudes were used as the outcomes. The traditional meta-analysis showed that medium and high-intensity FSW therapy had reliably higher success rates and pain reduction than the placebo, while the effectiveness of low-intensity FSW therapy and RSW therapy appeared less convincing because of very large confidence intervals. After employing network meta-analysis, the probability of being the best therapy was the highest in RSW therapy, followed by low-, medium-, or high-intensity FSW therapy. The meta-regression indicated that the success rate of FSW therapy was not related to its intensity, whereas elevated energy efflux densities tended to relieve pain more.

CONCLUSIONS

Setting the highest and mostly tolerable energy output within medium intensity ranges is the ideal option when applying FSW therapy on plantar fasciitis. RSW therapy is considered an appropriate alternative because of its lower price and probably better effectiveness.

Ultrasonographic evaluation of low energy extracorporeal pulse activated therapy (EPAT) for chronic plantar fasciitis

BACKGROUND

Ultrasonographic measurement of the plantar fascia can be used to objectively diagnose plantar fasciitis. The purpose of this study was to determine the long-term effectiveness of Extracorporeal Pulse Activated Therapy (EPAT) for the treatment of plantar fasciitis using ultrasonographic measurement as an objective outcome measure, with a minimum followup of 12 months.

METHODS

Patients with chronic recalcitrant plantar fasciitis were prospectively recruited and underwent EPAT. Ultrasound measurement of the plantar fascia and patient-rated pain scores were collected before treatment and at followup (minimum of 12 months post-treatment). Twenty-five subjects (35 feet) met the inclusion criteria. The average followup time was 29.4 +/- 13.1 (M +/- SD; range, 12 to 54) months.

RESULTS

The average thickness of the plantar fascia of the symptomatic heels was 7.3 +/- 2.0 mm before treatment and 6.0 +/- 1.3 mm after treatment (p < 0.001). The average change in thickness of the treated heels was -1.3 mm (-0.8 to -1.8 mm; 95% CI, p < 0.0001). No correlation was found between length of followup and change in ultrasound measured plantar fascia thickness (r = -0.04, p = 0.818).

CONCLUSION

For patients with a greater than 12-month history of heel pain, EPAT can effectively decrease plantar fascia thickness as demonstrated objectively by ultrasound evaluation and reduce patient-reported pain. No relationship between length of followup and change in plantar fascia thickness was found after 12 months.

Intra- and interobserver reliability of quantitative ultrasound measurement of the plantar fascia

PURPOSE

To determine intra- and interobserver reliability and measurement precision of sonographic assessment of plantar fascia thickness when using one, the mean of two, or the mean of three measurements.

METHODS

Two experienced observers scanned 20 healthy subjects twice with 60 minutes between test and retest. A GE LOGIQe ultrasound scanner was used in the study. The built-in software in the scanner was used to measure the thickness of the plantar fascia (PF). Reliability was calculated using intraclass correlation coefficient (ICC) and limits of agreement (LOA).

RESULTS

Intraobserver reliability (ICC) using one measurement was 0.50 for one observer and 0.52 for the other, and using the mean of three measurements intraobserver reliability increased up to 0.77 and 0.67, respectively. Interobserver reliability (ICC) when using one measurement was 0.62 and increased to 0.82 when using the average of three measurements. LOA showed that when using the average of three measurements, LOA decreased to 0.6 mm, corresponding to 17.5% of the mean thickness of the PF.

CONCLUSIONS

The results showed that reliability increases when using the mean of three measurements compared with one. Limits of agreement based on intratester reliability shows that changes in thickness that are larger than 0.6 mm can be considered actual changes in thickness and not a result of measurement error.

Comparison of radial versus focused extracorporeal shock waves in plantar fasciitis using functional measures

BACKGROUND

Recent literature shows evidence for effective treatment for plantar fasciitis using either focused or radial shock waves. Up to now no research has been available which compares these different procedures. We hypothesized (H(0) Hypothesis) that for plantar fasciitis, outcomes following focused or radial shock wave treatment were equal.

MATERIALS AND METHODS

For this pilot study, 39 patients suffering from recalcitrant plantar fasciitis were randomized in two groups. Treatment was performed in three sessions. Once a week 2000 impulses of radial (0.17 mJ/mm(2)) or focused (0.20 mJ/mm(2)) shock waves were applied. Efficacy was determined by multivariate analysis of eight single variables including changes in Foot Functional Index, neuromuscular performance (Single leg drop and long jump, postural stability, isokinetic testing), and by a composite score from baseline to 12 weeks followup. Multivariate Wilcoxon tests (Wei-Lachin procedure) and formal meta-analytic procedure with adjustment for subgroups was performed to determine the adjusted effect sizes with their corresponding confidence intervals.

RESULTS

The overall result (;;Crude Pooling'') shows ;;small'' superiority of the focused extracorporeal shock wave therapy (MW = 0.55, LB-CI = 0.4644). Adjusted for age the focused treatment exhibited ;;more than small'' superiority (MW = 0.59, LB-CI > 0.5) and this result is statistically significant (LB-CI = 0.5067, benchmark for equality = 0.5).

CONCLUSION

This study provides some evidence for focused extracorporeal shock wave treatment being superior to radial extracorporeal shock wave therapy for recalcitrant plantar fasciitis.

Shockwaves increase T-cell proliferation and IL-2 expression through ATP release, P2X7 receptors, and FAK activation

Shockwaves elicited by transient pressure disturbances are used to treat musculoskeletal disorders. Previous research has shown that shockwave treatment affects T-cell function, enhancing T-cell proliferation and IL-2 expression by activating p38 mitogen-activated protein kinase (MAPK) signaling. Here we investigated the signaling pathway by which shockwaves mediate p38 MAPK phosphorylation. We found that shockwaves at an intensity of 0.18 mJ/mm(2) induce the release of extracellular ATP from human Jurkat T-cells at least in part by affecting cell viability. ATP released into the extracellular space stimulates P2X7-type purinergic receptors that induce the activation of p38 MAPK and of focal adhesion kinase (FAK) by phosphorylation on residues Tyr397 and Tyr576/577. Elimination of released ATP with apyrase or inhibition of P2X7 receptors with the antagonists KN-62 or suramin significantly weakens FAK phosphorylation, p38 MAPK activation, IL-2 expression, and T-cell proliferation. Conversely, addition of exogenous ATP causes phosphorylation of FAK and p38 MAPK. Silencing of FAK expression also reduces these cell responses to shockwave treatment. We conclude that shockwaves enhance p38 MAPK activation, IL-2 expression, and T-cell proliferation via the release of cellular ATP and feedback mechanisms that involve P2X7 receptor activation and FAK phosphorylation.

Plantar fasciopathy

Plantar fasciopathy is the most common cause of plantar heel pain. Featuring pain and tenderness on the medial plantar aspect of the calcaneus, clinical diagnosis seems straightforward. The role of various management strategies should be considered in the light of the selflimiting nature of plantar fasciopathy with more than 80% of patients experiencing resolution within 12 months, regardless of management. As there are no data from high-quality, randomized, controlled trials that support the efficacy of surgical management, the most prudent approach is to employ conservative modalities first. Recently, several randomized, controlled trials proved efficacy of extracorporeal shockwave treatment after the failure of more common conservative methods. Shockwave treatment helped to avoid surgery and its associated risks such as transient swelling of the heel pad, calcaneal fracture, injury of the posterior tibial nerve or its branches, and flattening of the longitudinal arch with resultant midtarsal pain. Surgical treatment is therefore considered in only a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months.

Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis

OBJECTIVE

To compare radial shockwave treatment and conventional physiotherapy for plantar fasciitis.

MATERIALS AND METHODS

Thirty-two patients with plantar fasciitis were included in this study. They were randomly divided into two groups. Group 1 was composed of 16 patients who underwent 10 physiotherapy sessions each, consisting of ultrasound, kinesiotherapy and instruction for stretching exercises at home. Group 2 was composed of 16 patients who underwent three applications of radial shockwaves (once a week) and received instruction for stretching exercises at home. Pain and ability to function were evaluated before treatment, immediately afterwards, and three months later. The mean age of the patients was 47.3 +/- 10.3 years (range 25-68); 81% were female, 87% were overweight, 56% had bilateral impairment, and 75% used analgesics regularly.

RESULTS

Both treatments were effective for pain reduction and for improving the functional abilities of patients with plantar fasciitis. The effect of the shockwaves was apparent sooner than physiotherapy after the onset of treatment.

CONCLUSION

Shockwave treatment was no more effective than conventional physiotherapy treatment when evaluated three months after the end of treatment.