Effectiveness of Extracorporeal Shock Wave Therapy Without Local Anesthesia in Patients With Recalcitrant Plantar Fasciitis: A Meta-Analysis of Randomized Controlled Trials

Sonographic and clinical effects of manual physical therapy for plantar fasciitis: randomized prospective controlled trial

OBJECTIVE

This study aimed to evaluate the efficacy of manual physiotherapy on clinical outcomes, morphology of plantar fascia (PF), thicknesses of calcaneal fat pad (CFP) and Kager's fat pad (KFP) with ultrasound imaging in plantar fasciitis (PFS) patients. Also, to evaluate the PF thickness, pain and foot functional outcomes among PFS phases.

METHODS

A randomized controlled trial was conducted on 122 subjects divided into three groups: group A (40 patients with PFS) underwent manual physiotherapy, group B (42 patients with PFS) without any intervention and group C (40 healthy subjects) were matched by age, gender and BMI with each patient in group A and B. The following outcomes were evaluated at baseline and one-month of follow-ups: morphology of PF and thicknesses of CFP and KFP, pain, foot functional limitation.

RESULTS

PF thickness was significantly thickened in group A and B compared to group C (P < 0.001). A significant decrease in incidence of PF echogenicity and CFP thickness were found in group A and B compared to group C. Moreover, significant improvement was observed in PF thickness (P < 0.001), PF echogenicity (P < 0.001) and CFP thickness (P = 0.002) in group A at one-month after the treatment. Furthermore, pain intensity and foot functional limitation was significantly improved within group A after receiving the treatment. Significant improvement was noted in PF thickness, pain intensity and foot functional limitation among patients with acute phase.

CONCLUSION

The manual physiotherapy is effective in treatment of PF thickening, hypoechogenicity, pain intensity and activity limitations, particularly in patients associated with acute PFS.

Potentially inappropriate medication and frailty in older adults: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to systematically assess existing studies to demonstrate the association between potentially inappropriate medication (PIM) and frailty.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched major electronic databases (PubMed, Web of Science, the Cochrane Library, Embase, CINHAL, PsycInfo, China National Knowledge Infrastructure, China Biology Medicine disk, Weipu, and Wanfang) from their inception until February 25, 2023 (data updated on May 4, 2023), for observational studies investigating PIM and frailty. I2 was used to measure the heterogeneity between studies quantitatively. A random effect model calculated pooled effect size owing to high heterogeneity. Subgroup analysis was conducted to explore sources of heterogeneity. Additionally, the studies' quality was evaluated using the Newcastle Ottawa Scale (a modified Newcastle Ottawa Scale was used to evaluate cross-sectional studies).

RESULTS

Twenty-four studies were included for systematic review, 14 of which were included in the meta-analysis. After pooling the effect size, the odds ratio with PIM as the dependent variable was 1.12 (95%CI: 1.01-1.25), and that with frailty as the dependent variable was 1.75 (95%CI: 1.25-2.43), indicating a bidirectional association between PIM and frailty.

CONCLUSIONS

PIM and frailty interact with each other and have a bidirectional association, thus providing additional information for early clinical identification and prevention of frailty, and medication safety management.

Effects of local vibration combined with extracorporeal shock wave therapy in plantar fasciitis: a randomized controlled trial

OBJECTIVE

To compare the effects of local vibration combined with extracorporeal shock wave therapy and extracorporeal shock wave therapy alone for plantar fasciitis.

METHODS

A randomized controlled trial including 34 participants with a mean age of 37.5 years. Participants were randomly allocated to a group treated with extracorporeal shock wave therapy combined with local vibration (ESWT-LV group) or a group treated with extracorporeal shock wave therapy alone (ESWT-alone group). All participants in each group underwent 2 treatment sessions weekly for 5 weeks. Thickness of the plantar fascia, plantar pain, and foot function were measured using ultrasonography, numerical rating scale for pain, and Foot Function Index, respectively, at baseline and at the end of the 5-week intervention.

RESULTS

Significant improvements were measured in both groups in the thickness of the plantar fascia, numerical rating scale, and Foot Function Index values (p < 0.05). In addition, the thickness of the plantar fascia and pain was significantly more decreased in the ESWT-LV group than in the ESWT-alone group (p < 0.05). However, the differences between groups in Foot Function Index values were not significant (p > 0.05).

CONCLUSION

Local vibration combined with extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis.

Ledderhose's Disease: An Up-to-Date Review of a Rare Non-Malignant Disorder

Plantar fibromatosis (or Ledderhose's disease) is a rare benign condition, difficult to treat, defined by gradual-growing nodules in the central medial part of the plantar fascia, with the possibility of sclerosis and shrinkage of the entire fascia or, rarely, contractures of the toes. From a histopathological point of view, it is linked to Dupuytren's contracture of the hand and Peyronie's disease of the penis, being part of a large group of fibromatoses, based on a proliferation of collagen and fibroblasts. Its etiology is still not fully understood, even though it has been associated with trauma, diabetes mellitus, use of anticonvulsants, frozen shoulder, alcohol consumption, and liver disease. Typically, ultrasound confirms the diagnosis, and magnetic resonance imaging is used for more aggressive and advanced types. Several conservative treatment techniques, such as steroid injections, verapamil, imatinib, radiation therapy, extracorporeal shock wave therapy, tamoxifen, sorafenib, mitomycin C, and collagenase, have been documented. When non-operative care fails, surgical measures may be considered, even though recurrence is expected. We attempted to provide a better understanding of this disease by covering all of the important aspects: its history, clinical and radiologic findings, diagnosis, pathophysiology features, conservative and surgical treatment, recurrence rate, and prognosis.

Feasibility Using Telehealth for Planning Use of Extracorporeal Shockwave Therapy in a Sports Medicine Clinic

(1) Background: The purpose of this study is to describe whether telehealth compared with in-person visits, led to a similar agreement of primary diagnosis reached at the time of procedure using extracorporeal shockwave therapy. (2) Methods: This retrospective study consisted of chart reviews of all new patients evaluated in a sports medicine clinic prior to performing extracorporeal shockwave therapy from April 2020 to March 2021. The primary outcome of the study was describing agreement in primary diagnosis at the time of evaluation (telehealth and in-person) and during the procedure using extracorporeal shockwave therapy. Logistic regression was utilized to identify patient characteristics that may predict agreement of diagnosis using telehealth. (3) Results: The chart review identified 166 patients (45 telehealth and 121 in-person) evaluated for extracorporeal shockwave therapy. Agreement of diagnosis was similar for patients evaluated using telehealth compared to in-person visits (84% vs. 92%, Χ² = 1.90, p = 0.168). Agreement on diagnosis was more likely in patients who started shockwave within the 1 week of initial visit (OR = 8.27, 95% CI = 1.69-45.29), patients over age 60 (OR = 0.94, 95% CI = 0.90-0.99), and in patients without a history of osteoarthritis (OR = 14.00, 95% CI = 1.88-113.46). (4) Conclusions: Telehealth resulted in a similar agreement to in-person visits to identify a primary diagnosis for planning extracorporeal shockwave therapy. Telehealth may be a reasonable alternative to in-person visits for procedural planning of extracorporeal shockwave therapy.

The Efficacy of Focused Extracorporeal Shock Wave Therapy and Ultrasound Therapy in the Treatment of Calcar Calcanei: A Randomized Study

The prospective, simple randomized study assesses the effect of focused extracorporeal shock wave therapy (f-ESWT) on pain intensity and calcification size compared to the application of ultrasound physical therapy in treating patients with calcar calcanei. A total of 124 patients diagnosed with calcar calcanei were consecutively included in the study. The patients were divided into two groups: the experimental group (n = 62), which included the patients treated with f-ECWT, and the control group (n = 62), consisting of patients treated with the standard ultrasound therapy method. The experimental group's patients received ten therapy applications spaced seven days apart. The patients in the control group had ten ultrasound treatments on ten consecutive days over two weeks. All patients in both groups were tested using the Visual Analog Scale (VAS) to measure pain intensity before the beginning and at the end of treatment. The size of the calcification was assessed in all patients. The study hypothesizes that f-ESWT reduces the pain and the size of the calcification. Pain intensity reduction was registered in all patients. The calcification size in patients in the experimental group was reduced from the initial range of 2 mm-15 mm, to a content of 0.0 mm-6.2 mm. The calcification size in the control group ranged from 1.2 to 7.5 mm, without any change. None of the patients experienced any adverse reactions to the therapy. Patients treated with standard ultrasound therapy did not have a statistically significant reduction in the calcification size. In contrast, the patients in the experimental group treated with f-ESWT showed a substantial decrease in the calcification size.

Prevalence of motoric cognitive risk syndrome among older adults: a systematic review and meta-analysis

OBJECTIVE

Motoric cognitive risk syndrome (MCR) is a newly proposed pre-dementia syndrome. Several studies on the prevalence of MCR have been published; however, the data vary across studies with different epidemiological characteristics. Thus, this study aimed to quantitatively analyse the overall prevalence and associated epidemiological characteristics of MCR among older adults aged ≥ 60 years.

METHODS

The Cochrane Library, PubMed, Web of Science, CINAHL, Embase, Scopus, PsycInfo, China National Knowledge Infrastructure, Weipu Database, China Biology Medicine disc and Wanfang Database were searched from their inception to January 2022. A modified Newcastle-Ottawa Scale evaluated the risk of bias. Statistical heterogeneity among the included studies was analysed using Cochran's Q and I² tests. A random effect model calculated pooled prevalence owing to study heterogeneity. Begg's and Egger's tests were used to assess the publication bias. Additionally, subgroup analysis and meta-regression were performed based on different epidemiological characteristics to determine heterogeneity sources.

RESULTS

Sixty-two studies comprising 187,558 samples were obtained. The pooled MCR prevalence was 9.0% (95% confidence interval: 8.3-9.8). A higher MCR prevalence was observed in females, older adults with a low educational level, depression and cardiovascular risk factors, South American populations, and studies with small sample sizes and cross-section designs. Furthermore, subjective cognitive complaint using scale score and gait speed using instrument gait showed higher MCR prevalence.

CONCLUSION

MCR is common in older adults, and various epidemiological characteristics influence its prevalence. Thus, preventive measures are required for older adults with higher MCR prevalence.

The Efficacy of Instrumental Physical Therapy through Extracorporeal Shock Wave Therapy in the Treatment of Plantar Fasciitis: An Umbrella Review

(1) Background: Plantar fasciitis (PF) is the most common cause of heel pain in adults. Extracorporeal shockwave therapy (ESWT) is a minimally invasive treatments commonly used for treating PF. Our aim is to provide a complete overview of which treatments have been compared to ESWT, with a focus on the modalities that have been used. (2) Methods: A thorough search of the literature was performed on Medline via Pubmed, Cochrane Database of Systematic Reviews (CDSR) of the Cochrane Library and Physiotherapy Evidence Databases (PEDro) up to 18 November 2021. In the study were included only systematic reviews and meta-analysis in English language, published from 2010 to date. (3) Results: A total of 14 systematic reviews and meta-analysis were included in the umbrella review. A total of eight studies compared the efficacy of ESWT treatment with placebo, three studies compared ESWT with another therapy (two studies compared ESWT and corticosteroids, one study ESWT and ultrasound therapy), and three studies had more than one comparison. (4) Conclusions: When compared to placebo, ESWT demonstrated to be effective. More randomized trials with specific comparisons between different types and intensity of SW are needed to obtain more precise information on SW effectiveness.

Comparison of Ultrasound-Guided Prolotherapy Versus Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis: A Randomized Clinical Trial

This study aimed to compare the effectiveness of extracorporeal shockwave therapy (ESWT) versus dextrose prolotherapy on pain and foot functions in patients with chronic plantar fasciitis with a prospective randomized-controlled trial. A total of 29 patients in whom conservative care failed were enrolled for the study after the clinical and ultrasonographic assessment. The patients were randomly assigned to receive ESWT (ESWT group, n = 15) or dextrose prolotherapy (dextrose prolotherapy group, n = 14). ESWT group received 1800 to 2000 focused shock waves (session of 0.20-0.30 mJ/mm² with a frequency of 4-6 Hz) followed by soft tissue 3000 to 3500 radial pulses (session of 1.8-3.0 bar with a frequency of 15-21 Hz). Dextrose prolotherapy group underwent an injection of 5 ml 15% dextrose solution with 2% lidocaine. ESWT and dextrose prolotherapy were repeated 3 times by 2 weeks apart. A 100-mm Visual Analog Scale (VAS) for overall and morning pain, Foot Function Index (FFI) and the Roles and Maudsley Scale score (RMS) were assessed at baseline, 6 weeks, and 12 weeks after the last intervention. Overall VAS, Morning VAS, RMS and FFI scores improved significantly in both treatment groups at 6 weeks and 12 weeks compared to baseline (p < .001). Comparison of changes in overall VAS, Morning VAS, RMS and FFI scores did not show a significant difference between the groups at each time point (p > .05) In our study dextrose prolotherapy and ESWT had similar effectiveness in patients with chronic plantar fasciitis who have not respond to conservative care. The results showed ESWT and dextrose prolotherapy were not superior to each other.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

Similar Functional Gains Using Radial Versus Combined Shockwave Therapy in Management of Plantar Fasciitis

Plantar fasciitis is a common condition that causes foot pain. While shockwave therapy has been shown to provide successful results, comparative outcomes from different forms of shockwave therapy have yet to be described for this condition. In this retrospective cohort study, we describe findings from a quality improvement initiative assessing safety and functional outcomes for patients with plantar fasciitis treated with radial shockwave therapy (n = 20) or radial and focused shockwave therapy (combined shockwave, n = 18). Most were runners (n = 31, 81.6%), mean age was 43.3 ± 12.9 years, and average symptom duration 12.1 ± 11.1 months. All patients were prescribed an exercise program focusing on foot intrinsic strengthening. We hypothesized both groups would have improvement in function using the foot and Ankle Ability Measure, with a similar safety profile. Both radial and combined groups received similar number of total treatments (4.9 ± 2.5 and 4.1 ± 2.4, respectively; p = .33). Within group score changes for the Activities of Daily Living and Sports subscales were observed for both the radial (16.5 ± 16.3, p < .001; 31.7 ± 23.1, p < .001) and combined groups (19.8 ± 10.8, p = .001; 26.0 ± 21.5, p = .003). There was no difference in proportion of patients meeting the minimal clinically important difference between radial and combined groups regarding the Activities of Daily Living (14 (70%) vs 14 (77.8%), p = .58) and Sports subscales (17 (85%) vs 12 (75%), p = .45). Collectively, these findings suggest that a majority of patients with chronic plantar fasciitis may achieve functional gains using either form of shockwave therapy.

[Current evidences in shockwave treatment. SETOC (Spanish Society of Shockwave Treatment) recommendations]

This SETOC consensus document shows the scientific evidence of the technology in shockwaves (SW) and radial pressure waves (RPW) in a variety of spasticity disorders, musculoskeletal, skin, urological diseases, etc. SW and RPW, without anesthesia, are an effective, safe, non-invasive, cost-effective treatment, which reduces the need for surgery, lower risk of complications, faster recovery and greater acceptability to patients than surgery. Consequently, SW and RPW should be the first therapeutic option in the aforementioned chronic pathologies, when conservative alternatives have failed. SETOC advises to follow the recommendations given in this article, including the ones given by SW scientific societies and best evidence for each technology as well.

Autoregulated heavy slow resistance training combined with radial shockwave therapy for plantar heel pain: Protocol for a mixed-methods pilot randomised controlled trial

BACKGROUND

Plantar heel pain (PHP) is considered a tendinopathy and it affects up to 10% of the population. Both heavy slow resistance training (HSRT) and extracorporeal shockwave therapy (ESWT) have shown effectiveness for treating PHP in isolation. However, more comprehensive exercise protocols and progression methods are needed due to poor long-term outcomes, and better standardisation of ESWT protocols are required. Autoregulation of resistance training involves self-selecting exercise dosage based on individual factors. Although autoregulation has proven effective for strength gains in athletes, it has not been investigated in tendinopathy. Recent studies recommend that PHP should not be treated by one treatment intervention in isolation. However, there is a dearth of research investigating the feasibility and effectiveness of combined treatment interventions for PHP. Currently, no studies have investigated autoregulated HSRT combined with ESWT, despite their individual efficacy. The optimal treatment protocol for PHP is unknown, and there is a need to ascertain whether the addition of ESWT to autoregulated HSRT leads to better outcomes compared to either alone.

METHODS

A three-arm randomised controlled trial (RCT) comparing these groups would be the ideal way to investigate this question, with a pilot RCT testing trial procedures and process evaluation required prior to a definitive RCT. Patients expectations, feasibility and acceptability of combined ESWT and exercise for PHP also remain unknown. Therefore, the addition of qualitative interviews in a mixed-methods pilot RCT would help ascertain acceptability and help explain the intervention outcomes.

Early-Application Extracorporeal Shockwave Therapy for Plantar Fasciitis in a Chiropractic Clinic: A Case Report

Objective

The purpose of this report is to describe the successful management of plantar fasciitis (PF) using only extracorporeal shockwave therapy.

Clinical Features

A 26-year-old male former athlete presented with insidious right posterior medial foot pain of 3 months' duration. He reported a past history of similar symptoms 12 years previously and was successfully treated with tape, ice, and electric stimulation. For the current episode, he attempted to manage with orthotics, motor nerve stimulation, and ice, and when that was insufficient, he sought care in our clinic. Initial history and evaluation found provocation of pain and functional limitations while wearing dress shoes, running, and playing basketball. Examination found palpatory tenderness at the medial aspect of the distal right calcaneus, and pain with right ankle dorsiflexion. Radiographs were unremarkable. Patient presentation and exam findings supported a working diagnosis of PF.

Intervention and Outcomes

Treatment was applied with a Richard Wolf WellWave low-energy shockwave therapy unit with focused dosage of 4000 shock pulsations at 10-mm depth to the site of pain. Treatment was applied 11 × over 5 weeks, after which the patient reported a complete resolution of pain and resumption of all activities.

Conclusion

Extracorporeal shockwave therapy appeared to be an effective treatment approach for the management of this patient's PF.

Current Concepts of Minimally Invasive Treatment Options for Plantar Fasciitis: a Comprehensive Review

PURPOSE OF REVIEW

Chronic foot pain constitutes a large portion of the chronic pain burden in the overall population. Plantar fasciitis is one of the most common and most easily identifiable causes of chronic foot pain. The syndrome has been estimated to cause 11 to 15% of foot pain visits, requiring professional care. Moreover, studies have suggested that 1 in 10 people will develop plantar fasciitis at some point in their life. Conservative management has been shown to be effective and considered first-line treatment. Minimally invasive treatment options are typically reserved for those who fail conservative management. With the advent of new techniques and improvements in current therapeutic options, there has been an expansion of available minimally invasive treatment options. The purpose of this review is to provide a comprehensive update on the current understanding of minimally invasive treatments of plantar fasciitis.

RECENT FINDINGS

This review shows that conservative management continues to be the first-line therapy, whereas other treatment options were those who failed conservative management using modern techniques that have shown improving effectiveness, with successful restoration of patient functionality, recovery, and satisfaction. However, a multitude of these minimally invasive treatment options are evolving.

CONCLUSION

While conservative management continues to be the mainstay of treatment for plantar fasciitis, multiple minimally invasive treatment options are emerging with potential effectiveness in reducing pain and improving the function.

Follow-up of clinical and sonographic features after extracorporeal shock wave therapy in painful plantar fibromatosis

Background

Extracorporeal shock wave therapy (ESWT) has been used as a safe alternative treatment for refractory musculoskeletal diseases, such as plantar fasciitis, Achilles tendinopathy and gluteal tendinopathy, and various forms of fibromatosis including palmar or penile fibromatosis. However, there is limited published data for clinical and sonographic features of plantar fibromatosis after ESWT. The purpose of this study was to evaluate the long-term clinical outcome of ESWT in ultrasonography-confirmed plantar fibromatosis and ultrasonographic changes of plantar fibroma after ESWT.

Methods

Medical charts of 26 patients (30 feet) with plantar fibromatosis confirmed by ultrasonography were reviewed. Finally, a total of 10 feet who underwent ESWT for “Poor” or “Fair” grade of Roles-Maudsley Score (RMS) and symptoms persisted for >6 months were included in this study. Short-term follow-up was conducted one week after ESWT and long-term follow-up time averaged 34.0 months. The Numerical Rating Scale (NRS) and RMS were collected for the evaluation of clinical features. Follow-up ultrasonography was conducted at long-term follow-up and changes of plantar fibroma was assessed. A greater than 50% reduction in the NRS and achievement of a “good” or “excellent” grade in the RMS were regarded as treatment success. Additionally, medical charts of 144 patients (168 feet) with plantar fasciitis confirmed by ultrasonography were reviewed and subsequently, 42 feet who underwent ESWT with the same protocol were included for the comparison of clinical features.

Results

In plantar fibromatosis, baseline NRS (6.2 ± 1.3) and RMS (3.5 ± 0.5) were significantly improved at short-term follow-up (NRS, 1.8 ± 1.0; RMS, 2.0 ± 0.8, P < .001, respectively) and long-term follow-up (NRS, 0.6 ± 1.1; RMS, 1.4 ± 0.8, P < .001, respectively). Treatment success was recorded in seven feet (70.0%) at short-term follow-up and 8 feet (80%) at long-term follow-up, which is comparable to that of the plantar fasciitis group (28 feet, 66.7%; 35 feet, 83.3%, respectively). In long-term follow-up ultrasonography, mean fibroma thickness was reduced from 4.4±1.0 to 2.6±0.8 mm (P = .003); however, length and width were not significantly changed. There were no serious adverse effects.

Conclusion

While these are preliminary findings, and must be confirmed in a randomized placebo control study, ESWT can have a beneficial long-term effect on pain relief and functional outcomes in painful plantar fibromatosis. However, ESWT is unlikely to affect the ultrasonographic morphology of plantar fibroma, with the exception of reducing the thickness.

Level of evidence

Level III, retrospective cohort study.

Association between trigger points in hamstring, posterior leg, foot muscles and plantar fasciopathy: A cross- sectional study

BACKROUND

Plantar Fasciopathy (PF) is soreness or irritability experienced underneath infero-medial aspect of the heel. It is a multifactorial disorder where myofascial involvement also seems to be associated with it, in which, muscles of posterior thigh, leg and foot muscles are affected. Trigger points in these muscles may interfere with biomechanics and normal functioning of the lower limb.

OBJECTIVE

To find an association between trigger points of the posterior thigh, leg and foot muscles and plantar fasciopathy.

STUDY DESIGN

A cross sectional study.

METHODS

100 patients with plantar fasciopathy who fulfilled inclusion criteria were included in this study. They were examined for trigger points by manual palpation in posterior thigh, leg and foot muscles. Totally 15 muscles were examined on both affected and unaffected side.

RESULTS

Results showed that myofascial trigger points were more prevalent in medial gastrocnemius (98%, Chi-square: 110.07, p < 0.05, Phi-0.74), quadratus plantae (83%, Chi-square:126.96, p < 0.05, Phi- 0.79), soleus (69%, Chi-square: 28.88, p < 0.05, Phi-0.38), tibialis posterior (46%, Chi-square 41.98 p<0.05%, Phi-0.50), abductor hallucis (42%, Chi-square: 43.61 p<0.05% Phi-0.46), flexor halluces longus (41%, Chisquare: 39.25, p < 0.05, Phi-0.44) than other muscles on the affected side. Whereas, on the unaffected side, trigger points were more prevalent among peroneus longus (50%, Chi-square: 26.14, p < 0.05, Phi-0.36) followed by medial gastrocnemius (26%, Chisquare: 110.07, p < 0.05, Phi-0.74).

CONCLUSION

Plantar fasciopathy is strongly associated with trigger points of medial gastrocnemius, quadratus plantae followed by soleus, tibialis posterior, abductor hallucis and flexor hallucis longus.

The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

BACKGROUND

Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT.

METHODS

A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects.

RESULTS

Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis (n = 11), plantar fasciitis (n = 7) and osteonecrosis of the femoral head (n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI -4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI -0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes.

CONCLUSIONS

SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.

Extracorporeal Shock Wave Therapy for the Treatment of Osteoarthritis: A Systematic Review and Meta-Analysis

Background

Osteoarthritis is the most common musculoskeletal disease. Extracorporeal shockwave therapy had shown an effect on osteoarthritis in both some animal experiments and clinical studies, but there was no systematic review to confirm the value of shockwave therapy in the treatment of all types of osteoarthritis and compare it with other traditional therapies (especially traditional Chinese medicine).

Method

PubMed, Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Chinese National Knowledge Infrastructure, WANFANG database, and VIP database were searched up to December 10, 2019, to identify randomized controlled trials comparing shockwave therapy and other treatments for osteoarthritis. Visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index were extracted and analyzed by RevMan and STATA software as outcomes of pain reduction and functional improvement. Adverse reactions were recorded to evaluate the safety of shockwave therapy.

Results

Shockwave therapy had significant improvement in both pain reduction and functional improvement compared with placebo, corticosteroid, hyaluronic acid, medication, and ultrasound (P < 0.05). In functional improvement, shockwave therapy showed statistical improvement compared with kinesiotherapy and moxibustion (P < 0.05) but not with acupotomy surgery (P = 0.24). A significant difference between shockwave therapy and platelet-rich plasma was observed in pain reduction (P < 0.05) but not in functional improvement (P = 0.89). Meanwhile, a statistical difference was found between shockwave therapy and fumigation in functional improvement (P < 0.05) but not in pain reduction (P = 0.26). Additionally, there was no statistically significant difference between shockwave therapy and manipulation in both pain reduction (P = 0.21) and functional improvement (P = 0.45). No serious adverse reaction occurred in all of studies.

Conclusions

Extracorporeal shockwave therapy could be recommended in the treatment of osteoarthritis as a noninvasive therapy with safety and effectiveness, but the grade of recommendations needs to be discussed in a further study.

Effectiveness of physical therapy treatment in addition to usual podiatry management of plantar heel pain: a randomized clinical trial

Background

Many patients will seek care from a podiatrist for plantar heel pain (PHP), while few of these patients will also be seen by a physical therapist. Physical therapists can provide treatment that is not a part of routine podiatric care for PHP and may provide additional improvement. Therefore, the purpose of this study was to examine the effects of interdisciplinary care for PHP that incorporated physical therapy treatment after initiating podiatric treatment.

Methods

Eligible individuals with PHP that presented to a podiatrist were randomized to receive usual podiatric care (uPOD) or usual podiatric care plus physical therapy treatment (uPOD+PT). The primary outcome was change in foot and ankle ability measure (FAAM) at 6-months. Secondary outcomes included change in numeric pain rating scale (NPRS), patient-reported success, and 6-week and 1-year endpoints. Patient-reported success was defined as the top two global rating of change scale rankings. Primary analysis was intention-to-treat (ITT) using analysis by covariance adjusted to baseline scores, and a secondary per-protocol (PP) analysis was performed analyzing only those who completed treatment.

Results

Ninety-five individuals participated and were included in the ITT analysis, and 79 were included in the PP analysis. For the primary outcome of FAAM change from baseline to 6-months, both groups improved significantly (uPOD+PT: 26.8 [95% CI 21.6, 31.9]; uPOD: (20 [15.6, 24.4]), but there was no between-group difference (4.3 [− 1, 9.6]). For secondary outcomes, the uPOD+PT group demonstrated greater improvement in NPRS at 6 weeks (0.9 [0.3, 1.4]) and 1 year (1.5 [0.6, 2.5]) in the ITT analysis. In the PP analysis, the uPOD+PT group demonstrated greater improvement in FAAM at 6 months (7.7 [2.1, 13.3]) and 1 year (5.5 [0.1, 10.8]), NPRS at 6 weeks (0.9 [0.2, 1.6]), 6 months (1.3 [0.6, 2.1]) and 1 year (1.3 [0.6, 2.1]), and in patient-reported success (relative risk [95% CI]) at 6 weeks (2.8 [1.1, 7.1]), 6 months (1.5 [1.1, 2.1]), and 1 year (1.5 [1.1, 1.9]).

Conclusions

There was no significant benefit of uPOD+PT in the primary outcome of FAAM change at 6 months. Secondary outcomes and PP analysis indicated additional benefit of uPOD+PT, mostly observed in individuals who completed treatment.

Trial registration

Prospectively registered May 24, 2013 at www.clinicaltrials.gov (NCT01865734).

Pain on the Plantar Surface of the Foot

BACKGROUND

Plantar fasciitis (PF) is characterized by pain on weight-bearing in the medial plantar area of the heel, metatarsalgia (MTG) by pain on the plantar surface of the forefoot radiating into the toes. Reliable figures on lifetime prevalence in Germany are lacking.

METHODS

This review is based on pertinent publications retrieved from a selective search in PubMed, on guidelines from Germany and abroad, and on the authors' clinical experience.

RESULTS

Plantar fasciitis is generally diagnosed from the history and physical examination, without any ancillary studies. In 90-95% of cases, conservative treatment (e.g., stretching exercises, fascia training, ultrasound therapy, glucocorticoid injections, radiotherapy, shoe inserts, and shock-wave therapy) brings about total, or at least adequate, relief of pain within one year. Intractable pain is an indication for surgical treatment by plantar fasciotomy and/or calf muscle release. In metatarsalgia, a directed diagnostic work-up to find the cause is mandatory, including a search for excessive mechanical stress due to abnormal foot posture, neuropathic pain, rheumatoid arthritis, aseptic bony necrosis, or malignant disease; imaging studies and pedobarography are needed. For causally oriented treatment, a wide range of conservative and surgical measures can be considered.

CONCLUSION

The reported results of treatments for plantar fasciitis and metatarsalgia are heterogeneous. The efficacy of the individual measures should be studied in randomized controlled trials.

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.

Prolotherapy vs Radial Extracorporeal Shock Wave Therapy in the Short-term Treatment of Lateral Epicondylosis: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to compare the efficacy of prolotherapy with hypertonic dextrose and radial shock wave therapy in chronic lateral epicondilosis.

DESIGN

Prospective single-blind randomized clinical trial.

SETTING

Physical medicine and rehabilitation clinic.

SUBJECTS

Thirty-three patients with at least three months of signs and symptoms of lateral epicondilosis, as well as failure of at least one of the conservative treatments, randomly allocated into two groups.

METHODS

Sixteen patients received three sessions of shock wave therapy, and 17 received one session prolotherapy. Severity of pain via visual analog scale (VAS), grip strength via Baseline Pneumatic Dynamometer, pressure pain threshold (PPT) by algometer and Disabilities of Arm, Shoulder, and Hand quick questionnaire (Quick DASH) were assessed at baseline, four weeks, and eight weeks after the intervention.

RESULTS

Within-group analysis showed that in both groups, differences between all of the outcome measures were significant after four and also eight weeks. Between-group analysis after four and eight weeks showed that the VAS and Quick DASH had significantly more improvement in the shock wave group. However, the two groups were similar regarding grip strength and PPT. No complication was observed in the two groups.

CONCLUSIONS

Based on the results of this study, a regiment of three sessions (weekly) of radial extracorporeal shock wave therapy is significantly more effective than one session of prolotherapy with 20% dextrose regarding pain and function in the management of chronic lateral epicondylosis in short-term follow-up.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain

Adult acquired inferior calcaneal heel pain is a common pathology seen in a foot and ankle practice. A literature review and expert panel discussion of the most common findings and treatment options are presented. Various diagnostic and treatment modalities are available to the practitioner. It is prudent to combine appropriate history and physical examination findings with patient-specific treatment modalities for optimum success. We present the most common diagnostic tools and treatment options, followed by a discussion of the appropriateness of each based on the published data and experience of the expert panel.

Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions: A Narrative Review

Extracorporeal shockwave therapy (ESWT) is a technology that was first introduced into clinical practice in 1982 for urologic conditions. Subsequent clinical applications in musculoskeletal conditions have been described in treatment of plantar fasciopathy, both upper and lower extremity tendinopathies, greater trochanteric pain syndrome, medial tibial stress syndrome, management of nonunion fractures, and joint disease including avascular necrosis. The aim of this review is to summarize the current understanding of treatment of musculoskeletal conditions with ESWT, accounting for differences in treatment protocol and energy levels. Complications from ESWT are rare but include 2 reported cases of injury to bone and Achilles tendon rupture in older adults using focused shockwave. Collectively, studies suggest ESWT is generally well-tolerated treatment strategy for multiple musculoskeletal conditions commonly seen in clinical practice. LEVEL OF EVIDENCE: III.

Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination

Background:

Plantar fasciitis (PF) affects 7% to 10% of the population. The long-term prognosis is unknown.

Purpose:

Our study had 4 aims: (1) to assess the long-term prognosis of PF, (2) to evaluate whether baseline characteristics (sex, body mass index, age, smoking status, physical work, exercise-induced symptoms, bilateral heel pain, fascia thickness, and presence of a heel spur) could predict long-term outcomes, (3) to assess the long-term ultrasound (US) development in the fascia, and (4) to assess whether US-guided corticosteroid injections induce atrophy of the heel fat pad.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

From 2001 to 2011 (baseline), 269 patients were diagnosed with PF based on symptoms and US. At follow-up (2016), all patients were invited to an interview regarding their medical history and for clinical and US re-examinations. Kaplan-Meier survival estimates were used to estimate the long-term prognosis, and a multiple Cox regression analysis was used for the prediction model.

Results:

In all, 174 patients (91 women, 83 men) participated in the study. All were interviewed, and 137 underwent a US examination. The mean follow-up was 9.7 years from the onset of symptoms and 8.9 years from baseline. At follow-up, 54% of patients were asymptomatic (mean duration of symptoms, 725 days), and 46% still had symptoms. The risk of having PF was 80.5% after 1 year, 50.0% after 5 years, 45.6% after 10 years, and 44.0% after 15 years from the onset of symptoms. The risk was significantly greater for women (P < .01) and patients with bilateral pain (P < .01). Fascia thickness decreased significantly in both the asymptomatic and symptomatic groups (P < .01) from 6.9 mm and 6.7 mm, respectively, to 4.3 mm in both groups. Fascia thickness (P = .49) and presence of a heel spur (P = .88) at baseline had no impact on prognosis. At follow-up, fascia thickness and echogenicity had normalized in only 24% of the asymptomatic group. The mean fat pad thickness was 9.0 mm in patients who had received a US-guided corticosteroid injection and 9.4 mm in those who had not been given an injection (P = .66).

Conclusion:

The risk of having PF in this study was 45.6% at a mean 10 years after the onset of symptoms. The asymptomatic patients had PF for a mean 725 days. The prognosis was significantly worse for women and patients with bilateral pain. Fascia thickness decreased over time regardless of symptoms and had no impact on prognosis, and neither did the presence of a heel spur. Only 24% of asymptomatic patients had a normal fascia on US at long-term follow-up. A US-guided corticosteroid injection did not cause atrophy of the heel fat pad. Our observational study did not allow us to determine the efficacy of different treatment strategies.