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

The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Tendinopathy is a common condition that affects the body's tendon structures, causing discomfort, restricted movement, and reduced functionality. In this study, we looked at how extracorporeal shock wave therapy (ESWT) affected pain levels in individuals with various forms of tendinopathy around the world.

DESIGN

This study is a comprehensive review and meta-analysis of previously published randomized controlled trials. To gather relevant data, the researchers performed keyword searches in international databases, including PubMed (Medline), Scopus, Web of Sciences, Cochrane Central Register of Controlled Trials (CENTRAL), Research Registers of ongoing trials (ClinicalTrials.gov), as well as Embase. The search was conducted up until March 2023. The quality of the selected articles was assessed using the Cochrane risk-of-bias method for randomized trials (RoB2).

RESULTS

Based on the results of the meta-analysis, which included 45 clinical studies, the use of ESWT was found to have a significant impact on reducing pain in various conditions. The standardized mean difference (SMD) in patients with plantar fasciitis (PF) was reduced by 1.63 (SMD: -1.63, 95% CI: -3.04, -0.21; I2: 77.36%; P heterogeneity: 0.0001). For lateral epicondylitis (LE), the SMD was 0.63 (SMD: -0.63, 95% CI: -1.11, -0.16; I2: 67.50%; P heterogeneity: 0.003). In the case of chronic Achilles tendinopathy, the SMD was 1.38 (SMD: -1.38, 95% CI: -1.66, -1.10; I2: 96.44%; P heterogeneity: 0.0001). Additionally, in individuals with rotator cuff tendinopathy, the SMD for pain reduction was 2.37 units (SMD: -2.37, 95% CI: -3.58, -1.15; I2: 98.46%; P heterogeneity: 0.0001).

CONCLUSION

This study suggests that ESWT can be a highly effective therapy option for relieving pain in people with tendinopathy. Nonetheless, it is encouraged to make additional recommendations based on high-quality clinical research and more accurate information in order to define the optimal therapeutic options for each type of tendinopathy.

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.

Myofascial points treatment with focused extracorporeal shock wave therapy (f-ESWT) for plantar fasciitis: an open label randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common cause of heel pain. Among the several conservative treatment options, extracorporeal shock wave therapy (ESWT) is considered the standard treatment. However, recent studies suggest that PF may be sustained by a myofascial impairment proximal to the pain area with a biomechanical disequilibrium of the entire limb and pelvis.

AIM

By combining the concepts of fascial manipulation and ESWT, the purpose of this study was to evaluate the effectiveness of the ESWT on myofascial points in a sample of subjects with PF.

DESIGN

Open label randomized controlled clinical trial.

SETTING

Outpatient clinic.

POPULATION

Patients with PF were randomly assigned to an experimental treatment group (EG), treated with focused ESWT on myofascial points, and a control group (CG), treated with the focused ESWT traditional approach on the medial calcaneal tubercle.

METHODS

Every patient underwent a 3-session program and follow-up after 1 and 4 months. Outcome measures included the Foot and Ankle Outcome Score (FAOS) and the Italian Foot Functional Index (17-iFFI).

RESULTS

Thirty patients were enrolled in the study. Four patients of the CG dropped out the study, therefore twenty-six patients were included in the final analysis. Improvement in 17-iFFI and FAOS scores was observed in both groups starting from the third treatment and confirmed at the 1-month and 4-month follow-ups, with earlier improvement in the score values observed in the EG.

CONCLUSIONS

Treatment of the myofascial points with ESWT in subjects suffering from plantar fasciitis could be an effective treatment option. It fosters the hypothesis that a global biomechanical re-equilibrium of the body would be necessary to completely solve the pathology.

CLINICAL REHABILITATION IMPACT

ESWT on myofascial points could provide an interesting alternative with better outcomes in terms of time needed for recovery compared to traditional ESWT for the conservative management of PF.

Platelet rich plasma versus glucocorticoid for plantar fasciitis: A protocol for systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Plantar fasciitis (PF) is the most common cause of heel pain in adult. There are a variety of ways to treat PF, but these treatments have varied result in their effectiveness, and exist different degrees of limitations. At present, clinical studies focus on the effect of glucocorticoid (GC) and platelet rich plasma (PRP) in the treatment of PF, but there is a lack of systematic evaluation PRP and GC's clinical effect towards PF. This study aims to evaluate the long-term efficacy of GCs and PRP in the treatment of PF by means of meta-analysis.

METHODS

The literature of a randomized controlled clinical trial of PRP in the treatment of plantantifasciitis was searched on the Internet. Retrieve 7 databases. EndNote X9 software was used for document management. The Jadad scale was used to score the literature. Risk assessment of the literature was conducted according to Cochrane's systematic evaluation manual 5.0. RevMan5.3 software was used for literature risk bias analysis. Stata12.0 software is used for sensitivity analysis.

RESULTS

This study will provide effective evidence-based evidence for the long-term efficacy of PRP and GC in treating PF.

CONCLUSION

A systematic review and meta-analysis were conducted for the comparison of the long-term effect of PRP and GC on plantar fascia in the treatment of PF.

Dextrose prolotherapy versus radial extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: A randomized, controlled clinical trial

In the recent years, prolotherapy is increasingly being used in the field of musculoskeletal medicine. However, few studies have investigated its effectiveness in plantar fasciitis (PF). The purpose of this study was to compare the effectiveness of ultrasound-guided dextrose prolotherapy with radial extracorporeal shock wave therapy (ESWT) in the treatment of chronic PF. This randomized controlled trial was conducted on 59 patients with chronic PF. Patients were randomly assigned into two groups receiving three sessions of radial ESWT (29 patients) vs. two sessions of ultrasound-guided intrafascial 2 cc dextrose 20% injection (30 patients). The following outcome measures were assessed before and then six weeks and 12 weeks after the treatments: pain intensity by visual analog scale (VAS), daily life and exercise activities by Foot and Ankle Ability Measure (FAAM), and the plantar fascia thickness by ultrasonographic imaging. The VAS and FAAM scales showed significant improvements of pain and function in both study groups 6 weeks and 12 weeks after the treatments. A significant reduction was noted for plantar fascia thickness at these intervals (all p < .05). The inter-group comparison revealed that except for the FAAM-sport subscale which favored ESWT, the interaction effects of group and time were not significant for other outcome measures. Dextrose prolotherapy has comparable efficacy to radial ESWT in reducing pain, daily-life functional limitation, and plantar fascia thickness in patients with PF. No serious adverse effects were observed in either group. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

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.

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.

Shear wave elastography for treatment monitoring of plantar fasciitis

BACKGROUND

Plantar fasciitis is a common cause of heel pain. Monitoring therapy effects is challenging with conventional B-mode ultrasound. Shear wave elastography (SWE) provides important diagnostic information beyond B-mode, with typically lower tissue stiffness in symptomatic plantar fascia. Up to now little is known about SWE features for therapy monitoring in plantar fasciitis. We evaluated the clinical effects of a 3-month physical therapy based treatment and its influence on B-mode and SWE ultrasound findings in patients suffering from plantar fasciitis, correlating ultrasound findings to score-based symptom development.

METHODS

Prospective, IRB-approved clinical study in plantar fasciitis patients undergoing a 3-month physical therapy based treatment. Measurement time points were before (T0), after 1 (T1) and 3 (T2) months of treatment, consisting of clinical orthopedic (FFI, AOFAS-Score) and multimodal radiologic sonographic examinations (B-mode/SWE) using a high-resolution linear 18-MHz probe.

RESULTS

A total of 33 patients with 43 symptomatic plantar fascia were included. We found a significant (P<0.001) clinical score improvement (AOFAS +14, FFI-Pain -21, FFI-Function -18) between T0 and T2. Mean initial thickness (T0) of symptomatic plantar fascia was 4.2 (±1.2) mm, compared to 3.2 (±0.7) mm at the asymptomatic contralateral side (P<0.001). No significant thickness changes were seen at T1 (4.2±1.1 mm) and T2 (4.5±1.3 mm), even though clinical scores improved significantly. Mean initial stiffness (T0) of symptomatic plantar fascia was 59.57 (±43.3) kPa, compared to 83.23 (±47.3) kPa at the asymptomatic contralateral side (P<0.001). In contrast to B-mode ultrasound, SWE values increased significantly between T0 (59.6±43.3 kPa), T1 (82.6±47.3 kPa) and T2 (102.5±47.2 kPa) (P<0.001-0.009), with positive correlations for AOFAS/FFI-Pain/Function scores (r=0.285-0.473, P<0.001-0.002).

CONCLUSIONS

A physical therapy based treatment relieves plantar fasciitis symptoms during a 3-month period. In line with symptom reduction, stiffness (Young's-moduli) of plantar fascia increased significantly, while B-mode ultrasound revealed no measurable changes during the healing process. Shear wave elastography was able to quantify plantar fascia pathologies and their recovery under therapy.

Short-Term Efficacy of Kinesiotaping versus Extracorporeal Shockwave Therapy for Plantar Fasciitis: A Randomized Study

BACKGROUND

Plantar fasciitis is a degenerative condition that is one of the most common causes of heel and foot pain. Among noninvasive management of plantar fasciitis, extracorporeal shockwave therapy (ESWT) has been extensively studied and found to be effective, but few studies have assessed the effectiveness of kinesiotaping (KT) method.

OBJECTIVE

This study aimed to show the effectiveness of KT compared with ESWT in the management of plantar fasciitis.

METHODS

A total of 84 patients with plantar fasciitis were enrolled from a single center and randomized into KT and ESWT treatment groups in a 1:1 ratio (i.e., 42 patients in each group); only one foot was considered for each patient. Both KT and ESWT were applied once a week for 6 weeks. Patients' pain, functional status and quality of life were evaluated with the visual analog scale (VAS), Foot Function Index (FFI) and the Short-Form-36 (SF-36) health survey, respectively. Patients' fat pat and plantar fascia thickness were measured using ultrasonography. All evaluations were performed before and immediately after the 6-week intervention.

RESULTS

In the KT group, six patients were lost to follow-up; therefore, the final analysis only included 36 patients. After the intervention, there was a statistically significant improvement in the VAS and SF-36 scores of both groups (P = 0.001), but the FFI score improvement was statistically significant only in the KT group (P = 0.001). In both groups, the mean thickness of plantar fascia decreased after treatment and the mean thickness of the fat pat increased; however, the change was not statistically significant (P = 0.935 and P = 0.832, respectively).

CONCLUSION

Both KT and ESWT treatments improved pain levels and quality of life in patients with plantar fasciitis, but KT also improved functionality. Multicentered studies with larger sample size and longer follow-ups are required to further validate these findings.

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.

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.