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Three Part Question

In [Plantar Fasciitis, acute and chronic] is [Extracorporeal Shock wave Therapy (ECSWT)] more effective than [other conservative treatments (such as orthotics, physiotherapy including stretches, massage, taping and exercise)]?

Clinical Scenario

47year old gentleman presents to physiotherapy with a 6 month history of right heel pain, worse in the morning, particularly the first few steps. Previous conservative management failed. Physiotherapy including calf stretches, taping, activity modification and soft tissue techniques was unsuccessful. Insoles provided by podiatry were not effective. This patient has been told about shockwave therapy by a friend and would like to try it.

Search Strategy

Medline 1966-09 using the PubMed Clinical queries database was searched using the following terms:
(Therapy/Broad[filter]) and [Plantar Fasciitis or Heel Pain] and Ultrasound Shockwave Therapy;

(Therapy/Broad [filter]) AND (Shockwave Therapy); Therapy/Broad [filter] AND (Shockwave [All Fields] AND (“therapy” [Subheading] OR “therapy” [All Fields] OR “therapeutics” [MeSH Terms] OR “therapeutics” [All Fields]))


In addition the Best BETS database was searched using similar terms. Finally, the PEDrO (Physiotherapy best evidence) database was searched, as above, with only papers already rated as 7/10 on the quality score being selected for inclusion.
PEDrO (Physiotherapy best evidence database): http://www.pedro.org.au/
Pub Med: http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Best BETS http://www.bestbets.org

Search Outcome

Altogether 315 titles were identified from the combined searches, after duplicates had been removed. 13 abstracts were identified as being possibly relevant and the full articles retrieved.
Reference lists were then checked and 28 additional papers were identified as being potentially relevant. Abstracts were divided up between members of the team and screened. Full papers were obtained for those papers that answered, or potentially answered the three part search question. These papers were rated for quality and risk of bias using a standard proforma (See appendix 1) with papers scoring over 7/10 being summarised in Table 1. This process resulted in 4 papers being rated as good quality and directly answering the PICO question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Maley DS, Pressman MM, Assili et al 2006 USA	Plantar fasciitis 122 active : ESWT 61 placebo: ESWT with absorbing foam on dial and low frequency delivered Only one treatment dose	RCT	Heel pain measured with Pressure Spec device: VAS at 1,2 and 3 months	Only recorded participants with decrease in pain 50% of <4cm on VAS . 1/12: ESWT : 19.8% placebo 16.7%. 2/12: 34.2% : 16.7%.3/12 42.9% : 19.6%	In placebo group they still experienced some ESWT as they could not stop all energy Only one treatment
			Change in function and activity ( dichotomous change in 1 point over baseline a success)	No significant difference
			Change in pain medications : 3 points: increased no change, decreased	1/12: inc 6.3% : 9.3%. 2/12: inc 1.1% : 10.6%. 3/12: inc 1% : 11.08%
Buchbinder R Ptasznik R, Gordon, C et al 2002 Australia	160 patients with heel pain >6/52 with US changes (thickening of PF origin >4mm Control group (85) given tiny dose at same intervals for weekly for 3/52	RCT	VAS pain (overall, morning and activity), Maryland foot score, SF36, walking ability, problem elicitation technique. Measured at 6 and 12 week F/Us	Significant improvements in overall pain in both groups.No difference between ESWT and placebo. Anaesthetic was used.	No longer term f/u
Rompe JD, Decking J, Schoellner C et al 2003 Germany	45 long distance runners with > 12 month history of heel pain. Group 1 3 x 2100 impulses of low energy shock waves and the other Group 2 received sham treatment	Prospective randomized placebo controlled trial.	Subject’s self assessment of pain on first walking in the morning VAS scale.	After 6 months 60% of patients in the treatment group and 27% in the sham group reported more than a 50% improvement in pain. After 12 months 72% in the treatment group and 35% in the sham group had > 50% improvement.	Small sample size (38) at end follow up. Only valid in long distance runners. One author received financial benefit
			American Orthopaedic Foot and Ankle Society’s Ankle-Hindfoot Scale.	An increase in the Ankle – Hindfoot Scale in both groups 37.2 points in treatment group and 19.4 in sham group.
Gerdesmeyer, L, Frey, C, Vester J, et al 2008 Germany	245 chronic plantar fasciitis 3 x ESWT vs control group	RCT	VAS at baseline compared to post treatment	Radial ESWT proved significantly superior to placebo with a reduction of VAS by 72.1% compared to 44%	Supported by manufacturer Administrator of ESWT not blinded
			Single VAS of heel pain in morning , During ADLs and during applied pressure	Overall success rate at 12 weeks: 61% : 42.2%

Comment(s)

Very few articles passed the appraisal checklist. Of the 4 papers that passed, the outcomes were mixed, with one paper (Buchbinder, 2002) reporting no difference compared to placebo, and another (Gerdesmayer, 2008) reporting significant difference to placebo at both short and long term follow-up. The variations in the results could be due some studies using local anaesthetic. The papers which proved the success of ESWT did not use anaesthetic and were therefore more able to identify the localised area of tenderness.

Clinical Bottom Line

There is not sufficient evidence to support ESWT for Plantar Fasciitis in the clinical setting. Further good quality studies in this area are warranted.

References

1. Maley DS, Pressman MM, Assili et al Extracorporeal Shockwave Therapy Versus Placebo for the Treatment of Chronic Proximal Plantar Fasciitis: Results of a Randomized, Placebo-Controlled, Double-Blinded, Multicenter Intervention Trial THE JOURNAL OF FOOT & ANKLE SURGERY (2006) 196- 210
2. Buchbinder R Ptasznik R, Gordon, C et al Ultrasound-Guided Extracorporeal Shock Wave Therapy for Plantar Fasciitis A Randomized Controlled Trial JAMA 2002:18 288 (11) 1364 – 1372
3. Rompe JD, Decking J, Schoellner C et al Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes: A Prospective, Randomized, Placebo-Controlled Trial. Am J Sports Med 2003 31: 268
4. Gerdesmeyer, L, Frey, C, Vester J, et al Radial Extracorporeal Shock Wave Therapy Is Safe and Effective in the Treatment of Chronic Recalcitrant Plantar Fasciitis Results of a Confirmatory Randomized Placebo-Controlled Multicenter Study. The American Journal of Sports Medicine 2008;1-10