SLR - April 2011 - Saadia Whatley

Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy as Initial Treatment of Plantar Fasciopathy 

Reference:  Jan D. Rompe, Angelo Cacchio, Lowell Weil, Jr. John P. Furia, Joachim Haist, Volker Reiners, Christoph Schmitz and Nicola Maffulli. J Bone Joint Surg Am. 2010;92:2514-2522. Doi:10.2106/JBJS.I.061651

Scientific Literature Review

Reviewed by: Saadia Whatley, DPM
Residency program: Central Alabama Veterans Hospital

Podiatric Relevance: 
The cause of plantar fasciopathy, whether with or without a heel spur, is poorly understood and most of the time multifactorial.  In runners it usually occurs with overuse, training errors or excessive wear or improper footwear. In sedentary adults it usually can be attributed to contracted gastrocnemius, a secondary acquired pes planus, or obesity. Nonsurgical methods are the mainstay of managing plantar heel pain.  This study was performed as a randomized controlled study to measure the effectiveness of repetitive plantar fascia-specific stretching or repetitive low-energy shock wave therapy as initial treatment for plantar fasciopathy of up to six weeks of duration.  The null hypothesis was that plantar fascia specific shock wave therapy and stretching would produce equivalent outcomes at two months baseline.

Materials and Methods: 
102 pts with acute plantar fasciopathy were randomly picked to perform in an eight week plantar fascia specific stretching program (Group 1 n=54) or to receive repetitive low-energy radial shock-wave therapy w/o local anesthesia, administered weekly for three weeks(Group 2, n =48). No previous tx had been received.  All patients had maximum pain on palpation of the medial tubercle, worsening of symptoms with weight-bearing activities. Group 1 was given instructions of specific stretching exercises to be done 3 x daily for eight weeks.  Group 2 received three sessions of radial shock therapy at weekly intervals. At each session 2000 pulses were applied with treatment frequency of 8 pulses/second. No local was used. Pts were advised that increased pain in the plantar fascia could appear during the first two weeks of therapy. If needed an NSAID could be taken.  Pts were evaluated at a baseline and at 2, 4, and 15 months after baseline.  A pain subscale of validated Foot Function Index, (0=no pain, 10=worst pain) and a patient-relevant outcome measures(SROM) questionnaire related to pain, function, and satisfaction with treatment was assessed.

Results: 
Both groups reported an overall reduction in pain. Two months after baseline, the pain subscale score showed significantly greater changes for patients in Group 1 that had undergone plantar fascia stretching than those who were managed with shock wave therapy (p<0.001), as well as individually for item 2 (p=0.002), the pt-relevant outcome measures in regard to pain and satisfaction with treatment.  65% of pts in Group 1 vs 29% of pts in Group 2 were satisfied with treatment outcomes.  The following findings persisted at four months as well, but at fifteen months after baseline, no significant between-group difference was measured.

Conclusions: 
The study demonstrated that manual stretching exercises specific to plantar fascia were superior to low energy radial shock wave therapy for initial management of acutely presenting plantar fasciopathy.  Shock wave therapy works by reducing  substance P and calcitonin gene-related peptide which normally works to cause neurogenic inflammation/pain, and also triggers physiological healing when there is a failed healing response as with delayed unions, or nonunions, tendinopathy or fasciopathy.  Some strengths of the study were that it was prospective and randomized and over a significant period of time for followup. Weaknesses were perhaps in the case of shock wave therapy, a longer period of 2month followup may have been needed to allow the therapy to work, as a failed healing response (which takes time) needs to occur before any healing can be triggered by the therapy.

Educational Opportunities

Upcoming