SLR - September 2015 - Michael Corpuz

Clinically Relevant Effectiveness of Focused Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis

Reference: Gollwitzer H, Saxena A, DiDomenico LA, Galli L, Bouche RT, Caminear DS, Fullem B, Vester JC, Horn C, Banke IJ, Burgkart R, Gerdesmeyer L. Clinically Relevant Effectiveness of Focused Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis: A Randomized, Controlled Multicenter Study. J Bone Joint Surg Am. 2015 May 6;97(9):701-8.

Scientific Literature Review

Reviewed By: Michael Corpuz, DPM
Residency Program: Cedars-Sinai Medical Center, Los Angeles, CA

Podiatric Relevance: Heel pain originating from plantar fasciitis continues to be a prevalent problem in the realm of podiatric practice. The advent of extracorporeal shock wave therapy (ESWT) and its implementation in treating such chronic inflammatory heel pain have shown promising effectiveness by inducing hyperemia, stimulating neovascularization, and regenerating tendinous tissue. The authors of this publication aimed to further explore this treatment modality, hypothesizing that ESWT would demonstrate clinically significant effectiveness in treating chronic plantar fasciitis.

Methods: This was a double-blind, randomized, placebo-controlled trial performed at five different centers in the United States. Included patients had chronic heel pain associated with plantar fasciitis, were unresponsive to at least six months of non-operative treatment with at least two pharmocological and two non-pharmocological interventions. The intention-to-treat populations were the ESWT group (n = 125) and the placebo group (identical sham device w/ absent shockwaves, n = 121). Treatments consisted of three weekly sessions of 2000 impulses (0.25 mJ/mm2). The treating physician was non-blinded, however the patient and evaluating physicians were blinded to the randomization. Outcome measures consisted of a composite VAS score before intervention and after 12 weeks, a Roles and Maudsley (R&M) score quantifying functional improvement, a subjective global judgment of treatment effectiveness, and patient satisfaction. Treatment “success” was defined as at least 60 percent reduction in two of three VAS scores, if the participant was able to work, was satisfied with the treatment outcome, and required no additional therapy to alleviate any remaining heel pain.

Results: At 12 weeks post-intervention, a statistically significant favorable difference was found in regards to composite VAS score, R&M scores, and “treatment success” in the ESWT group in comparison to the placebo group (69.2 vs 34.5 percent, 60.8 vs 37.2 percent, and 64.8 vs 46.3 percent, respectively). Further improvement was noted in 71 of 81 patients re-evaluated at one year follow-up with better VAS and R&M scores.

Conclusions: Based on their findings, the authors of the publication concluded that ESWT provided significant and clinically relevant superiority compared to absent treatment in patients with chronic heel pain secondary to plantar fasciitis that was unresponsive to prior non-operative treatment modalities. They suggest that the regimen used, focused shock waves every week for three weeks, yields effective treatment for such a commonplace pathology in our profession.

Notably absent from this study is the inclusion of corticosteroid injection use, which might provide equally effective and a more economic solution for heel pain. Reviewing this publication demonstrates that further high-evidence literature that compares ESWT to other modalities (such as corticosteroids, biologics injections, a supervised physical therapy / stretching program, etc) is warranted. The clinical value of this study is apparent, and the practicing podiatric physician can consider adding extracorporeal shock wave therapy as an adjunctive intervention in their arsenal to combat stubborn plantar fasciitis.

Educational Opportunities