Utilizing meta-analysis, the authors have reviewed the available literature to assess the biologic and therapeutic effects of shockwaves on patients with chronic plantar fasciitis and the credibility of these published studies.
Methods:
Meta-analysis is a systematic method for statistical analysis that combines data from various independent studies, allowing the assessment of potential benefits of various treatments when conclusions based on individual studies may be difficult to evaluate. We hypothesized that extracorporeal shockwave therapy provided a reasonable nonoperative therapeutic alternative to surgical intervention in the treatment of chronic proximal plantar fasciitis.
Results:
Eight of 20 published studies fulfilled our type A to C criteria for acceptable studies of sufficient duration (one year or more after treatment). These eight studies involved 840 patients, with success rates of as much as 88%. The other 12 studies had methodological variables or lack of appropriate follow-up data that would limit their validity, although the success rates were comparable to the A to C studies.
Conclusions:
This meta-analysis shows that the directed application of shockwaves to the enthesis of the plantar fascia at the inferior calcaneus is a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome that has been refractory to other commonly used nonoperative therapies. The results suggest that this therapeutic procedure should be considered before any surgical intervention, and may be preferable prior to cortisone injection, which has a recognized risk of rupture of the plantar fascia and a frequent recurrence of symptoms.
BhandariM.MorrowF.KulkarniAVTomettaP.III: Metaanalyses in orthopaedic surgery. J. Bone Joint Surg. (Am.), 83A: 15–24, 2001.
9.
BrunnerW. R.ThuringerG.AscherA. et al.: Die extrakorporelle Stoßwellentherapie in der Orthopadie—Drei Monats Ergebnisse in 443 Fallen. Orthop. Praxis, 33: 461–464, 1997.
10.
BuchM.SchlangmannBALübbersC.TrägerD.SiebertWE: Results of shockwave therapy of calcaneal spur from the orthopaedic hospital in Kassel: Influence of various parameters on the outcome. In: SiebertW.BuchM.): Extracorporeal shockwaves in Orthopaedics, Springer Verlag, Berlin, 1997, pp. 30–35.
11.
BuchM.SiebertW.: Shockwave treatment for heel pain syndrome—A prospective investigation. In CoombsR.SchadenW.ZhouSS). Musculoskeletal shockwave Therapy. Greenwich Medical Media, London, 2000, pp. 73–77.
12.
ChenH. S.ChenL. M.HuangT. W.: Treatment of painful heel syndrome with shockwaves. Clin. Orthop., 387: 41–46, 2001.
13.
CoombsR.SchadenW.ZhouSS (eds): Musculoskeletal shockwave Therapy. Greenwich Medical Media, London, 2000.
14.
DahmenG.FrankeP.GoncharsV. et al.: Die Behandlung knochennaher Weichteilschmerzen mit Extracorporaler Stoßwellentherapie (ESWT): Indikation, Technik, und bisherige Therapie. In: ChaussyC.EisenbergerF.JochumD.WilbertD.): Die Stoßwelle—Forschung und Klinik. Attempto-Verlag, Tubingen, 1995, pp. 175–186.
15.
DaviesMSWeissGASaxbyTS: Plantar fasciitis: How successful is surgical intervention? Foot Ankle, 20: 803–807, 1999.
DieschR.HauptG.: Extracorporeal shockwaves in the treatment of pseudarthrosis, tendinosis calcarea of the shoulder and calcaneal spur. In: SiebertW.BuchM.): Extracorporeal shockwaves in Orthopaedics. Springer Verlag, Berlin, 1997, pp. 131–135.
19.
DieschR.StraubT.PenningerE.FrolicjT.SchollJ.: Conventional versus ballistic shockwave treatments for calcaneal spur. In: CoombsR.SchadenW.ZhouSS). Musculoskeletal shockwave Therapy, Greenwich Medical Media. London, 2000, pp. 71–72.
20.
FuselierHAPratsL.FontenotC.GauthierA.Jr.: Comparison of mobile lithotripters at one institution: HealthTronics LithoTronTM, Dornier MFL-5000 and Dornier DoLi. J. Endourol., 13: 539–542, 1999.
21.
GentileATZizzoCJDahukeyA.BermanSS: Traumatic pseudoaneurysm of the lateral plantar artery after endoscopic fasciotomy. Foot Ankle, 18: 821–823, 1997.
22.
HaistJ.Von Keitz StengerD.MohrG.SchulzeG.WeberF.: The orthopaedic shockwave therapy in the treatment of chronic insertion tendopathy and tendinosis calcarea. In: SiebertW.BuchM.): Extracorporeal shockwaves in Orthopaedics. Springer Verlag, Berlin, 1997, pp. 159–163.
23.
HammerDSRuppS.EnsslinS.KohnD.SielR.: Extracorporeal shockwave therapy in patients with tennis elbow and painful heel. Arch. Orthop. Trauma Surg., 120: 304–307, 2000.
24.
HauptG.: Use of extracorporeal shockwaves in the treatment of pseudarthrosis, tendinopathy and other orthopaedic diseases. J. Urology, 158: 4–11, 1997.
25.
HauptG.HauptA.EkkernkampA.GeretyB.ChvapilM.: Influence of Shockwaves on fracture healing. Urology, 39: 529–532, 1992.
26.
HedrickMR: The plantar aponeurosis. Foot Ankle, 17: 646–649, 1996.
27.
HelbigK.SchostokT.BrownM.HerbertC.ThieleR.: Correlations between pain and success. In: CoombsR.SchadenW.ZhouSS): Musculoskeletal shockwave Therapy, Greenwich Medical Media. London, 2000, pp. 43–48.
28.
HellerKDNiethardFU: Der Einsatz der extrakorpalen Stoßwellentherapie in der Orthopäde-ein Metaanalyse. Z. Orthop. Ihre Grenzgeb., 136: 390–401, 1998.
29.
HendrixCLJollyGPGarbalosaJCBlumeP.RemediosDos E.: Entrapment neuropathy: The etiology of intractable chronic heel pain syndrome. J. Foot Ankle Surg., 37: 273–279, 1998.
30.
HowesN.ChagaL.ThorpeM.McCullochP.: Surgical practice is evidence based. Br. J. Surg., 84: 1220–1223, 1997.
31.
JakobeitC.WelpL.WiniarskiB. et al.: Ultrasound-guided extracorporeal shockwave therapy of tendinosis calcarea of the shoulder, of symptomatic plantar calcaneal spur (heel spur) and of epicondylopathia radialis et ulnaris. In: SiebertW.BuchM.): Extracorporeal shockwaves in Orthopaedics. Springer Verlag, Berlin, 1997, pp. 165–180.
KimW.VoloshinAS: Role of plantar fascia in the load bearing capacity of the human foot. J. Biomech., 28: 1025–1033, 1995.
34.
KinleyS.FrasconeS.CalderoneD. et al.: Endoscopic plantar fasciotomy versus traditional heel spur surgery: A prospective study. J. Foot Ankle Surg., 32: 595–601, 1993.
35.
KitaokaHBLuoZPAnKNChaoKN: Mechanical behavior of the foot and ankle after plantar fascia release in the unstable foot. Foot Ankle, 18: 8–15, 1997.
36.
KrischekO.RompeJDHerbsthoferB.NafeB.: Symptomatische niedrigenergetische Stoßwellentherapie bei Fersenschmerzen und radiologisch nachweisbarem plantaren Fersensporn. Z. Orthop. Ihre Grenzgeb;135: 169–174, 1998.
37.
LeachRESeaveyMSSalterDK: Results of surgery in athletes with plantar fasciitis. Foot Ankle, 7: 156–161, 1986.
38.
LewisG.GattiA.BarryLDGreenbergPMLevensonM.: The plantar approach to heel surgery: A retrospective study. J. Foot Surg;30: 542–546, 1991.
39.
MantD.: Can randomized trials inform clinical decisions about individual patients? Lancet, 353: 743–746, 1999.
40.
MartinRLIrrgangJJConteSF: Outcome study of subjects with insertional plantar fasciitis. Foot Ankle, 19: 803–811, 1998.
41.
McLeodRS: Issues in surgical randomized controlled trials. World J. Surg;23: 1210–1214, 1999.
42.
MillerRATorresJ.McGuireM.: Efficacy of first-time steroid injection for painful heel syndrome. Foot Ankle, 16: 610–614, 1995.
43.
MurphyGAPneumaticosSGKamaricE. et al.: Biomechanical consequences of sequential plantar fascia release. Foot Ankle, 19: 149–152, 1998.
44.
NierenbergG.HoffmanA.EngelA.SteinH.: Pseudoaneurysm with an arteriovenous fistula of the tibial vessels after plantar fasciotomy: A case report. Foot Ankle, 18: 524–527, 1997.
PaiVS: Rupture of the plantar fascia. J. Foot Ankle Surg., 35: 39–40, 1996.
50.
PowellM.PostWRKeenerJ.WeardenS.: Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: A crossover prospective randomized outcome study. Foot Ankle, 19: 10–18, 1998.
51.
RolfC.GuntnerP.EricsaterJ.TuranI.: Plantar fascia rupture: Diagnosis and treatment. J. Foot Ankle Surg., 36: 112–114, 1997.
52.
RompeJD: Stoßwellentherapie: Therapeutische Wirkung bei spekulativem Mechanismus. Z. Orthop. Ihre Grenzgeb;134: 13–19, 1996.
53.
RompeJDHopfC.NafeB.BürgerR.: Low energy extracorporeal shockwave therapy for painful heel: A prospective controlled single-blind study. Arch. Orthop. Trauma Surg;115: 75–79, 1996.
54.
RompeJDKirkpatrickCJKüllmerK.SchwitalleM.KrischekO.: Dose related effects of Shockwaves on rabbit tendo Achilles. A sonographic and histological study. J. Bone Joint Surg;80B: 546–552, 1998.
55.
RompeJDKüllmerK.EyselP. et al.: Niedrigenergetische extrakorporale Stoßwellentherapie (ESWT) beim plantaren Fersensporn. Orthop. Prax., 32: 271–275, 1996.
56.
RompeJDKüllmerK.RiehleHM et al.: Effectiveness of low-energy extracorporeal shockwaves for chronic plantar fasciitis. Foot Ankle Surg., 2: 215–221, 1996.
RussoS.GigliottiS.De DuranteC. et al.: Results with extracorporeal shockwave therapy in bone and soft tissue pathologies. In: SiebertW.BuchM.): Extracorporeal shockwaves in Orthopaedics, Springer Verlag, Berlin, 1997, pp. 149–155.
59.
SchepsisAALeachREGorzycaJ.: Plantar fasciitis: Etiology, treatment, surgical results, and review of the literature. Clin. Orthop., 266: 185–196, 1991.
60.
SchöllnerC.RiedelC.SchwitalleM.RompeJDHeineJ.: Shockwave treatment for plantar heel pain. In CoombsR.SchadenW.ZhouSS). Musculoskeletal shockwave Therapy. London. Greenwich Medical Media53–59, 2000.
61.
SiebertW.BuchM. (eds): Extracorporeal shockwaves in Orthopaedics. Springer Verlag, Berlin, 1997, pp. 165–180.
62.
SellmanJR: Plantar fascia rupture associated with corticosteroid injection. Foot Ankle, 15: 376–381, 1984.
63.
TheileR.: The German extracorporeal shockwave society. In: SiebertW.BuchM.): Extracorporeal shockwaves in Orthopaedics. Springer Verlag, Berlin, 1997, pp. 189–200.
64.
TheodorouDJTheodoruSJFarookiS.KakitsubataY.ResnickD.: Disorders of the plantar aponeurosis: A spectrum of MR imaging findings. Am. J. Roentgen., 176: 97–104, 2001.
65.
ThordarsonDBKumarPJHedmanTPEbramzadehE.: Effect of partial versus complete fasciotomy on the windlass mechanism. Foot Ankle, 18: 16–20, 1997.
66.
UeberleF.: Shockwave technology. In: SiebertW.BuchM.): Extracorporeal shockwaves in Orthopaedics, Springer Verlag, Berlin, 1997, pp. 59–87.
67.
User's guide to evidence-based surgery: How to use an article evaluating surgical interventions. Canada J. Surg., 44: 95–100, 2001.
68.
WangCJChenLMChenWSChenHS: Heel spurs. In: CoombsR.SchadenW.ZhouS. S.). Musculoskeletal shockwave Therapy. Greenwich Medical Media, London, 2000, pp. 61–69.
69.
WildC.KheneM.WankeS.: Extracorporeal shockwave therapy in orthopedics. Assessment of an emerging health technology. Int. J. Technol. Assess. Health Care, 16: 199–209, 2000.
70.
WilliamsPLSimbertJGCoxR. et al.: Imaging study of the painful heel syndrome. Foot Ankle, 7: 345–349, 1987.
71.
WolfT.BreitenfelderJ.: Erste Erfahrungen mit der ESWT bei Schmerzzuständen des Bewegungsapparates mit umschriebener Lokalisation. Orthop. Praxis, 32: 480–483, 1996.
72.
YuJS: Pathological and postoperative conditions of the plantar fascia: Review of MR imaging appearances. Skeletal. Radiol;29: 491–501, 2000.
73.
YuJSSmithG.AshmanC.KaedingC.: The plantar fasciotomy: MR imaging findings in asymptomatic volunteers. Skeletal Radiol;28: 447–452, 1999.
74.
YuJSSpigosD.TomczakR.: Foot pain after a plantar fasciotomy: An MR analysis to determine potential causes. J. Comput. Assist. Tomogr;23: 707–712, 1999.
