Shock Waves for Plantar Fasciitis

Abstract & Commentary

Synopsis: Low-energy shock waves improved night pain, walking and rest pain, patient satisfaction, and reduced the need for surgery in patients with plantar fasciitis.

Source: Rompe JD, et al. J Bone Joint Surg Am. 2002;84-A(3):335-341.

Plantar fasciitis is not an uncommon cause of foot pain in recreational and competitive athletes that can be quite disabling. Pain is typically the worst with the first steps in the morning. Stretching and NSAIDs, possibly with corticosteroid injections, are the mainstay of conservative management, and the condition frequently persists for several months. Surgery to release the plantar fascia origin from the calcaneus is occasionally recommended for refractory cases.

Extracorporeal shock waves have been explored as a treatment modality for a variety of musculoskeletal conditions, including tennis elbow or tendinopathies at various sites, and plantar fasciitis for which it is now FDA approved. This is similar to the technology used to break up kidney stones. Rompe and his colleagues from Germany used 3 treatments of 1000 low-energy shock waves each spaced a week apart and compared it to a control group receiving only 10 impulses each time. Flouroscopy was used to position the shock wave beam. All patients had failed nonoperative treatment first, including various combinations of physical therapy, NSAIDs, injections, inserts, and night splints.

One hundred twelve patients were randomized prospectively and the observers were blinded. Confounding treatment variables were controlled and limited for 6 weeks before and during the study period. At 6 months, the rate of good or excellent outcomes as measured by the Roles and Maudsley pain score were 47% better for the treated group than the nontreated group. Half of the treated group could walk without pain compared to none of the nontreated group. At 5 years, 58% of the nontreated group had required surgery and 23% were still undergoing conservative treatment of some form, compared to only 13% having surgery in the treated group and none having ongoing conservative treatment. These differences at both time points were statistically significant.

Comment by David R. Diduch, MS, MD

Lithotripsy for plantar fasciitis? How does this work? Not even the investigators know. But there is mounting evidence, including this well-designed study, that it does work. Rompe et al demonstrated measurable differences in pain, walking ability, need for surgery, and need for continued nonoperative therapy. It was prospective, randomized, and blinded for the observers although not blinded for the patients. Confounding treatments were well controlled. It would appear that there is something to this. Other studies, especially in Europe, support its use as well. The FDA has now approved this technique for treatment of heel pain in the United States. But, Rompe et al emphasize that it should not be considered a first-line treatment modality.

The fact that these were low-energy shock waves is important as some applications use higher energy impulses. Studies such as this are important to help determine how this actually works and what other applications are appropriate. We are about to begin a similar prospective, multi-center, randomized, controlled trial with this technology for rotator cuff tendonitis and bursitis. We will see. One thing is for sure, this shock wave can hurt. I tried it on myself and can attest to that. Rompe et al called it "unpleasant," but for the high energy impulses, I would use a stronger word. Patient compliance may be a concern, so more studies to help determine how much is enough are indicated.

Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA,is Editor of Sports Medicine Reports.