Clinical practice. Plantar fasciitis.

A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia (tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated.

https://bjsm.bmj.com/content/bjsports/39/7/411.full.pdf

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

Background:Plantar fasciitis is a relatively common disorder of the foot, yet little is known about its prevalence, what types of physicians see patients with the disorder, or how, on a national sc...

Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors.

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

/pdf/extracorporeal-shockwave-therapy-in-musculoskeletal-4atujxco70.pdf

Extracorporeal shockwave therapy in musculoskeletal disorders

Background
Ten percent of people may experience pain under the heel (plantar heel pain) at some time. Injections, insoles, heel pads, strapping and surgery have been common forms of treatment offered. The absolute and relative effectiveness of these interventions are poorly understood.

Objectives
The objective of this review was to identify and evaluate the evidence for effectiveness of treatments for plantar heel pain.

Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (September 2002), the Cochrane Central Register of Controlled Trials Register (The Cochrane Library issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1988 to September 2002) and reference lists of articles and dissertations. Four podiatry journals were handsearched to 1998. We contacted all UK schools of podiatry to identify dissertations on the management of heel pain, and investigators in the field to identify unpublished data or research in progress. No language restrictions were applied.

Selection criteria
Randomised and quasi-randomised trials of interventions for plantar heel pain in adults.

Data collection and analysis
Two reviewers independently evaluated randomised controlled trials for inclusion, extracted data and assessed trial quality. Additional information was obtained by direct contact with investigators. No poolable data were identified. Where measures of variance were available we have calculated the weighted mean differences based on visual analogue scale (VAS) scores.

Main results
Nineteen randomised trials involving 1626 participants were included. Trial quality was generally poor, and pooling of data was not conducted. All trials measured heel pain as the primary outcome. Seven trials evaluated interventions against placebo/dummy or no treatment. There was limited evidence for the effectiveness of topical corticosteroid administered by iontophoresis, i.e. using an electric current, in reducing pain. There was some evidence for the effectiveness of injected corticosteroid providing temporary relief of pain. There was conflicting evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term (6 and 12 weeks) and therefore its effectiveness remains equivocal. In individuals with chronic pain (longer than six months), there was limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. There was no evidence to support the effectiveness of therapeutic ultrasound, low-intensity laser therapy, exposure to an electron generating device or insoles with magnetic foil. No randomised trials evaluating surgery, or radiotherapy against a randomly allocated control population were identified. There was limited evidence for the superiority of corticosteroid injections over orthotic devices.

Authors' conclusions
Although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in randomised controlled trials.

At the moment there is limited evidence upon which to base clinical practice. Treatments that are used to reduce heel pain seem to bring only marginal gains over no treatment and control therapies such as stretching exercises. Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. Orthoses should be cautiously prescribed for those patients who stand for long periods; there is limited evidence that stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than eight hours per day.

Well designed and conducted randomised trials are required.

Interventions for treating plantar heel pain

ContextExtracorporeal shock wave therapy (ESWT) is increasingly used for plantar
fasciitis, but limited evidence supports its use.ObjectiveTo determine whether ultrasound-guided ESWT reduces pain and improves
function in patients with plantar fasciitis.DesignDouble-blind, randomized, placebo-controlled trial conducted between
April 1999 and June 2001.SettingParticipants were recruited from the community-based referring physicians
(primary care physicians, rheumatologists, orthopedic surgeons, and sports
physicians) of a radiology group in Melbourne, Australia.ParticipantsWe screened 178 patients and enrolled 166; 160 completed the 15-week
protocol. Entry criteria included age at least 18 years with plantar fasciitis,
defined as heel pain maximal over the plantar aspect of the foot of at least
6 weeks' duration, and an ultrasound-confirmed lesion, defined as thickening
of the origin of the plantar fascia of at least 4 mm, hypoechogenicity, and
alterations in the normal fibrillary pattern.InterventionsPatients were randomly assigned to receive either ultrasound-guided
ESWT given weekly for 3 weeks to a total dose of at least 1000 mJ/mm2 (n = 81), or identical placebo to a total dose of 6.0 mJ/mm2 (n = 85).Main Outcome MeasuresOverall, morning, and activity pain, measured on a visual analog scale;
Maryland Foot Score; walking ability; Short-Form–36 Health Survey (SF-36)
score; and Problem Elicitation Technique score, measured at 6 and 12 weeks
after treatment completion.ResultsAt 6 and 12 weeks, there were significant improvements in overall pain
in both the active group and placebo group (mean [SD] improvement, 18.1 [30.6]
and 19.8 [33.7] at 6 weeks [P = .74 for between-group
difference], and 26.3 [34.8] and 25.7 [34.9] at 12 weeks [P = .99], respectively). Similar improvements in both groups were also
observed for morning and activity pain, walking ability, Maryland Foot Score,
Problem Elicitation Technique, and SF-36. There were no statistically significant
differences in the degree of improvement between treatment groups for any
measured outcomes.ConclusionWe found no evidence to support a beneficial effect on pain, function,
and quality of life of ultrasound-guided ESWT over placebo in patients with
ultrasound-proven plantar fasciitis 6 and 12 weeks following treatment.

/pdf/ultrasound-guided-extracorporeal-shock-wave-therapy-for-4wadcwqr0b.pdf

Joylene Buchanan

Papers

Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial.