Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs

Abstract

Background: Plantar fasciitis is the most common cause of heel pain. It may remain symptomatic despite conservative treatment with orthoses and analgesia. There is conflicting evidence concerning the role of extracorporeal shock wave therapy (ESWT) in the management of this condition.

Questions/purposes: We investigated whether there was a significant difference in the change of (1) VAS scores and (2) Roles and Maudsley scores from baseline when treated with ESWT and placebo. Specifically we compared overall improvement from baseline composite VAS, reduction in overall VAS pain, success rate of improving overall VAS pain by 60%, success rate of improving VAS pain by 60% when taking first steps, doing daily activities, and during application of a pain pressure meter.

Methods: MEDLINE, Embase, and CINAHL databases were searched from January 1980 to January 2013 and a double extraction technique was used to obtain relevant studies. Studies had to be prospective randomized controlled trials on adults and must not have used local anesthesia as part of their treatment protocol. Studies must have specifically recruited patients who continued to be symptomatic despite a minimum of 3 months of conservative treatments. All papers were assessed regarding their methodologic quality and a meta-analysis performed. Seven prospective randomized controlled trials were included in this study. There were 369 patients included in the placebo group and 294 in the ESWT group.

Results: After ESWT, patients had better composite VAS scores (random effects model, standardized mean difference [SMD] = 0.38; 95% CI, 0.05, 0.72; z = 2.27). They also had a greater reduction in their absolute VAS scores compared with placebo (random effects model, SMD = 0.60; 95% CI, 0.34, 0.85; z = 4.64). Greater success of improving heel pain by 60% was observed after ESWT when taking first steps (random effects model, risk ratio [RR] = 1.30; 95% CI, 1.04, 1.62; z = 2.29) and during daily activities (random effects model, RR = 1.44; 95% CI, 1.13, 1.84; z = 2.96). Subjective measurement of pain using a pressure meter similarly favored ESWT (random effects model, RR = 1.37, 95% CI, 1.06, 1.78; z = 2.41). There was a significant difference in the change to "excellent - good" Roles and Maudsley scores in favor of the ESWT group.

Conclusions: ESWT is a safe and effective treatment of chronic plantar fasciitis refractory to nonoperative treatments. Improved pain scores with the use of ESWT were evident 12 weeks after treatment. The evidence suggests this improvement is maintained for up to 12 months. We recommend the use of ESWT for patients with substantial heel pain despite a minimum of 3 months of nonoperative treatment.

Figures

Fig. 1

The flowchart shows the process of study selection.

Fig. 2

This forest plot shows the overall percentage of improvement in mean VAS composite scores after 12 weeks. IV = inverse variance; Std. = standard; ESWT = extracorporeal shock wave therapy.

Fig. 3

This forest plot shows the reduction in overall heel pain after 12 weeks. IV = inverse variance; Std. = standard; ESWT = extracorporeal shock wave therapy.

Fig. 4

This forest plot shows the success rate of heel pain improvement when taking first steps after 12 weeks. M-H = Mantel-Haenszel; ESWT = extracorporeal shock wave therapy.

Fig. 5

This forest plot shows the success rate of heel pain improvement when taking first steps after 12 weeks. M-H = Mantel-Haenszel; extracorporeal shock wave therapy.

Fig. 6

This forest plot shows the success rate of heel pain improvement while doing daily activities after 12 weeks. M-H = Mantel-Haenszel; extracorporeal shock wave therapy.

Fig. 7

This forest plot shows the success rate of heel pain improvement after application of pressure meter after 12 weeks. M-H = Mantel-Haenszel; ESWT = extracorporeal shock wave therapy.