Extra-corporeal Shockwave Therapy (ESWT) for Plantar Fasciitis
What is shockwave therapy?
shockwave therapy is a relatively new technology used to treat chronic (long-term) soft tissue disease such as plantar fasciitis that has failed to respond to normal treatment. The technology is based on lithotripsy, which has been used for many years to treat kidney stones. High-energy sound waves are created and focused on the injury using a special applicator. Shockwaves are repeatedly appl ied to the injury area, which breaks down scar tissue and calcifications in the area. The body's own natural healing capacity will usually fulfill this role however in chronic cases the body is sometimes unable to repair itself. As the shockwave breaks down the tissue, it re-induces the acute phase of healing and so the body starts generating new tissue leading to healing. It's like giving your body a second chance to heal itself.
Does it really work?
Current research has demonstrated positive outcomes in terms of pain relief and quality of life measures (Lee et al 2003; Malay et al 2006; Gollwitzer et al 2007; Chuckpaiwong et al 2009). Another study has demonstrated a decrease in plantar fascia thickness under ultrasound examination after ESWT (Androsoni et al 2013). Furthermore, a recent systematic review supported the use of ESWT for plantar fasciitis treatment (Speed 2012). On the other hand, there are studies which have failed to demonstrate a difference between ESWT and pl acebo (Buchbinder 2002; Marks et al 2008).
The National Institute for Health and Care Excellence (NICE), which provides national UK guidance believe that the current evidence on its efficacy is inconsistent. However, it should be pointed out that their guidance was last updated in 2009 and since then further research has been provided supporting the use of ESWT. Furthermore NICE made this statement due to a large diversity in treatment protocols including; the technology used to administer shockwaves, the number of treatment sessions, the time interval between treatment sessions, as well as the option to administer local anaesthesia which has been reported to influence the outcome of shockwave therapy. NICE Guidance does not recommend a specific number sessions stating 'between one and several.' The guidance also reports different energies can be used. Finally, NICE recommends that clinicians conduct audit and review clinical outcomes for all patients having ESWT for refractory plantar fasciitis (cases that aren't responding to previous treatments).
Shockwave therapy and heel spurs
An interesting study noted the irrelevance of heel spurs when treating plantar fasciitis with ESWT. In a large prospective study by Lee et al (2003) consisting of 435 patients with chronic proximal plantar fasciitis, 283 (65%) had an inferior calcaneal bone spur of variable size evident prior to treatment with high-energy ESWT. This included 308 patients who received extracorporeal shockwave treatments and 127 placebo patients. At both initial (3 months) and final (12 months) evaluations after receiving ESWT, no patient who received shockwave applications had significant disappearance or change in the X-ray appearance of the heel spur. Clinical outcome after ESWT was satisfactory in 168 patients (82%) with a demonstrable heel spur on x-ray and in 81 patients (79%) without such a heel spur. The results showed no correlation between the presence or absence of the heel spur and the eventual treatment outcome. In essence, the presence or absence of a heel spur did not matter.
The latest evidence for ESWT is very promising with around 75% success rate in chronic plantar fasciitis that has failed to respond to usual treatment including stretching, footwear modifications, insoles.
Are there any risks?
Generally, shockwave therapy for plantar fasciitis is very safe. It is non-invasive and does not require a local anaesthetic. Commo n risks include a potential for hemorrhage and local soft tissue damage which may lead to bruising. Patients on anticoagulant treatment (blood thinners) will need to stop their medication before receiving shockwave therapy due to increased risk of bleeding. It is advised to seek medical advice if you are considering shockwave therapy.
ESWT is a good treatment option for chronic cases (longer than 3 months) of plantar fasciitis. In my experience, over 70% of cases are chronic before patients decide to seek treatment. This is often due to patients ignoring their initial symptoms in the hope that the pain will self-resolve or waiting to be referred to see a podiatrist before starting treatment, which in the UK, can take a long time due to demand on the NHS. This often means that the degenerative changes within the plantar fascia are more advanced and are less likely to heal despite normal treatment. This is when shockwave therapy is an excellent treatment option to repair tissue degeneration and kick start the healing process. However, it should not be used as an isolated treatment as it does not address the underlying cause of the condition. shockwave therapy increases your body's own ability to heal itself and should, therefore, be used as an adjunctive treatment with other mechanical treatments such as stretching, orthoses, night splint, and footwear modification.
Shockwave therapy is proven to be as effective as traditional surgery and doesn’t involve an operation, being in plaster, or a long rehabilitation period which can last over 6 months. Shockwave therapy only requires one treatment weekly over 3-4 weeks. Treatment is safe, non-invasive, only takes 10 minutes and is as good as results achieved by surgery.
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