Trip Answers

Question answered:03/08/07 Warning! this question is over two years old.

We have interpreted this question to mean is there any evidence for the use of ultrasound in the treatment of plantar fasciitis.

 

We located two guidelines on the management of heel pain. A 2003 guideline on heel spur syndrome lists extracorporeal shockwave therapy as one out of ten conservative treatments for this condition. This intervention appears at the bottom of the list which may suggest this is a treatment to be tried after the first nine have been used. The  American College of Foot and Ankle Surgeons guideline on heel pain makes no reference to using ultrasonography in either the diagnosis or treatment of plantar fasciitis [1 & 2]

 

A DARE appraised systematic review, published in 2007, reported:

 

“The lack of convergent findings from randomized trials of extracorporeal shock wave treatment (ESWT) for chronic plantar fasciitis suggests uncertainty about its effectiveness. The evidence reviewed in this bulletin does not support the use of this technology for this condition.” [3]

 

Clinical Evidence has a chapter on plantar fasciitis which concludes ESWT to be of “unknown effectiveness”. In summary, it notes:

 

“One systematic review compared extracorporeal shock wave therapy versus placebo, sham, or low dose extracorporeal shock wave therapy, in people with heel pain, and found a small but statistically significant difference in pain.” [4]

 

We searched the TRIP, Cochrane and  Medline databases for studies of ESWT, published since Clinical Evidence last updated its literature search in October 2005, and located three additional studies (two placebo-controlled trials and one comparing ESWT to a range of conservative treatments). [4]

 

Malay et al, randomised 172 patients (n=115 ESWT, n=57 placebo control group) and reported:

 

“[At three months] On the visual analog scale, the blind assessor's objective assessment of heel pain displayed a mean reduction of 2.51 in the shockwave group and 1.57 in the placebo group; this difference was statistically significant (P=.045). On the visual analog scale, the participant's self-assessment of heel pain displayed a mean reduction of 3.39 in the shockwave group and 1.78 in the placebo group; this difference was statistically significant (P<.001). No serious adverse events were observed at any time.” [5]

 

Wang et al examined the long term efficacy of ESWT in chronic plantar fasciitis

 

“In the shockwave group [n=79 patients with 85 heels], patients received 1500 impulses of shockwaves at 16 kV to the affected heel in a single session. Patients in the control group [n=70 with 83 heels] received conservative treatment consisting of nonsteroidal anti-inflammatory drugs, orthotics, physical therapy, an exercise program, and/or a local cortisone injection. Patients were evaluated at 60 to 72 months (shockwave group) or 34 to 64 months (control group) with a 100-point scoring system including 70 points for pain and 30 points for function. The clinical outcomes were rated as excellent, good, fair, or poor.

 

RESULTS: Before treatment, the groups showed no significant differences in the scores for pain and function. After treatment, the shockwave group showed significantly better pain and function scores as compared with the control group. The overall results were 69.1% excellent, 13.6% good, 6.2% fair, and 11.1% poor for the shockwave group; and 0% excellent, 55% good, 36% fair, and 9% poor for the control group (P < .001). The recurrence rate was 11% (9/81 heels) for the shockwave group versus 55% (43/78 heels) for the control group (P < .001). There were no systemic or local complications or device-related problems.” [6]

 

Finally, Kudo et al note:

 

“Despite numerous publications and clinical trials, the results of treatment of recalcitrant chronic plantar fasciitis with extracorporeal shockwave therapy (ESWT) still remain equivocal as to whether or not this treatment provides relief from the pain associated with this condition.”

 

In their trial:

 

“The patients, 114 adult subjects with chronic plantar fasciitis, recalcitrant to conservative therapies for at least 6 months, were randomized to two groups. Treatment consisted of approximately 3,800 total shock waves (+/-10) reaching an approximated total energy delivery of 1,300 mJ/mm(2) (ED+) in a single session versus placebo treatment. This study demonstrated a statistically significant difference between treatment groups in the change from baseline to 3 months in the primary efficacy outcome of pain during the first few minutes of walking measured by a visual analog scale. There was also a statistically significant difference between treatments in the number of participants whose changes in Visual Analog Scale scores met the study definition of success at both 6 weeks and 3 months posttreatment; and between treatment groups in the change from baseline to 3 months posttreatment in the Roles and Maudsley Score.” [7]

References
1. Academy of Ambulatory Foot and Ankle Surgery. Heel spur syndrome. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. http://www.guideline.gov/summary/summary.aspx?doc_id=4245&nbr=3245&ss=6&xl=999
2. American College of Foot and Ankle Surgeons. The diagnosis and management of heel pain: clinical practice guideline. 2001. (http://www.acfas.org/NR/rdonlyres/1B45BD7A-6F08-4BAA-AEE9-218805A964ED/0/HeelpainCPG.pdf).
3. DARE.Extracorporeal shock wave treatment for chronic plantar fasciitis (heel pain). There is uncertainty about the effectiveness of this intervention. 2007. (http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?View=Full&ID=32007000117)
4. Clinical Evidence. Plantar heel pain and fasciitis. Literature search to October 2005. (http://www.clinicalevidence.com/ceweb/conditions/msd/1111/1111.jsp)
5. Malay DS, Pressman MM, Assili A et al.  Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. 2006. (http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/024/CN-00571024/frame.html).
6. Wang CJ, Wang FS, Yang KD et al Long-term results of extracorporeal shockwave treatment for plantar fasciitis.  2006. (http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/589/CN-00563589/frame.html)
7. Kudo P, Dainty K, Clarfield M et al. Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study.  2006. (http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/642/CN-00554642/frame.html).

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