Shockwave Therapy Protocol for Plantar Fibromatosis
Based on the available evidence, extracorporeal shock wave therapy (ESWT) is an effective treatment for plantar fibromatosis that can significantly reduce pain and soften nodules, with a recommended protocol of two sessions one week apart using high-energy focused ESWT at 2000 impulses, 3 Hz, and 1.24 mJ/mm² per session.
Evidence for ESWT in Plantar Fibromatosis
The most recent and highest quality evidence specifically for plantar fibromatosis comes from studies showing significant pain reduction and functional improvement:
- High-energy focused ESWT demonstrated significant pain reduction in plantar fibromatosis patients, with pain scores decreasing from 6±2 at baseline to 2±1 after 14 days and 1±1 after 3 months 1
- Long-term follow-up studies showed sustained pain relief and functional improvement for up to 34 months after ESWT treatment 2
- Ultrasound follow-up showed reduction in fibroma thickness from 4.4±1.0 to 2.6±0.8 mm, although length and width dimensions remained unchanged 2
Recommended Protocol
Based on the research evidence, the optimal protocol includes:
- Device type: High-energy focused ESWT (such as Storz Duolith SD1) or radial ESWT
- Number of sessions: 2 sessions
- Interval between sessions: 7 days
- Energy settings:
- 2000 impulses per session
- Frequency of 3 Hz
- Energy flux density of 1.24 mJ/mm²
- No anesthesia required: Unlike some other ESWT applications, anesthesia is not necessary for this procedure 3
Expected Outcomes
Patients can expect:
- Significant pain reduction beginning within 1-2 weeks of treatment
- Continued improvement for several months after treatment
- Softening of nodules reported by most patients
- Potential reduction in nodule thickness (though not necessarily in length or width)
- Success rates of 70-80% for pain relief and functional improvement 2
Advantages Over Other Treatments
ESWT offers several advantages for plantar fibromatosis:
- Non-invasive alternative to surgical intervention
- No need for anesthesia during treatment
- Demonstrated long-term treatment success (6-12 months)
- Low risk of complications or adverse effects
- Quick recovery with minimal downtime
Limitations and Considerations
- While ESWT effectively reduces pain and improves function, it may not completely eliminate the fibroma
- Ultrasound studies show reduction in thickness but not necessarily in length or width of lesions 2
- Limited high-quality research specifically on plantar fibromatosis exists, though evidence from related conditions (plantar fasciitis) supports its use
Monitoring and Follow-up
- Assess pain using a numerical rating scale before treatment and at follow-up intervals
- Consider functional assessment using a validated tool like the Roles-Maudsley Score
- Ultrasound imaging can be used to monitor changes in nodule dimensions
- Schedule follow-up evaluations at approximately 1 week, 3 months, and 6-12 months after treatment
While the International Working Group on the Diabetic Foot (IWGDF) guidelines note that evidence for shockwave therapy in diabetic foot ulcers is inconclusive 4, the specific evidence for plantar fibromatosis shows promising results for pain reduction and functional improvement.