Is shockwave therapy effective for treating plantar fasciitis?

Effectiveness of Shockwave Therapy for Plantar Fasciitis

Shockwave therapy is an effective treatment option for chronic plantar fasciitis that has not responded to conservative treatment measures, with evidence showing significant pain reduction and functional improvement lasting up to one year after treatment. 1, 2

Evidence-Based Treatment Algorithm for Plantar Fasciitis

First-Line Treatments (0-6 weeks)

• Begin with patient-directed conservative measures including:
  • Regular calf-muscle stretching exercises 3
  • Cryotherapy (ice application) for 10-minute periods 3
  • Over-the-counter heel cushions and arch supports 3
  • Weight loss if indicated 3
  • Activity limitation and avoidance of flat shoes and barefoot walking 3
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term pain relief 3
  • Padding and strapping of the foot 3

Second-Line Treatments (6 weeks - 3 months)

If no improvement occurs after six weeks of first-line treatment:

• Continue initial treatment measures 3
• Consider customized orthotic devices 3
• Night splinting 3
• Limited corticosteroid injections (with caution) 3
• Casting or use of a fixed-ankle walker-type device during activity 3

Third-Line Treatments (>3 months)

If no improvement occurs after 2-3 months of second-line treatments:

• Extracorporeal shock wave therapy (ESWT) is recommended for chronic plantar fasciitis that has failed conservative treatment 4, 2
• Surgical intervention (plantar fasciotomy) may be considered if ESWT fails 3

Effectiveness of Shockwave Therapy

Clinical Evidence

• Radial shock wave therapy has shown statistically significant improvement in pain and functional capacity that persists through one year of follow-up 1
• Pain scores during morning first steps decreased from 6.28 before therapy to 0.52 at 12 months follow-up (p<0.001) 1
• Functional scores improved from baseline to one year follow-up (p<0.001) 1
• A randomized controlled trial found that 47% of patients receiving active ESWT had completely successful results at 3 months compared to 30% in the placebo group (p=0.008) 2
• For all patients receiving one or more ESWT treatments, 76.8% had good or excellent results 2
• Another study showed that three treatments with low-energy shock waves reduced morning pain from 6.9 to 1.5 points (on a visual analog scale) at 12 months 5

Treatment Protocol

• Typical protocols include:
  • Five sessions of radial shock wave therapy with 2500 shocks per session at 2.5 bars pressure 1
  • Alternatively, three applications of 2100 impulses of low-energy shock waves 5
  • Or 100 graded shocks starting at 0.12 to 0.22 mJ/mm², followed by 1400 shocks at 0.22 mJ/mm² 2

Important Considerations and Caveats

Patient Selection

• ESWT should be considered only after failure of multiple conservative treatments for at least 3 months 4
• Coverage criteria typically limit ESWT to three conditions: Achilles tendinopathy, calcific tendinitis of shoulder, and plantar fasciitis 4

Safety Profile

• ESWT has been shown to be a safe non-invasive method of treatment 1
• No patients were made worse by the procedure in clinical trials 2
• Both radial and combined (radial and focused) shockwave therapy show similar safety profiles and functional outcomes 6

Limitations of Evidence

• The International Working Group on the Diabetic Foot (IWGDF) recommends against using physical therapies including shockwaves for diabetic foot ulcers 3
• Some guidelines note that while ESWT may be effective for plantar fasciitis, evidence for other conditions is more limited 4

Cost-Effectiveness

• While formal cost-effectiveness studies are limited, ESWT may provide a reasonable non-operative alternative to surgical intervention for chronic plantar fasciitis 7
• Meta-analysis suggests that ESWT should be considered before any surgical intervention and may be preferable prior to cortisone injection, which has a recognized risk of plantar fascia rupture 7