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It is believed that shockwave therapy alleviates pain due to insertional tendinopathy by the
induction of neovascularization and improvement
of blood supply to the tissue, and initiat-
ing repairs of the chronically inflamed tissues by tissue regeneration.
Clinical applications
Proximal plantar fasciitis
Many studies investigated the effect of shockwave therapy in the treatment of proximal
plantar fasciitis and reported a success rate ranging from 34% to 88% [
1 , 45 , 46 , 47 , 48 ,
49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ]. The majority of the published papers
reported a positive and beneficial effect of ESWT in proximal plantar fasciitis. Rompe et
al suggested that three weekly treatments with 1,000 impulses of low
- energy shockwave at
0.06 mJ/mm
2
appear to be an effective therapy for plantar fasciitis with significant allevia-
tion of pain and improvement in function [ 58 ]. Wang et al treated 79 patients (85 heels)
with plantar fasciitis including 59 women and 20 men with an average age of 47 years
(range 15
- 75 years) with shockwave therapy. At one - year follow - up, the overall results
were 75.3% complaint free, 18.8% significantly better, 5.9% slightly better and none un-
changed or worse. The recurrent rate was 5% [
60 ]. It was concluded that shockwave thera-
py is a safe and effective modality in the treatment of proximal plantar fasciitis.
In contrast, few studies reported the opposite results of ESWT in the treatment of plantar
fasciitis [
7 , 24 , 25 , 63 , 64 ]. Buchbinder R et al compared 81 patients who received ultra-
sound - guided ESWT given weekly for 3 weeks to a total dose of at least 1,000 mJ/mm
2
with 85 patients in the placebo group who received treatment to a total dose of 6.0 mJ/
mm
2
, and concluded that no evidence to support a beneficial effect of ESWT over placebo
on pain, function and quality of life [ 24 ]. Haake M et al compared 135 patients allocated
to ESWT with 137 patients allocated to placebo and the results showed that ESWT is inef-
fective in the treatment of chronic plantar fasciitis
[ 64 ]. In a randomised double blind con-
trol trial, Speed CA et al concluded that no treatment effect of moderate dose of ESWT in
subjects with plantar fasciitis. Efficacy may be highly dependent upon machine types and
treatment protocol
[ 25 ]. Therefore, controversy exists on the effect of ESWT in the treat-
ment of chronic plantar fasciitis. The differences are probably due to the difference in
methodology of the study, the patient selection criteria, the use of different devices, differ-
ent energy levels and the total energy and the outcome measurements.
Several studies compared the effect of ESWT with surgery, local corticosteroid injection
or physical therapy in the treatment of proximal plantar fasciitis [
62 , 65 , 66 ]. Surgical
treatment by plantar fasciotomy and ESWT showed comparable functional outcomes,
however, ESWT incurred no surgical risks including surgical pain [
62 ]. Physical therapy
has shown to be comparable or better effect than ESWT in proximal plantar fasciitis, how-
ever, physical therapy is time consuming and inconvenient [
63 ]. Corticosteroid injection
shows better short - term effect, but the long - term results favor ESWT [ 66 ].
The application of ESWT in proximal plantar fasciitis is performed with either local anes-
thesia or no anesthesia. Several reports showed that ESWT is less effective when the treat-
ment is performed with the use of local anesthesia [
67 , 68 ]. The majority of our patients
were treated with no local anesthesia. However, our observations failed to distinguish any
difference between treatment with or without local anesthesia. In case patient is unable to
tolerate the procedure because of pain during treatment, the anesthesia with constant seda-
tion can be used.