EXTRACORPOREAL SHOCK WAVE THERAPY IN THE TREATMENT OF CHRONIC PLANTAR FASCIITIS

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1 ZAGAZIG UNIVERSITY MEDICAL JOURNAL EXTRACORPOREAL SHOCK WAVE THERAPY IN THE TREATMENT OF CHRONIC PLANTAR FASCIITIS By Magdy Husseiny Ahmad Mansour Rheumatology &Rehabilitation Department Faculty of Medicine-Zagazig University ABSTRACT Patients with plantar fasciitis(pf) typically describe their pain after getting out of bed in the morning or after a period of inactivity. They state that the pain decreases after walking on the foot for a while. Most patients tolerate the condition before seeking medical help. Present conservative treatments for plantar fasciitis include rest, physical therapy, heel cushion, non steroidal anti-inflammatory drugs, corticosteroid injections, taping, orthotics, shoe modifications, night splinting, and cast. A fairly new method of treatment is extracorporeal shock wave therapy (ESWT). Despite numerous publications and clinical trials, one orthopedic application of extracorporeal shockwave therapy ( ESWT), which still remains highly equivocal, is the treatment of chronic plantar fasciitis. The aim of this work was to determine the role of the extracorporeal shockwave therapy in the treatment of recalcitrant chronic plantar fasciitis. This study was carried out on 90 patients suffering from chronic plantar fasciitis recalcitrant to conservative therapies for at least 6 months. They were collected from outpatient clinic of Physical Medicine & Rehabilitation department, King Saud Hospital, Onaizah, AlQassim region, Saudi Arabia (KSA). All subjects were assessed according to the inclusion and exclusion criteria in the study protocol. Absence of calcaneal fracture, bony abnormality and other pathology was confirmed with lateral radiograph prior to treatment Subjects were divided into two groups. Active group included 60 patients (20 males and 40 females) with a mean age of 52.1± 8.5 years and the control group comprised 30 patients (12 males and 18 females) with a mean age of 47.7±7.8 years.active group received Low Energy Shock Wave Thereby (LESWT) that was applied in four sessions as weekly interval using 2000 impulses (pressure bar, frequency Hz) with an average energy flux density of 0.02 to m j/ mm 2. No anesthesia was used. The control group received placebo treatment of only 20 shocks with a negligible energy density of 0.02mj/mm 2. An assessment of pain by means of visual analogue scale (VAS) ranging from zero (no pain) to ten (maximal pain) was established at 4 weeks, 8weeks, and three months after treatment. BTL-5000 SWT basic unit was used for ESWT (pressure 1-5 bar, frequency 1-15Hz). All treatments were performed according to instructions in operating manual.with regard to the outcome measure,a statistically significant difference was found in the change from baseline to 3 months in the VAS scores of the treated versus placebo group (p<0.01).in the Active group,the mean pain score decreased from 7.8 to 3.8at 3 months(p <0.001),resulting in a mean percentage improvement 49.7%.In the placebo group, the mean pain score decreased from7.8 to 5.4 at 3 months (p<0.001), a mean percentage improvement 32.1%.. In the Active group, 48.3%(29 of 60)of the subjects achieved greater than 60 % improvement in pain, and in the Placebo group only 23.3 %(12 of 30 )met the same criteria. ESWT is a non-invasive, safe and effective treatment for recalcitrant plantar fasciitis. INTRODUCTION T he plantar fascia is a strong aponeurosis that originates from the medial process of the calcaneal tuberosity and fans out into a medial, central and lateral slip. The fascia blends in with the flexor plate distally and has a connection with the plantar aspect of the toes. The central slip is the thickest, the lateral slip acts as a covering to the abductor hallucis muscle (1). The plantar fascia acts as a windlass and pulls the arch up with dorsiflexion of the metatarsophalangeal joints. Poor foot biomechanics can lead to 73 increase tension on the fascia, causing inflammation and pain. This can occur with patients who have increase subtalar joint pronation, pes planus, and limited dorsiflexion. The increase pronatory forces stretch the plantar fascia and cause a pulling at the origin. This, in turn, causes pain and inflammation. Patients with a pes cavus foot type are also prone to this condition. These patients have a more rigid foot type and cannot absorb shock as well as at heel strike, and that places more stress on the plantar fascia (2).

2 Patients with plantar fasciitis (PF) publications and clinical trials, application typically describe their pain after getting of extracorporeal shockwave therapy out of bed in the morning or after a period (ESWT) still remains highly equivocal, for of inactivity. They state that the pain the treatment of chronic plantar decreases after walking on the foot for a fasciitis. (1,5&6). while. Most patients tolerate the condition The aim of the work was to determine before seeking medical help (1). the role of the extracorporeal shockwave On clinical exam, there is tenderness on therapy in the treatment of recalcitrant the medial plantar aspect of the heel. Some chronic plantar fasciitis. patients may have discomfort under the PATIENTS AND METHODS mid - calcaneal region of the heel. There This study was carried out on 90 may be tightness of the Achilles tendon patients suffering from chronic plantar insertion along with tightness to the medial fasciitis recalcitrant to conservative slip of the plantar fascia. Poor foot therapies for at least 6 months. They were biomechanics such as pes cavus or planus collected from outpatient clinic of Physical deformity might be present, along with a Medicine &Rehabilitation department, compensated forefoot varus deformity. King Saud Hospital, Onaizah, AlQassim Upon x- ray exam, there may be a region, Saudi Arabia (KSA) during the calcaneal heel spur forming parallel to the period from June 2007 till April All weight bearing surface. The heel spur is subjects were assessed according to the not pathognomonic for this condition. The inclusion and exclusion criteria in the spur does not cause pain to the heel. The study protocol. Absence of calcaneal heel spur is the byproduct of the chronic fracture, bony abnormality and other pulling of the fascia off the calcaneous. pathology was confirmed with lateral Standard care at present is conservative radiograph prior to treatment. treatment, but about 10% of patient fail to Inclusion criteria: respond or heal spontaneously. This Greater than 20 years old and extremely painful condition has reported to symptoms present for greater than 6 effect up to 20% of general population months. over their lifetime, and is responsible for A single site of tenderness and pain approximately 1 million patient visits per with local pressure over the medial year in the United States. The goals of calcaneal tuberosity on passive treatment are to reduce the pain and dorsiflexion of foot. inflammation and correct poor foot Visual Analog Scale (VAS) score biomechanics (3,4). of > 5 during first few minutes of walking A fairly new method of treatment is in the morning. extracorporeal shock wave History of 6 months of therapy(eswt). This is a noncutting unsuccessful conservative therapy to procedure. It is not fully understood how include any non-steroidal anti this promotes healing; however, the use of inflammatory drug and at least two of the electrohydraulic shock waves converts a following therapies ( rest, heel cushions, chronic condition into an acute condition. heat, ice, ultrasound, steroid injection, and Patients who do not want the traditional or night splinting). endoscopic surgical procedure may Compliance with a physician consider this alternative because of the prescribed stretching program for plantar lower risks attached to the procedure. The fasciitis within the last 6 months. current standard before considering this type of procedure is 6 months of conservative care. Despite numerous 74

3 Exclusion criteria: (no pain) to ten (maximal pain) was Previous treatment with antiinflammatory medications, rest, stretching, three months after treatment. BTL-5000 established before 4 weeks, 8weeks, and heat, ice, ultrasound, massage, orthotic or SWT basic unit was used for ESWT( other aids, casting, taping, or night pressure 1-5 bar, frequency 1-15 Hz). All splinting, within two weeks of treatment. treatments were performed according to Previous treatment with instructions in the operating manual. corticosteroid injection within one month (Fig.1) (Fig. 2) of treatment. Previous surgery for plantar fasciitis or unresolved infection in the treatment area. Reflex sympathetic dystrophy or Clubfoot. History or documented evidence of bleeding disorder of hemophilia or use Anticoagulant therapy ( including aspirin) within 7 days of treatment. Cardiac pacemaker. Bilateral symptoms. Pregnancy. History of systemic inflammatory disease such as rheumatoid arthritis, ankylosing spondylitis, Reiter s syndrome BTL-5000 SWT basic unit etc. (Fig. 1) Subjects were divided into two groups. Active group received ESWT and control group received placebo treatment. Active group included 60 patients(20 males and 40 females) with a mean age of 52.1± 8.5 years and the control group comprised 30patients(12 males and 18 females) with a mean age of 47.7±7.8 years. The subjects were placed prone on the examination table with the study foot placed in supported position. Prior to shock wave exposure, the area of pain was marked with an x on the skin to assist in focusing the delivery of the shock waves. In active group, Low Energy Shock Wave Thereby (LESWT) was applied in four BTL-5000 SWT Screen sessions as weekly interval using 2000 (Fig. 2) impulses(pressure bar, frequency Hz) with an average energy flux The control group received treatment of density of 0.02 to m j/ mm 2. No only 20 shocks with a negligible energy anesthesia was used. flux density of 0.02mj/mm 2. All subjects An assessment of pain by means of were instructed to eliminate activities and visual analogue scale ranging from zero pain medication post therapy until followup evaluation. 75

4 Statistical analysis was done using the was no significant difference in number of Statistical Package for Social side effects(table 1). Science(SPSS ) version 8.0 soft ware (7). No statistically significant difference RESULTS was found in the change from baseline to 4 The demographic characteristics of the post treatment between treatment groups study groups are presented in(table1). as regards outcome measures (Table2). Clinical success was defined as >60% There was a statistically significant improvement from baseline in VAS score difference(p<0.05) between treatment for pain during the first few minutes of groups in the change from baseline to 8 walking. Table (1) shows that at 3 months weeks after treatment in the VAS scores after treatment, there was a statistically during the first few minutes of walking significant difference between the (table 3). percentage of Active treatment and With regard to the outcome measure, a Placebo treatment subjects that met the statistically significant difference(p<0.01) above definition of a success. In the Active was found in the change from baseline to 3 group,48.3%(29 of 60) of the subjects months in the VAS scores of the treated achieved greater than60% improvement in versus placebo group. In the Active pain, and in the Placebo group only treatment group, the mean pain score 23.3%(7 of 30) met the same criteria decreased from 7.8 to 3.8 at 3 months (p<0.001) (Table1). (p<0.001),resulting in a mean percentage Adverse events reported during improvement of 49.7 %. In the placebo treatment or in the first 3-5 days after group, the mean pain score decreased from treatment were relatively few, and there 7.6 to 5.4 at 3 months (p<0.001),a mean percentage improvement 32.1% (Table4). 1. Age (years) Mean ± SD 2. Duration of heel pain (months) Table (1): Characteristics of the study groups. Group I( Active Treatment) N = 60 Group II Placebo (Control) N = ± ± 7.8 > ± ± 22.8 >0.05 P 3. Gender Male No(%) Female No(%) 20 (33.3%) 40 (66.7%) 12 (40%) 18 (60%) > Affected side Right No(%) Left No(%) 5. Clinical improvement* (no of subjects) 19 (31.7%) 41 (68.3%) 10 (33.3%) 20 (66.7%) 29 (48.3%) 7 (23.3%) >0.05 < Adverse events Pain Paraesthesia Edema 6 (10 %) 1 (1.7%) 1 (3.3%) 3 (10%) 1 (3.3%) 0 (0.0%) >0.05 >0.05 >0.05 *Defined as > 60% improvement from baseline in VAS scores for pain during the first few minutes of walking. 76

5 Table (2): Results of follow up measures at baseline and 4 weeks post treatment. Active Group Placebo Group Outcome measures N==60 N=30 P Baseline 4 weeks Baseline 4 weeks 1. Pain during the first few minutes of walking scored on VAS 7.8 ± ± ± ± 1.8 > VAS pain during normal daily activity 6.3 ± ± ± ± 2.2 > VAS pain during sport activity 7.6 ± ± ± ± 2.3 > Pain on palpation scored on VAS 5.9 ± ± ± ± 2.6 >0.05 Table (3): Results of follow up measures at baseline and 8 weeks post treatment. Outcome measures Active Group N==60 Placebo Group N=30 P Baseline 8 weeks Baseline 8 weeks 1. Pain during the first few minutes of walking scored on VAS 7.8 ± ± ± ± 2.3 < VAS pain during normal daily activity 6.3 ± ± ± ± 3.0 > VAS pain during sport activity 7.6 ± ± ± ± 3.4 > Pain on palpation scored on VAS 6.9± ± ± ± 2.3 >0.05 Table (4): Results of follow up measures at baseline and 3 months post treatment. Outcome measures 1. Pain during the first few minutes of walking scored on VAS 2. VAS pain during normal daily activity 3. VAS pain during sport activity 4. Pain on palpation scored on VAS Active Group N==60 Placebo Group N=30 Baseline 3 Month Baseline 3 Month 7.8 ± ± ± ± 2.6 < ± ± ± ± 2.4 < ± ± ± ± 2.8 > ± ± ± ± 2.3 < P

6 DISCUSSION Plantar fasciitis is a painful inflammatory condition of the foot caused by excessive wear to plantar fascia that supports the arches of the foot or by biomechanical faults that cause abnormal pronation (8). Present conservative treatments for plantar fasciitis include rest, physical therapy, heel cushion, non steroidal anti-inflammatory drugs, corticosteroid injections, taping, orthotics, shoe modifications, night splinting, and casting. ESWT is proposed as an additional conservative treatment to be used to avoid surgery, when other available conservative methods have failed (6). The present work aimed to determine whether ESWT can relieve the pain associated with recalcitrant chronic plantar fasciitis compared to placebo treatment. Our study demonstrated a statistically significant difference between groups in the outcome measures of change from baseline to 3 months after treatment in VAS pain scores in the first few minutes of walking (In the Active treatment group, the mean pain score decreased from 7.8 to 3.8 at 3 months (p<0.001),resulting in a mean percentage improvement of 49.7 %. In the placebo group, the mean pain score decreased from 7.6 to 5.4 at 3 months (p<0.001),a mean percentage improvement 32.1%(table2).Our results coincide with the findings of Kudo et el (6). Although improvement was noted in the Placebo group, this phenomenon could simply reflect the spontaneous remission or natural history of plantar fasciitis as a self-limiting condition or a sustained placebo effect. Standard treatment for plantar fasciitis is conservative, but about 10% of patients fail to respond or heal spontaneously (9). As regards clinical success, our study showed that, in the Active group 48.3%(29 of 60) of the subjects achieved greater than 60% improvement in pain, and in the Placebo group only 23.3%(7 of 30) met 78 the same criteria (p< ) and this in agreement of Theodore et el. (10) and Kudo et el. (6) Although both Placebo and Active groups also reported significant improvement in their pain with the normal activity, leisure / sport activity, the improvement in the Active group were consistently numerically superior to placebo with marginal statistical significance between treatment in these clinical outcome and this in agreement of Theodore et el. (10) and Kudo et el. (6) while it disagrees with Buchbinder et el. (11). In human application, depending largely on the amount of energy flux density used, ESWT is painful, may aggravate symptoms for a short period of time and may induce reversible local swelling reddening and formation of haematoma. In the present study, adverse events reported during treatment were few. There was no significant difference in number of side effects reported between groups through 3 months. Adverse events included pain, transient paraesthesia and mild edema. These results coincide with that of Theodore et el. (10) and Kudo et el. (6) Independent of the device, many physical effects depend on the energy involved. The concentrated shock wave energy per focal area is one important variable. Physicist use the term energy flux density (unit: mj/mm 2 ) to illustrate the fact that the shock wave energy flows through an area with perpendicular orientation to the direction of propagation. Low-energy flux application (<0.2 mj/mm 2 ) is generally tolerated well, with mild-to-moderate discomfort. High-energy flux applications (>0.2 mj/mm 2 ) usually require local or regional anaesthesia (12). Localizing the delivery of SWT is another factor that influences the outcome of SWT and makes comparison of studies difficult. Two methods of localization are commonly used. Image-guided focusing may be accomplished via guided ultrasound,fluoroscopy or computed

7 tomography. These methods of focusing One study evaluated the outcome of allow delivery of shock waves to a very LESWT of chronic PF in runners. Fortyfive specific area. Unfortunately, the paingenerating running athletes were either assigned area of pathology may not to a treatment group that received 3 correlate with these anatomic locations. A sessions of 2100 impulses of 0.09 mj/mm 2 second method of localization is clinical or placebo, without LA. At 24 weeks, 60% focusing, in which the shock waves are versus 27% of patients reported 50% directed to the most painful area with the reduction of pain on first walking in the aid of patient feedback. This method is the morning (19). most reliable at directing the shock waves Using low-energy radial SWT, 242 to the painful region. Clinical focusing randomized patients received active allows adjustment of the shock wave treatment with 3 sessions of 2000 pulses at direction on a patient-by-patient basis. weekly intervals or sham, without LA. Because of the need for patient input, no About 57% versus 40% achieved anaesthetics can be used with this method, successful alleviation of their morning a fact that limits the amount of energy that pain (20). Malay et al. (21) compared the may be delivered through the shock wave. outcomes of 172 participants treated with a High-energy shock waves are poorly new planar SWT device with those treated tolerated in the absence of with placebo. SWT with 3800 shocks or anaesthesia (13,14). placebo was administered without LA. In our study, the second method of Amount of energy delivered was not localization was used in the absence of specified in this study. At 12 weeks, 43% anaesthesia as shock waves were directed versus 20% of patients reported a 50% to the most painful area. This method is decrease of pain from baseline. The study the most reliable at directing the shock from Rompe et al. (17) and Cosentino et waves to the painful region. Our results are al (18) used image guidance (fluoroscopic or in consistent with that obtained by Ogden ultrasonic), whereas Rompe et al. (19), et al. (13) and Sems et al. (14). Weil (20) and Malay et al. (21) relied on Considerable controversy has emerged regarding the use of SWT for plantar heel pain (14,15,16). In the first controlled study ever to explore the pain-alleviating effect of LESWT in chronic plantar fasciitis, 30 patients received 3 sessions of 1000 impulses of 0.06 mj/mm 2 at weekly intervals or placebo, without local anaesthesia(la). Twelve weeks after the last treatment, patients experienced a significant alleviation of pain and improvement of function in the treatment group (17). In 60 patients undergoing 6 sessions of 1200 low-energy impulses at weekly intervals or placebo, without LA, a significant decrease in visual analogue scale (VAS) was only seen in the treatment group at 12weeks (18). 79 clinical focusing to the point of maximum tenderness. Image guidance was used to direct the shock wave to the tip of the calcaneal spur, followed by clinical focusing of the shockwave to the area of maximal pain. Our results are in agreement with that obtained in all the trials described earlier as the repetitive treatments were administered at weekly intervals, and none used any form of LA. Follow-up was at least 12 weeks after SWT. Speed et al. (22) changed the therapeutic regimen described earlier.eighty-eight adults with chronic PF received either 3 sessions of 1500impulses of 0.12 mj/mm2 or sham therapy without LA, at monthly intervals. Follow-up was 4 weeks only: 37% and 24% of the groups showed a 50% improvement from baseline with respect to pain (not significant). Haake et al. (23) also deviated from the therapeutic regimen

8 described earlier. Two hundred and seventy-two patients with chronic PF were allocated to SWT with 3 sessions of 4000 impulses of 0.08 mj/mm 2 under LA or placebo SWT under LA, at weekly intervals. The success rate 12 weeks after intervention was 34% in the SWT group and 30% in the placebo group (not significant). Labek et al. (24) were the first to focus on a possible interference of LA on the outcome after SWT. Sixty patients with a chronic PF were enrolled in a triple-arm pilot trial. Patients received either active SWT without LA [3 sessions of 1500 shocks of 0.09 mj/mm 2 (group A)],SWT with LA [3sessions of 1500 shocks of 0.18 mj/mm2 (group B)]or SWT with LA [3 sessions of 1500 shocks of 0.09 mj/mm2 (group C)], at weekly intervals. At 6 weeks, a reduction in pain of at least50% was achieved in 60% of group A, 36% of group B and 30% of group C. LA significantly influenced the clinical results after LESWT in a negative way. Higher energy levels could not balance the disadvantage of this effect. A confirmatory study was based on Labek s data. Eightysix patients with chronic PF were randomly assigned to receive either 3 sessions of 2000 pulses of 0.09 mj/mm2 without LA, at weekly intervals, or identical SWT with LA. At 12 weeks, significantly more patients of group I achieved 50% reduction in pain when compared with group II(67% versus 29%).As in the experimental study from Klonschinski et al. (25), LA applied prior to treatment reduced the efficiency of LESWT. The results of these trials directly question the negative findings of the placebo-controlled study from Haake et al. (23) who had applied LESWT under LA, concluding that LESWT was ineffective in the management of chronic PF. Ogden et al (26) performed a placebocontrolled trial of a single SWT with 1500 shocks of 0.22 mj/mm 2, using ankle-block anaesthetic, in 302 patients with chronic 80 PF. At 12 weeks, 62% versus 43% of the patients had a minimum 50% improvement over baseline in investigator assessment of pain. Outcomes of three other criteria also favored the active treatment, but none was statistically significant. A further report (27) was considered a re-analysis of the previously published trial with substantially different sample sizes (28,29) Although the results appeared similar, the authors now reported a significant difference in the mean score for the subjective self-assessment of pain at 12 weeks favoring the active treatment group. Twelve weeks after treatment, 47% of the actively treated patients had a completely successful result when compared with 30% of the placebo-treated patients. However, statistical comparison of mean scores for subjective self-assessment of pain at 12 weeks on the basis of the data published in the original trial report submitted to the US Food and Drug Administration demonstrated no significant difference between groups. Buch et al. (30) examined 150 patients in another multicoated placebo-controlled study to assess the clinical safety and effectiveness of HESWT for chronic PF. The active group underwent a single application of 3800 pulses of 0.36 mj/mm 2 or sham treatment, under regional anesthesia. Ultrasound guidance was used. At 12 weeks,62% of the patients in the active group reported good or excellent outcome and 40% in the placebo group (significant). In contrast to surgery, either open or endoscope, SWT does not require that patients avoid weight bearing or a prolonged time for return to work. Several studies have indicated that PF responds to SWT. SWT is non invasive, well-tolerated and relatively inexpensive when compared with surgical treatment. SWT allows patients to return to activities of daily life within 1 or 2 days with immediate return to most jobs and normal daily shoe wear. Complications of SWT for PF have been

9 virtually non-existent.because of the and non-invasive and associated with only multiple variables inherent in the use of minor, transient side effects. SWT SWT in the management of PF, strict circumvents the need for immobilization comparisons of published results are and restricted weight bearing and generally problematic. Currently, there is no has a relatively short recovery time. Lost consensus on the use of repetitive LESWT time from work is usually minimal, and,which does not require LA, and on the use often practically non-existent. In the end, of HESWT, which requires LA or regional financial concern is the only issue that may anesthesia. There is no consensus for keep patients and physicians from opting differentiating between low-energy and for ESWT. high-energy shock waves as multiple REFERENCES physical variables are involved. In the only 1. Kolodin, E. L. and Vitale, T.: Foot randomized controlled trial (RCT) Disorders. In: Physical Medicine and comparing an identical protocol of Rehabilitation, Principles and Practice edited by, Delisa, J. A., Gaus, B. M., repetitive HESWT versus repetitive LESWT, no difference was found (12). Walsh, N. E. et.al., Lippincott Williams and Wilkins, Philadelphia, USA, At this time, one should consider SWT 2005;879. part of a care pathway for PF. Currently, 2. Body, P.M.; Neale, D. and Rendall, O.: there are two options available: repetitive The adult foot. In: Lorimer D, ed. Neale's LESWT at weekly intervals for 3 6 weeks, common foot disorders. London: Churchill clinical focusing, without LA, beneficial Livingstone, 1993; Middleton, J. A. and Kolodin, E. L.: outcome in ~60% of patients after 12 Plantar fasciitis: Heel pain in athletes. J weeks or single HESWT, image-guided Ath Train; 1992;1: focusing, regional or block anesthesia 4. Riddle, D. L. and Schappert, S. M.:,beneficial outcome in~ 50% of patients Volume of ambulatory care visits and after 12 weeks. Future research may reveal patterns of care for patients diagnosed whether it is appropriate to introduce SWT with plantar fasciitis: A national study of earlier in the care pathway plan of patients. medical doctors. Foot Ankle Int; 2004;25: Additionally, it is possible that SWT 5. Norris, D. M.; Kimberly, M. E. and will actually reduce overall costs if less Bruce, R. W: "Effectiveness of money is spent on non-productive Extracorporeal Shock wave Treatment in conservative care and physician visits and 353 Patients with Chronic Plantar if there is less chance of lost productivity Fasciitis". Journal of the American and days off work from pain, physician Podiatric Medical Association; 2005;95 visits and surgical recovery (12). (6): Kudo, P.; Danity, K.; clarfield, M. et. CONCLUSION al.: Randomized, placebo controlled, For patients with chronic PF, a Double Blind Clinical trial evaluation conservative approach is recommended. the treatment of plantar fasciitis with an Present conservative treatments for plantar Extracorporeal shock wave therapy fasciitis include rest, physical therapy, heel (ESWT) Device: A North American cushion, non steroidal anti-inflammatory Confirmatory Study. J Ortho Pres; drugs, corticosteroid injections, taping, 2005;24: Noursis, M.: Statistical Package for Social orthotics, shoe modifications, night Science (SPSS) base 8.0 for Windows splinting, and casting. ESWT is proposed User's Guide Chichag, IL: SPSS as an additional conservative treatment to 8. Barrett, S. L. and Robert, O.: "Plantar be used to avoid surgery, when other fasciitis and other causes of heel pain". available conservative nonsurgical American Family Physician; 1999;59 (8): methods for chronic plantar fasciitis have failed. ESWT produces pain relief, is safe 81

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