A Randomized Clinical Trial on the Effects of Extracorporeal Shockwave Therapy, Joint Mobilizations and Exercise on Plantar Heel Pain in Patients with Plantar Fasciitis

Plantar fasciitis (PF) is the most common cause of heel pain today impacting on the patient’s walking ability, work tolerance, and ability to participate in active sport. Two million people in the United States (US) are treated for PF yearly with heel pain accounting for 11 to 15% of visits to medical professionals. It is estimated that 10% of the US population will develop PF during their lifetime. Treatment for PF may include a variety of interventions ranging from conservative treatment to surgical interventions. One of the suggested treatments for PF is the use of extracorporeal shockwave therapy (ECSWT). ECSWT is a relatively new therapeutic modality that has been used in the treatment of PF and a variety of other musculoskeletal disorders with some success reported. Normally healthcare providers do not treat with the use of only one modality or treatment approach but rather a combination of treatments in an attempt to obtain a desired positive effect on the patient. The research available on the use of ECSWT is limited in that it has not been determined whether this modality used in isolation, or in combination is the most effective. Research has been conducted comparing ECSWT to placebo and a variety of controls but the effectiveness of combinations of treatment has not been studied. Therefore, the purpose of this study was to compare the effects of ECSWT alone, to ECSWT and joint mobilization, and ECSWT and exercise, on heel pain in patients with PF, as measured by the visual analog scale (VAS) and Lower Extremity Functional Scale (LEFS). Subjects (N=75) were randomly assigned into 3 groups: ECSWT, ECSWT and joint mobilizations to the talocrural, subtalar, and first metatarsophalangeal (MTP) joint, or ECSWT and stretching for the gastrocnemius, soleus, and plantar fascia and strengthening for the ankle. Subjects received three treatments in total spaced one week apart. A VAS for pain and LEFS were measured pre-treatment and three months post-treatment. All groups demonstrated statistically significant improvement over time in all VAS scores and in the LEFS (P<.05). There was a statistically significant difference in VAS for heel pain following activity between the ECSWT and joint mobilization group and ECSWT and exercise group (F= 3.577, p= .033) with a greater reduction in pain in the ECSWT and joint mobilization group. Further research is required using an alternative study design to compare the combinations of treatment to a control or placebo group. The findings of this study, however, indicate that if ECSWT is going to be combined with another treatment, then the combination of ECSWT and joint mobilization may be more effective than combining ECSWT with exercise.