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Objective To investigate the long-term effect of low-energy extracorporeal shock wave therapy (ESWT) for plantar
fasciitis (PF) according to ultrasonography (US) findings.
Methods Thirty feet of 25 patients with clinical diagnosis of PF were enrolled and divided into two groups
(Apparent-US and Uncertain-US) according to US findings, such as plantar fascia thickening or hypoechogenicity.
Inclusion criteria were symptom duration >6 months and a fair or poor grade in Roles-Maudsley score (RMS).
ESWT (0.10 mJ/mm2, 600 shocks) was given once a week for 6 weeks. Numeric rating scale (NRS) and RMS were
evaluated prior to each ESWT session, at short-term follow-up (one week after all ESWT sessions) and long-term
follow-up telephone interview (mean 24 months after ESWT). Good and excellent grade in RMS were considered
as treatment success.
Results Repeated measure ANOVA demonstrated that NRS significantly decreased with time after ESWT up to
the long-term follow-up (time effect, p<0.001) without group-time interaction (p=0.641), indicating that ESWT
equally decreased pain in both groups. Overall success rate was 63.3% (short-term follow-up) and 80.0% (long-term
follow-up). In comparative analysis between groups, success rate of Apparent-US and Uncertain-US at short-term
follow-up was 61.9% and 66.7%, respectively, and 85.7% and 66.7%, respectively, at long-term follow-up.
Conclusion If other causes of heel pain are ruled out through meticulous physical examination and
ultrasonography, low-energy ESWT in PF seems to be beneficial regardless of US findings. In terms of success rate,
however, long-term outcome of Apparent-US appears to be superior to Uncertain-US.
Keywords Plantar fasciitis, Extracorporeal shock wave therapy (ESWT), Ultrasonography, Treatment outcome
Subjects
Between 2008 and 2013, 70 patients (96 feet) with
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Jong-Wan Park, et al.
Fig. 2. Apparent ultrasonographic abnormal finding Fig. 3. Apparent ultrasonographic abnormal finding
shows a plantar fascia thickness >3.8 mm. shows hypoechogenicity in the plantar fascia.
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Comparative Analysis According to Ultrasonographic Findings
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Jong-Wan Park, et al.
fascia thickness in symptomatic feet compared to as- of PF. In the present study, we used these Korean criteria
ymptomatic sides. As a general rule, increased thickness as the reference value for the determination of Apparent-
(>4 mm) and decreased echogenicity of plantar fascia US and Uncertain-US.
are considered as consistent US findings in PF [28,29]. In Repeated measure ANOVA revealed no significant
Korean, Yoon et al. [20] reported that increased thickness group-time interaction (p=0.641 for interaction). In addi-
(>3.8 mm), difference of thickness between symptomatic tion, the pain scores at short-term and long-term follow-
and asymptomatic sides (>1.0 mm) and hypoechogenici- ups did not show a significant difference between the
ty of plantar fascia were clinically meaningful US findings study groups. These findings suggest that ESWT equally
improve subjective pain in both study groups regardless
of presence or absence of apparent abnormalities on US,
which are consistent with prior finding that plantar fascia
thickness does not influence the outcome of ESWT [25].
However, the present results are contrary to the common
understanding that plantar fascia thickness influences
treatment outcomes [14]. Plantar fascia thickness can be
marked increased in PF [17,18] and substantially reduced
after ESWT, showing a correlation with pain reduction
[30,31].
Several considerations about the main problem with
US may to some extent explain such conflicting results.
Operator-dependent technique and factors, such as lack
of standardization of measurement points or machine
settings, may affect the measured thickness value and
appearance of plantar fascia, and make it difficult to de-
termine reference values for designation of Apparent-
Fig. 4. Repeated measure ANOVA test demonstrates that
pain score decreases with time up to long-term follow- US or Uncertain-US [32]. Indeed, large differences in
up (mean 24 months after ESWT) (time effect, p<0.001) the mean plantar fascia thickness were measured in the
without significant group-time interaction (p=0.641 for previous studies, in which the mean values varied from
interaction). The pain scores at short-term follow-up 2.9−8.1 mm in patients with PF. Ranges of plantar fascia
(one week after completion of all ESWT sessions) and thickness in patients with PF were 3.2−6.8 mm in one
long-term follow-up do not show significant difference
study [26] and 4.3−8.1 mm in another [27]. Yet another
between the study groups. ESWT, extracorporeal shock
wave therapy; NRS, numeric rating scale; Apparent-US, study reported a mean plantar fascia thickness of 2.9 mm
apparent ultrasonographic abnormal group; Uncertain- in patients with unilateral heel pain [17]. Additionally, US
US, uncertain ultrasonographic group. evaluation of hypoechoic changes in the plantar fascia
Table 3. Success rate at short-term and long-term follow-ups according to ultrasonographic findings
Follow-up Apparent-US (n=21) Uncertain-US (n=9) Total (n=30)
Short-term
Success rate (%) 61.9 66.7 63.3
Excellent 1 0 1
Good 12 6 18
Long-term
Success rate (%) 85.7 66.7 80.0
Excellent 3 1 4
Good 15 5 20
Apparent-US, apparent ultrasonographic abnormal group; Uncertain-US, uncertain ultrasonographic group.
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Comparative Analysis According to Ultrasonographic Findings
was reported to display surprisingly low agreement [33], mally invasive techniques. Radiol Med 2008;113:486-
which could be attributed to the fact that the definition 95.
of echogenicity is dependent on the adjacent muscle, 4. Tsai WC, Wang CL, Tang FT, Hsu TC, Hsu KH, Wong
but there is no adjacent muscle for comparison when MK. Treatment of proximal plantar fasciitis with
examining the plantar fascia with US. For these limita- ultrasound-guided steroid injection. Arch Phys Med
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findings is necessary when using US in routine clinical tiveness of calf muscle stretching for the short-term
practice. Nevertheless, US is important to rule out other treatment of plantar heel pain: a randomised trial.
causes of heel pain or to establish the diagnosis of PF. BMC Musculoskelet Disord 2007;8:36.
One limitation of the present study is the small number 6. Sperling JW, Antuna SA, Sanchez-Sotelo J, Schleck C,
of patients studied. In addition, it has been reported that Cofield RH. Shoulder arthroplasty for arthritis after
body mass index [34], walking hours per day, diabetes instability surgery. J Bone Joint Surg Am 2002;84:1775-
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treatment outcome [25], but we did not consider these 7. Babcock MS, Foster L, Pasquina P, Jabbari B. Treat-
factors since this information was not available. ment of pain attributed to plantar fasciitis with botuli-
In conclusion, if other causes of heel pain are ruled out num toxin a: a short-term, randomized, placebo-con-
and diagnosis of PF is established through meticulous trolled, double-blind study. Am J Phys Med Rehabil
physical examination and US, low-energy ESWT appears 2005;84:649-54.
to be beneficial regardless of US finding. In terms of suc- 8. May TJ, Judy TA, Conti M, Cowan JE. Current treat-
cess rate, however, long-term outcome of patients with ment of plantar fasciitis. Curr Sports Med Rep 2002;1:
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superior to those with uncertain US findings. 9. Malay DS, Pressman MM, Assili A, Kline JT, York S,
Buren B, et al. Extracorporeal shockwave therapy
CONFLICT OF INTEREST versus placebo for the treatment of chronic proximal
plantar fasciitis: results of a randomized, placebo-
No potential conflict of interest relevant to this article controlled, double-blinded, multicenter intervention
was reported. trial. J Foot Ankle Surg 2006;45:196-210.
10. Theodore GH, Buch M, Amendola A, Bachmann C,
ACKNOWLEDGMENTS Fleming LL, Zingas C. Extracorporeal shock wave
therapy for the treatment of plantar fasciitis. Foot
The authors thank Ms. Miyeon Lee, Medical Informa- Ankle Int 2004;25:290-7.
tion Library in Kangbuk Samsung Hospital for her advice 11. Rompe JD, Decking J, Schoellner C, Nafe B. Shock
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