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Shock-wave therapy in the treatment of heel spurs (plantar fascia)

Radial extracorporeal shock-wave therapy in the treatment of heel spurs (plantar fasci)

Gerald Hupt[1], Rupert Diesch[2], Thomas Straub[3], Emil Penninger3, Thomas Frlich[4], Jakob Schеll[5], Heinz Lohrer5, Dr. Theodor Senge[6]

Heel Sporp Treatment



The overall prevalence of the plantar fasci is 15%. The lateral X-ray study of the polar population revealed plantar and / or dorsal heel spurs in 15.7%, among which the defeat of both legs was 11% [32]. The number of diseases increases with age and comparable for various continents, such as Europe, Africa and America [2].

The primary symptom is pain, which is often associated with limited movements (ODO) [3, 9, 14]. Many conservative methods of treatment [30, 40, 41] are described. They include ultrasound [10, 37], iontophoresis [16] and low-energy laser [12] into adding to physiotherapy, injections of steroids and non-steroidal anti-inflammatory funds, but their applicability today is a form-free. Operational treatment is recommended only as a result of the ineffectiveness of conservative methods [1].

The introduction of extracorporeal shock waves into urolithiasis therapy produced a radical fracture in renal stones therapy. Additional applications focused on other stones therapy, such as gallbladder stones, pancreatic stones and stones of the salivary glands [28, 34, 35].

Since 1986, we have been testing the effect of shock waves on wound healing and bone fractures on experimental models and first demonstrated the osteogenic potential of shock waves [21-23]. This led to the therapy of pseudoarthrosis by shock waves. Finally, in recent years, such diseases of soft tissues, like a calcining shoulder tendinite, lateral and medial epicondylitis and plantar fasciates, have been severely treated [7, 15, 31].

In addition, conventional shock waves, which can also be formed by ballistic (lithotripter), were first used in urology (for endoscopic stones fragmentation). This process is much more economical. Our own studies on the soft tissues and bones of rabbits and monkeys showed that the results of treatment with ballisticly produced radial shock waves coincide with the results obtained due to therapy with focused extracorporeal waves. Consequently, shock waves regardless of the method of producing them are comparable in the rendered biological effects. This study studied the effect of radial shock waves on the plantar fasci.

Materials and methods

All therapeutic manipulations with shock waves were carried out using SWISS DolorClast®, a modified device comparable to SWISS Lithoclast®, which is used for endoscopic stones treatment [27, 42]. The impact was carried out and was evaluated on animals, the studies were carried out on rabbits and rear Macakes [19]. For plantar healing pain, the tip of the applicator was located at the point of maximum pain, which the patient localized himself. Shock waves were delivered by the standard method (ultrasonic gel).

The patients

One hundred and three patients with chronic plantar fasciites were studied in a multicenter, promising, randomized and slatvenocontrollable study. Patients were included in the study if they have analogously marked pain during at least 6 months with a minimum of two unsuccessful attempts to conservative treatment, which indicated the need for surgical treatment. Exception criteria were a weak health condition (carofan index <70), specific (operational) interventions over the last two weeks, pregnancy, coagulation disorders, tumors in the field of treatment and systemic diseases that could be interpreted as probable sources of differential diagnostics (for example , collagenosis, rheumatic diseases).

Patients were randomized in a 1: 1 ratio to a true or fictitious group. Meanwhile, both groups received identical treatment, the procedure in the control group was changed in such a way that the shock waves were not transmitted. Three therapy sessions were carried out without local anesthesia. Local anesthesia was prescribed only in exceptional cases when the pain was already more unbearable. Control inspections were carried out after 1, 4, 12 and 52 weeks.

  General True Group Control group
Age (years)
50,4 ± 11,7
50,4 ± 11,3
50,6 ± 12,3
Right position
Left position
Duration of pain (months)
24,0 ± 27,5
23,7 ± 27,4
24,6 ± 28,1

Table 1. Demographic data.

If the pain continued after 4 weeks in patients from the control group, the patient's blind maintained and the patient was taken to the Medical Group.

The questionnaire was anonymously filled with an orthopedic doctor or surgeon and was transferred to a research center for statistical assessment (ITSO).


One hundred and three patients were involved in the study. Fifty-five patients were randomized into a true group, 48 - in the control group. Demographic data (Table 1), as well as symptoms, and initial data (Table 2) showed homogeneity at the initial level.

The treatment was carried out with initial pressure of 4 bar, 2000 shock waves. Local anesthesia was required in 5 patients (9%) of the true group and 3 patients (6%) of the control group. Local symptoms could be seen immediately after treatment (Table 3), but they disappeared after 1 week.

Eighty-five patients were examined to 52 weeks after the last Refów. Night pain, pain in peace and pain during the walk significantly decreased in the medical group compared to the placebo group. In fact, an increasing improvement was observed during the entire observation period. The control group did not have significant changes between the initial data and subsequent inspection data. Patients who came out of the control group 4 weeks after RSWT due to persistent pain received "non-stop" active therapy. In the end, they reached the same results as in the first therapeutic group.


  General True Group Control group
Night pain
Limit in daily activity
Restriction in sports
Disability restriction
Maximum walking time
Not limited
Starting pain
Injection places
Clumsily (Bear Stop)
Pes equinocavus

Table 2. Pathology and observations, expressed in percent (%)

  General True Group Control group
Petechial bleeding

Table 3. Postoperative side effects (%)

The restriction in time of walking and daily activity in the true group remained relentless at 36% and 34%, respectively. Restrictions in sports and professional activities were promised by 52% and 50%, despite the fact that the duration of these restrictions has decreased significantly. Compared to the control group, the values ​​were above 70%.

Most patients repeated treatment after 1 week. This value remains unchanged in the true group. In the control group, the value decreased after 4 weeks and decreased again after 12 weeks. This observation correlated with patient satisfaction. After 12 weeks, more than 90% of patients reported on improvements and more than 60% were even fully satisfied with the result. In the control group, this value was equal.

The clinically significant side effects were found, but minor phetechial bleeding and swelling reported.


Over the past 30 years, the effects of many physical factors affecting the healing process and soft tissues have been studied. When considering extracorporeal shock waves for the treatment of urolithiasis, the new physical environment was introduced into medicine [4, 5]. Shock waves can cause exposure without any surgical intervention. These shock waves were used in the treatment of urolithiasis. According to the data for 1985, the stones of the gallbladder and stones of salivary ducts were also treated with the use of shock waves [28, 34, 35]. Common for these therapy is fragmentation of stones with shock waves.

The shock waves were used for the first time in 1986 with the aim of stimulating healing processes rather than in order to fragmentation of stones. It was known that low-energy shock waves stimulate healing processes, while high-energy shock waves - no. These processes were observed in the surface wounds of pigs [20]. In addition, the shock waves demonstrated the osteogenic (costh-forming) effect, which led to the use of shock waves for the treatment of pseudoarthrosis [11, 15, 17, 18, 22, 24, 25, 36, 36, 39]. The positive effect on the wound healing is no longer used until recent studies have shown this effect again. The effect of the wound healing is further discussed in Chapel written by Wolfgang (Wolfgang Schaden) and Richard Tile (Richard Thiele). In the case of the plantar fasci, there were almost no multicenter, controlled studies characterizing conservative or surgical treatment for a long time. Meanwhile, several promising randomized slave-controlled studies of the effects of focused ESWT were published, some of them with partially contradictory results [43, 44, 45]. Consequently, the final evaluation of the efficacy of focused ESWT is impossible, but it is undoubted that conservative ESWT therapy is shown to surgery. Recent reviews have witnessed evidence in the treatment of shock waves of chronic healing pain.


This study first describes the effect of radial ESWT (RSWT) in the treatment of heel spurs. The patient was involved in the study if he had at least two unsuccessful attempts to apply conservative therapy and the duration of pain was more than 6 months. This corresponded to a negative selection.

The subjective proportion of successful attempts of conventional extracorporeal shock-wave therapy ranged from 50 to 70% of the absence of pain or a significant decrease of it [6, 8, 29, 33]. Radial shock-wave therapy showed a comparable share of successful attempts. The well-known placebo effect, in which the device was also used, was carried out using an imaginary RSWT group. A significant difference and advantage in comparison with the conventional focused shock-wave therapy was that RSWT are easily managed, does not require visualization, does not require local anesthetics and its value is significantly less. In the event of the failure of RSWT, surgical options always remain. The side effects of radial therapy are similar to the side effects of focused ESWT: transient pain, phetechial bleeding or subcutaneous hematoma were observed in 4% of patients [26]. However, local skin symptoms are undoubtedly most common when radial therapy, which is easily explained, since high-precision energy is located next to the tip of the applicator. After 1 week, no side effect was found or neurological disorder. The emergence of local irritation did not reach clinical significance.

The use of shock waves in orthopedics remains discussion and continues to be described by inappropriate research [13]. A lot of studies on shock waves were published, but there are only a few promising randomized controlled studies. Despite this therapy of the plantar fascia, was noted in its effectiveness and is no longer classified as the therapy of the "lifestyle". High recommendations from patients and doctors confirm the clinical data that ESWT is more efficient than any other other surgical or injectable techniques.
The radial shock-wave therapy studied in our study was clinically effective without side effects. Therefore, it is advisable to use RSWT for the treatment of chronic fasci. In addition to the above, RSWT provides very economical treatment in comparison with conventional shock-wave procedures.


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