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What's the evidence supporting focused shockwave therapy as a treatment for musculoskeletal foot pain?

This article explores the new study about shock wave therapy in the foot and whether focused shock wave therapy results differ from the radial type - read more below.

Extracorporeal shockwave therapy has gained popularity over the years as a treatment for several musculoskeletal disorders and the pain that often accompanies them. Since the early '80s, shockwave therapy has gone from a novel treatment that some in the medical community viewed with suspicion to standard practice in multiple medical fields, including orthopaedics and sports medicine. As the evidence base for the efficacy of shockwave therapy has grown, much of the initial scepticism has receded.

However, while the evidence base has grown, not all of the research has been of high quality. Furthermore, interpreting the results of the entire body of evidence and drawing sound conclusions has been challenging due to variations in the quality of studies and the protocols and devices used between studies. Because of the difficulties mentioned above, the UK-based Cambridge Centre for Health and Performance conducted a systematic review of the available evidence summarized below.

First we ask the question:

Is the current evidence for shockwave therapy unreliable?

No, there is plenty of reliable evidence that shockwave therapy is a safe and beneficial treatment for a range of conditions affecting the feet, elbows, and knees. However, there is still no consensus among doctors, physical therapists, and even the manufacturers of shockwave therapy equipment as to how shockwave therapy should be standardised.

Because there is no universal standard for shockwave therapy equipment, two patients receiving shockwave therapy from two different doctors who each use equipment from a different manufacturer may not get the exact same treatment. The shock waves their equipment generate can vary in several ways. Similarly, a lack of standardised protocols means that doctors treating patients with the same equipment will use different schedules and protocols for their patients. The goal of standardisation is to establish a set of standards that those administering shockwave therapy can follow to provide the greatest benefit for their patients.

Each provider offering shockwave therapy has to decide for themselves what protocols they should use, how to calibrate their equipment etc. It's helpful, therefore, if there is reliable research they can refer to and use to make these decisions. However, this is more difficult without standardisation.

For example, some studies reference high and low energy shockwaves. The energy of the shockwaves is used to determine the 'dose' patients receive. However, there's no consensus on how to define high and low energy shockwaves. Similarly, shockwave systems can generate shockwaves in one of three ways. Each method produces waves with different characteristics, and while all three methods produce similar results, there's no agreement on which method is the best.

A single study showing a particular outcome doesn't mean much unless it's supported by other studies that use the same methodology and produce the same results. So, while there are lots of individual studies showing that shockwave therapy is effective, the variations outlined above mean that those in the field need to be careful when drawing conclusions from the research.

 had a higher success rate. The researchers concluded that low-dose focused shockwaves were ineffective for treating plantar fasciitis. One study suggested that radial shockwave therapy might also be effective at treating this condition.

Why is this research important?

Usually, when researchers want to look at the results across multiple studies that measure the same thing, they will use a meta-analysis. A meta-analysis takes all the results from each study and pools them together. Researchers can then use statistical analysis to draw conclusions from the entire body of evidence instead of individual studies. However, researchers can only use a meta-analysis if the studies they pool together are similar enough. In the case of shockwave therapy, a meta-analysis wouldn't be useful because there is so much variation between different studies.

When a meta-analysis isn't viable, a systematic review can be used instead. A systematic review also aims to analyse multiple studies and draw sound conclusions, but the process is different. Systematic reviews use studies that measure the same thing but vary from one another in some way.

The research we discuss below is a systematic review of the evidence for the efficacy of shockwave therapy for several conditions. The researcher's goal was to produce a single study that would provide reliable evidence to the researchers and practitioners in the field based on the results of multiple individual studies.

What did the Cambridge researchers do?

The Cambridge researchers began by conducting a thorough search for relevant studies published across a range of sources, including online databases and sports and medicine journals, among others. They then went through the studies they found to find high-quality studies with sound designs that focused principally on the participant's pain levels and measured those levels for at least 12 weeks.

A range of exclusion criteria was used to ensure that there were no confounding variables. Any study that fit one or more of the exclusion criteria was discarded. Exclusion criteria included things like a lack of a control group to compare participants against, studies that included participants with coexisting diseases, inappropriate statistical analysis of the results, and those with methodology errors. The researcher's aim was to produce a sample of well-designed and reliable studies.

Ultimately, the researchers were left with 23 studies that formed the basis of their analysis. They then combined the evidence from all 23 studies to assess the effectiveness of shockwave therapy for several conditions, including plantar fasciitis.

What were the results of the review?

The researchers found that when the results of all 23 studies were taken into account, they provided good evidence that shockwave therapy was an effective treatment for plantar fasciitis and Achilles tendinopathies. They also noted that the benefits of focused shockwave therapy appeared to be dose-dependent, with higher doses leading to more successful outcomes.

Plantar fasciitis - Shock Wave Treatment Conclusions From Study

High-energy focused shockwaves(>0.12 mJ/mm2) was shown to be an effective treatment for patients with chronic recalcitrant plantar fasciitis. One of the 23 studies also showed that patients who hadn't responded to shockwave therapy could benefit from moving to higher doses, which had a higher success rate.

The researchers concluded that low-dose focused shockwaves were ineffective for treating plantar fasciitis. One study suggested that radial shockwave therapy might also be effective at treating this condition.

What Is Plantar fasciitis?

Plantar fasciitis causes pain on the soles of your feet, mainly around the heel and arch. Plantar fasciitis is a common affliction that usually passes relatively quickly and can be caused by something as simple as wearing the wrong shoes. However, some people experience prolonged or frequent bouts of Plantar fasciitis, and certain groups are more susceptible to it than the general population.

What did researchers find out about Plantar fasciitis treatment with SWT?

The researchers found that high energy focused shockwave therapy was an effective and reliable treatment option in cases of chronic Plantar fasciitis. They also found that higher doses (meaning shockwaves with higher energies) were more effective. The excellent safety profile of shockwave therapy means that increasing the dose of treatments is easy and rarely presents any issues, even when the dose increase is significant. The studies also suggested that in cases where shockwave therapy hadn't helped patients, higher doses could still produce results for many. There was no evidence that low-dose/low energy focused shockwave therapy was helpful in treating Plantar fasciitis, indicating treatment should begin at a high dose.

Anyone struggling with ongoing Plantar fasciitis who wants to try focused shockwave therapy should Our location, on St Andrews Close, Wimbledon SW19, is easy to reach via public transport; Wimbledon and Haydons Road stations are both close by. 

What Are Achilles tendinopathies?

& what did researchers find out shock wave treatment on the Achilles?

Achilles tendinopathies occur when the Achilles tendon suffers a tissue injury.

A twist to the heel cord typically gives a mid-portion sensitivity (non-insertional) whereas a pull/ yank gives insertional tendonitis pain.

Shockwave therapy has been explored as a pain relief mechanism and potential treatment. The researchers reported mixed results for the use of shockwave therapy in Achilles tendinopathies.

While there was very limited evidence suggesting shockwave therapy may help with mid-portion and insertional Achilles tendinopathies, there are no high-quality studies with enough cases to draw any conclusions.

High-dose focused shockwave therapy was shown to provide benefits in patients where the mid-portion of the tendon was affected.

There was no benefit to low-dose focused shockwave therapy only a higher dose is indicated.

And it's more comfortable to active higher dose treatments with the focused type of shock wave therapy.

What conclusions can we draw from these results?

In their conclusion, the researchers noted that shockwave therapy had proven to be an exceptionally safe treatment, with adverse reactions being minor and rare. There was clear evidence that focused shockwave therapy in numerous musculoskeletal conditions affecting soft tissue.

The researchers also concluded that the benefits of focused shockwave therapy appeared to be dose-dependent, with higher doses generally producing greater benefits.

All these factors made shockwave therapy a viable alternative to surgery for plantar fasciitis in patients managing recalcitrant conditions and recommended that it be considered as a preventative measure for certain procedures.

However, while the researchers found that existing studies provided evidence of the benefits of shockwave therapy, they highlighted several areas where the overall quality of future studies could be improved. Using consistent standards for protocols, equipment, and doses in treatment guidelines, instead of treating all shockwave therapy as the same, would make future studies easier to design and the results more reliable.

This research is good news for foot pain sufferers and shockwave therapy practitioners, and patients.

The review showed that the existing body of research into shockwave therapy as a treatment option contained good evidence that it is effective and safe.

While there is limited evidence for its use in some conditions, there is good evidence for its use in plantar fasciitis and Achilles tendinopathies at high doses.