Efficacy and tolerability of extracorporeal shock wave therapy in patients with plantar fasciopathy: a systematic review with meta-analysis and meta-regression

Abstract

Introduction: Plantar fasciopathy (PF) is a common musculoskeletal condition characterized by heel pain and functional impairment. Extracorporeal shock wave therapy (ESWT) has gained increasing interest in the treatment of PF, but the optimal ESWT program is still debated. Therefore, this systematic review with meta-analysis and meta-regression aimed at providing a comprehensive assessment of the efficacy and tolerability of ESWT in PF management.

Evidence acquisition: Randomized controlled trials (RCTs) published until February 2023 were systematically searched on PubMed/MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and PEDro. Studies assessing adult patients with PF treated with ESWT were considered. The primary outcome was the tolerability of ESWT, measured by treatment adherence, dropouts, and safety. Secondary outcomes were pain intensity and functional outcomes. Meta-analysis and meta-regression were performed to examine the relationship between ESWT program characteristics and treatment outcomes. The quality of included studies was assessed using the Jadad scale and the Cochrane risk-of-bias tool.

Evidence synthesis: Eleven studies met the inclusion criteria and were included in the analysis. Our findings showed that ESWT is effective in reducing pain intensity assessed by Visual Analogue Scale [focal-ESWT: -2.818 (SE 0.803, -4.393, -1.244; P< 0.0001; radial-ESWT: -3.038 (SE 0.428, -3.878, -2.199; P<0.001)]. Meta-regression analysis indicated a positive relationship between specific ESWT parameters (frequency, number of pulses, energy flux density and frequency, and number of pulses, pressure) and pain intensity (all P<0.05) and dropout (all P<0.05).

Conclusions: ESWT seems to be an effective and tolerable treatment for PF, albeit the peculiarity of parameters might affect both the efficacy in pain relief and the adherence to the treatment. Physicians should consider individual patient characteristics when selecting the ESWT parameters for PF treatment. Further high-quality studies are warranted to establish the optimal ESWT protocol to treat PF.

Figure 1

—PRISMA 2020 flow chart.

Figure 2

—Meta-analysis of overall effect size of VAS change. A) Focal-ESWT;^{, ,} B) radial-ESWT.^{, -} ESWT: extracorporeal shockwave therapy; VAS; Visual Analogue Scale.

Figure 3

—Random-effect meta-regression of moderators on adherence. A) Regression of Logit event rate on SW frequency (Hz) focal-ESWT; B) Regression of logit event rate on pulse-focal-ESWT; C) regression of logit event rate on energy flux density (mJ/mm²)- focal-ESWT; D) regression of logit event rate on SW frequency (Hz)-radial-ESWT; E) regression of logit event rate on pulse-radial-ESWT; F) regression of logit event rate on pressure (bar)-radial-ESWT. Coeff: coefficient; ESWT: extracorporeal shockwave therapy; SW: shockwave.

Figure 4

—Random-effect meta-regression of moderators on dropouts. A) regression of logit eventrate on SW frequency; (Hz)–focal-ESWT; B) regression of logit event rate on pulse-focal-ESWT; C) regression of logit event rate on energy flux density (mJ/mm²)-focal-ESWT; D) regression of logit event rate on SW frequency (Hz)-radial-ESWT; E) regression of logit event rate on pulse-radial-ESWT; F) regression of logit event rate on pressure(bar)-radial-ESWT. Coeff: coefficient; ESWT: extracorporeal shockwave therapy; SW: shockwave.

Figure 5

—Random-effect meta-regression of moderators on VAS. A) Regression of VAS mean difference on pulse-focal ESWT; B) regression of VAS mean difference on energy flux density (mJ/mm²)-focal-ESWT; C) regression of VAS mean difference on SW frequency (Hz)-radial-ESWT; D) regression of VAS mean difference on pulse-radial-ESWT; E) regression of VAS mean difference on pressure (bar)-radial-ESWT. Coeff: coefficient; ESWT: extracorporeal shockwave therapy; SW: shockwave.

Figure 6

—Risk of bias summary of the included studies.^-