Shockwave Therapy for Plantar Fasciatis

What is the plantar fascia?

The plantar fascia is a thick connective tissue structure extending over the underside of the foot.  Its function is to help support the arch of the bottom of the foot.  The attachment at the heel is to the medial calcaneus (heel bone) and extending forward to the heads of the metatarsal bones.  The fibres of the plantar fascia are orientated along the length of its structure, which is an important aspect to consider when understanding the mechanics of how the foot works and how plantar fasciitis occurs.
The plantar fascia can be split into 3 portions, which are the medial portion, central (largest and most prominent) and lateral portions.
An interesting point is that the plantar fascia in younger people has a direct fascial connection with the Achilles tendon, this becomes thinner with age and reduces to have no communicating fibres in more senior people.  The Achilles and plantar fascia also have separate insertion points directly into the calcaneus.
The Plantar fascia supports about 14% of the total load in each foot and is heavily involved with complex biomechanical process that occur to allow normal gait to occur.  Most of the stress of force transmission occurs at the attachment to the calcaneus, cadaver studies show that on maximal loading the force focuses on this area.
During weight bearing the plantar fascia acts like a spring to conserve and dissipate energy.  During walking gait the increased tension in the plantar fascia, due to the dorsi-flexion of the toes, increases the foot stiffness and allows for excellent propulsion of force through the foot.  This is known as the windlass mechanism (Hicks 1954), which helps in creating foot stiffness by drawing the arch upwards and making the long axis of the foot shorter and stiffer.  The theory uses the analogy of tightening the windlass of a drum to explain the complex series of events that occurs in response to force application on the plantar fascia due to its anatomical orientation.  The windlass effect is heightened by a supinatory effect caused by the combined effects of the flexor digitorum longus, flexor hallucis longus, peroneus longus and achilles tendon, further adding to the stiffness of the foot during this propulsive phase of the gait cycle.
The function of the foot is 3 fold.  The foot is able to stiffen in response to force placed upon it, to adapt to uneven terrain and to absorb shock.  The orientation and attachments of the plantar fascia allow it to be an integral part of the functioning of the foot and low it to be so ‘accommodating’ during gait and weight bearing.

What is plantar fasciitis and heel pain?

Plantar fasciitis is the abnormal inflammation of the plantar fascia tissue on the under side of the foot.  The insertion point to the calcaneus is the main focus of this.  The main causes of mechanical plantar fasciitis are related to poor control of the foot during weight bearing.
Prolonged over pronation can result in irritation to the plantar fascia.  People suffering with over pronation issues generally speaking have a much more mobile foot type, which also tends to have a lower medial longitudinal arch.  However, that is not to say that the pes cavus or high arched foot type will not pronate.
The tibialis posterior muscle has been shown to be heavily involved with the control of arch height during weight bearing.  The muscle is loaded eccentrically and needs to be strong and neurally geared towards controlling the effects of load on the arch height.  Exercises are often directed at this muscle to help activate it more and correct faulty firing patterns.  The net effect of this is the reduction of stress placed on the plantar fascia during weight bearing, with a proper functioning muscle.
Controlling pronation is therefore key in this particular foot type.
Plantar fasciitis may also occur in the high arched foot and results from the inability to dissipate force.  The calcaneus and metatarsal heads are much closer together, the tarsal bones have less intra-osseous mobility and the first ray is often held in plantar flexion, which lead to a foot which is great at force transmission but exceptionally poor at shock absorbing.
Generally the solution to this is to try and increase the flexibility in the foot in relation to creating other structures that are able to absorb shock.

What other treatments are available for plantar fasciitis and heel pain?

There is little scientific evidence about the types of treatments that help plantar fasciitis.  New research into shockwave and its applications has been very positive and gives sufferers of this painful condition hope.  Other possible treatments for plantar fasciitis include;
  1. Orthotics
  2. Taping
  3. Corrective exercises
  4. Ice Massage
  5. Acupuncture
  6. Stretching
  7. Night Splinting
  8. Self Massage
  9. Rest
  10. Heel Pads
  11. Steroid Injections
  12. Surgical Release
  13. Pain killers
  14. Shockwave
  15. Laser
  16. Ultrasound

How is shockwave therapy applied in plantar fasciitis?

Shockwave therapy for plantar fasciitis and heel pain is applied following a set protocol.  The clinician will carry out a thorough case history taking which isolates the area that is painful and begins to understand the clinical history behind the condition.  It is important to make sure that the condition being treated is actually a plantar fasciitis and heel pain and is therefore treatable with shockwave therapy.
During the examination period a tender point where the pain is maximal will be located, upon which a water-based medium will be applied.  This aids the transmission of the impulses into the desired area.
The probe will then be placed over the desired area and then treatment for your plantar fasciitis and heel pain will begin.  At first the clinician will ensure the discomfort is kept to a minimum.  After a while as the impulses increase little pain is felt.  Although, more often than not there is some pain felt over the area of application.  After treatment you should feel very little pain and this may last for a few days.  After then an aching sensation can occur.  After subsequent treatments there will be a definite improvement in symptoms leading to reduction in the original pain felt.

How long will shockwave therapy take to work?

Generally most applications of shockwave for plantar fasciitis and heel pain and most conditions will resolve within 3-4 sessions of 30 minutes (roughly).  This obviously can depend on the exact presentation of the condition.  Making sure you see someone quickly to have the condition diagnosed can reduce the number of sessions needed.
It is vital that you continue to work with a physical therapist to maintain the exercise regime you should already be carrying out for plantar fasciitis and heel pain, prior to consulting for shockwave treatment.  This will involve balancing exercises, strength exercises and a good eccentric loading programme depending on your stage of plantar fasciitis and heel pain.

What is the evidence for shockwave therapy for plantar fasciitis?

Although there has been little positive scientific for treatments which are beneficial for plantar fasciitis there does seem to be a growing volume of literature, all of which are drawing the same conclusions.  The most effective non-operative treatment for plantar fasciitis appears to be shockwave therapy (Aqil 2013,  Cutts 2012)
Saxena 2012 compared shockwave therapy to surgery and agreed that the outcomes for return to sport and continuation of sport whilst undergoing treatment were in favour of shockwave therapy for plantar fasciitis.  Although, Endoscopic plantar fasciotomy (operations) were superior in outcomes but with the associated risks.  Athletes were able to have shockwave therapy and maintain playing their chosen sport, whilst the surgical group had to stop playing sport.
Vahdatpour 2012 produced a study, which showed the morphological changes associated with shockwave therapy for plantar fasciitis.
Most studies also show that, alone, the shockwave therapy can reduced significantly pain and suffering associated with plantar fasciitis but it is clear that biomechanical factors need to be addressed and maintained to allow optimal functioning of the foot during weight bearing.

Where can I get shockwave therapy for plantar fasciitis?

One is able to get shockwave therapy at a few specialist clinics in the UK.  There are a growing number of clinics providing this specialist form of treatment.  It is beneficial to make certain the type of machine they use is a swiss dolor clast machine as this is the only one that has been tested to high level in research papers.
At Pefect Balance Clinic we often see people with different types of Tendinopathy who have tried other forms of treatment.  Shockwave for us has been the one form of treatment that has consistently delivered results for Tendinopathy.

How long will the treatment last for?

If everything goes to plan with your shockwave therapy for plantar fasciitis and heel pain then the treatment should make a significant contribution to reducing the pain and improving the function of your plantar fasciitis and heel pain.  In most cases the shockwave will get rid of the patellar tendinitis.
With some tendon surgery there is a 75% success rate at 18 months, with shockwave for the same condition it has been shown that up to 80% of patients who have received the shockwave therapy at 18 months have a good to excellent result.  Shockwave is better than surgery for certain tendinopathy and more research is being done with this in mind.

Conclusion

Shockwave therapy is a safe and effective form of treatment in the management of plantar fasciitis.  The results of which are comparable to surgery but without the necessary recovery period, morbidity and reduced participation in sport that can often accompany surgery.

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