Efficacy and tolerability of extracorporeal shock wave therapy in patients with plantar fasciopathy: a systematic review with meta-analysis and meta-regression.
Lorenzo Lippi, Arianna Folli, Stefano Moalli and 4 others
PMID 39257331WHAT IT FOUND
ESWT for plantar fasciopathy was well tolerated: adherence 82.19% to 100%, dropout 7.78%, side effects mostly minor.
Pooled pain scores fell 2.818 points after focal and 3.038 after radial ESWT, but those are pre-to-post changes within ESWT groups, not a comparison against control.
Key findings
01ESWT for plantar fasciopathy was well tolerated across the 11 trials: adherence ran from 82.19% to 100% in the radial ESWT groups and was 84.45% and 97.39% in the focal ESWT groups, and cumulative dropout was 7.78% among the 1081 randomised participants (7.02% among the 555 randomised to ESWT alone).
02In meta-regression, higher ESWT settings (frequency, number of pulses, energy flux density, pressure) were significantly associated with better adherence and fewer dropouts, and with greater falls in pain scores.
03Pooled pain scores fell after both focal ESWT (mean decrease 2.818) and radial ESWT (mean decrease 3.038), but these are changes from before to after treatment within the ESWT groups. The review reports no pooled comparison of ESWT against a control group.
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How it was doneWhat they foundWhat it means for PTs
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What it does not show
Only 11 trials were included, most of them small, and the authors say this limits how far the results can be generalised. There was considerable variation between the studies that the ESWT settings examined did not explain: all Q values were significant with large I-squared values, which the authors accept means other factors are affecting the results. The pain estimates pooled only three or four trials each and report the change from before to after treatment inside the ESWT groups; no pooled comparison against a control group is given, and the control conditions ranged from sham ESWT to steroid injection, prolotherapy, platelet-rich plasma, laser, ultrasound and simply a different ESWT intensity. Eight of the 11 trials were rated as having some concerns for risk of bias, mainly because they did not describe how they handled intention-to-treat, and three had concerns about missing outcome data. The review calls every trial high quality on the Jadad scale, but the quality table records five trials as having no blinding of participants and two with no blinding of outcome assessors, so the Jadad verdict should be read with that in mind. The review excluded trials that combined ESWT with another treatment, so it says nothing about ESWT used alongside other therapy, and it reports no long-term follow-up. The authors note that the person delivering the treatment and their level of experience may influence results, which the included trials did not account for.
Declared interests
The authors declare no conflict of interest with any financial organisation regarding the material discussed in the manuscript. No funding source is stated in the text supplied.
The easy way to misread this
Do not read the pooled 2.818 and 3.038 point pain reductions as proof that ESWT works. They are the average change from before to after treatment inside the ESWT groups, with no pooled comparison against a control condition, and the control conditions in these trials were not the same as one another. Do not treat the meta-regression as a validated dosing protocol either: each analysis rests on three or four small trials and the authors report substantial variation between studies that their model did not explain.
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