Plantar fasciitis with heel spurs is a common cause of heel pain, and is often not sensitive to conservative treatment, including insole supports, non-steroidal anti-inflammatory drugs, local steroid injection, and physical therapy.^1,2 In patients in whom conservative treatment fails, surgical intervention is recommended.³

Recently, extracorporeal shock wave therapy has been introduced for the alleviation of painful heel and other conditions such as tennis elbow, calcifying tendinopathy of the shoulder, and non-union of fractures of the long bones.^4–7

The presence and size of the heel spurs do not correlate with the clinical symptoms.^4,8

Twenty patients aged between 40 and 70 years were treated. Exclusion criteria were degenerative diseases and/or inflammation of the ankle or foot joints, neurological abnormalities, nerve entrapment syndrome, pregnancy, infectious or neoplastic diseases, ulcerations, and bursitis.

Inclusion criteria were painful heel for a minimum of 12 months with heel spur radiologically examined and unsuccessful conservative treatment during the 6 months before referral to our hospital. No other treatment or drug was used during the 4 weeks before the trials began or during the study period, only the use of insole supports was permitted. An electrohydraulic system was used (Orthima; Direx Medical System Ltd).

Five treatments were given (one every 7 days), each treatment comprising 1200 shocks with a frequency of 120 shocks a minute. As the treatment may be initially painful, the energy density used on starting treatment was 0.03 mJ/mm², which was gradually increased to 0.4 mJ/mm².

Variations in the bone mineral content (BMC) of enthesophytosis were evaluated by fan-beam dual x ray absorptiometry (DXA) using a Lunar-Expert version 1.72, at baseline and 1 month after the end of treatment.⁹ This method allows rapid scanning of particular skeletal regions, and provides a radiographic-like image.¹⁰ Scans of 1 mA were applied to the heel, the foot was placed in complete extra-rotation, using a plastic support specific for a DXA evaluation of small bone structures. A region of interest was created in each patient, with a side at the base of the enthesophytosis, to include the enthesophytosis and to exclude the os calcis cortex; this region of interest remained unchanged for later controls (fig 1). The short term precision of the method was 0.5% (coefficient of variation) in vivo, as calculated in 10 patients scanned four times.

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Figure 1

 Fan-beam DXA of the heel.

Pain levels were evaluated (before treatment, at the end of treatment, and 3 and 6 months later) by visual analogue scale (VAS) ranging from 0 = no pain to 10 = maximum pain, at rest, after walking on awakening, and after normal daily activity. A significant decrease of VAS (p<0.0001, Wilcoxon test) was seen (table 1).

DXA analysis of enthesophytosis showed a significant decrease in BMC (p<0.001, paired Student’s t test) from an average of 0.162 g to a mean of 0.111 g.

In conclusion, we found that extracorporeal shock wave therapy significantly improved the painful symptoms; in our study this reduction in pain was accompanied by a significant decrease of the BMC of the heel spur.