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Table 4 Imaging outcome measures for plantar fasciitis and heel spurs

From: The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

Author (year) SWT type Comparator Imaging outcome Follow-up
Period Baseline - F/U
Mean ± SD
P value
Within group Between group
Bicer (2018) [44] R-SWT None MRI was used to assess changes in the soft tissue and BME, plantar fascia thickness (PFT) and the presence of heel spurs. MRIs were scored semi-quantitatively. PFT was measured 1 cm from the insertion and thickness > 3 mm was considered abnormal 3 months 12/23 (52.1%) showed improvement in PFT. 21/30 (70%) and 10/19(52.6%) had improvement in soft tissue and BME respectively. No significant change in heel spur < 0.05 NA
Chew (2013) [45] F-SWT Autologous Conditioned Plasma (ACP) and conventional Ultrasonography of plantar fascia (PF) was performed to manually measure the point of maximal proximal PFT at the medial calcaneal tubercle insertion site. 1,3,6 months The median PFT improvement in the ACP group at the 6-month follow-up was 1.3 mm compared with the SWT and conventional treatment groups, which both showed improvements of 0.6 mm. NR SWT vs conventional treatment =0.934
ACP vs SWT = 0.027
Daniel-Lucian (2013) [43] NR None Ultrasonography was used to measure PFT 3 months The mean PFT decreased from 5.84 to 5.21 in the females, and from 5.87 to 5.14 in the male subjects NR NR
Gerdesmeyer (2015) [46] F-SWT None Measurements of bone mass density (BMD) and bone mass concentration (BMC) were performed with a Lunar DEXA. The square-shaped analysis field (Region of Interest, ROI) was placed in the cancellous part of the calcanei and BMD and BMC were measured. 6,12 weeks The mean BMD (g/cm2) values changed from 0.5 ± 0.1 to 0.557 ± 0.1 in the SWT group and from 0.54 ± 0.1 to 0.52 ± 0.09 in the control group after 12 weeks.
The mean BMC (g) values changed from 2.03 ± 0.38 to 2.22 ± 0.38 in the SWT group and from 2.16 ± 0.4 to 2.08 ± 0.36 in the control group after 12 weeks
0.001 < 0.01
Hammer (2005) [47] F-SWT None The PFT was measured about 2 cm distal of the medial calcaneal tuberosity using ultrasonography 6,12,24 weeks The mean PFT in 16 subjects changed from 5.2 ± 1.5 to 4.4 ± 1 after 6 months. There was no significant change of PFT on the control side < 0.05 < 0.05
Hocaoglu (2017) [48] R-SWT Ultrasound-guided local corticosteroid injection PFT and its echogenicity were examined through ultrasonography. A linear probe was positioned longitudinally over the medial tubercle of the calcaneus. PFT was measured at the proximal point of insertion of the fascia into the calcaneal tubercle. A PFT of 4 mm was considered evidence of fasciitis. 1,3,6 months PFT was found to be significantly reduced in both groups at all measurement endpoints compared with baseline with no significant differences between groups < 0.01 > 0.05
Lai (2018) [49] F-SWT Corticosteroid injection PFT was measured at the PF insertion 5 mm distal to calcaneus tuberosity using ultrasonography. 1,3 months At 4th week, the mean PFT changed in SWT group from 0.37 ± 0.07 to 0.46 ± 0.08 cm, and in the CSI group from 0.38 ± 0.06 to 0.43 ± 0.09 cm
At the 12th week, the mean PFT changed in the SWT group from 0.37 ± 0.07 to 0.38 ± 0.07 cm, and the CSI group from 0.38 ± 0.06 to 0.39 ± 0.07 cm
NR At 4th week =0.048
At 12th week =0.326
Lee (2003) [50] R-SWT Placebo Axial, lateral, and oblique radiographs of the calcaneus were performed to examine the presence of any osseous abnormalities of the calcaneus or for the presence of inferior calcaneal spurs 3,12 months 205/308 (67%) in the EWST group had an inferior calcaneal spur. In the sham treatment group, 78/127 (61%) had a spur.
No patient treated with SWT had subsequent fragmentation or disappearance of the heel spur at 3 or 12 months. Similarly, no patient had evidence of reactive new bone formation in or around the spur, nor apparent elongation of the spur
Maki (2017) [51] F-SWT None On MRI, 4 items were examined: PFT, high-signal intensity area (HSIA) inside the PF, edema around the PF, and BME of the calcaneus. For the PFT, the maximum diameter of the PF at the calcaneal attachment was measured on T1-weighted coronal images. 6 months The mean PFT changed from 4.4 ± 1.6 to 4.6 ± 1.8 after 6 months.
The numbers of feet showing HSIA inside the PF changed from 15 to 6, in edema around the PF from 16 to 2, and in BME of the calcaneus from 11 to 4.
> 0.05 NA
Moretti (2006) [52] F-SWT None A lateral weight-bearing X-ray of the foot and ultrasound evaluation was performed. 45 days, 6,24 months There was no heel spur fragmentation observed. The ultrasound evaluation at 24 months showed a complete disappearance of the inflammatory signs in 33(61%) patients. NR NA
Saber (2012) [53] F-SWT Ultrasound-guided local corticosteroid injection PFT was measured at the thickest portion from the base of the medial calcaneal tubercle where a bright echogenic line was easily visible using ultrasonography 20 (12–24) weeks The mean PFT in the SWT group changed from 5.93 ± 0.54 to 3.37 ± 0.42, and in the ultrasound guided injection group from 5.96 ± 0.46 to 3.54 ± 0.31 < 0.01 =0.079
Sorrentino (2008) [54] F-SWT Corticosteroid injection Ultrasonography was performed in prone position with ankles dorsiflexed. The focus was adjusted to the depth of the PF. The sonographic diagnosis established based on: 1) fascial thickening > 5 mm, 2) biconvex morphology and 3) abnormal fascial echostructure, specifically hypoechogenicity, heterogeneity and ill-defined margins. PFT was measured 1 cm from the calcaneal insertion with electronic calipers 6 weeks In the SWT group, PFT with perifascial edema was reduced to 4.6 ± 0.6 mm and up to 4 ± 0.3 mm among PFT without perifascial edema.
In the corticosteroid
Injection, PFT with perifascial edema was reduced to
4.3 ± 0.4 mm and up to 4.6 ± 0.4 mm among PFT without perifascial edema
Ulusoy (2017) [55] R-SWT low-level laser therapy (LLLT) and therapeutic ultrasound (US) The maximum thickness of the proximal PF where it attaches to the calcaneus was measured using electronic calipers on fluid-sensitive MRI sequences in the sagittal and coronal planes. The intrafacial and perifacial soft tissue edema and calcaneal BME were assessed in the sagittal plane on short tau inversion recovery sequences, and the presence of the calcaneal spurs was evaluated on T1-weighted sequences 1 month The mean PFT in the SWT group changed from 5.17 ± 0.89 to 4.31 ± 0.82, in the LLLT group from 4.33 ± 0.59 to 3.75 ± 0.69, and in the US group, from 4.76 ± 0.72 to 3.99 ± 0.62 seen on MRI coronal plane <.01 NS
Vahdatpour (2012) [56] F-SWT and R-SWT Placebo Sagittal imaging of the PF was performed with the ultrasound transducer aligned along the longitudinal axis of the aponeurosis. PFT was measured about 2 cm distal of the medial calcaneal tuberosity. Qualitative assessment was performed including echogenic appearance of plantar fascia and its fibrillary pattern 3 months The mean PFT in the SWT group changed from 4.1 ± 1.3 to 3.6 ± 1.2, in the placebo group from 4.1 ± 0.8 to 4.5 ± 0.9 <.01 =0.02
Yalcin (2012) [57] R-SWT None Lateral radiographs evaluated variations in the dimensions of calcaneal spurs. The radiographic variations included classification as reductions in the dimensions and the angle of calcaneal spurs NR No significant disappearance of heel spurs, but 19(17.6%) had a decrease in the angle of the spur, 23(21.3%) had a decrease in the dimensions of the spur, and 1(0.93%) had breakage of the spur NR NA
Zhu (2005) [58] F-SWT None Prior to MRI, a vitamin E capsule was taped to the heel that could be readily seen on MRI, where the point of maximal intensity of pain was delineated with a permanent marker. MRI assessed the presence and severity of soft tissue and calcaneal marrow edema, heel spur and PFT. 24 h 16/18(89%) had subcutaneous soft tissue and perifascial edema before SWT. After SWT, all 18 showed subcutaneous soft tissue and perifascial edema. Calcaneal marrow edema was seen in 8 heels. After SWT, edema increased in 1 heel and 1 new heel edema was developed.
Heel spur was seen in 9(50%) that was unchanged.
17(94%) had an abnormal PFT (> 4 mm) before SWT that remained unchanged following SWT
  1. BME bone marrow edema, F-SWT focused SWT, R-SWT radial SWT, NA not applicable, NR not reported, NS not significant