Original Article

Enhancement of the Effectiveness of Extracorporeal Shock Wave Therapy

with Topical Corticosteroid in Treatment of Chronic Plantar Fasciitis:
A Randomized Control Clinical Trial

Abstract Babak Vahdatpour,

Background: Chronic recalcitrant plantar fasciitis is a disabling condition. We presumed if shock Arghavan
wave could increase the permeability of skin and facilitate penetration of topical corticosteroid Mokhtarian,
through the skin; the combinational therapeutic effect would be stronger than using shock wave
alone. The study purpose was to utilize the synergistic effect of shock wave and topical corticosteroid Seyed Ahmad
in treatment of plantar fasciitis. Materials and Methods: Patients in both groups (n = 40) received Raeissadat1,
four sessions of shock wave with the same protocol at weekly intervals. At 30 min before each Farnaz Dehghan,
session, we used an occlusive dressing of topical clobetasol for the intervention group and Vaseline Nafiseh Nasr2,
oil for the control group. Pain severity was assessed with visual analog scale (VAS) and modified Mahsa Mazaheri
Roles and Maudsley score (RMS) at baseline and 1 month and 3 months after intervention. Plantar
From the Departments of
fascia (PF) thickness was measured with ultrasonography at baseline and 3 months after intervention.
Physical Medicine and
Results: One month after intervention, VAS morning showed significant improvement in intervention Rehabilitation and 2Radiology,
group (P = 0.006) and RMS showed better improvement in intervention group (P = 0.026). There Alzahra Hospital, Isfahan
was no significant difference between the two groups after 3 months in RMS or VAS score. PF University of Medical Sciences,
thickness was decreased significantly in both groups, but it was not significant between the two Isfahan, 1Physical Medicine and
groups (P = 0.292). Conclusions: This combinational therapy yielded earlier pain reduction and Rehabilitation Research Center,
functional improvement than using shock wave alone; topical corticosteroid could enhance the School of Medicine, Shahid
effectiveness of shockwave in short-term in the treatment of recalcitrant plantar fasciitis. Modarres Hospital, Shahid
Beheshti University of Medical
Keywords: Extracorporeal shock wave, plantar fasciitis, transdermal drug delivery Sciences, Tehran, Iran

Introduction Chronic recalcitrant plantar fasciitis is

a disabling condition and could have
Plantar fasciitis is a common cause of
a negative impact on patients’ quality
heel pain affecting 10% of the general
of life.[1]
population.[1] Its etiology is unclear and
likely to be multifactorial. It is believed Standard treatment for plantar fasciitis
to be the result of an acute or chronic is a conservative treatments, such as
injury, too much tension of the fascia, anti-inflammatory drugs, corticosteroid
biomechanical abnormalities of the foot or injections, splints, orthotics, casts, and
inflammation of the plantar fascia (PF). The physical therapy.[4] Corticosteroid injection
clinical symptoms are pain and tenderness is a commonly used modality in the
in the medial calcaneal tuberosity on management of plantar fasciitis.[5,6] It Address for correspondence:
weight bearing. The pain may be severe, can provide short term relief,[7] but it has Dr. Arghavan Mokhtarian,
complications, such as plantar fascial Department of Physical
resulting in the alteration of daily activities. Medicine and Rehabilitation,
Heel spur may be present at the origin of rupture, plantar fat pad atrophy, lateral Alzahra Hospital, Isfahan
the PF.[2] plantar nerve injury secondary to injection, University of Medical Sciences,
and calcaneal osteomyelitis.[8,9] Fascial Isfahan, Iran.
The typical patient describes symptoms E-mail: arghavan.mokhtarian@
rupture and fat pad atrophy are especially
during the first steps after rising in the gmail.com
serious complications that can lead to
morning. In most patients, these symptoms
intractable complications.
vary in intensity and may resolve after
Ninety percent of patients respond Access this article online
a variable period from a few steps to a
few hours. In most cases, symptoms then to conservative therapy,[10] but about Website: www.advbiores.net
increase as the day progresses.[3] DOI: 10.4103/abr.abr_40_17
Quick Response Code:
How to cite this article: Vahdatpour B, Mokhtarian A,
This is an open access journal, and arƟcles are distributed under Raeissadat SA, Dehghan F, Nasr N, Mazaheri M.
the terms of the CreaƟve Commons AƩribuƟon-NonCommercial-
Enhancement of the Effectiveness of Extracorporeal
ShareAlike 4.0 License, which allows others to remix, tweak, and
build upon the work non-commercially, as long as appropriate
Shock Wave Therapy with Topical Corticosteroid in
credit is given and the new creaƟons are licensed under the Treatment of Chronic Plantar Fasciitis: A Randomized
idenƟcal terms. Control Clinical Trial. Adv Biomed Res 2018;7:62.

For reprints contact: [email protected] Received: March, 2017. Accepted: May, 2017.

© 2018 Advanced Biomedical Research | Published by Wolters Kluwer - Medknow 1

 Vahdatpour, et al.: Enhancement of the effectiveness of ESWT with topical corticosteroid

10% fail to respond. After unsuccessful conservative 6 months and refractory to conservative treatment). Only
treatment, surgery is eventually recommended.[4] Recently, patients with Roles and Maudsley score (RMS) of 4 and
extracorporeal shock wave therapy (ESWT) has been PF thickness of >4 mm were enrolled in this study. Plantar
approved by the FDA and recommended for treatment fasciitis was considered present when the PF thickness
of chronic plantar fasciitis in patients unresponsive to was >4 mm with reduced echogenicity.[22-24]
conservative treatment.[11-14] ESWT is a new non-invasive
Criteria for exclusion were patients who suffered from
therapeutic modality with good efficacy and safety in the
diabetes, peripheral neuropathy, coagulopathies, vasculitis,
treatment of chronic plantar fasciitis. The complication
or vascular problems. Patients with any foot and ankle
rates are low and negligible.[15-18]
pathology including tarsal tunnel syndrome, instability,
ESWT induces a cascade of biological responses arthritis or evidence of malignancy, acute infection, and
and molecular changes, including the ingrowth of dermatological problems were excluded from the study.
neovascularization and up-regulation of angiogenic Patients with open growth plate or pregnant ones were not
growth factors leading to the improvement in blood enrolled into this study. Other reasons for exclusion were
supply and tissue regeneration. There is a close a history of surgical interventions or recent trauma to the
relationship between the decrease of substance P release foot and ankle or plantar fasciitis corticosteroid injection in
and pain reduction in the treatment of tendon insertion the preceding 6 weeks.
diseases.[19] Informed consent was obtained from all patients and
Recently, many drug delivery techniques have been the process of treatment and probable side effects were
introduced using a different form of energy to facilitate explained completely. The patients were informed that it
absorption of drugs through the skin. Shock wave is is possible to quit the study at any time. The protocol of
thought to act on cells mechanically with three main this study was approved by Ethics Committee of Isfahan
consequences: cell destruction, cell detachment, and cell University of Medical Sciences with the reference number
permeabilization. The mechanisms which are responsible of IR.MUI.REC.1394.3.764.
for the permeabilization of cells are not yet fully All patients received plantar fasciitis adjuvant therapy:
understood. However, they are probably based on direct • Calf muscle and PF stretching
interactions between the pressure wave and the cell or on • Passive dorsiflexion of the toes
the generation of cavitation bubbles.[20,21] • Intrinsic foot muscle strengthening
Among various options for treatment of chronic plantar • Shoes modification like soft medial longitudinal arch
fasciitis, ESWT and corticosteroid injection are the most support or silicon heel pad (as needed).
effective ones; therefore, we aimed to utilize the synergistic The patients were asked to limit physical activity and avoid
effect of the shock wave and topical corticosteroid, using nonsteroidal anti-inflammatory drug tablets during
considering potentiality of the shock wave in the field of the intervention period.
drug delivery. Relying on previous studies, we presumed
if shock wave could increase the permeability of skin Patients in both groups received four sessions of low
and facilitate penetration of topical corticosteroid through energy ESWT with the same protocol at weekly intervals
deep layers, the combinational therapeutic effect would be by Storz Medical Duolith SD1 machine (FDA approved
stronger than using ESWT alone. this device at January 2016 for chronic plantar fasciitis).
• Focus-SW Shock: 2000 Energy: 0.2–0.3 mJ/mm2
Materials and Methods Frequency: 4 Hz Fixed
• Radial-SW Shock: 3000 Energy: 1.8–3 mJ/mm2
This clinical trial was designed as a randomized, controlled,
Frequency: 15H movable.
triple-blind with two parallel groups and randomization
with a 1:1 allocation. The point of maximal tenderness was palpated and marked
with a skin marker as the target area for shock wave. The
Participants
procedure was performed in the clinic without anesthesia.
This clinical trial was conducted on patients with clinical
30 min before each shock wave session, we applied topical
diagnosis of plantar fasciitis referred to the physical
clobetasol ointment (three fingertip unit) with an occlusive
medicine and rehabilitation clinic of the Alzahra hospital
dressing for the intervention group and Vaseline oil with
from December 2015 to October 2016.
occlusive dressing for the control group.
Diagnosis of plantar fasciitis was made based on the
For adequate saturation of stratum corneum which is an
patient’s history and physical findings of point tenderness
important barrier to transcutaneous drug absorption, we
at or near the medial calcaneal insertion of the PF.
used occlusive dressing to maintain moisture and enhanced
Criteria for inclusion were patients older than 18 years absorption capacity of the skin.[25] Furthermore, the skin
with chronic recalcitrant plantar fasciitis (lasting at least denuded of the stratum corneum has a greater potential for

2 Advanced Biomedical Research | 2018

 Vahdatpour, et al.: Enhancement of the effectiveness of ESWT with topical corticosteroid

allowing drug diffusion,[26] we asked patients to scrub the was measured twice, and the average was recorded to avoid
plantar skin with pumice for safe removal of dead skin and error due to transducer obliquity.
calluses areas before each session. After occlusive dressing,
Response to treatment was defined as following by primary
patients hung their feet from examination table for better
outcomes (changes in pain score measured by VAS and
blood circulation in extremities and increasing absorption
RMS) and secondary outcome (changes in PF thickness).
of the topical drug.[26] After 30 min of dressing, we cleaned
• Changing the modified Roles and Maudsley score to 1
the feet with wet wipe and used coupling gel on the
or 2 in follow-up studies[29]
point of tenderness to utilize the shock wave potential for
• Score ≤4 on the 11 point scale (VAS) or improvement
increasing the permeability of the skin.
of more than 50% over baseline in follow-up studies[30]
Pain severity was assessed using visual analog scale (VAS) • Reduced PF thickness; we considered a true reduction
at baseline and 1 and 3 months after intervention (0 = no in PF thickness to be more than 0.7 mm to eliminate
pain, 10 = the worst imaginable pain). the measurement error.[31]
We recorded VAS score as follows: All patients were followed for any possible side effect or
• Heel pain while taking the first steps in the complications such as:
morning (VAS morning) • Possible transient moderate increase in pain
• Heel pain while doing a daily activity (VAS daily). • Redness and swelling
• Hematoma and petechial hemorrhage
Activity limitation due to pain was assessed with the modified
• Short-term hypesthesia.
RMS 1 and 3 months after intervention. The modified Roles
and the Maudsley score is a four-point scale to evaluate the Considering type I error (alpha) of 0.05 and study power
patients’ pain in relation to normal daily activities. of 90%, the sample size was calculated as at least forty
1. RMS 1: Excellent quality of life (no symptoms; unlimited patients in each group of intervention and control.
walking ability without pain; patient satisfied with the We used for randomization
treatment outcome [when assessed after intervention]) the GraphPad software (GraphPad software, Inc.,
2. RMS 2: Good quality of life (ability to walk more than California, USA) to generate random numbers with a 1:1
1 h without pain; symptoms substantially decreased allocation. For concealment, the project assistant defined
after treatment; patient satisfied with the treatment groups as A and B (Intervention: A and Control: B); no one
outcome) except the assistant was aware of this coding.
3. RMS 3: Acceptable quality of life (inability to walk
more than 1 h without pain; symptoms somewhat better This study is a triple-blind clinical trial. To reduce the
and pain more tolerable than before treatment; patient bias, the project assistant packed clobetasol and Vaseline
slightly satisfied with the treatment outcome) oil in new similar containers with coding A (clobetasol)
4. RMS 4: Poor quality of life (inability to walk without and B (Vaseline oil). Neither patients nor the people who
severe pain; symptoms not better or even worse after involved in this project (PM and R resident, radiologist
treatment; patient not satisfied with the treatment and analyzer) were aware of the coding. Only after data
outcome). analyses, decoding was done.
We used ultrasonography for diagnosis of plantar fasciitis Data were analyzed using the SPSS Statistics 20 for
and measuring PF thickness. It is an effective diagnostic tool windows (SPSS Inc., Chicago, IL, USA).
by documenting inflammatory findings and fascia thickness.
It is non-invasive, cost-effective, and free of radiation.[27] PF
thickness is postulated as an objective outcome measure for
the assessment of treatment response.[28]
Sonographic examinations were performed bilaterally
at baseline and 3 months after intervention with a
commercially available scanner (Affinity 70; Philips) and a
5.0–12.0 MHz linear transducer [Figure 1]. All ultrasound
examinations were performed by the same radiologist,
who was unaware of the patient’s group. The patients
lay prone with their feet hanging free over the end of the
examination table (knee in full extension and ankles in 90°
of dorsiflexion). Sagittal imaging was performed with a
perpendicular approach, and PF thickness was measured at
a standard reference point where the PF crosses the anterior
aspect of the inferior border of the calcaneus. PF thickness Figure 1: Ultrasound examination of plantar fasciitis

Advanced Biomedical Research | 2018 3

 Vahdatpour, et al.: Enhancement of the effectiveness of ESWT with topical corticosteroid

Descriptive analyses are presented as mean ± standard Three months after intervention, PF thickness
deviation or number (%). decreased (>7 mm) in 55% of the intervention group
and 60% of control group, the difference was not
We used Chi-squared and independent t-test for sex, BMI
significant (P = 0.653).
and age.
Comparison of treatment success in both groups regarding
We used Fisher’s exact test and Chi-squared test to
VAS (morning and daily), RMS and PF thickness are
compare the treatment success regarding RMS, VAS, and
shown in Table 2.
fascia thickness between the two groups.
There was no significant difference in compression of PF
Paired samples t-test was used to assess the PF thickness
thickness between the two groups at baseline (P = 0.618)
before and after intervention. Independent t-test was used
and 3 months after intervention (P = 0.292) but PF
for detecting any significant differences in PF thickness
thickness was decreased significantly (P = 0.001)
between the two groups.
in both groups after intervention compared with
A P ≤ 0.05 was considered statistically significant in all baseline [Table 3].
analyses.
One month after intervention, patients with RMS
Results 4 (refractory, since our inclusion criteria were RMS 4)
or the ones who get worst were excluded from the study
Patients’ baseline characteristics are summarized in to receive another therapeutic option. The percent of
Table 1. There was no significant difference between the refractory patients was not statistically significant between
two groups (P > 0.05). the two groups (P = 0.501).
The total number of 80 patients were randomized into Three months after intervention, RMS
intervention and control groups. improvement (defined as RMS 1, 2) was 70% in
Patients’ flow diagram from enrollment to analyses is on intervention group and 60% in control group, the difference
Figure 2. was not significant (P = 0.351).
Treatment success was calculated as follows: Recurrence was defined as regression of RMS to 3 or 4
after primary improvement in RMS.
The number of patients who recover regarding our
improvement criteria divided by the total initial The recurrence rate was not statistically significant between
number of patients in each group; 1 and 3 months after the two groups (P = 0.398).
intervention. The patients’ RMS distribution is summarized in Table 4.
One month after the intervention, RMS score showed Side effects
better improvement in the intervention group compared to
control group (65% vs. 40%, P = 0.026), but there was no In follow-ups for evaluating side effects or
significant difference in RMS improvement between the complications, some people reported of transiently
two groups after 3 months (P = 0.351). increased pain after shock wave therapy. We did not
have any report of hematoma, swelling or any serious
One month after intervention, VAS morning score showed complications.
significant improvement in intervention group compared
to control group (75% vs. 45%, P = 0.006), but there was Discussion
no significant difference between the two groups after
Among various options for treatment of chronic plantar
3 months (P = 0.135).
fasciitis, ESWT, and corticosteroid injection are the most
There was no significant difference between the two groups effective ones.
regarding the VAS daily score 1 month (P = 0.653) and
3 months after intervention (P = 0.351). To the best of our knowledge, this study would be the first
one which evaluates the combinational effect of ESWT
and a topical corticosteroid, considering potentiality of
Table 1: Patients’ baseline characteristic the shock wave in the field of drug delivery. Shock wave
Characteristic Intervention (n=40) Control (n=40) P was performed on painful heels to take advantage of its
Sex (%) therapeutic effect on plantar fasciitis and also to penetrate
Females 34 (85) 32 (80) 0.558
topical clobetasol through the deep layers with mentioned
Age (year) 51.4±6.9 48.1±8.9 0.067
below possible mechanisms; cavitation and disruption of
BMI (kg/m²) 28.5±3.4 29.7±3.3 0.113
stratum corneum.
PF thickness (mm) 5.17±0.73 5.24±0.5 0.618
Data are presented as mean±SD or n (%). SD: Standard deviation, As previously stated, many drug delivery techniques
BMI: Body mass index, PF: Plantar fascia have been introduced that using a different form of

4 Advanced Biomedical Research | 2018

 Vahdatpour, et al.: Enhancement of the effectiveness of ESWT with topical corticosteroid

Assessed for eligibility

Enrollment
(n = 150)

Excluded (n = 70)
• Not meeting inclusion criteria
(n = 60)
• Declined to participate (n = 10)

Randomized (n = 80)

Allocation

Allocated to intervention (n = 40) Allocated to intervention (n = 40)

Follow-Up
Lost to follow-up (one patient refused to Discontinued intervention (n = 6)
come for Sonographic follow up) (n = 1)
Refractory patients with RMS 4 excluded
Discontinued intervention (n = 4) Refractory from the study one month after intervention
patients with RMS 4 excluded from study one to receive another therapeutic option
month after intervention to receive another
therapeutic option
Analysis

Analysed (n = 35) Analysed (n = 34)

Figure 2: Patients’ flow diagram

Table 2: Comparison of treatment success in both groups regarding visual analogue scale score, modified Roles and
Maudsley score and plantar fascia thickness
Treatment success 1 month after treatment (n=40) P 3 months after treatment (n=40) P
Intervention, n (%) Control, n (%) Intervention, n (%) Control, n (%)
RMSa 26 (65) 16 (40) 0.026 28 (70) 24 (60) 0.351
VAS morningb 30 (75) 18 (45) 0.006 32 (80) 26 (65) 0.135
VAS dailyc 24 (60) 22 (55) 0.653 28 (70) 24 (60) 0.351
PF thickness d
22 (55) 24 (60) 0.653
Data are presented as n (%). aChanging the RMS to 1 or 2 in follow up studies. b,cIf score was ≤4 on the 11 point scale (VAS) or
improvement of >50% over baseline in follow up studies. dPF thickness reduction >0.7 mm. RMS: Roles and Maudsley score, VAS: Visual
analogue scale, PF: Plantar fascia

Table 3: Comparison of the plantar fascia thickness A pressure wave or shock wave can facilitate the delivery
between the two groups and before and after of macromolecules in the epidermis and deep into the
intervention in each group dermis through disruption of the hydrophilic domains of
PF thickness Baseline After 3 months Pa the stratum corneum.[20] Shock waves have been shown
Intervention 5.17±0.73 4.51±0.98 0.001 to cause a transient increase in the permeability of the
Control 5.24±0.50 4.31±0.68 0.001 cell membrane in vitro and in vivo. The mechanism of
Pb 0.618 0.292 permeabilization is probably based on the generation
Data are presented as mean±SD. aP value before and after of cavitation bubbles.[20,21] In addition, recent studies
intervention in each group. bP value between the two groups. have demonstrated ultrasound cavitational effect leading
SD: Standard deviation. PF: Plantar fascia to reduced skin barrier efficiency.[35,36] Cavitation does
not lead to cell death and enables the transfer of large
energy to facilitate absorption of drugs through the molecules into the cells. Some of the energy from
skin. Iontophoresis and phonophoresis are emerging cavitation is transformed into other forms of energy
technologies capable of enhancing drug penetration such as heat, shock waves, or hydrodynamic shear
through the stratum corneum that is the principal barrier to fields, which can disrupt biological tissues and facilitate
percutaneous absorption.[32-34] diffusion.[37,38]

Advanced Biomedical Research | 2018 5

 Vahdatpour, et al.: Enhancement of the effectiveness of ESWT with topical corticosteroid

Table 4: Patients’ modified Roles and Maudsley score distribution at the end of study
RMS distribution Refractorya (%) Recurrenceb (%) RMS 3d (%) Improvementc (%)
Intervention (n=40) 4 (10) 4 (10) 4 (10) 28 (70)
Control (n=40) 6 (15) 2 (5) 8 (20) 24 (60)
P 0.501 0.398 0.213 0.351
Data are presented as n (%). 1 month after intervention, patients with RMS 4 or the ones who get worst (refractor) were excluded from
a

the study to receive another therapeutic option. bRecurrence was defined as regression of RMS to 3 or 4 in follow up studies after primary
improvement in RMS. cChanging the RMS to 1 or 2 in follow up studies. dNot met our improvement criteria. RMS: Roles and Maudsley score

Permeabilization of tumor cells using shock waves provides This study has shortcomings to its novelty. We cannot
a useful tool for introducing molecules into cells which compare our results to previous investigations since this
might be of interest for drug targeting in tumor therapy study was conducted for the first time.
in vivo.[21] Enhancement of chemotherapeutic effects with
We did not use medication gel because its impact as a
focused shock waves seems to be as a result of increased
changed conductive medium on shock wave penetration
intracellular concentration of the agent.[37] Furthermore,
was not clear. The aim was to take advantage of shock
needle-less vaccine delivery using micro-shock waves
wave effects both therapeutic and drug delivery potential
seems promising.[39]
rather than just transferring medication like phonophoresis,
One month after the intervention, VAS morning and RMS that is why we used the occlusive dressing for saturating
decreased significantly in the intervention group due to the stratum corneum instead of medication gel. The effect
the synergistic effect of shock wave therapy and topical of medication gel on shock wave should be addressed
corticosteroid, but 3 months after intervention, the results in future studies. We used both radial and focus probes.
were not significantly different between the two groups. Comprehensive studies are needed to perform with different
shock wave protocols to define the most appropriate
The expected mechanism for better improvement in
shocks, sessions, and intervals as they are still not defined
short-term is that shock wave had facilitated delivery of
precisely.
topical clobetasol from saturated stratum corneum through
deep layers. Further research with a larger sample size is Conclusions
needed for clarifying this issue; reproducible results are
valuable. In a study about corticosteroid iontophoresis, The study shows that combination of ESWT with topical
Gudeman et al. found that dexamethasone iontophoresis corticosteroid yielded earlier pain reduction and functional
is effective in improving pain immediately after treatment, improvement than using shock wave alone; topical
but not more than placebo in the longer term.[40] corticosteroid could enhance the effectiveness of shock
wave in short-term in the treatment of recalcitrant plantar
VAS morning decreased more significantly than VAS daily fasciitis.
in intervention group. This is probably on account of VAS
morning is less correlated with patients’ physical activity Using topical corticosteroid does not require extra
and environment factors. equipment or cost and easily applied. In addition, it is
without serious side effects of corticosteroid injection such
We found comparable long-term results between the two as PF rupture or heel pad atrophy.
groups evident by both subjective and objective measures.
This could be the result of long-term biological effects of The combination of ESWT with topical corticosteroid is a
shock wave or patients spontaneous recovery. novel idea and further comparative studies are required.

Maier et al. showed that the initial burst of pain came from Financial support and sponsorship
an increase of release of substance P. However this initial Nil.
release is followed by a subsequent decrease in levels
of substance P within 24 h. This reduction in substance Conflicts of interest
P release lasts for over 6 weeks and may go on as long There are no conflicts of interest.
as 2 years.[41] This study suggests that shock wave effects
could be started within a few hours and continue for a long References
time. Obliviously, this time frame varies from patient to 1. Irving DB, Cook JL, Young MA, Menz HB. Impact of chronic
patient. plantar heel pain on health-related quality of life. J Am Podiatr
Med Assoc 2008;98:283-9.
Chronic recalcitrant plantar fasciitis is a disabling condition
2. Gill LH. Plantar Fasciitis: Diagnosis and conservative
and has a negative impact on patients’ quality of life. management. J Am Acad Orthop Surg 1997;5:109-17.
This combinational therapy is effective in reducing pain 3. Kibler WB, Goldberg C, Chandler TJ. Functional biomechanical
expeditiously in short-term and it is worthwhile for these deficits in running athletes with plantar fasciitis. Am J Sports
patients. Med 1991;19:66-71.

6 Advanced Biomedical Research | 2018

 Vahdatpour, et al.: Enhancement of the effectiveness of ESWT with topical corticosteroid

4. Davis PF, Severud E, Baxter DE. Painful heel syndrome: Results 22. Abul K, Ozer D, Sakizlioglu SS, Buyuk AF, Kaygusuz MA.
of nonoperative treatment. Foot Ankle Int 1994;15:531-5. Detection of normal plantar fascia thickness in adults via
5. Porter MD, Shadbolt B. Intralesional corticosteroid injection the ultrasonographic method. J Am Podiatr Med Assoc
versus extracorporeal shock wave therapy for plantar fasciopathy. 2015;105:8-13.
Clin J Sport Med 2005;15:119-24. 23. Cardinal E, Chhem RK, Beauregard CG, Aubin B, Pelletier M.
6. Pribut SM. Current approaches to the management of plantar heel Plantar fasciitis: Sonographic evaluation. Radiology
pain syndrome, including the role of injectable corticosteroids. 1996;201:257-9.
J Am Podiatr Med Assoc 2007;97:68-74. 24. Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan B,
7. Crawford F, Atkins D, Young P, Edwards J. Steroid injection for Gibney R, et al. The role of ultrasonography in the
heel pain: Evidence of short-term effectiveness. A randomized diagnosis and management of idiopathic plantar fasciitis.
controlled trial. Rheumatology (Oxford) 1999;38:974-7. Rheumatology (Oxford) 2001;40:1002-8.
8. Acevedo JI, Beskin JL. Complications of plantar fascia 25. Saliba S, Mistry DJ, Perrin DH, Gieck J, Weltman A.
rupture associated with corticosteroid injection. Foot Ankle Int Phonophoresis and the absorption of dexamethasone in the
1998;19:91-7. presence of an occlusive dressing. J Athl Train 2007;42:349-54.
9. Snow DM, Reading J, Dalal R. Lateral plantar nerve injury 26. Byl NN. The use of ultrasound as an enhancer for transcutaneous
following steroid injection for plantar fasciitis. Br J Sports Med drug delivery: Phonophoresis. Phys Ther 1995;75:539-53.
2005;39:e41. 27. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in
10. McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, plantar fasciitis. J Foot Ankle Surg 2007;46:442-6.
Godges JJ. Heel pain – Plantar fasciitis: Clinical practice 28. Mohseni-Bandpei MA, Nakhaee M, Mousavi ME, Shakourirad A,
guildelines linked to the international classification of function, Safari MR, Vahab Kashani R. Application of ultrasound in the
disability, and health from the orthopaedic section of the assessment of plantar fascia in patients with plantar fasciitis: A
American Physical Therapy Association. J Orthop Sports Phys systematic review. Ultrasound Med Biol 2014;40:1737-54.
Ther 2008;38:A1-18. 29. Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I,
11. Alvarez R. Preliminary results on the safety and efficacy of et al. Extracorporeal shock wave therapy for plantar fasciitis:
the OssaTron for treatment of plantar fasciitis. Foot Ankle Int Randomised controlled multicentre trial. BMJ 2003;327:75.
2002;23:197-203.
30. Ogden JA, Alvarez RG, Levitt RL, Johnson JE, Marlow ME.
12. Buch M, Knorr U, Fleming L, Theodore G, Amendola A, Electrohydraulic high-energy shock-wave treatment for chronic
Bachmann C, et al. Extracorporeal shockwave therapy in plantar fasciitis. J Bone Joint Surg Am 2004;86-A: 2216-28.
symptomatic heel spurs. An overview. Orthopade 2002;31:637-44.
31. McMillan AM, Landorf KB, Gilheany MF, Bird AR, Morrow AD,
13. Eslamian F, Shakouri SK, Jahanjoo F, Hajialiloo M, Notghi F. Menz HB. Ultrasound guided corticosteroid injection for plantar
Extra corporeal shock wave therapy versus local corticosteroid fasciitis: Randomised controlled trial. BMJ 2012;344:e3260.
injection in the treatment of chronic plantar fasciitis, a single
32. Kassan DG, Lynch AM, Stiller MJ. Physical enhancement of
blinded randomized clinical trial. Pain Med 2016;17:1722-31.
dermatologic drug delivery: Iontophoresis and phonophoresis.
14. Wang CJ, Chen HS, Huang TW. Shockwave therapy for patients J Am Acad Dermatol 1996;34:657-66.
with plantar fasciitis: A one-year follow-up study. Foot Ankle Int
33. Menon GK, Kollias N, Doukas AG. Ultrastructural evidence of
2002;23:204-7.
stratum corneum permeabilization induced by photomechanical
15. Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP.
waves. J Invest Dermatol 2003;121:104-9.
Extracorporeal shock wave therapy is effective in treating
chronic plantar fasciitis: A meta-analysis of RCTs. Clin Orthop 34. Prausnitz MR, Langer R. Transdermal drug delivery. Nat
Relat Res 2013;471:3645-52. Biotechnol 2008;26:1261-8.
16. Aronow MS. Commentary on an article by Hans Gollwitzer, MD, 35. Machet L, Boucaud A. Phonophoresis: Efficiency, mechanisms
et al. Clinically relevant effectiveness of focused extracorporeal and skin tolerance. Int J Pharm 2002;243:1-15.
shock wave therapy in the treatment of chronic plantar fasciitis: 36. Rao R, Nanda S. Sonophoresis: Recent advancements and future
A randomized, controlled multicenter study. J Bone Joint Surg trends. J Pharm Pharmacol 2009;61:689-705.
Am 2015;97:e44. 37. Delius M, Adams G. Shock wave permeabilization with ribosome
17. Ogden JA, Alvarez RG, Levitt R, Marlow M. Shock wave inactivating proteins: A new approach to tumor therapy. Cancer
therapy (Orthotripsy) in musculoskeletal disorders. Clin Orthop Res 1999;59:5227-32.
Relat Res 2001:387:22-40. 38. Kodama T, Doukas AG, Hamblin MR. Shock wave-mediated
18. Vahdatpour B, Sajadieh S, Bateni V, Karami M, Sajjadieh H. molecular delivery into cells. Biochim Biophys Acta
Extracorporeal shock wave therapy in patients with plantar 2002;1542:186-94.
fasciitis. A randomized, placebo-controlled trial with 39. Jagadeesh G, Prakash GD, Rakesh SG, Allam US, Krishna MG,
ultrasonographic and subjective outcome assessments. J Res Med Eswarappa SM, et al. Needleless vaccine delivery using
Sci 2012;17:834-8. micro-shock waves. Clin Vaccine Immunol 2011;18:539-45.
19. Notarnicola A, Moretti B. The biological effects of extracorporeal 40. Tatli YZ, Kapasi S. The real risks of steroid injection for plantar
shock wave therapy (ESWT) on tendon tissue. Muscles fasciitis, with a review of conservative therapies. Curr Rev
Ligaments Tendons J 2012;2:33-7. Musculoskelet Med 2009;2:3-9.
20. Doukas AG, Kollias N. Transdermal drug delivery with a 41. Maier M, Averbeck B, Milz S, Refi or HJ, Schmitz C.
pressure wave. Adv Drug Deliv Rev 2004;56:559-79. Substance P and prostaglandin E2 release after shock wave
21. Gambihler S, Delius M. In vitro interaction of lithotripter shock application to the rabbit femur. Clin Orthop Relat Res
waves and cytotoxic drugs. Br J Cancer 1992;66:69-73. 2003;406:237-45.

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