Fatih Bagcier, Nurdan Yilmaz.

    The Journal of Foot and Ankle Surgery 59(4), 689-693, April 2020.  doi: 10.1053/j.jfas.2019.09.038

    Abstract

    This study aimed to evaluate the efficiency of extracorporeal shockwave therapy (ESWT) and dry needling (DN) combination on pain and functionality in plantar fasciitis.

    Forty patients who were clinically diagnosed with plantar fasciitis were included in the study.  The patients were randomly divided into 2 groups.  The ESWT-DN group was applied 3 sessions of ESWT to plantar fascia and DN to the trigger points in the gastrosoleus muscles.  The ESWT group was applied only ESWT treatment to plantar fascia.  We used visual analog scale (VAS) for pain and a pressure algometer for pressure pain threshold.  The functionality of the patients was evaluated with Foot Function Index (FFI).  Also, maximum painless standing time and maximum painless walking distance were recorded.  All assessments were repeated twice; first, pretreatment and second 1 month after the treatment.  In both groups, there were statistically significant improvements in VAS, pressure pain threshold, maximum painless standing time, maximum painless walking distance, and FFI’s pain, disability, and activity limitation subscales scores (p ≤ .001).

    In intergroup comparison; it was showed that VAS scores, maximum painless standing time (p = .002), maximum painless walking distance (p ≤ .001), and FFI pain subscale scores (p = .034) were statistically superior in the ESWT-DN group.  There was no statistically difference between the groups in pressure pain threshold (p = .132), FFI disability (p = .081), and FFI activity limitation subscale (p = .226) scores.

    ESWT and DN combination therapy in plantar fasciitis was seen to be superior in the pain scores.  Further studies with larger patients’ groups and longer-term results of this combination are needed for a better comparison.

    Commentary

    This study, from Turkey, reports an RCT showing significant benefit of adding dry needling to ESWT. 

    One group received three sessions at weekly intervals of ESWT with cold application, to the plantar fascia.  They were also all given “a home exercise program of plantar fascia stretching exercises” and recommended to use a portable arch support.  The other group received the same, plus DN to the gastro-soleus muscles.  Active and latent MTPs were identified and needled with manipulation until a twitch was obtained.  They did not report how many, nor their locations.  The paper says they used 0.6*50 mm acupuncture needles.  I guessed this was a typo and the author kindly confirmed that they actually used 0.3*60 mm needles. 

    No other muscles were examined for MTPs.  The focus here was not on myofascial pain per se, but on treating MTPs in order to increase flexibility and reduce discomfort during stretching exercises and so facilitate the self-help program.  There seems an incongruity here, in that the stretching exercises focused on the plantar fascia, while the needling focused on the calf.  It would be nice to see an explanation for this.

    A range of OCMs were recorded, by a blinded assessor, before and one month after treatment.

    There were significant improvements in both groups, following treatment, in all parameters.  Comparison of the groups showed the DN results to be significantly superior in all pain measures (VAS morning, activity and resting pain; Standing-without-pain duration and walking-without-pain duration; FFI pain subscale).  Significance was not reached for the other measures (Pressure pain threshold; FFI disability and activity subscales).

    Given the rationale for using DN (to facilitate home stretching) it would have been good to assess its effectiveness, by logging activities done, asking patients if it helped, assessment of range of ankle movement, etc.  However, the end result seems to validate the rationale, in that we see a distinct benefit from DN even in patients who are already getting significant benefit from a raft of other interventions.