fasciitis, with a low major complication rate. Two hundred and fifty patients with chronic plantar fasciitis nonresponsive to at least six months of nonoperative treatment consisting of at least two pharmacological and at least two nonpharmacological treatments were randomized to three weekly sessions of 2000 impulses of focused extracorporeal shock wave therapy or placebo, with none of the patients opting for local anesthesia. Outcome measures included three visual analog scale (VAS) scores and their sum composite score, the Roles and Maudsley score, the investigator’s global judgment of treatment effectiveness, and patient satisfaction. Treatment was considered successful if the study participant had at least 60% reduction of pain in two of three VAS scores or if the participant was able to work, was satisfied with treatment outcome, and required no concomitant therapy to control heel pain. More than 98% of the participants were available for intention-to-treat analysis at twelve weeks, with significantly higher treatment success in the extracorporeal shock wave therapy group (64.8%) compared with the placebo group (46.3%), a significantly higher Roles and Maudsley score in the extracorporeal shock wave therapy group (60.8%) compared with the placebo group (37.2%), and a significant reduction in the composite heel pain VAS score in the extracorporeal shock wave therapy group (69.2%) compared with the placebo group (34.5%). Of the eighty-one patients given extracorporeal shock wave therapy who were considered to have successful treatment, seventy-one (88%) were reevaluated at the one-year follow-up, with further improvement in their average VAS and Roles and Maudsley scores. Both groups reported similar subjective tolerance of the procedure itself. With respect to adverse effects, the specific types thereof and statistical analysis were not provided by the authors, but there were seventy-seven adverse effects in forty-three patients undergoing extracorporeal shock wave therapy and twenty-four adverse effects in seventeen subjects receiving placebo. Most of these adverse effects were considered minor untoward effects of treatment (pain and/or discomfort during treatment, pain after treatment, and swelling), but there were twelve adverse events in subjects undergoing extracorporeal shock wave therapy and thirteen adverse events in placebo subjects that were not considered related to treatment and were not described by the authors.

In their excellent article, Gollwitzer et al. provide additional Level-I evidence that, when properly performed, extracorporeal shock wave therapy can be an effective treatment for chronic plantar The most relevant question that this study raises is what role extracorporeal shock wave therapy should play in the treatment of plantar fasciitis. The vast majority of patients respond to nonoperative treatment, including plantar fascia and triceps surae stretching exercises, intrinsic foot-strengthening exercises, topical and oral anti-inflammatory medications, anti-inflammatory modalities including ice, over-the-counter and custom orthoses, shoe-wear modifications, night splints, corticosteroid injections, and immobilization. Although it is possible that extracorporeal shock wave therapy may lead to quicker resolution of acute plantar fasciitis in patients limited in their ability to work or to play sports, there is also evidence that corticosteroid injections are at least equally efficacious and more cost-effective. There is a subset of patients who have symptomatic chronic plantar fasciitis nonresponsive to at least six months of appropriate nonoperative treatment often including corticosteroid injections. Gollwitzer et al. provide and reference from the literature evidence that properly performed extracorporeal shock wave therapy may be beneficial for many of these patients, although in their article, the authors do not specify the exact percentage of their study participants whose pharmacological treatment included corticosteroid injections.