Journal CME December 2025: Comparative efficacy and acceptability of different intensity levels of extracorporeal shock wave therapy in adults with plantar heel pain: A systematic review and network meta-analysis-PM R - 2025 - Zhao - Comparative efficacy and acceptability of different intensity levels of extracorporeal shock wave

PM R - 2025 - Zhao - Comparative efficacy and acceptability of different intensity levels of extracorporeal shock wave

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This systematic review and network meta-analysis by Zhao et al. (2025) evaluated the comparative efficacy and acceptability of different intensity levels of extracorporeal shock wave therapy (ESWT)—low (L-ESWT), medium (M-ESWT), and high (H-ESWT)—for treating plantar heel pain (PHP) in adults. The analysis included 22 randomized controlled trials (RCTs) with 2,299 participants, comparing ESWT at different intensities to placebo and to each other.

Key findings include:

1. <strong>Efficacy:</strong> All ESWT intensity levels demonstrated superior treatment success compared to placebo, with odds ratios (ORs) ranging from 2.29 to 5.50. However, there were no statistically significant differences among the three intensities in efficacy.

2. <strong>Acceptability:</strong> No significant differences existed between any ESWT intensity level and placebo regarding treatment discontinuation rates, indicating similar tolerability.

3. <strong>Pain Relief and Function:</strong> Medium-intensity ESWT (M-ESWT) was superior to placebo in reducing pain (standardized mean difference, SMD, -0.60) and improving function. High-intensity ESWT (H-ESWT) showed some pain relief benefit but no significant difference in functional improvement. Low-intensity ESWT (L-ESWT) did not significantly differ from placebo in pain or function.

4. <strong>Types of Shock Waves and Anesthesia:</strong> Focused medium-intensity ESWT was more effective than radial ESWT. Use of local anesthesia did not significantly alter outcomes.

5. <strong>Quality and Limitations:</strong> Most included studies had unclear or high risk of bias, and the overall quality of evidence was low to very low. Variability in treatment protocols and definitions of success contributed to heterogeneity.

The authors suggest that while all ESWT intensities effectively treat PHP compared to placebo, M-ESWT offers the best balance of efficacy, pain relief, functional improvement, and acceptability. They recommend considering ESWT as an alternative therapy for patients not responding to conservative treatments. Future high-quality, large-scale RCTs are needed to clarify optimal intensity and protocols, including longer follow-ups.

In summary, ESWT is a safe, noninvasive treatment for PHP, with moderate intensity levels most consistently beneficial for pain and function. This comprehensive analysis aids clinical decision-making by ranking ESWT options and highlights the need for standardized outcome definitions and further research.

Keywords

extracorporeal shock wave therapy

plantar heel pain

ESWT intensity levels

low-intensity ESWT

medium-intensity ESWT

high-intensity ESWT

randomized controlled trials

pain relief

functional improvement

treatment acceptability