Plantar Heel Pain Research Articles

Ultrasound-Guided Radiofrequency Denervation of the Medial Calcaneal Nerve

Plantar fasciosis is a common complaint of athletes, particularly for runners. The medial calcaneal nerve (MCN) may play a role in the pain syndrome, and radiofrequency (RF) denervation has been previously reported. The hypothesis is that ultrasound-guided denervation of the MCN results in symptomatic improvement. Retrospective cohort. Private practice. Twenty-nine patients previously receiving ultrasound-guided RF denervation of the MCN, having failed conservative therapy, were assessed in 2 groups, those more than (group 1, n = 16) or less than (group 2, n = 13) 6 months since the procedure. Ultrasound-guided RF denervation of the MCN. Pain scores before denervation, as well as at maximal pain relief and the time of the interview. Levels of satisfaction and attitudes toward surgery were also assessed. Pain scores decreased significantly in both groups, for both best and residual pain scores. Group 1 mean pain scores were 8.56 before procedure, 2.81 (P < 0.001 compared to baseline) at best pain score, and 3.75 (P < 0.01) residual pain score. Group 2 mean pain scores were 7.23 before procedure, 3.77 (P < 0.01) at best pain score and 4.92 (P < 0.01) residual pain score. Levels of satisfaction were predominantly positive (69% of group 1% and 54% of group 2 were either somewhat or very satisfied), with attitudes toward surgery unchanged. For patients with refractory plantar heel pain, ultrasound-guided denervation of the MCN can potentially improve symptoms, although efficacy needs assessing in comparative studies. Ultrasound-guided denervation of the MCN provides a further management option for patients with refractory plantar fasciosis.

Physical interventions (orthoses, splints, exercise and manual therapy) for treating plantar heel pain

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects (benefits and harms) of physical interventions (orthoses, splints, exercise and manual therapy) for treating plantar heel pain.

Depression, Anxiety, and Stress in People With and Without Plantar Heel Pain.

Depression, anxiety, and stress are prevalent in patients with musculoskeletal pain, but the impact of these emotional states has not been evaluated in people with plantar heel pain. The aim of this study was to evaluate the association between depression, anxiety, and stress with plantar heel pain. Forty-five participants with plantar heel pain were matched by sex and age (±2 years) to 45 participants without plantar heel pain. Levels of depression, anxiety, and stress were measured using the Depression, Anxiety and Stress Scale (short version) in participants with and without plantar heel pain. Logistic regression was conducted to determine if levels of depression, anxiety, or stress were associated with having plantar heel pain. Univariate analysis indicated that participants with plantar heel pain had greater levels of depression (mean difference = 4.4, 95% CI 2.3 to 6.5), anxiety (mean difference = 2.6, 95% CI 0.9 to 4.3), and stress (mean difference = 4.8, 95% CI 1.9 to 7.8). After adjusting for age, sex, BMI, and education, for every 1 unit increase in depression, anxiety, or stress (in the DASS subscales), the odds ratios for having plantar heel pain were increased by 1.3 (95% CI 1.1 to 1.6), 1.3 (95% CI 1.1 to 1.5), and 1.2 (95% CI 1.1 to 1.3), respectively. Symptoms of depression, anxiety, and stress were independently associated with plantar heel pain. Larger prospective studies are necessary to evaluate the temporal association between these emotional states and plantar heel pain. Level III, cross sectional, observational.

Impaired Foot Plantar Flexor Muscle Performance in Individuals With Plantar Heel Pain and Association With Foot Orthosis Use.

Study Design Controlled laboratory study. Background Plantar heel pain is one of the most common foot and ankle conditions seen in clinical practice, and many individuals continue to have persisting or recurrent pain after treatment. Impaired foot plantar flexor muscle performance is a factor that may contribute to limited treatment success, but reliable methods to identify impairments in individuals with plantar heel pain are needed. In addition, foot orthoses are commonly used to treat this condition, but the implications of orthosis use on muscle performance have not been assessed. Objectives To assess ankle plantar flexor and toe flexor muscle performance in individuals with plantar heel pain using clinically feasible measures and to examine the relationship between muscle performance and duration of foot orthosis use. Methods The rocker-board plantar flexion test (RBPFT) and modified paper grip test for the great toe (mPGTGT) and lesser toes (mPGTLT) were used to assess foot plantar flexor muscle performance in 27 individuals with plantar heel pain and compared to 27 individuals without foot pain who were matched according to age, sex, and body mass. Pain ratings were obtained before and during testing, and self-reported duration of foot orthosis use was recorded. Results Compared to the control group, individuals with plantar heel pain demonstrated lower performance on the RBPFT (P = .001), the mPGTGT (P = .022), and the mPGTLT (P = .037). Longer duration of foot orthosis use was moderately correlated to lower performance on the RBPFT (r = -0.52, P = .02), the mPGTGT (r = -0.54, P = .01), and the mPGTLT (r = -0.43, P = .03). Conclusion Ankle plantar flexor and toe flexor muscle performance was impaired in individuals with plantar heel pain and associated with longer duration of self-reported foot orthosis use. J Orthop Sports Phys Ther 2016;46(8):681-688. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6482.

Three single leg standing tests for clinical assessment of chronic plantar heel pain syndrome: static stance, half-squat and heel rise

ObjectiveTo assess reliability and validity of three single leg standing clinical tests in patients with plantar heel pain syndrome (PHPS). DesignCross-sectional reliability study. ParticipantsForty patients diagnosed with PHPS. Main outcome measuresPatients stood on their affected foot in a static stance for up to 30seconds, a half squat for up to 10 repetitions, and a heel rise for up to 10 repetitions. The first sensation of pain (p1) determined the termination of each test, and established a positive test result. The level of p1 was measured using a visual analogue scale (VAS); time or repetitions for each test were recorded. Prior to performing the tests, all patients completed the Foot & Ankle Computerized Adaptive Test to measure functional status (FS). ResultsDetection of p1 in each test showed good reliability for inter- and intrarater assessment (Kappa=0.60 to 0.78 and 0.56 to 0.77, respectively). The intraclass correlation coefficient for the VAS measures was 0.85 to 0.95 for inter-rater assessment and 0.78 to 0.92 for intrarater assessment. However, the Bland and Altman limits of agreement were wide, indicating that these measures were less reliable than the correlation coefficients suggested. Thirty-five patients (88%) experienced a positive pain response to at least one test. Significant correlations were found between the VAS measures in each test and FS (r=0.63 to 0.72). ConclusionsThe static stance, half squat and heel rise tests were easily implemented, and found to be reliable and valid according to one analysis, yet less reliable with another, for pain provocation and VAS levels in patients with PHPS. All three VAS levels correlated well with FS.

Endoscopic Decompression of the First Branch of the Lateral Plantar Nerve and Release of the Plantar Aponeurosis for Chronic Heel Pain

Entrapment of the first branch of the lateral plantar nerve is a commonly missed cause of recalcitrant plantar heel pain. The diagnosis is made on a clinical ground with maximal tenderness at the site of nerve entrapment. Treatment of the nerve entrapment is similar to that for plantar fasciitis, with rest, activity modification, nonsteroidal anti-inflammatory drugs, stretching exercise, and local steroid injection. Surgical release of the deep abductor hallucis fascia is indicated when conservative treatment failed. Endoscopic release of the nerve through the dorsal and plantar portals, as well as endoscopic plantar aponeurosis release, is a feasible approach.

The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review

Objectives: Plantar heel pain is common and can be severely disabling. Unfortunately, a gap in the literature exists regarding the optimal intervention for this painful condition. Consequently, a systematic review of the current literature regarding manual therapy for the treatment of plantar heel pain was performed.Methods: A computer-assisted literature search for randomized controlled trials in MEDLINE, EMBASE, Cochrane, CINAHL, and Rehabilitation & Sports Medicine Source, was concluded on 7 January 2014. After identification of titles, three independent reviewers selected abstracts and then full-text articles for review.Results: Eight articles were selected for the final review and underwent PEDro scale assessment for quality. Heterogeneity of the articles did not allow for quantitative analysis. Only two studies scored ≥7/10 on the PEDro scale and included joint, soft tissue, and neural mobilization techniques. These two studies showed statistically greater symptomatic and functional outcomes in the manual therapy group.Discussion: This review suggests that manual therapy is effective in the treatment of plantar heel pain; however, further research is needed to validate these findings given the preponderance of low quality studies.

Treatment of Chronic Plantar Heel Pain With Radiofrequency Neural Ablation of the First Branch of the Lateral Plantar Nerve and Medial Calcaneal Nerve Branches

From March 2012 to February 2013, 37 patients experiencing plantar heel pain for ≥6 months despite treatment with physical therapy and other conservative treatment modalities were followed up. If neurogenic heel pain originating from the first branch of the lateral plantar nerve was present, with or without the medial calcaneal nerve, diagnostic nerve blocks to these nerves were performed for confirmation. If the pain was determined to be of neurogenic origin, radiofrequency neural ablation (RFNA) was applied to the corresponding sensory nerve endings. Pain was evaluated using the visual analog scale, and patients were followed for at least one year. A total of 41 feet from 37 patients (30 [81.1%] females, 7 [18.9%] males; mean age, 50.7 ± 1.6 years; mean body mass index, 30.6 ± 0.7 kg/m2) were included. The mean visual analog scale scores improved significantly from 1 to 6 to 12 months after the procedure relative to before the procedure, with 88% of all patients rating the treatment as either very successful or successful at 12 months postoperatively. RFNA applied to both the first branch of the lateral plantar nerve and the medial calcaneal nerve sensory branches (16 [39%] feet) and only the first branch of the lateral plantar nerve sensory branches (25 [61%] feet) showed similarly high levels of success. Of the 41 feet, 28 [68.3%] had received extracorporeal shockwave therapy, 35 [85.4%] had received steroid injections, and 22 [53.7%] had received both extracorporeal shockwave therapy and steroid injections before RFNA as an index procedure. All were unresponsive to these previous treatments. In contrast, almost all (88%) were treated successfully with RFNA. Despite a high incidence of neurologic variations, with a precise diagnosis and good application of the technique using the painful points, chronic plantar heel pain can be treated successfully with RFNA.

Pain Threshold Tests in Patients With Heel Pain Syndrome.

Pressure pain threshold (PPT) is a useful tool for evaluating mechanical sensitivity in patients suffering from various musculoskeletal disorders. However, no previous study has investigated PPT in the heel of patients experiencing plantar heel pain syndrome (PHPS). The aim of this study was to compare PPT levels and topographic presentation of sensitivity in the heel of patients with PHPS and in healthy controls. The reliability of PPT testing in patients with PHPS was assessed for intra- and interrater recordings. The PPT levels of 40 feet in each group were then assessed on 5 predetermined sites in the heel using a standardized measurement protocol. Patient functional status (FS) as measured by the Foot & Ankle Computerized Adaptive Test was employed as an external reference. Multivariate analysis of covariance revealed no group differences for PPTs at all sites (P = .406). Age (P = .099) or BMI (P = .510) did not affect PPT values, although there was an effect on gender (P = .006). The analysis revealed significant differences between sites (P < .001) demonstrating a diverse topographic distribution. In the PHPS group, PPT levels at the anterior/medial, posterior/medial and central sites were significantly lower than at the posterior/lateral and anterior/lateral sites (P < .05). For the control group, PPT levels at the anterior/medial site were significantly lower than all other sites (P < .001). No significant differences were found between PPT of the PHPS patients and controls, therefore, PPT cannot be recommended as an assessment tool for these patients. The topographic distribution indicated low PPT levels at the anterior/medial area of the heel in patients with PHPS and controls. Level II, comparative study.

Contribution Levels of Intrinsic Risk Factors to the Management of Patients with Plantar Heel Pain A Pilot Study.

Of all of the lower-extremity injuries with multifactorial causes, heel pain represents the most frequent reason for visits to health-care professionals. Managing patients with heel pain can be very difficult. The purpose of this research was to identify key variables that can influence foot health in patients with heel pain. A cross-sectional observational study was performed with 62 participants recruited from the Educational Welfare Unit of the University of Malaga, Malaga, Spain. Therapists, blinded for the study, acquired the anthropometric information and the Foot Posture Index, and participants completed the Foot Health Status Questionnaire. The most significant results reveal that there is a moderate relationship between clinical variables such as footwear and Foot Health Status Questionnaire commands such as Shoe (r = 0.515; P < .001). The most significant model domain was General Health (P < .001), with the highest determination coefficient (beta not standard = 34.05). The most significant predictable variable was body mass index (-0.110). The variables that can help us manage clinical patients with heel pain are age, body mass index, footwear, and Foot Posture Index (left foot).

Posterior heel pain

Heel pain is widely perceived to be a minor ailment that usually runs a self limiting course. This is not always the case however, and a proportion of the millions of people affected each year will suffer chronic symptoms. Heel pain can be broadly classified as posterior or plantar heel pain. Posterior heel pain may be from non-insertional or insertional Achilles tendon problems, or occasionally due to pathology of the surrounding structures. Most sufferers will improve with a combination of time and proper stretching regimens. A proportion of patients, however, have resistant symptoms which can be difficult to manage and require operative treatment. This article, focussing on posterior heel pain, offers a pragmatic approach to assessment and management.

The Effectiveness of Multimodal Care for Soft Tissue Injuries of the Lower Extremity: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

ObjectiveThe purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the lower extremity. MethodsWe systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Random pairs of independent reviewers screened studies for relevance and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. ResultsWe screened 6794 articles. Six studies had a low risk of bias and addressed the following: plantar heel pain (n = 2), adductor-related groin pain (n = 1), and patellofemoral pain (n = 3). The evidence suggests that multimodal care for the management of persistent plantar heel pain may include mobilization and stretching exercise. An intensive, clinic-based, group exercise program (strengthening, stretching, balance, agility) is more effective than multimodal care for the management of adductor-related groin pain in male athletes. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Our search did not identify any low risk of bias studies examining multimodal care for the management of other soft tissue injuries of the lower extremity. ConclusionA multimodal program of care for the management of persistent plantar heel pain may include mobilization and stretching exercise. Multimodal care for adductor-related groin pain is not recommended based on the current evidence. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain.

Analysis of Pressure Pain Hypersensitivity, Ultrasound Image, and Quality of Life in Patients with Chronic Plantar Pain: A Preliminary Study.

To evaluate widespread pressure pain in patients with chronic plantar heel pain compared with that in healthy controls and to investigate the differences in ultrasound imaging and quality of life between these two groups. A total of 22 patients (11 female) with chronic plantar heel pain and the same number of healthy patients, matched according to age and gender, were included in this pilot study. Pressure pain thresholds (PPTs) were bilaterally assessed over the calcaneus bone, the plantar fascia, the first and fifth metatarsals, the soleus muscle, the second metacarpal, and the zygapophyseal joint of C5-C6. Plantar fascia thickness was measured via ultrasound imaging. In addition, quality of life and physical function were assessed using the Short-Form 36 (SF-36) questionnaire and the Foot and Ankle Ability Measure (FAAM) questionnaire, respectively. Analysis of covariance (ANCOVA) results showed significant differences in the PPTs at all points between the groups (P < 0.001), but not between sides. The PPTs were significantly lower in the patients than in the controls at all sites (P < 0.05). The results showed significant increases in fascia thickness at the calcaneus insertion (group: F = 74.172, P ≤ 0.001; side: F = 8.920, P ≤ 0.001) and the middle fascia point (group: F = 133.685, P = <0.001; side: F = 11.414, P = <0.001) on ultrasound in the patient group compared with the matched control group. The analysis also revealed that the patient group had a significantly lower score on every subscale of the SF-36 and FAAM questionnaires (all P < 0.001), except for the mental component, compared with the matched control group. Patients suffering from chronic plantar heel pain showed widespread and bilateral hypersensitivity, increased thickness of the plantar fascia in the affected foot, and deterioration in quality of life and physical functioning compared with matched controls.

Treatment of plantar fasciitis with dexamethasone with lidocaine hydrochloride

Background: Plantar heel pain is a commonly occurring foot complaint. Various electrotherapy modalities are frequently utilized as a treatment. Objective: To determine the effects of a combination of dexamethasone with lidocaine hydrochloride for the treatment of patients with plantar fasciitis (PF). Materials and Methods: A total of 40 patients suffering from PF were divided into two groups; Group A received iontophoresis with distilled water along with 4 mg/mL dexamethasone and 2 cm3 of lidocaine hydrochloride (4% lidocaine hydrochloride), and Group B received iontophoresis with distilled water. Both groups received stretching of plantar fascia and calf muscles, followed by ultrasound for 5 min. Treatment for each patient was for a period of 2 weeks with 3 sessions per week. Result: Group A showed significant decrease in symptoms of PF posttreatment. Conclusion: Iontophoresis with lidocaine hydrochloride showed better results in decreasing symptoms of PF as compared to iontophoresis with distilled water only.

Metastatic calcaneal adenocarcinoma from lung primary: A case report

Although the skeletal system is a common site for metastatic disease, metastasis to the calcaneus is very rare, especially from a lung primary; furthermore, calcaneal metastasis as the presenting symptom of a malignant process is rarer still. Only two cases of calcaneal metastasis from a primary lung cancer have previously been reported. The presenting symptom of metastatic lesions of the calcaneus is typically plantar-heel pain; idiopathic plantar-heel pain is a common complaint in and of itself, which obfuscates the diagnosis of metastatic cancer. As a result, calcaneal metastases are difficult to diagnose. We present the rare case of a patient with calcaneal metastasis from a primary lung adenocarcinoma along with a review of literature as a reminder that occasionally, though common things are common, uncommon things do occur.

Conservative Treatment of Plantar Fasciitis and Posterior Heel Pain: A Review

This review focuses on the various techniques of conservative treatment of plantar fasciitis and posterior heel pain. Being the optimal therapy controversial, the intent is to drive surgeons and rehabilitation specialists in the choice of the strategies. The Data sources were MEDLINE, PubMed, CINAHL, EMBASE, and Psych INFO databases using the selected key words. Studies have been selected for review using as criteria English, adults, clinical population and intervention. Among several published studies about rehabilitation and fasciitis, only a few showed bases on scientific evidence. Moreover, many studies were heterogeneous and included different outcomes and evaluations. There is consensus that a specific rehabilitation program is necessary to avoid chronicity. However, the real efficacy of every specific treatment (orthoses, stretching, radiotherapy, botulin toxin, shock waves, corticosteroid therapy, and platelet rich plasma) is still questionable, and often related to the experience of the authors. In conclusion, patients undergoing physiotherapy obtain a better and faster outcome achievement than non-treated patients; however, evidence-based treatments, protocols and clinical trials are recommended.

Effect of Calcaneal Taping on Peak Plantar Pressure of Forefoot and Rearfoot during Gait

Purpose: The purpose of this study was to determine the effects of calcaneal taping on peak plantar pressure of rearfoot and forefoot while walking. Methods: Fifteen healthy subjects with normal feet participated in this study. Inclusion criteria were as follows: (1) no disturbance of gait and foot pain, (2) normal range of motion of ankle joint, (3) no foot deformity. Pedoscan was used for recording of plantar pressure data during walking. The participants walked along a 12-m walkway before and after application of calcaneal taping. The plantar pressure gait was measured 3 times under barefoot and calcaneal taping conditions randomly at a speed practiced with the metronome during gait. The peak plantar pressure data were calculated for medial and lateral areas of the rearfoot and forefoot. The paired t-test was used to determine significant differences in peak plantar pressure of rearfoot and forefoot before and after application of calcaneal taping. A p-value less than 0.05 was accepted as significant. Results: The calcaneal taping resulted in statistically significant decreases in peak plantar pressure of the rearfoot (medial side: p=0.03; lateral side: p=0.01). However, there were no significant changes in peak plantar pressure of the forefoot (medial side: p=0.45; lateral side: p=0.40). Conclusion: The calcaneal taping is recommended to reduce plantar pressure of the rearfoot in weight-bearing activities in subjects with plantar heel pain caused by atrophy of the fat pad.

Orthosis-Shaped Sandals Are as Efficacious as In-Shoe Orthoses and Better than Flat Sandals for Plantar Heel Pain: A Randomized Control Trial.

ObjectiveTo investigate efficacy of a contoured sandal being marketed for plantar heel pain with comparison to a flat flip-flop and contoured in-shoe insert/orthosis.Method150 volunteers aged 50 (SD: 12) years with plantar heel pain (>4 weeks) were enrolled after responding to advertisements and eligibility determined by telephone and at first visit. Participants were randomly allocated to receive commercially available contoured sandals (n = 49), flat flip-flops (n = 50) or over the counter, pre-fabricated full-length foot orthotics (n = 51). Primary outcomes were a 15-point Global Rating of Change scale (GROC: 1 = a very great deal worse, 15 = a very great deal better), 13 to 15 representing an improvement and the 20-item Lower Extremity Function Scale (LEFS) on which participants rate 20 common weight bearing activities and activities of daily living on a 5-point scale (0 = extreme difficulty, 4 = no difficulty). Secondary outcomes were worst level of heel pain in the preceding week, and the foot and ankle ability measure. Outcomes were collected blind to allocation. Analyses were done on an intention to treat basis with 12 weeks being the primary outcome time of interest.ResultsThe contoured sandal was 68% more likely to report improvement in terms of GROC compared to flat flip-flop. On the LEFS the contoured sandal was 61% more likely than flat flip-flop to report improvement. The secondary outcomes in the main reflected the primary outcomes, and there were no differences between contoured sandal and shoe insert.Conclusions and RelevancePhysicians can have confidence in supporting a patient's decision to wear contoured sandals or in-shoe orthoses as one of the first and simple strategies to manage their heel pain.Trial RegistrationThe Australian New Zealand Clinical Trials Registry ACTRN12612000463875

The effect of custom foot orthotics and footwear on first-step pain in people with plantar heel pain: A pragmatic randomized controlled trial

The effect of custom foot orthotics and footwear on first-step pain in people with plantar heel pain: A pragmatic randomized controlled trial

A randomized clinical trial on the effects of extracorporeal shockwave therapy, joint mobilizations and exercise on plantar heel pain in patients with plantar fasciitis.

Plantar fasciitis (PF) is the most common cause of heel pain today impacting on the patient’s walking ability, work tolerance, and ability to participate in active sport. Two million people in the United States (US) are treated for PF yearly with heel pain accounting for 11 to 15% of visits to medical professionals. It is estimated that 10% of the US population will develop PF during their lifetime. Treatment for PF may include a variety of interventions ranging from conservative treatment to surgical interventions. One of the suggested treatments for PF is the use of extracorporeal shockwave therapy (ECSWT). ECSWT is a relatively new therapeutic modality that has been used in the treatment of PF and a variety of other musculoskeletal disorders with some success reported. Normally healthcare providers do not treat with the use of only one modality or treatment approach but rather a combination of treatments in an attempt to obtain a desired positive effect on the patient. The research available on the use of ECSWT is limited in that it has not been determined whether this modality used in isolation, or in combination is the most effective. Research has been conducted comparing ECSWT to placebo and a variety of controls but the effectiveness of combinations of treatment has not been studied. Therefore, the purpose of this study was to compare the effects of ECSWT alone, to ECSWT and joint mobilization, and ECSWT and exercise, on heel pain in patients with PF, as measured by the visual analog scale (VAS) and Lower Extremity Functional Scale (LEFS). Subjects (N=75) were randomly assigned into 3 groups: ECSWT, ECSWT and joint mobilizations to the talocrural, subtalar, and first metatarsophalangeal (MTP) joint, or ECSWT and stretching for the gastrocnemius, soleus, and plantar fascia and strengthening for the ankle. Subjects received three treatments in total spaced one week apart. A VAS for pain and LEFS were measured pre-treatment and three months post-treatment. All groups demonstrated statistically significant improvement over time in all VAS scores and in the LEFS (P<.05). There was a statistically significant difference in VAS for heel pain following activity between the ECSWT and joint mobilization group and ECSWT and exercise group (F= 3.577, p= .033) with a greater reduction in pain in the ECSWT and joint mobilization group. Further research is required using an alternative study design to compare the combinations of treatment to a control or placebo group. The findings of this study, however, indicate that if ECSWT is going to be combined with another treatment, then the combination of ECSWT and joint mobilization may be more effective than combining ECSWT with exercise.