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Manuscript Title: 
PIEZOELECTRIC FOCAL SHOCK WAVE THERAPY IS AN EFFECTIVE  TREATMENT IN CHRONIC PLANTAR FASCIITIS

Author information:
Vamonde-Lorenzo L, Cuenca- Gonz�lez C, Monle�n- Llorente L, Chiesa- Estomba R,  Labrada- Rodr�guez Y.H, Castro-Portal JA  and Garvin- Ocampos L .a
a Servicio de Medicina F�sica y Rehabilitaci�n, Hospital Cl�nico San Carlos, Madrid, Espa�a
Corresponding Author:
Lucia Vaamonde-Lorenzo	lucia.vlor@gmail.com
Concepci�n Cuenca-Gonz�lez  HYPERLINK "mailto:cuchacuenca@gmail.com" cuchacuenca@gmail.com

.Abstrac
Introduction: Plantar fasciitis is one of the most frequent causes of thalalgia. The effectiveness of extracorporeal shock wave therapy is an ideal alternative to conservative treatments.
Objetive: To evaluate the effectiveness of the treatment with Piezoelectric Focal Shock Wave with echographic support and maintenance of the effect at 3 and 6 months.
Methods: This was a descriptive, retrospective statistical study from June 2015 to June 2017  of  90 patients, 36.6% men and 63.3% women, with a mean age of 52 years, diagnosed with plantar fasciitis. Three sessions (one weekly for 3 weeks) of shock wave therapy (PiezoWave F10 G4 generator) were performed, with echographic support and weekly revision and at 3 and 6 months. Main variables: pain, using Visual Analog Scale before and after each session and at 3 and 6 months and Roles and Maudsley  Scale at the end of treatment and at 3 and 6 months.
Results: With an energy intensity of 0.45 mJ / mm2, median frequency of 8 MHz and median depth of focus of 15 mm, 2000 pulses per session were applied. Statistically significant improvement was observed in the Visual Analog Scale  between the 3 treatment sessions and after 3 and 6 months post-treatment, obtaining a statistically significant improvement in all values (p <0.05). According to the Roles and Maudsley scale, 69.7% of the patients considered the result to be good or excellent at 3 months and 68.9% at 6 months (statistically significant result).
Conclusion: Treatment with piezoelectric focal  shock waves in plantar fasciitis reduces pain  from the first session and achieves a subjective perception of improvement, maintaining these results at 6 months post -treatment.
Key words: Piezolecetric Focal shock wave therapy, treatment, chronic plantar fasciitis




Text
INTRODUCTION�:

Plantar fasciitis (PF) is one of the most frequent causes of foot pain in adults. Clinically appears as pain on calcaneal tuberosity, proximal insertional place of the plantar fascia (1). It is more prevalent between 40 and 60 years old, even bilateral in a third of cases, both athletes and the general population, thus a ten percent (10%) will suffer it during their lives (2,3). Even though its etiology is not completely clear, probably there is not a unique cause and there are several factors that contributes to its presentation, as feminine sex, overweight, sitting and stand up, anatomical conditions as foot architecture (pes cavus, pronated foot, less mobile hallux), posterior leg muscle contracture, plantar fat pad atrophy (4,5).

PF is a musculoskeletal disorder which presents pain, more intense at the beginning of walking in the morning or after a period of rest, it gets worse with prolonged standing or impact activity (6).

Diagnosis is made through the medical history, physical exam and it is confirmed by ultrasound that discards small torns and determines the thickness of the fascia, being the diagnosis criterion over 4mm. Ultrasound and MRI represent the first and second election image test for PF diagnosis (7). 

Plantar fasciitis treatment goes through a change of lifestyle. Oral analgesics and NSAIDs, fascia stretching exercises, massage and local cold, are the first line treatments. Before an absence of improvement should consider rehabilitation management with physiotherapy (eccentric stretching exercise, myofascial massage, electrotherapy), plantar orthosis, local corticoid infiltrations, PRP (8,9) or botulin toxin (10,11)

Recently a new treatment has demonstrated its security and effectiveness, the extracorporeal shock- wave therapy (ESWT), especially in patients with chronic plantar fasciitis refractory to other treatments (12, 13,14). Nowadays the use of the ultrasound is more extended, so it can be used to focus the shockwave treatment area. 

In the present study, the results after one-year of treatment with extracorporeal piezoelectric shock- wave therapy are disclosed, in patients of the rehabilitation service from Hospital Clinico San Carlos at Madrid- Spain. 

METHODS AND MATERIALS�:

This study design is descriptive, inferential statistics and retrospective, from June 2015 to June 2017. 

Inclusion criteria:
We included patients from Reumathology, Traumatology and our own service, older than 18 years, with chronic plantar fasciitis (more than 6 months of evolution), that already had other treatments (orthosis, physiotherapy, corticoid infiltration), patients above 4 score on the Visual Analog Scale (VAS), and every patient that signed the informed consent form. 
A previous ultrasound was made for diagnosis and confirmation of the pathology and for minimizing the complications. 



Exclusion criteria:
Patients with contraindications for the treatment according to the Spanish Shockwave Treatment Society criteria were excluded (15) (table 1). Also, patients with corticosteroids infiltration less than  6-weeks and with VAS under 4 were excluded. As well as anyone who refuses treatment. 


INTERVENTION
With ultrasound support (6- 12 Hz linear probe),  we locate the focus with a mean measure of 15mm depth and then we applied the extracorporeal shockwave treatment with the piezoelectric generator PiezoWave F10G4. All patients were positioned prone on the examination table. Each patient received an energy density of 0,45mj/mm2 (according to their tolerance), with a frequency of 8Hz in every case and 2000 pulses every session, for a total of 3 sessions, one per week. At the beginning of each session patients were asked about their pain during rest and activity according to VAS, and at the end of each session they were asked alike.  All patients were recommended to do stretching exercises at home. At the end of the last session, the patients rated the treatment results with Roles and Maudsley score. 
Follow-up evaluation was at the 3rd and 6th month,  with Roles and Maudsley score and with VAS during rest and activity, at the consulting room in the third month, and by phone in the sixth month.

STATISTICS ANALYSIS:
All the data was analyzed with SPSS software for Windows, version 23. To compare two qualitative variables was used chi-squared test and Wilcoxon signed- rank test for qualitative variables that do not follow a normal distribution. It was considered statistically significant p <0.05. 

RESULTS: 
The total number of treated patients was 90, 57 female and 33 male, the mean age was 52 years. The average time of evolution was 16 months. Table 2 specifies sample characteristics regarding to risk factors and life habits related to the development of plantar fasciitis.  

The main study variable was the improvement of pain according to VAS; in second place were analyzed the rest of variables, presence or not of calcaneal spur, previous physiotherapy, corticosteroids infiltrations 3 months before, use of orthosis, sport or impact work, ankle limited range of motion (exploring dorsal and plantar flexion), body mass index above or below 30 and labour status active or not. There was no statistical significance relationship between any of these variables and pain intensity. Also, there was no relation between the intensity used to apply the treatment and increase or decrease of pain. 

In terms of VAS results, the patients from our sample had a mean value of 3.5 with rest and 8.6 with activity, at the 3rd and 6th month follow-up was 1.6 and 3.1 respectively. Comparing the VAS values during treatment with those at 3rd and 6th months follow up, there was a statistically significant improvement (p<0.05) in all values. (Table 3).

In accordance with Roles and Maudsley score, that classified the result of the treatment according to the patients assessment in excellent, good, fair or poor, at the 3 months follow up 36% of the patients referred an excellent result, 33.7% good, 19,1% fair and 11.2% poor. At the 6 months follow up the figures are similar, 37.7% was excellent, 31.2% good, 19.5% fair and 11.7% poor. During follow-up 11 patients were lost from the 6 months analysis. 

With this treatment, we had no records of complications or adverse effects in any case. 



DISCUSION�:

Numerous studies analyze various alternatives of treatment for plantar fascitis (16,17,18,19,20), this is a very prevalent pathology with multiple risk factors with no effective treatment in many cases. 

PF is a limited disorder. The symptomatology will disappear in 10 months in an 80% to 90% of  cases. However, this interval is frustrating for the patient and also for the treating specialist. This is why the sooner is diagnosed and treated, the greater will be the probability of cure.

In a systematic review from D�az L�pez A.M, y Guzm�n Carrasco P (21), about the effectiveness of different conservative treatments: orthopedic, physiotherapy (dressing, stretching), electrotherapy (ultrasound, shockwave, laser, iontophoresis, magnetic therapy), and acupuncture�; they analyzed 32 studies,  the most used techniques were stretching, and shockwave, although the best results were obtained combining several techniques. Shockwaves were effective when other techniques failed.

The first line treatment of PF is conservative. Physical therapies used in different studies have shown to be effective, in different measure, to reduce pain or to relieve symptoms. Surgical treatment is not usually performed because it does not always give good results and its recurrence is 30%.

The shockwave therapy has been proposed as an option for plantar fasciitis treatment in addition to other musculoskeletal conditions. Wang et al in a review published in 2012(22) concluded, about shockwave therapy in plantar fasciitis, that with so many confusion factors influencing the results of this therapy, there could be controversy in the results obtained.  However, most of the reviewed studies are in favor of the ESWT, with a success rate from 34% to 88%. 

There is no consensus as to the energy density to apply nor treatment parameters. In a meta-analysis, Dizon et al (23), reviewed and analyzed the results as to pain and functionality refers,  according to the intensity of the energy applied, observing, likewise, the adverse events register in each one, they concluded that shockwave with moderate and high intensity is effective with pain reduction and functionality in chronic plantar fasciitis and, although it could cause pain, this was well tolerated and non durable. As for the protocol to follow, Rompe et al (24), suggest 3 sessions per week of 1000 pulses and low energy  is an effective therapy, nevertheless Wang et al (25), in one of his works administer a unique session of treatment reporting good results even 72 months later. 
There are 3 ways to generate the focal shockwave, with an electrohydraulic generator, an electromagnetic generator, and piezoelectric. The last one has high intensity over the focus but this focus is the smaller one, that is why the total energy is less. As an advantage is less painful and well tolerated for the patients. With this observational study, we expose our experience with shockwave treatment with a piezoelectric generator, existing few published studies with this type of generator. Liang et al (26) study randomized groups with plantar fasciitis, one group gets high-intensity shockwaves (0.56 mj/mm2) and the other low intensity (0.12mj/mm2), they get similar results with functionality and pain improvement both with high and low intensity, although high intensity is associated with less pain, this was not reflected on the favorable results, that went from 67% at 3 months to 58% at the 6 months follow-up. 

When the differences in the mean values of VAS are analyzed, between the first session of treatment and consecutive, and with the 3rd to 6th month follow up (table 3), it is appreciated how the difference between VAS mean values is rising, with a slight descend at 6th month follow up. 

Comparing the mean VAS values in rest and activity referred by the patient between the first session and successives (2nd and 3rd) and later with the post-treatment figures at 3rd and 6th month follow up, there is an increase of difference between these figures in time, resulting in sustained improvement in the medium and long term of pain, according to our study. This slight difference at 6th month  could have been influenced by the lost of 11 patients during the follow-up. 

In Sun et al. (27) meta-analysis it is compared the  efficacy of the general extracorporeal shockwave therapy (ESWT), focal shockwave (FSW) and radial shockwave (RSW) with placebo, to evaluate its effectiveness in chronic plantar fasciitis. They concluded that FSW therapy can relieve pain as an ideal alternative, while firm conclusions can not be drawn from the overall effectiveness of the general ESWT or the RSW, because of the variations between included studies, additional clinical studies are needed to validate these conclusions. 

There are few studies that analyze shockwave efficacy in PF with a piezoelectric device so it would be interesting to determine which type of shockwave generator could be more effective and if lower total energy density on the focus, as occurs with piezoelectric, influence the efficacy of this treatment.

As limitations of the present study, highlight  that could not be objectified if there was or not changes in lifestyle of the patients that received the treatment. This  may imply that favorable results could be influenced by these changes, because of the natural course of the disease or because the use of orthosis, and not only because of ESWT. 


CONCLUSION:
According to the results obtained in our study, focal piezoelectric shockwave therapy with high energy reduces pain in plantar fasciitis since the first session, improving and sustaining this result even 6 months later; and this improvement  was statistically significant. In the same way, most of the treated patients consider having obtained a positive result with this therapy (Roles and Maudsley score) and they refer to be satisfied 

Focal piezoelectric shockwave therapy constitutes an effective therapeutic alternative for the treatment of plantar fasciitis, much safer and better tolerated than other interventional techniques, as infiltrations, and it should be well known and consider by professional in the musculoskeletal pathology field.


BIBLIOGRAPHY�:
(1)	Cutts S., Obi N., Pasapula C., Chan W. Plantar fasciitis. Ann R Coll Surg Engl 2012;94:539-542.
(2)	Furey JG. Plantar fasciitis. The painful heel syndrome. J Bone Joint Surg Am 1975 Jul;57(5):672-673. 
(3)	Nuba O, Ireland J. Plantar fasciitis. Ital J Orthop Traumatol 1986 Dec;12 (4):533-535. 
(4)	Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport 2006 May; 9(1-2):11-22
(5)	Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003 May; 85-A(5):872-877
(6)	Lafuente A, O�Mullony I, Escrib �M, Cura P. Fascitis plantar revision del tratamiento basado en la evidencia. ReumatolClin.2007; 3 (4):159-65. 
(7)	Draghi F, Gitto S, Bortolotto C, Draghi A.G and Belometti G.O. Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging. Insights Imaging (2017) 8:69�78. DOI 10.1007/s13244-016-0533-2
(8)	Mahindra P, Yamin M, Selhi HS, Singla S, Soni A. Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo. Orthopedics. 2016 Mar-Apr;39(2):e285-9
(9)	Celik D, Ku_ G, S1rma S�. Joint Mobilization and Stretching Exercise vs Steroid Injection in the Treatment of Plantar Fasciitis: A Randomized Controlled Study. Foot Ankle Int. 2016 Feb;37(2):150-6
(10)	Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E, Mendoza-Lemus O, Acosta-Olivo C. A comparison of botulinum toxin a and intralesional steroids for the treatment of plantar fasciitis: a randomized, double-blinded study. Foot Ankle Int. 2013 Jan;34(1):8-14
(11)	D�az-Llopis IV, G�mez-Gallego D, Mond�jar-G�mez FJ, L�pez-Garc�a A, Climent-Barber� JM, Rodr�guez-Ruiz CM. Botulinum toxin type A in chronic plantar fasciitis: clinical effects one year after injection. Clin Rehabil. 2013 Aug;27(8):681-5
(12)	Krukowska J, Wrona J, Sienkiewicz M, Czernicki J. A comparative analysis of analgesic efficacy of ultrasound and shock wave therapy in the treatment of patients with inflammation of the attachment of the plantar fascia in the course of calcaneal spurs. Arch Orthop Trauma Surg. 2016 Sep;136(9):1289-96
(13)	Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res. 2013 Nov;471(11):3645-52
(14)	Zhiyun L, Tao J, Zengwu S. Meta-analysis of high-energy extracorporeal shock wave therapy in recalcitrant plantar fasciitis. Swiss Med Wkly. 2013 Jul 7;143
(15)	 http://www.setoc.es/?p=page/html/indicaciones 
(16)	Roca B, Mendoza MA, Roca M. Comparison of extracorporeal shock wave therapy with botulinum toxin type A in the treatment of plantar fasciitis. Disabil Rehabil 2016;38:2114�21
(17)	Mardani-Kivi M, Karimi Mobarakeh M, Hassanzadeh Z, et al. Treatment outcomes of corticosteroid injection and extracorporeal shock wave therapy as two primary therapeutic methods for acute plantar fasciitis: a prospective randomized clinical trial. J Foot Ankle Surg 2015;54:1047�52
(18)	 Eslamian F, Shakouri SK, Jahanjoo F, et al. Extra corporeal shock wave therapy versus local corticosteroid injection in the treatment of chronic plantar fasciitis: a single blinded randomized clinical trial. Pain Med 2016;17:1722�31
(19)	Radwan YA, Mansour AM, Badawy WS. Resistant plantar fasciopathy:shock wave versus endoscopic plantar fascial release. Int Orthop 2012;36: 2147�56.
(20)	Yan W, Sun S, Li X. Therapeutic effect of extracorporeal shock wave combined with orthopaedic insole on plantar fasciitis. Zhong Nan Da Xue Xue Bao Yi Xue Ban2014;39:1326�30
(21)	D�az L�pez A.M y Guzm�n Carrasco P. Efectividad de distintas terapias f�sicas en el tratamiento conservador de la fascitis plantar. Revision sistematica Rev Esp Salud P�blica 2014; 88:157-178.
(22)	Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res 2012 Mar 20;7: 11-799X-7-11
(23)	Dizon JN, Gonzalez-Suarez C, Zamora MT, Gambito ED. Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis. Am J Phys Med Rehabil 2013 Jul;92(7):606-620
(24)	Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg- Am. 2002;84(3):335�41
(25)	Wang CJ, Wang FS, Yang KD, Weng LH, Ko JY. Long-term results of extracorporeal shockwave treatment for plantar fasciitis. Am J Sports Med. 2006;34(4):592�6
(26)	Liang HW, Wang TG, Chen WS, Hou SM. Thinner plantar fascia predicts decreased pain after extracorporeal shock wave therapy. Clin Orthop Relat Res. 2007 Jul;460:219-25
(27)	Sun et al. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis. A meta-analysis of RCTsMedicine (2017) 96:15






Acknowledgement
The authors report no conflicts of interest.

The study has not been funded by any Public or Private institution.

Ethical Responsibilities
Protection of people and animals: The authors state that no experiments have been performed on humans or animals for this investigation
Confidentiality of the data: The authors state that they have followed the protocols of their work center for the publication of patient data.
Right to privacy and informed consent: The authors state that no patient data appears in this article

References
(1)	Cutts S., Obi N., Pasapula C., Chan W. Plantar fasciitis. Ann R Coll Surg Engl 2012;94:539-542.
(2)	Furey JG. Plantar fasciitis. The painful heel syndrome. J Bone Joint Surg Am 1975 Jul;57(5):672-673. 
(3)	Nuba O, Ireland J. Plantar fasciitis. Ital J Orthop Traumatol 1986 Dec; 12 (4):533-535. 
(4)	Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport 2006 May; 9(1-2):11-22
(5)	Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003 May; 85-A (5):872-877
(6)	Lafuente A, O�Mullony I, Escrib �M, Cura P. Fascitis plantar revision del tratamiento basado en la evidencia. ReumatolClin.2007; 3 (4):159-65. 
(7)	Draghi F, Gitto S, Bortolotto C, Draghi A.G and Belometti G.O. Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging. Insights Imaging (2017) 8:69 78. DOI 10.1007/s13244-016-0533-2
(8)	Mahindra P, Yamin M, Selhi HS, Singla S, Soni A. Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo. Orthopedics. 2016 Mar-Apr; 39(2):e285-9
(9)	Celik D, Ku_ G, S1rma S�. Joint Mobilization and Stretching Exercise vs Steroid Injection in the Treatment of Plantar Fasciitis: A Randomized Controlled Study. Foot Ankle Int. 2016 Feb; 37 (2):150-6
(10)	Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E, Mendoza-Lemus O, Acosta-Olivo C. A comparison of botulinum toxin a and intralesional steroids for the treatment of plantar fasciitis: a randomized, double-blinded study. Foot Ankle Int. 2013 Jan; 34 (1):8-14
(11)	D�az-Llopis IV, G�mez-Gallego D, Mond�jar-G�mez FJ, L�pez-Garc�a A, Climent-Barber� JM, Rodr�guez-Ruiz CM. Botulinum toxin type A in chronic plantar fasciitis: clinical effects one year after injection. Clin Rehabil. 2013 Aug;27(8):681-5
(12)	Krukowska J, Wrona J, Sienkiewicz M, Czernicki J. A comparative analysis of analgesic efficacy of ultrasound and shock wave therapy in the treatment of patients with inflammation of the attachment of the plantar fascia in the course of calcaneal spurs. Arch Orthop Trauma Surg. 2016 Sep;136(9):1289-96
(13)	Aqil A, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Clin Orthop Relat Res. 2013 Nov;471(11):3645-52
(14)	Zhiyun L, Tao J, Zengwu S. Meta-analysis of high-energy extracorporeal shock wave therapy in recalcitrant plantar fasciitis. Swiss Med Wkly. 2013 Jul 7; 143
(15)	 http://www.setoc.es/?p=page/html/indicaciones 
(16)	Roca B, Mendoza MA, Roca M. Comparison of extracorporeal shock wave therapy with botulinum toxin type A in the treatment of plantar fasciitis. Disabil Rehabil 2016;38:2114�21
(17)	Mardani-Kivi M, Karimi Mobarakeh M, Hassanzadeh Z, et al. Treatment outcomes of corticosteroid injection and extracorporeal shock wave therapy as two primary therapeutic methods for acute plantar fasciitis: a prospective randomized clinical trial. J Foot Ankle Surg 2015;54:1047�52
(18)	 Eslamian F, Shakouri SK, Jahanjoo F, et al. Extra corporeal shock wave therapy versus local corticosteroid injection in the treatment of chronic plantar fasciitis: a single blinded randomized clinical trial. Pain Med 2016;17:1722�31
(19)	Radwan YA, Mansour AM, Badawy WS. Resistant plantar fasciopathy:shock wave versus endoscopic plantar fascial release. Int Orthop 2012;36: 2147�56.
(20)	Yan W, Sun S, Li X. Therapeutic effect of extracorporeal shock wave combined with orthopaedic insole on plantar fasciitis. Zhong Nan Da Xue Xue Bao Yi Xue Ban2014; 39:1326�30
(21)	D�az L�pez A.M y Guzm�n Carrasco P. Efectividad de distintas terapias f�sicas en el tratamiento conservador de la fascitis plantar. Revision sistematica Rev Esp Salud P�blica 2014; 88:157-178.
(22)	Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res 2012 Mar 20; 7: 11-799X-7-11
(23)	Dizon JN, Gonzalez-Suarez C, Zamora MT, Gambito ED. Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: a meta-analysis. Am J Phys Med Rehabil 2013 Jul; 92(7):606-620
(24)	Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg- Am. 2002;84(3):335�41
(25)	Wang CJ, Wang FS, Yang KD, Weng LH, qrsv��������������ʼ����}pfpYLYpB5h�S�h�S�OJQJ^Jh�\WOJQJ^JhRdh�7�OJQJ^JhRdh�S�OJQJ^Jh�[�OJQJ^JhRdh	ZoOJQJ^JhafWOJQJ^J#h�[�hRd5�CJOJQJ^JaJ#h�[�h	Zo5�CJOJQJ^JaJ hhh�S�CJOJQJ^JaJhu7CJOJQJ^JaJ hhh�igCJOJQJ^JaJ#h�[�hK=�5�CJOJQJ^JaJ#h�[�hh5�CJOJQJ^JaJrs�	v	�	�	

 
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(27)	Sun et al. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis. A meta-analysis of RCTsMedicine (2017) 96:15
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