Comparative Effectiveness of Acupuncture Versus Non-surgical Modalities for Treating Plantar Fasciitis: A Network Meta-Analysis

Plantar fasciitis is a condition that causes intense pain in the heel region, primarily affecting adults who spend long periods standing. It is characterized by inflammation of the plantar fascia, a structure that supports the arch of the foot, causing excruciating pain especially during the first steps in the morning. This condition can be triggered by various factors, including obesity, inappropriate footwear, hard walking surfaces, and muscle weakness. Although several treatment options are available, there is no clear consensus on which approach is most effective.

First-line treatments include anti-inflammatory medications and physical therapy, while second-line options involve extracorporeal shock wave therapy, ultrasound, corticosteroid injections, and platelet-rich plasma. Recently, acupuncture has gained popularity as a therapeutic alternative, but studies directly comparing its efficacy with other non-surgical treatments were lacking.

This study aimed to determine whether acupuncture represents a viable alternative for the treatment of plantar fasciitis when compared with other therapeutic modalities. The researchers conducted a network meta-analysis, a sophisticated type of statistical analysis that allows multiple treatments to be compared directly and indirectly. Five scientific databases were analyzed, including PubMed, Google Scholar, and a Chinese database, covering the period from January 2000 to October 2020. Of the 1,258 studies initially identified, only 32 met the inclusion criteria, totaling 2,390 participants.

The rigorous criteria included adult patients with a medical diagnosis of plantar fasciitis, studies comparing at least two of the treatments of interest, and those using the visual analog pain scale as the primary measure. This scale, which ranges from 0 to 10, where zero represents no pain and ten represents unbearable pain, was chosen because it is the parameter most consistently used in the available studies.

The analysis revealed interesting results that varied according to follow-up time. After one month of treatment, acupuncture demonstrated the greatest pain reduction when compared with placebo, with a mean difference of -1.33 points on the pain scale. This result suggests that acupuncture was more effective than the other treatments in the short term. However, at three months of follow-up, the scenario changed significantly.

Platelet-rich plasma emerged as the treatment with the greatest pain reduction, presenting a difference of -2.67 points compared with placebo, followed by corticosteroid injections. It is important to highlight that, although these numbers suggest superiority of some treatments, the statistical analyses showed there were no statistically significant differences between treatments when compared with each other. This means that, from a scientific standpoint, all the treatments studied showed similar efficacy.

For patients suffering with plantar fasciitis, these results bring an encouraging perspective. Acupuncture can be considered a valid second-line treatment option, especially for those who have not been successful with initial conservative approaches or who prefer alternatives to medication. The efficacy demonstrated in the first month is particularly relevant, since many patients seek rapid symptom relief. For healthcare professionals, the study provides evidence that acupuncture can be integrated into the therapeutic arsenal for plantar fasciitis, offering patients another evidence-based alternative.

The decision about which treatment to choose can take into account factors such as patient preference, treatment availability, cost, and clinician experience. It is important that patients understand that different treatments may be more effective at distinct moments in the course of the disease.

The study has some important limitations that should be considered when interpreting the results. First, relatively few studies on acupuncture were included, mainly because research on this modality is less frequently published in English-language scientific journals. In addition, acupuncture studies face unique methodological challenges, such as the impossibility of conducting true double-blind studies, since neither the patient nor the acupuncture practitioner can be completely "blinded" to the treatment. The complexity and individualization of acupuncture also poses a challenge, since in Traditional Chinese Medicine treatment is personalized according to each patient's specific diagnosis, making the standardization required for rigorous scientific studies difficult.

Another limitation was the inability to assess long-term effects due to the scarcity of studies with prolonged follow-up. Finally, most studies analyzed isolated treatments, while in clinical practice it is common to combine different therapeutic modalities.

In conclusion, this pioneering study demonstrates that acupuncture is an effective and safe option for the treatment of plantar fasciitis, especially for short-term pain control. Patients and clinicians may consider acupuncture as a valid alternative alongside conventional treatments, with the choice being individualized considering patient preferences, availability, and clinician experience. It is important that treatment be performed by appropriately qualified professionals, since acupuncture requires specialized knowledge and extensive clinical practice. Although this study provides valuable evidence on the comparative efficacy of treatments, more long-term research is still needed to better understand the lasting benefits of acupuncture.

In addition, future studies investigating treatment combinations may offer even more relevant insights for clinical practice, since integrated approaches often provide better outcomes for patients.