Radiotherapy in painful heel spurs (plantar fasciitis)--results of a national patterns of care study.
ABSTRACT After a general patterns of care study, the German Cooperative Group on Radiotherapy for Benign Diseases conducted a multicenter cohort study to analyze radiotherapy (RT) in painful heel spur syndrome (HSS).
In 2001, a patterns of care study was conducted in all German RT institutions using a standardized structured questionnaire. Patient accrual, patient number, pretreatment, pain record, treatment indications, RT technique, and target volume concepts for painful HSS were assessed. In addition, the functional and subjective outcomes were evaluated.
Of the institutions, 146 (79.3%) returned the questionnaire: 10 (6.8%) reported no clinical experience with RT for HSS, and 136 (93.2%) treated 3621 patients annually, a median of 23 cases/institution. The indications for treatment were chronic or therapy refractory pain. The total dose ranged between 2.5 and 18.75 Gy (median 6), and single fractions ranged between 0.3 and 1. 5 Gy (median 1). Of the responding institutions, 44.9% applied two fractions and 37.5% three fractions weekly. RT was delivered with orthovoltage units (38.2%), linear accelerators (53.7%), (60)Co units (5.1%), or other treatment units (3%). Seventy-six institutions presented their retrospective clinical evaluation in a total of 7947 patients. Pain reduction for at least 3 months was reported in 70%, and persistent pain reduction was reported in 65% of the treated patients. In 19 institutions, a second RT series was applied for inadequate pain response or early pain recurrence. No radiogenic acute or chronic side effects were observed.
The study comprised the largest number of cases reported of RT for painful HSS. Despite variations in the daily RT practice, this national patterns of care study represents a very large number of painful and refractory HSS cases that were treated effectively with RT.
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ABSTRACT: Nach einer Patterns-of-Care-Studie (PCS) der AG Strahlentherapie gutartiger Erkrankungen der Deutschen Gesellschaft für Radioonkologie (DEGRO) 2003/2004 ist eine Vielzahl von einzelnen PCS zu unterschiedlichen gutartigen Erkrankungen durchgeführt worden. Hier wird nun die PCS betreffend Radiotherapie (RT) bei schmerzhafter Gonarthrose (GNA) vorgestellt.Von 2006 bis 2008 wurden alle deutschen strahlentherapeutischen Institutionen mit Hilfe eines standardisierten Fragebogens hinsichtlich Patientenzuweisung und -anzahl, Anamnese, Vorbehandlungen, Bestrahlungsindikationen und -techniken, Zielvolumenkonzepten usw. sowie Behandlungsergebnissen betreffend RT bei schmerzhafter GNA befragt.Insgesamt beantworteten 238/248 (95,9%) der strahlentherapeutischen Einrichtungen in Deutschland den Fragebogen. 188/238 (79%) der strahlentherapeutischen Einrichtungen führen eine RT bei schmerzhafter GNA durch. Jährlich wurden in Deutschland 4 544 Patienten (im Median 15 pro Institution; ein bis 846) mit schmerzhafter GNA bestrahlt. Indikationen waren akute Schmerzen in 18,9%, chronische Schmerzen in 95,3% sowie therapierefraktäre Schmerzen in 81,1%. Die im Median applizierte Gesamtdosis betrug 6 Gy (3–12 Gy) bei einer medianen Einzeldosis von 1 Gy (0,25–3 Gy). 40,4% der Institutionen bestrahlten zweimal pro Woche, 51,4% dreimal pro Woche. Die RT wurde in 25% der Fälle mit einem Orthovoltgerät, in 79,6% mit einem Linearbeschleuniger und in 8,3% mit einem Cobalt-60-Gerät durchgeführt. 42 Einrichtungen evaluierten die Resultate der RT von insgesamt 5 069 behandelten Patienten. Eine mediane Schmerzreduktion von mindestens 3 Monaten konnte in 60% (5–100%), eine mediane Schmerzreduktion von mindestens 12 Monaten in 40% (10–100%) und eine mediane dauerhafte Schmerzreduktion in 27,8% (10–85%) der bestrahlten Patienten erreicht werden. Im Median erhielten 30% (7–100%) der Patienten eine zweite Bestrahlungsserie. Es wurden keine radiogenen Akut- und Spätreaktionen angegeben.Die vorliegende PCS bestätigt mit der bisher weltweit größten Fallzahl die traditionell weite Verbreitung der RT bei der schmerzhaften GNA in Deutschland sowie die damit verbundenen sehr guten Resultate. Die RT bei schmerzhafter GNA kann als effektive und nebenwirkungsfreie Option vor operativen Eingriffen durchgeführt werden.Strahlentherapie und Onkologie 01/2010; 186(1). · 2.73 Impact Factor
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ABSTRACT: Въведение: Ръководството се състои от две основни глави- „ Лъчелечение на нетуморните заболявания“ и „Лъчелечение на доброкачествени тумори“. След всяка от главите с Библиография. Ръководството е предназначено за широк кръг от лекари- лични лекари, редица специалисти (кожни, очни, ушни, невролози, педиатри и т.н.), разбира се и за лъчетерапевти с цел разширяване на техните познания. След обширен литературен обзор от световната практика и международно приети консенсуси, както и от нашия скромен опит, се постарахме да представим ефективното лъчелечение при доброкачествените заболявания. Нашата основна цел е чрез разширяване на познанията на медицинските специалисти да подобрим качеството на живот на много пациенти, които действително се нуждаят от качествено лъчелечение. Въпреки риска от късни лъчеви реакции (предимно от страна на кожата, карциногенеза и генетични промени) след облъчване с йонизиращи лъчения, ЛЛ продължава да е актуално, приемливо и ефикасно за редица доброкачествени заболявания. След натрупан световен опит чрез редица рандомизирани проспективни проучвания, бе отчетен траен противовъзпалителен и противоболков ефект при много възпалителни и ставнодегенеративни заболявания, както и благоприятен ефект върху ставната подвижност. Изключително важно е трайното лъчелечебно подобряване на качеството на живот при много пациенти. Високата лъчерезистентност на доброкачествените тумори, често налага ЛЛ на малки туморни обеми (КМО) с високи канцерицидни дози (достатъчни за унищожаване на диференцираната туморна клетка). Лъчелечението се базира на подобни на онкологичните лъчетерапевтични изисвания и стандарти. Голяма част от доброкачествените тумори са дълбоко разположени, факт изискващ високоенергийно фотонно ЛЛ, генерирано от линеен ускорител. За максимална защита на околните нормални тъкани и органи, се налага конформално ЛЛ с модерна високоенергийна лъчетерапевична апаратура –ускорител или гаманайф, прилагане на високотехнологични лъчетерапевтични режими- стереотактично лъчелечение, три-D конформално ЛЛ и интензивно модулирано ЛЛ. Основната цел при ЛЛ на доброкачествените тумори е подтискане на клетъчната пролиферация, което определя ДОД – от 1,8-3 Gy и общата огнищна доза (ООД) 45-60Gy. Целта е постигане на туморна ерадикация или спиране на туморния растеж при значимо минимизиране на късната детерминирана лъчева токсичност на нормалните тъкани и органи.Галакта- Колор принт edited by Доц. д-р Лена Маринова,дмн, 05/2010; , ISBN: 978-957-92254-5-7
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ABSTRACT: This review updates the radiotherapy indications for non-malignant diseases, except those treated by radiosurgery. Since the last 2005 review, there have been no major changes in the indications: the prevention of heteropic bone formation and keloids remain classical indications, while the treatment of macular degeneration or the prevention of coronary restenosis are now past history. Nevertheless, the radiation treatment for benign diseases should have the same criteria as for malignant diseases: information of the patient on risks, benefits and treatment quality.Cancer/Radiothérapie 10/2014; · 1.11 Impact Factor
CLINICAL INVESTIGATIONBenign disease
RADIOTHERAPY IN PAINFUL HEEL SPURS (PLANTAR
FASCIITIS)—RESULTS OF A NATIONAL PATTERNS OF CARE STUDY
OLIVER MICKE, M.D.,* M. HEINRICH SEEGENSCHMIEDT, M.D., PH.D.,†AND THE
GERMAN COOPERATIVE GROUP ON RADIOTHERAPY FOR BENIGN DISEASES
*Department of Radiotherapy, Mu ¨nster University Hospital, Mu ¨nster, Germany;†Department of Radiation Oncology,
Therapeutic Radiology and Nuclear Medicine, Alfried Krupp Hospital, Essen, Germany
Purpose: After a general patterns of care study, the German Cooperative Group on Radiotherapy for Benign
Diseases conducted a multicenter cohort study to analyze radiotherapy (RT) in painful heel spur syndrome
Methods and Materials: In 2001, a patterns of care study was conducted in all German RT institutions using a
standardized structured questionnaire. Patient accrual, patient number, pretreatment, pain record, treatment
indications, RT technique, and target volume concepts for painful HSS were assessed. In addition, the functional
and subjective outcomes were evaluated.
Results: Of the institutions, 146 (79.3%) returned the questionnaire: 10 (6.8%) reported no clinical experience
with RT for HSS, and 136 (93.2%) treated 3621 patients annually, a median of 23 cases/institution. The
indications for treatment were chronic or therapy refractory pain. The total dose ranged between 2.5 and 18.75
Gy (median 6), and single fractions ranged between 0.3 and 1. 5 Gy (median 1). Of the responding institutions,
44.9% applied two fractions and 37.5% three fractions weekly. RT was delivered with orthovoltage units
(38.2%), linear accelerators (53.7%),60Co units (5.1%), or other treatment units (3%). Seventy-six institutions
presented their retrospective clinical evaluation in a total of 7947 patients. Pain reduction for at least 3 months
was reported in 70%, and persistent pain reduction was reported in 65% of the treated patients. In 19
institutions, a second RT series was applied for inadequate pain response or early pain recurrence. No radiogenic
acute or chronic side effects were observed.
Conclusion: The study comprised the largest number of cases reported of RT for painful HSS. Despite variations
in the daily RT practice, this national patterns of care study represents a very large number of painful and
refractory HSS cases that were treated effectively with RT.© 2004 Elsevier Inc.
Heel spur syndrome, Insertion tendinopathy, Plantar fasciitis, Radiotherapy, Patterns of care study, Benign
The term “heel spur syndrome” (HSS) derives from Plettner
(1) in 1900, who coined the German term “Kalkaneussporn”
(or calcaneal spur). His first radiologic study (1) described
an exostotic plantar bone formation at the insertion of the
plantar fascia and muscles, which resulted in the term “plan-
tar heel spur.” In contrast, the exostosis at the insertion of
the Achilles tendon was termed “dorsal” heel spur or “Ha-
glund exostosis.” The latter disorder develops less often and
often remains asymptomatic. Plantar and dorsal heel spurs
can develop in the same individual, and bilateral manifes-
tations are often observed (2). Today, the phrases “painful
heel spur” and “HSS” encompass different entities and
terms, which have been synonymously used: plantar or
dorsal heel spur, Haglund exostosis, calcaneal spur, achil-
lodynia, and calcaneodynia (3). Anglo-American countries
also use the term “plantar fasciitis” for HSS (4).
The prevalence of HSS ranges from 8% to 10% (5). Data
on the gender ratio vary considerably (6). Usually, patients
are ?40 years old. In most cases, the spurs measure 4–6
mm, but shorter and longer dimensions are possible. No
strong correlation exists between spur size and the extent
and strength of pain. Typically, the pain is stinging and
occurs under the heel or at the insertion of the Achilles
Reprint requests to: Oliver Micke, M.D., Klinik und Poliklinik
fu ¨r Strahlentherapie, Radioonkologie, Universita ¨tsklinikum Mu ¨n-
ster, Albert-Schweitzer-Str. 33, Mu ¨nster 48129 Germany. Tel:
Presented at the 44th Annual Meeting of the American Society
for Therapeutic Radiology and Oncology, New Orleans, LA, Oc-
tober 6–10, 2002.
Acknowledgments—The authors and the German Cooperative
Group on Radiotherapy for Benign Diseases are grateful to all
institutions and radiation oncologists who participated in this
study. Their cooperation in providing information made this
unique national survey possible.
Received Mar 11, 2003, and in revised form Jul 21, 2003.
Accepted for publication Jul 25, 2003.
Int. J. Radiation Oncology Biol. Phys., Vol. 58, No. 3, pp. 828–843, 2004
Copyright © 2004 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/04/$–see front matter
tendon. It can be an extensive heel pain that may radiate into
the leg or forefoot. This pain leads to a marked impairment
of gait and mobility. Often, a local tenderness at the medial
and distal aspect of the tuber calcanei is observed (4). The
chronic damage to the insertion of the plantar aponeurosis
and the small foot muscles owing to the increased strain
plays an important role in the etiology of the disorder. The
increased strain is supposed to be the result of a foot
deformity (e.g., splay-foot), obesity, or specific sports ac-
tivities (7–9). The chronic damage is followed by a de-
creased elasticity of the insertional cartilage. Gaps in the
impaired cartilage are invaded by mesenchymal cells, which
later form scar tissue. After the invasion of neovascular
vessels, the scar slowly ossifies, which may lead to the
development of the typical bony spurs at the insertion zone
Similar to the therapy of osteoarthritis, various treatments
have been proposed for HSS, primarily including rest and
decrease of body weight (10), orthopedic shoe modifica-
tions, ortheses or heel pads (11, 12), different types of
physical therapies (13, 14), and local electrophysical mea-
sures, including cold or heat applications or local infiltration
with corticoid crystal suspensions and anesthetics (15, 16).
In addition, systemic nonsteroidal antiinflammatory drugs,
iontophoresis, and laser, microwave, and ultrasound appli-
cations are often used (17–22).
Recently, extracorporal shock wave therapy (ESWT) has
generated great promise (23–25), but long-term outcome
data are to come for most of these methods. Different
surgical techniques have been proposed and are in use for
the more complicated cases and those with a chronic pain
syndrome (26–28). Despite this variety of treatment op-
tions, none has yet demonstrated a clear superiority with
convincing results (17, 29, 30).
Radiotherapy (RT) for painful HSS or other musculoskel-
etal degenerative and inflammatory disorders has been well
established in Germany and other countries of Central and
Eastern Europe (31) for about 100 years (32), with very
good treatment results (33, 34). Nevertheless, only few
reports exist with a statistically significant high level of
evidence (35). Northern European and Anglo-American
countries regard RT for nonmalignant disorders with great
skepticism (36, 37). Thus, the implementation of treatment
guidelines and suitable tools for quality assurance are cru-
cial for additional promotion of this treatment (38, 39).
Patterns of care studies (PCSs) provide an important
instrument for the definition and evaluation of treatment
standards and quality assurance; thereby, practice stan-
dards, treatment guidelines, and accomplishments can be
assessed continuously (31, 40–43). After a general PCS
about RT for benign disease with ?20,000 patients
treated in Germany annually (44), the German Coopera-
tive Group on Radiotherapy for Benign Diseases (GCG-
BD) initiated a disease-specific PCS on RT for painful
HSS in Germany.
MATERIALS AND METHODS
In 2001, the Patterns of Care Study in Benign Diseases
Panel (Appendix A) of the GCG-BD of the German Society
for Radiation Oncology developed a structured standardized
questionnaire (Appendix B) and mailed it to all RT depart-
ments in Germany with the aim to identify their institutional
experience with RT for painful HSS.
In this systematic approach, patient accrual, total patient
number, number and type of pretreatments, pain record,
treatment indication, RT, and target volume concept for
each institution were analyzed. In addition, the functional
and subjective outcome results of all participating institu-
tions, which consistently used scores with subjective and
objective parameters, were analyzed from published, as well
as unpublished, clinical data. In the case of unclear or
incomplete data acquisition, interviews or visits to the in-
stitutions were used to acquire the appropriate institutional
and clinical information. The relatively high response rate
(146 institutions [79.3%]) allowed an extensive and repre-
sentative data analysis for Germany. The records of 7947
patients were prospectively evaluated to obtain the clinical
outcome data. The reported follow-up period for these pa-
tients was a median of 28 months (range 3–335).
The statistical description of all relevant parameters in-
cluded the median, mean, standard deviation, and range for
all continuous variables, and the absolute and relative values
for all categorical variables. The differences between the
frequencies of the groups were analyzed with Fisher’s exact
test and the chi-square test. The mean values of the group
frequencies were analyzed with Student’s t test. All statis-
tical analyses were performed using the commercially avail-
able program package, Statistical Package for Social Sci-
ences, version 10.0.7 (SPSS, Chicago, IL).
Because only a few institutions (14.5%) used validated
pain scores (e.g., the modified score of Rowe et al. ) or
the score proposed by the GCG-BD (46) (Appendices C and
D), for practical reasons, the outcome analysis was based on
the 5-item pain scale first described by the German radiol-
ogist Gu ¨nter von Pannewitz (47). He used five categories of
response: pain free, substantial pain improvement, moderate
pain improvement, pain unchanged, and worse pain (Ap-
pendix E). Treatment success was defined as (pain free plus
substantial pain improvement).
As suggested by Hanks et al. (43) and Coia and Hanks
(48), this PCS was structured and analyzed according to the
model for quality assessment set up by Donabedian (49, 50)
in three major components: structure, process, and outcome.
To determine the interrelationship between these factors, a
multivariate analysis was performed by analysis of vari-
Of the 146 institutions participating in the survey, 36
were university hospitals (24.6%), 81 were community hos-
829 Radiotherapy in painful heel spurs ● O. MICKE et al.
pitals (55.5%), and 29 were private RT institutions (19.9%)
(Table 1). Ten (6.8%) reported no experience with RT for
painful HSS. Therefore, the current analysis was based on
the answers of the remaining 136 institutions (93.2%). For
the baseline year, 2001, the participating institutions re-
ported a total of 3,621 patients treated annually. The median
number of patients per institution was 23 (range 1–242).
The referral for RT came primarily from orthopedic sur-
geons (n ? 82; 60.3%), followed by general practitioners (n
? 45; 33.1%) and other disciplines (n ? 9; 6.6%; e.g.,
The therapeutic measures used before RT (several an-
swers possible) were shoe modifications (n ? 72), oral
medication with nonsteroidal antiinflammatory drugs (n ?
70), local injections with corticosteroids or local anesthetics
(n ? 69), various physiotherapeutic measures (n ? 59),
ESWT (n ? 47), surgical interventions (n ? 44), and other
treatments (n ? 10). Most patients referred for RT had
undergone extensive pretreatments, predominantly with two
to three types of therapy (n ? 58; 42.6%). In 7 institutions
(5.1%) only, RT was given as the primary treatment. All
results are summarized in Fig. 1.
In 73 institutions (53.7%), the technical equipment used for
RT consisted of linear accelerators (median energy 6 MeV,
range 4–9); in 52 institutions (38.2%), orthovoltage units (60–
200 kV) were used; and in 7 (5.1%),60Co machines and in 4
(3%) other treatment units (e.g.,137Cs) (Fig. 2).
The main area of maximal pain indicated by the patients
was the plantar region (80%), followed by the dorsal region
(14%) or both areas of the heel (6%). The typical indication
for the use of RT was “chronic heel pain” in 100 institutions
(73.5%), “acute pain” and “both pain types during a period
of 6–8 weeks” or “therapy refractory pain after more than
two unsuccessful treatment attempts” in 36 institutions
(26.5%). In addition to the typical clinical symptoms, al-
most one-half of the RT institutions (49.2%; n ? 67)
demanded a minimal period of pain symptoms of at least 6
months. However, only 41 institutions (30.1%) considered
an imaging or radiologic finding to be indispensable before
the indication and use of RT.
A broad range of RT dose and fractionation concepts were
applied. The total RT dose ranged from 2.5 to 18.75 Gy
(median 6; Fig. 3); the single RT dose fraction ranged from 0.3
to 1.5 Gy (median 1.0). A total of 40 institutions (33.1%) used
Table 1. Type and distribution of participating institutions
Fig. 1. Number of treatment attempts before initiation of RT. n.s. ? not stated.
830 I. J. Radiation Oncology ● Biology ● Physics Volume 58, Number 3, 2004
0.5 Gy and 67 (55.4%) 1.0 Gy as a standard daily single dose.
Most institutions delivered two to three RT fractions weekly:
61 (44.9%) used two fractions and 51 (37.5%) three fractions
weekly (Fig. 4). In two-thirds of cases (n ? 90), patient
positioning and RT setup was performed clinically without
treatment planning and localization at a simulator. The large
majority of institutions (89.7%) prescribed the dose to a spec-
ified tissue depth, mostly the mid-plane of the heel; only a few
centers (11.3%) used the “surface dose” for dose specification.
Nearly all institutions (95.6%) indicated a second RT series
would be done if the pain response was inadequate or early
pain recurrence developed within 6–8 weeks after the first RT
All institutions reported quite different concepts for cover-
age of the target volume (Fig. 5): 58 (42.6%) included the
part of the plantar fascia within the treatment portal; 27
(19.9%) included the dorsal part of the calcaneus and the
insertion and lower parts of the Achilles tendon; 44 (32.4%)
used a smaller field with the calcaneus and both insertion
zones; and a very small group (n ? 7) of institutions and
radiotherapists (5.1%) used a large field that included major
parts of the plantar fascia and the Achilles tendon. Irradiation
was applied via a single plantar or dorsal field in 85 institutions
(62.5%) or by two lateral opposing fields in 51 institutions
A total of 76 institutions provided detailed data for clin-
ical evaluation of treatment outcome. The clinical data since
Fig. 2. Technical equipment used for RT for painful heel spurs.
Linear accelerator, 53.7% (n ? 73); orthovoltage, 38.2% (n ? 52);
60Co, 5.1% (n ? 7); other, 3.0% (n ? 4).
Fig. 3. Different concepts for total dose.
831 Radiotherapy in painful heel spurs ● O. MICKE et al.
1960 and the treatment results for 7947 patients irradiated
for painful HSS are reported. The reported follow-up period
for these patients amounted to a median 28 months (range
A total of 65 (85.5%) of the above-mentioned institutions
used subjective pain scores for the evaluation of clinical
outcome (e.g., the pain scale first described by the German
radiologist von Pannewitz  who used five categories of
response [Appendix E]). In contrast, only 11 institutions
(14.5%) used orthopedic functional scores, including both
subjective and objective response criteria (e.g., the modified
score of Rowe et al. ), or the score proposed by the
GCG-BD (46) (Appendices C and D).
Complete pain relief for ?3 months was reported in a
median of 70% (range 25–100%) of all treated patients and
persisting pain relief for a minimum of 12 months in a
median of 65% (range 19–99%). A median of 15% of all
treated patients had no symptomatic improvement (range
5–50%). In a median of 19% cases, a second RT series was
required for inadequate pain relief or early pain recurrence,
and in a median of 3% of all treated cases a third RT series
was necessary. All participating institutions reported no
RT-related side effects. In particular, no secondary malig-
nancies were observed during the reported follow-up pe-
riod, with a maximal follow-up of nearly 28 years.
Of all radiation oncologists in this national survey, 95%
considered RT for painful HSS as a worthwhile and neces-
sary treatment indication.
The multivariate analysis of all patients included in the
analysis revealed a pain history of ?6 months vs. a pain
history of ?6 months to be a statistically significant (p
?0.05) prognostic factor indicating a successful treatment
outcome. Other favorable prognostic parameters were fewer
than two previous treatment attempts vs. two or more pre-
treatments, and one RT series vs. two or three RT series. In
contrast, no statistically significant dose–response relation-
ship was found and no significant statistical correlation was
observed between fractionation, treatment equipment, or
target volume definition and the treatment success of RT. In
addition, a statistical correlation with the type of pretreat-
ment could not be established, although a trend toward a
worse outcome after surgery was noted. A complete over-
view of all results of the multivariate analysis is given in
Since their first implementation in the United States in
1973, the PCS has been established as a valuable tool for
periodic evaluation of RT practice (48, 51). Its primary
function is, as the founder Simon Kramer (52) stated, “to
Fig. 4. Different fractionation concepts.
832 I. J. Radiation Oncology ● Biology ● PhysicsVolume 58, Number 3, 2004
improve the quality and accessibility of radiation care in the
United States. To this end the PCS seeks to establish how
and by whom radiation therapy is being practiced in the
United States and to evaluate the factors [that] affect the
levels of care presently being delivered.” Since these early
steps, the evaluation of the quality of care has become a
most critical issue in medical practice, and it is particularly
important in the multidisciplinary management of cancer
patients (53, 54). The method of PCS was successfully
transported to many other countries outside the United
States; for example, Japan (42, 55). Nevertheless, for a long
period, most PCSs were restricted to the management of
malignant diseases (40, 52, 54, 56–58).
Obviously, the use of RT for nonmalignant disorders should
be performed under the same conditions in terms of quality
assurance and standards of care as for malignant diseases (38),
although nonmalignant disorders do not carry the same fatal-
ities as most malignancies. Nevertheless, even nonmalignant
diseases can lead to a significant restriction in quality of life, as
well as large socioeconomic damage (39). Thus, a major scope
of PCS in the area of nonmalignant disorders. So far, one
PCSs on specific indications (59–62) have been performed in
Germany—a country with a very long-standing tradition and
well-evolved experience in the treatment of nonmalignant dis-
eases (32, 63). The current PCS focused on RT for painful
HSS, one of the most frequent indications for RT, representing
11% in the general survey in Germany (44). PCSs analyze the
patient with regard to technical and interpersonal components
Understanding the relationships of these three factors leads to
the measurement of quality in any specialty (43).
The structural analysis revealed that experience in using
RT for painful HSS is widespread (81%). The distribution
of academic vs. nonacademic institutions of about 1:4 is
similar to that described in the former general PCS (44, 60)
and in other PCSs on malignant disorders (42, 65, 66). The
reasons for this higher prevalence of RT use in HSS in
nonacademic institutions could be that most RT patients in
Germany are treated in nonacademic institutions and that
academic institutions focus more on the treatment of ma-
lignant diseases with specialized techniques (e.g., brachy-
therapy, intensity-modulated RT, stereotactic RT) or on the
setting of multimodality therapies (44).
The referral for RT came primarily from orthopedic sur-
geons in private practice; they should be the major partners
for communication about the interdisciplinary treatment of
these patients. Most patients referred for RT had been
heavily pretreated with two, three, or even more unsuccess-
ful treatment attempts. Primarily, shoe modifications, oral
nonsteroidal antiinflammatory drugs, local injections with
corticosteroids or anesthetics, physiotherapy, and ESWT
were applied. In our opinion, these therapy options should
always be discussed and explained to the patient, and all
conventional measures should be exhausted before initiating
RT as a “salvage treatment.” However, the multivariate
analysis of this PCS demonstrated that a greater number of
Fig. 5. Different target volume concepts.
833 Radiotherapy in painful heel spurs ● O. MICKE et al.
pretreatments and a longer pain history were related to a
significantly worse treatment outcome. These findings
should challenge the GCG-BD to introduce RT much earlier
in the treatment of painful HSS.
The applied technical equipment described in this PCS
was predominated by linear accelerators with low energies
between 4 and 9 MeV, which were used in more than
one-half of the institutions. This finding stands in contrast
with the clinical data of 16 clinical studies extracted from a
literature review (published between 1933 and 2002) sum-
marizing the data from 3,472 patients (67). In that study,
nearly three-fourths of all institutions used orthovoltage
treatment units. The use of linear accelerators may have
some economic disadvantages, because the reimbursement
for machine costs and personal required for the labor-
intensive linear accelerators is very low for nonmalignant
disorders. However, this practice contradicts an old para-
digm that orthovoltage with its higher bone and soft-tissue
absorption should be superior in outcome compared with
linear accelerator photons (68). However, so far no biologic
in vitro, in vivo (69), or clinical outcome data exist (70–72)
to support this theoretical assumption, and the multivariate
analysis of this PCS could not detect a relationship between
the use of different treatment units and clinical outcome.
The indication for treatment of painful HSS is primarily
cases refractory to conventional treatment. This coincides
with recently established treatment guidelines that recom-
mend the use of RT in treatment refractory inflammatory
degenerative tendinopathy (38). Refractory HSS represents
most of the indications reported in the literature (6, 34, 35,
73). However, it is known that a long pain history and more
treatment attempts before RT may lead to less success with
regard to pain response (6, 34, 71, 72). This observation has
been confirmed by the multivariate analysis of our national
PCS. When the first RT series has failed, implementation of
a second RT series is very common. Our multivariate anal-
ysis confirmed that patients who undergo a second RT series
respond worse, not because of this second treatment series,
but rather because of their chronic and refractory pain
process (74). Nevertheless, in general, a long-term pain
control rate of ?70% can be expected (75). In our PCS, the
standardized RT dose concepts revealed a large variation,
with total doses between 3 and 6 Gy and single doses
between 0.5 and 1 Gy. Usually, two or three fractions
weekly were applied. This is also the most common regimen
reported in the literature (67).
To date, in this PCS, no dose–response relationship could
be established (35, 76). Multivariate analysis showed no
also correlation between dose and treatment outcome. Thus,
the next task is a prospective clinical trial assessing a
possible dose reduction without loss of efficacy.
In the national practice, the target volume concepts ex-
hibited considerable variations that did not translate into
different treatment outcomes. To date, a clear consensus
exists about the inclusion of the calcaneal insertion of the
plantar fascia or the Achilles tendon depending on the
irradiation of the painful plantar or dorsal insertion zones.
Apparently, larger treatment portals did not interfere with
the treatment response, but from the standpoint of quality
assurance, portals that are too small should be avoided, and
a standardization of the daily practice and setup of portals
would be mandatory in controlled clinical studies.
Outcome analysis in the context of PCS is an important tool
to set up a national benchmark on treatment outcome, which
should be expected, after RT in a specific disorder (40, 43, 48).
To date, the national PCS on painful HSS has collected the
largest number of cases (7,947 patients from 76 institutions)
ever reported on the use of RT for painful HSS. Nevertheless,
only a minority of the institutions used modern functional
and objective criteria. This strengthens the continuous efforts
of the GCG-BD to establish modern and orthopedic scores in
the daily clinical practice of radiotherapists (77). It would
allow interdisciplinary (e.g., orthopedic and radiotherapeutic)
Table 2. Results of multivariate outcome analysis
Pain history (mo)
First (prior) treatment
RT series (n)
Abbreviations: ESWT ? extracorporeal shock wave therapy;
NS ? not statistically significant (p ? 0.05).
834 I. J. Radiation Oncology ● Biology ● Physics Volume 58, Number 3, 2004
comparisons, interobserver, as well as inter-institutional, com-
parisons, and outcome analysis for painful HSS (39). The
overall subjective treatment results revealed complete pain
relief for ?3 months in 70% of patients and persisting pain
relief in 65% of patients. Only 19% required a second RT
series. These results are very encouraging compared with the
results of conventional treatment (17, 78–80). Our clinical
data were compared with data from a literature review encom-
passing 16 studies with a total of 3472 patients (6, 34, 35, 63,
71–74, 76, 81–87). The response rates (complete and partial)
varied between 67% and 100% (median 80%), in the same
range as our PCS demonstrated. Only a few studies had a
prospective design (6, 35, 74). The studies and outcome data
are summarized in Table 3. Thus, despite large experience,
limited evidence-based outcome data on the use of RT in
painful HSS exist. In addition, the exact radiobiologic mech-
anisms of the effect of ionizing radiation on HSS have been
incompletely investigated and understood (88, 89). However,
cell death and inhibition of proliferation as seen during cancer
treatment are not expected to be involved in the response to
these low doses (90). Older theories described an influence on
the vascular endothelium with improved tissue perfusion; de-
struction of inflammatory cells (especially lymphocytes) with
release of cytokines and proteolytic enzymes; modulation of
the vegetative nervous system; alteration of the tissue pH; and
increased membrane permeability (91–94). Recent studies
showed that effects of low-dose ionizing radiation also exist on
the molecular and cellular level involving adhesion molecules,
apoptosis, cytokine expression, and inflammation cascade (69,
95–103). A new and very interesting hypothesis is the inhibi-
tion of oxidative burst formation in human phagocytic cells
(90, 104). Most likely, radiation acts, not through a single
mechanism, but through a complex interaction of different
effects. As already shown by von Pannewitz (63) in a rabbit
arthritis model in 1933, low-dose RT is able to reduce the
joints. Thesefindings may explain why a longer pain history or
more pretreatment attempts were associated with a worse out-
come. A longer course of disease, which is mostly accompa-
nied by a larger number of unsuccessful treatment attempts,
may lead to morphologic chances that cannot be reversed by
The most important competing treatment option is
ESWT. Recently, encouraging results in HSS were demon-
strated. Pain relief was achieved in up to 80% (24). Similar
to RT, the biologic mechanisms are poorly understood
(105). Moreover, ESWT has not always shown convincing
outcome data in controlled clinical trials (106).
All participating institutions reported no RT-related acute
and chronic side; in particular, no radiation-associated ma-
lignancies were reported with a median follow-up of 28
months and a maximum of 335 months. This confirms other
reports describing or calculating a low carcinogenesis risk
after RT for nonmalignant disorders (107–109). It is not
unexpected that the vast majority of all German radiother-
apists asked in this national survey judged RT for painful
heel spur to be a worthwhile treatment indication.
This PCS comprised the largest number of cases reported of
RT for painful HSS. RT provides an excellent alternative for
patients with refractory pain or contraindications to conven-
tional therapy. Despite some variations of the routine RT
practice, this national PCS presents a very large number of
painful HSS treated effectively by RT. The results of this
Table 3. Overview of literature results of RT for painful heel spurs
von Pannewitz, 1933 (63)
Mitrov and Harbou, 1967 (81)
Zschache, 1972 (82)
Mantell, 1978 (83)
Basche et al., 1980 (84)
Sautter-Bihl et al., 1993 (85)
Scha ¨fer et al., 1995 (73)
Seegenschmiedt et al., 1996 (35)
72 at 12 Gy
98 at 3–5 Gy
Oehler et al., 2000 (86)
Koeppen et al., 2000 (76)
Scheiber et al., 2000 (87)
Heyd et al., 2001 (6)
Glatzel et al., 2001 (34)
Mu ¨cke et al., 2001 (71)
Schlehuber et al., 2001 (72)
Schneider et al., 2002 (74)
HV, MV, OV,60Co
Abbreviations: RT ? radiotherapy; CR ? complete response, complete pain relief, pain free; PR ? partial response, partial pain relief,
substantial improvement; NC ? no change, unchanged pain; OV ? orthovoltage; HV ? high voltage; MV ? megavoltage.
* CR plus PR rates.
835Radiotherapy in painful heel spurs ● O. MICKE et al.
national PCS will lead the GCG-BD to the following tasks: (1)
the standardization of RT practice for painful HSS; (2) the
establishment of validated orthopedic scores, including subjec-
tive and objective criteria in clinical routine and controlled
clinical practice; and (3) the initiation of prospective clinical
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The members of the Patterns of Care Study in Benign
Disease Panel are as follows: M. H. Seegenschmiedt (Chair-
person and Coordinator), Alfried Krupp Krankenhaus, Essen,
Germany; O. Micke (Co-Chairperson and Secretary), Mu ¨nster
University Hospital, Mu ¨nster, Germany; F. Bruns, Hannover
University Hospital, Hannover, Germany; U. Scha ¨fer, Mu ¨nster
University Hospital, Mu ¨nster, Germany; and H.-Br. Makoski,
Staedtische Kliniken, Duisberg, Germany.
838 I. J. Radiation Oncology ● Biology ● PhysicsVolume 58, Number 3, 2004
Questionnaire sent out by German Cooperative Group on
Radiotherapy for Benign Diseases for patterns of care study
on radiotherapy for heel spur syndrome/plantar fasciitis/
839 Radiotherapy in painful heel spurs ● O. MICKE et al.
840I. J. Radiation Oncology ● Biology ● Physics Volume 58, Number 3, 2004
Form to use when determining heel pain score according
to criteria suggested by German Cooperative Group on
Radiotherapy for Benign Diseases.
841Radiotherapy in painful heel spurs ● O. MICKE et al.
842I. J. Radiation Oncology ● Biology ● Physics Volume 58, Number 3, 2004