Botulinum toxin A versus platelet rich plasma ultrasound-guided injection in the treatment of plantar fasciitis: A randomised controlled trial.

BACKGROUND: Platelet-rich plasma (PRP) and botulinum toxin type A (BTX-A) injections have proven effective in clinical trials for plantar fasciitis treatment but have not been directly compared. We aimed to compare clinical outcomes in patients undergoing PRP or BTX-A injections. METHODS: We performed a randomised controlled trial (59 patients; 1-year follow-up) to assess efficacy, using pain and functional scales (VAS, AOFAS Hindfoot-scale and FAAM questionnaire) and fascia thickness reduction, in control and single ultrasound-guided BTX-A or PRP injection groups. RESULTS: The BTX-A group showed better results at 1-month after treatment. Conversely, the PRP injection was more effective in the long-term, with significant pain reduction and functional improvement. Plantar fascia thickness significantly reduced from months 1 and 3 in the PRP and BTX-A groups, respectively. CONCLUSION: PRP and BTX-A injections are effective in patients with plantar fasciitis with BTX-A achieving better short-term pain reduction and PRP better long-term results. LEVEL OF EVIDENCE: Level I; Randomised Controlled Trial.

Comparison of mean pain score of oral non-steroidal anti-inflammatory agents and locally injectable steroid for the treatment of plantar fasciitis.

OBJECTIVE: To compare the efficacy of oral non-steroidal anti-inflammatory drugs with locally injectable steroids in the treatment of plantar fasciitis. METHODS: This comparative study was conducted from 10 May 2013 to 10 December 2013 at the Department of Orthopaedic Surgery, Punjab Medical College/Allied Hospital, Faisalabad, Pakistan, and comprised patients of either gender aged 26-60 years having unilateral plantar fasciitis who were not on any prior treatment and had moderate to severe pain intensity. The patients who received diclofenac sodium 50mg and acetaminophen 500mg twice a day for 4 weeks were assigned as Group-A, and those who received a single of 40mg (1ml) of methylprednisolone combined with 2ml of 0.5% bupivacaine into the tender most point of the inflamed plantar fascia were assigned as group - B. Pain was assessed using visual analogue scale at baseline and after 2 months of regular follow-up. Data was analysed using SPSS 10. RESULTS: Of the 140 patients, there were 70(50%) in each of the two groups. There were 102(72.9%) males and 38(27.1%) females, with an overall mean age of 42.24±9.30 years. While pain intensity decreased in both the groups, it was significant in group B (p=0.0001), but non-significant in group A (p=0.723). CONCLUSIONS: Locally injectable steroid was found to be a better modality for the management of plantar fasciitis in reducing mean pain score and sustained pain relief compared to non-steroidal anti-inflammatory drugs.

Efficacy of Individualized Homeopathic Medicines in Plantar Fasciitis: Double-blind, Randomized, Placebo-Controlled Clinical Trial.

INTRODUCTION: Plantar fasciitis (PF) is a chronic degenerative condition causing marked thickening and fibrosis of the plantar fascia, and collagen necrosis, chondroid metaplasia and calcification. There is little convincing evidence in support of various approaches, including homeopathy, for treating PF. This study was undertaken to examine the efficacy of individualized homeopathic medicines (IHMs) compared with placebo in the treatment of PF. METHODS: A double-blind, randomized, placebo-controlled trial was conducted at the outpatient departments of Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, West Bengal, India. Patients were randomized to receive either IHMs or identical-looking placebo in the mutual context of conservative non-medicinal management. The Foot Function Index (FFI) questionnaire, as an outcome measure, was administered at baseline, and every month, up to 3 months. Group differences (unpaired t-tests) and effect sizes (Cohen's d) were calculated on an intention-to-treat sample. The sample was analyzed statistically after adjusting for baseline differences. RESULTS: The target sample size was 128; however, only 75 could be enrolled (IHMs: 37; Placebo: 38). Attrition rate was 9.3% (IHMs: 4, Placebo: 3). Differences between groups in total FFI% score favored IHMs against placebo at all the time points, with large effect sizes: month 1 (mean difference, -10.0; 95% confidence interval [CI], -15.7 to -4.2; p = 0.001; d = 0.8); month 2 (mean difference, -14.3; 95% CI, -20.4 to -8.2; p <0.001; d = 1.1); and month 3 (mean difference, -23.3; 95% CI, -30.5 to -16.2; p <0.001; d = 1.5). Similar significant results were also observed on three FFI sub-scales (pain%, disability%, and activity limitation%). Natrum muriaticum (n = 14; 18.7%) and Rhus toxicodendron and Ruta graveolens (n = 11 each; 14.7%) were the most frequently prescribed medicines. No harms, serious adverse events, or intercurrent illnesses were recorded in either of the groups. CONCLUSION: IHMs acted significantly better than placebo in the treatment of PF; however, the trial being underpowered, the results should be interpreted as preliminary only. Independent replications are warranted. TRIAL REGISTRATION: CTRI/2018/10/016014.

Cutaneous Mucormycosis After Elective Outpatient Gastrocnemius Recession for Plantar Fasciitis in an Immunocompetent Host: A Case Report.

CASE: A healthy 21-year-old man underwent an elective gastrocnemius recession for plantar fasciitis. At 10 days postoperatively, he developed a severe limb-threatening cutaneous mucormycotic infection that led to multiple debridements and eventual skin grafting. CONCLUSION: Cutaneous mucormycosis is a rare but severe fungal infection. Early recognition, deep surgical biopsy for diagnosis, and aggressive treatment with frequent thorough surgical debridements and antifungal pharmacotherapy are necessary. Although mucormycosis is more frequently seen in the immunocompromised host, it can occur in the immunocompetent patient most commonly after trauma. If not aggressively treated, it can be limb and life threatening.

Platelet-rich plasma has better mid-term clinical results than traditional steroid injection for plantar fasciitis: A systematic review and meta-analysis.

INTRODUCTION: Recently, local platelet-rich plasma (PRP) injection has been gradually used in the treatment of plantar fasciitis (PF). However, compared with traditional steroid injection, the clinical results of local PRP injection for PF patients remain controversial. Therefore, we performed a systematic review to focus on two questions as follows: (1) is PRP more effective than steroid to relieve pain in PF patients? (2) is PRP more effective than steroid to improve the foot and ankle function of PF patients? HYPOTHESIS: The PRP could be more effective to relieve pain and improve the foot and ankle function in PF patients. MATERIAL AND METHODS: We systematically searched electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Web of Science, and Embase) from inception to October 20, 2019. The data of clinical results, including visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) scores, were extracted and analyzed. RESULTS: Finally, twelve randomized controlled trials (RCT), involving 653 PF patients, were enrolled. All enrolled trials were considered to be of high quality. The results showed that the VAS of the PRP group was significantly lower than that of the steroid group at 6-month (p=0.02), 1-year (p=0.02), and 1.5-year (p<0.00001) follow-up. The AOFAS scores of the PRP group were significantly higher than that of the steroid group at 1-year (p=0.005) follow-up. DISCUSSION: Compared to local steroid injection, local autologous PRP injection is more effective in relieving pain and improving the foot and ankle function at mid-term follow-up. LEVEL OF EVIDENCE: II; Systematic review and Meta-analysis.

Outcomes of platelet-rich plasma for plantar fasciopathy: a best-evidence synthesis.

BACKGROUND: Plantar fasciopathy (PF) is a very common disease, affecting about 1/10 people in their lifetime. Platelet-rich plasma (PRP) had been demonstrated to be useful in achieving helpful effects for plantar fasciopathy. The purpose of this study was to compare the pain and functional outcomes between PRP and corticosteroid (CS) or placebo for plantar fasciopathy through meta-analysis and provide the best evidence. METHODS: Literature was searched systematically to explore related studies that were published in Cochrane Library, PubMed, Embase, Medline, SpringerLink, OVID, and ClinicalTrials.gov . Articles regarding comparative research about the outcomes of PRP therapy and CS or placebo injection were selected. Data of pain and functional outcomes was extracted and imported into Reviewer Manager 5.3 to analyze. RESULTS: Thirteen RCTs were included and analyzed. Analysis results showed significant superiority of PRP in outcome scores when compared with CS (VAS: MD = - 0.85, P < 0.0001, I2 = 85%; AOFAS: MD = 10.05, P < 0.0001, I2 = 85%), whereas there is no statistical difference in well-designed double-blind trials (VAS: MD = 0.15, P = 0.72, I2 = 1%; AOFAS: MD = 2.71, P = 0.17, I2 = 0%). In the comparison of the PRP and the placebo, the pooled mean difference was - 3.76 (P < 0.0001, 95% CI = - 4.34 to - 3.18). CONCLUSIONS: No superiority of PRP had been found in well-designed double-blind studies, whereas it is implied that the outcomes of PRP are better than placebo based on available evidence.

Comparing effectiveness of polydeoxyribonucleotide injection and corticosteroid injection in plantar fasciitis treatment: A prospective randomized clinical study.

BACKGROUND: This study aimed to compare the efficacy and safety of polydeoxyribonucleotide (PDRN) injection and corticosteroid injection for plantar fasciitis. METHODS: This study included 44 patients with plantar fasciitis, randomly allocated to the PDRN and corticosteroid groups. Evaluation using the visual analogue scale (VAS) pain score and Manchester-Oxford foot questionnaire (MOXFQ) was conducted at baseline, 1, 2, 6weeks and 6months. The thickness and echogenicity of the plantar fascia in ultrasonography and complications were recorded. RESULTS: Corticosteroid injection elicited more pain relief than did PDRN injection at 2 (p=0.010) and 6weeks (p=0.016); however, it showed no superiority at 6months (p=0.523). MOXFQ showed similar outcomes. The thickness and echogenicity did not differ between groups and no complications were reported in either group. CONCLUSIONS: We demonstrated that PDRN injection could be an effective and safe option for plantar fasciitis and was comparable to corticosteroid injection after 6months follow up. LEVEL OF EVIDENCE: II, comparative study.

Neural therapy of an athlete's chronic plantar fasciitis: a case report and review of the literature.

BACKGROUND: The focus of this case report is on the role of inflammation as a contributor to pain in plantar fasciitis and its cure by the injection of local anesthetics. CASE PRESENTATION: This is a case report on a 24-year-old white man, a middle-distance runner, with chronic unilateral plantar fasciitis and perceived heel pain for almost 1.5 years. He was treated with neural therapy (that is, injection of < 1 ml procaine 1% which is a local anesthetic with strong anti-inflammatory properties) of the surgical scar and along the surgical puncture channel. The follow-up period from the time of first presentation until publication was 2.5 years. At admission, pain intensity (visual analog scale) in the affected leg was severe (10 cm, visual analog scale; range 0-10 cm) when walking and moderate (5 cm, visual analog scale) when standing. After the first session of injections he could stand pain-free and pain when walking was markedly reduced (- 90%). After the third session, he reported no pain in the affected leg and could return to sports at his former level (no difference in training load compared to non-injured state). There was no recurrence of inflammatory signs or heel pain despite intense athletics training up to the date of publication. CONCLUSIONS: In prolonged cases of plantar fasciitis, inflammation is an important component in the development of persistent pain. The results of our case describe the effects of three neural therapy sessions that abolished inflammation and associated heel pain. Neural therapy might be an effective and time-efficient approach in the treatment of plantar fasciitis, enabling an early return to sports.

Short-term efficacy and safety of hyaluronic acid injection for plantar fasciopathy.

PURPOSE: Plantar fasciopathy is the most common cause of plantar heel pain and is considered to be a type of enthesopathy. The short-term efficacy, safety, and dose-response relationship of high-molecular-weight hyaluronic acid (HA) was investigated in patients with plantar fasciopathy. METHODS: In this multicenter, prospective, randomized, double-blind, placebo-controlled trial, 168 patients with persistent pain from plantar fasciopathy for more than 12 weeks were randomly assigned to receive 2.5 mL of 1% HA (H-HA), 0.8 mL of 1% HA (L-HA), or 2.5 mL of 0.01% HA (control group) once a week for 5 weeks. The primary endpoint was improvement in visual analogue scale (VAS) score for pain from baseline to week 5. RESULTS: The VAS scores (least squares mean ± standard error) in each group decreased gradually after the start of treatment, a change of -3.3 ± 0.3 cm for the H-HA group, -2.6 ± 0.3 cm for the L-HA group, and -2.4 ± 0.3 cm for the control group, with the H-HA group improving significantly more than the control group (P = 0.029). No serious adverse events were reported. There was no difference between the groups in the incidence rates of adverse drug reactions. CONCLUSION: The administration of five injections of high-molecular-weight HA is an effective treatment with no serious adverse drug reactions and is a conservative treatment option for plantar fasciopathy. This treatment contributed to alleviation of pain in patients with plantar fasciopathy and improvement in their activities of daily living. LEVEL OF EVIDENCE: I.

Mycobacterium abscessus Osteomyelitis of the Calcaneus Presenting as Tumor-Mimicking Lesions: A Case Report.

CASE: We present the case of a 51-year-old immunocompetent man with refractory heel pain who initially had been treated for plantar fasciitis. However, the pain was proven to be caused by a Mycobacterium abscessus infection of the calcaneus. The process of diagnosis and treatment is described. CONCLUSION: Although rare, chronic heel pain can be caused by an atypical mycobacterial infection of the calcaneus. Because of its indolent clinical course, misdiagnosis is not uncommon with calcaneal osteomyelitis. Physicians should note that this rare infection should be considered in patients with refractory heel pain.

Shall We Inject Superficial or Deep to the Plantar Fascia? An Ultrasound Study of the Treatment of Chronic Plantar Fasciitis.

We compared the effectiveness of ultrasound (US)-guided corticosteroid, injected superficial or deep to the fascia, in patients with plantar fasciitis. Thirty patients (24 females [75%] and 6 males [25%]) with unilateral chronic plantar fasciitis were divided into 2 groups according to the corticosteroid injection site: superficial (n = 15) or deep (n = 15) to the plantar fascia. Patient heel pain was measured using a Likert pain scale and the Foot Ankle Outcome Scale (FAOS) for foot disability, evaluated at baseline and repeated in the first and sixth weeks. The plantar fascia and heel pad thicknesses were assessed on US scans at baseline and the sixth week. The groups were similar in age, gender, and body mass index (p > .05 for all). Compared with the baseline values, the Likert pain scale (p < .001 for all) and FAOS subscale (p < .01 for all) scores had improved at the first and sixth week follow-up visits in both groups. Although the plantar fascia thickness had decreased significantly in both groups at the sixth week (p < .001 for both), the heel pad thickness remained unchanged (p > .05 for both). The difference in the FAOS subscales (pain, p = .002; activities of daily living, p = .003; sports/recreational activities, p = .008; quality of life, p = .009) and plantar fascia thickness (p = .049) showed better improvement in the deep than in the superficial injection group. US-guided corticosteroid injections are safe and effective in the short-term therapeutic outcome of chronic plantar fasciitis. Additionally, injection of corticosteroid deep to the fascia might result in greater reduction in plantar fascia thickness, pain, and disability and improved foot-related quality of life.

Sonoelastography in the Evaluation of Plantar Fasciitis Treatment: 3-Month Follow-Up After Collagen Injection.

OBJECTIVE: The aim of this study was to investigate whether ultrasound elastography can demonstrate the outcome of the treatment in comparison with gray-scale imaging. METHODS: Sixteen patients (mean age, 46.9 years) with plantar fasciitis were prospectively enrolled after unsuccessful conservative treatment. Individuals graded their heel pain on a 100-mm visual analogue scale (VAS) and underwent gray-scale ultrasonography and sonoelastography. Collagen was injected in the heels. Fascial thickness and hypoechogenicity, perifascial edema, and plantar fascial elasticity were evaluated. Follow-up sonoelastography and VAS grading were done 3 months after the injection. Statistical analyses were performed by the paired t test and the Fisher exact test. A P < 0.05 was considered statistically significant. RESULTS: Mean plantar fascial thickness showed insignificant decrease on follow-up (from 4.30 [1.37] to 4.23 [1.15] mm, P = 0.662). Fascial hypoechogenicity and perifascial edema did not change significantly after treatment. The mean strain ratio of the plantar fascia was significantly increased (from 0.71 [0.24] to 1.66 [0.72], P = 0.001). Softening of the plantar fascia decreased significantly after injection (from 12 to 3 ft, P = 0.004). Twelve (75%) of 16 patients showed significant VAS improvement at the follow-up. CONCLUSIONS: Sonoelastography revealed a hardening of the plantar fascia after collagen injection treatment and could aid in monitoring the improvement of the symptoms of plantar fasciitis, in cases where gray-scale imaging is inconclusive.

Long-Term Outcome of Open Plantar Fascia Release.

BACKGROUND: Plantar fasciitis is thought to be a self-limiting condition best treated by conservative measures, but despite this many patients have a prolonged duration of symptoms and surgery may be indicated. Partial plantar fascial release is reported to have a short-term success rate of up to 80%, but anecdotally this was not thought to represent our local experience. METHODS: An audit of long-term patient-reported outcomes following open partial plantar fascia release was performed. A total of 30 patients (33 feet) were identified over a 10-year period and case notes were reviewed. Patients were contacted by letter and invited to complete 2 validated patient-reported outcome score questionnaires (Visual Analog Scale-Foot and Ankle [VAS-FA] and Manchester Oxford Foot Questionnaire [MOXFQ]). Responses were received from 24 patients (26 feet). The average ages were 42.4 (range 24-61) for male and 46.2 (range 33-60) for female patients, with a female/male ratio of 2.7:1. The average duration of treatment prior to operative intervention was 3.1 years (range 1-5). Preoperatively, our cohort underwent a range of conservative measures. All patients were reviewed postoperatively, and average time from surgery to completion of questionnaires was 80 months (range 14-130). RESULTS: The outcomes were worse in patients who had received preoperative steroid injections and this was found to be statistically significant. The mean MOXFQ score was 33.6 ± 3.9 (0-64). Mean VAS-FA score was 57.8 ± 4.9 (24-100). CONCLUSION: This study found a negative correlation between duration of follow-up and outcome, in both MOXFQ and VAS-FA, showing that patients continued to improve many years postoperatively. The authors also found worse outcomes with preoperative steroid injections, better outcomes in older patients, and a weak gender bias, suggesting results in men were better than those in women. A prolonged recovery period and generally poor outcomes leads the authors to suggest that open plantar fascia release is of questionable clinical value and that patients may improve in the natural course of the disease, in spite of surgery. LEVEL OF EVIDENCE: Level III, comparative study.

Prospective Randomized Comparison of the Effectiveness of Radiation Therapy and Local Steroid Injection for the Treatment of Plantar Fasciitis.

PURPOSE: The purpose of this study was to conduct a randomized trial of radiation therapy for plantar fasciitis and to compare radiation therapy with local steroid injections. METHODS AND MATERIALS: Between March 2013 and April 2014, 128 patients with plantar fasciitis were randomized to receive radiation therapy (total dose of 6.0 Gy applied in 6 fractions of 1.0 Gy three times a week) or local corticosteroid injections a 1 ml injection of 40 mg methylprednisolone and 0.5 ml 1% lidocaine under the guidance of palpation. The results were measured using a visual analog scale, a modified von Pannewitz scale, and a 5-level function score. The fundamental phase of the study was 3 months, with a follow-up period of up to 6 months. RESULTS: The median follow-up period for all patients was 12.5 months (range, 6.5-18.6 months). For the radiation therapy patients, the median follow-up period was 13 months (range, 6.5-18.5 months), whereas in the palpation-guided (PG) steroid injection arm, it was 12.1 months (range, 6.5-18.6 months). After 3 months, results in the radiation therapy arm were significantly superior to those in the PG steroid injection arm (visual analog scale, P<.001; modified von Pannewitz scale, P<.001; 5-level function score, P<.001). Requirements for a second treatment did not significantly differ between the 2 groups, but the time interval for the second treatment was significantly shorter in the PG steroid injection group (P=.045). CONCLUSION: This study confirms the superior analgesic effect of radiation therapy compared to mean PG steroid injection on plantar fasciitis for at least 6 months after treatment.

Targeting the Plantar Fascia for Corticosteroid Injection.

Plantar fasciitis is often a difficult condition to treat. It is related to repetitive strain of the fascia at its attachment to the heel bone. This condition quite often appears with the concomitant presence of a plantar calcaneal heel spur. Corticosteroid injection is a popular treatment choice for plantar fasciitis, and accurate localization of the injected medication is essential for successful resolution of symptoms after the injection. In the present brief technical communication, a method for targeting the attachment of the plantar fascia to the medial tubercle of the tuberosity of the calcaneus is described. The targeting method uses the lateral radiograph of the foot to aid in localization of the proximal attachment of the plantar fascia to the calcaneus.

Acute Compartment Syndrome of the Foot due to Infection After Local Hydrocortisone Injection: A Case Report.

High-energy trauma associated with calcaneal fracture or Lisfranc fracture dislocation and midfoot crushing injuries are known causes of compartment syndrome in the foot. Suppurative infection in the deep osseofascial compartments can also cause compartment syndrome. We describe the case of a 29-year-old female who had developed a suppurative local infection that resulted in acute compartment syndrome after receiving a local hydrocortisone injection for plantar fasciitis. We diagnosed the compartment syndrome, and fasciotomy was promptly undertaken. After more than 2 years of follow-up, she had a satisfactory functional outcome without substantial morbidity. To our knowledge, no other report in the English-language studies has described compartment syndrome due to abscess formation after a local injection of hydrocortisone. The aim of our report was to highlight this rare, but serious, complication of a routine outpatient clinical procedure.

Plantar fascia calcification a sequelae of corticosteroid injection in the treatment of recalcitrant plantar fasciitis.

We report the case of a 72-year-old woman suffering with severe plantar fasciitis who received a therapeutic corticosteroid injection. Two-and-a-half years after the injection she developed a small calcified lump under the skin which subsequently caused ulceration and infection. She went on to develop a diabetic foot infection requiring an extended course of intravenous antibiotics.

The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis.

INTRODUCTION: In this study, the results of local injection of platelet-rich plasma (PRP) and corticosteroids in the treatment of plantar fasciitis were compared. PATIENTS AND METHODS: Sixty patients who were diagnosed as plantar fasciitis and treated conservatively for at least 3 months and had no response to conservative treatment modalities were involved in this study. The first 30 consecutive patients were treated by local injection of 2 mL of 40 mg Methylprednisolone with 2 mL of 2% prilocaine (metilprednizalone) and the second 30 patients were treated by injecting 3 mL PRP after 2 mL of 2% prilocaine injection. Patients were evaluated according to the modified criteria of the Roles and Maudsley scores and visual analog scale before injection and 3 weeks and 6 months following injection. RESULTS: The mean VAS heel pain scores measured 6 months after treatment were 3.4 in steroid group and 3.93 in PRP group, and the scores in both groups were significantly lower when compared with pretreatment levels (6.2 in steroid group and 7.33 in PRP group). There was no significant difference between steroid and PRP groups in visual analog scale scores and modified criteria of the Roles and Maudsley scores measured at 3 weeks and 6 months (P > 0.05). CONCLUSION: Our results revealed that both methods were effective and successful in treating plantar fasciitis. When the potential complication of corticosteroid treatment was taken into consideration, PRP injection seems to be safer and at least having same effectivity in the treatment of plantar fasciitis.