Effect of radial shock wave and ultrasound therapy combined with traditional physical therapy exercises on foot function and dorsiflexion range in plantar fasciitis: a prospective randomized clinical trial.

OBJECTIVE: This study aimed to assess the effect of radial shock wave and ultrasound therapy combined with traditional physical therapy on foot function and range of motion in chronic plantar fasciitis. PATIENTS AND METHODS: Sixty-nine participants with chronic plantar fasciitis (25-56 years) were allocated randomly into three groups. Group (A) received ultrasound (US) therapy plus conventional physical therapy exercises (in the form of stretching, strengthening exercise, and deep friction massage), Group (B) received a radial shock wave (RSW) therapy plus conventional physical therapy exercises, and Group (C) received a combination of both RSW and US therapy in addition to conventional physical therapy exercises, with 3 sessions per week for US therapy and one session for RSW therapy, in addition to 45 minutes of exercises for all groups for 4 consecutive weeks. Foot function was assessed using the foot function index (FFI), and ankle dorsiflexion range of motion was measured using the Baseline® bubble inclinometer at baseline and 4 weeks following treatment. RESULTS: ANOVA revealed significant differences (p<0.05) in the measured outcomes among the groups after treatment. Tukey's honest significant difference post-hoc test demonstrated a highly statistically significant (p<0.001) improvement in the assessed outcomes of group C in the post-intervention settings when compared to the other groups. After 4 weeks of intervention, the mean (SD) of FFI in groups A, B, and C were (64.54±4.91, 61.93±4.17, and 45.16±4.57) respectively, and the active range of motion (ROM) of the ankle dorsiflexion were (35.27±3.22, 36.59±2.91, and 41.85±3.04) respectively. CONCLUSIONS: The addition of RSW to US with the conventional physical therapy program improved foot function and ankle dorsiflexion range of motion significantly for patients with chronic plantar fasciitis.

Ultrasound-Guided Injection of Dextrose Versus Corticosteroid in Chronic Plantar Fasciitis Management: A Randomized, Double-Blind Clinical Trial.

DESIGN: Chronic plantar fasciitis (PF) is a common cause of chronic heel pain, with different conventional treatment options. In this randomized clinical trial, the effect of ultrasound-guided injection of dextrose versus corticosteroid in chronic PF was evaluated and compared. METHODS: A total of 44 patients suffering from chronic PF who visited the physical medicine and rehabilitation clinic were enrolled in the study. Two table-randomized groups were formed. They received an ultrasonography-guided, single injection of either 40 mg methylprednisolone or 20% dextrose. Numeric Rating Scale (NRS), Foot and Ankle Ability Measure questionnaire with 2 subscales, Activities of Daily Living (FAAM-A) and Sports (FAAM-S), along with ultrasonographic parameters were evaluated before and at 2 and 12 weeks after the injection. Results. A total of 40 participants completed the study. Both interventions significantly improved pain and function at 2 and 12 weeks postinjection. After 2 weeks, compared with the dextrose prolotherapy, the corticosteroid group had significantly lower daytime and morning NRS scores (2.55 vs 4.1, P = .012, and 2.75 vs 4.65, P = .004), higher FAAM-S (66.84 vs 54.19; P = .047), and lower plantar fascia thickness at insertion and 1 cm distal to the insertion zone (3.89 vs 4.29 mm, P = .004, and 3.13 vs 3.48 mm, P = .002), whereas FAAM-A was similar in both groups (P = .219). After 12 weeks, all study variables were statistically similar between corticosteroid and dextrose prolotherapy groups. No injection-related side effects were recorded in either group. CONCLUSION: Both methods are effective. Compared with dextrose prolotherapy, our results show that corticosteroid injection may have superior therapeutic effects early after injection, accompanied by a similar outcome at 12 weeks postinjection. LEVELS OF EVIDENCE: Level II.

Effects of dry needling and stretching exercise versus stretching exercise only on pain intensity, function, and sonographic characteristics of plantar fascia in the subjects with plantar fasciitis: a parallel single-blinded randomized controlled trial.

OBJECTIVES: Plantar fasciitis is a common problem in the foot region which has negative considerable impact on foot function. METHODS: In this parallel blinded randomized controlled trial, a total of thirty-seven subjects with plantar fasciitis (forty feet) were enrolled randomly to either the control group (stretching exercise) or the experimental group (stretching exercise plus dry needling). All interventions lasted six weeks and both groups were followed for two weeks. Primary outcomes were first step pain, pain, and activity daily function subscales of the FAOS questionnaire and secondary outcomes were plantar fascia thickness, and echogenicity. RESULTS: The mixed model ANOVAs showed significant group × time interactions for all primary outcomes. In both groups, first step pain and both subscales of the FAOS questionnaire were improved compared to baseline measurements. There were considerable differences between the two groups and the experimental group experienced more improvements in primary outcomes compared to the control group. For secondary outcomes, plantar fascia thickness at insertion significantly decreased, and the echogenicity in the two regions significantly increased in the experimental group compared to the control group. CONCLUSION: These results suggest that the combination of dry needling and stretching exercises can be an effective conservative treatment for plantar fasciitis subjects.

Comparison of Ultrasound-Guided Prolotherapy Versus Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis: A Randomized Clinical Trial.

This study aimed to compare the effectiveness of extracorporeal shockwave therapy (ESWT) versus dextrose prolotherapy on pain and foot functions in patients with chronic plantar fasciitis with a prospective randomized-controlled trial. A total of 29 patients in whom conservative care failed were enrolled for the study after the clinical and ultrasonographic assessment. The patients were randomly assigned to receive ESWT (ESWT group, n = 15) or dextrose prolotherapy (dextrose prolotherapy group, n = 14). ESWT group received 1800 to 2000 focused shock waves (session of 0.20-0.30 mJ/mm2 with a frequency of 4-6 Hz) followed by soft tissue 3000 to 3500 radial pulses (session of 1.8-3.0 bar with a frequency of 15-21 Hz). Dextrose prolotherapy group underwent an injection of 5 ml 15% dextrose solution with 2% lidocaine. ESWT and dextrose prolotherapy were repeated 3 times by 2 weeks apart. A 100-mm Visual Analog Scale (VAS) for overall and morning pain, Foot Function Index (FFI) and the Roles and Maudsley Scale score (RMS) were assessed at baseline, 6 weeks, and 12 weeks after the last intervention. Overall VAS, Morning VAS, RMS and FFI scores improved significantly in both treatment groups at 6 weeks and 12 weeks compared to baseline (p < .001). Comparison of changes in overall VAS, Morning VAS, RMS and FFI scores did not show a significant difference between the groups at each time point (p > .05) In our study dextrose prolotherapy and ESWT had similar effectiveness in patients with chronic plantar fasciitis who have not respond to conservative care. The results showed ESWT and dextrose prolotherapy were not superior to each other.

Dextrose prolotherapy versus radial extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: A randomized, controlled clinical trial.

In the recent years, prolotherapy is increasingly being used in the field of musculoskeletal medicine. However, few studies have investigated its effectiveness in plantar fasciitis (PF). The purpose of this study was to compare the effectiveness of ultrasound-guided dextrose prolotherapy with radial extracorporeal shock wave therapy (ESWT) in the treatment of chronic PF. This randomized controlled trial was conducted on 59 patients with chronic PF. Patients were randomly assigned into two groups receiving three sessions of radial ESWT (29 patients) vs. two sessions of ultrasound-guided intrafascial 2 cc dextrose 20% injection (30 patients). The following outcome measures were assessed before and then six weeks and 12 weeks after the treatments: pain intensity by visual analog scale (VAS), daily life and exercise activities by Foot and Ankle Ability Measure (FAAM), and the plantar fascia thickness by ultrasonographic imaging. The VAS and FAAM scales showed significant improvements of pain and function in both study groups 6 weeks and 12 weeks after the treatments. A significant reduction was noted for plantar fascia thickness at these intervals (all p < .05). The inter-group comparison revealed that except for the FAAM-sport subscale which favored ESWT, the interaction effects of group and time were not significant for other outcome measures. Dextrose prolotherapy has comparable efficacy to radial ESWT in reducing pain, daily-life functional limitation, and plantar fascia thickness in patients with PF. No serious adverse effects were observed in either group. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Similar effect of ultrasound-guided platelet-rich plasma versus platelet-poor plasma injections for chronic plantar fasciitis.

BACKGROUND: There are conflicting reports regarding the therapeutic effect of platelet-rich plasma (PRP) versus autologous whole-blood (platelet poor plasma, PPP) injections for plantar fasciitis. Therefore, this study was conducted to compare the effectiveness of a single ultrasound (US)-guided PRP versus PPP injection in patients with chronic plantar fasciitis. MATERIALS AND METHODS: 36 patients were recruited with clinical and sonographic evidence of chronic (>6 months) plantar fasciitis, refractory to analgesics and physical therapy in a double-blinded, randomized, prospective study. The patients were randomly allocated into two groups with a sealed envelope method. Group A included 18 patients who underwent a single US-guided PRP injection and group B included another 18 patients who underwent PPP injection with the same technique. Follow-up was set at 3 and 6 months; no patient was lost to follow-up. Pain, function and satisfaction were assessed using visual analogue scales, and occurrence of complications. RESULTS: All scores statistically significantly improved for both groups from baseline at the 3- and 6-month follow-up evaluation, without, however, any statistically significant differences between the two groups with respect to pain, function and satisfaction scores. Complications were not observed. CONCLUSIONS: A single US-guided PRP injection yields similar results with PPP injection in patients with chronic plantar fasciitis. Both treatments provide significant improvement at 3 and 6-month follow-up after the injection.

Magnetic Resonance Imaging and Clinical Outcomes of Laser Therapy, Ultrasound Therapy, and Extracorporeal Shock Wave Therapy for Treatment of Plantar Fasciitis: A Randomized Controlled Trial.

We determined and compared the effectiveness of low-level laser therapy (LLLT), therapeutic ultrasound (US) therapy, and extracorporeal shock wave therapy (ESWT) using magnetic resonance imaging (MRI). We performed a randomized, prospective, comparative clinical study. A total of 60 patients with a diagnosis of chronic plantar fasciitis were divided randomly into 3 treatment groups: group 1 underwent 15 sessions of LLLT (8 J/cm2; 830 nm); group 2 underwent 15 sessions of continuous US (1 mHz; 2 W/cm2); and group 3 underwent 3 sessions of ESWT (2000 shocks). All patients were assessed using the visual analog scale (VAS), heel tenderness index (HTI), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, Roles-Maudsley score, and MRI before and 1 month after treatment. The primary efficacy success criterion was the percentage of decrease in heel pain of >60% from baseline at 1 month after treatment for ≥2 of the 3 heel pain (VAS) measurements. Significant improvement was measured using the mean VAS, AOFAS scale, and HTI scores for all 3 groups. The thickness of the plantar fascia had decreased significantly on MRI in all 3 groups. The treatment success rate was 70.6% in the LLLT group, 65% in the ESWT group, and 23.5% in the US group. LLLT and ESWT proved significantly superior to US therapy using the primary efficacy criterion (p = .006 and p = .012, respectively), with no significant difference between the LLLT and ESWT groups (p > .05). The treatment of chronic plantar fasciitis with LLLT and ESWT resulted in similar outcomes and both were more successful than US therapy in pain improvement and functional outcomes.

Low-Level Laser Therapy at 635 nm for Treatment of Chronic Plantar Fasciitis: A Placebo-Controlled, Randomized Study.

Plantar fasciitis affects nearly 1 million persons in the United States at any one time. Conservative therapies have been reported to successfully treat 90% of plantar fasciitis cases; however, for the remaining cases, only invasive therapeutic solutions remain. This investigation studied newly emerging technology, low-level laser therapy. From September 2011 to June 2013, 69 subjects were enrolled in a placebo-controlled, randomized, double-blind, multicenter study that evaluated the clinical utility of low-level laser therapy for the treatment of unilateral chronic fasciitis. The volunteer participants were treated twice a week for 3 weeks for a total of 6 treatments and were evaluated at 5 separate time points: before the procedure and at weeks 1, 2, 3, 6, and 8. The pain rating was recorded using a visual analog scale, with 0 representing "no pain" and 100 representing "worst pain." Additionally, Doppler ultrasonography was performed on the plantar fascia to measure the fascial thickness before and after treatment. Study participants also completed the Foot Function Index. At the final follow-up visit, the group participants demonstrated a mean improvement in heel pain with a visual analog scale score of 29.6 ± 24.9 compared with the placebo subjects, who reported a mean improvement of 5.4 ± 16.0, a statistically significant difference (p < .001). Although additional studies are warranted, these data have demonstrated that low-level laser therapy is a promising treatment of plantar fasciitis.

Autologous platelet-rich plasma versus dextrose prolotherapy for the treatment of chronic recalcitrant plantar fasciitis.

OBJECTIVE: To determine the efficacy of autologous platelet-rich plasma (PRP) compared with dextrose prolotherapy (DP) in patients with chronic recalcitrant plantar fasciitis (PF) DESIGN: A single-blinded, randomized, controlled study. SETTING: Department of Physical Medicine and Rehabilitation of a university hospital. PARTICIPANTS: Twenty-one patients with a clinical diagnosis of chronic PF confirmed by diagnostic ultrasound (plantar fascia thickness >4 mm) were randomly assigned to the PRP group (n = 10) or the DP group (n = 11). INTERVENTIONS: Each patient received 2 injections into the plantar fascia through a peppering technique under ultrasound guidance at an interval of 2 weeks, either with 2 mL of autologous PRP or 2 mL of 15% dextrose/lidocaine solution. MAIN OUTCOME MEASUREMENTS: The outcome measures included the pain, disability, and activity limitation subscales, measured by means of the Foot Functional Index. Data were collected before the first injection, at 2 weeks (before the second injection), and at the 2- and 6-month follow-ups. RESULTS: All patients completed the follow-ups, with the exception of 1 patient in the PRP group. The mean Foot Functional Index total and subcategory score improvements were greater in the PRP group compared with the DP group (improvement with PRP vs DP, total: 30.4% vs 15.1%, pain: 29.7% vs 17.1%, disability: 26.6% vs 14.5%, activity limitation: 28.0% vs 12.4%). However, no statistically significant difference was noted at any follow-up. In the pain and disability subcategories, both groups showed significant improvements at the last re-evaluation. The PRP group also showed significant improvements in the disability and activity limitation subscales at the second re-evaluation. CONCLUSIONS: Each treatment seems to be effective for chronic recalcitrant PF, expanding the treatment options for patients in whom conservative care has failed. PRP treatment also may lead to a better initial improvement in function compared with DP treatment.

Ultrasonographic evaluation of plantar fasciitis after low-level laser therapy: results of a double-blind, randomized, placebo-controlled trial.

The aim of this study was to investigate the effect of low-level laser therapy (LLLT) on plantar fasciitis documented by the ultrasonographic appearance of the aponeurosis and by patients' pain scores. Thirty individuals with diagnosis of unilateral plantar fasciitis were enrolled in a randomized, double-blind, placebo-controlled trial, but 25 participants completed the therapeutic protocol. The contralateral asymptomatic fascia was used as control. After enrolment, symptomatic individuals were randomly assigned to receive LLLT, or identical placebo, for 6 weeks. Ultrasonography was performed at baseline and after completion of therapy. The subjective subcalcaneal pain was recorded at baseline and after treatment on a visual analogue scale (VAS). After LLLT, plantar fascia thickness in both groups showed significant change over the experimental period and there was a difference (before treatment and after treatment) in plantar fascia thickness between the two groups. However, plantar fascia thickness was insignificant (mean 3.627 +/- 0.977 mm) when compared with that in the placebo group (mean 4.380 +/- 1.0042 mm). Pain estimation on the visual analogue scale had improved significantly in all test situations (after night rest, daily activities) after LLLT when compared with that of the placebo group. (P=0.006 and P=0.01, respectively). Additionally, when the difference in pain scores was compared between the two groups, the change was statistically significant (after night rest P=0.000; daily activities P=0.001). In summary, while ultrasound imaging is able to depict the morphologic changes related to plantar fasciitis, 904 nm gallium-arsenide (GaAs) infrared laser may contribute to healing and pain reduction in plantar fasciitis.

Extracorporeal shock wave therapy in the treatment of chronic tendinopathies.

Many clinical trials have evaluated the use of extracorporeal shock wave therapy for treating patients with chronic tendinosis of the supraspinatus, lateral epicondylitis, and plantar fasciitis. Although extracorporeal shock wave therapy has been reported to be effective in some trials, in others it was no more effective than placebo. The multiple variables associated with this therapy, such as the amount of energy delivered, the method of focusing the shock waves, frequency and timing of delivery, and whether or not anesthetics are used, makes comparing clinical trials difficult. Calcific tendinosis of the supraspinatus and plantar fasciitis have been successfully managed with extracorporeal shock wave therapy when nonsurgical management has failed. Results have been mixed in the management of lateral epicondylitis, however, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. Extracorporeal shock wave therapy has consistently been more effective with patient feedback, which enables directing the shock waves to the most painful area (clinical focusing), rather than with anatomic or image-guided focusing, which are used to direct the shock wave to an anatomic landmark or structure.