Physical Examination Variables Predict Response to Conservative Treatment of Nonchronic Plantar Fasciitis: Secondary Analysis of a Randomized, Placebo-Controlled Footwear Study

Ultrasonography-Guided Dextrose Prolotherapy Versus Platelet-Rich Plasma Injections for the Treatment of Plantar Fasciitis: A Randomized Controlled Trial

INTRODUCTION

Heel pain is prevalent in foot and ankle practice, with plantar fasciitis being a common cause of chronic heel pain in adults. It is a degenerative condition of the plantar fascia, rendering the term fasciitis inaccurate. The condition has several alternative names, including painful heel syndrome and heel spur syndrome. It is found that a significant number of people suffer from plantar fasciitis at some stage of their lives; athletes and women between 40 and 60 years and adults aged more than 65 suffer the most. Patients typically report tenderness at the medial aspect of the heel, and pain is mostly under the surface of the heel, especially with initial morning steps. Plantar fasciitis is predominantly unilateral. Treatment options include prolotherapy and platelet-rich plasma (PRP), with this randomized controlled trial (RCT) aiming to evaluate the efficacy of PRP versus 25% dextrose prolotherapy in alleviating plantar fasciitis symptoms.

AIMS AND OBJECTIVES

This study aimed to assess the comparative effectiveness of USG-guided 25% dextrose prolotherapy and autologous PRP injections on pain intensity, foot function, and ankle outcomes in plantar fasciitis cases.

METHODOLOGY

The study took place at the Department of Physical Medicine and Rehabilitation (PMR), King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India, with eligible patients evaluated. Group A received 25% dextrose prolotherapy, while Group B was administered autologous platelet-rich plasma. Outcome measures, including pain by Pain Intensity Scale (PIS) and assessment of disability by Foot Function Index (FFI) and Foot and Ankle Outcome Score (FAOS), were assessed at baseline and the third and sixth weeks after intervention.

RESULTS

A total of 44 patients were randomized into two groups of 22. Group A received dextrose prolotherapy, while Group B was treated with PRP injections as per the study protocol. The average age of participants in our study was 36.10±10.0 years. Female participants were more affected than male participants in both groups. Overall, the male-female ratio was 38.6:61.4, while in Group A and Group B, this ratio was 45.5:54.5 and 31.8:68.2, respectively. The presentation of plantar fasciitis was bilateral (40.9%), on the right side (40.9%), and on the left side (18.2%). The right side was more frequently involved than the left side of the plantar fascia. There was a decrease in the average PIS score of Groups A and B at the baseline, which was 7.27±1.24 and 7.55±1.26, respectively, which was reduced to 3.18±1.30 and 2.50±0.67 after six weeks of follow-up. The average FFI score of Groups A and B at the baseline was 98.64±17.68 and 95.36±19.01, respectively, which was reduced to 79.77±12.77 and 63.77±18.50 after six weeks of follow-up. The average FAOS score of Groups A and B at the baseline was 71.36±13.95 and 74.86±28.72, respectively, which was reduced to 74.86±28.72 and 42.09±5.03 after six weeks of follow-up.

CONCLUSION

Both 25% dextrose prolotherapy and PRP injections are effective treatments for plantar fasciitis. Both are minimally invasive and safe treatments for plantar fasciitis.

Effects of radial extracorporeal shockwave therapy versus high intensity laser therapy in individuals with plantar fasciitis: A randomised clinical trial

This study aimed to compare the effects of radial extracorporeal shockwave therapy (rESWT) to the effects of high-intensity laser therapy (HILT) in the treatment of individuals with plantar fasciitis. Thirty-two individuals with unilateral plantar fasciitis were randomized into two groups: rESWT and HILT. In each group, the individuals underwent the intervention two sessions per week, for three weeks. Outcome measures included morning pain, resting pain, pain at 80 newtons (N) pressure, skin blood flow and temperature, plantar fascia (PF) and flexor digitorum brevis (FDB) thickness, and Foot Function Index (FFI). There was no significant difference in baseline characteristics of the individuals in both groups. All outcome measures, except skin blood flow and temperature, and FDB thickness, were significantly different (p < 0.05) over time. Skin blood flow was significantly different between groups at the end of the program. Either HILT or rESWT could alleviate pain in individuals with plantar fasciitis significantly. However, HILT was better at reducing FFI (functional limitation domain) rather than rESWT. This study was a randomized clinical trial and was approved by Mahidol University-Central Institutional Review Board (MU-CIRB) following the Declaration of Helsinki, COA no. MU_CIRB 2020/207.0412, the Thai Clinical Trials Registry (TDTR) numbered TCTR2021012500.

Prevalence and Distribution of Ankle Joint Equinus in 249 Consecutive Patients Attending a Foot and Ankle Specialty Clinic

BACKGROUND

The definition of equinus varies from less than 0° to less than 25° of dorsiflexion with the foot at 90° to the leg. Despite its pervasive nature and broad association with many lower-extremity conditions, the prevalence of ankle equinus is unclear. Furthermore, there are few data to suggest whether equinus is predominantly a bilateral finding or isolated to the affected limb only.

METHODS

We conducted a prospective cohort study examining consecutive patients attending a single foot and ankle specialty practice. Participation involved an assessment of ankle joint range of motion by a single rater with more than 25 years of clinical experience. We defined ankle equinus as ankle joint dorsiflexion range of motion less than or equal to 0° and severe equinus as less than or equal to -5°. Patients who had previously experienced an Achilles tendon rupture, undergone posterior group lengthening (ie, Achilles tendon or gastrocnemius muscle lengthening), or had conservative or surgical treatment of equinus previously were excluded.

RESULTS

Of 249 included patients, 61% were female and 79% nondiabetic. The prevalence of ankle equinus was 73% [183 of 249], and nearly all of these patients had bilateral restriction of ankle joint range of motion (prevalence of bilateral ankle equinus was 98.4% [180 of 183] among those with equinus). We also found that ankle equinus was more common in patients with diabetes, higher body mass indexes (BMIs), or overuse symptoms.

CONCLUSIONS

The prevalence of ankle equinus in this sample was higher than previously reported, and nearly all of these patients had bilateral involvement. These data suggest that many people attending foot/ankle specialty clinics will have ankle equinus, and select groups (diabetes, increased BMI, overuse symptoms) are increasingly likely.

Predictors of response to foot orthoses and corticosteroid injection for plantar heel pain

Background

Foot orthoses and corticosteroid injection are common interventions used for plantar heel pain, however few studies have investigated the variables that predict response to these interventions.

Methods

Baseline variables (age, weight, height, body mass index (BMI), sex, education, foot pain, foot function, fear-avoidance beliefs and feelings, foot posture, weightbearing ankle dorsiflexion, plantar fascia thickness, and treatment preference) from a randomised trial in which participants received either foot orthoses or corticosteroid injection were used to predict change in the Foot Health Status Questionnaire foot pain and foot function subscales, and first-step pain measured using a visual analogue scale. Multivariable linear regression models were generated for different dependent variables (i.e. foot pain, foot function and first-step pain), for each intervention (i.e. foot orthoses and corticosteroid injection), and at different timepoints (i.e. weeks 4 and 12).

Results

For foot orthoses at week 4, greater ankle dorsiflexion with the knee extended predicted reduction in foot pain (adjusted R² = 0.16, p = 0.034), and lower fear-avoidance beliefs and feelings predicted improvement in foot function (adjusted R² = 0.43, p = 0.001). At week 12, lower BMI predicted reduction in foot pain (adjusted R² = 0.33, p < 0.001), improvement in foot function (adjusted R² = 0.37, p < 0.001) and reduction in first-step pain (adjusted R² 0.19, p = 0.011). For corticosteroid injection at week 4, there were no significant predictors for change in foot pain or foot function. At week 12, less weightbearing hours predicted reduction in foot pain (adjusted R² = 0.25, p = 0.004) and lower baseline foot pain predicted improvement in foot function (adjusted R² = 0.38, p < 0.001).

Conclusions

People with plantar heel pain who use foot orthoses experience reduced foot pain if they have greater ankle dorsiflexion and lower BMI, while they experience improved foot function if they have lower fear-avoidance beliefs and lower BMI. People who receive a corticosteroid injection experience reduced foot pain if they weightbear for fewer hours, while they experience improved foot function if they have less baseline foot pain.

Effect of Surgical Weight Loss on Plantar Fasciitis and Health-Care Use

BACKGROUND:

Plantar fasciitis (PF) is one of the most common causes of heel pain. Obesity is recognized as a major factor in PF development, possibly due to increased mechanical loading of the foot due to excess weight. The benefit of bariatric surgery is documented for other comorbidities but not for PF.

METHODS:

A retrospective medical record review was performed for patients with PF identified from a prospectively maintained database of the Cleveland Clinic Bariatric and Metabolic Institute. Age, sex, surgery, excess weight loss, body mass index (BMI), and health-care use related to PF treatment were abstracted. Comparative analyses were stratified by surgery type.

RESULTS:

Two hundred twenty-eight of 10,305 patients (2.2%) had a documented diagnosis of PF, of whom 163 underwent bariatric surgery and were included in the analysis. Eighty-five percent of patients were women, mean ± SD age was 52.2 ± 9.9 years, and mean ± SD preintervention BMI was 45 ± 7.7. Postoperatively, mean ± SD BMI and excess weight loss were 34.8 ± 7.8 and 51.0% ± 20.4%, respectively. One hundred forty-six patients (90%) achieved resolution of PF and related symptoms. The mean ± SD number of treatment modalities used for PF per patient preoperatively was 1.9 ± 1.0 ( P = .25). After surgery, the mean ± SD number of treatment modalities used per patient was reduced to 0.3 ± 0.1 ( P = .01).

CONCLUSIONS:

We present new evidence suggesting that reductions in BMI after bariatric surgery may be associated with decreasing the number of visits for PF and may contribute to symptomatic improvement.

Clinical and Functional Characteristics of People With Chronic and Recent-Onset Plantar Heel Pain

BACKGROUND

Plantar heel pain is a common condition that reduces health-related quality of life. Recovery usually occurs within 12 months; however, up to 20% of people remain symptomatic beyond this time frame. The level of pain and function in this chronic heel pain group is not well described.

OBJECTIVE

To identify clinical and functional characteristics associated with chronic plantar heel pain compared with heel pain of recent onset.

DESIGN

Cross-sectional study.

SETTING

University research laboratory and private physiotherapy clinic.

PARTICIPANTS

A total of 71 people with plantar heel pain for longer than 12 months and 64 people with plantar heel pain for less than 6 months were recruited from the general public.

METHODS

Functional characteristics of participants in both heel pain groups were assessed with a variety of clinical measures and the Foot Health Status Questionnaire. Clinical measures included body mass index, foot and ankle muscle strength using hand-held dynamometry, as well as ankle and first metatarsophalangeal joint range of motion. The Foot Health Status Questionnaire was used to collect self-reported measures of foot pain severity, foot function and physical activity.

MAIN OUTCOME MEASUREMENTS

Univariate analyses of variance were performed to detect differences between the 2 groups for each of the variables measured.

RESULTS

The chronic heel pain group exhibited reduced ankle dorsiflexor and toe flexor strength yet better self-reported foot function. There was no difference between groups for body mass index, ankle and first metatarsophalangeal joint range of motion, inversion strength, eversion strength, calf endurance, self-reported foot pain, and physical activity.

CONCLUSIONS

Chronic plantar heel pain is associated with selective weakness of foot and ankle muscle groups but less affected foot function compared with heel pain of recent onset. Those with chronic symptoms may moderate or make adaptations to their daily activities, or simply accept their condition, enabling more effective coping. Strength deficits, although possibly a cause or consequence of chronic symptoms, suggest a need to include resistance exercise in the management of plantar heel pain.

LEVEL OF EVIDENCE

IV.