Fascitis Plantar

American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print
DOI: 10.1097/PHM.0000000000001900
Comparison of the Effect of Ultrasound-Guided Injection of Botulinum
Toxin Type-A and Corticosteroid in the Treatment of Chronic Plantar
Fasciitis: A Randomized Controlled Trial
Tannaz Ahadi1, Sasan Sadeghi nik2, Bijan Forogh3, Seyed Pezhman Madani4,5, Gholam
D
Reza Raissi6
TE
1
MD, Associate professor of Physical Medicine and Rehabilitation, Neuromusculoskeletal
Research Center, Iran University of Medical Sciences, Tehran, Iran. Ahadi.t@iums.ac.ir

2
MD, Resident of Physical Medicine and Rehabilitation, Neuromusculoskeletal Research
EP
Center, Iran University of Medical Sciences, Tehran, Iran. sadeghinik.s@gmail.com
3
MD, Professor of Physical Medicine and Rehabilitation, Neuromusculoskeletal Research
Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
Forogh.b@iums.ac.ir
C
4
MD, Associate professor of Physical Medicine and Rehabilitation, Neuromusculoskeletal
Research Center, Iran University of Medical Sciences, Tehran, Iran.

C
5
MD, ALS Clinical and Research Fellow. Montreal Neurological Institute and Hospital.
McGill University, Montreal, Canada. seyedpezhman.madani@mail.mcgill.ca

A
6
MD, Professor of Physical Medicine and Rehabilitation, Neuromusculoskeletal Research
Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
raissi.gh@iums.ac.ir
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Corresponding author: Gholam Reza Raissi, MD, Professor of Physical Medicine and
Rehabilitation, Neuromusculoskeletal Research Center, Firoozgar Hospital, Iran University
of Medical Sciences, Tehran, Iran. E-Mail: raissi.gh@iums.ac.ir; Phone: (98)21-82141229;
Fax: (98)21-88942970.
Competing Interests
The authors have no proprietary interest in the materials presented herein.
D
Funding or grants or equipment provided for the project from any source
None.
TE
Financial benefits to the authors
EP
None.
Details of any previous presentation of the research, manuscript, or abstract in any

C
form
None.
C
A
Abstract
Objective: To compare the efficacy of ultrasound-guided injection of botulinum toxin type A
(BTA) with corticosteroid in patients with chronic plantar fasciitis (PF).
Design: This randomized controlled trial was conducted on 35 patients with chronic PF.
Participants were randomly allocated into two groups; one group received
methylprednisolone in to the plantar fascia (n=18) and the other group received BTA
injection into the flexor digitorum brevis and quadratus plantae (n=17). All injections were
D
performed under ultrasound (US) guidance. Patients were evaluated using the VAS, FAAM
TE
and plantar fascia thickness before the intervention, 3 weeks, 12 weeks, and 6 months after
the treatment.
Results: In both groups, patients’ pain and function improved significantly up to 3 weeks
after injection. In the BTA group, morning VAS improved significantly at 12 weeks after
EP
intervention and the improvement was sustained for another 3 months. In the BTA group,
FAAM-S improved in all evaluated points, while in the corticosteroid group, the
improvement was significant only when comparing follow-ups values to baseline.

C
Conclusions: Both US-guided BTA and corticosteroid injection were effective in the
treatment of PF. Our study showed that the effects of BTA injection last longer than those of
C
steroid injection.
Keywords: Plantar Fasciitis, Ultrasonography, Botulinum Toxin Type A, Corticosteroid,

A
Visual Analog Scales.
What is known: Corticosteroid injection is the most common injection for acute and chronic
PF with limited and short-term therapeutic effects and several complications. In the recent
years, botulinum toxin type a (BTA) injection into the foot intrinsic muscles has been
investigated as a treatment option for chronic PF with promising results, but with limited
available studies.
What is New: In the short-term, both treatments were effective in patients with chronic PF,
D
but the effects of BTA injection last longer than those of steroid injection. BTA injection can
be considered as an effective intervention in patients with chronic PF.
TE
EP
C
C
A
Introduction
Plantar fasciitis is the most common clinical cause of plantar heel pain in the general
population. It is generally thought to result from overuse injuries or repetitive micro-traumas
of the plantar fascia, causing degeneration and inflammation of the plantar fascia at its
insertion to the calcaneus bone. Also, biomechanical imbalances such as severe ankle
pronation, limited ankle dorsiflexion, and leg length discrepancy can lead to disproportionate
stretching along the plantar fascia, which contribute to inflammation of the plantar fascia and
D
1-4
peri-fascial structures. The diagnosis of plantar fasciitis is based primarily upon the
5
TE
clinical presentation and physical examination. However, imaging modalities like
ultrasonography and x-ray may be required when the presenting features are atypical or the
diagnosis is unclear. 6
EP
The treatment of PF is primarily conservative, usually with rest, stretching, supportive heel
7, 8
support, night splints, and physical therapy modalities. In small number of cases who do
9
not respond to such treatments, surgical intervention is suggested. Local corticosteroids
C
injection is a well-established non-surgical intervention in patients with PF. 10 However, there
are concerns regarding the adverse effects associated with corticosteroid injections such as
C
increased risk of plantar fascia rupture or fat pad atrophy. 10, 11

A
In the recent years, botulinum toxin type A (BTA) injection into the foot intrinsic muscles has
been investigated as a treatment option for chronic PF.12 BTA reversibly inhibits the
presynaptic release of neurotransmitters, mainly the acetylcholine. Other neurotransmitters
are also affected like substance P, calcitonin gene-related peptide (CGRP), and glutamate. By
affecting these neurotransmitters, BTA can result in anti-nociceptive and analgesic effect and
local anti-inflammatory action.13-16
The need to compare novel treatments with existing therapies has always been emphasized in
the literature. Limited data exist in the literature regarding the efficacy of BTA in chronic PF.
In this study, we compared the effectiveness of ultrasound-guided BTA and corticosteroid
injections on pain intensity, functional status, and plantar fascia thickness of patients with
chronic PF.
Material and methods
D
Study design, setting, and participants
TE
This prospective, randomized controlled trial was conducted from January to December 2020
on patients with PF presenting to physical medicine and rehabilitation out-patient clinics
affiliated to Iran University of Medical Sciences, Tehran, Iran. This research followed the
tents of the Declaration of Helsinki and the protocol of the study was approved by the
EP
regional ethics committee of Iran University of Medical Sciences. A written informed
consent was obtained from all patients before enrollment in the study. The process of the
treatment was fully explained to the patients, and they were advised that they could withdraw
C
from the study at any time. The trial was registered in Iranian Registry of Clinical Trial
(registration ID: IRCT20190428043404N1). This study conforms to all CONSORT

C
guidelines and reports the required information accordingly (see Supplementary Checklist,
Supplemental Digital Content 1, http://links.lww.com/PHM/B400).

A
The primary inclusion criteria were patients aged 18-65 years, diagnosed with PF for at least
2 months, and pain intensity of ≥ 4/10. The clinical diagnosis of PF was based on the
presence of tenderness at the medial calcaneal tuberosity and history of heel pain in the first
steps after a rest period which would dwindle after few steps walking. The diagnosis of PF
was confirmed with the ultrasonographic (US) study (plantar fascia thickness (PFT) of >
4mm (measured 1 cm away from the insertion point to the bone) and areas of
hypoechogenicity.5,17
At the time of clinical presentation, all patients received a full series of weight-bearing foot x-
ray radiographs to screen for trauma, mass, and bony injuries. Patients with history of direct
trauma, positive tarsal Tinel’s sign, S1 radiculopathy, uncontrolled diabetes mellitus (defined
as fasting blood sugar > 125 with no appropriate treatment), gout, history of surgery or
D
injection for PF in the last 6 months, presence of a mass or cyst at the pain location,
simultaneous numbness or paresthesia, coagulative disorder, pregnancy, corticosteroid
TE
sensitivity, infection signs at the injection site and posterior calcaneal pain were not included.
Furthermore, participants who received anti-inflammatory medications, physical modalities,
splint, iontophoresis, phonophoresis, or ESWT in less than last two months were also
EP
excluded.
Thirty eight patients with PF were randomly assigned into 2 groups using randomly
C
generated treatment allocations: the corticosteroid group (n = 19) and the BTA group (n =
19). The physician who evaluated the outcome measures, the participants, and the person who
C
analyzed the data were all blinded to the group allocations.

A
Intervention
Subjects were placed in a prone position, feet hanging from the edge of the examination bed.
The skin over the heel plantar aspect was prepped with antiseptic and local anesthesia was
performed with a 20-gauge needle containing 1cc of lidocaine 1%. Patients received their
treatment injection under real-time US guidance. The US-guided injection was performed
with a Medison Samsung (SonoACE X8-2013- South Korea) ultrasound device (with a 5-12
MHz linear transducer) by an experienced physiatrist using a long axis (in-plane) technique,
while the linear US probe was covered with a sterile barrier. In the corticosteroid group, US-
guided injection was performed via a medial approach. After visualizing plantar fascia, a 4-
cm 21-gauge needle was positioned into the area of maximal plantar fascia thickness, and an
intrafascial injection of 1 mL of methylprednisolone plus 1 mL of normal saline was
performed under US-guidance. In the BTA group, after identifying foot intrinsic muscles
with the US guidance, 150Unit (U) of botulinum toxin A (Dysport®) diluted in 1.5 mL of
D
normal saline, was injected (100U in the flexor digitorum brevis [FDB] and 50U in quadratus
plantae) (Figure 1).
TE
After injections, the patients were recommended to apply a cold pack over the injection site
for about 10 minutes at home 3 times a day for 24 hours. They were advised to avoid pressure
EP
on the injected heel for the next 48 hours and in case of pain, only could use acetaminophen.
Two days after the injections, the patients of both groups were asked to perform daily
stretching exercises of the calf and heel cord muscles, hold for about 30 seconds, five to six
C
times and repeat 2-3 sessions per day, along with strengthening exercises of the intrinsic foot
muscles.
C
Outcome measures
A
Patients were assessed by the Visual Analogue Scale (VAS), Foot and Ankle Ability
Measures (FAAM) and US features. All outcome measures were assessed before the
intervention, 3 weeks and 12 weeks after. Furthermore, the VAS was reevaluated 6 months
after treatment.
The 100-mm VAS was used to assess the patient’s pain intensity. Patients were asked to point
the place on the VAS ruler representing their morning and daily pain level (0 = no pain at all
and 100 = the worst pain possible).
The Foot and Ankle Ability Measure (FAAM) is one of the most appropriate instruments to
evaluate physical function in individuals with foot and ankle related impairments. It is
composed of 29 items divided into 2 subscales: 21-item ADL Subscale (FAAM-A) and 8-
D
item Sports Subscale (FAAM-S). Each item is scored on a 5-point Likert scale (4 to 0) from
‘no difficulty at all’ to ‘unable to do’. Item score totals range from 0 to 84 for the ADL
TE
subscale and 0 to 32 for the Sports subscale and presented as percentage scores. Higher
scores indicate higher levels of function for each subscale. The validity and reliability of the
Persian version of FAAM have been described by Mazaheri et al.18

EP
Furthermore, the ultrasound measures of PFT at the level of its insertion to the calcaneus
(PFT-I) and 1 cm distal to this level (PFT-1cm) were measured and reported.
C
Statistical analysis
C
Outcome measures were analyzed using SPSS software V24. The Kolmogorov-Smirnov test
was used to verify the normal distribution of variables. The interaction effect of time and
A
group on outcome measures was evaluated using mixed ANOVA and post hoc tests
(Bonferroni test). The significant threshold was considered to be less than 0.05. For baseline
values that were significantly different, these values were entered as co-variance in ANOVA
analysis and did not change the results.
Results
The study was carried out with 2 groups of 19 patients. During the study, 3 participants
dropped out (1 case in the corticosteroid group did not show for follow-up sessions, and 2
subjects were excluded from the BTA group due to post-injection pain and administration of
anti-inflammatory medication). Finally, data for 18 patients in the corticosteroid group (16
females and 2 males with a mean age of 43.94 ± 8.61 years) and 17 in the BTA group (11
females and 6 males, with a mean age of 47.29 ± 9.91 years) was analyzed.
D
TE
No significant difference was observed between two treatment groups regarding baseline
demographics and characteristics except for baseline daily VAS, and PFT-1cm and PFT-I
(Table 1). As a result, we conducted analysis only on morning VAS, FAAM-A, and FAAM-s
variables. The inter-group analyses of outcome measures are demonstrated in table 2. There
EP
was a significant interaction between time and group in terms of morning VAS ( p<0.001)
andFAAM-S (p=0.49). This implied that the behavior of our treatment groups did differ
regarding the changes of the above-mentioned outcomes in favor of the BTA group.. The
C
morning VAS improvement was also significantly higher in the BTA group in all time
periods except between baseline and 1st and 2nd (week-12) follow-up. In the period between
C
1st and 2nd follow-up, a higher change in FAAM-S was observed in the BTA group. In
periods between baseline and 2nd visit and between 1st and 2nd visit, significant changes were
A
observed in favor of the BTA group. Of note, significant difference was observed between
two treatment groups in neither outcome regarding short-term changes (between baseline and
1st visit).
10
The inter- and intra-group analyses of outcome measures are demonstrated in table 3. In the
BTA group, the morning VAS improved significantly toward 12 weeks after intervention and
the improvement was sustained for another 3 months. FAAM-A improved significantly in all
follow-ups compared to baseline in both groups. In the BTA group, FAAM-S improved in all
evaluated points, while in the corticosteroid group, the improvement was significant only
when comparing follow-ups values to baseline.No serious adverse effects were observed in
either group.
D
Discussion
TE
Local corticosteroid injection has long been established as an effective treatment for PF. 10 In
the recent years, BTA injection into the foot intrinsic muscles has been suggested to be an
effective treatment for PF; however, few studies have compared its effectiveness with
EP
intrafascial corticosteroid injection. In this study, 35 patients with PF were randomly assigned
into two groups to receive either corticosteroid or BTA injections. The study intended to
compare different outcome measures including morning VAS and functional status as
C
measured by FAAM-A and FAAM-S. Based on our findings, both groups showed significant
reduction in morning VAS and improvements in FAAM scores; however, longer functional
C
improvement and VAS reduction were observed with BTA injection.

A
In recent years, few randomized controlled trials have been conducted exploring the relative
efficacy of new and emerging therapies such as BTA in comparison with local corticosteroid
19-23
injection as an established treatment for PF . Diaz-Llopis et al.19 conducted the first trial
comparing BTA with corticosteroid in PF. After one month evaluation, patients in both
treatment groups demonstrated marked improvements without significant difference.
However, after 6-month evaluation, patients who received BTA injection continued to show
11
clinical improvements. In contrary, the patients in the corticosteroid group did not show
12
further improvements. In another study by Elizondo-Rodriguez et al. , both BTA and
corticosteroid injections were associated with improvement up to 1 month after treatment.
The improvement was sustained in the BTA group until 6 months of follow-up, but not in the
corticosteroid group. Moreover, BTA was associated with better and more rapid short-term
therapeutic effects. In our study, similar to the findings of Diaz-Llopis et al.19and Elizondo-
Rodriguez et al. 12, both treatments showed to be effective in reducing pain and improving the
D
function, but the effects of BTA injection last longer than those of steroid injection.
TE
The short-term and long-term efficacy of BTA was also shown in a trial by Babcock et al. 20,
in which BTA resulted in significant improvements in pain relief and overall foot function at
both 3 and 8 weeks after treatment. In another engaging study, Ahmad et al., 13
conducted a
EP
randomized placebo controlled trial comparing 50 patients with PF. The authors reported
significant improvement in subjective pain scores following the administration of BTA into
the plantar fascia after a period of six months and one year when compared to a placebo of
C
saline.
C
Although the exact nature of PF is not fully understood, several mechanisms have been
described for the pain induced by PF. These include excessive tension in the fascia, local
A
inflammation, chronic pressure and ischemic pain due to thickened plantar fascia,
accumulation of pain neurotransmitters and central sanitization.24,25 BTA injection could
relieve patients’ symptoms primarily by its action on relaxing muscles and thus, recovering
the windlass mechanism of the plantar fascia, which results in decreased tension on the
plantar fascia and local neurovascular structure. (2) As our study result suggests, BTA
injection was followed by a stable decrease in fascia thickness for 12 weeks. The PFT is
12
regarded as an indicator of the extent of inflammation, in which increased thickness is
associated with more severe inflammation.26 This effect, combined with the expected reduced
tension of intrinsic muscles could lead to significant pain relief and functional improvement.
Besides, several authors suggested that BTA is associated with local anti-inflammatory and
analgesic effects by its role on local neurotransmitters including Substance-P and glutamate
21
.
D
There are several techniques of ultrasound-guided plantar fascia injection in the literature,
including superficial, deep and intrafascial injections. Intrafascial injection is the most
TE
27
commonly used technique in the literature . There are some concerns regarding
corticosteroid injection superficial to the plantar fascia, as it may cause fad pad atrophy 28. In
addition, corticosteroid injection in the calcaneal region may increase the risk of plantar
EP
fascia rupture. To our knowledge, to date, there is no definite consensus upon the most
appropriate technique for PF injection. In the present study, we used intrafascial injection as
this technique was used in several similar studies with no adverse events.
C
This study has a number of limitations. The main limitations were the relatively small sample
C
size and lack of a control group, which decrease the generalizability of the results. Other
limitations were the lack of power analysis for missing data and the impossibility of complete
A
blinding (the therapist) due to the nature of the interventions. More studies with a greater
sample size and appropriate blinding of the patients are needed to establish the efficacy of
BTA in patients with PF.
13
Conclusions
Both corticosteroid and BTA injections were effective in the treatment of PF. Our study
showed that the effects of BTA injection last longer than those of steroid injection. No
serious adverse effects were observed in either group. BTA injection can be considered as an
effective intervention in patients with chronic PF.
D
Conflicts of interest
None
Acknowledgements
TE
The present study was performed as thesis, Iran University of Medical Sciences, Tehran, Iran.
The authors wish to express their gratitude to Dr. Masoume ZoghAali and Dr. Khatereh
EP
Abdolmaleki for their contribution in preparation of the manuscript.
C
C
A
14
References
1. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. 2004;350(21):2159-66
2. Dyck DD Jr, Boyajian-O'Neill LA. Plantar fasciitis. Clin J Sport Med. 2004;14(5):305-9.
3. Orchard J. Plantar fasciitis. BMJ. 2012;345:e6603.
4. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician.
2011;84(6):676-82.
5. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot
D
Ankle Surg. 2007;46(6):442-6.
TE
6. League AC. Current concepts review: plantar fasciitis. Foot Ankle Int. 2008;29(3):358-66.
7. Luffy L, Grosel J, Thomas R, So E. Plantar fasciitis: A review of treatments. JAAPA.
2018;31(1):20-24.
8. Raissi G, Arbabi A, Rafiei M, Forogh B, Babaei-Ghazani A, Khalifeh Soltani S, Ahadi T.

EP
Ultrasound-Guided Injection of Dextrose Versus Corticosteroid in Chronic Plantar
Fasciitis Management: A Randomized, Double-Blind Clinical Trial. Foot Ankle Spec.
2021 Jan 19:1938640020980924.

C
9. Al-Boloushi Z, López-Royo MP, Arian M, Gómez-Trullén EM, Herrero P. Minimally
invasive non-surgical management of plantar fasciitis: A systematic review. J Bodyw

C
Mov Ther. 2019;23(1):122-137.
10. David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected
A
corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev.
2017;6(6):CD009348.
11. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with
corticosteroid injection. Foot Ankle Int. 1998;19(2):91-97.
12. Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E,
Mendoza-Lemus O, Acosta-Olivo C. A comparison of botulinum toxin a and
15
intralesional steroids for the treatment of plantar fasciitis: a randomized, double-
blinded study. Foot Ankle Int. 2013;34(1):8-14.
13. Ahmad J, Ahmad SH, Jones K. Treatment of Plantar Fasciitis With Botulinum Toxin.
Foot Ankle Int. 2017;38(1):1-7.
14. Huang YC, Wei SH, Wang HK, Lieu FK. Ultrasonographic guided botulinum toxin type
A treatment for plantar fasciitis: an outcome-based investigation for treating pain and
gait changes. J Rehabil Med. 2010;42(2):136-40.
D
15. Tsikopoulos K, Vasiliadis HS, Mavridis D. Injection therapies for plantar fasciopathy
('plantar fasciitis'): a systematic review and network meta-analysis of 22 randomised
TE
controlled trials. Br J Sports Med. 2016 Nov;50(22):1367-1375.
16. Placzek R, Deuretzbacher G, Buttgereit F, Meiss AL. Treatment of chronic plantar
fasciitis with botulinum toxin A: an open case series with a 1 year follow up. Ann
EP
Rheum Dis. 2005;64(11):1659-61.
17. McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic imaging for
chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res.
C
2009;2:32.
18. Mazaheri M, Salavati M, Negahban H, et al. Reliability and validity of the Persian
C
version of Foot and Ankle Ability Measure (FAAM) to measure functional limitations
in patients with foot and ankle disorders. Osteoarthritis Cartilage. 2010;18(6):755-9.

A
19. Diaz-Llopis IV, Rodriguez-Ruiz CM, Mulet-Perry S, Mondejar-Gomez FJ, Climent-
Barbera JM, Cholbi-LLobel F. Randomized controlled study of the efficacy of the
injection of botulinum toxin type A versus corticosteroids in chronic plantar fasciitis:
results at one and six months. Clin Rehabil. 2012;26(7):594-606.
16
20. Babcock MS, Foster L, Pasquina P, Jabbari B. Treatment of pain attributed to plantar
fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled,
double-blind study. Am J Phys Med Rehabil. 2005;84(9):649-54.
21. Huang Y-C, Wei S-H, Wang HK, Lieu F-K. Ultrasonographic guided botulinum toxin
type A treatment for plantar fasciitis: An outcome-based investigation for treating
pain and gait changes. Journal of rehabilitation medicine : official journal of the
UEMS European Board of Physical and Rehabilitation Medicine. 02/01 2010;42:136-
D
140. doi: 10.2340/16501977-0491.
22. Peterlein CD, Funk JF, Hölscher A, Schuh A, Placzek R. Is botulinum toxin A effective
TE
for the treatment of plantar fasciitis? Clin J Pain. 2012;28(6):527-33.
23. Abbasian M, Baghbani S, Barangi S, Fairhurst PG, Ebrahimpour A, Krause F, Hashemi
M. Outcomes of Ultrasound-Guided Gastrocnemius Injection With Botulinum Toxin

EP
for Chronic Plantar Fasciitis. Foot Ankle Int. 2020;41(1):63-68.
24. Akfirat M, Sen C, Günes T. Ultrasonographic appearance of the plantar fasciitis. Clin
Imaging. 2003;27(5):353-7
C
25. Alfredson H, Lorentzon R. Chronic tendon pain: no signs of chemical inflammation but
high concentrations of the neurotransmitter glutamate. Implications for treatment?

C
Curr Drug Targets. 2002;3(1):43-54.
26. Gökoğlu F, Ceceli E, Ramadan SU, Yorgancioglu ZR, Koşar U. Ultrasonographic

A
evaluation of hand and foot tendons in Behçet's disease. Arch Med Res.
2008;39(7):709-13.
27. Gurcay E, Kara M, Karaahmet OZ, Ata AM, Onat ŞŞ, Özçakar L. Shall We Inject
Superficial or Deep to the Plantar Fascia? An Ultrasound Study of the Treatment of
Chronic Plantar Fasciitis. J Foot Ankle Surg. 2017;56(4):783-787.
17
28. Babaei-Ghazani A, Fadavi HR. Reply to the Letter to the Editor: Ultrasound-Guided
Plantar Fascia Injections: (Where) Are You Putting the Gas or Steroids? Pain Med.
2019;20(2):418-419.
D
TE
EP
C
C
A
18
Figures and legends
Figure 1 A longitudinal sonogram view of a patient with plantar fasciitis, showing the flexor
digitorum brevis and quadratus plantae muscles. CB: calcaneus bone; FDB: flexor digitorum
brevis; QP: quadratus plantae
D
TE
EP
C
C
A
19
Figure 1
D
TE
EP
C
C
A
20
Table 1. Participants’ demographics and baseline evaluations
Characteristic Corticosteroid BTA P- value

Number 18 17
Sex, n (%)
Male 2 (11.1%) 6 (35.3%)
0.121
Female 16 (88.9%) 11 (64.7%)
Age (year) 43.9 ± 8.6 47.2 ± 9.9 0.607
Pain duration (month) 14.3 ± 17.4 14.1 ± 14.5 0.727
Height (cm) 160.1 ± 5.3 165.5 ± 6.5 0.140
Weight (kg) 75.0 ± 13.4 78.8 ± 15.1 0.519
2
BMI (kg/m ) 0.741
D
29.1 ± 4.4 28.7 ± 5.0
Daily VAS 49.4 ± 9.9 70.0 ± 11.1 < 0.001
Morning VAS 66.6 ± 19.7 78.8 ± 15.7 0.53
FAAM-A 60.2 ± 16.1 57.3 ± 15.4 0.597
TE
FAAM-S 44.6 ± 20.9 44.6 ± 21.5 0.995
PFT-I (mm) 2.88 ± 0.6 2.1 ± 0.8 0.003
PFT-1cm (mm) 3.73 ± 0.4 4.5 ± 0.6 < 0.001
Data are presented as number (%), or mean ± standard deviations.
Abbreviations: BTA: Botulinum toxin; tDCS: Transcranial direct current stimulation; BMI: Body Mass
Index, VAS: Visual Analogue Scale, FAAM-A: Foot and Ankle Ability Measures - Activities of Daily
EP
Living Subscale; FAAM-S: Foot and Ankle Ability Measures - Sports Subscale; PFT-I: Plantar Fascia
Thickness at insertion level; PFT-1cm: Plantar Fascia Thickness 1 cm distal to insertion
C
C
A
21
Table 2. The inter-group analysis of outcome measures
Group and
Before After 3 After 6
Outcome After 12 weeks Time
intervention weeks months
Interaction
Morning VAS, mean ± Std. deviation

30.00 ± 56.11 ±
66.67 ± 19.70 28.89 ± 29.68A
Corticosteroid 25.90B 25.24B
< .001
49.18 ± 24.41 ±
BTA 78.82 ± 15.77 30.59 ± 13.91A
19.72B 15.46B
FAAM-A, mean ± Std. deviation
D
74.21 ±
60.20 ± 16.13 76.65 ± 20.36A
Corticosteroid 19.97A
.530
70.79 ±
BTA 57.35 ± 15.42 79.72 ± 20.62A
17.76A
TE
FAAM-S, mean ± Std. deviation
63.72 ±
44.62 ± 20.92 68.97 ± 25.15A
Corticosteroid 22.02A
.049
59.74 ± A
BTA 44.67 ± 21.56 79.41 ± 13.31
24.08A
EP
A: no statistical significance between Corticosteroid and BTA group. ± P-Value > 0.05
B: statistical significance between Corticosteroid and BTA group. ± P-Value ≤ 0.05
C
C
A
22
Table 3. The inter- and intra-group analysis of outcome measures in different time periods.
Baseline compared Baseline compared 3-week compared

Outcome
to 3-week to 12-week to 12-week
Morning VAS, mean Difference ± Std. Error

Corticosteroid 36.67 ± 4.92B 37.78 ± 6.08B 1.11 ± 3.51A
BTA 29.65 ± 5.56B 48.24 ± 4.64B 18.59 ± 4.07B
Between-group P-value .350 .184 .003
FAAM-A, mean Difference ± Std. Error

Corticosteroid -14.01 ± 3.44B -16.45 ± 3.94B -2.45 ± 2.60A
BTA -13.44 ± 4.21B -22.38 ± 5.78B -8.93 ± 6.21A
D
FAAM-S, mean Difference ± Std. Error

Corticosteroid -19.10 ± 4.25B -24.36 ± 4.90B -5.26 ± 3.96A
TE
BTA -15.07 ± 3.96B -34.74 ± 3.83B -19.67 ± 4.02B
Baseline compared 3-week compared to 12-week compared

Outcome
to 6-month 6-month to 6-month
Morning VAS, mean Difference ± Std. Error

EP
Corticosteroid 10.56 ± 4.73A -26.11 ± 4.85B -27.22 ± 3.80B
BTA 54.12 ± 4.87B 24.47 ± 4.99B 5.88 ± 3.91A
Between-group P-value < .001 < .001 < .001
A: No statistical significance. ± P-Value > 0.05

B: statistical significance. ± P-Value ≤ 0.05
C
C
A
23

Fascitis Plantar

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fascitis Plantar

Uploaded by

Copyright:

Available Formats

American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print

Comparison of the Effect of Ultrasound-Guided Injection of Botulinum

Toxin Type-A and Corticosteroid in the Treatment of Chronic Plantar

Fasciitis: A Randomized Controlled Trial

Research Center, Iran University of Medical Sciences, Tehran, Iran. Ahadi.t@iums.ac.ir

Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.

Research Center, Iran University of Medical Sciences, Tehran, Iran.

McGill University, Montreal, Canada. seyedpezhman.madani@mail.mcgill.ca

Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.

Rehabilitation, Neuromusculoskeletal Research Center, Firoozgar Hospital, Iran University

of Medical Sciences, Tehran, Iran. E-Mail: raissi.gh@iums.ac.ir; Phone: (98)21-82141229;

The authors have no proprietary interest in the materials presented herein.

Details of any previous presentation of the research, manuscript, or abstract in any

Objective: To compare the efficacy of ultrasound-guided injection of botulinum toxin type A

(BTA) with corticosteroid in patients with chronic plantar fasciitis (PF).

improvement was significant only when comparing follow-ups values to baseline.

Keywords: Plantar Fasciitis, Ultrasonography, Botulinum Toxin Type A, Corticosteroid,

Visual Analog Scales.

be considered as an effective intervention in patients with chronic PF.

population. It is generally thought to result from overuse injuries or repetitive micro-traumas

injection is a well-established non-surgical intervention in patients with PF. 10 However, there

increased risk of plantar fascia rupture or fat pad atrophy. 10, 11

presynaptic release of neurotransmitters, mainly the acetylcholine. Other neurotransmitters

local anti-inflammatory action.13-16

In this study, we compared the effectiveness of ultrasound-guided BTA and corticosteroid

Material and methods

on patients with PF presenting to physical medicine and rehabilitation out-patient clinics

(registration ID: IRCT20190428043404N1). This study conforms to all CONSORT

Supplemental Digital Content 1, http://links.lww.com/PHM/B400).

simultaneous numbness or paresthesia, coagulative disorder, pregnancy, corticosteroid

Furthermore, participants who received anti-inflammatory medications, physical modalities,

analyzed the data were all blinded to the group allocations.

intrafascial injection of 1 mL of methylprednisolone plus 1 mL of normal saline was

plantae) (Figure 1).

and 100 = the worst pain possible).

Persian version of FAAM have been described by Mazaheri et al.18

analysis and did not change the results.

improvement and VAS reduction were observed with BTA injection.

treatment groups demonstrated marked improvements without significant difference.

corticosteroid injections were associated with improvement up to 1 month after treatment.

accumulation of pain neurotransmitters and central sanitization.24,25 BTA injection could

BTA in patients with PF.

effective intervention in patients with chronic PF.

1. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. 2004;350(21):2159-66

3. Orchard J. Plantar fasciitis. BMJ. 2012;345:e6603.

5. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot

7. Luffy L, Grosel J, Thomas R, So E. Plantar fasciitis: A review of treatments. JAAPA.

8. Raissi G, Arbabi A, Rafiei M, Forogh B, Babaei-Ghazani A, Khalifeh Soltani S, Ahadi T.

Fasciitis Management: A Randomized, Double-Blind Clinical Trial. Foot Ankle Spec.

2021 Jan 19:1938640020980924.

9. Al-Boloushi Z, López-Royo MP, Arian M, Gómez-Trullén EM, Herrero P. Minimally

invasive non-surgical management of plantar fasciitis: A systematic review. J Bodyw

Mov Ther. 2019;23(1):122-137.

corticosteroid injection. Foot Ankle Int. 1998;19(2):91-97.

12. Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E,

Mendoza-Lemus O, Acosta-Olivo C. A comparison of botulinum toxin a and

blinded study. Foot Ankle Int. 2013;34(1):8-14.

Foot Ankle Int. 2017;38(1):1-7.

gait changes. J Rehabil Med. 2010;42(2):136-40.

('plantar fasciitis'): a systematic review and network meta-analysis of 22 randomised

16. Placzek R, Deuretzbacher G, Buttgereit F, Meiss AL. Treatment of chronic plantar

in patients with foot and ankle disorders. Osteoarthritis Cartilage. 2010;18(6):755-9.

19. Diaz-Llopis IV, Rodriguez-Ruiz CM, Mulet-Perry S, Mondejar-Gomez FJ, Climent-