Citations(0)

Content

How to Cite This Article

Download Download [ PDF ]

Email Send to a friend

Page Views Page Views(1355)

Facebook ShareFacebook Share

Twitter ShareTwitter Share

Year : 2014 Month : April Volume : 3 Issue : 16 Page : 4145-4149

COMPARATIVE STUDY OF EFFICACY OF LOCAL STEROID INJECTION AND EXTRACORPOREAL SHOCKWAVE THERAPY IN THE TREATMENT OF PLANTAR FASCITIS

Rajan Sarad1, Rajan Sharma2, Gagan Khanna3

1. Assistant Professor, Department of Orthopaedics, Sri Guru Ram Das Institute of Medical Sciences, Vallah, Amritsar, Punjab.
2. Assistant Professor, Department of Orthopaedics, Sri Guru Ram Das Institute of Medical Sciences, Vallah, Amritsar, Punjab.
3. Associate Professor, Department of Orthopaedics, Sri Guru Ram Das Institute of Medical Sciences, Vallah, Amritsar, Punjab.

CORRESPONDING AUTHOR

Dr. Rajan Sharma,
Email : sharmarajan29@yahoo.com

ABSTRACT

CORRESPONDING AUTHOR:
Dr. Rajan Sharma,
#184, Medical Enclave,
Amritsar, Punjab, PIN – 143001.
E-mail: sharmarajan29@yahoo.com

ABSTRACT: INTRODUCTION: Plantar fasciitis is a common condition causing misery to lot of patients. The etiology and treatment of plantar fasciitis are poorly understood. The results from such treatments vary considerably, and there is no consensus of opinion on the best method. MATERIAL AND METHODS: We conducted a controlled trial in our institute to compare the results of local steroid injections & the use of Extra-corporeal shock wave therapy (ESWT) for managing plantar fasciitis. 200 patients with 240 painful heels were evaluated. All patients with moderate to severe heel pain who had already taken ten days of unsatisfactory treatment with oral NSAIDS were divided in two main groups. Group A of 100 patients received 1000 impulses of shock waves in three sessions at weekly interval. In Group B of 100 patients up to three local injections of 40 mg methyl prednisone mixed with 1 ml. of 2% lignocaine were given at biweekly interval. Pain assessment was done using VAS scale and the results were evaluated at six weeks, three months and six months after the completion of the therapy. CONCLUSIONS: There was a significant difference between two groups of patients being treated. The group B patients had significantly greater improvement in pain scale and early return to daily activities.

KEYWORDS: Plantar fasciitis, ESWT, Local steroid injection.

INTRODUCTION: Plantar fasciitis or painful heel syndrome is a common musculoskeletal condition and is found significantly in middle aged,1 overweight patients, whose work involves prolonged standing. It denotes a clinical condition of pain in the plantar aspect of the heel, characteristically worse on arising in the morning and after periods of prolonged sitting.2 As the pain in the heel is aggravated on weight bearing, it affects adversely daily activities. The etiology and treatment of plantar fasciitis are poorly understood. The results from such treatments vary considerably, and there is no consensus of opinion on the best method.3- 5 Extracorporeal shockwave treatment was recently introduced for the alleviation of pain due to plantar fasciitis, with mixed short-term results6-11. It is approved by FDA for tennis elbow and plantar fasciitis. Potential complication are temporary, namely numbness, erythema, syncope and small hematoma locally. ESWT has been used by urologists for urinary calculi and most recently in orthopedic conditions like Achilles/patellar tendonitis, pseudo-arthrosis, plantar fasciitis, tennis elbow and avascular necrosis. The control of pain by intense stimulation is ascribed to mechanisms in the brain stem which exert a descending inhibitory control of transmission through the dorsal horns as well as higher level in the somatic projection system.

If other conservative methods fail, local corticosteroid injections can be used to relieve pain in short term. Complications from repeated steroid injection include hypo-pigmentation and fat atrophy. The purpose of this study was to compare the efficacy of local steroid injection and ESWT in the treatment of plantar fasciitis.

MATERIALS AND METHODS: A prospective study was done in 200 patients with 240 painful heels with moderate to severe pain. These patients had already taken treatment with NSAIDS for about ten days with no or less improvement of pain. This entity constitutes to 12% of total Orthopedic OPD in SGRDIMSR over a span of 2 years. Tenderness in the heel on weight bearing and firm pressure with thumb by palpation especially at the medial side of heel were two main criteria for the diagnosis plantar fasciitis. Patients of plantar fasciitis in presence of other systemic disease like diabetes mellitus, rheumatoid arthritis, gout etc. were excluded from study. Patients with any neurological pathology were excluded. A lateral X-ray of both heels was taken to demonstrate the presence or absence of a calcaneal spur in painful heel for all cases. An informed consent was taken from the patients and according to the will of patient they were included in either group.

Group A: The patients were given daily ESWT for ten minutes. Both high-dose and low-dose protocols have been investigated. A high-dose protocol consists of a single treatment of high-energy shock waves. This painful procedure requires anaesthesia. A low-dose protocol consists of multiple treatments, spaced 1 week to 1 month apart, in which a lower dose of shock waves is applied. This protocol does not require anaesthesia. All patients in this group received low dose waves 1, 000 impulses of 0.08mJ/mm2 at frequency of 3 Hz per session of twenty to thirty minutes at weekly interval. They were prescribed NSAIDS along with sponge heel cushion in footwear. Pregnant women, patient less than 18 yrs., those with history of bleeding disorder or on anti-coagulant therapy were excluded from this group.

Group B: These patients were given local steroid injection in the form of 40 mg methyl prednisone mixed with 1ml of 2% lignocaine at biweekly intervals up to a maximum of three injections and anti – inflammatory medications on SOS basis for a couple of days

Patients were assessed as per Visual Analogue Scale (VAS) at the start of treatment and then at 1.5 months, 3 months and 6 months. Results were graded as excellent (0), good (0-30), fair (30-60) and poor (60-100) depending on the VAS score. All patients completed treatment and turned up regularly for follow up.

RESULTS: In our study male to female ratio was 112:88 with majority of patients (152) falling between age group of 31-50 years. The occupational incidence varied as shown in Table 1.

 

Category

Group A

Group B

Total

Police constables

10

8

18

Farmers

22

24

46

Teachers

10

12

22

Shopkeepers

42

38

80

Housewives

12

11

23

Laborers

4

7

11

Table 1: Occupational incidence

Duration of pain was more than three weeks on an average. 82 (41%) patients were found to be obese (above 70 kg. wt.). Bilateral plantar fasciitis was found in 40 patients. The results at six weeks follow up were encouraging towards Group B as 96 patients had excellent and good results whereas only 8 patients had good results in group A.

 

Grades

Group A

Group B

Excellent

--Nil--

8

Good

8

88

Fair

84

4

Poor

8

--Nil--

Total

100

100

Table 2: Group wise evaluation of six weeks of treatment regimen

At three months the number of satisfied patients fell down to 88 while in group A the results were same as at six weeks. The number of patients with poor results increased to 20 in group A.

 

Grades

Group A

Group B

Excellent

--Nil --

16

Good

8

72

Fair

72

12

Poor

20

--Nil--

Total

100

100

Table 3: Group wise Results at Three Months Follow up

At the end of the study the no. of satisfied patients in group B were 96 while 4 had a fair result. In contrast only 47 patients had a satisfactory result in group A while 14 had a poor result.

 

Grades

Group A

Group B

Excellent

--Nil--

16

Good

47

80

Fair

39

4

Poor

14

--Nil--

Total

100

100

Table 4:  Group wise Results at Six Months Follow up

 

DISCUSSION: The etiology and treatment of plantar fasciitis, the most common cause of plantar heel pain are poorly understood. The patient usually in middle years develops pain beneath the heel for no apparent reason on following minor injury to foot. For some time, there is no pain but after a few weeks a painful heel develops. Trauma alone cannot become the whole cause of the lesion, not only because the injury is trivial but it may affect both heels.

It is significant that most patients are middle aged, an age when other inflammatory condition affecting collagen fibres, where they attach to bone are common, like tennis elbow, supraspinatus tendinitis etc. Obesity is also a potent initiating factor in plantar fasciitis and tends to make the lesion refractory to treatment. The presence of spur does not always mean that the patient is suffering from a painful. In our clinical study we found that corticosteroid injection was more efficacious and multiple times more cost effective than ESWT in the treatment of plantar fasciitis.11 In our study no systemic adverse effects were reported in both treatment groups. In Group A, 4 patients suffered from local redness and slight swelling at the point of application of shock waves. In Group B, 2 patients had local complication in the form of temporary local infection treated with oral antibiotics, while 1 patient suffered from skin/ fat atrophy.

CONCLUSION: We conclude that both steroid injection and ESWT are simple outdoor procedures for the treatment of plantar fasciitis. Although both have a role in decreasing pain of plantar fasciitis but corticosteroid injection mixed with local anaesthetic is more effective in the treatment of plantar fasciitis as indicated in our study and similar studies in the past. Further randomized longitudinal trials are required to study the exact role of both these modalities.

REFERENCES:

  •  Lapidus P, Guldotti F. Painful heel: report of 323 patients with 364 painful heels. Clin Orthop 1965; 39:178-86.
  • Furey JG. Plantar fasciitis - The painful heel syndrome. J Bone Joint Surg (Am). 1975; 57:672.
  • Gill L, Kebzak G. Outcome of nonsurgical treatment of plantar fasciitis. Foot Ankle Int.1996; 17:527-32.
  • Freiberg J. The diagnosis and treatment of common painful conditions of the foot. Am Acad Orthop Surg 1957; 14: 238.
  1. Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of non-operative treatment. Foot Ankle Int.1994;15:97-102.
  2. Rompe JD, Hopf C, Nafe B, Burger R. Low Energy Extracorporeal shock wave therapy for painful heel: a prospective controlled single blind study. Arch Orthop Trauma Surg.1996;115:75-79.
  3. Gerdesmeyer L, Frey C, Vester J et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med 2008; 36(11):2100-9.
  4. Gollwitzer H, Diehl P, von Korff A et al. Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg 2007; 46(5):348-57.
  5. Greve JM, Grecco MV, Santos-Silva PR. Comparison of radial shockwaves and conventional physiotherapy for treating plantar fasciitis. Clinics (Sao Paulo) 2009; 64(2):97-103.
  6. Ibrahim MI, Donatelli RA, Schmitz C et al. Chronic plantar fasciitis treated with two sessions of radial extracorporeal shock wave therapy. Foot Ankle Int 2010; 31(5):391-7.
  7. Porte MD, Shadbolt B. Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med. 2005 May; 15(3):119-24.

 

 

 

Videos :

watch?v