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Comparision between Physiotherapy ( Stretching Exercise) VS Platelet- Rich Plasma in Chronic Plantar FascitisMohammed Abdul Azeem1, Ravindra Patil 2*1,2 Associate Professor in the Department of Orthopaedics Dr.VRK Women Medical College, Aziz Nagar, Hyderabad Telangana*Corresponding Author :Email : [email protected],__________________________________________________________________________________Abstract Introduction : Plantar fascitis is a degenerative tissue disease rather than an inflammation. Many treatment options are available like non-steroidal anti-inflammatory drugs, corticosteroid injections, orthosis, and physiotherapy. This study compared the effects of Physiotherapy (Stretching exercise) vs local injection of platelet-rich plasma in the treatment of chronic plantar fasciitis.

Material and Method: Patients were divided randomly into 2 groups of 25 each. Patients were assessed before and after treatment at 4 weeks, 8 wk and at 4-month follow-up.

Results : Mean visual analog scale score in Physiotherapy (Stretching exercise) and platelet-rich plasma groups decreased from 7.24 and 7.02 before treatment to 2.82 and 3.34 at final follow-up. Mean AOFAS score in the physiotherapy and Platelet-rich plasma groups improved from 51.56 and 53.72 before treatment to 87.24 and 81.32 at final follow-up. There was a significant improvement in visual analog scale score and AOFAS score in the Physiotherapy ( Stretching exercise ) and platelet-rich plasma groups at 4 weeks and at 4-month follow-up.Conclusion : The authors concluded that Physiotherapy is also as effective as Platelet-rich plasma injection in treating chronic plantar fascitis.Keywords : Plantar fascitis, treatment, Physiotherapy, Platelet-rich plasma injection__________________________________________________________________________________IntroductionPlantar fascitis is a common cause of heel pain. The diagnosis is based on history and clinical examination. It is well acceptable that reduced plantar flexion, obesity, prolonged weight bearing and are risk factors1. Conservative treatment options are non-steroidal anti-inflammatory drugs (NSAIDs), night splints, ice packs, plantar fascia stretching exercises, corticosteroid injections, and extracorporeal shock wave therapy. In more than 70%-80% of patients, symptoms resolve with non-operative measures2 .In 20% of cases, patients do not improve with conservative management and the disease becomes chronic3 . Delay in treatment, obesity, and bilateral disease are risk factors for chronic disease.4This study is the randomized study in our tertiary centre to compare the effectiveness of Physiotherapy (Stretching exercise ) vs Platelet-rich plasma in chronic plantar fasciitis. To the best of the author’s knowledge, no study has evaluated the effect of Physiotherapy ( Stretching exercise ) VS Platelet-rich plasma in chronic plantar fasciitis. Although previous studies compared platelet-rich plasma and corticosteroid injection with variable results is important in showing that the improvement is the result of treatment only and not the routine course of disease. Platelet-rich plasma local injection is an impressive latest concept in treating tendon and ligament pathologies, including plantar fasciitis. Platelet-rich plasma injection delivers platelets and growth factors in high concentrations directly to the site of injury, which otherwise is inaccessible to growth factors as a result of hypovascularity and hypocellularity.5Table 1 Patient Demographic CharacteristicsCharacteristic Group A (n=25) Group B (n=25) Age, mean±SD, y 32.72±7.42 30.92±8.61 Sex, male:female6:19 9:16 Table 2 Comparison Between Groups A and BScore/Group Before treatment 4 Weeks 4 MonthsVisual analog scale score, mean±SDGroup A 7.24±1.04 3.66±1.53 2.82±1.71Group B 7.02±1.17 2.64±1.46 3.34±1.62P .37 .35 .22American Orthopaedic Foot and Ankle Society score, mean±SDGroup A 51.56±11.1 82.92±12.12 87.24±8.76Group B 53.72±11.79 87.6±6.77 81.32±6.39P .22 .31 .00Materials and MethodsIn our study we included 50 patients with chronic plantar fasciitis and 25 patients in each group .Patients diagnosed on the history and physical examination, including heel pain and tenderness over the plantar- medial aspect of the calcaneal tuberosity, near the insertion of the plantar fascia. In our study we included patient who did not responded to conservative treatment for 6 weeks with unilateral pain. Treatment with NSAIDs was discontinued 10 days before treatment. Patients were divided into 2 groups. Group A was assigned for Physiotherapy in the form of toe walking twice daily for 10 minutes and roller stretching exercises for 3 minutes twice daily, whereas Group B was receive Platelet-rich plasma local injection at the maximum point of tenderness in the heel with a 22-g needle using a single skin portal and 4 to 5 penetrations of the fascia. Injections were given under aseptic conditions as a day procedure. After the injection, patients were advised to apply ice for pain relief if required and to continue to wear comfortable shoes with cushions. All patients had physical therapy to stretch the calf muscle and plantar fascia. Patients were assessed before treatment and during follow-up at 4 weeks and 4 months. Assessment was conducted with the visual analog scale for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot score. In groups A and B, before treatment visual analog scale and AOFAS scores were compared with visual analog scale and AOFAS scores at 4 weeks and 4 months of follow-up. ResultsMean age of the patients in Groups A and B, was 32.72, 30.92, years (Table 1). Mean visual analog scale score in groups A & B before treatment was 7.24, 7.02, which improved to 3.66, 2.64, respectively, at 4 weeks and 2.82, 3.34 at 4 months of follow-up. Mean AOFAS score in groups A & B before treatment was 51.56, 53.72, which improved to 82.92, 87.06 at 4 weeks and 87.24, 81.32 at 4 months of follow-up.Comparison of groups A and B showed no significant difference in visual analog scale and AOFAS scores before treatment (visual analog scale score, P=.37; AOFAS score, P=.22). At 4 weeks of follow-up, Group B had better outcome (low visual analog scale score and high AOFAS score) compared with group A, but the difference was not significant (visual analog scale score, P=.35; AOFAS score, P=.31). At 4 months of follow-up, group A had a significantly higher AOFAS score than group B, but the difference in visual ana- log scale score was not significant (visual analog scale score, P=.22; AOFAS score, P=.00) (Table 2).DiscussionMany authors consider plantar fasciitis a degenerative tissue condition rather than inflammation at the site of origin of the plantar fascia at the medial tuberosity of the calcaneous.6,7 Degeneration of collagen occurs at the site of the lesion because of microtears of the fascia that do not heal. The histologic features of chronic plantar fasciitis show no inflammatory cell invasion at the site of the lesion, and the normal fascia and surrounding tissue are replaced by angiofibroblastic hyperplastic tissue.7,8 Platelet-rich plasma injection delivers platelets with growth factors in high concentrations directly to the site of the lesion, which otherwise is inaccessible to growth factors because of hypovascularity and hypocellularity.9 The cytokines in platelet alpha granules affect the healing stages necessary to reverse chronic plantar fasciitis by enhancing fibroblast migration and proliferation, increase vascularization, and improve collagen deposition.10Previous studies described platelet- rich plasma injection as an effective treatment option for chronic plantar fasciitis Monto11.Shetty et al12 compared the effective ness of platelet-rich plasma and corticosteroid injections in 60 patients and found no significant difference at 6 months of follow-up. The our current study we found that physiotherapy is as good as local platelet-rich plasma at 4 weeks and 4 months of follow-up. Platelet-rich plasma showed significant difference compare to physiotherapy group at 4 weeks of follow-up. At 4 months of follow-up, physiotherapy had significant better outcome compare to platelet-rich plasma injection, based on AOFAS score, but both had the same outcomes, based on visual analog scale score.LimitationsThe sample size in the current study was small, and further study with a larger sample is required to confirm the results and required long duration of follow-up.ConclusionThe authors concluded that Physiotherapy is as effective as Platelet-rich plasma injection in treating chronic plantar fasciitis at 4 months of follow-up and to avoid modern, high tech and expensive options where we can achieve same results with traditional treatment.ReferencesIrving DB, Cook JL, Menz HB. Factors associ- ated with chronic plantar heel pain: a system- atic review. J Sci Med Sport. 2006; 9:11-22.Porter MD, Shadbolt B. Intralesional cortico- steroid injection versus extracorporeal shock wave therapy for plantar fasciopathy. Clin J Sport Med. 2005; 15:119-124.Goff JD, Crawford R. Diagnosis and treat- ment of plantar fasciitis. Am Fam Physician. 2011; 84:676-682.Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994; 15:97-102.Roles NC, Maudsley RH. Radial tunnel syn- drome: resistant tennis elbow as a nerve entrap- ment. J Bone Joint Surg Br. 1972; 54:499-508.Buchbinder R. Clinical practice: plantar fasci- itis. N Engl J Med. 2004; 350:2159-2166.Lemont H, Ammirati K, Usen N. Plantar fas- ciitis: a degenerative process (fasciosis) with- out inflammation. J Am Podiatr Med Assoc. 2003; 93:234-237.Barrett SL, Robert OM. Plantar fasciitis and other causes of heel pain. Am Fam Physician. 1999; 59:2200-2206.Fenwick SA, Hazleman BL, Riley GP. The vas- culature and its role in the damaged and healing tendon. Arthritis Res. 2002; 4:252-260.Molloy T, Wang Y, Murrell G. The roles of growth factors in tendon and ligament heal- ing. Sports Med. 2003; 33:381-394.Monto RR. Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot Ankle Int. 2014; 35:313-318.Shetty VD, Dhillon M, Hegde C, Jagtap P, Shetty S. A study to compare the efficacy of corticosteroid therapy with platelet-rich plas- ma therapy in recalcitrant plantar fasciitis: a preliminary report. Foot Ankle Surg. 2014; 20(1):10-13.

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