A Comparison of Botulinum Toxin A and Intralesional Steroids for the Treatment of Plantar Fasciitis: A Randomized, Double-Blinded Study

SLR - July 2013 - Adam Caton

Reference:  Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E, Mendoza-Lemus O, Acosta-Olivo C.  Foot Ankle Int. 2013 Jan;34(1): 8-14.

 

Scientific Literature Review

Reviewed by: Adam Caton, DPM

Residency Program: Southern Arizona VA Health Care System

Podiatric Relevance: Plantar fasciitis is the most frequent cause of chronic heel pain and has been attributed to biomechanical defects which increase the stress applied to musculofascial structures and soft tissues via an elongation of the plantar fascia. This pathology may be treated with a wide variety of therapies including intralesional application of steroids, platelet-rich plasma, intralesional botulinum toxin A (BTX-A), extracorporeal shock wave therapy; all in combination with stretching exercises of the gastrocnemius, soleus muscles, and/or the plantar fascia. This article provides a comparison of intramuscularly applied botulinum toxin A (BTX-A) in the gastroc-soleus complex versus intralesional steroids for the treatment of plantar fasciitis.
 

Methods: Patients were randomized into two groups according to the treatment received over a six month period. The outcome measures included the Visual Analog Scale (VAS), Maryland Foot and Ankle score, Foot and Ankle Disability Index (FADI), and American Orthopaedic Foot and Ankle Society (AOFAS) score. Patients were instructed to perform plantar fascia stretching exercises over the course of the study. The final number of patients was 36, of whom 19 (10 men and nine women) received BTX-A and 17 (6 men and 11 women) received steroids.

Results:  There were no significant differences in the initial evaluation between the two groups with respect to the results obtained for pain using the VAS. At the second patient visit, a decrease in pain perception in both groups was observed, but there was no difference between the VAS scores. Beginning with the third visit, the group receiving BTX-A exhibited a significant improvement compared to the steroid group. At the end of the study, the patients receiving BTX-A averaged 1.1 ± 1.5 points, whereas for the steroid group, the final average was 3.8 ± 1.15 points.
 

The initial FADI scores were similar for the two groups (75.4 ± 6.92 points for the toxin group and 77.0 ± 3.21 points for the steroid group). A significant improvement in the FADI scores beginning with the second visit was observed, and this improvement was maintained through the end of the study. The same results were obtained with respect to the scales used to measure pain and functionality (i.e., AOFAS, FADI, and Maryland Foot and Ankle scores). Both groups exhibited improvement at the second visit; however this improvement was greater and more sustained in the group receiving BTX-A.

Conclusions: This study suggests that a combination of BTX-A applications into the gastroc-soleus complex and plantar fascia stretching exercises yielded better results for the treatment of plantar fasciitis than intralesional steroids. It is important to note that patients must perform plantar fascia stretching exercises to obtain a rapid and sustained improvement of plantar fasciitis. Only performing exercises to stretch the plantar fascia resulted in a limited short-term benefit which might have reflected a significant longer term improvement. Both short-term and long-term improvement was shown with use of BTX-A. The use of steroids, however, appears to generally result in short-term patient improvement.