Randomized controlled trial on outcome and sonographic changes in Plantar Fascia among Iraqi patients with Plantar Fasciitis treated with manual physiotherapy

Plantar fasciitis (PFS) is one of the common causes of heel pain in the general population. A clinical investigation can provide valuable diagnosis for PFS but it is considered a subjective method that may be affected by the experience of investigator. To performed more accurate diagnosis, medical imaging can be used. Ultrasound imaging can evaluate the morphology of foot muscles and soft tissues such as PF, as well as evaluates the quantitative and qualitative changes that occur in these tissues during the treatment. This study was designed to evaluate the sonographic features of PF, thickness and cross-sectional area (CSA) of Achilles tendon, intrinsic and extrinsic foot muscles, thickness of calcaneal fat pad (CFP) and Kager’s fat pad (KFP) and clinical outcomes in patients with PFS before and after MPT compared to those without MPT and healthy controls. It also aimed to evaluate the efficacy of MPT on these measurements and clinical scores in patients with acute, subacute and chronic PFS. In this randomized controlled trial, a total of 122 subjects were assigned into three groups: PFS with MPT group (40 patients), PFS without MPT group (42 patients) and healthy group (40 subjects). PF (thickness, vascularity, echogenicity, fluid collection and calcifications), thickness and CSA of Achilles tendon, thickness of CFP and KFP, thickness and CSA of intrinsic and extrinsic foot muscles were assessed using ultrasound. Clinical outcomes including pain intensity and FFI (pain, disability and activity limitations) were evaluated by VAS and FFI questionnaire, respectively. The outcome measures were assessed at baseline and one-month after the treatment/follow-ups. PF thickness at calcaneal insertion, 2 cm and 4 cm distal to the insertion was significantly reduced in PFS with MPT group after the treatment (p<0.001, p<0.001 and p=0.002, respectively). Furthermore, a significant reduction in number of patients with hypoechoic PF was reported after MPT (p<0.001). The thickness of CFP (p=0.002), the thickness of AHB (p=0.025) and FHB (p=0.045), thickness (p=0.026) and CSA (p=0.036) of FDB were significantly increased PFS with MPT group. Similarly, the thickness of EDL (p=0.041), thickness (p=0.046) and CSA (p=0.036) of PER was significantly greater in patients after the treatment. Moreover, significant improvement in the VAS-R, VAS-A, FFI-pain and FFI-activity limitation scores was observed in favor of PFS with MPT group. For phases of PFS, the thickness of PF and CFP, thickness and CSA of FDB, pain intensity and activity limitations were improved more among acute phase. Logistic regression analysis showed that PF in patients receiving MPT were less likely by 0.179 times to be hypoechoic than that in patients who did not receive MPT (EXP (B)= 0.179, P<0.001). In conclusion, this study was the first trial mainly used ultrasound to evaluate the effect of MPT on PF, Achilles tendon, fat pads, intrinsic and extrinsic foot muscles in patients with PFS. MPT was effective for treatment PFS by improving, the thickness and echogenicity of PF, thickness of AHB, FHB, EDL and CFP, thickness and CSA of FDB and PER muscles, pain and activity limitation, particularly in those with acute phase.

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