Therapeutic Effect of Botulinum Toxin A for the Treatment of Plantar Fasciitis.

May 23, 2020 updated by: Carlos A Acosta-Olivo, Universidad Autonoma de Nuevo Leon

Plantar fasciitis is the most common cause of plantar heel pain and is commonly present in people 40 years of age or older, overweight, sedentary or with intense physical activity. It is caused by the over-stretching of the plantar fascia, which is a band of connective tissue that extends to the base of the phalanges. This produces micro-tears more commonly in its origin in the medial tuberosity of the calcaneus which causes an inflammatory process and pain. This pain usually occurs when the person gets up in the morning after sleeping or after sitting for a long time. That is when the fascia is stretched after being in a contraction position.

There are a great variety of treatments for this pathology, of these, one of the most common is the use of intralesional steroids, which a weighing that reduces symptomatology in many cases also has undesirable effects such as subcutaneous fat atrophy, rupture of the plantar fascia, peripheral nerve injury, muscle damage and stress fractures. Other treatments are extracorporeal shock waves, application of platelet-rich plasma and application of botulinum toxin A intralesional. All of them are accompanied by insoles, night splints and stretching exercises of the Achilles tendon and the plantar fascia.

Recent studies have shown that the application of botulinum toxin A intralesional in patients with plantar fasciitis helps to improve the symptomatology to decrease pain in both intensity and presentation time. Decreased inflammation of the plantar fascia has also been demonstrated. This is the sale of the usual form of action of the botulinum toxin, which is applied regularly in the muscles to block the release of acetylcholine in the neuromuscular plaque and obtain its relaxation and not directly in the pain points. We believe that the botulinum toxin can be applied intralesional currently, since there is information that the toxin has analgesic and anti-inflammatory effect and not just muscle relaxation.

The aim of our work demonstrate that the use of botulinum toxin A and intralesional stretching exercises is superior to intralesional steroids and stretching trying to establish a safer and less painful therapy avoiding complications prior to the application of steroid application.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Plantar fasciitis represents the most frequent cause of chronic heel pain, usually occurs in patients 40 years or older, overweight, sedentary or with intense physical activity.

The plantar fascia function is to prevent foot collapse by its anatomical orientation and by its tensile forces; It originates at the base of the calcaneus and extends distally to the phalanges. The plantar fascia stretching prevents the displacement of the calcaneus and the metatarsals and maintains the medial longitudinal arch. Simulates a cable attached to the calcaneus and metatarsophalangeal joints. The windlass mechanism described by Hicks, for the action of the plantar fascia is usually explained when a dorsiflexion of the fingers occurs, this leads to an effective shortening of the length of the plantar fascia causing an elevation of the arch. The extension of the fingers increases the arch of tension with the metatarsophalangeal joint as axis or anchor point. The shortening of the plantar fascia resulting from the dorsiflexion of the hallux is the essence of the windlass mechanism. When a fasciotomy is performed, this mechanism is lost, decreasing the stability of the arch and this does not allow a phase of stable terminal stay.

Historically the development of plantar fasciitis is attributed to biomechanical defects such as hyperpronation, this contributes to excesive mobility of the foot, which increases the stress applied to the musculofascial structures and soft tissue through an elongation of plantar fascia. There are other studies that have shown that one of the main factors for the appearance of this disease is the mechanical overload and it has been reported that the tension necessary for the rupture of the windlass mechanism ranges from 1.4 to 3.4 of the body weight of the subject.

There is a great variety of therapies reported for the treatment of this pathology, intralesional application of steroids, platelet-rich plasma, intralesional botulinum toxin A, treatments such as extracorporeal shock waves, all of which are assisted by stretching excercises of the gastrocnemius and sole muscles or stretching of the plantar fascia.

The clinical use of botulinum toxin A has expanded beyond the original indications by its effects on cholinergic neurons. The increased interest in the potential role to treat conditions of chronic pain is partially based on the effects of the toxin on the modulation of the release of substance P, on the calcitonin-related gene peptide and glutamate. On the other hand, the toxin has shown its effect on the inhibition of inflamatory pain and on the release of neurotransmitters from primary sensory neurons in a rat model. It also inhibits peripheral sensitization, which leads to an indirect decrease in central sensitization. It is unclear whether the treatment of chronic plantar fasciitis with botulinum toxin A works by causing muscle paralysis or by analgesic anti-inflamatory effects or by both mechanisms. A combined effect, induction of paresia of the muscles originating in the medial calcaneus process and direct analgesia due to analgesic anti-inflamatory properties.

We performed a previous study, where we compared the use of botulinum toxin A against intralesional steroids; The application of botulinum toxin A was performed in the twin and sole muscle wombs, while dexamethasone was applied in the area of greatest fascia pain. Patients who received botulinum toxin had a faster and more sustained improvement than patients who received steroids.

Another common form of treatment for plantar fasciitis is the application of intralesional steroids; however, there are reports of complications associated with these drugs and one of the main ones is the rupture of the plantar fascia, which ranges from 2.4% to 5.7% ; Despite pain relief due to rupture, many patients have other associated complications such as lateral plantar nerve dysfunction, stress fractures, among others, mainly after 2 applications.

Objective and originality: The aim of our study is to demonstrate that the use of botulinum toxin A for the treatment of plantar fasciitis is superior to treatment with intralesional steroids. We try to establish a safer and less painful treatment therapy for the patient, since the use of steroids is associated with complications. We believe that the botulinum toxin A can also be applied intralesional, since there is information that indicates that this toxin has analgesic and anti-inflammatory effect in its local application and not only by the action of muscle relaxation by blocking the release of acetylcholine at the neuromuscular junctions.

General objective:

To assess the therapeutic effect of botulinum toxin A in patients diagnosed with plantar fasciitis.

Hypothesis:

The application of botulinum toxin A presents better results in the treatment of plantar fascitis than the use of intralesional steroids.

Material and Methods:

All patients who are recruited for the study will be explained regarding the treatment protocol, and will also sign informed consent prior to inclusion in the study. Measurement of the plantar fascia using ultrasound and measurement of ranges of movement of ankle flexion, as well as measuring and weighing patients to know their body mass index. They will be randomized into one of three treatment groups. Group 1 (control) treatment with 5 ml of anesthetic (Ropivacaine 7.5%), Group 2 (steroids) application of 1ml of Betamethasone plus 3 ml of local anesthetic and Group 3 (botulinum toxin A) 250 U, in the insertion zone of the plantar fascia. All patients will receive a detailed explanation of the stretching exercises of the plantar fascia, as well as their frequency and duration. Afterwards, the patients will be evaluated by a blinded investigator, at 2 weeks, 1 month, 3 months and 6 months after infiltration; evaluation scales will be applied: Visual Analogue Scale (EVA), Maryland Foot & Ankle Score, Foot & Ankle Outcome Score (AOFAS), Foot & Ankle Disability Index (FADI).

Study Type

Interventional

Enrollment (Actual)

60

Phase

  • Phase 1

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Mexico
    • Nuevo Leon
      • Monterrey, Nuevo Leon, Mexico, 64460
        • Universidad Autonoma de Nuevo Leon

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Patients with chronic pain in the heel at the insertion of the plantar fascia in the posteroinferior tuberosity of the calcaneus.
  • Patients who agreed to be part of the study and signed informed consent.
  • Patients older than 18 years.
  • Patients with two or more weeks of evolution.

Exclusion Criteria:

  • Patients with another associated pathology such as knee or ankle dysfunction, osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, etc.
  • Neurological abnormalities: mental retardation or some psychiatric abnormality.
  • Pregnant patients.
  • Previous surgery on the heel.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Control
5 ml of local anesthetic (ropivacaine 7.5%)
Drug: Ropivacaine
Other Names:
  • Ropiconest
Active Comparator: Steroid
1ml of steroid Betamethason Sodium Phosphate (Celestone®) and local anesthetic (ropivacaine 7.5%)
Drug: Ropivacaine
Other Names:
  • Ropiconest
Drug: Betamethason Sodium Phosphate
Other Names:
  • Celestone Soluspan
Experimental: BTX-A
200U Botulinum Toxins, Type A
Drug: Botulinum Toxins, Type A
Other Names:
  • Dysport

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Foot and Ankle Disability Index
Time Frame: 6 months
We decided to include the FADI score because this type of pathology occurs in patients with sports activity and often causes disability in them, Values activities such as standing, walking on flat or uneven surfaces, inclined planes, time without discomfort while walking, and includes a module where sports activities are valued. Also it counts on an evaluation of the pain in foot and ankle. The best result obtained is 136 points.
6 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Maryland Foot Score
Time Frame: 6 months
Is divided into several sections where pain is assessed, giving 45 points when there is no pain and 0 when there is inability to work, a function that is divided into two sections, walking and daily activities; And a section that evaluates the shape of the foot, the best score is 100, which means that there is no problem with the foot, and the lowest score is 0.
6 months
Ankle-Hindfoot Scale
Time Frame: 6 months
American Foot and Ankle Orthopedic Society
6 months
Visual Analogue scale
Time Frame: 6 months
Values the pain on a numerical scale of 0-10, where 0 means no pain and 10 greater degree of pain experienced by the patient, it is also complemented by a color scale, where green is equal to painless and red is the more intense pain the patient has had.
6 months
Measurement of the plantar fascia using ultrasound
Time Frame: 6 months
Measure the thickness of the plantar fascia at the beginning and end of the protocol, placing the transducer at the insertion site of the plantar fascia.
6 months
Body Mass Index
Time Frame: 15 minutes
Measure height and weight of patients at the beginning of the protocol.
15 minutes
Measure degrees of dorsiflexion
Time Frame: 6 months
Use a goniometer as a tool to measure degrees of dorsiflexion.
6 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Universidad Autonoma de Nuevo Leon

Investigators

  • Principal Investigator: Carlos Acosta-Olivo, MD, PhD, Universidad Autonoma de Nuevo Leon

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Helpful Links

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

January 1, 2015

Primary Completion (Actual)

March 1, 2020

Study Completion (Actual)

April 1, 2020

Study Registration Dates

First Submitted

February 13, 2017

First Submitted That Met QC Criteria

February 14, 2017

First Posted (Actual)

February 15, 2017

Study Record Updates

Last Update Posted (Actual)

May 27, 2020

Last Update Submitted That Met QC Criteria

May 23, 2020

Last Verified

May 1, 2020

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • OR15-001

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

Clinical Trials on Plantar Fascitis

Clinical Trials on Ropivacaine

Search Similar Trials

Sponsors and Collaborators

Medical Conditions

Drug Interventions

CROs by country

CROs in Hong Kong

Conditions

Rare Diseases

Drug Interventions

Dietary Supplements

Sponsor/Collaborators

Locations

3
Subscribe