Comparative Efficacy of MLS Laser, ESWT, and Exercise Therapy on Plantar Fasciitis Outcomes: A Randomized Controlled Trial

Comparative Efficacy of MLS Laser, ESWT, and Exercise Therapy on Plantar Fasciitis Outcomes: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Efficacy of MLS Laser, ESWT, and Exercise Therapy on Plantar Fasciitis Outcomes: A Randomized Controlled Trial İbrahim Ethem KİREZ, Didem Sezgin ÖZCAN, Ahmet ÜŞEN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5762566/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Plantar fasciitis (PF) is a common cause of heel pain in adults. This study aimed to assess the effects of exercise, Multiwave locked system (MLS) laser, and extracorporeal shock wave (ESWT) treatments on pain, functionality, and quality of life (QoL) in PF patients, and to compare the effectiveness of these treatments. Methods Sixty patients diagnosed with PF were randomized into three groups: exercise therapy alone, exercise plus MLS laser therapy, and exercise plus ESWT. Patients were evaluated using the visual analog scale (VAS), foot ankle outcome score (FAOS), foot function index (FFI), heel tenderness index (HTI), and a fall risk analysis before and one month after treatment. Results All groups showed significant improvements in VAS, HTI, FAOS, FFI, and fall risk scores. The laser group demonstrated more improvement in FFI-pain, FFI-total, FAOS-work-daily life, and FAOS-sports-recreation compared to the exercise group. The ESWT group showed more improvement in VAS, HTI, FFI-pain, FFI-total, and FAOS-sports-recreation compared to the exercise group. There was no significant difference between the laser and ESWT groups. Conclusions In conclusion, exercise, exercise with MLS laser, and exercise with ESWT treatments all reduced pain and improved functionality and QoL in PF patients. ESWT and MLS laser therapies, when combined with exercise, provided better overall improvements than exercise alone. Both are cost-effective, accessible, and non-invasive treatment options that can be safely used for PF. Fasciitis Plantar Exercise Lasers Extracorporeal Shockwave Therapy Pain Quality of Life Figures Figure 1 INTRODUCTION Plantar fasciitis (PF) is a prevalent condition characterized by the degeneration of the plantar fascia, a band of connective tissue that originates from the calcaneus to the proximal phalanges and the skin of the foot's anterior part. Despite common misconceptions, plantar fasciitis is not primarily an inflammatory process but results from repetitive microtears leading to a secondary inflammatory reaction of the plantar fascia. [ 1 , 2 ] Potential risk factors for the development of PF include obesity, prolonged standing, flat feet, and reduced ankle dorsiflexion. [ 3 ] Diagnosis primarily relies on patient history and physical examination findings, with hallmark symptoms being pain in the heel that worsens with the first steps in the morning or after periods of rest. [ 4 ] Despite the condition's self-limiting nature, with 70–80% of patients experiencing symptom relief through conservative treatment alone, a combination of treatments is often necessary for many. [ 1 ] Conservative interventions include rest, cold application, stretching and strengthening exercises, orthotic devices, lifestyle modifications, weight loss, and night splints. Additionally, non-invasive physical therapy modalities such as Extracorporeal Shock Wave Therapy (ESWT), laser, and ultrasound have shown to be cost-effective and accessible treatment options. Invasive treatments, including injections and surgery, are considered for resistant cases. [ 5 ] Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment modality that utilizes high-amplitude pressure waves focused on a targeted body area to induce therapeutic changes without affecting the surface tissue, promoting deep tissue modification. This technique facilitates reversible cellular membrane changes, stimulates cells, and leads to the mechanical breakdown of membranes and bone trabeculae, aiding in the healing process by stimulating tissue structures and dissolving pathological calcifications found in various musculoskeletal disorders. [ 6 ] ESWT is differentiated into focused shock wave therapy (FSWT) and radial shock wave therapy (RSWT), where the former reaches its maximum energy at deeper tissue levels and the latter imparts maximum energy more superficially. [ 7 ] ESWT is also known for its analgesic effects, attributed to two main hypotheses: the degeneration of nerve fibers from small immunoreactive neurons reducing the concentration of pro-inflammatory mediators, and the activation of the diminished inhibitory system in pain control, triggering the release of endorphins and other analgesic molecules. [ 8 ] Laser therapy, another non-invasive method preferred in the treatment of PF, functions by stimulating tissue at various biological levels. [ 9 – 11 ] The FDA categorizes lasers into four safety classes. Low-Level Laser Therapy (LLLT), classified under class 3, uses wavelengths between 620 and 904 nm to stimulate anti-inflammatory responses, cell growth, microcirculation, vascular neoformation, and collagen production. On the other hand, another widely used class 4 laser, High-Intensity Laser Therapy (HILT), operates within the 660 to 1275 nm wavelength range. Its controlled emission laser systems enable therapeutic, photothermal, and photomechanical effects without damaging tissues. [ 12 , 13 ] The Multiwave Locked System (MLS) laser, a class 4 laser system, represents a relatively new advancement in laser therapy, distinguishing itself from LLLT and HILT through its unique combination of continuous and pulsed emission modes. [ 9 , 14 ] The continuous emission operates at a wavelength of 808 nm with a peak power of 1000 mW and an average power of 500 mW, while the pulsed emission features a 905 nm wavelength, reaching a peak power of 25 W and an average power of 54 mW at a frequency of 1500 Hz. This dual-emission approach allows for simultaneous absorption by different mitochondrial complexes, influencing multiple areas within the cellular Krebs cycle and thereby affecting cellular energy metabolism. The continuous emission mode primarily yields anti-inflammatory and anti-edema effects, whereas the pulsed emission mode impacts superficial nociceptors and afferent nerve fibers, modulating nerve transmission and reducing pain. [ 9 , 10 , 15 , 16 ] Previous studies have examined the effectiveness of ESWT, LLLT, HILT, and exercise treatments in patients with PF, demonstrating their efficacy. [ 12 , 17 – 19 ] Although there are studies investigating the effectiveness of MLS laser therapy on various musculoskeletal pathologies, to our knowledge, there is no study specifically examining its efficacy on PF. This study aims to evaluate the effectiveness of exercise combined with ESWT, exercise combined with MLS laser therapy, and exercise alone in female patients diagnosed with unilateral PF, using Visual Analog Scale (VAS), Heel Tenderness Index (HTI), Foot and Ankle Outcome Score (FAOS), Foot Function Index (FFI) and fall risk, as clinical parameters to assess any differences in effectiveness levels among these treatments. MATERIALS AND METHODS This prospective, randomized, single blind, and comparative study was conducted from May 2021 to April 2022 in the Department of Physical Medicine and Rehabilitation at Istanbul Medipol University Faculty of Medicine. The study's inclusion criteria were as follows: (1) age between 18–65 years, (2) female gender, (3) symptoms persisting for at least 6 weeks, (4) unilateral plantar fasciitis and (5) consent to participate in the study. The exclusion criteria included: (1) male gender, (2) bilateral PF (3) treatment with ESWT, laser or injection therapy for PF in the previous year, (4) participation in a physical therapy program for PF in the last six months, (5) history of systemic inflammatory disease, (6) history of lower extremity fracture or surgery, (7) pregnancy, (8) history of epilepsy, (9) malignancy, (10) active infection, (11) coagulation disorders, (12) severe cardiac disease or history of pacemaker, (13) history of neuromuscular disease affecting balance parameters, and (14) regular use of NSAIDs, muscle relaxants, or antidepressants for any reason. Given the predominance of female patients in clinic visits and to address potential gender-related differences in the evaluation of fall risk, it was determined appropriate to focus the research exclusively on female. Patients were thoroughly informed about the study's purpose, treatment methods, treatment duration, and potential side effects. Informed consent was obtained from all participants. This study adheres to the principles of the Declaration of Helsinki and received approval from the Ethics Committee of Istanbul Medipol University Faculty of Medicine on May 20, 2021, under decision number E-10840098-772.02-2504. The trial protocol is registered at clinicaltrails.gov; NCT06446167. Study Design According to the analysis conducted by reviewing reference publications, the estimated sample size was calculated based on the comparison results of AOFAS and VAS scores between groups, and 17 patients were required for each group with a 5% type 1 error level and 80% power. [ 20 ] Sample calculation was performed using G*Power Software version 3.1.9.2 program. Following clinical and radiological evaluations, PF was diagnosed in 66 patients who presented to the outpatient clinic with heel pain. 60 patients met the eligibility criteria and were enrolled in the study. The eligible participants were randomized into three distinct groups each comprising 20 individuals: an exercise alone group (Exercise group), an exercise combined with MLS laser therapy group (Laser group), and an exercise combined with ESWT group (ESWT group). Randomization was conducted using a computer-assisted program. The CONSORT flow diagram depicting the study's progression is illustrated in Fig. 1 . Sociodemographic information, comorbid conditions (hypertension, diabetes mellitus, hypercholesterolemia, asthma) and detailed complaints of the patients were recorded. Fall risk analysis was performed before and after treatment using the Biodex balance system. Patients were not allowed to use any analgesics during the treatment process. Patients were evaluated at two separate times: before treatment and one month after the start of treatment. The evaluation of outcomes was performed by an assessor blinded to the treatment allocation. Outcome measures Visual Analog Scale (VAS): The pain experienced by patients throughout the day (General-VAS) and the pain felt upon the first step after waking up in the morning (VAS-0) were evaluated using VAS. VAS is a scale 10 cm in length, starting from "no pain" and ending with "unbearable pain" (0: no pain, 10: unbearable pain). Patients indicate the severity of their pain by marking the appropriate point on this scale. The distance between "no pain" and this marked point is measured and recorded in centimeters. [ 21 ] Foot Function Index (FFI): The FFI is a self-reported questionnaire designed to assess the impact of foot pathology on three domains: pain (9 items), disability (9 items), and activity limitation (5 items). Each item is rated on a scale from 0 (no issue) to 10 (severe issue). The scores are normalized to a 100-point scale for each domain, offering a detailed metric for functional impairment. To calculate the Total FFI score, the average of the scores from the three subheadings is taken. Higher scores are associated with more severe illness. [ 22 ] The Turkish adaptation of the FFI was conducted by Yalıman et al. [ 23 ] Foot and Ankle Outcome Score (FAOS): Adapted from the knee injury and osteoarthritis outcome score, the FAOS is a detailed tool that evaluates five domains: symptoms and stiffness (7 items), pain (9 items), daily living activities (17 items), sports and recreational activities (5 items), and quality of life (4 items). Each question has 5 different responses that can be scored from 0 for the best condition to 4 for the worst condition, based on the intensity of the complaint. The result ranges from 0 to 100. A score of 0 indicates the worst possible foot and ankle symptoms, while a score of 100 indicates no foot and ankle symptoms. The Total FAOS score is calculated by taking the percentage of responses given to all 42 questions, regardless of the subheadings. [ 24 ] The Turkish adaptation of the FAOS was conducted by Karatepe et al. in 2009. [ 25 ] Heel Tenderness Index (HTI): The HTI quantifies pain sensitivity in the heel through clinical palpation. It is scored from 0 (no pain) to 3 (severe pain with withdrawal reflex), enabling objective assessment of localized tenderness. [ 26 ] Biodex Fall Risk Assessment: The Biodex balance system SD-2014 is a robotic device equipped with computer software that allows tilting up to 20° in all directions, enabling objective assessment of balance and fall risk. High scores indicate impaired balance and increased risk of falling. [ 27 ] During measurement, patients are asked to remove their shoes and step onto the platform, maintaining a comfortable position while visually monitoring themselves on the screen to stay centered. Patients are instructed to maintain this position throughout the measurements. Subsequently, according to the fall risk measurement protocol of the device, fall risk calculations are performed at levels 12 − 8, with 20-second test durations repeated 3 times. The fall risk resulting from these 3 measurements is provided as the overall stability index (OSI) score. Treatment Modalities Exercise Therapy: All groups received a regimen of daily exercises, including stretches for the plantar fascia and Achilles tendon, and strengthening exercises for the calf muscles and foot intrinsic muscles. Each type of exercise was demonstrated to the participants by the same physiotherapist at the beginning of the treatment process, to be performed twice a day with 10 repetitions each time. MLS Laser Therapy: The MLS Laser applied to the treatment group was administered using an ASA brand Mphi model device. Patients in the Laser group were positioned in a prone position. Treatment was applied continuously for 7 minutes along the plantar fascia, sole of the foot, heel area, and Achilles tendon in accordance with the plantar fasciitis treatment program on the device, at a dose of 1.73 J/cm2 and a frequency of 700 Hz. A treatment program was established with 3 sessions per week, totaling 10 sessions. Extracorporeal Shock Wave Therapy (ESWT): The treatment group was administered with the Swiss DolorClast Master ESWT device, which produces radial shock waves. Patients in the ESWT group were positioned in a prone position. The most painful point in the heel area was identified through palpation. Gel was applied to this area, followed by the surrounding soft tissues, towards the plantar fascia and the attachment area of the Achilles tendon at the dorsal aspect of the heel. Radial ESWT treatment was applied at a frequency of 10 Hz, pressure of 2.5 bars, and 2000 impulses per session, once a week for a total of 4 sessions. Statistical Analysis The analyses were conducted using IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 26.0. (Statistical Package for the Social Sciences). The distribution of continuous variables was evaluated using the Shapiro-Wilk test. Descriptive statistics were presented as mean ± standard deviation (SD) for continuous variables, median (minimum-maximum) for discrete variables, and as counts and percentages n(%) for categorical variables. The Kruskal-Wallis test compared more than two independent groups, while the Mann-Whitney U test was used for two-group comparisons. The Wilcoxon test assessed paired differences in non-normally distributed data. Statistical significance was set at p < 0.05. As a post-hoc test, the Bonferroni-corrected Mann-Whitney U test was employed. Following Bonferroni correction, a p-value threshold of 0.016 was determined for statistical significance. RESULTS In this study, patients in all three treatment groups—exercise group (n = 20), laser group (n = 20), and ESWT group (n = 20)—successfully completed their respective treatment protocols with no adverse effects reported. The mean age of participants was 43.32 ± 9.84 (23–61) years and the average symptom duration prior to the study was 9.5 ± 7.39 months. Socio-demographic and clinical data comparisons are detailed in Table 1 , showing no statistically significant differences among the treatment groups (p > 0.05). Only 2 of the 60 patients (3.3%) displayed pathological fall risk scores according to OSI, assessed prior to treatment interventions. Table 1 Comparison of socio-demographic and clinical characteristics of patients in exercise, laser and ESWT groups Exercise Group Median (Min-Max) Laser Group Median (Min-Max) ESWT Group Median (Min-Max) p 1 Age (Year) 41.5 (25–53) 49 (23–61) 47 (25–60) 0.527 BMI (kg/m²) 28.34 (22.58–38.95) 31.24 (20.93–38.29) 29.1 (23.53–34.96) 0.278 Disease Duration (month) 8 (1.5–24) 11 (1.5–24) 6.5 (1.5–36) 0.932 N % N % N % Foot Side Right - Left 13 − 7 65 − 35 15 − 5 75 − 25 12 − 8 60 − 40 0.592 Comorbid Disease Yes - No 12 − 8 60 − 40 10–10 50–50 11 − 9 55 − 45 0.817 Socio Economic Statue Low 7 35 8 40 9 45 0.923 Medium 11 55 11 55 9 45 High 2 10 1 5 2 10 Education Status Illiterate 1 5 0 0 1 5 0.756 Low 13 65 16 80 13 65 High 6 30 4 20 6 30 Epin Calcanei Yes - No 14 − 6 70 − 30 13 − 7 65 − 35 14 − 6 70 − 30 0.926 BMI : Body Mass Index, ESWT : Extracorporeal Shock Wave Therapy Baseline clinical assessments revealed no significant differences among groups in all evaluated clinical scales. Post-treatment, significant improvements were noted in all groups in terms of the VAS, HTI, FFI, and FAOS across all subgroups. Significant differences were observed among the groups regarding the levels of change in clinical parameters including general-VAS, VAS-0, HTI, FFI-pain and disability, FFI-total, and the FAOS- Work-Daily Living and Sports-Recreation, as determined by the Kruskal-Wallis test (p < 0.05). Although there was a statistically significant reduction in the risk of falls in all groups after treatment, the decrease in risk associated with the treatment did not show a significant difference between the groups. (Kruskal Wallis test p > 0.05). (Table 2 , Table 3 and Table 4 ) Table 2 Comparison of VAS values ​​of exercise, laser and ESWT groups before and after treatment Exercise Group Laser Group ESWT Group p 1 General VAS Median (Min-Max) Before Treatment 7 (5–9) 7 (4–10) 7.5 (4–9) 0.722 After Treatment 3.5 (1–7) 2 (0–7) 2.5 (0–7) 0.074 p 2 < 0,001 < 0,001 < 0,001 Score difference -3.5 (-6–1) -5 (-7–1) -5 (-9-0) 0.023* VAS-0 Median (Min-Max) Before Treatment 8 (5–10) 9 (4–10) 9 (4–10) 0.243 After Treatment 4.5 (2–7) 4 (0–8) 3 (0–5) 0.033 p 2 < 0,001 < 0,001 < 0,001 Score difference -3 (-6–1) -4.5 (-9-0) -6 (-10–2) 0.002* Heel Tenderness Index Median (Min-Max) Before Treatment 1.5 (1–3) 2 (1–3) 2 (1–3) 0.102 After Treatment 1 (0–1) 0 (0–1) 0 (0–1) 0.238 p2 < 0,001 < 0,001 < 0,001 Score difference -1 (-2-0) -1 (-2–1) -2 (-3–1) 0.001* Fall Risk Median (Min-Max) Before Treatment 1.3 (0.6–2.4) 1.25 (0.4–2.2) 1.3 (0.7–3.6) 0.415 After Treatment 1.1 (0.7-2) 1 (0.5–2.8) 1.1 (0.8–2.2) 0.123 p 2 0,004 0,045 0,017 Score difference -0.2 (-0.8-0.2) -0.1 (-1.1-0.9) -0.2 (-1.8-0.7) 0.711 VAS : Visual Analog Scale, ESWT : Extracorporeal Shock Wave Therapy p 1 : The Kruskal-Wallis Test, p 2 : The Wilcoxon Test Table 3 Comparison of FFI values ​​before and after treatment in exercise, laser and ESWT groups Exercise Group Laser Group ESWT Group p 1 FFI Pain Median (Min-Max) Before Treatment 59 (30–92) 71 (28–95) 77 (46–92) 0.068 After Treatment 27 (8–78) 21 (3–60) 21 (0–57) 0.345 p 2 < 0,001 < 0,001 < 0,001 Score difference -33.5- (-50–6) -43- (-65–17) -50- (-92–7) < 0.001*,** FFI Disability Median (Min-Max) Before Treatment 59.5 (30–84) 62 (28–96) 72 (36–95) 0.446 After Treatment 28.5 (6–80) 21 (4–81) 20 (3–66) 0.165 p 2 < 0,001 < 0,001 < 0,001 Score difference -30- (-47-0) -40- (-66-19) -46- (-91–2) 0.030 FFI Activity Limitation Median (Min-Max) Before Treatment 26 (6–42) 32 (8–58) 34 (0–56) 0.199 After Treatment 8 (0–36) 8 (2–36) 8 (0–32) 0.926 p2 < 0,001 < 0,001 < 0,001 Score difference -16- (-26-2) -22- (-48–4) -22- (-46-0) 0.131 FFI Total Median (Min-Max) Before Treatment 47.8 (28–70) 54.6 (21.3–83) 57.3 (34–78) 0.111 After Treatment 21.65 (5.3–64.6) 17.3 (3.6–58) 17.3 (1.3–43.6) 0.354 p 2 < 0,001 < 0,001 < 0,001 Score difference -27- (-38–1.4) -37.3- (-59.7–5.3) -42.3- (-76.3–3.7) 0.006*,** FFI : Foot Function Index, ESWT : Extracorporeal Shock Wave Therapy p 1 : The Kruskal-Wallis test, p 2 : The Wilcoxon test Table 4 Comparison of exercise, laser and ESWT groups in terms of FAOS before and after treatment Exercise Group Laser Group ESWT Group p 1 FAOS Symptoms-Stiffness Median (Min-Max) Before Treatment 84 (54–93) 82 (32–100) 77 (36–96) 0.815 After Treatment 91 (39–100) 96 (64–100) 89 (64–100) 0.546 p 2 0,004 < 0,001 < 0,001 Score difference 8.5 (-15-15) 10 (0–40) 11 (-7-28) 0.312 FAOS Pain Median (Min-Max) Before Treatment 57 (25–72) 47 (22–83) 53 (33–86) 0.295 After Treatment 81 (53–94) 83 (39–97) 83 (50–100) 0.949 p 2 < 0,001 < 0,001 < 0,001 Score difference 23.5 (12–47) 30 (11–59) 22.5 (3–53) 0.490 FAOS Function, Daily Living Median (Min-Max) Before Treatment 60.5 (34–75) 53 (28–84) 57.5 (37–88) 0.199 After Treatment 84 (51–97) 87.5 (53–94) 86 (50–100) 0.698 p2 < 0,001 < 0,001 < 0,001 Score difference 22.5 (9–50) 31 (10–60) 24 (4–47) 0.031** FAOS Sports and Recreational Activities Median (Min-Max) Before Treatment 50 (15–70) 47.5 (0–70) 40 (15–65) 0.254 After Treatment 60 (35–95) 67.5 (35–95) 67.5 (25–100) 0.659 p 2 < 0,001 < 0,001 < 0,001 Score difference 12.5 (-5-55) 27.5 (-5-55) 25 (0–70) 0.009*,** FAOS Quality of Life Median (Min-Max) Before Treatment 34.5 (13–56) 31 (0–63) 25 (6–50) 0.175 After Treatment 63 (38–88) 66 (31–94) 69 (38–100) 0.960 p2 < 0,001 < 0,001 < 0,001 Score difference 25 (6–44) 31 (0–50) 34.5 (12–87) 0.212 FAOS Total Median (Min-Max) Before Treatment 59.5 (40–74) 53.5 (23–80) 54.5 (39–76) 0.376 After Treatment 80 (46–94) 83 (51–95) 82 (50–100) 0.703 p 2 < 0,001 < 0,001 < 0,001 Score difference 21 (6–32) 28 (12–49) 22.5 (10–44) 0.069 FAOS : Foot and Ankle Outcome Score, ESWT : Extracorporeal Shock Wave Therapy By post-hoc pairwise comparison; * : Exercise – ESWT group, ** : Exercise – Laser group p 1 : The Kruskal-Wallis test, p 2 : The Wilcoxon test Post-hoc pairwise comparisons indicated significant differences between the exercise group and the laser group in changes in FFI-Pain, FFI-Total, and FAOS scores for Function-Daily Living and Sports-Recreation, with the exercise group showing less improvement. Similarly, between the exercise and ESWT group, significant differences were found in the General-VAS, VAS-0, HTI, FFI-Pain, FFI-Total, and FAOS-Sports and Recreation, with lesser improvements observed in the exercise group (Mann-Whitney U test p < 0.016, Bonferroni correction). No significant differences were noted in the changes in clinical parameters between the laser and ESWT groups, suggesting comparable efficacy between these two treatments. (Table 5 ) Table 5 Post-hoc pairwise comparisons p 2 Exercise vs Laser group Exercise vs ESWT group Laser vs ESWT group General VAS difference 0,035 0,011 0,718 VAS 0 difference 0,035 0,001 0,081 Heel Tenderness Index difference 0,277 0,002 0,024 FFI Pain difference 0,012 < 0,001 0,116 FI Disability difference 0,038 0,021 0,339 FFI Total difference 0,015 0,005 0,172 FAOS Function, Daily Living difference 0,007 0,947 0,068 FAOS Sports and Recreational Activities difference 0,005 0,012 0,799 (p 1 : <0.05; p 2 : Bonferroni correction < 0.016; significant) DISCUSSION The degenerative condition known as PF arises from an inflammatory reaction due to repeated microtears of the fascia. [ 1 ] It is generally recommended that patients with plantar fasciitis initially explore conservative treatment options before proceeding to more invasive interventions. [ 28 ] This study aimed to evaluate the effectiveness of three distinct non-invasive treatment modalities for PF in female patients. These modalities included exercise alone, exercise combined with MLS laser therapy, and exercise combined with ESWT. We assessed these treatments using a variety of clinical parameters, including the VAS, HTI, FFI, FAOS and Biodex Fall Risk Assessment. Our findings demonstrate significant improvements across all treatment groups in terms of pain reduction, functionality, quality of life metrics and fall risk. The ESWT and Laser groups showed greater pain reduction and functional improvements compared to the exercise-only group. Particularly, the ESWT and Laser treatments were similarly effective, showing no significant differences between them, highlighting their comparable efficacy. Throughout their treatment period, all participants were instructed to perform designated foot exercises twice daily. These exercises, comprising both stretching and strengthening routines, are recognized for their effectiveness, affordability, and feasibility. This approach is designed to mitigate risk factors associated with tension in these areas and intrinsic muscle weakness. Historically, emphasis was placed on stretching the Achilles tendon, as limited ankle dorsiflexion was identified as a risk factor for plantar fasciitis. Recent studies, however, have indicated that stretches specifically targeting the plantar fascia may offer greater benefits. [ 29 ] One notable randomized controlled trial involving 82 patients demonstrated a 52% improvement in heel pain in the group performing plantar fascia-specific stretches, as opposed to a 22% improvement in the group focusing on Achilles tendon stretches. [ 19 ] Another comparative study found that patients who underwent a high-intensity strength training program experienced more significant improvements than those who only performed stretching exercises, although both groups showed improvement. [ 30 ] Based on these findings, our study incorporated a comprehensive exercise program for all treatment groups, consisting of stretches for the plantar fascia and Achilles tendon, and strengthening exercises for the calf muscles and the foot's intrinsic muscles. In the assessment conducted at the end of the treatment, it was determined that improvement was observed in all parameters evaluating pain, functionality, quality of life, and fall risk, even when patients were subjected to exercise therapy alone. Extracorporeal Shock Wave Therapy operates on the principle of delivering high-amplitude pressure waves to targeted body areas and in our study, we implemented radial type ESWT as an adjunct to exercise therapy for one of the treatment groups. The hypothesized mechanisms behind ESWT's effectiveness include hyperstimulation analgesia and the stimulation of neovascularization and collagen synthesis in degenerative tissues. [ 31 ] ESWT is recommended as a preferred option over corticosteroid injections, which carry a risk of causing plantar fascia rupture. [ 32 ] The impact of ESWT on plantar fasciitis has been the subject of numerous studies, including systematic reviews and meta-analyses, which collectively affirm its efficacy in decreasing plantar fascia thickness, and significantly improving heel pain compared to placebo treatments. [ 32 – 34 ] Our study corroborates these findings, showing significant improvements in all clinical parameters following ESWT treatment. In the comparative analyses, we determined that compared to the group receiving only exercise, the treatment was superior in reducing general pain and the pain during initial heel contact, as well as in improving heel sensitivity and function. Notably, no significant differences were observed between the ESWT and laser therapy groups regarding the changes in clinical parameters, indicating the similar effectiveness of both treatments. Low-Level Laser Therapy and HILT have gained widespread use since their respective approvals by the FDA. But our study utilized the MLS laser system, which uniquely combines continuous and pulsed laser emissions from a single source, enhancing the therapeutic effects. [ 16 ] Although studies have demonstrated the efficacy of LLLT and HILT in treating plantar fasciitis, research specifically examining the effectiveness of MLS laser therapy for this condition is scant. Research has explored the impact of the MLS laser system on musculoskeletal disorders, showing that it provides significant benefits, especially when combined with physical exercises. Notably, in conditions like chronic neck pain and knee osteoarthritis, MLS laser therapy has been linked to greater improvement compared to LLLT and placebo treatments, as evidenced by higher improvement rates and significant improvements in clinical parameters such as VAS and WOMAC. [ 16 , 35 , 36 ] Our study sought to address a gap in patients with plantar fasciitis, finding significant improvements in all clinical parameters following MLS laser therapy, with outcomes comparable to those achieved with ESWT. When compared with the group that received exercise therapy alone, we found that better results were achieved in terms of FFI-pain subgroup and FFI-total scores indicating better pain relief and function with MLS laser treatment. In the literature, there are studies supporting the observation that patients with PF exhibit an increased risk of falling and balance disorders. In a study evaluating foot problems and the risk of falling, it was determined that female gender, the presence of knee osteoarthritis, and especially the presence of PF increased the risk of falling and affected balance. [ 37 ] To eliminate potential gender-based variations in the assessment of fall risk, only female patients were included in our study. Another study on patients diagnosed with PF showed that postural balance was impaired along the anterior-posterior axis, increasing the risk of falls. [ 38 ] Kamonseki et al. demonstrated in their study that strengthening the plantar flexor muscles decreased pain and improved dynamic stabilization in patients diagnosed with PF. [ 39 ] In our study, the fall risk assessed by OSI scores before treatment was found to be within pathological limits in only 2 patients (1.66%) according to age groups. Although fall risk scores significantly decreased in all three groups with treatment in our study, the differences among the treatment groups were not statistically significant. However, considering these results and the fact that the initial values were mostly within normal limits, this improvement with treatments may not be clinically significant. Limitations While our findings are promising, this study has several limitations that must be acknowledged. Firstly, the study's duration was short, with assessments made only up to one month post-treatment. Longer follow-up periods are needed to assess the sustainability of these improvements over time. Secondly, our study focused exclusively on female patients, which limits the applicability of the results to the general population, including male patients who may experience PF differently due to biomechanical or hormonal differences. In conclusion, our study identified significant improvements across all three treatment groups in terms of pain, functionality, daily life activities, quality of life and fall risk within the first month of treatment. The combination of exercise therapy with either ESWT or MLS laser therapy was found to provide greater improvements in pain and function than exercise therapy alone. No clear superiority was determined among the treatments concerning fall risk and quality of life. These findings highlight the importance of incorporating foot exercise programs into the treatment regimen for PF, emphasizing the role of education in ensuring patient compliance. Both MLS laser and ESWT therapies emerge as cost-effective, accessible, and non-invasive options that can be safely utilized in patients with PF. Future studies should more diverse populations and extend follow-up periods to better understand the long-term outcomes of these treatments especially including MLS laser treatment. Additionally, research into the cost-effectiveness of these treatments could significantly impact clinical decision-making, especially in resource-limited settings. Declarations Ethics approval This study adheres to the principles of the Declaration of Helsinki and received approval from the Ethics Committee of Istanbul Medipol University Faculty of Medicine on May 20, 2021, under decision number E-10840098-772.02-2504. Conflict of interest The authors have no conflicts of interest or competing interests to declare related to the content of this article. Funding There are no funding sources to declare. Author Contribution All writers and contributors who participated in the preparation of the manuscript are listed as authors. References Tong KB, Furia J (2010) Economic burden of plantar fasciitis treatment in the United States. Am J Orthop (Belle Mead NJ) 39(5):227–231 Lee WC, Wong WY, Kung E, Leung AK (2012) Effectiveness of adjustable dorsifl exion night splint in combination with accommodative foot orthosis on plantar fasciitis. J Rehabil Res Dev 49(10):1557–1564 Rano JA, Fallat LM, Savoy-Moore RT (2001) Correlation of heel pain with body mass index and other characteristics of heel pain. J Foot Ankle Surg 40:351 Goff JD, Crawford R (2011) Diagnosis and treatment of plantar fasciitis. 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Foot Ankle Int 23(7):619–624 Becker BA, Childress MA (2018) Common foot problems: over-the-counter treatments and home care. Am Fam Physician 98(5):298–303 Rathleff MS, Mølgaard CM, Fredberg U et al (2015) High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 25(3):e292–e300 Sun J, Gao F, Wang Y, Sun W, Jiang B, Li Z (2017) Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs. Medicine 96:e6621 Ogden JA, Alvarez RG, Marlow M (2002) Shockwave therapy for chronic proximal plantar fasciitis: A meta-analysis. Foot Ankle Int 23:301–308 Speed C (2014) A systematic review of shockwave therapies in soft tissue conditions: Focusing on the evidence. Br J Sports Med 48:1538–1542 Al-Abbad H, Allen S, Morris S, Reznik J, Biros E, Paulik B, Wright A (2020) The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: A systematic review and meta-analysis with meta-regression. BMC Musculoskelet Disord 21:275 Dakowicz A et al (2017) june. Assessment of the Effectiveness of MLS Laser Therapy in the Treatment of Patients with Knee Osteoarthritis. Polish Journal of Applied Sciences, [S.l.], v. 1, n. 4, pp. 124–129, ISSN 2451 – 1544 Alayat M, Ibrahim Salem M (2017) Efficacy of class IV diode laser on pain and dysfunction in patients with knee osteoarthritis: a randomized placebo-control trial. Bulletin of Faculty of Physical Therapy Chaiwanichsiri D, Janchai S, Tantisiriwat N (2009) Foot disorders and falls in older persons. Gerontology 55:296–302 Ağırman M (2019) Evaluation of Balance and Fall Risk in Patients with Plantar Fasciitis Syndrome. Sisli Etfal Hastan Tip Bul 53(4):426–429 Published 2019 Nov 19 Kamonseki DH, Gonçalves GA, Yi LC, Júnior IL (2016) Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial. Man Ther 23:76–82 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5762566","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401979488,"identity":"afeb3a5f-72f7-4599-8cf9-a8cbece3bdbb","order_by":0,"name":"İbrahim Ethem KİREZ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYBACNiA8AKTlQJwDD0jRYgzWkkCsPSCQ2AAiidLCx96WeLiioi59ftjhh0Bb7OR0GwjZwXPswMEzZ9hyN95OMwBqSTY2O0BIi0R6w8HGNp7cjbMTQFoOJG4jqEX+OVDLP4l0w9npH4jUIsF24GBjg0GCvHQOsbbwpCUcbDiWYLhBOqfgQIIBEX6Rbz9m/LGhpk5efnb65g8fKuzkCGqBAwOwSgNilYOtayBF9SgYBaNgFIwoAAAfU0WTzV7eHwAAAABJRU5ErkJggg==","orcid":"","institution":"Istanbul Health Sciences University, Bagcilar Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"İbrahim","middleName":"Ethem","lastName":"KİREZ","suffix":""},{"id":401979489,"identity":"395e0414-1b42-4122-a773-5e8af50ce3c0","order_by":1,"name":"Didem Sezgin ÖZCAN","email":"","orcid":"","institution":"Medicana International Ankara Hospital","correspondingAuthor":false,"prefix":"","firstName":"Didem","middleName":"Sezgin","lastName":"ÖZCAN","suffix":""},{"id":401979490,"identity":"40a77c1c-84ea-4837-b2f0-af2df88029d6","order_by":2,"name":"Ahmet ÜŞEN","email":"","orcid":"","institution":"Medipol University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ahmet","middleName":"","lastName":"ÜŞEN","suffix":""}],"badges":[],"createdAt":"2025-01-04 09:08:13","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5762566/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5762566/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74247426,"identity":"8e49b5f5-2eb0-4da9-9de3-2d39e8797597","added_by":"auto","created_at":"2025-01-20 10:04:18","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":72654,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study design. ESWT: Extracorporeal Shock Wave Therapy, VAS: Visual Analog Scale, FFI: Foot Function Index, FAOS: Foot and Ankle Outcome Score, HTI: Heel Tenderness Index\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5762566/v1/14fe2845451a7ef6f99b6bd0.jpeg"},{"id":90211615,"identity":"6f794698-5875-4f3e-a8f3-629933ac2ed3","added_by":"auto","created_at":"2025-08-30 03:16:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1645274,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5762566/v1/2a6a89e8-8c58-4939-a504-d5e29b6fe6be.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Efficacy of MLS Laser, ESWT, and Exercise Therapy on Plantar Fasciitis Outcomes: A Randomized Controlled Trial","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePlantar fasciitis (PF) is a prevalent condition characterized by the degeneration of the plantar fascia, a band of connective tissue that originates from the calcaneus to the proximal phalanges and the skin of the foot's anterior part. Despite common misconceptions, plantar fasciitis is not primarily an inflammatory process but results from repetitive microtears leading to a secondary inflammatory reaction of the plantar fascia. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Potential risk factors for the development of PF include obesity, prolonged standing, flat feet, and reduced ankle dorsiflexion. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Diagnosis primarily relies on patient history and physical examination findings, with hallmark symptoms being pain in the heel that worsens with the first steps in the morning or after periods of rest. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Despite the condition's self-limiting nature, with 70\u0026ndash;80% of patients experiencing symptom relief through conservative treatment alone, a combination of treatments is often necessary for many. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Conservative interventions include rest, cold application, stretching and strengthening exercises, orthotic devices, lifestyle modifications, weight loss, and night splints. Additionally, non-invasive physical therapy modalities such as Extracorporeal Shock Wave Therapy (ESWT), laser, and ultrasound have shown to be cost-effective and accessible treatment options. Invasive treatments, including injections and surgery, are considered for resistant cases. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eExtracorporeal shock wave therapy (ESWT) is a non-invasive treatment modality that utilizes high-amplitude pressure waves focused on a targeted body area to induce therapeutic changes without affecting the surface tissue, promoting deep tissue modification. This technique facilitates reversible cellular membrane changes, stimulates cells, and leads to the mechanical breakdown of membranes and bone trabeculae, aiding in the healing process by stimulating tissue structures and dissolving pathological calcifications found in various musculoskeletal disorders. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] ESWT is differentiated into focused shock wave therapy (FSWT) and radial shock wave therapy (RSWT), where the former reaches its maximum energy at deeper tissue levels and the latter imparts maximum energy more superficially. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] ESWT is also known for its analgesic effects, attributed to two main hypotheses: the degeneration of nerve fibers from small immunoreactive neurons reducing the concentration of pro-inflammatory mediators, and the activation of the diminished inhibitory system in pain control, triggering the release of endorphins and other analgesic molecules. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLaser therapy, another non-invasive method preferred in the treatment of PF, functions by stimulating tissue at various biological levels. [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The FDA categorizes lasers into four safety classes. Low-Level Laser Therapy (LLLT), classified under class 3, uses wavelengths between 620 and 904 nm to stimulate anti-inflammatory responses, cell growth, microcirculation, vascular neoformation, and collagen production. On the other hand, another widely used class 4 laser, High-Intensity Laser Therapy (HILT), operates within the 660 to 1275 nm wavelength range. Its controlled emission laser systems enable therapeutic, photothermal, and photomechanical effects without damaging tissues. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The Multiwave Locked System (MLS) laser, a class 4 laser system, represents a relatively new advancement in laser therapy, distinguishing itself from LLLT and HILT through its unique combination of continuous and pulsed emission modes. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The continuous emission operates at a wavelength of 808 nm with a peak power of 1000 mW and an average power of 500 mW, while the pulsed emission features a 905 nm wavelength, reaching a peak power of 25 W and an average power of 54 mW at a frequency of 1500 Hz. This dual-emission approach allows for simultaneous absorption by different mitochondrial complexes, influencing multiple areas within the cellular Krebs cycle and thereby affecting cellular energy metabolism. The continuous emission mode primarily yields anti-inflammatory and anti-edema effects, whereas the pulsed emission mode impacts superficial nociceptors and afferent nerve fibers, modulating nerve transmission and reducing pain. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePrevious studies have examined the effectiveness of ESWT, LLLT, HILT, and exercise treatments in patients with PF, demonstrating their efficacy. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Although there are studies investigating the effectiveness of MLS laser therapy on various musculoskeletal pathologies, to our knowledge, there is no study specifically examining its efficacy on PF. This study aims to evaluate the effectiveness of exercise combined with ESWT, exercise combined with MLS laser therapy, and exercise alone in female patients diagnosed with unilateral PF, using Visual Analog Scale (VAS), Heel Tenderness Index (HTI), Foot and Ankle Outcome Score (FAOS), Foot Function Index (FFI) and fall risk, as clinical parameters to assess any differences in effectiveness levels among these treatments.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis prospective, randomized, single blind, and comparative study was conducted from May 2021 to April 2022 in the Department of Physical Medicine and Rehabilitation at Istanbul Medipol University Faculty of Medicine. The study's inclusion criteria were as follows: (1) age between 18\u0026ndash;65 years, (2) female gender, (3) symptoms persisting for at least 6 weeks, (4) unilateral plantar fasciitis and (5) consent to participate in the study. The exclusion criteria included: (1) male gender, (2) bilateral PF (3) treatment with ESWT, laser or injection therapy for PF in the previous year, (4) participation in a physical therapy program for PF in the last six months, (5) history of systemic inflammatory disease, (6) history of lower extremity fracture or surgery, (7) pregnancy, (8) history of epilepsy, (9) malignancy, (10) active infection, (11) coagulation disorders, (12) severe cardiac disease or history of pacemaker, (13) history of neuromuscular disease affecting balance parameters, and (14) regular use of NSAIDs, muscle relaxants, or antidepressants for any reason. Given the predominance of female patients in clinic visits and to address potential gender-related differences in the evaluation of fall risk, it was determined appropriate to focus the research exclusively on female. Patients were thoroughly informed about the study's purpose, treatment methods, treatment duration, and potential side effects. Informed consent was obtained from all participants. This study adheres to the principles of the Declaration of Helsinki and received approval from the Ethics Committee of Istanbul Medipol University Faculty of Medicine on May 20, 2021, under decision number E-10840098-772.02-2504. The trial protocol is registered at clinicaltrails.gov; NCT06446167.\u003c/p\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003cp\u003eAccording to the analysis conducted by reviewing reference publications, the estimated sample size was calculated based on the comparison results of AOFAS and VAS scores between groups, and 17 patients were required for each group with a 5% type 1 error level and 80% power. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Sample calculation was performed using G*Power Software version 3.1.9.2 program.\u003c/p\u003e \u003cp\u003eFollowing clinical and radiological evaluations, PF was diagnosed in 66 patients who presented to the outpatient clinic with heel pain. 60 patients met the eligibility criteria and were enrolled in the study. The eligible participants were randomized into three distinct groups each comprising 20 individuals: an exercise alone group (Exercise group), an exercise combined with MLS laser therapy group (Laser group), and an exercise combined with ESWT group (ESWT group). Randomization was conducted using a computer-assisted program. The CONSORT flow diagram depicting the study's progression is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Sociodemographic information, comorbid conditions (hypertension, diabetes mellitus, hypercholesterolemia, asthma) and detailed complaints of the patients were recorded. Fall risk analysis was performed before and after treatment using the Biodex balance system. Patients were not allowed to use any analgesics during the treatment process. Patients were evaluated at two separate times: before treatment and one month after the start of treatment. The evaluation of outcomes was performed by an assessor blinded to the treatment allocation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOutcome measures\u003c/p\u003e \u003cp\u003eVisual Analog Scale (VAS): The pain experienced by patients throughout the day (General-VAS) and the pain felt upon the first step after waking up in the morning (VAS-0) were evaluated using VAS. VAS is a scale 10 cm in length, starting from \"no pain\" and ending with \"unbearable pain\" (0: no pain, 10: unbearable pain). Patients indicate the severity of their pain by marking the appropriate point on this scale. The distance between \"no pain\" and this marked point is measured and recorded in centimeters. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFoot Function Index (FFI): The FFI is a self-reported questionnaire designed to assess the impact of foot pathology on three domains: pain (9 items), disability (9 items), and activity limitation (5 items). Each item is rated on a scale from 0 (no issue) to 10 (severe issue). The scores are normalized to a 100-point scale for each domain, offering a detailed metric for functional impairment. To calculate the Total FFI score, the average of the scores from the three subheadings is taken. Higher scores are associated with more severe illness. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] The Turkish adaptation of the FFI was conducted by Yalıman et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFoot and Ankle Outcome Score (FAOS): Adapted from the knee injury and osteoarthritis outcome score, the FAOS is a detailed tool that evaluates five domains: symptoms and stiffness (7 items), pain (9 items), daily living activities (17 items), sports and recreational activities (5 items), and quality of life (4 items). Each question has 5 different responses that can be scored from 0 for the best condition to 4 for the worst condition, based on the intensity of the complaint. The result ranges from 0 to 100. A score of 0 indicates the worst possible foot and ankle symptoms, while a score of 100 indicates no foot and ankle symptoms. The Total FAOS score is calculated by taking the percentage of responses given to all 42 questions, regardless of the subheadings. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] The Turkish adaptation of the FAOS was conducted by Karatepe et al. in 2009. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHeel Tenderness Index (HTI): The HTI quantifies pain sensitivity in the heel through clinical palpation. It is scored from 0 (no pain) to 3 (severe pain with withdrawal reflex), enabling objective assessment of localized tenderness. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBiodex Fall Risk Assessment: The Biodex balance system SD-2014 is a robotic device equipped with computer software that allows tilting up to 20\u0026deg; in all directions, enabling objective assessment of balance and fall risk. High scores indicate impaired balance and increased risk of falling. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] During measurement, patients are asked to remove their shoes and step onto the platform, maintaining a comfortable position while visually monitoring themselves on the screen to stay centered. Patients are instructed to maintain this position throughout the measurements. Subsequently, according to the fall risk measurement protocol of the device, fall risk calculations are performed at levels 12\u0026thinsp;\u0026minus;\u0026thinsp;8, with 20-second test durations repeated 3 times. The fall risk resulting from these 3 measurements is provided as the overall stability index (OSI) score.\u003c/p\u003e \u003cp\u003eTreatment Modalities\u003c/p\u003e \u003cp\u003eExercise Therapy: All groups received a regimen of daily exercises, including stretches for the plantar fascia and Achilles tendon, and strengthening exercises for the calf muscles and foot intrinsic muscles. Each type of exercise was demonstrated to the participants by the same physiotherapist at the beginning of the treatment process, to be performed twice a day with 10 repetitions each time.\u003c/p\u003e \u003cp\u003eMLS Laser Therapy: The MLS Laser applied to the treatment group was administered using an ASA brand Mphi model device. Patients in the Laser group were positioned in a prone position. Treatment was applied continuously for 7 minutes along the plantar fascia, sole of the foot, heel area, and Achilles tendon in accordance with the plantar fasciitis treatment program on the device, at a dose of 1.73 J/cm2 and a frequency of 700 Hz. A treatment program was established with 3 sessions per week, totaling 10 sessions.\u003c/p\u003e \u003cp\u003eExtracorporeal Shock Wave Therapy (ESWT): The treatment group was administered with the Swiss DolorClast Master ESWT device, which produces radial shock waves. Patients in the ESWT group were positioned in a prone position. The most painful point in the heel area was identified through palpation. Gel was applied to this area, followed by the surrounding soft tissues, towards the plantar fascia and the attachment area of the Achilles tendon at the dorsal aspect of the heel. Radial ESWT treatment was applied at a frequency of 10 Hz, pressure of 2.5 bars, and 2000 impulses per session, once a week for a total of 4 sessions.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe analyses were conducted using IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 26.0. (Statistical Package for the Social Sciences). The distribution of continuous variables was evaluated using the Shapiro-Wilk test. Descriptive statistics were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for continuous variables, median (minimum-maximum) for discrete variables, and as counts and percentages n(%) for categorical variables. The Kruskal-Wallis test compared more than two independent groups, while the Mann-Whitney U test was used for two-group comparisons. The Wilcoxon test assessed paired differences in non-normally distributed data. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. As a post-hoc test, the Bonferroni-corrected Mann-Whitney U test was employed. Following Bonferroni correction, a p-value threshold of 0.016 was determined for statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eIn this study, patients in all three treatment groups\u0026mdash;exercise group (n\u0026thinsp;=\u0026thinsp;20), laser group (n\u0026thinsp;=\u0026thinsp;20), and ESWT group (n\u0026thinsp;=\u0026thinsp;20)\u0026mdash;successfully completed their respective treatment protocols with no adverse effects reported. The mean age of participants was 43.32\u0026thinsp;\u0026plusmn;\u0026thinsp;9.84 (23\u0026ndash;61) years and the average symptom duration prior to the study was 9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.39 months. Socio-demographic and clinical data comparisons are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, showing no statistically significant differences among the treatment groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Only 2 of the 60 patients (3.3%) displayed pathological fall risk scores according to OSI, assessed prior to treatment interventions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of socio-demographic and clinical characteristics of patients in exercise, laser and ESWT groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eExercise Group Median (Min-Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eLaser Group Median (Min-Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eESWT Group Median (Min-Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e41.5 (25\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e49 (23\u0026ndash;61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e47 (25\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e28.34 (22.58\u0026ndash;38.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e31.24 (20.93\u0026ndash;38.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e29.1 (23.53\u0026ndash;34.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisease Duration (month)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e8 (1.5\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e11 (1.5\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e6.5 (1.5\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFoot Side\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRight - Left\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u0026thinsp;\u0026minus;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u0026thinsp;\u0026minus;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75\u0026thinsp;\u0026minus;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u0026thinsp;\u0026minus;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e60\u0026thinsp;\u0026minus;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.592\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbid Disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes - No\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u0026thinsp;\u0026minus;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u0026thinsp;\u0026minus;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11\u0026thinsp;\u0026minus;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55\u0026thinsp;\u0026minus;\u0026thinsp;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSocio Economic Statue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.923\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMedium\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEducation Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIlliterate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEpin Calcanei\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes - No\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026thinsp;\u0026minus;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u0026thinsp;\u0026minus;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u0026thinsp;\u0026minus;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65\u0026thinsp;\u0026minus;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14\u0026thinsp;\u0026minus;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e70\u0026thinsp;\u0026minus;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cb\u003eBMI\u003c/b\u003e: Body Mass Index, \u003cb\u003eESWT\u003c/b\u003e: Extracorporeal Shock Wave Therapy\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBaseline clinical assessments revealed no significant differences among groups in all evaluated clinical scales. Post-treatment, significant improvements were noted in all groups in terms of the VAS, HTI, FFI, and FAOS across all subgroups. Significant differences were observed among the groups regarding the levels of change in clinical parameters including general-VAS, VAS-0, HTI, FFI-pain and disability, FFI-total, and the FAOS- Work-Daily Living and Sports-Recreation, as determined by the Kruskal-Wallis test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Although there was a statistically significant reduction in the risk of falls in all groups after treatment, the decrease in risk associated with the treatment did not show a significant difference between the groups. (Kruskal Wallis test p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of VAS values ​​of exercise, laser and ESWT groups before and after treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExercise Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaser Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eESWT Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eGeneral VAS Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (4\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.5 (4\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.722\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 (1\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5 (0\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-3.5 (-6\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5 (-7\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-5 (-9-0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.023*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eVAS-0 Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (5\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (4\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (4\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5 (2\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (0\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-3 (-6\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.5 (-9-0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-6 (-10\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eHeel Tenderness Index Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.5 (1\u0026ndash;3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1 (0\u0026ndash;1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-1 (-2-0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1 (-2\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2 (-3\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFall Risk Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3 (0.6\u0026ndash;2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25 (0.4\u0026ndash;2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.3 (0.7\u0026ndash;3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1 (0.7-2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.5\u0026ndash;2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.1 (0.8\u0026ndash;2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,045\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0,017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.2 (-0.8-0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.1 (-1.1-0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.2 (-1.8-0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eVAS\u003c/b\u003e: Visual Analog Scale, \u003cb\u003eESWT\u003c/b\u003e: Extracorporeal Shock Wave Therapy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e: The Kruskal-Wallis Test, \u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e: The Wilcoxon Test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of FFI values ​​before and after treatment in exercise, laser and ESWT groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExercise Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaser Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eESWT Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFFI Pain Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (30\u0026ndash;92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (28\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77 (46\u0026ndash;92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (8\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (3\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (0\u0026ndash;57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-33.5- (-50\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-43- (-65\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-50- (-92\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*,**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFFI Disability Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.5 (30\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (28\u0026ndash;96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72 (36\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.5 (6\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (4\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (3\u0026ndash;66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-30- (-47-0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-40- (-66-19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-46- (-91\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFFI Activity Limitation Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (6\u0026ndash;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (8\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (0\u0026ndash;56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (0\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (2\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (0\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-16- (-26-2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-22- (-48\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-22- (-46-0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFFI Total Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.8 (28\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.6 (21.3\u0026ndash;83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.3 (34\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.65 (5.3\u0026ndash;64.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.3 (3.6\u0026ndash;58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.3 (1.3\u0026ndash;43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.354\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-27- (-38\u0026ndash;1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-37.3- (-59.7\u0026ndash;5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-42.3- (-76.3\u0026ndash;3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.006*,**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eFFI\u003c/b\u003e: Foot Function Index, \u003cb\u003eESWT\u003c/b\u003e: Extracorporeal Shock Wave Therapy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e: The Kruskal-Wallis test, \u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e: The Wilcoxon test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of exercise, laser and ESWT groups in terms of FAOS before and after treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExercise Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaser Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eESWT Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFAOS Symptoms-Stiffness Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (54\u0026ndash;93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82 (32\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77 (36\u0026ndash;96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (39\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96 (64\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89 (64\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.546\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5 (-15-15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (0\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (-7-28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFAOS Pain Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (25\u0026ndash;72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (22\u0026ndash;83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53 (33\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (53\u0026ndash;94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83 (39\u0026ndash;97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83 (50\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.5 (12\u0026ndash;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (11\u0026ndash;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.5 (3\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.490\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFAOS Function, Daily Living Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.5 (34\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (28\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.5 (37\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (51\u0026ndash;97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.5 (53\u0026ndash;94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86 (50\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.698\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5 (9\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (10\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (4\u0026ndash;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.031**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFAOS Sports and Recreational Activities Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (15\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.5 (0\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (15\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (35\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.5 (35\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.5 (25\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.659\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5 (-5-55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.5 (-5-55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (0\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.009*,**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFAOS Quality of Life Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.5 (13\u0026ndash;56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (0\u0026ndash;63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (6\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (38\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66 (31\u0026ndash;94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69 (38\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (6\u0026ndash;44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (0\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.5 (12\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFAOS Total Median (Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBefore Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.5 (40\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.5 (23\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.5 (39\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAfter Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (46\u0026ndash;94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83 (51\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82 (50\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.703\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eScore difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (6\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (12\u0026ndash;49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.5 (10\u0026ndash;44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eFAOS\u003c/b\u003e: Foot and Ankle Outcome Score, \u003cb\u003eESWT\u003c/b\u003e: Extracorporeal Shock Wave Therapy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBy post-hoc pairwise comparison; \u003cb\u003e*\u003c/b\u003e: Exercise \u0026ndash; ESWT group, \u003cb\u003e**\u003c/b\u003e: Exercise \u0026ndash; Laser group\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e: The Kruskal-Wallis test, \u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e: The Wilcoxon test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePost-hoc pairwise comparisons indicated significant differences between the exercise group and the laser group in changes in FFI-Pain, FFI-Total, and FAOS scores for Function-Daily Living and Sports-Recreation, with the exercise group showing less improvement. Similarly, between the exercise and ESWT group, significant differences were found in the General-VAS, VAS-0, HTI, FFI-Pain, FFI-Total, and FAOS-Sports and Recreation, with lesser improvements observed in the exercise group (Mann-Whitney U test p\u0026thinsp;\u0026lt;\u0026thinsp;0.016, Bonferroni correction). No significant differences were noted in the changes in clinical parameters between the laser and ESWT groups, suggesting comparable efficacy between these two treatments. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-hoc pairwise comparisons p\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExercise vs\u003c/p\u003e \u003cp\u003eLaser group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExercise vs\u003c/p\u003e \u003cp\u003eESWT group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaser vs ESWT group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeneral VAS difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,718\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS 0 difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeel Tenderness Index difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFFI Pain difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0,012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFI Disability difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,339\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFFI Total difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0,015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,172\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFAOS Function, Daily Living difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0,007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFAOS Sports and Recreational Activities difference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0,005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,799\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003e(p\u003c/em\u003e\u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e: \u003cem\u003e\u0026lt;0.05; p\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e: \u003cem\u003eBonferroni correction\u0026thinsp;\u0026lt;\u0026thinsp;0.016; significant)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe degenerative condition known as PF arises from an inflammatory reaction due to repeated microtears of the fascia. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] It is generally recommended that patients with plantar fasciitis initially explore conservative treatment options before proceeding to more invasive interventions. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] This study aimed to evaluate the effectiveness of three distinct non-invasive treatment modalities for PF in female patients. These modalities included exercise alone, exercise combined with MLS laser therapy, and exercise combined with ESWT. We assessed these treatments using a variety of clinical parameters, including the VAS, HTI, FFI, FAOS and Biodex Fall Risk Assessment. Our findings demonstrate significant improvements across all treatment groups in terms of pain reduction, functionality, quality of life metrics and fall risk. The ESWT and Laser groups showed greater pain reduction and functional improvements compared to the exercise-only group. Particularly, the ESWT and Laser treatments were similarly effective, showing no significant differences between them, highlighting their comparable efficacy.\u003c/p\u003e \u003cp\u003eThroughout their treatment period, all participants were instructed to perform designated foot exercises twice daily. These exercises, comprising both stretching and strengthening routines, are recognized for their effectiveness, affordability, and feasibility. This approach is designed to mitigate risk factors associated with tension in these areas and intrinsic muscle weakness. Historically, emphasis was placed on stretching the Achilles tendon, as limited ankle dorsiflexion was identified as a risk factor for plantar fasciitis. Recent studies, however, have indicated that stretches specifically targeting the plantar fascia may offer greater benefits. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] One notable randomized controlled trial involving 82 patients demonstrated a 52% improvement in heel pain in the group performing plantar fascia-specific stretches, as opposed to a 22% improvement in the group focusing on Achilles tendon stretches. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Another comparative study found that patients who underwent a high-intensity strength training program experienced more significant improvements than those who only performed stretching exercises, although both groups showed improvement. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Based on these findings, our study incorporated a comprehensive exercise program for all treatment groups, consisting of stretches for the plantar fascia and Achilles tendon, and strengthening exercises for the calf muscles and the foot's intrinsic muscles. In the assessment conducted at the end of the treatment, it was determined that improvement was observed in all parameters evaluating pain, functionality, quality of life, and fall risk, even when patients were subjected to exercise therapy alone.\u003c/p\u003e \u003cp\u003eExtracorporeal Shock Wave Therapy operates on the principle of delivering high-amplitude pressure waves to targeted body areas and in our study, we implemented radial type ESWT as an adjunct to exercise therapy for one of the treatment groups. The hypothesized mechanisms behind ESWT's effectiveness include hyperstimulation analgesia and the stimulation of neovascularization and collagen synthesis in degenerative tissues. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] ESWT is recommended as a preferred option over corticosteroid injections, which carry a risk of causing plantar fascia rupture. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] The impact of ESWT on plantar fasciitis has been the subject of numerous studies, including systematic reviews and meta-analyses, which collectively affirm its efficacy in decreasing plantar fascia thickness, and significantly improving heel pain compared to placebo treatments. [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Our study corroborates these findings, showing significant improvements in all clinical parameters following ESWT treatment. In the comparative analyses, we determined that compared to the group receiving only exercise, the treatment was superior in reducing general pain and the pain during initial heel contact, as well as in improving heel sensitivity and function. Notably, no significant differences were observed between the ESWT and laser therapy groups regarding the changes in clinical parameters, indicating the similar effectiveness of both treatments.\u003c/p\u003e \u003cp\u003eLow-Level Laser Therapy and HILT have gained widespread use since their respective approvals by the FDA. But our study utilized the MLS laser system, which uniquely combines continuous and pulsed laser emissions from a single source, enhancing the therapeutic effects. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Although studies have demonstrated the efficacy of LLLT and HILT in treating plantar fasciitis, research specifically examining the effectiveness of MLS laser therapy for this condition is scant. Research has explored the impact of the MLS laser system on musculoskeletal disorders, showing that it provides significant benefits, especially when combined with physical exercises. Notably, in conditions like chronic neck pain and knee osteoarthritis, MLS laser therapy has been linked to greater improvement compared to LLLT and placebo treatments, as evidenced by higher improvement rates and significant improvements in clinical parameters such as VAS and WOMAC. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] Our study sought to address a gap in patients with plantar fasciitis, finding significant improvements in all clinical parameters following MLS laser therapy, with outcomes comparable to those achieved with ESWT. When compared with the group that received exercise therapy alone, we found that better results were achieved in terms of FFI-pain subgroup and FFI-total scores indicating better pain relief and function with MLS laser treatment.\u003c/p\u003e \u003cp\u003eIn the literature, there are studies supporting the observation that patients with PF exhibit an increased risk of falling and balance disorders. In a study evaluating foot problems and the risk of falling, it was determined that female gender, the presence of knee osteoarthritis, and especially the presence of PF increased the risk of falling and affected balance. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] To eliminate potential gender-based variations in the assessment of fall risk, only female patients were included in our study. Another study on patients diagnosed with PF showed that postural balance was impaired along the anterior-posterior axis, increasing the risk of falls. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Kamonseki et al. demonstrated in their study that strengthening the plantar flexor muscles decreased pain and improved dynamic stabilization in patients diagnosed with PF. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] In our study, the fall risk assessed by OSI scores before treatment was found to be within pathological limits in only 2 patients (1.66%) according to age groups. Although fall risk scores significantly decreased in all three groups with treatment in our study, the differences among the treatment groups were not statistically significant. However, considering these results and the fact that the initial values were mostly within normal limits, this improvement with treatments may not be clinically significant.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eWhile our findings are promising, this study has several limitations that must be acknowledged. Firstly, the study's duration was short, with assessments made only up to one month post-treatment. Longer follow-up periods are needed to assess the sustainability of these improvements over time. Secondly, our study focused exclusively on female patients, which limits the applicability of the results to the general population, including male patients who may experience PF differently due to biomechanical or hormonal differences.\u003c/p\u003e \u003cp\u003eIn conclusion, our study identified significant improvements across all three treatment groups in terms of pain, functionality, daily life activities, quality of life and fall risk within the first month of treatment. The combination of exercise therapy with either ESWT or MLS laser therapy was found to provide greater improvements in pain and function than exercise therapy alone. No clear superiority was determined among the treatments concerning fall risk and quality of life. These findings highlight the importance of incorporating foot exercise programs into the treatment regimen for PF, emphasizing the role of education in ensuring patient compliance. Both MLS laser and ESWT therapies emerge as cost-effective, accessible, and non-invasive options that can be safely utilized in patients with PF. Future studies should more diverse populations and extend follow-up periods to better understand the long-term outcomes of these treatments especially including MLS laser treatment. Additionally, research into the cost-effectiveness of these treatments could significantly impact clinical decision-making, especially in resource-limited settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003eThis study adheres to the principles of the Declaration of Helsinki and received approval from the Ethics Committee of Istanbul Medipol University Faculty of Medicine on May 20, 2021, under decision number E-10840098-772.02-2504.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest\u003c/strong\u003e \u003cp\u003eThe authors have no conflicts of interest or competing interests to declare related to the content of this article.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThere are no funding sources to declare.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll writers and contributors who participated in the preparation of the manuscript are listed as authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTong KB, Furia J (2010) Economic burden of plantar fasciitis treatment in the United States. 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Bulletin of Faculty of Physical Therapy\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaiwanichsiri D, Janchai S, Tantisiriwat N (2009) Foot disorders and falls in older persons. Gerontology 55:296\u0026ndash;302\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAğırman M (2019) Evaluation of Balance and Fall Risk in Patients with Plantar Fasciitis Syndrome. Sisli Etfal Hastan Tip Bul 53(4):426\u0026ndash;429 Published 2019 Nov 19\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamonseki DH, Gon\u0026ccedil;alves GA, Yi LC, J\u0026uacute;nior IL (2016) Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial. Man Ther 23:76\u0026ndash;82\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Fasciitis, Plantar, Exercise, Lasers, Extracorporeal Shockwave Therapy, Pain, Quality of Life","lastPublishedDoi":"10.21203/rs.3.rs-5762566/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5762566/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePlantar fasciitis (PF) is a common cause of heel pain in adults. This study aimed to assess the effects of exercise, Multiwave locked system (MLS) laser, and extracorporeal shock wave (ESWT) treatments on pain, functionality, and quality of life (QoL) in PF patients, and to compare the effectiveness of these treatments.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSixty patients diagnosed with PF were randomized into three groups: exercise therapy alone, exercise plus MLS laser therapy, and exercise plus ESWT. Patients were evaluated using the visual analog scale (VAS), foot ankle outcome score (FAOS), foot function index (FFI), heel tenderness index (HTI), and a fall risk analysis before and one month after treatment.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll groups showed significant improvements in VAS, HTI, FAOS, FFI, and fall risk scores. The laser group demonstrated more improvement in FFI-pain, FFI-total, FAOS-work-daily life, and FAOS-sports-recreation compared to the exercise group. The ESWT group showed more improvement in VAS, HTI, FFI-pain, FFI-total, and FAOS-sports-recreation compared to the exercise group. There was no significant difference between the laser and ESWT groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn conclusion, exercise, exercise with MLS laser, and exercise with ESWT treatments all reduced pain and improved functionality and QoL in PF patients. ESWT and MLS laser therapies, when combined with exercise, provided better overall improvements than exercise alone. Both are cost-effective, accessible, and non-invasive treatment options that can be safely used for PF.\u003c/p\u003e","manuscriptTitle":"Comparative Efficacy of MLS Laser, ESWT, and Exercise Therapy on Plantar Fasciitis Outcomes: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-20 10:04:13","doi":"10.21203/rs.3.rs-5762566/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d81acfae-acf1-484f-91e5-7abe3c109f69","owner":[],"postedDate":"January 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-30T03:08:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-20 10:04:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5762566","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5762566","identity":"rs-5762566","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}