Raiyyan Tahsan

Raiyyan Tahsan
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TC(1019).(05).Orthopedics Case No 97:-  Plantar fasciitis

1) Definition / সংজ্ঞা

Plantar fasciitis হলো পায়ের তলার plantar fascia—যা heel bone থেকে toes পর্যন্ত যায় এবং foot arch support করে—এর origin, বিশেষ করে medial calcaneal tubercle-এ repetitive strain/micro-tear ও degenerative irritation-এর কারণে heel pain হওয়া। নামের শেষে “-itis” থাকলেও অনেক chronic case-এ classic inflammation-এর চেয়ে degenerative fasciopathy/fasciosis বেশি থাকে।

2) Causes / Etiology — কারণগুলো point আকারে

  • Repetitive microtrauma / overuse: দীর্ঘক্ষণ দাঁড়িয়ে থাকা, বেশি হাঁটা/দৌড়ানো, হঠাৎ activity বাড়ানো—plantar fascia-তে বারবার টান পড়ে micro-tear হয়।
  • Obesity / overweight: body weight বেশি হলে heel ও plantar fascia-তে load বাড়ে।
  • Tight calf muscle / tight Achilles tendon: ankle dorsiflexion কমে যায়, হাঁটার সময় fascia-তে traction বাড়ে।
  • Flat foot বা high arch: abnormal biomechanics-এর কারণে medial heel ও fascia origin-এ stress বাড়ে।
  • Hard surface occupation: শিক্ষক, healthcare worker, factory worker, security personnel—যারা hard surface-এ দীর্ঘক্ষণ দাঁড়িয়ে থাকেন।
  • Poor footwear: পাতলা sole, worn-out shoe, inadequate arch support, barefoot walking on hard floor.
  • Age: 40–60 বছর বয়সে বেশি দেখা যায়।
  • Sports-related: running, dancing, jumping, football/basketball—high-impact repetitive loading.
  • Systemic association: bilateral heel pain হলে seronegative spondyloarthropathy, inflammatory arthritis, gout, diabetes-related neuropathy ইত্যাদি consider করতে হবে।

3) Symptoms / Clinical Features — লক্ষণগুলো

  • Heel pain: পায়ের তলার heel-এর নিচে বা medial side-এ sharp/stabbing pain।
  • First-step pain: সকালে ঘুম থেকে উঠে প্রথম কয়েক কদমে বেশি ব্যথা—classic feature।
  • Rest-এর পর pain: অনেকক্ষণ বসে/শুয়ে থাকার পর হাঁটা শুরু করলে ব্যথা বাড়ে।
  • Walking শুরু করলে কিছুটা কমে: কয়েক মিনিট হাঁটার পর pain কমতে পারে, কিন্তু দিনের শেষে বা prolonged standing-এর পরে আবার বাড়ে।
  • Exercise-এর পরে বেশি pain: exercise চলার সময় না, বরং exercise শেষের পর pain বেশি হতে পারে।
  • Local tenderness: heel bone-এর সামনে plantar fascia origin-এ চাপ দিলে ব্যথা।
  • Tightness feeling: calf/sole/arch tight লাগতে পারে।
  • Severe case: limp, walking difficulty, activity limitation, knee/hip pain due to altered gait.

4) Clinical Diagnosis — কীভাবে clinically diagnosis করবেন

Plantar fasciitis মূলত clinical diagnosis; সব রোগীর routine imaging লাগে না।

A) History

  • Morning first-step heel pain আছে কি না
  • Pain location: plantar medial heel
  • Recent walking/running/standing/activity increase
  • Occupation: long standing
  • Footwear history
  • Weight gain/obesity
  • Bilateral pain, back pain, morning stiffness, joint swelling থাকলে inflammatory cause ভাবতে হবে

B) Physical examination

  • Palpation: medial calcaneal tubercle/proximal plantar fascia-তে point tenderness
  • Windlass / Jack test: great toe passive dorsiflexion করলে plantar fascia tight হয়ে pain reproduce হলে positive
  • Ankle dorsiflexion check: limited dorsiflexion থাকলে tight gastrocnemius/Achilles suggest করে
  • Foot posture: pes planus/pes cavus/pronation/supination
  • Gait assessment: antalgic gait আছে কি না
  • Neurological exam: numbness/tingling থাকলে tarsal tunnel/Baxter nerve entrapment exclude করা

5) Investigations — specific indication সহ

Routine case-এ

  • Investigation usually দরকার নেই—typical history + exam থাকলে diagnosis clinical।

কখন investigation করবেন

  • Atypical pain
  • Trauma history
  • Night pain/rest pain
  • Fever, swelling, redness
  • Bilateral heel pain with inflammatory symptoms
  • Neurological symptoms
  • Conservative treatment 6–12 weeksেও improve না হলে
  • Stress fracture/tumor/infection suspicion

Recommended tests

Investigationকখন করবেনকী পাওয়া যায়
X-ray foot lateral viewfracture, arthritis, calcaneal spur rule outheel spur দেখা যেতে পারে; কিন্তু spur pain-এর cause না-ও হতে পারে।
Ultrasound plantar fasciapersistent/uncertain caseplantar fascia thickening, hypoechogenicity, perifascial fluid; thickness >4 mm suggestive।
MRI foot/anklered flag, stress fracture, tear, tumor, persistent refractory painfascia thickening, signal change, tear, stress fracture।
ESR/CRP, uric acid, RF/anti-CCP, HLA-B27only if inflammatory arthritis/gout/systemic disease suspiciondifferential diagnosis support

6) Differential Diagnosis

  • Calcaneal stress fracture
  • Heel pad syndrome/fat pad atrophy
  • Tarsal tunnel syndrome
  • Baxter nerve entrapment
  • Achilles tendinopathy/insertional Achilles tendinitis
  • Retrocalcaneal bursitis
  • Gout/inflammatory arthritis
  • Seronegative spondyloarthropathy
  • Osteomyelitis/tumor — rare but red flag থাকলে ভাবতে হবে

7) Complications — রোগের জটিলতা

  • Chronic heel pain: দীর্ঘদিন pain থাকলে walking, work, exercise limited হয়ে যায়।
  • Altered gait: ব্যথা এড়াতে হাঁটার ভঙ্গি বদলে গেলে knee, hip, low back pain হতে পারে।
  • Plantar fascia rupture: disease progression বা repeated corticosteroid injection-এর পর risk বাড়তে পারে।
  • Fat pad atrophy/necrosis: বিশেষ করে steroid injection complication হিসেবে হতে পারে।
  • Arch flattening: plantar fascia weakness/rupture হলে longitudinal arch কমে যেতে পারে।
  • Recurrence: footwear/load correction না করলে বারবার pain ফিরে আসতে পারে।

8) Treatment Management — Stepwise

A) Non-pharmacological management — first-line

Guideline-based management-এ প্রথমে stretching + load modification + footwear/orthosis সবচেয়ে গুরুত্বপূর্ণ। JOSPT 2023 guideline-এ plantar heel pain management-এ manual therapy, stretching, taping, foot orthoses, night splints, exercise/load management গুরুত্বপূর্ণ হিসেবে আলোচিত হয়েছে।

  • Relative rest: running/jumping/long standing temporarily reduce
  • Ice rolling: frozen bottle দিয়ে sole-এ 15–20 min, দিনে 2–4 বার
  • Plantar fascia stretch: সকালে বিছানা থেকে নামার আগে 10 sec hold × 10–20 reps
  • Calf/Achilles stretch: wall stretch, 10–30 sec hold × 10–20 reps
  • Footwear: cushioned sole, arch support, worn-out shoe replace
  • Heel cup/silicone heel pad: heel load কমায়
  • Taping: short-term pain relief
  • Night splint: morning first-step pain বেশি হলে 1–3 months consider; AAOS night splint effective বলে উল্লেখ করে।
  • Physiotherapy: stretching, strengthening, manual therapy, gait correction
  • Weight reduction: BMI high হলে essential
  • Refractory case: ESWT, PRP, steroid injection, surgery—specialist decision। Surgery সাধারণত 6–12 months conservative failure-এর পরে last option।

9) Pharmacological treatment — Bangladesh commonly used prescription drugs

Important prescribing rule

  • একসাথে একাধিক oral NSAID দেওয়া যাবে না।
  • NSAID সাধারণত short course 5–10 days, maximum 2–4 weeks only with review. AAOS NSAID 1 month-এর বেশি doctor review ছাড়া না নিতে বলে।
  • Steroid injection short-term pain relief দিতে পারে, কিন্তু long-term benefit limited এবং rupture/fat pad atrophy risk আছে; Cochrane review অনুযায়ী steroid injection pain up to 1 month সামান্য কমাতে পারে, পরে benefit clear নয়।

1) Generic name: Paracetamol / Acetaminophen

  1. Generic name: Paracetamol
  2. Therapeutic category: Analgesic, antipyretic
  3. Pharmacological class: Para-aminophenol derivative; non-opioid analgesic
  4. Bangladesh available brand name with mg: Napa 500 mg/665 mg/1000 mg, Reset 500 mg/665 mg, Fast 500 mg/1000 mg, Ace 500 mg, Pyrex 500 mg, Tamen XR 665 mg — MedEx-এ paracetamol brand list আছে।
  5. Adult dose: 500 mg–1 g orally every 6–8 hours PRN; max usually 3–4 g/day, liver disease/alcohol use হলে lower max.
  6. Duration: 3–7 days PRN; persistent pain হলে review.
  7. Why used: pain relief; inflammation কমায় না, কিন্তু NSAID contraindicated হলে safer first option।
  8. Side effects: nausea, rash rare; overdose/liver disease/alcohol use-এ hepatotoxicity।
  9. Interactions: alcohol, chronic warfarin use, enzyme-inducing drugs, isoniazid—liver/bleeding risk consideration।
  10. Purpose: mild-to-moderate heel pain control.

2) Generic name: Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: Non-selective NSAID; COX inhibitor
  4. Bangladesh available brand name with mg: Advel 400 mg, Flamex 400 mg, Profen 400 mg, Reumafen 400 mg, Intaflam 400 mg, Neurofen 400 mg, Alflam 400 mg — MedEx lists ibuprofen as NSAID and brand names.
  5. Adult dose: 400 mg orally 2–3 times daily after food.
  6. Duration: 5–7 days; maximum 10–14 days without reassessment.
  7. Why used: acute painful flare with inflammatory component; morning pain/standing pain কমাতে।
  8. Side effects: dyspepsia, gastritis, GI bleed, renal impairment, fluid retention, BP rise, bronchospasm in NSAID-sensitive asthma।
  9. Interactions: aspirin/warfarin/DOAC/clopidogrel/SSRI/steroid → bleeding risk; ACEi/ARB + diuretic → AKI risk; lithium/methotrexate toxicity risk; other NSAID avoid।
  10. Purpose: short-term pain + inflammation control.

3) Generic name: Naproxen / Naproxen sodium

  1. Generic name: Naproxen sodium / Naproxen
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: Non-selective NSAID
  4. Bangladesh available brand name with mg: Naproxen 500 mg, Naproxin 250/500 mg, Gloxen 250/500 mg, Napgin 500 mg, Napier 500 mg, Naspro 250/500 mg; combination: Naproxen sodium + Esomeprazole 500 mg + 20 mg brands include Naprosyn Plus, Naprox Plus, Naxin Plus, Progesic, NapExa, Naprozol etc.
  5. Adult dose: Naproxen 250–500 mg orally twice daily after food.
  6. Duration: 5–10 days; chronic use avoid unless doctor review.
  7. Why used: longer duration NSAID; heel pain with prolonged standing/activity-related flare.
  8. Side effects: GI upset/ulcer/bleeding, renal impairment, edema, BP rise, dizziness।
  9. Interactions: anticoagulants/antiplatelets/SSRIs/steroids/alcohol increase GI bleed; ACEi/ARB/diuretic renal risk; lithium/methotrexate risk; avoid with other NSAIDs।
  10. Purpose: short-term anti-inflammatory analgesia; high GI-risk হলে PPI cover/combination may be considered.

4) Generic name: Diclofenac sodium — oral/topical

  1. Generic name: Diclofenac sodium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; COX inhibitor
  4. Bangladesh available brand name with mg: Diclofen 50 mg/SR 100 mg/Gel 1%, Clofenac 50 mg/SR 100 mg, Diclorex 50 mg/SR 100 mg/75 mg injection, Ultrafen SR 100 mg, Erdon Gel 1%, Fastfit Gel 1%, Panfre Gel 1% — MedEx lists oral and topical diclofenac brands.
  5. Adult oral dose: 50 mg orally 2 times daily after food; SR 100 mg once daily may be used.
  6. Topical dose: Diclofenac gel 1% 2–4 g locally 3–4 times daily; MedEx states diclofenac gel is for external use and 2–4 g may be applied 3–4 times daily.
  7. Duration: Oral 3–7 days; topical 1–2 weeks.
  8. Why used: topical option localized heel painে useful; oral form acute flare-এ।
  9. Side effects: oral—GI bleed, renal injury, BP rise, edema; topical—skin irritation/rash।
  10. Interactions: same NSAID interactions; diclofenac has cardiovascular risk consideration, so IHD/HF/uncontrolled HTN-এ avoid/prefer alternative।
  11. Purpose: localized pain/inflammation control; topical route GI side effect কমায়।

5) Generic name: Aceclofenac

  1. Generic name: Aceclofenac
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; COX inhibitor
  4. Bangladesh available brand name with mg: Reservix 100 mg/SR 200 mg, Avenac 100 mg, Biofenac 100 mg, Ceclofen 100 mg, Celofen 100 mg, Paino 100 mg, Ternilla 100 mg/SR 200 mg, Ufenac 100 mg/SR 200 mg — MedEx lists aceclofenac as NSAID and brand names.
  5. Adult dose: 100 mg orally twice daily after food; SR 200 mg once daily may be used.
  6. Duration: 5–7 days; reassess if persistent.
  7. Why used: musculoskeletal pain/inflammation relief; Bangladesh prescription practice-এ common NSAID option।
  8. Side effects: dyspepsia, nausea, GI ulcer/bleed, renal impairment, edema, BP rise, rash।
  9. Interactions: anticoagulant/antiplatelet/SSRI/steroid/alcohol → GI bleed; ACEi/ARB/diuretic → renal risk; methotrexate/lithium toxicity risk।
  10. Purpose: pain + inflammation control when no NSAID contraindication.

6) Generic name: Etoricoxib

  1. Generic name: Etoricoxib
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: Selective COX-2 inhibitor NSAID
  4. Bangladesh available brand name with mg: Tory 60/90/120 mg, Ribox 60/90/120 mg, Setorib 60/90/120 mg, Recox 120 mg, Riox 60/90/120 mg, Rito 60/90/120 mg, Etorica 60/90/120 mg, Torcox 60/90/120 mg — MedEx lists etoricoxib as NSAID with multiple strengths.
  5. Adult dose: 60 mg once daily for musculoskeletal pain; severe acute painে 90 mg once daily short course may be used depending on risk.
  6. Duration: 3–7 days; use lowest effective dose, shortest duration.
  7. Why used: GI intolerance risk তুলনামূলক কম হতে পারে, once-daily dosing convenient; কিন্তু CV risk বেশি হলে avoid।
  8. Side effects: edema, hypertension, dyspepsia, renal impairment, dizziness; cardiovascular thrombotic risk consideration।
  9. Interactions: warfarin/antiplatelet/SSRI/steroid bleeding risk; ACEi/ARB/diuretic renal risk; lithium/methotrexate; avoid other NSAIDs।
  10. Purpose: short-term pain/inflammation control, especially where nonselective NSAID GI intolerance concern আছে কিন্তু CV risk low।

7) Generic name: PPI gastroprotection — Pantoprazole / Omeprazole / Esomeprazole

  1. Generic name: Pantoprazole / Omeprazole / Esomeprazole
  2. Therapeutic category: Anti-ulcerant, gastroprotection
  3. Pharmacological class: Proton pump inhibitor
  4. Bangladesh available brand name with mg: Pantoprazole—Protonil 20/40 mg, Pantodac 20/40 mg, Otonix 20/40 mg, Gaspain 40 mg; Omeprazole—Omesic 20 mg, Losectil 20 mg, Seclo 20 mg, DP 20 mg; Esomeprazole—Nexum/Nexium-type brands vary. MedEx lists PPIs for peptic ulcer/GERD/NSAID-induced ulcer indications.
  5. Adult dose: Pantoprazole 20–40 mg once daily 30 min before breakfast; Omeprazole 20 mg once daily.
  6. Duration: NSAID course চলাকালীন 5–14 days; high GI-risk হলে physician-directed longer.
  7. Why used: NSAID-associated gastritis/ulcer/bleeding risk কমাতে।
  8. Side effects: headache, diarrhea/constipation, nausea; long-term useে B12/Mg deficiency, fracture/C. difficile risk।
  9. Interactions: Omeprazole/esomeprazole clopidogrel effect কমাতে পারে; warfarin/phenytoin monitoring; long-term with methotrexate caution।
  10. Purpose: NSAID নেওয়ার সময় gastric protection—বিশেষ করে dyspepsia/ulcer history/older patient/high-risk patient।

8) Generic name: Local corticosteroid injection — specialist use only

Option A: Methylprednisolone acetate

  1. Generic name: Methylprednisolone acetate injection
  2. Therapeutic category: Corticosteroid injection
  3. Pharmacological class: Glucocorticoid; depot corticosteroid
  4. Bangladesh available brand name with mg: Depo-Medrol 40 mg/ml or 80 mg/2 ml, Depomed 40 mg/ml or 80 mg/2 ml, Depo-pred 40 mg/ml, Methsolon 40 mg/ml — MedEx lists these available brands.
  5. Usual local dose: 20–40 mg local injection mixed with local anesthetic; ultrasound-guided preferable.
  6. Duration/frequency: single injection; avoid repeated frequent injection.
  7. Why used: severe persistent pain, conservative treatment failure, short-term pain relief.
  8. Side effects/complications: post-injection flare, infection, skin depigmentation, fat pad atrophy, plantar fascia rupture, transient hyperglycemia in diabetes।
  9. Interactions/cautions: anticoagulant/bleeding disorder, local infection, uncontrolled diabetes, repeated steroid exposure।
  10. Purpose: short-term pain reduction to allow rehab/stretching.

Option B: Triamcinolone acetonide injection

  1. Generic name: Triamcinolone acetonide injection
  2. Therapeutic category: Corticosteroid injection
  3. Pharmacological class: Glucocorticoid
  4. Bangladesh available brand name with mg: Alfacort 40 mg/ml, Cynocort 40 mg/ml, Emicort 40 mg/ml, Intracort 40 mg/ml, Trialon 40 mg/ml, Triamon 40 mg/ml — MedEx lists triamcinolone injection brands.
  5. Usual local dose: 10–40 mg local injection depending on clinician protocol.
  6. Why used: refractory plantar heel pain with clear plantar fascia tenderness.
  7. Caution: steroid injection should not replace stretching/orthosis; repeated injection increases rupture/fat pad risk.

9) Generic name: Lidocaine injection — injection procedure adjunct

  1. Generic name: Lidocaine hydrochloride injection
  2. Therapeutic category: Local anesthetic
  3. Pharmacological class: Amide local anesthetic
  4. Bangladesh available brand name with mg: Lidocaine 2%, Locaine 2%, G-Lidocaine 2%, Jasocaine 1%/2%, Chemocain 2% — MedEx lists available injection brands.
  5. Use: corticosteroid injection procedure-এ local anesthesia/pain reduction.
  6. Side effects: local numbness, dizziness, metallic taste, CNS toxicity/seizure rare if overdose/intravascular injection।
  7. Interactions/cautions: arrhythmia, class I antiarrhythmic drugs, severe liver disease; aspirate before injection to avoid intravascular administration।
  8. Purpose: injection pain কমানো, immediate anesthetic effect.

10) Bangladesh doctors commonly prescribe — practical list

  • Mild pain: Paracetamol 500 mg PRN + stretching + heel pad
  • Acute painful flare: Ibuprofen 400 mg BD/TDS or Naproxen 500 mg BD or Aceclofenac 100 mg BD — one NSAID only
  • Localized heel pain / GI-risk patient: Diclofenac gel 1% locally + paracetamol
  • NSAID-induced dyspepsia/GI-risk: Pantoprazole 20/40 mg OD or Omeprazole 20 mg OD during NSAID course
  • Severe refractory pain after conservative failure: Ultrasound-guided local steroid injection—Methylprednisolone acetate or Triamcinolone acetonide + Lidocaine, specialist setting
  • Not routinely indicated: antibiotics, uric-acid-lowering drugs, pregabalin/gabapentin, muscle relaxant—unless another diagnosis exists.

11) Prevention — কীভাবে prevent করবেন

  • সকালবেলা bed থেকে নামার আগে plantar fascia stretch
  • Daily calf stretching
  • Hard floor-এ barefoot walking avoid
  • Cushioned shoe + arch support ব্যবহার
  • Worn-out running shoe replace
  • Activity suddenly বাড়াবেন না; 10% rule দিয়ে gradual increase
  • Weight management
  • Long standing job হলে soft mat/periodic sitting break
  • Exercise-এর পরে ice rolling
  • Flat foot/high arch থাকলে orthotic/heel cup
  • Pain শুরু হলে early load reduction; pain নিয়ে running চালাবেন না

12) Overview / Summary

Plantar fasciitis হলো medial heel pain-এর common cause, যেখানে plantar fascia origin-এ repetitive strain ও degeneration হয়। Diagnosis সাধারণত history + exam দিয়ে হয়: morning first-step pain, plantar medial heel tenderness, positive windlass test। Routine imaging লাগে না; atypical/chronic/refractory case-এ X-ray, ultrasound, MRI করা হয়। Treatment-এর core হলো stretching, footwear, heel pad/orthosis, activity modification; medicine শুধু pain control-এর জন্য।

13) Actionable Plan / Steps

  1. First 2 weeks: relative rest + ice rolling + plantar fascia/calf stretch + cushioned shoe/heel pad।
  2. Pain control: paracetamol বা একটিমাত্র NSAID short course; GI-risk থাকলে PPI।
  3. 2–6 weeks: physiotherapy, taping/orthosis, weight/load correction।
  4. Morning pain persistent: night splint 1–3 months consider।
  5. 6–12 weeksেও pain থাকলে: ultrasound/X-ray; differential diagnosis exclude।
  6. Refractory severe case: specialist referral for US-guided steroid injection/ESWT/PRP consideration।
  7. 6–12 months conservative failure: surgery only last option।

14) Reference List

Textbook / Core medical sources

  1. Davidson’s Principles and Practice of Medicine, musculoskeletal pain and locomotor system clinical approach chapters.
  2. Harrison’s Principles of Internal Medicine, pain, rheumatologic differential diagnosis, and NSAID safety principles.
  3. Apley & Solomon’s System of Orthopaedics and Trauma, foot and ankle pain/heel pain sections.
  4. Maheshwari & Mhaskar, Essential Orthopaedics, foot disorders and heel pain sections.

Guideline / Clinical references

  1. Koc TA Jr, Bise CG, Neville C, et al. Heel Pain – Plantar Fasciitis: Revision 2023. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(12):CPG1–CPG39. DOI: 10.2519/jospt.2023.0303.
  2. AAOS OrthoInfo. Plantar Fasciitis and Bone Spurs—symptoms, risk factors, examination, imaging, nonsurgical treatment, steroid injection caution.
  3. StatPearls/NCBI Bookshelf. Plantar Fasciitis—etiology, clinical diagnosis, evaluation, treatment, complications.

Peer-reviewed / DOI references

  1. David JA, Sankarapandian V, Christopher PRH, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017;6:CD009348. DOI: 10.1002/14651858.CD009348.pub2.
  2. Draghi F, Gitto S, Bortolotto C, Draghi AG, Belometti GO. Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging. Insights Imaging. 2017;8:69–78. DOI: 10.1007/s13244-016-0533-2.
  3. Drake C, Whittaker GA, Kaminski MR, et al. Medical imaging for plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2022;15:4. DOI: 10.1186/s13047-021-00507-2.

Bangladesh drug/brand source
MedEx Bangladesh pages for Paracetamol, Ibuprofen, Naproxen, Diclofenac, Aceclofenac, Etoricoxib, PPIs, Methylprednisolone acetate, Triamcinolone acetonide injection, and Lidocaine injection.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Monday,Time:-07-17-12 Pm

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