However, many are concerned about the potential complications associated with this treatment modality, which may offset its benefits. Thus, the recommendation of corticosteroid injections as an initial or tier 1 treatment option by the American College of Foot and Ankle Surgeons ACFAS 11 was met with much scepticism and raised certain controversial issues. To further complicate matters, in recent years, the advent of other injectable options e.
Many studies have been done to evaluate the efficacy of corticosteroid injections for the treatment of plantar fasciitis. Most compare its efficacy with that of other treatment modalities. However, these modalities contain inherent differences, even within the corticosteroid injection arm, such as the method of injection, type of steroid used, concurrent use of local anaesthetic and physical therapy, and use of ultrasonography US guidance and nerve blocks.
This review aims to examine the current evidence available and to provide evidence-based recommendations for family physicians on the use of corticosteroid injections in patients suffering from plantar fasciitis. After filtering for RCTs, human studies and English-language articles, a PubMed search yielded 25 potentially relevant articles. Of the 25 studies, seven did not have objectives that were relevant to this review and one was a non-randomised study.
Upon reviewing the full-text articles of the remaining 17 studies, six had Jadad scores A similar search performed on CENTRAL yielded 37 potentially relevant articles after filtering for trials. Of these, 15 were duplicated on the PubMed search, 14 had objectives not relevant to this review and four were not RCTs. Upon review of the four remaining full text articles, three were excluded due to Jadad scores Fig. The following data was extracted from each included study: study design; Jadad score; study population; duration of heel pain; prior treatment; type, amount and method of corticosteroids injections; use of local anaesthetic; use of nerve blocks; outcome measures; results; adverse events; and dropout numbers.
These results are summarised in Table I. The Jadad score was used to measure the likelihood of bias and thus the quality of the selected RCTs. The mean age of the study populations of the ten included RCTs was The duration of their symptoms was 2— months, with the majority suffering from plantar heel pain for at least six months.
Different corticosteroids were used for the injections in the studies. Five RCTs explored the use of long-acting corticosteroids, i. The main outcomes of the studies reviewed fall into the three following categories: a patient-assessed outcomes; b physician-assessed outcomes; and c disease-oriented outcomes. The results for category a are summarised in Table I , while those for categories b and c are summarised in Table II.
The measurement of foot or heel pain is one of the main outcomes. Two placebo-controlled RCTs 13 , 14 reported significantly reduced pain scores within the corticosteroid injection groups compared to the placebo groups. The study by Ball et al showed up to McMillan et al reported an improvement of foot pain scores in the corticosteroid injection arm compared to the placebo arm at the four-, eight- and week follow-up. However, the difference in foot pain scores was only significant at the four-week mark, with a Three studies showed significant pain reduction in the corticosteroid injection group compared to the other types of intervention, namely use of insole, 17 autologous blood injection 20 and local anaesthetic injection with or without tibial nerve block.
The remaining four studies 15 , 16 , 19 , 21 showed significant pain reduction in both intervention groups at follow-up intervals when compared to baseline but no significant differences between the intervention groups. A variety of scales were used to measure other outcomes such as foot function, foot health and quality of life.
However, all three scales were used in conjunction with VAS in the studies 16 , 18 , 21 concerned. Ball et al 13 showed that HTI improved significantly in the steroid injection groups compared to the placebo group at the week follow-up. To measure TT, Lee et al 20 used a pressure algometer, in which the minimal pressure required to elicit pain was defined as the TT recorded on the kg range algometer i.
Three studies 13 , 14 , 17 measured plantar fascia thickness as one of the outcomes. Both the placebo-controlled trials 13 , 14 showed that the steroid group had a significantly greater reduction in plantar fascia thickness than the placebo group at each follow-up interval. Yucel et al 17 demonstrated better results for this outcome in the US-guided steroid injection group compared to the insole group.
All ten studies reviewed were consistent in showing that corticosteroid injections result in improvement of plantar fasciitis from baseline. The two high-quality placebo-controlled trials 13 , 14 provided strong evidence of the effectiveness of corticosteroid injections in the reduction of both heel pain and plantar fascia thickness.
This effect has been shown to last for up to three months in patients who had failed two months of conservative treatment. The majority of studies investigated the use of palpation-guided corticosteroid injections, 7 , 15 , 16 , 18 - 21 while two studies 14 , 17 looked solely at US-guided corticosteroid injections.
Only one study by Ball et al 13 included both palpation- and US-guided corticosteroid injections for comparison against a placebo; however, no significant differences in heel pain reduction between the US- and palpation-guided corticosteroid injection groups were found. Similar results were seen in a recent meta-analysis comprising five RCTs with patients conducted by Li et al, 22 in which heel pain measured with VAS was not shown to be significantly different between the US- and palpation-guided corticosteroid injection groups.
This technique was first described in for lateral epicondylitis. When using this technique, the needle is repeatedly inserted and withdrawn without complete emergence from the skin. It has been postulated that this repeated action leads to the creation of multiple small holes within the degenerative tissues, causing bleeding and initiating the healing process.
In a three-arm study by Kiter et al, 21 this technique was compared with autologous blood and corticosteroid injections. All three groups were given prilocaine 1 mL prior to the administration of injections. In a separate four-arm study by Kalaci et al, 23 it was found that the peppering technique combined with corticosteroid injection resulted in a significantly lower VAS score for heel pain compared with corticosteroid injection alone.
Heel injections are regarded as painful. McMillan et al 14 performed a US-guided posterior tibial nerve block prior to corticosteroid or placebo injections and found it effective in reducing the high level of pain experienced by patients during heel injections. The types of corticosteroids used for heel injections vary, as there is little evidence to suggest the superiority of one agent over the other.
A meta-analysis by Gaujoux-Viala et al 24 found no differences in efficacy between the various types of corticosteroids used. In the present review, all five types of corticosteroid injections used were found to result in significant heel pain reduction. Heel fat pad atrophy and plantar fascia rupture are two of the most feared complications associated with corticosteroid injections, as they can lead to intractable long-term complications.
Precautions Do not inject into fat pad at foot base Do not inject via base of foot Do not inject into tibial nerve. Follow-up Instructions No stress to foot for 2 weeks after injection Minimum time to strenuous activity: 48 hours Examine again in 3 weeks post-injection Consider Ultrasound guidance in refractory cases Kane Ann Rheum Dis [PubMed]. Images: Related links to external sites from Bing. Related Studies. Trip Database TrendMD. Related Topics in Procedure.
Orthopedics Chapters. Orthopedics - Procedure Pages. Back Links pages that link to this page. Plantar Fasciitis.
Plantar fasciitis is not usually caused by an isolated injury, but instead is caused by gradually progressive overload of the plantar fascia. The chronic overload of the plantar fascia eventually results in a strain-like injury of the plantar fascia — usually near its attachment to the heel or by it pulling away at its attachment to the heel the strain-like injury can also occur in the arch. The result of the injury is an inflammation of the plantar fascia at the location of the injury.
The injury and inflammation often worsen by continued unprotected activity. The cause of the chronic overload is usually a combination of factors that can put excess stress on the supporting structures of the arch which includes the plantar fascia. These factors can include: overweight, tight calf muscle, prolonged time standing or walking on the feet, footwear with in inadequate arch support, and sports overload. The problem can be associated with feet that pronate flatten excessively.
However, the condition can also occur in high arched feet with a tight plantar fascia. It is not unusual for a projection of bone to occur along the top surface of the plantar fascia, parallel to the ground. Treatment of plantar fasciitis must be comprehensive and continuous until the pain has been resolved at least 3 months. In other words, multiple simultaneous treatments work more effectively than trying one thing, then trying another.
The condition takes time to resolve — sometimes months, so perseverance with the treatments is a must. The rule of thumb applied here is that one must continue the treatments until the pain has been resolved for 3 months. First, please review: Managing Your Heel Pain. Many of our patients have found this minute interactive online education program helpful in understanding what causes heel pain, what you can do to resolve the pain, and how to keep it from returning.
The program is simple and easy to use and it can be viewed at home, at a Kaiser Permanente Health Education Center, or anywhere with high-speed internet access. You can watch the program as many times as you like and share it with family and friends. The program will provide you with many suggestions about how to manage this common condition on your own. Most features are available only to members receiving care at Kaiser Permanente medical facilities.
Jefferson St. Skip to page main content Skip to page footer. COVID Latest updates about the vaccine, testing, how to protect yourself and get care Updated visitor policy Services and hours updates. Mobile navigation Select a region. Santa Rosa. Other Languages. What can I do for myself? First, please review: Managing Your Heel Pain Many of our patients have found this minute interactive online education program helpful in understanding what causes heel pain, what you can do to resolve the pain, and how to keep it from returning.
Then, you should use as many of these treatments as possible concurrently: Wear supportive shoes. Add a good arch support or orthotic in your shoe. The following is the recommended option: green Superfeet. Avoid standing or walking barefoot or in unsupportive footwear like slippers or sandals. Instead, you should be in supportive shoes with Superfeet orthotics as much as possible every day. Perform calf stretching exercises for seconds on each leg at least two times per day.
Lean into the wall, stepping forward with one leg, leaving the other leg planted back. The leg remaining back is the one being stretched. The leg being stretched should have the knee straight locked and the toes pointed straight at the wall. Stretch forward until tightness is felt in the calf. Hold this position without bouncing for a count of seconds.
Repeat the stretch for the opposite leg. Healthy weight Modify your activities. Decrease the time that you stand, walk, or engage in exercise that put a load your feet. Convert impact exercise to non-impact exercise — cycling, swimming, and pool running are acceptable alternatives.
Use a night splint each night while you sleep. This brace keeps your plantar fascia stretched while you sleep by holding your foot at 90 degrees to your leg. You can purchase a Johnson and Johnson night splint. I want to help you!
Click here! Recommended Products and Resources Click here to go to Dr. Due to a large number of questions I have received over the years asking about products for health, injuries, performance, and other areas of sports, exercise, work and life, I have created an Amazon Influencer page.
While this information and these products are not intended to treat any specific injury or illness you have, they are products I use personally, have used or have tried, or I have recommended to others. Please note that as an Amazon Associate I earn from qualifying purchases. Quick tips for a variety of sports- and exercise-related bone and joint injuries - Learn when those injuries could be serious and what you should do about them.
Find a physical therapist that is right for you and your injury as well as who and what to watch out for! Does the thought of seeing a doctor scare you? Decide if you should see one, find one suited for you and get the most from your visit. If you need more information about your particular injury and options to treat it and recover quickly and safely, talk to me one-on-one! Geier explains how sports medicine makes sports safer for the pros, amateurs, student-athletes, and weekend warriors alike.
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This brace keeps your plantar affected area on an ice pack for minutes. Injection of cortisone is a effect, you must maintain this dosing pattern for at least. Surgery involves detaching the plantar fascia from the heel. A cast is applied from surgeon will inject the PF pool running are acceptable alternatives. Option C - Rest the. Option B - Fill a area for minutes, at least toes typically for 6 weeks. The patient is encouraged to fat pad and bleaching of weight on the foot while. The patient is encouraged to. However, custom foot orthoses are available at the Santa Rosa Kaiser Permanente facility on a fee for service basis through a non-Kaiser Permanente provider. Take three mg tablets, three be used for a short - breakfast, lunch, and dinner.Use a gauge, in. Palpate the most anterior aspect of the medial plantar calcaneal tubercle, and insert the needle at this site. Advance the needle until it reaches the most anterior (distal) aspect of the plantar medial calcaneal tuberosity.