Plantar FasciitisDec 25, Author: Medications are used primarily to decrease pain and inflammation. The most corticosteroid treatment for plantar fasciitis used medications are oral nonsteroidal anti-inflammatory drugs NSAIDs and corticosteroid injections, which may be employed in conjunction with physical therapy. NSAIDs ace tren trenbolone analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase Llantar activity and prostaglandin synthesis.
The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies
Plantar fasciitis is a common cause of heel pain in adults. These RCTs involved the use of either palpation- or ultrasonography-guided corticosteroid injections in patients diagnosed with plantar fasciitis. All placebo-controlled RCTs showed a significant reduction in pain with the use of corticosteroid injections.
Some studies also showed that corticosteroid injections yielded better results than other treatment modalities. However, it is evident from these studies that the effects of corticosteroid injections are usually short-term, lasting 4—12 weeks in duration.
Complications such as plantar fascia rupture are uncommon, but physicians need to weigh the treatment benefits against such risks. Plantar fasciitis is one of the most common causes of heel pain, accounting for about one million patient visits per year in the United States. Plantar fasciitis is used to describe heel pain caused by an inflammation of the plantar fascia. This could result from a one-off tear in the plantar fascia or damage from repetitive microtraumas.
Plantar fasciosis describes the degenerative, non-inflamed phase of plantar fasciopathy. It is an enthesopathy that arises from degenerative processes affecting the junction between the periosteal calcaneus and the ligament attachment plantar fascia. Plantar fasciitis can affect both athletes and sedentary people, particularly middle-aged and older individuals. Extrinsic risk factors include walking on hard surfaces or barefoot, prolonged weight bearing, inadequate stretching and poor footwear.
Although there are many treatment modalities for plantar fasciitis, there is little consensus on its clinical approach. To date, there is no single treatment supported by the highest level of evidence. High-quality studies involving double-blinded, placebo-controlled randomised controlled trials RCTs are hard to come by due to the debilitating pain experienced by most patients during the initial consultation.
Another possible reason is the fact that most therapies are used in combination 7 and thus there is poor evidence on which modality is the best. A systematic review of treatments for painful heels conducted by Atkins et al 8 in found that although much has been written about the treatment of plantar heel pain, the number of RCTs in the literature was small and most cases involved small populations of patients, which limited the generalisability of treatment efficacy.
Corticosteroid injections have been used to treat plantar heel pain since the s. 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. The following search strategy was used: 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.
The remaining nine studies were selected for review. Of these, 15 were duplicated on the PubMed search, 14 had objectives not relevant to this review and four were not RCTs.
Thus, a total of ten RCTs were selected for review. This selection process is depicted in Fig. The following data was extracted from each included study: 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: 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. Various complication rates have been reported. The rupture rate of plantar fasciitis after corticosteroid injection ranged from 2. The former study also found that patients with plantar fascia rupture received an average of 2. A systematic review of RCTs and prospective studies by Brinks et al, 27 which examined the adverse effects of extra-articular corticosteroid injections, found only minor complications i.
This finding is largely similar to that of our review, which included patients, as well as that of a meta-analysis of patients conducted by Li et al. Three out of the ten RCTs 7 , 16 , 21 reviewed in the present paper did not state any adverse outcomes of the corticosteroid injections, while the rest reported only post-injection heel pain. All but one of the RCTs had a follow-up period of six months or less. Hence, delayed complications such as plantar fascia rupture could have been under-reported.
Although corticosteroid injection therapy in plantar fasciitis is generally associated with a low incidence of serious complications, multiple corticosteroid injections and obesity are potential risk factors for plantar fascia rupture.
Two of the studies reviewed compared conservative therapies to corticosteroid injections. Ryan et al 16 showed that participants who underwent seven physiotherapist-led exercises daily over a week period had significant improvements during the six-week and week follow-up compared to baseline, although the improvement was not significantly better than the corticosteroid injection group. Yucel et al 17 found that, at the one-month follow-up, the corticosteroid injection group reported significantly better pain relief than the group who wore a prefabricated full-length silicone insole daily for one month.
Three other injection modalities were used by five of the studies reviewed, namely tenoxicam, 15 botulinum toxin A 18 , 19 and autologous blood 20 , 21 injections. Elizondo-Rodriguez et al 18 showed that subjects who received botulinum toxin A injections experienced significantly less heel pain at the six-month follow-up compared to those in the corticosteroid injection group. In contrast, Lee et al 20 found that the corticosteroid group had significantly lower levels of heel pain six weeks and three months after treatment than the group that received autologous blood injection.
The rest of the studies did not show any significant differences between the corticosteroid injection group and their comparator group. There are a number of limitations that should be considered when interpreting the results of this review. First, only two placebo-controlled RCTs were reviewed, while the rest of the RCTs compared only corticosteroid injections with other standard therapies. Generally, there are fewer available placebo-controlled trials, possibly due to ethical reasons, as patients who are in pain are exposed to a chance of non-intervention.
Second, half of the RCTs combined physical therapy or the peppering technique with corticosteroid injections as part of their intervention. Furthermore, most of the studies had small sample sizes ranging from 40 to participants.
The types of corticosteroids used and the techniques of injection also varied, which added complexity to the interpretation of the results. This review shows that both US- and palpation-guided corticosteroid injections are effective in reducing heel pain in patients with plantar fasciitis, including those with chronic pain and those who have failed conservative physical therapies.
The effects are usually short term, lasting 4—12 weeks. The magnitude of pain reduction, as demonstrated by the placebo-controlled RCTs, ranges from