Do You Inject The Plantar Fascia On The First Visit For Plantar Heel Pain?

Over the past 12 months, I have treated three patients who presented with an acute rupture of the plantar fascia. Two of these patients were serious long-distance runners who experienced a crippling “pop” on the bottom of the foot during a run. The other patient tore his fascia pushing an automobile down the street. All three patients had experienced chronic heel pain for several months prior to their acute injury and none of them had ever received a corticosteroid injection.

This experience underscores my 30 years of practicing sports medicine, during which I have seen many patients who suffered a traumatic tear of the plantar aponeurosis. The vast majority had never received a corticosteroid injection prior to their injury. Yet there continues to be controversy about the use of corticosteroid injections in patients with plantar heel pain syndrome.

Last year, the American College of Foot and Ankle Surgeons (ACFAS) published a revised clinical practice guideline for the treatment of plantar heel pain.1 These guidelines are based upon scientific evidence and the panel provides specific treatment recommendations based upon the strength of this evidence. The manuscript is well constructed by a panel of podiatric physicians who propose that there are multiple causes of heel pain and one must first determine the etiology before initiating treatment. Furthermore, the panel of authors recognize the term “plantar fasciitis” may be a misnomer as the scientific evidence indicates that this syndrome is actually a degenerative condition, which should be labeled as a “fasciosis.”

What might surprise some practitioners is the position taken by the panel on the use of corticosteroid injections in the initial treatment of plantar heel pain.1 The guidelines advocate the use of this treatment with a Grade B level of evidence. In other words, corticosteroid injections are listed as a Tier 1 treatment option along with stretching and arch taping.

However, a recent article in Lower Extremity Review by Groner points out the divergence of opinion about the use of steroid injections for heel pain.2 Groner contrasts the guidelines for treatment of plantar heel pain published by ACFAS with the recent publication of guidelines by the American Physical Therapy Association (APTA).3 While the ACFAS found incomplete evidence for the benefits of physical therapy, the APTA found ample evidence. Also, the APTA made no mention of corticosteroid injections.

Groner also quoted a podiatrist and a physical therapist who strongly condemn the use of corticosteroid injections in the initial treatment of patients presenting with plantar heel pain.3 They speculated that corticosteroids would weaken the fascia and would only cover up symptoms without providing any true healing.

I am less skeptical of the use of corticosteroid injections in the treatment of plantar heel pain. I am aware of many studies documenting the effects of steroids on tendons and connective tissue, and I realize there can be benefit in reducing collagen hypertrophy, which abounds in plantar fasciosis. I am not worried about spontaneous rupture for the aforementioned reasons. I am in agreement with the ACFAS treatment guidelines as there are cases in which a corticosteroid injection is indicated as a Tier 1 intervention.

I am curious what my colleagues think about this controversy and invite you to share your views.

References

1. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010; 49(3 Suppl):S2.

2. Croner G. Heel pain revisited: new guidelines emphasize evidence. Lower Extremity Rev. 2010; 2(6):14-20. Available at http://www.lowerextremityreview.com/cover_story/heel-pain-revisited-new-... .

3. McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guidelines. J Orthop Sports Phys Ther 2008; 4(38):A1–18.



Chris Robertsonsays: March 29, 2011 at 8:01 pm

Dr. Richie,

I am a third-year podiatric medical student with some comments/questions. In your article, you mention how current research indicates that "fasciitis" should be replaced by "fasciosis". I would agree with you on that point. But my thought would be, if plantar fasciosis is not primarily an inflammatory process, why are we injecting corticosteroids in the first place?

If this is an issue of degeneration (i.e. fasciosis), wouldn't steroids impede the healing process? I do not ask this as a challenge. I honestly would just like to hear your opinion and what literature you have read on the subject.

Chris Robertson, PMS-3 CSPM class 2012

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Doug Richiesays: April 9, 2011 at 4:56 pm

Chris,

You are raising an excellent question. There is much confusion in the understanding of the histopathology of "tendinitis" compared to "tendinosis" as well as the role of corticosteroids to affect these conditions.

One of the best references on this subject is: Paavola M, Kannus P, Jarvinen TAH, Jarvinen TLN, Jozsa L, Jarvinen M. Treatment of tendon disorders: Is there a role for corticosteroid injection? Foot Ankle Clin N Am 7 (2002) 501-513. This article, authored by six MD-PhDs, provides an excellent review of the positive and negative effects of corticosteroids on both inflammation and connective tissue degeneration and hypertrophy as seen in tendinopathy.

While the focus of the paper is on tendon, the degenerative processes seen are very similar to plantar "fasciosis." In short, corticosteroids will reduce proliferation of fibroblasts and inhibit the runaway production of collagen which highlight the degenerative process -- not inflammation, which is seen in the plantar fascia biopsied from patients with plantar heel pain.

While it is speculated that these effects may help reverse the degenerative process, proof that corticosteroids promote healing is another question.

Doug Richie, Jr., DPM, FACFAS

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bensmithsays: April 4, 2011 at 1:47 pm

"Groner also quoted a podiatrist and a physical therapist who strongly condemn the use of corticosteroid injections in the initial treatment of patients presenting with plantar heel pain.3 They speculated that corticosteroids would weaken the fascia ... ." Obviously the individuals quoted are not in private practice!

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Doug Richiesays: April 8, 2011 at 10:29 am

The podiatrist quoted is well known and in private practice. Read the entire article by Groner for more details. The physical therapist is an academic researcher. Also consider the fact that physical therapists would not advocate steroid injections since they are not within their scope of practice.

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nickcampisays: April 5, 2011 at 11:52 am

Doug,

I would have to agree that corticosteroids should not be indicated as a first line therapy for plantar fasciitis. The ACFAS guidelines are not adequately written in my opinion. They discuss PT in the article but on the algorithm that is printed, PT is not listed.

Much of the new literature being published on running and running shoes are demonstrating that we actually do not even need to support the arch. I have collaborated with Vibram Five Fingers and we are performing several studies to help establish evidence that strengthening intrinsics will treat plantar fasciitis.

I have treated a friend and colleague who suffers from plantar fasciitis for 3-4 years with the entire realm of conservative therapy as well as injections with no success. He is a runner. Recently, we changed his gait and he now lands on his midfoot instead of his heel, and is wearing a New Balance minimus. I am very excited to tell you his plantar fasciitis is finally resolving.

My collaboration has also extended to the community of physical therapists and we are devising a protocol to strengthen intrinsics and show evidence that it helps plantar fasciitis.

Thanks!

Dr. Nick Campitelli
www.drnickcampi.com

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Doug Richiesays: April 8, 2011 at 9:40 pm

Nick,
I am actually in favor of injecting the plantar fascia as a first-line treatment when the patient presents with a history of greater than six months of symptoms. I applaud your interest and research into the effects of footwear on plantar heel pain and on development of the plantar intrinsics.

I wish to point out that there is no credible evidence in the medical literature to support the notion that barefoot running or certain shoes can strengthen the plantar intrinsic musculature. I also question your assertion that there is valid research to support your claim that we "do not even have to support the arch" ( presumably in the treatment of plantar heel pain). As someone who wants to stay abreast of the latest published studies in peer-reviewed journals, I would welcome any citations you can provide to back up your observations. At the same time, I do believe there is merit in any effort we can make to strengthen the plantar intrinsics to promote foot health.

Doug Richie, Jr., DPM, FACFAS

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Justin Hudson, DPM, FACFASsays: April 5, 2011 at 11:53 am

I am an advocate for the use of steriod injections to treat plantar fasciitis. I typically will use up to three injections spaced out every four weeks for each episode of plantar fasciitis. I try to avoid more than three injections per heel each year but never give more than four per 12-month period. With this regimen (combined with NSAIDS, orthotics, stretching and sometimes night splints), I have found a success rate of roughly 85% - which is similar to success seen with studies involving surgical intervention for this condition.

I have seen approximately 4 or 5 plantar fascial ruptures (out of several hundreds of patients treated over the past 10 years) in patients who have received the full series of three injections. I warn all of my patients that this is a possibility. However, I have not found plantar fascial rupture to be detrimental in the long term as all of these patients went on to become pain free without recurrence of infracalcaneal heel pain.

In my opinion, the effect of plantar fascial rupture following steriod injections is no different from surgical plantar fasciotomy and I therefore do not consider a plantar fascial rupture to be a "complication" of steroid injections.

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Robert Scott Steinberg, DPM, DABLESsays: December 27, 2011 at 8:43 pm

Dr. Richie,

When the pain level is bad enough and the patient basically "begs" for relief, I inject with Celestone Soluspan superior to the PF just distal to its origin. I too have a busy sports medicine practice. In 36 years of practice, I have not seen a rupture post injection.

Two weeks ago, I had a new patient who stated he felt a "pop" just in front of his heel while boosting himself onto a stage. An MRI indicated a central band rupture. He had no history of PF injections but is overweight and has very large calf muscles.

I am seeing an increase in acute plantar fasciitis in runners wearing fad shoes. I am really ticked at New Balance for them buying into marketing over research.

Disclaimer: I have no interest, financial or otherwise, in any shoe company, and accept that ethics prevents me from supporting any unproven "science" !

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