On the first visit, what percentage of your patients with plantar heel pain receive a corticosteroid injection?

None
20% (119 votes)
10 to 20 percent
25% (146 votes)
21 to 30 percent
13% (75 votes)
31 to 40 percent
6% (35 votes)
41 to 50 percent
9% (51 votes)
over 50 percent
28% (165 votes)
Total votes: 591

Comments

Depends more on the level of pain of the patient. If there is pain every step, then injection is recommended.

The use of fibrolytic medicines in an area of ligamentous inflammation is something that I think should be avoided. There are many ways that we can heal inflammation by provoking a primary inflammatory response instead of suppressing chronic pathways of inflammation. Since it is primary inflammation that repairs our cells, this is what we need to key in on.

Following a thorough exam, I inquire as to previous injections at the site of corticosteroids. If there has been fewer than 3 injections at the site, I will offer an injection of steroid or the use of NSAID and discuss the need for conjunctive therapy. I will also inform the patient of the risks of repeated corticosteroid injections at the same site.

I seldom give more than two injections in the course of treatment. Injections are not without some risk. They sometimes promote significant patient fear and patients incur some pain. Having the success I have 80% to 90% of the time without an injection, I am just not trigger happy on the first visit.

I would agree with Jon. I would be reluctant on the first visit. I would be mindful of the patient's pain level and any other treatments sought prior this visit. I tend to go with a NSAID and ultrasound therapy with one week and re-evaluate.

The "Weil Group" clinical guidelines for 1st visit with a history of 3 months or less of PFasciitis (no prior treatment) call for eccentric Achilles stretching, ice water soak of heel for 10 minutes, NSAIDs, avoidance of flat shoes, and OTC insert. One of our studies show that with this program, 75% of patients feel better within 6 weeks. If not, a cortisone shot and other modalities are recommended.

Having said that, if an active person with close to normal BMI comes in with a pain scale of 8/10 and has to travel in the next couple of weeks, I will offer a cortisone shot on visit 1. (I chose 10% of the time in this poll.)

A permanent injury to the plantar fascia following a single cortisone injection is highly overrated. We see 1,500 new patients a year with heel pain and have less than 5 PF ruptures, all of which are usually partial.

Sorry for the lecture.

Lowell Scott Weil, Sr., DPM, FACFAS

Though I am one of the respondents that does inject 50% or more, I also dispense a good number of walking boots when the pain level warrants. (No, I don't inject and dispense the boot.) Remember, the ultimate goal when the patient leaves is for him or her to be as close to pain free as possible. Patients just appreciate being able to stand without any or limited pain. When I see them back in 3 weeks after icing, NSAIDs, stretching, they are usually ready for an injection.

By the time most patients have come in to the office, they are in moderate to severe pain. They want this fixed ... now. They usually don't want to hear about trying this therapy for a few weeks or this medicine. They want whatever is going to get them pain free the fastest. In most cases, I can achieve that with an injection.

While I endeavor to avoid cortisone on first visit, taking into account duration and prior Tx Hx. (self or by clinician), pt weight, foot type/mechanics and type of activity, if upon palpation, the patient experiences severe pain, cortisone may be indicated.

I typically apply a low Dye/longitudinal strapping held on with knee high for 3 to 5 days and gauge improvement. If there is 30-50% improvement, I dispense a trial OTC arch support. If strapping is given with injection, you cannot tell what did what.

Just some thoughts.

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