Cath Lab Digest

Can Peppering Augment Injections For Plantar Fasciitis?

By Brian McCurdy, Senior Editor

   A new study in the Journal of the American Podiatric Medical Association (JAPMA) concludes that a peppering injection technique can boost the effect of corticosteroids and provide greater pain relief.

   The prospective, randomized, multicenter study consisted of 100 patients divided into four groups of equal sizes. Patients in group A received a 2 mL injection of autologous blood. Group B received 2 mL of lidocaine along with peppering injections. Group C received 2 mL of the corticosteroid triamcinolone (Kenalog, Bristol Myers-Squibb). Group D received 2 mL of triamcinolone plus peppering. Follow-up occurred at three weeks and six months after injection.

   Researchers determined that at three weeks post-injection, the combination of corticosteroid injections with a peppering technique (Group D) facilitated the lowest pain level out of the four patient groups. At six months post-injection, the Group D patients had “significantly lower” pain levels than those groups that had autologous blood or local anesthetic injections alone. The authors conclude that corticosteroid injection with peppering can be a first alternative in plantar fasciitis for patients in whom other conservative methods have failed.

   How does peppering work? The study authors would insert the needle, inject, withdraw without emerging from the skin, slightly redirect the needle and reinsert the needle. According to the JAPMA article, the authors would feel a “cracking” sensation during the injection and would continue the injections “until this sensation was lost.” They hypothesize that the peppering technique may create new channels through the degenerative myxoid tissue in which bleeding occurs.

What Is The Verdict On Peppering?

   Patrick Nunan, DPM, a Fellow and Past President of the American Academy of Podiatric Sports Medicine, says corticosteroids are relatively inexpensive and easy to use. The main advantage of corticosteroid injections is that they break the pain cycle of plantar fasciitis, according to Charles Peebles, DPM, a Fellow of the American College of Foot and Ankle Surgeons. If functional support, stretching and night splints do not work, Dr. Peebles says corticosteroids can reduce inflammation and assist with healing.

   Dr. Peebles does not think peppering would benefit standard corticosteroid injections. However, Dr. Nunan says several studies have shown the use of a peppering technique can decrease plantar fasciitis pain whether one uses the technique with radiofrequency devices, autogenous blood preparations or corticosteroids. Dr. Nunan does acknowledge that the use of radiofrequency devices or autogenous blood preparations “requires special equipment and may require conscious sedation from an anesthesiologist.”

   Stephen Barrett, DPM, notes that the peppering technique is essentially microdebridement of the plantar fascia, which stimulates the tissue cascade of healing. In his experience in using autologous platelet concentrate to treat severe cases of plantar fasciosis, Dr. Barrett says increased peppering (or what he prefers to call debridement) facilitates better clinical outcomes.

   Drs. Nunan and Barrett express concern about the peppering technique described by the study authors and suggest that high-resolution diagnostic ultrasound would be helpful in guiding injections.

   Dr. Barrett, an Adjunct Associate Professor in the Arizona Podiatric Medical Program at Midwestern University College of Health Sciences, has used diagnostic ultrasound to document definable objective changes both in thickness and signal intensity of the plantar fascia. He says his technique has evolved to the point where he can administer any of the injections painlessly.

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