Noting that corticosteroid injections have the risk of plantar fascia rupture and do not address the degenerative nature of plantar fasciopathy, this author says stretching and orthotics help remedy common risk factors such as posterior leg muscle tightness and increased pronation.
By Benn Boshell, MSc, BSc (Hons)
When one applies sound biomechanical principles, clinical reasoning and evidence-informed rationale, it is clear that orthotics and stretching are superior to injections for plantar heel pain.
In my experience, one of the most important components of treatment success is establishing the underlying causative factor(s) that contribute to each individual patient’s condition. In most cases, plantar fasciopathy is associated with certain risk factors. The reality is, that in my observations of clinical practice, the majority of patients who present with plantar fasciopathy are middle-aged (40 to 60 years old), have calf and hamstring muscle tightness, increased foot pronation, increased body mass index (BMI), and tend to be female.
This is not a coincidence. This is a result of underlying risk factors that causes excessive levels of tissue stress on the plantar fascia, subsequently lead ing to tissue pathology and injury. Some of these risk factors are more significant than others and not all patients will have all the aforementioned risk factors. For instance, increased BMI is an evidence-based risk factor closely associated with plantar fasciopathy but there are many patients with plantar fasciopathy who have a normal BMI.1,2
Recognizing The Significance Of Posterior Leg Muscle Tightness
Another example of a relevant risk factor is soft tissue ankle equinus as a result of a tight calf muscle. Various researchers have demonstrated a strong association between increased calf muscle tightness and plantar fasciopathy.3-8 We can make sense of this association by looking at biomechanical studies that have measured the relationship between tensile force in the Achilles tendon and plantar fascia strain.9,10
In one study, the researchers applied a tensile force to cadaver Achilles tendons and measured strain on the plantar fascia with an extensometer.9 The researchers found that as they increased the tensile force on the Achilles tendon, plantar fascia strain increased proportionately. They also measured plantar fascia strain with the toes dorsiflexed at zero, five, 30 and 45 degrees. This showed that dorsiflexion of the toes tightens the plantar fascia (via the windlass effect) and increases the effect that a tensile force in the Achilles tendon has on the tensile strain and tensile force in the plantar fascia.9
Furthermore, studies have also demonstrated excellent results in treating recalcitrant cases of plantar fasciopathy with gastrocnemius recession.11-17 Unlike most surgical procedures that involve operating at the site of pathology, one performs the gastrocnemius recession at the proximal aspect of the calf muscle. This is not even close to the plantar fascia yet the results are very promising. This is not a coincidence but instead another piece of evidence linking the cause and effect relationship between ankle equinus and plantar fasciopathy.
There is also some evidence demonstrating an association between hamstring tightness and plantar fasciopathy.18,19 While there are currently a limited number of studies that have investigated this link, I believe this is an area that has been overlooked by clinicians and researchers in the past. In my practice, I routinely assess hamstring flexibility in patients with plantar fasciopathy and prescribe stretching exercises if there is reduced flexibility.
If there is a good body of evidence to demonstrate the link between posterior leg tightness (gastroc-soleus and hamstring) and plantar fasciopathy, why are the outcomes for stretching exercises relatively modest and show mixed results?20-24 If muscular tightness is a main cause and stretching addresses this problem, why aren’t the results better?
I feel there are a couple of reasons why prescribed stretching exercises are not always effective. The first is poor patient adherence. When we ask patients about their stretching exercises, the response is often “Well I haven’t been doing them as much as you recommended.” Yet they wonder why they aren’t getting better, become disengaged and start to turn to alternative quick-fix options such as steroid injections.
It takes a resilient clinician to take this opportunity to reexamine the patient’s calf and hamstring flexibility, and inform the patient that this may be why his or her symptoms are not improving. However, it has been my experience that many podiatrists will give up fighting with the patient to get on board with the exercises. The doctor then becomes somewhat passive in the treatment plan and ends up going along with trying something else such as a steroid injection.
The second reason stretching exercises may not be effective is due to chronic contracture of the soft tissue, which happens very slowly over time. We can understand this by applying Davis’s law in which soft tissue contracts to the shortest position possible when given the opportunity. In some cases, the shortening may become rigid or fixed and even when patients are diligent with their exercise regime, they may not be able to increase flexibility. Accordingly, the symptoms do not improve.
One cannot overstate the significance of posterior muscle tightness and ankle equinus in plantar fasciopathy. Injection does not properly address these findings whereas stretching or other treatments that modify this tightness make more sense. I would strongly encourage interested readers to look at some of the published articles by Amis and DeHeer for more on this topic.25,26
How Does One Address Foot Pronation Most Effectively?
The evidence demonstrating foot pronation as a risk factor for plantar fasciopathy is less established. This begs the question: how relevant is foot pronation in the development of plantar fasciopathy? Despite the lack of concrete evidence to suggest foot pronation is a risk factor, my rationale for prescribing foot orthoses as a frequent part of my treatment plan comes from the tissue stress theory first described by McPoil and Hunt in 1995.27
The plantar fascia is one of the main soft tissue structures supporting the arch of the foot along with the tibialis posterior and abductor hallucis muscles. Increased foot pronation leads to increased loading on all three of these structures as they function primarily as supinators of the foot. Therefore, if one designs a foot orthosis to effectively increase the supination moment on the foot, this will result in decreased tissue stress on these structures. Indeed, a biomechanical study published in 2011 demonstrated decreased plantar fascia strain via semi-custom molded orthoses while walking in comparison to walking without orthoses.28
If we take a brief look at the latest evidence on foot orthoses for plantar fasciopathy, it is confusing. Two systematic reviews recently published in the British Journal of Sports Medicine had contradictory results.29,30 The first study by Whittaker and colleagues found moderate evidence for effective pain reduction with foot orthoses that were superior to sham devices in a medium-term time period.29 On the other hand, a second study by Rasenberg and colleagues concluded that foot orthoses were not superior in comparison with sham treatment or other conservative treatment for heel pain.30
To help make sense of these contradictory findings, Whittaker and colleagues published a follow-up editorial article to provide an explanation for why these studies had contrasting findings.31 It comes down to different outcome measures the researchers used to extract data, which resulted in differences in the effect size and confidence intervals between the two studies.
Aiming to clarify the uncertainty, Whittaker and colleagues stated: “To put the findings of both reviews in context for health practitioners, both the Rasenberg et al review and our review found small effect sizes (favoring) foot orthoses. (They) found the effect (was) not statistically significant while we found it was statistically significant (based on the lower confidence limit crossing or not crossing zero, respectively).”31
My personal experience is much more in line with the findings of Whittaker and team in that I have found that quality foot orthoses are an effective treatment method in my overall plan for plantar fasciopathy. By addressing any overpronation or other biomechanical abnormalities, I am able to relieve the tissue strain that leads to the overuse associated with plantar heel pain.
Why I Do Not Use Corticosteroid Injections For Plantar Fasciopathy
Corticosteroid injections are a commonly used treatment option for plantar fasciopathy. However, when one reviews the literature, it is clear that these injections only offer a short-term benefit and they are a poor option for long-term success.32,33 A systematic review of 39 studies including 2,942 participants with plantar fasciitis concluded that there is low quality evidence that steroid injections may slightly reduce heel pain for up to one month after administration but not thereafter.33
Personally, I am not a proponent of the use of corticosteroid injections for plantar fasciopathy for a number of reasons. First, the consensus among the podiatry profession is that plantar fasciopathy is a degenerative tissue disease, as demonstrated by Lemont and colleagues in their well-known histology study, in which they examined 50 heel samples.34 The authors point out that there was no evidence of inflammation in their samples and recommend that plantar fasciitis should be renamed plantar fasciopathy as a more accurate term. Since corticosteroid injections are potent anti-inflammatory agents, it does not make sense to use an anti-inflammatory for a non-inflammatory condition.
Secondly, corticosteroid injections carry the risk of plantar fascia rupture, which can result in deleterious effects on the foot. A retrospective case series demonstrated a plantar fascia rupture rate of 10 percent in patients who had previously received corticosteroid injections in the plantar heel.35 Third, corticosteroid injections do not address the common underlying causative factors of plantar fasciopathy such as ankle equinus and foot pronation as I previously discussed. Fourth, even if plantar fasciopathy is actually an inflammatory condition (which has yet to be proven), the evidence does not support the use of corticosteroid injections.
For all of these reasons, I do not recommend corticosteroid injections and believe clinicians should turn to alternative options for treating plantar fasciopathy.
An effective clinician’s principles of management should be based on a sound understanding of the pathology and physiology of the condition he or she is treating. This should certainly be the case when one is treating plantar fasciopathy. With this in mind, clinicians should focus on the underlying causes of plantar fasciopathy and seek to address these causes as part of their treatment planning. Therefore, as they more directly address underlying pathology, I feel orthotics and stretching are superior primary treatment options for plantar fasciopathy in comparison to steroid injection.
Mr. Boshell completed his MSc in Podiatric Surgery at the University of Brighton. He is the Podiatry Head of Service at Hatt Health and Movement Clinic in the United Kingdom. He is also the author of The Plantar Fasciitis Bible and host of The Heel Pain Expert podcast.
Sharing insights from his experience as well as the literature, this author maintains that corticosteroid injections offer a viable adjunctive modality and effective first-line option in the treatment of plantar heel pain.
By Alan MacGill, DPM, FACFAS
Plantar fasciitis, also known as plantar fasciopathy, is estimated to account for 1 million patient visits per year. It is the most common cause of heel pain in adults with an average incidence of 10 percent and an increased incidence in women 40 to 60 years of age.1 Risk factors for plantar fasciitis in non-athletes include equinus, body mass index greater than 27 kg/m2, pes planus, pes cavus and occupations requiring prolonged standing or walking.2 The duration of symptoms can be divided into acute (four to six weeks), subacute (six to 12 weeks), and chronic (greater than three months).
There are many non-surgical treatment options for plantar fasciitis. These include plantar fascia and Achilles-focused stretching exercises, functional orthoses, oral anti-inflammatory medications, injection therapy, radial soundwave and extracorporeal shockwave therapy. Injection therapy can further be divided into corticosteroid, amniotic allograft, platelet-rich plasma, stem cell and botulinum toxin.
Though most patients respond to conservative therapies, a smaller percentage do not and may require surgical intervention. Many surgical options exist and include partial plantar fasciotomy, gastrocnemius recession, cryosurgery and bipolar radiofrequency ablation. Partial plantar fasciotomy, which one can perform open or endoscopically, is the most common procedure for this problem. More recently, surgeons have performed this procedure via percutaneous ultrasonic debridement.3
What Studies And Consensus Recommendations Say About Corticosteroid Injections
There are many benefits of corticosteroid injection therapy for plantar fasciitis. The cost to the practitioner and patient is relatively low, and the modality is readily available. Cortisone injections offer a quick onset of pain relief and a good duration of effect. In a 2009 prospective, randomized trial comparing four different injection modalities, Kalaci and colleagues found excellent results and superior pain relief at three weeks and six months with corticosteroid injections and a peppering technique.4
Rupture of the plantar fascia following steroid injection is a concern for some practitioners. However, in a retrospective review of 120 patients who received cortisone injections for plantar fasciitis, Kim and colleagues found a 2.4 percent rupture rate after an average of 2.67 injections and concluded that due to the low incidence, corticosteroid injection therapy was a safe and effective form of non-operative therapy.5
In 2001, Thomas and colleagues published the American College of Foot and Ankle Surgeons’ Clinical Practice Guideline for the diagnosis and treatment of heel pain.6 With this consensus guideline, the authors divided the treatment of plantar heel pain into tiers with corticosteroid injection listed as a tier 1 or first-line option. In 2010, this same group published a revision to their recommendations, maintaining that corticosteroid injection was a tier 1 option that had a grade B recommendation based on the available clinical evidence.7 The grade of recommendation is based on the criteria set forth by the Oxford Centre for Evidence-Based Medicine (CEBM). A grade B recommendation is based on consistent level 2 or 3 studies, or extrapolations from level 1 studies.8 Furthermore, the authors listed repeat cortisone injection as a tier 2 option for unsatisfactory improvement and noted a grade B recommendation for this modality as well.
The American College of Foot and Ankle Surgeons revisited this yet again in 2018 when Schneider and colleagues published a clinical consensus statement on the diagnosis and treatment of adult-acquired infracalcaneal heel pain.9 The panel of experts concluded that “corticosteroid injections are safe and effective in the treatment of plantar fasciitis.”
In 2015, Celik and colleagues looked at steroid injection versus joint mobilization and stretching for the treatment of plantar fasciitis in a level 2, randomized, controlled trial.10 The study involved 43 patients with an average of 45 years of age and patients received either one corticosteroid injection in the area of maximal tenderness or did joint mobilization and stretching exercises three times per week for three weeks. Researchers measured functional scores and pain levels at baseline, three-week, six-week, 12-week and one-year follow-ups. Celik and coworkers demonstrated significantly improved outcomes at the three-, six-, and 12-week follow-ups for both groups, but the corticosteroid group exhibited better outcomes at all three of these time points.10
In their recently published systematic review and meta-analysis, Chen and coworkers examined the comparative efficacy of corticosteroid injection and non-invasive treatments (including physical therapy, insoles, shockwave therapy and non-steroidal anti-inflammatory drugs) for plantar fasciitis.11 They reviewed nine randomized controlled trials that compared corticosteroid injection with four different types of non-invasive treatments with the primary outcome on pain reduction. Chen and colleagues concluded that corticosteroid injection was more effective than physical therapy after 1.5 months and overall more effective than non-invasive therapy at three months.11
These findings were echoed by a systematic review and meta-analysis from Whittaker and colleagues in 2018.12 They looked at 47 randomized trials with over 2,200 people receiving a corticosteroid injection for plantar heel pain, focusing on “first step pain” and function. The group found that corticosteroid injection was more effective for reducing pain than some comparators (specifically autologous blood injection and orthoses) and more effective for improving function than physical therapy in the short term.
Perhaps the most compelling study and one that reaffirms my personal approach to this pathology is the level 1 study from Johannsen and colleagues, who looked at the effects of corticosteroid injections and physical therapy on plantar fasciitis.13 The single-blinded, randomized superiority trial involved 90 patients, who received either three months of strength training and stretching; monthly corticosteroid injections monthly (maximum of three injections until plantar fascial thickness was less than 4.0 mm); or a combination of the two treatments. The main outcomes they evaluated were improvements in pain and function at six months. All groups improved significantly over time but the combination of injection and strength training/physical therapy had a superior effect at all time points. The group concluded that this combination therapy was the best in the short- and long-term, and should be a first-line treatment option for patients with plantar fasciitis.
Plantar fasciitis is one of the most common presenting complaints we see as foot and ankle specialists. Researchers have demonstrated in the literature that utilizing a multifaceted approach including corticosteroid injections decreases patient pain and improves function in comparison to just orthoses and stretching. Furthermore, this modality is readily available, inexpensive and is supported as an acceptable first-line treatment by our professional organizations.
Dr. MacGill is the Director of the Foot and Ankle Surgery Residency Program at Northwest Medical Center in Margate, Fla. He is the Southeast Region President of the American College of Foot and Ankle Surgeons, and is a Clinical Instructor at the Barry University School of Podiatric Medicine. Dr. MacGill is in private practice at Spine and Orthopedic Center in Coral Springs, Fla.
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