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Are plantar fascia injections impossible? Some observations.

Discussion in 'General Issues and Discussion Forum' started by Mart, Jun 27, 2009.

  1. Mart

    Mart Well-Known Member

    Members do not see these Ads. Sign Up.
    Has anyone else noticed the impossibility of injecting into the plantar fascia?
    I have done several hyperosmolar dextrose shots into resistant plantar heel pain patients.
    My technique was always to mark location of degenerated plantar fascia on plantar skin using Diagnostic ultrasound, tibial nerve block, then planto-dorsal 20g needle directly into region gently to bone, back off slightly and try and inject. Always I have never been able to expel ANY fluid (even with full pressure from thumb, I am no weakling) until backing needle considerable distance.
    Last week I decided to inject myself (I have recent chronic plantar fasciosis distally) to try and understand a couple of things. (Simon F . . . . . yes I know . . . . . . . . . .. )
    Firstly I did not do a tibial block, I used a Madajet medial to site by approximately 10mm to allow painless needle insertion.
    Then using Diagnostic ultrasound (short axis view) I visualised slow needle insertion in lateral plantar direction which was entirely painless until I touched the superficial margins of the degenerated portion of the plantar fascia.
    I had intense instant pain which radiated to my forefoot. Because this was so unpleasant I decided to infiltrate about 0.5 mls of 50/502% lidocaine/50 sterile dextrose right there, at plantar fascia margin and remove needle. I had instant and complete pain relief to very deep pressure at degenerated site, normally I would not have tolerated this.
    I then reinserted the needle and gently guided into plantar fascia under Diagnostic ultrasound guidance without any pain. I tried to inject and noticed same resistance as with my prior patients, no possibility of injection, I spent about 2 minutes carefully probing within the entire plantar fascia segment from margin to margin, without pain and then tried to inject again, no luck. Thinking that perhaps the needle was somehow “blocked” with fascial tissue I drew it back to slightly outside of the plantar fascia and there had no resistance to injection what so ever.
    I have never seen this observation written about and am curious to hear of others experiences.
    It strikes me that it is possible that when people think they are injecting into the plantar fascia perhaps they are not. If this is true what does it say about the nature of this therapy? Also I am curious, at least in my own foot regarding the location of the nociceptors which appear to have been on the plantar fascia margins not within the ECM of the plantar fascia. This also raises some interesting possibilities.
    I am keeping a diary of my progress both symptomatically and sonographically which I will post if there is any interest.
    Anyone else thinking about this or have any opinions to explain what I am noticing?
    My suspicion is the plantar fascia ECM is much too stiff to permit infiltration of fluid, if this is true it tells us something regarding the material properties of degenerated plantar fascia at least in my cases which is a bit of a holy grail of mine for in vivo evidence. It also suggests the possibility that the plantar fascia itself may be insensate. I have never found any reference within the literature which tells us precisely the sensory nature of the plantar fascia, anyone have any leads on that issue?



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
  2. Mart

    Mart Well-Known Member

    I had also meant to add to the end of my thread that I believe the most plausible explanation I can fathom for the pain attributed to chronic plantar fasciosis is from increased pressure against the plantar fascia margins. I have mulled over this idea for many months and can find nothing in the literature or from my own experience to contradict this idea and my recent experience adds strength to my idea.

    For fun (and learning) please try and find reasons I may be wrong, I have read the literature pretty thoroughly and should be able to give reasonable responses.



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  3. Martin:

    I inject the plantar fascia (i.e. central component of the plantar aponeurosis) routinely with a mixture of local anesthetic (2.0 cc of 0.5% Marcaine plain) and a cortisone solution of either Celestone Soluspan or Depomedrol. I inject from plantar, directly into the point of maximum tenderness while the patient is prone, with their knee is flexed to 90 degrees, so that, while I am standing, I am looking directly down on the area of injection. I first mark the plantar skin with a pen with an "X" to indicate the point of maximum tenderness. I use a alcohol swab to clean the skin. I then use ethyl chloride spray to anesthetize the skin (about 10 seconds), then while injecting (with a 25 gauge, 1.25" needle), move the needle plantar and dorsal through the painful area of the plantar fascia, piercing it about 10 times, while depositing the local anesthetic/cortisone solution plantar and dorsal to the fascia to bathe the most inflamed areas.

    Even though little cortisone solution probably goes directly into the plantar fascia, I'm sure that some of it does go into the fascia while most of it goes into the inflamed tissues immediately surrounding the fascia. Using this method, one can feel when the needle contacts the plantar fascia and feel the change in resistance when the hypodermic needle pierces through the fascia, so that one can be absolutely certain that they are injecting directing into (and dorsal and plantar to) the fascia in the area of maximum tenderness. I do about 10-15 of these injections per week. The injection takes less than one minute. I have been using this technique for the past 20+ years and find it to be a very good way to make sure I am delivering the medication into the exact anatomic area that I want it to be in.

    Hope this helps.
  4. Mart

    Mart Well-Known Member

    Thanks for the description of your technique Kevin.

    Clearly you have had way more experience performing this than me.

    I am still curious though that you dont mention having noticed this phenomena which I have found of not being able to advance the plunger at all whilst the needle is within the plantar fascia (by which I also mean central band). Perhaps I have only injected a very skewed sample of people. With he excepton of my own foot they all had extremely thickenned (> 9.0 mm) wide and long standing (> 9 months) fusiform thickenning which were sonographicaly and VAS pain scored amoungst the worse I have come across.


  5. Martin:

    Surgically, when one inspects the plantar fascia, it is a very dense collection of parallel collagen fibers....I describe it somewhat like a thin belt to my patients. A syringe and hypodermic needle will have little chance of being able to actually push fluid into the dense collagen fibers of the plantar fascia since the plantar adipose which is located plantar to the plantar fascia, and the flexor digitorum brevis muscle which is located dorsal to the plantar fascia are much less dense so the fluid from the injection will naturally collect along the paths of least resistance dorsal and plantar to the fascia. If you do feel you actually want to be inside the plantar fascia with your injection, then do your injection with a 1 ml tuberculin syringe since this will give you the greatest pressure head at the hypodermic needle aperture and the greatest chance of pushing the fluid between the collagen fibers of the plantar fascia.
  6. Lawrence Bevan

    Lawrence Bevan Active Member

    Thanks for your description of your technique Kevin. I find plantar fascia injections from a medial apporach ok but following your description I have wondered if a plantar approach might be far simpler and accurate.

    I have just ordered a can of "cryogesic" and I will try it!

    Also I note you "pepper" the fascia, there was a recent paper in JAPMA that lent some support to the effectivenes of this technique but again this is likely far easier with a plantar approach.
  7. Lawrence Bevan

    Lawrence Bevan Active Member

    HI Kevin

    Having used the freeze spray now for heel injection, I noticed that you need to use a fair bit to get good skin numbness and this only last a couple of seconds.

    If you do 10-15 injections like this per week, i guess you get through a few cans of spray?? I reckon you'll get about that many per can?

    What do you find the optimal distance for it from the skin, I was working on about 15 cm?

  8. Mart

    Mart Well-Known Member

    Hi Kevin

    Good thinking regarding the syringe, basic mechanics . . . . I should of thought of that although I wonder if the fluid will simply spurt out of the fascia with removal of the needle. If I find out I'll post a comment.

    I am curious to develop a deeper understanding of how these various injection techniques might work and if they can be finessed by more careful localisation. Since the aetiology of chronic plantar fasciosis remains unknown we seem a long way from an understanding currently.


  9. Mart

    Mart Well-Known Member

    Kevin, when I look a the plantar fascia on US there is usually a definite very thin hyperechoic margin along its entire length which appears distinct but for some reason only clearly visible in saggital but not coronal views (this makes coronal views trickier to interpret). My assumption, which may be wrong, is that the plantar fascia has a thickenned fibrous sleeve which is denser than the surrounding tissue. This should be visible in both planes on US, but in my hands at least, doesnt seem to be the case. I have never seen this written about, any observations from surgical inspection?


  10. Lawrence:

    I use a ethyl chloride fine pinpoint spray that comes in a bottle. Spray time is generally for 4-6 seconds, and is used to prevent the patient from feeling the needle puncture. I would imagine I get about 100 sprays from each bottle (but have never counted).

    The further the bottle is from the skin, the colder will be the spray stream when it hits the skin, as long as the spray hasn't spread out in too wide a diameter by the time it hits the skin. [The heat lost by rapid evaporation of the ethyl chloride makes the liquid ethyl chloride rapidly cool which is then transferred as a cooling agent to the skin.] I hold the bottle about 16-18" from the skin (about 2.5-3 times the distance you are using) since this makes the skin freeze faster than using a shorter distance. You may want to experiment on your own skin to see which distance it optimum since it will greatly depend on the spray diameter and chemical within the spray.

    BTW, when I am bored and need some instant entertainment in my office, I will turn over my coffee mug, put a teaspoon of water in the base of the mug, and use the ethyl chloride spray to turn the water into small heet of ice within about 5 seconds.
    Last edited: Jul 2, 2009
  11. Martin:

    The plantar fascia does not have a sleeve or skin on it. When we section it during plantar fasciotomy, it appears homogeneous from plantar to dorsal. Probably what you are noting on ultrasound exam is the junction between the much less dense plantar adipose layer plantarly and the much more dense plantar fascia dorsally. The coronal vs sagittal ultrasound difference is likely some type of ultrasound artifact. Try putting a thin leather belt under water or inside a gelatin mold (um, yummy) and examine it both in a "coronal" and "sagittal" fashion to see if the appearance changes on ultrasound exam. Looking forward to your results, as usual.:drinks
  12. Martin:

    One thing I have thought I could try is to needle the plantar fascia with a larger gauge needle (18g) a number of times along its medial half to see if I can weaken it some, and allow it to stretch without a surgery being necessary. This certainly makes sense from a mechanical standpoint and I think this technique may have already been used in another country, if my memory serves me correct.
  13. Mart

    Mart Well-Known Member

    Thanks for the clarification of the plantar fascia surface Kevin.

    Yes you are correct regarding percutaneous needle technique, I have been considering trying this since it makes so much sense. . . here's the citation.

    Folman, Y., G. Bartal, et al. (2005). "Treatment of recalcitrant plantar fasciitis by sonographically-guided needle fasciotomy." Foot and Ankle Surgery 11(4): 211-214.

    Plantar fasciotomy was carried out in 32 patients who had typical heel pain that had persisted for three months or longer. Following induction of local anesthesia, an 18-gauge needle was guided toward and into the plantar fascia by real-time sonography. The criterion for operative success was the appearance of an acoustic window within the plantar fascia. Pain intensity was graded on an 11-point visual analog scale (VAS). Questionnaires combining the VAS and a 0-100 point Daly score were filled out after treatment to determine the effectiveness of the procedure. The follow-up averaged 13.5 months. 78% were overweight (BMI>25). The mean pain score decreased by 6.72 points, a 73±21% improvement (P<0.001). The mean post-operative Daly score was 88.3±16.2. There were no complications during or after the procedure. Sonographically-guided needle fasciotomy is a safe and effective method for the relief of conservatively unmanageable heel pain due to plantar fasciitis. © 2005 European Foot and Ankle Societ. Published by Elsevier Ireland Ltd. All rights reserved.

    Were I am coming from in trying to understand more about the plantar fascia margins come from Benjamin's work, here's a chunk from

    Benjamin, M. (2009). "The fascia of the limbs and back--a review." J Anat 214(1): 1-18.

    Fascial innervation;
    Several reports suggest that fascia is richly innervated, and
    abundant free and encapsulated nerve endings (including
    Ruffini and Pacinian corpuscles) have been described at a
    number of sites, including the thoracolumbar fascia, the
    bicipital aponeurosis and various retinacula (Stilwell, 1957;
    Tanaka & Ito, 1977; Palmieri et al. 1986; Yahia et al. 1992;
    Sanchis-Alfonso & Rosello-Sastre, 2000; Stecco et al. 2007a).
    However, it is sometimes difficult to decide from the literature
    whether a particular piece of deep fascia is itself innervated
    or whether the nerve fibres lie on its surface or in areolar
    or adipose tissue associated with it. Changes in innervation
    can occur pathologically in fascia, and Sanchis-Alfonso &
    Rosello-Sastre (2000) report the ingrowth of nociceptive
    fibres, immunoreactive to substance P, into the lateral knee
    retinaculum of patients with patello-femoral malignment

    Stecco et al. (2008) argue that the innervation of deep
    fascia should be considered in relation to its association
    with muscle. They point out, as others have as well (see below
    in ‘Functions of fascia’) that many muscles transfer their pull
    to fascial expansions as well as to tendons. By such means,
    parts of a particular fascia may be tensioned selectively so
    that a specific pattern of proprioceptors is activated.
    Despite the contribution of the above studies, our understanding
    of fascial innervation is still very incomplete and
    it is likely that there are regional differences of functional
    significance, as with ligaments. It is worth noting therefore
    that Hagert et al. (2007) distinguish between ligaments at the
    wrist that are mechanically important yet poorly innervated,
    and ligaments with a key role in sensory perception thatare richly innervated.

    There is a corresponding histological
    difference, with the sensory ligaments having more conspicuous
    loose connective tissue in their outer regions (in
    which the nerves are located). Comparable studies are not
    available for deep fascia, although Stecco et al. (2007a)
    report that the bicipital aponeurosis and the tendinous
    expansion of pectoralis major are both less heavily innervated
    than the fascia with which they fuse. Where nerves are
    abundant in ligaments, blood vessels are also prominent
    (Hagert et al. 2005). One would anticipate similar findings
    in deep fascia.
    From comparisons with tendons and ligaments, where
    nerve and blood vessels are generally a feature of the
    associated loose connective tissue sheaths (Hagert et al.
    2007), it might be anticipated that fascial nerves would
    also be commonly surrounded by areolar connective
    tissue. The levels of mechanical loading to which dense
    connective tissue is adapted are not likely to be conducive
    to having nerves and densely packed collagen fibres too
    close together. Abnormal levels of mechanical loading
    have been suggested to cause nerve damage in knee
    retinacula (Sanchis-Alfonso & Rosello-Sastre, 2000). Nevertheless,
    Stecco et al. (2007a) do show evidence of fascial
    nerves that are closely related to densely packed collagen
    fibres and thus lie within the fascia itself. In the distal
    part of the iliotibial , however, it is the tissue adjacent to
    deep fascia that is more conspicuously innervated than the
    fascia itself (Fairclough et al. 2006; Fig. 5).
    Some of the nerve fibres associated with fascia are
    adrenergic and likely to be involved in controlling local
    blood flow, but others may have a proprioceptive role.
    Curiously, however, Bednar et al. (1995) failed to find any
    nerve fibres in thoracolumbar fascia taken at surgery from patients with low back pain.


  14. Stanley

    Stanley Well-Known Member

    Hi Martin,

    I know exactly what you are talking about. When I inject into the plantar fascia, there is a lot of resistance and the patient experiences exquisite pain. For years I injected just superior to the plantar fascia for a much more comfortable injection.
    Now with the research showing that the needling of the plantar fascia is helpful in the treatment, I inject the plantar fascia.
    The trick is to inject the medication as you withdraw the needle.
    Here is another trick on injecting. Make believe your needle is an extension of your finger, and feel what the needle is touching. You will be able to feel where you are in all different types of injections.


  15. Mart

    Mart Well-Known Member

    Hi Stanley

    I am also interested in the needling concept though I think we need much better evidence than exists right now to understand if it does work, if so how and to whom. I did needle my own fascia last week and will post some US findings on this once the effects have settled. I was able to clearly demonstrate blood flow within the degenerated portion which was not present before needling. Unfortunately I also injected dextrose superfical to site, which may have caused this so it was a lousy experiment really! :eek:

    I have been working up a technique to use accupuncture needle to probe plantar fascia for nociceptors. The difficulty is getting it through the thick plantar skin. Anyhow I found that I could insert an accupuncture needle through a 31 guage needle and advance it easily through the adipose layer. I need to order some longer needles so that I can get good reach whilst watching with US probe. If anyone else reading this with Diagnostic ultrasound kit wants to collaborate I have a plan to map the sensation of the plantar fascia, drop me a line and we can work up a little study.

    My notion of an investing layer which Kevin seems to have refuted is sort of based on my US observation and nicely done dissections I have looked at. I have attatched one from Benjemin's paper. It is easy to get the impression of a overlying superficial investing layer rather like the fascia covering a muscle belly.



    Attached Files:

  16. Martin:

    Never saw a plantar fascia with an "investing layer". When we do the "in-step" plantar fasciotomy (I just did two of them a week ago), we directly visualize the plantar fascia from plantar, there is only fascia there with no detectable covering, no sheath and no investing layer that I have ever seen.
  17. Lawrence Bevan

    Lawrence Bevan Active Member


    Thanks for your reply. I was using an "aerosol" version of Ethyl Chloride and this did work for surface analgesia. The liquid may be more effective in smaller doses. I will switch and try again.

  18. Informer

    Informer Welcome New Poster

    Can anybody give me some advice on this please.
    I have suffered with plantar faciitis for three years and tried all treatments,from cheap orthotics
    to properly made orthotics,shock wave treatment which I beleive set me back at least six months as I was in such pain after this I was made to wear an aircast boot for four weeks because of the damage it caused.Also over the years I have had three correctly administered cortisone injections,which were very painful but now I have been told that these have thinned the fat pad protection on the heel am I being sold a line here although it is much better now than this time last year. It would be nice to be pain free or am I consigned to trainers with
    orthotics for the rest of my life.
    You people seem so knowledgable all I can do is ask.....laymans language please.

    Thanks in advance.

  19. Mart

    Mart Well-Known Member

    Hi painful Heels.

    Unfortunately I don’t think it likely that anyone on this forum can give you useful advice about what you should do from an email consult. You appear to be amongst a small group of people who don’t get better within a year or so irrespective of using one of many tried therapies (or doing nothing). What remains confusing for patients and clinicians alike is that we do not understand yet what causes chronic heel pain, this in spite of what you may have been told or read about in magazines etc. Be a bit healthily sceptical; treatment of heel pain is a multimillion dollar business and much that is touted outside of the medical community (and sometimes within) is questionable!

    There are many plausible theories, and it is likely depending on the individual they may be of different or more than one cause on a case by case basis. The Science of plantar heel pain is very incomplete and basically tells us that we don’t have sufficient evidence to be sure about what to do about it. Therefore the decision about what or what not to do has to be made on the basis of balancing the degree of disability and the perceived risk and cost of the therapy.
    Sorry to be so non specific but that is the reality. One of the main reasons this forum is useful is that we get to mull these issues over across the planet, this can help shape opinions and develop new ideas.

    Good luck in becoming painless heels.

  20. Lawrence Bevan

    Lawrence Bevan Active Member

    Ok. I have now tried with liquid ethyl chloride! I can confirm that a combination of 3 minutes of my heel on a gel ice pack and 5 seconds of ethyl chloride and I reckon I could have put a nail in my plantar heel and not felt it.

    Thanks Kevin

  21. Mart

    Mart Well-Known Member

    So far there seems to be a 3/3 consensus that it is unlikely that there is much if any fluid injected in the PF, how about you Laurence, you seem to do a lot of shots for PHP?

    I am a bit suprised there have not been more responses: anyone lurking care to add a voice?

    It may be an important issue. Anyone think that our frustrated sufferer who was told that he/she has an iatrogenic atrophied fatty pad may have been adversely affected by steroid shots? I have seen a couple of cases where there was suspicion of this, problem of course is not being able to quantify compliance of tissues before and after Tx.

    I have seen patients who were injected with steroid into heel with no evidence of abnormality of PF. Currently do most people on initial presentation of pain to palapation of medial calc tubercle and pain on rising from bed in morning get dx of plantar fasciitis ? . . . That seems to be true for most pts I see for second opinion, however on imaging with US evidence of inflamation in cases of long standing PHP is rare.

    Given current level of evidence it seems to me that there is no indication for injecting steroid for PHP without US confirmed presence of inflamation and even then care should be taken over where the fluid is placed. I am unaware of any study which shows significant efficacy of steroid for PHP over any other injection therapy (although there are some dodgy studies published). Perhaps I am being overly strident but would be keen to flesh this issue out a bit.

    Does anyone have a citation or personal experience of a cross sectional microscopic anatomy of the PF? I cannot find anything in the literature which addresses this; histologic studies either report presence of certain components but no "map". I would like to start a thread to discuss what we can reasonably infere of the microanatomy of the PF from imaging (MRI or US) vs what we can see with the naked eye (fresh cadaver and surgery) vs "gold standard" (histology). To my suprise I cannot find "gold standard" in literature.



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  22. Lawrence:

    Glad to be of assistance. Let me know if you have any technical difficulties using the technique and I'll be happy to help.
  23. Martin:

    Here's a photo from a book of a nice dissection of the three components of the plantar aponeurosis.

    Attached Files:

  24. Mart

    Mart Well-Known Member

    Now that is a work of art!

    Kevin what do you make of these images. Perhaps I am :deadhorse: but I think it shows nicely the strengths and weaknesses of MRI and US for non invasive visualisation of the plantar fascia.

    Notice the corelation between the apparent visible covering later in the fresh section sagittal slice and the hyperechoic margin on US. MRI seems to miss this because it measures an entirely different property than sound and light reflection. What do you make of this or is it still :deadhorse:?

    [FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B]Fig. 4 a
    Sagittal T1-weighted SE MRI (500/12, 320×256 matrix, 16-
    cm field of view) showing the central portion of the plantar
    aponeurosis, which measures 3 mm (

    [FONT=AdvTT50a2f13e.I][FONT=AdvTT50a2f13e.I][FONT=AdvTT50a2f13e.I]white arrow[/FONT][/FONT][/FONT]). [FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B]b [/FONT][/FONT][/FONT]Ultrasonography
    in a sagittal plane showing the central portion of the plantar
    aponeurosis, which also measures 3 mm (

    [FONT=AdvTT50a2f13e.I][FONT=AdvTT50a2f13e.I][FONT=AdvTT50a2f13e.I]white markers[/FONT][/FONT][/FONT]). [FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B]c[/FONT][/FONT][/FONT][FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B]
    [/FONT]Corresponding anatomic slice of

    [FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B]a [/FONT][/FONT][/FONT]and [FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B][FONT=AdvTTb8864ccf.B]b [/FONT][/FONT][/FONT]showing the central portion
    of the plantar aponeurosis, which measures 6 mm (

    [FONT=AdvTT50a2f13e.I][FONT=AdvTT50a2f13e.I][FONT=AdvTT50a2f13e.I]black arrow[/FONT][/FONT][/FONT]). CA,
    calcaneus; CB, cuboid

    Moraes do Carmo, C. C., L. I. Fonseca de Almeida Melao, et al. (2008). "Anatomical features of plantar aponeurosis: cadaveric study using ultrasonography and magnetic resonance imaging." Skeletal Radiol 37(10): 929-35.



    Attached Files:

    • 1.jpg
      File size:
      60 KB
  25. My answer: :deadhorse:

    I think you are reading too much into image comparisons. However, just to be sure, maybe you can find a paper on the histology of the plantar aponeurosis, which would be the gold standard for comparison.
  26. Mart

    Mart Well-Known Member

    Thanks Kevin, I agree about GS, having searched as best I can though with surprisingly with baren results. I have ordered a paper from the 1950s on histology of plantar fibromatosis to see if that sheds any light. If anyone knows of such a study please post it.


  27. Lawrence Bevan

    Lawrence Bevan Active Member


    My red flag for using a steroid injection is primarily self-reported pain. Those that are of a "lower"grade of pain - more chronic, grumbling in nature are generally put straight into orthotics.

    More "acute" pain is offered cortisone injection. It helps to reduce pain, can be done in combination with either strapping or immobilisation and makes the patient more amenable to orthotics.

    lately I am citing:

    Treatment of Plantar Fasciitis Using Four Different Local Injection Modalities
    A Randomized Prospective Clinical Trial
    Aydiner Kalaci, MD *, Hüsamettin Çakici, MD , Onur Hapa, MD , Ahmet Nedim Yanat, MD *, Yunus Dogramaci, MD * and Teoman Toni Sevinç, MD *


    Background: To determine the effectiveness of four different local injection modalities in the treatment of plantar fasciitis.

    Methods: In a prospective randomized multicenter study of plantar fasciitis, 100 patients were divided into four equal groups and were treated using four different methods of local injection: group A was treated with 2 mL of autologous blood alone; group B, an anesthetic (2 mL of lidocaine) combined with peppering; group C, a corticosteroid (2 mL of triamcinolone) alone; and group D, a corticosteroid (2 mL of triamcinolone) combined with peppering. The outcome was defined by using a 10-cm visual analog scale and modified criteria of the Roles and Maudsley score 3 weeks and 6 months after the injection and compared with the pretreatment condition.

    Results: The successful results in all of the groups after injections were higher than those in the pretreatment condition (P = .000). In groups C and D, in which local corticosteroid injections were used, excellent results were obtained, with superior effect in the group in which peppering was used (P < .05).

    Conclusions: In the treatment of plantar fasciitis, combined corticosteroid injections and peppering is effective and produces better clinical results. (J Am Podiatr Med Assoc 99(2): 108–113, 2009)

    Re ultrasound I believe that the evidence that it improves outcome for injections is mixed or though I may be wrong?

    Moreover does the absence of visable changes on ultrasound conclusively mean that the patient does not have high, painful tensile strain in their fascia??
  28. Mart

    Mart Well-Known Member


    I just noticed your reply . . . . . sorry not replied earlier.

    You are right; there is mixed evidence regarding effectiveness of US vs blind injections in the literature. I have not done proper critical review of these studies so cannot comment about what this amounts to, that review should be done though (if I get time I might take that on).

    I do not think that absence of changes on US with pain resolution indicates anything about the tensile strain, I am curious about why (other than limitations in my technique which I feel is sound) this "short term" observation might be though.



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774pegfootclinic.com
  29. Mart

    Mart Well-Known Member

    As usual you are spot on with this.

    I did a couple of US guided plantar fascia injections injections this week.

    To test your idea I initially used my regular 3ml syringe and could not inject because pressure was to high, plunger would not budge.

    Leaving 25g needle in situ I swaped syringe with 1ml tuberculin and fluid injected with little resistance.

    If I get a moment I'll post a short vidio clip which shows the plantar fascia getting "pumped up" for entertainment.

    More seriously I feel increasingly confident that the invervation for the plantar fascia arrives via the superficial fat layer, this has important possibilities I feel in allowing definitive test for root of heel pain (ruling out peripheral neuropathy) and in making plantar fascia injection therapy a more civilised affair. I'll make my idea clearer in a new post next week when I get a chance to jot down a reasonable argument for this.



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  30. Mart

    Mart Well-Known Member

    this may help us understand these issues a little more




    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918

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