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Plantar Fascia steroid injection; a group participation meta-analysis

Discussion in 'General Issues and Discussion Forum' started by Mart, Nov 3, 2009.

  1. Mart

    Mart Well-Known Member

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    Since I have started doing injections for plantar heel pain a couple of things became apparent.

    Firstly, whilst doing US guided injection using a standard 3 mls syringe and a 25g needle I was unable physically to inject into the plantar fascia in most instances and attributed this to being unable to develop sufficient pressure to overcome fascia stiffness. I started a thread on “podarena” suggesting that when people think they inject into the fascia they actually cannot.

    From the few respondents there was implied agreement. It was also suggested by Kevin Kirby that if wanting to inject into fascia a thin diameter tuberculin syringe would work, I tried this and this seems to be true, although in some instances extremely difficult.

    Secondly when injecting into tendons and the plantar fascia with corticosteroids there seems to be concern that we put these structures at increased risk of rupture and this is a reason to avoid injecting into them. However some studies explicitly state aiming to inject into fascia, some imply this is the target, some implicitly avoid the fascia . . . . so as clinicians what should we be doing?

    I have looked ay quite a bit of the literature and have noted that recently US guidance is increasing being used. It may be that much of the literature is not explicit about intended site simply because image guidance was not available, however there may have been some implicit target written about.

    My interest is to clarify how science has so far been able to look at this, not as a primary objective (the studies are largely to test injection efficacy regardless) but incidentally within the general descriptive text.[/FONT][/SIZE][/COLOR]

    Primary information;

    What agents are being injected.
    Is there any implicit or explicit notion of which tissues are targeted and/or avoided?
    How is site located?
    Is any form of guidance used to verify site of drug delivery during injection?

    Associated information;

    Diagnostic criterion
    Outcome measures
    Secondary (deleterious) outcomes

    I have set up a draft spreadsheet to collect the data in a way which should allow some fairly painless analysis. The idea is to do a simple quasi meta-analysis and split the task amongst a group of interested to spread the load. There are some podiatrists locally who are going to participate, if podarena members are interested, please email mail me and I’ll add you to the list. I have a couple of buddies who are in process of compiling papers for creating some new Cochrane reviews on related subjects who will help search and provide the papers.

    I think that we need to use the same language to objectify what we find and have categorised data into discrete fields.

    To get a sense of how this might work I have attached a paper and then analysed it using these fields as an example.

    Since we are going to invest some time and trouble please have a look at my plan and circulate any ideas to the group to support, modify or change the process over the next week or so. Even if you are not interested in doing any analysis I’d appreciate your input so that this exercise has optimal value.

    Once the analysis method is finalised I will circulate the citation list for us to work on.

    Does anyone have access to:

    Cyriax JH, Cyriax PJ. Illustrated Manual of Orthopaedic Medicine.
    London: Butterworth; 1983:123.

    The injection technique described is cited in many papers and I do not have access to a copy to find out what it amounts to.

    Look forward to getting the ball rolling

    NB when replying please do so to whole group not just me to generate some discussion, but personally if wanting to participate and I’ll add you to the distribution list.



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

    Attached Files:

    • 45.pdf
      File size:
      98.3 KB
  2. Mart

    Mart Well-Known Member

    I was unable to attatch the spreadsheet (it is recognised an invalid format) will upload to my website and post the link when I get a few minutes to do this.
  3. Mart

    Mart Well-Known Member

    to download spreadsheet go to


    click on podarena icon and should be able to download

    most of the fields have a dropdown menu to pick value from, try it so that you can see how the data options are collected.
  4. Mart

    Mart Well-Known Member

    Here's my Santa wish list for this year: a bunch of papers to complete the literature review which I am so far unable to get my mits on.

    I have been relatively good podiatrist this year so feel somewhat deserving. If anyone can help out I'll put in a good word for them next time I visit with the elves.

    Please post or email me any pdf from list below



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

    ACEVEDO, J. I. & BESKIN, J. L. (1998) Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int., 19, 91-97.
    ADLER, R. S. & SOFKA, C. M. (2003) Percutaneous ultrasound-guided injections in the musculoskeletal system. Ultrasound Q, 19, 3-12.
    DASGUPTA, B. & BOWLES, J. (1995) Scintigraphic localisation of steroid injection site in plantar fasciitis. Lancet, 346, 1400-1.
    FOYE, P. M., SULLIVAN, W. J., PANAGOS, A., ZUHOSKY, J. P., SABLE, A. W. & IRWIN, R. W. (2007) Industrial medicine and acute musculoskeletal rehabilitation. 6. Upper- and lower-limb injections for acute musculoskeletal injuries and injured workers. Arch Phys Med Rehabil, 88, S29-33.
    FRATER, C., VU, D., VAN DER WALL, H., PERERA, C., HALASZ, P., EMMETT, L. & FOGELMAN, I. (2006) Bone scintigraphy predicts outcome of steroid injection for plantar fasciitis. J Nucl Med, 47, 1577-80.
    KAMEL, M. & KOTOB, H. (2000) High frequency ultrasonographic findings in plantar fasciitis and assessment of local steroid injection. J Rheumatol, 27, 2139-41.
    LOGAN, L. R., KLAMAR, K., LEON, J. & FEDORIW, W. (2006) Autologous blood injection and botulinum toxin for resistant plantar fasciitis accompanied by spasticity. Am J Phys Med Rehabil, 85, 699-703.
    MCCOLL, G. J., DOLEZAL, H. & EIZENBERG, N. (2000) Common corticosteroid injections. An anatomical and evidence based review. Aust Fam Physician, 29, 922-6.
    MELEGATI, G., TORNESE, D., BANDI, M. & CASERTA, A. (2002) The influence of local steroid injections, body weight and the length of symptoms in the treatment of painful subcalcaneal spurs with extracorporeal shock wave therapy. Clin Rehabil, 16, 789-94.
    OGDEN, J., ALVAREZ, R. G., CROSS, G. L. & JAAKKOLA, J. L. (2005) Plantar fasciopathy and orthotripsy®: The of prior cortisone injection. Foot and Ankle International, 26, 231-233.
    PAI, V. S. (1996) Rupture of the plantar fascia. J Foot Ankle Surg, 35, 39-40.
    PLACZEK, R., DEURETZBACHER, G. & MEISS, A. L. (2006) Treatment of chronic plantar fasciitis with Botulinum toxin A: preliminary clinical results. Clin J Pain, 22, 190-2.
    QUINN, M. & GOUGH, A. (1998) Ultrasound guided injection of plantar fasciitis. Ann Rheum Dis, 57, 749-50.
    RAGHAVENDRAN, R. R., PEART, F. & GRINDULIS, K. A. (2008) Subcutaneous calcification following injection of triamcinolone hexacetonide for plantar fasciitis. Rheumatology (Oxford), 47, 1838.
    SAXENA, A. & FULLEM, B. (2004) Plantar fascia ruptures in athletes. Am J Sports Med, 32, 662-5.
    SELLMAN, J. R. (1994) Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int., 15, 376-381.
    WONG, S. M., LI, E. & GRIFFITH, J. F. (2001) Ultrasound guided injection of plantar fasciitis. Ann Rheum Dis, 60, 639.

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