Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Plantar fasciitis treated with local steroid injection

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Dec 16, 2005.

  1. admin

    admin Administrator Staff Member

    Members do not see these Ads. Sign Up.
    Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance.

    J Clin Ultrasound. 2005 Dec 13;34(1):12-16 [Epub ahead of print]
  2. Would be interesting to know if they injected plantarly or medially into the heel. I believe that plantar injections are much more effective at resolving pain than medial injections. Did the article say how the injections were given?
  3. Lawrence Bevan

    Lawrence Bevan Active Member

    Given the recent evidence showing the lack of "inflammation" with plantar fascia pain (forget the reference - recent histology study in JAPMA). What is it that steroid injections do in this condition?
  4. GarethNZ

    GarethNZ Active Member

    I am no expert in the area of histology and pharmacology, but some of the Sports Doctors suggest that it could be acting on substance P, very similar to that of what happens in achilles/patella tendinopathy. A significant break in the pain cycle with the possible ability to be able to load the fascia up more heavily. Not sure on the last comment.
  5. Matt Dilnot

    Matt Dilnot Member

    Pl Fasciitis/Fasciopathy is the same underlying process of excessive up regulation of cellular activity in response to overloading that we see in achilles tendinopathy. Similar to hypergran tissue in the absence of IGT, useless tissue that is very painful and very vascular.

    Steroid down regulates cellular activity, reduces ground substance (which is the hydrophilic aspect of the fasciopathy), reduces vascular growth of small capillaries into the tissue that are associated with pain fibres, and of course the needle itself would most likely stimulate a more appropriate healing response by traumatising the area which would lead to fibroblastic activity and remodelling.

    It would appear from my simple analysis that it is a highly appropriate treatment when used correctly. Combine injection with orthotic support (of any type) and/or strapping and improvement in biomechanics through stretching/strengthening where appropriate.

  6. Berms

    Berms Active Member

    In this and other recent threads, there has been reference to plantar fasciitis being a fasciosis without inflammation, but rather a degeneratiion of the fascial tissue (incl. the JAPMA histology study). This is very interesting and plausible, but I am confused as to the difference between "excessive cellular activity described above in relation to plantar fasciitis/fasciosis, and a generalised "inflammatory response". Is it not one and the same? :confused:
    If there is no inflammation of the fascial tissue in plantar fasciosis, and it is simply a degenerative condition, what accounts for the often classic clinical presentation of localised tissue swelling, first-step pain, redness and pooling of fluids at the site?

  7. Matt Dilnot

    Matt Dilnot Member

    The degenerative tissue has higher levels of ground substance which as I mentioned is hydrophilic. Hence it acts as a sponge when you take pressure off it (weightbearing). Thus pain in morning.

    The generalised swelling is more likely due to abnormal ankle range in people with nasty cases. This has been documented before in that they have reduced heel contact and reduced ROM use during gait cycle. Hence pumping action is reduced in venous/lymph system plus there is abnormal use of muscles which also aid in normal pumping action.

    I am not completely convinced there is a total absence of inflammation but I agree with past papers that it is not a significant effect.

  8. Matt:

    I have read your comments about plantar fasciitis not being inflammatory in nature. I have also read the paper by Lemont et al on their study regarding fasciitis being a "fasciosis" and not inflammatory. However, my clinical experience in treating thousands of these patients seems to point to the fact that this painful condition responds to ice and NSAIDS, both anti-inflammatories. In addition, these patients also respond, sometimes to the point of the pain being cured, to cortisone injections, also anti-inflammatory. Therefore, I don't agree with you that plantar fasciitis doesn't involve some form of inflammation surounding the damaged plantar fascial tissue, since if there isn't inflammation, why is the condition responding to anti-inflammatory measures and why is it painful in the first place??!!

    Until you, or Lemont et al, or anyone else can explain with a scientifically coherent manner why plantar fasciitis responds well to anti-inflammatory measures and can explain what the pain in plantar fasciitis is caused by, then I will remain sceptical that plantar fasciitis does not have some form of an inflammatory component.

    By the way, not all researchers agree with the results of the study by Lemont et al:

  9. Matt Dilnot

    Matt Dilnot Member

    The same could be said of achilles tendinopathy. For many years it has been treated with NSAID's, etc and continues to be treated so until this day. Yet some unquestionable shift has occurred in its treatment through recent histological studies and understanding.

    Evidence for an effect is weak for NSAID's and from the studies I have read no better than placebo. Analgesic action could explain its effect.

    Cortisone clearly has an effect on ground substance which could more easily explain its effect on the treatment of fasciopathy. Why else would the effect be sustained? How has reducing inflammation ever cured musculoskeletal problems if the underlying problem is not cured? In fact the effect of cortisone seems to be ideal on paper for the treatment in all fasciopathy and tendinopathy when used appropriately (not to say that it should be).

  10. If you are correct, then how do you explain the results of the study from Jarde et al that I posted: " Histological examination found inflammation in all cases (fasciitis or rupture)".

    In addition, I have to admit that I have not stayed up on my histology since learning it over 20 years ago in podiatry school. Has the definition of inflammation changed over the past 20 years?? When I was taught about the inflammatory response, when a ligament or tendon was damaged, an inflammatory response was mounted which caused pain, thus ice, NSAIDS and cortisone are used to dampen the inflammatory response and decrease the pain. Are you saying now that this is not true? What then causes the pain when someone has a small tear in the plantar fascia if it is not the inflammatory response that is mounted by the body to repair it?
  11. admin

    admin Administrator Staff Member

  12. Matt Dilnot

    Matt Dilnot Member

    Hi Kevin,

    Good to get a bit of interest in this debate. I think what you have said is a fair point. However, I was looking more at the precise point of the role of inflammation. If inflammation caused the problem, then stopping inflammation would cure the problem. Inflammation is obviously secondary to something else therefore is not the underlying problem in plantar fasciitis. Controlling inflammation may help cure the problem but it is not the pathological process that leads to the fasciitis. This would be the same for all musculoskeletal injuries.

    Therefore the "cure" would aim to treat the underlying cause. This may be any one of biomechanics, stretching, strengthening, etc.

    My belief is that by dealing with these points I do not have to resort to NSAID's and its own associated list of problems, or the hassles of icing. I especially don't need to use these now that I believe it is a more degenerative process than inflammatory.

    On the point of the articles I think it is interesting that there is so much disagreement. You would think histology and biochemistry would not be such an inexact science. It appears they are still trying to work out what exactly causes the pain in achilles tendinopathy also and that has been studied to death.

  13. When you read the article by Lemont et al, they make it very clear in both the title and the body of their paper that they believe that inflammation is not a part of what we call plantar fasciitis (Lemont H, Ammirati KM, Usen N: Plantar Fasciitis: A Degenerative Process (Fasciosis) Without Inflammation. JAPMA, 93: 234-237, 2003). I think that this is, at best, misleading. The title on their article reminds me a little of one of Rich Blake's articles on running limb varus (Tristant S, Blake RL: The myth of running limb varus. JAPMA, 6:325-327, 1991). I don't think authors should be allowed to have titles like these in scientific medical journals since these titles certainly do tend to make the authors out to be much more confident of their opinions than they really should be.

    I think that you will find most podiatrists believe that inflammation is not the primary etiology of plantar fasciitis since they feel, like I do, that inflammation is the result of the chronic mechanical stresses and tissue injury (fasciosis) that occur within the substance of the central component of the plantar aponeurosis during weightbearing activities. To say that plantar fasciitis does not involve inflammation by doing a histological study like Lemont et al is probably like looking at healing metatarsal fractures under the microscope and seeing no inflammation within the bone, but ignoring the swelling in the soft tissues adjacent to the bone (here's the title of the article: Healing Bone Fractures: A Reparative Process Without Inflammation). ;) .

    Certainly, there is an inflammatory component to plantar fasciitis but it may not actually be within the collagen fibers of the fascia, but in the tissues surrounding the fascia. When I inject a patient that has severe plantar fascial tenderness with cortisone, they have a whole lot of pain compared to those patients that have little plantar fascial tenderness. Is this pain from a "fasciosis" or more from a "fasciitis"? I believe that the increased pain is caused more from the latter than the former.

    Good discussion. Makes me want to dust off my histology textbook again....
  14. totalpod

    totalpod Welcome New Poster

    Dr. Kirby (Kevin)--

    Thank you to both yourself and Dr. Matt Dilnot for tackling a topic that also puzzles and divides many podiatrists I know. It was interesting to hear your thoughts. I continue to administer steroid injections with some frequency while also informing my patients of the need for prevention of recurrence based on underlying causes.

    I couldn't agree more with your thought regarding articles such as that from JAPMA on plantar fasciosis. Declaring inflammation irrelevant to plantar fasciitis or that which we PERCEIVE as fasciitis? Tantamount to facilitating dogma, I feel, until we have a better understanding of the cellular pathology. This type of blanket statement adds to that part of the foundation of podiatric research which is less than evidence-based, from which we, as a profession, are fortunately moving away.

    Tanya M. Barton, DPM
    Minocqua, WI
  15. Tanya:

    Good to see you taking the initiative to comment on this topic, Tanya.

    To say that inflammation is not a part of plantar fasciitis, or what we now call plantar fasciitis, is misleading. However, to think that plantar fasciitis is only inflammatory in nature without having any component of cellular damage to the central component of the plantar aponeurosis is also wrong.

    I believe that part of the problem with histological studies, especially if the researchers are not careful at how they set up their study (or their goal is to prove a "pet point" of theirs), is that they often only look at the structure that is offered up as a specimen and not at the local or systemic effects of the pathologic process as a whole. Can't see the forest for the trees??? If the trees being sampled are healthy, but 60% of the trees of the forest are infected with a pathogen, would it be correct to conclude from the experimental sample that the forest is healthy?

    Research literature must be read with a careful eye. If it doesn't make sense, the objective physician should raise a question as to its validity and accuracy. Keep a slight skepticism about you because you can't believe everything you read, even in the best scientific journals.
  16. GarethNZ

    GarethNZ Active Member

    Having only read the JAPMA study regarding plantar fasciosis and not able to access the article that Kevin K talks about, my view is very narrow. In this study they gave no figures on what they determined as "chronic". Was this 6 months, 2 years. Is there a component of fasciitis in the early stages and then as time goes by there becomes more of a degenerate change within the aponeurosis as more of the cellular changes that Matt Dilnot explains occur. Is there a grading that we should be giving our patients? Could this be possibly defined by the different types of symptoms? With this should we then be able to more accurately follow their progress with treatments, and be better able to give evidence at which stage of the pathology which treatment should work better.

    Maybe we need to follow in the work of Alfredson et al and the work they are doing with tendons and aim to investigate the plantar aponeurosis in a similar manner. They seem to be going to great lengths to gain more knowledge about how best to understand what is happening inside the tendon.

    Asked more questions than answers here...
  17. I agree with Kevin's "wood and trees" analogy. I'd go further and say that there is a lot more anatomy located in and around the classic site for "plantar fasciitis pain" than just the plantar fascia. I'm not convinced the plantar fascia is always the source of pain/ inflammation, but it gets labelled as plantar fasciitis because the symptoms seem to fit. If you only think about the plantar fascia, you only see one pathology... :cool:
  18. NewsBot

    NewsBot The Admin that posts the news.

    From latest British Journal of Sports Medicine
  19. You have to be pretty ignorant of foot anatomy to hit the lateral plantar nerve when injecting the plantar calcaneus for plantar fasciitis. Ignorance of foot anatomy is way too prevalent within the podiatry profession. Ignorance of foot anatomy is the norm in non-podiatric health professionals. Bagging the lateral plantar nerve is inexcusable in plantar fascial injections since no one should be poking a needle around inside the foot unless they know exactly where all the major neurological structures are located.
  20. NewsBot

    NewsBot The Admin that posts the news.

    Plantar Fasciitis

    Bone Scintigraphy Predicts Outcome of Steroid Injection for Plantar Fasciitis.
    J Nucl Med. 2006 Oct;47(10):1577-1580
    Frater C, Vu D, Van der Wall H, Perera C, Halasz P, Emmett L, Fogelman I
  21. Hylton Menz

    Hylton Menz Guest

    Much of the disagreement on this topic stems from different definitions of the term "inflammation". An editorial and thorough review on this topic were recently published in the British Journal of Sports Medicine:

    What is "inflammation"? Are we ready to move beyond Celsus? (editorial)

    What do we mean by the term "inflammation"? A contemporary basic science update for sports medicine

    Well worth a read. In addition to these papers, an intentionally provocative editorial by these authors was also published in the BMJ:

    Time to abandon the "tendinitis" myth

    The correspondence in relation to this editorial also makes for an interesting read, and addresses many of the issues discussed in this thread.


  22. HJM41

    HJM41 Member

    Just An Odd Note I Do Not Beleive That A Study Of Such Small Numbers Should Have Us Jumping Threw Hoops. I Have Been Injectinging Across From The Medial Side For Some Time Now And Seem To Get Good Results. But If You Explain How Injecting Plantar Is Better In Less Then Ten Studies Would Love To Here It.
  23. Bizarre post above! :confused:. I'm not at all sure about injectinging!

    Simon wrote
    This is a subject close to my heart. I can't help feeling the PF is often the "fall guy" for the more subtle master criminals of planter foot pain. Its back to the "if you have a hammer everything looks like a nail" problem. I have had pain reffered to me as pf on areas ranging from the medial aspect of the navicular to the area just inferior to the lateral malleolus. GPs and some physios are the worst culprits but the "sideshow" podiatrist brigade are also frequent offenders. You then have to spend ages trying to convince your patient that they do NOT have planter fascitis. Not an easy task as people love to be told they have a problem with a cool sounding name and Planter Fascitis is as neat and serious sounding as it is vague unhelpful.

    "You're heels hurt cos you have a laminate floor and don't wear slippers when standing still ironing for hours on end"

    just does'nt trip off the tongue the same way and they will fight to the death to avoid a diagnosis of

    "forefoot pain due to 3 inch heels for 4 hours worth of shopping".

    :mad: :mad: :mad:

    Sorry. Got carried away. Rant over. Calm now.


  24. Griff

    Griff Moderator

    What is everyones experience of neural involvement with plantar fascia like symptoms? I tend to test neural tissue in any presenting heel pain (by slump and/or SLR) - is this something most practitioners do?
  25. Nikki

    Nikki Active Member

    Couldn't agree more! Trying to explain to patients they have something different (whether diagnosed by physio, GP, other foot health professional, Podiatrist or even their best friends' mothers' aunt!!!) is a daily nightmare. The next biggest problem I find is trying to get across that as their foot barely fits in the shoe how the heck is an insole going to get in there as well!!, let alone be of any use.

    Probably the most bizzare referral I recieved from a GP was for "a painful plantar faciitis, with an unusual bump on the lateral side of the calcaneum"

    Turns out to be a very large Haglunds deformity, and the pain was an Achilles tendonitis/osis, later confirmed by ultrasound.


  26. musmed

    musmed Active Member

    Dear Ian

    Why would anyone perform a straight leg raise? It tells you nothing.

    AS back pain is very prevelant in the community, almost anything that moves the back will cause pain.

    If you do the maths and use likelihood ratio (this remove prevelance) the ratio reduces to about 0.48 to -.54 depending on whose study you follow.

    A Likelihood ratio of tossing a coin is one, ie. heads or tails. Thus if the ratio is less than one, you are worse off for having performed the test. You are better off asking you receptionist for to answer the question do you think there is a back problem in this patient.

    A good likelihood of 4 plus means there are good chances that you have power in your test or data.

    The highest I have read for musculoskeletal testing is about 3.4 and the ood 4.0. Basically extremely poor on any test you care to name.

    There are studies on plantar fasciitis regarding causes picking on obesity. Those who have a BMI of greater than 30 the likelihood is ovewr 9.0 and those who have a BMI >35 the likelihood Is 14.

    I have yet to see better result on likelihood anywhere in the literature.

    Conclusion, do not perform a SLR, you are wasting your time in more ways than one.

  27. Asher

    Asher Well-Known Member

    I know of the slump test but admit I don't use it (for no particular reason). I would also be interested in others experiences, including yours Ian.

    Thanks in advance for your advice.

  28. Scorpio622

    Scorpio622 Active Member

    iH hjm41,


  29. Scorpio622

    Scorpio622 Active Member


    I disagree. I use neural tension testing both diagnostically and for treatment. If I have a patient with heel pain and symptoms atypical of plantar fasciitis (no first step pain, night pain, neuritic sensations, etc). I will slump test them. It is more than performing a simple SLR. I have the patients sit of the end of the table. I will extend the knee, DF the ankle, with the hip at 90. I will then have them curve the T and L spine into flexion and monitor symptoms. I will then have them flex the C spine (chin to chest) while in this position- if heel pain/symptoms result, then I am dealing with a neural issue and not typical plantar fasciitis. Treatment is then directed toward the nerves. This test really impresses the patient as they increase/decrease the pain with movements of the head only.

    Of note- I do not perform this test in patients with garden variety PF signs/symptoms.

  30. DaFlip

    DaFlip Active Member

    let's say you do this slump test, the one which 'is more than performing a simple SLR', and bam, it lights them up like a christmas tree. What information is gathered, where is the problem based from the information gained with test, and what do you do with your treatment 'directed towards the nerves'?

    So the problem with their foot is in their head?
    Nick, maybe you have hit on something much greater than you ever knew possible.
    DaFlip :D
  31. David Smith

    David Smith Well-Known Member


    aH Ha Ha! Hee eHe! Shrek wIth LaRfter OOh Stop It! Laughed so much I nearly peed myself. (apologies HJM41 it was just a funny observation)

  32. GarethNZ

    GarethNZ Active Member

    Hey yo, Da flip. Amongst other things, have you heard of neural stretching before?
  33. DaFlip

    DaFlip Active Member

    GarethNZ i am very tempted to say come back to me when you have more than neural stretching champion. However i would never be so rude. Especially not now that i have found peace with my track career and set a blistering new PB of 19.39, hand timed, for the 100 with a flying start, i feel the love man. I feel the love.
    But back to your neural stretching.
    Where is the problem with the neural tissue if the slump test is positive for reproducing plantar fascial pain?
    Does a positive slump test indicate it's usage as a form of therapy?
    Why stretch in a pain evoking position?

    Man i am feeling the love today!
    DaFlip :D
  34. NewsBot

    NewsBot The Admin that posts the news.

    Comparison of ultrasound-, palpation-, and scintigraphy-guided steroid injections in the treatment of plantar fasciitis.
    Yucel I, Yazici B, Degirmenci E, Erdogmus B, Dogan S.
    Arch Orthop Trauma Surg. 2008 Oct 7. [Epub ahead of print]
  35. Carsten

    Carsten Welcome New Poster

    I would be interested in how you quantified hypoechogenicity at the proximal plantar fascia - if that was the case?

  36. drsarbes

    drsarbes Well-Known Member

    Good thread.
    I've always felt that when my treatment did not give positive results then it was my diagnosis that was wrong.

    No one can discount the fact that a cortisone injection for "fasciitis" will often give very good results, sometimes for long periods, or that sometimes it does nothing.

    No one can discount the fact that not all patients relate the same character of their "fasciitis" pain. Some are an ache, some sharp, some only after rest, some all day, some radiating, some centrally located, some around the periphery of the heel, some more intense laterally, some sudden onset, some insidious, some activity related.............

    Isn't it obvious that we are dealing with different pathologies? Is it safe to assume some of these are inflammation of the fascia, some periostitis, some bursitis, some medial calcaneal nerve pathology, some tarsal tunnel, some lateral plantar nerve pathology, some L4, L5, S1, some achilles, some local manifestation of a generalized disease state, on and on.........

    Would this not account for the fact that ALL of us do not have ONE treatment for fasciitis that ALWAYS works? I can't even begin to count the number of patients I have had over the years with a history of seeing numerous specialists for numerous treatments for heel spurs/fasciitis; all of them having failed, only to diagnose a Tarsal Tunnel Syndrome.

    These are different pathologies. My take is that often NON FASCIITIS patients are included in studies for fasciitis. A patient undergoing a fascia release will not show improvement if they in fact have a porta pedis nerve entrapment that was not diagnosed. Someone with os calcis periostitis will not improve with a cortisone injection at the medial plantar tubercle.

    That's my 2 cents.

  37. mgeiger

    mgeiger Welcome New Poster

    Do you use Ethyl Chloride for pre-injection anesthesia? Does anyone know the difference between Ethyl Chloride and that stuff called "Cold Spray." There seems to be a large price difference. I'm sceptical. Thanks, Mark
  38. drsarbes

    drsarbes Well-Known Member

    I've used Gebauer's ethyl chloride spray for a very long time. I like the mist in the can.
    I'm not really sure, if you know how to give a shot, that it makes THAT much difference, but patients seem to think so. They love it.

    I'm not sure if there is a difference.....cold spray / ethyl chloride spray.

  39. NewsBot

    NewsBot The Admin that posts the news.

    It can make you blind:

    Plantar fasciitis and impaired vision: A case report
    B. Anupama , N. Puthran, V. Hegde and S. Andrews
    The Foot; Article in Press
  40. facfsfapwca

    facfsfapwca Active Member

    I have a series of questions I have never seen asked and would like very much clarified. Please answer with specifics as trhose using ultrasound desire to treat specific areas I was lead to believe.

    2. Inferior calcaneal bursitis is a smaller area to be treated does ultra sound Definitively show the Bursa ?

    3.Has anyone actually seen the Bursa on Ultra sound

    4. I have never seen a picture of a visualized bursa in ads or articles that show pictures of the plntar fascia?
    Why not?

    4. The steroid injection should be in the area of inflammation is this area a pinpoint size or what is the general size?

    5. What is the general size of the effect of the steroid. 1 cubic cm area about the point of the needle, 2 cubic cm about the point of the needle three cubic cm about the point of the neele etc Please choose one.

    6. One person mentioned the needle point does damage that causes (healing/ damage) which one? Is this done by needling the area or a simple injection. If needling how many cubicc CCs of tissue are needled?

    7. Plantar fascitis is not a pinpoint area to be treated. So we do not need pin point accuracy in treatment. Yes or No ? If No explain.

Share This Page