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Plantar Heel Cortisone Injection Technique

Discussion in 'General Issues and Discussion Forum' started by Kevin Kirby, May 12, 2014.

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    During my Biomechanics Fellowship from 1984-85, the late Jack Morris, DPM, taught me this plantar heel injection technique for proximal plantar fasciitis that now, 30 years later, I still use nearly on a daily basis. Even though I have modified Dr. Morris's technique over the years, I still am basically doing the same injection technique that he taught me originally.

    Here is Dr. Morris's plantar heel injection technique, step by step:

    1. The point of maximum tenderness (PMT) is marked while the patient is sitting on the examination table with the knee extended and the ankle dorsiflexed. I mark a small "X" on the foot with a ball point pen at the PMT.

    2. Patient is then positioned prone on table with knee flexed to 90 degrees and ankle dorsiflexed to 90 degrees so that the plantar aspect of the foot is parallel to the top of the examining table. An alcohol swab is used to swab the plantar heel at the "X".

    3. Using Gebauer's Ethyl Chloride spray held from the foot about a 12" distance from the foot, my assistant sprays the "X" on the plantar heel for about 5-8 seconds or until the skin starts to "frost" over in the area of Ethyl Chloride spray application (see first photo).

    4. Using a 5 cc syringe with a 1.5" long, 25 gauge needle, with 2.0 cc of 0.5% Marcaine plain mixed with 1.0 cc of celestone soluspan solution (I also will Depomedrol on occasion for the cortisone injection), the needle is penetrated through the "X" in the plantar skin and then advanced slowly towards the plantar fascia.

    5. Once the resistance of the plantar fascia is felt (by more manual force being required to push the needle deeper into the heel), the injection is begun. The cortisone/local anesthetic solution is injected both plantar and dorsal to the plantar fascia no more than 2 mm away from the plantar fascia. The needle is pulled out of the plantar fascia by enough distance so that the needle can be "fanned" (about 5-6 times) to spread the cortisone/local anesthetic solution over, approximately, a 10 mm diameter area of the plantar fascia (see next two photos).

    6. During the actual injection, my assistant massages the leg to distract the patient away from the pain of the injection and then puts a band-aid on the injection site immediately after the injection.

    Since the needle penetrates the plantar fascia at nearly a 90 degree angle when using this prone plantar heel injection technique, there is no chance the plantar fascia will be missed by the injection. In addition, there is no need for ultrasound guidance since the plantar fascia can easily be palpated and even sometimes audibly heard as a slight "celery crunch" when the needle passes into it. Total time from beginning to step #1 to the end step #6 of the injection is about 2-3 minutes.

    Hopefully by illustrating this technique for all of you, you will find Dr. Morris's technique as helpful for your patients as it has been for my patients over the last three decades of clinical practice.:drinks
  2. Admin2

    Admin2 Administrator Staff Member

  3. Paul Bowles

    Paul Bowles Well-Known Member

    Its arguably one of the best ways to give this injection. Thanks Kevin, I heard you describe this when I was in my early surgical residency many years ago and along with some of the education provided by Gary Dockery on skin lesions I think this should form a "must learn" part of any Podiatrists treatment arsenal. Cheers mate.
  4. W J Liggins

    W J Liggins Well-Known Member

    I still feel that it is - arguably - preferable to carry out this treatment under tibial block.
    The pros: much less painful and therefore great accuracy of administration; PF is an inflammatory pathology and basic technique argues against injection into an area of inflammation (again, pain); the patient is much more relaxed; the patient is more likely to attend for further treatment in the future.
    The cons: takes longer (but patient can wait in waiting room for block to take effect); the patient cannot drive afterwards (unless in an automatically geared car with only the left foot treated).

    All the best

    Bill Liggins
  5. Paul:

    Glad you like the technique. Jack Morris performed this injection technique on me when I had plantar fasciitis during my Biomechanics Fellowship and I was impressed at how simple and direct it was. Yes it hurt, but no more than getting an injection from my dentist. I've used the technique ever since and think it is a vast improvement over the medial heel approach for plantar fasciitis injections that I was trained in at CCPM.:drinks
  6. Lab Guy

    Lab Guy Well-Known Member

    Kevin, I agree, the plantar injection technique is quick, accurate and the discomfort is very well tolerated when administered properly. It boggles my mind why anyone would need an ultrasound to guide the needle to the proper placement.

  7. Lab Guy

    Lab Guy Well-Known Member

    Bill, I have given thousands of plantar heel injections and never saw the need to consider a posterior tibial block to give an injection. The PT block can be more painful and also anesthetizes the entire plantar foot while a medial calcaneal nerve block anesthetizes only the plantar heel region.

  8. In addition, if you stick the needle into the posterior tibial nerve by accident, which isn't hard to do with this injection, you could cause pain and parasthesias in the patient for months upon months. No thanks, I would rather trade some slight to moderate transient pain in exchange for the risk of months of pain and parasthesias in the posterior tibial nerve for my patients.
  9. Lab Guy

    Lab Guy Well-Known Member

    Good point, Kevin. Neuropraxia secondary to posterior tibial nerve blocks is a potential complication that one has to be cognizant of when ascertaining if their patient really needs that PT block.

    The last thing we want to do is give our patients a new problem that they did not present with at their first visit. This has happened to me and probably all of us at one time or another (makes you want to change careers) so we have to carefully evaluate the risks and benefits of our selected treatment.

  10. W J Liggins

    W J Liggins Well-Known Member

    Kevin and Steven. I suppose it is a matter of practitioner choice, as I indicated in my posting. I have carried out thousands of tibial (to be pedantically correct) nerve blocks and thousands of heel injections and have never had a patient suffer from neuropraxia, although that is a potential adverse reaction. It is really a matter of weighing the sometimes severe pain of the direct injection against the very slight potential for inadvertent intra arterial injection and neuropraxia. As I say, practitioner judgement.

    All the best

  11. Bill:

    Maybe how plantar fascia injections are performed by podiatrists are regionally based. I don't know of a single podiatrist here in the USA who uses a posterior tibial nerve block to give cortisone injections for plantar fasciitis. Maybe posterior tibial nerve blocks for plantar fascial cortisone injections is more common in the UK, Australia, Spain, etc??
  12. PodAus

    PodAus Active Member

    Our Podiatrists administer either direct plantar or medial calc injections on a daily basis and just dont consider tib n blocks, although they were taught as a suggestion only.
  13. drsarbes

    drsarbes Well-Known Member

    I use the medial approach. If you angle it correctly you can also inject into the porta pedis for those who may need it.

    I have had a few secondary tarsal tunnels syndromes following post tib injections but only on patients who were under sedation while being injected.

    I have not seen a need to perform a post tib block for a simple fasciitis injection. I have noticed, as others have, that the syringe size to needle gauge matters. The larger the syringe and the smaller the needle the faster the solution comes out and the more it will hurt.

    I try and always use a tuberculin syringe with a 25 g needle for fasciitis. Fairly painless (with a little chloroethyl spray)

  14. W J Liggins

    W J Liggins Well-Known Member

    Fine. My paper and that of Pavier The use of 0.5% bupivacaine hydrochloride plain solution Injections in the Treatment of Chronic Plantar Fasciitis British Journal of Podiatry 2001, 4(3) 90-94 noted that: "Many of the patients in this series had undergone single/multiple steroid injections in the affected heel, with transient but incomplete relief of symptoms. These patients were reluctant to undergo further heel injections but were readily treated following tibial nerve block." In fairness, all of these patients suffered from recalcitrant PF and had undergone multiple previous treatments; additionally, the technique required 5 injections carried out on a weekly basis.

    Maybe I'm just too gentle, or maybe Yanks and Aussies are tough! Anyway, if there are any peer reviewed papers out there on the subject of PF t/t using the direct technique described with or without ethyl chloride and with or without tibial block, I'd be very interested if readers would kindly post.

    Many thanks

  15. PodAus

    PodAus Active Member

    Same aspect / approach, but reduced gauge and 'gentler' practitioner can make all the diference with patient tolerance.

    I use 27 Gauge frequently
  16. drsarbes

    drsarbes Well-Known Member

    Hi Bill

    I'm sure there is more than one proper way to deliver cortisone into a painful heel.

    The art of medicine.

    I can only speak for myself relative to my experience, I have not performed any studies.
    We perform so many injections for heel spurs/fasciitis on a daily basis that we just do not have the time to perform a PT block, wait for it to numb, then re enter the exam room and give a heel injection. It's just simpler and, in our hands at least, not really painful at all to just inject the heel and be done with it.

    I might also comment on the frequency of injections.

    I have found that if 2 injections fail to give relief then more is not really indicated. I base this on success being defined as relief of pain for a 12 month period without lifestyle change.

    How does one predetermine that a patient needs 5 weekly injections without evaluating the success of the previous injection. Certainly if we give an injection and the patient is pain free we would not consider additional injections. Our routine is to give the injection, schedule the patient for 7-14 days, however instruct them that if they are pain free to call and cancel their appointment. They call if the pain begins to return.


    First, if they are pain free then there really is no need to see them.

    Second, we cannot fill our schedule with patients that have to complaints.

    Third, I do not buy into the argument that injecting a pain free fascia will somehow render longer lasting relief.

  17. W J Liggins

    W J Liggins Well-Known Member

    Thanks for your reply Steve.

    The technique to which I referred was an alternative to cortisone. It would be a bold practitioner indeed who would give 5 cortisone injections on a weekly basis (it would probably cure the condition at the expense of rupturing the PF!)

    Unfortunately, on this side of the Atlantic, the profession has in the past relied on 'experience' (which is not to be derided) rather than formal peer reviewed RCTs carried out with the approval of the hospital Ethics Committee. The study to which I refer was my very small contribution (and that of my co-worker) to address that situation. The study offers detail of response, and in cases that had resolved prior to the 5th injection, no further injection was given, of course.

  18. Blaise Dubois

    Blaise Dubois Active Member

    Please tell me you don'T do cortisone injection in the pan tar fascia anymore
  19. Craig Payne

    Craig Payne Moderator

    A number of good RCT's shows that it works. .... so why not use it?

    Plantar fasciitis: corticosteroid injection versus chiropractic therapy (embarrassingly bad study, but the cortisone worked!)
    Ultrasound guided corticosteroid injection for plantar fasciitis (don't get much better than this one)
    Plantar fascia rupture following corticosteroid injection (yes, there can be problems)
    Use of Primary Corticosteroid Injection in the Management of Plantar Fasciopathy Is It Time to Challenge Existing Practice? (interesting read)
    Steroid injection for inferior heel pain: a randomised controlled trial. (clear benefits over placebo)
    Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. (ok)
  20. Let me guess: Blaise thinks that all cases of plantar fasciitis must be treated by foot strengthening exercises and wearing minimalist shoes. I would love to see him try to present his ideas to a crowd of podiatrists or orthopedic surgeons...that would be a good laugh.:butcher::bang::boxing::craig:
  21. Blaise Dubois

    Blaise Dubois Active Member

    the 2 studies showing a clear benefit (And there is others showing positive effect on pain) have a clearly to short follow-up to assess long term side effect and the recurancy of the pathology

    Kevin, I taught 4 years in Medicine, and I often give conference with orthopaedic surgeon and sport doc... and most of them agree we the new thinking (versus old 'protective / symptom based' medicine). Cortisone injection is really a last alternative.
  22. drsarbes

    drsarbes Well-Known Member

    Dr. Duboise
    I'd be interested in your treatment protocol for heel pain diagnosed as plantar fasciitis, especially if it does not include injections.

    Thank you

  23. Blaise Dubois

    Blaise Dubois Active Member

  24. Blaise Dubois

    Blaise Dubois Active Member

  25. drsarbes

    drsarbes Well-Known Member

    Thank you for the link.

    Perhaps we see a different patient population, but I have many many patients that have been through this type of treatment and have not gotten better.

  26. Paul Bowles

    Paul Bowles Well-Known Member

    Steve you are 100% correct. Management plans can and should vary based on individual patients. I am yet to find a good peer reviewed research study which states corticosteroid has no value in the treatment of plantar heel pain. I hate the "ladder" approach to medicine - cortisone is not the "last" option for patients, it may in fact be the first option for many patients based on their activity, presentation and symptoms. The "old" concept of laddered management plans comes from the old approach to surgery where it was "always" though of as a last resort. Problem is its hard to raise the titanic once it hits the ocean floor right? Better to stop it sinking in the first place.....

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