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Ultrasound guided corticosteroid injection for plantar fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, May 23, 2012.

  1. toomoon

    toomoon Well-Known Member

    Well I am good with this Kevin, but if we look at the pain generating condition as a 'syndrome', which personally I think it is, I believe this implies, as you rightly include, several conditions, with the possibility of more than one occurring simultaneously.
    This being the case, I think we probably need to include the nerve involvement, which can be quite subtle and not necessarily produce overt neurological signs, but which I believe is quite often an important part of the symptomatology of chronic "plantar fascia stress syndrome", and may well be one of the reasons corticosteroid infiltration offers short term pain relief.
    regards

    S
     
  2. Mart

    Mart Well-Known Member

    One of the things I like about this forum is not feeling quite a odd a usual for being a nerd; what joy to share being animated about plantar heel pain :)

    Anyhow Kevin's suggestion "Plantar fascia stress syndrome" sits well with me; I feel that the term syndrome generally implies a group of things which share a similar presentation, give the impression of some limited knowledge but in the spirit of Simon's prior post says to be candid

    "we don't know"

    what this about for sure

    Simon what instrument do you play and is it a serious addiction?

    Cheers

    Martin


    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  3. toomoon

    toomoon Well-Known Member

    '73 360 Rickenbacher
    "71 Gretsch Steven Stills reissue
    American Standard Strat
    97 Fender Tele
    96 Fender Jagstang (the dirtiest guitar of al la k. cobain)
    Gibson Les Paul Robot series one
    Gretsch Chet Aitkins
    1960 Gibson Les Paul Gold top reissue
    Martin DC-16RGTE
    Maton Lyrebird
    Fender Telecoustic
    Yamaha 'Silent Guitar'
    Martin Classic collection
    Ovation "performance'

    according to my wife.. it is a serious addiction.. for me.. I need a '57 Strat amongst others and do not believe I have any issues at all..
     
  4. Mart

    Mart Well-Known Member

    Oh dear . .. . . these are mostly controlled instruments . . . plus denial you need help.

    have you tried bagpipes or banjos? . . . . they are good for withdrawal . . . worked for me


    Cheers

    Martin
     
  5. Simon:

    After looking at that last list, I better get my vocal chords ready to rock n' roll.;)

    Anyway, back to the classification of plantar fasciitis, I wouldn't recommend nerve involvement for this "plantar fascial stress syndrome" since I would consider these to be different pathologies (e.g. Baxter's neuritis, medial calcaneal neuritis, lateral calcaneal neuritis) and not specifically pathologies of the central component of the plantar aponeurosis.

    Rather the purpose for the "plantar fascial stress syndrome" label would be to eliminate any reference to the inflammation of "fasciitis" and eliminate any reference to the degeneration of the "fasciosus" so that a syndrome that can include varying degrees of both inflammation and degeneration to the central component of the plantar aponeurosis could be better described, which, in all reality, is the true nature of the condition we all treat on a daily basis.:drinks
     
  6. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effectiveness of Device-Assisted Ultrasound-Guided Steroid Injection for Treating Plantar Fasciitis
    Chen, Chien-Min MD; Chen, Jenq-Shyong PhD; Tsai, Wen-Chung MD, PhD; Hsu, Hung-Chih MD; Chen, Kai-Hua MD; Lin, Chu-Hsu MD
    American Journal of Physical Medicine & Rehabilitation, 6 December 2012
     
  7. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Treatment of Plantar Fasciitis of Foot- Local Steroid Infiltration in Comparison with Conventional Treatment- A Randomized Controlled Trial
    IMRAN KHAN WAZIR, MUHAMMAD INAM, MUHAMMAD ARIF, M SAEED, ABDUL SATAR
    Journal of Pakistan Orthopaedic Association 2013 VOL.25 (1)
     
  8. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Sonographically guided deep plantar fascia injections: where does the injectate go?
    Maida E, Presley JC, Murthy N, Pawlina W, Smith J.
    J Ultrasound Med. 2013 Aug;32(8):1451-9.
     
  9. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    CASE REPORT
    Plantar fascia calcification a sequelae of corticosteroid injection in the treatment of recalcitrant plantar fasciitis

    Thomas Peter Fox, Govind Oliver, Caesar Wek, Thomas Hester
    BMJ Case Reports 2013; doi:10.1136/bcr-2013-200303
     
  10. bmjones1234

    bmjones1234 Active Member

    Two and a half years later and it was still associated to the injection?! Surely there are other factors at play besides the simple injection? If anything would you not expect osteoporosis of the joint area before a calcification formation?
     
  11. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Sonographically guided deep plantar fascia injections: where does the injectate go?
    Maida E, Presley JC, Murthy N, Pawlina W, Smith J.
    J Ultrasound Med. 2013 Aug;32(8):1451-9
     
  12. Paul Bowles

    Paul Bowles Well-Known Member

    I would say 90% of patients who present to my clinic with diagnostic US images showing fasciosis and clinical diagnosis of heel pain respond extremely well to short term 100-150mg/day of oral diclofenac. If there is no inflammation how does that work?

    I think the answer might be staring us straight in the face.....
     
  13. Mart

    Mart Well-Known Member

    Not me ..... please help out Paul

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  14. Ben Lovett

    Ben Lovett Active Member

    I know this relates to tendons rather than aponeurosis but it may well shed some light on this conundrum.

    Ben
     

    Attached Files:

  15. Mart

    Mart Well-Known Member

    Thanks Ben ......: good paper

    cheers Martin
    Sent from my Iphone
     
  16. Paul Bowles

    Paul Bowles Well-Known Member

    Mart after our last discussion on fungal nails and now heel pain I am starting to get concerned ;) How much oral diclofenac do you put them on? Whats the dosing regime? Whats the patient population you see your heel pain in - mostly elderly and overweight? Fit and active? Sedentary? Don't get me wrong - NSAIDs arent the only line of defense but they are mighty fine tool to have on the belt when used effectively.

    I've found different NSAIDs can be less effective - meloxicam for example I find does almost nothing with regards to pain associated with fasciosis or intrasubstance fascial tears.

    I would be interested to see if the majority of patients who respond to oral diclofenac have intrasubstance tears - i would suggest intrasubstance tears are far more common that anyone gives them credit for and if you have a good ultrasonoghrapher and MSK radiologist they aren't to hard to pick up. We routinely see tears either partial or complete intrasubstance longitudinal ranging from 3mm - 2.25cm in length. As a protocol our clinic now gets a MSK diagnostic US for every heel pain patient that walk in the door.

    Ben highlights a good point with that paper above - I just don't see the "bible belt" evidence that suggests inflammation is not part of this type of injury. Common sense and clinical reasoning suggests strongly that it is. These injuries have a clinical history of responding to injectable corticosteroid, oral NSAIDs, high dose paracetamol, physical therapy, deep tissue work, stretching (although I maybe the only person here who goes out on a limb and says that concept is BS and extremely flawed). These are all anti inlammatory modalities to a large extent used to treat inflammation. Yet we dismiss the inflammation in fasciosis concepts? How about orthoses - the research they do well right in treating plantar heel pain? Certainly - but not all those patients get better either. So how do orthoses work? Tissue stress reduction - probably. Does this cause a reduction in localized inflammation?

    So Mart - what do you do for them exactly? Orthoses? Stretching? Manipulation?

    Its a great discussion to have.....maybe we should finalize this once and for all - any Podiatrist here have a case of chronic fasciosis they are willing to let someone segment and biopsy? Sure - its gonna hurt and you may never run the same again but look at your contribution to science!!!!! ;)
     
  17. Mart

    Mart Well-Known Member

    Hi Paul

    What follows is essentially no more than a blog of my thoughts and therefore beautifully biased so warning to stop now if that is unappealing.

    Please feel to criticize my reasoning but don't expect evidence :wacko:.

    Firstly we probably have a skewed cohort of people with PHP. most people we see with PHP have not improved with first line recommendation of stretching, icing, massage, laser, ultrasound, NSAIDs. Typically they are at least six months post onset and frustrated with pain.

    I believe that the majority of foot and ankle MSK problems we see have improved diagnostic sensitivity and specificity using high-resolution ultrasound US to augment our physical exam. It is both safe and inexpensive and can provide fast useful information in the hands of the examining clinician (who is competent). I can’t substantiate that idea: If we look at the literature the role of US to investigate plantar heel pain is unclear, partly because some of the evidence is conflicting about the value of sonography, largely because methodology lacks rigor.

    Regardless what might US have to offer for plantar heel pain?

    The questions it will answer for me are:

    Does the plantar aponeurosis show sonographic signs of degeneration, if so where and how much?

    Why is that important to me? Although unusual, we find people who have a clinical presentation suggestive of chronic plantar fasciosis with a normal looking fascia, that being true we will re-examine and reconsider our ranking of DDx . If there is distal fasciosis which is contributory we may use US to index site and create an accommodation to mitigate compression irritation in those proceeding to foot orthoses which we believe can be cause of intolerance to foot orthoses ground reaction force.

    Is there plantar fibromatosis? If so then we also offload that in addition to tensile protection.

    If there an enthesite? Why is that important?

    There is small body of evidence which suggests that compressional stress associated with enthesites or plantar fibro-fatty pad might be associated with PHP. Therefore we have, for the past year, used a 7mm deep plug of shore 20 viscoelastic polymer embedded within foot orthoses under medial and lateral calcaneal tuberosity in every patient with an enthesite. We have found this greatly improved outcomes for pain relief and believe this merits a decent study – i.e. look at the effect of foot orthoses design according to sonographic presentation. I believe that the polymer may reduce compressional forces within the fat pad and/or possibly torsional stress to the enthesite; that would be difficult to study well.

    Is there neovascularisation?

    The paper which Ben posted usefully focussed somewhat on the limited understanding of what neovascularisation might tell us about response to injury.

    Currently I tend to find signal with power Doppler imaging in an acute plantar aponeurosis injury or an injurious insult to pre-existing plantar fasciosis and the magnitude of pain seems to match the intensity of PDI signal. Also that generally those with recent onset plantar heel pain, particularly sudden onset vs insidious (which I don’t see that often) have intra-fascia signal with PDI.

    I believe that signal indicates neovascularisation, and in these cases is evidence of a normal inflammatory cascade.

    With that reasoning, because the pain in these cases is likely modulated as part of normal inflammation I believe that NSAIDs and other anti-inflammatory measures may plausibly improve comfort and recommend that, otherwise I do not treat assuming acute inflammatory pain.

    Although Diclofenac has a relatively poor risk profile compared to alternatives which makes me wary of recommending it, I have noticed that those I see who use it, even in absence of signal with power Doppler imaging seem to get better pain relief compared to other NSAIDs, I have found topical diclofenac unhelpful and don’t recommend it now to patients.

    In those I find signal with PDI I will check retrocalcaneal bursa and tendo-calcaneus enthesis for evidence of signal too and also for associated bone erosion. This is to check for evidence suggestive of reactive arthritides as opposed to trauma which otherwise might be missed.

    I find it interesting that many people I see with insertional tendo-calcaneus and tibialis posterior tendonosis which becomes pain free continue to have signal with power Doppler imaging within tendon or peritendon tissues and struggle to find a convincing explanation for that.

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  18. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Ultrasound- versus Palpation-Guided Injection of Corticosteroid for Plantar Fasciitis: A Meta-Analysis
    Zonghuan Li et al
    PLoS ONE 9(3): e92671. doi:10.1371/journal.pone.0092671
     
  19. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The “Bodily Pain” Scale of the Short Form-36 Questionnaire is a Predictor of Outcome in Patients who Receive Ultrasound-Guided Corticosteroid Injection for Plantar Fasciitis—A Preliminary Study
    Chien-Min Chen, MD et al
    Journal of Musculoskeletal Pain
     
  20. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Comparative Study of: Non-Invasive Conservative Treatments with Local Steroid Injection in the Management of Planter Fasciitis
    Ramesh Narula, Aftab Ahmed Iraqi, Kusum Narula, Rashmi Katyal, Mridul Shanker Saxena
    Journal of Clinical and Diagnostic Research. 2014 | Month : September | Volume : 8 | Issue : 9 | Page : LC05 - LC07
     
  21. Mart

    Mart Well-Known Member

    I find problems in the methodology of this study (Ramesh Narula et Al).

    The inclusion criteria make no mention of the duration of severity of plantar heel pain and there was no objective comparison of level of pain or imaging to evaluate injury to plantar fibro-fatty pad, plantar aponeurosis, or perifascial tissue.

    There was no control. There was NO use of diagnostic US for Dx or corticosteroid injection guidance.

    If subjects had mild early chronic plantar fasciosis, bone stress reaction or simply non specific overload intolerance they may have reported same outcomes with no intervention simply because of the expected natural course of their problem. :mad:

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
    Last edited: Sep 30, 2014
  22. daisyboi

    daisyboi Active Member

    Just a wee thought on this paper. Given the discussion regarding the authors use of US one would imagine that since this paper formed part of a PhD, the US was used in order to eliminate doubt regarding needle placement. Whether this is a required element in clinical practice is doubtful but for the purposes of a PhD it makes absolute sense. It leaves this paper less open to criticism as there is proof as to the accuracy of needle placement. Imagine if his results suggested that there was no benefit over placebo for steroid injection. The first question we would all be asking would be "how accurate was the needle placement?". The researcher covered this doubt well by using US. An excellent paper I feel.
     
  23. Mart

    Mart Well-Known Member

    Re: Ultrasound guided corticosteroid injection for plantar fasciitis4536071215705407

    Looks like you were reading a different paper to that I was being critical of - the paper I cited did not use Diagnostic ultrasound and was comparing entirely different interventions. Take a look at it and see what you think - not sure why it was tagged under US guided CSIs it should have that tag removed.

    cheers Martin Send from my Iphone
     
  24. bodthepod

    bodthepod Welcome New Poster

    On the subject of steroid injections (UK )
    I have been reviewing my PGD for triamcinolone and Depomedrone, and after discussion with our Pharmacy lead - I have submitted a PGD for Triamcinolone and NOT for depomedrone because of the exemptions list with MHRA that has existed since 2011

    I do not have POMs like some of the more recently qualified pods, so i worked under a PGD for depomedrone - but the extract from MHRA looks to show that as long as I have LA and am SOCAP accredited for corticosteroid injection, I dont need any PGD for methylprednisolone

    I posted because
    A)it was news to me, so it may be news to some of you
    B)I'm looking for reassurance that my understanding of this is correct...

    see extract below

    thanks

    David Houghton (working is Gt Yarmouth area) (NHS)



    Chiropodists and podiatrists: ExemptionsPrinter friendly version (new window)
    Related information:
    Other sites:
    (open in a new window)

    Council Directive 93/42/EEC of 14 June 1993 concerning medical devices
    Help viewing PDFs:
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    With effect from 1 July 2011: Updated legal provisions for chiropodists/podiatrists to sell, supply and administer medicines.

    POM P GSL
    Sale
    /Supply Amoxicillin

    Amorolfinehydrochloride cream where the maximum strength of the Amorolfine in the cream does not exceed 0.25 per cent by weight in weight

    Amorolfine hydrochloride lacquer where the maximum strength of Amorolfine in the lacquer does not exceedd 5 per cent by weight in volume

    Co-Codamol
    Co-dydramol 10/500 tablets
    Codeine Phosphate
    Erythromycin
    Flucloxacillin
    Silver Sulfadiazine
    Tioconazole 28%

    Topical hydrocortisone where the maximum strength of the hydrocortisone in the medicinal product does not exceed 1 per cent by weight in weight

    (Conditions: Registered chiropodists/podiatrists only. Medicine must be pre-packed and sale or supply must be in the course of their professional practice. Must hold certificate of competence in the use of the medicines)

    These medicines may also be sold or supplied by a pharmacist against an order written by a suitable qualified chiropodist/podiatrist. a) The following pharmacy medicines for external use:

    Potassium permanganate
    Ointment of heparinoid and hyaluronidase 9.0% Borotanic complex
    10.0% Buclosamide
    3.0% Chlorquinaldol
    1.0% Clotrimazole
    10.0% Crotamiton
    5.0% Diamthazole
    1.0% Econazole
    1.0% Fenticlor
    10.0% Glutaraldehyde
    0.4% Hydrargaphen
    2.0% Mepyramine
    2.0% Miconazole
    2.0% Phenoxyporpan
    20.0% Podophyllum
    10.0% Polynoxylin
    70.0% Pyrogallol
    70.0% Salicylic acid
    0.1% Thiomersal
    Terbinafine
    Griseofulvin 1%

    (Conditions: Registered chiropodist/podiatrists only. Medicine must be pre-packed and supply must be in the course of their professional practice)

    b) Ibuprofen
    a) any GSL
    medicine

    (Subject to usual GSL conditions: medicine must be pre-packed and supplied from premises which can be locked to exclude the public)

    b) any GSL medicines for external use.

    (Conditions: medicine must be pre-packed and supply must be in the course of their professional practice)


    Administer Bupivacaine
    Bupivacaine with adrenaline
    Lignocaine
    Lignocaine with adrenaline
    Mepivacaine
    Prilocaine
    Adrenaline (Epinephrine) Inj BP
    Methylprednisolone
    Levobupivacaine Hydrochloride
    Ropivacaine Hydrochloride

    (Conditions: Registered chiropodists/podiatrists only. Must hold certificate of competence in the use of analgesics. Where the medicine includes a combination of substances on the list for administration, they must not have been combined by the chiropodist or podiatrist.)
     
  25. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Targeting the Plantar Fascia for Corticosteroid Injection
    Andrea Emilio Salvi, MD
    The Journal of Foot and Ankle Surgery; Articles in Press
     
  26. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effectiveness of Corticosteroid Injections on the Treatment of Plantar Fasciitis
    Shanna L. Karls, Kelli R. Snyder, and Peter J. Neibert
    JSR In Press
     
  27. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Corticosteroid versus placebo injection for plantar fasciitis: A meta-analysis of randomized controlled trials.
    Li Z, Yu A, Qi B, Zhao Y, Wang W, Li P, Ding J
    Exp Ther Med. 2015 Jun;9(6):2263-2268
     
  28. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Ultrasound-guided versus palpation-guided local corticosteroid injection therapy for treatment of plantar fasciitis
    Emmanuel Kamal Aziz Saba, , Sherine Mahmoud El-Sherif
    The Egyptian Rheumatologist; 17 July 2015
     
  29. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The effectiveness of corticosteroid injection in the treatment of plantar fasciitis.
    Ang TW.
    Singapore Med J. 2015 Aug;56(8):423-432.
     
  30. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Objective assessment of corticosteroid effect in plantar fasciitis: additional utility of ultrasound.
    Moustafa AM et al
    Muscles Ligaments Tendons J. 2016 Feb 13;5(4):289-96.
     
  31. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Ultrasound guided Vs Palpatory steroid injection for
    plantar fasciitis – A comparative outcome study

    Dr. Anantharaman C, Dr. Tholgapiyan T, Dr. Karthikeyan and
    Dr. Kathir Azhagan S
    International Journal of Orthopaedics Sciences 2017; 3(3): 173-175
     
  32. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Relationship Between Anthropometric Findings and Results of Corticosteroid Injections Treatment in Chronic Plantar Heel Pain.
    Valizadeh MA et al
    Anesth Pain Med. 2018 Feb 17;8(1):e64357.
     
  33. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis
    G. Whittaker, S.E. Munteanu, H.B. Menz, D.R. Bonanno, J.M. Gerrard, K.B. Landorf
    Annals of the Rheumatic Diseases 2018;77:577-578
     
  34. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    TREATMENT OF PLANTAR FASCIITIS BY CORTICOSTEROID INJECTION: TO RELY ON YOUR FINGERS OR THE ULTRASOUND PROBE
    Dr Rahul Pandey, Dr Animesh Vatsa, Dr Sandeep Mehrotra, Dr Smita Pathak, Dr Sanjeev Kumar, Dr Narendra Kotwal
    INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH Vol 7, No 6 (2018)
     
  35. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Heavy-slow resistance training in addition to an ultrasound-guided corticosteroid injection for individuals with plantar fasciopathy: a feasibility study
    Henrik RielJens Lykkegaard OlesenMartin Bach JensenBill VicenzinoMichael Skovdal Rathleff
    Pilot and Feasibility Studies December 2019
     
  36. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Comparing effectiveness of polydeoxyribonucleotide injection and corticosteroid injection in plantar fasciitis treatment: A prospective randomized clinical study
    Dong-OhLeeaJeong-HyunYooaHyung-InChoaSoonghwanChoaHyung RaeChob
    Foot and Ankle Surgery; 4 September 2019
     
  37. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The Effect of Addition of Buffered Dextrose 5%
    Solution on Pain Occurring During Local Steroid
    Injection for Treatment of Plantar Fasciitis:
    A Randomized Controlled Trial

    A. Moshrif, M. Elwan
    Nr 2019;9 (4):525-530
     
  38. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    A prospective study to compare clinical outcome of use
    of corticosteroid vs its combination with physiotherapy
    in patients of plantar fasciitis

    Dr. Kasturi Mohan Batra, Dr. Shekhar Tank, Dr. Avinash Kumar Singh,
    Dr. Dhamelia Dhyey Shambhubhai, Dr. Arora Jatin and Dr. Savsaviya
    Ram Gordhanbhai
    International Journal of Orthopaedics Sciences 2020; 6(3): 881-883
     
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