September 2014

Debating corticosteroid injections for heel pain

9plantarfasciitis-shutterstock_114613207Some practitioners find plantar fasciitis patients respond to corticosteroid injection when other treatments have failed, but concerns about complications make others cautious. With evidence-based guidelines in short supply, the decision often comes down to clinical experience.

By Larry Hand

A seemingly never-ending question continues to exist among practitioners who treat patients with plantar fasciitis: whether to use corticosteroid injections to relieve pain and inflammation, or rely on more conservative nonsurgical modalities. Many practitioners depend on their own experiences, because what also continues to exist is a shortage of evidence-based guidance on use of the injections.

“In clinical practice we observe all kinds of different philosophies by treating doctors in regard to their use of steroid injections for plantar fasciitis,” said Jeffrey Johnson, MD, professor of orthopedic surgery and chief of the foot and ankle service at Washington University in St. Louis, MO. “I feel many of the injections are not indicated, and there are some downsides. The problem in proving the relationship between the injection and the plantar fasciitis rupture is that these cases are so anecdotal.”

Johnson was lead author of an article published in 2011 in Foot & Ankle International,1 detailing the results of a 2007 to 2008 survey by the American Orthopaedic Foot & Ankle Society (AOFAS) on the use of corticosteroid injection in clinical practice.

LER-Resource-Guide-Products-Plantar-Fasciitis

“Rupture of the plantar fascia is a real [issue regarding corticosteroid injections]. The problem is getting a handle on how commonly this occurs. That’s why we did the survey,” he said.

In the article, the authors concluded, “Despite many case reports of complications, our survey indicates that the incidence of complications was perceived to be low and generally related to the injection site (skin depigmentation, atrophy, flare reaction).”

Endoscopic view of the plantar fascia as part of an endoscopic plantar fascia release. (Image courtesy of Daniel C. Farber, MD.)

Endoscopic view of the plantar fascia as part of an endoscopic plantar fascia release. (Image courtesy of Daniel C. Farber, MD.)

Specifically, in the survey, AOFAS members reported injection complications and rates of other complications including skin depigmentation (5.1%), atrophy (4%), flare reaction (3.5%), plantar fascia rupture (1.5%), and heel pad atrophy (1.4%). However, the authors noted the survey results reflected AOFAS members’ understanding of the current indications for injections and the perceived complications that the injections may have caused, and that the paper was not a review of patients who had complications from injections.

The American College of Foot and Ankle Surgeons (ACFAS) did include corticosteroid injection among first- and second-line treatments for heel pain in its 2010 revised guidelines,2 based on what the authors called “fair” evidence. However, they also noted, “Plantar fascia rupture has also been reported as a complication of heel corticosteroid injection.”

In a 2013 review article in the Journal of the American Podiatric Medical Association,3 researchers wrote that core literature has wide-ranging outcomes that are largely supportive of short- and long-term benefits of corticosteroid injections for plantar fasciopathy, and cited the ACFAS guidelines including it as a first-line therapy.

For this article, LER interviewed practitioners across a spectrum of specialists to gain a sense of the status quo in the US for use of corticosteroids to treat patients with plantar fasciitis.

Has a place, but …

“It has a place in the spectrum of care for plantar fasciitis,” Johnson of Washington University told LER. “It does not have a role in plantar heel pad pain, because I think the steroid itself can degrade and thin out and atrophy the subcutaneous fat under the heel, wherever you place the steroid. I think it is important to keep in mind that, for most patients, this is a condition that will get better with time, and our role should be to provide treatment that does not cause harm.”

Johnson doesn’t consider it first-line therapy, however.

“You don’t start with an injection into the plantar fascii,” he said. “Typically we start with the traditional things like plantar fascia stretching, icing, anti-inflammatory medication, night splinting, over-the-counter foot orthotics, and soft-sole shoes. All those things are first, and then, if there is minimal improvement over the next eight to twelve weeks, second-line could be injection.”

He uses severity of the disease and location of pain to guide his decision.

“If somebody says, my pain is in this general area, and they draw a circle the size of a tennis ball, there is no way, but if they say it’s right here and it’s the size of a quarter, then yes,” Johnson said. “Having the pain discreet in its location, classic in its presentation—those patients are better ones for the injection. I’m not sure what we’re actually treating sometimes when patients have large areas of pain.”

Quick mechanism

Leslie Campbell, DPM, who practices at the Presbyterian Hospital in Plano and Allen, TX, said she is “fairly conservative” in her use of injections.

“As far as the injection, itself, it can be easily administered, and it’s a quick mechanism to relieve discomfort, without a lot of side effects,” Campbell said. “Benefits can last days to weeks to months.”

She added, “I tell patients that it’s going to relieve localized inflammation in the general area that it is injected. When they’re having acute pain, they generally have more rapid response.”

But it isn’t for everyone.

“I initiate treatment with biomechanical control of foot function with shoe therapy and custom prescription orthotics. I usually will start with shoe therapy, a heel lift and taping for people who have mild fasciitis. If people have recalcitrant or long-term pain or it’s very acute, that’s when I involve the corticosteroid injection [for moderate to severe patients],” Campbell said.

She advises caution with some types of patients.

“In people with dark skin, generally it can cause either a lightening of the skin or whitening of the skin right at the injection site subcutaneously. If anybody has a tendency to have any type of bleeding disorder, we have to be very, very careful,” Campbell said.

The injections can also lead to systemic complications, she said.

“We have to be very careful, for instance, in people who are diabetic, because they can temporarily elevate their glucose level.4 So I’ll always tell my patients: Don’t be surprised if they’re monitoring their glucose level, that they might have a spike. [Corticosteroid injection] can cause an increase in HgA1C, so I advise patients to inform their family physician or endocrinologist that they have undergone corticosteroid injection therapy and record the date of injection for their medical record.”

She continued, “Some people can get a facial flushing after injection therapy. Their face will get red. I’ve seen it more commonly in women. Sometimes that flushing will persist for a couple of days. It frightens people; they think they’re allergic to cortisone. But, in essence, it’s just a short-lived or sensitivity reaction. We all produce cortisone, and it’s very rare to have an allergic reaction to cortisone.”

Temporary fix?

The injections are also second-line treatments for Daniel C. Farber, MD, assistant professor of clinical orthopaedic surgery at the University of Pennsylvania Health System in Philadelphia.

“I rarely use it on first visit. I tell patients that the injections for the most part are a temporary fix. I like to use them for patients who are really having such discomfort that they can’t do exercises, the stretching, and [conservative measures] to get better,” Farber told LER. “I tell folks that the risks involved are, rarely but occasionally, rupture of the plantar fascia, and that’s an even longer, more chronic problem that doesn’t have a good solution. The injection is not the cure, so we try to hold that in our back pocket to use when absolutely necessary or when other things are not working.”

He advises stretches, heel cups, and three months of conservative treatment before considering injections, and he often sends patients to physical therapy to learn proper stretching techniques.

He also commonly prescribes night splints.

“I’m somewhat partial to the dorsal night splints as these are better tolerated by patients than the traditional night splints and thus compliance—as well as activity modification measures— are better,” he said.

Prolonged course

Knowing that the disease may just run its course puts some patients at ease.

“Plantar fasciitis follows a prolonged course, and it rarely gets better quickly. But it does usually come to a point of tolerability and manageability. I just try to tell patients that it’s going to take a while,” Farber said.

James Jastifer, MD, an orthopedic surgeon at the Coughlin Clinic in Boise, ID, counsels patients not to expect their symptoms to resolve completely after a month.

But, with good results to conservative treatment, said Jastifer, “generally things are twenty-five percent better after a month, then after several months it’s maybe fifty percent better, and if you can get to that point it tends to burn itself out.”

He doesn’t use corticosteroid injections as a rule.

“In my practice, there is a very limited role for corticosteroids in patients with plantar fasciitis,” Jastifer said. “In fact, that would be far down the list of things to try, while ninety percent of people who will get better within ten months with various other nonoperative techniques such as Achilles stretching, plantar fascia-specific stretching, night splinting, orthotics, and casting. Almost universally patients get better.”

He uses mostly over-the-counter soft orthotic devices such as arch supports, and sometimes heel cups.

Alan MacGill, DPM, a foot and ankle surgeon in Boynton Beach, FL, sometimes uses corticosteroid injection as a first-line treatment for plantar fasciitis.

“If a person comes in with heel pain, and they say that it’s on the milder scale, I tend to hold off on the injection at an initial visit. I would instruct them to do stretching, icing, modify activities and shoewear, as well as avoid walking barefoot on hard surfaces. Occasionally I’ll prescribe anti-inflammatory medications by mouth,” MacGill said. “If a patient comes in with more severe pain, in the absence of any kind of trauma, and I don’t suspect that there’s any kind of rupture of the plantar fascia, then I’m more likely to give them the cortisone injection.”

The decision also depends on what treatments a patient may have already tried.

“Some patients come to the initial visit and they’ve done absolutely nothing. So a lot of times they’re going to get some improvement with aggressive stretching, ice therapy, and some kind of arch support,” he said.

The arch support consists of foot strapping or a prefabricated or custom foot orthosis.

“Most patients with a relatively normal foot type will get a prefabricated orthotic,” MacGill said. “If they have a significant deformity, or I don’t think they’ll tolerate a prefabricated device, then I’ll recommend a custom device.”

MacGill sees less of a risk than some other practitioners for plantar fascia rupture.

“Based on my experience, the risk of rupture after steroid injection is very low,” he said. “What I try to explain to patients is that a rupture in and of itself is not necessarily the worst thing, especially if they have been dealing with the condition for a long time. A rupture achieves the same endpoint as when we intervene with surgery. When we do address it surgically, most of the time we do end up doing a plantar fasciotomy where we’re cutting that ligament, which relieves the tension and some of the pain.”

Patient activity level can also be a factor in MacGill’s decision to perform a corticosteroid injection, he said.

“When I do give someone an injection, I always recommend that they continue to try to stay off the foot. I never want someone to go back to running immediately, even if they have pain relief,” he said. “I think that, sometimes with the cortisone injection, people have less pain and therefore they think that they can do more, and that increased activity can sometimes make them more prone to having a rupture.”

More than whether

Perhaps even more dividing a question than whether to use corticosteroid injections for patients with plantar fasciitis, is how many times to inject over what period of time.

“That’s controversial,” MacGill said. “There’s somewhat of an unwritten rule in our profession that we shouldn’t give more than three in a calendar year. I know practitioners who follow that strictly, and I know practitioners who don’t believe in that at all. I tend to follow that. Most patients of mine will receive one injection. There’s a few who may receive a second. Very, very infrequently do I give a third. And if I do give a third injection, it’s not for many months past the first injection.”

Campbell recommends at least six weeks between injections and no more than three to four injections per year.

“I believe the benefits certainly outweigh the risks as long as this is used very judiciously,” she said.

Farber says he rarely does more than one or two injections, and Johnson says he sees no role for multiple injections given less than three months apart.

“I’m not a big multi-injector of the plantar fascia for fear of rupturing it,” Johnson said. “I’m also concerned about it atrophying the soft tissues in the bottom of the foot.”

A 2010 systematic review of the literature on extra-articular corticosteroid injection found that atrophy was mentioned as a complication in five prospective studies, with a frequency ranging from 1.5% to 40%.5

And how?

Injection technique can also make a difference in the risks of complications, experts say.

“I’ve seen a number of patients who have had nerve injuries from having their plantar fascia injected,” Johnson said. “The needle is placed and it injures either the heel or the lateral plantar nerve. I’ve seen some permanent injuries from that.”

To avoid directly injecting into the substance of the plantar fascia or injuring the plantar nerves around the heel, he recommends injecting from the medial side, rather than from the bottom of the heel, and placing the corticosteroid near, not in, the plantar fascia.

Even advocates of corticosteroid injection believe it is just one piece of a complex treatment puzzle.

“The best treatment for me has always been a multifaceted approach,” MacGill said. “That’s having them do Achilles and plantar fascia-specific stretching, and [use] some kind of support for the foot such as an orthotic or strapping that relieves tension on the plantar fascia. And then also the injection. I almost never give someone an injection without having them do the other things, because I just don’t think that’s the best approach.”

Larry Hand is a writer in Massachusetts.

REFERENCES
  1. Johnson JE, Klein SE, Putnam RM. Corticosteroid injections in the treatment of foot & ankle disorders: an AOFAS survey. Foot Ankle Int 2010;32(4):394-399.
  2. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010;49(3 Suppl):S1-S19.
  3. Kirkland P, Beeson P. Use of primary corticosteroid injection in the management of plantar fasciopathy: is it time to challenge existing practice? J Am Podiatr Med Assoc 2013;103(5):418-429.
  4. Kim WH, Sim WS, Shin BS, et al. Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus. Pain Physician 2013;16(6):557-568.
  5. Brinks A, Koes BW, Volkers ACW, et al. Adverse effects of extra-articular corticosteroid injections: A systematic review. BMC Muculoskelet Disord 2010;11:206.
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