#140 Healing the Heel: Corticosteroid shots for plantar fasciitis
CLINICAL QUESTION
Are corticosteroid injections effective for plantar fasciitis?
BOTTOM LINE
Small, randomized controlled trials (RCTs) demonstrate that corticosteroid injections significantly reduce plantar fasciitis pain for 1 in 3 people at four weeks. Benefit beyond 12 weeks has not been well demonstrated. Risk of rupture is likely less than what has been reported in observational studies.
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EVIDENCE
Two double-blind, RCTs:
- 65 patients, randomized to ultrasound guided corticosteroid (20 mg methylprednisolone acetate), palpation guided corticosteroid, or ultrasound guided placebo:1
- Significant mean improvement in pain score on 100 point Visual Analogue Scale (VAS) for both steroid groups at six and 12 weeks, respectively:
- Ultrasound guided steroid: 28.9, 33.6.
- Unguided steroid: 35.2, 37.3.
- Improvement with Placebo: 5.1, 2.2.
- Minimal clinically important difference (MCID) for VAS ~12.2
- Limitations: Small size, follow up only 12 weeks.
- No adverse events (i.e. rupture) reported.
- Significant mean improvement in pain score on 100 point Visual Analogue Scale (VAS) for both steroid groups at six and 12 weeks, respectively:
- 82 patients, randomized to ultrasound guided corticosteroid (4 mg dexamethasone sodium phosphate) versus placebo:3
- Significant mean improvement in pain on 100 point questionnaire at four weeks:
- Corticosteroid: 22.1 points.
- Placebo: 11.7 points.
- MCID for questionnaire=13 points.4
- Number Needed to Treat (NNT) for one successful outcome for pain=3.
- Trend towards improvement at eight and 12 weeks (corticosteroids better by 5.6 and 5.3 points on 100 point scale respectively) but not statistically significant.
- No adverse events (i.e. rupture) reported.
- Significant mean improvement in pain on 100 point questionnaire at four weeks:
- Plantar fasciitis is a self-limiting condition and will generally resolve within one year regardless of treatment.5
- Concerns regarding plantar fascia rupture with corticosteroid injections are frequently cited6 with estimates ranging from 2.4%7 to 10%.8 These estimates are observational rates of patients referred to specialty care centers and not necessarily reflective of primary care.
- A systematic review of five RCTs (149 patients) comparing ultrasound versus palpation guided corticosteroid injection for plantar fasciitis reported no difference in VAS scores [Standard Mean Difference = -0.35, 95%CI (-0.83, 0.14)].9 No incidence of rupture was reported for the 149 patients receiving injection.
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