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#140 Healing the Heel: Corticosteroid shots for plantar fasciitis

Are corticosteroid injections effective for plantar fasciitis?

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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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 o100 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. 
  • 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.
  • 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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  • Adam Keough MD
  • Christina Korownyk MD CCFP

1. Ball EM, McKeeman HM, Patterson C, et al. Ann Rheum Dis. 2013; 72:996-1002.

2. Kelly AM. Emerg Med J. 2001; 18:205-7.

3. McMillan AM, Landorf KB, Gilheany MF, et al. BMJ. 2012;344:e3260.

4. Landorf KB, Radford JA, Hudson S. J Foot Ankle Res. 2010; 3:7.

5. Crawford F, Thomson C. Cochrane Database Syst Rev. 2003; 3:CD000416.

6. Sellman JR. Foot Ankle. 1994; 15:376.

7. Kim C, Cashdollar MR, Mendicino RW, et al. Foot Ankle Spec. 2010; 3:335-7.

8. Acevedo J, Beskin J. Foot Ankle Int. 1998; 19:91-7.

9. Li Z, Xia C, Yu A, et al. PLoS One. 2014; 9:e92671.

Authors do not have any conflicts of interest to declare.