Can a Family Doctor Give Shots for Heel Spurs

Singapore Med J. 2015 Aug; 56(eight): 423–432.

The effectiveness of corticosteroid injection in the treatment of plantar fasciitis

Abstract

Plantar fasciitis is a mutual cause of heel pain in adults. Although it is unremarkably a cocky-limiting condition, the pain may go prolonged and astringent enough to cause pregnant distress and disruption to the patient's daily activities and piece of work. PubMed and Cochrane Central Register of Controlled Trials databases were searched for randomised controlled trials (RCTs) and a total of ten RCTs were selected for evaluation. These RCTs involved the utilise of either palpation- or ultrasonography-guided corticosteroid injections in patients diagnosed with plantar fasciitis. All placebo-controlled RCTs showed a pregnant reduction in hurting with the use of corticosteroid injections. Some studies also showed that corticosteroid injections yielded ameliorate results than other treatment modalities. Even so, it is evident from these studies that the effects of corticosteroid injections are ordinarily short-term, lasting four–12 weeks in duration. Complications such every bit plantar fascia rupture are uncommon, but physicians need to counterbalance the handling benefits confronting such risks.

Keywords: corticosteroid injection, effectiveness, heel hurting, plantar fasciitis, randomised controlled trials

INTRODUCTION

Plantar fasciitis is ane of the nearly common causes of heel pain, bookkeeping for most i million patient visits per year in the The states.(one) Although information technology is unremarkably a self-limiting condition with a bulk of cases resolving within ten months, almost 10% of patients develop chronic plantar fasciitis.(2) Many patients seek assist from their family physicians and foot specialists when the hurting becomes severe plenty to cause significant distress and disruption to their daily activities and work.

Plantar fasciitis is used to depict heel pain acquired past an inflammation of the plantar fascia. This could effect from a one-off tear in the plantar fascia or damage from repetitive microtraumas. Plantar fasciosis describes the degenerative, non-inflamed phase of plantar fasciopathy. Information technology is an enthesopathy that arises from degenerative processes affecting the junction between the periosteal (calcaneus) and the ligament attachment (plantar fascia).(3)

Plantar fasciitis can affect both athletes and sedentary people, particularly middle-anile and older individuals.(4) Intrinsic gamble factors include obesity, human foot planus, pes cavus and a shortened Achilles tendon. Extrinsic gamble factors include walking on hard surfaces or barefoot, prolonged weight begetting, inadequate stretching and poor footwear.(v) People who walk more during work are shown to be at a higher risk for developing this condition.(6)

Although there are many treatment modalities for plantar fasciitis, in that location is little consensus on its clinical approach. To appointment, there is no single treatment supported by the highest level of bear witness. Loftier-quality studies involving double-blinded, placebo-controlled randomised controlled trials (RCTs) are hard to come up by due to the debilitating pain experienced by near patients during the initial consultation. Another possible reason is the fact that near therapies are used in combination(7) and thus there is poor prove on which modality is the best. A systematic review of treatments for painful heels conducted by Atkins et al(viii) in 1999 found that although much has been written about the treatment of plantar heel hurting, the number of RCTs in the literature was small and virtually cases involved minor populations of patients, which limited the generalisability of handling efficacy.

Corticosteroid injections accept been used to treat plantar heel pain since the 1950s.(9) Both orthopaedic surgeons and rheumatologists have been known to use them ofttimes.(10) The advantages of corticosteroid injections include low toll, low complexity and rapid pain relief (i.due east. it tin be administered by most family unit physicians in an outpatient setting). Still, many are concerned about the potential complications associated with this treatment modality, which may offset its benefits. Thus, the recommendation of corticosteroid injections every bit an initial or tier 1 handling option by the American Higher of Foot and Ankle Surgeons (ACFAS)(eleven) was met with much scepticism and raised certain controversial issues. To further complicate matters, in recent years, the advent of other injectable options (e.thousand. platelet-rich plasma, autologous blood and botulinum toxin) have also made it more than difficult for family physicians to decide on the most appropriate course of action for their patients.

Many studies take been washed to evaluate the efficacy of corticosteroid injections for the treatment of plantar fasciitis. About compare its efficacy with that of other treatment modalities. However, these modalities comprise inherent differences, fifty-fifty inside the corticosteroid injection arm, such equally the method of injection, blazon of steroid used, concurrent use of local anaesthetic and physical therapy, and use of ultrasonography (United states) guidance and nerve blocks.

This review aims to examine the current show available and to provide evidence-based recommendations for family physicians on the utilise of corticosteroid injections in patients suffering from plantar fasciitis.

METHODOLOGY

Information sources

A data search was performed on PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) databases up to ten August 2014. The post-obit search strategy was used: [plantar fasciitis OR heel pain OR painful heel OR plantar fasciosis OR plantar fasciopathy] AND [corticosteroid injection OR steroid injection OR glucocorticoid injection].

Study selection

RCTs that studied the use of corticosteroid injections in patients with plantar fasciitis and had Jadad scores ≥ 3 were included. After filtering for RCTs, man studies and English-language manufactures, a PubMed search yielded 25 potentially relevant articles. Of the 25 studies, vii did not accept objectives that were relevant to this review and one was a not-randomised study. Upon reviewing the full-text articles of the remaining 17 studies, six had Jadad scores < iii, one was a non a RCT and 1 had no trial results. The remaining 9 studies were selected for review.

A similar search performed on CENTRAL yielded 37 potentially relevant articles after filtering for trials. Of these, xv were duplicated on the PubMed search, 14 had objectives not relevant to this review and four were not RCTs. Upon review of the four remaining full text articles, three were excluded due to Jadad scores < 3, leaving just one study for inclusion in this review. Thus, a full of x RCTs were selected for review. This pick procedure is depicted in Fig. 1.

Menstruum chart shows the written report selection process.

Data extraction

The post-obit data was extracted from each included study: report design; Jadad score; report population; elapsing of heel pain; prior treatment; type, corporeality and method of corticosteroids injections; use of local anaesthetic; use of nervus blocks; result measures; results; adverse events; and dropout numbers. These results are summarised in Table I.

Table I

Summary of selected randomised controlled trials (RCTs).

RESULTS

Study quality

The Jadad score was used to measure the likelihood of bias and thus the quality of the selected RCTs.(12) 2 of the RCTs had a Jadad score of five,(13,14) 2 had a score of 4(vii,15) and 6 had a score of 3.(16-21)

Characteristics of the study population

The mean age of the report populations of the ten included RCTs was 41.four–57.0 years. The duration of their symptoms was two–180 months, with the majority suffering from plantar heel pain for at least six months.(7,13,16,17,19-21) Five of the ten RCTs included written report populations that had failed conservative therapies for at least 2–vi months.(13,15,19,21)

Corticosteroid injections

Different corticosteroids were used for the injections in the studies. Five RCTs explored the use of long-interim corticosteroids, i.due east. dexamethasone(xiv,sixteen,18) and betamethasone,(17,19) while the other 5 investigated the employ of intermediate-interim corticosteroids, i.e. methylprednisolone,(13,xv,21) prednisolone(7) and triamcinolone.(twenty) To guide the corticosteroid injections, seven RCTs used the palpation method,(7,15,16,18-21) ii used U.s.a.-guidance,(14,17) and one used both US- and palpation-guided injections in dissimilar arms.(thirteen) Three approaches of injections were employed in the studies: viii RCTs adopted the medial approach,(7,fourteen-20) one adopted the posterior approach(xiii) and one involved injections through the plantar aspect of the heel pad.(21)

Outcomes

The main outcomes of the studies reviewed fall into the three following categories: (a) patient-assessed outcomes; (b) doc-assessed outcomes; and (c) illness-oriented outcomes. The results for category (a) are summarised in Table I, while those for categories (b) and (c) are summarised in Table II.

Table Ii

Summary of physician-assessed and disease-oriented outcomes.

Patient-assessed effect: foot pain

The measurement of foot or heel pain is one of the main outcomes. The instruments used to measure human foot pain include the Visual Analogue Scale (VAS) and the foot pain domain of the Foot Wellness Status Questionnaire (FHSQ). All studies used the VAS equally one of the scales to mensurate foot pain, except McMillan et al and Díaz-Llopis et al, which used the FHSQ.(fourteen,nineteen)

2 placebo-controlled RCTs(xiii,14) reported significantly reduced pain scores within the corticosteroid injection groups compared to the placebo groups. The written report by Ball et al showed upward to 47.ii% and 52.eight% hurting reduction at half-dozen and 12 weeks, respectively, in the corticosteroid injection arm compared to the placebo arm. McMillan et al reported an improvement of foot pain scores in the corticosteroid injection arm compared to the placebo arm at the four-, eight- and 12-week follow-up. Even so, the difference in pes hurting scores was simply significant at the iv-calendar week mark, with a 22.nine% pain reduction in the intervention grouping.

Iii studies showed significant pain reduction in the corticosteroid injection group compared to the other types of intervention, namely use of insole,(17) autologous blood injection(20) and local anaesthetic injection with or without tibial nerve block.(seven) Ane study(18) reported improve results in the botulinum toxin A injection group (intervention group) compared to the corticosteroid injection grouping. The remaining four studies(fifteen,16,19,21) showed significant pain reduction in both intervention groups at follow-upwards intervals when compared to baseline but no significant differences betwixt the intervention groups.

A variety of scales were used to measure out other outcomes such as foot role, foot health and quality of life. Some of these scales were not designed to assess patients with plantar fasciitis; for example, the Maryland Foot Score was designed to appraise pes injuries, the American Orthopaedic Pes and Ankle Lodge'south Talocrural joint-Hindfoot Scale was designed to appraise ankle and hindfoot joint injuries, while the Foot and Talocrural joint Disability Index (FADI) is used to observe functional limitations in subjects with chronic ankle instability. However, all three scales were used in conjunction with VAS in the studies(xvi,xviii,21) concerned.

Physician-assessed outcomes

The 2 physician-assessed outcomes used in the studies were the Heel Tenderness Index (HTI) and Tenderness Threshold (TT). Ball et al(13) showed that HTI improved significantly in the steroid injection groups compared to the placebo group at the 12-week follow-up. Yucel et al(17) establish significant comeback in HTI in both the Usa-guided/steroid injection group and the insole group from baseline, although there was no significant difference between the two groups. To measure TT, Lee et al(xx) used a pressure algometer, in which the minimal pressure required to elicit pain was defined as the TT recorded on the eleven-kg range algometer (i.e. maximal pressure level is 11 kg/cm^two). Lee et al'due south study found that the steroid grouping had a significantly higher TT than the autologous blood group at the six-week, three-month and six-month post-treatment follow-upwards.(xx)

Disease-oriented outcomes

3 studies(13,14,17) measured plantar fascia thickness as one of the outcomes. Both the placebo-controlled trials(13,14) showed that the steroid grouping had a significantly greater reduction in plantar fascia thickness than the placebo group at each follow-up interval. Yucel et al(17) demonstrated better results for this consequence in the US-guided steroid injection group compared to the insole group.

DISCUSSION

All ten studies reviewed were consistent in showing that corticosteroid injections event in comeback of plantar fasciitis from baseline. The two high-quality placebo-controlled trials(xiii,14) provided strong testify of the effectiveness of corticosteroid injections in the reduction of both heel pain and plantar fascia thickness. This consequence has been shown to final for up to three months in patients who had failed two months of conservative treatment.

The states- and palpation-guided corticosteroid injections

The majority of studies investigated the employ of palpation-guided corticosteroid injections,(vii,15,sixteen,eighteen-21) while 2 studies(14,17) looked solely at US-guided corticosteroid injections. Only one study past Brawl et al(xiii) included both palpation- and Us-guided corticosteroid injections for comparison against a placebo; however, no significant differences in heel pain reduction between the United states- and palpation-guided corticosteroid injection groups were plant. Similar results were seen in a recent meta-assay (comprising five RCTs with 149 patients) conducted by Li et al,(22) in which heel hurting measured with VAS was not shown to be significantly different between the Us- and palpation-guided corticosteroid injection groups.

Peppering technique

This technique was first described in 1964 for lateral epicondylitis. When using this technique, the needle is repeatedly inserted and withdrawn without complete emergence from the pare. It has been postulated that this repeated action leads to the cosmos of multiple small holes within the degenerative tissues, causing bleeding and initiating the healing process. In a 3-arm study past Kiter et al,(21) this technique was compared with autologous blood and corticosteroid injections. All three groups were given prilocaine 1 mL prior to the administration of injections. The half-dozen-month cess showed an improvement from baseline in all three groups (65%–68%) but no significant differences betwixt the groups. In a separate four-arm study by Kalaci et al,(23) it was found that the peppering technique combined with corticosteroid injection resulted in a significantly lower VAS score for heel hurting compared with corticosteroid injection lonely. Kalaci et al's study was excluded from the nowadays review, as it used consecutive patients instead of randomisation.

Local anaesthesia and tibial nerve block

Heel injections are regarded as painful. Thus, all the studies used either local or regional anaesthesia to mitigate the patients' pain. McMillan et al(14) performed a US-guided posterior tibial nervus block prior to corticosteroid or placebo injections and found it effective in reducing the loftier level of pain experienced by patients during heel injections. Crawford et al's four-arm study,(7) which examined the efficacy of corticosteroid injections, local anaesthesia and tibial nervus block, reported improvements in the mean pain scores of all the groups at the one-calendar month follow-up compared to the baseline; however, the two corticosteroid injection groups in the study showed significantly meliorate results compared to the non-steroid groups.

Pick of corticosteroids

The types of corticosteroids used for heel injections vary, every bit in that location is fiddling bear witness to propose the superiority of 1 agent over the other. A meta-analysis by Gaujoux-Viala et al(24) found no differences in efficacy between the various types of corticosteroids used. In the present review, all five types of corticosteroid injections used were establish to result in pregnant heel pain reduction.

Adverse effects

Heel fat pad cloudburst and plantar fascia rupture are ii of the about feared complications associated with corticosteroid injections, equally they tin can lead to intractable long-term complications. Various complication rates accept been reported. The rupture rate of plantar fasciitis afterwards corticosteroid injection ranged from 2.4%(25) to 6.7%(26) in two retrospective studies. The old written report also found that patients with plantar fascia rupture received an boilerplate of two.67 injections and had an average body mass index of 38.6 kg/m². A systematic review of RCTs and prospective studies by Brinks et al,(27) which examined the adverse effects of extra-articular corticosteroid injections, found but minor complications (i.e. post-injection heel hurting) in 368 patients who were treated for plantar fasciitis and heel pain. This finding is largely similar to that of our review, which included 622 patients, as well as that of a meta-analysis of 149 patients conducted by Li et al.(22)

Three out of the ten RCTs(seven,16,21) reviewed in the present paper did not state any agin outcomes of the corticosteroid injections, while the rest reported only mail service-injection heel pain. All but one of the RCTs had a follow-upwards menses of vi months or less. Hence, delayed complications such as plantar fascia rupture could have been nether-reported. Although corticosteroid injection therapy in plantar fasciitis is mostly associated with a low incidence of serious complications, multiple corticosteroid injections and obesity are potential risk factors for plantar fascia rupture.

Comparison with other handling modalities

Two of the studies reviewed compared conservative therapies to corticosteroid injections. Ryan et al(16) showed that participants who underwent vii physiotherapist-led exercises daily over a 12-calendar week menstruation had meaning improvements during the six-week and 12-calendar week follow-up compared to baseline, although the improvement was not significantly better than the corticosteroid injection grouping. Yucel et al(17) found that, at the 1-month follow-up, the corticosteroid injection grouping reported significantly better hurting relief than the group who wore a prefabricated total-length silicone insole daily for 1 month.

Three other injection modalities were used by v of the studies reviewed, namely tenoxicam,(xv) botulinum toxin A(xviii,19) and autologous blood(xx,21) injections. Elizondo-Rodriguez et al(18) showed that subjects who received botulinum toxin A injections experienced significantly less heel pain at the six-month follow-upwards compared to those in the corticosteroid injection group. In contrast, Lee et al(20) found that the corticosteroid group had significantly lower levels of heel pain vi weeks and three months after handling than the group that received autologous blood injection. The rest of the studies did not show any significant differences between the corticosteroid injection group and their comparator group.

Limitations

There are a number of limitations that should exist considered when interpreting the results of this review. First, just two placebo-controlled RCTs were reviewed, while the rest of the RCTs compared only corticosteroid injections with other standard therapies. Generally, in that location are fewer bachelor placebo-controlled trials, possibly due to upstanding reasons, equally patients who are in pain are exposed to a chance of non-intervention.

Second, half of the RCTs combined physical therapy or the peppering technique with corticosteroid injections every bit function of their intervention.(fourteen-sixteen,18,19) This made it more difficult to translate the magnitude of improvement resulting from corticosteroid injection alone. Furthermore, near of the studies had small sample sizes ranging from twoscore to 106 participants. The types of corticosteroids used and the techniques of injection also varied, which added complexity to the interpretation of the results.

RECOMMENDATIONS

1. As the corticosteroid injections are associated with significant pain, local or regional anaesthesia should exist used. However, there is currently no evidence to advise that local or regional amazement tin can bring almost significant heel hurting reduction in plantar fasciitis.

2. In that location is currently no indication for family physicians to change the injection technique from palpation-guided to Usa-guided, as the latter has non been shown to produce better results in our RCTs. In fact, patients in this arm experienced more pain during the procedure and typically required regional anaesthesia.

3. Although the peppering technique has been reported to be an effective technique in the treatment of lateral epicondylitis and tendinopathies in some studies, there is currently bereft bear witness to bear witness that it is effective in treating plantar fasciitis.

4. There is currently no show to suggest the superiority of one blazon of corticosteroid over some other. Therefore, the choice may depend on availability and the preference of the family physician.

5. There is some evidence to suggest that botulinum toxin A injections may produce better results than corticosteroid injections. However, further study is required to provide the necessary evidence.

6. Although the overall incidence of serious complications such as heel fatty pad cloudburst and plantar fascia rupture is low, they may be associated with long-term sequelae. Thus, physicians need to counterbalance the risks and benefits of the corticosteroid injection therapy for each patient.

7. There is a office for corticosteroid injections in patients with plantar fasciitis who still experience debilitating heel pain after unsuccessful bourgeois physical therapy. Not-obese patients who accept not had prior corticosteroid injections are better candidates, every bit they are at a lower risk for plantar fascia rupture.

CONCLUSION

This review shows that both US- and palpation-guided corticosteroid injections are effective in reducing heel hurting in patients with plantar fasciitis, including those with chronic pain and those who have failed conservative physical therapies. The furnishings are usually short term, lasting 4–12 weeks. The magnitude of pain reduction, as demonstrated by the placebo-controlled RCTs, ranges from 22.nine% to 52.viii%.(13,xiv) No serious complications such equally heel fat pad atrophy or plantar fascia rupture were reported past the studies reviewed in this newspaper. Although the incidence of such complications has been low in near studies, they may exist associated with long-term sequelae. Thus, physicians need to weigh the risks and benefits of corticosteroid injection therapy for each patient.

ACKNOWLEDGEMENTS

I would like to thank the following for their help and guidance in making this enquiry newspaper possible: Dr Tan Ngiap Chuan, Senior Consultant, SingHealth Polyclinics; and A/Prof Gerald Koh, Associate Professor, Saw Swee Hock Schoolhouse of Public Health and Joint Associate Professor, Dean's Role, Yong Loo Lin School of Medicine, National University of Singapore.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4545130/

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