Plantar Fasciitis Injection

Plantar Fasciitis Injection with a cortisone shot is an effective way to treat acute fasciitis if conservative treatments (oral NSAIDs drugs) have failed. It’s the second line of treatment.

Acute fasciitis is a condition characterized by pain and inflammation in the heel area. It can be caused by various factors, including idiopathic reasons, overuse, obesity, or wearing inappropriate footwear. Clinical examination reveals pain on the inner side of the heel pad, especially when weight is applied first thing in the morning. Additionally, there is tenderness observed over the medial edge of the fascia where it originates from the calcaneus. Diagnosing and effectively managing this condition is crucial in orthopedic practice.

Related Anatomy

The plantar fascia is the thick central portion of the fascia investing the plantar muscles. It extends between the medial process of the tuber calcanei and the proximal phalanges of the toes. It provides some attachment to the flexor muscles of the toes.

Distally, the plantar fascia becomes continuous with the fibrous sheats enveloping the flexor tendons passing to the toes. At the anterior extremity of the sole – inferior to the heads of the metatarsal bones – the plantar aponeurosis forms the superficial transverse metatarsal ligament.

See Also: Foot Anatomy

Equipment Needed

• Syringe: 2 ml
• Needle: Green, 21 gauge, 2 inches (50 mm)
• Kenalog 40: 20 mg
• Lidocaine: 1.5 ml, 2%
• Total volume: 2 ml

Plantar Fasciitis Injection Technique

The Plantar Fasciitis Injection Technique involves the following steps:

1. Position the patient: The patient is placed in a prone position, lying face down, while the foot is securely held in a strong dorsiflexed position. This positioning helps provide better access to the affected area.
2. Locate the tender spot: Identify the tender area on the medial side of the heel. This is typically where the plantar fascia, a thick band of tissue that supports the arch of the foot, originates.
3. Prepare for the injection: Sterilize the injection site and gather the necessary supplies, including a syringe and an appropriate needle for the procedure. It’s important to ensure all equipment is sterile to minimize the risk of infection.
4. Insert the needle: Insert the needle perpendicularly into the soft part of the sole, just distal to the heel pad. The needle is then advanced at a 45-degree angle towards the calcaneus until it touches the bone. This angle helps ensure proper placement and targeting of the affected area.
5. Administer the solution: Inject the desired medication or solution, commonly a corticosteroid or a local anesthetic, into the fascia at its medial bony origin. The injection is typically administered in two rows, effectively delivering the medication along the length of the fascia.

After Plantar Fasciitis Injection, advise gel heel raises in both ankle boots for men or low-heeled shoes in women after the injection, followed by intrinsic muscle exercise and daily active stretching of the fascia. Rolling the foot on a golf ball or dense squash ball to apply deep friction can be helpful, and orthotics or taping can be applied.

Notes

The best treatment for plantar fasciitis is the combination of corticosteroid injections and training (strength training and stretching). This combined treatment is superior both in the short- and in the longterm. Plantar fasciitis corticosteroid injection combined with controlled training are recommended as first line treatment in patients with plantar fasciitis (single blinded randomized controlled study).

The classic occurrence of pain beneath the heel upon placing weight on the foot in the morning upon awakening is typically indicative.

While this may seem like a highly painful injection, this method is much gentler compared to directly piercing the heel pad with the needle. Patients typically tolerate it surprisingly well, and administering a few drops of the solution while the needle passes through the tissue produces an anesthetic effect.

Heel spurs are frequently observed on x-rays of this region and may be an unintended discovery. If this is the underlying cause, the patient experiences more pain during stationary weight-bearing. Using a pad with a hole in the center can alleviate the symptoms, but surgical intervention might be considered.

Risks associated with Plantar Fasciitis Injection may include the following:

1. Connective tissue rupture: Steroid injections can weaken tendons, potentially leading to connective tissue rupture, similar to tendon rupture. This risk is observed for up to 14 days after the injection.
2. Collagen necrosis: Steroids can cause collagen necrosis in tendons, which can affect their strength and integrity.
3. Suppression of cellular metabolism and collagen synthesis: Glucocorticoids (steroids) can suppress cellular metabolism and collagen synthesis in tenocytes, which are cells responsible for tendon maintenance and repair.
4. Suppression of proteoglycan synthesis: Steroids can also suppress proteoglycan synthesis, which is important for the extracellular matrix and collagen matrix fibrillinogenesis. Reduced proteoglycan synthesis may contribute to the risk of spontaneous rupture.
5. Plantar fascial rupture: Complications associated with plantar fasciitis injection include plantar fascial rupture. Fascial rupture disrupts the normal function of the foot and can promote further inflammation and pain.
6. Plantar fat pad atrophy: Steroid injections can lead to plantar fat pad atrophy, diminishing subcalcaneal cushioning. This can increase the vulnerability of the plantar fascia to injury and result in more pain.
7. Lateral plantar nerve injury: Injection-related injuries to the lateral plantar nerve can occur as a complication of steroid injections for plantar fasciitis.
8. Calcaneal osteomyelitis: Although uncommon, calcaneal osteomyelitis (infection of the heel bone) has been noted as a potential complication of steroid injections for plantar fasciitis.
9. Skin burning (with iontophoresis): Iontophoresis, a method of delivering medication through the skin using electrical current, can cause burning of the underlying skin.

References & More

1. Injection Techniques in Musculoskeletal Medicine. A Practical Manual for Clinicians In Primary And Secondary Care. Fifth Edition
2. Johannsen FE, Herzog RB, Malmgaard-Clausen NM, Hoegberget-Kalisz M, Magnusson SP, Kjaer M. Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training. Knee Surg Sports Traumatol Arthrosc. 2019 Jan;27(1):5-12. doi: 10.1007/s00167-018-5234-6. Epub 2018 Nov 15. PMID: 30443664.
3. Tatli YZ, Kapasi S. The real risks of steroid injection for plantar fasciitis, with a review of conservative therapies. Curr Rev Musculoskelet Med. 2009 Mar;2(1):3-9. doi: 10.1007/s12178-008-9036-1. Epub 2008 Sep 19. PMID: 19468912; PMCID: PMC2684947.