Plantar Fasciitis and heel pain: How many injections does it take?

Plantar Fasciitis: How Many Injections Does it Take?

Foot Diagram
Over the past 2 months I have seen an increase in referrals from a foot and ankle surgeon, and my number of cases of plantar fasciitis have increased.  I am all about what is best for my patients and what is the best treatment for them.  So as a physical therapist, I feel I can show great results with patients with plantar fasciitis (of course! ha ha) and I wonder why so many physicians implement corticosteroid injections for plantar fasciitis, and even sometimes give multiple injections over weeks to months, use steroid dose packs, and oral anti-inflammation when post acute plantar fasciitis has no S/S of inflammation and research has shown it is more of a degenerative tendinopathy?  I try to step back and look at the big picture and maybe the only patients that get referred to physical therapy are the complex ones that don’t respond to injections and other anti-inflammatory methods.  Maybe a high percent of their patients respond well with a injection with a good outcome and never need physical therapy (PT).  Why even use anti-inflammatories?  Do physicians have evidence to support multiple injections and their clinical decision making? What about recurrence rates?  Why focus on short term outcomes and not only long term outcomes?  Why is it months to years before the patient gets referred to PT?  What is best practice for plantar fasciitis?
In 2008 JOSPT published clinical guidelines for the treatment of plantar fasciitis with orthotics only showing strong evidence to support, and stretching, modalities, and night splints showing moderate evidence to support.  Manual therapy has poor/theoretical evidence! but why does it work in the clinic for me?  Maybe the research as not caught up to clinical practice with high quality RCT, especially when good outcomes are already established?  A physician article shows a 90% success rate with conservative interventions, but this consisted of physical therapy, stretching, and injections.  These physical therapy guidelines were published in 2008 and may need to be updated: they do not have baxter’s nerve entrapment in differential diagnosis and new high quality research may have been performed.  So then I performed a current Pub Med search for physical therapy and plantar fasciitis, and it showed no new current high quality research.  most of the research looks at more specific interventions such as corticosteroid injections, shockwave therapy for chronic plantar fasciitis, and orthotics.  This would be a great research topic to look at the outcomes of physical therapy care vs physician care in patients with plantar fasciitis in a RCT!  Looking at long term outcomes, cost effectiveness, and efficacy. Also, i would love to see treatment outcomes in plantar fasciitis with dry needling!  I could go on forever about physical therapy, so i will stop now.
The American College of Physicians and the Annals of Internal Medicine published physician guidelines for the treatment and management of plantar fasciitis for physicians in the clinic.  A Pub Med search using corticosteroid injections and plantar fasciitis was also performed.   I was shocked to see all of the evidence (the number of publications and quality of research) that has been performed to support physician interventions and the lack of evidence physical therapy has?  Maybe this is why they do not send patients to PT first.   Most of the research supports the use of corticosteroid injections for the short term treatment of plantar fasciitis, but their guidelines recommend to use injections as a second line of treatment.  I don’t think this ever happens.  Poor long term outcomes were noted in patients with chronic plantar fasciitis and corticosteroid injection.  The physician guidelines state:” due to the degenerative nature of plantar fasciitis, corticosteroids may have only limited effectiveness, and they have many potential side effects, including infection, tendon rupture, fat pad atrophy, and skin atrophy.”  One study showed a small increase in plantar fascia ruptures after an average of 2.67 injections when reviewed 120 cases.  I see patients after 4-6 injections sometimes?  I even had patients return and say that the physician told them it takes 5-7 injections sometime?  Where is the research to support this?  I have searched for the past week and still cannot find anything to support multiple injections.  Isn’t the definition of insanity is doing something over again, (and again), and expecting a different outcome.  The physician guidelines further state:

“a meta-analysis of 5 studies showed that although a cortisone injection may have some benefits, they were short-term in nature and that there was no difference in long-term outcome.”
Overall, it looks like a conservative approach and a corticosteroid  injection can assist with good short term outcomes.  Other interventions are recommended with chronic plantar fasciitis, such as surgery and shock wave therapy.   More research needs to be performed to support the use of physical therapy interventions.  I have not found any research to support the use of multiple corticosteroid injections in the treatment of plantar fasciitis.   I still would like to see how my clinical outcomes would change if i saw patients with plantar fasciitis prior to physician corticosteroids injections.RECOMMENDATION TO PATIENTS: Roughly 90% of plantar fasciitis patients get better.   Research supports a conservative approach (physical therapy and stretching) and you may benefit from an early corticosteroid injection to decrease pain for plantar fasciitis.  Patient education is the key!  If you can treat it early, you may be able to prevent it from progressing to a chronic problem and getting a better outcome with faster results.  If you do not respond to an injection or anti-inflammatories, the plantar fasciitis may have progressed to more of a degenerative chronic stage, but conservative treatment can still help so consult your physical therapist!  No need for multiple injections that have already not helped you.   Many states have direct access to physical therapy services so you can consult your physical therapist and get treated now instead of waiting for symptoms to worsen.
Ron Miller, DPT, OCS


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