Skip to main content
SpringerLink
Log in

Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training

  • Award winner: Best paper at the ESSKA Congress in Glasgow 2018
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Plantar fasciitis is a very common (lifetime incidence ~ 10%) and long-lasting injury with major impact on daily function. Combining corticosteroid injection and physical training (strength training and stretching) was hypothesized to result in a superior effect compared to each treatment separately.

Methods

A single blinded randomized controlled superiority trial conducted in 2013–2014 with a 2-year follow-up (end Sept 2016). 123 consecutive patients (20–65 years) referred to two study centers in Denmark: Institute of Sports Medicine, Bispebjerg Hospital, University of Copenhagen and a private rheumatology clinic with symptoms of plantar fasciitis, and ultrasound measured thickness above 4.0 mm were invited. 25 did not fulfill the inclusion criteria (mainly ultrasound criteria) and 8 refused participation. 90 patients were randomized (pulling sealed envelopes) to 3 groups: (1) 3 months strength training and stretching (n = 30), (2) corticosteroid injections with monthly intervals until thickness < 4.0 mm (maximum 3 injections) (n = 31), (3) combination of the two treatments (n = 29). During the 3 months intervention period load reduction was recommended (cushioning shoes and insoles and abstaining from running and jumping). The main outcome was improvement in Pain at function on a 100-mm VAS score and in Foot Function Index (FFI, range 0–230) at 6 months (Clinicaltrials.gov Identifier: NCT01994759).

Results

All groups improved significantly over time, but the combination of corticosteroid injection and training (strength training and stretching) had a superior effect at all time points. The mean difference between the combined treatment and training was 40 points in FFI (95% confidence interval (CI) 63–17 points, p < 0.001) and 20 mm for VAS function pain (CI 35–5 mm, p < 0.01). The mean difference between the combined treatment and corticosteroid injections only was 29 points in FFI (CI 52–7 points, p < 0.01) and 17 mm for VAS function pain (CI 32–2 mm, p < 0.05). All differences were clinically relevant.

Conclusion

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. Corticosteroid injections combined with controlled training are recommended as first line treatment in patients with plantar fasciitis.

Level of evidence

1.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Ball EM, McKeeman HM, Patterson C, Burns J, Yau WH, Moore OA et al (2013) Steroid injection for inferior heel pain: a randomised controlled trial. Ann Rheum Dis 72:996–1002

    Article  PubMed  Google Scholar 

  2. Budiman-Mak E, Conrad KJ, Roach KE (1991) The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol 44:561–570

    Article  PubMed  CAS  Google Scholar 

  3. Coombes BK, Bisset L, Vicenzino B (2010) Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 376:1751–1767

    Article  PubMed  CAS  Google Scholar 

  4. Crawford F, Atkins D, Young P, Edwards J (1999) Steroid injection for heel pain: evidence of short-term effectiveness. A randomized controlled trial. Rheumatology 38:974–977

    Article  PubMed  CAS  Google Scholar 

  5. David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS (2017) Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev 6:CD009348

    PubMed  Google Scholar 

  6. Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE et al (2006) Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Jt Surg Am 88:1775–1781

    Article  Google Scholar 

  7. Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E, Mendoza-Lemus O, Acosta-Olivo C (2013) A comparison of botulinum toxin a and intralesional steroids for the treatment of plantar fasciitis: a randomized, double-blinded study. Foot Ankle Int 34:8–14

    Article  PubMed  Google Scholar 

  8. Guner S, Onder H, Guner SI, Ceylan MF, Gokalp MA, Keskin S (2013) Effectiveness of local tenoxicam versus corticosteroid injection for plantar fasciitis treatment. Orthopedics 36:e1322–e1326

    Article  PubMed  Google Scholar 

  9. Gurcay E, Kara M, Karaahmet OZ, Ata AM, Onat SS, Ozcakar L (2017) Shall we inject superficial or deep to the plantar fascia? An ultrasound study of the treatment of chronic plantar fasciitis. J Foot Ankle Surg 56:783–787

    Article  PubMed  Google Scholar 

  10. Johannsen F, Jensen S, Stallknecht SE, Olsen LO, Magnusson SP (2016) Sonographic measurements of the achilles tendon, plantar fascia, and heel fat pad are reliable: a test–retest intra- and intertester study. J Clin Ultrasound 44:480–486

    Article  PubMed  Google Scholar 

  11. Jorgensen JE, Andreasen J, Rathleff MS (2015) Translation and validation of the Danish foot function index (FFI-DK). Scand J Med Sci Sports 25:e408–e413

    Article  PubMed  CAS  Google Scholar 

  12. Kalaci A, Cakici H, Hapa O, Yanat AN, Dogramaci Y, Sevinc TT (2009) Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial. J Am Podiatr Med Assoc 99:108–113

    Article  PubMed  Google Scholar 

  13. Kiter E, Celikbas E, Akkaya S, Demirkan F, Kilic BA (2006) Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial. J Am Podiatr Med Assoc 96:293–296

    Article  PubMed  Google Scholar 

  14. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH et al (2009) Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 19:790–802

    Article  PubMed  CAS  Google Scholar 

  15. Landorf KB, Radford JA (2008) Minimal important difference: values for the foot health status questionnaire, foot function index and visual analogue scale. Foot 18:15–19

    Article  Google Scholar 

  16. Mahindra P, Yamin M, Selhi HS, Singla S, Soni A (2016) Chronic plantar fasciitis: effect of platelet-rich plasma, corticosteroid, and placebo. Orthopedics 39:e285–e289

    Article  PubMed  Google Scholar 

  17. Mahowald S, Legge BS, Grady JF (2011) The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc 101:385–389

    Article  PubMed  Google Scholar 

  18. McMillan AM, Landorf KB, Gilheany MF, Bird AR, Morrow AD, Menz HB (2012) Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial. BMJ 344:e3260

    Article  PubMed  Google Scholar 

  19. Monto RR (2014) Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot Ankle Int 35:313–318

    Article  PubMed  Google Scholar 

  20. Mulherin D, Price M (2009) Efficacy of tibial nerve block, local steroid injection or both in the treatment of plantar heel pain syndrome. Foot (Edinb) 19:98–100

    Article  CAS  Google Scholar 

  21. Neufeld SK, Cerrato R (2008) Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg 16:338–346

    Article  PubMed  Google Scholar 

  22. Radford JA, Landorf KB, Buchbinder R, Cook C (2006) Effectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord 7:64

    Article  PubMed  PubMed Central  Google Scholar 

  23. Rathleff MS, Molgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT et al (2015) High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 25:e292–e300

    Article  PubMed  CAS  Google Scholar 

  24. Ryan M, Hartwell J, Fraser S, Newsham-West R, Taunton J (2014) Comparison of a physiotherapy program versus dexamethasone injections for plantar fasciopathy in prolonged standing workers: a randomized clinical trial. Clin J Sport Med 24:211–217

    Article  PubMed  Google Scholar 

  25. Tsai WC, Hsu CC, Chen CP, Chen MJ, Yu TY, Chen YJ (2006) Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. J Clin Ultrasound 34:12–16

    Article  PubMed  Google Scholar 

  26. Werner RA, Gell N, Hartigan A, Wiggerman N, Keyserling WM (2010) Risk factors for plantar fasciitis among assembly plant workers. PM R 2:110–116 (quiz 111 p following 167)

    Article  PubMed  Google Scholar 

Download references

Funding

The study was funded by the research fund for Danish Practitioner Specialists and Danish Medical Research Council: “Fonden for Faglig udvikling af speciallægepraksis”.

Author information

Authors and Affiliations

  1. Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

    Finn E. Johannsen, Nikolaj M. Malmgaard-Clausen, Maren Hoegberget-Kalisz, S. Peter Magnusson & Michael Kjaer

  2. Department of Physical and Occupational Therapy, Bispebjerg Hospital, Copenhagen, Denmark

    Robert B. Herzog & S. Peter Magnusson

  3. Gentofte, Denmark

    Finn E. Johannsen

Authors
  1. Finn E. Johannsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robert B. Herzog
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nikolaj M. Malmgaard-Clausen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Maren Hoegberget-Kalisz
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. S. Peter Magnusson
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael Kjaer
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content. FEJ, RBH, SPM and MK have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data; have been involved in drafting the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. FEJ has included all patients, made all the ultrasoundscannings and injected all the corticosteroid injections. RBH took care of the physiotherapist training instructions. NMMC and MHK were blinded evaluators. SPM did all the statistics blinded. All authors have been involved in revising the manuscript critically for important intellectual content and have given final approval of the version to be published.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

All procedures in this study was in accordance with the Helsinki declaration and approved by the local ethical committee.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Johannsen, F.E., Herzog, R.B., Malmgaard-Clausen, N.M. et al. Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training. Knee Surg Sports Traumatol Arthrosc 27, 5–12 (2019). https://doi.org/10.1007/s00167-018-5234-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-018-5234-6

Keywords

Search

Navigation