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

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.

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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

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Authors

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.

Corresponding author

Correspondence to Finn E. Johannsen.

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.

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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

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Keywords

  • Plantar fasciitis
  • Tendinopathy
  • Exercise therapy
  • Strength training
  • Stretching
  • Corticosteroid injection