Injection Therapy for

Insertional Plantar

Fasciitis

James M. Mahoney, DPM Associate Professor, CPMS

Ruth Ranum, BS 3rd year student, CPMS

Relevant to the content of this presentation, Dr. Mahoney and Ms. Ranum have nothing to disclose.

Objectives

At the conclusion of this presentation, the participant will be able to:

▫ Describe current best evidence for the proper administration and usage of corticosteroids injections for plantar fasciitis

▫ Compare/contrast the efficacy of novel injection treatments for plantar fasciitis

Sorry to disappoint!!!

For any soft tissue injection, no single study identifies:

▫ The most efficacious steroid to use

▫ The correct concentration of steroid to administer for clinical efficacy

▫ The correct interval of time between injections

▫ The annual limit of injections

Best steroid to use?

• Acetates are more potent (longer duration of action) than phosphates when administered intra-articularly due to increased insolubility 11 [Level IV]

• Phosphates are more potent when administered orally and IV 19 [Level V]

Best steroid to use?

There may be a geographical preference 1 [Level III]:

▫ West-Kenalog® (triamcinolone acetonide)

▫ East-Depo-Medrol® (methylprednisolone acetate)

▫ Midwest-Aristospan® (triamcinolone hexacetonide)

Efficacy Evidence • Steroid is better than placebo at 6 and 12 weeks 4

[Level II] • Steroid had successful therapeutic response after

3 months 5 [Level II] • Steroid resulted in significant reduction in pain

up to 25.3 months after injection 6 [Level II] • Lower visual analog scales and higher tenderness

thresholds at 3 weeks and 3 months 7 [Level II] • Significant pain relief did not continue beyond 4

weeks 8 [Level I] • VAS scores decreased at 2 weeks, 2 months, one

year compared to pre-injection level 9 [Level II] • VAS scores decreased at 1 month and further at 6

months 10 [Level II]

What is correct dosage?

Experienced clinical opinion is the principal rationale for injection practices; little rationale is based on formal scientific evidence 2 [Level III] ▫ Example: Trigger finger injections

5 mgs of methylprednisolone was determined to be the effective dose in the literature 32% of respondents used this dose

28% used twice the dose

9% used at least 3 times the dose

Dosage: Are DPM’s using too much? • 0.5 to 3 mgs (.2 to .75 cc) for soft tissue:

dexamethasone phosphate (4 mg/cc) 3 [Level V]

• 2 to 10 mgs (.05 to .25 cc) for soft tissue: triamcinolone acetonide (40 mg/cc) 3

[Level V]

With or without local anesthetic? • Mixture does not increase efficacy • Benefits 12 [UpToDate] ▫ Less tendency to cause soft tissue atrophy ▫ Decrease post-injection flare ▫ Immediate relief suggests proper

placement of injection (?) • Risks ▫ Lidocaine parabens can decrease

bioavailability of acetate steroids 1 [Level III]

▫ Increase risk of infection using multi-dose vials

Medial or Plantar Injection? Medial

▫ 3 hour uptake was uniformly more medial and posterior than the situation of heel tenderness. This may mean that the best injection approach is the medial heel border at a point posterior to the heel tenderness 13 [Level IV]

Ultrasound-guided or Palpation?

• Equal amount of pain relief, decrease in fascial thickness, and hypoechogenicity in both groups at 2 weeks, 2 months, and 1 year ▫ Recurrence rate higher in palpation group 9

[Level II] ▫ Ultrasound had lower VAS scores and higher

tenderness thresholds 7 [Level II] • No difference in improvements in fascial

thickness, fat pad thickness and VAS ⁶ [Level II]

• No difference in VAS scores at 6 and 12 weeks ⁴ [Level II]

Frequency of Injection(?)

• Based solely on intra-articular habits

• From 4 injections per lifetime in any joint with DJD to 12 injections per year in any joint with RA 12 [UpToDate]

Side Effects

• Post-Injection Flare

• Fascial Rupture

• Fat Pad Atrophy

• Neurotoxicity

Side Effect: Post-Injection Flare • Occurs in 2 to 4% of patients 19 [Level V]

• Caused by insoluble (long-acting) agents

▫ Methylprednisolone (Depo-Medrol®) and triamcin0lone acetonide (Kenalog®) cause it the least among long-acting agents

• Phosphate preparations (e.g. dexamethasone) might be more appropriate

Side Effect: Plantar Fascial Rupture

• Incidence varies from 2.4% 14 [Level IV] to 5.7% 15 [Level III]

▫ DynaMed 2014 lists this as Level 2 (mid-level) evidence

Side Effect: Fat Pad Atrophy

• Atrophy of skin and subQ tissues occurs approximately 1% of the time 19 [Level V]

• Less soluble agents increase risk of soft tissue atrophy 3 [Level V]

• In a survey 16[Level III], 11% used dexamethasone, 35% used triamcinolone acetonide for DeQuervain’s tenosynovitis.

Side Effect: Neurotoxicity(?)

• Intrafascicular injection of steroid into rat sciatic nerve caused varying degrees of neurotoxicity 17 [Level V]

▫ Dexamethasone - minimal

▫ Triamcinolone acetonide - moderate

▫ Methylprednisolone - moderate

▫ Triamcinolone hexacetonide - severe

Additional Injection Therapies

• Corticosteroid Injection with Peppering Technique

• Autologous Blood Injections • Platelet Rich Plasma Injections • Botulinum Toxin Injections • Ultrasound Guided Dextrose

Prolotherapy All injection therapies require further research

Corticosteroid Injection with Peppering Technique

• Peppering: Inserting, injecting, withdrawing without emerging from the skin, slightly redirecting, and reinserting.

• Area is peppered with small injections • Prospective randomized trial with 100 pts 20

[Level II] ▫ A: Autologous Blood Injection ▫ B: Peppering with Local Anesthetic ▫ C: Corticosteroid Injection ▫ D: Peppering with Corticosteroid (peppered 40-

50 times) • Results: Improvement in all groups, Group C

and D had excellent results – Group D had superior results (p<0.05)

Autologous Blood Injection

• Blood drawn from patient and injected into site of pain

▫ attempt to cause a physiological response that will ease pain and increase function

• Not better than corticosteroid injection 20 [Level II]

• Triamcinolone injection may be more effective for pain relief than autologous blood injection 21 [Level II]

Platelet Rich Plasma Injection

• Blood drawn from patient, spin blood down to produce a layer of platelet rich plasma, and injected into the site of pain

▫ Less local inflammation

▫ Requires larger blood draw

• PRP no more effective than placebo for Achilles tendinopathy 22 [Level II]

Botulinum Toxin Injection

• Regularly used to paralyze muscles and paralyze or deaden sensory nerves and thereby relieve pain

• Short term improvement in pain and overall foot function 23 [Level II]

• At 6 months, botulinum toxin had significantly better results than corticosteroid injections 24 [Level II]

Ultrasound Guided Dextrose Prolotherapy • 80% reported a good to excellent

outcome 25 [Level IV]

References 1. Centeno LM, Moore ME. Preferred intra-articular corticosteroids and associated practice: a

survey of members of the American College of Rheumatology. Arthritis Care Res 1994; 7:151.

2. Kegel G et al. Steroid injections in the upper extremity: experienced clinical opinion versus evidence-based practices. Orthopedics 2013; 36(9):e1141-e1148.

3. Cardone DA et al. Joint and soft tissue injections. Am Fam Physicians 2002; 66(2):283-289

4. Ball EM et al. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis 2013; 72(6): 996-1002.

5. Yucel I et al. Comparison of high-dose extracorporeal shockwave therapy and intralesional corticosteroid injection in the treatment of plantar fasciitis. JAPMA 2010; 100(2):105-110.

6. Yucel I et al. Comparison of ultrasound-, palpation- and scintigraphy-guided steroid injections in the treatment of plantar fasciitis. Arch Orthop Trauma Surg 2009; 129(5):695-701

7. Chen CM et al. Effectiveness of device-assisted ultrasound-guided steroid injection for treating plantar fasciitis. Am J Phys Med Rehabil 2013; 92(7):597-605

8. McMillan AM et al. Ultrasound guided corticosteroid injection for plantar fasciitis: randomized controlled trial. BMJ 2012; 344:e3260

9. Tsai WC et al. Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. J Clin Ultrasound 2006; 34(1):12-16.

10. Genc H et al. Long-term ultrasonographic follow-up of plantar fasciitis patients treated with steroid injection. Joint Bone Spine 2005; 72(1):61-65

11. Derendorf H et al. Pharmacokinetics and pharmacodynamics of glucocorticoid suspensions after intra-articular administration. Clin Pharmacol Ther 1986; 39:313-317

12. UpToDate 2014

13. Dasgupta B, Bowles J. Scintigraphic localisation of steroid injection site in plantar fasciitis. Lancet 1995; 346(8987): 1400-1401

14. Kim C et al. Incidence of plantar fascia ruptures following corticosteroid injection. Foot Ankle Spec 2010; 3(6):335-337

15. Acevedo J, Beskin J. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998; 19(2):91-97.

16. Faldale FD, Wiggins ME. Corticosteroid injections: their use and abuse. J Am Acad Orthop Surg 1994; 2:133-140.

17. Mackinnon SE et al. Peripheral nerve injection injury with steroid agents. Plastic Reconst Surg 1982; 69(3):482-489

18. Drug Facts and Comparisons, 2012 edition. St. Louis, Mo: Wolters Kluwer Health.

19. Caldwell JR. Intra-articular corticosteroids: guide to selection and indications for use. Drugs 1996; 52(4):507-514.

20. Kalaci et al. Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial. J Am Podiatr Med Assoc 2009; 99(2):108-13.

21. Lee T, Ahmad T. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trail. Foot Ankle Int 2007; 28(9):984-90.

22. De Vos RJ et al. Platelet-rich plasma injection for chronic achilles tendinopathy: a randomized controlled trial. JAMA 2010; 303(2):144-9.

23. Babcock et al. Treatment of pain attributed to plantar fasciitis with botulinum toxin: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil 2005; 84(9):649-54.

24. Diaz-Llopis IV et al. Randomized controlled study of the efficacy of the injection of botulinum toxin type A versus corticosteroids in chronic plantar fasciitis: results at one and six months. Clin Rehabil 2012; 26(7):594-606.

25. Ryan MB et al. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med 2009; 43(4): 303-6.