Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Steroid Injection for Plantar Fasciitis

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Plantar fasciitis is inflammation of the fascia (tough connective sheath tissue) that encloses the muscles and tendons that traverse the bottom of the foot. It is a syndrome of overuse, caused by excessive walking or running, particularly associated with repetitive impact upon the bottom of a foot that is improperly cushioned or without appropriate arch support. Symptoms include pain in the bottom of the foot (ball, arch, and/or heel), worsened by repetitive weight bearing. The pain is often worse with the first steps in the morning or after a period of inactivity. It occurs commonly in athletes and long-distance hikers, particularly if they wear poorly fitting shoes or boots. When examining the foot, pain may elicited by applying pressure to the forward-inside area of the heel.

Treatment consists of rest, elevation of the foot with cold (ice packs) applied to the tender areas at the end of the hiking day, wearing orthotics, gentle stretching (e.g., pulling back the toes and front part of the foot), and administration of an oral nonsteroidal anti-inflammatory drug, such as ibuprofen. Worn at night, a splint that holds the foot in neutral position—thus keeping the plantar fascia slightly stretched - may help, as may avoiding walking barefoot or in flat-soled shoes. If the sufferer must continue to walk on the painful foot, it can be taped to provide arch support; this can do much to reduce pain.

In a recent article by Andrew M. McMillan and colleagues entitled “Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial” (British Medical Journal 2012;344:e3260 doi: 1136/bmj.e3260), the authors investigated the effectiveness of ultrasound-guided corticosteroid (“steroid”) injection in the treatment of plantar fasciitis. The subjects were either injected with 1 milliliter of liquid containing 4 mg of dexamethasone or with 1 milliliter of normal saline (placebo). Before they were injected into the area of fasciitis, which would be quite painful, they received an ultrasound-guided blocking injection of 2% lidocaine into the posterior tibial nerve (to numb the bottom of the foot where the next injection would occur). The outcome measurements of the study were pain and plantar fascia thickness, measured by ultrasound at 4,8, and 12 weeks.

The conludions were that a single ultrasound-guided dexamethasone injection is a safe and effective short term treatment for plantar fasciitis. They noted that it provides greater pain relief than does placebo at 4 weeks and reduces abnormal swelling of the plantar fascia for up to 3 months. However, significant pain relief did not continue beyond 4 weeks.

It is difficult to know exactly how this approach will change therapy, unless it is shown that resolution of plantar fasciitis can be reduced from an average or 12 months to a shorter period with this therapy, or that the ultimate anatomical outcome is better. This would need to be determined in a future study.

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Tags: General Interest

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Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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