The plantar fascia is a strong fibrous band between the heel and forefoot and helps support the ankle and foot arch. Injury to the plantar fascia is common in elite athletes or weekend warriors. Swelling of the plantar fascia, also known as plantar fasciitis or heel spurs, is often managed with simple treatments such as stretching and massage. However, complex cases might need a plantar fasciitis injection. So, is a plantar fascia ultrasound injection worth it?

What are the typical features of plantar fasciitis? 

Plantar fasciitis is throbbing or burning pain at the inside part of the heel. Pain is gradual over weeks to months, although it sometimes occurs suddenly. The pain worsens in the morning or at the beginning of an activity. Also, continuous movement, such as walking or running, can improve it.

How do we diagnose plantar fasciitis? 

Firstly, an assessment by a doctor is often enough. For example, a history of warming up heel pain and tenderness at the heel is typical. Secondly, it is essential to find factors that have led to an injury, such as training errors, muscle tightness, or weakness in the lower legs.

Generally, imaging assists in the diagnosis. Usually, ultrasound is the first choice to detect typical swelling changes and thickening of the plantar fascia. It can also exclude other conditions, such as plantar fibroma. On the other hand, MRI is used for complex cases or when we think pain is due to other causes, such as bone stress fractures or cysts.

What is the treatment of heel spurs?

Most cases will improve with a simple treatment of rest, stretching, and foot strengthening exercises. Rolling the plantar fascia with a tennis or golf ball may help. A simple insole for your shoes is helpful for support. A recent study on the treatment of plantar fasciitis found that rest, self-monitoring of pain, suitable footwear, and stretching successfully relieved pain.

Generally, taping of the heel is effective at reducing heel spur pain. We use two types of taping – low dye and calcaneal taping. Also, we find night splints effective.

What do you do if these simple measures fail?

It is essential to see a doctor to make the correct diagnosis for stubborn cases.

In addition, referral to a therapist for exercise is beneficial. For example, calf raises on a step usually improve pain. Furthermore, a podiatrist can help with shoe selection and orthotics. However, we don’t know whether the more expensive casted orthotics are better than cheaper off-the-shelf orthotics.

Shockwave therapy (ESWT) is effective for troublesome plantar fasciitis. We think shockwave works by sending a sound wave to the affected tissue. These sound waves stimulate the body’s healing response. Generally, 3-5 sessions at weekly intervals are required. However, a recent study suggests radial and focussed shockwaves are equally effective. Also, combining shockwave with exercise gives a better result.

 

shockwave for plantar fasciitis

Is a cortisone injection for plantar fasciitis a good option? 

In some cases, plantar fascia ultrasound injections are performed. For example, in a study co-authored by Dr. Masci, there is evidence that ultrasound-guided injections help plantar fasciitis.

Pros and cons of a steroid injeciton for plantar fasciitis

Studies on a cortisone injection reveal short-term pain relief of a few months. This relief can last for a few months and perhaps longer. However, there are risks of steroid injection for plantar fasciitis, including skin thinning, fat atrophy, and plantar fascia rupture. These risks can be reduced by performing a plantar fascia ultrasound injection. We think ultrasound improves accuracy and effectiveness. It also decreases the risk of accidental injection directly into the plantar fascia or the fat pad. 

A recent randomised controlled trial found that a cortisone injection provided no additional benefit to physiotherapy and heel cups. 

PRP injection for plantar fasciitis

Finally, recent studies show that platelet-rich injections have a longer-lasting effect than cortisone. For example, a recent review comparing platelet-rich plasma with cortisone injections for plantar fasciitis found that PRP injection was more effective at three months and a year. In addition, at least ten studies show better effects of PRP injection for plantar fasciitis than cortisone. Also, in severe cases of plantar fasciitis, PRP was better than cortisone and safer than surgery. 

Whether you have cortisone or PRP injection for plantar fasciitis, you should perform plantar fascia ultrasound injections to improve accuracy and effectiveness. 

Do plantar fasciitis injections hurt?

Yes. We know that injections for plantar fasciitis hurt. However, there are techniques to reduce pain. First, performing a plantar fascia ultrasound injeciton improves accuracy and reduces pain overall. Second, performing a nerve block such as a tibial nerve block reduces pain associated with a plantar fascia ultrasound injection.

Dr. Masci performs a tibial nerve block inside the ankle to reduce pain and make the injection more comfortable. 

How do we perform a tibial nerve block? 

A tibial nerve bock targets the tibial nerve just above the inside of the ankle joint. It is performed about 15 minutes before a plantar fascia ultrasound injeciton. Using ultrasound guidance, we inject a small dose of local anaesthetic around the tibial nerve.

Most people get good pain relief from a tibial nerve block, making the plantar fascia ultrasound injection much less painful (and more accessible for the doctor to reach the right spot!).

 

plantar fasciitis injection

Plantar fasciitis surgery: Is it worth it?  

Generally, plantar fasciitis surgery is the last resort if other treatments (including one or two injections) fail. A recent study comparing all surgical options for plantar fasciitis found no substantial evidence to support one type of surgery over others. As 80% of cases of plantar fasciitis resolve after 12 months, the authors suggest delaying surgery for at least 12 months.

Traditionally, surgery involves the partial or complete release of the plantar fascia from the heel bone. However, we have concerns with this procedure as a plantar fascia release reduces the support for the medial arch. Consequently, a dropped medial arch can tear the critical spring ligament inside the ankle or increase forces on the forefoot. 

However, one type of surgery called gastrocnemius release shows some promise in plantar fasciitis. A recent study found that releasing the inside gastrocnemius fascia in the calf combined with stretching led to better outcomes than stretching alone. Also, this procedure avoids surgery directly at the heel. So overall, while we don’t recommend surgery, the gastrocnemius release is probably the better surgical option if you’ve failed all other treatments.

 

Other frequently asked questions about plantar fasciitis: 

Can plantar fasciitis cause ankle pain?

Generally not. If someone has ankle and heel pain, I think about other causes, such as calcaneal stress fracture or subtalar joint arthritis.

Why won’t my heel spur go away? 

While most cases settle within 18 months, a small minority continue for years. In these cases, we consider invasive treatments such as injections or surgery.

“I just want a quick-fix injection for my plantar fasciitis.”Is a steroid injection for plantar fasciitis sensible? 

Many people want their heel pain to go away. However, we would caution against a quick-fix steroid injection for plantar fasciitis. Sometimes, cortisone injections can cause harm, like plantar fascia rupture and fat atrophy. Generally, we recommend other treatments such as stretching, orthotics, and shockwave first.

However, if you decide on a cortisone injection, you should have the injection with ultrasound guidance. A recent study found that a plantar fascia ultrasound injection improves pain relief compared to injections without ultrasound. 

Can I continue to walk with plantar fasciitis? 

Yes, but it depends on how sore your heel is after the walk. Try to keep pain levels low (2-3/10) during and after walking.

PRP injection for plantar fasciitis: Is it helpful? 

Overall, we think it has a place. Compared to steroid injections for plantar fasciitis, PRP injections are more effective at 3 and 6 months. If other treatments fail, we prefer PRP injection rather than cortisone for plantar fasciitis. 

PRP injection for plantar fasciitis: what happens after the injection?

Generally, plantar fascia pain gets worse in the short term before it gets better. It is important to offload the foot for about a week.

Example of PRP injection recovery time for plantar fasciitis

  • Day 0-7: Rest your foot in a short walking boot. Resume upper body weights on day 2. Re-engage with swimming on day 3.
  • Day 7-14: Wear supportive training shoes for gentle walking. Continue upper body weights and swimming. Start foot intrinsic strengthening exercises.
  • Day 14-21: Start cycling and increase walking (10-15 minutes daily). Commence seated calf raises from floor level using therabands or seated calf raise machine 3x/week.
  • Day 21-28: Add standing weighted calf raises to seated calf raises. Continue cycling, swimming, and faster walking (greater than 20 minutes walking).
  • Day 28-42: Start progressive walk/run program.

Can I drive home after a plantar fascia injection?

If your doctor performs a tibial nerve injection as part of the procedure, you will experience numbness in the ankle and the foot. Therefore, we suggest you avoid driving until the numbness disappears.

Final word from Sportdoctorlondon about a plantar fascia ultrasound injection

Most plantar fasciitis will improve with simple treatments such as rest, stretching, and foot strengthening. For complex cases, shockwave therapy is beneficial. A cortisone or platelet-rich plasma plantar fasciitis injection is an excellent next step, dependent on preference for challenging issues. However, evidence is trending toward PRP due to better longer-term effects without the risks associated with cortisone. Finally, we only consider surgery as a last resort.

Other foot and ankle conditions:

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.