The plantar fascia is a strong, fibrous band that connects the heel to the forefoot. It helps support the ankle and arch of the foot. Injury to the plantar fascia is common in elite athletes and 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, in cases of severe plantar fasciitis, an injection may be necessary. So, is a plantar fascia ultrasound injection worth it, and is a plantar fasciitis steroid injeciton a risky procedure?

What are the Typical Features of Plantar Fasciitis?  

Plantar fasciitis causes throbbing or burning pain in the inside part of the heel. It occurs gradually over weeks to months, although it can sometimes happen suddenly. Sometimes, you suffer from a plantar fascia tear. The pain worsens in the morning or at the beginning of an activity. 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. Your doctor will ask about the location and characteristics of plantar fascia pain. It is essential to identify factors that have contributed to the injury, such as training errors, muscle tightness, or weakness in the lower legs.

Generally, imaging assists in the diagnosis. Typically, ultrasound is the first choice for detecting swelling of the plantar fascia. It can also exclude other conditions, such as plantar fibroma. On the other hand, MRI is used when we think pain is due to different causes, such as bone stress fractures or cysts.

What is the Treatment of Heel Spurs?

Most cases can be improved with simple treatments, including rest, stretching, and foot strengthening exercises.

Rolling the plantar fascia with a tennis or golf ball may help. A simple insole for your shoes can provide support. A recent study on the treatment of plantar fasciitis found that rest, suitable footwear, and stretching were effective in relieving pain.

Other helpful treatments include heel taping and night splints.

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 physical therapist for exercise is beneficial. For example, calf raises on a step usually improve pain. Furthermore, a podiatrist can assist with selecting the right shoes and recommending orthotics. However, we don’t know whether the more expensive custom-made orthotics are better than simple off-the-shelf orthotics.

Shockwave therapy (ESWT) is effective for troublesome plantar fasciitis. We believe shockwaves work by sending sound waves to the affected tissue, thereby stimulating the body’s natural healing response. Generally, 3-5 sessions are required at weekly intervals. A recent study suggests radial and focused shockwaves are equally effective. Additionally, combining shockwaves with exercise yields better results.

Is a Cortisone Injection for Plantar Fasciitis a Good Option?

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

Pros and cons of a steroid injeciton for plantar fasciitis

Studies on cortisone injection for plantar fasciitis have revealed short-term pain relief that lasts for a few months. This relief can last longer than a few months on occasion. 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 believe that ultrasound enhances 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

Recent studies have shown that platelet-rich injections have a longer-lasting effect than cortisone injections. For example, a recent review comparing platelet-rich plasma with cortisone injections found that PRP injections were more effective at three months and one year. Additionally, at least 15 studies have demonstrated that PRP injections have more effective outcomes. Additionally, in severe cases of plantar fasciitis, PRP was found to be more effective than cortisone and safer than surgery.

Whether you have cortisone or PRP injections for plantar fasciitis, consider performing plantar fascia ultrasound injections to enhance accuracy and effectiveness.

Do plantar fasciitis injections hurt?

Yes. We know that injections for plantar fasciitis can be painful. However, specific techniques reduce pain. First, performing a plantar fascia ultrasound injeciton improves accuracy and reduces pain overall. Second, performing an ankle nerve block relieves pain associated with a plantar fascia ultrasound injection.

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

How do we perform a tibial nerve block?

A tibial nerve block targets the tibial nerve just above the inside of the ankle joint. It is performed about 15 minutes before a plantar fascia ultrasound injection. 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.

plantar fasciitis injection

Plantar fasciitis surgery: Is it worth it?

Generally, plantar fasciitis surgery is considered a last resort when other treatments have failed. A recent study comparing all surgical options for plantar fasciitis found no evidence to support one type of surgery over others. As 80% of cases of plantar fasciitis resolve after 12 months, we suggest delaying surgery for at least 12 months.

Traditionally, surgeons cut the plantar fascia from the heel bone. However, we have concerns about this procedure, as releasing the plantar fascia reduces support for the medial arch, potentially leading to a flat foot. Flat feet cause problems in the ankle and foot. 

However, one type of surgery, known as gastrocnemius fascia release, shows promise in treating plantar fasciitis. A recent study found that releasing the inner gastrocnemius fascia in the calf, combined with stretching, led to better outcomes than stretching alone. Also, this procedure avoids surgery directlyont the heel. Overall, while we don’t recommend surgery, the gastrocnemius release is the better option if surgery is considered. 

Other frequently asked questions about plantar fasciitis: 

Can plantar fasciitis cause ankle pain?

Generally not. If someone experiences ankle and heel pain, we consider other potential causes, such as a 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 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 caution against a 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 therapy, as initial options.

However, if you decide on a cortisone injection, it is recommended that you receive the injection with ultrasound guidance. A recent study found that a plantar fascial ultrasound-guided injection improves pain relief compared to injections without ultrasound guidance. 

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. 

Moreover, the optimal PRP formula for plantar fasciitis is one with a high platelet concentration and a high white blood cell count. These systems take a higher blood volume with a double spin. 

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

Generally, plantar fascia pain worsens in the short term before it improves. 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 using the seated calf raise machine three times/week.
  • Day 21-28: Add standing weighted calf raises to seated calf raises. Continue cycling, swimming, and walking at a faster pace for more than 20 minutes.
  • Day 28-42: Start progressive walk/run program.

Can I drive home after a plantar fascia injection?

If your doctor performs a nerve block injection, you may experience numbness in the ankle and foot. Therefore, it is advisable to avoid driving until the numbness has disappeared.

Final word from Sportdoctorlondon about a plantar fascia ultrasound injection

Most cases of plantar fasciitis can be effectively treated with simple measures, including rest, stretching exercises, and foot strengthening exercises. For complex cases, shockwave therapy is a beneficial treatment option. A cortisone injection for plantar fasciitis is an excellent next step. However, evidence is trending toward PRP due to better, longer-term effects without the risks. Ultimately, surgery is a last resort.

Other foot and ankle conditions:

Dr Masci is a specialist sports doctor in London. 

He specialises in muscle, tendon and joint injuries.