The plantar fascia is a strong fibrous band between the heel and forefoot and helps support the arch of the ankle and foot. Injury to the plantar fascia is common in elite athletes or weekend warriors. Swelling of the plantar fascia also known as plantar fasciitis occurs at the heel near the attachment to the heel bone. In general, some cases respond to a plantar fasciitis injection.

What are the typical features of plantar fasciitis?

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

How do we diagnose plantar fasciitis? 

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

Generally, medical imaging assists in the diagnosis. Usually, ultrasound is the first choice to detect typical changes of swelling 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 plantar fasciitis?

In general, 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 useful for support. In fact, a recent study on the treatment of plantar fasciitis found that rest, self-monitoring of pain, good footwear, and stretching had the most success in relieving pain.

What do you do if these simple measures fail?

For stubborn cases, it is important to see a doctor to make the right diagnosis. In addition, referral to a therapist for exercise is useful. For example, calf raises on a step usually improves 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.

Overall, 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. A recent study suggests that radial and focussed shockwave is effective.

shockwave for plantar fasciitis

Is a cortisone injection for plantar fasciitis a good option?

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

Pros and cons of a cortisone shot 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 cortisone injections for plantar fasciitis including skin thinning, fat atrophy, and plantar fascia rupture. Dr Masci discusses the pros and cons of cortisone injections for plantar fasciitis in this blog. 

Alternatively, doctors can repeatedly needle the plantar fascia under local anesthetic to encourage inflammation and healing. Needle tenotomy is performed on tennis elbow and hamstring origin tendonitis with reasonably good success.

Finally, recent studies show platelet-rich injections have a longer-lasting effect than cortisone. A recent review comparing platelet-rich plasma with cortisone injections for plantar fasciitis found that PRP injection for plantar fasciitis was more effective at 3 months and a year. In addition, there are at least another 8 studies showing better effects of PRP injection for plantar fasciitis compared to cortisone. Finally, in severe cases of plantar fasciitis, PRP was better than cortisone and safer than surgery. 

Irrespective of whether you have cortisone, needle tenotomy, or PRP injection for plantar fasciitis, all injections should be performed with ultrasound to make the injection more accurate.

Do plantar fasciitis injections hurt?

Generally, the answer is yes. We know that injections for plantar fasciitis hurt. However, Dr Masci performs an injection with a tibial nerve block at the inside of the ankle to reduce pain and make the injection more comfortable. Overall, a plantar fascia injection is better tolerated with a tibial nerve block.

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.

Traditionally, surgery involves the partial or full 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 lead to tearing of the important spring ligament on the inside of the ankle or increased forces on the forefoot.

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

Final word from Sportdoctorlondon

Most plantar fasciitis will improve with simple treatments such as rest, stretching, and foot strengthening. For cases that are difficult, shockwave therapy is useful. For challenging cases, a plantar fasciitis injection of cortisone or platelet-rich plasma is a good next step dependent on preference. 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.

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