Procedure

Local Corticosteroid Injection of Plantar Fascia

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Local Corticosteroid Injection of Plantar Fascia, Plantar Fascia Injection

  • See Also
  1. Tendon Sheath Injection
  • Indications
  1. Avoid if possible (See Complications below)
  2. Plantar Fasciitis refractory to other measures
  • Preparation
  1. Foot XRay prior to injection (rule-out tumor)
  2. Needle
    1. Gauge: 25-27 (some references recommend 22 gauge)
    2. Length: 1.5 inches
  3. Syringe: 5 ml
  4. Anesthetic
    1. Lidocaine 1%: 2 ml or
    2. Bupivacaine 0.25% or 0.5%: 2 ml
    3. Ropivacaine 0.5% 2 ml
  5. Corticosteroid options
    1. Betamethasone (Celestone) 1 ml of 6 mg/ml
    2. Triamcinolone (Kenalog) 1 ml of 40 mg/ml
    3. Methylprednisolone (Depo-Medrol): 1 ml of 40 mg/ml
  6. Platelet-Rich Plasma
    1. Alternative to Corticosteroid for injection
    2. May result in improved outcomes when compared with Corticosteroid Injection
    3. Hohmann (2021) Am J Sports Med 49(5):1381-93 +PMID: 32822236 [PubMed]
  • Technique
  • Anatomic
  1. Patient position
    1. Lateral decubitus position with affected foot down
  2. Anatomic Landmarks
    1. Distal longitudinal crease at medial sole
      1. Proximal base of longitudinal arch
      2. Point is typically in-line with the posterior margin of the medial malleolus
    2. Level of medial process of calcaneal tuberosity (medial tubercle)
      1. Soft tissue slightly distal to Calcaneus
    3. Identify point of maximal tenderness and swelling
  3. Mark needle insertion site based on landmarks
  4. Sterilize local skin with Betadine or Hibiclens
  5. Insert needle at medial foot landmark
    1. Important: See precautions below
    2. Needle inserted perpendicular to skin and perpendicular to the side of the foot
      1. Anteromedial to the most Tender Point
      2. Direct needle toward the plantar fascia at the medial tubercle of Calcaneus
    3. Insert needle past midline of foot
      1. Needle tip contacts the deep fascia or calcaneal spur
    4. Inject preparation into middle third of foot width
  6. Patient lies supine for several minutes after procedure
    1. Distribute with passive foot range of motion
  1. Use similar patient positioning and site preparation as for anatomic technique
    1. Patient in lateral decubitus position with affected foot down
  2. Preparation
    1. Local Skin Preparation with Betadine or Hibiclens
    2. Use a high frequency linear probe with sterile probe cover and sterile gel
  3. Ultrasound Landmarks
    1. Identify the plantar fascia in longitudinal plane (long axis of foot) at the medial Calcaneus
    2. Rotate the Ultrasound probe 90 degrees into Transverse Plane (foot short axis)
      1. Translate the probe over the Calcaneus from proximal to distal
      2. Identify the point at which the medial tubercle of the Calcaneus recedes and the plantar fascia inserts
  4. Insert needle in plane to Ultrasound probe (transverse, short axis of foot)
    1. Advance needle from medial to lateral
    2. Direct needle along the deep surface of the fascia
    3. Inject adjacent to the deep surface insertion of fascia
      1. Avoid penetrating plantar fascia fibers with injection
  • Precautions
  1. Do not inject into fat pad at foot base
  2. Do not inject via base of foot
  3. Do not inject into tibial nerve
  • Complications
  1. Fat pad atrophy
  2. Plantar fascia rupture (2.4% to 10% risk)
    1. More common with repeat injections, and associated with prolonged Disability (>1 year in some cases)
    2. Acevedo (1998) Foot Ankle Int 19(2): 91-7 [PubMed]
    3. Sellman (1994) Foot Ankle Int 15:376-81 [PubMed]
  • Efficacy
  1. Improvement in >70% of cases (Ultrasound-guided)
    1. Kane (1998) Ann Rheum Dis 57:383-4 [PubMed]
  • Follow-up Instructions
  1. No stress to foot for 2 weeks after injection
    1. Minimum time to strenuous activity: 48 hours
  2. Examine again in 3 weeks post-injection
  3. Consider Ultrasound guidance in refractory cases
    1. Kane (1998) Ann Rheum Dis 57:383-4 [PubMed]
  • References
  1. Greene (2001) Musculoskeletal Care, AAOS, p. 491-2
  2. Tallia (2003) Am Fam Physician 68(7):1356-62 [PubMed]
  3. Young (2001) Am Fam Physician 63(3):467-78 [PubMed]
  4. Wilcox (2026) Am Fam Physician 113(5): 431-9 [PubMed]