Corticosteroid injections compared to foot orthoses for plantar heel pain: protocol for the SOOTHE heel pain randomised trial

Biomechanical Effects of Plastic Heel Cup on Plantar Fasciitis Patients Evaluated by Ultrasound Shear Wave Elastography

The plastic heel cup has been adopted to treat plantar heel problems for years. However, its mechanisms and biomechanical effects are yet to be fully understood. The purpose of this study was to investigate the effects of the plastic heel cup on the microchamber and macrochamber layers of the heel pad by comparing the stiffness (in terms of the shear wave speed) and thickness of these two layers with and without a plastic heel cup during static standing. Fifteen patients with unilateral plantar fasciitis were recruited. The shear wave speed and thickness of the microchamber and microchamber layers of each symptomatic heel pad during standing measured by ultrasound shear wave elastography were compared between conditions with and without a plastic heel cup. It was found that a plastic heel cup reduced the shear wave speed of the microchamber layer to 55.5% and increased its thickness to 137.5% compared with the condition without a plastic heel cup. For the microchamber layer, the shear wave speed was reduced to 89.7%, and thickness was increased to 113.6% compared with the condition without a plastic heel cup. The findings demonstrate that a plastic heel cup can help to reduce the stiffness and increase the thickness for both layers of the heel pad during standing, suggesting that the mechanism of a plastic heel cup, and its resulting biomechanical effect, is to reduce the internal stress of the heel pad by increasing its thickness through confinement.

Predictors of response to foot orthoses and corticosteroid injection for plantar heel pain

Background

Foot orthoses and corticosteroid injection are common interventions used for plantar heel pain, however few studies have investigated the variables that predict response to these interventions.

Methods

Baseline variables (age, weight, height, body mass index (BMI), sex, education, foot pain, foot function, fear-avoidance beliefs and feelings, foot posture, weightbearing ankle dorsiflexion, plantar fascia thickness, and treatment preference) from a randomised trial in which participants received either foot orthoses or corticosteroid injection were used to predict change in the Foot Health Status Questionnaire foot pain and foot function subscales, and first-step pain measured using a visual analogue scale. Multivariable linear regression models were generated for different dependent variables (i.e. foot pain, foot function and first-step pain), for each intervention (i.e. foot orthoses and corticosteroid injection), and at different timepoints (i.e. weeks 4 and 12).

Results

For foot orthoses at week 4, greater ankle dorsiflexion with the knee extended predicted reduction in foot pain (adjusted R² = 0.16, p = 0.034), and lower fear-avoidance beliefs and feelings predicted improvement in foot function (adjusted R² = 0.43, p = 0.001). At week 12, lower BMI predicted reduction in foot pain (adjusted R² = 0.33, p < 0.001), improvement in foot function (adjusted R² = 0.37, p < 0.001) and reduction in first-step pain (adjusted R² 0.19, p = 0.011). For corticosteroid injection at week 4, there were no significant predictors for change in foot pain or foot function. At week 12, less weightbearing hours predicted reduction in foot pain (adjusted R² = 0.25, p = 0.004) and lower baseline foot pain predicted improvement in foot function (adjusted R² = 0.38, p < 0.001).

Conclusions

People with plantar heel pain who use foot orthoses experience reduced foot pain if they have greater ankle dorsiflexion and lower BMI, while they experience improved foot function if they have lower fear-avoidance beliefs and lower BMI. People who receive a corticosteroid injection experience reduced foot pain if they weightbear for fewer hours, while they experience improved foot function if they have less baseline foot pain.

Effectiveness of Foot Orthoses Versus Corticosteroid Injection for Plantar Heel Pain: The SOOTHE Randomized Clinical Trial

BACKGROUND

Plantar heel pain is a common foot complaint that causes significant disability and poorer health-related quality of life. Foot orthoses and corticosteroid injection are effective treatments for plantar heel pain; however, it is unclear whether one is more effective than the other.

OBJECTIVE

The aim of this trial was to compare the effectiveness of foot orthoses and corticosteroid injection for plantar heel pain.

METHODS

In this parallel-group, assessor-blinded, randomized clinical trial, participants received prefabricated, arch-contouring foot orthoses or a single ultrasound-guided corticosteroid injection. The primary outcome measure was the foot pain subscale of the Foot Health Status Questionnaire at 4 and 12 weeks.

RESULTS

One hundred three participants aged 21 to 72 years (63 female) with plantar heel pain were recruited from the community and received an intervention. For the primary outcome of foot pain, corticosteroid injection was more effective at week 4 (adjusted mean difference, 8.2 points; 95% confidence interval: 0.6, 15.8 points). However, foot orthoses were more effective at week 12 (adjusted mean difference, 8.5 points; 95% confidence interval: 0.2, 16.8 points). Although these findings were statistically significant, the differences between the interventions did not meet the previously calculated minimal important difference value of 12.5 points.

CONCLUSION

Corticosteroid injection is more effective than foot orthoses at week 4, but this effect does not last; and appropriately contoured foot orthoses are more effective than corticosteroid injection at week 12. However, patients may not notice a clinically worthwhile difference between the interventions.

LEVEL OF EVIDENCE

Therapy, level 1b. J Orthop Sports Phys Ther 2019;49(7):491-500. Epub 26 May 2019. doi:10.2519/jospt.2019.8807.

Effect of 3D Printing Individualized Ankle-Foot Orthosis on Plantar Biomechanics and Pain in Patients with Plantar Fasciitis: A Randomized Controlled Trial

BACKGROUND Traditional ankle-foot orthoses (AFOs) are not effective in treating plantar fasciitis, while customized 3-dimensional (3D) printed ankle-foot orthoses are effective in treating many ankle-foot diseases. This study investigated the effects of customized 3D printed AFOs on biomechanics and comfort of the plantar foot in plantar fasciitis. MATERIAL AND METHODS Sixty patients with bilateral plantar fasciitis aged 31-60 years participated in this study. At week 0, patients were randomly assigned into 2 groups: the control group consisting of those wearing separate shoes with prefabricated AFOs; and the experimental group consisting of those wearing a separate shoe and customized 3D-printed AFO. The Footscan® system recorded maximum pressure, maximum strength, and contact area of patients' hallux, toes 2-5, first to fifth metatarsal, midfoot, lateral heel, and midfoot heel at weeks 0 and 8. Patients used visual analogue scale scores at weeks 0 and 8 to assess overall comfort of foot orthosis, to determine the credibility and comfort of both orthopedic insole conditions. RESULTS At week 0, in the experimental group, peak pressure in the hallux and first metatarsal area was significantly higher than the control group (P<0.05), while mid-heel and lateral heel peak pressures were significantly lower than the control group (P<0.05). After 8 weeks, all groups reported more comfort compared with the same group in week 0 (P<0.05). The comfort scores reported by the experimental group were significantly lower than those of the control group (P<0.05). CONCLUSIONS This study supports the efficiency of customized 3D printing AFO for reducing damage associated with plantar lesions and improving comfort in patients with plantar fasciitis compared with prefabricated AFO. Customized AFO is useful in the treatment of plantar fasciitis compared with prefabricated AFOs.

Injected corticosteroids for treating plantar heel pain in adults

BACKGROUND

Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach.

MAIN RESULTS

We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality.

AUTHORS' CONCLUSIONS

We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.