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Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial

BMJ 2012; 344 doi: (Published 22 May 2012) Cite this as: BMJ 2012;344:e3260

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Re: Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial

Whether one calls it ‘Plantar Fasciitis’ (for which term there is little histological evidence ) or ‘Bruised Heel’ ( which reflects perhaps it’s commonest aetiology ), sufferers from this common and disabling condition should be grateful that this paper makes it less likely that they will be offered steroid injections. Even with,but particularly without, a posterior tibial nerve block, injections into the heel are not for the faint hearted. Especially when the outcome after 4 weeks is unremarkable.

The authors suggest that immobilisation in Plaster may be the most effective option.
This does not reflect the anecdotal impressions of many sufferers and practitioners, who have found that a more simplistic approach has much to commend it.

We all recognise that bruising of subcutaneous tissues rapidly resolves, if the causative trauma is not repeated.
Careful histories taken from bruised heel patients often reveal that the symptoms began after a change of footwear, or a change in walking habit. New shoes, looser ones, flipflops, boots of any sort, are mentioned. Unusual exercise, walking on hard surfaces, even jumping from a height, are often remembered.

No doubt the majority of people who develop bruising of the heel tissues in such circumstances, experience rapid resolution, if they avoid the type of repetitive minor trauma which seems so important in those with chronic symptoms.

Examining the footwear, and the gait, of chronic sufferers, is vital.
Most will have shoes that are insufficiently close fitting, and which allow the heel of the shoe or sandal to tap the heel tissues of the wearer, on every step that is taken.
Many chronic sufferers will have an odd gait , walking on the lateral aspect of the affected foot.
There may be demonstrable weakness of their intrinsic foot muscles.

If these common features are found and their natural history understood, a good prognosis can be confidently given.

Shoes should have air cushion heels.Avoid flip flops and boots of all sorts.
Wear thick socks, maybe two pairs, so that the foot and shoe move as one, preventing the heel of the shoe tapping against bruised tissues at every step.

Chronic sufferers may not recover fully, until their weak intrinsic foot muscles are strengthened, restoring a normal gait. They need to be carefully taught how to elevate their mid foot, initially for seconds at a time, while keeping heel and toe pads flat on the ground.
Those who find these exercises difficult, may get similar effect from walking uphill or upstairs, using their toes and forefoot as a propulsive lever on every pace.

This safe, cheap and satisfying approach is worth a try.

Approached in this way, bruised heel is one of a triad of disabling conditions that affect multitudes, for want of simple muscle strengthening, based on clinical awareness.
Knee pain and dysfunction, acute and chronic, may not resolve or improve, without conscientious Quads exercises.
Recurrent ankle instability will not improve without attention to the lower leg muscles and the proprioceptive reflex arc.

Competing interests: No competing interests

08 July 2012
Noel Thomas
semi retired GP
BronyGarn, Maesteg, CF34 9AL