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