Prior to 1994, plantar fascia ruptures were considered as an acute injury that occurred primarily in athletes. However, plantar fascia ruptures have recently been reported in the setting of preexisting plantar fasciitis. We analyzed risk factors causing plantar fascia rupture in the presence of preexisting plantar fasciitis.
We retrospectively reviewed 286 patients with plantar fasciitis who were referred from private clinics between March 2004 and February 2008. Patients were divided into those with or without a plantar fascia rupture. There were 35 patients in the rupture group and 251 in the nonrupture group. The clinical characteristics and risk factors for plantar fascia rupture were compared between the 2 groups. We compared age, gender, the affected site, visual analog scale pain score, previous treatment regimen, body mass index, degree of ankle dorsiflexion, the use of steroid injections, the extent of activity, calcaneal pitch angle, the presence of a calcaneal spur, and heel alignment between the 2 groups.
Of the assessed risk factors, only steroid injection was associated with the occurrence of a plantar fascia rupture. Among the 35 patients with a rupture, 33 had received steroid injections. The odds ratio of steroid injection was 33.
Steroid injections for plantar fasciitis should be cautiously administered because of the higher risk for plantar fascia rupture.
I’ve advised against cortisone injections for tendon injuries for a long time. In my opinion, they are about the only thing you shouldn’t do. Everything else is at worst a pseudoscientific waste of time, but cortisone shots leave tendons worse off than no treatment at all. The plantar fascia has not historically been considered a tendon. However, now it’s being described as an aponeurosis, which is a “white flattened ribbon like tendinous expansion”. In my experience, it responds considerably better to tendinitis type strengthening protocols than it does to more traditional treatments of stretches and orthotics.
When stretch and orthotics fail to fully resolve symptoms, as they frequently do, the next step is often one or more cortisone injections. Cortisone is known as a catabolic steroid, which is the opposite of an anabolic steroid athletes take to make their muscles stronger. Catabolic steroids make muscles and tendons weaker; this has been known for decades. To me, this just doesn’t sound like a very smart thing to do for a condition known to result from intrinsic foot muscle weakness just adjacent to and/or around the plantar fascia. This study found that there were not any factors (including BMI, high or low arches, amount of time spent standing, etc.) significantly associated with plantar fascia rupture, with the exception of cortisone injections. What’s more, the risk with cortisone was considerable. They found that a single cortisone injection to the plantar fascia increased the risk of rupture by 18.8 times (not 18% but 1,880%) which is huge in medical terms; 2 injections increased the risk 34.6 times; and 3 or more injections increased the risk of plantar fascia rupture a whopping 125.8 times!
With plantar fasciitis being a very painful condition, people understandably want a quick fix. However, a cortisone shot on average only gives temporary comfort at the expense of increased risk of long term pain. This study showed a very high increase in risk of plantar fascia rupture which can lead to permanent disability. So my advice is: just don’t do it. It’s much better to tough it out for a few weeks, do your physical therapy exercises which hopefully include a fair amount of foot, leg and hip strengthening exercises and EMS as opposed to just stretching, orthotics and various soft tissue techniques (which are so 1990s) but still better than a cortisone injection.
As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.
Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.