Plantar Fasciitis: One Cortisone Shot = 19X Risk of Rupture

Risk factors affecting chronic rupture of the plantar fascia. Foot Ankle Int. 2014 Mar;35(3):258-63. Lee HS1, Choi YR, Kim SW, Lee JY, Seo JH, Jeong JJ.

Abstract
BACKGROUND:
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.

METHODS:
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.

RESULTS:
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.

CONCLUSION:
Steroid injections for plantar fasciitis should be cautiously administered because of the higher risk for plantar fascia rupture.

My comments:

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.

8 thoughts on “Plantar Fasciitis: One Cortisone Shot = 19X Risk of Rupture

  1. Hi Chad, thanks for your article. How was rupture caused? Was it through normal daily use or athletics? I have had PF for 4 months and my doctor mentioned today getting a cortisone shot. I have tried everything: 3xshock wave, 2x ultrasound, stretching lots, alleve, voltaren, rest,ice,etc. I am a half ironman top age grouper and am baffled. Any thoughts? Much appreciated. Cheers, Mike

    • Hi Mike,

      The paper is at my office and I’m at home right now, but I don’t recall them mentioning how the plantar fascia was ruptured, just whether it did or not. Rereading the abstract the only significant risk factor was a prior cortisone shot, so I would expect proportionally as many couch potatoes ruptured their plantar during normal activities as athletes did during running or jumping.

      And yeah, unfortunately, I wouldn’t expect any of those things you have tried to have done any good. The good news is I have LOTS of ideas and in my experience the more of those ideas you combine, the better they work. Definitely check out my blog category on ‘plantar fasciitis.’ In it I mention why I never stretch the plantar fascia anymore, but why I might stretch the calves. I talk about why I would definitely strengthen the calves, and why I think the best bet for anyone, particularly an endurance athlete like yourself, is a general core/lower body strength program done maybe twice a week using good multi joint exercises like squats, RDLs, lunges, calf raises and focused hip abduction and adduction strengthening. I did a blog on stress fractures where I commented that the bulk of the research on running related injuries seems to be from the same thing. That being the muscles somewhere (if not everywhere) in the foot, legs, and particularly the hips aren’t strong enough to support the ligaments, tendons, bone, and joints, when running, with the result being an injury in whatever is the person’s weakest link.

      While I think it’s relatively easy to target all the most of muscles needed with progressive resistance exercise, I think to really hit the foot intrinsic muscles there is nothing better than EMS where you stand on the electrodes. I did a blog and video describing what and how I do that, with my method being exactly as described by sprint coach Charlie Francis for his runners. The cool thing about the EMS is not only does it strengthen the foot muscles better than anything else, but in my experience it also significantly decreases the pain in the short term. So definitely check out that blog. The exercises do work by themselves but I think the EMS is a substantial boost and I use it on all my plantar fasciitis patients, unless they have a pacemaker/defibrillator.

      So check out some of that stuff and if you have any other questions be sure to let me know. If you decide to give EMS a try I think the Globus Genesy 300, combined with rubber carbon electrodes is the sweet spot for power and function with regards to plantar fasciitis, and you can do a lot more with it. That’s a lot of links, hope it helps.

  2. I had a cortisone injection for plantar fasciitis 5 weeks ago. A few days after injection, I started having intermittent intense pain in the area of the injection. I also have intermittent pain on the sole of the ball/front of my foot. After first such pain, about two weeks after injection, there is a sensation of numbness (with pain?!?!) on the surface of that part of my foot. I also am having varying degrees of swelling of foot and redness on the bottom of that foot. I saw the podiatrist again today and he only offered me an orthotic (at the cost, to me as not covered by insurance, of $500) – but, did not mention a diagnosis other than something like “non-specific pain in the foot”. I told him I would have to think about it as I have no confidence in this doctor right now. Could these symptoms be from a tear in the plantar fascia? I don’t know where to go from here, but walking is difficult and painful. (I am a 70 year-old female with fibromyalgia and Hashimoto’s, if that helps.)

    • Hi Rose Anne,

      It’s definitely possible that your plantar fascia ruptured, but there is probably not a lot different you can do about that now. I wouldn’t get any more shots if it were me. I wouldn’t think you would need to spend $500 on orthotics as the last time I looked the research showed over the counter arch supports worked just as well, but still not a panacea. However, if comfortable they might be worth a try. If you went to a runner’s store they should have a wall of them you can try out and buy the one that’s most comfortable.

      I would think the long term answer for plantar fasciitis is to start exercising and getting the legs and hips strong in general, with maybe some EMS to the intrinsic foot muscles. At least that’s how I treat plantar fasciitis. I have a series of blogs on plantar fasciitis since it is such a problem in them I think I discuss most of what I do. Definitely check out the one on strengthening.

  3. Hi Chad,

    What if it is bursitis directly under the heel(fat pad) that hasn’t healed for over 6 months with trying physical therapy, stability shoes, chiropractor treatments, gel heel cushions, ice, stretching, acupuncture and diet/Epsom salt baths(only thing I haven’t tried is a night splint), would you still avoid a cortisone injection and how would you treat this situation otherwise?

    Thanks,

    Victor

    • Hi Victor,

      If it’s bursitis a cortisone shot might help, but there is no research I have seen on that either way. The only paper I could find on subcalcaneal bursitis was a single case study that recommended surgical excision of the bursa. Cortisone to the bursa might be well contained and not affect the plantar fascia or fat pad, but I’m far from an expert on that. Also I think you would want to know if the bursitis is causing the pain, or if it’s just there and the plantar fasciitis is still causing the bulk of the pain. If it’s plantar fasciitis I can understand why it wouldn’t feel better after 6 months of treatment because it sounds like none of the treatments you have had, have done anything to increase foot intrinsic, or extrinsic (to include hip) strength/endurance, which I think is really important. I’ve done a number of blogs regarding my thoughts on all of that. I hope some of that helps.

  4. Hi Chad,

    I had a partial rupture in 2017 and a year later the rupture has healed but I am still symptomatic and MRI shows lots of scarring and thickening at origin of PF. I did not have any types of injections prior to the rupture, but I did have plantar fasciosis at the time. So rupture happened because my plantar was weakened already.

    Two questions:
    1) Could increased risk associated with steroid injection simply reflect the poor shape of the plantar in folks who elect to get the shot rather than the shot itself?
    2) Given that my problem is scar tissue that persists a year after injury and I have not run at all to stress the tissue, would a catabolic treatment actually be a good idea to try to break down the bad tissue so I can so some loading protocols to build it back up? I think if it hasn’t healed after a year, it won’t heal at all unless I do something to get rid of the scarring.

    Thanks for your thoughts.

    • Hi Paul,

      1) I could be, but more than a few researchers have injected cortisone into a lot of different tendons over the years and have noted long term outomes to be worse with the steroid injections. My recollection is that pain and function in the steroid groups pretreatment were not worse than the non-steroid group in any of the studies that would indicate a worse injury to begin with.

      2) I doubt it. A year after injury really isn’t that long. A good number of these tendinous type injuries take around 18 months to heal. The scarring and thickening may be present, but is probably par for the course. With Achilles tendinopathy in particular, the tendon is known to swell when injured, and with treatment (daily resistance exercise) it returns thins back to normal over time as the pain resolves. I recall a paper that looked at the combination of exercise and cortisone with tennis elbow, and the cortisone slowed recovery and I expect (on average) it would be the same with plantar fasciitis. That said, you could get lucky but I wouldn’t get the shot if it were my foot. I think of the arch of the foot like a bridge, and with plantar fasciitis the bridge support is collapsing, so the last thing you want to do is anything that lessens support. Rather I would try and increase support on the bridge from the top, from underneath, and take weight off the bridge by losing weight if needed.

      If it were me and I were overweight I would try intermittent fasting until I was ideal weight. I would do a total body strength training program, with an emphasis on hip abduction, hip extension, calf strengthening and stretching. If you don’t have access to a gym I would consider Spinal Flow Yoga, which is my new (non-stretchy) routine for neck and back pain, but it efficiently strengthens all the above body parts and more. Those are the cheap fixes. A more expensive fix, which I think works synergistically with the other exercises is EMS. EMS can directly target the foot intrinsic muscles for which support your arch from underneath, as there aren’t any good regular exercises to hit the muscles on the bottom of the feet as well as electric stimulation can, plus the EMS helps lessen pain. EMS costs more with decent EMS machines with electrodes and straps can be had for $110, and the best in the world machine for $700 but that gets to be a long story.

      Part of me is wondering if the Spinal Flow Yoga, since it’s barefoot, has balancing, calf raises, and exercises that target the peroneal muscles and tibialis posterior in particular might be reasonably effective on it’s own without the EMS but I would expect the EMS to be a big boost. A couple minutes of calf stretching in addition to Spinal Flow might also add to it. From what I know of tendinopathy (for which plantar fasciitis isn’t exactly tendinopathy but I think it’s best treated if you assume it is) is that as the tendon (or in this case fascia) gets strong and is supported the scarring should go away. The scarring itself is your body adapting to the injury, rather than the cause of the injury if that makes sense.

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.