Plantar Fasciitis – PT vs Steroid injection, a critical review
A prospective, single-blinded, randomized, controlled trial study shows that a corticosteroid injection improves short term pain and function in treating plantar fasciitis, but has no more benefit than physiotherapy at 12 month followup.
Study appraised: Celik D, Kus G, Sirma SO. Joint Mobilization and Stretching Exercise vs Steroid Injection in the Treatment of Plantar Fasciitis: A Randomized Controlled Study. Foot Ankle Int. 2016 Feb;37(2):150-6.
What question did the study ask?
Purpose: To compare physiotherapy (joint mobilizing + exercises) to steroid injection for the treatment of plantar fasciitis.
Patients: 43 patients were randomly assigned to two treatment groups. Unilateral plantar fasciitis was diagnosed based on pain on palpation of the plantar fascia origin and positive windlass test.
Intervention: Three treatments per week for three weeks including the following manual therapy:
- Subtalar traction
- Gr I and II talocrural AP’s
- Subtalar lateral glides
- 1st TMT dorsal glides
- Gatroc stretch 30” x10
- Plantar fascia stretch 30” x10
Comparison: A single injection of either 1 mL of corticosteroid (40 mg methylprednisolone acetate) or 4 mL of 2% prilocaine hydrochloride was injected using a 22-gauge needle to the most tender point at baseline.
Sum of the Foot and Ankle Ability Measure ADL and sports subscales: Significant improvement seen in both steroid injection and PT groups at 3, 6, and 12 weeks. Patients undergoing steroid injection had significantly higher function scores at 3, 6 and 12 weeks than the PT group. Only the PT group continued to improve until 12 months after baseline, and there was no significant difference at 12 months between the groups in terms of function.
Visual Analog Pain Scale: Both groups’ pain scores improved significantly over 3. 6, and 12 weeks. Patients undergoing the steroid injection had significantly less pain at 3, 6, and 12 weeks compared to the PT group. At 12 months there was no difference between groups in terms of pain.
ARE THE RESULTS OF THE TRIAL VALID?
1a. R- Was the assignment of patients to treatments randomized?
Yes. Randomization was achieved through computer generated numbers delivered via sealed envelopes and assignment was after the initial assessment.
1b. R- Were the groups similar at the start of the trial?
There was no significant difference in demographics between the two groups in terms of age, gender, duration of symptoms, BMI, and dorsiflexion ROM.
2a. A- Aside from the allocated treatment, were groups treated equally?
Other than interventions described, each group was treated the same.
2b. A- Were all patients who entered the trial accounted for? – and were they analysed in the groups to which they were randomized?
Yes, all patients were accounted for. 43 patients were randomly assigned to the two groups meetng their diagnositic criteria for plantar faciitis. Two patients dropped out of the PT group, one during the intervention period and one after. Two patients dropped out of the Injection goup: one before the intervention and one after. All patients were followed up and an intention to treat analysis performed.
- M – Were measures objective or were the patients and clinicians kept “blind” to which treatment was being received?
The individual assigning patients to their groups was blinded to their information.
Outcomes were self reported so no blinding occurred.
Participant and treating therapist blinding did not occur.
WHAT WERE THE RESULTS?
- How large was the treatment effect?
- A treatment effect occurred in both groups resulting in reduced pain (VAS) and improved function(FAAM) 3, 6 and 12 weeks post treatment: p<.05.
- Improvements at the 12 week and 1 year followup were only significant in the PT group (P=0.002)
- How precise was the estimate of the treatment effect?
VAS and FAAM: Improvement exceeded MCID for both measures. Study was well powered with well over the recommended 12 people per group needed to have an alpha level of 0.05, and beta level of 20%.
Will the results help me in caring for my patient? (External Validity/Applicability)
- Results of this study are applicable to patients presenting in an outpatient physiotherapy clinic with unilateral plantar fasciitis with tenderness over the medial tubercle of the calcaneus, and pain with palpation of the proximal insertion of the plantar fascia, heel pain during weight bearing activity, a negative tarsal tunnel test, and a positive windlass test.
- Steroid injection is superior to PT in terms of short term benefit; however, is not superior to PT over the long term. PT presents less risks when compared to steroid injection. Steroid injections are associated with increased risk of rupture, fat pad atrophy, lateral plantar nerve injury, infection and osteomyelitis.
- Results cannot necessarily be applied to individuals with arthritis, neurological impairments or comorbidities.
Link to full article: http://opensample.info/joint-mobilization-and-stretching-exercise-vs-steroid-injection-in-the-treatment-of-plantar-fasciitis-a-randomized-controlled-study