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SA Orthopaedic Journal

versão On-line ISSN 2309-8309
versão impressa ISSN 1681-150X

SA orthop. j. vol.13 no.3 Centurion Set. 2014




Letter received from Dr JP Driver-Jowett


Dr JP Driver-Jowett

To: The Editor-in-Chief, SA Orthopaedic Journal
From: Dr JP Driver-Jowitt
13 March 2013

RE: A randomised control trial of steroid injection in the management of plantar fasciitis

Mohamed Abdihakin, Khamala Wafula, Saidi Hasan, Jana MacLeod
Department of Surgery and Orthopedics, Aga Khan University Hospital
South African Orthopaedic Journal, Summer 2012, Vol 11 No 4 page 33

The above paper purports to demonstrate that injecting the plantar fascia with steroids has no therapeutic benefit.

'Plantar fasciitis' is not a specific term. It includes, at least, enthesopathic pain at the origin of the plantar fascia at the calcaneum as well as tears in the body of the plantar fascia distal to its origin. Sub-calcaneal bursitis and variants of tarsal tunnel and other entrapment neuropathies can be difficult to distinguish from plantar fasciitis.

There is no record of the number of persons performing the injections.

That 12.5% of the subjects had 'flat foot' (whatever that might mean to the researchers since it is undefined) is highly significant, and should have placed these subjects into a distinct research category.

Individuals with 'flat foot' frequently suffer pain perceived to be in the plantar aspect of the foot, which might be entirely distinct from 'plantar fasciitis' (but not necessarily distinguishable by the subjects).

The term 'steroid injection for the treatment of plantar fasciitis' is also meaningless. Which part of the plantar fascia was injected? Was needle localisation confirmed radiologically? Was a lateral, medial or plantar approach used?

What anaesthetic was used prior to the injection? This is important since individuals who suffer pain whilst being injected are less likely to tolerate accurate placement of the needle.

The only pertinent revelations was that increase in BMI increases the incidence (and perhaps the severity) of plantar pain. But do we not know that anyway?

A useful study would be to determine the benefit of raised heels in plantar fasciitis, which was implied by this paper.

Response from the authors

From: Dr Abdihakin Mohamed

I would like to respond to comments by Dr JP Driver-Jowitt regarding our study on plantar fasciitis: A randomised control trial of steroid injection in the management of plantar fasciitis (South African Orthopaedic Journal, Summer 2012, Vol 11 No 4 page 33).

Our study was designed to determine the efficacy of steroid injections in the treatment of plantar fasciitis especially the effect on pain scores and the Foot Function Index. The follow-up period in the published data was two months , but a further 6-month follow-up of the same group of patients (unpublished) did not reveal any difference in results; this was not unexpected as shown by previous studies on plantar fasciitis. The detailed description of plantar fasciitis could not be undertaken in the context of the manuscript and we agree that it is sometimes difficult to differentiate plantar fasciitis, which over the decades has had multiple pseudonyms and has been difficult to manage, from other foot and ankle conditions as described. Our study used the American Association of Foot and Ankle Surgeons criteria for diagnosing plantar fasciitis to describe this ubiquitous condition in our patient group as a means of standardisation - this was fairly straightforward and all exclusion factors were adhered to. The number of patients with flat foot in our study was not adequate enough to be described as a distinct entity and the study was not powered to study that. The few studies (all of which have a very small number of patients) that looked at needle localisation have not shown any significant difference in outcomes and that was not pursued in our study. All patients received anaesthetic injections during the injection of either placebo or steroid. Needle placement was also not affected by the patients' subjective feeling of pain as this was done at points of most tenderness, the same as in all previous studies. BMI and flat foot were all secondary and more numbers will be required to evaluate these factors that can affect outcomes of treatment.

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