Plantar fasciitis: the painful heel
The painful heel is an acutely tender spot in the middle of the heel pad, which can be accurately palpated by firm pressure. The pain is caused by plantar fasciitis, which is a strain of the long plantar ligament at its insertion into the calcaneum. The condition may occur alone or in other forms of arthritis such as Reiter's disease and ankylosing spondylitis.
Injection technique
Use 1 ml triamcinolone acetonide mixed with lidocaine (1% plain) in a 2 ml volume syringe with a 2.5 cm needle.
Allow the patient to lie prone on the examination couch with the heel facing uppermost. First swab the area to be injected liberally with 70% alcohol. Although the skin of the heel is thicker and tougher on the plantar surface, it is better to inject from the centre of the heel pad rather than from the side of the heel pad (where the skin is thinner). This will ensure more accurate localisation of the injection. Infiltrate the skin and subcutaneous area with 1% lidocaine plain and infiltrate lidocaine deeply down to the calcaneal spur, and then change the syringe leaving the needle in situ; the tip of the needle is accurately placed at the point of maximum tenderness, often touching the periosteum, before 0.5–1 ml of steroid mixed with 1 ml 1% lidocaine solution is injected. The whole lesion should preferably be infiltrated by moving the needle point to each tender spot to cover the whole lesion – as described for tennis elbow.
Since this is a painful injection, it is best to mix the steroid solution with lidocaine and infiltrate the skin as much as possible, while at the same time advancing the needle towards the most tender spot. As the duration of action of lidocaine is only between two and four hours, bupivacaine plain 0.25% or 0.5% may be used instead of the lidocaine in recurrent cases. As the duration of action of bupivacaine may last for up to 16 hours, it is often kinder for the patient in order to ensure an anaesthetic effect until the anti-inflammatory effect of the steroid takes over.
Simple analgesia, avoiding walking on the affected heel for a couple of days and perhaps wearing a sponge rubber heel pad for a few days is sound post-injection advice.
This extract is taken from Joint and Soft Tissue Injection 5th Edition, by Dr Trevor Silver which is now available to purchase from Radcliffe Publishing with an exclusive 20% discount available until 30th September – simply quote PULSETS12.
- Confidently diagnose conditions of the joints and soft tissue.
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