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Correspondence |
Brooklyn, New York
To the Editor:
Plantar fasciitis is characterized by pain and stiffness involving the heel and plantar surface of the foot with maximum tenderness at the insertion of plantar fascia on the calcaneal tuberosity, often associated with exuberant anterior calcaneal osteosis (spur).
Steroid injections have been used to treat heel pain since the 1950s and are one of the most frequently described treatments for painful heel in the medical literature.1 Injection of the plantar fascia is best accomplished through a lateral or medial approach, or through the pedal pad of fat.2 If corticosteroid flows back along the needle track, rupture of plantar fascia or atrophy of plantar skin and calcaneal fat pad might occur, resulting in bone-on-skin in the critical weight bearing pressure point of the heel.3 Another drawback is the extreme pain experienced by patients during infiltration of tissues surrounding the calcaneum and many end up by withdrawing the heel during the process of injection leading to accidental corticosteroid flow back, resulting in unsatisfactory therapeutic response or enhanced complication rate.
We examined the efficacy of posterior tibial nerve block in relieving pain during corticosteroid injection for treatment of calcaneal spur, and the effects on patients’ comfort, compliance and possible complications.
After obtaining Institutional Review Board approval and informed consent patients were randomized into two groups of ten each. In Group I posterior tibial nerve block was done 10–15 min (5 mL of 1% lidocaine) before injection of 2 mL of 40 mg•mL-1 methylprednisolone acetate. Patients in Group II received 2 mL of methylprednisolone acetate without blocking the posterior tibial nerve. To ensure uniformity in the deposition of injected material in all patients, the needle was guided fluroscopically.
Pain during the procedure was assessed using a simple, categorical, verbal rating scale. Except for a mild burning sensation, pain during posterior tibial block was negligible in all cases. In Group I, nine patients had no pain during methylprednisolone injection, and one patient suffered from mild pain while in Group II, seven patients had severe pain and three patients suffered from moderate pain.
The Table shows that patients receiving posterior tibial nerve block prior to methylprednisolone injection had no complications and were able to complete treatment when compared with the other group (P < 0.001).
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Our preliminary results indicate that patient’s perception of pain from steroid injection and compliance with treatment were significantly altered by prior administration of tibial nerve block.
References
1 Atkins D, Crawford F, Edwards J, Lambert M. A systematic review of treatments for the painful heel. Rheumatology 1999; 38: 968–73.
2 Alastair SE, Younger, Bruce S. Pain in the leg, ankle, and foot. In: John DL (Ed.). Bonica’s Management of Pain. Philadelphia: LR; 2001: 1614–46.
3 Acevedo JI, Baskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998; 19: 91–7.[Medline]
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