Injected corticosteroids for treating plantar heel pain in adults

• Published in: Cochrane database of systematic reviews 2017-06, Vol.6 (6), p.CD009348
• Main Authors: David, Judy A, Sankarapandian, Venkatesan, Christopher, Prince Rh, Chatterjee, Ahana, Macaden, Ashish S
• Format: Article
• Language: English
• Subjects: Adrenal Cortex Hormones - administration & dosage; Adult; Anesthetics, Local - administration & dosage; Foot Diseases - drug therapy; Heel; Humans; Mechanical heel pain; Middle Aged; Non-Randomized Controlled Trials as Topic - statistics & numerical data; Orthopaedics & trauma; Pain - drug therapy; Pain Measurement; Publication Bias; Randomized Controlled Trials as Topic - statistics & numerical data; Treatment Failure
• ISSN: 1469-493X; 1469-493X
• DOI: 10.1002/14651858.CD009348.pub2

Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections. To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017. Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion. At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach. We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term