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Ultrasound superior to palpation-guided injection of corticosteroid for plantar fasciitis
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May 2014
Ultrasound superior to palpation-guided injection of corticosteroid for plantar fasciitis
Study Type:Meta analysis
OE Level Evidence:1
Journal Level of Evidence:N/A
Ultrasound versus Palpation-Guided Injection of Corticosteroid for Plantar Fasciitis: A Meta-Analysis
PLoS One. 2014 Mar 21;9(3):e92671. doi: 10.1371/journal.pone.0092671. eCollection 2014Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
5 randomized control trials containing 149 patients were analyzed in this meta-analysis to determine the efficacy of ultrasound versus palpation-guided corticosteroid injections for plantar fasciitis. Patients who received ultrasound-guided corticosteroid injections had a higher tenderness threshold, thinner plantar fascial thickness, and a lower incidence of hypoechogenicity compared to palpation-guided corticosteroid injections. Other outcomes including pain, the heel tenderness index, response rate, and heel pad thickness were not significantly different between groups.
Publication Funding Details
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Funding:
Non-funded
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
3/4
Accessing Data
3/4
Analysing Data
4/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Approximately 80% of all heel pain in adult patients is caused by plantar fasciitis. Conservative treatments for plantar fasciitis include rest, nonsteroidal anti-inflammatory drugs, stretching, physical therapy, and foot padding. If these fail, patients tend to seek corticosteroid injections as an alternative treatment option. Various randomized control trials have compared ultrasound and palpation-guided corticosteroid injection for the treatment of plantar fasciitis, but the results are conflicting. Therefore, this meta-analysis was needed to determine the efficacy of ultrasound- versus palpation-guided corticosteroid injections.
What was the principal research question?
Is the efficacy of ultrasound-guided corticosteroid injections superior to palpation-guided corticosteroid injections for the treatment of plantar fasciitis?
Study Characteristics
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Data Source:
An electronic search was conducted using MEDLINE, Cochrane library, and EMBASE from inception to August 30, 2013. Reference lists from selected studies were also evaluated.
Index Terms:
Index terms included: plantar fasciitis, heel pain, painful heel, ultrasound, sonograph, ultrasonography, palpation, unguided, and blind.
Study Selection:
Two investigators independently examined reports to ensure studies were randomized control trials that compared ultrasound-guided and palpation-guided injections in patients with plantar fasciitis, and reported one or more of the following outcomes: VAS, tenderness threshold (TT), heel tenderness index (HTI), response rate, plantar fascial thickness (PFT), hypoechogenicity, or heel pad thickness (HPT). Final results were confirmed by two senior authors. 5 RCTs (n=149) were selected for meta-analysis.
Data Extraction:
Two investigators independently extracted data from the selected studies, including: first author, published year, location, sample size, average age, male/female ratio, body mass index (BMI), and intervention and study design. Any outcomes (mentioned in the study selection above) were also extracted, and the methodological quality of each study was assessed.
Data Synthesis:
Relative risk (RR) with 95% confidence intervals (CI) was used to analyze dichotomous data, while mean difference (MD) with 95% CI was used to analyze continuous variables. I-squared statistics determined statistical heterogeneity: if I-squared was <50%, a fixed-effects model was used, and if I-squared was >50%, a random effects model was used. Egger's Test determined publication bias among selected studies. Statistical analyses were performed using RevMan version 5.2 and Stata version 12.0, and a p value <0.05 was considered statistically significant.
What were the important findings?
- All 5 RCTs in this meta-analysis reported VAS pain, and found pain was not significantly different between ultrasound-guided and palpation-guided corticosteroid injections (SMD= -0.35, 95%CI (-0.83, 0.14), p=0.16).
- 2 studies reported that ultrasound-guided injections result in a higher tenderness threshold than palpation-guided injections (MD=2.17, 95%CI (1.28, 3.06), p=0.00).
- 2 studies reported the heel tenderness index did not differ significantly between ultrasound- and palpation-guided injections (MD= -0.25, 95%CI (-0.63, 0.13), p=0.20).
- 3 studies (93 patients) revealed that response rate did not differ significantly between groups (RR=1.29, 95%CI (0.94, 1.76), p=0.11).
- 4 studies reported that ultrasound-guided injections resulted in thinner plantar fascial thickness than palpation-guided injections (MD= -0.12, 95%CI (-0.22, -0.01), p=0.03).
- 3 studies reported that ultrasound-guided injections resulted in less hypoechogenicity than palpation-guided injections (RR=0.30, 95%CI (0.12, 0.77), p=0.01).
- 2 studies reported heel pad thickness did not differ significantly between groups (MD=0.62, 95%CI (-1.84, 3.09), p=0.62), meaning no atrophy occurred.
What should I remember most?
Patients who received ultrasound-guided corticosteroid injections had a higher tenderness threshold, thinner plantar fascial thickness, and a lower incidence of hypoechogenicity compared to palpation-guided corticosteroid injections. Pain, heel tenderness index, response rate, and heel pad thickness were similar between groups.
How will this affect the care of my patients?
Based on the presented evidence, an ultrasound-guided injection of corticosteroid appears to be more effective than palpation-guided injections for plantar fasciitis. Additional well designed, high-quality, randomized control trials with larger sample sizes are needed to confirm these results.
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Orthopaedic Surgeon - Canada
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