Can I use oral steroids for plantar fasciitis, Achilles tendinosis, or bursitis?

Oral Steroids for Plantar Fasciitis, Achilles Tendinosis, and Bursitis

Oral steroids are not recommended for plantar fasciitis, Achilles tendinosis, or bursitis due to their unfavorable risk-benefit profile compared to other treatment options. 1

Treatment Recommendations by Condition

Plantar Fasciitis

1. First-line treatments:

   • Patient-directed measures: regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions/arch supports, weight loss if indicated 1
   • Activity limitation and avoidance of flat shoes/barefoot walking
   • NSAIDs (oral or topical) 2
   • Padding and strapping of the foot

2. Second-line treatments (if no improvement after 6 weeks):

   • Customized orthotic devices
   • Night splinting
   • Local corticosteroid injections (limited number) 1, 3
   • Casting or fixed-ankle walker-type device

3. Third-line treatments (if no improvement after 2-3 months):

   • Cast immobilization
   • Surgery (plantar fasciotomy)
   • Extracorporeal shock wave therapy

Achilles Tendinosis

1. First-line treatments:

   • Open-backed shoes to reduce pressure
   • Heel lifts or orthoses
   • NSAIDs
   • Decreased activity
   • Stretching exercises
   • Weight loss if indicated 1

2. Important caution:

   • Local injections of corticosteroids are NOT recommended for Achilles tendinosis 1
   • Peri-tendon injections around Achilles, patellar, and quadriceps tendons should be avoided due to risk of tendon rupture 1

3. For refractory cases:

   • Immobilization cast or fixed-ankle walker-type device 1

Bursitis (including Haglund's Deformity)

1. First-line treatments:

   • Open-backed shoes
   • Orthoses and accommodative padding
   • NSAIDs
   • Corticosteroid injections (avoiding the Achilles tendon) 1
   • Weight loss if indicated
   • Physical therapy

2. For persistent symptoms (after 6-8 weeks):

   • Immobilization cast or fixed-ankle walker-type device
   • Bursa injection may be considered
   • Surgical consultation for resection of prominent posterior superior calcaneus and inflamed bursa

Why Oral Steroids Are Not Recommended

1. Risk-benefit profile:

   • The FDA label for prednisone lists numerous potential adverse effects including immunosuppression, increased risk of infection, hypertension, fluid retention, hyperglycemia, and adrenal suppression 4
   • Limited evidence supporting efficacy for these specific conditions

2. Guidelines specifically recommend:

   • Local treatments (injections where appropriate) rather than systemic steroids 1
   • The American College of Rheumatology specifically states "there was little evidence to support long-term treatment with systemic glucocorticoids" 1

3. Better alternatives exist:

   • For plantar fasciitis, the combination of corticosteroid injections with controlled training (strength training and stretching) has shown superior outcomes 3
   • NSAIDs have demonstrated benefit with fewer systemic risks 2

Special Considerations

• Injection technique: When local corticosteroid injections are used (for plantar fasciitis or bursitis), proper technique is essential to avoid complications
• Contraindications to local injections: Avoid injections around the Achilles tendon due to risk of tendon rupture 1
• Alternative treatments: For patients who don't respond to conservative treatment, options like dry needling have shown efficacy comparable to corticosteroid injections for plantar fasciitis 5
• Monitoring: If oral steroids are absolutely necessary (which is rare), patients should be monitored for adverse effects and the treatment duration should be as short as possible 4

Remember that most cases of plantar fasciitis, Achilles tendinosis, and bursitis respond well to conservative measures and targeted local treatments, making the risks of systemic steroids unnecessary in most clinical scenarios.