Can I use oral steroids, such as prednisone, for a short 5-day course in treating plantar fasciitis and Achilles tendinosis?

Oral Steroids for Plantar Fasciitis and Achilles Tendinosis

Short courses of oral steroids are not recommended as first-line treatment for plantar fasciitis and Achilles tendinosis due to their limited evidence of long-term efficacy and potential side effects.

Current Treatment Recommendations

First-Line Treatments

1. NSAIDs:

   • NSAIDs are recommended as first-line pharmacological treatment for both plantar fasciitis and Achilles tendinosis 1
   • They provide pain relief and reduce inflammation while having a more favorable risk profile than oral steroids for these conditions

2. Physical Therapy Interventions:

   • Supervised exercise programs are conditionally recommended over passive interventions 2
   • Stretching of the plantar fascia and Achilles tendon has shown significant long-term improvement (10 months) 3

3. Local Treatments:

   • For plantar fasciitis, local corticosteroid injections have demonstrated effectiveness and are preferred over oral steroids 4, 5
   • A study comparing local injectable steroid with oral NSAIDs found that local injection was more effective with less recurrence of heel pain 6

Role of Oral Steroids

Oral steroids (such as prednisone) have several limitations for these conditions:

• Limited Evidence: There is insufficient evidence supporting oral steroids as effective treatment for plantar fasciitis or Achilles tendinosis
• Risk-Benefit Ratio: The potential systemic side effects outweigh the benefits for localized conditions
• Better Alternatives: Local corticosteroid injections provide more targeted therapy with fewer systemic effects 4

Treatment Algorithm

For Plantar Fasciitis:

1. Initial Treatment:

   • NSAIDs at maximum tolerated dosage 2
   • Stretching exercises and physical therapy
   • Foot orthoses/heel cups
   • Night splints

2. If Inadequate Response:

   • Consider local corticosteroid injection (more effective than oral NSAIDs) 6
   • Combine with controlled training for superior results 4

3. For Persistent Cases:

   • Consider extracorporeal shockwave therapy
   • Platelet-rich plasma injections have shown effectiveness equal to or greater than corticosteroid injections 5

For Achilles Tendinosis:

1. Initial Treatment:

   • NSAIDs for pain control
   • Eccentric strengthening exercises
   • Activity modification

2. If Inadequate Response:

   • Physical therapy with progressive loading
   • Avoid local corticosteroid injections around Achilles tendon due to risk of tendon rupture 2

Important Considerations

Risks of Oral Steroids

• Short-term: Mood changes, sleep disturbances, increased appetite, fluid retention
• Potential longer-term risks with repeated courses: Osteoporosis, avascular necrosis, hyperglycemia, immunosuppression

Specific Cautions

• Corticosteroid injections around the Achilles, patellar, and quadriceps tendons should be avoided due to risk of tendon rupture 2
• For plantar fasciitis, if corticosteroid injections are used, they should be combined with ultrasound monitoring to reduce complications 3

When Limited Use Might Be Considered

In very specific circumstances, short courses of oral steroids might be considered:

• As a bridging option while awaiting the effect of other treatments 2
• When other first-line treatments have failed and local injections are contraindicated
• When multiple sites are affected simultaneously

However, even in these cases, the treatment should be limited to 5 days at appropriate doses (e.g., prednisone 30-35 mg/day) 2 with careful monitoring for adverse effects.

Conclusion

For plantar fasciitis and Achilles tendinosis, a combination of NSAIDs, physical therapy, and targeted local treatments provides better outcomes with lower risks than oral steroids. If corticosteroids are needed, local injection (for plantar fasciitis only) combined with controlled training has shown superior results compared to either treatment alone.