Hello Lower Limb Lovers,
After a run of busy billing fortnights, this one is quiet on the schedules, so the issue leans on research. The deep dive takes on the injection question for stubborn heel pain: what the evidence actually backs, which option suits which patient, and whether any of it beats a good loading program.
The five-minute version:
Money & Rules: nothing moved, but check the DVA discipline schedules before you trust them.
Deep dive: there is no single best treatment for stubborn plantar fasciitis. The right one follows the patient's goal.
PRP is not one evidence bucket: a real case in the fascia, a weak one in the Achilles.
Then football boots, sprint style, foot strengthening and landing mechanics to round it out.
Let's get into it.
Money & Rules
Genuinely quiet fortnight. Nothing moved on the fee schedules, so the figures from 1 July are all still current: the $63.40 Medicare rebate, the NDIS 2026-27 schedule, and the Queensland, Victoria and South Australia workers comp tables.
The one still worth a look is DVA. The 1 July software vendor file is finally published, but the individual discipline schedules on the DVA page have not been replaced, so do not build a fee sheet off those PDFs. I have updated the Billing Reference with the detail.
The deep dive
Which treatment actually works for stubborn plantar fasciitis?
Every recalcitrant heel eventually gets the injection question, and most of us answer it as if injection were one thing. A run of papers says it is not, and that the right choice depends on the patient's timeframe and goal.
The centrepiece is a network meta-analysis of 63 randomised trials and 4,170 people, comparing shockwave, prolotherapy, PRP, botulinum toxin A, corticosteroid, autologous blood and local anaesthetic. A network meta-analysis links treatments that were never tested head to head so you can rank them. No single option won. Botulinum toxin A gave the biggest short-term pain and fascia-thickness improvement, corticosteroid the biggest short-term function gain, prolotherapy the most durable pain relief, and PRP the best long-term function and thickness. Shockwave was the all-rounder, useful across every outcome and timepoint.
A second review put radial shockwave head to head with the other machines and found it no better than laser or ultrasound for pain or function, with laser actually edging it on function, on high-risk-of-bias trials. And an MRI study of 108 patients found the heel is rarely the only thing going on: they had larger Achilles tendons and more retrocalcaneal bursitis and Achilles tendinopathy than controls.
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So how do you use it? Let the patient's goal pick the injection. Function fast, for a wedding or a season, corticosteroid, and be upfront that it fades. Durable pain relief, prolotherapy. The long game with a shot at changing the fascia itself, PRP. And be specific about PRP, because a separate review this fortnight showed it is not one evidence bucket: solid for plantar fasciitis and talar osteochondral lesions, mixed for Achilles and ankle osteoarthritis. A fresh meta-analysis of 337 people confirmed PRP does not beat placebo in the Achilles, so the same injection that has a case in the fascia does not have one up the leg.
Two habits worth keeping. None of these papers compared any of it against loading, which is still the base treatment, so read this as choosing your adjunct, not skipping the exercise. And for the heel that keeps relapsing through a good fascia program, check the calf: palpate the Achilles, test dorsiflexion and calf capacity, and treat what you find.
Also worth your time
Football boots and sprint style change where the injury lands
A review of 32 studies looked at how boot design affects injury risk, which is handy because patients and parents ask about boots all the time and most of the advice out there is guesswork. Three things stood out. Aggressive studs, the screw-in and bladed kinds, grip too hard on firm and artificial surfaces and can hold the foot planted while the leg keeps turning, which is linked to ACL, ankle and metatarsal injuries. Sole stiffness cuts both ways: too stiff and too soft each raise the risk. And high-cut boots steady the ankle but seem to push the load up to the knee, so they are not an ankle brace. Two of the authors work for a boot manufacturer, worth knowing.
A separate seven-season study of 85 professional rugby players found that how a player sprints predicts where they get injured. Short, quick steps went with hamstring injuries; long, bounding steps went with calf injuries, each around two and a half times the risk. So when you are getting a runner back to sport, their sprint style is a clue to which muscle to strengthen and keep an eye on.
Quick hits
Foot strengthening and fear of falling: a 12-week intrinsic foot muscle program in older adults did not shift maximum gait speed, but the training group reported a clear drop in concerns about falling, on a small assessor-blinded trial of 33. Worth framing foot work as part of balance and falls confidence, not just arch mechanics. Read the study
Neuromuscular training beats bolting on a screen: in 55 young female athletes, six weeks of neuromuscular training improved landing mechanics and calmed sensorimotor brain activity, but adding visual biofeedback did not beat a sham version. The training is doing the work, not the gadget on top. Read the study
Turning the foot in or out shifts the load: in young adults with flexible flatfoot, changing the angle of the foot during walking changed how much load went through the knee and the ankle. A toe-in or toe-out cue can take pressure off one joint and add it to another, so it is worth trying and then rechecking, not applying to everyone the same way. Read the study
Reply and tell me what you want more of: billing, research, or the business side of running a clinic. I read everything.
Cam
The Lower Limb Report