Evidence Behind Corticosteroid Injections of the Foot and Ankle
Previously, we have reviewed CSI of the shoulder region, elbow and wrist and the hip and knee. Last in the series, we will continue to discuss the evidence related to corticosteroid injections by moving distally to the foot and ankle. As with others, we will cover randomized controlled trials and systematic reviews on corticosteroid injections for issues common to orthopedics such as ankle osteoarthritis, plantar fasciitis and Morton’s neuroma.
Ankle osteoarthritis. Between 6% and 13% of individuals suffer from ankle osteoarthritis which can be a chronic source of ankle pain (Thomas, 2003). Nearly 70% of ankle osteoarthritis is post-traumatic (Thomas, 2003). Patients will typically present with anterior ankle pain with weight bearing or while pushing off with their foot. The patient may have limited or painful range of motion. First line treatment usually includes NSAIDs, activity modification, rocker sole shoes and possibly bracing.
There is limited research evaluating corticosteroid injections and ankle osteoarthritis. Most studies have been geared more towards hyaluronic acid or platelet rich plasma. A 2008 study involving 18 patients (6 lost to follow up) with bilateral ankle osteoarthritis had significant improvement after a single injection of 40 mg of methylprednisolone. Maximum benefit was at 4 weeks and patients reported relief ranging from 6 months to 1 year (Ward, 2008). A study involving children and adolescents with chronic ankle arthritis were injected with triamcinolone-hexacetonide and all 21 ankle joints injected showed improvement at 1 week and 7 weeks with suppression of inflammation and pain without negative effects on cartilage (Huppertz, 1995).
Plantar fasciitis. Plantar fasciitis is a source of foot pain that typically affects adults over 40, with an incidence of around 7% (Clement, 1981). It also accounts for around 25% of all foot disorders in athletes (Cole, 2005). It is also a common diagnosis among running athletes with an incidence from 8% to 12 % (Knobloch, 2008). Patients usually complain of pain under the heel and medial sole of the foot that is worst with the first steps in the morning or after prolonged sitting or rest. It can also bother patients with prolonged walking or weight bearing. Tenderness along the origin of the plantar fascia is common and can be exacerbated by toes and ankles in dorsiflexion and diagnosis can usually be made clinically.
A 2017 Cochrane review concluded that there is low quality evidence favoring corticosteroid injections at one month when compared to placebo or no intervention (David, 2017). A 2012 study compared PRP (platelet rich plasma) to corticosteroid injection in 60 patients that failed conservative therapy and showed decreased VAS scores and improved function in both groups at 3 weeks and 6 months. Both of these methods had comparable results (Aksahin, 2012). One trial with long term ultrasound follow-up showed a decrease in plantar fascia thickness and heel pain after 1 month and 6 months following a corticosteroid injection (Genc, 2005) and another showed relief at 6 months (Kalaci, 2010). One randomized double blind controlled trial with 82 patients showed no difference at one and two months (Abdihakin, 2012). In several studies, ultrasound guidance was not superior to palpation guided injections (Kane, 2001; Gill, 1996). It has been shown to be a relatively safe procedure, but there was plantar fascia rupture in 2/699 patients where adverse reactions were reported (David, 2017).
Morton’s neuroma. Morton’s neuroma, an interdigital neuroma with unclear etiology, causes paroxysmal neuralgia and a common cause of forefoot pain. It presents in most cases with sharp burning pain in the web space and involves the third and fourth toes around 80% of the time (Singh, 2005). Physical exam may reveal a clicking sensation (Mulder's sign) when palpating the involved interspace while simultaneously squeezing the metatarsal joints. There may also be tenderness to palpation between the wb spaces. Ultrasound and MRI have been used to confirm the diagnosis, although diagnosis can be made clinically in most cases. Nonoperative and noninvasive management is first line treatment including treatment with orthotics and adequate footwear modifications.
A 2004 Cochrane review concluded there was insufficient evidence to recommend corticosteroid injections for Morton’s neuroma due to lack of well-designed randomized studies. More recent studies have generally shown favorable results. One patient-blinded study with 131 patients underwent an ultrasound guided corticosteroid injection and global assessment of foot health including pain and function was improved at both one and three months (Thomson, 2013). A 2008 trial with 35 patients that underwent a single ultrasound guided corticosteroid injection had 66% percent of patients report complete satisfaction or satisfaction with minor reservations at 9 months (Markovic, 2008). Another 2007 study with 54 patients showed similar results with 67% satisfaction with treatment using the Johnson Satisfaction Score and 63% reported no limitations at 9 months (Hassouna, 2007). Ultrasound was also shown to be effective in targeting and characterizing Morton’s neuroma and showed a 76 % cure rate at 7 days following corticosteroid injection (Sofka, 2007). One recent randomized-controlled trial showed no difference at 3 and 6 months following corticosteroid injection compared to local anesthetic in 41 patients in terms of pain and function (Lizano-Díez, 2017). Adverse reactions are rare but the dorsal approach is preferred due to decreased risk of metatarsal fat pad atrophy (Wu, 1996).
Tarsal tunnel syndrome. Tarsal tunnel syndrome is another cause of foot pain and is caused by tibial nerve compression in the medial ankle as the nerve passes under the transverse tarsal ligament. It is most commonly caused by a fracture of the talus, calcaneus or medial malleolus, but can also be caused by a mass. Common complaints include pain behind the medial malleolus along with burning, aching and numbness in the sole of the foot, the distal foot or toes. Symptoms seem to be exacerbated during the night and while driving. A Tinel’s test of the tibial nerve can reproduce numbness into the plantar aspect of the foot. EMG studies are commonly done to aid in diagnosis.
There is paucity of data when it comes to corticosteroid injections and tarsal tunnel syndrome. Local anesthetic injection is more commonly done to aid in diagnosis. There is one case report showing greater than 80% improvement in symptoms at one month (Kapoor, 2017). One study with nine patient showed a good or excellent outcome in six of the nine patients with a localized corticosteroid injection (Mondelli, 1998). There was one 1985 patient reporting poor outcomes in eight patients that subsequently underwent surgical release with good results (Ricciardi-Pollini, 1985) . It was also recommended as a treatment by authors of a review article (Lau, 1999). More randomized controlled trials are needed before recommendations regarding corticosteroid injections and tarsal tunnel syndrome.
Conclusions. In summary, there is limited data on corticosteroid injection as treatment for ankle osteoarthritis and relief was shown to be up to 6 months. Plantar fascia corticosteroid injections do carry a small risk of plantar fascia rupture, but studies have consistently shown at least short term relief. More recent studies have shown about two-thirds of patients undergoing injections for Morton’s neuroma report relief or satisfaction and there have been reports of cure of symptoms following localized corticosteroid injection. There is paucity of data regarding tarsal tunnel syndrome and corticosteroid injections and cannot be recommended with confidence.
1. Thomas RH, Daniels TR: Ankle arthritis. J Bone Joint Surg Am 85:923- 936, 2003
2. Ward ST, Williams PL, Purkayastha S: Intra-articular corticosteroid injections in the foot and ankle: A prospective 1-year follow-up investigation. J Foot Ankle Surg 47:138-144, 2008
3. Huppertz, Tschammler, Horwitz, & Schwab. (1995). Intraarticular corticosteroids for chronic arthritis in children: Efficacy and effects on cartilage and growth. The Journal of Pediatrics,127(2), 317-321.
4. C. Cole, C. Seto, J. GazewoodPlantar fasciitis: evidence-based review of diagnosis and therapy Am Fam Physician, 72 (2005), pp. 2237-2242
5. Clement DB, Tauton JE, Smart GW, et al: A survey of overuse running injuries. Phys Sports Med 9:47-58, 1981
6. Knobloch K, Yoon U, Vogt PM. Acute and overuse injuries correlated to hours of training in master running athletes. Foot & Ankle International 2008;29(7):671–6.
7. David, J., Chatterjee, A., Macaden, A., Sankarapandian, V., & Christopher, P. (2017). Injected corticosteroids for treating plantar heel pain in adults. Cochrane Bone, Joint and Muscle Trauma Group, Cochrane Database of Systematic Reviews, 2017
8. Aksahin E, Dogruyol D, Yuksel HY, Hapa O, Dogan O, Celebi L, et al. The comparison of the effect of corticosteroids and platelet-rich plasma for the treatment of plantar fascia. Arch Orthop Trauma Surg 2012;132:781–5.
9. Genc H, Saracoglu M, Nacir B, Erdem HR, Kacar M (2005) Long term ultrasonographic follow-up of plantar fasciitis patients treated with steroid injection. Jt Bone Spine 72:61–65
10. Kalaci A, Cakici H, Hapa O, Yanat AN, Dogramaci Y, Sevinç TT (2009) Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial. J Am Podiatr Med Assoc 99:108–113
11. Abdihakin M, Wafula K, Hasan S, et al. A randomised controlled trial of steroid injection in the management of plantar fasciitis. SA Orthop J 2012; 11:33–8.
12. Kane D, Greaney T, Shanahan M, DuVy G, Bresnihan B, Gibney R, FitzGerald O (2001) The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology (Oxford) 40:1002–1008 19.
13. Gill LH, Kiebzak GM (1996) Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int 17:527–532 20. Frater C, Vu D, Van der Wall H, Perera C, Halasz P, Emmett L, Fogelman I (2006) Bone scintigraphy predicts outcome of steroid injection for plantar fasciitis. J Nucl Med 47:1577–1580
14. Singh A, Loli JP, Chiodo C: The surgical treatment of Morton’s neuroma. Curr Orthop 19:379-384, 2005
15. Thomson CE, Beggs I, Martin DJ, et al. Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial. J Bone Joint Surg Am 2013; 95:790.
16. Markovic M, Crichton K, Read JW, et al. Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton's neuroma. Foot Ankle Int 2008; 29:483.
17. Hassouna H, Singh D, Taylor H, Johnson S. Ultrasound guided steroid injection in the treatment of interdigital neuralgia. Acta Orthop Belg 2007; 73:224.
18. Sofka CM, Adler RS, Ciavarra GA, Pavlov H. Ultrasound-guided interdigital neuroma injections: short-term clinical outcomes after a single percutaneous injection--preliminary results. HSS J 2007; 3:44.
19. Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, et al. Corticosteroid injection for the treatment of Morton’s neuroma: a prospective, double-blinded, randomized, placebo-controlled trial. Foot Ankle Int. 2017;38(9): 944-51.
20. Wu KK. Morton's interdigital neuroma: a clinical review of its etiology, treatment, and results. J Foot Ankle Surg 1996; 35:112.
21. Kapoor, R. (2017) Ultrasound Guided Tarsal Tunnel Injection for Diagnosis and Treatment of Tarsal Tunnel Syndrome: A Case Report. PM&R, 9(9), S211
22. Mondelli M, Giannini F, Reale F. Clinical and electrophysiological findings and follow-up in tarsal tunnel syndrome. EEG Clin Neurophysiol 1998;109:418–25.
23. Ricciardi-Pollini, P., Moneta, M. and Falez, F. The tarsal tunnel syndrome: a report of eight cases. Foot Ankle, 1985, 6: 146–149.
24. Lau JT, Daniels TR: Tarsal tunnel syndrome: A review of the literature. Foot Ankle Int 1999;20(3):201-209