Abdel is the principal podiatrist of Sydney Foot Clinic. He is endorsed to prescribe scheduled medicines and is a fourth year registrar with the Australasian College of Podiatric Surgery (ACPS).
Abdel Kak, a podiatrist who is endorsed for scheduled medicine, explains the reasons for administering cortisone injections where warranted; as well advising as when not to administer cortisone.
As podiatrists know, corticosteroids are a class of drugs that act to reduce inflammation and pain. Corticosteroid medications mimic the effect of the natural hormone cortisol (produced in the adrenal gland) to help lower the levels of prostaglandins. This reduces the interaction of white blood cells (T-Cell and B-cell) and ultimately reduces the inflammatory response. (1)
Once administered, the corticosteroid molecule diffuses across cell membranes and binds to the glucocorticoid receptor. The receptor-glucocorticoid complex moves into the cell nucleus, combine with glucocorticoid responses elements and ultimately inhibits transcription factors that control the synthesis of pro-inflammatory mediators such as macrophages, eosinophils, lymphocytes, mast cells and dendritic cells. (2) In addition, corticosteroids inhibit genes responsible for the expression of cyclooxygenase two and tumour necrosis factor, which directly affect inflammation and pain in the body. (2,3)
Evidence supports the use of corticosteroid injections. Its anti-inflammatory properties can provide pain relief and help restore function. They are often combined with local anaesthetics, which acts as the solvent for the corticosteroids, provides volume for the injectate to distribute in the area, and provide localised anaesthesia. (4) In addition, the local anaesthetic effect can aid clinical assessment, often giving diagnostic information relating to a potential pain source.
Corticosteroid injections are indicated when there is a need to reduce inflammation and improve function, secondary to the inflammatory, traumatic or degenerative process. (4) Generally, they are most valuable when performed with a multi-modality treatment approach (i.e. in conjunction with additional conservative care tactics, such as musculoskeletal or ortho-mechanical). (5)
Some standard foot and ankle musculoskeletal conditions/symptoms that can be treated with corticosteroid injections include plantar fasciopathy, neurofibrosis (e.g. Morton’s neuroma), sinus tarsi syndrome, symptoms associated with lower extremity osteoarthritis and rheumatic diseases, bursitis, benign soft tissue lesions and tendon pathology. (6) Corticosteroid injection has been shown to lower inflammation and reduce pain and improve scar tissue or adhesions. (7)
While it is not in the scope of this article to outline all the different applications and steroid preparations for use in the foot and ankle, in most cases, the clinician will administer a long-acting corticosteroid (such as betamethasone), which will take effect within one to three weeks and can have lasting benefits between one to nine months (depending on the condition and its severity). If a repeat injection is required, then a three-week interval between doses is generally suggested. To avoid adverse effects, there is a general clinical consensus that no more than three corticosteroid injections should be administered to the same body part within a 12-month period. The National Institute for Health and Care Excellence reinforces this consensus by recommending that the same joint should not be injected more than three times a year. (4)
Corticosteroid injections can be performed in the clinical setting under aseptic technique. They can be performed ‘blind’ or with ultrasound guidance. Of interest, recent literature identifies no statistical significant difference between the two techniques for patients with a Morton’s neuroma. (8) A recent systematic review has shown that corticosteroid injections are more effective than comparator treatments (such as foot orthoses, shockwave therapy, dry needling, platelet rich plasma injections) for the short term reduction of pain and improvement in function with people with plantar heel pain. (9)
Podiatrists endorsed for scheduled medicines can purchase, store and administer corticosteroid injections which include; Betamethasone, Dexamethasone, Methylprednisolone and Triamcinolone. The use of corticosteroids can be used in inflammatory conditions of the foot and ankle where non pharmacological treatment has failed to reduce inflammation. (10)
Corticosteroid injections are generally uneventful and side effects are not common. However occasionally patients may experience a localised ‘flare’ or inflammation at the injection site which can be present for a few days.(4) Some other related side effects may include:
There are contraindications to corticosteroid injections that one needs to consider, including:
Cortisone is an anti-inflammatory medication that is often used to treat musculoskeletal conditions. Corticosteroid therapeutic action occurs intracellularly which allows for persistent anti-inflammatory properties which can provide pain relief and help restore function. Research has shown that if performed with the correct technique, corticosteroid injections can provide medium to long term relief.
As an endorsed podiatrist, corticosteroid injections provide your patients with an additional safe treatment modality that you can use for an array of foot and ankle pathologies.
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