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).

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)

How it works

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. 

When to consider corticosteroids as a treatment?  

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) 

 

 

Who can supply and administer corticosteroid injections?  

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) 

Adverse effects & contraindications 

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: 

  • Temporary facial flushing  
  • Temporary increase in blood sugar levels 
  • Skin discolouration at the site of the injection which can last a few weeks 
  • Atrophy of the fat cells at the injection site 
  • Cartilage damage 
  • Tendon rupture – although much of the research supporting this theory is anecdotal, care should be taken not to inject the corticosteroid directly into the tendon and excessive strenuous activity should be avoided for a short time following the injection   

There are contraindications to corticosteroid injections that one needs to consider, including:  

  • Local cellulitis 
  • Local or intra-articular sepsis 
  • Broken skin at site of injection 
  • Fracture or joint instability 
  • Allergy to constituents of the injectate (previous reaction to a corticosteroid injection) 
  • Prosthetic joint (relative contraindication) 

Conclusion 

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. 

 

 

References  

  1. Ramamoorthy, S., & Cidlowski, J. A. (2016). Corticosteroids: mechanisms of action in health and disease. Rheumatic Disease Clinics, 42(1), 15-31. 
  2. Williams, D. M. (2018). Clinical pharmacology of corticosteroids. Respiratory care, 63(6), 655-670. 
  3. Barnes, P. J. (2006). How corticosteroids control inflammation: quintiles prize lecture 2005. British journal of pharmacology, 148(3), 245-254 
  4. Shah, A., Mak, D., Davies, A. M., James, S. L., & Botchu, R. (2019). Musculoskeletal corticosteroid administration: current concepts. Canadian Association of Radiologists Journal, 70(1), 29-36 
  5. Dale, R., & Stacey, B. (2016). Multimodal treatment of chronic pain. Medical Clinics, 100(1), 55-64 
  6. Urits, I., Smoots, D., Franscioni, H., Patel, A., Fackler, N., Wiley, S., … & Viswanath, O. (2020). Injection techniques for common chronic pain conditions of the foot: a comprehensive review. Pain and therapy, 9(1), 145-160. 
  7. Salinas, J. D., & Rosenberg, J. N. (2011). Corticosteroid injections of joints and soft tissues. Drugs, Diseases & Procedures
  8. Edwards, Steven & Fleming, Susannah & Landorf, Karl. (2021). Efficacy of a Single Corticosteroid Injection for Morton’s Neuroma in Adults: A Systematic Review. 10.13140/RG.2.2.36645.01768. 
  9. Whittaker, G. A., Munteanu, S. E., Menz, H. B., Bonanno, D. R., Gerrard, J. M., & Landorf, K. B. (2019). Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis. BMC musculoskeletal disorders, 20(1), 1-22. 
  10. Podiatry Board of Australia REGISTRATION STANDARD: ENDORSEMENT FOR SCHEDULED MEDICINES 1 August 2018 
  11. MacMahon, P. J., Eustace, S. J., & Kavanagh, E. C. (2009). Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology, 252(3), 647-661. 

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