This document reviews the literature on steroid injections in the foot and ankle. It finds that ultrasound-guided corticosteroid injections provide improvement for plantar fasciitis patients over placebo, and steroid injections are effective for inferior heel pain. Intra-articular injections can help diagnose arthritis and predict fusion success. SPECT-CT is more accurate than other imaging for determining pain sources. Steroid injections also show therapeutic benefits for conditions like accessory joint communications and Morton's neuroma. The document concludes more research is needed on plantar fasciitis treatment and injections are an effective option compared to surgery.

1. STEROID INJECTIONS IN
THE F&A : A LITERATURE
REVIEW
Dr Meghan Dares
MBBS, MIPH, FRACS,
FA(Orth)A
Foot and Ankle Fellow
Queen Alexandra Hospital
; Portsmouth

2. HCLA IN THE FOOT
AND ANKLE
Plantar Fasciitis
Intraarticular injections – diagnostic and
therapeutic
Morton’s neuroma

3. HCLA AND PLANTAR FASCIITIS
McMillan et al - Ultrasound
guided corticosteroid injection
for plantar fasciitis: randomised
controlled trial BMJ 2012
 Foot pain domain of the Foot Health
Status Questionnaire (0 – 100) &
plantar fascia thickness
 HCLA 10 point improvement over
placebo 4/52; no difference at 8 or 12
weeks
 Improvement (.35mm) fascial thickness
 Excluded diabetics and inflammatory
arthritides

4. HCLA AND PLANTAR FASCIITIS
CONTD
- Ball et al , Annals of rheumatic
disease, Steroid injection for
inferior heel pain: a randomised
controlled trial
- USS Versus Blind HCLA Versus
placebo
- Significant improvements in
VAS in both blinded and USS
guided at 6/52 and 3/12
- counterargument - self limiting
condition reports 4 – 18/12 for
90% resolution

5. INTRAARTICU
LAR
INJECTIONS –
DIAGNOSTIC
ROLEClose anatomy makes it
difficult clinical localise
source of pain
AJR 1995 Mitchell et al
 VAS scores post injection &
blinded radiographer
assessment of arthritis (0-2
scale) – degree of correlation
 Where significant pain relief
15/32 plain films ; 5/32
normal Xray joints significant
pain relief achieved
 8 /18 CT

6. ACCURATE IN PREDICTING
ARTHRODESIS SUCCESSKhoury et al AJR 1996
 17/22 significant pain relief fusions post
successful HCLA (77%)
 3 minimal relief and surgical plan altered
 1 – HCLA relief but + fusion (STJ)
 1 - 50% relief , 35% from fusion
 dVAS 3 or more advised surgery

7. PREDICTION OF FUSION SUCCESS
CONTD- Stegemen et al BMC Musculoskeletal Disorders 2014

8. SUPERSEDE
D BY SPECT
CT
SPECT – CT
- Classen et al, Biomed
research international
2014) - Retrospective
analysis of success in
predicting – 65% had
treatment changed ; 93%
had improvement ; better
for Chopart and TMTJs
- Singh – 2013 – Dx value
of SPECT CT – Changed Rx
in 78% and 92%
improvement

9. DIFFICULTY
Soft tissue injections – peroneal
tendon for STJ
Accessory communications - FAI
2009 ; 389 arthrograms
 TNJ and CCJ 42%
 13% of TTJ and STJ
 STJ and Navicular- cuneiform 8%
 STJ and CCJ – 9%
 Nav-Cuneiform and TMTJ – 1%

10. THERAPEUTIC ROLE OF HCLA
Calder et al FAI 2016 – Efficacy of
F&A Corticosteroid Injections
 Retrospective review of 365 patients
 86% significant improvement
 66% had complete resolution
 24% operative intervention
 14% further
 Complications – 1% (no infections)

11. COST EFFICACY - LOCATION
NHS has a projected 2 billion deficit 15 – 16 financial year ; 22 billion
No cost benefit analysis of theatre versus outpatient radiology

12. MORTONS NEUROMA
- Thomson et al JBJS (Am) 2013 –
Single blinded pragmatic study –
USS guided steroid injection –
significant global improvement
scores at 3/12
- MortISE (double blinded
multicentre RCT) looking further
results

13. CONCLUSIONS
Plantar fasciitis – need for USS?
Intraarticular
 Dx – HCLA more accurate than plain or
cross sectional radiography in
delineating the source of pain ;
superseded SPECT CT ; head to head
trial
 Rx – retrospective evidence favourable
results
Morton’s Neuroma – good single
blinded ; await double blinded
results