Steroid Injections: Are They Overutilized In Athletes?
When treating athletes, podiatrists may use corticosteroid injections to treat various conditions. However, are such injections overutilized in athletes? Here is what our expert panelists have to say about what factors to consider in using injectable steroids, differences in treating athletes and non-athletes, and the type of steroids to use.
Q: When treating an athlete, which condition are you most likely to treat with corticosteroid injection?
A: Mike Lowe, DPM, and Amol Saxena, DPM, both use corticosteroid injections for neuromas. As Dr. Lowe notes, the injections should reduce the scarring and swelling to the nerve, and provide at least a temporary relief of symptoms. However, when DPMs are injecting into a neuroma of the second interspace, Dr. Lowe says one should be wary of predislocation syndrome occurring simultaneously since the corticosteroid injection may further damage, weaken or dislocate the second metatarsophalangeal joint (MPJ).
Dr. Saxena and James Losito, DPM, use the injections for plantar fasciitis. Although proximal plantar fasciitis is a ubiquitous condition, Dr. Losito almost never uses corticosteroids on a patient’s first visit. He prefers to maximize the use of Achilles stretching and the use of orthoses and physical therapy.
Douglas Richie Jr., DPM, most commonly uses corticosteroid injections for plantar heel pain syndrome when treating athletes. He notes that the few ruptures of the plantar fascia that he has treated have occurred in patients who never received a corticosteroid injection. “The benefits of such an injection far outweigh the risk based upon my 26 years of clinical practice,” says Dr. Richie.
Stephen Pribut, DPM, uses corticosteroid injections for chronic inflammatory conditions. However, he says he will initially employ less invasive approaches. For acute conditions, Dr. Pribut suggests measures such as protection, rest, ice, compression and elevation (PRICE).
Q: Is there a condition which you would condemn utilizing a steroid injection to treat?
A: Several panelists have reservations about injecting the Achilles tendon area. Dr. Richie says he would never inject the tendo-Achilles of an athlete. Dr. Losito points out that injecting a tendon insertion such as the Achilles would be contraindicated even in a non-athlete.
In addition, Dr. Losito opposes injecting steroids more than twice in any given area of the foot. He notes that he condemns injecting steroids in lateral ankle ligaments when pain or instability are present.
Similarly, Dr. Pribut would not inject into a tendon sheath and also does not recommend injecting around the Achilles tendon. “I would not numb and inject someone before he or she is about to participate in ballistic exercise,” he explains.
Although he would not “condemn” such usage, Dr. Saxena is uncomfortable with injecting most weightbearing tendons. However, he says from a posterior approach, one can inject the flexor hallucis longus tendon in the back of the ankle for impingement and stenosing tenosynovitis.
Dr. Lowe does not recommend injecting a corticosteroid into or around the Achilles tendon or the retrocalcaneal bursa. He cites research by Iwanami showing that betamethasone (Celestone Soluspan, Schering Plough) caused apoptosis and therefore contributed to the weakening and degradation of the tendon structure.1
Q: What factors do you consider when deciding to use a steroid injection?
A: First, Dr. Lowe considers the history and the duration of the injury. He notes that injuries and inflammatory conditions with a long, ongoing history will not have healthy tissue and the corticosteroid injection will cause further tissue degradation and possible rupture.
Dr. Losito considers the patient’s age and when the athlete must return to play or practice. Dr. Lowe concurs, emphasizing the importance of a high level athlete being able to take a minimum of a week off from high intensity workouts before returning to high level activities so as to not compromise tissue and proprioceptive protective skills.