Purpose of Review
This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches.
Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in activities of daily living (ADLs), as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy. Injection therapy is challenging when the etiology is anatomical or compressive. Morton’s neuroma is a budging of the interdigital nerve. Steroid, alcohol, and capsaicin injections provide some benefit, but it is short lived. Hyaluronic acid (HA) injection provided long-term relief and could prove to be a viable treatment option. Achilles tendinopathy (AT) is most likely secondary to repeat tendon stress—platelet-rich-plasma (PRP) and prolotherapy have been trialed for this condition, but more evidence is required to show efficacy. Similar injections were trials for plantar fasciitis and achieved only short-term relief; however, some evidence suggests that PRP injections reduce the frequency of required therapy. Tarsal tunnel syndrome, a compressive neuropathy carries a risk of permanent neural injury if left untreated. Injection therapy can provide a bridge to surgery; however, surgical decompression remains the definitive therapy. When the etiology is inflammatory, steroid injection is more likely to provide benefit. This has been shown in several studies for gout, as well as osteoarthritis of the foot and ankle and treatment-refractory rheumatoid arthritis. HA showed similar benefit, possibly due to anti-inflammatory effects. Stem cell injections may provide the additional benefit of structure restoration.
Chronic foot pain is common in the general population and has significant associated morbidity and disability. Traditionally treated with surgery, these are costly and only somewhat effective. Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.
This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches.
Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in ADLs, as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy.
Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.
Foot and ankle pain is a common ailment in the general population but frequently affects one in five people over the age of 50 . People with foot pain often have limited mobility and decreased ability to do everyday activities [2, 3]. In addition to this, people with foot pain are often at a higher risk for falling and locomotive disability due to their pain . In addition to chronic foot pain being physically debilitating, Belatti et al. calculated that since 2000, foot and ankle surgery for chronic pain has cost the Medicare population around 11 billion dollars . This review discusses non-surgical injection techniques for common foot pain conditions: Morton’s neuroma, Achilles tendinopathy, tarsal tunnel syndrome, plantar fasciitis, gout, ankle osteoarthritis, rheumatoid arthritis, and posterior tibial tendon dysfunction. The selection of which injection technique would be most beneficial should be done by the clinical practitioner on an individual patient basis. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.
Morton’s neuroma (MN), a form of metatarsalgia, is pain in the forefoot region usually located in the third intermetatarsal region of the foot . MN is the result of a bulging of the interdigital nerve distal to the metatarsal transverse ligament and can result in sharp burning pain and numbness either diffused throughout the foot or localized to a specific section [5, 6]. The pain can be exacerbated by wearing tight shoes or high heels and is often described as “walking on marbles” or “walking on piece of stone or pebble” [5, 6]. MN more commonly presents in women in their 50s that perform activities such as running, walking, and dancing . Diagnosis of MN is often done clinically by first examining the patient’s shoes for wear and tear locations towards the distal end of the foot . Diagnosis of MN can also be confirmed with the Mulder maneuver, where pressure and tightening is exerted on the metatarsals, resulting in pain and a distinct clicking or the Silfverskiöld test to assess gastrocnemius muscle tightness are useful in diagnosing MN [5,6,7]. Surgical treatment of MN is traditionally a neurectomy; however, non-surgical treatments first are now becoming more recommended [5, 8]. A non-surgical option is preferred due to the large spectrum of potential causes of MN, patients declining surgical options, or not being suitable for surgery due to contraindications [5, 8].
Steroid treatment is commonly used to alleviate symptoms along with changes in footwear and stretching . Principal findings by Lizano-Diez et al. showed that corticosteroid injections with local anesthetics did improve symptoms temporarily between the experimental and control groups (P = 0.012). However, the beneficial effects diminished over a short period of time . In addition to the short-term effects, Perini et al. also noted diminished short-term pain after injection in 73% of their patients (P < 0.001) . However, there were side effects that resulted in pain in the injection site, skin lesions, tissue alterations consist with “steroid flare,” tissue atrophy, and pigment alterations [9, 11].
Alcohol injections are another method to treat MN instead of corticosteroid injections. Alcohol is usually mixed with a local anesthetic and guided via ultrasound into the neuroma . The concentration of alcohol that is injected for MN varies, although the beneficial results are amplified as the concentration of alcohol increases . There is local transient pain at the site of injection as the concentration of alcohol is increased from 30 to 50%, but it is short lived . More research needs to be conducted on alcohol-based treatments and this therapy should only be used if more evidence-based treatments fail to produce beneficial results [9, 11].
Capsaicin, the chemical found in hot peppers, is a selective transient receptor potential vanilloid 1 (TRPV1) receptor agonist that results in the reversible loss of nociceptor afferents [12, 13]. In high doses (20 µg/20 µl), it can be applied topically to the neuroma to treat the pain for at least 12 weeks . Due to activation of the TRPV1 receptors, patients usually experience a burning, stinging sensation at the site of application . To avoid this, capsaicin can be injected directly into the neuroma with similar beneficial results and localized pain at the injection site that usually subsided after 4 h .
Hyaluronic acid (HA) injection treatment has anti-inflammatory properties and promotes cell proliferation that are used in the treatment of tendon injuries and osteoarthritis . Hyaluronic acid can have positive effects on facilitating the regeneration and organization of damaged axons due to its chemical properties . Lee et al. used these properties for treatment of MN via injection of HA directly into the neuroma . Results showed that MN pain was reduced for over a year and was able to lessen inflammation at the site . However, there was no evidence of its ability to help regenerate the nerve and further studies need to be conducted .
The Achilles tendon is formed when the gastrocnemius muscle merges with the soleus muscle . This merging can occur in two different ways: Type 1 (the most common one) has the aponeuroses of the gastrocnemius and soleus muscles merge 12 cm proximal to the calcaneal insertion . Type 2 has the gastrocnemius aponeuroses directly insert into the aponeuroses of the soleus . The exact cause of AT is currently unknown; however, the main cause is thought to be excessive and receptive stress to the tendon itself [16, 17]. Excessive heel striking while running is believed to cause a “whipping action” on the tendon that causes inflammation and/or degenerative damage to the tendon, predisposing it to tendinopathy . Besides repetitive exertion to the tendon, other intrinsic factors that might cause AT are vascularization of the tendon, age, sex, body weight, height, and ankle stability [16, 18]. Patients with AT typically complain of tenderness at the posterior aspect of their heel and difficulty wearing footwear . Clinical diagnosis of AT shows tenderness and swelling at the insertion point of the Achilles tendon with palpation then ultrasound (US) or magnetic resonance imaging (MRI) can be used to determine the extent of the degeneration of the tendon [19, 20].
While clinicians are able to diagnose AT clinically, the use of radiography imaging is beneficial to determine the severity of the tendinopathy . When comparing US vs. MRI, both are able to diagnose AT; however research shows that US diagnosis is more accurate compared to MRI [22, 23]. In addition to being more accurate, US is more cost-effective and has the ability to dynamically assess muscles compared to MRI .
Injection techniques are a relatively newer treatment method for AT pain. However, there is not a sufficient amount of evidence to support it being recommended as a treatment option . One form of treatment currently being researched is platelet-rich plasma (PRP) injections, which is thought to reduce chronic pain in patients with AT . PRP treatment involves injection of a solution of increased platelet count compared to baseline of the body to promote platelet-derived growth factor levels (TGF-beta) to increase and promote healing . In 2017, Chen et al. looked at PRP treatment in various tendon and ligament injuries and found that there was a significant decrease in short-term pain in PRP injection groups compared to control groups . They saw an overall mean decrease in pain for rotator cuff injuries, anterior cruciate ligament (ACL) injuries, and lateral epicondylitis injuries between the experimental and control groups (MD = − 0.72, 95% CI − 1.10 to − 0.34; P < 0.01) . However, in 2018 a study conducted by Zhang et al. looked at PRP injection benefits in AT treatment and they saw that there was no difference in mean improvements of Victorian Institute of Sport Assessment—Achilles scores (VISA-A) between the PRP and saline control groups (MD: 5.3, 95% CI [− 0.7 to 11.3] P = 0.085) . Overall, both research groups state that there needs to be more research done on PRP therapy before it is recommended for treatment purposes [25, 26].
Another promising therapy is prolotherapy injection treatment. Yelland et al. reported in 2011 an increase in mean VISA-A score by 79% compared to eccentric loading exercises (ELE) at 73% (MD 27.5; 95% CI 12.8 to 42.2; P < 0.0005) . There was a decrease in pain and limitation of activity after injection compared to ELE treatment for the first 12 months (P < 0.0005) . However, the difference between the prolotherapy treatment group and ELE group was not significant overtime overall (P = 0.105) .
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve or its branches within the tarsal tunnel, a fibro-osseous space located deep to the flexor retinaculum and postero-inferior to the medial malleolus [28, 29]. Causes of nerve entrapment include soft tissue irregularity (i.e., hypertrophic flexor retinaculum), space-occupying (i.e., osteophyte, tumor), inflammatory (i.e., rheumatoid arthritis), trauma, biomechanical, obesity, or lower leg edema . Symptoms include paresthesia or hyperesthesia in the areas of the distal tibial nerve exacerbated by standing, walking, or foot eversion and dorsiflexion, which can progress to irreversible nerve injury, weakness, or muscle atrophy [30,31,32]. TTS is relatively uncommon with an unknown incidence, although it is more prevalent in adults, females, athletes, and individuals with prolonged standing or walking . Diagnosis is based on clinical history and physical exam findings including a positive Tinel sign at the tarsal tunnel, and can be confirmed with MRI and nerve conduction studies [28, 31, 33].
In TTS, injection therapy with anesthetics or corticosteroids is considered a conservative measure often used as initial therapy, especially in cases in which nerve pain is not accompanied by a persistent neurological deficit [30, 31]. Decompression of the tibial nerve through surgical tarsal tunnel release is a frequently used treatment when conservative therapy fails [31, 34].
No randomized controlled studies on injection techniques in TTS have been conducted to date, attributable to the low incidence of the condition and the high frequency of surgical release. A study on electrophysiology outcomes in TTS noted that of the nine patients who received local tibial nerve steroid injections, six experienced symptomatic relief, while only two demonstrated nerve conduction improvement. Because all nine patients were treated by different providers, type and dosage of steroid injection was not included . In a case report, a pediatric patient with TTS was treated by tibial nerve block performed under ultrasound guidance with 20 mg of tetracaine and 40 mg of methylprednisone acetate suspension. There was complete resolution of symptoms after two blocks 90 days apart .
Lipografting has shown initial potential as an adjunct to surgical tarsal tunnel release. Morandi et al. described a patient who, after an initial unsuccessful surgical tarsal tunnel release, presented with excess scar tissue, nerve compression, and distal denervation. During the revision tunnel release procedure, abdominal fat collected with liposuction was grafted to the released tarsal tunnel in an attempt to prevent repeat nerve compression. At follow-up, the patient had decreased pain and electromyogram showed signs of distal reinnervation. A concern with lipografting is the unpredictable fat graft resorption rate of between 30 and 80% in the first 3 months . Overall, considering the frequent use of injections as conservative treatment for TTS despite a paucity of data on the subject, future randomized studies would be beneficial to determine optimal injection regimen and ensure safety for these patients.
Plantar fasciitis is characterized by heel pain due to tissue degeneration along the plantar fascia as a result of biomechanical overuse [38,39,40]. The prevalence is approximately 10% of the population, with an increased incidence in the middle aged, the elderly, and runners . Risk factors include reduced ankle dorsiflexion, prolonged standing in the workplace, and obesity . Diagnosis is based on clinical symptoms, including pain along the medial tubercle of the calcaneus that is worse upon taking the first steps in the morning and weight bearing .
Multiple reviews and clinical studies have investigated injection techniques for plantar fasciitis. A review exploring the efficacy of injected corticosteroids (ICS) compared to placebo found that while ICS improved heel pain within 1 month of injection, they had no effect on average heel pain between 1 and 6 months after injection .
Platelet-rich plasma (PRP) contains growth factors that stimulate healing through angiogenesis and cell proliferation . A meta-analysis found that PRP injections were associated with better outcomes than ICS only at 3-month follow-up, but not at 1, 6, or 12 month follow-up. Upon limiting analysis to only RCTs or high-sensitivity analyses, no difference existed between the two groups in function or pain at any time point . More recently, one randomized study indicated that though both treatments improved outcomes for 18 months, corticosteroids had a greater improvement than PRP within 1 month of injection, and PRP had a more positive effect than ICS at 6-, 12-, and 18-month follow-ups . Conversely, two other studies found that ICS and PRP both improved outcomes up to 16 weeks and 6 months, respectively, with no difference between level of improvement due to the two treatments [8, 9].
Shock wave therapy (SWT) is a pulsed sound wave that improves outcomes in plantar fasciitis by an unclear mechanism . One meta-analysis found SWT and ICS both effectively improved pain and function with no inter-group difference at 3-month follow-up except a more improved visual analog scale (VAS) score in the SWT group. However, another meta-analysis suggested that pain improvement and success rate correlated with energy intensity level, with outcomes improved most by high-intensity SWT, followed by ICS, and lastly low-intensity SWT [47, 48]. A different study indicated that SWT provided better outcomes than placebo at 24-month follow-up .
To determine the longer-term effects of these treatments, Ugurlar and colleagues directly compared ICS, PRP, SWT, and prolotherapy with 36-month follow-up. PRP and prolotherapy were effective between the 3- and 12-month follow-up points. Pain was most effectively treated with ICS in the first 3 months, and was treated by SWT for the first 6 months. Notably, at the 36-month follow-up, there was no difference in VAS score among the four groups from before treatment, indicating that no treatment option produced long-term improvement in outcome .
Comparison of these conflicting results indicates that there is still significant ambiguity regarding the extent and duration of effects of each therapy. ICS, PRP, and SWT have all been reported as safe with side effects limited to brief erythema or throbbing pain at the therapy site [38, 39, 46, 47, 49]. Studies have shown that PRP is associated with decreased requirement for reinjection or surgery in the long term and positive effects on soft tissue regeneration and inflammation reduction, but its higher cost must also be considered when choosing a treatment [38, 45]. Considering that the study by Ugurlar and colleagues with longest follow-up for plantar fasciitis treatment found no difference in pain or function at 36 months compared to baseline, it would be beneficial to conduct further long-term studies directly comparing these treatments to elucidate outcomes.
Gout is the most common form of inflammatory arthritis. It is characterized by disruptions in purine metabolism and urate excretion leading to increased serum uric acid levels, causing monosodium urate (MSU) crystal formation and deposition mainly in and near joints [50,51,52]. The four phases of the disease course are asymptomatic hyperuricemia, acute gouty attack, an intercritical period, and chronic tophaceous gout . Risk factors include increased age, purine-rich diet including high consumption of meat and alcohol, obesity, hypertension, diabetes, and genetic predisposition [50, 51, 53]. In the United States, the prevalence is 3.9% among adults with men more affected than women . In 43–76% of patients, acute arthritis of the first metatarsophalangeal (MTP) joint is the first symptom of gout . Gout is diagnosed by clinical findings and can be confirmed by MSU crystals in synovial fluid visualized under polarized light .
Although intra-articular corticosteroid injections are used frequently for plantar gout, there are no randomized controlled trials on the topic [56,57,58]. Kang and colleagues published a trial with 21 patients evaluating the safety and efficacy of intra-articular corticosteroid injections for acute gout flare of the first MTP joint. Under ultrasound guidance, the affected joint was injected with 0.5 ml (20 mg) triamcinolone with 0.5 ml of 2% lidocaine. All 21 patients experienced significant improvement in pain, general disability, and walking disability within 48-h post-treatment with average reduction on visual analog scale (VAS) of 48 mm (SD 27), 35 mm (SD 26), and 39 mm (SD 26), respectively. No adverse events occurred within the first 7 days post injection, the duration of the study .
Fernandez and colleagues reported on a case series of 19 patients who received intra-articular triamcinolone acetonide for acute gout attacks. The affected joints included 11 knees, four first MTP joints, three ankles, and two wrists. Patients were given 10 mg in knees and 8 mg in small joints. Based on VAS, 11 joints were resolved within 24 h and the remaining nine joints were resolved by 48 h, and no patients presented for return of pain in the initial joint within the next 30 days .
Despite the lack of randomized trial data on intra-articular corticosteroid injections for gout, they are generally considered to have good safety profiles. Intra-articular glucocorticoids have been shown to be safe and effective in treating knee osteoarthritis and rheumatoid arthritis compared to placebo, and these findings have been generalized to gout treatment as well [57, 61, 62]. Intra-articular steroid injections are recommended by both European League Against Rheumatism and the American College of Rheumatology for the treatment of gout [58, 63]. They are often used when systemic steroids, colchicine, or non-steroidal anti-inflammatory drugs are contraindicated . The ACR recommends that dosing be based on the size of the affected joint . Further testing should be specifically conducted in patients with gout to generate both acute and long-term data about efficacy, symptom recurrence, and safety.
Recent estimates predict that 10–15% of all adults over the age of 60 suffer from some form of osteoarthritis (OA), making it a leading cause of disability worldwide . Various factors contribute to this high incidence of OA including increasing population age, trauma, exercise, genetics, and obesity . It is predicted that as the population ages and incidence of obesity continues to rise, the disease burden of osteoarthritis will rise with it .
OA of the foot and ankle is not as well studied as OA of the knee and hip, although data suggests that the incidence of foot OA is comparable to knee OA in some populations [65,66,67]. Pain in foot and ankle OA is largely managed conservatively, with physical therapy, foot orthotics, non-steroidal anti-inflammatory medications, and intra-articular (IA) injections . Given the recent understanding of the high prevalence of foot and ankle OA, a more in-depth understanding of conservative treatment options for these joints is needed.
When considering the treatment of foot and ankle OA with IA injections, it is important to first establish the appropriate injection technique. In a comparison between use of superficial landmarks alone vs. ultrasound-guided injection into cadaveric midfoot joints, accuracy of injection was found to be significantly better in US-guided injection (64 vs. 24% in landmark only) . The results of this study were put into practice by Dankarini et al., showing significant clinical improvement of foot pain following US-guided injections for up to 3 months in the majority of those treated . As the use of ultrasound in clinical practice continues to rise, US-guided injections could prove to be a safe way to manage foot and ankle OA pain non-surgically, however more data is needed to assess its efficacy and cost-effectiveness .
Corticosteroids (CS) have been widely used as non-surgical treatment for OA in clinical practice, yet very few studies have been done to prove its efficacy in foot and ankle OA . The use of IA corticosteroids for ankle OA is limited to two studies . Sarkin studied the effects of IA injections in 100 patients with ankle OA and found significant evidence that patients with less severe OA benefit more from corticosteroid injections . More recently, Fox et al. found a significant reduction in pain following injection of triamcinolone acetonide and bupivacaine into the tibiotalar joint, although there was no follow-up pain assessment after the initial injection so the effects of the steroids vs. anesthetic is unclear .
The only RCT involving the use of IA corticosteroid for foot OA was done by Pons et al., who compared treatment of foot OA with hyaluronic acid (HA) vs. CS injection in 40 patients. While both patient populations had significant improvement in pain for up to 56 days following injection, patients who received HA had significantly improved pain with walking when compared to CS patients . The only other three clinical studies involving IA corticosteroids for foot OA have supported its clinical efficacy, with each finding a majority of patients achieving significant pain relief for up to 3 months following injection (n = 180) [70, 72, 77]. Importantly, one study noted that patients with a BMI < 30 had sustained pain relief for up to 12 months following treatment .
Currently, there are a total of 18 studies assessing the effectiveness of IA injections of HA in the treatment ankle OA, seven RCTs, nine case series, and two prospective cohort studies [73, 78]. Each case series and the two prospective cohort studies concluded that intra articular HA was an effective and tolerable in the treatment of osteoarthritic ankle pain, with some studies noting pain relief for up to 12–18 months following injection [73, 78]. All seven RCTs concluded that intra-articular HA injections lead to significant relief of ankle pain. Of note, three RCTs observed the effects of HA vs. saline injection. Two of the three found a significant improvement in pain relief with HA compared to saline, however DeGroot et al. did not [79,80,81]. Despite this discrepancy, pooled data between these three studies did show a significant difference in pain relief at 6 months with HA over saline injection .
Two RCTs have been done assessing the use of HA in treatment of foot OA, comparing HA to either saline  or corticosteroid injection . Both trials showed clinical improvement of pain for 3 months following injection. As previously mentioned, Pons et al. found that HA had significantly better results than CS injection, although both resulted in significant pain reduction . Munteanu et al. found that HA was no better than saline in reducing pain, although both treatment groups did report significant pain relief for up to 6 months .
Platelet-Rich Plasma (PRP)
Three studies have been done to assess the efficacy of IA PRP in ankle OA [83,84,85]. The first study assessing PRP in ankle OA was conducted on five patients with OA and found no benefit in treatment on 3- or 6-month follow-up . More recently, both Fukawa et al. and Repetto et al. found that injections of PRP were safe and efficacious in ankle OA, with significant pain reduction for up to 24 weeks for Fukawa and an average of 17.7 months for Repetto [83, 84].
Mesenchymal Stem Cells (MSC)
One study exists using MSCs in the treatment of ankle OA . Emadedin et al. studied six patients with ankle OA and found dramatic improvement in ankle pain and function. Patients improved from an average walking distance of 1010 m at baseline to 2333 m at 30 months and an average Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score of 40.0 at baseline to 8.3 at 30 months.
Rheumatoid arthritis (RA) is a chronic autoimmune synovitis characterized by swelling, tenderness, and destruction of synovial joints leading to severe disability . It has proven to be the most common cause of autoimmune arthritis in adults with an estimated 1.3 million Americans currently affected . Several treatments exist for the treatment for symptomatic RA including disease-modifying anti-rheumatic drugs (DMARDs), biologics, tofacitinib, and glucocorticoids . However, when pharmacological treatment fails, or when one joint remains symptomatic despite medical treatment, further methods of treatment should be considered. Intra-articular glucocorticoids have shown to exert their effects in patients with RA by reducing synovial perfusion and volume, increasing joint fluid viscosity, and decreasing erythema, heat, and tenderness in affected joints .
Intra-articular steroids have been used to treat synovitis for over 60 years  and since then have remained a mainstay of treatment in patients with RA despite a relative paucity of controlled studies assessing its effectiveness . One of the few controlled studies, the CIMESTRA trial, showed that treatment of early RA with oral methotrexate combined with intra-articular injections of corticosteroid resulted in significant symptomatic improvement by ACR20 criteria .
Multiple studies assessed the efficacy of US-guided injections in patients with RA of the ankle and found significant evidence suggesting that US-guided injection was significantly more accurate than clinically examined injection [92, 94] with one study noting the accuracy of the injection was correlated significantly with improvement of joint function up to 6 weeks following injection .
Current studies examining the effects of intra-articular steroids for patients with RA affecting the ankle have been limited. Lopes (n = 54), Cunnington (n = 25), and Furtado (n = 45) all found significant improvement in VAS score for ankle pain following IA corticosteroid injection, although length of significant pain relief varied vastly from 1 week to 12 weeks following injection [92, 94, 95].
One study compared the effects of IA injections of methotrexate (MTX) to IA corticosteroids in 100 patients with RA of multiple medium-sized joints (58 ankles) and found that both groups achieved significant pain relief up to 20 weeks following injection, however MTX had a significantly longer anti-inflammatory effect than corticosteroids as confirmed by degree of synovial inflammation on power Doppler . While the results of these trials are promising, more randomized controlled trials are needed assessing IA injections for the treatment of ankle RA.
Posterior Tibial Tendon Dysfunction
Posterior tibial tendon dysfunction (PTTD), also known as flatfoot, is a collapse of the medial longitudinal arch of the foot . The posterior tibial tendon is the main tendon that provides dynamic support of the longitudinal arch of the foot. If this tendon is damaged, it will result in flattening of the foot . PTTD is the result of a multifactorial process: hypo-vascularization of the tendon, obesity, and genetics . Its severity is graded by the Johnson and Strom classification system from I–III, which was expanded upon by Myerson by adding stage IV to the system in 1997 . Stage I consists of posterior tibial tendon tenosynovitis with no arch collapse; stage II will have arch collapse and be unable to perform a single leg heel raise; stage III has fixed deformity with hindfoot valgus and forefoot abduction; and finally stage IV will have fixed foot deformity with degenerative changes in the ankle joint [97,98,99]. PTTD affects around 3.3–10% of the population, most commonly in elderly women over the age of 40 [97, 100, 101]. Diagnosis of PTTD is typically done with an anteroposterior (AP), lateral, and hindfoot weight-bearing radiography [97, 100]. Simmons angle, increased talo-first metatarsal angle, will be present on the AP footage, foot abduction at the talonavicular joint, and access the degree of arch collapse [97, 100]. Magnetic resonance imaging (MRI) is not as useful in evaluating PTT; however, it can be helpful to determine any ligamentous involvement for surgical purposes .
Non-surgical treatment of PTTD is often injection of anesthesia directly into the PTT under US imagining guidance . Cooper et al. conducted a trial to determine the effectiveness of 1% lidocaine treatment on PTT symptoms and noted that 100% of the ankles injected with anesthesia initially had complete relief of symptoms . However, it was also noted that 88% of the ankles had abnormal increased fluid signals within the sheath and mild tendinosis . In the past, clinicians typically inject anesthesia blindly into the upper third of the anterior portion of the tibia due to the large “safety window” compared to the posterior portion . However, there was a risk of improper injection location in the posterior tibial tendon (11%) or neurovascular injury [103, 104]. Rha et al. used US to greatly increase the effectiveness and accuracy of injection of anesthesia into the upper third of the tibialis posterior muscle (p < 0.01) . They concluded that compared to conventional needle injection techniques, US guidance was able to increase the accuracy of the placement in the “safety window” and lower the incidence of neurovascular injury . Botulinum toxin, another potential treatment for PTTD, also requires precise and proper injection into the tendon due to the diffuse-adverse side effects that result from a large dose . US guidance showed an increased rate of accurate injection of botulinum toxin into the posterior tibial tendon and increase the effect of the treatment on the patient.
Chronic foot and ankle pain is a common ailment in the general population and causes limited mobility and pain that can put patients at a higher risk of falling and decreased ability to perform activities of daily living. Traditional management of this pain is surgical intervention that can be costly, have long recovery times, and have variable degrees of efficacy. To combat this, minimally invasive injection-based treatments have been in development with the goal to decrease pain, improve mobility, and increase overall quality of life. Injection therapy may provide pain relief and improvement in the clinical condition but they do not come without certain limitations including potential failure. In the event that injections are not beneficial for the discussed syndromes, evaluation for surgical intervention may need to be obtained. While there appears to be positive outcomes due to injection-based treatment in small-scale trials, further studies are needed to evaluate the positive effects of injection-based treatment for chronic foot and ankle pain.
Thomas MJ, Roddy E, Zhang W, Menz HB, Hannan MT, Peat GM. The population prevalence of foot and ankle pain in middle and old age: a systematic review. Pain. 2011;152(12):2870–80.
Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res. 2008;1(1):2.
Menz HB, Dufour AB, Casey VA, Riskowski JL, McLean RR, Katz P, Hannan MT. Foot pain and mobility limitations in older adults: the Framingham foot study. J Gerontol A Biol Sci Med Sci. 2013;68(10):1281–5.
Belatti D, Phisitkul P. Economic burden of foot and ankle surgery in the US Medicare population. Foot Ankle Int. 2014;35(4):334–40.
Gougoulias N, Lampridis V, Sakellariou A. Morton’s interdigital neuroma: instructional review. EFORT Open Rev. 2019;4(1):14–24.
Hodes A, Umans H. Metatarsalgia. Radiologic clinics of North America, vol. 56. Philadelphia: W.B. Saunders; 2018. p. 877–92.
Di Caprio F, Meringolo R, Shehab Eddine M, Ponziani L. Morton’s interdigital neuroma of the foot: a literature review. Foot and ankle surgery, vol. 24. Amsterdam: Elsevier Ltd; 2018. p. 92–8.
Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton’s neuroma): a systematic review and meta-analysis. J Foot Ankle Res. 2019;12:12.
Santos D, Morrison G, Coda A. Sclerosing alcohol injections for the management of intermetatarsal neuromas: a systematic review. Foot. 2018;35:36–47.
Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. 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.
Perini L, Perini C, Tagliapietra M, Varotto D, Valcarenghi A, Postorino A, Volpe A. Percutaneous alcohol injection under sonographic guidance in Morton’s neuroma: follow-up in 220 treated lesions. Radiol Med. 2016;121(7):597–604.
Campbell CM, Diamond E, Schmidt WK, Kelly M, Allen R, Houghton W, Brady KL, Campbell JN. A randomized, double-blind, placebo-controlled trial of injected capsaicin for pain in Morton’s neuroma. Pain. 2016;157(6):1297–304.
Anand P, Bley K. Topical capsaicin for pain management: therapeutic potential and mechanisms of action of the new high-concentration capsaicin 8 patch. Br J Anaesth. 2011;107:490–502.
Lee K, Hwang IY, Ryu CH, Lee JW, Kang SW. Ultrasound-guided hyaluronic acid injection for the management of Morton’s neuroma. Foot Ankle Int. 2018;39(2):201–4.
Wang KK, Nemeth IR, Seckel BR, Chakalis-Haley DP, Swann DA, Kuo JW, Bryan DJ, Cetrulo CL. Hyaluronic acid enhances peripheral nerve regeneration in vivo. Microsurgery. 1998;18(4):270–5.
Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 2002;36:239–49.
Reiman M, Burgi C, Strube E, Prue K, Ray K, Elliott A, Goode A. The utility of clinical measures for the diagnosis of Achilles tendon injuries: a systematic review with meta-analysis. J Athl Train. 2014;49(6):820–9.
Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc. 2018;26(1):16–30.
Weinfeld SB. Achilles tendon disorders. Med Clin N Am. 2014;98(2):331–8.
Zellers JA, Bley BC, Pohlig RT, Alghamdi NH, Silbernagel KG. Frequency of pathology on diagnostic ultrasound and relationship to patient demographics in individuals with insertional Achilles tendinopathy. Int J Sports Phys Ther. 2019;14(5):761–9.
Matthews W, Ellis R, Furness J, Hing W. Classification of tendon matrix change using ultrasound imaging: a systematic review and meta-analysis. Ultrasound Med Biol. 2018;44(10):2059–80.
Warden SJ, Kiss ZS, Malara FA, Ooi ABT, Cook JL, Crossley KM. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med. 2007;35(3):427–36.
Westacott DJ, Minns JI, Foguet P. The diagnostic accuracy of magnetic resonance imaging and ultrasonography in gluteal tendon tears—a systematic review. HIP Int. 2011;21:637–45.
Dilger CP, Chimenti RL. Nonsurgical treatment options for insertional Achilles tendinopathy. Foot Ankle Clin. 2019;24(3):505–13.
Zhang Y-J, Xu S-Z, Gu P-C, Du J-Y, Cai Y-Z, Zhang C, Lin X-J. Is platelet-rich plasma injection effective for chronic Achilles tendinopathy? A meta-analysis. Clin Orthop Relat Res. 2018;476(8):1633–41.
Chen X, Jones IA, Park C, Vangsness CT. The efficacy of platelet-rich plasma on tendon and ligament healing. Am J Sports Med. 2017;46(8):2020–32.
Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011;45(5):421–8.
Wong GNL, Tan TJ. MR imaging as a problem solving tool in posterior ankle pain: a review. Eur J Radiol. 2016;85(12):2238–56.
Ferkel E, Davis WH, Ellington JK. Entrapment neuropathies of the foot and ankle. Clin Sports Med. 2015;34(4):791–801.
McSweeney SC, Cichero M. Tarsal tunnel syndrome—a narrative literature review. Foot. 2015;25(4):244–50.
Antoniadis G, Scheglmann K. Posterior tarsal tunnel syndrome diagnosis and treatment. Dtsch Arztebl. 2008;105(45):776–81.
Morinaga K, Shimizu T. Diagnosing bilateral tarsal tunnel syndrome. Am J Med. 2017;130(10):e437–8.
Rinkel WD, Cabezas MC, Van Neck JW, Birnie E, Hovius SER, Henk Coert J. Validity of the Tinel sign and prevalence of tibial nerve entrapment at the tarsal tunnel in both diabetic and nondiabetic subjects: a cross-sectional study. Plast Reconstr Surg. 2018;142(5):1258–66.
Gould JS. Recurrent tarsal tunnel syndrome. Foot Ankle Clin. 2014;19(3):451–67.
Mondelli M, Giannini F, Reale F. Clinical and electrophysiological findings and follow-up in tarsal tunnel syndrome. Electroencephalogr Clin Neurophysiol Electromyogr Mot Control. 1998;109(5):418–25.
Sobey JH, Franklin A. Ultrasound-guided tibial nerve block for definitive treatment of tarsal tunnel syndrome in a pediatric patient. Am Soc Reg Anesth Pain Med. 2016;41(3):415–6.
Morandi EM, Loizides A, Gruber H, Löscher WN, Pierer G, Baur EM. Lipografting as a novel therapeutic option in secondary tarsal tunnel release. Muscle Nerve. 2017;55(1):E1–2.
Shetty SH, Dhond A, Arora M, Deore S. Platelet-rich plasma has better long-term results than corticosteroids or placebo for chronic plantar fasciitis: randomized control trial. J Foot Ankle Surg. 2019;58(1):42–6.
Uğurlar M, Sönmez MM, Uğurlar ÖY, Adıyeke L, Yıldırım H, Eren OT. Effectiveness of four different treatment modalities in the treatment of chronic plantar fasciitis during a 36-month follow-up period: a randomized controlled trial. J Foot Ankle Surg. 2018;57(5):913–8.
Singh P, Madanipour S, Bhamra JS, Gill I. A systematic review and meta-analysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy. Int Orthop. 2017;41(6):1169–81.
Rastegar S, Baradaran Mahdavi S, Hoseinzadeh B, Badiei S. Comparison of dry needling and steroid injection in the treatment of plantar fasciitis: a single-blind randomized clinical trial. Int Orthop. 2018;42(1):109–16.
Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case–control study. J Bone Joint Surg Am. 2003;85(5):872–7.
Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25(5):303–10.
David JA, Sankarapandian V, Christopher PR, Chatterjee A, Macaden AS. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017;6:9348.
Acosta-Olivo C, Elizondo-Rodriguez J, Lopez-Cavazos R, Vilchez-Cavazos F, Simental-Mendia M, Mendoza-Lemus O. Plantar fasciitis—a comparison of treatment with intralesional steroids versus platelet-rich plasma: a randomized, blinded study. J Am Podiatr Med Assoc. 2017;107(6):490–6.
Jain SK, Suprashant K, Kumar S, Yadav A, Kearns SR. Comparison of plantar fasciitis injected with platelet-rich plasma vs corticosteroids. Foot Ankle Int. 2018;39(7):780–6.
Li S, Wang K, Sun H, Luo X, Wang P, Fang S, Chen H, Sun X. Clinical effects of extracorporeal shock-wave therapy and ultrasound-guided local corticosteroid injections for plantar fasciitis in adults: a meta-analysis of randomized controlled trials. Med (United States). 2018;97(50):1–9.
Xiong Y, Wu Q, Mi B, Zhou W, Liu Y, Liu J, Xue H, Hu L, Panayi AC, Liu G. Comparison of efficacy of shock-wave therapy versus corticosteroids in plantar fasciitis: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg. 2019;139(4):529–36.
Ibrahim MI, Donatelli RA, Hellman M, Hussein AZ, Furia JP, Schmitz C. Long-term results of radial extracorporeal shock wave treatment for chronic plantar fasciopathy: a prospective, randomized, placebo-controlled trial with 2 years follow-up. J Orthop Res. 2017;35(7):1532–8.
Kuo CF, Grainge MJ, Zhang W, Doherty M. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol. 2015;11(11):649–62.
Ragab G, Elshahaly M, Bardin T. Gout: an old disease in new perspective—a review. J Adv Res. 2017;8(5):495–511.
Zhang Q, Gao F, Sun W, Ma J, Cheng L, Li Z. The diagnostic performance of musculoskeletal ultrasound in gout: a systematic review and meta-analysis. PLoS One. 2018;13(7):1–14.
Evans PL, Prior JA, Belcher J, Mallen CD, Hay CA, Roddy E. Obesity, hypertension and diuretic use as risk factors for incident gout: a systematic review and meta-analysis of cohort studies. Arthritis Res Ther. 2018;20(1):1–15.
Chen-Xu M, Yokose C, Rai SK, Pillinger MH, Choi HK. Contemporary prevalence of gout and hyperuricemia in the United States and decadal trends: the National Health and Nutrition Examination Survey, 2007–2016. Arthritis Rheumatol. 2019;71(6):991–9.
Stewart S, Dalbeth N, Vandal AC, Rome K. The first metatarsophalangeal joint in gout: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2016;17(1):69.
Wechalekar MD, Vinik O, Moi JHY, Sivera F, Van Echteld IAAM, Van Durme C, Falzon L, Bombardier C, Carmona L, Aletaha D, Landewé RB, Van Der Heijde DMFM, Buchbinder R. The efficacy and safety of treatments for acute gout: results from a series of systematic literature reviews including Cochrane reviews on intraarticular glucocorticoids, colchicine, nonsteroidal antiinflammatory drugs, and interleukin-1 inhibitors. J Rheumatol. 2014;41(SUPPL. 92):15–25.
Wechalekar MD, Vinik O, Schlesinger N, Buchbinder R. Intra-articular glucocorticoids for acute gout. Cochrane Database Syst Rev. 2013;4:9920.
Richette P, Doherty M, Pascual E, Barskova V, Becce F, Castañeda-Sanabria J, Coyfish M, Guillo S, Jansen TL, Janssens H, Lioté F, Mallen C, Nuki G, Perez-Ruiz F, Pimentao J, Punzi L, Pywell T, Bardin T. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29–42.
Kang MH, Moon KW, Jeon YH, Cho SW. Sonography of the first metatarsophalangeal joint and sonographically guided intraarticular injection of corticosteroid in acute gout attack. J Clin Ultrasound. 2015;43(3):179–86.
Fernandez C, Noguera R, Gonzalez JA, Pascual E. Treatment of acute attacks of gout with a small dose of intraarticular triamcinolone acetonide. J Rheumatol. 1999;26(10):2285–6.
Wallen MM, Gillies D. Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis. Cochrane Database Syst Rev. 2006;1:2824.
Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, Uthman I, Khy V, Tremblay JL, Bertrand C, Pelletier JP. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48(2):370–7.
Khanna D, Khanna PP, Fitzgerald JD, Singh MK, Bae S, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Lioté F, Choi H, Jasvinder AS, Terkeltaub R. 2012 American college of rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. 2012;64(10):1447–61.
Wittenauer R, Smith L, Aden K. Background paper 6.12 osteoarthritis. 2013.
Paterson KL, Gates L. Clinical assessment and management of foot and ankle osteoarthritis: a review of current evidence and focus on pharmacological treatment. Drugs Aging. 2019;36(3):203–11.
Murray C, Marshall M, Rathod T, Bowen CJ, Menz HB, Roddy E. Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: a systematic review and cross-sectional study. PLoS ONE. 2018;13:e0193662.
Roddy E, Thomas MJ, Marshall M, Rathod T, Myers H, Menz HB, Thomas E, Peat G. The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot. Ann Rheum Dis. 2015;74(1):156–63.
Roddy E, Menz HB. Foot osteoarthritis: latest evidence and developments. Therap Adv Musculoskelet Dis. 2018;10:91–103.
Khosla S, Thiele R, Baumhauer JF. Ultrasound guidance for intra-articular injections of the foot and ankle. Foot Ankle Int. 2009;30(9):886–90.
Drakonaki EE, Kho JSB, Sharp RJ, Ostlere SJ. Efficacy of ultrasound-guided steroid injections for pain management of midfoot joint degenerative disease. Skelet Radiol. 2011;40(8):1001–6.
Daniels EW, Cole D, Jacobs B, Phillips SF. Existing evidence on ultrasound-guided injections in sports medicine. Orthop J Sports Med. 2018;6:232.
Protheroe D, Gadgil A. Guided intra-articular corticosteroid injections in the midfoot. Foot Ankle Int. 2018;39(8):1001–4.
Vannabouathong C, Del Fabbro G, Sales B, Smith C, Li CS, Yardley D, Bhandari M, Petrisor BA. Intra-articular injections in the treatment of symptoms from ankle arthritis: a systematic review. Foot Ankle Int. 2018;39(10):1141–50.
Sarkin TL. Indications for intra-articular steroid in osteoarthritis of the ankle and big toe joints. S Afr Med J. 1974;48(49):2067–8.
Varenika V, Harter J, Chu E, Steinbach L. The posterolateral approach for fluoroscopy-guided tibiotalar joint injection. Skelet Radiol. 2017;46(8):1113–5.
Pons M, Alvarez F, Solana J, Viladot R, Varela L. Sodium hyaluronate in the treatment of hallux rigidus. A single-blind, randomized study. Foot ankle Int. 2007;28(1):38–42.
Grice J, Marsland D, Smith G, Calder J. Efficacy of foot and ankle corticosteroid injections. Foot Ankle Int. 2017;38(1):8–13.
Younger ASE, Penner M, Wing K, Veljkovic A, Nacht J, Wang Z, Wester T, Harrison A. Nonanimal hyaluronic acid for the treatment of ankle osteoarthritis: a prospective, single-arm cohort study. J Foot Ankle Surg. 2019;58(3):514–8.
DeGroot H, Uzunishvili S, Weir R, Al-omari A, Gomes B. Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study. J Bone Jt Surg Am. 2012;94(1):2–8.
Cohen MM, Altman RD, Hollstrom R, Hollstrom C, Sun C, Gipson B. Safety and efficacy of intra-articular sodium hyaluronate (Hyalgan®) in a randomized, double-blind study for osteoarthritis of the ankle. Foot Ankle Int. 2008;29(7):657–63.
Salk R, Chang T, D’Costa W, Soomekh D, Grogan K. Viscosupplementation (hyaluronans) in the treatment of ankle osteoarthritis. Clin Podiatr Med Surg. 2005;22(4):585–97.
Munteanu SE, Zammit GV, Menz HB, Landorf KB, Handley CJ, Elzarka A, Deluca J. Effectiveness of intra-articular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial. Ann Rheum Dis. 2011;70(10):1838–41.
Fukawa T, Yamaguchi S, Akatsu Y, Yamamoto Y, Akagi R, Sasho T. Safety and efficacy of intra-articular injection of platelet-rich plasma in patients with ankle osteoarthritis. Foot Ankle Int. 2017;38(6):596–604.
Repetto I, Biti B, Cerruti P, Trentini R, Felli L. Conservative treatment of ankle osteoarthritis: can platelet-rich plasma effectively postpone surgery? J Foot Ankle Surg. 2017;56(2):362–5.
Angthong C, Khadsongkram A, Angthong W. Outcomes and quality of life after platelet-rich plasma therapy in patients with recalcitrant hindfoot and ankle diseases: a preliminary report of 12 patients. J Foot Ankle Surg. 2013;52(4):475–80.
Emadedin M, Ghorbani Liastani M, Fazeli R, Mohseni F, Moghadasali R, Mardpour S, Hosseini SE, Niknejadi M, Moeininia F, Aghahossein Fanni A, Baghban Eslaminejhad R, Vosough Dizaji A, Labibzadeh N, Mirazimi Bafghi A, Baharvand H, Aghdami N. Long-term follow-up of intra-articular injection of autologous mesenchymal stem cells in patients with knee, ankle, or hip osteoarthritis. Arch Iran Med. 2015;18(6):336–44.
Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JMW, Hobbs K, Hawker G. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis and Rheumatism, vol. 62. Hoboken: John Wiley and Sons Inc; 2010. p. 2569–81.
Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, Liang MH, Kremers HM, Mayes MD, Merkel PA, Pillemer SR, Reveille JD, Stone JH. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. 2008;58(1):15–25.
Singh JA, Saag KG, Bridges SL, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O’Dell J, King C, Leong A, McAlindon T. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2016;68(1):1–26.
Pekarek B, Osher L, Buck S, Bowen M. Intra-articular corticosteroid injections: a critical literature review with up-to-date findings. Foot. 2011;21:66–70.
Hollander JL, Brown EM, Jessar RA, Brown CY. Hydrocortisone and cortisone injected into arthritic joints: comparative effects of and use of hydrocortisone as a local antiarthritic agent. J Am Med Assoc. 1951;147(17):1629–35.
Lopes RV, Furtado RNV, Parmigiani L, Rosenfeld A, Fernandes ARC, Natour J. Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis. Rheumatology. 2008;47(12):1792–4.
Hetland ML, Stengaard-Pedersen K, Junker P, Lottenburger T, Ellingsen T, Andersen LS, Hansen I, Skjødt H, Pedersen JK, Lauridsen UB, Svendsen A, Tarp U, Pødenphant J, Hansen G, Lindegaard H, De Carvalho A, Østergaard M, Hørslev-Petersen K. Combination treatment with methotrexate, cyclosporine, and intraarticular betamethasone compared with methotrexate and intraarticular betamethasone in early active rheumatoid arthritis: an investigator-initiated, multicenter, randomized, double-blind, parallel-group, placebo-controlled study. Arthritis Rheum. 2006;54(5):1401–9.
Cunnington J, Marshall N, Hide G, Bracewell C, Isaacs J, Platt P, Kane D. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum. 2010;62(7):1862–9.
Furtado RNV, Machado FS, da Luz KR, dos Santos MF, Konai MS, Lopes RV, Natour J. Intra-articular injection with triamcinolone hexacetonide in patients with rheumatoid arthritis: prospective assessment of goniometry and joint inflammation parameters. Rev Bras Reumatol (English Ed.). 2017;57(2):115–21.
Mortada MA, Abdelwhab SM, Elgawish MH. Intra-articular methotrexate versus corticosteroid injections in medium-sized joints of rheumatoid arthritis patients—an intervention study. Clin Rheumatol. 2018;37(2):331–7.
Arain A, Harrington MC, Rosenbaum AJ. Adult acquired flatfoot (AAFD). Treasure Island: StatPearls; 2019.
Kohls-Gatzoulis J, Woods B, Angel JC, Singh D. The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. Foot Ankle Surg. 2009;15(2):75–81.
Ross MH, Smith MD, Mellor R, Vicenzino B. Exercise for posterior tibial tendon dysfunction: A systematic review of randomised clinical trials and clinical guidelines. BMJ Open Sport and Exercise Medicine, vol. 4. London: BMJ Publishing Group; 2018.
Knapp PW, Constant D. Posterior tibial tendon dysfunction. Treasure Island: StatPearls; 2019.
Ross MH, Smith M, Plinsinga ML, Vicenzino B. Self-reported social and activity restrictions accompany local impairments in posterior tibial tendon dysfunction: a systematic review. J Foot Ankle Res. 2018;11:49.
Cooper AJ, Mizel MS, Patel PD, Steinmetz ND, Clifford PD. Comparison of MRI and local anesthetic tendon sheath injection in the diagnosis of posterior tibial tendon tenosynovitis. Foot Ankle Int. 2007;28(11):1124–7.
Rha D-W, Im SH, Lee SC, Kim S-K. Needle insertion into the tibialis posterior: ultrasonographic evaluation of an anterior approach. Arch Phys Med Rehabil. 2010;91(2):283–7.
Chin TYP, Nattrass GR, Selber P, Graham HK. Accuracy of intramuscular injection of botulinum toxin A in juvenile cerebral palsy: a comparison between manual needle placement and placement guided by electrical stimulation. J Pediatr Orthop. 2005;25(3):286–91.
Oddy MJ, Brown C, Mistry R, Eastwood DM. Botulinum toxin injection site localization for the tibialis posterior muscle. J Pediatr Orthop Part B. 2006;15(6):414–7.
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Ivan Urits, Daniel Smoots, Henry Franscioni, Anjana Patel, Nathan Fackler, Seth Wiley, Amnon A. Berger, Hisham Kassem, Richard D. Urman, Laxmaiah Manchikanti, Alaa Abd-Elsayed and Omar Viswanath. Alan D. Kaye is a member of the journal’s Editorial Board.
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Urits, I., Smoots, D., Franscioni, H. et al. Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review. Pain Ther 9, 145–160 (2020). https://doi.org/10.1007/s40122-020-00157-5
- Achilles tendinopathy
- Ankle arthritis
- Foot pain
- Injection techniques
- Morton neuroma
- Plantar fasciitis
- Tarsal tunnel syndrome