Steroid Injections in the Foot

Often, the subject of concern is that we need to look at this form of treatment objectively.

This article on steroid injections features:

• Risks

• Common Questions

• Why steroid injections fail

While waiting in our local hospital for my partner to finish her scan, I picked up one of the NHS imaging department's informational leaflets. I have written about steroid injections before, but the information resonated with me as I was putting the finishing touches to my latest book, due out this September (2025).

Morton's Neuroma is due out this Autumn 2025 from Amazon Books. This covers steroid injections as well as evidence from other methods.

The information leaflet was entitled "Musculoskeletal (MSK) Ultrasound and Image-Guided Steroid Injections." I won't delve into whether ultrasound should or shouldn't be used, as this decision is dependent on several factors. I want to look more at the value of injectable steroids for MSK problems.

I commenced using steroids for injectable therapy in 1981. By the time I retired in 2018, I had performed more steroid injections than I could recall, as well as publishing the first UK Podiatry paper on a clinical review of steroids in my speciality field in 1998 (Tollafield & Williams). As time progressed, I set up dedicated monthly steroid clinics in my local X-ray departments with colleagues, which became popular and highly effective in avoiding foot surgery in a number of cases.

Risks from a steroid injection

At the top of the list for me would be a flare and discolouration in the skin (depigmentation). The thinning of skin is more pronounced in areas without deep fat, so the back of the heel should be considered with caution.

Tendon Rupture & My Experience

One can never say never, but a one-time injection with repture would really be bad luck. I have injected around, rather than into tendons, and have never seen a rupture, but they have been documented.

As with all treatments, post-injection guidelines are essential, so rest and gentle return to activity are important.

In my book on Morton's Neuroma, steroids are one of the key treatment methods where the plantar digital neuroma fails to respond to conservative care. Much of the book covers self-management and has been expanded from the First Edition, 2018.

Steroid Injections in the Foot

Professional Management of Morton's Neuroma

(The following material has been reproduced from the forthcoming book mentioned)

Common Questions

I’m not good with needles, the patient tells me for the hundredth time.

     I say, I know, it is normal not to like needles – who does! I try to reassure patients with practical responses, such as:

o    This could cure you.

o    It takes moments to do.

o    I have done hundreds.

o    I have had an injection myself.

o    The needle I use is similar in diameter to an acupuncture needle.

o    I use an anaesthetic so you won’t feel the substance going in.

Out of these six statements, one is a fib. It is the last statement, but the fib is only a perception of the truth. I use an anaesthetic and the needle pierces the skin as if it is going into butter, the discomfort is minimal because the needle is so fine. I’ve had done this to myself. As I inject the anaesthetic, the local nerves register the pressure of the fluid as swelling increases with the volume injected. If any inflammation is present, the local anaesthetic may cause a stinging sensation. This is because the anaesthetic is slightly acidic to preserve the drug. The stinging sensation lasts for less than 30 seconds. Once done, the actual treatment, which involves a steroid, is not noticeable. The needle is placed around the nerve, not into the nerve.

Worries about Steroids

—‘Steroids aren’t good for you, are they?’

This is not that kind of steroid. You will not put on weight even though small amounts go into the bloodstream.

‘Yes, but they only work for a short period?’

This is not strictly true but it can be. Let me explain. The injection of steroids will set about reducing both inflammation and swelling but will also reduce the scar tissue around the nerve, allowing some recovery. I set up a study of 60 patients in 1988 (Tollafield & Williams) and found that 38% benefitted beyond six months with a steroid. Those who didn’t were provided with surgery.

‘I’m going abroad and the injection did help so please can I have another one to tide me over?’

While the ethics behind this judgement might be queried, I am on the patient’s side as another won’t hurt, but it might not last long. I might even inject the joint to rule out inflammation causing pressure.

‘Can I be worse off after an injection?’

Actually yes, you can, although it is unusual. Injections fail for several reasons. The most common reason is that the nerve swelling and damage will not resolve with an injection, and success may last for only a few days or weeks. That is clinically quite helpful indiocating that we know we should not use more steroid.

Injection into the nerve can cause pain for a while, although this is rare, and unfortunately it can also damage the nerve in some circumstances. A flare up creates a local inflammatory reaction where the body fights the drug and goes ballistic. This sort of pain can arise in 3–4% of patients, but more so with joint injections than with those for neuroma. Discomfort settles with local ice, rest and taking suitable pain medication (analgesics) within 72 hours.

‘Could I get an infection?’

Needles are sterile; infection is rare, but can arise. Infection may be due to formation of a haematoma, if blood swells into the tissue from a small vessel puncture. If you see bruising this might have occurred, but is, as mentioned low risk. The puncture of a small vessel does not constitute grounds for negligence unless some unlikely reason the technique has been reckless, or carried out by someone unqualified to provide an injection.

‘What could arise if I have an infection?’

You may need time off work, and treatment with antibiotics. The risk of infection is low from a steroid injection and can be treated quickly. I have not seen this arise in my own practice.

     During surgery some steroids create harmless deposits, but generally do not cause tissue damage in the small amounts used.

‘Do steroids work straight away?’

Steroids may take up to six weeks to work. I am emphasising this as it is not uncommon for patients to think it is a waste of time. It is not. I found my own injection was of immediate help because the local anaesthetic dulled the pain initially. It had an effective life span of two days. It was then that I knew surgery was the only outcome for me. I call this a positive diagnostic outcome. Patients rarely refuse an injection. It is quick to deliver and you can walk away – although a modicum of rest on the day is best. The injection is both therapeutic (treatment) and diagnostic (investigative), i.e, it benefits the patient by showing how significant the nerve damage is. In my book on shoulder pain, where I write about my personal experience, steroid treatment has been highly effective and lasting, but took around six weeks to offer benefit.

More guidebooks for patients, broadening factsheets with a deeper understanding of treatment and the value of steroid injections. Published 2025.

Why Don't Steroids Work

Like all treatments, failure to understand the value of this drug, based on a powerful anti-inflammatory medicine, will only add to the problem. Where a site has no infection, the goal is to reduce inflammatory activity, which can include reducing fluid accumulation around a problem area, such as a joint, tendon, or deeper tissue.

The best analogy is someone trying to bail water from the bottom of a boat with a bucket of water. There comes a time when the hole allowing water in overpowers the effect of the bailer. You cannot use steroids alone to deal with all problems. There has to be a fighting chance.

The second aspect is the size of the problem, or pathology. The body is brilliant at self-repair, and steroid injectables can certainly support healing, but by reducing fluid. An additional method may be required to help, and this includes rest. Going out and running or actively moving a part already inflamed won't help.

Steroids do not work instantly; they require time, often 2-6 weeks. Therefore, during this period, we need to respect the part in play. Rest and changing our routine.

Returning to the plantar digital neuroma, research indicates that once the problem reaches a specific size, the chances of resolution diminish.

Repeat injections

Because steroids are powerful, they will also weaken structures, and so overuse is poor practice. This is where the story of the tendon rupture arises. Steroid injections can be repeated, but only over time. A second injection, where the first fails, is unlikely to bring additional benefit. However, it is not negligent if a repeat injection is attempted, but one must be aware that it might not be effective. In my book - shoulder pain/rotator cuff, I discuss the use of steroids for my own shoulder problem. The left side was injected a second time after the first failed, and this lasted indefinitely. It had been a long shot, but the ultrasound image showed fluid and that was targetted.

Moral of the Tale

Steroid injections for MSK problems are an essential part of management, but may not be the only solution, and can support repair.

The failure of a steroid does not mean that the clinician was wrong; in some cases, failure allows us to determine that the condition may require alternative treatment, including surgery. The repeated use of steroids is not recommended, but patients do not need to fear having such treatment. They only work for a short period, which may be too brief for the medication to be effective.

Thanks for reading about Steroid Injections in the Foot. I hope this brings a better understanding of the value of MSK care.

ConsultingFootPain is part of Busypencilcase Communications & Publishing Est. 2015.