Syringe vs symptoms: what steroid injections really offer in foot and ankle osteoarthritis | Find Your Stride | Edinburgh Podiatrist
- Joshua Francois
- 3 days ago
- 4 min read
A look at steroid injections for foot and ankle osteoarthritis
Foot and ankle osteoarthritis (OA) is common, performance-limiting, and often painful in push-off phases that matter to runners and field-sport athletes. In clinic, steroid injections are frequently used to “calm inflammation” and "buy a training window". This new systematic review and meta-analysis asks a simple question: what is the actual randomised-trial evidence for intra-articular corticosteroid injections in foot and ankle OA?
What the review did
Searched major databases and trial registries to June 2024 for randomised or quasi-randomised trials in adult foot/ankle OA, with outcomes in pain, function, QoL, safety, or cost-effectiveness.
Found only two randomised controlled trials (total n=57). Both were single-centre, published in 2023, and graded “some concerns” for risk of bias.
What the two trials showed
First MTP joint OA (hallux rigidus), single injection: corticosteroid (methylprednisolone + lidocaine) versus prolotherapy (dextrose + lidocaine) showed no between-group differences in pain or function across 8 weeks. Both groups improved similarly, and without a placebo arm we can’t separate true treatment effect from regression to the mean or contextual effects.
Post‑traumatic subtalar OA, series of three weekly injections: corticosteroid alone versus corticosteroid plus hyaluronic acid. The combo group reported lower pain and better function at 12 and 24 weeks; no difference at 4 weeks. Importantly, there was no arm with hyaluronic acid alone, and sample sizes were tiny (12–13 per group). This leaves open whether the benefit came from HA, the series dosing, or simply expectation effects plus time.
No included study compared corticosteroid to placebo in foot/ankle OA, and neither reported quality-of-life or cost-effectiveness. Adverse events were minimal in the short follow-up windows.
Strengths worth acknowledging
Pre-registered protocol and Cochrane-consistent methods.
Clear reporting of the evidence gap rather than overreaching on conclusions.
Transparent risk-of-bias appraisal and pragmatic narrative synthesis (meta-analysis wasn’t possible).
Key limitations that matter in sports practice
Evidence base is wafer-thin: two small RCTs with heterogeneous joints, injectates, and dosing schedules; no placebo control; underpowered for clinically meaningful differences.
No performance-oriented endpoints: gait mechanics, push-off power, run tolerance, or return-to-sport timelines were not evaluated.
Short follow-up in the MTPJ study; subtalar study’s signal appears after three injections and at 12–24 weeks—hard to generalize to single-shot “quick fix” expectations.
Safety is under-described. While no major events were reported, known potential risks (chondrotoxicity, fat pad atrophy, infection, tendon effects) weren’t powered for detection here and remain relevant for athletes who repetitively load forefoot and hindfoot structures.
What this means for athletes and clinicians
For first MTPJ OA, a single corticosteroid injection does not outperform an active comparator by 8 weeks—and we still don’t know if it beats placebo. Expectation of a reliable, short-term “reset” is not evidence-backed.
For subtalar OA after trauma, three weekly injections of steroid plus hyaluronic acid outperformed steroid alone at 12–24 weeks. If you are considering injections for hindfoot OA, this points toward:
Series dosing over a one-off jab.
Considering HA co-administration in protocols, with informed discussion that we don’t know whether HA alone could do the same.
Don’t extrapolate from knee OA. Joint-specific biomechanics and cartilage biology matter; the foot and ankle are not small knees.
Practical counselling for the running and sport population
Set expectations:
Pain relief is uncertain for MTPJ with a single steroid shot; any benefit, if present, is likely short term.
For subtalar OA, if injections are pursued, discuss a series and the potential role of HA; plan re-evaluation at 12 weeks.
Keep injections adjunctive, not standalone:
Couple with load management (step count and run intensity caps), footwear tuning (rocker soles for MTPJ OA; rearfoot stability for subtalar OA), orthoses targeting sagittal plane facilitation, and strength work (intrinsics, calf-soleus complex, hip extension).
Use objective milestones: pain during/after a 2–3 km easy run, 24–48 hr symptom echo, hop testing asymmetry, and walk-to-run progression.
Timing for competition:
Avoid injections inside a 2–3 week window before key races. Post-injection load spikes may mask pain without improving tissue capacity.
Frequency and risk:
Limit repeat steroids; if a first shot “fails,” don’t reflexively chase diminishing returns. Consider diagnostic clarity (joint source vs. periarticular pain), imaging guidance, or alternate strategies (HA alone, PRP in select cases, surgical pathways).
Imaging guidance:
Especially for subtalar and midfoot targets, guidance can improve accuracy; the review couldn’t assess this, but practice standards and anatomic complexity support it.
For researchers and guideline writers
The field needs adequately powered, placebo-controlled, joint-specific RCTs that include:
Athlete-relevant outcomes: run tolerance, return-to-sport timelines, sensor-based load metrics, and gait parameters alongside pain/function scales.
Comparators that matter: HA alone, series vs single dosing, image guidance vs landmark.
Safety surveillance beyond 6–12 weeks, including cartilage status and fat pad integrity.
Cost-effectiveness in real-world sports and working-age populations.
Bottom line
Current randomised evidence is insufficient to endorse routine corticosteroid injections for foot and ankle OA in athletes.
If injections are used, frame them as a short, conditional adjunct within a structured load and rehab plan, and consider a series with HA for subtalar OA—with clear disclosure that evidence is preliminary and joint-specific.
For first MTPJ OA, prioritise footwear-rocker strategies, orthoses, progressive loading, and run-program modifications; reserve injections for refractory flares and specific event timing, with sober expectations.
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Citation
Jones K, Lewis TL, Nolan CN, Munteanu SE, Menz HB, Backhouse MR, Bruce J. Intra-articular corticosteroid injections for the treatment of people with foot and ankle osteoarthritis: a systematic review. Rheumatology Advances in Practice. 2025;9(2):rkaf030. doi:10.1093/rap/rkaf030. Advance access 11 March 2025.
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