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Foot & Ankle Ultrasound guided injections
We perform diagnostic ultrasound and ultrasound guided steroid injections for a variety of foot & ankle problems. These include:
Frequently asked questions about foot & ankle pain and injections
What injection treatment options are available for foot and ankle pain?
Different injection treatment options are used to manage foot & ankle pain. The type of treatment will depend on the underlying condition, severity, previous treatments and your aims. Generally, there are 4 types of injection options used to manage the different knee conditions mentioned above:
Steroid injections have an anti-inflammatory effect to help reduce the pain and swelling associated with the condition and allow for a more effective rehabilitation program. Intra-articular hyaluronic acid injections aim to support the joint fluid's lubricant and shock absorbent effect. Platelets-rich plasma (PRP) injections have a high concentration of different growth factors that can help the healing process when injected into a joint or tendon. Please click the relevant links to read more about these different treatment options.
When shall I consider a foot or ankle cortisone injection?
Generally, managing most ankle and foot conditions starts with physiotherapy treatment and progressive rehabilitation. The duration of this depends on the condition. If the response from the above is slow or not satisfactory, then an ultrasound-guided cortisone injection may be considered. Injection therapy can be very useful in reducing pain and improving function, allowing for more effective rehabilitation. Injection therapy would be useful, especially if your severe pain interferes with sleep and daily activities. The anti-inflammatory effect from the injection is usually very effective in reducing pain, allowing you to undergo more efficient rehabilitation. We always advise performing foot and ankle injections under ultrasound guidance by an experienced doctor to ensure accurate delivery of the medicine to the targeted area.
What is a cortisone injection?
Corticosteroid (cortisone) is a potent anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis, arthritis and tendinosis). A cortisone injection will reduce the inflammation in the injected area and allow you to manage the condition, usually by undergoing a physiotherapy program. To find out more, please see our FAQs.
Should foot & ankle injections be done under ultrasound guidance?
Yes. This is our routine practice, as there is plenty of evidence supporting the use of ultrasound guidance when performing joint injections. Doing injections under ultrasound/imaging guidance allows for direct visualisation of the needle to ensure accurate placement into the area of pain/inflammation (like a bursa, an arthritic joint or an inflamed tendon sheath). Ultrasound guidance results in more accurate, less painful and faster procedures, with better outcomes than these injections without guidance. Ultrasound guidance avoids any sensitive structures (like nerves and vessels) during the procedure.
Are foot cortisone injections safe?
Yes, generally these injections are very safe and routinely done in our practice. There is a very small risk of infection (about 1:10.000). The procedure will be explained to you in detail during your appointment and all your questions will be addressed. To find out more about cortisone injection in general, please see our FAQs.
What are the commonly used steroid medicines in foot & ankle injections?
The commonly used types of steroid injections for musculoskeletal conditions are triamcinolone (Kenalog) and methylprednisolone (Depo-medrone). These preparations are long-acting steroid injections that normally take a few days to start working.
How long will the effect of a foot cortisone injection last?
Current evidence suggests that cortisone can improve pain and function for up to 3 months, but in some cases, it can last longer. The duration of pain relief depends on the diagnosis and severity of the condition. The steroid injection will provide a window of opportunity to undergo effective rehabilitation and attempt to address the underlying cause to enhance the pain relief achieved from the injection.
How soon will a steroid injection start to work?
A steroid injection usually takes a few days (1-3) before you notice the effect, although sometimes the pain relief can start on the same day. The injected area will often feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection.
What is the benefit of imaging in patients with foot & ankle pain?
Imaging plays a vital role in establishing the correct diagnosis, assessing the condition's severity and deciding the best treatment options. To get the correct diagnosis, you must be assessed by an experienced practitioner (a foot & ankle specialist doctor or an experienced physiotherapist). In most cases, imaging will be needed to confirm the diagnosis and assess the severity of the condition before any treatment decisions. Ultrasound is very useful for assessing the tendons and nerves around the foot and ankle j injection therapy into the ankle and foot joints.
Do steroid injections just hide/mask the pain?
Steroid injections do not just mask or hide the pain, but they act by reducing the inflammation in the targeted area, thus providing a strong and local anti-inflammatory effect to help control the symptoms and allow the patient to manage the condition, usually by undergoing effective rehabilitation.
How many steroid injections can I have?
We advise reducing the number of cortisone injections if possible, by combining any injection therapy with an effective physiotherapy programme to address the underlying cause. Repeated steroid injection into the same area should be avoided if the previous injection was less than 3-4 months ago.
Are foot injections painful?
Pain is very subjective and people have different pain thresholds. The majority of patients experience minimal discomfort during the injection but the corticosteroid is usually mixed with a local anaesthetic (numbing medicine) to enhance the pain relief effect. This will provide immediate pain relief that usually lasts for a few hours. We use ultrasound-guidance to ensure that the procedure is quick and efficient. Ultrasound ensures needle visualisation to choose the safest path for the injection and avoid any important or sensitive structures.
How long should I rest after a foot/ankle injection?
Usually, we advise patients to rest for 48-72 hours after having the injection. The period of rest can cary depending on the underlying condition and the severity of disease. We usually advice a longer period of rest (5-7 days) in cases of Achilles tendon intervention.
Foot & Ankle conditions
Osteoarthritis is a painful degenerative condition characterised by loss of the articular cartilage (the protective layer that covers the joint's bone surface and provides a friction-free surface for joint movement). This can happen due to the normal wear and tear process or previous intra-articular fractures (fractures involving the bones at the joint). Altered foot mechanics that cause increased stress on the joint can also lead to ankle arthritis. The symptoms of ankle osteoarthritis include a feeling of dull ache with possible periods of sharp pain. The pain is usually worse after activities and at the end of the day. This is usually associated with joint stiffness and swelling. To find out more, please see our article about Ankle arthritis.
If your symptoms do not respond to conservative management, an ultrasound-guided steroid injection might be suitable. Steroids are potent anti-inflammatory medications and have been routinely used to manage osteoarthritis. For more information, please see Foot ultrasound-guided steroid injections.
Hallux rigidus/big toe arthritis
Gout is a systemic rheumatological disease. It is due to the deposition of a special type of crystal (urate crystals) within the joint. It is more common in men (up to 9 times more susceptible to Gout) and is also linked to high consumption of red meat and alcohol. Acute Gout attack usually causes acute pain in a single joint (often the big toe), but it can also affect other joints anywhere in the body. To find out more, please see our article about Gout arthritis. Ultrasound-guided steroid injections into a joint or a tendon sheath can help control the symptoms and reduce inflammation if medical treatment is not controlling the disease.
The plantar fascia is a thick band of tissue that runs from underneath the heel bone to the toes. Plantar fasciitis can happen secondary to injury or sudden changes in activity that can put extra stress on the plantar fascia. Plantar fasciitis usually results in burning-type heel pain on the inside and underneath the heel. The treatment options for Plantar fasciitis include rest, physiotherapy exercises and using supportive insoles. To find out more, please see our article about plantar fasciitis.
If conservative management is not controlling the condition, an ultrasound-guided steroid injection might be suitable. For more information, see our article about ultrasound-guided steroid injection. PRP injection is also a treatment option for resistant plantar fasciitis.
Morton’s neuroma is caused by the thickening and irritation of a small nerve (called the plantar interdigital nerve) between the forefoot bones. It can be accompanied by intermetatarsal bursitis (inflammation of a small fluid-filled sac next to the neuroma). It is most common between the 3rd and 4th toes and also can be seen between the 2nd and 3rd toes. It usually causes sharp pain localised to the neuroma, usually at the sole between the toes. Activities and walking and direct pressure over the area usually exacerbate the pain.
Some patients mention a feeling of walking on small pebbles. Please see our article about Morton's neuroma to learn more about the condition.
Ultrasound examination is very useful in assessing forefoot pain when there is suspicion of Morton’s neuroma or bursitis. It also allows for dynamic assessment, in which the radiologist performs certain movements to the toes and observes the appearance of the ultrasound images. This is very useful in establishing the diagnosis of Morton’s neuroma and differentiating it from other conditions that can present with forefoot pain.
If your symptoms do not respond to conservative management, an ultrasound-guided steroid injection might be suitable. Steroids are potent anti-inflammatory medications and can reduces the inflammation associated with Morton’s neuroma and intermetatarsal bursitis. Injecting under ultrasound guidance will ensure accurate medicine delivery into the area. Strong evidence shows that performing these under ultrasound guidance is more ef landmark-guided injections.
Achilles tendinopathy refers to inflammation of the Achilles tendon. Achilles tendon inflammation can be categorised into insertional (lower down) and non-insertional (mid-portion) problems. It can be very restrictive to movement and activities. Ultrasound is very useful in the assessment of the Achilles tendon. First, it will confirm the diagnosis and assess whether the changes are insertional or mid-portion, as the management can differ. It will assess the degree of changes and if there is any tear within the tendon. It will also assess for increased vascularity within the tendon and the deep fat pad. If this is present, then ultrasound-guided high-volume injection can be useful in the treatment. Ultrasound will also assess for heel bursitis, which can be associated with insertional Achilles tendon problems. To find out more, please see our article about Achilles tendinopathy.
What is ultrasound guided high volume Achilles tendon injection?
In this procedure, the radiologist uses ultrasound guidance to inject a mixture of medicine (usually contains numbing medication, normal saline/sterile water and sometimes low dose steroid). This is injected accurately under ultrasound guidance to separate the Achilles tendon from the deep fat pad. There is evidence that patients with Achilles tendinopathy develop small nerves that run from the fat pad into the Achilles tendon, contributing to the pain sensation. This procedure aims to destroy these nerves and thus reduce the pain. To find out more, please see our article about ultrasound guided high volume injection
There are two small bursae (thin-walled fluid sacs) within the heel area that reduce the friction between the Achilles tendon and the bone at the back of the heel (calcaneus). Bursitis mean inflammation of the bursa. This more commonly involves the bursa between the calcaneum and the Achilles tendon (the retrocalcaneal bursa). It is often associated with inflammation of the lower portion of the Achilles tendon (insertional Achilles tendinosis). Heel bursitis can also be seen in inflammatory conditions such as rheumatoid arthritis. To find out more, please see our article about Heel bursitis. Ultrasound-guided heel bursitis steroid injections can be used in resistant cases, not responding to conservative management.
The peroneal tendons consist of two tendons that run at the outer aspect of the ankle, just behind the bony prominence at the outside of the ankle (called the lateral malleolus). These tendons are important for ankle and foot stability and movement. Peroneal tendinopathy means abnormal changes to the tendons and their surrounding layer (called the tendon sheath). This can range from tendon thickening and surrounding inflammation to tendon thinning and tearing. Ultrasound is also very useful to assess the peroneal tendons. To find out more, please see our article about ankle tendinosis.
Ultrasound-guided peroneal tendon sheath steroid injection can be considered for the management of peroneal tendinopathy if the alternative measures are failing. The steroid is injected into the tendon sheath, which is a thin layer of tissue that completely surrounds the tendon to help reduce inflammation. Therefore, it is essential to perform this under ultrasound guidance to ensure accurate placement of the needle to increase efficiency and reduce local side effects.
Tibialis posterior tendinosis
The tibialis posterior tendon forms above the ankle level and descends towards the foot, passing at the inner aspect of the ankle, just behind the bony prominence at the inner aspect of the ankle (called the medial malleolus). The tendon plays an important role in providing support to the arch of the foot. At the ankle level, the tibialis posterior tendon, in particular, is prone to tendinopathy. This means abnormal changes to the tendon (from tendon thickening and surrounding inflammation to tendon thinning and tearing). The condition is more common in females over 40 and is usually related to repetitive stress. To find out more, please see our article about ankle tendinosis. Ultrasound is an excellent modality to assess the tibialis posterior tendon to establish the diagnosis and assess the severity of the changes.
If simple measures are not helping, then an ultrasound-guided tibialis posterior tendon sheath steroid injection can be considered. The steroid is injected into the tendon sheath, which is a thin layer of tissue that completely surrounds the tendon to help reduce inflammation. We always perform injections under ultrasound guidance to ensure accurate delivery of the medicine to the exact site of inflammation.
Foot & Ankle conditions and treatments
The Musculoskeletal Ultrasound & Injections clinic
169 Richmond Road
Kingston upon Thames
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