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.

“If the time off is not available, then the risk of injury to the athlete goes up with the rapid return to activities,” cautions Dr. Lowe. “In the highly paid athlete, if injury occurs post-injection, then it will appear to be your fault, not the athlete’s, and there is not enough malpractice insurance to cover most of those salaries earned in the NBA today.”

In a similar vein, Dr. Richie considers the urgency for rapid healing versus a situation in which time for recovery is not a factor. In addition, the patient’s specific pathology affects his decision about using a corticosteroid injection, adding that he is reluctant to inject the Achilles and the tibialis anterior tendon. When there is no deformity, Dr. Richie says he may inject the posterior tibial tendon and has no reservation about injecting the peroneal tendons or the extensor tendons around the foot and ankle. Dr. Richie says he has the least concern about injecting the plantar fascia in athletes.

For Dr. Saxena, one factor is the inability to resolve symptoms with non-injection therapies. He says he will sometimes try physical therapy modalities, iontophoresis and phonophoresis initially.

Dr. Lowe and Dr. Losito both consider the history of previous injections. Dr. Lowe says previous injections will add up to ongoing tissue changes and raise the patient’s risk of degenerative changes to structure/collage tissue that can cause tissue failure. National Basketball Association (NBA) athletes with a history of multiple injections done during the season have asked Dr. Lowe for injections prior to game time. For example, Dr. Lowe notes that multiple injections of a corticosteroid for chronic fasciitis (which in reality may be a degenerative fasciosis), will certainly lead to more trauma (rupture).

Q: Are there misconceptions about steroid injections for athletes in the medical community and in the athletic community?
A: Dr. Richie points to a misconception about the healing attributes of a steroid injection versus the perceived “quick fix” of such a treatment. He notes that corticosteroids can block the essential stages of inflammation (tendinitis) and degeneration (tendinosis) of the tendon. With appropriate adjunctive therapy, corticosteroids can be an effective treatment for tendon injury in the athlete, according to Dr. Richie.

“I do not think a steroid injection is a magic bullet,” adds Dr. Pribut. “There is much to be said though about eliminating pain and regaining a normal motion within a biomechanical structure.”

Dr. Pribut cites Lemont’s recent terminology designating much of the plantar heel pain syndrome as a non-inflammatory problem termed plantar fasciosis. With this study in mind, Dr. Pribut says one should keep in mind that while corticosteroid injections may be helpful, the relief afforded appears to be from factors other than their anti-inflammatory effects.2

“I truly believe we really do not understand the full extent to which corticosteroid injections work,” comments Dr. Lowe.

Dr. Lowe questions whether the injection solely suppresses inflammation or if it involves connective tissue adhesions between tendon and pertendinous tissue by inhibiting collagen production and granulation tissue production. He says corticosteroid injection must also have some effect on stimulating nociceptors via the chemical released by the damaged tissue. Dr. Lowe adds that if the nociceptor is covered over or inhibited, the athlete really does not have a normal protective response to the injury.

Dr. Losito has observed two misconceptions originating with the public. The first is that one should avoid any steroid injection “like the plague.” Second, he notes a misconception, shared by some physicians, that one can safely give steroid injections three times a year in the same area.

As Dr. Saxena notes, some practitioners are “overly afraid of using” catabolic steroids via injection but conversely, others sometimes administer the injections in an unsafe manner. He says practitioners should have documentation ready for elite athletes who may be drug-tested as false positives for anabolic steroids can occur after the therapeutic injections.

Q: Do you think steroid injections are overutilized in athletes?
A: Drs. Losito and Lowe both feel steroids are used too frequently in athletes. Dr. Losito says they are “significantly overused.” When he has given steroid injections to athletes, Dr. Lowe notes he has done so “very carefully and only with well informed discussion among the athlete, doctor and trainer of expectations, workout requirements and follow-up of any discomfort or changes post-injection.”

In contrast, Drs. Saxena and Richie do not feel steroids are utilized too much. “There is probably a paranoia, which is unfounded, about the local use of corticosteroids in the treatment of injuries in the athlete,” argues Dr. Richie.

Dr. Richie says practitioners would be more cautious about using injectable steroids in an athlete versus a sedentary patient when the opposite scenario is actually true.

“There may be a misconception about the use of local injection of steroids in the athlete due to publicity about abuse of systemic steroids in this population,” he notes. “Athletic patients are probably a better risk for use of injectable corticosteroids for musculoskeletal injury than less healthy, sedentary patients.”

He reminds practitioners that local steroid injections are contraindicated in patients who are at risk for tendon injury. These patients include those with hyperlipidemia, diabetes, those who are overweight and smokers.

While many practitioners use steroids and some may use them too often, Dr. Pribut says they “are used in this manner at even the highest levels of competition.”

“We all see too many patients who come in telling us they know of someone who had the same problem as they did, be it an Achilles tendon issue or plantar heel pain. Their friend reportedly had one ‘cortisone’ injection and it was cured,” notes Dr. Pribut. “Recently, I had a patient with a partial avulsion of his Achilles tendon state he had a friend tell him that he also had a ‘spur’ on his heel that was cured with one injection of ‘cortisone.’ However, the patient remains in his pneumatic walker and is doing quite well.”

Dr. Pribut also does not recommend an approach based on the premise that if an injection does not work, one will fix the problem with surgery. However, Dr. Saxena says if a problem can be taken care of surgically with a good chance of success, then one should consider surgery. Injections will not take away a loose body in the ankle or a continually painful accessory navicular, notes Dr. Saxena.

Q: Is your use of steroid injections different for an athletic patient compared to the non-athletic patient?
A: Several panelists indicate different approaches to athletes and non-athletes. Dr. Richie says he is “far more inclined” to use corticosteroids to treat an athletic injury than to treat a similar injury in a sedentary patient.

Dr. Saxena says there is a need to hold athletes back from plantar fascia injections and that athletes also must not jump or run for two weeks.

As Dr. Losito reiterates, the two basic differences in treatment are that he will not use steroid injections in athletes initially and that he will use a moderate acting preparation for athletes.

Although athletes and non-athletes do have some of the same restrictions, such as the fact that neither will get an injection in the Achilles tendon, Dr. Lowe notes that non-athletes can take time off and allow an inflammatory site more time to heal as opposed to an athlete in mid-season. He notes that one can easily inject an arthritic patient intraarticularly without a concern of returning such a patient to high-velocity activities. As he cautions, athletes should not immediately return to activity due to proprioceptive/nociceptive changes, which will only permit more trauma on an already inflamed or injured tissue.

“The injury is always more than just inflammation,” says Dr. Lowe. “It also involves restoration of the injured tissue and the kinetic environment.”

Dr. Pribut says he probably uses steroids less than most practitioners in both athletes and non-athletes. He notes there seems to be a trend toward less use of steroids among various practitioners.

Q: What type of steroid do you use when performing injections?
A: Drs. Saxena and Losito both use Celestone Soluspan, with the latter preferring a 0.5 cc dosage. Dr. Saxena uses 1.5 cc for plantar fasciitis and 1 cc for neuromas. Dr. Richie says he prefers Celestone Soluspan’s combination of a short-acting phosphate and a long-acting acetate, saying he uses 0.5 cc for plantar fasciitis and 0.25 cc for neuromas.

Dr. Lowe prefers using 10 mg/cc of triamcinolone (Kenalog, Bristol-Myers Squibb), which he says provides a more intermediate action than a phosphate.

Dr. Pribut prefers using both soluble and semi-soluble steroids.

Q: Do you ever use oral steroid therapy for athletic injuries?
A: Occasionally, Dr. Losito will use methylprednisolone (Medrol Dose Pack, Pfizer) if an injectable steroid is inappropriate for the patient or if symptoms are not focused in a distinct area.

Dr. Pribut says he would use oral steroids for a cross-country runner who has run into a poison ivy patch and had a gout attack. However, he says it has not often been necessary to use oral steroids for athletic injuries.

Dr. Richie is reluctant to treat athletes with systemic steroids. He cites reports of a loss of bone density with short-term doses of systemic corticosteroids. Dr. Richie prefers local injections since the effects tend to remain local and there are minimal systemic implications.

Oral steroid use is “extremely rare” for Dr. Saxena. He cites a recent survey in the British Journal of Sports Medicine, which notes that most orthopedic sports medicine specialists do not use oral steroids since they fear causing avascular necrosis, and the study indicated an incidence of the condition of 10 percent.3

Although Dr. Lowe does not use oral steroids, he often sees others using them. Although he has seen such steroids given infrequently in athletes, Dr. Lowe says orthopedists usually do give oral steroids for intevertebral disc herniation.

References:

1. Iwanami K. Intratendinous corticosteroid injection induces apoptosis of the rat tendon fibroblasts. Journal of Medical Sciences 32 (1), pp. 39-46, 2005
2. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003 May-Jun;93(3):234-7.
3. Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med 41:211-216, 2007.