Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety.
Evidence Acquisition:
An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles.
Study Design:
Clinical review.
Level of Evidence:
Level 4.
Results:
Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results.
Conclusions:
Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.
AbbasianMBaghbaniSBarangiS, et al. Outcomes of ultrasound-guided gastrocnemius injection with botulinum toxin for chronic plantar fasciitis. Foot Ankle Int. 2020;41:63-68.
2.
Acosta-OlivoCElizondo-RodriguezJLopez-CavazosRVilchez-CavazosFSimental-MendiaMMendoza-LemusO.Plantar fasciitis—a comparison of treatment with intralesional steroids versus platelet-rich plasma: a randomized, blinded study. J Am Podatri Med Assoc. 2017;107:490-496.
3.
AhmadJAhmadSHJonesK.Treatment of plantar fasciitis with botulinum toxin: a randomized, controlled study. Foot Ank Int. 2017;38:1-7.
4.
AkşahinEDoğruyolDYükselHY, et al. The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012;132:781-785.
5.
AltmanRDLattaLKeerRRenfreeKHornicekFBanovacK.Effect of nonsteroidal antiinflammatory drugs on fracture healing: a laboratory study in rats. J Orthop Trauma. 1995;9:392-400.
6.
AokiK.Review of a proposed mechanism for the antinociceptive action of botulinum toxin type A. Neurotoxicology. 2005;26:785-793.
7.
ÅströmM.Partial rupture in chronic Achilles tendinopathy: a retrospective analysis of 342 cases. Acta Orthop Scand. 1998;69:404-407.
8.
BaxterJDForshamPH.Tissue effects of glucocorticoids. Am J Med. 1972;53:573-589.
9.
BoesenAPHansenRBoesenMIMalliarasPLangbergH.Effect of high-volume injection, platelet-rich plasma, and sham treatment in chronic midportion Achilles tendinopathy: a randomized double-blinded prospective study. Am J Sports Med. 2017;45:2034-2043.
10.
BoswellSGSchnabelLVMohammedHOSundmanEAMinasTFortierLA.Increasing platelet concentrations in leukocyte-reduced platelet-rich plasma decrease collagen gene synthesis in tendons. Am J Sports Med. 2014;42:42-49.
CardoneDATalliaAF.Joint and soft tissue injection. Am Fam Physician. 2002;66:283-288.
15.
ChenCMLeeMLinCHChangCHLinCH.Comparative efficacy of corticosteroid injection and non-invasive treatments for plantar fasciitis: a systematic review and meta-analysis. Sci Rep. 2018;8:4033.
16.
ChowSBrandserE.Diagnostic and therapeutic foot and ankle injections. Semin Musculoskelet Radiol. 1998;2:421-432.
17.
ColeBJSchumacherJrRH. Injectable corticosteroids in modern practice. J Am Acad Orthop Surg. 2005;13:37-46.
18.
de JongeSde VosRJWeirA, et al. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011;39:1623-1630.
19.
de VosRJWeirATolJVerhaarJWeinansHVan SchieH.No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy. Br J Sports Med. 2011;45:387-392.
20.
DicksonECShevkyR.Botulism. Studies on the manner in which the toxin of clostridium botulinum acts upon the body: I. The effect upon the autonomic nervous system. J Exp Med. 1923;37:711-731.
21.
DietzelDPHedlundEC.Injections and return to play. Curr Sports Med Rep. 2004;3:310-315.
22.
DordoniPVenturaMDStefanelliA, et al. Effect of ketorolac, ketoprofen and nefopam on platelet function. Anaesthesia. 1994;49:1046-1049.
23.
DrakosMBirminghamPDelosD, et al. Corticosteroid and anesthetic injections for muscle strains and ligament sprains in the NFL. HSS J. 2014;10:136-142.
24.
DugowsonCEGnanashanmugamP.Nonsteroidal anti-inflammatory drugs. Phys Med Rehab Clin. 2006;17:347-354.
25.
FarquharWMorganAZambraskiEKenneyW.Effects of acetaminophen and ibuprofen on renal function in the stressed kidney. J Appl Physiol. 1999;86:598-604.
26.
FetterolfDESnyderRJ.Scientific and clinical support for the use of dehydrated amniotic membrane in wound management. Wounds. 2012;24:299-307.
27.
FitzpatrickJBulsaraMKMcCroryPRRichardsonMDZhengMH.Analysis of platelet-rich plasma extraction: variations in platelet and blood components between 4 common commercial kits. Orthop J Sports Med. 2017;5:2325967116675272.
28.
FlandersMTischlerAWiseJWilliamsFBeneishRAugerN.Injection of type A botulinum toxin into extraocular muscles for correction of strabismus. Can J Opthomol. 1987;22:212-217.
29.
FréchetteJPMartineauIGagnonG.Platelet-rich plasmas: growth factor content and roles in wound healing. J Dent Res. 2005;84:434-439.
30.
FreireVBureauNJ.Injectable corticosteroids: take precautions and use caution. Semin Musculoskelet Radiol. 2016;20:401-408.
31.
GiannoudisPMacDonaldDMatthewsSSmithRFurlongADe BoerP.Nonunion of the femoral diaphysis: the influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br. 2000;82:655-658.
32.
GriceJMarslandDSmithGCalderJ.Efficacy of foot and ankle corticosteroid injections. Foot Ankle Int. 2017;38:8-13.
33.
GrossCEHsuARChahalJHolmesGBJr.Injectable treatments for noninsertional Achilles tendinosis: a systematic review. Foot Ankle Int. 2013;34:619-628.
34.
HainlineBDermanWVernecA, et al. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med. 2017;51:1245-1258.
35.
HallMPBandPAMeislinRJJazrawiLMCardoneDA.Platelet-rich plasma: current concepts and application in sports medicine. J Am Acad Orthop Surg. 2009;17:602-608.
36.
HanselmanAELalliTASantrockRD.Topical review: use of fetal tissue in foot and ankle surgery. Foot Ankle Spec. 2015;8:297-304.
37.
HanselmanAETidwellJESantrockRD.Cryopreserved human amniotic membrane injection for plantar fasciitis: a randomized, controlled, double-blind pilot study. Foot Ankle Int. 2015;36:151-158.
HuntKJGeorgeEHarrisAHDragooJL.Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004-2005 to 2008-2009. Clin J Sport Med. 2013;23:278-282.
40.
HuntKJPhisitkulPPiroloJAmendolaA.High ankle sprains and syndesmotic injuries in athletes. J Am Acad Orthop Surg. 2015;23:661-673.
41.
IlancheranSMichalskaAPehGWallaceEMPeraMManuelpillaiU.Stem cells derived from human fetal membranes display multilineage differentiation potential. Biol Reprod. 2007;77:577-588.
42.
IrvinJDanchikCRallJ, et al. Bioactivity and composition of a preserved connective tissue matrix derived from human placental tissue. J Biomed Mater Res B Appl Biomater. 2018;106:2731-2740.
43.
JainSKSuprashantKKumarSYadavAKearnsSR.Comparison of plantar fasciitis injected with platelet-rich plasma vs corticosteroids. Foot Ankle Int. 2018;39:780-786.
44.
JardeODieboldPHavetEBouluGVernoisJ.Degenerative lesions of the plantar fascia: surgical treatment by fasciectomy and excision of the heel spur. A report on 38 cases. Acta Orthop Belg. 2003;69:267-274.
45.
JohnT.Human amniotic membrane transplantation: past, present, and future. Ophthalmol Clin North Am. 2003;16:43-65.
46.
KantrowitzDEPadakiASAhmadCSLynchTS.Defining platelet-rich plasma usage by team physicians in elite athletes. Orthop J Sports Med. 2018;6:2325967118767077.
47.
KerlanRGlousmanR.Injections and techniques in athletic medicine. Clin Sports Med. 1989;8:541-560.
48.
KiblerWBGoldbergCChandlerTJ.Functional biomechanical deficits in running athletes with plantar fasciitis. Am J Sports Med. 1991;19:66-71.
49.
KmiecikGNiklińskaWKućP, et al. Fetal membranes as a source of stem cells. Adv Med Sci. 2013;58:185-195.
50.
KudaşSDönmezGIşıkÇÇelebiMÇayNBozkurtM.Posterior ankle impingement syndrome in football players: case series of 26 elite athletes. Acta Orthop Traumatol Turc. 2016;50:649-654.
51.
LaverLCarmontMRMcConkeyMO, et al. Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial. Knee Surg Sports Traumatol Arthrosc. 2015;23:3383-3392.
52.
LeadbetterW.Anti-inflammatory therapy in sports injury. The role of nonsteroidal drugs and corticosteroid injection. Clin Sports Med. 1995;14:353-410.
53.
LeeTGAhmadTS.Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int. 2007;28:984-990.
MaffulliN.Rupture of the Achilles tendon. J Bone Joint Surg Am. 1999;81:1019-1036.
56.
MamedeACCarvalhoMAbrantesAMLaranjoMMaiaCBotelhoM.Amniotic membrane: from structure and functions to clinical applications. Cell Tissue Res. 2012;349:447-458.
57.
MarxRE.Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg. 2004;62:489-496.
58.
MatavaMBraterDCGritterN, et al. Recommendations of the National Football League Physician Society Task Force on the use of Toradol® ketorolac in the National Football League. Sports Health. 2012;4:377-383.
59.
MetcalfeDAchtenJCostaML.Glucocorticoid injections in lesions of the Achilles tendon. Foot Ankle Int. 2009;30:661-665.
60.
MolloyTWangYMurrellGA.The roles of growth factors in tendon and ligament healing. Sports Med. 2003;33:381-394.
MouhsineECrevoisierXLeyvrazPAkikiADutoitMGarofaloR.Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement. Knee Surg Surg Traumatol Arthrosc. 2004;12:250-253.
63.
NeppleJJMatavaMJ.Soft tissue injections in the athlete. Sports Health. 2009;1:396-404.
64.
NicholsAW.Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005;15:370-375.
65.
OrchardJW.Benefits and risks of using local anaesthetic for pain relief to allow early return to play in professional football. Br J Sports Med. 2002;36:209-213.
66.
OrchardJW.Is it safe to use local anaesthetic painkilling injections in professional football?Sports Med. 2004;34:209-219.
67.
OrchardJWSteetEMasseyADanSGardinerBIbrahimA.Long-term safety of using local anesthetic injections in professional rugby league. Am J Sports Med. 2010;38:2259-2266.
68.
PhillipsWJCurrierBL.Analgesic pharmacology: II. Specific analgesics. J Am Acad Orthop Surg. 2004;12:221-233.
69.
RachulCRaskoJECaulfieldT.Implicit hype? Representations of platelet rich plasma in the news media. PLoS One. 2017;12:e0182496.
70.
ReadM.Safe relief of rest pain that eases with activity in achillodynia by intrabursal or peritendinous steroid injection: the rupture rate was not increased by these steroid injections. Br J Sports Med. 1999;33:134-135.
71.
RibohJSaltzmanBYankeAFortierLColeB.Effect of leukocyte concentration on the efficacy of platelet-rich plasma in the treatment of knee osteoarthritis. Am J Sports Med. 2016;44:792-800.
72.
RobinsonPBollenSR.Posterior ankle impingement in professional soccer players: effectiveness of sonographically guided therapy. AJR Am J Roentgenol. 2006;187:W53-W58.
73.
SamantPDKaleSYAhmedSAsifAFefarMSinghSD.Randomized controlled study comparing clinical outcomes after injection botulinum toxin type A versus corticosteroids in chronic plantar fasciitis. Int J Res Orthop. 2018;4:672-675.
74.
SamraDJSmanADRaeKLinklaterJRefshaugeKMHillerCE.Effectiveness of a single platelet-rich plasma injection to promote recovery in rugby players with ankle syndesmosis injury. BMJ Open Sport Exerc Med. 2015;1:e000033.
75.
SawyerGAAndersonBCRaukarNPFadalePD.Intramuscular ketorolac injections in the athlete. Sports Health. 2012;4:319-327.
76.
SchrockJBCarverTJKraeutlerMJMcCartyEC.Evolving treatment patterns of NFL players by orthopaedic team physicians over the past decade, 2008-2016. Sports Health. 2018;10:453-461.
77.
SingerAJMynsterCJMcMahonBJ.The effect of IM ketorolac tromethamine on bleeding time: a prospective, interventional, controlled study. Am J Emerg Med. 2003;21:441-443.
78.
SobhaniSDekkerRPostemaKDijkstraPU.Epidemiology of ankle and foot overuse injuries in sports: a systematic review. Scand J Med Sci Sports. 2013;23:669-686.
79.
TetzlaffJE.The pharmacology of local anesthetics. Anesthesiol Clin North Am. 2000;18:217-233.
80.
ThomasJChristensenJKravitzS, et al; American College of Foot and Ankle Surgeons Heel Pain Committee. The diagnosis and treatment of heel pain: a clinical practice guideline—revision 2010. J Foot Ankle Surg. 2010;49:S1-S19.
81.
VadiveluNGowdaAMUrmanRD, et al. Ketorolac tromethamine—routes and clinical implications. Pain Pract. 2015;15:175-193.
82.
VernecASlackAHarcourtPR, et al. Glucocorticoids in elite sport: current status, controversies and innovative management strategies—a narrative review. Br J Sports Med. 2020;54:8-12.
83.
WeiJPNawataMWakitaniS, et al. Human amniotic mesenchymal cells differentiate into chondrocytes. Cloning Stem Cells. 2009;11:19-26.
84.
WeibrichGKleisWKGStreckbeinPMoergelMHitzlerWEHafnerG.Comparison of point-of-care methods for preparation of platelet concentrate (platelet-rich plasma). Int J Oral Maxillofac Implants. 2012;27:762-769.
85.
WerberB.Amniotic tissues for the treatment of chronic plantar fasciosis and Achilles tendinosis. J Sports Med (Hindawi Publ Corp). 2015;2015:219896.
86.
YanRGuYRanJ, et al. Intratendon delivery of leukocyte-poor platelet-rich plasma improves healing compared with leukocyte-rich platelet-rich plasma in a rabbit Achilles tendinopathy model. Am J Sports Med. 2017;45:1909-1920.
87.
ZelenCMPokaAAndrewsJ.Prospective, randomized, blinded, comparative study of injectable micronized dehydrated amniotic/chorionic membrane allograft for plantar fasciitis—a feasibility study. Foot Ankle Int. 2013;34:1332-1339.
