What are the treatment options for a reaction to a cortisone (corticosteroid) injection in the foot?

Management of Corticosteroid Injection Reactions in the Foot

For a reaction to a cortisone injection in the foot, immediately stop any further injections, assess the severity of symptoms, and treat mild reactions (pain, swelling, redness) with ice, NSAIDs, and observation, while moderate-to-severe reactions (hypotension, respiratory symptoms, widespread urticaria) require immediate epinephrine 0.3 mg IM, IV fluids, and emergency medical evaluation. 1

Immediate Assessment and Classification

When a patient presents with a reaction following foot corticosteroid injection, rapidly classify the severity:

Mild Reactions

• Localized injection site pain, swelling, or erythema 2
• Pruritus limited to injection area 1
• Facial flushing or sweating (common steroid side effect) 1
• Back pain or joint pain 1

Moderate Reactions

• Mild symptoms PLUS transient cough, shortness of breath, or tachycardia 1
• Hypotension (drop in systolic BP ≥30 mmHg from baseline or SBP ≤90 mmHg) 1
• Localized urticaria spreading beyond injection site 1

Severe/Life-Threatening Reactions (Anaphylaxis)

• Sudden onset with rapid symptom intensification 1
• Loss of consciousness 1
• Angioedema of tongue or airway 1
• Involvement of two or more organ systems (cardiovascular, respiratory, skin, gastrointestinal) 1

Treatment Protocol by Severity

For Mild Reactions

Stop any ongoing treatment and monitor for 15 minutes. 1 Most mild reactions are self-limiting and resolve spontaneously. 1

• Apply ice through a wet towel for 10-minute periods to reduce pain and swelling 3, 4
• Administer oral NSAIDs for pain relief (topical NSAIDs preferred to avoid gastrointestinal side effects) 3, 4
• Maintain IV access with normal saline at keep-vein-open rate if in clinical setting 1
• Continue monitoring vital signs (BP, pulse, respiratory rate, O2 saturation) until stable 1

If symptoms persist beyond 15 minutes or worsen: Consider IV hydrocortisone 100-500 mg (or equivalent) and IV H2 antagonist such as famotidine 20 mg. 1

For Moderate Reactions

Immediately stop any injection, switch IV line to normal saline, and notify physician. 1

• Recline patient onto back if hypotensive 1
• Administer NS bolus of 1000-2000 mL for hypotension 1
• Give oxygen by mask or nasal cannula if hypoxemic 1
• Administer IV corticosteroid: hydrocortisone 100-500 mg IV 1
• Consider IV H2 antagonist: famotidine 20 mg IV 1
• Monitor continuously for at least 15 minutes and reassess 1

Symptom-directed treatment:

• For nausea: ondansetron 4-8 mg IV 1
• For urticaria: second-generation antihistamine (loratadine 10 mg PO or cetirizine 10 mg IV/PO) 1
• Avoid first-generation antihistamines like diphenhydramine as they can exacerbate hypotension, tachycardia, and sedation 1

For Severe Reactions/Anaphylaxis

Immediately call emergency services or resuscitation team. 1

• Administer epinephrine (1 mg/mL) 0.3 mg IM into anterolateral mid-thigh immediately 1
• May repeat epinephrine once if no improvement 1
• Recline patient flat and elevate legs 1
• Administer aggressive IV fluid resuscitation: NS bolus 1000-2000 mL 1
• Provide high-flow oxygen 1
• Consider β2 agonist nebulizer: albuterol 0.083% via nebulizer for bronchospasm 1
• Continuous monitoring of vital signs 1

Post-Reaction Management

Patient Education on Delayed Reactions

Educate patients that delayed reactions can occur hours to days after injection, including: 1

• Flu-like symptoms, arthralgias, myalgias, and fever (typically lasting up to 24 hours) 1
• These delayed symptoms are easily managed with NSAIDs 1
• Symptoms persisting beyond a few days require medical evaluation to rule out other pathologies 1

Common Injection Site Reactions (Not True Allergic Reactions)

Most injection site reactions are not immunogenic or allergic and include: 2

• Localized pain, swelling, erythema at injection site (reported in 1.3-14% of foot/ankle injections) 1, 5
• "Steroid flare" - temporary worsening of pain within 24-48 hours post-injection 5
• These reactions do not correlate with drug efficacy or development of antidrug antibodies 2

Management of steroid flare: Ice application, oral NSAIDs, and reassurance that symptoms typically resolve within 48 hours. 3, 4

Critical Safety Considerations

Prevention of Future Reactions

• Never inject corticosteroids directly into tendon substance - only peritendinous injection is safe, as intratendinous injection reduces tensile strength and predisposes to spontaneous rupture 3, 6, 4
• Use ultrasound guidance to ensure proper anatomical placement and avoid neurovascular structures 6, 7
• Limit to maximum 2-3 corticosteroid injections before considering alternative treatments 6

Serious Complications (Rare)

While rare, be aware of potential serious complications: 1, 5

• Infection (extremely rare - no infections reported in series of 365 foot/ankle injections) 5
• Plantar plate rupture (reported in <1% of cases) 5
• Transient sciatic nerve block from anterior capsular disruption (can occur with sacroiliac injections) 1

Systemic Corticosteroid Effects

Even with local injection, systemic absorption can occur, potentially causing: 1, 8

• Hyperglycemia (particularly important in diabetic patients) 1
• Immunosuppression with increased infection risk 1, 8
• Hypothalamic-pituitary axis suppression 1
• Decreased bone mineral density with prolonged use 1

When Reactions Are NOT Contraindications to Treatment

Important: Most injection site reactions (pain, swelling, erythema) are not true allergic reactions and do not necessitate discontinuation of corticosteroid therapy. 2 Misunderstanding the pathophysiology may result in unnecessary treatment discontinuation. 2

However, true anaphylaxis is an absolute contraindication to future use of that specific corticosteroid formulation. 1