Hit and miss: The accuracy of intra-articular injections of the first metatarsophalangeal joint





steroid injection, injection accuracy, synovial joint, hallux limitus


Introduction: Therapeutic injections provide a treatment option for patients with joint and periarticular pain, those who are not surgical candidates, whom conservative treatment has failed, or those that are awaiting surgery.  Injectable glucocorticoids are one of the most common therapeutic interventions in musculoskeletal healthcare and are widely used in pathologies of the first metatarsophalangeal joint.  The aim of this paper is to highlight current concepts around first metatarsophalangeal joint injection injection accuracy.

Anatomy: The first metatarsophalangeal joint is a condyloid synovial juncture and consists of the head of the first metatarsal, the base of the proximal phalanx, six muscles, eight ligaments and two sesamoid bones, with associated ligamentous attachments.  The joint capsule is shaped like a box.

Methods: To achieve the research aim, a scoping review was undertaken with a search strategy that identified evidence via the following sources: Electronic databases, Google scholar, and Reference lists. 

Results: The search yielded 193 articles, 48 of which appeared of potential relevance.  After removing duplicate articles this total was reduced to 37 articles.  After scanning the content, 27 were excluded to leave 10 articles. Twenty eight further articles were found through related author research, examination of reference  lists and free text searches of Google Scholar.  One reference was unobtainable.  The final count of papers utilised for review was 37 which produced three themes, one of which was injection accuracy.

Injection accuracy: In the long history of injection therapy, infiltrations have often been performed without image guidance, i.e., using palpation guidance, anatomical landmarks and clinical judgement to direct needle entry and advancement.  Needle placement may also be confirmed by use of diagnostic imaging.  Typical imaging modalities are fluoroscopy or ultrasound, used alone or in combination with contrast media.

Discussion: The perceived wisdom is that if an injectate misses its target it is likely to be less effective and lead to false negative reporting of poor treatment outcomes, but the literature is not equivocal.  This article discusses the recent literature in the field.

Conclusions: The literature suggests that steroid injections are safe and effective for the short-term relief of joint pain.  When injecting small synovial joints using palpated-guided methods, clinicians must be alert to the potential for failure of technique from the needle penetrating too far into the articulation and exiting the joint on the contralateral side from the entry point.  Use of shorter needles and use of imaging, +/- the use of contrast media, might reduce the number of such failures.


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How to Cite

Reilly IN. Hit and miss: The accuracy of intra-articular injections of the first metatarsophalangeal joint. J Int Foot Ankle [Internet]. 2022 Nov. 1 [cited 2024 Jul. 13];1(11). Available from: https://internationalfootankle.org/journal/index.php/JIFAF/article/view/38