03/15/2014    Bryan C. Markinson, DPM

Post-Injection Heel Complications (Lawrence Oloff, DPM)

I appreciate Dr. Oloff's response to my recent
post and thank him for his kind reflection about
my prior posts. I have also received several
private e-mails from colleagues expressing intense
disagreement with my contention that soluble
steroid preparations have no utility in podiatric
musculoskeletal treatment. However, it seems as
though my remarks were interpreted as if I stated
that it is wrong or inappropriate to use soluble
steroids. I had no such intention.

In support of Dr. Oloff's charge that my
information is innacurate, he states that he knows
rheumatologists who use the soluble preparations,
which in part is a retort to my observation that
the orthopods and rheumatologists that I know
never use them. Obviously, I did not and do not
mean to speak for all rheumatologists and
orthopods.

In further support of his opinion, Dr. Oloff cites
in part a reference which states the following: "A
short-acting solution, such as dexamethasone
sodium phosphate (Decadron), is less irritating
and less likely to cause a postinjection flare
than a long-acting dexamethasone suspension. "

Well of course! 65% of the injected dose is
excreted in the kidneys within 24 hours. Locally,
the solution is dispersed within one hour. The
kinetics may be a little different with intra-
articular injections, but not much different.

Because of this, I conclude that there is no
utility and the effects that everyone talks about
(in combination preparations) being that the short
acting preparation works by providing relief until
the insoluble takes effect is close to a fantasy
(IMHO). Even if I am dead wrong, I would argue
that the local anesthetic injected with the
cocktail is just as good as the soluble steroid,
but no way does either the soluble part or the
anesthetic give you the 24-48 hour window often
needed for the insoluble to "kick in."

I encourage all of my colleagues to continue to
use soluble steroids alone or in combination if
they believe that they are efficacious. My own
opinions that the use of soluble preparations seem
wasteful is only my opinion, for your
consideration only, and not a critique of anyone
who finds them useful. I apologize for any other
unintended impressions.

Bryan C. Markinson, DPM, NY, NY,
bryan.markinson@mountsinai.org

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