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Indications

This injection procedure is used to diagnose and treat Morton’s metatarsalgia and Morton’s neuroma.

Techniques

After informed consent is obtained, the patient is positioned for optimal access to the dorsal aspect of the foot. The metatarsal joint interspaces are palpated for swelling and tenderness. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1-in. (2-cm), 25-gauge needle is inserted at the point of maximal tenderness, perpendicular to the skin, and advanced about 1 cm. After negative aspiration, a 2-mL mixture of 5 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected (Fig. 67-59).

FIGURE 67-59. Metatarsal joint injection. Approach for metatarsal joint aspiration and injection.

Comments

Morton’s metatarsalgia often involves the first and second interdigital spaces. Morton’s neuroma is neuritis of the plantar digital nerves located between the third and fourth metatarsal heads and occasionally in the nerve between the second FIGURE 67-59. Metatarsal joint injection. Approach for metatarsal joint aspiration and injection. (From Katz J. Atlas of Regional Anesthesia. Norwalk, CT: Appleton & Lange; 1994:93, with permission.) and third metatarsal heads. This procedure is used to treat postoperative scar pain often present after surgical removal of a Morton’s neuroma.

Complications

Serious complications are uncommon with appropriate needle placement.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Metatarsophalangeal joint injection is a useful procedure in the treatment of joint inflammation secondary to rheumatoid arthritis.

Techniques

After obtaining informed consent, the patient is positioned for optimal access to the dorsal surface of the foot. The metatarsophalangeal joints are palpated for swelling and point tenderness. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. Light traction is applied to the toe of the joint to be injected. A ½- to 1-in. (1.5- to 2.5-cm), 25-gauge needle is inserted perpendicular to the skin, directly into the joint space. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration is completed. After negative aspiration or the aspirated fluid is noninflammatory (clear and viscous), the joint is injected with a 0.5-mL mixture of 5 mg of triamcinolone acetate (or equivalent) and local anesthetic (see Fig. 67-58B).

FIGURE 67-58. Foot injections. A: Approach for plantar fasciitis or calcaneal bursitis injection. B: Approach for aspiration and injection of metatarsophalangeal joint.

Comments

These joints are often limited to 0.5 mL of solution. The first metatarsophalangeal joint may be approached from the medial side with the needle advanced tangentially under the extensor tendon.

Complications

Corticosteroids should not be injected if there is any suspicion that the joint is infected. If the fluid appears infected, then it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Retrocalcaneal bursa injection is a useful therapeutic procedure for bursitis secondary to repetitive overuse disorder or rheumatoid arthritis.

Techniques

After informed consent is obtained, the patient is situated in the side lying position. The lateral malleolus and the Achilles tendon are palpated. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 23- to 25-gauge needle is inserted between the lateral malleolus and the Achilles tendon perpendicular to the skin. The needle is advanced slowly to about half the thickness of the width of the Achilles tendon. After negative aspiration, a 2-mL mixture of 2 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected (Fig. 67-57).

FIGURE 67-57. Retrocalcaneal bursa injection. Approach for retrocalcaneal bursa aspiration and injection.

Comments

This disorder may be seen in runners as they increase mileage early in the season or from an improperly fitting running shoe.

Complications

Corticosteroids should not be injected if there is any suspicion that the bursa is infected. If the fluid appears infected, then it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Plantar heel fascia injection is used to treat inflammation at the insertion of the long plantar ligament at the anterior aspect of the calcaneus, secondary to chronic overuse disorder or spondyloarthritides.

Techniques

After informed consent is obtained, the patient is placed in the prone position with the feet extending over the end of the examination table. The plantar aspect of the heel is palpated in the area of the attachment of the plantar fascia to the calcaneus to determine the point of maximal tenderness. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 23- to 25-gauge needle is inserted at the point of maximum tenderness on the plantar surface of the heel, perpendicular to the skin. The needle is gently advanced until the tip touches the underlying bone and then is withdrawn 2 mm. After negative aspiration, a 2-mL mixture of 20 to 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected. If proper palpation of the point of maximal tenderness is difficult, one half of the mixture of local anesthetic and corticosteroid should be injected into the region of maximal tenderness and the remainder injected in a fanwise manner around the plantar fascia attachment (Fig. 67-58A).

FIGURE 67-58. Foot injections. A: Approach for plantar fasciitis or calcaneal bursitis injection. B: Approach for aspiration and injection of metatarsophalangeal joint.

Comments

This is a significantly painful procedure with or without cutaneous anesthesia. After injection, the patient is discouraged from excessive walking until the local anesthetic wears off and is encouraged to wear a heel cushion inside the shoe.

Complications

Serious complications are uncommon with appropriate needle placement.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

Indications

Subtalar joint injection is used to treat inflammation secondary to rheumatoid arthritis and other inflammatory arthritides.

Techniques

After informed consent is obtained, the patient is placed in the prone position with the feet extending over the end of the examination table and the foot flexed to about 90 degrees. The location of the subtalar joint, about 1 to 2 cm distal to the tip of the lateral malleolus and posterior to the sinus tarsus, should be palpated and marked. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21-gauge needle is inserted perpendicular to the skin at the mark and advanced medially into the subtalar joint. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration is completed. If the aspirated fluid is noninflammatory (clear and viscous), the joint should be injected with a 2-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-56).

FIGURE 67-56. Subtalar (talocalcaneal) joint injection. Approach for subtalar (talocalcaneal) joint aspiration and injection.

Comments

Injection of this joint is usually secondary to osteoarthritis resulting from trauma or from repetitive overuse injury such as from ballet dancing. Gout is not an indication for injecting this joint.

Complications

Corticosteroids should not be injected if there is any suspicion that the joint is infected. If the fluid appears infected, then it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

Comments