FIGURE 8.40 Lateral aspect of the right foot. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
PATIENT POSITION
- Supine on the examination table.
- The ankle and the knee on the affected side are supported by placing rolled towels underneath them.
- The ankle is in a neutral position.
- Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.
LANDMARKS
1. With the patient lying supine on the examination table, the clinician stands lateral to the affected foot.
2. While the foot is held in a position of active eversion, identify tenderness at and immediately proximal to the head of the fifth metatarsal bone.
3. Palpate the fibularis brevis tendon along its course from posterior and distal to the lateral malleolus to its insertion into the head of the fifth metatarsal bone.
4. Locate the area of maximal tenderness.
5. At that site, press firmly with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.
6. After the landmarks are identified, the patient should not move the ankle.
ANESTHESIA
- Local anesthesia of the skin using a topical vapocoolant spray.
EQUIPMENT
- 3-mL syringe
- 25-gauge, 5/8 in. needle
- 0.5 mL of 1% lidocaine without epinephrine
- 0.5 mL of the steroid solution (20 mg of triamcinolone acetonide)
- One alcohol prep pad
- Two povidone–iodine prep pads
- Sterile gauze pads
- Sterile adhesive bandage
- Nonsterile, clean chucks pad
TECHNIQUE
1. Prep the insertion site with alcohol followed by the povidone–iodine pads.
2. Achieve good local anesthesia by using a topical vapocoolant spray.
3. If treating tendonitis at the insertion of the fibularis brevis on the fifth metacarpal:
a. Position the needle and syringe at an angle of 30 degrees to the skin with the needle tip directed distally.
b. Using the no-touch technique, introduce the needle at the insertion site.
c. Advance the needle slowly until the needle tip touches the tendon/bone junction. Back up the needle 1 to 2 mm.
d. Inject the steroid solution slowly as a bolus around the insertion of the fibularis brevis tendon into the head of the fifth metatarsal. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.
4. If treating tendonitis along the course of the fibularis brevis tendon proximal to its insertion:
a. Position the needle and syringe at an angle of 30 degrees to the skin with the needle tip directed proximally.
b. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.41).
c. Advance the needle slowly until the needle tip touches the tendon. Back up the needle 1 to 2 mm.
d. Inject the steroid solution slowly as a bolus around the fibularis brevis tendon. A small bulge in the shape of a sausage may develop in the tendon sheath. The injected solution should flow smoothly into the tenosynovial space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.
5. Following injection of the corticosteroid solution, withdraw the needle.
6. Apply a sterile adhesive bandage.
7. Instruct the patient to move his or her ankle through its full range of inversion and eversion. This movement distributes the steroid solution throughout the fibularis brevis tenosynovial sheath.
8. Reexamine the foot in 5 min to confirm pain relief.
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