FIGURE 8.42 Medial right foot—sagittal section. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
PATIENT POSITION
- Supine on the examination table with the hip in full external rotation, the knee slightly flexed, and the ankle in a neutral position.
- Alternatively, lying on the examination table on the affected side with the knee slightly flexed and the ankle 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 medial to the affected foot.
2. Identify the point of maximal tenderness over the plantar aspect of the foot. This is usually just medial of midline over the medial tubercle of the calcaneus.
3. Draw a vertical line down the posterior border of the tibia.
4. Draw a horizontal line one fingerbreadth above the plantar surface.
5. Mark the point where these two lines intersect over the medial aspect of the foot.
6. At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.
7. After the landmarks are identified, the patient should not move the foot or ankle.
ANESTHESIA
- Local anesthesia of the skin using a topical vapocoolant spray.
EQUIPMENT
- 3-mL syringe
- 25-gauge, 1½ in. needle
- 1 mL of 1% lidocaine without epinephrine
- 1 mL of the steroid solution (40 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 topical vapocoolant spray.
3. Position the needle and syringe perpendicular to the skin and the intersection of the two landmark lines with the tip of the needle directed laterally.
4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.43).
5. Advance the needle toward the medial tubercle of the calcaneus until the needle tip is located at the origin of the plantar fascia.
6. Inject the steroid solution as a bolus at the origin of the plantar fascia. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.
7. Following injection of the corticosteroid solution, withdraw the needle.
8. Apply a sterile adhesive bandage.
9. Instruct the patient to massage the area and then take several steps. This movement distributes the steroid solution along the plantar fascia.
10. Reexamine the foot in 5 min to confirm pain relief.
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