FIGURE 8.46 Dorsal aspect of the right foot. (Adapted 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 knee on the affected side is placed in 90 degrees of flexion.
- The ankle is slightly plantar flexed so that the plantar surface is in full contact with the chucks pad covering the exam table.
- Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.
LANDMARKS
- With the patient lying supine on the examination table, the clinician stands or sits distal to the affected foot.
- Locate the site of maximal tenderness. This is found between the heads of the metatarsals. The most common site is between the second and third metatarsals.
- The injection point is on the dorsal aspect of the distal foot directly over the area of maximal tenderness. A tender nodule may be palpated occasionally at this site.
- 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.
- After the landmarks are identified, the patient should not move the foot.
ANESTHESIA
- Local anesthesia of the skin using topical vapocoolant spray.
EQUIPMENT
- 3-mL syringe
- 25-gauge, 1 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 topical vapocoolant spray.
3. Position the needle and syringe perpendicular to the skin with the tip of the needle directed inferiorly between the affected metatarsal heads.
4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.47).
5. Advance the needle until the needle tip is located between the metatarsal heads.
6. Inject the steroid solution as a bolus around the neuroma. 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 of injection. This movement distributes the steroid solution around the neuroma.
10. Reexamine the foot in 5 min to confirm pain relief.
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