FIGURE 8.44 Medial aspect of the right foot—bony anatomy. (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
1. With the patient lying supine on the examination table, the clinician stands medial to the affected foot.
2. Locate the first MTP joint with simultaneous palpation and flexion/extension of the great toe proximal phalanx. The patient will report tenderness in this joint, and there may be associated erythema and swelling.
3. The injection point is directly over the first MTP joint.
4. 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.
5. After the landmarks are identified, the patient should not move the foot or toe.
ANESTHESIA
- Local anesthesia of the skin using topical vapocoolant spray
EQUIPMENT
- 3-mL syringe
- 3-mL syringe—for optional aspiration
- 25-gauge, 1/2 in. needle
- 0.25 to 0.5 mL of 1% lidocaine without epinephrine
- 0.25 to 0.5 mL of the steroid solution (10 to 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 into the center of the joint.
4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.45).
5. Advance the needle until the tip is located in the joint capsule. If the needle contacts bone or cartilage, back up the needle 1 to 2 mm.
6. If aspirating, withdraw fluid using the 25-gauge, 1/2 in. needle with a 3-mL syringe.
7. If injection following aspiration is elected, remove the 3-mL syringe from the 25-gauge needle and then attach the 3-mL syringe filled with the steroid solution.
8. If only injecting corticosteroid solution, use a 25-gauge, 1/2 in. needle with the 3-mL syringe.
9. Inject the steroid solution as a bolus into the joint capsule. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.
10. Following injection of the corticosteroid solution, withdraw the needle.
11. Apply a sterile adhesive bandage.
12. Instruct the patient to move his or her toe through its full range of motion. This movement distributes the steroid solution throughout the joint capsule.
13. Reexamine the first MTP joint in 5 min to confirm pain relief.
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