FIGURE 8.32 Medial 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 with the hip in full external rotation, 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 or sits medial to the affected ankle.
2. Palpate the medial malleolus of the tibia.
3. Locate the tibialis posterior tendon immediately behind and below the medial malleolus.
4. Determine the location of maximal tenderness along the tendon.
5. Identify a point along the tendon 1 cm distal to the point of maximal tenderness and mark it in ink.
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 ankle.
ANESTHESIA
- Local anesthesia of the skin with 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 topical vapocoolant spray.
3. Position the needle and syringe with the needle tip directed proximally at a 30-degree angle to the surface of the skin.
4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.33).
5. Advance the needle until it touches the tibialis posterior tendon. Back up the needle 1 to 2 mm.
6. Slowly inject the volume of the syringe around the tendon. The injected solution should flow smoothly into the synovial sheath. 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. Instruct the patient to move his or her ankle through its full range of motion. This movement distributes the steroid solution throughout the tibialis posterior tendon sheath.
9. Reexamine the tendon in 5 min to confirm pain relief.
Related posts:
