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Plantar Fascia steroid injection; an experiment

Discussion in 'General Issues and Discussion Forum' started by Mart, Oct 25, 2009.

  1. Mart

    Mart Well-Known Member


    Members do not see these Ads. Sign Up.
    I did a couple of injections into my plantar fascia this week and noticed a few interesting behaviours which I thought worth posting and hopefully stimulate some discussion.

    Having aggravated a degenerative mid portion experimenting with it* (had been comfortable for approximately three weeks prior) I decided to see what effect corticosteroid injected into that segment would have.

    *

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=39053


    I believe, based on my sensory experiment, that the kind of volumes (around 3-5 mls) which seem to be used for plantar heel pain injections may be excessive and possibly to be avoided. It would seem appropriate when injecting steroid into the plantar fascia (as opposed to intentionally injecting deposit into adjacent muscle or fat pad) to localise it within the target zone ie degenerated/inflamed segment.

    I am enclosing some images which are annotated to show the effects of injecting at total of 0.2 mls of 50/50 mixture of 40ml/ml dexamethasone /2%plain lidocaine.

    coronal section
    blue arrow points to hyperechoic reflection of cross section of needle tip

    MCC PF SA.jpg

    saggital section
    yellow arrow shows cleavage of fascia by injected fluid (not the needle itself)

    MCC PF post dexo shot.jpg


    coronal section
    arrow shows cross sectional area of injected fluid (needle has been withdrawn from foot)
    MCC PF post dexo shot 2 axial.jpg

    I did the shot through a madajet wheal placed in same location I used for sensory testing and then infiltrated 0.3 mls lidocaine along subcutaneous fat towards fascia to allow painless needle placement for shot. Needle was a 27g I inserted it into centre of thickened portion under guidance with no pain whatsoever. However the ejection of the 0.2 mls was very unpleasant.

    This represents around 3% of the dosage of corticosteroid which seems to be regularly used.

    What was very striking to me other than the tiny volume needed to restrict within target zone was that fluid tracked a very thin linear course, this was confirmed by scanning the coronal plane, the cross sectional diameter of the volume was less than 0.5 mm.

    On reflection this is not that surprising since we know that the plantar fascia microscopically has linear longitudinally oriented dense collagen fibre construction and that line of least resistance might be along that plane.

    What also seems to be possible and more surprising is that there is little communication between these adjacent fascial columns. I mentioned in the sensation experiment thread how a 0.5 mls injection caused detectable cleavage distally to the forefoot, it would seem reasonable to avoid this.

    You can see from US that I have distal chronic plantar fasciosis, there is no flow with power doppler imaging.

    My assumption was that this was unlikely an inflammatory condition and did not expect steroid to reduce pain. This based on lack of evidence of neovascularisation seen with US which is widely regarded to be a very sensitive measure of presence of the vascularity associated with inflammation.

    Prior to the injection I had classic chronic plantar fasciosis symptoms; pain on rising from bed in morning (3-5 mins) pain to palpation distal to medial process of calcaneal tuberosity at degenerated portion seen on US , slight discomfort with weight-bearing heel raise at same site.

    6hrs after shot site was slightly tenderer.

    @ 12 hrs after shot pain was completely resolved and remains so.

    My initial thoughts were concerning why the injection was so painful only whilst expelling the fluid and why it seemed to have eliminated pain.
    With my understanding of inflammation it seemed plausible that;

    the steroid had modified some component of inflammation causing pain,

    that possibly in my case the inflammatory process did not involve production of ingredients into “the soup” which cause neovascularisation therefore this was not seen with power doppler imaging,

    and lastly that the inflammatory process had created a hypersensitivity of nociceptors within the plantar fascia.

    To test this I repeated the same injection 2 days later.

    There was absolutely no pain this time when ejecting the fluid which was same technique, volume and composition.

    Although this is very weak level evidence (n=1) it does support the possibility that pain associated with chronic plantar fasciosis may be result of inflammation induced hypersensitive nocioception within the plantar fascia.

    Also that inflammation (because of inherently complex and variable nature) may not manifest itself with neovascularisation on US. This might be lack of vasoactive mediators or some other reason. For the time being at least, this has shifted my belief about the likely nature of pain in chronic plantar fasciosis.

    The experiment I feel should provoke some reflection on how and why we use steroids for this condition. Immediate thoughts for me are:

    How important is the dosage? I may find the effect wears off very quickly, on the other hand may be not.

    When most people do a blind to point of maximum tenderness injection it would seem likely that the steroid could be deposited into muscle, fat or fascia. It may be localised to zone or spread to forefoot. This may not be important, for example; perhaps benefits of depositing a 3 mls dose of insoluble steroid into muscle may allow diffusion into fascia over a long period and have good effect as opposed to minute dose of soluble into fascia which may prove very short lived.

    I am also curious regarding technique of needling prior to injection, it would seem likely that this would permit greater volume to be localised within degenerated portion by allowing more inter fascial plane fluid flow which might be desirable, especially if the small dose I used doesn’t sustain relief. I shall be exploring the behaviour during the next few shots I do.

    In the mean time I plan to change the way I plan my steroid shots for plantar heel pain by minimising the dose within the fascia until there is better evidence.

    I plan to inject my contra lateral “normal” plantar fascia and see if it is painful to inject and also if it cleaves in same way with same volume.

    Any thoughts for discussion?

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  2. This article seems to back up your claims that Plantar fasciitis is not an inflammation response.
     

    Attached Files:

  3. Lawrence Bevan

    Lawrence Bevan Active Member

    Was this from a medial heel direction?

    I tend to inject only 1ml of Depomedrone, 3-5 mls would indeed be a lot.
     
  4. Mart

    Mart Well-Known Member

    Hi Michael

    thanks for posting paper which I regard as an important one.

    This issue has fascinated me for a while.

    I certainly DO NOT claim that chronic plantar fasciosis is NOT an inflammatory response although I have been persuaded by this paper and several other papers/articles which hypothesis this idea as plausible.

    I have more recently shifted my view based on several thoughts around the evidence both from the lit and my own observations.

    I need a bit of time to post a decent case and will try a do something useful later this week.

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  5. Thanks Martin.

    Look forward to the next set of Ultra-sound pictures. I have thought of investing in one but I can clearly see that It takes time to see the soft tissue still looks a mess to me.
     
  6. W J Liggins

    W J Liggins Well-Known Member

    Sorry, that should have been to Mart and to Mike for posting Mart's paper.

    All the best

    Bill
     
  7. Mart

    Mart Well-Known Member

    An important issue with US is that much of the information to interpret is dynamic, particularly where there is little difference in impedance from adjacent tissues.

    When doing a US exam of the complex and small anatomy in the foot identification is often only achieved when active/passive motion of selected structures is done or compression applied to allow the differential stiffness to become apparent. The brain can then identify what would be otherwise unintelligible boundaries provided you have developed a very precise 3D map in your mind to make sense of this.

    As anyone who knows me will attest, I am an unashamed diagnostic ultrasound exam evangelist.

    I regard it as the most important skill and investment I have made in my practice since graduating 24 yrs ago, so I have some bias to take care of J. However I continue to believe that as podiatrists we should embrace this technology vigorously and develop as soon as possible a good education system to ensure its value is not undermined by poor application. I mention this because in certain jurisdictions this has happened.

    Notwithstanding there are, as any modality, limitations which need to understood and pitfalls to avoid, I have noticed what I regard as unreasonable attitude towards US, particularly surgeons who are more familiar with and find MRI more intuitive. Often they have been given poor interpretation and/or images (not different to the one you find messy which just appear like a bunch of meaningless dot (reaction is . . . so how could they be reliable or useful?). When presenting a single US image it often and necessarily optimized to demonstrate a single feature. The image you had problems with was optimized simply to show needle tip which is oblique to the coronal plane. This was not optimized to show muscle boundaries. A slice (at that instant in time) optimized for muscle boundaries may have missed the needle tip which in the context of my post would be useless.

    I regard US as an extension of my physical exam; I leave my machine running and will include a quick exam for virtually every MSK problem I see to confirm refute the evidence from other aspects of my exam.

    Anyhow, enough of my hyperbolic rhetoric!!

    I would like to encourage you to take this seriously since your interest is obviously well considered.

    I have my machine set up for live video mentoring over the internet. If you or anyone is interested and have broadband internet set up a Skype Account and I'll try and find time to give you a quick live demo of the issues I just mentioned if you email me interest to do this.

    cheers

    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    pone [204]7 FOOT (3668)
    fax [24] 774 9918
    www.winnipegfootclinic.com
     
  8. Martin:

    Even though I don't have anything specific to add to your self-experiment discussion, I just wanted you to know that, throughout the history of science and medicine, there have been others that have performed experiments on their own body to try and answer a research question.

    When I read your description of the needle and ultrasound experiment on your foot, I recalled how, in the early 1670s, Sir Isaac Newston had slid a darning needle behind his eyeball to press on the posterior surface of his eyeball to see what type of colors he would see as a result. Newton had hypothesized that the eye's ability to see color was somehow related to changing pressure on the eyeball, which is why he was sticking a needle behind his eye. However, possibly due to the information he learned in his "self-experiments", Newton later on was the first to discover and propose that white light is a combination of colors in his experiments with prisms and was the first to design a reflecting telescope (versus the more common refracting telescope of his era) which didn't have the troublesome problem of chromatic aberration.

    Therefore, Martin, when you are sticking needles in your foot, you are certainly in good scientific company.:drinks
     
  9. Mart

    Mart Well-Known Member

    Hi Kevin

    :good:

    that is some serious encouragement, not that I really need it but . . . . . .. Jeeze . . . . Mr Newton himself – isn’t he the guy who invented gravity or something?


    Would you mind if I add to my resume something like this

    “ The experimental approach adopted by Martin Colledge in his early work investigating the nature of heel pain has been compared by leading biomechanics researcher and author, Prof Keven Kirby to that of no less than Sir Isaac Newton”.

    . . . .. erm . . . . I’ll buy you a pint if you say yes :D.


    Don’t worry I’ll keep taking the tablets and won’t let delusions of grandeur get the better of me to the point of sticking needles in my eyes . . . . . .. but you know what . . . I seem to recall that the vitreous humour comprises mostly of type IX collagen and that may turn out to be similar to the degenerated portion of the plantar fascia.......... I wonder what steroid might do to that and the eye should image quite nicely and . . . . . .. . . . . .. .. naaah . . .. . . . . . . now where did I put those tablets?

    :drinks

    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  10. Mart

    Mart Well-Known Member

    Michael

    Here is an example regarding optimisation of an image to demonstrate a particular feature. Realize also that these images are compressed and are poor resolution compared to what I see on my machine.

    The image below is an extended view sagittal section of my fascia; its purpose is to show the location of the abnormal segment of fascia relative to the entire structure, it is poorly optimised for much else. arrows delineate the superfcial and deep boundaries of the plantar fascia. The calipers measure the widest part at the enthesis A, and mid portion B. This is more accurately done on coronal (short axis) view thought. Note that A is within normal limits B is not. point of maximum tenderness is at B which was injection site for image below.

    MCC PF extended view 2.jpg

    The image below is a similar shot but sub optimal to show the quality of the fascia, what it is intended to demonstrate is that there is a linear cleavage which resulted from the 0.5 mls LA shot mentioned earlier at point B above. Notice how it traveled in both directions extending from medial process of calcaneal tuberosity almost to digits. Because the plane of the cleavage was not perfectly linear it shifts in and out of the image at certain points, but this is the best single image I could make. the green arrows denote line of cleavage and the red the superficial and deep margins of the plantar fascia. Blue arrow is medial process of calcaneal tuberosity. D is degenerated zone.

    MCC PF extended view 1.jpg

    The image below I took this evening and I am quite surprised and excited about.

    MCC PF SA 2.jpg


    One of the things I think about when trying to take measurements using US is how to mitigate error from the variation in the way the measured object is sectioned. If you imagine slicing a perfect cylinder, depending on the plane you take the image may be a circle, orthogonally a straight line or obliquely an ellipsoid. So when measuring a the diameter of the cross section of the degenerated fascia how to make that meaningful in terms of deciding if it has changed thickness? What I do is simply try to make that cross section as narrow as possible at its widest point; this ensures that the plane is tangential to the longitudinal surface at the point of measurement. Generally I am able to get repeatable results doing this; I estimate within 0.2 mm. It would make a worthwhile study and something I want to try with cadavers if I can persuade GE to loan me a decent portable unit.

    Anyhow the reason I mention this is that when I looked at my injected fascia; the widest part has changed from 5.6 pre injection to 4.4 mm today. I have never seen that kind of change before with any of the therapies I have tried and I have been studying my foot for several years. There are a couple of explanations for this other than my error which I will try and encompass, but I need to make the post I promised earlier to make sense of this and the missus needs some attention this evening!

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  11. Mart

    Mart Well-Known Member

    Hi Laurence

    If you look at the URL I cited earlier for the post I started for the experiment to map the sensation of the fascia I posted a photo of the position of the probe and the needle entry point which was distal, lateral and oblique to the injected segment.

    This was the same for the steroid shot. Although unconventional I do this to avoid the MCN branches which are pretty touchy and also because I believe there is more diagnostic value for ruling out MCN compression issues using the lateral approach and infiltrating the subcutaneous adipose with LA before entering the fascia with the steroid loaded needle. It makes the needle insertion painless but seems to leave the fascia sensate.

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  12. Martin:

    I am extremely impressed with your inquisitiveness and your zeal for scientific investigation. There not many podiatrists in this small world of ours who would do to themselves what you have done: injecting their own feet with different solutions to see how they looked under diagnostic ultrasound. You are a man after my own heart!

    As far as Sir Isaac Newton is concerned, you need to read this short biography on him at your earliest convenience. He is one of the most inspiring scientists of all time. If you have time for his full biography, here is the one I have enjoyed the most, by James Gleick.

    Keep up the good work.:drinks
     
  13. Martin I´ll will take you up on this in the future. Probably in the new year I´ll shoot of a email. Keep the post comming.
     
  14. Funkster

    Funkster Member

    Interesting. To summarise your thoughts I think you are saying that there was little evidence of neovasulariation on ultrasound with doppler despite the history.

    I think it would be sensible to (at least temporarily) accept that the neovasulisation is a good marker for inflammation as this is the knowledge base would suggest this. If this is the case your experiment suggests that the pain in your case the pain is most likely coming from senitised neural tissue. If this is the case one wonders if it is the LA or the needling which is working and not the steroid. I remeber having a steroid explosion years ago when no steroid was injected into the patient but the patient thought there was. Needless to say he got better! Anecdotal I know but.... only playing devils advocate. We are trying to get an ultrasound machine but at the moment I either refer or inject blind.
     
  15. Mart

    Mart Well-Known Member


    I think neovascularisation MUST be an index of inflammation since I cannot see any other plausible explanation for its presence. As you probably realise it is widely regarded in rheumatology that US exam with power doppler imaging of synovium is THE most sensitive marker for inflammatory arthritides.

    Another indices from US are alteration in impedance (ie increased hypoechoicity) and thickness. The hypoechoicity strongly suggests increased presence of water molecules. The most likely sources of increased hydration are; oedema, increased ECM; alteration to composition of ECM, and alteration to type/mix of collagen being created by fibroblasts. The thickness could also be explained by the same features but we don't know for sure.

    US cannot give us more information directly, but it may be possible to infer. What I think may be possible is to consider how the material properties of the fascia might vary according to its makeup and see if that correlates to behaviour.

    What surprised me in my experiment was the cleavage of the fascia with small vol of fluid. If the hypoechoicity was due to edema I would have expected the fluid to behave differently.

    The behaviour I noticed suggested to me a material property of a longitudinally rigid and non compliant stratified material.

    When separated by increased ECM or collagen modified to a more hydrophilic form, thickening without losing longitudinal stiffness may occur.

    If the structure is modified by trauma eg a tear or poking around with a needle the collagen strata may be disrupted and the internal pressures possible reduced when damaged in this way.

    US may be able to infer some info about this.

    I think that it is possible that neovascular signs on US may be a function of the mechanical properties of the fascia rather than the presence or absence of inflammatory mediators.

    Neovascular signs are easily obliterated by applying too much pressure with the probe, when doing joint exams it is important to apply no pressure or the vessels will be compressed and invisible.

    If you look at the studies using US for seroneg arthritides for plantar heel pain it may be important that the vascularity is at the proximal end of the fascia where it likely has least compressive force from body weight and intra fascial tension. This also seems to be where the bone erosion takes place.

    Perhaps in normal fascia there is too much resistance for the vessels to grow unless the ECM becomes more compliant or the linear architecture of the collagen fibrils is damaged either by trauma of injury or a needle.

    Neovascularisation in the tendo-achilles and all tendon sheaths is the norm with tendinopathy; why not the fascia?

    I believe it may be to do with the difference in mechanical properties and or day to day environment.

    I was very struck recently when I had the chance to do a cadaver study by the differences in tendo-achilles and plantar fascia simply to tugging and probing with my fingers and then looking at the texture under low power microscopy.

    Given the complexity of inflammation I don’t think we can assume that neovascularity and inflammation are mutually dependant although it would seem to be unusual and perhaps for the reasons I mentioned it may be a special case.

    From what I understand of gene regulation of collagen under the influence of different the chemical/cellular inflammatory mediators and also same potential for corticosteroids to do the same there is much we don’t fully understand.

    Some of the “inflammatory soup” has the capacity to lower the sensitivity threshold of nociceptors so it seems possible that the steroid may have effected my pain, but perhaps this was insignificant, irrelevant or did not happen.


    As far as the needling. The evidence from my experiment suggests the opposite of your interpretation. Recall; I mentioned that before I did the sensation experiment my fascia, although degenerated and thickened above normal values did not hurt. After needling it hurt which is why I tried the steroid shot. Also I have done guided intra-fascial hyperosmotic dextrose into my fascia several months ago when it hurt. What I found was that it was more painful for approximately one week after doing this and interestingly created neovascular changes visible on US which prior to that were absent. This was the same reaction with patients who I have tried this for.

    Michael posted earlier in the thread a paper which was very influential in my beliefs the regarding the fasciitis vs fasciosis issue.

    I have read it a few times over the past several years and I now think there may be several flaws to it. It would make a very interesting exercise to take it apart.


    Anyone up to do this?

    I don’t have time do all the research needed to make a decent critique but wouldn’t mind splitting the tasks up and spreading them out.

    Email me if anyone is interested. Basically it needs a reference check, a methodology check and a premise check. I think I could break that down into 10 segments – 10 takers?it would make a great learning exercise.

    Cheers


    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  16. G Flanagan

    G Flanagan Active Member

    Martin,

    I seem to remember being sat with you on the Pod Surgery MSc lectures having a fruitful discussion about your passion for US.

    I wish you good luck with your fight for US as a first line diagnostic tool, testing on yourself shows good determination / borderline obsessive. ;)

    Although you show me an inventor / breakthrough scientist who isn't :good:
     
  17. Mart

    Mart Well-Known Member

    Hi George

    Good to hear from you and hope your studies are going well or even finished now?

    Of course you are right about the obsessive thing. I have thought about that a bit over the years; as an ex touring musician who trained to be a podiatrist to subsidize his music habit I would have been shocked to find my obsession moving away from music.

    I think obsessiveness can be very constructive so long as there are people around who you respect and are comfortable to give you a poke in a more balanced direction from time to time.

    My wife tends to do this, especially when I get my foot skeleton out from under my pillow on Saturday nights (Mondays are OK). I am also fortunate to have a couple of mentors right now who on this and similar issues are not only generous with their time and knowledge but gently pop my balloon form time to time.

    :drinks

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  18. I think we could make quite a band, if many of us biomechanics types ever got together. I sang in an oldies rock band for a few years in high school and early college. Dr. Spooner was in a rock band in his youth. Chris Nester was in a band also, I believe as a guitarist in his younger days. Ray Anthony, who wrote a book on foot orthosis construction (Anthony, Raymond: The Manufacture and Use of the Functional Foot Orthosis. Karger, Basel, 1991), was trained in classical singing and is a fine guitar player. Simon Bartold plays a mean guitar...the last time I saw him we did a duet for a group of podiatrists with him on his guitar and me singing the Beatles song, "You've Got to Hide Your Love Away". Very interesting....:cool:
     
  19. drsarbes

    drsarbes Well-Known Member

    One comment on the original post:

    "However the ejection of the 0.2 mls was very unpleasant."

    You stated the needle was 27G but didn't mention the size of the syringe. The larger the syringe and the smaller the needle bore the faster the solution will exit and (in my opinion) the more painful the injection.

    Also: I don't know anyone who injects 5 ccs of anything into a painful plantar fascia.

    I usually use a tuberculin syringe (1 cc) with .5cc cortisone + .5cc Marcaine along with a 25 G needle.
    Fairly painless.

    Kevin: "I know all the chords!"

    Steve
     
  20. Mart

    Mart Well-Known Member

    Syringe was tuberculin syringe (1 cc), it was my foot, I did the shot, I am not a wimp, it was F**** painful.

    The fine bore syringe will allow generation of greater fluid ejection pressure, without this I have found it impossible to inject into the fascia in most cases.

    How do you qualify "fairly" and what approach do you use?

    I have a suggestion to examine the lit on the volumes issue and some other stuff which you and others might want to help with, I'll post some info later if interested.

    check out the following; the methodology was for 3 mls, I mentioned noticing range of 3-5 mls from memory of papers I have read, but may be wrong, certainly not about the 3mls anyhow.

    Intralesional corticosteroid injection versus extracorporeal shock wave therapy for plantar fasciopathy.
    Porter MD, Shadbolt B.
    Orthopaedic Department, Ipswich Hospital, Ipswich, QLD 4305, Australia. mark.porter@webone.com.au

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668[204] 774 9918
    www.winnipegfootclinic.com
     
  21. drsarbes

    drsarbes Well-Known Member

    "Syringe was tuberculin syringe (1 cc), it was my foot, I did the shot, I am not a wimp, it was F**** painful.

    The fine bore syringe will allow generation of greater fluid ejection pressure, without this I have found it impossible to inject into the fascia in most cases.

    How do you qualify "fairly" and what approach do you use?"

    ====================================

    EFENPAINFUL!! That is ..........a......funny! Sorry.

    Well, maybe you ARE a woussie. haha

    I use a medial approach and do not inject into resistance. Pretty standard stuff. If all my heel injections were EFFENPAINFUL my days would be VERY long.

    Well.......maybe the lesson here is "don't give yourself an injection"

    Steve
     
  22. Mart

    Mart Well-Known Member

    Hi Steve

    Well . . . . what do you think of the idea (based on the premises I posted) that we should be injecting into the the resistant zone?

    Do you NOT inject the resistant zone because;

    you want to keep your days short,

    YOU are such a woosie that you dont have enough strength in your fingers to do the business :empathy::empathy::empathy::empathy:

    or something more reasonable (employing the idea of "charity in critical thinking process" glad we seem to be on the same wavelength on that score at least... sorry that is an in Joke between steve and me)?

    As far as self experimentation; what persuades you that I am not one of those rare mutants who simultaneously enjoys being a sadist and a masochist?

    BTW did you ever get that Diagnostic ultrasound machine?



    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
    Last edited: Oct 28, 2009
  23. drsarbes

    drsarbes Well-Known Member

    "As far as self experimentation; what persuades you that I am not one of those rare mutants who simultaneously enjoys being a sadist and a masochist?

    BTW did you ever get that Diagnostic ultrasound machine"

    HAHA - You are too funny.

    US - I'm almost embarrassed to say that I have not purchased one yet. I do have a salesman coming in early November to show me another one. My plan (as it was last year) is to get one by the end of the year. The ones I liked (Terason 7000, the new Nanomaxx) are fairly pricey. I may end up getting a lower end without the Doppler.

    Hey, anything I can do that will not create LONG days in the office I'm all for!!!!

    I've had a couple of patients over the years that ENJOYED having injections! Gotta love them!

    I seem to get the best response from cort inj. for PF when I inject the Porta Pedis, the area just deep to the medial plantar tubercle and the area just above (an area I fondly refer to as Arbes' Cove. It's formed by the dorsal surface of the spur and the inferior surface of the OS Calcis. It looks like a small "cove" which disappears when the spur is removed, obviously!) No resistance in any of these areas. I always go from the medial side. It also helps if the patient hasn't had symptoms for more than 6 months.

    Now.......when I get my new US I may alter my technique since I'll (hopefully) be using it for needle guidance.

    BTW: If your going to treat yourself I would assume you're happy (as we all are) that we are not proctologists!

    Steve
     
  24. Mart

    Mart Well-Known Member

    Hi Steve

    I assume that you are likely injecting into the FDL and/or AbHal muscles, do you agree?

    Part of point of my self experimentation is to try and get a better handle on how we might optimize this injection. Joking aside I have met more patients than not who have had such a bad experience from other clinicians who gave their heel injection that they refuse to return for further review/Tx. It would be too easy to assume as that clinician that a good job was done since pt did not need to return, ie problem was fixed!

    From the little evidence I have come across, injecting as you describe is likely to be better tolerated pain wise than intra-fascial one, consistent with your experience too. It seems plausible that the drug could diffuse to the adjacent fascia if that was important which currently I believe is.

    If depositing into muscle I would assume greater systemic effect since this is standard way of administration the drug for that purpose.

    Since there are reports in lit regarding risk of PF rupture it would seem a good idea to try and understand/ mitigate this if possible, dose and location are likely issues.

    We need to talk about US machines, power doppler is really important for foot exams. Please phone me for a chat, I just helped a buddy of mine here get a great used machine for less than $15K, it is a great time to buy used machines for MSK in US if you know what to look for.

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  25. Mart

    Mart Well-Known Member

    Hi Kevin

    Your suggestion got the better of me and I spent the morning procastinating from more important stuff rooting around in my basement and started a new thread as a result. See what you think!

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=39446

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  26. drsarbes

    drsarbes Well-Known Member

    Hi Mart:

    Yes, my injections are almost always deep to the fascia.

    US - not to worry, I won't spend any $$$$ before I call you.

    Steve
     
  27. Mart

    Mart Well-Known Member


    Steve


    to add a bit of "weight" to my suggestion that power doppler imaging should be regarded as more than a bit useful

    check this thread

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=39794

    cheers


    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  28. Mart

    Mart Well-Known Member

    Just came across this in my travels. There are a lot of interesting MSK US horse foot studies and thought this was pertinent to what I noticed in my own foot. . . .. . . .. . . .Neigh . . . .


    van den Belt, A. J., P. R. Keg, et al. (1993). "The correlation between the dose and distribution of intratendinous fluid injections in the flexor tendons/ligaments of the horse." Zentralbl Veterinarmed A 40(9-10): 713-9.

    An in vitro study was carried out to define the correlation between the dose and distribution of intratendinous fluid injections in the different flexor tendons/ligaments of the palmar/plantar, metacarpal/metatarsal region of the horse. Injection of 0.1-0.2 ml resulted in a local intratendinous fluid depot showing minimal abaxial spreading and more extensive proximodistal expansion. If 0.3-0.5 ml was injected the abaxial spreading remained minimal but the proximodistal expansion increased significantly, the depots in the axial proximal, mid and distal region flowing together. Also minimal peritendinous fluid accumulation was visible. Increasing the dose from 0.5 to 2 ml resulted in extensive abaxial spreading and peritendinous accumulation. These findings indicate that the 2 ml injection recommended in the veterinary literature probably represents an oversized dose. If a small lesion is present a 0.1-0.2 ml intratendinous injection should be adequate. The injection should preferably be guided by ultrasonography to allow precise deposition of the drug into the lesion. In larger local defects a depot of 0.3-0.5 ml apparently is sufficient. If a very large portion of the tendon is injured, several depots of 0.3-0.5 ml approximately 5 cm apart is preferred to cover the full proximodistal extension of the lesion

    cheers'

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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