Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Sesamoid; FHB injection techique

Discussion in 'General Issues and Discussion Forum' started by Mart, Nov 10, 2009.

Tags:
  1. Mart

    Mart Well-Known Member


    Members do not see these Ads. Sign Up.
    Patient has single bipartite sesamoid, evidence of DJD on US between segements and limited benefit so far with offloading with foot orthoses.

    I am considering going a US guided shot, have no prior experience for this and assuming this will be pretty unpleaseant without doing a tibial nerve block first.

    Anyone have any recomendations based on their experience regarding making a corticosteroid injection into tibial sesamoid joint a civilised affair in terms of pain.

    TIA

    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. pod29

    pod29 Active Member

    Hi Mart

    I have no experience giving cortisone injections, however I have had some success with prolotherapy or just plain lignicaine (2%) injections on the tibial sesamoid. When doing this procedure I would have the patient apply a "cup" of ice to this region of their foot for 15minutes previous to the injection. It has seemed to be effective in reducing injection related pain. I have always made sure to choose the patients wisely fo these injections though, because they aren't particularly pleasant (not that any injections are!).

    Cheers

    Luke
     
  3. Mart

    Mart Well-Known Member

    Thanks Luke, why don't you do a tibial nerve block to do this? Why would prolo help DJD?

    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
     
  4. pod29

    pod29 Active Member

    Hi Mart

    at the time I didn't feel it necessary to do a tibial nerve block. Generally the injection related pain isn't too bad, definatley no worse than a cortisone injection in the heel!

    Why does prolo work in DJD?
    Good question! :drinks I can't say that I really can explain why prolo works in general. Is it the needle pecking the bone? Is it the addition of a substance that disturbs cellular balance and promotes healing? Is it placebo? I really don't know! BUT, I will also add that clinically speaking, patients do report symptomatic relief from this treatment. I'm not too sure if the effect is any greater than injecting a local anaesthetic or dry needle alone though.

    Why not try using a dry needle on the surface on the sesamoid, with a pecking technique. Under tibial nerve block of course. I suspect that you would get a positive result after a couple of treatments, without the worry of any medicaments.


    I have had success with these injection and needling methods as an alternative to using foot orthoses in the rare case where (for whatever reason) people are reluctant to use foot orthoses. Not my first line of treatment, but an extra weapon in my armoury, just in case!

    Cheers
     
  5. drsarbes

    drsarbes Well-Known Member

    Hi Mart:
    Shouldn't be too bad if it's the Tibial sesamoid.
    I inject these from the medial side with the hallux plantar flexed.
    You can enter the sesamoidal-metatarsal joint very easily even without
    US guidance. This joint is slightly more proximal than you might think.
    It's not a very sensitive area, especially with a bit of cold spray.

    Fibular sesamoid is a bit more difficult (and less common) - I try to inject from dorsal to plantar through the interspace (helps if they have a met. primus adductus) if not then go plantarly (which is not a comfortable injection site.)

    Good luck.

    Steve
     
    Last edited: Nov 11, 2009
  6. Mart

    Mart Well-Known Member

    Thanks Steve that is reassuring at this stage.

    Any suggestions for volume and drug, my concern also would be spilling out of the joint into the plantar fibro-fatty pad and adjacent FDB tendons. Since I have US I will use it to watch and this may mitigate spillage, curious how you approach this.

    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
     
  7. drsarbes

    drsarbes Well-Known Member

    Hi Martin:
    I think you're a tad overly concerned with "spillage" - one or two injections of cortisone is not going to damage any surrounding tissues.

    For this small joint I use a 1cc syringe with .5cc decadron (4 mg/ml) and .5 cc .5% Marcaine, 25G 1 1/4" needle.
    You can use other cortisone solutions but I find the fast acting dexamethasone has given me very good results over the years.

    Good luck

    Steve
     
  8. Ian Reilly

    Ian Reilly Active Member

    Hi Mart

    the other alternative is just to do a normal MTP injection as you would do dorsally and the juice will soon swich round the whole joint. I only do the plantar medial approcah now as a teaching case. But if you do want to go medially, use a skinny needle...! (27g)

    ATB

    Ian
     
  9. Mart

    Mart Well-Known Member

    Ian and Steve

    Thanks for advice. The patient concerned from US exam has irregular cortical margins and flow on power doppler imaging at the plantar space between the 2 segments of the Tib Ses. Problem is of course the US is unable to see the deep parts of the joint.

    Perhaps I should do Dx LA injection into MTP dorsally - see if that eliminates pain, if not then go plantar? Unfortunately I have no axial radiographic exam to look at deep articular surfaces and not convinced that there is justification to order this given this as a plan.

    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
     
  10. Ian Reilly

    Ian Reilly Active Member

    Hi Mart

    yes - diagnostic block would be a good idea first ... then steroid .... can you charge the patient twice... ;-)

    Ian
     
  11. Mart

    Mart Well-Known Member

    Ahh . . . . . . .. . so that's how I get to drive a Porsche

    cheers

    Martin
     
  12. simonf

    simonf Active Member

    Try as I might, you driving a porsche is a difficult image to generate:drinks
     
  13. Mart

    Mart Well-Known Member

    Jeeze you sports car freeks and destroyers of the planet!

    For your info the primary care physician I used to work with used to drive a Porche, and he did let me take it for a spin one day.

    For some reason he insisted that I remove my cycle clips first. He was IMHB overly concerned about appearances . . . . I have to say though it was pretty uncomfortable compared to my trusty old reliant K.

    When I think about it I never had any problem picking up chicks when I used to drive my shaggin wagon which had about the same amount of leg room as a Porsche if you know what I mean , can't beat a a Reliant Robin I say.

    Whatever works I guess!

    :drinks
     
  14. drsarbes

    drsarbes Well-Known Member

    Mart:
    I think you may be "over thinking" this.
    If the pain is plantar in the sesamoid area then inject that. If you feel it's intra-articular MTPJ pain then inject that. Of course you know that they do communicate so anything you put into the MTPJ will work it's way into the Sesamoidal Met joint. If you inject xylocaine I'm sure the symptoms will (temporarily) decrease - why wouldn't it if your anesthetizing the area.

    If you are unsure whether it's intra articular or extra articular then this makes a bit more sense.

    The cortisone injection to the tibial sesamoid is a relatively simple injection (and contrary to other posts, almost painless)

    Have fun

    Steve
     
  15. Mart

    Mart Well-Known Member

    Hi Steve

    Overthinking??? . . . . that's what make life intersting :eek:

    My overthought more precisely is; on US the patient had evidence of pathology at junction of bipatite segments plantarly and those segments appear very tightly bound to each other with no passive motion detectable between them. It is possible that pain is extra articular to metatarsal head/sesamoid articulations but equivocal, hence rational for dorsal shot to discriminate the possibilities. Turns out that may be mute because on follow up foot orthoses offloading seems to have done the business regardless. Thanks for comments though.

    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. drsarbes

    drsarbes Well-Known Member

    "Turns out that may be mute because on follow up foot orthoses offloading seems to have done the business regardless. "

    Don't you just hate it when patients get better before you can have some fun??????

    Steve
     
Loading...

Share This Page