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posterior tibial nerve block

Discussion in 'Foot Surgery' started by srd, Oct 31, 2010.

  1. srd

    srd Active Member

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    I want to learn how to do a post tib nerve block. I tried and was unsuccessful. Does anyone have any good references or personal advice? I'm not certain on angle of insertion or depth of needle. Is this best performed prone or supine?


  2. admin

    admin Administrator Staff Member

  3. Dr. Bates

    Dr. Bates Member

    Look at my facebook site where I answered your question.
  4. drsarbes

    drsarbes Well-Known Member

    I am wondering where you practice and where you were trained.
    Did you not learn this in school or in your clinical training?

    I'm not being disrespectful, I just think it odd that if you do not have formal training how you can just pick up this skill post degree and then utilize it on patients.

    The other question is, did you attempt a posterior nerve block on a patient as your FIRST attempt ever (without supervision?)

  5. blinda

    blinda MVP

    Post tib blocks are not routinely taught at undergraduate level in the UK. Neither is local infiltration.....:bang:

    I sought out a practitioner who was willing to mentor me during my second year summer break. When I included his `signing off` as competent in post tibs for the required log for LA training my tutors were quite suprised!

    There is certainly a gap in the market for post grad LA technique training....

  6. bob

    bob Active Member

    Respectfully, this statement is not entirely accurate. I have first hand experience of at least 2 universities who were teaching ankle blocks as part of the undergraduate podiatry degrees a few years ago. I am unsure of the current curriculum of all UK university podiatry degrees, but would find it unbelievably depressing if this was omitted given the work of the PA and subsequently SCP in establishing use of LA for podiatrists in the UK (apologies for the acronyms). We should all have training in these techniques and should be the most proficient clinicians in carrying out local anaesthetic techniques to the foot and ankle - they are ours after all!
  7. blinda

    blinda MVP

    Couldn`t agree more!

    I graduated in 2007. We were informed that we would only ever need to do digital ring blocks and were thus only trained in such. As I said, I took it upon myself to obtain other LA relevant training.

    Maybe other universities had a different approach....I do hope so.
  8. blinda

    blinda MVP

  9. bob

    bob Active Member

    I'm really sorry to hear that. Perhaps we should name and shame the universities that adopt this attitude to a fundamental aspect of training in podiatry. It's sort of like saying "...most of you won't see osteomyelitis on a regular basis, so we won't bother teaching you about it." Not exactly, but you get my point. I suppose educators need to be selective in their delivery of training in podiatry due to time constraints, but I can not see a reasonable excuse for neglecting to teach useful practical techniques such as this. Undergraduate level study relies on the student to be self-supporting and 'teach themselves' a great deal of of topics, but practical skills such as ankle blocks need to be experienced rather than read from a book or paper. It's a real shame that your uni lecturers didn't offer this, but you were obviously a good student and self-motivated enough to go out and learn the technique for yourself. Bizarre.
  10. Ian Reilly

    Ian Reilly Active Member

    Hi Belinda

    >>Now that`s what I call music! Go on Ian....you know you want to!

    Stuart and I ran a number of these. Ankle block practical was always the best received.

    I'm semi-retired these days but Stuart still runs the course. I think his last one was Dec 2009.


  11. blinda

    blinda MVP

    Thanks for that Ian, I`ll have a chat with Stuart. He`s just landed a post very near to my practice!

    Quite. Not sure about me being a good student though, challenging maybe ;)

  12. twirly

    twirly Well-Known Member

    Hi Bel' ,

    I was at Huddersfield 1995 - 1998.

    Jim Pickard was in charge of the local anaesthesia training then. Which included ankle blocks. We practised on each other. :D Only my opinion but I consider this the best way to learn.

    Personally I think it is a disgrace if this is no longer the case in UK podiatry schools.


  13. blinda

    blinda MVP

    Wocha Mand`

    I agree. Unfortunately, students are no longer allowed to (officially) practice on each other...stupid, eh? Still, I just used to practice on myself, still do if I`ve nothing better to do! Keeps me off the streets.

  14. G Flanagan

    G Flanagan Active Member

    I'm just being a pain in the rectum i know, but there is no such thing as the posterior tibial nerve. Artery yes, nerve no.

    I always here people call it this and get a little frustrated.


  15. twirly

    twirly Well-Known Member

    In my world too George ;)
  16. bob

    bob Active Member

    Hello George,
    Whilst we're being pedantic - it should be 'hear' not 'here' in your 2nd paragraph. ;)
    Seriously though you're right!
  17. G Flanagan

    G Flanagan Active Member

    Ah yes Bob, your right. I wasn't being pedantic just venting as I hear many people refer to it as this.

  18. Nothing wrong with pedantry. Its just correction with an embarrassed expression on its face.

    When I was at school we saw tib blocks, and did the theory, but never practiced them. Like bel, I learned the technique since and found it to be invaluable in everyday practice.

    I've seen it done several different ways, all of which work for their proponent so I guess there is always room for learning. Bel and I have a challenge set for the next time we see each other, who can get a block on the other with the least amount of scandonest.

    I bid 1-1.5 mls. ;)
  19. blinda

    blinda MVP

    Hmmm....we shall see. We`ll require an adjudicator.:drinks
  20. and which lucky loser will let you two have a go on a foot each to see which is most numb - with less local. And then sit there waiting for the local to wear off. Sounds like a fun way to spend an arvo - hey don´t you both know Del. ;)
  21. Ian Reilly

    Ian Reilly Active Member


    and as a gentle suggestion, would we prefer to use a larger dose (that would last longer) of a more potent drug (that would last longer) that is les cardio-toxic???

    personal thing, but i think there are better drugs than scandonest on the market... and which will reduce the need for post op meds after the LA has worn off.

    ... and if using scandonest - i'll assume with a dental syringe - how do you aspirate round the posterior compartment???

    just a thought!

  22. Never had any problems with scandonest, Its always lasted well long enough for me. Why would I want someone numb for longer than necessary? I'm assuming it can't be all that cardiotoxic or it would not be licensed for use. But by all means, what do you prefer?

    Re aspiration, I generally use a self aspirating dental syringe, occasionally a standard syringe with a 27 guage needle. Both capable of aspiration. I'm sure not all of those 3 exclamation marks are needed.
  23. Ian Reilly

    Ian Reilly Active Member

    Hi Robert

    I'm quite the fan of levobupivacaine and ropivacaine. Very useful in the larger dosages I use...

    as I say, just a thought ...


  24. Maybe next time I order a batch of LA I'll give it a punt. Where do you buy it from?
  25. Ian Reilly

    Ian Reilly Active Member

    Hospital pharmacy... its always in the cupboard/theatre!
  26. Could be a challenge If you don't work in a hospital!!

    I get mine from my local Pharmacy. I'm sure they'd track it down for me.

  27. DTT

    DTT Well-Known Member

    Dont encourage them Michael ,I have enough trouble controlling the" puppies" as it is now !!!!:D

  28. blinda

    blinda MVP

    Sorry Dad ;)
  29. mej.gillies

    mej.gillies Welcome New Poster

    Hi Robert

    I had a problem getting levobupivicaine from my local pharmacy. However I managed to get it directly from Abbott Laboratories 01759 580099. It works out about £15 for a box of 10 x 10ml ampuoles. Hope this is of help.


  30. Indeed, for me and any lurkers. Thankyou.
  31. twirly

    twirly Well-Known Member

    Hi Ian,

    Antony Wilkinson (Pod' surgeon in South Yorkshire) also recommended Ropivacaine during our last anesthesia CPD. May I ask what % concentration do you use?

    Many thanks,

  32. Page23

    Page23 Active Member

    I studied at Plymouth University - 1996-1999. As students we performed ankle blocks, dig blocks, infiltration, etc. on each other. Our exams also consisted of performing both an ankle and dig block on a peer.

    I recently performed a tibial block in order to treat a rather nasty 15 year old neuro HD.
  33. DTT

    DTT Well-Known Member

    That's my girl :D
  34. Ian Reilly

    Ian Reilly Active Member


    7.5 mg/mL solution - 0.75% - good and strong!


  35. blinda

    blinda MVP

    So, 1.1 ml of mepivacaine later......it worked. But only the medial planter nerve went off :rolleyes:

    I still paid my £10.00 as it was `a block` of sorts even if it was distal to the bifurcation...
  36. You fib missy! Since only half the forefoot went off I paid you back a fiver of that if you remember!

    But still. 1 ml of LA, I was quite pleased with that. Next time I'll see if I can do the same trick a bit more proximal.
  37. blinda

    blinda MVP

    Where was I fibbin`? It worked as a medial plantar nerve block. A good demo in dermatones anyway.

    OK, I appreciated the fiver ;)
  38. lucycool

    lucycool Active Member

    Is there anyone north of the border who would be willing to let me come and observe this? I'd love to add this to my repertoire and QMU only teach digital blocks.
    I've just bought Stuart Medcalf's book, but I suspect 1st hand experience may be just slightly better.. but off the watch the DVD so you never know!

    Any offers gratefully received!!!

  39. blinda

    blinda MVP

    Old thread I know, but you`ve convinced me now Ian. I shall put an order in for levobupivacaine tomorrow :drinks


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