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Tibial nerve block to promote plantar diabetic ulcer healing

Discussion in 'Diabetic Foot & Wound Management' started by Guito, Nov 21, 2010.

  1. Guito

    Guito Member

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    I am currently treating a 61 year old mildly obese diabetic male. He has a pressure ulcer plantar to his 2nd met head. I have been treating him for over 6 months with debriding and deflecting pressure away from the 2nd met head. He is progressing OK and we are generally winning. It started out as 1cm diameter and deep and is now very shallow and 2-3mm diameter. His ulcer's progression can take a step backwards if he does a lot of walking/ standing on his feet.

    I have been considering lately the option of a tibial nerve block with 0.5% Bupivicaine for prolonged hyperaemia to accelerate healing. Has anyone had experience with serial injections for this and whether it made a difference to ulcer healing rates.


  2. Guito

    Guito Member

    I forgot to mention his Post tibial pulse is WNL (2-3/3). His rear and midfoot skin temperature is warm and his forefoot is cool. SCVPFT is WNL.
  3. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    So how again do you think this is going to help? Essentially you are saying that his arterial perfusion is pretty normal. I assume his 2nd MT head lesion is purely neuropathic and mechanical in origin.

    Offload, offload, offload some more.

  4. Lab Guy

    Lab Guy Well-Known Member

    I would say that tibial nerve blocks can be useful when vasoconstriction is occurring due to the sympathetic NS in over drive in cases like regional complex pain syndrome. A tibial block in this case will cause a temporary symp block allowing vasodilation and increased blood flow.

    Giving a tibial block when the sympathetics are working fine will not help. To heal the wound is to off-load the underlying metatarsal. I would commonly surgically elevate the metatarsal and excise the ulcer and this worked well long-term. I would not remove the met head as this would only lead to excess pressure on the adjacent bone. I would do the surgery when proper shoes and accommodative orthotics was ineffective.

    When I wanted to cause vasodilation when vasospasm is present, I would Rx Nitroglycerin ointment 2%. I would have the patient apply a thin layer over the Post Tib nerve and this would cause hyperemia without the injections.

    I think the major point is to treat the underlying etiology and in this case its not vascular related but pressure related. Find a way to resolve the pressure on a permanent basis and for the next 6 weeks, keep the foot NWB.

  5. Guito

    Guito Member

    Thanks Steven and LL for replies and advice.

  6. kitos

    kitos Active Member

    It's early in the morning. I have a full clinic today and my brain is full of it.

    Please someone tell me what SCVPFT means?

    Life is difficult enough without even more abbreviations.:bang:

  7. Guito

    Guito Member

    Subcutaneous venous plexus filling time
  8. kitos

    kitos Active Member

    Thanks Guito. I am very grateful for your response, it's worried me all day :)


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