Hello everyone,
I am a third year podiatry student in need of advice/help. For one of my assignments I need to have some evidence about the number of podiatrists that don't use local anaesthesia for further clinical purpose other than nail surgery.
I've searched the literature but I can't find anything, have you ever came across to this information?
If you look in the last copy of Podiatry Now, there was an article in it (part of) which suggested that we should use it more. Perhaps you could contact the writer and he could give you more details?
Hi Nick
Thank you very much for the suggestion. I did read the article but I didn't think of
writing the author. Sometimes I can miss the obvious, but thanks to you and WJ Liggins I can move forward with my assigment.
Thank you for answering to my post, it really helped me
Rosa
I am considering using local anesthetic on one of my patients who is having trouble with post op scar tissue along the inferior head of the lateral malleolus.
This would allow me to manually "break down" and help reorganise the collagen fibres.
The Scar tissue seems to be inhibiting normal ROM due to a pulling pain ( as well as hypersensitiviy and allodonyia from post op sural nerve damage diagnosed by NCS).
She has had US used for scar tissue breakdown in the past but found it too stressful and painful.
I haven't done this before and don't know any one who has... any thoughts would be much appreciated.
I often use LA for a very similar purpose. I have several patients with ongoing O.A of the 1st MTPJ, yet are unable/unwilling to have a surgical solution. So I give them 3-4ml of plain Lignocaine just proximal and lateral to the 1st MTPJ (not inter-articular). Then I encourage them to both walk and or manually manipulate the joint without the usual pain from either adhesions/muscle contracture/spasm. Works a treat and last for several months. A full explanation about 'why' I use the LA and what it does, how it will temporarily numb the area so that we can manipulate the full ROM etc etc, is a must of course.
Best aspect is that the Pts are actually very happy with the temporary but effective resolution of pain, allowing full ROM without resorting to a full procedure.
I can't speak knowledgeably about your Pt, but in some of my cases - this modality works very well along a very similar principle/objective.
Let me know what you/your Pt decide - I'd be interested to hear back?
I never thought of using LA like that before although it makes total sense and is very Interesting!
When you say YOu use it for patients with OA in the 1st MPJ, does that include those with Hallux limitus?
and what radiographic qualities do you look for that
1) would indicate that the patient would tolerate this treatment?
2)
would be a contraindication?
How many visits and at what intervals is average at getting results with your patients?
Do you advice to ice or use NSAIDs post manipulation always or only if painful?
SOrry about the bombardment of questions but this stuff really interests me. If there are alternatives treatments that can help my patients, then I want to know about them.
My patient case never had surgery to repair any joint issue it was just to repair a longitudinal tear in the Peroneus Brevis muscle , following a LAS with a cuboid fracture.
I will go ahead with my proposed treatment prior to explaining in depth the risks and proposed outcomes.
ANd I'll be sure to let you know how it turns out.
Conditions: OA, moderate HAV, Limitus but clearly not the inflammatory arthritides (RA etc.). Essentially a joint where there is a clear limitation of ROM/QOM +/- pain on reaching end ROM. But there must be a 'degree' of flexibility in the joint and a quality of soft-tissue rather than bony resistance at end ROM.
Radiographically: Evidence of mild-moderate DJD/OA is fine, but overt bony peaks and/or OP are either contraindicated or warnings for extra caution.
Remember you are not injecting into the intra-articular space, rather between and a few mm's proximal to the 1st and 2nd MTPJ's inter-articular space simply using plain Lignocaine 2% in the amount of just 3-4 mls. Your target here is muscle 'guarding' post accident/wear and tear, and/or soft-tissue adhesion's that are causing a reduced and painful ROM - not the OA/Limitus itself. In a sense you are addressing the surrounding soft-tissue issues, but just resolving/reducing them will aid your Pt greatly.
Results:
Rapid anesthesia of the painful joint (in minutes), must encourage walking and/or manual manipulation by the patient after showing them cautious ROM exercises (encourages them to help themselves) to be done straight away. You'll find that the patients will actively participate, as previously just moving the joint small amounts was painful - now they can do it freely, they will LOVE you!
I don't advise physical modalities or NSAIDS post-injection, as the LA and their own movement suffices. Make them aware they 'may' have some residual pain after the LA wears off - this is just to cover yourself as none of mine report any pain after the LA wears off.
Generally, one injection, if they follow your advice, should give them quantifiable relief for 1- 4 months based on anecdotal experience.
I have been doing this on one lady for the last 6 years, she drives in from the country specifically for it, the Tx gives her relief for 3-4 months, then she notices a return of symptoms and returns for another Tx.
Sample patient: Lady in her mid-50's with mild deviation of the 1st MTPJ and OA, walks regularly but has discomfort after exercise specifically at the 1st MTPJ. Wears heels, doesn't quite want/need a surgical Rx.
Hope this helps, I should take some digital pics and post next time I perform one! Any more questions feel free to ask, I'm happy to 'waffle' on some more!
For your case, I recall Jeff Peters from WA (FACPS) was very good at scar reduction by using an LA mix injection - just cannot recall the other 'ingredient' on a botched GP plantar verrucae excision. The resultant plantar scar was very calloused, and Jeff was able to break-down the scar, dress it and reduce the degree of scarring to a large extent.
I was one of Jeff's student interns back in the day and just goggled his name to find him still in WA in Booragoon, I won't post his phone number due to privacy concerns - but you'll find it easily yourself. Just phone him up, tell him Julian (he may not remember me!) recalled his scar reduction technique from Sir Charles Gairdner Hospital and you'd love to know more. I am sure he can also refer you to literature about it as well.
Remember you are not injecting into the intra-articular space, rather between and a few mm's proximal to the 1st and 2nd MTPJ's inter-articular space simply using plain Lignocaine 2% in the amount of just 3-4 mls. Your target here is muscle 'guarding' post accident/wear and tear, and/or soft-tissue adhesion's that are causing a reduced and painful ROM - not the OA/Limitus itself. In a sense you are addressing the surrounding soft-tissue issues, but just resolving/reducing them will aid your Pt greatly.
mmmm, not sure I agree with that bit!
The muscles gaurd the painful movement.
Therefore, take away the pain, take away the gaurding.
I inject INTO the joint, usually with steroid, and then do the MUA stufff.
Alas if only to have legislated access to injectable streroids?
Whilst I have qualifications in advanced podiatric pharmacology - the backwater where I live/practice is about 20 yrs out of date. Only MD's/Dentists etc can access them directly. I suspect that Steve is also operating under similar restrictions - hence the advice regarding plain Lignocaine and inter-articular injection. Since the inter-articular injection has worked well, and I avoid the small amount of risk from injecting into the joint.
I haven't tried using plain LA in the joint space though as I am not sure their is any real difference?
my thoughts... is that the LA is really useful and underused - as per the start of this thread.
I think blocking the pain is the key.
I do it INTRA artcular 'cos its quick, but you could do it more effectively via an ankle block then you know it will loosen up!!
I think the steroid adds a lot, both in terms of intra-joint chemistry and effect on collagen.
Might be something in the following, i suspect ... ;)
The final project is going to be a qualitative research, I had to change the original idea.
I wanted to explore the feelings of podiatrists in the use of LA. However, finding the appropriate literature to support different use of LA has been a challenge (still is).
Ja99 and Saab I found very interesting your postings, is there any evidence you could suggest?
I did a qualitative paper too. If you want to contact me, I don`t mind participating in your project. I use LA for nail surgery, needling VP`s and NV corns.
Yeah, I heard Soton are doing that now. Personally, I think it`s a shame you miss the chance to get your diss published at undergrad level.....but who am I to say, eh?
Hi Julian,
Is there any chance of letting me know some more re where you inject etc please? I am really interested in this and would like to incorporate it into my own practice and my own hallux too !
I found the original research in "Clinics in Podiatric Medicine" (Monthly journal with a predominantly US focus) somewhere in the early to mid 90's. I'll try and find more material...
So provided you have some ROM and you suspect that muscular guarding is limiting your motion and contributing to pain etc etc. Simply inject 3-4 mls of plain lignocaine (for the 1st MTPJ) proximal and medial to the 1st MTPJ. Essentially between the 1st and 2nd MTPJ's, but about 1-2 cm proximal to the MTPJ. I do not inject intra-articular because (A) increased risks and (B) no need as this technique works really well.
Encourage the pt to walk immediately after the LA takes effect to fully extend the joint without painful guarding. Of dozens of cases each reported that the LA reduced pain immediately and had no return from anywhere between a few weeks and a few months. No adverse effects, and as long as you explain it is a temporary solution they respond very well. From a business perspective it also is a point of differentiation over colleagues, is quick, cheap and the pts will love you!
sorry...must dash out...ask more questions and I will reply!
Hi Julian,
Thanks for that - a few other questions please.
How about if you have excess osetophytic/arthritic changes to the joint with or without the extensor tendons firing all the time?
>>proximal and medial to the 1st MTPJ. Essentially between the 1st and 2nd MTPJ's, but about 1-2 cm proximal to the MTPJ.<<
Sorry is that me reading that wrongly or did you mean lateral to the 1st and therefore inbetween 1st and 2nd and I am guessing that you do mean inject from the dorsum?
How deep are you going with the needle? Are you using a 27 gauge long needle (as per nail surgery) or a shorter length?
Can other LA be used instead of Lignocaine as I always use Mepivicaine plain for nail surgery and other longer lasting LA's are now available to us in the UK.
Nick,
I would use Lidocaine for the procedure as it is said to interfere with EDGF (endothelial growth factors which I belive has a role to play in inflammation but I need to find the details and post).
Needles 27g long with luer lok syringe - as advised by Ian Reilly (really must buy the book :))
Angie
I have only had a go at my own hallux but don't think I went deep enough to cause the removal of pain as it still hurts :empathy:, can' t seem to get the needle into the joint either!
I'll have another go tomorrow and report back.
I do, however, use prolotherapy for I/D neuritis and capsulitis which is a similar procedure with a great deal of success.
Hi, yes it is very good at any inflammatory condition including plantar fasciitis.
I have used it quite alot and the only failures are from not getting the fluid or enough fluid, into the right area.
For example, one PF I did was too anteriorly to be any good, hence it failed.
Knees, again, the positions for injection were marked by my osteopath, but I think if I had marked them the treatment may have been more successful.
Neuroma and capsulitis excellent results.
On another note, tennis elbow - brilliant, arthritic knuckle - brilliant, arthritic wrist - brilliant, sinus tarsi - brilliant and the list goes on.
It's a good job I have willing group of volunteers - family:D
I have also achieved good results for shoulder capsulitis and sacroilliac (low back) pain!
Angie do you have, by any chance, any articles you could recomend me to read?
I've seen some evidence for this treatmet in the spine and elbow, but nothing for the lower limb.
Where did you learn this procedure? I would be interested
Rosa