This article, the final in a series...

This article, the final in a series upon diagnostic and therapeutic injections, protects the ankle and foot. The rationale, indications, contraindications, and general approach to this action are covered in the first article in this series. (1) succeeding articles have covered injections of the shoulder, push wrist and hand, hip, and knee regions. (2-5)

The ankle and base are susceptible to multiple injuries and inflammatory conditions6 that are amenable to diagnostic and therapeutic injection. (7) This article shrouds the anatomy, pathology, diagnosis, and injection technique at used by all sites for which these operations are applicable. These areas include the plantar fascia, ankle joint, tarsal subterranean passage interdigital space, and first metatarsophalangeal joint (Figure 1)

Plantar Fascia

The plantar fascia, a band of connective tissue shrewd to the fat layer of the base (plantar aspect) of the bottom spans from the medial plantar tuberosity of the calcaneus to the base of the digits. It helps support the medial longitudinal arch of the foot

INDICATIONS AND DIAGNOSIS

The plantar fascia is repeatedly a site of chronic pain. (89) Patients typically complain of pain that starts with the first pace on arising in the morning or after put offed sitting. Pain onset is usually insidious nevertheless also may commence after a traumatic injury. Diagnosis is made by way of eliciting pain with palpation in the region of the origin of the plantar fascia. Pain may be worsened by the agency of passive dorsiflexion of the lower extremity Overpronation, pes cavus, and restricted paw dorsiflexion are common with this condition, although paw pronation itself has not been demonstrated to be a predisposing factor. (10)

TIMING AND OTHER CONSIDERATIONS

In plantar fasciitis, corticosteroid injection is a treatment option, usually after other therapeutic modalities have failed. These therapies include active stretching, and use of nonsteroidal anti-inflammatory physics (NSAIDs), cushioning heel cups, nighttime plantar fascia splints, and base orthoses. (11-13) Corticosteroid injection effectively provides pain relief, (14) although it carries the risk of plantar fascia rupture15 and fat pad atrophy.

TECHNIQUE

Pharmaceuticals and equipment are listed in Table 1 The patient is placed in the lateral recumbent position with the affected side down. The physician identifies the medial aspect of the lower part and palpates the soft tissue just distal to the calcaneus, locating the point of maximal tendernes or swelling.

APPROACH AND NEEDLE ENTRY

General technique, including premedication, is discussed in the first article in this series. At the defined plastic tissue area, a 25-gauge, 1.5-inch needle is inserted perpendicular to the skin (Figure 2) The needle should be inserted directly down past the midline of the width of the base The physician should not inject into the fat pad at the base of the foot

The pharmaceutical material is injected slowly and evenly [i]or[/i] part of to the other the middle one third of the width of the twelve inches while the needle is being withdrawn. The physician should avoid injecting [i]or[/i] part of to the other the base of the twelve inches because this approach can end in the complications of pharmaceutical leakage and fat pad atrophy.

The patient should remain in the supine position for several minutes after the injection. The physician may impose the injected region through passive range of motion. The patient should remain in the office for 30 minutes after the injection to be monitored for adverse reactions. In general, patients should avoid any strenuous activity involving the injected region for at least 48 hours. Patients should be cautioned that they may experience worsening symptoms during the first 24 to 48 hours. This is related to a possible steroid flair, which can be treated with ice and NSAIDs (eg ibuprofen, naproxen). A follow-up examination within three weeks should be arranged.

Ankle Joint

The ankle joint is formed from the articulation of the talus with the tibia and fibula. The medial and lateral malleoli of the tibia and fibula stabilize the talus.

INDICATIONS AND DIAGNOSIS

Arthritis of the ankle joint may be met with in athletes with a history of trauma to the area, and in older patients, and can be an indication for corticosteroid joint injection. Besides osteoarthritis, rheumatoid arthritis, and acute traumatic arthritides, other indications for joint injection include crystalloid deposition disease, mixed connective tissue disease, and synovitis. (1617) Pain and disability are the usual presenting complaints, and examination can reveal pain with limitation of motion, tendernes swelling, crepitus, and deformity. Gait disturbance, erythema, and warmth to palpation also may be current Radiographs may be helpful to support the diagnosis.

TIMING AND OTHER CONSIDERATIONS

Aspiration of the joint must be performed if infection is suspected. Infection is an absolute contraindication to corticosteroid joint injection. Aspiration also can be useful for confirming certain arthropathies like as crystalloid deposition disease and Lyme arthritis.