Review
Diagnostic and therapeutic injections of the foot and ankle—An overview

https://doi.org/10.1016/j.fas.2017.02.001Get rights and content

Highlights

  • The understanding of anatomical landmarks of the foot and ankle is crucial for correct placement of diagnostic and therapeutic injections.

  • Joint injections can help in the decision-making for surgical treatment and surgical planning, especially if the source of pain is not completely elucidated by physical and imaging examination.

  • The ankle joint is the most common injected joint but a variety of other foot and ankle locations and disorders are also feasible to diagnostic and therapeutic injections.

  • Ultrasound and fluoroscopy-guided injections are better than imaging studies in identifying the source of pain.

  • Duration of pain relief after an injection procedure is predictive of good surgical outcomes.

Abstract

Foot and ankle injections are useful diagnostic and therapeutic tools, particularly when the pain etiology is uncertain. A variety of foot and ankle injuries and pathologies, including degenerative joint disease, plantar fasciitis and different tendinopathies are amenable to injections. Understanding the foot and ankle anatomical landmarks, a thorough physical exam and knowledge of the different injection techniques is key for a successful approach to different pathologies. The objective of this study is to review the use of foot and ankle injections in the orthopaedic literature, present the readers with the senior author's experience and provide a comprehensive clinical guideline to the most common foot and ankle diagnostic and therapeutic injections.

Section snippets

Background

Disabling conditions that can profoundly hinder patient’s life-style and activities commonly affect joints, tendons and ligaments of the foot and ankle. Joint and soft tissue injections of the affected structures represent a useful diagnostic and therapeutic tool for physicians dealing with these conditions.

A variety of foot and ankle injuries and pathologies, including degenerative joint disease, plantar fasciitis and different tendinopathies are amenable to diagnostic and therapeutic

What can be injected?

Generally, injections are composed of anesthetics, corticosteroids or both. The use of local anesthetics alone as a symptom relief test is also helpful for diagnostic purposes. The recommendation for the patient to return to their regular activities following a diagnostic or therapeutic injection can also help in the evaluation of symptoms improvement. Corticosteroid and anesthetic mixtures have the added value of providing midterm anti-inflammatory activity in addition to the analgesic effect.

Injection techniques

  • Free-hand injections

Easier to be performed at the office environment.

Limited use for small joints or severe foot and ankle deformity.

Unable to confirm correct placement of the needle or the presence of inter joint communication.

  • Ultrasound-guided injections

May also be performed at the office.

Allows concurrent evaluation of tendons and joints.

Accuracy of the injection is operator dependent [23].

Different studies demonstrate improved reliability and efficacy of foot and ankle injections with

Tibiotalar joint

Injections of the tibiotalar joint can be used to differentiate intra-articular and extra-articular causes of pain. It is the most common injected joint of the foot and ankle, performed by 97% of the AOFAS members [1].

Technique for anteromedial ankle joint injection (Fig. 1)

  • 1.

    Patient supine, ankle positioned straight, with neutral or minimal plantar flexion and slight external rotation of the hip.

  • 2.

    Palpate and mark down the trajectory of the anterior tibial or dorsalis pedis artery pulse to avoid

Conclusion

Foot and ankle injections are useful diagnostic and therapeutic tools, particularly when the pain etiology is uncertain.

Corticosteroid are commonly used to lengthen the therapeutic benefit, but physicians should be aware of possible side effects including a flare of symptoms, tendon/fascial rupture, skin atrophy and depigmentation.

Image guidance, such as ultrasound, fluoroscopy, and computed tomography can be useful in confirming proper needle placement.

Knowledge of the foot and ankle anatomy

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Funding

There is no funding source.

Conflict of interest

The authors declare that they have no conflict of interest related to this manuscript.

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    The research was performed at Medstar Union Memorial Hospital

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