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Mosaic verrucae-help with treatment

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  #541  
Old 29th December 2011, 03:30 PM
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Default Re: Mosaic verrucae-help with treatment

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. . . oh . . . and they bathed the feet in some kind of formaldehyde soak that apparently improved the lesion somewhat - not sure of the details. (was kinda half watching it)
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  #542  
Old 29th December 2011, 05:33 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by podpod View Post
. . . oh . . . and they bathed the feet in some kind of formaldehyde soak that apparently improved the lesion somewhat - not sure of the details. (was kinda half watching it)
care to share the details of the trial???
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  #543  
Old 29th February 2012, 05:25 AM
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Default Re: Mosaic verrucae-help with treatment

Interesting thread, thanks for all the pictures and links to literature.

Can anyone advise of someone that offers the needling technique in or near Leeds?

I saw a 50odd yr old otherwise fit and healthy diabetic chap yesterday with multiple focal VP's who has been having them frozen, agno3'd for 2 years with no effect. It's something I'd like to try myself but the NHS trust have a blanket "No VP Rx" policy at the moment.

I note that Northampton uni is cited as offering this but it's a bit of a trek.

Any recommendations are welcome.
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  #544  
Old 29th February 2012, 12:51 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by drsarbes View Post
OK:

THIS is really unbelievable!

I just saw my patient S.M., my initial attempt at needling a verrucae.

He is now 8 weeks post needling. If you check back in this thread you will see more of his photos, but I have uploaded one of the photos from TODAY along with one of his pre-needling photos.

I cannot really believe the response we obtained. His warts are just about erradicated - ALL of them! I needled one relatively small area at the base of the 5th digit.
As you can see there are just 2 very tiny areas that represent old verrucae. ALL of his interdigital, heel verrucae as well as the rather nasty one in the central area of his forefoot are all gone!

The post picture is just the way he came in, no debridement was done.

What can I say? This works - and after MANY MANY failed attempts at chemo destruction/debridement.

NEEDLE ON.

Steve
Hi there

Great pics....am I correct in thinking you used a 25g needle on this patient rather than an 18g needle?

Julian
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  #545  
Old 29th February 2012, 01:03 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by Ian G View Post
Is anyone currently offering this needling in London?

Thanks

Ian
Hi Ian

I do quite a lot of needling, mostly use tibial nerve blocks and disrect subcut infiltration. Getting pretty good results....

Julian
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  #546  
Old 29th February 2012, 01:20 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by Ian G

Is anyone currently offering this needling in London?

Thanks

Ian


Quote:
Originally Posted by Julian Head View Post
Hi Ian

I do quite a lot of needling, mostly use tibial nerve blocks and disrect subcut infiltration. Getting pretty good results....

Julian
Hi Ian
Robert and I do a needling clinic also using tibial blocks every 3 weeks on a Friday ( at the moment fully booked for the forseeable future but arranging a secondry list)
Also practicing" pain free podiatry" at my clinic.
Hope that helps
Cheers

D
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  #547  
Old 1st March 2012, 12:17 AM
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Default Re: Mosaic verrucae-help with treatment

I just noted that my first posting that described the needling technique of Falknor was made three years ago, on February 27, 2009. In that time, this thread now has had over 500 posts, has generated much discussion from multiple contributors and, even possibly, will stimulate someone to write up this technique in a peer-reviewed journal.

I would be interested in knowing how many of you who have now tried this procedure, after having read about it first here on Podiatry Arena, are still using the needling technique for verrucae plantaris and find it a useful part of your clinical practice? What type of results are you now getting and do you have any good clinical case stories or pearls to share?
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  #548  
Old 1st March 2012, 04:28 AM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by Julian Head View Post
Hi Ian

I do quite a lot of needling, mostly use tibial nerve blocks and disrect subcut infiltration. Getting pretty good results....

Julian
Quote:
Originally Posted by DTT View Post
Hi Ian
Robert and I do a needling clinic also using tibial blocks every 3 weeks on a Friday ( at the moment fully booked for the forseeable future but arranging a secondry list)
Also practicing" pain free podiatry" at my clinic.
Hope that helps
Cheers

D
Thanks chaps. There's nothing like a prompt response to a question, and given that I asked that 20 months ago (post #230 back on page 8) then I guess this is quite literally nothing like a prompt response to a question
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  #549  
Old 2nd March 2012, 03:12 AM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by Ian G View Post
Thanks chaps. There's nothing like a prompt response to a question, and given that I asked that 20 months ago (post #230 back on page 8) then I guess this is quite literally nothing like a prompt response to a question
Sorry Griff, you know me , never miss an opportunity!!!!
I remember you asking me now but you found a more local pod in central London ??
See the memory aint that bad for an oldun
Cheers Fella
D
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  #550  
Old 2nd March 2012, 05:24 AM
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Default Re: Mosaic verrucae-help with treatment

:p

always happy to be of assistance...........

:)
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  #551  
Old 4th March 2012, 11:13 PM
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Default Re: Mosaic verrucae-help with treatment

I read about the "puncture technique" from Kevin about 7months or so ago. I now use it on all warts small or large, single or mosaic. 100% success and counting. Its easy, virtually painless and very quick. Definately worth doing. I have found that needling any of the lesions works - doesnt matter which 1 came first - just go to town on a couple and watch the magic happen.

- Peter
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  #552  
Old 7th March 2012, 08:01 AM
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Default Re: Mosaic verrucae-help with treatment

Hi,
I am a final year student at Northampton university, and we have been told of this technique and seen demonstrations, it is a technique we can use once qualified apparently.

The university run CPD days on various subjects for qualified practitioners and i understand it is also included in the 'injection therapies module' as part of the MSc in Podiatry.


Colin :-)
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  #553  
Old 25th April 2012, 09:33 PM
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Default Re: Mosaic verrucae-help with treatment

Afternoon all and hello from sunny Christchurch, New Zealand. Like many of the posters before me, I've spent an afternoon avidly reading this thread and I'm very interested to learn the technique. Does anybody locally currently perform this procedure and could I come and watch?
Like a lot of UK qualified pods (qualified 2003) I havn't done any local infiltration LA only lots of digital blocks.
I've got a great bottle of Cuban rum for any willing mentors out there!
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  #554  
Old 26th April 2012, 09:04 AM
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Default Re: Mosaic verrucae-help with treatment

Does anyone know of any local anaesthesia courses being run in the south? All the ones I can find are too far away from me to be practical.
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  #555  
Old 27th April 2012, 02:37 AM
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Default Re: Mosaic verrucae-help with treatment

Hi all,

I have done a few of these now and, although it took me a while to get to grips with the ankle block procedure, (Thanks Rob and Caroline!) I'm getting generally consistent and good results so far.

Many thanks to Kevin and others for the useful information in this thread and for bringing this excellent treatment to my attention!

Regards,

Tim
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  #556  
Old 27th April 2012, 02:41 AM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by Suzannethefoot View Post
Does anyone know of any local anaesthesia courses being run in the south? All the ones I can find are too far away from me to be practical.
I Believe Marin Harvey is running one in Tamworth in the not to distant future ??

May be worth sending him a PM on here to get the details?

Hope that helps
Cheers
D
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  #557  
Old 27th April 2012, 11:11 AM
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Default Re: Mosaic verrucae-help with treatment

Call me thick, but can anyone explain why an ankle block would be indicated?
All my needlings have been done with local infiltration using approx 0.5 to 1ml scandonest 3%.

regards
CM
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  #558  
Old 27th April 2012, 11:25 AM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by cornmerchant View Post
Call me thick, but can anyone explain why an ankle block would be indicated?
All my needlings have been done with local infiltration using approx 0.5 to 1ml scandonest 3%.

regards
CM
OK your thick

Do your patients scream a lot when you do a direct infiltration into the plantar surface???

The idea of the ankle block is to make the procedure......painless .
Hope that helps
Cheers
D
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  #559  
Old 27th April 2012, 12:27 PM
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Default Re: Mosaic verrucae-help with treatment

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OK your thick

Do your patients scream a lot when you do a direct infiltration into the plantar surface???

The idea of the ankle block is to make the procedure......painless .
Hope that helps
Cheers
D
I never use an ankle block with the needling procedure. Ethyl chloride spray is used always with plantar, or dorsal injections. Posterior tibial nerve blocks, to me, seem like overkill when only an area of skin 1.5 cm in diameter is necessary to be anesthetized for the procedure.
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  #560  
Old 27th April 2012, 01:56 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by Kevin Kirby View Post
I never use an ankle block with the needling procedure. Ethyl chloride spray is used always with plantar, or dorsal injections. Posterior tibial nerve blocks, to me, seem like overkill when only an area of skin 1.5 cm in diameter is necessary to be anesthetized for the procedure.
Kevin,
every time I have witnessed a plantar infiltration it has been extremely painful for the patient and is well documented as being so.

IMHO ANY procedure that makes a Painless procedure is the way to go overkill or not.

Having had many years ago a procedure done with only the use of Ethyl chloride I can personaly state is is as effective as a chocolate teapot

Having a doctor tell me "it wasent hurting" and carrying on was to say the least sadistic and unnessasary but that was then so perhaps things have changed without my knowledge.

I have suffered much pain and suffering from dentists in my time because I am a difficult patient to "numb up". 8 years ago I met a dentist who told me "the age of painless dentistry is here".

He never caused me ANY pain in all the Tx he gave me from fillings to root canal work.

I believe that is where we should be heading, to remove the fear of Tx from the nervous patient.

So Yep when your over let me stick a needle through the plantar surface of one foot and then do a PT block on the other see which you prefer .

Cheers
Derek
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  #561  
Old 27th April 2012, 04:10 PM
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Default Re: Mosaic verrucae-help with treatment

Quote:
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Kevin,
every time I have witnessed a plantar infiltration it has been extremely painful for the patient and is well documented as being so.

IMHO ANY procedure that makes a Painless procedure is the way to go overkill or not.

Having had many years ago a procedure done with only the use of Ethyl chloride I can personaly state is is as effective as a chocolate teapot

Having a doctor tell me "it wasent hurting" and carrying on was to say the least sadistic and unnessasary but that was then so perhaps things have changed without my knowledge.

I have suffered much pain and suffering from dentists in my time because I am a difficult patient to "numb up". 8 years ago I met a dentist who told me "the age of painless dentistry is here".

He never caused me ANY pain in all the Tx he gave me from fillings to root canal work.

I believe that is where we should be heading, to remove the fear of Tx from the nervous patient.

So Yep when your over let me stick a needle through the plantar surface of one foot and then do a PT block on the other see which you prefer .

Cheers
Derek
Derek:

You can believe what you like. In my hands, ethyl chloride spray with proper local anesthetic technique is the way to go, and has no risk of injury to the posterior tibial nerve.
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  #562  
Old 28th April 2012, 06:12 AM
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Default Re: Mosaic verrucae-help with treatment

Hi Kevin ,

Always keen to learn. Would you mind setting out in greater detail your protocol for local infiltration. In particular, equipment used and how long you spray the area for prior to injection.

Much obliged to you.

Regards

Tim
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Old 28th April 2012, 10:41 AM
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Default Re: Mosaic verrucae-help with treatment

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Hi Kevin ,

Always keen to learn. Would you mind setting out in greater detail your protocol for local infiltration. In particular, equipment used and how long you spray the area for prior to injection.

Much obliged to you.

Regards

Tim
Yep me too Kevin, I'm up for ANY pain free Tx

Cheers
D
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Old 30th April 2012, 12:58 AM
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Smile Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by DTT View Post
I Believe Marin Harvey is running one in Tamworth in the not to distant future ??

May be worth sending him a PM on here to get the details?

Hope that helps
Cheers
D
Thanks for that.

Do you mean Martin Harvey though?

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Old 30th April 2012, 02:45 AM
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Default Re: Mosaic verrucae-help with treatment

Quote:
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Thanks for that.

Do you mean Martin Harvey though?

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Old 30th April 2012, 05:50 AM
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Default Re: Mosaic verrucae-help with treatment

I've done a goodly number of these now, certainly into the low hundreds. I've tried both ankle blocks and local infiltrations quite a bit.

I make it a habit to ask how painful a patient finds a proceedure after I've done it, on a scale of one to ten. With tibial blocks they generally report something in the 2 or 3 range. With infiltration its much, much higher, especially if one is injecting into the plantar skin. That tibial blocks hurt less than infiltrations is not in any doubt for me. Provided of course the practitioner has good technique. If its somebodies first time and they spear the PT nerve then wiggle the needle about some, take it out, stab it again etc it's bowel looseningly painful. Believe. *

Quote:
You can believe what you like. In my hands, ethyl chloride spray with proper local anesthetic technique is the way to go, and has no risk of injury to the posterior tibial nerve.
The lesser pain of the tibial block must, of course, be balanced against the risk of injury to the tibial nerve. As with any risk assessment, one must judge both sides. You've been at this a long time Kevin, how many injuries to the PT nerve have you caused?

Besides that the only benefit of Infiltration over Tib block which I can see is convenience. Personally, I'll swallow a bit of inconvenience if it means saving the patient a bit of pain.

Robert

*Of course careful supervision by an experienced clinician should prevent this
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  #567  
Old 1st May 2012, 02:58 AM
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Default Re: Mosaic verrucae-help with treatment

This sounds like a random question, but when doing the multiple puncture technique, what should the patient experience? Someone says the lesion turns black? How long before they see any improvement?

I have only just learnt how to do the technique and am yet to see the end result!
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Old 1st May 2012, 06:35 AM
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blinda blinda is offline
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Default Re: Mosaic verrucae-help with treatment

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Originally Posted by Robertisaacs View Post
I've done a goodly number of these now, certainly into the low hundreds. I've tried both ankle blocks and local infiltrations quite a bit.

I make it a habit to ask how painful a patient finds a proceedure after I've done it, on a scale of one to ten. With tibial blocks they generally report something in the 2 or 3 range. With infiltration its much, much higher, especially if one is injecting into the plantar skin. That tibial blocks hurt less than infiltrations is not in any doubt for me. Provided of course the practitioner has good technique. If its somebodies first time and they spear the PT nerve then wiggle the needle about some, take it out, stab it again etc it's bowel looseningly painful. Believe. *
Oh,I`m a Believer. I tend to use tibial blocks more as, like you, I always ask the pt to describe any injection discomfort. I did 3 needlings today and, as usual, local infiltration scored higher. However, I do use ethyl chloride, which eases much of the initial `prick` when I use local infiltration, for example, in the Sural nerve dermatome area.

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Originally Posted by Robertisaacs View Post
The lesser pain of the tibial block must, of course, be balanced against the risk of injury to the tibial nerve. As with any risk assessment, one must judge both sides. You've been at this a long time Kevin, how many injuries to the PT nerve have you caused?
Indeed. Maybe it`s a bit over the top but I also like to demonstrate to the pt that I have identified where their artery is by using the doppler and inject posterior to that. Part of the theatre I suppose (pinging machines and all that jazz), but appropriate technique and identifying where the nerve is rather important, eh Robert?

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Originally Posted by pd6crai View Post
This sounds like a random question, but when doing the multiple puncture technique, what should the patient experience? Someone says the lesion turns black? How long before they see any improvement?
Hi pd6crai,

Be nice to have a name..The pt shouldn`t experience pain, obviously. Pinpoint bleeding must occur at every puncture so a scab should form, which I suppose could be described as black. They should notice deep rubour during the inflammatory process, then the lesion should shrink and completely resolve. This can take anything between 4 and 8 weeks in my experience.

Cheers,
Bel
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  #569  
Old 1st May 2012, 05:57 PM
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Kevin Kirby Kevin Kirby is offline
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Default Re: Mosaic verrucae-help with treatment

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Originally Posted by Tim VS View Post
Hi Kevin ,

Always keen to learn. Would you mind setting out in greater detail your protocol for local infiltration. In particular, equipment used and how long you spray the area for prior to injection.

Much obliged to you.

Regards

Tim
Tim and Colleagues:

I am certain that a posterior tibial (PT) nerve block can be less uncomfortable for the patient when doing the verrucae needling technique. However, PT nerve blocks also take much longer until he patient's plantar foot is anesthetized, are much less reliable in achieving complete anesthesia (in my hands) and puts the patient at substantial risk for posterior tibial nerve symptoms, for weeks to months, if this large nerve is penetrated by the needle.

I have accidentally speared a few PT nerves in my 26+ years of practice and it is not a pretty site for the patient. Most of them describe it as having their foot hooked up to a 220 volt circuit and will complain of parasthesias, or worse, for up to 6 months following sticking a needle into the nerve. Not my idea of good medicine.

When I perform the local anesthetic injection for the verrucae needling technique, I will use a 1.5 inch, 25 gauge needle on a 5 cc hypodermic syringe loaded with 5.0 cc of 0.5 % Marcaine (bupivicaine) plain (without epinephrine). If at all possible, I will do the injection either from dorsal or from the medial or lateral side of the foot where there is less cutaneous nerve density to make things more comfortable for the patient. However, I often do the injecton from plantar if necessary and have no problems with injecting any plantar location of the foot, as long as I have ethyl chloride spray at my disposal.

I start the injection procedure with the patient lying flat, in a supine or prone position (i.e. whichever position is easier for me to do the procedure in). I then use ethyl chloride spray for about 10-15 seconds in a circular motion of about 10 mm diameter or until the skin starts to "frost". [The ethyl chloride spray works better if the bottle is held at least 12-18 inches from the foot which ensures that the liquid spray will be colder once it hits the foot.]

As soon as the skin is frozen with the ethyl chloride spray, the hypodermic needle is immediately punctured through to the subcutaneous tissues. The patient normally does not feel this needle puncture. Then, very slowly, I start to infiltrate the subcutaneous fat directly dorsal to the plantar verrucae (about 3 mm from the dermis) with the local anesthetic injecting a little anesthetic then advancing the needle forward a little more, then injecting a little more anesthetic. The needle is then repositioned a few more times slowly so that the whole plantar verrucae lesion starts to blanche to a whiter color. The patient will always be completely numb at the plantar lesion within 15 seconds of finishing the local anesthetic injection.

The injection rate is about 1 cc for every 15 seconds so that the normal injection of 4ccs will take about 60 seconds. This is uncomfortable for the patient but not unduly so. Most patients describe the pain about the same as getting a local anesthetic injection from the dentist. The patient is then prepped with a betadine solution and a fenestrated drape is used to isolate the area of the plantar lesion and the needling is immediately started. Time from ethyl chloride spray to start of the needling procedure is about 3-4 minutes.

You must remember, though, that I have been giving local anesthetic injections for over 28 years, taught students and surgery residents at CCPM on ankle block technique 27 years ago, and give about 3-6 cortisone and local anesthetic injections per day in my office so I am very comfortable with my injection techniques. In addition, in further support of the use of plantar injections without PT nerve blocks, all of my cortisone injections for plantar heel pain (i.e. proximal plantar fasciitis) are done with the patient prone, their affected knee flexed to 90 degrees and using ethyl chloride spray for a direct plantar heel injection at the point of maximum tenderness. I learned this technique from Jack Morris, DPM, one of my Biomechanics Professors, when I was a Biomechanics Fellow at CCPM in 1984 and it is the best technique, in my opinion, for giving cortisone injections for plantar fasciitis. I do about 10 of these plantar heel injections, directly plantarly on the heel, every week.

Maybe someday I will try to do a video of these techniques and post them up on youtube if I ever get the time. Right now, however, things are very busy as I am starting to get ready for a series of three seminars I will be lecturing at in June.

Hope this helps.
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Kevin

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  #570  
Old 2nd May 2012, 12:57 AM
stevewells stevewells is offline
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Default Re: Mosaic verrucae-help with treatment

Quote:
Originally Posted by Kevin Kirby View Post

I start the injection procedure with the patient lying flat, in a supine or prone position (i.e. whichever position is easier for me to do the procedure in). I then use ethyl chloride spray for about 10-15 seconds in a circular motion of about 10 mm diameter or until the skin starts to "frost". [The ethyl chloride spray works better if the bottle is held at least 12-18 inches from the foot which ensures that the liquid spray will be colder once it hits the foot.]

.
Hi Kevin - thank you very much for this - just one question - do you use the stream type ethyl chloride or the aerosol type?

Steve
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