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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?


Thank you very much in advance for your help

You're trying to research a negative. You could try a survey and extrapolate the figures although the result will be questionable.

Better to enumerate the uses of L.A. and then take that forward.

Bill Liggins

Thank you so much for this. It does make sense.

Hi,

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?

Best wishes

Nick

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Nick

My location

Those without humour are at the mercy of the rest of us!

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

Agreed...strange to start with a null hypothesis so to speak. How can you determine who 'doesn't' use LA for anything other than Nail surgery.

Airamaser - Perhaps get your lecturer to clarify!

Otherwise as Bill suggests, explore who does use LA for alternative purposes - then argue the negative.

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A bientot...

Julian
Podiatrist-at-large

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.

Interesting.

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?

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A bientot...

Julian
Podiatrist-at-large

Thank you Julian for your reply,

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.

Stevo

Steve,

My pleasure to pass on the little I know!

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.

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A bientot...

Julian
Podiatrist-at-large

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.

... but i'm still learning. I could be wrong!!

respectfully

Ian Reilly

Hi Ian,

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?

Your thoughts....

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A bientot...

Julian
Podiatrist-at-large

Hi Steve

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 ...

http://www.amazon.co.uk/Foot-Ankle-I...6335096&sr=8-1

ATB

Ian