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Posts for tag: injection

January 09, 2015
Category: F.Y.I.

Sclerosing Injections are a series of injections often used to treat a painful Morton's Neuroma in the foot.  A Morton's Neuroma is a nerve inflammation or neuritis that occurs when a nerve on the bottom of the foot, usually between the third and fourth toes, becomes compressed or otherwise irritated and enlarges.  It is NOT a tumor, despite the name given to it many years ago by Dr. Morton.  Pain and numbness starting in the ball of the foot and radiating into the toes is a common symptom, and it often becomes worse as the nerve becomes more inflamed or enlarged.  There are several ways to treat neuromas, with surgery being done less and less often.

 Steroid (cortisone) injecions and orthotic devices are probably used in the majority of cases first, especially if padding and changes in shoes do not help.  Unlike steroid injections which are given to shrink the nerve, often temporarily, sclerosing injections are given to cause a chemical neurolysis of the nerve, basically making the nerve no longer work.  While nothing is successful 100% if the time, a series of sclerosing injections, often between 3 and 7 of them spaced 10 to 14 days apart, is often very helpful in reducing and often eliminating the pain, numbness, burning, and tingling of a neuroma.

  Typically, a very small amount of the medication, often less than 1.0cc, is infiltrated directly into or on the nerve.  It is helpful to use ULTRASONIC GUIDANCE for this treatment to be sure the medication is right at or in the nerve.  With steroid injections, a larger amount of fluid is injected near the nerve, so that the medication "bathes" the nerve.  It is more important with a sclerosing injection to give the medication right at or behind the bifurcation (the y-shaped area where the nerve splits into two branches). 

A very small needle can be used for this, usually smaller than that used for a steroid injection, as long acting steroid medications are "thicker" and are not easily administered through a very thin needle.  The procedure takes only a few minutes, and the patient is helpful in communicating with the doctor when she feels the doctor is "getting close to the nerve."  Sharp, electrical shock type pains, which are relatively brief, will tell the patient the needle is very close to the nerve.  The medication is given in that spot, and then the procedure is over.

  The sclerosing mixture used is often a mixture of absolute alcohol, Marcaine (a long acting anesthetic), and epinephrine.  In the U.S., it is common to use a 4% solution, but in europe, where the procedure has been done for a much longer period of time, high concentrations of the medication are used.  This increases the effectiveness, and may reduce the number of injections needed, but it does carry some risk of "burning" the skin.  I, personally, have found that a 10% mixture works well in a majority of cases, and have had no untoward effects with that strength.  I have heard of mixtures as high as 20% being used in Europe, with a high success rate, but also a sometimes unacceptable rate of side effects.  In any case, the sclerosing injections are usually given every 10-14 days until the patient sees a nearly complete resolution of symptoms.  I have found, in my practice, that anywhere from 3 to 7 are needed.  We usually then evaluate the patient several weeks to a few months later, to be sure there is no recurrence.

Dr. Richard S. Eby

(423) 622-2663

December 15, 2014
Category: F.Y.I.

HEEL INJECTIONS can be of more than one type.  For the purposes of this discussion, we will be talking about STEROID INJECTIONS for heel pain, primarily for Plantar Fasciitis.  Injection  into the bottom of the heel for plantar fasciitis, or what has often been called "heel spur syndrome" is very common, and in many cases, very effective. 

Note that I said IN MANY CASES.  The term Plantar Fasciitis implies that there is inflammation within the ligament we know as the plantar fascia, and that is what causes the pain that heel pain sufferers are very familiar with - pain on arising first thing in the morning, pain that gets worse after walking following a period of rest, pain that is often worse barefoot or when wearing flat or non-supportive shoes.  But the pain we are talking about is due to a MECHANICAL cause, and NOT an inflammatory cause.  There is usually no swelling, redness, or other signs of inflammation in the heel or arch. 

There may be thickening or degeneration of the plantar fascia, which can be seen on Ultrasonic imaging of the foot, and can be very helpful.  But there is NO real inflammation.  Microscopic studies of the "diseased" or thickened plantar fascia that was removed surgically have consistently showed NO signs of inflammation.  So why do non-steroidal medications taken by mouth and steroid injections usually help, at least to a degree?  They have PAIN relieving properties as well as anti-inflammatory properties. 

It has also been showed that the act of "needling" the fascia can help in reducing pain.  It is possible that the act of putting a needle into the fascia can cause it to repair itself, at least to a degree.  Injections can be given into the heel under ULTRASONIC GUIDANCE, making the delivery of the steroid medication more precise.  While steroid injections are not without their risks, the bottom of the heel, with its typically thick pad of fat, is a much safer area to inject than thin skinned areas such as the sides and tips of the toes, or especially the BACK of the heel, where the Achilles Tendon can be damaged or even rupture, especially with repeated injections. 

It is possible to rupture the plantar fascia with steroid injections, but this is fairly uncommon, and since the plantar fascia is not a tendon or muscle, and simply a ligament, there is no loss of function if that should occur.  Surgery for plantar fasciitis, which should only be considered when conservative treatment fails, involves a deliberate cutting of the tight plantar fascia.   Steroid injections should NOT be given haphazardly or repeatedly if no benefit is being obtained with them, but in may cases, corticoteroid injections can give significant relief to the plantar heel pain sufferer, and may eliminate the need for invasive surgery. 


Richard S. Eby, DPM

(423) 622-2663