The Pain Source

Transducer: SonoSite C60 (curved)

Structures visualized:

• Acetabulum
• Femoral head
• Femoral neck
• Femoral shaft
• Joint capsule and cartilage
• Femoral joint space — injection site
• Femoral artery and vein

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Transducer: SonoSite L25 probe

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Machine:

Transducer:

Related Content:

• Ultrasound – Shoulder Exam Setup
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By Chris Faubel, MD –

Just need to get the needle under the joint capsule, not necessarily inside the joint.

aka. “Great toe injection”, “Big toe injection”

Indications

• First metatarsophalangeal (1st MTP) joint painful osteoarthritis
• Gout (in the “great toe” joint) — most common location
• Turf Toe
  
• **see all ICD-9 and ICD-10 codes at end of post

CPT code: 20600 “Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)”

Materials Needed

• Pen – clicking type
• Gloves – non-sterile
• Alcohol swabs (or povidone-iodine)
• Band-aid
• Tuberculin needle/syringe OR 1-ml syringe with 25-gauge 5/8″ needle (depending on body habitus)
• Injectate
  • 0.5-ml of 40mg/ml Depo-Medrol or Kenalog (or 0.5ml of 6mg/ml Celestone)
  • 0.5-ml of 1% lidocaine

Technique / Procedure Steps

1. Always start with informed consent from the patient, and then a time-out to verify correct patient and injection site.
2. Mark the injection site with the pen tip in order to leave an impression in the skin.
3. Clean the skin thoroughly with as many alcohol swabs as needed (usually only 1-2 are needed).
4. Patient position: Perform lying supine with the foot off the end of the table, OR, supine with knee bent and foot flat on the table.
5. With the tuberculin needle/syringe, enter perpendicular to the skin.  If bony resistance is met, redirect the needle until you feel you are inside the joint.  Note: Ultrasound may be needed if extensive osteophytes make it difficult to find an entry path.  Also, the needle tip does NOT need to be inside the joint; just under the capsule surrounding the joint.
6. Aspirate to make sure you’re not in any vessel.
7. After negative aspiration, inject the full contents of the syringe.  Should flow easily.
8. Withdraw the needle after syringe if fully empty, and apply band-aid.

Tips

• Finding the injection site
  • Can palpate the joint space best on the medial surface.
  • May help to distract the phalanx distally to open the joint space.
• Numbing the skin
  • Find out all about “Taking the Sting Out” (of injections) by going here.
  • Since I use a tiny tuberculin needle, most patients have no problem with the injection and don’t need any extra lidocaine skin wheal or freezing spray.
    • I tell them numbing the skin with lidocaine will probably hurt more than the actual injection.
    • Because this is a sensitive area, ethyl chloride “numbing” spray may be used.
• After the injection
  • Have the patient move their toe around while you throw away supplies.
  • Then, re-mobilize the 1st MTP joint so they can see the immediate results of the lidocaine.
  • Explain to the patient that the lidocaine will wear off in an hour or so, and that they will be back to their normal pain until the steroids start kicking in (anywhere from 1-7 days).
  • May also ask the patient to not do much activity on that foot for 12-24 hours.

Diagnostic Codes

• First metatarsophalangeal (1st MTP) joint painful osteoarthritis
  • ICD-9 codes:
    • 715.17 “osteoarthrosis, localized, primary, ankle and foot”
    • 719.47 “pain in joint, ankle and foot”
  • ICD-10 codes:
    • M19.071 “primary osteoarthritis, right ankle and foot”
    • M19.072 “primary osteoarthritis, left ankle and foot”
    • M79.674 “pain in right toe(s)
    • M79.675 “pain in left toe(s)
• Gout (in the big toe joint)
  
  • ICD-9 code:
    • 274.0 “gouty arthropathy”
    • 274.9 “gout, unspecified”
  • ICD-10 code:
    • M1a.071 “idiopathic chronic gout, right ankle and foot”
    • M1a.072 “idiopathic chronic gout, left ankle and foot”
    • M10.071 “idiopathic gout, right ankle and foot”
    • M10.072 “idiopathic gout, left ankle and foot”
• Sprain of first metatarsophalangeal joint (turf toe)
  • ICD-9 code:
    • 845.12 “sprain of metatarsophalangeal (joint) of foot”
  • ICD-10 code:
    • S93.5 “sprain and strain of toe(s)”

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By Chris Faubel, MD –

Medial Approach. Advance needle at about 15-20 degrees from midline.

Indications

• Osteoarthritis of the knee
  
• Rheumatoid arthritis of the knee
• Gout (in the knee)
• Calcium pyrophosphate dyhydrate (CPPD)
  
• **see all ICD-9 and ICD-10 codes at end of post
  

CPT code: 20610 “Arthrocentesis, aspiration and/or injection; major joint or bursa”

Read the full story

Related Content:

• First Metatarsophalangeal Joint Injection – Technique and Tips
• Pes Anserine Bursa Injection – Technique and Tips
• Distal Interphalangeal (DIP) Joint Injection – Technique and Tips
• Prepatellar Bursa Aspiration and Injection – Technique and Tips
• Plantar Fascia Injection – Technique and Tips

By Chris Faubel, MD –

PM&R. 2010 Mar;2(3):174-81.
The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology.
Maslowski E, Sullivan W, Forster Harwood J, Gonzalez P, Kaufman M, Vidal A, Akuthota V.
Department of Physical Medicine and Rehabilitation, University of Colorado Denver, Mail Stop F-493, 12631 East 17th Avenue, Academic Office 1, Room 2513, Aurora, CO 80045, USA. elmaslow@hotmail.com

http://www.pmrjournal.org/article/S1934-1482%2810%2900051-1/abstract

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