II. Indications
- Turf Toe (First MTP Sprain)
- Hallux Rigidus
- Severe Arthritis of first MTP joint
III. Contraindications
- Septic Arthritis (rule-out before steroid injection)
IV. Preparation
- Needle
- Gauge: 25 to 27
- Length: 1.0 to 1.5 inches
- Syringe: 3 to 5 ml
-
Corticosteroid options
- Betamethasone (Celestone) 0.25 ml of 6 mg/ml
- Methylprednisolone (Sol-umedrol): 0.25 ml of 40 mg/ml
-
Anesthetic
- Lidocaine 1%: 1 ml or
- Bupivacaine 0.25% or 0.5%: 1 ml
V. Technique
- Images
- Patient position
- Supine position with knee flexed over towel roll
- Foot in neutral position against exam table
- Slightly plantar flex great toe
- Landmarks
- Mark dorsum of first metatarsophalangeal joint (MTP)
- Consider ethyl chloride spray prior to needle insertion
- Sterilize local skin with Betadine or Hibiclens
- Insert needle into skin at MTP on dorsal surface
- Angle needle 60 degrees distally
- Insert needle into joint (relatively shallow depth)
- Aspirate before injection
- Aspiration pointers
- Apply negative pressure on syringe
- Back and forth motion for 5 seconds
- Release negative pressure before exiting skin
- Avoids blood in sample (obscures crystal exam)
- Spray quickly onto slide and apply cover slip
- Send for polarized crystal exam at CLIA approved lab
VI. Follow-up Instructions
- No stress to foot for 2 weeks after injection
- Examine again in 3 weeks post-injection