2. Place the patient in supine position with affected leg straight and externally rotated and foot inverted. Palpate and mark the tendon just under the posterior edge of the medial malleolus.
3. Insert the needle tangent to the skin in the direction of the tendon, aspirate before injection to avoid intra-arterial injection, and injection should be against no or little resistance. Parasthesia could be a sign of neurovascular bundle engagement. One possible complication is the rup- ture of posterior tibialis tendon if the needle is misplaced or injection is done under resistance.
Morton’s Neuroma
Many patients are present with symptoms suggesting Morton’s neuroma. However, it is uncommonly diagnosed with certainty.
Clinical diagnoses should be supported with radiological findings to confirm diagnosis. The nerve located between the third and fourth toes is the most commonly affected.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml (or equivalent), and 0.5 ml of lidocaine (2%) in a 2 ml volume syringe, using 25 gauge, 5/8 in. needle.
2. Palpate and mark the place of entry which should be half way between the MTP heads and ½ in. proximal from the Web space from the dorsal side. Insert the needle perpen- dicular to the skin and advance it through the resistance of transverse tarsal ligament. A giving away sensation is felt when the needle passes through the ligament.
Metatarsophalangeal Joint Injection
Aspiration and injection could be very beneficial for the diagnosis and management of gout flare affecting usually the first MTP joint. It can also be indicated for inflammatory MTP joints arthritis.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml (or equivalent), and 0.5 ml of lidocaine (2%) in a 2 ml volume syringe, using 25 gauge, 5/8 in. needle.
2. Palpate and mark the MTP joint space medial or lateral to the extensor tendon from the dorsal side. Medial approach is preferred for the first MTP. Insert the needle perpendicular to skin with mild plantar flexion of the MTP joints.
Aspiration of the first MTP joint content before injection is important diagnostically if crystal arthropathy is suspected.
123 13 Arthrocentesis in the Elderly
Real Time Technique
This technique requires using sterile gel and probe sleeves if available. The needle is inserted under ultrasound monitor- ing of its progression in the screen. Lateral approach could be used, where the needle is inserted perpendicular to the beam in longitudinal view, where the needle appears as a hyperechoic thin band. Coaxial approach could be used, where the needle is inserted in transverse scan and appears as a small hyperechoic circular object. Attention should be given to the tip of the needle. However, if the needle tip can- not be visualized clearly, injecting a small amount of the ste- roid containing microbubbles, due to mixing with local anesthetic, can be used. This gives a clear hyperechoic shadow which can confirm the placement. In the case of injecting a deep tissue, such as the hip joint, the needle may be difficult to visualize. In this situation, the needle position
can be known by moving the needle slightly forward and backward which moves the tissue around.
Conclusion
Joints injections with corticosteroid can be very useful in treating many resistant rheumatologic problems. Joints aspi- ration is also very important to exclude conditions like septic and crystal arthritis. Joints injection is a relatively safe procedure that can be managed by clinician in the outpatient clinic. Some rare complications could be encountered;
however, if the precautions are taken, the procedure should be safe and convenient. The injection becomes more effec- tive when combined with pharmacological, physiotherapy, and occupational rehabilitation regimen.
Fig. 13.6 Ultrasound-guided injection of the median nerve.
MN median nerve
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Y. Nakasato and R.L. Yung (eds.), Geriatric Rheumatology: A Comprehensive Approach, 125 DOI 10.1007/978-1-4419-5792-4_14, © Springer Science+Business Media, LLC 2011
Abstract Physical activity offers an effective, nonphar- macological means to improve the health of older adults, including those with arthritis. Clinical practice guidelines identify a substantial therapeutic role for physical activity in osteoarthritis and rheumatoid arthritis. For older adults, including those with arthritis, regular physical activity counteracts the reduction in fitness, stamina, and loss of muscle strength associated with aging, prevents the development of physical limitations, and can reduce falls and reduce the risk of developing many chronic conditions.
Evidence from randomized clinical trials in patients with osteoarthritis (OA) and rheumatoid arthritis (RA) supports both muscle strengthening exercise and aerobic activity to improve function and relieve joint symptoms, including pain. These have led to recommendations for older adults both with and without arthritis that encourage physical activity. Despite the documented benefits of physical activity, persons with arthritis are generally not physically active, and their physicians often do not encourage them to engage in regular physical activity. In order to help overcome these challenges, physician assessment and promotion of physical activity should be a key component of disease management for arthritis patients.
Keywords Physical activity • Osteoarthritis • Rheumatoid arthritis • Function • Pain