Sports Medicine: Just the Facts

CHAPTER 72 • FOOTWEAR AND ORTHOTICS 433

junction between the skin of the sole of foot and

the skin of the lower extremity.

3. Technique: This examination is best administered
   with the patient in the supine position. The needle
   is inserted medial to lateral toward the point of
   maximal tenderness, which is generally at the plan-
   tar insertion into the medial calcaneal tubercle.
   Avoid injecting through the plantar fad pad as this
   may induce fat pad atrophy. If pain is felt radiating
   across the heel or into the arch, or there is exces-
   sive resistance, withdraw, change the angle
   slightly, and reinsert.


4. Needle size and dosage: A 25- to 27-gauge needle
   may be used, 1- to 1^1 / 2 -in. long; 1 mL of corticos-
   teroid may be injected with 1 to 2 mL of anesthetic.

• Morton’s neuroma

1. Indications: Morton’s neuroma is thought to be the
   result of perineural fibrosis of an interdigital nerve.


2. Clinical anatomy/Landmarks: Key are the metatarsal
   heads.
   3.Technique: The point of maximal discomfort
   should be identified between the metatarsal heads;
   the neuroma is typically between and slightly plan-
   tar to the metatarsal heads. The patient should be
   placed in the supine position with a pillow under
   the knee so that the foot can be slightly plantar
   flexed. The nerve is approached from a dorsal
   approach, with the needle entering between the
   metatarsal heads, advanced perpendicular through
   the transverse tarsal ligament. The depth of inser-
   tion is approximately^1 / 2 -in. A giving way can be
   felt as the needle passes through the ligament.


3. Needle size and dosage: A 25-gauge 1-in. needle is
   appropriate; 0.5 mL of corticosteroid with 1 to 2 mL
   of local anesthetic.

• Myofascial trigger points

1. Indications: Diagnosis and treatment of myofascial
   trigger points


2. Clinical anatomy/Landmarks: Dependent on loca-
   tion of trigger points; knowledge of local anatomy
   is recommended, as well as knowledge of common
   trigger point sites and their referral patterns.


3. Technique: Trigger points are often palpable as
   fusiform firm nodules running parallel to the fibers
   in a muscle. The nodule should be identified and
   trapped with the fingers of the nondominant hand.
   After a sterile prep, the skin is penetrated in a per-
   pendicular fashion with the needle in to the center
   of the trigger point. Occasionally a local twitch
   response may be noted, where the muscle twitches
   as the center of the trigger point is entered.


4. Needle size and dosage: A 25- to 27-gauge needle,
   1- to 1^1 / 2 -in. is used; 1 to 5 mL of anesthetic is used
   for injection.

REFERENCES

Anderson BC: Office orthopedics for primary care. Philadelphia,

PA, W.B. Saunders, 1994.

Genovese MC: Joint and soft tissue injection: a useful adjuvant to

systemic and local treatment. Postgraduate Med103(2):125–

134, 1998.

Klippel JH, Dieppe PA: Practical rheumatology. Baltimore, MD,

Mosby, 1997.

McNabb JW: Evidence-based medicine evaluation of steroid

injections, in Joint Injections. Dallas, TX, AAFP Scientific

Assembly Monograph, 2000.

Paluska AS: Indications, contraindications, and overview for aspi-

rating or injecting a joint or related structure, in Phenninger JL

(ed.): The Clinics Atlas of Office Procedures—Joint Injection

Te c hniques: vol. 5 (no. 4).December 2002.

Pfenninger JL: Joint and soft tissue aspiration and injection, in

Pfenninger JL, Fowler GC (eds.): Procedures for Primary

Care Physicians. St. Louis, MO, Mosby, 1994.

Safran MR: Injections, in Safran MR, McKeag DB, Van Camp

SP (eds.): Manual of Sports Medicine. Philadelphia, PA,

Lippincott-Raven Publishers, 1998.

Saunders S, Cameron G: Injection Techniques in Orthopedic

and Sports Medicine. Philadelphia, PA, W.B. Saunders,

1997.

Turner JL, McKeag DB: Complications of joint aspirations and

injections, in Phenninger JL (ed.): The Clinics Atlas of Office

Procedures—Joint Injection Techniques:vol. 5 (no. 4).

December 2002.

White RD: Supplies and equipment needed for joint injection, in

Phenninger JL (ed.): The Clinics Atlas of Office Procedures—

Joint Injection Techniques:vol. 5 (no. 4): December 2002.

72 FOOTWEAR AND ORTHOTICS

Eric Magrum, PT OCS FAAOMPT

Jay Dicharry, MPT CSCS

ORTHOTICS

INTRODUCTION

• Prescription custom foot orthoses are frequently used
  as part of a management strategy for the treatment of
  various lower quarter injuries in the athlete.


• Significant success treating many common lower
  quarter injuries with orthotic intervention has been
  shown. James reported 78% of runners were able to
  return to prior level of running following a knee injury
  with orthotic management (James, Bates, and