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Interphalangeal Joint of the Foot Injection

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Other Names

  • Interphalangeal Joint Injection
  • Interphalangeal Joints of the Foot Injection
  • Great Toe interphalangeal joint injection

Background

Joints of the foot[1]
Radiographs highlighting the interphalangeal joints of the foot[2]

Key Points

  • Needle: 25 gauge, 1-1.5 inch
  • Transducer: high frequency, linear array

Anatomy of the Interphalangeal Joints of the Foot

  • Interphalangeal joints (IPJ) are the articulation between consecutive phalanges of the foot
  • Each foot has 9 total (2 for each of the lateral 4, 1 for the great toe)
  • Proximal interphalangeal joint: head of proximal phalanx, base of middle phalanx
  • Distal interphalangeal joint: head of middle phalanx, base of distal phalanx
  • Great toe: only has an interphalangeal joint between proximal and distal
  • Stabilized by extensor tendons dorsally, collateral ligaments on the sides, plantar ligament on the flexor surface
  • Motion is flexion and extension

Palpation Guidance vs Ultrasound Guidance

  • Palpation guided injections have been described by Boxer et al[3]
  • Reach et al found 100% success with ultrasound guided injections[4]
  • Balint et al found success with palpation guided aspiratoin to be 32% vs ultrasound guidance at 97%[5]
  • Raza also found palpation guidance to be inferior at 59% compared to 96% with ultrasound guided injections[6]

Indications

  • Interphalangeal Joint pain

Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Can be treated with less invasive means
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Needle and probe position for long axis, out of plane approach[7]

Equipment

Long-axis imaging over second interphalangeal joint shows the proximal phalanx (open arrow), proximal interpha�langeal (PIP) joint space (asterisk), and distal phalanx (thin arrow). axis[7]
  • Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid
  • Sterile probe cover

Ultrasound Findings

  • Transducer: high frequency, linear array
    • Typical depth is 1-2 cm
  • Common ultrasound findings include:
    • Cortical irregularities
    • Joint space narrowing
    • Calcifications
    • Synovial hypertrophy
    • Joint effusions

Ultrasound Guided Technique: Long Axis, Out of Plane

  • Patient Position
    • The patient is supine
    • Foot flat on table with knee flexed
  • Transducer Position
    • Long axis to the interphalangeal joint
  • Anatomic, sagittal to the joint
  • Needle Approach/ Orientation
    • Out of plane
    • Medial to lateral or lateral to medial
  • Target
    • Dorsomedial or dorsolateral aspect of the joint
  • Pearls and Pitfalls
    • Staying dorsal can help you avoid the interdigital nerve

Ultrasound Guided Technique: Long Axis, In Plane

  • Patient Position
    • The patient is supine
    • Foot flat on table with knee flexed
  • Transducer Position
    • Long axis to the interphalangeal joint
    • Anatomic, sagittal to the joint
  • Needle Approach/ Orientation
    • In plane
    • Proximal to distal
  • Target
    • Proximal aspect of interphalangeal joint
  • Pearls and Pitfalls
    • Staying dorsal can help you avoid the interdigital nerve
    • Avoid the extensor tendon
    • Short axis approach preferred

Aftercare

  • Motor exam should be intact
  • No major restrictions in most cases
  • Can augment with ice, NSAIDS

Complications

  • Infection
  • Damage to surrounding tissue

See Also

Internal

External

References

  1. ↑ Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 99469
  2. ↑ Image courtesy of https://www.orthopaedia.com/
  3. ↑ Boxer, Myron C. "Osteoarthritis involving the metatarsophalangeal joints and management of metatarsophalangeal joint pain via injection therapy." Clinics in podiatric medicine and surgery 11.1 (1994): 125-132.
  4. ↑ Reach, John S., et al. "Accuracy of ultrasound guided injections in the foot and ankle." Foot & ankle international 30.3 (2009): 239-242.
  5. ↑ Balint PV, Kane D, Hunter J, et al. Ultrasound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study. Journal of Rheumatology. 2002;29(10):2209–2213.
  6. ↑ Raza K, Lee CY, Pilling D, et al. Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology (Oxford). 2003;42(8):976–979
  7. ↑ 7.0 7.1 Malanga, Gerard A., and Kenneth R. Mautner. " Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
Created by:
John Kiel on 25 August 2025 19:36:17
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Last edited:
25 August 2025 19:57:53
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