Nerve Blocks: Part II. Lower Extremity

 

Am Fam Physician. 2020 Jun 1;101(11):669-679.

This is part II of a two-part article on nerve blocks. Part I, “Upper Extremity,” appears in this issue of AFP.

Author disclosure: No relevant financial affiliations.

Family physicians use anesthesia to provide diagnostic and procedural analgesia for conditions such as neuropathies, fracture reduction, foreign body removals, and complex wound management. Local infiltration of anesthetics is commonly used in this setting because of the ease of use, safety, and effectiveness of the procedure. Nerve blocks are a specific regional anesthesia technique that blocks nerve function distal to the injection site. An understanding of the sensory distribution of the peripheral nervous system is essential in determining the safest and most effective nerve block for the procedure. There are various nerve block techniques, including landmark-guided and ultrasound-guided. Ultrasound guidance increases the effectiveness of the nerve block while decreasing complications when compared with other techniques. Depending on the required area of anesthesia for the procedure, various points throughout the lower extremity can be used to block the lateral femoral cutaneous, common peroneal, saphenous, tibial, deep peroneal, superficial peroneal, and sural nerves.

Family physicians use various techniques to provide effective anesthesia in outpatient procedures, including local, field, or nerve blocks. Local infiltration of anesthetics is commonly used in this setting because of the ease of use, safety, and effectiveness of the procedure. Local anesthesia is provided by infiltrating the anesthetic into the procedural field, whereas field blocks are performed by infiltrating the anesthetic around the procedural area, leaving the procedural field undisturbed. Both of these procedures anesthetize branches of sensory nerves locally. This article, part II of a two-part series, focuses on nerve blocks of the lower extremity. Part I discusses the guiding principles of nerve block administration and nerve blocks of the elbow and wrist.1

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Preprocedural tibial nerve blocks effectively reduce the pain of plantar fascia injections.8,9

B

Small, low-quality randomized controlled trials

The location for an ultrasound-guided superficial peroneal nerve block is different than that for a landmark-guided injection. The nerve is smaller at the landmark-guided location and challenging to identify with ultrasonography, whereas the nerve is larger at the ultrasound-guided location but has a variable position.12

C

Expert clinical review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Preprocedural tibial nerve blocks effectively reduce the pain of plantar fascia injections.8,9

B

Small, low-quality randomized controlled trials

The location for an ultrasound-guided superficial peroneal nerve block is different than that for a landmark-guided injection. The nerve is smaller at the landmark-guided location and challenging to identify with ultrasonography, whereas the nerve is larger at the ultrasound-guided location but has a variable position.12

C

Expert clinical review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Nerve blocks are used in managing conditions such as neuropathies, fracture reduction, foreign body removals, and complex wounds. Table 1 lists conditions that warrant consideration for lower extremity nerve blocks. Nerve blocks are performed by infiltrating an anesthetic in the perineural space of the sensory nerves that innervate the procedural area. The nerve block is performed proximal to the site of the procedure, providing regional anesthesia distal to the block. Figure 1 illustrates cutaneous innervation of the lower extremity.2

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TABLE 1.

Select Indications for Lower Extremity Nerve Blocks

NerveIndication

Lateral femoral cutaneous nerve

Meralgia paresthetica or procedures on the anterior thigh

Distal sciatic nerve

Any procedure crossing multiple dermatomes of the lower leg

Ankle*

 Saphenous nerve

Procedures over the medial malleolus

 Tibial nerve

Tarsal tunnel or plantar fascia injection

 Deep peroneal nerve

Procedures around the first web space

 Superficial peroneal nerve

Procedures on the dorsum of the foot

 Sural nerve

Procedures on the posterior lateral calf or the dorsolateral little toe


*—Complete nerve block requires anesthetizing all of these nerves.

The Authors

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JACQUELINE L. YURGIL, DO, CAQSM, is a family and sports medicine physician at the Family Medicine Residency at Offutt Air Force Base, Neb. At the time this article was written, she was a sports medicine fellow at the Uniformed Services University of the Health Sciences, Bethesda, Md....

CHAD D. HULSOPPLE, DO, CAQSM, is assistant program director of the Sports Medicine Fellowship and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

JEFFREY C. LEGGIT, MD, CAQSM, is director of health care operations and associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Jeffrey C. Leggit, MD, CAQSM, 4301 Jones Bridge Rd., Bethesda, MD 20814 (email: jeff.leggit@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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8. David JA, Sankarapandian V, Christopher PR, et al. Injected corticosteroids for treating plantar heel pain in adults. Cochrane Database Syst Rev. 2017;(6):CD009348.

9. Govindarajan R, Bakalova T, Doss NW, et al. Posterior tibial nerve block in the therapeutic management of painful calcaneal spur (plantar fasciitis): a preliminary experience. Can J Anaesth. 2003;50(8):862–863.

10. American Association of Neuromuscular and Electrodiagnostic Medicine. Foot and ankle disorders. Capturing motion with ultrasound: blood, muscle, needle, and nerve. September 2011. Accessed January 10, 2020. https://bit.ly/2QQPfBC

11. Delfaut EM, Demondion X, Bieganski A, et al. Imaging of foot and ankle nerve entrapment syndromes: from well-demonstrated to unfamiliar sites. Radiographics. 2003;23(3):613–623.

12. De Maeseneer M, Madani H, Lenchik L, et al. Normal anatomy and compression areas of nerves of the foot and ankle: US and MR imaging with anatomic correlation [published online August 18, 2015]. Radiographics. Accessed June 13, 2019. https://pubs.rsna.org/doi/10.1148/rg.2015150028

13. Kelikian AS, Sarrafian SK, eds. Nerves. In: Sarrafian's Anatomy of the Foot and Ankle. 3rd ed. Wolters Kluwer Lippincott Williams & Wilkins; 2011:381–427.

 

 

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