Original Research| Volume 49, ISSUE 2, P143-146, March 2010

Download started.


A Randomized Controlled Trial to Compare Two Techniques for Partial Digital Local Anesthetic Blocks


      The administration of local anesthetic before surgery to the great toe is often associated with significant difficulties, delaying surgery and increasing risk. Anxious patients can faint, refuse injection, or withdraw the foot while an anesthetic is being delivered. Such events led us to consider whether delivering a small amount of anesthetic throughout the injection site, before the main injection, may reduce pain intensity and duration. This study was designed to test this possibility. A randomized controlled, single-blinded, parallel-grouped clinical trial was carried out with a sample of 50 patients. All study participants received each injection method (1 or 2 stage) to either the medial or lateral side of the great toe. The primary end points were pain intensity, measured by scores on a visual analogue scale and duration, recorded by the patient with a stopwatch. The 2-stage method was associated with less intense pain (reduced from moderate to mild visual analogue scale level) of a shorter duration. The differences were highly statistically significant. In the 2-stage method, it is believed that they were due to the initial infiltration of a small quantity of the anesthetic solution throughout the injection site, with the remainder being administered, after a 2-minute interval, into tissue that was predominantly anesthetized. This differs from raising a traditional bleb where a small amount of anesthetic is infiltrated into superficial tissue. The 2-stage technique is therefore recommended as the method of choice for adults.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Thomson C.E.
        • Morrow L.J.
        • Martin D.J.
        A randomised double blind trial to compare pain on digital injection of warm and cold anesthetic.
        The Foot. 1998; 8: 89-92
        • Metcalfe S.
        Does the administration of entonox gas during local anesthetic injection for elective foot surgery significantly reduce injection discomfort?.
        The Foot. 2001; 11: 85-88
        • Browne J.
        • Fung M.
        • Donnelly M.
        • Cooney C.
        The use of EMLA reduces the pain associated with digital ring block for in-growing toenail correction.
        Eur J Anaesthesiol. 2000; 17: 182-184
        • Hayward S.
        • Landorf K.
        • Redmond A.
        Ice reduces needle-stick pain associated with a digital nerve block of the hallux.
        Australas J Dermatol. 2007; 48: 60-61
        • Malamed S.F.
        Handbook of Local Anesthesia.
        ed 4. Mosby, London1997
        • Jensen M.P.
        • Chen C.
        • Brugger A.M.
        Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain.
        J Pain. 2003; 4: 407-414
        • Todd K.H.
        • Funk K.G.
        • Funk J.P.
        • Bonacci R.
        Clinical significance of reported changes in pain severity.
        Ann Emerg Med. 1996; 27: 485-489
        • Gallagher E.J.
        • Liebman M.
        • Bijur P.E.
        Prospective validation of clinically important changes in pain severity measured on a visual analog scale.
        Ann Emerg Med. 2001; 38: 633-638
        • DeLoach L.J.
        • Higgins M.S.
        • Caplan A.B.
        • Stiff J.L.
        The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale.
        Anesth Analg. 1998; 86: 102-106