Lower Limb Injections

Published on 18/03/2015 by admin

Filed under Rheumatology

Last modified 22/04/2025

Print this page

This article have been viewed 5139 times

Section 4 Lower Limb Injections

Examination of the lower limb 153

Acute or chronic capsulitis 160

Gluteal bursa 162

Chronic bursitis 162

Psoas bursa 164

Chronic bursitis 164

Trochanteric bursa 166

Acute or chronic bursitis 166

Adductor tendons 168

Chronic tendinitis 168

Hamstring tendon and ischial bursa 170

Acute or chronic tendinopathy or ischial bursitis 170

Lateral cutaneous nerve 172

Meralgia paraesthetica 172

Acute or chronic capsulitis 174

Superior tibiofibular joint 176

Acute or chronic capsulitis 176

Baker’s cyst aspiration 178

Iliotibial band bursa 180

Chronic bursitis 180

Infrapatellar bursa 182

Acute or chronic bursitis 182

Pes anseurine bursa 184

Chronic bursitis 184

Coronary ligaments 186

Ligamentous sprain 186

Medial collateral ligament 188

Chronic, or rarely, acute sprain 188

Infrapatellar tendon 190

Chronic tendinitis 190

Quadriceps expansion 192

Muscle sprain 192

Ankle joint 194

Chronic capsulitis 194

Subtalar joint 196

Acute or chronic capsulitis 196

Midtarsal joints 198

Acute or chronic capsulitis 198

Acute or chronic capsulitis 200

Achilles bursa 202

Chronic bursitis 202

Deltoid ligament 204

Chronic, or occasionally acute, sprain 204

Lateral ligament 206

Acute, or occasionally chronic, sprain 206

Achilles tendon 208

Chronic tendinopathy 208

Peroneal tendons 210

Acute or chronic tendinopathy 210

Plantar fascia 212

Acute fasciitis 212

Morton’s neuroma 214

Plantar digital neuritis 214

Summary of suggested lower limb dosages 216

Examination of the lower limb

The capsular pattern is a set pattern of loss of motion for each joint. It indicates that there is some degree of joint capsulitis caused by degeneration, inflammation or trauma. There may be a hard endfeel in advanced capsulitis

Hip tests
*In supine*	*In prone*
Passive lateral rotation	Passive extension
medial rotation	Resisted lateral rotation
flexion	medial rotation
abduction	knee extension
adduction
Resisted flexion
abduction
adduction
Hip capsular pattern: most loss of medial rotation, less of flexion and abduction, least of extension
Knee tests
Passive flexion	Draw test
extension	Glide test
valgus	Meniscal tests
varus	Resisted extension
rotation	flexion
medial rotation

Knee capsular pattern: more loss of flexion than extension
Ankle and foot tests
Ankle	Subtalar	Forefoot
Passive dorsiflexion	Passive abduction	Passive abduction
plantarflexion	adduction	adduction
eversion		extension
inversion		flexion
Resisted dorsiflexion
plantarflexion
eversion
inversion
Ankle/foot capsular patterns:
Ankle: More loss of plantarflexion than dorsiflexion
Subtalar joint: More loss of adduction
Forefoot: Loss of adduction, dorsiflexion and supination
Big toe: More loss of extension than flexion
Toes: More loss of flexion than extension

Hip Examination – In Supine

1 Passive lateral rotation

2 Passive medial rotation

3 Passive flexion

4 Passive abduction

5 Passive adduction

All photographs © Stephanie Saunders 2012.

6 Resisted flexion

7 Resisted abduction

8 Resisted adduction

Hip Examination – In Prone

9 Passive extension

10 Resisted lateral rotation

11 Resisted medial rotation

All photographs © Stephanie Saunders 2012.

12 Resisted knee extension

Knee Examination

1 Passive flexion

2 Passive extension

3 Passive valgus

4 Passive varus

5 Passive lateral rotation

All photographs © Stephanie Saunders 2012.

6 Passive medial rotation

9 Meniscal tests

10 Resisted extension

11 Resisted flexion

All photographs © Stephanie Saunders 2012.

Ankle Examination

1 Ankle passive dorsiflexion

2 Ankle passive plantarflexion

3 Ankle passive eversion

4 Ankle passive inversion

5 Subtalar passive abduction

All photographs © Stephanie Saunders 2012.

6 Subtalar passive adduction

7 Subtalar eversion

8 Forefoot inversion

9 Resisted dorsiflexion

10 Resisted plantarflexion

11 Resisted eversion

All photographs © Stephanie Saunders 2012.

12 Resisted inversion

Hip joint

Acute or chronic capsulitis

Causes and findings

• Osteoarthritis, rheumatoid arthritis or traumatic capsulitis with night pain and severe radiating pain no longer responding to physiotherapy

• Buttock, groin and/or anterior thigh pain

• Painful limitation in capsular pattern – most loss of medial rotation, hard endfeel

Equipment

Anatomy

The hip joint capsule attaches to the base of the surgical neck of the femur so if the needle is touching the neck, the solution will be deposited within the capsule. The greater trochanter is a triangular bone with a sharp angulation of the apex overhanging the neck. This part is difficult to palpate, especially on large patients, so allow at least a thumb’s width proximal to the most prominent part of the trochanter. The safest and easiest approach is from the lateral aspect.

Technique

• Patient lies on pain-free side with lower leg flexed and upper leg straight resting horizontally on pillow

• Palpate the triangular greater trochanter with caudal thumb and middle finger placed either side of the base and identify the apex of the bone with index finger

• While passively abducting leg, identify dip at superior point of apex with cephalic index

• Insert needle perpendicularly about a thumb’s width proximal to palpable apex of trochanter until it touches the neck of femur

• Inject solution as a bolus

Comments

The lateral approach to the hip joint is both simple and safe. It is not necessary to do the technique under fluoroscopy and the procedure is not painful. There is usually no sensation of penetrating the capsule. This injection is usually given to patients who are on a waiting list for surgery, but the joint should not be injected within at least 6 weeks of surgery because reduced immunity could result in greater possible risk of infection. It is usually successful in giving temporary pain relief and can, if necessary, be repeated at intervals of no less than three 3 months. An annual X-ray monitors degenerative changes.

Alternative approaches

For large patients the total volume can be increased to 8–10 ml. 40 mg Adcortyl, giving 4 ml of volume, might be the preferred steroid here. For large individuals, a longer spinal needle might be required. During the early stages of the degenerative process, when the pain is local, there is minimal night pain and endfeels are still elastic with reasonably good function, physiotherapy can be effective.

Aftercare

Patient gradually increases pain-free activity maintaining range with a home stretching routine but limits weight-bearing exercise.

Gluteal bursa

Chronic bursitis

Causes and findings

• Pain and tenderness over the upper lateral quadrant of the buttock

• Painful: passive flexion, abduction and adduction; resisted abduction and extension

Equipment

Anatomy

Gluteal bursae are variable in number, size and shape. They can lie deep to the gluteal muscles on the blade of the ilium and also between the layers of the three muscles. Palpation for the centre of the painful site guides the placement of the needle but comparison between the two sides is essential as this area is always tender.

Technique

• Patient lies on unaffected side with lower leg extended and upper leg flexed

• Identify and mark centre of tender area in upper outer quadrant of buttock

• Insert needle perpendicular to skin until it touches bone of ilium

• Inject solution in areas of no resistance while moving needle in a circular manner out towards surface – imagine the needle walking up a spiral staircase

Comments

There are no major blood vessels or nerves in the area of the bursae so the injection is safe. Feeling for a loss of resistance beneath and within the glutei guides the clinician in depositing the fluid. Pain referring from the lumbar spine or sacroiliac joint can often be mistaken for gluteal bursitis. The mere presence of tenderness mid-buttock, normal in most individuals, should not be considered diagnostic of an inflamed bursa.

Alternative approaches

For large individuals, a longer spinal needle might be required.

Aftercare

The patient must avoid overusing the leg for a week and can then gradually resume normal activities. Addressing any muscle tightness or imbalance and retraining in the causative sporting activity is necessary.

Psoas bursa

Chronic bursitis

Causes and findings

• Overuse – especially activities involving repeated hip flexion, e.g. running, hurdling

• Pain in groin

• Painful: passive flexion, adduction, abduction, extension; resisted flexion and adduction. Scoop test – passive compression of femur from full flexion into adduction

Equipment

Anatomy

The psoas bursa lies between the iliopsoas tendon and the anterior aspect of the capsule over the neck of the femur. It is situated deep to three major structures in the groin – the femoral vein, artery and nerve, lying at the level of the inguinal ligament. For this reason, careful placement of the needle is essential. Following the instructions below ensures that the needle will pass obliquely beneath the neurovascular bundle.

Technique

• Patient lies supine

• Identify femoral pulse at mid-point of inguinal ligament. Mark a point three fingers distally and three fingers laterally, in line with the anterior superior iliac spine on medial edge of sartorius

• Insert needle at this point and aim 45° cephalad and 45° medially. Visualize the needle sliding under the three major vessels through the psoas tendon until point touches bone on anterior aspect of neck of femur

• Withdraw slightly and inject as bolus deep to tendon

Comments

Although this injection might appear intimidating to the clinician at the first attempt, the approach outlined above is safe and effective. Very occasionally it is possible to catch a lateral branch of the femoral nerve and temporarily lose power in the quadriceps. If the patient complains of a tingling or burning pain during the process, reposition the needle before depositing solution. Differential diagnoses include local lesions such as hip joint pathology, adductor strain, hernia, abdominal muscle sprain, cutaneous nerve entrapment, pubic symphysitis, testicular disease, fracture and referred symptoms from lumbar spine, sacroiliac joint and genitourinary organs. Suspicion of any of these should be maintained until the clinician is satisfied of the cause of the symptoms. If in doubt, a diagnostic injection of local anaesthetic alone is advisable.

Alternative approaches

For large individuals, a longer spinal needle might be required.

Aftercare

Absolute avoidance of the activities that irritated the bursa must be maintained for at least a week, then stretching of hip extension and muscle-balancing programme is initiated.

Trochanteric bursa

Acute or chronic bursitis

Causes and findings

• Usually a direct blow or fall onto hip; occasionally overuse or, in the thin elderly patient, lying on the same side every night on a hard mattress

• Pain and tenderness over greater trochanter

• Painful: passive hip abduction, adduction, possibly flexion and extension; resisted abduction

Equipment

Anatomy

The trochanteric bursa lies over the greater trochanter of the femur. It is approximately the size of a golf ball and is usually tender to palpation.

Technique

• Patient lies on unaffected side with lower leg flexed and upper leg extended

• Identify and mark centre of tender area over greater trochanter

• Insert needle perpendicularly at centre of tender area and advance to touch bone

• Inject by feeling for area of no resistance and introduce fluid there as a bolus

Comments

A fall or direct blow onto the trochanter will often cause a haemorrhagic bursitis. This calls for immediate aspiration of blood prior to the infiltration.

Aftercare

Patient should avoid overuse for 1 week and then gradually return to normal activity. If the cause is lying on a hard mattress, the trochanter can be padded with a large ring of sticky felt. A change of lying position is encouraged and the mattress might need to be changed. Stretching of the iliotibial band can also help.

Adductor tendons

Chronic tendinitis

Causes and findings

• Overuse or trauma

• Pain in groin at origin from pubis or mid-tendon

• Painful: resisted adduction; passive abduction

Equipment

Anatomy

The adductor tendons arise from the pubis and are approximately two fingers wide at their origin. The lesion can lie at the teno-osseous junction or in the body of the tendon. The technique described is for the more common site at the teno-osseous junction.

Technique

• The patient lies supine with leg slightly abducted and laterally rotated

• Identify and mark the origin of the tendon

• Insert needle into tendon, angle towards pubis and touch bone

• Pepper solution into teno-osseous junction

Comments

Sprain of these tendons is commonly thought to cause ‘groin strain’. However, there are many alternative causes of pain in the groin (see psoas bursa technique) and these should be eliminated carefully.

Alternative approaches

For the less common site at the body of the tendon, the solution is peppered into the tender area in the body, but deep friction massage and stretching may be more effective here.

Aftercare

Rest for at least a week then start a graduated stretching and strengthening programme. Deep friction massage may be used as well to mobilize the scar.

Hamstring tendon and ischial bursa

Acute or chronic tendinopathy or ischial bursitis

Causes and findings

• Friction overuse, e.g. prolonged cycling; trauma e.g. fall onto buttock

• Pain in buttock over tuberosity

• Painful: resisted extension; passive straight leg raise

Equipment

Anatomy

The hamstring tendons have a common origin arising from the ischial tuberosity and are approximately three fingers wide here. The ischial bursa lies between the gluteus maximus and the bone of the ischial tuberosity.

Technique

• Patient lies on unaffected side with lower leg straight and upper leg flexed

• Identify ischial tuberosity and mark tendon lying immediately distal

• Insert needle into mid-point of tendon and angle up toward tuberosity to touch bone

• Pepper solution into teno-osseous junction of tendon or inject as bolus

Comments

Tendinitis and bursitis can occur together at this site, in which case a larger volume is drawn up and both lesions infiltrated. As usual, it is difficult to differentiate between the two lesions, but if there is a history of a fall or friction overuse and extreme tenderness at the tuberosity, bursitis is suspected.

Occasionally, haemorrhagic bursitis can occur as a result of a hard fall. Aspiration of the blood is then performed prior to infiltration.

Aftercare

Avoidance of precipitating activities such as sitting on hard surfaces or prolonged running is maintained for at least a week and then a graduated stretching and strengthening programme is started.

Lateral cutaneous nerve

Meralgia paraesthetica

Causes and findings

• Entrapment neuropathy from compression of nerve by obesity, pregnancy or prolonged static flexed positions

• Defined oval area of numbness over anterolateral thigh; occasionally painful paraesthesia

• Tender at inguinal ligament or where nerve emerges through fascia

Equipment

Anatomy

The lateral cutaneous nerve of the thigh arises from the outer border of the psoas and crosses over the iliacus. It passes under or through the inguinal ligament, through the femoral fascia and emerges superficially about 10 cm distal and in line with the anterior superior iliac spine.

Technique

• Patient lies supine

• Identify tender area at inguinal ligament or at distal point in thigh

• Inject as bolus around compressed nerve, avoiding nerve itself

Comments

Differential diagnoses include referred symptoms from lumbar spine or sacroiliac joint lesions, or local lesions such as hip joint pathology, arterial claudication, herpes zoster. As with other nerve compression injections, the nerve itself must not be injected. If the patient reports increased tingling or burning pain, the needle point should be moved before the steroid is injected.

Alternative approach

This lesion often spontaneously resolves. Advice on avoidance of compression and reassurance as to the nature and normal outcome of the condition might be all that is required.

Aftercare

Removing the cause is of prime importance, i.e. losing weight, avoiding tight clothing, correcting sitting posture. If the patient is pregnant the compression might be from the growing fetus, and symptoms will normally abate after delivery.

Knee joint

Acute or chronic capsulitis

Causes and findings

• Osteoarthritis, rheumatoid arthritis, gout or trauma

• Pain in knee joint, possible heat and effusion

• Painful and limited: more passive flexion than extension, hard endfeel

Equipment

Anatomy

The knee joint has a potential capacity of approximately 120 ml or more in the average-sized adult. The capsule is lined with synovium, which is convoluted and so has a large surface area; in the large knee, therefore, more volume will be required to bathe the entire surface. Plicae, which are bands of synovium, might exist within the joint and can also become inflamed. The suprapatellar pouch is a continuum of the synovial capsule and there are many bursae around the joint.

Technique

• Patient sits with knee supported in extension

• Identify and mark medial edge of patella

• Insert needle and angle laterally and slightly upwards under patella

• Inject solution as bolus or aspirate if required

Comments

The injection will give temporary relief from pain and, provided the knee is not overused, this can last for some time. Repeat injections can be given at intervals of not less than three months with an annual X-ray to monitor joint degeneration. As with the hip joint, the patient might be awaiting surgery; the injection should not be given for at least 6 weeks prior to this.

Alternative approaches

There are several ways to infiltrate or aspirate the knee joint – through the ‘eyes of the knee’, the supralateral approach into the suprapatella pouch just above the lateral pole of the patella, laterally at mid-point of patella or the medial approach as shown here⁴². One study showed that there was more successful intra-articular placement using the lateral patella approach than through the ‘eyes of the knee’, but did not compare the lateral with this medial approach. The advantage of this approach is that there is normally plenty of space to insert the needle between the medial condyle and the patella, where even small amounts of effusion can be aspirated. The same approach can be used whether infiltrating or aspirating serous fluid or blood. Using the larger volume of 40 mg of Adcortyl, giving 4 ml of volume, enables more of the joint surface to be bathed. Hyalgen or similar substances can also be injected here but are more expensive than corticosteroids and do not appear to have longer-lasting benefits (page 33).

Aftercare

The patient avoids undue weight-bearing activity for at least a week and is then given strengthening and mobilizing exercises to continue at home. One study indicated that total bed rest for 24 hours after injection in rheumatoid knees showed better results; however, the rest involved a hospital stay, which would not be cost effective.

Superior tibiofibular joint

Acute or chronic capsulitis

Causes and findings

• Usually trauma e.g. fall with forced medial rotation and varus on flexed knee

• Pain over lateral side of knee

• Painful: resisted flexion of knee; full passive medial rotation of knee

Equipment

Anatomy

The superior tibiofibular joint runs medially under the lateral slope of the tibia from superior to inferior. The anterior approach is safer as the peroneal nerve lies posterior to the joint.

Technique

• Patient sits with knee at right angle

• Identify head of fibula and mark joint line medial to it

• Insert needle at mid-point of joint line and aim obliquely laterally to penetrate capsule

• Deposit solution in bolus

Comments

Occasionally the joint is subluxed and has to be manipulated before infiltration. The condition also occasionally occurs after severe ankle sprain.

Alternative approach

The unstable joint can be treated with sclerotherapy and taping.

Aftercare

Advise relative rest for at least a week and then resumption of normal activities. Strengthening of the biceps femoris might be necessary.

Baker’s cyst aspiration

Causes and findings

• Spontaneous insidious onset, usually in osteoarthritic joint

• Obvious swelling in the popliteal fossa – often quite large

• Limited: active and passive knee flexion

Equipment

Anatomy

A Baker’s cyst is a sac of synovial fluid caused by seepage through a defect in the posterior wall of the capsule of the knee joint, or by effusion within the semimembranosus bursa. The popliteal artery and vein and posterior tibial nerve pass centrally in the popliteal fossa and must be avoided.

Technique

• Patient lies prone

• Mark spot two fingers medial to mid-line of fossa and two fingers below the popliteal crease

• Insert needle at marked spot and angle laterally at 45° angle

• Aspirate fluid found

Comments

If anything other than clear synovial fluid is removed, a specimen should be sent for culture and the appropriate treatment instigated. Invariably the swelling returns at some point but can be re-aspirated if the patient wishes.

Aftercare

A firm compression bandage can be applied for a day or two.

Iliotibial band bursa

Chronic bursitis

Causes and findings

• Overuse – especially long-distance runners

• Pain on the outer side of the knee above the lateral femoral condyle

• Painful: resisted abduction of leg; passive adduction of leg

Equipment

Anatomy

The bursa lies deep to the iliotibial band just above the lateral condyle of the femur and is approximately the size of a golf ball.

Technique

• Patient sits with knee supported

• Identify and mark tender area on lateral side of femur

• Insert needle into bursa passing through tendon to touch bone

• Deposit solution in bolus

Comments

The lower end of the iliotibial tract itself can be irritated, but invariably the bursa is also at fault. If both lesions are suspected, infiltration of both at the same time can be performed.

Aftercare

Absolute rest must be maintained for about 10 days and then a stretching and strengthening programme initiated. Footwear and running technique should be checked and corrected if necessary.

Infrapatellar bursa

Acute or chronic bursitis

Causes and findings

• Overuse – prolonged running or kneeling; trauma – direct blow

• Pain anterior knee below patella

• Painful: resisted extension of knee; full passive flexion of knee

Equipment

Anatomy

There are two infrapatellar bursae – one lies superficial and one deep to the tendon. In a small study it was found that the deep bursa consistently lay posterior to the distal third of the tendon and was slightly wider; a fat pad apron extends from the retropatellar fat pad to partially compartmentalize the bursa. The technique described is for the deep bursa, which is more commonly affected.

Technique

• Patient sits with leg extended and knee supported

• Identify and mark tender area at mid-point of tendon

• Insert needle horizontally at lateral edge of the tendon just proximal to the tibial tubercle. Ensure that the needle does not enter the tendon

• Deposit solution as bolus

Comments

It would be tempting to believe that pain found at mid-point of the patella tendon is caused by tendinitis, but in the experience of the authors this is extremely rare at this site. Infrapatellar tendinitis is found consistently at the proximal teno-osseous junction on the patella, or rarely at insertion into the tibial tubercle. Pain here in an adolescent boy should be considered to be Osgood–Schlatter’s disease and should not be injected.

For the superficial infrapatella bursa and the prepatellar bursa, palpate for the centre of the tender area and, using the same needle and dose, inject just deep to the skin and superior to the bone. Free flow of the fluid confirms the correct placement within the structure. Use hydrocortisone with thin, dark skinned individuals.

Aftercare

The patient must avoid all overuse of the knee for at least a week. When the cause is occupational, such as in carpet layers, a pad with a hole in it to relieve pressure on the bursa should be used. Graded stretching and strengthening exercises are then begun.

Pes anseurine bursa

Chronic bursitis

Causes and findings

• Overuse – especially dancers or runners

• Pain just proximal to insertion of medial flexors of knee

• Painful: resisted flexion of knee

Equipment

Anatomy

The pes anseurine, or goose’s foot, is the combined tendon of insertion of the sartorius, gracilis and semi-tendinosus. It attaches on the medial side of the tibia just below the knee joint line. The bursa lies immediately under the tendon just posterior to its insertion and is extremely tender to palpation in the normal knee.

Technique

• Patient sits with knee supported

• Identify the pes anseurine tendon by flexing knee against resistance. Follow tendons distally to where they disappear at insertion into tibia. Mark tender area slightly proximal to insertion

• Insert needle into centre of tender area through tendon to touch bone

• Deposit solution in bolus

Comments

It is important to remember that the bursa is extremely tender to palpation on everybody so comparison testing must be done on both knees.

Aftercare

The patient should avoid overuse activities for at least a week, when graded stretching and strengthening exercises are started.

Coronary ligaments

Ligamentous sprain

Causes and findings

• Trauma – a strong forced rotation of the knee with or without meniscal tear

• Pain usually at medial joint line

• Painful: passive lateral rotation; possibly meniscal grind tests

Equipment

Anatomy

The coronary ligaments are small thin fibrous bands attaching the menisci to the tibial plateaux. The medial coronary ligament is more usually affected. It can be found by flexing the knee to a right angle and turning the foot into lateral rotation. This brings the tibial plateau into prominence and the tender area is sought by pressing in and down onto the plateau.

Technique

• Patient sits with knee at right angle and planted foot laterally rotated

• Identify and mark tender area on tibial plateau

• Insert needle vertically down onto plateau

• Pepper all along tender area

Comments

This lesion is commonly misdiagnosed; apparent meniscal tears, anterior cruciate sprain and patellofemoral joint lesions might be simple coronary ligament sprains.

Alternative approaches

These ligaments usually respond extremely well to deep friction massage – it is not uncommon to cure the symptoms in one session. The injection should be kept for where the friction treatment is not available or where the pain is too intense to allow the pressure of the finger. Tear or subluxation of the meniscus should be treated first by manipulation to attempt to reduce the tear.

Aftercare

Early mobilizing exercise to full range of motion without pain is started immediately.

Medial collateral ligament

Chronic, or rarely, acute sprain

Causes and findings

• Trauma – typically flexion, valgus and lateral rotation of the knee e.g. skiing fall

• Pain along medial knee joint line

• Painful: passive valgus; passive lateral rotation of the knee

Equipment

Anatomy

The medial collateral ligament of the knee passes distally from the medial condyle of the femur to the medial aspect of the shaft of the tibia and is approximately a hand’s width long and three fingers wide at the joint line. It is difficult to palpate the ligament as it is so thin and is part of the joint capsule. It is usually sprained at the joint line.

Technique

• Patient lies with knee supported and slightly flexed

• Identify and mark medial joint line and tender area of ligament

• Insert needle at mid-point of tender area. Do not penetrate right through joint capsule

• Pepper solution along width of ligament in two rows

Comments

Occasionally the distal or proximal end of the ligament is affected, so the solution should be deposited there.

Alternative approaches

Sprain of this ligament rarely needs to be injected, as early physiotherapeutic treatment with ice, massage and mobilization is very effective. The injection approach can be used when this treatment is not available or the patient is in a great deal of pain.

Aftercare

For the acute ligament, gentle passive and active movement within the pain-free range is started immediately. For the chronic sprain, one session of deep friction massage and mobilization may be all that is required to obtain full movement.

Infrapatellar tendon

Chronic tendinitis

Causes and findings

• Overuse – jumpers and runners

• Pain at inferior pole of patella

• Painful: resisted extension of knee

Equipment

Anatomy

The infrapatellar tendon arises from the inferior pole of the patella and it is here that it is usually inflamed. The tendon is at least two fingers wide at its origin. It is an absolute contraindication to inject corticosteroid into the body of the tendon as it is a large, weight-bearing and relatively avascular structure. Tenderness at mid-point of the tendon is usually caused by infrapatellar bursitis.

Technique

• Patient sits with knee supported and extended

• Place web of cephalic hand on superior pole of patella and tilt inferior pole up. Mark tender area at origin of tendon on distal end of patella

• Insert needle at mid-point of tendon origin at an angle of 45°

• Pepper solution along tendon in two rows. There should always be some resistance to the needle to ensure that the needle is not intra-articular

Comments

Injecting the origin of the infrapatellar tendon at the inferior pole is very safe, provided adequate rest is maintained afterwards and that no more than two injections are given in one attack. In an ageing patient with a chronic tendinopathy, scanning is recommended first to ensure that there are no degenerative changes in the substance of the tendon.

Alternative approach

In the case of the committed athlete or if scanning shows changes as above, deep friction, electrotherapy and taping should be given as potential danger of rupture is more real.

Aftercare

Absolute rest is recommended for at least 10 days before a stretching and strengthening programme is initiated.

Quadriceps expansion

Muscle sprain

Causes and findings

• Pain usually on superior medial side of patella on going downhill or stairs

• Painful: resisted extension of the knee

Equipment

Anatomy

The quadriceps muscle inserts as an expansion around the edges of the patella. The usual site of the lesion is at the superior medial pole. This is found by pushing the patella medially with the thumb and palpating up and under the medial edge with a finger to find the tender area.

Technique

• Patient half lies on table with knee relaxed

• Identify and mark tender area usually on medial edge of superior pole of patella

• Insert needle and angle horizontally to touch bone of patella

• Pepper solution along line of insertion

Comments

This lesion usually responds very well to two or three sessions of strong deep friction. The injection is used therefore when the friction is not available, the area is too tender, or to disinflame the expansion prior to friction a week later, in a combination approach. The same dose and technique may be used to inject inflamed plicae around the patella rim.

Aftercare

Patient avoids overusing the knee for at least a week and, when pain free, begins a progressive strengthening and stretching programme.

Ankle joint

Chronic capsulitis

Causes and findings

• Post-trauma

• Pain at front of, or within, ankle

• Painful and limited: more passive plantarflexion than dorsiflexion with hard endfeel

Equipment

Anatomy

The easiest and safest entry point to the ankle joint is at the junction of the tibia and fibula just above the talus. A small triangular space can be palpated here.

Technique

• Patient lies with knee bent to 90° and foot slightly plantarflexed

• Identify and mark small triangular space by passively flexing and extending the ankle while palpating

• Insert needle into joint angling slightly medially and proximally into joint space

• Deposit solution as bolus

Comments

The ankle joint rarely causes problems except after severe trauma or fracture, and then often many years later. The infiltration is usually successful in giving long-lasting pain relief and can be repeated if necessary at intervals of at least three months with an annual X-ray to monitor degenerative changes.

Aftercare

Excessive weight-bearing activities are avoided for at least a week. The patient should be warned that heavy overuse will cause a recurrence of symptoms and therefore long-distance running should be avoided. Weight control is also advised and footwear should be checked to ensure correct support.

Subtalar joint

Chronic capsulitis

Causes and findings

• Trauma – usually after fracture or severe impaction injury, often years later. Overuse in older obese patient

• Pain deep in medial and lateral sides of heel

• Painful and limited: passive adduction of the calcaneus

Equipment

Anatomy

The subtalar joint is divided by an oblique septum into anterior and posterior portions. It is slightly easier to enter the joint just above the sustentaculum tali, which projects a thumb’s width directly below the medial malleolus. It is necessary to deposit half the solution in the posterior cavity and the rest in the anterior.

Technique

• Patient lies on side with foot supported so that medial aspect of heel faces upwards

• Identify bump of sustentaculum tali

• Insert needle perpendicularly immediately above and slightly posterior to sustentaculum tali

• Deposit half solution here

• Withdraw needle slightly, angle obliquely anteriorly through septum into anterior compartment of joint space and deposit remaining solution here

Comments

This is a difficult injection to perform due to the anatomical shape of the joint. It can be repeated at infrequent intervals if necessary.

Aftercare

The patient should avoid excessive weight-bearing activities for at least a week. Orthotics and weight control are helpful in preventing recurrence.

Midtarsal joints

Acute or chronic capsulitis

Causes and findings

• Overuse or trauma – dancers who over-point or footballers

• Pain on dorsum of foot – usually at third metatarsocuneiform joint line

• Painful and limited: adduction and inversion of midtarsal joints

Equipment

Anatomy

There are several joints in the mid-tarsus, each with its own capsule. Gross passive testing in all six directions followed by local joint gliding and palpation should identify the joint involved.

Technique

• Patient lies with foot supported in neutral

• Identify and mark tender joint line

• Insert needle down into joint space

• Pepper some solution into capsule and remainder as bolus into joint cavity

Comments

This is a successful treatment provided sensible attention is paid to aftercare.

Aftercare

Avoidance of excessive weight-bearing activities for at least a week is advised. Mobilizing and strengthening exercises and retraining of causal activities follow. Orthotics and weight control, if necessary, are useful additions.

Toe joints

Acute or chronic capsulitis

Causes and findings

• Overuse or trauma. Hallux valgus may be present

• Pain locally in toe joint/s

• Painful and limited: extension of the big toe, flexion of other toes

Equipment

Anatomy

The first metatarsophalangeal joint line is found by palpating the space produced at the base of the metatarsal on the dorsal aspect, while passively flexing and extending the toe. Palpation of the collateral ligaments at the joint line on the sides of the other toes will identify the affected joint.

Technique

• Patient lies with foot supported

• Identify and mark joint line and distract affected toe with one hand

• Insert needle perpendicularly into joint space avoiding extensor tendons

• Deposit solution as bolus

Comments

As with the thumb joint injection, this treatment can be very long-lasting. The other toe joints are injected from the medial or lateral aspect while under traction using smaller dose and volume e.g. 20 mg Kenalog plus 0.5 ml Lidocaine 1 ml total volume.

Aftercare

Avoidance of excessive weight-bearing activities for at least a week, together with taping of the joint and a toe pad between the toes. Care in choice of footwear and orthotics might be necessary.

Achilles bursa

Chronic bursitis

Causes and findings

• Overuse – runners and dancers

• Pain posterior to tibia and anterior to body of Achilles tendon

• Painful: resisted plantarflexion, especially at end range; full passive plantarflexion

Equipment

Anatomy

The Achilles bursa lies in the triangular space anterior to the tendon and posterior to the base of the tibia and the upper part of the calcaneus. It is important to differentiate between tendinitis and bursitis here because both are caused by overuse. In bursitis there is usually more pain on full passive plantarflexion when the heel is pressed up against the back of the tibia, thereby squeezing the bursa. Also, palpation of the bursa is very sensitive and the pain is usually felt more at the end of rising on tip-toe rather than during the movement. The safest approach is from the lateral side to avoid the posterior tibial artery and nerve.

Technique

• Patient lies prone with foot held in some dorsiflexion

• Identify and mark tender area on lateral side of bursa

• Insert needle into bursa avoiding piercing the tendon

• Deposit solution as bolus

Comments

It is important to avoid penetrating the Achilles tendon and depositing the solution there. Any resistance to the needle requires immediate withdrawal and repositioning well anterior to the tendon.

Aftercare

Avoid overuse activities for at least 10 days, then start a stretching and eccentric exercise programme. Female ballet dancers need to avoid over-plantarflexing the ankle when on point.

Deltoid ligament

Chronic, or occasionally acute, sprain

Causes and findings

• Trauma, obesity or overuse. Overpronation of the foot

• Pain over medial side of heel below medial malleolus

• Painful: passive eversion of ankle in plantarflexion

Equipment

Anatomy

The deltoid ligament is a strong cuboid structure with two layers. It runs from the medial malleolus to the sustentaculum tali on the calcaneum and to the tubercle on the navicular. Sprains here are not as common as at the lateral ligament, but because they do not seem to respond well to deep friction and mobilization, injection is worth trying. The inflamed part is usually at the origin on the malleolus.

Technique

• Patient sits with medial side of foot accessible

• Identify lower border of medial malleolus and mark mid-point of ligament

• Insert needle and angle upwards to touch bone at mid-point of ligament

• Pepper solution along attachment to bone

Comments

This is an uncommon but usually successful injection. Often physiotherapeutic treatment with deep massage, mobilization, muscle and balance rehabilitation works well, especially with podiatric advice and weight control.

Aftercare

Activity should be limited for at least a week. To prevent recurrence, the biomechanics of the foot must be carefully checked. Orthotics are almost always necessary and, in the overweight patient, advice on diet must be given.

Lateral ligament

Acute, or occasionally chronic, sprain

Causes and findings

• Inversion injury

• Pain at lateral side of ankle

• Painful: passive inversion of ankle

Equipment

Anatomy

The anterior talofibular ligament runs distally and medially from the anterior inferior edge of the lateral malleolus to attach to the talus. It is a thin structure, approximately the width of the little finger. The bifurcate calcaneocuboid ligament runs from the calcaneus to the cuboid and is often also involved in ankle sprains. Both ligaments run parallel to the sole of the foot. The calcaneo-fibular runs obliquely distally and posteriorly from the posterior edge of the lateral malleolus to the calcaneum and is approximately two fingers’ width in length. It is more rounded so more palpable than the other two ligaments.

Technique

• Patient lies supported on table

• Identify and mark anterior inferior edge of lateral malleolus

• Insert needle to touch bone

• Pepper half solution around origin of ligament

• Turn needle and pepper remainder into insertion on talus

Comments

This is not a common injection, but is an option when the pain is very acute or where conservative treatment has failed in the chronic stage.

Alternative approaches

This lesion responds very well in the acute stage to a regimen of ice, elevation, gentle massage, active and passive mobilization and taping. In the chronic stage, physiotherapeutic treatment with deep massage, manipulation, muscle and balance rehabilitation works well.

Aftercare

For the first few days, ice, elevation and taping in eversion are helpful, together with a pressure pad behind the malleolus to control swelling. The patient keeps the ankle moving within the pain-free range. Exercises to strengthen the peronei and proprioception techniques usually need to be given.

Achilles tendon

Chronic tendinopathy

Causes and findings

• Pain at posterior aspect of ankle on sides of tendon

• Painful: resisted plantarflexion on one foot or from full dorsiflexion

Equipment

Anatomy

The Achilles tendon lies at the end of the gastrocnemius as it inserts into the posterior surface of the calcaneus. It is absolutely contraindicated to infiltrate the body of the tendon because this is a large, weight-bearing, relatively avascular tendon with a known propensity to rupture.

Technique

• Patient lies prone with foot held in dorsiflexion over end of bed. This keeps the tendon under tension to facilitate the procedure

• Identify and mark tender area of tendon – usually along the sides

• Insert needle on medial side and angle parallel to tendon. Slide needle along side of tendon, taking care not to enter into tendon itself

• Deposit half solution while slowly withdrawing needle

• Insert needle on lateral side and repeat procedure with remaining solution

Comments

Although there are reports of tendon rupture after injection here, this has usually occurred as a result of repeated injections of large dose and volume into the body of a degenerate tendon and with excessive exercise postinjection. Because of this recognized risk therefore, we recommend always scanning the tendon prior to injecting to ascertain the extent of the degeneration (page 18). Degenerative changes within the substance of the tendon, rather than just around the periphery, would indicate an absolute contraindication to injection.

Depositing the solution along the sides is safe and effective but should not be repeated more than once in one attack. The committed athlete should preferably be offered deep friction and a graduated stretching/strengthening programme.

Alternative approaches

No one method has been entirely successful in treating this condition. Recent novel approaches include the continuous application of topical glyceryl trinitrate, injection of a sclerosing local anaesthetic or autologous blood preparation (page 34).

Aftercare

Absolute avoidance of any overuse is essential for about 10 days. Deep friction to the site should then be given a few times, even if the patient is asymptomatic, to prevent recurrence. When pain free, graded stretching and strengthening exercises are begun and should be continued indefinitely. Eccentric exercises, once considered the best treatment, are now shown to be not so effective but could still be tried. Orthotics and retraining in the causal activity is often necessary.

Peroneal tendons

Acute or chronic tendinopathy

Causes and findings

• Pain above, behind or below lateral malleolus

• Painful: resisted eversion of the foot; passive inversion

Equipment

Anatomy

The peroneus longus and brevis run together in a synovial sheath behind the lateral malleolus. The longus then divides to pass under the arch of the foot to insert at the base of the big toe, and brevis inserts into the base of the fifth metatarsal. The division of the two tendons is the entry point for the needle to slide inside the sheath, and can be found by having the patient hold the foot in strong eversion and palpating for the V-shaped fork of the tendons.

Technique

• Patient lies supine with foot supported in some medial rotation

• Identify and mark division of the two tendons

• Insert needle perpendicularly at this point, turn and slide horizontally under skin towards malleolus

• Deposit solution into combined tendon sheath. There should be minimal resistance and often a sausage-shaped bulge is observed

Comments

This lesion often occurs together with an acutely sprained lateral ligament of the ankle. Examination of the joint should ascertain if one or more ligaments are affected and all should be treated if necessary.

Alternative approaches

Occasionally the tendinopathy occurs at the insertion of the peroneus brevis. The same amount of solution is then peppered into the teno-osseous junction by inserting the needle parallel to the skin to touch the base of the fifth metatarsal.

Aftercare

Avoid any overuse for about a week. Resolution of symptoms should then lead to consideration of change in footwear, orthotics and strengthening of the evertors.

Plantar fascia

Acute fasciitis

Causes and findings

• Idiopathic, overuse, poor footwear

• Pain on medial aspect of heel pad on weightbearing in the morning

• Tender area over medial edge of origin of fascia from calcaneus

Equipment

Anatomy

The plantar fascia, or long plantar ligament, arises from the medial and lateral tubercles on the inferior surface of the calcaneus. The lesion is invariably found at the medial head and the area of irritation can be palpated by deep pressure with the thumb.

Technique

• Patient lies prone with foot supported in dorsiflexion

• Identify tender area on heel

• Insert needle perpendicularly into medial side of soft part of sole just distal to heel pad. Advance at 45° towards calcaneus until it touches bone

• Pepper solution in two rows into fascia at its medial bony origin

Comments

Although this would appear to be an extremely painful injection, this approach is much kinder than inserting the needle straight through the heel pad, and patients tolerate it well.

Aftercare

A heel support is used for at least 1 week after the injection, followed by intrinsic muscle exercise and stretching of the fascia. Standing on a golf ball to apply deep friction can be helpful and orthotics can be applied. Taping can also be used.

Morton’s neuroma

Plantar digital neuritis

Causes and findings

• Poor footwear, overpronated foot, abnormal gait

• Burning pain/paraesthesia in first or second interspace between metatarsal heads

• Painful: squeezing metatarsal heads or pressure at site

Equipment

Anatomy

A painful fusiform swelling develops in the common digital nerve below the transverse intermetatarsal ligament, usually in the first or second interspace between or slightly distal to the metatarsal heads. The history of burning pain, especially at night, and squeezing of the heads or stretching the nerve by hyperextending the toes usually is indicative of this lesion.

Technique

• Patient sits supported with foot placed flat on the table

• Identify and mark tender area between the metatarsal heads

• Insert needle perpendicularly and gently through dorsal skin at this point

• If a sharp burning sensation is reported, slightly withdraw needle tip

• Deposit solution around inflamed neuroma

Comments

As with all injections around neural tissue, care must be taken to approach the nerve slowly as the sudden sharp pain induced may make the patient jump. The sensation, however, is helpful in confirming correct placement. The drug is deposited around the neuroma, not into the substance of the nerve.

Aftercare

This injection is often successful in relieving symptoms, but these may recur unless the patient is prepared to forego wearing thin-soled, very high heels or other inappropriate footwear. Placing a small pad just proximal to the metartarsal head to lift the bone and reduce the compression for the first week post injection is helpful. Recurrent return of symptoms usually indicates that the patient should discuss surgical options with a foot surgeon.

Summary of suggested lower limb dosages

Related

Injection Techniques in Musculoskeletal Medicine A Practical Man