Lower Limb Injections

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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

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