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REVIEW ARTICLE

Ultrasound-Guided Interventional Procedures in


Pain Medicine
A Review of Anatomy, Sonoanatomy, and Procedures. Part V: Knee Joint
Philip W. H. Peng, MBBS, FRCPC, Founder (Pain Medicine),* and Hariharan Shankar, MD
Abstract: Ultrasound-guided injection in pain medicine is emerging as a
popular technique for pain intervention. It can be applied to the intraarticular injection of the knee joint. The first objective of this review was
to describe and summarize the anatomy and sonoanatomy of the knee
and associated structures relevant for intra-articular injection. The second
objective was to examine the feasibility, accuracy, and effectiveness of injections as well as injection techniques.
(Reg Anesth Pain Med 2014;39: 368380)

rthritis involving the knee joint is a common cause for pain


and disability. Conservative management includes weight
loss, physical therapy, and pharmacologic interventions. Patients
unresponsive to conservative management are usually offered
intra-articular (IA) injections, which may be performed blindly
or with image guidance using fluoroscopy or ultrasound. Ultrasound guidance has provided an additional tool to identify the target pathology, improving accuracy without the harmful effects
of radiation.
This review, focusing on interventions to the knee joint,
aimed to describe and summarize the anatomy and sonoanatomy
of the knee and associated structures relevant for IA injection.
The second objective was to examine the feasibility, accuracy,
and effectiveness of injections and injection techniques.

METHODS
We performed a literature search of the MEDLINE database
from January 1980 to June 2013 using the search terms knee,
arthritis, ultrasound, pain, and treatment to identify reports of the use of IA injections for the amelioration of knee arthritis, the agents used, and the use of image guidance and their
accuracy and efficacy.

Muscles and Tendons


Muscles and tendons surrounding the knee joint may
be grouped based on their location or function. The extensor
mechanismthe most prominent contributor to the knee joint
comprises the quadriceps femoris muscle and the patella. The
quadriceps muscle consists of rectus femoris, vastus medialis,
vastus intermedius, and vastus lateralis, forming a common tendon that is inserted into the tibial tubercle (Fig. 1). The common
tendon (quadriceps and patellar tendons) houses the patella,
which is a large sesamoid bone spanning the knee joint anteriorly.
The quadriceps tendon is a trilaminar structure composed of superficial (from rectus femoris), intermediate (from amalgamation
of the vastus medialis and lateralis), and deep (from the vastus
intermedius) layers, which merge to form a common tendon
(Fig. 2). The patellar tendon has high tensile strength and arises
from the apex and the medial and lateral sides of the patella.
The knee flexors are located predominantly posteriorly and include the biceps femoris, semimembranosus, and semitendinosus
muscles (Fig. 3). Other flexors include gastrocnemius, which primarily plantar flexes the foot, and the gracilis, which is located
posteromedially and acts as a hip adductor as well as a flexor of
the knee and hip joints. The only anteriorly located knee flexor is
the sartorius, which functions as a hip flexor as well as abductor
and spans from the iliac crest, crossing over medially before
inserting into the tibia. Pes anserinus (Latin for gooses foot) is
the insertion of the conjoint tendons of semitendinosus, gracilis,
and sartorius onto the anteromedial (AM) aspect of proximal tibia
(Fig. 4). Popliteus is also a knee flexor, but only when the knee is
hyperextended; in other positions, it functions as a medial rotator
of the tibia on the femur (Fig. 4).

Ligaments

DISCUSSION
Anatomy of Knee Joint and Surrounding Structures
The knee joint is a complex joint consisting of 3 components:
the femorotibial, patellofemoral, and superior tibiofibular joints.

From the *Department of Anesthesia, Toronto Western Hospital, University of


Toronto, Toronto, Ontario, Canada; and Department of Anesthesiology, Clement
Zablocki VA Medical Center, Medical College of Wisconsin, Milwaukee, WI.
Accepted for publication June 19, 2014.
Address correspondence to: Philip W. H. Peng, MBBS, FRCPC, McL 2-405,
Department of Anesthesia, Toronto Western Hospital, 399 Bathurst St,
Toronto, Ontario, Canada M5T 2S8 (email: philip.peng@uhn.ca).
Institutional funding was received for this study.
P.W.H.P. received equipment support from SonoSite Canada. H.S. received
equipment support from SonoSite, BK Medical, and Philips and an
honorarium from Dannemiller.
Copyright 2014 by American Society of Regional Anesthesia and Pain Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000135

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This review focuses on the anatomy of the knee relevant to IA


knee injections.

The stability of the knee is maintained primarily by 4 ligaments (Fig. 4). Both the anterior and posterior cruciate ligaments
are intracapsular but extrasynovial structures. The anterior cruciate ligament originates from the posteromedial aspect of the lateral femoral condyle and has its attachment to the front of the
intercondylar eminence on the tibia. The stronger posterior cruciate ligament originates from the posterolateral surface of the medial condyle and is attached to the posterior intercondylar fossa
of the tibia. The medial collateral ligament is inserted to the medial epicondyle of the femur and the medial tibial condyle
with the deep fibers attaching to the medial meniscus (Fig. 4).
It is buttressed between the tendons of pes anserinus and
semimembranosus. The lateral collateral ligament spans between
the lateral epicondyle of the femur and the head of the fibula.

Joints
The femorotibial joint is composed of 2 compartments: medial and lateral. The fibrocartilaginous medial and lateral menisci

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increase the surface area of contact between the convex femoral


condyles and flat tibia plateau. The articular capsule is reinforced
by various structures surrounding the joint: muscles and tendons,
retinaculum, and ligaments. Anteriorly, they are quadriceps and
patella tendons, medial and lateral patellofemoral ligaments, and
retinaculum from vastus medialis and lateralis. Medially, it is reinforced by medial collateral ligament. Laterally, it is strengthened
by iliotibial band, lateral collateral ligament, and the bicep tendons
and their fascial expansion.
There are many recesses to the femorotibial joint, but the
widest is the suprapatellar recess (SPR) (Fig. 4), which originates
from the fusion of the subquadriceps bursa with the joint cavity
and allows an access for injection into the joint cavity.

US in Pain Medicine: Knee Joint

common popliteal cyst (defined as a fluid-filled mass in the popliteal fossa), the terms should not be used synonymously as there
are other causes of popliteal cysts. In adult, almost all Bakers
cysts are secondary, which means that communications exist between the bursae and knee joint.1

Sonoanatomy
The knee may be examined from anterior, medial, lateral, and
posterior surfaces to identify various structures and pathologies. A
linear array transducer at frequencies of 6 to 12 MHz is usually
ideal for the examination of the knee. Higher frequencies are used
to examine the more superficial structures in details.

Anterior Knee
Bursa
Around the knee joint, there are multiple bursae, which serve
to reduce the friction between various structures (bones, tendons,
ligaments, or skin), allowing a smooth and independent gliding
of these structures during joint movements. The anatomical locations of these bursae are summarized in Table 1 and Figure 4. Of
these bursae, the most well-known is the semimembranosus or
semimembranosus-gastrocnemius bursa. Abnormal distension of
this results in Bakers cyst. Although Bakers cyst is the most

When examining the knee anteriorly, the patient is placed in


supine position with the knee slightly flexed 20 to 30 degrees on a
bolster to keep the quadriceps tendon taut. The sequence of examination starts from above the patella to evaluate the quadriceps
femoris (Fig. 5). Just beneath the tendon of the quadriceps femoris
is the suprapatellar bursa appearing as a thin hypoechoic line. Voluntary contraction of the quadriceps may help identify smaller effusions.2 The prefemoral fat pad is located over the femur, and the
suprapatellar fat pad is underneath the quadriceps tendon. The

FIGURE 1. Anterior view of the thigh and knee. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
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suprapatellar bursa is commonly chosen as the site for access to


the knee joint. The medial and lateral recesses may be examined
in a transverse view by the side of the patella (Fig. 6). When the
knee is fully flexed, the condyles may be visualized as a curved
hyperechoic line with an acoustic shadow beneath it. Lining the
condyles is the hypoechoic hyaline cartilage (Fig. 7).
Scanning longitudinally inferior to the patella helps identify
the patellar tendon inserting into the tibial tuberosity, and beneath
the tendon, the intracapsular Hoffas fat pad is located (Fig. 8).
The infrapatellar bursa lies over the tibia and the distal portion
of this tendon (Fig. 4).

Medial Knee
Examination is best performed with the patients knee externally rotated while maintaining 20- to 30-degree flexion. Placing
the ultrasound probe over the long axis of medial collateral ligament reveals the superficial layer and the deep meniscofemoral
and meniscotibial components of the ligament (Fig. 9). In general,
the ligament is examined for the entire length and with dynamic
scanning during valgus stress for the possible pathology and assessment of integrity. The medial meniscus appears as a
hyperechoic triangular structure between the femur and tibia
(Fig. 9). Moving the ultrasound probe distally to the AM aspect
of the tibial metaphysis, the tendons of sartorius, gracilis, and

semitendinosus are seen blended together, forming the pes


anserinus complex (Fig. 9).

Lateral Knee
Examination of the lateral knee is performed with the patients knee internally rotated while maintaining 20- to 30degree flexion. The ultrasound probe is first placed over the long
axis of iliotibial band, with the distal segment best revealed in the
coronal plane. The iliotibial band is seen as a thin, fibrillar structure that inserts onto the Gerdy tubercle, a bony prominence on
the anterolateral (AL) aspect of the tibial epiphysis (Fig. 10).
The lateral collateral ligament is best examined by placing the
lower part of the ultrasound probe over the fibula head with the
proximal part of probe rotating over the femur. When the probe
is aligned with the ligament, it gives the longest view of the ligament. With a proper scan, the popliteus tendon and the lateral meniscus can be seen (Fig. 10).

Posterior Knee
The examination is performed while the patient is prone position with the knee extended. The ultrasound probe is placed on the
posteromedial aspect of the knee over the medial femoral condyle.
The following structures are seen from medial to lateral in shortaxis scan: sartorius, gracilis, semimembranosus, semitendinosus,

FIGURE 2. Lateral view of the knee showed the details of the trilaminar nature of the quadriceps tendon. The insert on the right upper corner
was the expanded view of the rectangle over the quadriceps tendon. Reproduced with permission from Dr Philip Peng from Philip Peng
Educational Series.

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Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014

and medial head of gastrocnemius muscle (Fig. 11). The semimembranosus or semimembranosus-gastrocnemius bursa is located
between the tendons of semimembranosus and the medial head of
gastrocnemius. Moving the probe laterally, the short-axis scan of
the popliteal fossa reveals the neurovascular bundle (Fig. 11). Moving the probe further laterally, the biceps femoris muscle and tendon
are examined in the long-axis scan (Fig. 11).

Accuracy
Although the knee IA injections are commonly performed
with landmark-based technique by rheumatologists, orthopedic surgeons, and general practitioners, the accuracy of the landmarkbased technique in clinical studies is approximately 79% (range,
40%100%).3 Three factors influence accuracy: use of image guidance, experience of practitioners, and approach of injection.
Literature supports the superiority of image guidance in
terms of accuracy.4 Comparison studies reveal pooled accuracy
rates of 81.0% and 96.7% for landmark-based versus image guidance (fluoroscopy or ultrasound) techniques, respectively.4 In contrast to fluoroscopy, ultrasound allows the procedure to be
performed in office-based settings. The accuracies of landmarkbased versus ultrasound guidance techniques were also significantly different, 77.8% and 95.8%, respectively.4 Although the
presence of an effusion greatly enhances the accuracy of
landmark-based IA needle placement in the knee,5,6 loss of resistance is not indicative of an IA location. This was supported by a

US in Pain Medicine: Knee Joint

cadaver study examining the reasons for the failure of the


landmark-based injection, with most of the inaccuracies due to
the injection into the Hoffas fat pad (81%).7
Experience can be an important contributor to the accuracy.
The only controlled study looking at the influence of practitioners
experience in knee injection compares the accuracy of a trainee
with 10 months of landmark-based knee injection experience
and a staff physician with 13 years experience in the same. This
study demonstrated a huge difference in success rate, 55% versus
100% for the trainee and staff physician, respectively.8 However,
another important finding of this study was that both achieved
100% accuracy with ultrasound-guided technique (the levels of
experience with ultrasound imaging guidance were 10 months
and 3 years for the trainee and staff physician, respectively). This
study echoed the improvement in accuracy with ultrasound guidance for the less experienced practitioners in another study, in
which patients who received injections at various sites (shoulder,
elbow, wrist, knee, and ankle) were randomized to ultrasoundguided injections or injections using the landmark-based technique.9 The ultrasound technique was exclusively performed
by 1 junior trainee with 9 months of rheumatology experience
and 8 sessions of musculoskeletal ultrasound training. The
landmark-based technique was performed by a group of rheumatologists with more training, with approximately two-thirds of injections by 9 rheumatologists with median experience of 15 years
and one-third of injections by 9 senior rheumatology trainees with
median rheumatology experience of 3 years. The accuracy was

FIGURE 3. Posterior view of the thigh and knee showed the flexors of the knee. Reproduced with permission from Dr Philip Peng from Philip
Peng Educational Series.
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Peng and Shankar

Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014

significantly better for the junior trainee who performed all the
ultrasound-guided injections (accuracy rates of 83% vs 66% for
ultrasound and landmark-based technique, respectively). Confidence or satisfaction of injection by the practitioner using
landmark-guided technique did not result in a better success rate.9

This is similar to the confidence factor of the practitioner in shoulder injections reviewed previously.10
Accuracy is also influenced by the approaches. When performing landmark-based technique knee injections, there are
generally 6 approaches: superolateral (SL), superomedial, medial

FIGURE 4. Four views of the knee showed the ligaments and bursae. A, Medial view. B, Anterior view. C, Lateral view. D, Posterior view. In the
posterior view, the medial head of gastrocnenimus was removed to reveal the IA structures. F indicates fibula; T, tibia. Reproduced with
permission from Dr Philip Peng from Philip Peng Educational Series.

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US in Pain Medicine: Knee Joint

TABLE 1. Bursae of the Knee


Bursa
Anserine
Subcutaneous prepatellar
Suprapatellar
Subcutaneous infrapatellar
Deep infrapatellar
Semimembranosus
Popliteus

Location Between
Pes anserinus
Skin
Quadriceps tendon
Skin
Patella tendon (ligament)
Semimembranosus tendon
Popliteus tendon

midpatellar (MMP), lateral midpatellar (LMP), AM, and AL


(Fig. 12). The details of the approaches are reviewed elsewhere.11
The first 4 approaches are performed with the knee in extension,
whereas AM and AL approaches are performed with knee in
90-degree flexion with or without the modification of degree of

Tibia and medial collateral ligament


Anterior surface of patella
Femur
Tibial tuberosity
Anterior surface of tibia
Medial head of gastrocnemius
Lateral condyle of tibia

flexion as suggested by Waddell et al.12 The SL approach resulted


in the highest accuracy of 91% (95% confidence interval [CI],
84%99%). There are also different approaches for ultrasound
guidance. Only 1 study compared the accuracies of different
ultrasound-guided approaches.13 The SL and LMP approaches

FIGURE 5. A, Sonogram of the suprapatellar view of the normal knee. The insert showed the position of the patient and the ultrasound probe.
B, Sonogram of the details of quadriceps tendon. C, Sonogram of the suprapatellar view of a patient with knee effusion. Note the presence
of effusion fluid filling the space between prefemoral fat pad and quadriceps tendon. SPFP indicates suprapatellar fat pad; PFFP, prefemoral fat
pad; P, patella; F, femur. ** indicates the SPR. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
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FIGURE 6. A and C, Pictures show the position of the ultrasound probes and the manipulation of the patella by the examiner. The patella was
pushed to the medial and lateral sides, respectively in A and C. B and D, The respective sonograms (B and D) show the medial and lateral
views, respectively. MFC indicates medial femoral condyle; LFC, lateral femoral condyle. Stars indicate the Hoffa fat pad; chain of trapezoid
indicates the cartilage. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.

were significantly more accurate than MMP approach (accuracy rates of SL, LMP, and MMP were 100%, 95%, and
75%, respectively).
Ultrasound improves accuracy of IA injection, which is important to both outcome and safety. Still, there is some controversy
regarding the effect of imaging method for needle placement

improved clinical outcome.14 It is important to recognize that knee


injections can be used to deliver various therapeutic medications
(eg, corticosteroids or viscosupplements) or biologic agents (eg,
platelet-rich plasma or stem cells) to reduce pain and improve
function in patients with knee disorders.15,16 While therapeutic effect can occur with suboptimal location of corticosteroid in the

FIGURE 7. Sonogram of both femoral condyles. The picture on the left shows the position of the knee and the ultrasound probe. The hyaline
cartilage was marked with trapezoids. QT indicates quadriceps tendon. *Muscle of vastus medialis. Reproduced with permission from
Dr Philip Peng from Philip Peng Educational Series.

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US in Pain Medicine: Knee Joint

FIGURE 8. Sonogram of the infrapatellar region. The picture on the left shows the position of the ultrasound probe. The arrow indicates the
patella tendon, and * indicates the Hoffa fat pad. T indicates tibia; TT, tibial tuberosity. Reproduced with permission from Dr Philip Peng
from Philip Peng Educational Series.

knee joint,17,18 other agents require precise deposition in the IA


space. There is sufficient literature evidence showing that improved accuracy of IA corticosteroid injection correlated with better pain relief, functional outcome, and cost-effectiveness.9,1923
In addition, precise placement of needle minimizes procedurerelated pain, tissue trauma, crystal synovitis, hemarthrosis, and articular cartilage atrophy.4,19,24,25

Efficacy of IA Knee Injections


The main indication for IA knee injection is osteoarthritis
(OA), and the injection agents commonly used by practitioners
are corticosteroid and hyaluronic acid (HA).15 Efficacy of other
medications and biologic agents has been examined elsewhere,15
but only corticosteroid and HA are reviewed here.
Three systematic reviews consistently concluded that IA corticosteroid was more effective than IA placebo for pain reduction

(weighted mean difference, 21.91; 95% CI, 29.93 to 13.89)


and patient global assessment (relative risk, 1.44; 95% CI,
1.131.82).2628 However, these reviews also suggested that IA
corticosteroid provided only short-term benefit (<3 weeks), and
there was a lack of evidence for efficacy in functional improvement. Research comparing different preparations of corticosteroid
suggests that triamcinolone is more effective than betamethasone
and methylprednisolone, 2 other commonly used corticosteroids.
However, not all studies considered using a validated outcome
measure such as the visual analog scale pain scale.29
Viscosupplementation is indicated for symptomatic OA of
the knee without complete collapse of joint space.15 The use of
this in the management of knee OA has become a controversial
subject lately.30 Viscosupplementation refers to IA injection of
HA, which is a natural substance normally found in the synovial
fluid of joints. It provides the rheological properties (viscosity
and elasticity) of the synovial fluid and functions as a lubricant

FIGURE 9. A, Sonogram of long-axis view of the medial collateral ligament. Open arrowheads indicate superficial layer of the collateral
ligament, which is deep to the superficial fascia (open arrows); closed arrow, the deeper meniscofemoral ligament connecting the
meniscus (*) and the femur (F). B, Sonogram of long-axis view of the pes anserinus complex inserting into the anterolateral aspect of the tibial
metaphysis. At this level, the 3 tendons of sartorius, gracilis, and semitendinosus cannot be differentiated from each other. The lower
diagram is the color Doppler showing the inferior medial genicular artery (dark arrowhead). The inserts show the position of the probe and
patient as well as the corresponding anatomical structures in the sonogram. Note that the leg was externally rotated and rested on a
small pillow. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
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FIGURE 10. A, Sonogram of the long-axis view of iliotibial band (hyperechoic structures indicated by the arrows) inserting into the
Gerdy tubercle (GT). The GT and the fibula (F) were marked on the skin. B, Sonogram of the long-axis view of lateral collateral ligament
(arrows) inserting into the fibular head. The popliteus tendon (open arrowhead) is seen deep to the collateral ligament at this level and
inserted in the small fossa (closed arrowheads) located on the lateral aspect of the lateral femoral condyle. The insert shows the position
of the probe and the position of the patient. The leg was internally rotated resting on a small pillow. Reproduced with permission from
Dr Philip Peng from Philip Peng Educational Series.

and shock absorber of the joint. The rheological properties of HA


depend on both the concentration and the molecular weight of the
HA in the synovial fluid. There are various products on the market
for viscosupplementation. These include HA preparations of relatively low molecular weight (Hyalgan and ARTZ), of intermediate
molecular weight (Orthovisc), and a cross-linked hyaluronan of
high molecular weight (Synvisc).
A very detailed evidence-based review on knee injections for
arthritis published in 2012 summarized that there were 7 metaanalyses on the effectiveness of IA injection of HA for the treatment of knee OA.15 Compared with placebo or IA corticosteroid
injection, 5 of 7 analyses found IA injection of HA efficacious
in the management of OA. In addition, 9 of 10 guidelines on management of knee OA provide positive recommendations on the use
of HA.15 The therapeutic benefit over placebo of IA HA for knee
OA was more long-lasting than IA corticosteroid. There was a significant improvement in pain scores from baseline by 26% and
function by 27% during the period of fifth to 13th week.31 However, the included studies were variable in design and outcomes.31
A closer examination of this review from 2012 revealed that
the most recent meta-analysis quoted in this article was published
in 2009, and there were 7 trials published outside of this metaanalysis.3238 The American Academy of Orthopedic Surgeons
recently published a meta-analysis that included all those recent
trials. Unlike other systematic reviews, they excluded those studies that recruited fewer than 30 patients in each treatment group
and included only those trials that demonstrated clinical efficacy
beyond 4-week treatment period.30 They also interpreted the result
using the terms minimum clinically important improvement,
which was expressed as meaningfully important difference
units. They included 14 studies (3 high-strength studies and 11
moderate-strength studies). This was in contrast to the latest
Cochrane review, which included 40 studies. Although all analyses of the WOMAC (Western Ontario and McMaster Universities
Arthritis Index) pain, function, and stiffness subscales scores revealed statistically significant treatment effects, none of these

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improvements met the minimum clinically important improvement thresholds. They showed that the overall improvement (pain
and function outcome) was less than 0.5 meaningfully important
difference units. This suggested a low likelihood that an appreciable number of patients achieved clinically important benefits in
the outcome.39 When the high- and low-molecular-weight HAs
were analyzed separately, they showed that most of the statistically significant outcomes were associated with high-molecular
cross-linked HA (Synvisc), but when compared with midrange
molecular-weight HA, statistical significance was not maintained.
Based on their review method, they did not recommend the use of
HA for knee OA. The strength of this recommendation was strong
and was based on lack of efficacy, not on potential harm
Based on the above information, should we consider knee injection in managing patient with OA of knee? Both injection medications clearly show benefits in terms of pain and function.
However, the clinical benefit of IA corticosteroid is short term.
Literature on viscosupplementation supports improvement in pain
and function as well. The controversy is whether the benefits are
clinically significant. In deciding the management options to patients with knee OA, clinician should balance the benefits and
risks of IA injection with the other conservative and surgical options in the management algorithm.

Ultrasound-Guided Injection Technique


Because the suprapatellar or SL approach is the most wellstudied ultrasound approach and was shown to have the highest
efficacy, this approach is described here.
The procedure is performed with the patient placed in supine
position with the knee slightly flexed and supported. Following
sterile preparation, a high-frequency linear probe (6-13 Hz) is
placed over the patella and quadriceps tendon (Fig. 13). With
proper positioning, the SPR between the suprapatellar and
prefemoral fat pads should be revealed. A couple of maneuvers
can be used to augment the SPR when the synovial fluid is scant:
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US in Pain Medicine: Knee Joint

FIGURE 11. A, Sonogram showing the various muscles and tendons in the posteromedial region of the knee. Deep to the sartorius
muscle (Sa), the tendon of gracilis (arrow) and saphenous nerve (line arrows) were revealed. Semitendinosus tendon (closed arrowheads)
was seen as a round hyperechoic structure resting on the semimembranosus muscle (SM), similar to a cherry on the cake. B, By moving
the ultrasound lateral to the medial femoral condyle (MC), the medial head of gastrocnemius (GH) and its tendon (asterisk) were
revealed. Between the space between the medial head of gastrocnemius and semimembranosus muscle is the semimembranosus or
semimembranosus-gastrocnemius bursa (outlined by dotted line), which is hypoechoic in normal state because of the apposition of synovial
walls. Because of lack of fluid in normal state, one should apply very light pressure to the ultrasound probe to reveal its presence. The hyaline
cartilage was indicated by white rhombi. C, Sonogram of the central portion of the posterior knee. Color Doppler shows the popliteal
artery (blue structure indicated by the arrow). The sciatic nerve was also revealed posterior to the artery. D, Sonogram of the biceps femoris
in the posterolateral region of the knee. The biceps muscle (BFm) continues as a tendon (arrows) inserting into the fibular head (F) as a clear
hyperechoic structure. * Indicates lateral meniscus; T, tibia. The inserts in each figure show the position of the patient, the position of the
probe, and the anatomical structures corresponding to the sonogram. Reproduced with permission from Dr Philip Peng from Philip Peng
Educational Series.

(1) to ask the patient to perform isometric contraction of the


quadriceps or (2) to apply pressure in the parapatellar space to
squeeze the synovial fluid to the SPR. Once the SPR is seen,
the ultrasound probe is rotated 90 degrees above the patella. A
20- or 22-gauge needle is inserted from lateral to medial in-plane
toward the SPR. Alternatively, the ultrasound probe is rotated
45 degrees with the cephalad end directed to the lateral side (SL
position). The rotation of the probe is to avoid needle trauma to
the quadriceps tendon. Aspiration of synovial fluid should always
be considered. Five milliliters of corticosteroid (40 mg methylprednisolone or triamcinolone diluted in 5 mL of local anesthetic)
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or viscosupplement is injected following hydrolocation of the location of the needle (avoid injecting into the fat pad).

CONCLUSIONS
Knee IA injections are commonly performed with landmarkbased technique by general practitioners and specialists. The accuracy of IA injection is influenced by 3 factors: use of image
guidance, experience of practitioners, and the approach of injection. Literature supports better accuracy with ultrasound guidance

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FIGURE 12. Diagram shows the various landmark-based approach. The dark dots mark the sites of needle entry; the arrows show the direction
of needle entry. The knee was put in extension for SL, superomedial (SM), LMP, and MMP approaches. The AM and AL approaches are
performed with knee in 90-degree flexion with or without the modification of degree of flexion as suggested by Waddell et al.12 Reproduced
with permission from Dr Philip Peng from Philip Peng Educational Series.

over landmark-based technique. Better experience of the practitioner improves the accuracy of landmark-based technique, but
the use of ultrasound guidance can boost the accuracy of the less experienced. Superolateral approach appears as the most reliable
approach for both the ultrasound-guided or landmark-based techniques. Ultrasound enhances the accuracy of knee IA injection,

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which in turns improves the clinical outcome. Literature supports


the efficacy of IA injection of corticosteroid, but the benefits are
of short term (<3 weeks). Viscosupplementation provides significant improvement in pain scores and function up to 3 months.
However, controversy exists on whether the benefits are clinically significant. Clinicians should balance the benefits and risks
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Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014

US in Pain Medicine: Knee Joint

FIGURE 13. Picture shows the injection technique. The ultrasound probe is placed between the patella and quadriceps tendon initially and
then turned 90 degrees upon visualization of the SPR. The needle is then approached from lateral to medial to avoid puncturing the
quadriceps tendon. The needle is indicated by the arrowheads and the SPR by asterisks (****). R indicates retinaculum; Q, quadriceps tendon;
F, femur. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.

with the other conservative and surgical options in the management algorithm.
ACKNOWLEDGEMENT
The authors thank Dr Richelle Kruisselbrink for assisting
with the construction of the sonogram.
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