Indications

Irritation of the patellar ligament and the distal area of musculus quadriceps femoris

Patellar chondropathy and arthrosis of the knee joint

Pes anserinus tendinosis

Patellar tendinitis (jumper’s knee)

Irritation of the infrapatellar nerve

Differential Diagnoses

Inflammation of the knee joint (gonarthritis)

Referred pain in disorders of the rectus femoris

Referred pain in shortening of the vastus lateralis

Radiating pain in inflammatory changes of the sural nerve and radicular symptoms in the L 4 segment

Material

Local anesthetic: 3–5mL

Needle: 0.4 × 40 mm

Technique

The needle is inserted on the median line, inferior to the easily palpable patellar tip and is advanced approximately 1–1.5 cm. Following aspiration (to avoid intra-articular injection), 1–1.5 mL of a local anesthetic is injected.

The next injections are performed in the pain area, approximately 1 finger width next to the midline, on the medial aspect of the knee. 1–1.5 mL of a local anesthetic is injected at points 1–1.5 cm apart across the joint, with the patient’s knee extended. The needle is inserted only 0.5–1 cm. Aspiration is vital to avoid intraarticular injection.

In addition, superior to the patella, medially and laterally to the attachment site of the rectus femoris, 1 mL of a local anesthetic is injected. The borders of the muscle can be easily palpated by having the patient lift the extended leg.

Risks

Unintentional intra-articular injection occurs very easily. Superficial injection suffices at this location; therefore, the insertion depth of 0.50–1 cm must not be exceeded and prior aspiration is required.

Concomitant Therapies

Depending on the underlying disorder, physical strain must be adjusted through corrections to the soles of shoes (internal and external sole lift) and adjustments regarding the foot statics or leg length. Frequently, especially in younger patients, considerable imbalance of the vastus medialis and the vastus lateralis can be seen. This requires adjuvant strengthening exercises for the vastus medialis. If the tibiofibular joint is affected, joint mobilization through manual therapy is recommended.

In persistent irritations and positive McMurray test result or Cooper sign, the joint should be assessed using arthroscopy or MRI. Osteochondritis dissecans and osteochondral necrosis may be ruled out using radiologic assessment.

In acute pain, temporary respite from athletic activities is recommended.

In knee pain without organic correlation but with headache, a combination of acupuncture points ST-36, close to the knee, and ST-6, ST-8, and LI-4 has been successful.

Additional injection of 0.5 mL of a local anesthetic in the area of GB-34 and GB-40, yuan source point, is helpful. Always inquire about functional disorders of the lumbar spine in combination with headache.

Indications

Median knee attachment tendinosis

Overstrain syndrome of the knee joint capsule

Adjuvant treatment in median gonarthritis

Material

Local anesthetic: 3 mL

Needle: 0.4 × 40 mm

Technique

With the patient’s knee in extension, a strong tapering muscular bulge at the medial joint line can be palpated. If it is palpated distally, its attachment at the tibial head is located. Here, the needle is inserted pointing superiorly and the attachment area is flooded with a local anesthetic in a fan-shaped pattern.

On a vertical cranial line that initially deviates slightly posteriorly, two to three additional intracutaneous quaddles are set 2 cm apart. Each quaddle receives 0.2 mL of the injectable.

Risks

Anesthesia of the saphenous nerve and its infra-patellar branch

Intra-articular injection

Intra-articular injection can be safely avoided if the needle is inserted as indicated, cranially at a shallow angle. If the saphenous nerve is temporarily anesthetized, the patient must be informed about the temporary characteristics.

Concomitant Therapies

Iontophoretic treatment, local cryogenic friction massage

Relaxation of the sartorius, semitendinosus, and gracilis using physical therapy

Anti-inflammatory occlusive bandage

Alternating knee affusion according to Kneipp

Indications

Painful lateral edge of the knee joint, painful fibular head

Myotenositis of the biceps femoris

Differential Diagnoses

Lesion of the lateral meniscus

Irritation of the infrapatellar nerve

Maisonneuve fracture

Material

Local anesthetic: 2 mL

Needle: 0.4 × 40 mm

Technique

The fibular is easily located through palpation. The needle is inserted 1 cm superior, pointing toward the fibular head.

After bone contact has been made, the injectable is administered as the needle is retracted.

Risks

Anesthesia of the peroneus nerve. The nerve reaches the fibular head from posteriorly, and spirals around it in a superior direction. Anesthesia of the peroneus nerve can be safely avoided if the needle makes bone contact prior to injection.

Concomitant Therapies

Mobilization of the tibiofibular joint using manual therapy

Friction massage

Ultrasound applications

Cryotherapy

Acupuncture (ST-36, ST-35)

Indications

Pain appears especially near the knee joint superior to the patella and in terms of lower patellar pole syndromes.

Adjuvant treatment in patellar chondropathy and retropatellar arthrosis

Differential Diagnoses

Free joint body

Prepatellar bursitis

Gonarthrosis, gonarthritis

Material

Local anesthetic: 3 mL

Needle: 0.4 × 44 mm

Technique

The superior edge of the patella is palpated and three or four injections are performed superior to the palpable bony edge. First an intracutaneous quaddle is set, the needle is then advanced 0.5 cm, and 0.3 mL of a local anesthetic is injected at each site.

In the area of the inferior patellar pole, the procedure is repeated. The insertion is directed toward the bone. Below the bone, close to the patellar periosteum, 0.5 mL of a local anesthetic is injected. The depth of insertion is 0.5 cm.

Finally, in the area of the palpable tibial tuberosity, a quaddle is set at its superior edge. The needle is then advanced until bone contact is made. After the needle has been retracted 1 mm, 0.5 mL of a local anesthetic is injected.

Risks

Unintentional intra-articular injection; this can be avoided by observing the depth of insertion and making bone contact with the needle prior to injection.

Concomitant Therapies

Traction mobilization of the patella

In muscular imbalances, it is frequently necessary to strengthen the vastus medialis through exercises.

Prescription of quadriceps support aids, for example, negative heel

Priessnitz compress

Medical exercise therapy

Indications

Calf pain, radiating into the Achilles tendon

Adjuvant treatment in:

– achillodynia

– knee flexion contracture

– contracted drop foot

– calf cramps at night

Differential Diagnoses

Venous insufficiency

Deep vein thrombosis

Compartment syndrome

Peripheral arterial occlusion

Material

Local anesthetic: 5 mL

Needle: 0.5 × 50 mm

Technique

The patient is in the pronated position and attempts plantar flexion of the foot against resistance. This requires tensing the gastrocnemius and the soleus. The superior border of the two gastrocnemius heads is located. The needle is inserted 2 cm and 0.5 mL of a local anesthetic is injected on each side.

Five centimeters distally, on top of the muscle bellies, the needle is inserted 2 cm and 0.5 mL of a local anesthetic is injected bilaterally. The needle is then advanced another 2 cm and the injectable is administered again.

The distal conjunction of the gastrocnemius heads is located. A notch on the median line indicates the precise injection site. The needle is inserted vertically 2 cm and 0.5 mL of a local anesthetic is injected.

Risks

Injection into the small saphenous vein

If the needle is advanced excessively, the tibial nerve may be anesthetized.

Concomitant Therapies

Muscular relaxation using physical therapy

Connective-tissue massage

Traction mobilization of the knee joint and the ankle joint

Supportive heel lift, if applicable

Calf affusion according to Kneipp

Priessnitz compress, cupping therapy

Indications

Pain in the area of the lateral lower leg

Pain along the course of the tendon at the lateral malleolus

Adjuvant treatment in:

– genua vara (bow legs)

– dysfunction of the upper and lower ankle joints

– partial weakness after disk herniation at L4/L5

Differential Diagnoses

Compartment syndrome

Peripheral arterial occlusion

Material

Local anesthetic: 3 mL

Needle: 0.4 × 40 mm

Technique

The patient is in the lateral position. The prominent fibular head is palpated. The first injection is performed directly inferior to the fibular head, at the transition onto the muscle attachment. The needle is inserted vertically until bone contact is made. The needle is then retracted 1 mm and 0.5 mL of a local anesthetic is injected.

On a straight line down to the lateral malleolus, two additional injections are performed 4 cm apart. The needle is inserted vertically 1 cm and 0.5 mL of a local anesthetic is administered.

The final injection is performed posterior to the lateral malleolus. Nearly parallel to the peroneal tendon, the needle is inserted caudally at a shallow angle into the tendon sheath. Then, 0.5 mL of a local anesthetic is injected.

Risks

If the injectable is administered posterior to the fibular head, the peroneal nerve may be anesthetized and temporary weakness in dorsal flexion of the foot may result.