Aspiration and Injection Techniques of the Lower Extremity

Christopher P. Chiodo, MD; Catherine Logan, MD, MBA, MSPT; Cheri A. Blauwet, MD


J Am Acad Orthop Surg. 2018;26(15):e313-e320. 

In This Article

Foot and Ankle Region

Tibiotalar Joint

The tibiotalar joint is a common site of arthritis, synovitis, osteochondral injury, and impingement. Both the anterolateral and anteromedial approaches to the tibiotalar joint are useful to access the joint (Table 2; Figure 4). The needle is placed just medial to the tibialis anterior tendon for the anteromedial approach and just lateral to the peroneus tertius for the lateral approach.

Figure 4.

Photograph showing the palpation-guided anteromedial approach to aspiration or injection of the ankle joint.

With regard to the use of image guidance, Wisniewski et al[24] found superior accuracy of US-guided versus nonguided anteromedial tibiotalar joint injections (100% versus 85%, respectively) in a cadaver model. Reach et al[25] similarly reported 100% accuracy of US-guided anteromedial injections to the tibiotalar joint; however, no comparison group existed.

Subtalar Joint

The subtalar (talocalcaneal) joint allows for inversion and eversion of the hindfoot. Three anatomic approaches have been described (ie, anterolateral, posterolateral, posteromedial), with the posterolateral often preferred because of its distance from neurovascular structures[5,9] (Table 2). Reach et al[25] reported slightly less accuracy (90%) in their investigation of US-guided injection of the subtalar joint in the cadaver model. Henning et al[9] evaluated the accuracy of three US-guided approaches (ie, anterolateral, posteromedial, posterolateral) to inject the posterior subtalar joint and found that all three approaches provided accurate needle placement while also minimizing the risk of needle entry into adjacent soft-tissue structures. In a comparison of the palpation-guided anterolateral and the posterolateral approach in 68 cadaver models, 23 (67.7%) of the anterolateral injections were successful compared with 31 (91.2%) of the posterolateral injections.[26] The greater accuracy of the posterolateral approach was statistically significant (P = 0.016).

Peroneal Tendon Sheath

In the supramalleolar region, the peroneal tendon complex comprises the peroneus longus tendon and the more medial peroneus brevis muscle and tendon. As the complex courses distally, the peroneus longus courses posterior to the brevis tendon. Trauma to the tendons occurs from a forceful contraction of the muscles, with the foot in plantar flexion and inversion. Anatomic variations, such as a shallow or flat retrofibular groove, which houses the tendons as they course behind the fibula, may contribute to persistent or recurrent subluxation of the tendons. Tenosynovitis or tendinopathy occurs secondary to trauma or repetitive microtrauma. Anesthetic injections may be used for diagnostic purposes to assist in the clinical decision-making process and to assess for surgical appropriateness.

The patient is positioned supine, with the hip internally rotated and a towel roll placed under the medial aspect of the ankle (Table 2). Injections to the sheath are performed via palpation or with image-guided assistance. In one cadaver study, US-guided peroneal tendon sheath injections were markedly more accurate than palpation-guided injections (100% versus 60%, respectively).[27] Accuracy is particularly important in the peritendinous injection to minimize the chance of an intratendinous injection, particularly if corticosteroid is used. Reach et al[25] similarly reported 100% accuracy with US guidance for injections of the posterior tibialis and flexor hallucis longus tendon sheaths.

Midfoot and Forefoot

Khosla et al[28] reported on the accuracy of intra-articular injections using palpation versus dynamic US in a cadaver model and reported 100% accuracy in subtalar and ankle joint injections in both techniques. However, using palpation, the needle was correctly placed into the first transmetatarsal joint in 3 of 14 cadavers, compared with 10 of 14 cadavers using US. Similar results were obtained with placement into the second transmetatarsal joint (ie, four with palpation versus eight with US).

The first metatarsophalangeal (MTP) joint comprises the articulation between the first metatarsal and the proximal phalanx of the hallux. Pain at the MTP joint may be acute or chronic in nature and the result of trauma, gout, or other inflammatory arthritides. Variation exists in the size and shape of MTP joints; therefore, palpation in the setting of conditions such as advanced degenerative arthritis may prove challenging.[29] If necessary, distraction of the joint is helpful during needle placement (Table 2). Diagnostic aspiration or therapeutic injection may be useful in the management of advanced osteoarthritis, rheumatoid arthritis, and gout (Figure 5).

Figure 5.

Photograph showing the ultrasonography-guided approach to aspiration or injection of the first metatarsophalangeal joint.

Few data are available on the comparison between palpation and image-guided techniques for injection or aspiration of the first MTP joint. Reach et al[25] report 100% accuracy when using US guidance; however, this analysis was performed without a comparison group. Balint et al[10] reported markedly lower accuracy rates in the conventional, palpation-guided technique for joint and soft-tissue aspiration compared with the US-guided technique. In the conventional group, successful aspiration was achieved in only 32% of the joints, compared with 97% of the aspirations in the US-guided group. The mean volume of fluid obtained with successful aspirations was similar in both groups.