Distal Biceps Femoris Injection
Other Names
- Distal Biceps Femoris Injection
- Distal Biceps Femoris Tenotomy
- Distal Biceps Femoris Fenestration
Background
Key Points
- Transducer: high frequency, linear
- Needle: variable, depending on site and procedure
- Procedures include injection, needle tenotomy and fenestration depending on the pathology
- Ultrasound is useful diagnostically and procedurally
Anatomy of distal Biceps Femoris
- Part of the hamstring muscle group and posterior compartment of the thigh
- Distally, it aids in leg flexion and stability of the knee joint
- Origin is the ischial tuberosity (long head) and linea aspera of femur (short head)
- Myotendinous junction is 3-4 cm above the knee joint
- Insertion is primarily head of fibula, but can attach in multiple places
- Tendon envelopes distal lateral collateral ligament
- Posterior lateral geniculate artery lies underneath the muscle
- Common Peroneal Nerve and/or its branches are also found at the tendon
Palpation Guidance vs Ultrasound Guidance
- Ultrasound is highly recommended given the complex anatomy of the posterior knee
- There is no literature comparing palpation guidance to ultrasound guidance
Indications
- Distal Hamstring Strain
- Distal Hamstring Tear
- Distal Hamstring Tendinopathy
Contraindications
- Absolute
- Anaphylaxis to injectates
- Overlying cellulitis, skin lesion or systemic infection
- Relative
- Can be treated with less invasive means
- Hyperglycemia or poorly controlled diabetes
- Lack of symptom improvement with previous injection
Procedure
Equipment
- Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
- Gloves
- Needle: typically 21-25 gauge, 1.5 inch
- Syringe: 5-10 mL
- Gauze
- Ethyl Chloride
- Bandage
- Injectate
- Local anesthetic
- Corticosteroid
- Sterile probe cover
Ultrasound Findings
- Long axis
- Tendon is located just posterior to lateral knee joint
- Trace distally to identify bifurcation
- This occurs at the level of the LCL/ fibular head
- Can be difficult to decipher short head, treat as a complex
- Visualize in short axis using the LCL
- Superficial/deep heads are noted just proximal to fibula
- Superficial head typically larger
- Dynamic scanning can be helpful
- Elucidate subtle findings, correlate with pain
- Occasionally, snapping biceps femoris can be seen
- Ultrasound findings
- Tendon thickening
- Hypoechoic area within tendon suggesting tendinosis
- Increased doppler signal
- Anechoic areas may represent injury
- Tenosynovitis may be suggested by fluid in tendon sheath
- Bursal distension
- Rarely, avulsion fracture of fibular head
Technique: Long Axis, In Plane
- Patient Position
- Patient is prone or side lying
- Knee is flexed 10-20 degrees
- Transducer position
- Long axis to the tendon
- Slide to pathologic area
- Needle Approach/ Orientation
- In plane
- Typically proximal to distal
- Target
- Distal head of biceps femoris around/at fibular head
- If fluid is present, target the fluid
- Fenestration/Tenotomy
- Multiple fenestrations may be required depending on the pathology
- If calcifications are present, may need to break up
- Consider injecting PRP
- Peritendinous Injection
- Most commonly indicated around 5-10 cm above the attachment at the myotendinous junction
- Pearls and Pitfalls
- Avoid injecting steroids into the tendon or LCL
- Do not be tricked by anisotropy of the tendon
- Find the common peroneal nerve prior to initiating injection and avoid
Aftercare
- No major restrictions in most cases
- Can augment with ice, NSAIDS
- Consider Knee Compression Sleeve to reduce re-accumulation/ swelling
Complications
- Infection
- Damage to surrounding tissue
See Also
Internal
References
Created by:
John Kiel on 13 March 2025 15:41:23
Authors:
Last edited:
13 March 2025 17:09:47
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