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Distal Quadriceps Injection and Tenotomy

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Other Names

Basic illustration of the extensor mechanism of the knee[1]
  • Distal Quadriceps Injection
  • Quad Injection
  • Quad Tenotomy
  • Distal Quadriceps Needle Tenotomy

Background

Key Points

  • Needle: 1.5 to 2.5 inch, 18-22 gauge needle
  • Transducer: high frequency, linear
  • Long axis, in-plane is optimal approach
  • Corticosteroid injection should not be performed in the quadriceps tendon

Anatomy of the Quadriceps Tendon

Palpation Guidance vs Ultrasound Guidance

  • There are no papers comparing palpation and ultrasound guidance
  • Strongly encouraged to use ultrasound to confirm needle placement given paucity of literature

Indications

  • Quadriceps Tendinopathy
    • Refractory to conservative management
    • No corticosteroids
    • Consider autologous whole blood, platelet rich plasma, stem cell therapy
    • Consider needle tenotomy

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

Long axis, in plane sonogram of quadriceps tendon. Side by side comparison of the asymptomatic tendon (normal thickness) and symptomatic tendon (thicker, more hypoechoic and shows power doppler flow signals).[2]
Needle and transducer position for long axis, in plane[3]
Long axis, in plane view with needle visualized in area of tendinosis[3]

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

  • Transducer: Linear, high frequency
  • Visualize in both short and long axis
  • Common ultrasound findings include:
    • Thickening
    • Hypoechogenicity
    • Loss of normal fibrillar pattern

Technique: Long Axis, In Plane

  • Transducer position
    • Suprapatellar tendon in long axis
    • Alternative: short axis to tendon
  • Needle Approach/ Orientation
    • Preferred technique: in plane
    • Alternative: out of plane
    • Proximal to distal
  • Target
    • Tendinotic area of quadriceps tendon
  • Pearls and Pitfalls
    • Careful survey of tendon prior to starting procedure
    • Focus on pathologic tendon, avoid normal tendon
    • Consider needling enthesis to encourage angiogenesis from periosteum

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

References

  1. ↑ Image courtesy of drerikhohmann.com, "Knee Extensor Mechanism"
  2. ↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 25215
  3. ↑ 3.0 3.1 Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
Created by:
John Kiel on 9 January 2025 16:41:40
Authors:
Last edited:
16 January 2025 19:28:40
Category:
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