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Infrapatellar Bursa Injection

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Other Names

  • Infrapatellar Bursa Injection
  • Superficial Infrapatellar Bursa Injection
  • Deep Infrapatellar Bursa Injection
  • Infrapatellar Bursa Aspiration

Background

The superficial and deep infrapatellar bursa are illustrated[1]

Key Points

  • Transducer: high frequency, linear
  • Needle: 1.5 inch, 20-22 (injection) or 18 (aspiration)
  • In plane approach in either short or long axis

Anatomy

Palpation Guidance vs Ultrasound Guidance

  • To date, there are no studies comparing ultrasound and palpation guided approaches to the infrapatellar bursa
  • Multiple studies have shown that ultrasound improves accuracy when injecting other bursa[2]
  • The superficial bursa may be accessible with palpation guidance; the deep bursa will not

Indications

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

Distension of the deep infrapatellar bursa with hypoechoic fluid in long axis[3]
Localized fluid collection with thin septa and without wall vascularity is noted superficial to distal patellar tendon.[4]
(A) Setup for a right knee sonographically guided, lateral-to-medial, deep infrapatellar bursa injection, in plane with the transducer. A similar approach can be used to target the superficial infrapatellar bursa. Proximal is left. (B) Sonographic longitudinal view showing fluid (asterisk) within the superficial and deep infrapatellar bursae, superficial and deep to the patellar tendon near its insertion into tibia. (C) Sonographic transverse view of a lateral-to-medial injection, in plane with the transducer into the deep infrapatellar bursa, between the tibia and patellar tendon. (D) Sonographic longitudinal view of a lateral-to-medial injection, out of plane with the transducer, into the deep infrapatellar bursa. The needle tip is identified between the arrows. (E) Sonographic transverse view of a lateral-to-medial superficial infrapatellar bursa injection, in plane with the transducer. Needle tip is superficial to the patellar tendon near its insertion into the tibia. HFP, Hoffa fat pad; PT, patellar tendon[5]
Long axis, needle in plane positioning[1]
Infrapatellar bursa injection using a long axis, out of plane technique (not described)[6]

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

  • Best visualized in long axis of the patella tendon
  • Superficial infrapatellar bursa
    • Difficult to visualize if normal
  • Deep infrapatellar bursa
    • May be seen as a flat 2-3 mm anechoic structure just superficial to the tibial epiphysis[7]
    • Hourglass appearance in the transverse/ short axis plane
  • Common findings in bursitis
    • Anechoic fluid collection
    • Bursal wall thickening
    • Hyperemia on color doppler
    • Pain with sono-palpation
    • If patellar tendinopathy is present, the patellar tendon can appear pathologic

Superficial Infrapatellar Bursa: Long Axis, In Plane

  • Patient Position
    • Supine, knee flexed to about 30 degrees
    • Place a towel/ rolled up sheet behind the knee
  • Transducer position
    • Long axis to the patellar tendon
  • Needle Approach/ Orientation
    • In plane
    • Cranial to caudal
  • Target
    • Superficial infrapatellar bursa
  • Pearls and Pitfalls
    • Avoid injecting into the patellar tendon
    • Fluid is easily compressed with probe pressure

Superficial Infrapatellar Bursa: Short Axis, In Plane

  • Patient Position
    • Supine, knee flexed to about 30 degrees
    • Place a towel/ rolled up sheet behind the knee
  • Transducer position
    • Short axis to the patellar tendon
  • Needle Approach/ Orientation
    • In plane
    • Lateral to medial/ medial to lateral
  • Target
    • Superficial infrapatellar bursa
  • Pearls and Pitfalls
    • Avoid injecting into the patellar tendon
    • Fluid is easily compressed with probe pressure

Deep Infrapatellar Bursa: Short Axis, In Plane

  • Patient Position
    • Supine, knee flexed to about 30 degrees
    • Place a towel/ rolled up sheet behind the knee
  • Transducer position
    • Short axis to the patellar tendon
  • Needle Approach/ Orientation
    • In plane
    • Lateral to medial/ medial to lateral
  • Target
    • Deep infrapatellar bursa
  • Pearls and Pitfalls
    • Avoid injecting into the patellar tendon
    • Fluid is easily compressed with probe pressure

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. ↑ 1.0 1.1 Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
  2. ↑ Finnoff, Jonathan T., et al. "American Medical Society for Sports Medicine position statement: interventional musculoskeletal ultrasound in sports medicine." Clinical Journal of Sport Medicine 25.1 (2015): 6-22.
  3. ↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 86278
  4. ↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 32224
  5. ↑ Lueders, Daniel R., Jay Smith, and Jacob L. Sellon. "Ultrasound-guided knee procedures." Physical Medicine and Rehabilitation Clinics 27.3 (2016): 631-648.
  6. ↑ Nakase, Junsuke, et al. "No superiority of dextrose injections over placebo injections for Osgood–Schlatter disease: a prospective randomized double-blind study." Archives of Orthopaedic and Trauma Surgery 140 (2020): 197-202.
  7. ↑ Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. Heidelberg, Germany: Springer; 2007:683–684.
Created by:
John Kiel on 3 February 2025 14:48:11
Authors:
Last edited:
13 February 2025 15:53:20
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