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Tibial Collateral Ligament Bursa Injection

From WikiSM

Other Names

  • Tibial Collateral Ligament Bursa Injection
  • MCL Bursa Injection
  • Voshell's Bursa Injection
  • MCL Bursa Aspiration

Background

Coronal illustration of the knee. The superficial and deep portions of the tibial collateral ligament are depicted in orange and red, respectively. The grey circles represent location of the tibial collateral bursa. The yellow triangle represents the medial meniscus[1]

Key Points

  • Needle: 18 gauge for aspiration, 25 gauge for injection
  • Transducer: high frequency, linear

Anatomy of the Medial Collateral Ligament and Bursa

  • MCL (also known as tibial collateral ligament) is the medial stabilizer of the knee
  • Originates on posterior aspect of medial femoral epicondyle, inserts on tibia near the pes anserinus
  • MCL Bursa is found between the superficial and deep portions of the ligament[2]

Palpation Guidance vs Ultrasound Guidance

  • There are no studies comparing palpation and ultrasound guidance
  • We strongly recommend the use of ultrasound to increase precision and ensure needle guidance into the bursa

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

Long axis, in plane with position of transducer and needle position[1]
Ultrasound view with needle demonstrated for long axis, in plane approach[1]
Long axis, out of plane transducer and needle position[1]
Ultrasound view with needle trajectory marked for long axis, out of plane[1]

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 with high frequency transducer
  • Common ultrasound findings include:
    • Hypoechoic/anechoic fluid with the bursa
    • Bursa may/may not be septated

Bursa Injection: Long Axis, In Plane

  • Patient Position
    • Supine
    • Hip slightly externally rotated, knee flexed
  • Transducer position
    • Long axis to MCL
  • Needle Approach/ Orientation
    • In plane
    • Anterior to posterior
  • Target
    • MCL Bursa
  • Pearls and Pitfalls
    • Creating a gel standoff can be useful to improve visualization
    • Precision is required, it is easy to place the needle into the joint or too superficial
    • Accidental block of the saphenous nerve can occur

Bursa Injection: Long Axis, Out of Plane

  • Patient Position
    • Supine
    • Hip slightly externally rotated, knee flexed
  • Transducer position
    • Long axis to MCL
  • Needle Approach/ Orientation
    • Out of plane
    • Superficial to deep
  • Target
    • MCL Bursa
  • Pearls and Pitfalls
    • Creating a gel standoff can be useful to improve visualization
    • Precision is required, it is easy to place the needle into the joint or too superficial
    • Accidental block of the saphenous nerve can occur

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

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
  2. ↑ Maeseneer M, Van Roy F, Lenchik L, et al. Three layers of the medial capsular and supporting structures of the knee: MR imaging-anatomic correlation. Radiographics 2000;20:83–89
Created by:
John Kiel on 27 March 2025 16:49:08
Authors:
Last edited:
17 April 2025 14:20:42
Category:
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