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Tibial Nerve Injection at the Posterior Knee

From WikiSM

Other Names

  • Tibial Nerve Injection at the Posterior Knee
  • Tibial Nerve Block

Background

Tibial nerve and associated anatomy[1]

Key Points

  • Needle: 22-25 gauge, 2 inch
  • Transducer: high frequency, linear
  • Recommend in-plane approach

Anatomy of the Tibial Nerve

  • Larger of the two branches of the sciatic nerve as it descends the posterior thigh
  • Sends off the medial sural cutaneous nerve at the popliteal fossa
  • Sural nerve is formed when when combined with the lateral sural cutaneous nerve (from CPN)
  • Popliteal artery runs anteromedial to the nerve superior to the knee joint
  • Moves anterior and then anterolateral as it passes the joint

Palpation Guidance vs Ultrasound Guidance

  • There are no studies comparing palpation and ultrasound guidance
  • This procedure can not be safely or reliably performed without ultrasound guidance

Indications

  • Tibial Neuropathy
  • Tibial Nerve Block

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

Normal tibial nerve seen in short axis[2]
Ultrasound view of the tibial nerve injection at the posterior knee[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

  • Identify the bifurcation of the sciatic nerve in short axis
  • Follow the tibial nerve inferiorly, typically at a depth of 3-4 cm[4]
  • Popliteal artery and vein can be seen below the nerve

Technique: Short Axis, In Plane

  • Patient Position
    • Prone
  • Transducer position
    • Short axis to the knee joint in the popliteal fossa or just above
  • Needle Approach/ Orientation
    • In plane
    • Medial to lateral
  • Target
    • Perineureum of the tibial nerve
  • Pearls and Pitfalls
    • Must scan to find optimal approach
    • Identify and maintain visualization of all neurovascular structures
    • Lateral approach discouraged to avoid the common peroneal nerve
    • Avoid directly piercing the nerve

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. ↑ Morton DA, Foreman KB, Albertine KH, eds. The Big Picture: Gross Anatomy. New York: McGraw-Hill; 2011: figure 37-4A
  2. ↑ Image courtesy of acepnow.org
  3. ↑ Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
  4. ↑ Gruber H, Kovacs P. Sonographic anatomy of the peripheral nervous system. In: Baert AL, Knauth M, Sartor K, eds. High Resolution Sonography of the Peripheral Nervous System. 2nd rev. ed. Berlin: Springer-Verlag; 2008:37–39, 52–54.
Created by:
John Kiel on 3 April 2025 19:03:47
Authors:
Last edited:
3 April 2025 19:43:19
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