Sports Medicine: Just the Facts

perpendicular to the skin; and slowly advanced

to the greater trochanter, depth of penetration

may vary from^1 / 2 to 1^1 / 2 in. (up to 4–5 in. if there

is significant adipose tissue). If paresthesias are

appreciated the needle should be withdrawn and

reinserted laterally. Once bone is appreciated,

the needle should be slightly withdrawn, aspira-

tion performed, and then gentle pepperingof the

bursa is performed.

4. Needle size and dosage: A 21- to 23-gauge needle,
   11 / 2 -in. long should be used; 1 mL of corticosteroid
   with 3 to 5 mL of local anesthetic.

• Knee joint

1. Indications: Inflammatory or degenerative arthritis


2. Clinical anatomy/Landmarks: Patellar tendon and
   medial and lateral joint lines


3. Technique: Injections are most easily adminis-
   tered through the lateral joint line recess just lat-
   eral to the patellar tendon. This injection can be
   accomplished in the seated position or in the
   supine position with the knee flexed to approxi-
   mately 90°. The portal for injection should be
   identified as lateral and inferior to the patellar
   tendon border at the level of the joint line. The
   needle is directed toward the center of the knee,
   medially, posteriorly, and slightly cephalad. Depth
   of insertion is approximately 1 in. One should be
   careful to insure needle clearance of the fat pad,
   and avoid injecting the anterior cruciate ligament;
   there should be a free flow to the injection, with
   any resistance prompting needle repositioning. An
   alternative injection technique is to inject the
   patient in the supine position in the suprapatellar
   space. This space is most commonly reached by
   identifying a portal one fingerbreadth superior and
   one fingerbreadth lateral to the superolateral
   aspect of the patella.


4. Needle size and dosage: A 22–25-gauge, 1^1 / 2 -in.
   needle is recommended; 1 mL of corticosteroid
   should be mixed with 2 to 3 mL of anesthetic.

• Illiotibial band syndrome

1. Indications: Recalcitrant illiotibial band friction
   syndrome


2. Clinical anatomy/Landmarks: The key landmark is
   the lateral femoral epicondyle, which is the site of
   repetitive irritation. The bursa lies deep to the illi-
   otibial band just above the lateral condyle of the
   femur.


3. Technique: The injection may be performed in a
   seated position or in a lateral decubitus position.
   The knee should be flexed to 90°, and the maximal
   point of tenderness identified; the intent is to inject
   between the epicondyle and the illiotibial band. The
   skin is entered to the point of maximal tenderness

and angled posteriorly and slightly medially. The

needle is inserted to a depth of^1 / 4 - to^3 / 8 -in. just

above the periosteum. If bone is contacted, with-

draw the needle very slightly, aspirate, and then

inject. Additionally it is important not to inject the

iliotibial(IT) band itself; if resistance is felt with

injection, withdraw, redirect the needle, aspirate,

and inject.

4. Needle size and dosage: A 25- to 27-gauge, 1-in.
   needle is recommended; 0.5 mL of corticosteroid
   with 0.5- to 1-mL of anesthetic.

• Pes anserine bursitis

1. Indications: Pes anserine bursitis


2. Clinical anatomy/Landmarks: Medial aspect of the
   proximal tibia, where the sartorious, gracilis, and
   semitendinosus insert. The Pes is identified by
   making the patient strongly flex the knee against
   resistance. The bursa is found as an area of tender-
   ness deep to the insertion.


3. Technique: This injection can be administered in
   the supine or seated position; I prefer the seated
   position. The objective of the injection is to slip
   the needle between the tibia and the pes tendons.
   The skin should be entered just lateral to the point
   of maximal tenderness, with the needle angled
   posteriorly and medially. Depth of insertion is
   approximately^1 / 4 in. If resistance is felt with the
   injection, withdraw, redirect the needle, aspirate,
   and inject.


4. Needle size and dosage: A 25-gauge needle, 1-in.
   long is recommended; 0.5 mL of corticosteroid with
   0.5 to 1 mL of anesthetic.

• Ankle joint

1. Indications: Diagnostic injection for synovitis;
   chronic capsulitis. Can be used to treat soft tissue
   impingement.


2. Clinical anatomy/Landmarks: There is a readily
   identifiable hollow between the medial malleolus,
   and the articulation between the tibia and the talus.
   This area is readily located just medial to the ante-
   rior tibial tendon.


3. Technique: The patient may be seated or lying
   supine with a towel beneath the knee. Distraction
   of the ankle can be accomplished by an assistant.
   The skin is entered just medial to the anterior tibial
   tendon in the anteromedial recess; depth of inser-
   tion is approximately^1 / 2 to 1 in.


4. Needle size and dosage: A 25-gauge needle, 1- to
   11 / 2 -in. long may be used; 0.5 mL of corticosteroid
   may be injected with 3 to 5 mL of anesthetic.

• Plantar fascia

1. Indications: Recalcitrant plantar fasciitis
   2.Clinical anatomy/Landmarks: Key landmarks
   include the medial calcaneal tubercle and the

432 SECTION 5 • PRINCIPLES OF REHABILITATION