Genicular Nerves Block

Anatomy
The innervation of the capsule of the knee joint can be simplified by dividing it into an anterior
and a posterior group of nerves.

The anterior group originates from branches of (1) the femoral nerve, through its muscular
branches to the vastus medialis, vastus lateralis, and vastus intermedius, and the saphenous nerve,
and (2) the common peroneal nerve through its recurrent and lateral retinacular branches. In really,
all these genicular nerves anastomose with each other and with the posterior group of genicular
nerves to innervate the entire knee joint capsule.
The posteror group of nerves originate from the sciatic nerve, mainly through the articular
branches of its tibial branch, and in variable number of cases through the articular branches from
the posterior branc of the obturator nerve. All these articular branches from a plexus, the posterior
genicular plexus, closely related to the popliteal vessels.

Figure showing the anterior group of genicular nerves of the knee. The genicular nerves are labelled in
blue.
Figure showing the group of genicular nerves that form the posterior genicular nerve plexus and innervate
the posterior joint knee capsule.

Ultrasonography Techniques
A high-resolution linear transducer, 8-13 Mhz or higher, is commonly used. The genicular nerves
are usually very small and can be difficult to clearly define using ultrasound. The most important
preparation is to know the urface landmarks of the genicular nerves and their course. Tracing the
genicular arteries that accompay the genicular nerves using power Doppler can be very useful
technique to identify these small nerves. Since some of the genicular nerves are surfacing from a
deeper layers in their course, slight tilting of the probe to minimize anisotropy can improve
visualization of the genicular nerve.
Also some of the genicular nerves pass through intramuscular or intermuscular septum or fascia,
they will be “shadowed” by edge artifacts, and therefore toeing the probe to change the direction
of the “shadows” can help to locate the nerves. Finally the “zoom” function of the ultrasound
machines can also help in localizing these genicular nerves. With recent advances in the ultrasound
technology and resolution of the ultrasound machines, the newer high-resolution machines can
help in visualizations of these small genicular nerves.
Surface anatomical landmarks to locate the genicular nerves on the anterior and medial aspect of the knee.
The superomedial genicular nerve supplies the joint capsule between the anterior border of the adductor
magnus tendon and the medial border of the patella.

Figure showing the position of the ultrasound transducer for a longitudinal scan of the superomedial
genicular nerve (SMGN). Once can aso perform a short axis linear slide from just anterior to the adductor
tubercle to the medial border of the patella. (B) Sonoanatomy of the SMGN in the long-axis with the
probe anterior to the adductor tubercle. (C) Simulated path of the block needle (highlighted using yellow
dotted lines) during an in-plane needle insertion technique. SMGN & Art: superomedial genicular nerve
and artery.
(A) Figure showing the ultrasound probe aligned in the short-axis of the SMGN. Note the ultrasound
probe is being tilted to try and insonate the ultrasound beam at right angles to the SMGN and better
visualize the nerve. (B) Sonoanatomy of the structure in the short-axis just proximal to the adductor
tubercle. (C) Simulated path of the block needle (highlighted using yellow dotted lines) during an
ultrasound guided SMGN injection. SMGN & Art: superomedial genicular nerve and artery.

(A) Figure showing the position of the ultrasound trasnducer and needle during and ultrasound guided
superomedial genicular nerve (SMGN) injection. Note the ultrasound transducer is aligned in the
long-axis of the SMGN and the block needle is inserted in-plane. (B) Sonoanatomy of the structures
in the long-axis just proximal and anterior to the adductor tubercle. (C) In-plane needle insertion with
the trajectory of needle insertion highlighted using yellow dotted lines. SMGN & Art: superomedial
genicular nerve and artery. A video showing the injection technique can be viewed at the following
link https://youtu.be/au1u16tKDnc.
 (A) Figure showing the position of the ultrasound transducer and needle during and ultrasound guided
superomedial genicular nerve (SMGN) injection. Note the transducer is aligned in the short axis of
the SMGN with the needle in-plane. (B) Sonoanatomy of the structure in short-axis just proximal to
the adductor tubercle. (C) In-plane needle insertion with the trajectory of the block needle
highlighted using yellow dotted lines. SMGN & Art: superomedial genicular nerve and artery. A
video showing the injection technique can be viewed at the following link
https://youtu.be/GKFXVvrXp-s.

Surface anatomical landmarks to locate the genicular nerves on the anterior and lateral aspect of the knee.
The superolateral genicular nerve supplies the superolateral joint capsule and structures lateral to the
inervation of the vastus lateralis and beneath iliotibial band.
(A) Figure showing the ultrasound transducer aligned transverse to the femur at the junction of the lateral
epicondyle and the shaft of the femur to image the superolateral genicular nerve (SLGN). (B)
Sonoanatomy showing the transverse view of the SLGN. It runs lateral to the vastus lateralis tendon,
deep to the iliotibial band (ITB) and very close to the superolateral genicular artery. (C) Simulated
path of the block needle (highlighted using yellow dotted line) during an ultrasound guided SLGN
injection. VL, vastus lateralis, SLGN & Art, superolateral genicular nerve and artery.

(A) Figure showing the ultrasound transducer aligned trenasverse to the femur at the level of the
myotendinous junction of the vastus lateralis. (B) Sonoanatomy showing the transverse view of the
SLGN at the level of the myotendinous junction of the vastus lateralis muscle. It runs lateral to the
vastus lateralis tendon and deep to the iliotibial band. The superolateralgenicular artery is just about
to wrap around the femur from a posterior to anterior direction. VL, vastus lateralis, SLGN & Art,
superolateral genicular nerve and artery, ITB, iliotibial band. (C) Simulated path of the block needle
(highlighted using yellow dotted lines) during in-plane needle insertion technique.
 (A) Figure showing the ultrasound transducer aligned oblique to the femur and longitudinal to the
superolateral genicular nerve (SLGN) and superolateral genicular artery. (B) Sonoanatomy showing
the long-axis view of the SLGN and superolateral genicular artery. The superolateral joint recess and
synovial membrane can also be seen. (C) Superolateral genicular artery Doppler signal. SM, synovial
membrane, SLGN & Art, superolateral genicular nerve and artery.

(A) Figure showing the position of the ultrasound trasnducer and needle during an ultrasound guided
superolateral genicular nerve (SLGN) injection. Note the transducer is aligned transverse to the
SLGN and the femur, and at the level of the junction of the lateral epicondyle and the shaft the
femur. (B) Sonoanatomy of the SLGN in the short-axis, at the level of the junction of the lateral
epicondyle and the shaft of the femur. (C) Simulated path of the block needle (highlighted using
yellow dotted lines) during the in-plane needle insertion technique. SLGN & Art, superolateral
genicular nerve artery, VL, vastus lateralis, ITB, iliotibial band.
(A) Figure showing the position of the ultrasound transducer and needle during an ultrasound guided
superolateral genicular nerve (SLGN) injection. Note the ultrasound transducer is aligned in the
short-axis of the SLGN and the femur, at hte level of the myotendinous junction of the vastus
lateralis muscle, and the block needle is being inserted in-plane. It is believed the SLGN has not
branched at this level. (B) Sonoanatomy of the SLGN in the short-axis, at the level of the
myotendinous junction of the vastus lateralis muscle. (C) The simulated path of the block needle
(highlighted using yellow dotted lines) during the in-plane needle insertion technique. SLGN & Art,
superolateral genicular nerve and artery, VL, vastus lateralis, ITB, iliotibial band.

(A) Figure showing the position of the ultrasound transducer and needle during an ultrasound guided
superolateral genicular nerve (SLGN) injection. Note the ultrasound transducer is aligned oblique to
the femur and at the superolateral joint recess. The block needle is being inserted in-plane. (B)
Longitudinal view of the sonoanatomy of the SLGN and superolateral genicular artery. The
superolateral joint recess and synovial membrane can also be clearly seen. (C) The simulated path of
the block needle (highlighted using yellow dotted lines) during the in-plane needle insertion
technique. SM, synovial membrane, SLGN & Art, superolateral genicular nerve and artery.
 Surface anatomical landmarks to locate the genicular nerves on the anterior aspect of the knee. The
middle genicular nerve (MGN) can be found in the superior most end of the suprapatellar fossa, as it is
the terminal branch of the motor nerve to the vastus intermedius. The MGN anastomoses with the
superolateral genicular nerve and the superomedial genicular nerve to supply the anterior and superior
joint capsule.

(A) Figure showing the position of the ultrasound transducer for a longitudinal scan of the middle
genicular nerve (MGN). Note the ultrasound transducer is aligned in the long-axis of the femur and
the quadriceps tendon. (B) Sonoanatomy of the middle genicular nerve. The MGN is usually located
underneath the rectus femoris tendon, at the most superior end of the suprapatellar bursa. It is also
accompanied by the middle superior genicular artery. Quad, quadriceps, MGN, middle genicular
nerve.
 (A) Figure showing the position of the ultrasound transducer for a transverse scan of the middle
genicular nerve (MGN). Note the ultrasound transducer is aligned transverse to the femur at the
superior most end of the suprapatellar bursa. (B) The MGN is visualized between the fascia of the
vastus intermedius, rectus femoris and the suprapatellar bursa; and also between the vastus medialis
and lateralis muscles. MGN, middle genicular nerve.

(A) Extended field of view of a suprapatellar effusion at the superior most end of a long axis view. The
swollen middle genicular nerves are highlighted by open yellow arrows. They are located between the
fascia of the vastus intermedius, articularis genius, rectus femoris and the suprapatellar bursa. (B)
Dual long axis view of the most superior end of a suprapatellar effusion. The swollen middle
genicular nerves are indicated by open yellow arrows. MGN, middle genicular nerve.
(A) Figure showing the position of the ultrasound transducer and needle during an ultrasound guided
middle genicular nerve injection. Note the transducer is aligned transverse to the femur and the needle
is inserted in-plane from a lateral to medial direction. (B) Transverse sonoanatomy of the middle
genicular nerve. (C) The simulated path of the block needle (highlighted using yellow dotted lines)
during the in-plane needle insertion technique. The needle tip is placed between the fascia of the
vastus intermedius and rectus femoris muscle. MGN, middle genicular nerve.

(A) Figure showing the position of the ultrasound transducer during an ultrasound scan for the
inferolateral genicular nerve (ILGN). The ultrasound transducer is aligned longitudinal, slightly
oblique to tibia, and anterior to the neck of the fibula just lateral to the Gerdy’s tubercle. (B)
Sonographic view of the long-axis of the ILGN, which accompanies the anastomosing branch from
the anterior tibial artery. (C) Power Doppler ultrasound demonstrating the anostomotic branch from
the anterior tibial artery. The simulated path of the block needle (highlighted using yellow dotted
lines) during the out-of-plane needle insertion technique.
(A) Figure showing the position of the ultrasound transducer during a transverse scan for the inferolateral
genicular nerve (ILGN). Note the transducer is aligned transverse to the tibial condyle so that it is in
short axis to the ILGN and the anastomosing artery. (B) Sonoanatomy of the ILGN at the level of the
tibial condyle. (C) The simulated path of the block needle (highlighted using yellow dotted lines)
during the in-plane needle insertion technique.

(A) Figure showing the position of the ultrasound transducer and needle during in-plane ultrasound
guided inferolateral genicular nerve (ILGN) injection. Note the ultrasound transducer is aligned
transverse to the tibial condyle and the block needle is inserted in-plane. (B) Sonographic view
showing the ILGN and the anastomosing branch from the anterior tibial artery that accompanies the
ILGN. (C) The simulated path of the block needle (highlighted using yellow dotted lines) during in-
plane needle insertion technique. ILGN, inferolateral genicular nerve, Art, artery.
(A) Figure showing the position of the ultrasound transducer and needle during an out-of-plane ultrasound
guided inferolateral genicular nerve (ILGN) injection. Note the ultrasound transducer is aligned
longitudinally, from the anterior edge of the neck of fibula to the lateral edge of the Gerdy’s tubercle,
and the block needle is inserted out-of-plane. (B) Sonoanatomy of the ILGN injection. (C) The
simulated path of the block needle (highlighted uding yellow dotted lines) during out-of-plane needle
insertion technique.

(B) Figure showing the position of the ultrasound transducer during a ultrasound scan for the
inferomedial genicular nerve (IMGN) in the short-axis. Note the ultrasound transducer is aligned in
the long-axis of the tibia but in the short axis of the IMGN and inferomedial genicular artery. (B)
Sonoanatomy of the IMGN with the probe aligned in the long-axis to the medial collateral ligament.
The IMGN passes deep to the medial collateral ligament accompanied by the inferomedial genicular
artery. IMGN & Art, inferomedial genicular nerve and artery, Lig, ligament. (C) The simulated path
of the block needle (highlighted uding yellow dotted lines) during out-of-plane needle insertion
technique.