Lower extremity nerve blocks: Techniques

Authors:
Christina L Jeng, MD
Meg A Rosenblatt, MD
Section Editor:
Lisa Warren, MD
Deputy Editor:
Marianna Crowley, MD

Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2017. | This topic last updated: Feb 21, 2017.

INTRODUCTION — Peripheral nerve blocks of the lower extremity are used for operative anesthesia and/or postoperative
analgesia for a variety of lower extremity surgeries.

This topic will discuss the innervation of the lower extremity, techniques and drugs used for lower extremity nerve blocks, and
complications specific to these blocks. Where appropriate, the use of perineural catheters for continuous nerve block will be
discussed. Indications, contraindications, comparison of techniques relevant to all peripheral nerve blocks, equipment, and
complications common to all nerve blocks are discussed separately. (See "Overview of peripheral nerve blocks".)

INNERVATION: LOWER EXTREMITY — The lumbar plexus is formed by the anterior divisions of the first three lumbar nerves (L1,
L2, L3) and part of the fourth lumbar nerve (L4). A branch from the 12th thoracic spinal nerve (T12) often joins the L1 nerve root
(figure 1).

The lumbar plexus is located in the posterior third of the psoas muscle, anterior to the lumbar transverse processes. It gives rise to
nerves that supply the muscular and cutaneous innervation to the lower extremity, including the iliohypogastric nerve, ilioinguinal
nerve, genitofemoral nerve, femoral nerve, lateral femoral cutaneous nerve, and obturator nerve (figure 2).

The femoral nerve (L2 to L4) runs through the psoas muscle and emerges at the lower border between the psoas and iliacus
muscles, beneath the inguinal ligament lateral to the common femoral artery. The femoral nerve provides motor branches to thigh
extensors and sensation to the anterior thigh, femur, knee joint, and medial leg (figure 3 and figure 4). The saphenous nerve is the
terminal sensory branch of the femoral nerve.

The lateral femoral cutaneous nerve (also called the lateral cutaneous nerve of the thigh) (L2 and L3) emerges from the lateral
border of the psoas major muscle, crosses the iliacus, and ultimately runs behind or through the inguinal ligament and in front of or
through the sartorius muscle into the thigh. The lateral femoral cutaneous nerve provides sensory innervation of the lateral thigh
(figure 2 and figure 1 and figure 3).

The obturator nerve originates from the anterior divisions of the L2 to L4 nerve roots. It runs along the medial border of the psoas
major muscle, passes through the obturator foramen, enters the medial thigh, and divides into anterior and posterior branches. The
anterior branch is located between the adductor longus and brevis muscles, and the posterior branch is located between the
adductor brevis and magnus muscles. The articular branch, which innervates a small area of the medial aspect of the knee, is
derived from the posterior branch of the obturator nerve (figure 2 and figure 1 and figure 3).

The sciatic nerve is the largest nerve in the body; it is derived from L4 through S3 and runs posteriorly down the thigh, continuing
below the knee after dividing into the tibial and peroneal (common fibular) nerves. It supplies the thigh flexor muscles, the motor
function of the lower leg, and most of the sensory function of the lower extremity below the knee (figure 2 and figure 3).

Sensory innervation of the posterior thigh is provided by the posterior femoral cutaneous nerve (also called the posterior cutaneous
nerve of the thigh), which is a branch of the sacral plexus (S1 to S3). It arises from the sacral nerve roots and runs through the
greater sciatic foramen beneath the pyriformis muscle along with the sciatic nerve.

Sensory innervation of the foot includes one branch of the femoral nerve (ie, the saphenous nerve) and four branches of the sciatic
nerve (ie, the superficial and deep peroneal, posterior tibial, and sural nerves). The superficial and deep peroneal (fibular) nerves
are branches of the peroneal (common fibular) nerve. The posterior tibial and sural nerves are branches of the tibial nerve (figure
2 and figure 5).

LUMBAR PLEXUS (PSOAS COMPARTMENT) BLOCK — A lumbar plexus block, also known as the psoas compartment block, is
an advanced-level block and should only be performed by an experienced clinician. The psoas compartment block is usually used
as a supplement to general anesthesia for lower extremity surgery and for management of postoperative pain. It may also be used
as a primary regional anesthetic to avoid the sympathectomy and bilateral lower extremity block that would result from neuraxial
anesthesia [1]. If anesthesia of the lower leg or posterior thigh is required for the procedure, the sacral nerve roots must be blocked
separately, typically with a sciatic nerve block [2]. (See 'Sciatic nerve block' below.)

Positioning — The patient is placed in the lateral decubitus position, operative side up, with the leg flexed at the hip and knee. The
iliac crests and the spinous processes of the lumbar spine are palpated and identified (figure 6).

Ultrasound-guided lumbar plexus block — This technique uses ultrasound to identify the transverse process and psoas muscle
and to determine the depth of needle insertion [3]. The curved, low-frequency ultrasound transducer is placed longitudinally adjacent
to the spine at the second to third lumbar (L2 to L3) level (picture 1) to image the vertebral transverse processes (image 1). Injection
can be performed in this orientation. Alternatively, the transducer may be turned 90 degrees (picture 2) to obtain a transverse view
of the psoas major muscle, which should appear lateral to the vertebral body and deep to the quadratus lumborum and erector
spinae muscles.

The lumbar plexus lies deep within the posterior one-third of the psoas major muscle, though it is not usually visualized directly with
ultrasound. The peritoneum can also be visualized and used as a landmark to avoid bowel puncture.

The needle is inserted at the cephalad edge (medial edge in transverse orientation) of the ultrasound probe using an in-plane
technique (picture 3). The full length of the needle should be seen as it approaches the target structure, which is the posterior
third of the psoas major muscle. After negative aspiration, local anesthetic (LA) is injected in 5-mL increments, with gentle
aspiration between injections. Because the psoas compartment is a large, loosely compacted space, a large volume of LA
(eg, up to 0.5 mL/kg) is required. Spread of LA within the muscle should be observed.

Nerve stimulator-guided lumbar plexus block — There are two methods for psoas compartment block using a nerve stimulator
(figure 6):

●A line is drawn from the iliac crest to the spinous process of the fourth lumbar vertebra (figure 6). An insulated needle is
inserted on that line, 4 cm lateral to the midline.
Or
●A line (line 1 in the figure) is drawn between the two iliac crests (figure 6). A second line (line 2) is drawn, connecting the
lumbar spinous processes. A third line (line 3) is drawn through the posterior superior iliac spine (PSIS) parallel to the second
line. A final line (line 4) is drawn perpendicular to lines 2 and 3 at the level of L4 and divided into thirds. The needle is inserted
1 cm cephalad to line 4, at the junction of the lateral and middle thirds of line 4.

When using either method, the insulated needle is inserted perpendicular to the skin and advanced until quadriceps muscle
stimulation is elicited or bony contact occurs. If bone (presumably the L4 transverse process) is encountered, the needle is
withdrawn and directed caudad. The needle is then "walked off" the bone until quadriceps stimulation is obtained with current
between 0.5 and 1 mA, although higher current levels can be used. Intraneural injection in this region can result in intrathecal
injection (ie, spinal anesthesia). After negative aspiration for blood or cerebrospinal fluid (CSF), 20 to 30 mL of LA is injected in 5-mL
increments, with gentle aspiration between injections.

Perineural catheter lumbar plexus block — Indwelling perineural catheters may be placed for continuous psoas compartment
block for prolonged postoperative analgesia after hip, femur, or knee surgery. The technique for placing catheters is the same as for
single-shot injections, using ultrasound guidance or nerve stimulation. An 18- or 19-gauge Tuohy needle is used rather than a block
needle, with the bevel oriented laterally to direct the catheter toward the plexus. A 20- or 19-gauge single- or multi-orifice epidural
catheter is threaded just far enough to allow the orifice (or orifices) to emerge beyond the needle tip. If resistance is encountered or
pain occurs, the needle position should be reassessed.

Some anesthesiologists prefer to perform the nerve block via the catheter instead of via the needle in order to confirm proper
placement of the catheter tip. This is particularly important when a nerve stimulator technique is used. When ultrasound guidance is
used, after removal of the needle, the location of the catheter can be confirmed by visualization of the catheter and spread of LA.
We inject several mL of LA through the needle under ultrasound guidance to confirm placement and inject the rest of the bolus
through the catheter while visualizing spread of LA.

The catheter is secured to the skin with a sterile dressing after applying a sterile surgical glue.

Continuous infusion of LA is administered at 5 to 12 mL/hour postoperatively. Our practice is as follows:

●For ambulatory patients, a continuous infusion of 0.2% ropivacaine is used, and the patient receives a comprehensive
instruction sheet that includes the signs and symptoms of LA toxicity, pump maintenance information, and the acute pain
service phone number prior to discharge.
●For inpatients, 0.1% bupivacaine is administered.

Side effects and complications — Because of the deep nature of this block, this is an advanced-level block that should only be
performed by experienced clinicians. The incidence of complications of psoas compartment block is low overall, but is higher than
with other peripheral nerve blocks [2]. The most common complication is epidural extension, leading to bilateral block. Other
complications include total spinal anesthesia, renal injury, and retroperitoneal hematoma; extensive retroperitoneal hematoma has
been reported after lumbar plexus block [4,5].

In contrast with many other peripheral nerve blocks, the American Society of Regional Anesthesia and Pain Medicine (ASRA)
recommends that anticoagulation guidelines for neuraxial blocks be followed when performing lumbar plexus block [6].
(See "Neuraxial (spinal, epidural) anesthesia in the patient receiving anticoagulant or antiplatelet medication".)

FEMORAL NERVE (3-IN-1) BLOCK — Femoral nerve block is used to provide anesthesia or postoperative analgesia for surgery of
the anterior thigh and knee (eg, anterior cruciate ligament repair, patella surgery, quadriceps tendon repair). Traditionally, this block
was also referred to as the "3-in-1" block, encompassing the femoral, lateral femoral cutaneous, and obturator nerves. This concept
was based on the purported existence of a suprainguinal fluid compartment between the femoral nerve sheath and the lumbar
plexus, capable of spreading local anesthetic (LA) proximally with a femoral injection. However, a human cadaver study has shown
that a fluid compartment between the femoral nerve sheath and the lumbar plexus does not exist [7], and several studies have
shown that a femoral block does not reliably block the obturator nerve, the lateral femoral cutaneous nerve, or the lumbar plexus [8-
11]. Since only the femoral nerve is reliably blocked by this technique, we usually now refer to it as the femoral nerve block.

Positioning — The patient is placed in the supine position.

Ultrasound-guided femoral block — The ultrasound transducer is placed in the inguinal crease (picture 4) to locate the
hyperechoic femoral nerve, which can be visualized lateral to the hypoechoic pulsatile common femoral artery (image 2). An in-
plane or out-of-plane approach can be used (picture 3). The needle is inserted and the tip placed adjacent to the nerve. After
negative aspiration, 20 to 40 mL of LA is injected in 5-mL increments, with gentle aspiration between injections. LA should be seen
spreading circumferentially around the nerve.

Nerve stimulator-guided femoral block — The common femoral artery and inguinal ligaments are palpated in the groin. The
insulated needle is inserted just below the inguinal ligament and 1.5 cm lateral to the artery (figure 7).

Stimulation of the femoral nerve produces twitches of the quadriceps muscle (ie, the "patellar snap"). Optimal needle position is
achieved when twitches persist at an output of 0.3 to 0.4 mA. After negative aspiration, 20 to 30 mL of LA is injected in 5-mL
increments, with gentle aspiration between injections.

Perineural catheter femoral block — Perineural catheters can be placed for continuous femoral nerve block to provide analgesia
after knee surgery, and are commonly placed after knee replacement. The technique for placing catheters is the same as for single-
shot injections, using ultrasound guidance or nerve stimulation. (See 'Perineural catheter lumbar plexus block' above.)

Side effects and complications — Because of the risk of quadriceps weakness after femoral nerve block, prolonged postoperative
analgesia for many ambulatory surgeries is now often accomplished with adductor canal blocks.

Continuous femoral perineural catheters may be associated with a higher risk of infection than other peripheral nerve blocks.
Bacterial colonization rates between 13 and 57 percent have been reported, though rates of local infection are much lower, between
0.05 and 3 percent [12-14]. Risk factors for local inflammation and signs of infection with catheter blocks include duration of catheter
use >48 hours, the femoral or axillary location, a stay in an intensive care unit (ICU), and frequent dressing changes.
When femoral or other perineural catheters are in place, the insertion site should be examined daily and the catheter removed if the
patient develops an unexplained fever or signs of local infection.

FASCIA ILIACA (LATERAL FEMORAL CUTANEOUS) BLOCK — The fascia iliaca block is an alternative to the femoral nerve
block and may more reliably block the lateral femoral cutaneous nerve than the femoral block (figure 1). It blocks the sensory
innervation of the lateral thigh. This block does not depend on deposition of local anesthetic (LA) near an individual nerve; instead, it
works by spread of the LA in a fascial plane. Therefore, this block is not performed with nerve stimulation. It can be done using
ultrasound guidance or with an anatomic approach.

Positioning — The patient is placed in the supine position.

Ultrasound-guided fascial iliaca block — A line is drawn between the anterior superior iliac spine (ASIS) and pubic tubercle and
divided into thirds (figure 8). An ultrasound probe is placed transversely to the leg at the junction between the middle and lateral
thirds (picture 5) to identify the fascia lata, iliacus muscle, and fascia iliaca (image 3). The needle is introduced in-plane (picture 3)
inferior to the inguinal ligament and guided beneath the fascia iliaca, and after negative aspiration, 30 mL of LA is injected in 5-mL
increments, with gentle aspiration between injections. Spread of LA in medial and lateral directions under the fascia iliaca is
evidence of correct needle placement.

A suprainguinal approach has also been described [15]. The technique is the same as above but is performed cephalad to the
inguinal ligament instead.

Landmark-based fascia iliaca block — An alternative approach to this block relies upon superficial anatomy and loss of resistance
with the block needle. The line between the ASIS and pubic tubercle is drawn and trisected. At the border between the lateral and
middle thirds, a perpendicular line 2 cm in length is drawn caudally. A blunt needle is inserted and directed cephalad at a 45-degree
angle. Two distinct "pops" should be felt as the needle passes through the fascia lata, and then the fascia iliaca. After negative
aspiration, 30 mL of LA is injected in 5-mL increments, with gentle aspiration between injections.

Ultrasound guidance has been shown to more successfully achieve femoral and obturator motor block and sensory block of the
medial thigh than an anatomic, loss-of-resistance technique [16]. There may be more than two fascial planes in the inguinal area
[16,17]. Therefore, the two "pops" felt using the loss-of-resistance technique do not reliably correlate with the fascia lata and fascia
iliaca; LA may thus be placed incorrectly using this technique.

Perineural catheter fascia iliaca block — Continuous infusion fascia iliaca block can be used as part of a multimodal pain control
protocol after hip fracture. The technique for placing catheters is the same as for single-shot injections, using ultrasound guidance or
an anatomic approach. Continuous infusion of 0.1% bupivacaine is administered at 8 to 10 mL/hour. (See 'Perineural catheter
lumbar plexus block' above.)

OBTURATOR NERVE BLOCK — This block provides anesthesia of the medial distal thigh and can be used in combination with
femoral, lateral femoral cutaneous, and sciatic blocks for procedures on the distal thigh and lower leg, and to prevent tourniquet pain
during lower leg surgery (figure 3).

The obturator nerve is occasionally blocked to prevent stimulation of the adductor muscles of the hip, which may lead to
complications during transurethral resection of lateral bladder wall lesions. The obturator nerve runs close to the lateral bladder wall,
where direct stimulation with the resectoscope can result in adductor spasm, which can result in bladder perforation and other
anatomic injuries.

Perineural catheter placement is not indicated with this block.

Positioning — The patient is placed in the supine position, with the leg externally rotated.

Ultrasound-guided obturator block — The ultrasound probe is placed in the inguinal crease (picture 6), and the femoral vein is
identified. The probe is moved medially to visualize the pectineus and adductor longus muscles (image 4). The anterior branch of
the obturator nerve is a hyperechoic structure found between the adductor longus (superficial) and brevis muscles. The posterior
branch is a hyperechoic structure found between the adductor brevis (superficial) and magnus muscles. The needle is inserted in-
plane or out-of-plane (picture 3) and is directed to the two intermuscular fascial planes described above. After negative aspiration, 5
to 10 mL of local anesthetic (LA) is injected into each of the intermuscular fascial planes while observing LA surrounding the
hyperechoic nerve structures and distending the planes between the muscles.
Nerve stimulator-guided obturator block — The femoral artery is palpated and the tendon of the adductor muscle is identified at
the pubic tubercle. This tendon is obvious when the leg is externally rotated; it is the only tendon inserting on the pubic tubercle in
the groin and medial thigh. In the inguinal crease, a line is drawn medially from the femoral artery to the adductor tendon. The
insulated needle is inserted at the midpoint of this line, aimed cephalad at a 45-degree angle. The needle is advanced until
stimulation of the adductor muscle is obtained (ie, posteromedial aspect of the thigh). After negative aspiration, 5 to 10 mL of LA is
injected in 5-mL increments, with gentle aspiration between injections.

SCIATIC NERVE BLOCK — The sciatic nerve block provides complete anesthesia of the leg below the knee, with the exception of
a strip of medial skin innervated by the saphenous nerve (figure 3). Combined with femoral or saphenous nerve block, it provides
analgesia for surgery of the distal anterior thigh; anterior knee; and lateral calf, ankle, or foot. The sciatic nerve block can be
performed using either an anterior or a posterior approach, with similar success rates for surgery below the knee [18].

The posterior femoral cutaneous nerve (PFCN) may be blocked along with the sciatic nerve when the sciatic block is performed very
proximally (eg, posterior approach or high anterior approach) [18,19]. PFCN block is required for surgery of the posterior thigh and
knee and may provide analgesia for a thigh tourniquet. However, the need for this block for tourniquet pain is disputed. As an
example, a prospective study of 60 patients who underwent foot surgery evaluated pain relief with continuous popliteal sciatic block,
which does not block the posterior cutaneous nerve. Only one patient required supplemental opioid for tourniquet pain [20].

Positioning — There are three methods for positioning patients for a sciatic nerve block:

●For the posterior approach to sciatic block, we usually position the patient prone and identify the ischial tuberosity.

Or

●For the classic posterior approach of Labat, the patient is placed in the lateral decubitus position with the extremity flexed 45
degrees at the hip and 90 degrees at the knee (Sims' position) (figure 9). The posterior superior iliac spine (PSIS), greater
trochanter, and sacral hiatus are identified and marked.

Or

●The patient can be positioned supine for the anterior approach to sciatic block. The block can be performed with the leg
straight, an advantage for many trauma patients, or with the hip abducted and externally rotated. The supine position can
also be used for the posterior approach, with the hip and knee flexed, aiming the needle between the greater trochanter and
the ischial tuberosity.

Posterior approach — Sciatic block using a posterior approach can be performed using either ultrasound guidance or nerve
stimulation.

Ultrasound-guided sciatic block — For an ultrasound-guided sciatic block, the ultrasound transducer is held transverse to the
course of the nerve (picture 7). The sciatic nerve is found lateral to the ischial tuberosity and deep to the gluteus maximus muscle
and appears hyperechoic, flat, and wide (image 5) [21,22]. The needle is inserted in-plane (picture 3) from the lateral aspect of the
transducer and positioned with the tip of the needle adjacent to the nerve. After negative aspiration, approximately 20 mL of local
anesthetic (LA) is injected in 5-mL increments, with gentle aspiration between injections.

Nerve stimulator-guided sciatic block — Sciatic nerve block using nerve stimulation can be performed in either the lateral
decubitus or prone positions.

●If the Labat, lateral decubitus position is used, anatomic landmarks including the posterior superior iliac spine (PSIS),
greater trochanter, and sacral hiatus are identified and marked (figure 9). A line is drawn between the PSIS and greater
trochanter (line 1 in the figure) and is bisected with a 3- to 5-cm line drawn perpendicularly toward the buttock (line 2). A line
is drawn from the greater trochanter to the sacral hiatus (line 3). The insulated needle is inserted at the intersection of these
last two lines (lines 2 and 3), perpendicular to the skin, until plantar flexion is achieved at 0.5 mA [23]. After negative
aspiration, approximately 20 mL of LA is injected in 5-mL increments, with gentle aspiration between injections.
●If the prone position is used, the needle is inserted lateral to the ischial tuberosity and advanced until plantar flexion is
achieved at 0.5 mA.

Anterior approach — The anterior approach is performed using combined ultrasound guidance and nerve stimulation.
 ●A curvilinear (2 to 8 MHz) ultrasound transducer is placed over the anteromedial thigh, 2 to 3 cm caudad to the inguinal
ligament. The femoral artery, and the profunda femoris artery deep to it, should be identified and avoided. The sciatic nerve is
visualized as a hyperechoic (ie, white), flattened oval structure between the adductor magnus and hamstring muscles, medial
to the femur, usually at a depth of 6 to 8 cm.
●A 100-mm, 21- or 22-gauge insulated needle is inserted in-plane (picture 3) in a medial-to-lateral direction and advanced
toward the sciatic nerve. A motor response in the calf or foot should be elicited at 0.5 mA with the nerve stimulator.
●After negative aspiration, 1 to 2 mL of LA is injected, visualizing spread around the sciatic nerve. If inadequate spread
occurs, the needle should be repositioned. Fifteen to 20 mL of LA is injected in 5-mL increments, with gentle aspiration
between injections.

Perineural catheter sciatic block — Indwelling perineural catheters may be placed for continuous sciatic nerve block for prolonged
postoperative analgesia after knee, ankle, or foot surgery. The technique for placing catheters is the same as for single-shot
injections, using ultrasound guidance or nerve stimulation. (See 'Perineural catheter lumbar plexus block' above.)

POPLITEAL BLOCK — The popliteal block anesthetizes the sciatic nerve in the popliteal fossa prior to its division into the tibial and
the common fibular (peroneal) nerves, and can be used for anesthesia and analgesia for posterior knee, lateral ankle, and foot
surgery (figure 2). It can be performed from a posterior (ie, intertendinous) or lateral approach to the nerve. Ultrasound guidance
increases the success of popliteal block and decreases onset time when compared with nerve stimulation techniques [24,25].

Positioning — For popliteal block, the patient is placed in one of three positions, depending on the block technique and patient
mobility, as follows:

●Prone – For either nerve stimulation or posterior approach ultrasound-guided block, the patient may be placed prone, with a
pillow under the foot to slightly flex the knee.
●Lateral decubitus – For ultrasound-guided block, the patient may also be placed in the lateral decubitus position, usually
with the operative side up, with the leg slightly flexed at the knee for a more anatomic position.
●Supine – For lateral approach ultrasound-guided block, the patient is positioned supine, with the leg and foot supported on
blankets, the hip flexed at about 45 degrees, and the leg flexed 90 degrees.

Ultrasound-guided popliteal block — Under ultrasound guidance, a popliteal block can be performed from either the posterior
(patient prone or lateral) or lateral (patient supine) needle approach.

●Posterior approach – The biceps femoris and semitendinosus/semimembranosus tendons are palpated (figure 10). The
ultrasound probe is placed transverse to the thigh and nerves in the popliteal crease (picture 8). The hyperechoic sciatic
nerve is located at the midpoint between the biceps femoris and semitendinosus/semimembranosus tendons (image 6). The
popliteal artery is an excellent landmark; the tibial nerve can be found superficial and lateral to the popliteal artery. The nerve
can be followed cephalad with the ultrasound probe to the point where the common fibular nerve joins the tibial nerve from
the lateral side to form the sciatic nerve (figure 2 and image 7). The sciatic nerve is blocked proximal to this point to ensure
that both the common fibular and tibial nerves are anesthetized. The needle may be inserted in-plane or out-of-plane until just
outside the sciatic nerve (picture 3). After negative aspiration, 20 to 30 mL of local anesthetic (LA) is injected in 5-mL
increments, with gentle aspiration between injections. Circumferential spread of LA around the entire sciatic nerve should be
visualized. Ultrasound imaging has demonstrated a paraneural sheath surrounding the popliteal sciatic nerve that acts as a
conduit for LA spread [26].
●Lateral approach – For the lateral approach, the ultrasound transducer is positioned between the tendons of the biceps
femoris and vastus lateralis muscles (figure 11 and picture 9). An 80- to 100-mm needle is inserted parallel to the probe, in-
plane, in the lateral thigh and directed towards the hyperechoic nerve before it divides. After negative aspiration, 20 to 30 mL
of LA is injected in 5-mL increments, with gentle aspiration between injections.

Nerve stimulator-guided popliteal block — With the patient in the prone position, the tendons of the biceps femoris (lateral) and
the semitendinosus/semimembranosus (medial) muscles are identified. The insulated needle is placed at the midpoint between
these tendons, approximately 7 cm above the popliteal crease (figure 10). When either
plantar flexion/inversion or dorsiflexion/eversion of the foot is elicited, the stimulating intensity is reduced until twitch is maintained at
0.4 mA. If no response is initially achieved, the needle is moved laterally. After negative aspiration, 30 mL of LA is injected in 5-mL
increments, with gentle aspiration between injections.
Perineural catheter popliteal block — Perineural catheters can be placed using either a posterior or lateral approach. The
technique for placing catheters is the same as for single-shot injections, using ultrasound guidance or nerve stimulation.
(See 'Perineural catheter lumbar plexus block' above.)

SAPHENOUS NERVE AND ADDUCTOR CANAL BLOCKS — The saphenous nerve is the terminal sensory branch of the femoral
nerve. The saphenous nerve block is useful for ambulatory surgeries of the superficial, medial lower leg and provides analgesia of
the medial ankle and foot. It can be blocked at the level of the tibial tuberosity below the knee, or above the knee using the adductor
canal block.

Adductor canal block — The saphenous nerve is blocked at the level of the mid-thigh with the adductor canal block using
ultrasound guidance.

Positioning — The patient is positioned supine, with the leg abducted at the hip and rotated externally.

Ultrasound-guided adductor canal block — The ultrasound probe is placed perpendicular to the thigh at the midpoint between
the anterior superior iliac spine and the distal end of the femur (picture 10). The nerve is identified as it exits from the adductor canal
adjacent to the femoral artery. It is followed distally as it becomes more superficial, traveling with an arterial branch just deep to the
sartorius muscle (image 8) [27]. Using an in-plane approach (picture 3), after negative aspiration, 10 mL of local anesthetic (LA) is
injected deep to the sartorius muscle, at the lateral border of the artery.

Perineural catheter adductor canal block — Perineural catheters can be placed for continuous adductor canal block. The
technique for placing catheters is the same as for single-shot injections, using ultrasound guidance or nerve stimulation.
(See 'Perineural catheter lumbar plexus block' above.)

Saphenous nerve block — The saphenous nerve can be blocked below the knee for surgery of the lower leg and ankle using an
anatomic approach. Perineural catheters are not used for saphenous nerve block below the knee.

●Positioning – The patient is positioned supine, with the leg straight.

●Anatomic approach – Saphenous nerve block can be performed at the level of the tibial tuberosity, which is marked (figure
12). A subcutaneous wheal with 5 to 10 mL of LA is injected posterior to the medial tibial condyle, or, alternatively, LA can be
injected around the saphenous vein if it is easily visualized [28].

Side effects and complications — The degree to which adductor canal blocks preserve the function of the quadriceps muscle, and
therefore the ability to safely ambulate postoperatively, is controversial. A number of studies have reported that these blocks result
in little or no quadriceps weakness, in particular compared with femoral nerve block [29-32]. However, quadriceps paralysis has
been reported after adductor canal block [33]. Therefore, patients should be monitored for motor strength to reduce the risk of fall.

ANKLE BLOCK — The ankle block consists of separate blocks of five nerves: four branches of the sciatic nerve (ie, superficial and
deep peroneal [fibular] nerves, tibial nerve, and sural nerve) and one cutaneous branch of the femoral nerve (saphenous nerve)
(figure 13 and figure 5). The ankle block is used for surgery on the foot and toes and is a purely sensory block (figure 3).

We perform ankle blocks with a landmark-based, anatomic technique. Ultrasound guidance can be used for the deep peroneal,
posterior tibial, and sural nerve blocks. In the experience of some other clinicians, ultrasound-guided ankle block may be more
successful for nondiabetic patients than the use of a landmark-based technique.

Positioning — The patient is positioned supine, with the foot elevated and supported on blankets or pillows, and the ankle is
rotated as necessary for needle placement.

Deep peroneal block — The deep peroneal (fibular) nerve innervates the first webspace of the foot and is blocked with an injection
in the dorsum of the foot at the ankle (figure 13 and figure 5). This block can be performed using anatomic landmarks or with
ultrasound guidance.

●Anatomic approach – For deep peroneal block, the dorsalis pedis artery is palpated between the flexor hallucis longus and
extensor digitorum longus tendons, which are identified by having the patient flex the great toe. The nerve lies just lateral to
the artery. At the mid-tarsal portion of the foot, the needle is inserted just lateral to the artery and advanced until bone is
encountered. As the needle is withdrawn, 2 to 3 mL of local anesthetic (LA) is injected.
●Ultrasound guidance – The ultrasound probe is placed in a transverse orientation on the dorsum of the foot at the level of
the extensor retinaculum. The nerve should appear lateral to the anterior tibial artery, lying on the tibia. The flexor hallucis
 longus tendon adjacent to the neurovascular structures may be mistaken for the nerve. Flexion and extension of the great toe
moves the tendon, thereby differentiating it from the nerve. The needle is inserted in-plane (picture 3); the tip is identified near
the nerve; and after gentle aspiration, 2 to 3 mL of LA is injected.

Superficial peroneal block — The superficial peroneal (fibular) nerve innervates the dorsum of the foot and is blocked by
subcutaneous infiltration of LA (figure 13 and figure 5). The needle is inserted at the injection site for deep peroneal nerve block as
above. A total of 5 to 10 mL of LA is injected subcutaneously over the dorsum of the foot medially and then laterally from the site of
needle insertion to the level of the malleoli.

Tibial block — The distal tibial nerve provides sensation to the calcaneus and plantar surface (sole) of the foot and is blocked at the
level of the medial malleolus (figure 13 and figure 5). This block can be performed using anatomic landmarks or with ultrasound
guidance.

●Anatomic approach – The posterior tibial artery is palpated behind the medial malleolus. The needle is inserted posterior
to the artery, aimed towards the malleolus at a 45-degree angle, and advanced until contact with bone. As the needle is
withdrawn, 2 to 3 mL of LA is injected. An additional 1 to 2 mL of LA is injected using a fan technique, medially and laterally,
to increase the success rate of the block.
●Ultrasound guidance – The ultrasound transducer is placed in a transverse orientation posterior to the medial malleolus,
and the nerve is identified posterior to the posterior tibial artery. The needle is inserted either in-plane or out-of-plane; the tip
is positioned adjacent to the nerve; and after negative aspiration, 3 to 5 mL of LA is injected. Circumferential spread of the LA
around the nerve is predictive of a successful block [34].

Sural nerve block — The sural nerve innervates the lateral ankle and foot, as well as the fifth toe. It runs within the subcutaneous
tissues behind the lateral malleolus (figure 13 and figure 5). Sural nerve block is usually performed using anatomic landmarks but
can be performed with ultrasound guidance.

●Anatomic approach – The nerve is blocked by injecting 2 to 3 mL of LA behind the lateral malleolus as a subcutaneous
wheal.
●Ultrasound guidance – The ultrasound probe is held in a transverse orientation just proximal to the lateral malleolus of the
ankle. The nerve appears as a small, hyperechoic structure next to the lesser saphenous vein. Five mL of LA is injected
around the vein; the LA should be observed spreading completely around the lesser saphenous vein.

Saphenous nerve block — The saphenous nerve innervates the medial aspect of the ankle and foot. It is blocked at the ankle
using anatomic landmarks (figure 13). The needle is inserted medial and superior to the medial malleolus and directed posteriorly
towards the Achilles tendon. After negative aspiration, a wheal of 3 to 5 mL of LA is injected around the great saphenous vein.

DIGITAL NERVE BLOCK (TOE) — Digital nerve block is discussed in detail elsewhere. (See "Digital nerve block".)

DRUG CHOICES — Local anesthetics (LAs) are chosen according to the goal of the block (surgical anesthesia or analgesia) and
the desired duration of the effect of the block (table 1). LAs and adjuvant drugs used for peripheral nerve blocks are discussed
separately. (See "Overview of peripheral nerve blocks", section on 'Drugs'.)

Our choices for LA for lower extremity blocks are as follows:

●Postoperative analgesia – 0.25 to 0.5% bupivacaine or 0.5% ropivacaine

●Surgical anesthesia – 2% lidocaine or 1.5% mepivacaine
●Surgical anesthesia and postoperative analgesia – Equal volumes of a short-acting LA (2% lidocaine or
1.5% mepivacaine) plus a long-acting LA (0.5% bupivacaine or 1% ropivacaine)
●Perineural catheter infusion:
•Inpatient – 0.1% bupivacaine, 5 to 10 mL/hour
•Ambulatory surgery – 0.2% ropivacaine, 5 to 10 mL/hour

SUMMARY AND RECOMMENDATIONS

●Peripheral nerve blocks of the lower extremity can be used for a variety of surgical procedures to provide surgical
anesthesia and/or postoperative analgesia.
●The lumbar plexus block, also known as the psoas compartment block, is a deep, advanced-level block that is usually used
to supplement general anesthesia for lower extremity surgery and for management of postoperative pain. It may also be used
as a primary regional anesthetic to avoid the sympathectomy and bilateral lower extremity block that would result from
neuraxial anesthesia. If anesthesia of the lower leg or posterior thigh is required, the sacral nerve roots must be blocked
separately, typically with a sciatic nerve block. (See 'Lumbar plexus (psoas compartment) block' above.)
●The sciatic nerve block achieves anesthesia of the leg below the knee, with the exception of a strip of medial skin
innervated by the saphenous nerve. Combined with femoral or saphenous nerve block, it provides analgesia for surgery of
the distal thigh, knee, calf, ankle, or foot. It will also provide analgesia when a thigh tourniquet is required, if the posterior
femoral cutaneous nerve is blocked as well. The sciatic nerve block can be performed using ultrasound guidance or nerve
stimulation. (See 'Sciatic nerve block' above.)
●The popliteal nerve block is a sciatic nerve block that is performed in the popliteal fossa. (See 'Popliteal block' above.)
●The femoral nerve block is used to provide anesthesia or postoperative analgesia for surgery on the anterior thigh and knee.
(See 'Femoral nerve (3-in-1) block' above.)
●The fascia iliaca block is an alternative to the femoral nerve block and may more reliably block the lateral femoral cutaneous
nerve to achieve analgesia of the lateral thigh. (See 'Fascia iliaca (lateral femoral cutaneous) block' above.)
●The obturator nerve block provides anesthesia of the medial distal thigh and can be used in combination with femoral,
lateral femoral cutaneous, and sciatic blocks for procedures on the distal thigh and lower leg, as well as to prevent tourniquet
pain during lower leg surgery. This block is occasionally performed to prevent stimulation of the adductor muscles of the hip
in order to avoid complications during transurethral resection of lateral bladder wall lesions. (See 'Obturator nerve
block' above.)
●The saphenous nerve can be blocked at the level of the tibial tuberosity below the knee, or above the knee using the
adductor canal block. The saphenous nerve block is useful for surgeries of the superficial, medial lower leg and provides
analgesia of the medial ankle and foot. (See 'Saphenous nerve and adductor canal blocks' above.)
●The ankle block is a purely sensory block that consists of separate blocks of five nerves: the superficial and deep peroneal
nerves, tibial nerve, sural nerve, and saphenous nerve. It provides anesthesia of the entire foot for procedures on the foot
and toes. (See 'Ankle block' above.)
●We perform blocks above the knee with ultrasound guidance. Nerve stimulation techniques are possible for psoas
compartment, sciatic, femoral, and obturator blocks. Anatomic landmarks can be used for fascia iliaca, saphenous, and ankle
blocks.
●Perineural catheters may be placed for continuous infusion of local anesthetic (LA) for postoperative pain using lumbar
plexus, femoral nerve, fascia iliaca, sciatic nerve, popliteal nerve, and adductor canal blocks. (See 'Perineural catheter
lumbar plexus block' above and 'Perineural catheter femoral block' above and 'Perineural catheter fascia iliaca block' above
and 'Perineural catheter sciatic block' above and 'Perineural catheter popliteal block' above and 'Perineural catheter adductor
canal block' above.)
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