CHRONIC AND INTERVENTIONAL PAIN
ORIGINAL ARTICLE
Anatomical Study of the Innervation of Anterior Knee
Joint Capsule
Implication for Image-Guided Intervention
John Tran, HBSc,* Philip W.H. Peng, MBBS,† Karen Lam, MD,† Ehtesham Baig, MD,†
Anne M.R. Agur, PhD,* and Michael Gofeld, MD†
Background and Objectives: The knee joint is the most common site
of osteoarthritis. While joint replacement is considered an ultimate solu-
tion, radiofrequency denervation may be contemplated in some cases. Ra-
diofrequency ablation requires precise localization of the articular branches
innervating the joint capsule. The objective of this cadaveric study was to
determine the source, course, relationships, and frequency of articular
branches innervating the anterior knee joint capsule.
Methods: Fifteen knees were meticulously dissected. The number and or-
igin of the articular branches were recorded, and their distribution defined
by quadrants. Their relationships to anatomical landmarks were identified.
Results: The articular branches terminated in 1 of the 4 quadrants with
minimal overlap. In all specimens, the superolateral quadrant was inner-
vated by the nerve to vastus lateralis, nerve to vastus intermedius, superior
lateral genicular and common fibular nerves; inferolateral by the inferior
lateral genicular and recurrent fibular nerves; superomedial by the
nerve to vastus medialis, nerve to vastus intermedius and superior medial
genicular nerve; and inferomedial by the inferior medial genicular nerve.
In 3 specimens, the inferomedial quadrant also received innervation from
the infrapatellar branch of saphenous nerve. All articular branches except
the nerves to vastus lateralis and medialis course at the periosteal level.
Conclusions: The frequency map of the articular branches provides an
anatomical basis for the development of new clinical protocols for knee
radiofrequency denervation and perioperative pain management.
(Reg Anesth Pain Med 2018;43: 00–00)
T he prevalence of symptomatic osteoarthritis of the knee in
individuals 45 years or older has been estimated to be 16.7%
in the United States.1 In 2010, the total number of hospital dis-
charges related to knee joint arthroplasties due to osteoarthritis
was 155,000 per quarter.2 Notwithstanding favorable outcomes
of the total knee arthroplasty, up to 44% of patients experience
persistent pain after apparently successful surgery.3
From the *Division of Anatomy, Department of Surgery, and †Department of
Anesthesia, University of Toronto, Toronto, Ontario, Canada.
Accepted for publication January 15, 2018.
Address correspondence to: Philip W.H. Peng, MBBS, Department of
Anesthesia, University of Toronto, 399 Bathurst St, McL 2-405 Toronto,
Ontario, Canada M5T 2S8 (e‐mail: philip.peng@uhn.ca).
The authors declare no conflict of interest.
Funding was provided through Merit Award in Research, Department of
Anesthesia, University of Toronto (to P.W.H.P.) and Physicians' Service
Incorporated Foundation award (to P.W.H.P. and K.L.).
Interim data from this work were presented at the 2017 Annual Meeting of
American Association of Clinical Anatomists in Minneapolis, MN, on
July 17 to 21, 2017; at the 2017 World Academy of Pain Medicine
Ultrasonography Annual Meeting and Workshop in Miami, FL, on
January 13 to 15, 2017; and at the 2017 Study in Multidisciplinary Pain
Research—International Symposium of Ultrasound in Regional Anesthesia
Congress in Florence, Italy, on March 29 to April 1, 2017.
Copyright © 2018 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000778
Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Radiofrequency ablation (RFA) has been used effectively in
the management of chronic pain due to spine and sacroiliac joint
degenerative conditions.4 Choi et al5 published the first random-
ized controlled trial in 2011 of fluoroscopic-guided knee RFA
targeting the genicular nerves. There has been much discussion
about this technique that has resulted in further clinical and
anatomical research.6,7
Even though the previous cadaveric studies have identi-
fied numerous sources of knee joint innervation including the
genicular, common fibular (peroneal), and femoral nerves,8–17
the majority of clinical RFA studies were focused on the
genicular and/or saphenous nerves.18–24 Optimizing the effec-
tiveness of knee denervation relies on the precise localization
of the articular branches innervating the joint capsule. There-
fore, the objectives of this cadaveric study were to (1) elucidate
the innervation of the anterior knee joint; (2) identify bony and
soft tissue landmarks related to the articular branches discernable
by ultrasound and/or fluoroscopy; (3) trace the nerves and esti-
mate how frequently each articular branch is present; (4) document
the distance of each articular branch from the bone surface; and
(5) define the articular branches innervating the superolateral,
inferolateral, superomedial, and inferomedial quadrants of the
knee joint.
METHODS
Fifteen formalin-embalmed cadaveric specimens with a
mean age of 80.5 ± 15.1 years (8 male and 7 female) were used
in this study. Sample size calculation was not possible because
of lack of previous data. Inclusion criteria included no visible
evidence of pathology, previous surgery, or trauma. Approval
was received from the University of Toronto Health Sciences
Research Ethics Board.
The dissection of the specimens was challenging and time
consuming and required meticulous dissection skills. A 3.5
magnification lens was used. The nerves to vastus medialis
(NVM), lateralis (NVL), and intermedius (NVI); saphenous nerve
(SN); common fibular nerve (CFN); recurrent fibular nerve
(RFN); obturator nerve (ON); and superior lateral (SLGN), infe-
rior lateral (ILGN), superior medial (SMGN), and inferior medial
(IMGN) genicular nerves were dissected from proximal to
distal from their point of origin. The dissection procedure is
outlined below.
The skin and superficial and deep fascia were removed. The
underlying quadriceps muscles were exposed, and the rectus
femoris and proximal sartorius excised. The femoral artery and
vein and branches of the femoral nerve were meticulously
dissected and separated in the adductor canal. Next, the femoral
artery and vein and their branches were carefully removed, main-
taining the integrity of the nerve branches. The NVI, NVL, NVM,
SN, and ON were delineated and traced distally to their termina-
tion. Next, the SLGN, ILGN, SMGN, and IMGN were identified
1
Tran et al Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018

and traced to the joint capsule. The genicular vessels were sepa-
rated from their respective nerves and removed. Branches from
CFN and RFN were also identified and followed to their termina-
tion. Articular branches of these nerves, if present, were docu-
mented (Fig. 1), and their trajectory mapped. All specimens
were photographed, and the distance of each articular branch from
the surface of the femur was documented.
The patterns of innervation were compared between speci-
mens and related to bony and soft tissue landmarks. The course
of each nerve was traced and consolidated onto a 3-dimensional
skeletal model to generate a frequency map of the innervation of
the anterior knee joint capsule. Based on the patterns of inner-
vation, the articular branches were defined by the quadrant of
the knee joint that they supplied (superolateral, inferolateral,
superomedial, and inferomedial).
RESULTS
The anterior knee joint was innervated, in all specimens, by
articular branches from NVI, NVL, NVM, SLGN, ILGN, SMGN,
IMGN, CFN, and RFN (Figs. 2–5). The infrapatellar branch of
saphenous nerve (IPBSN) was mainly cutaneous in distribution
with some small articular branches, in 3 specimens, penetrating the
inferomedial quadrant (Fig. 4, A and C). The articular branches
terminated in 1 of the 4 quadrants of the knee joint with minimal
overlap (Fig. 6). Inferiorly, the inferomedial and inferolateral quad-
rants received innervations from fewer nerves than the superomedial
and superolateral quadrants. The superolateral quadrant was in-
nervated by NVL, NVI, SLGN, and CFN; the inferolateral by
ILGN and RFN; the superomedial by SMGN, NVI, and NVM;
and the inferomedial by IMGN and IPBSN. No articular branches
from the obturator nerve were found supplying the anterior knee
joint capsule.
Superolateral Quadrant
The superolateral quadrant was innervated from anterior to
posterior by NVL, NVI, SLGN, and CFN (Figs. 2 and 6A). In
the thigh, NVL consistently coursed deep to the anteromedial
border of vastus lateralis (VL) and superficial to the muscle
belly of vastus intermedius (VI) (Fig. 3). Distally, at the level
of the superior border of patella, NVL terminated as 2 to 4
branches that penetrated the quadriceps tendon to supply the knee
joint capsule (n = 15).
The NVI originated from the femoral nerve and divided into
lateral and medial branches in all specimens, supplying the
superolateral and superomedial quadrants, respectively (Fig. 2C,
3C, and 4C). The lateral branch crossed the femur obliquely,
coursed within the muscle belly of VI, and terminated in the knee
joint capsule, superolaterally. While coursing through VI, the
lateral branch gave off motor branches to the muscle (Fig. 2C).
The SLGN was found to have 2 patterns of origin
(Fig. 2, A and B). The nerve arose either from the sciatic nerve
just superior to its bifurcation (n = 5) or more distally from an ar-
ticular branch of the CFN (n = 10). If the SLGN originated from
the sciatic nerve, it lay deep to the VI coursing inferiorly to the
knee joint along the posterolateral aspect of the femur, joining
the superior lateral genicular vessels distally (Fig. 2B). The
nerve was separated from the femur by fatty tissue. Alterna-
tively, if the articular branches of CFN gave rise to SLGN, it orig-
inated just superior to the lateral condyle of the femur. The articular
branch was short and coursed superiorly to join the superior lat-
eral genicular vessels just before entering the knee joint cap-
sule (Fig. 2, A and C).
The CFN, in all specimens, gave off a single long articular
branch that originated just inferior to the bifurcation of the sciatic
nerve. This articular branch followed the CFN distally to the supe-
rior border of the lateral condyle where it coursed anteroinferiorly
and divided into 2 to 3 articular branches (Fig. 2, A and B).
Inferolateral Quadrant
The inferolateral quadrant was innervated, in all specimens,
superiorly by ILGN and inferiorly by RFN. The ILGN was a con-
tinuation of the long articular branch of CFN. The ILGN coursed
inferiorly deep to the lateral collateral ligament and turned

FIGURE 1. Dissection photographs demonstrating the exposure of the lateral branch of the NVI (arrows), lateral views. A, Overview.
B, Proximal part. C, Termination of articular branches in knee joint capsule. F indicates femur; P, patella. Reprinted with permission from
Philip Peng Educational Series.

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Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018 Anterior Knee Joint Innervation

FIGURE 2. Innervation of the anterolateral aspect of the knee joint, lateral views. A and B, CFN, ILGN, SLGN, RFN, and lateral branch of NVI.
C, Lateral branch of NVI, CFN, and SLGN. BF indicates biceps femoris; F, femur; Lbr, lateral branch of NVI; P, patella; SCN, sciatic nerve;
SM, semimembranosus; ST, semitendinosus; X, proximal and distal attachments of lateral collateral ligament. Reprinted with permission
from Philip Peng Educational Series.

anteriorly just inferior to the lateral femoral condyle to innervate the
knee joint (Fig. 2, A and B). As the ILGN coursed deep to the
lateral collateral ligament, it joined the inferior lateral genicular
vessels. Inferior to the fibular head, the CFN gave rise to the
RFN in all specimens. The RFN coursed anterosuperiorly around
the neck of the fibula and terminated as 1 to 3 articular branches
innervating the inferior part of the quadrant (Fig. 2A).
(Fig. 3C). The medial branch coursed the length of the femur and
terminated in the anteromedial knee joint capsule (Fig. 3C and 4C).
The SMGN was found to be a terminal branch of the femoral
nerve originating in close proximity to the NVM (Fig. 4C). The
SMGN coursed deep to sartorius and distally followed the adduc-
tor magnus tendon, with the descending genicular artery, to supply
the posteromedial knee joint capsule (Fig. 5).

Superomedial Quadrant Inferomedial Quadrant

From anterior to posterior, the superomedial quadrant was
supplied by NVM, NVI, and SMGN. The NVM, in all specimens,
consistently gave off 2 to 3 large branches that coursed intramus-
cularly through the vastus medialis (VM) to innervate the anterior
region of the quadrant (Fig. 4, A and C). The articular branches of
NVM overlapped with those of NVI and SMGN (Fig. 6C).
In the thigh, the medial branch of NVI coursed along the
anteromedial aspect of the femur in a plane between VI and VM
The IPBSN supplied the superior part of the inferomedial
quadrant, whereas the IMGN supplied the inferior part. The
IPBSN originated anterior (n = 13) or posterior (n = 2) to sartorius
and coursed anteroinferiorly to provide mainly cutaneous inner-
vation but also a few articular branches to the knee joint capsule
(Fig. 4, A and C).
The IMGN, a branch of the tibial nerve, joined the inferior
medial genicular vessels to form a neurovascular bundle that

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Tran et al Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018

FIGURE 3. Innervation of the anterior aspect of the knee joint, anterior views. A and B, NVL. C, Exposure of the course of NVL, lateral
and medial branches of NVI. F indicates femur; Lbr, lateral branch of NVI; Mbr, medial branch of NVI; P, patella. Reprinted with permission
from Philip Peng Educational Series.

coursed inferior to the medial tibial condyle and then deep to the
medial collateral ligament (Fig. 4B). The IMGN divided into 2
to 3 articular branches that innervated the knee joint capsule.
Distance From Periosteum of Femur
The articular branches from NVI, SLGN, ILGN, SMGN,
IMGN, CFN, RFN, and IPBSN all coursed along the periosteum
of the femur prior to terminating in the anterior capsule. The
NVL and NVM were more superficial, that is, not located at the
periosteal level (Figs. 3 and 4C). The NVL coursed between the
VI and VL muscles to terminate in the capsule at the superolateral
aspect of the patella. At the level of the apex of the suprapatellar
bursa, identified during dissection, the NVL had a mean distance
of 0.97 ± 0.27 cm from the periosteum of the femur. The branches
of NVM, coursing intramuscularly in VM, at the level of the apex
of the suprapatellar bursa, were located a mean distance of
0.71 ± 0.28 cm from the periosteum of the femur.
DISCUSSION
To the best of our knowledge, this is the first comprehensive
study that describes complete innervation of the anterior knee
joint with reference to landmarks relevant to image-guided inter-
vention. The frequency map of the articular branches divided by
the quadrants of the knee joint should improve procedural accu-
racy by defining the optimal location for RFA.
Excluding case reports, 8 studies that investigated the
ablation of articular branches supplying the anterior knee joint
capsule were found.18–25 The increasing number of publications
concerning knee joint RFA is reflecting the growing clinical inter-
est in this method. In a recent review of knee RFA denervation,
Bhatia et al26 concluded that the anatomical basis for radiofrequency

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Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018 Anterior Knee Joint Innervation

FIGURE 4. Innervation of the anteromedial aspect of the knee joint, medial views. A, NVM, SMGN, and IPBSN. B, Medial branch of
NVI, SMGN, and IMGN. C. Medial branch of NVI, NVM, SMGN, and IPBSN. ADM indicates adductor magnus tendon; F, femur; GR, gracilis;
Lbr, lateral branch of NVI; Mbr, medial branch of NVI; MCL, medial collateral ligament; P, patella; PS, pes anserinus; RF, rectus femoris;
S, sartorius; SM, semimembranosus. Reprinted with permission from Philip Peng Educational Series.

cannula placement was often unclear. In addition, it was reported that
most studies “did not utilize… sonoanatomical characteristics to im-
prove the precision of RF cannula placement.”26 Thus, anatomically
sound data regarding the articular branches and their courses
amendable to intervention are paramount. Previous studies
have focused on a limited number of articular branches except
for Gardner8 (Table 1).8–17 The results of previous studies were
descriptive and typically presented with a small number of dissec-
tion photographs and schematic line illustrations.
Most studies reported the presence or absence of a certain
articular branch but not the frequency of innervation (Table 1).
Gardner,8 for example, described the presence of numerous
articular branches innervating the knee joint, but reported only
the frequency of innervation for SMGN, CFN, and RFN (Table 1).
In other studies, when the frequency was reported, the articular
branches consistently innervated the anterior knee joint in
90% to 100% of specimens, except for IPBSN, RFN, and SMGN
(Table 1). No previous studies were found that reported the
frequency of the SLGN and ILGN. In the current study, all previ-
ous articular branches reported in the literature were found to in-
nervate the anterior knee joint in all specimens, except for the
IPBSN, which had articular branches in 3 of 15 specimens.
The course of each nerve supplying the anterior knee joint
capsule, in the current study, was consistent with that reported in
the previous literature, with the exception of NVI. The NVI has
been described previously coursing anteromedially along the
femur.10 This corresponds to the medial branch of NVI reported
in the current study (Figs. 3C and 4C). However, the lateral branch
of NVI has not been described. The lateral branch was found to
course distally along the anterolateral surface of the femur to
supply the superolateral quadrant of the knee joint (Fig. 2).
In the literature, there is a lack of consensus regarding the or-
igin of the SMGN. Tibial nerve origin was reported by Gardner8
and Yasar et al,14 obturator nerve origin by Gardner,8 and femoral
nerve origin by Burckett-St Laurant et al.15 In the current study,
SMGN was found, in all specimens, to originate from the femoral

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Tran et al Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018

FIGURE 5. Distal exposure of course of superior medial genicular nerve, medial views. A, Distal VM intact. B, Distal VM reflected.
*Medial epicondyle. ADM indicates adductor magnus tendon; DGA, descending genicular artery; F, femur; FA, femoral artery; GR, gracilis;
NVM, nerve to vastus medialis; P, patella; RF, rectus femoris; S, sartorius; SM, semimembranosus; SMGA, superior medial genicular artery.
Reprinted with permission from Philip Peng Educational Series.

FIGURE 6. Frequency map of the innervation of the anterior knee joint. A, Lateral view. B, Anterior view. C, Medial view. Reprinted with
permission from Philip Peng Educational Series.

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Regional Anesthesia and Pain Medicine • Volume 43, Number 4, May 2018 Anterior Knee Joint Innervation

TABLE 1. Previous Cadaveric Studies of the Innervation of the Anterior Knee Joint

Superior Inferior Superior Inferior Nerve to Nerve to Nerve to

Lateral Lateral Medial Medial Common Recurrent Vastus Vastus Vastus
Reference Genicular Genicular Genicular Genicular Fibular Fibular Saphenous Lateralis Intermedius Medialis
Gardner8 ✓ ✓ 3/11 ✓ 10/11 11/11 ✓ ✓ ✓ ✓
(1948) (n = 11)
Kennedy et al9 X ✓a X X X ✓ ✓ ✓ ✓ ✓
(1982) (n = 15)
Horner and Dellon10 ✓ ✓a X X X ✓ 45/45 X 45/45 45/45
(1994) (n = 45)
Hirasawa et al11 ✓b ✓ ✓b X ✓ X ✓ ✓ X ✓
(2000) (n = 5)
Franco et al12 X X X X 8/8c 8/8 8/8 8/8 8/8d 8/8
(2015) (n = 8)
Kalthur et al13 NI NI NI NI NI NI 32/32 NI NI NI
(2015) (n = 32)
Yasar et al14 NI NI 10/10 10/10 NI NI NI NI NI NI
(2015) (n = 10)
Burckett-St Laurant et al15 NI NI 18/20 X NI NI 11/20 NI NI 20/20
(2016) (n = 20)
Orduña Valls et al16 X X X X 25/25c 8/25 25/25 25/25 25/25 25/25
(2017) (n = 25)
Sutaria et al17 ✓ NI NI NI ✓c NI NI NI NI NI
(2017) (n = 20)
a, Indicates lateral articular nerve; b, followed the popliteal vessels; c, lateral retinacular nerve; d, medial retinacular branch; n, specimens; NI, not
investigated; X, not found.

nerve (Fig. 4C), consistent with that reported by Burckett-St
Laurant et al.15 Although the posterior branch of the obturator
nerve can emerge from the anterior surface of the adductor
magnus and innervate the anteromedial knee capsule in some in-
stances, our findings showed that the obturator nerve was mainly
cutaneous with no branches supplying the anterior knee joint
capsule, consistent with previous literature.10,11,15,16
Clinically, identifying soft tissue and bony landmarks of all
the nerves innervating the anterior knee joint is critical for
image-guided RFA given the limited size of radiofrequency le-
sions. Early studies described the placement of a single small-tip
RFA cannula using bony landmark(s) under fluoroscopic guid-
ance.5 Considering the frequency map of the current study (Fig. 6),
the placement of a single small-tip RFA needle would not capture
all the nerves innervating the anterior knee joint. Multiple/
palisade lesions or a single large-size lesion delivered using a
cannula with expandable tines or an internally cooled electrode25
may contribute to better outcomes. Further clinical studies are re-
quired to explore this hypothesis.
A recent seminal article discussed the optimal choices of
nerve block for total knee arthroplasty, highlighting the importance
of understanding knee joint innervation in providing insights in
the choice of optimal analgesic block.27 The importance of bal-
anced analgesia, optimizing pain control and rehabilitation, was
also highlighted in 3 recent articles.27–29 An optimal analgesic
block should result in minimal to no motor blockade; however,
this has been difficult to achieve as the majority of nerves inner-
vating the knee have motor and sensory components. Our study
described the articular (sensory) branches supplying the anterior
knee joint capsule and their course relevant to bony and soft tissue
landmarks. These findings provide anesthesiologists with a better
understanding of the contribution of various nerve blocks in
intercepting the pain pathway from deep structures, thus allowing
the possibility of selectively blocking the sensory branches to the
capsule using ultrasound guidance without or with minimal
motor impairment.27,29
A limitation of this study is the relatively small sample size,
which may not represent the entire spectrum of variation of
anterior knee joint innervation. Nonetheless, given the labor-
intensive and time-consuming (approximately 30–40 hours per
specimen) nature of clinical anatomical studies, large-scale research
involving meticulous dissection and topographic mapping may not
be feasible. The frequency map demonstrated a consistent pattern
of the articular branches, and additional dissections would un-
likely result in cardinally different discovery.
In conclusion, the current study found the anterior knee
joint capsule was invariably innervated by articular branches
from NVI, NVL, NVM, SLGN, ILGN, SMGN, IMGN, CFN,
and RFN. The regional anatomy of the articular branches could
be categorized into 4 quadrants: superolateral (NVL, NVI, SLGN,
and CFN), inferolateral (ILGN and RFN), superomedial (NVM,
NVI, and SMGN), and inferomedial (IMGN and IPBSN).
The detailed map reflecting the courses of each individual
articular branch may provide an anatomical basis to design
optimal needle configuration for knee RFA and perioperative
pain management.
ACKNOWLEDGMENTS
The authors thank Ian Bell, Logan Richard, Trevor Robinson,
and Sara Matias for their valuable technical assistance. They also
thank the individuals who donate their bodies and tissue for the
advancement of education and research.
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