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Isometric Contraction of the Quadriceps Improves the Accuracy of Intra-Articular Injections into the Knee Joint via the Superolateral Approach

Wada, Makoto, MD1; Fujii, Tadashi, MD, PhD2; Inagaki, Yusuke, MD, PhD3; Nagano, Tatsuo, MD4; Tanaka, Yasuhito, MD, PhD3

doi: 10.2106/JBJS.OA.18.00003
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Background: Intra-articular injection is an important technique for treating rheumatoid arthritis and osteoarthritis of the knee. However, medication is often inaccurately injected outside of the joint. We devised an intra-articular injection method in which the needle is inserted into the suprapatellar bursa while the patient maintains isometric contraction of the quadriceps. This isometric contraction method is based on the concept that isometric contraction of the quadriceps induces contraction of the articularis genus muscle, thus expanding the lumen of the suprapatellar bursa.

Methods: Intra-articular injections were performed on 150 osteoarthritic knees without effusion. The knees were alternately assigned to the isometric quadriceps method group (75 knees) and non-activated quadriceps method group (75 knees). Prior to joint injection, the anterior-posterior dimension of each suprapatellar bursa was measured to ascertain its expansion. The isometric quadriceps method was performed with the quadriceps and the articularis genus muscle maintained in a contracted state. The non-activated quadriceps method was performed in a relaxed state. Ultrasound guidance was not used for either method. Subsequently, an ultrasonic probe was used only to confirm whether the intra-articular injections were successful. We compared the accuracy of injections performed between the 2 groups.

Results: Suprapatellar expansion was significantly larger (p < 0.001) using the isometric quadriceps method (2.1 ± 1.4 mm [range, 0 to 5 mm]) than using the non-activated quadriceps method (0.8 ± 0.7 mm [range, 0 to 2 mm]). The percentage of accurate intra-articular injections was significantly higher (p = 0.0287) using the isometric quadriceps method (93%) compared with the non-activated quadriceps method (80%).

Conclusions: In comparison with the non-activated quadriceps method, the isometric quadriceps method led to a larger expansion of the suprapatellar bursa, which should lead to more accurate intra-articular injections. The isometric quadriceps method is effective in reducing inaccurate injections into the synovium or surrounding fatty tissues.

Clinical Relevance: Putting force on the quadriceps muscle increases the success rate of intra-articular injection of the knee. The results of this study could provide a clinically relevant injection technique for future treatment.

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1Department of Orthopaedic Surgery, Wada Orthopaedic Clinic, Hirakata, Japan

2Department of Orthopaedic Surgery, Kashiba Asahigaoka Hospital, Kashiba, Japan

3Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Japan

4Department of Orthopaedic Surgery, Nagano Orthopaedic Clinic, Kashiba, Japan

E-mail address for M. Wada:

Investigation performed at the Department of Orthopaedic Surgery, Wada Orthopaedic Clinic, Hirakata, Japan, and the Department of Orthopaedic Surgery, Kashiba Asahigaoka Hospital, Kashiba, Japan

Disclosure: There was no source of external funding for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

© 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Journal of Bone and Joint Surgery, Incorporated.