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Torsional Anatomy of the Lower Limb

The Appearance of Anatomy in Hemispastic Position

Cianca, John*†; Dy, Rochelle*‡; Chiou-Tan, Faye Y.; John, Joslyn*; Taber, Katherine H.*∥¶

Journal of Computer Assisted Tomography: November/December 2018 - Volume 42 - Issue 6 - p 982–985
doi: 10.1097/RCT.0000000000000795
Graphic Anatomy

Objective The aim of the study was to determine whether there are relevant anatomical variations to the typical injection sites for antispasticity procedures in the lower limb.

Methods Sonographic images were obtained at traditional injection locations for spasticity in the lower limb. Images were recorded in neutral and contracted postures. Doppler imaging was obtained for sites that contained vasculature. The images were analyzed, and schematics were created that highlighted relevant findings.

Results The adductor longus in commonly used injection sites was close to vasculature making accidental injection of the latter a higher risk. The sciatic nerve was vulnerable to injections at the proximal biceps femoris injection side if injected too deeply. Hamstring injection sites can be adjusted to the midline to improve accuracy. The proximity of the tibial nerve to the flexor hallucis longus and the deep fibular nerve to the extensor hallucis longus puts these nerves at risk for accidental injection.

Discussion Contracted posture results in altered positions of lower extremity muscles that could lead to inadvertent neurovascular injection or decreased efficacy with injections. Findings in this study may be helpful for planning and executing injections to reduce spasticity in the lower extremity.

Conclusions Sonographic imaging allows a better localization of muscles associated with spasticity and can instruct the clinician to alter usual injection pathways. This article documents visual evidence that previous assumptions for injection strategies require updating.

From the *Department of Physical Medicine and Rehabilitation, Baylor College of Medicine;

Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center;

Department of Physical Medicine and Rehabilitation, Texas Children's Hospital;

§Center for Trauma Rehabilitation Research, Quentin Mease Hospital, Harris Health System, Houston, TX;

VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham; and

Research and Academic Affairs Service Line, Salisbury VA Health Care System, Salisbury, NC.

Received for publication August 1, 2018; accepted August 6, 2018.

Correspondence to: Faye Y. Chiou-Tan, MD, Department of Physical Medicine and Rehabilitation, Quentin Mease Hospital, Suite #240, 3601 N MacGregor Way, Houston, TX 77004 (e-mail:

J.C. is the owner of Musculoskeletal Ultrasound Consultants LLC. J.C. received grants from Houston Marathon Committee and Demos Medical Publishing.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.