Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-000015 on 30 January 2019. Downloaded from file:/ on 3 February 2019 by guest. Protected by copyright.
Anatomical study of the innervation of posterior knee
joint capsule: implication for image-
guided intervention
John Tran,1 Philip W H Peng,2 Michael Gofeld,2 Vincent Chan,2 Anne M R Agur1

1
Division of Anatomy, Abstract minimizing motor blockade. To achieve this, a
Department of Surgery, Background and objectives  Peripheral nerve block is detailed understanding of the sensory supply of the
University of Toronto, Toronto,
Canada an important component of the multimodal analgesia for knee joint is crucial as indicated by the increasing
2
Department of Anesthesia, total knee arthroplasty. Novel interventional techniques number of investigations and publications on this
University of Toronto, Toronto, of ultrasound-guided nerve block supplying the posterior topic.8–18 Previous anatomical studies of innerva-
Canada knee joint capsule require knowledge of the innervation tion of the posterior knee joint capsule are scarce,
of the posterior capsule. The objectives of this cadaveric with only two studies reporting the frequency of
Correspondence to study were to determine the course, frequency, and innervation by each nerve (table 1). The objectives
Philip W H Peng, Department
of Anesthesia, University of distribution of the articular branches innervating the of this cadaveric study were (1) to determine the
Toronto, Toronto, ON M5T 2S8, posterior knee joint capsule and their relationships to nerve supply to the posterior capsule, (2) to docu-
Canada; ​philip.​peng@​uhn.​ca anatomical landmarks. ment the course and frequency of the nerves inner-
Methods  Fifteen lightly embalmed specimens were vating the posterior capsule, and (3) to identify
Received 29 March 2018 bony and soft-tissue landmarks in close proximity
meticulously dissected. The origin of articular branches
Revised 27 May 2018
Accepted 6 June 2018 was identified, their frequency recorded, and the course to the articular branches that are visible using ultra-
documented in relation to anatomical landmarks. sound and/or fluoroscopy.
The capsular distribution of articular branches was
documented and a frequency map generated. Methods
Results  In all specimens, articular branches from the Fifteen lightly embalmed cadaveric specimens with a
posterior division of the obturator and tibial nerves mean age of 72.4±22.9 years (8M/7F) were used in
were found to supply the posterior capsule. Additionally, this study. Sample size calculation was not possible
articular branches from common fibular nerve and due to lack of previous data. Specimens with visible
sciatic nerve were found in eight (53%) and three (20%) evidence of pathology, previous surgery, or trauma
specimens, respectively. The capsular distribution of tibial were excluded. Dissection of nerves was carried out
nerve spanned the entire posterior capsule. The posterior using a ×3.5 magnification lens.
division of obturator nerve supplied the superomedial Following removal of the skin, superficial and
aspect of the posterior capsule overlapping with the deep fascia, the obturator (ON), sciatic (SCN),
tibial nerve. The superolateral aspect of the posterior common fibular (CFN), and tibial (TN) nerves
capsule was innervated by the tibial nerve and, when were traced to their termination to identify any
present, the common fibular/sciatic nerves. articular branches innervating the posterior knee
Conclusions  Frequency map of the course and joint capsule. The exposure of each nerve will be
distribution of the articular branches and their outlined below.
relationship to anatomical landmarks form an anatomical
basis for peripheral nerve block approaches that provide
analgesia to the posterior knee joint capsule. Obturator nerve
The sartorius, gracilis, and adductor longus were
reflected to expose the adductor brevis. The ante-
rior division of the obturator nerve (AON) and its
Introduction branches were meticulously dissected to their distal
In the USA, 705 649 knee replacements were termination. Next, the adductor brevis was released
performed in 2011,1 with an anticipated increase from its distal attachment to expose the posterior
to 3.48 million by 2030.2 Pain following total knee division of the obturator nerve (PON). The origin
arthroplasty (TKA) can be severe and limit early of PON from the ON was identified. Similar to the
mobilization and recovery.3 4 Femoral nerve blocks AON, the PON and its branches were traced distally
(FNBs) and adductor canal blocks (ACBs) are two to their termination. Any branches extending into the
of the most commonly performed peripheral nerve popliteal fossa were followed to their termination
© American Society of Regional after dissection of branches from the SCN, CFN, and
Anesthesia & Pain Medicine blocks (PNBs) as part of non-opioid multimodal
analgesia following TKA.5 These approaches target TN.
2019. No commercial re-use.
See rights and permissions. the nerve supply to the anterior knee joint capsule.
Published by BMJ. More recently, novel approaches targeting the nerve Sciatic, common fibular, and tibial nerves
To cite: Tran J, Peng PWH, supply to the posterior capsule have also been added The SCN was identified at the inferior border of
Gofeld M, et al. to supplement FNBs and ACBs following TKA.6 7 gluteus maximus. The long head of biceps femoris
Reg Anesth Pain Med In the context of effective TKA clinical pathway, was separated from the semimembranosus and semi-
2019;44:234–238. PNBs focus on maximizing analgesic effects while tendinosus to expose the SCN at its bifurcation into
234    Tran J, et al. Reg Anesth Pain Med 2019;44:234–238. doi:10.1136/rapm-2018-000015
 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-000015 on 30 January 2019. Downloaded from file:/ on 3 February 2019 by guest. Protected by copyright.
Table 1  Previous cadaveric studies of the innervation of posterior knee joint capsule
Tibial Posterior division Anterior division
nerve obturator nerve obturator nerve
Presence Origin Presence Origin/course Presence
Gardner8 11/11 A. Tibial portion of sciatic nerve 9/11 ns/through adductor magnus 1/11*
1948 (n=11) B. Popliteal fossa
Kennedy et al9 ✓ A. Above knee joint ✓ ns/with femoral artery into popliteal fossa x
1982 (n=15) B. Popliteal fossa
Horner and Dellon10 ✓ A. 10–25 cm above joint line ✓ Hunter’s canal/adductor hiatus x
1994 (n=45)
Orduña Valls et al16 ✓ A. Popliteal fossa ✓ Mid-femoral/through adductor magnus x
2017 (n=25)
Runge et al18 10/10 ns 10/10 ns/adductor magnus, hiatus and canal x
2017 (n=10)
*Anastomosed with saphenous nerve.
n, specimens; ns, not stated; x, not found.

the CFN and TN. The CFN was followed distally to the head of innervating the posterior knee joint capsule, were documented. All
fibula and the TN to the inferior border of the popliteal fossa, specimens were photographed, the course of each articular branch
while maintaining the integrity of any nerve branches. mapped, and the area of innervation of the posterior capsule was
Next, branches of ON, SCN, CFN, and TN that entered the recorded. Bony and soft-tissue landmarks were determined for
popliteal fossa were skeletonized by removal of the fatty tissue each articular branch innervating the posterior capsule.
lobules. The popliteal artery and vein were exposed as deeper fatty
tissue was removed. The popliteal artery and vein were traced
from the adductor hiatus to the junction of the medial and lateral Data analysis and frequency mapping
heads of gastrocnemius, and the superior and inferior genicular The distribution of articular branches innervating the posterior
vessels were followed medially and laterally to the margins of the capsule was recorded and their frequency quantified. The course
popliteal fossa. The isolated popliteal and genicular vessels were of each articular branch was traced and consolidated onto a 3D
carefully excised to enable dissection of the fine nerve branches to skeletal model to generate a frequency map (Paint.Net, dotPDN
their termination. The origin and termination of articular branches, LLC, Redmond, Washington, USA; Maya 2016, Autodesk, San

Figure 1  Cadaveric dissections of articular branches supplying the posterior knee joint capsule in three different specimens, posterior views. (A)
CFN, SBTN, and IBTN. Note that PON has not been exposed. (B) CFN, PON, SBTN, and IBTN, popliteal vessels intact. (C) CFN, PON, and IBTN, popliteal
vessels removed. Note absence of SBTN and posterior branch of CFN in this specimen. BF, biceps femoris; CFN, main common fibular nerve; IBTN,
inferior branch of the TN; LG, lateral head of gastrocnemius; MG, medial head of gastrocnemius; PON, posterior division of the obturator nerve; SBTN,
superior branch of the TN; SM, semimembranosus; ST, semitendinosus; TN, main tibial nerve; *, femoral condyle. Reprinted with permission from Philip
Peng educational series.
Tran J, et al. Reg Anesth Pain Med 2019;44:234–238. doi:10.1136/rapm-2018-000015 235
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Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-000015 on 30 January 2019. Downloaded from file:/ on 3 February 2019 by guest. Protected by copyright.
Figure 2  Exposure of the course of articular branches. (A) PON, SCN, and TN, popliteal vessels intact. Note the absence of SBTN in this specimen.
(B) Proximal course of PON exposed by separation of the adductor magnus, indicated by double-sided arrow. Note the absence of SBTN in this
specimen. (C) Enlargement of area indicated by yellow box in (B). Popliteal vessels removed to expose termination of PON, CFN, and TN in posterior
capsule. ADH (dashed white line), adductor hiatus; ADM, adductor magnus; BF, biceps femoris; CFN, main common fibular nerve; LG, lateral head
of gastrocnemius; MG, medial head of gastrocnemius; PA, popliteal artery; PON, posterior division of the obturator nerve; PV, popliteal vein; SBTN,
superior branch of the TN; SCN, sciatic nerve; SM, semimembranosus; ST, semitendinosus; TN, main tibial nerve; *, femoral condyle. Reprinted with
permission from Philip Peng educational series.

Rafael, California, USA; Amira for Life Sciences, Thermo Scien- and posterolateral capsule, respectively. In four specimens,
tific, Waltham, Massachusetts, USA). Based on the frequency map neither the CFN nor SCN had articular branches innervating
and dissected specimens, the most consistent bony and soft-tissue the posterior knee joint capsule (figure 1C). When present, the
landmarks to localize each articular branch were determined. posterior branch coursed distally, lateral to the popliteal vein, to
terminate in the superolateral aspect of the posterior capsule as
Results one to two articular branches. The posterior branch was located
The articular branches providing innervation to the posterior knee at the level of the lateral femoral condyle just prior to termi-
joint capsule came from the PON, SCN, CFN, and TN. nating in the capsule.

Obturator nerve
The posterior knee joint capsule was innervated, in all 15 speci- Tibial nerve
mens, by articular branches of PON. No articular branches from The TN innervated the posterior knee joint capsule in all 15
the AON were found to supply the posterior capsule. specimens (figures 1 and 2). The articular branches were found
The PON had numerous motor branches to the adductor either originating proximal or distal to the superior border of
muscles, but only one branch was found to extend distally to the medial femoral condyle and were referred to as the supe-
supply the posterior capsule (figures 1B,C and 2). This articular rior branch of the TN (SBTN) and inferior branch of the TN
branch coursed, deep to adductor longus, on the anterior surface (IBTN), respectively. Only the IBTN was found in eight speci-
of adductor magnus to the adductor hiatus. The articular branch mens (figure 2) and both SBTN and IBTN were found together
coursed through the adductor hiatus, with the femoral artery in seven specimens (figure 1B).
and vein, to enter the popliteal fossa. In the popliteal fossa, the The IBTN was shorter than the SBTN and, after originating
PON coursed along the anteromedial aspect of the popliteal from the TN, coursed transversely to the intercondylar region,
artery in 14 specimens and posterior to the popliteal artery in between the medial and lateral femoral condyles, where it
one specimen (figure 2A,B). In all 15 specimens, at the level of divided into three to five articular branches (figures 1C and
the femoral condyles, the articular branch further divided into 2C). As SBTN coursed distally, it was located medial, lateral,
two to three terminal branches that supplied the superomedial or between the popliteal artery and vein. At the intercondylar
aspect of the posterior capsule. region, the SBTN divided into two to three articular branches
that terminated in the posterior capsule. When IBTN and SBTN
Common fibular and sciatic nerves were both present, their articular branches interdigitated to form
Articular branches to the posterior knee joint capsule were found a plexus located on the posterior knee joint capsule.
in 11 of 15 specimens—8 originated from the CFN and 3 from
the SCN, with the same course and termination (figures 1A,B Frequency map
and 2). Regardless of origin, the articular nerve divided into The IBTN supplied the entire posterior capsule in eight spec-
anterior and posterior branches to innervate the anterolateral imens. However, when SBTN was present (n=7), it supplied
236 Tran J, et al. Reg Anesth Pain Med 2019;44:234–238. doi:10.1136/rapm-2018-000015
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Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-000015 on 30 January 2019. Downloaded from file:/ on 3 February 2019 by guest. Protected by copyright.
relationship with the bony and soft-tissue landmarks that are
discernible with ultrasound and/or fluoroscopy.
The TN and PON are the two major contributors to the inner-
vation of the posterior knee joint capsule as demonstrated by the
current study and the previous literature.8–10 16 18 Additionally,
Gardner found the AON anastomosed with the saphenous nerve
(1 out of 11 specimens) and “accompanied the femoral artery
into the popliteal space and thence to the back of the knee joint”
leading to the suggestion that the AON also supplied the poste-
rior capsule.8
Consistent with findings of Gardner and Runge et al,8 18we
also found TN innervation in 100% of specimens. The posterior
articular branch of TN has been reported to variably originate
either superior to the knee joint or within the popliteal fossa
(table 1). In the current study, we have quantified the frequency
of origin of the IBTN and SBTN. In eight specimens, there was
one branch, the IBTN, which originated from the TN distal to
the medial femoral condyle, and in seven specimens, there were
two branches, SBTN arising proximal and IBTN distal to the
superior border of the femoral condyles.
The contribution of PON innervation is important and was
reported in 82% of specimens (n=9/11) by Gardner,8 in 100%
of specimens (n=10/10) by Runge et al,18 and 100% of speci-
mens (n=15/15) in the current study. Additionally, in the current
study, the PON was found to course through the adductor hiatus
consistent with previous studies.9 10 No other study, except
Gardner, has suggested or found AON innervation to the poste-
rior knee joint capsule.8
In the current study, we found that articular branches of
the PON and TN interdigitated to form a fine plexus prior to
terminating in the posterior knee joint capsule. This interdig-
itation has also been described by Gardner and Kennedy et al
as a “dense plexus” and a “popliteal plexus” by Horner and
Dellon.8–10 In addition, a posterior branch of CFN/SCN, when
present (n=11), also provided articular branches to the plexus.
Interestingly, this branch has been only mentioned by Rüdinger
in 1857, but not in subsequent studies.19
We have defined the localization of the articular branches
supplying the posterior knee joint capsule in relationship to
bony and soft-tissue landmarks. The articular branches of PON
have been described by Gardner as “descending on the popli-
teal vessels… Its subsequent distribution is variable” and the TN
Figure 3  Frequency map of the innervation of the posterior knee joint, by Kennedy et al as “variable within the popliteal fossa”.8 9 In
posterior view. Arrows indicate course of (1) superior lateral genicular the current study, we localized the articular branches of PON in
nerve and anterior branch of common fibular nerve/sciatic nerve; (2) close proximity to the popliteal artery at the level of the medial
inferior medial genicular nerve; (3) recurrent fibular nerve. Dashed line: femoral condyle, the CFN/SCN by the popliteal vein at the level
attachment of knee joint capsule. Reprinted with permission from Philip of the lateral femoral condyle, and the TN by the superior border
Peng educational series. of the femoral condyles and the intercondylar fossa.
Our study provides an anatomical basis for the “Interspace
between the Popliteal Artery and the Capsule of the posterior
the superior one-third and the IBTN, the inferior two-thirds. Knee (iPACK) block” recently described by Sanjay Sinha.20 The
The PON innervated the superomedial aspect of the posterior iPACK block targets the articular branches innervating the poste-
capsule and the CFN/SCN, when present, provided additional rior knee joint by administration of local anesthetic into the
innervation to the superolateral aspect of the posterior capsule. interspace between the popliteal artery and posterior capsule of
In figure 3, the course of the anterior articular branches from the knee. The presence of the CFN/SCN, TN, and PON articular
the CFN/SCN (superior lateral genicular nerve, inferior lateral branches to the posterior capsule, as demonstrated in this study,
genicular nerve, recurrent fibular nerve) and TN (inferior medial highlights the anatomical targets for the iPACK block. Presently,
genicular nerve) are indicated with numbered arrows. only one randomized trial has been published to show that
combined ACB and iPACK block provides superior analgesia to
ACB alone.21 Our study also suggests that the injection along the
Discussion line joining the superior aspect of the two femoral condyles may
The present study is the first comprehensive cadaveric investiga- anesthetize most of the posterior articular branches.
tion detailing the innervation of the posterior knee capsule—the The limitation of our study is related to the small number
courses and the frequencies of each articular branches, and their of dissections, which is a characteristic of detailed anatomical
Tran J, et al. Reg Anesth Pain Med 2019;44:234–238. doi:10.1136/rapm-2018-000015 237
 Original article

Regional Anesthesia & Pain Medicine: first published as 10.1136/rapm-2018-000015 on 30 January 2019. Downloaded from file:/ on 3 February 2019 by guest. Protected by copyright.
research. This reflects the labor-intensive and time-consuming 7 Thobhani S, Scalercio L, Elliott CE, et al. Novel regional techniques for total knee
process involved in exposing the fine sensory nerves innervating arthroplasty promote reduced hospital length of stay: an analysis of 106 patients.
Ochsner J 2017;17:233–8.
the posterior knee joint capsule. Other anatomical variations are 8 Gardner E. The innervation of the knee joint. Anat Rec 1948;101:109–30.
possible. However, the frequency map compiled in the current 9 Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its
study suggests the innervation pattern is consistent. functional importance. Am J Sports Med 1982;10:329–35.
The importance of understanding the innervation of the knee 10 Horner G, Dellon AL. Innervation of the human knee joint and implications for surgery.
Clin Orthop Relat Res 1994;301:221–6.
joint is essential to develop an optimal analgesic block for TKA 11 Hirasawa Y, Okajima S, Ohta M, et al. Nerve distribution to the human knee joint:
with minimal-to-no motor blockade.22 Optimizing pain control anatomical and immunohistochemical study. Int Orthop 2000;24:1–4.
has been shown to improve rehabilitation outcomes and decrease 12 Franco CD, Buvanendran A, Petersohn JD, et al. Innervation of the anterior capsule
the length of hospital stay.7 23–25 Despite these advantages, poste- of the human knee: implications for radiofrequency ablation. Reg Anesth Pain Med
2015;40:363–8.
rior knee joint analgesic blocks are still in development.18 26Our 13 Kalthur SG, Sumalatha S, Nair N, et al. Anatomic study of infrapatellar branch of
results add to the literature regarding the innervation of the saphenous nerve in male cadavers. Ir J Med Sci 2015;184:201–6.
posterior knee joint by describing its nerve supply relative to 14 Yasar E, Kesikburun S, Kılıç C, et al. Accuracy of ultrasound-guided genicular nerve
bony and soft-tissue landmarks. This information serves as the block: a cadaveric study. Pain Physician 2015;18:E899–E904.
15 Burckett-St Laurant D, Peng P, Girón Arango L, et al. The nerves of the adductor
anatomical basis that will be useful for further work on image- canal and the innervation of the knee: an anatomic study. Reg Anesth Pain Med
guided PNBs targeting the posterior knee joint capsule. 2016;41:321–7.
16 Orduña Valls JM, Vallejo R, López Pais P, et al. Anatomic and ultrasonographic
Acknowledgements  The authors wish to thank Ian Bell, Logan Richard, and evaluation of the knee sensory innervation: a cadaveric study to determine anatomic
Harun Bola for their valuable technical assistance. We also wish to thank the targets in the treatment of chronic knee pain. Reg Anesth Pain Med 2017;42:90–8.
individuals who donate their bodies and tissue for the advancement of education 17 Sutaria RG, Lee SW, Kim SY, et al. Localization of the lateral retinacular nerve for
and research. diagnostic and therapeutic nerve block for lateral knee pain: a cadaveric study. Pm R
2017;9:149–53.
Competing interests  PWHP received equipment support from Sonosite Fujifilm 18 Runge C, Moriggl B, Børglum J, et al. The spread of ultrasound-guided injectate from
Canada. VC has received honorarium from Aspen Pharma, BBraun, Smiths Medical, the adductor canal to the genicular branch of the posterior obturator nerve and the
and SonoSite. popliteal plexus: a cadaveric study. Reg Anesth Pain Med 2017;42:725–30.
Ethics approval  Approval was received from the University of Toronto Health 19 Rüdinger N. Die Gelenknerven des menschlichen Körpers. Erlangen: Ferdinand Enke,
Sciences Research Ethics Board (approval no. 27210). 1857.
20 O’Donnell R, Dolan J. Anaesthesia and analgesia for knee joint arthroplasty. BJA Educ
2018;18:8–15.
21 Reddy DAVG, Jangale DA, Reddy DRC, et al. To compare effect of combined block
References of adductor canal block (ACB) with IPACK (Interspace between the Popliteal Artery
1 Agency for Healthcare Research and Quality. HCUP Nationwide Inpatient Sample and the Capsule of the posterior Knee) and adductor canal block (ACB) alone on
(NIS). Healthcare Cost and Utilization Project (HCUP). 2011. Available: www.​hcupus.​ total knee replacement in immediate postoperative rehabilitation. Int J Res Orthop
ahrq.​gov/​nisoverview.j​ sp 2017;3:141–5.
2 Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee 22 Bendtsen TF, Moriggl B, Chan V, et al. The optimal analgesic block for total knee
arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am arthroplasty. Reg Anesth Pain Med 2016;41:711–9.
2007;89:780–5. 23 Wang H, Boctor B, Verner J. The effect of single-injection femoral nerve block on
3 Taylor A, Stanbury L. A review of postoperative pain management and the challenges. rehabilitation and length of hospital stay after total knee replacement. Reg Anesth
Current Anaesthesia & Critical Care 2009;20:188–94. Pain Med 2002;27:139–44.
4 Cooney MF. Postoperative pain management: clinical practice guidelines. J Perianesth 24 Liu Q, Chelly JE, Williams JP, et al. Impact of peripheral nerve block with low dose local
Nurs 2016;31:445–51. anesthetics on analgesia and functional outcomes following total knee arthroplasty: a
5 Moucha CS, Weiser MC, Levin EJ. Current strategies in anesthesia and analgesia for retrospective study. Pain Med 2015;16:998–1006.
total knee arthroplasty. J Am Acad Orthop Surg 2016;24:60–73. 25 Chan E-Y, Fransen M, Parker DA, et al. Femoral nerve blocks for acute postoperative
6 Runge C, Børglum J, Jensen JM, et al. The analgesic effect of obturator nerve block pain after knee replacement surgery. Cochrane Database Syst Rev 2014;19.
added to a femoral triangle block after total knee arthroplasty: a randomized 26 Kardash KJ, Noel GP. The SPANK block: a selective sensory, single-injection solution to
controlled trial. Reg Anesth Pain Med 2016;41:445–51. posterior pain after total knee arthroplasty. Reg Anesth Pain Med 2016;41:118–9.

238 Tran J, et al. Reg Anesth Pain Med 2019;44:234–238. doi:10.1136/rapm-2018-000015