Anterolateral Portal Is Less Painful than Superolateral Portal in Knee Intra-Articular Injection

Abstract

Purpose:
Intra-articular knee injections are commonly performed in clinical practice for treating various knee joint disorders such as osteoarthritis and rheumatoid arthritis. When selecting the portal for injection, not only intra-articular needle accuracy but also procedural pain should be taken into consideration. The purpose of this study was to determine whether injection through anterolateral portal provokes less pain and provides better pain relief compared to superolateral portal.

Materials and methods:
A total of 60 patients with primary osteoarthritis of the knee receiving intra-articular injections were randomized into 2 groups according to the type of portal approach; anterolateral or superolateral. All patients received hyaluronic acid (20 mg) and triamcinolone (40 mg) as the first injection followed by second and third injections of hyaluronic acid on a weekly basis. Underlying knee pain, procedural pain, and knee pain at 4 weeks were evaluated using visual analogue scale (VAS).

Results:
Injection through anterolateral portal provoked less pain (VAS, 1.5±1.3) than the superolateral portal (VAS, 1.5 vs. 2.7; p=0.004). No differences were found in the degree of pain relief at weeks between the two groups (p=0.517).

Conclusions:
We recommend the use of anterolateral portal for intra-articular knee injection as it provokes less pain and comparably short-term pain relief than the superolateral portal.

Full text

Introduction
Intra-articular knee injection is a common, relatively simple
and safe procedure done in an outpatient setting for various knee
conditions. Injections of corticosteroids and hyaluronic acid (HA)
are most common for the treatment of knee osteoarthritis (OA).
Although several portals are available for knee injection1,2), each
has its own advantages and disadvantages. Accuracy of intra-
articular needle placement, portal site pain and experience of the
clinician are important factors to be considered before selecting a
portal for knee injection.
The two routinely used approaches for intra-articular knee
injections are superolateral and anterolateral. The superolateral
approach with the leg in extension is the most commonly studied
approach in the literature3). The anterolateral approach is familiar
among knee surgeons due to its routine use in arthroscopic sur-
gery. It allows the patient to remain in a sitting position with the
knee bent, and bilateral injections can be performed with ease
without changing the patient’s position. It is, therefore, useful
in patients whose knee cannot be extended, and furthermore, it
does not require manipulation of the patella4). It is reported that
these arthroscopic approaches involve little pain or discomfort5).
Accordingly, most of the previous studies stressed upon the ac-
curacy of intra-articular needle placement. Few studies have
described procedural pain and the degree of pain relief following
intra-articular knee injection through various portals.
Hence, we sought to determine whether injection through the
Anterolateral Portal Is Less Painful than Superolateral
Portal in Knee Intra-Articular Injection
Sung Yup Lee, MD1, Kiran Kumar GN, MS (Ortho)1, Byung June Chung, MD2, Sang Wook Lee, MD1, and
Tae Kyun Kim, MD1
1Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam; 2Joint Reconstruction Center, Knee and Spine Hospital, Seoul, Korea
Purpose: Intra-articular knee injections are commonly performed in clinical practice for treating various knee joint disorders such as osteoarthritis
and rheumatoid arthritis. When selecting the portal for injection, not only intra-articular needle accuracy but also procedural pain should be taken
into consideration. The purpose of this study was to determine whether injection through anterolateral portal provokes less pain and provides better
pain relief compared to superolateral portal.
Materials and Methods: A total of 60 patients with primary osteoarthritis of the knee receiving intra-articular injections were randomized into 2
groups according to the type of portal approach; anterolateral or superolateral. All patients received hyaluronic acid (20 mg) and triamcinolone (40
mg) as the first injection followed by second and third injections of hyaluronic acid on a weekly basis. Underlying knee pain, procedural pain, and
knee pain at 4 weeks were evaluated using visual analogue scale (VAS).
Results: Injection through anterolateral portal provoked less pain (VAS, 1.5±1.3) than the superolateral portal (VAS, 1.5 vs. 2.7; p=0.004). No
differences were found in the degree of pain relief at weeks between the two groups (p=0.517).
Conclusions: We recommend the use of anterolateral portal for intra-articular knee injection as it provokes less pain and comparably short-term pain
relief than the superolateral portal.
Keywords: Knee, Osteoarthritis, Intra-articular injection
Original Article
Knee Surg Relat Res 2015;27(4):228-232
http://dx.doi.org/10.5792/ksrr.2015.27.4.228
pISSN 2234-0726 · eISSN 2234-2451
Knee Surgery & Related Research
Received January 13, 2015; Accepted April 13, 2015
Correspondence to: Tae Kyun Kim, MD
Department of Orthopaedic Surgery, Seoul National University Bundang
Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620,
Korea
Tel: +82-31-787-7196, Fax: +82-31-787-4056
E-mail: osktk@snubh.org
228
This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Copyright © 2015 KOREAN KNEE SOCIETY www.jksrr.org

Knee Surg Relat Res, Vol. 27, No. 4, Dec. 2015 229
anterolateral portal provokes less pain and provides better pain
relief than the superolateral portal.
Materials and Methods
This prospective randomized controlled study was undertaken
in 60 patients from 30 June 2014 to 30 October 2014 at our ter-
tiary care center. Patients were adequately educated regarding
the nature of the study before the procedures. Written informed
consent and clearance from the local ethical committee were ob-
tained before the initiation of the study.
Inclusion criteria were patients with radiological Kellgren-
Lawrence grade II or III OA knee and ability to give informed
consent. Exclusion criteria were as follows: conditions other than
primary OA, systemic diseases that may affect the results, HA
and steroid injections within recent three months, allergy to HA
injection, the use of warfarin or antiplatelet therapy, or the pres-
ence of any infection.
Patients were recruited in our outpatient department and ran-
domly assigned to either the superolateral injection group or the
anterolateral injection portal group using computer-generated
permuted block randomization. There were 29 patients in the
superolateral group and 31 patients in the anterolateral group.
Demographic features and preoperative status of the patients
including the OA severity in the patellofemoral and tibiofemoral
joints and mechanical tibiofemoral angle were compared between
the two groups (Table 1). Underlying knee pain was recorded
using visual analogue scale (VAS), where 0 cm=no pain and 10
cm=unbearable pain6,7).
All patients received weekly injections for three weeks in ac-
cordance with the assigned route on an outpatient basis under
strict aseptic precautions. All procedures were carried out using
23 gauge needles blindly based on anatomic landmarks by an ex-
perienced surgeon. Injection through the anterolateral portal was
given with the patient in a sitting position with the knee flexed
to 90o at 1 cm proximal to the joint line, lateral to the patellar
tendon, the needle was directed towards the intercondylar notch
(Fig. 1). Injection through the superolateral portal was performed
with the patient in supine position. With the knee extended, the
needle was inserted 1 cm above and 1 cm lateral to the supero-
lateral margin of patella at a 45o angle in the cephalolateral to
caudomedial direction (Fig. 2). The first injection included HA
(20 mg) and triamcinolone (40 mg) and subsequently, the second
and third injections included only HA (20 mg).
The primary outcome variable was the degree of pain measured
at the portal site during the first injection, and the secondary out-
come variable was the degree of pain relief, which was evaluated
at 4 weeks after the last injection. Procedural pain and knee pain
were evaluated using a 0–10 VAS, where 0 indicates no pain and
10 indicates the most severe pain. In order to ensure the validity
and reliability of pain evaluation, a single investigator (Lee SY)
assessed pain levels for all patients. The investigator had substan-
Table 1. Comparisons of Demographic Features and Preoperative Status
between the Anterolateral Portal Group and the Superolateral Portal
Group
Variabl e
Anterolateral
group
(n=31)
Superolateral
group
(n=29)
p-value
Age (yr), mean (SD) 66.3 (7.8) 67.3 (7.5) 0.594
Sex (female) 28 (90.3) 28 (93.3) 0.613
OA severity by K-L grade
Patellofemoral jointa) 0.256
Grade I 16 (51.6) 12 (41.4)
Grade II 12 (38.7) 11 (37.9)
Grade III 3 (9.7) 6 (20.7)
Tibiofemoral jointa) 0.603
Grade II 12 (38.7) 14 (48.3)
Grade III 19 (61.3) 15 (51.7)
Pre-procedure pain (VAS),
mean (SD)
5.2 (1.1) 5.3 (1.0) 0.510
Values are presented as number of patients (%)
SD: standard deviation, OA: osteoarthritis, K-L: Kellgren-Lawrence,
VAS: visual analog scale.
a)There were no patients with K-L grade IV for the patellofemoral joint
and no patients with K-L grade I or IV for the tibiofibular joint.
Fig. 1. Photograph showing the anterolateral portal site (block arrow) in
the left knee with the patient sitting on the edge of a table.

230 Lee et al. Knee Intra-Articular Injection
tial experience in pain evaluation using a 0–10 VAS. Any compli-
cations pertaining to the injection site were promptly noted.
Statistical analysis was done using the SPSS ver. 20.0 (IBM Co.,
Armonk, NY, USA) and p-values of <0.05 were considered statis-
tically significant. The Chi-square test was used to compare cat-
egorical variables, and the Student t-test or paired t-test was used
to compare numerical variables.
Results
Injection through the anterolateral portal provoked less pain
than the superolateral portal, and no differences in the degree of
pain relief at 4 weeks after last injection were found between the
two groups. The mean procedural pain was lower in the antero-
lateral group than in the superolateral group (1.5 vs. 2.7, p=0.004)
(Table 2). No intergroup differences were found in pain level (2.9
vs. 3.1, p=0.517) or the degree of pain relief (2.3 vs. 2.2, p=0.883)
at 4 weeks after last injection. There were no immediate compli-
cations noted following injection, such as transient flushing reac-
tion or erythema at the injection site.
Discussion
Intra-articular injection of the knee joint is commonly per-
formed in clinical practice and is the most common invasive
procedure in sports medicine4,8-11). Although the accuracy of the
intra-articular needle placement through various routes has been
vastly studied, pain-related factors such as procedural pain were
barely touched in the literature. The present study hypothesized
that knee injection through the anterolateral portal would be less
painful and provide better short-term pain relief than the supero-
lateral portal. We found that injection through the anterolateral
portal provoked less pain than the superolateral portal, and no
differences in the degree of pain relief at 4 weeks after last injec-
tion were found between the two groups.
Findings in this study supported our primary hypothesis that
injection through the anterolateral portal would provoke less
pain as compared to the superolateral portal. Our findings are
in contrast with a previous study reporting no significant differ-
ence in procedural pain between the modified anterolateral and
lateral mid parapatellar portals12). On the contrary, our findings
are in line with another previous study on the anterior approach
for knee arthrography, where significant reduction was observed
in absolute and relative degree of pain for the anterolateral route
compared with the anterior paramedian route5). We speculate
that thinner soft tissue for the needle to transverse may be related
to less pain in injection through the anterolateral portal, particu-
larly when the knee is flexed to 90o. In addition, pain detected
during the superolateral approach can be explained by accidental
needle collision with the bone, quadriceps tendon, and suprapa-
tellar synovium13). Nonetheless, our study does not contain any
data explaining why and how injections through the anterolateral
portal provoke less pain than through the superolateral portal.
Future studies are warranted to scrutinize this issue.
In our study, the degree of pain relief at 4 weeks of follow-up
was comparable between the two groups. This does not support
our secondary hypothesis that injections through the anterolat-
eral portal offer better pain relief than through the superolateral
portal. There are only two studies that compared clinical out-
comes between different knee injection sites, and both studies
found no significant difference between each other: lateral mid
patellar injection vs. anterolateral injection12) and infrapatellar
injection vs. medial knee injection14). On the other hand, several
studies compared clinical outcomes of ultrasound-guided versus
blinded injections and reported that ultrasound-guided injections
provided better short-term clinical outcomes than blinded intra-
articular knee injections15,16). However, as the ultrasound-guided
injection technique requires expensive devices and trained skills,
Fig. 2. Photograph showing the superolateral portal site (block arrow) in
the right knee with the patient in the supine position.
Table 2. Comparisons of Portal Site Pain and Pain Relief at Four
Weeks after Injection between the Anterolateral Portal Group and the
Superolateral Portal Group
Variabl e a) Anterolateral
portal (n=31)
Superolateral
portal (n=29) p-value
Procedural pain 1.5 (1.3) 2.7 (1.5) 0.004
Pain at 4 wk 2.9 (1.5) 3.1 (1.2) 0.517
Reduction in pain score
at 4 wk from baseline
2.3 (1.2) 2.2 (1.3) 0.883
Values are presented mean (standard deviation).
a)Visual analog scale.

Knee Surg Relat Res, Vol. 27, No. 4, Dec. 2015 231
its clinical and practical values should be evaluated according to
the situation of each physician.
There are several limitations to our study. First, the accuracy of
intra-articular needle placement was not confirmed. Before the
initiation of this study, we considered ultrasonographic or radio-
graphic confirmation of the accuracy of intra-articular needle
placement, but it deemed impractical or unethical to expose
study participants to additional expense or radiation hazards.
Furthermore, we noted that even though the use of needle guid-
ance might improve the accuracy of knee injections, insufficient
evidence existed to prove that increased accuracy of knee injec-
tions would lead to improved therapeutic outcome. A previous
study reported that blinded knee injections were reasonably
accurate in the lateral injection sites5). Nonetheless, the lack of
accuracy information should be noted to interpret our findings.
A recent systematic review found that overall one in five blinded
knee injections were inaccurate17). In the systematic review, pool-
ing data across studies suggested blinded knee injection at the
superolateral portal site was most accurate (87%) while injec-
tions through medial mid-patellar portal (64%) and anterolateral
portal (70%) were less accurate. Therefore, whether injection
through the anterolateral portal is more accurate than injection
through the superolateral portal should be elucidated in future
studies. Second, all the procedures were performed by a single
experienced knee surgeon. The results of this study may have
been affected by the experience of the surgeon, which may limit
generalization of our findings. Third, only two lateral approaches
were investigated in this study. Hence, studies evaluating the de-
gree of pain through portals of different approaches are required.
Finally, this study should be regarded as a preliminary study us-
ing a small sample size, which prompts future studies with larger
sample sizes and sophisticated evaluation tools regarding needle
placement accuracy. Because of the small sample size, we could
not perform subgroup analyses according to various factors that
could influence the technical difficulty during injection or the de-
gree of pain relief such as body mass index, OA, severity, and the
presence or severity of patellofemoral joint. Therefore, we could
neither mention the effects of the confounders nor recommend
individualized portal selection.
Conclusions
We recommend the anterolateral portal for intra-articular knee
injections. It provokes less pain and provides better short-term
pain relief than the superolateral portal. Randomized trials to
evaluate pain upon multiple routes of injections as well as accu-
racy of needle placement are needed.
Conflict of Interest
No potential conflict of interest relevant to this article was re-
ported.
References
1. Courtney P, Doherty M. Joint aspiration and injection and
synovial fluid analysis. Best Pract Res Clin Rheumatol. 2009;
23:161-92.
2. Lockman LE. Practice tips. Knee joint injections and aspi-
rations: the triangle technique. Can Fam Physician. 2006;
52:1403-4.
3. Hermans J, Bierma-Zeinstra SM, Bos PK, Verhaar JA, Reij-
man M. The most accurate approach for intra-articular nee-
dle placement in the knee joint: a systematic review. Semin
Arthritis Rheum. 2011;41:106-15.
4. Jackson DW, Evans NA, Thomas BM. Accuracy of needle
placement into the intra-articular space of the knee. J Bone
Joint Surg Am. 2002;84:1522-7.
5. Moser T, Moussaoui A, Dupuis M, Douzal V, Dosch JC. An-
terior approach for knee arthrography: tolerance evaluation
and comparison of two routes. Radiology. 2008;246:193-7.
6. Myles PS, Troedel S, Boquest M, Reeves M. The pain visual
analog scale: is it linear or nonlinear? Anesth Analg. 1999;
89:1517-20.
7. Katz J, Melzack R. Measurement of pain. Surg Clin North
Am. 1999;79:231-52.
8. Altman RD, Moskowitz R. Intraarticular sodium hyaluro-
nate (Hyalgan) in the treatment of patients with osteoarthri-
tis of the knee: a randomized clinical trial: Hyalgan Study
Group. J Rheumatol. 1998;25:2203-12.
9. Leopold SS, Redd BB, Warme WJ, Wehrle PA, Pettis PD,
Shott S. Corticosteroid compared with hyaluronic acid
injections for the treatment of osteoarthritis of the knee: a
prospective, randomized trial. J Bone Joint Surg Am. 2003;
85:1197-203.
10. Neustadt DH. Intra-articular injections for osteoarthritis of
the knee. Cleve Clin J Med. 2006;73:897-8, 901-4, 906-11.
11. Schumacher HR, Chen LX. Injectable corticosteroids in treat-
ment of arthritis of the knee. Am J Med. 2005;118:1208-14.
12. Chavez-Chiang CE, Sibbitt WL Jr, Band PA, Chavez-Chiang
NR, Delea SL, Bankhurst AD. The highly accurate anteri-
olateral portal for injecting the knee. Sports Med Arthrosc

232 Lee et al. Knee Intra-Articular Injection
Rehabil Ther Technol. 2011;3:6.
13. Sanchis-Alfonso V, Rosello-Sastre E, Subias-Lopez A. Neu-
roanatomic basis for pain in patellar tendinosis (“jumper’s
knee”): a neuroimmunohistochemical study. Am J Knee
Surg. 2001;14:174-7.
14. Shah KD, Wright V. Intra-articular hydrocortisone in osteo-
arthrosis. Ann Rheum Dis. 1967;26:316-8.
15. Sibbitt WL Jr, Kettwich LG, Band PA, Chavez-Chiang NR,
DeLea SL, Haseler LJ, Bankhurst AD. Does ultrasound guid-
ance improve the outcomes of arthrocentesis and corticoste-
roid injection of the knee? Scand J Rheumatol. 2012;41:66-
72.
16. Sibbitt WL Jr, Band PA, Kettwich LG, Chavez-Chiang NR,
Delea SL, Bankhurst AD. A randomized controlled trial
evaluating the cost-effectiveness of sonographic guidance
for intra-articular injection of the osteoarthritic knee. J Clin
Rheumatol. 2011;17:409-15.
17. Maricar N, Parkes MJ, Callaghan MJ, Felson DT, O’Neill
TW. Where and how to inject the knee: a systematic review.
Semin Arthritis Rheum. 2013;43:195-203.