Spasticity: Lower Extremities • Flexed Hip • Adducted Thigh • Flexed Knee • Extended (Stiff) Knee • Equinovarus Foot • Valgus Foot

Flexed Hip Iliopsoas Rectus femoris Adductor longus Adductor brevis Adductor magnus

Rectus femoris The midbelly of the muscle is located at the Psoas :With ultrasound or fluoroscopic guidance lateral to the transverse spinous process of L4 or L5. Iliacus Injection site: two fingers’ width (3–4 cm) lateral to the femoral artery and one fingers’ width (1–2 cm) distal to the inguinal ligament. Injection depth: 2–4 cm depending on the thickness of the muscle Patient position: supine, the right leg slightly flexed Rectus femoris The midbelly of the muscle is located at the Midpoint between the anterior superior iliac spine and the patella.

Adducted Thigh Adductor magnus Adductor longus Adductor brevis

Adductor longus muscle: Patient lies supine. Abduct the leg to 15 degrees. Palpate the tendon arising from the pubic tubercle and insert the needle 2-4 finger breadths distal to the tubercle into the muscle belly.

Adductor magnus muscle: Patient lies supine. Abduct and externally rotate the leg. Insert the needle midway between the medial femoral epicondyle and the pubic tubercle.

Flexed Knee Medial hamstring Lateral hamstring Gastrocnemius

Medial hamstring muscles: Patient lies prone, Insert the needle at the midway on a line between the medial femoral epicondyle and the ischial tuberosity.

Lateral hamstring muscles: Patient lies prone. Insert the needle at the midway on a line between the fibula head and the ischial tuberosity.

Extended (Stiff) Knee Vastus intermedius Rectus femoris Vastus medialis Vastus lateralis

Vastus intermedius Rectus femoris Vastus medialis Vastus lateralis The midbelly of the muscle is midway between the anterior superior iliac spine and the patella. Vastus intermedius is often overlooked and can be a major contributor to knee extension. Rectus femoris The midbelly of the muscle is located at the midpoint between the anterior superior iliac spine and the patella. Vastus medialis The midbelly of the muscle is located midway between the pubic symphysis and the medial part of the knee joint. Vastus lateralis The midbelly of the muscle is located midway between the greater trochanter and the patella.

Rectus femoris: Patient lies supine Rectus femoris: Patient lies supine. Insert the needle on the anterior aspect of the thigh, midway between the superior border of patella and the anterior superior iliac spine.

Equinovarus Foot Soleus Gastrocnemius Tibialis posterior

Soleus Medial or lateral approach is midway to two-thirds the distance from the heel to the popliteal fossa. Can also be approached through the gastrocnemius. Insert the needle deep just distal to the belly of the gastrocnemius muscle, medial and anterior to the Achilles tendon.

Gastrocnemius The midbelly of the muscle is located one-quarter the distance from the popliteal fossa to the heel. Gastrocnemius, medial head: Patient lies prone, leg extended. Insert at the most prominent point of the medial muscle mass (approximately 3 fingers to one handbreadth below the popliteal crease.)

Tibialis posterior: Patient lies prone, with the leg in internal rotation. 1-2 cm medial to the margin of the tibia at the junction of the upper two-thirds with the lower third of the shaft. Direct the needle obliquely underneath the shaft through the soleus and flexor digitorum muscles.

Valgus Foot Peroneus longus Peroneus brevis Gastrocnemius Soleus

Peroneus longus The midbelly is located at the upper one-third of the lateral fibula. 5-7 cm below the fibular head along the lateral aspect of the fibula.

Peroneus brevis The midbelly is located at the lower one-third of the lateral fibula. 8-10 cm above the lateral malleolus just the lateral aspect of the fibula.