Ultrasound-Guided Multi-Branch Rectus Femoris Nerve Block for Spasticity Assessment

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Background: Stiff-knee gait commonly involves rectus femoris spasticity in patients with central nervous system lesions. Diagnostic nerve blocks aid in predicting treatment outcomes; however, current techniques may overlook multiple nerve branches that innervate the rectus femoris muscle, potentially resulting in an incomplete assessment of treatment outcomes. Methods: We present an ultrasound-guided approach that we currently use in our practice, using anatomical landmarks, including the femoral artery, the sartorius muscle, and the rectus femoris’ characteristic “J-shaped” internal tendon. The technique employs an “elevator” scanning method to identify all motor nerve branches (typically 2–3) entering the proximal third of the rectus femoris muscle. Each branch is blocked using an in-plane needle approach with 1–2 mL of 2% lidocaine. Results: The technique enables the visualization of hyperechoic nerve branches entering the rectus femoris muscle from medial to lateral, sometimes accompanied by small vascular branches that are identifiable with a Doppler ultrasound. Optimal ultrasound settings include probes >8 MHz, appropriate focus positioning, and dynamic range < 60 dB. The multi-branch approach produces rapid-onset motor weakness (5–10 min). Conclusions: This comprehensive multi-branch rectus femoris nerve block technique may enhance diagnostic accuracy for spasticity assessment, potentially leading to more informed treatment selection for stiff-knee gait.

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