Gonyalgia paresthetica

Gonyalgia paraesthetica (from the Greek gony = knee; algos = pain; paresthesia = abnormal sensation) can be described as a neuropathic pain and dysesthesia syndrome in the knee region caused by irritation or damage to sensory nerve branches.

The primary focus is on lesions or compression of superficial sensory nerves, particularly the saphenous nerve and its infrapatellar branch.

• Iatrogenic: Following knee arthroscopy, knee replacement, cruciate ligament surgery, or other surgical procedures; injury to small cutaneous nerve branches.
• Traumatic: Contusions, lacerations, scarring, local hematomas.
• Compressive: Mechanical irritation caused by kneeling, pressure, or postoperative fibrosis.
• Inflammatory: Local neuritis and perineural inflammatory processes.
• Proximal-neurogenic: Lesions of the femoral nerve, L3/L4 radiculopathies, or saphenous neuropathy in the adductor canal.

Damage to sensitive nerve fibers leads to ectopic neuronal discharges, altered stimulus processing, and, in some cases, peripheral or central sensitization. This results in neuropathic pain, paresthesias, dysesthesias, and neuropathic pruritus.

Characteristic symptoms include:

• Burning, stabbing, or electric-shock-like pain in the knee area.
• Tingling, pins-and-needles sensations, and numbness.
• Hypersensitivity to touch (allodynia).
• Hyperesthesia or hypoesthesia.
• Localized itching (neuropathic pruritus), occasionally as the primary symptom.
• Symptoms worsen with pressure, kneeling, or mechanical irritation.

In cases of a lesion of the infrapatellar branch, the area of discomfort is predominantly anteromedial or infrapatellar. Motor function is preserved in cases of an isolated lesion of this purely sensory branch.

The diagnosis is primarily clinical, based on the precise topographical localization of the affected skin area to a specific sensory nerve distribution area. Additionally:

• Sensory testing: touch, pain, temperature, allodynia, and hypoesthesia.
• Hoffmann-Tinel sign: Triggering of electric-shock-like sensations by tapping the affected nerve.
• Ultrasound: Detection of nerve thickening, neuromas, scar tissue, or causes of compression.
• Neurophysiology: Indicated when a proximal nerve lesion or radiculopathy is suspected; often of limited diagnostic value in cases of isolated lesions of small cutaneous branches.
• Diagnostic nerve block: Local anesthetic infiltration to confirm suspected focal neuropathy.

Treatment is carried out in stages and depends on the cause, severity, and duration of symptoms.

Pressure relief: Avoid kneeling, local compression, and mechanical irritation; basic measure

Lidocaine 5%: Patches for localized neuropathic pain and allodynia; off-label use

Capsaicin 8% patch: For chronic localized neuropathic pain; use under medical supervision

Gabapentin: Start with a low dose, e.g., 100–300 mg in the evening, then increase as needed; usual daily dose for neuropathic pain is 900–3,600 mg, divided into three doses

Pregabalin: Initial dose often 25–75 mg in the evening or twice daily; increase depending on tolerance; usual daily dose range 150–600 mg

Amitriptyline: Initial dose 10–25 mg in the evening, with gradual dose escalation; particularly effective for nighttime symptoms

Local nerve block: Ultrasound-guided infiltration with a local anesthetic, combined with a corticosteroid if necessary

Interventional therapy: For refractory symptoms, radiofrequency ablation, cryoablation, or peripheral nerve stimulation

Surgical therapy: Neurolysis, neuroma excision, or selective neurectomy in cases of a confirmed focal lesion and a positive diagnostic nerve block

Of particular dermatological relevance: Gonyalgia paraesthetica belongs to the group of localized cutaneous neuropathic dysesthesia syndromes, along with notalgia paraesthetica, meralgia paraesthetica, and cheiralgia paraesthetica. Itching without primary skin lesions can also be a manifestation of focal sensory neuropathy. Secondary hyperpigmentation may also develop as a result of scratching, excoriations, and lichenification.

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2. Boyle J et al. (2021): Infrapatellar Branch of the Saphenous Nerve: A Review. DOI: 10.1111/1754-9485.13141.
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4. Peng MSJ et al. (2026): Infrapatellar branch of the saphenous nerve: from anatomy and sonoanatomy to its clinical implications. Reg Anesth Pain Med. DOI: 10.1136/rapm-2025-106383.
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