HIP THIGH KNEE

Ultrasound –
Fundamental

STAFFORDSHIRE MSK STUDY DAY

BMUS

Kirstie Godson
Academic lecturer Leeds University
Why Ultrasound

 Readily available.
 Shorter waiting times.
 Less expensive than other modalities
 No radiation.
 No reactions.
 Increase interest within MSK ultrasound
 Rapidly growing and will continue – future improvements with technology.
Ultrasound structure
Equipment Overview
 Good quality Ultrasound Machine
 High resolution Multi Frequency Linear Ultrasound Probe. (17.5Mhz, 14.5, 9 mhz)
 Hockey stick probe/ Curvilinear probe
 Colour flow/ Power Doppler
 EFV (trapezoid function)/Panoramic
 Liberal use of ultrasound gel (hairy!)
HIP
What’s the big quanundrum

?
 Anatomy
Bone structures and Soft tissue structures

 Abdominal wall musculature

 Anterior hip
 Hip joint
 Ilio-psoas
 Adductor origin
Diagnostic difficulty!!

Complex regional anatomy

 Insertion of rectus abdominis,
adductor tendons, hip
joint/bursae, hip flexors (iliopsoas)
 Inguinal and femoral canals

Complex Nerve distribution

History taking

 How long pain present?

 Pain localised to a particular site?
 Sudden onset?
 What movements or actions precipitate the pain?
 Is there associated clicking or catching?
 Is there a palpable lump?
 GROIN/HIP
Causes of pain
 Rupture of the deep hip flexor
 Inflammation of the adductor (ruptura musculus iliopsoas)
muscle of the thigh  Outer snapping hip
 Rupture of the adductor muscle  Inner snapping hip
of the thigh
 Inguinal, femoral hernia
 Inflammation of the pubic joint
(osteitis pubis)  Stress fracture in the femoral
neck
 Bursitis on the front of the hip
joint (bursitis iliopectinea)  Nerve entrapment
 Other bursitis  Lumbago
 Fluid accumulation in the hip  Piriformis syndrome
joint  Hernia
 Degenerative arthritis in the  Lymphadenopathy
hip joint
 Undescended testicle
 Rupture of the superficial hip
flexor (ruptura musculus rectus  Varicocoele
femoris)  Hydrocoele of the canal of Nuk
 Urological problems
 Hip
 Pathology:
Joint effusion
Trochanteric Bursitis
Septic Arthritis- guided aspiration
Haematomas/Soft tissue masses

 Clinical Conditions:
Pain
Swelling
Redness
Soreness
Blood test results/spiking temp.
HIP

 ANTERIOR HIP
 LATERAL HIP
Rule out other causes
Plain film – X-ray
 MRI

Right Hip fracture and

Normal Pelvis oedema
CT
 Limited but useful for
determining
femoroacetabular
impingement
 33 year-old male with
cam type FAI. (A)
Preoperative computed
tomography shows a
bump on the head and
neck junction. (B)
Postoperative computed
tomography shows
removed bump after
femoroplasty. (C)
Arthroscopic findings
Ultrasound :Anterior Hip joint – Probe position –
Longitudinal along the line of the neck of femur
Anterior hip joint – Pathology

Joint Effusion Hip joint

effusion

FLUID

Femur
 Anterior Hip Joint

Iliopsoas bursitis, Snapping Paralabral cyst/tear

hip, frog leg flexion
Trochanteric Bursa
Therapeutic treatment
Steroid Injection
 GTPS Ultrasound
 Most commonly caused by gluteus minimis and gluteus medius injury/tear
or tendinopathy rather than bursitis
 Distension of bursa often accompany tendon tear, therefore careful
assessment of tendons
 Calcific tendinopathy
 Rare that bursae alone involved with the pain

Eur Radiol. 2007 Jul;17(7):1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome
Anatomy GT

 Gluteus minimus attaches to the

anterior facet GT
 Gluteus medius inserts
superoposterior and lateral facets
GT.
 Three bursae common:
trochanteric, subgluteus medius,
and subgluteus minimus
ULTRASOUND GTPS

CORONAL
Greater Trochanteric region
Probe position - Transverse
Calcific tendinopathy Small partial tear at the
insertion of Gluteus medius

Bursitis
Tensor fascia latae, iliotibial tract

 Lateral hip pain

 Runners proximal enthesopathy
ASIS
 Snapping hip – standing flexion and
extension - TS
IT Band

Leg position: extension; hip internally rotated

Tip: find Gerdy’s tubercle and follow proximally
MRI equivalent : frontal plane
HAMSTRINGS
 Posterior thigh - Hamstrings
Arise from the ischial tuberosity:
 Biceps femoris muscle lies :
laterally.Tendon inserts into head of
Fibula
 Semimembranosus muscle lies:-
medially – tendon inserts medial
condyle
 Semitendinosus muscle lies:-
medially inserts via long tendon
(Pes Anserinus Tendon)- onto the
medial side of the popliteal fossa
Muscle related Pathology

 Haematomas – bruise.
 Morel Lavallee lesion-
 Rupture of muscle – Partial/Complete tears.
 Abscess – Infection.
 Muscle fibrosis – formation of excessive fibrous bands of scar tissue
between muscle fibres.
 Seroma – A pocket of clear serous fluid.
 Myositis Ossificans- abnormal bone formation within deep muscle
tissue, usually associated with haematoma due to trauma.
 Muscle hernia -
Pathology- Haematoma

Vastus lateralis muscle

Gastrocnemius muscle
Muscle rupture

Biceps Femoris
seroma
stump
Muscle Fibrosis

Muscle fibrosis

Defect Normal muscle

Myositis ossificians

Calcification
Quadriceps tendon
 Clinical Conditions

 Pain
 swelling
 Inability to actively extend knee.
 Palpable defect.
Causes:
 Trauma – falls, direct blows, lacerations.
 Associated Conditions: Renal disease, DM, RA , gout, obesity, osteomalcia,
steroid use.
 Anatomy - Quadriceps tendon
It attaches the 4 Quadriceps muscle to the patella: function – knee flexion and
extension

1. Rectus Femoris -superficial– mid thigh – tendinous 3-5 cm

proximal to the patella.
2. Vastus Lateralis – Lateral side of femur- tendinous 3cm from
patella
3. Vastus medialis- Medial side of femur- tendinous 3 cm from
patella.
4. Vastus intermedius – In between – deep layer to RF.
Inserts onto the proximal section of the patella.
Technique Quadriceps tendon

 The anterior aspect of the knee is examined with the patient supine.
 A knee flexion of approximately 20°-30° obtained by placing a small pillow
beneath the popliteal space stretches the extensor mechanism
 avoids possible anisotropy related to the concave profile that the quadriceps
and patellar tendons assume in full extension.
Ultrasound Technique- Transverse section
Anterior thigh- Quad muscles
RF- Rectus Femoris VI Vastus intermedius
VL – Vastus Lateralis VM – Vastus Medialis
 Probe position - Longitudinal section

1
2
3

Supra-patellar fat

http://musculoskeletalmri.blogspot.co.uk/2011/07/stairs-and-tendon-tear.html
Pathology

 Tendinopathy
 Calcific tendinopathy
 Avulsion fracture
 Partial tear /Complete tear tendon
 Muscle tears
 Abscess
 Miscellanous - Cyst
Pathology

 Tendinopathy – term that describes predominantly degenerative conditions

that cause pain, swelling and stiffness ( NICE April 2010).
 Repeated overuse- causes degeneration and disorganization of the Collagen
fibres .
 Imbalance between pathological changes that occur in response to injury
 Complications – lead to tears/ruptures. (NICE April 2010)
Tendinopathy

 Focal thickening - tendon is against another structure which causes friction.

 Hypoechoic areas within the tendon.
 Disruption of the normal architecture of the tendon.
 Noticeable vascularity
Pathology -Tendinopathy.

Patella Patella
Calcific tendinopathy
 Partial /complete tears

 Partial tear/complete tear – generally over 40’s. Men.

• High grade partial tear of the quadriceps tendon.

• Red arrow Quads tendon as is the large hematoma Green arrow –
haematoma
• Pink arrow – Patella is positioned more inferiorly than normal
• White arrow - patellar tendon is lax, suggesting that this is
functionally a complete tear.
• The deep layer of the quadriceps tendon, composed of the vastus
intermedius (yellow arrow), remains intact

http://musculoskeletalmri.blogspot.co.uk/2011/07/stairs-and-tendon-tear.html
Avulsion Fracture

Avulsion fracture
RFM

Patella

Quads Tendon
Abscess

Quads
muscle abscess

femur
KNEE
 Extensor Mechanism
Tendons -Patella tendon
Quadriceps tendon
Popliteal fossa
Bursa

Medial and lateral Collateral ligament

Pes Anserinus
Patella Tendon
 5 cm in length
 Originates from Apex of Patella
 Inserts tuberosity of the Tibia
 Function: attaches the patella to
Tibia to allow straightening of
the knee.
 Patella tendon technique
 The anterior aspect of the knee is examined with the patient supine.
 A knee flexion of approximately 20°-30° obtained by placing a small pillow
beneath the popliteal space stretches the extensor mechanism
 avoids possible anisotropy related to the concave profile that the quadriceps
and patellar tendons assume in full extension
 from its cranial origin down to its distal insertion using long- and short-axis
planes.
 Because the lower pole of the patella has a V-shaped appearance, one should
be aware that the tendon inserts not only on the apex but also along the
inferolateral and inferomedial edges of the bone.
 Short-axis US images over the proximal patellar tendon should be also
performed
because tendinopathy may occur out of the midline.
Probe position – Longitudinal section

Patella Tendon

P Tibia
bursa
HFP
Patella tendon - Transverse Positioning.

Patella tendon

HFP
Clinical indications

 Pain
 Jumper’s Knee
 Injury- Falls/direct impact
 Chronic disease
 Osgood Schlatter Disease
 Pathology

 Tendinopathy- usually at insertion /in the mid tendon

 Ruptures:
Intrasubstance tear- small fluid filled pocket within the tendon
Partial – Some tendon fibres identified through the tear
Complete – Complete disruption of fibres, No fibres attached at
either ends of the tear.
 Chronic diseases- Weakens the tendon.
Pathology- Tendinopathy
Tendinopathy continued.
Jumper’s Knee

Tendonopathy at apex insertion, thickened patella tendon, micro

ruptures, increased cortico- irregularity and increased vascularity.
Partial – Tears/Ruptures

Patella
Tibia

Mid Tendon
Complete Rupture

To reattach the tendon, small holes are drilled in the kneecap (left) and
sutures are threaded through the holes to pull the tendon back to the bone (right).

This x-ray taken from the side shows the normal location of the kneecap.
(Right)
The kneecap has moved out of place due to a torn patellar tendon.
Popliteal Fossa

 Anatomy: - posterior aspect of the knee joint.

Medial and lateral heads of Gastronemius muscle

femoral condyle
Sartorius muscle
Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)
and Gastrocnemius tendon - important landmark.
Knee – Bursa

 Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011
Probe position

Sartorius

GT
SMT
Head of
Gastrocnemius
muscle

Medial
Femoral
Condyle
 Clinical Indications.
Pathology

Clinical indications.
 Pain
 Swelling
 Aching

Pathology:
 Baker’s cyst
 DVT
 Popliteal aneurysm
Popliteal fossa – Common pathology
Baker’s cyst

Baker’s
cyst

GT SMT

Tail
Neurovascular bundle

DVT – Popliteal vein

Popliteal aneurysm
Ligaments of the knee-
Medial and lateral collateral ligaments

 Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place:
 Clinical indications:
instability
 Pathology:
Rupture
Bowing of the meniscus/ligament
 Ultrasound technique for assessment
of medial aspect of knee
 For examination of the medial knee, the patient is asked to rotate the leg
externally with a 20°-30° of knee flexion.
 Place the transducer obliquely-oriented over the long-axis of the medial
collateral ligament.
 Care should be taken to examine the entire length of this ligament.
 Dynamic scanning during valgus stress can improve the assessment of its
integrity.
 Check the soft-tissues immediately superficial to the base of the medial
meniscus.

https://essr.org/content-essr/uploads/2016/10/knee.pdf 4/2017
Medial Collateral ligament
Probe positioning

Femur MCL Tibia

 Partial rupture of Medial Collateral
ligament.

Tibia

MM
Femur
Lateral Collateral ligament
Probe positioning

LM Tibia
femur FH
Meniscus

Bulging
LM
 Pes Anserinus – Goose feet
 The Pes Anserinus Tendon- formed by the conjoined
joining of
3 muscles :
 Sartorius
 Gracilis
 Semitendinosus muscles.
Arise from posteriorly lower thigh and go from medially
to laterally, Remember:
Say Grace before Tea
Clinical importance: Chronic knee pain and weakness.
Clinical conditions: Pain, swelling and tenderness
Pes anserinus
References
 Aaron DL, Patel A, Kayiaros S, Calfee R 2011 Four common types of bursitis: diagnosis and
management. J Am Acad Orthop Surg.19(6):359-67.
 https://theultrasoundsite.co.uk/ultrasound-guided-injection-of-the-hip-joint-tutorial Accessed
12/4/2017
 http://www.physiopedia.com/Diagnostic_Imaging_of_the_Hip_for_Physical_Therapists
 Chan Kang, MD, Deuk-Soo Hwang, MD 2012 Arthroscopic Treatment of Femoroacetabular
Impingement of the Hip: 5-7 Years Sep2012;24(3):237-244.
 Https://radiopaedia.org/articles/hip-joint-1 Accessed 12/4/2017
 https://essr.org/content-essr/uploads/2016/10/hip.pdf Accessed 12/4/2017
 https://radiopaedia.org/articles/knee-joint-1 Accessed 12/4/2017
 Eur Radiol. 2007 Jul;17(7):1772-83 MRI and US of gluteal tendinopathy in greater trochanteric
pain syndrome
 http://musculoskeletalmri.blogspot.co.uk/2011/07/stairs-and-tendon-tear.html. Accessed
12/4/2017
 http://www.ultrasoundcases.info Accessed 12/4/2017
 http://orthoinfo.aaos.org/topic.cfm?topic=a00512 Accessed 12/42017
 Christopher C Annunziata, MD Orthopedic Surgeon, Commonwealth Orthopedics and Rehabilitation; Assistant
Clinical Professor, Department of Orthopedic Surgery, Georgetown University Medical Center; Team Physician,
Washington Redskins; Orthopaedic Consultant, The Washington Ballet 2017. Patella tendon rupture and treatment
http://emedicine.medscape.com/article/1249472-treatment#d18 accessed 12/4/2017

 https://www.slideshare.net/saurabsharma/1-biomechanics-of-the-knee-joint-basics accessed 12/4/2017

 https://cks.nice.org.uk/pre-patellar-bursitis#!scenario Accessed 12/4/2017