Ultrasound Normal and Pathological

Anatomy of the Hip

Gi - young Park M.D., Ph.D.

Department of Rehabilitation Medicine

Daegu Catholic University School of Medicine

Learning Objectives

• Demonstration of the ultrasonographic

anatomy of the hip

• Demonstration of the routine ultrasonographic

evaluation of the hip

• To recognize the ultrasonographic appearances

of the hip pathology

• To learn ultrasonography-guided procedures

Hip Ultrasonography

Hip Joint Evaluation

• Longitudinal view

AH

Psoas

• A, acetabulum; H, femoral head;

fibrocartilage labrum (arrow);

iliofemoral ligament (arrow head)

Hip Joint Evaluation

• Longitudinal view• H, femoral head; collapsed

joint (arrow head)

H

Psoas

Hip Joint Evaluation

• Transverse view

Psoas

H

• H, femoral head; hyaline

cartilage (arrow); iliofemoral

ligament (arrow head)

Femur

Patella

Hip Joint Effusion

• Longitudinal (A) and transverse (B) ultrasonographic

images of the anterior hip demonstrate the hyperechoic

joint capsule (arrows), displaced from the echogenic

interface of the femoral neck (N) by a joint effusion

(asterisk). H (femoral head), I (iliopsoas).

• Left image: Longitudinal sonogram of the hip reveals a moderate joint effusion (yellow outline).

• Right image: Longitudinal sonogram acquired during ultrasound guided percutaneous aspiration demonstrates the needle (blue arrows) extending into the effusion.

Femur

Patella

Quadriceps tendon

Hip Effusion

Ultrasonography-guided Hip Injection

Ultrasonography-guided Hip Injection

Iliacus Hematoma

Iliacus Hematoma

Longitudinal view Transverse view

Iliacus Hematoma

Longitudinal view Transverse view

Iliacus Hematoma

Right Left

Snapping Hip Joint

Audible snap experienced during certain movement of the hip joint, which may or may not be painful

Ultrasound offers a distinct advantage over MRI for identifying the source of symptoms in patients who can reproduce their snapping

Intra-articular

Tears of acetabular labrum, osteophytes, osteochondromatosis, and loose bodies

Extra-articular

Lateral snapping: iliotibial band slides over greater trochanter

Medial snapping: iliopsoas tendon catching over iliopectineal eminence or body ridge of lesser trochanter

Alternate cause: long head of biceps snap over posterior aspect of ischial tuberosity

Causes of Snapping Hip Joint

Snapping Iliopsoas Tendon

When hip is flexed, externally rotated and abducted, iliopsoas

tendon shifts laterally relative to iliopectineal eminence (IE)

When hip return to extended position, iliopsoas tendon

impinges against iliopectineal eminence until snapping over it

and moving suddenly medially

Snapping Iliopsoas Tendon

Snapping Iliopsoas Tendon

Snapping Iliopsoas Tendon

Location of Three Greater

Trochanter Bursae

Gluteal Muscle and Bursa

Gluteus minimus

Gluteus medius

Gluteus maximus

Greater Trochanter Facet Anatomy

Greater Trochanter Facet Anatomy

Location of Three Greater

Trochanter Bursae

Greater Trochanter Evaluation

• Longitudinal view

• GT, greater trochanter; IT,

iliotibial tract; gluteus medius

tendon (arrows)

GT GT

ITIT

Greater Trochanter Evaluation

• GT, greater trochanter;

IT, iliotibial tract; gluteus

medius tendon (arrows)

GT

IT

Greater Trochanter Evaluation

• Transverse view • GT, greater trochanter; gluteus

medius tendon (arrows); gluteus

minimus tendon (arrow heads)

GT

Greater Trochanter Evaluation

• Longitudinal view • GT, greater trochanter;

iliotibial tract (arrows)

GT

Greater Trochanter Evaluation

• Longitudinal view• GT, greater trochanter; GM,

gluteus maximus muscle;

iliotibial tract (arrows)

GTGM

Greater Trochanter Evaluation

• Longitudinal view• GT, greater trochanter; GM,

gluteus medius muscle; gluteus

minimus tendon (arrows)

GT

GM

Greater Trochanteric Pain Syndrome

Trochanteric Tendinobursitis

Trochanteric Bursitis

Gluteal Bursitis

Typical Pain

Referred Pattern

Greater Trochanteric Pain Syndrome

• Defined as tenderness to palpation over the greater

trochanter with patient in side-lying position

Physical Examination

• Single-leg stance held for 30 seconds

• Resisted external derotation (resisted

realignment of the externally rotated hip)

• Active and resisted abduction of thigh

– Active abduction up to 25o, with thigh extended

– Resisted abduction with thigh successively

extended, then flexed at 45o and 90o

• Passive external rotation with thigh flexed 90o

Single Leg Stance

Resisted External Derotation Test

Diagnostic Value of Clinical Tests

Gluteus Tendon Tear

• Partial-thickness

tear of gluteus medius

• Full-thickness tear

of gluteus minimus

Gluteus Minimus Tendon Tear

Gluteus Medius Tendinosis

Gluteus Medius Tendinosis

Gluteal Bursitis

Gluteus Maximus

Gluteus Medius

Gluteal Bursitis

Gluteus Medius

Gluteus Maximus

Gluteus Maximus

Gluteus Medius

• Longitudinal sonogram shows a small anechoic focus

(arrows) in the superficial fibers of gluteus medius and

increased vascularity on power Doppler examination.

Partial Tear of Gluteus Medius Tendon

• 이 O O, M/55, C.C.: Rt. lateral hip pain for 1 year

• P/E: Atrophy at Rt. greater trochanter area, Rt. single leg

stance (+).

Partial Tear of Gluteus Medius Tendon

Partial Tear of Gluteus Medius Tendon

• Transverse ultrasound shows an anechoic focus (arrows) in

gluteus medius tendon. However, power Doppler examination

shows no increased vascularity.

• Small amount of fluid over right greater trochanter of femur

(under iliotibial band)

• No increased vascularity is noted

Subgluteus Maximus Bursitis

Subgluteus Maximus Bursitis

Rotator-cuff of Hip

• Iliopsoas and subscapularis: powerful internal

rotator which inserts into the lesser

trochanter/tuberosity

• Gluteus minimus and medius/supraspinatus and

infraspinatus: two abductors which insert into the

greater trochanter/tuberosity

• Reflected head of rectus femoris/long head of

biceps: tendon crossing the head

• Tears of the rotator cuff of the shoulder always

start in the supraspinatus tendon

• In the hip, such a tear starts in the insertion of

gluteus minimus and the anterior third of gluteus

medius near the digital fossa in the front of the

greater trochanter

• Pain attributed to trochanteric bursitis, however,

may be secondary to tearing of the gluteal muscles

Rotator-cuff Tear of Hip

Treatment

• Nonsteroidal anti-inflammatory drug

• Bed rest, physical therapy: ice, heat, ultrasound

• Hip & low-back muscle strengthening & stretching

exercise

• Local anesthetic injection with/without

corticosteroid

– 50 % of mixture at maximal tender point &

rest infiltrated widely around, needle length

(3.8 to 7.6 cm)

• Surgery for refractory cases

Injection

Ultrasonography Guided Injection

Ultrasonography Guided Injection

Iliopsoas Bursitis

• Pain felt the the groin, anterior thigh, knee

and leg

• Appears during walking and specific

movement, e.g. crossing the legs

• Untreated, the disorder can go on for years

•Generally overlooked, blamed on the slight

arthrosis on a radiograph

Location of Psoas and Ischial Bursae

Iliopsoas Bursa

Iliopsoas Bursitis

Injection

Injection

Necrotizing Fascitis

Necrotizing Fascitis

Necrotizing Fascitis

Necrotizing Fascitis

Necrotizing Fascitis

Necrotizing Fascitis

Necrotizing Fascitis

WFUMB 2011

WFUMB 2011

Dr. S. Bianchi

Dr. C. Martinoli

Thank Your for Your Attention