Hip normal

Lateral Hip

Anatomy of the lateral hip

Gluteal tendons
Bursae
Tensor fascia latae (TFL)
Ilio-tibial band (ITB)

Gluteus Maximus (purple)

Gluteus Medius (yellow)

Gluteus Minimus (Green)

Tensor Fascia Latae (blue)

Gluteus Maximus Trochanteric bursa (red arrow)

Gluteus Medius Trochanteric bursa (black arrow)

The gluteus minimus and medius attach distally to the greater trochanter.

Tendons of the lateral hip

Gluteus maximus
Gluteus minumus
Gluteus medius

This highlighted picture shows the relationship of the lateral hip structures.

The gluteus minimus is deep to the gluteus medius and it inserts anteriorly on the greater trochanter.

Transverse scan plane.

Transverse view of the gluteus Minimus and gluteus Medius Tendons.

Gluteus medius overlies the gluteus minimus muscle.

Gluteus medius in pink and minimus in blue.

Tensor fasciae Latae (TFL)

The origin of the tensor fasciae latae is from the ASIS and it courses laterally and caudal to meet the anterior tensor fascia latae which is superficial to the vastus lateralis.

Normal TFL coming off the ASIS.

Bursae of the lateral hip

Trochanteric
Sub gluteus minimus
Sub gluteus medius
Ischio-gluteal

Trochanteric bursa movement ultrasound

Ultrasound of a normal trochanteric bursa. This demonstrates the best method to mobilise the anatomy and identify the trochanteric bursa. Knees together. gently raise the top foot. The ITB will be seen sliding over the gluteal tendons (or on the bone if the gluteals are torn). The thin hypoechoic layer under the ITB is the trochanteric bursa.

Ischiogluteal Bursa

Move the probe posteriorly in a transverse plane till the ischium in visualised . The bursa is anterior to this and under the gluteus maximus.

Anterior Hip

Anatomy of the anterior hip

Bony joint
Capsule
Labrum
Iliopsoas tendon and bursa
Rectus femoris origin
Sartorius

The anterior joint capsule can be seen with ultrasound from the femoral head to the neck of femur.

The rectus femoris muscle is deep to the sartorius muscle.

The attachment is at the anterior inferior iliac spine (AIIS)

The AIIS can be palpated and the probe can be positioned longitudinally to see the tendon originating from the bony protuberance of the pelvis.

The rectus femoris should be observed in a transverse plane and moved from the proximal insertion to the muscle.

Rectus femoris origin

The rectus femoris origin at the Anterior Inferior Iliac Spine (AIIS)

ANATOMY

Iliopsoas muscle and sartorius

The iliopsoas muscle and tendon are seen in blue tracking caudally and inserting into the lesser trochanter distally. The sartorius muscle in yellow attaches proximally at the anterior superior iliac spine (ASIS) and has an oblique course throughout the thigh crossing medially to insert to the medial side of the proximal tibia.

The sartorius origin is seen in this image at the ASIS.

The sartorius muscle is the most anteriorly placed superficial rounded structure. It can be visualised in a transverse plane as seen here and followed to the origin.

Anterior hip joint and capsule

Capsule normal adult thickness <7mm.

This is the scan plane to assess the anterior hip joint and in particular to visualise an effusion.

Normal hip recess

Anterior hip ilio-psoas tendon and bursa

The musculo-tendinous junction of the iliacus and psoas muscles is approximately at the level of the hip joint.
The bursa underlies the tendon on the pubis.

Probe position to assess the ilipsoas tendon.

The probe is positioned to the right of the symphysis pubis.

A normal iliopsoas tendon in a transverse plane.

The iliacus is still approaching the musculotendinous junction.

Iliopsoas Tendon scan plane is in a sagittal plane. It inserts into the lesser trochanter.

Normal iliopsoas tendon distal insertion to the lesser trochanter.

Probe is positioned in the midline medially with the distal end at the lesser trochanter.

Normal psoas tendon insertion.

Posterior Hip Anatomy

To visualise the hamstrings the patient should be rolled decubitus with the affected side raised. The probe is positioned over the ischial tuberosity.

The long head of the biceps femoris (yellow) attaches proximally at the ischial tuberosity lateral to the semitendinosis tendon. (blue). and attaches distally at the fibula. The ST travels medially and attaches to the medial tibia.

Probe position for longitudinal and transverse view of hamstring tendons.

Origin of semimembranosus attachment

It is deep to the semitendinosis tendon on the ischial tuberosity.

The video has resected the long head of the biceps femoris to show the semimembranosus tendon (light blue) deep to the semittendinosis attachment (dark blue) on the ischial tuberosity.

The biceps femoris is seen by rolling the patient on their side and with some firm pressure on the ischial tuberosity the irigin is clearly seen here (yellow mouse over).

This is the biceps femoris in a transverse plane.

The semiteninosis is medial to the biceps femoris seen here inserting into the ischial tuberosity in a longitudinal plane.

The probe is swept medially from the biceps femoris.

The biceps femoris (yellow) and the semitendinosis (blue) both visualised together in a transverse plane. The ST is medial to the BF.

The semitendinosus is superficially seen here (red) overlying the semimembranosus tendon (green).

SCAN PROTOCOL

Role of Ultrasound

Ultrasound is a valuable diagnostic tool in assessing the following indications;

Muscular, tendinous and some ligamentous damage (chronic and acute)
Bursitis
Joint effusion
Vascular pathology
Haematomas
Soft tissue masses such as ganglia, lipomas
Classification of a mass eg solid, cystic, mixed
Post surgical complications eg abscess, oedema
Guidance of injection, aspiration or biopsy
Some bony pathology.

Limitations

The size of the patient can limit the visualisation of the normal anatomical landmarks.

Patient Preparation

Before scanning know the origins and insertion sites of the gluteus minimus, gluteus medius, gluteus maximus, piriformis tendons and the fascia latae position.
Know the 3 common sites of bursitis.
Roll patient onto unaffected side initially then assess supine and compare.
Start with a curved linear array probe approx 6-8Mhz to assess the muscles deep to the hip.
To evaluate the bursae use a 7-12MHz linear probe.
Use a multi focus.
Narrow the dynamic range.
Ask the patient where the pain is and scan there first.
Run the probe up and down the lateral hip aligned to the long axis of the femoral shaft, and then move anterior and posterior.
Look in coronal and transverse.
Compare sides.
Remember that fluid is mobile and gravity dependant so do not over compress and do look in supine .Also vary the patients leg position from extension to flexion and even abduction if this creates the pain. Look at the patient erect.

Equipment setup

Use of a high resolution probe (7-15MHZ) is essential.

Careful scanning technique to avoid anisotropy (and possible misdiagnosis).

Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons.

Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure.

Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

INDICATIONS FOR TROCHANTERIC BURSITIS

Pain over greater trochanter
Pain in buttock
Pain down lateral thigh
Aggravation with lying on side , walking, abduction, internal rotation and external rotation
More common in females
More common over 50 yrs

Common Pathology

Trochanteric Bursitis
Tendinopathy
Tendinosis
Enthesopathy
Tears
Snapping Hip
Tensor Fascia Latae Tendinopathy
Injections

SCANNING TECHNIQUE

There are 2 ways of approaching the lateral hip to start imaging.

Start posteriorly and work towards anterior greater trochanter.
Start anterior and work posteriorly.

The anterior-posterior technique (just adapt it in reverse if you prefer to work posterior to anterior).

Use a high frequency curved linear array probe to appreciate the entirety of the muscle bellies.
Start anteriorly to look at the linear hyperechoic band superficial to the gluteus minimus and gluteus medius muscles, this is the tensor fascia latae.
Change to a high frequency linear array probe 5-12MHz to scan in transverse and coronally.Check for tendinopathy at its origin or any fluid under it.
Now move posteriorly to visualize the anterior portion of the gluteus minimus and gluteus medius.The gluteus minimus is seen on the anterior surface of the greater trochanter.The muscle comes from deep below the gluteus medius and is a hyperechoic tendon.
The gluteus medius inserts further posteriorly but can be seen in a transverse view of the greater trochanter with the gluteus minimus insertion.
Run up and down to check its insertion into the greater trochanter.
As you move posteriorly the gluteus maximus comes into focus.
Usually a curved linear array probe is the only way to see it because it runs deeply and attaches into the lateral femur.
The piriformis,oblique muscles and quadratus femoris are not seen well enough to reliably diagnose pathology.

Ultrasound Appearance

Beware of anisotropy at the insertion of the gluteus tendons onto the greater trochanter. It can mimic a partial or full thickness tear.

Basic Hardcopy Imaging

A hip/buttock series should include the following minimum images:

Document the normal anatomy.
Any pathology found in 2 planes, including measurements and any vascularity.