Iliopsoas and Anterior Hip • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A

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Disclosures: Iliopsoas and Anterior Hip • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier

Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc.

Sonographic Technique: Hip

Outline: • Anterior – Hip joint • Iliopsoas complex – Anterior musculature –Iliopsoas bursa – Snapping iliopsoas –Snapping hip – Iliopsoas bursa – Lateral femoral cutaneous nerve • Rectus femoris • Transducers: – 10 – 15 MHz linear – <10 MHz curvilinear if needed

Iliopsoas Complex A Iliopsoas Bursa AIIS • Hip joint communication in 10%

A Ilium – Increased with hip joint pathology B – After joint replacement • May extend cephalad into abdomen • May be mistaken for psoas abscess – Look for hip joint communication

Pubis Radiology 1995; 197:853 Red: psoas major Femoral Orange: medial iliacus fibers Head Short Axis Purple: lateral iliacus fibers From: Guillin R. et al. Eur Rad 2009; 19:995

1 Iliopsoas Bursal Fluid Iliopsoas Bursa • Oblique-axial plane: – Superior to femoral head – Lateral to medial – Inject between tendon, ilium1 • Pain relief = successful iliopsoas surgical release2

IP 1Dauffenbach J et al. J Ultrasound Med 2014; 33:405 Femoral Head Long Axis 2Blankenbaker DG. I Skeletal Radiol 2006; Ilium Short Axis 35: 565

Peritendon Injection • Iliopsoas tendon Iliopsoas Hemorrhage Acetabular • Impingement from anterior Acet Cup rim of acetabular cup of • Hemophilia Head hip arthroplasty Neck • Anticoagulation • Pain relief = successful • Acute: iliopsoas surgical release – Hyperechoic, enlarged – May be extensive Wank R et al. J Clinical Ultrasound 2004; 32:354.

Iliopsoas Hemorrhage Snapping Hip Syndrome • Painful snap with hip motion • Intraarticular • Extraarticular: – Anterior: iliopsoas tendon – Lateral: iliotibial tract or gluteus maximus

2 Snapping Hip Syndrome: iliopsoas Snapping Hip Syndrome: iliopsoas 1 2

• Image long axis to inguinal ligament superior to femoral head • Extension of flexed abducted and externally rotated hip 3 • Abrupt movement of iliopsoas as iliacus muscle interposed between tendon and bone moves Deslandes et al. AJR Deslandes et al. AJR 2008; 190:576 2008; 190:576

Snapping Hip Syndrome: iliopsoas Anterior Hip: Rectus Femoris

From: Netter’s Atlas of Human Anatomy

Rectus Femoris Tendon: Direct Head Rectus Femoris Tendon: Indirect Head

3 Rectus Femoris Tendon Direct Origin Rectus Femoris Origin: Indirect Head

• Indirect or reflected head • Anterolateral hip: – Superior acetabular ridge – Hip joint capsule – Forms central aponeurosis Indirect • Oblique axial plane: 30° Origin – 34 (l) x 10 (w) x 4 (thick) mm • Injury more common than direct head

From: Moraux A et al. 2015 Eur Radiol 25:3614

Rectus Femoris: anatomy Rectus Femoris Injury

AIIS

Complete Tear Partial Avulsion

Courtesy of Y. Morag, Ann Arbor, MI

Aponeurosis Tear (Indirect Head): Aponeurosis Tear (Indirect Head): Rectus Femoris Rectus Femoris

Short Axis Long Axis Short Axis Long Axis

4 Direct Calcific Tendinosis: rectus femoris Calcific Tendinosis Head • Ultrasound-guided lavage and aspiration • 20 gauge spinal Long Axis AIIS needle

Long Axis

Short Axis Before After

Heterotopic Ossification Heterotopic Ossification: • Hyperechoic • Posterior acoustic shadowing and reverberation

• No surrounding soft tissue mass Longitudinal

J Ultrasound Med 1989; 8:463

Take-home points • Iliopsoas: – Bursa: usually related to joint process – Inject: deep to tendon – Snapping hip: dynamic evaluation • Rectus femoris: – Direct and indirect heads

– Calcific tendinitis See www.jacobsonmskus.com for syllabus and other educational material