PICTORIAL ESSAY Ultrasound Features of the Proximal Hamstring Muscle-Tendon-Bone Unit Marco Becciolini, MD , Giovanni Bonacchi, MD, Stefano Bianchi, MD The hamstring muscle complex is made by a group of posterior biarticular thigh muscles, originating at the ischial tuberosity, which extend the hip and flex the knee joint. Proximal hamstring injuries are frequent among athletes, commonly involving their long myotendinous junction during an eccentric contraction. In this pictorial essay, we describe the ultrasound technique to visualize the normal anatomy of the proximal hamstring muscle-tendon-bone complex and present ultrasound findings in patients with traumatic injuries and tendinopathies. Key Words—athlete injury; biceps femoris; hamstring; musculoskeletal; myotendinous injury; tendinopathy; thigh muscles; ultrasound he hamstring muscle complex comprises a group of posterior biarticular thigh muscles, originating at the ischial tuberosity: the long head of the biceps femoris, semimembranosus, and T 1 semitendinosus. These muscles extend the hip and flex the knee joint. Proximal hamstring muscle complex injuries are the most frequent among athletes, commonly involving the proximal myotendinous junction during an eccentric contraction.2,3 So far, magnetic resonance imaging (MRI) has been considered as the modality of choice to – evaluate tendinopathy and injuries.3 6 In this pictorial essay, our aims are to describe the ultrasound (US) technique for visualizing the proximal hamstring muscle complex and to illustrate US findings in patients with traumatic injuries and tendinopathies. This human study was performed in accordance with the Dec- laration of Helsinki. The study was approved by the Cabinet Ima- gerie Médicale. All parents, guardians, or next of kin provided written informed consent for the minors to participate in the study. All adult participants provided written informed consent to participate in the study. Received June 13, 2018, from the Misericordia di Pistoia, Pistoia, Italy (M.B., G.B.); Cabinet Imagerie Médicale, Geneva, Switzerland Ultrasound Anatomy (S.B.). Manuscript accepted for publication July 13, 2018. Technical Considerations Address correspondence to Marco Becciolini, A linear transducer with frequencies between 5 and 14 MHz is MD, Misericordia di Pistoia, Via Bonellina required. For a larger body habitus, the use of a lower-frequency – 1, 51100 Pistoia, Italy. transducer might be helpful.7 9 The patient lies prone with the hip E-mail: [email protected] and the knee in a neutral position; flexion of the hip using a pillow 8 Abbreviations may be used to avoid artifacts produced by the gluteal fold. MRI, magnetic resonance imaging; US, ultrasound Scanning Technique The examination begins with axial US scans at the level of the doi:10.1002/jum.14804 ischial tuberosity, which can be palpated, being a good anatomic © 2018 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2018; 00:1–16 | 0278-4297 | www.aium.org Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex landmark. The long head of the biceps femoris and which is present when a tendon is not scanned per- the semitendinosus muscle originate from a conjoint pendicularly, for tendinopathy.12,13 This action is tendon at the medial and posterior aspects of the needed because the conjoint and semimembranosus ischial tuberosity, whereas the semimembranosus tendons have different courses so that in a US scan, tendon has a more lateral and anterior origin one can appear hypoechoic to the other; in doubtful (Figure 1A).1,9 To improve image quality, we sug- and subtle cases, a comparison with the opposite gest using a slight lateral approach (Figure 1, A and side is advised. Lateral to the hamstring muscle com- B), and the patient should be informed that the plex tendon, the sciatic nerve, a fascicular and flat- transducer may have to be pressed hardly; this tened structure, can be easily shown: it descends maneuver is also recommended in symptomatic between and deep to the long head of the biceps patients to reproduce pain: so-called sonopalpa- femoris and the semimembranosus tendon, superfi- tion.10,11 The examiner should remember to slowly cial to the adductor magnus muscle.14 A smaller tilt the transducer to avoid mistaking anisotropy, nerve departing from the sciatic nerve, the posterior Figure 1. Hamstring muscle complex origin anatomy. A–C, Proximal-to-distal axial US scans (left), as described in the US anatomy part of the article, with MRI comparison (right); amt indicates adductor magnus tendon; ct, conjoint tendon; gm, gluteus maximus; it, ischial tuber- osity; smt, semimembranosus tendon; sn, sciatic nerve; and st, semitendinosus muscle. 2 J Ultrasound Med 2018; 00:1–16 Figure 2. Axial color Doppler US scan at the level of the ischial tuberosity (it) in a healthy 22-year-old man. In this slender volunteer, US is able to show a small branch of the inferior gluteal artery (a), interposed between the sciatic nerve (sn) and a small honeycomb structure (arrows), consistent with the posterior femoral cutaneous nerve. Note the close relationship of the nerve and the proximal tendons of the hamstring mus- cle complex, which can explain its irritation in proximal hamstring tendinopathy. The semimembranosus tendon (smt) in this view appears slightly hypoechoic because of anisotropy; ct indicates conjoint tendon; and gm, gluteus maximus. Figure 3. Proximal anatomy of the hamstring muscle complex. A–C, Proximal-to-distal axial US scans (left), as described in the US anatomy part of the article, with MRI comparison (right). Dashed lines in A indicate the Cohen triangle; am, adductor magnus muscle; arrowhead, semimembranosus membrane; arrows, semitendinosus raphe; ct, conjoint tendon; lbf, long head of biceps muscle; sm, semimembranosus muscle; smt, semimembranosus tendon; sn, sciatic nerve; and st, semitendinosus muscle. Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex femoral cutaneous nerve, may be sometimes (Figure 2); it distally passes superficial to the long depicted as well in healthy and slender patients, head of the biceps femoris and gradually surfaces up accompanied by the inferior gluteal artery to the cutaneous layer.15,16 Figure 4. Images from a 10-year-old boy who had sudden posterior pain while playing soccer. A and B, Axial and sagittal US scans obtained 4 days later. The cortical surface of the ischial tuberosity (it) of the affected side (left) appears irregular (arrows), and the hamstring muscle complex proximal origin (asterisks) looks swollen compared with the healthy side (right). Ultrasound palpation was painful. Clinical and US findings are compatible with a minimal apophyseal injury without tendon displacement. The patient was treated conservatively with a good outcome; ct indicates conjoint tendon; gm, gluteus maximus; and smt, semimembranosus tendon. Figure 5. Images from a 20-year-old man evaluated for chronic pain at the level of the left ischial tuberosity (it). Comparative longitudinal US scans depict a large calcification casting an acoustic shadow (arrow). The finding is consistent with a previous avulsion, as referred by the patient who recalled a hamstring muscle complex origin injury at the age of 12 years; ct indicates conjoint tendon; gm, gluteus maximus; and smt, semimembranosus tendon. 4 J Ultrasound Med 2018; 00:1–16 Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex The examination continues with axial caudal US to descend between the semitendinosus muscle and scans. At the distal medial tip of the ischial tuberosity, the adductor magnus muscle, giving a “membrane” another tendon originates: the adductor magnus, medially from which the first muscular fascicle of the which also has a wider pubofemoral insertion; because semimembranosus muscle originates. At this level, a of this anatomy, it is also called the “mini-hamstring” sigmoid raphe inside the semitendinosus muscle, which (Figure 1B).17 Below the ischial tuberosity, the semi- travels the muscle from proximal-medial to distal-lat- tendinosus muscle is the first to appear, medially to the eral, is another key anatomic landmark for a US evalua- conjoint tendon; at this level, the semimembranosus tion of the hamstring muscle complex (Figure 3B).8 At tendon starts to travel medially (Figure 1C). Caudally, the middle third of the thigh, the semimembranosus the second muscle to appear is the long head of the tendon reaches the muscle (Figure 3C); its total length biceps femoris; here, a good anatomic landmark, the according to van der Made et al1 is 24.3 ± 3.9 cm with Cohen triangle,8 is composed of the aponeurosis of the a myotendinous junction of 14.9 cm. Usually just conjoint tendon, the sciatic nerve, and the semimem- below this level, the long head of the biceps femoris, branosus tendon (Figure 3A). Considering the con- the semitendinosus muscle, and the semimembranosus joint tendon, according to a dissection study on muscle belly have a similar size.8 Anatomic variations, 56 hamstring muscle complexes by van der Made such as the absence of the semimembranosus muscle, et al,1 the total length of the semitendinosus tendon is or a separate origin of the long head of the biceps 12.3 ± 3.6 cm with a myotendinous junction of femoris and semitendinosus tendons, have been 12.2 cm, whereas the long head of the biceps femoris reported.2 We perform longitudinal-axis scans of the tendon is 19.6 ± 4.1cm with a myotendinous junction hamstring muscle complex in cases of disorders to con- of 14.6 cm. The semimembranosus tendon continues firm it and to show its craniocaudal involvement. Figure 6. Posttraumatic tendinopathy related to a partial-thickness tear with remodeling of the hamstring muscle complex origin in a 35-year- old soccer player, evaluated 2 months after an indirect trauma for persistent pain. A and C, Axial and sagittal US scans (left) of the left ischial tuberosity (it) show a swollen and inhomogeneous (arrows) conjoint tendon (ct) and semimembranosus tendon (smt) compared with the healthy contralateral side (right).