7

Hip

Mohini Rawat, DPT, MS, ECS, OCS, RMSK

Contents

• Anterior Hip
  
  
  
  • Joint Anatomy
    
  • Iliopsoas Tendon
    
  • Tendons Originating From the Anterior Superior Iliac Spine
    
  • Tendons Originating From the Anterior Inferior Iliac Spine
  
  
• Lateral Hip
  
  
  
  • Greater Trochanter and Gluteal Tendon Attachments
  
  
• Posterior Hip
  
  
  
  • Piriformis and Sciatic Nerve
    
  • Other Small Rotators of the Hip
    
  • Hamstring Tendon Origin at the Ischial Tuberosity
  
  
• Inguinal and Medial Hip Regions
  
  
  
  • Inguinal Canal and Its Contents
    
  • Adductor Group of Muscles

ANTERIOR HIP

Joint Anatomy

1. Patient position: Supine with the hip in extension and slight abduction
   
2. Probe/transducer position: The probe is along the long axis (LX) of the femur anteriorly at the level of greater trochanter (but not placed on the lateral aspect over the greater trochanter), and then the probe is rotated medially toward the midline and moved proximally to be along the LX of the femoroacetabular joint (Figures 7-1 through 7-3).
   
   
   

   

   
   

   Figure 7-1. Probe positioning for the LX view of the femoroacetabular joint.

   
   

   
   

   
   

   

   
   

   Figure 7-2. LX view of the hip joint. (A) Probe placement. (B) LX view of the hip joint showing the acetabulum (Ace), femoral head (FH), femoral neck (FN), iliopsoas muscle-tendon complex (IP), hyperechoic labrum (white arrow), and hyperechoic capsuloligamentous layer (yellow arrow).

   
   

   
   

   
   

   

   
   

   Figure 7-3. Short axis (SX) view of the hip joint. (A) Probe placement. (B) SX view of the hip joint showing the femoral head (FH), iliopsoas muscle-tendon complex (IP), hyperechoic femoral nerve (yellow arrow), and anechoic femoral artery (red arrow).

   
   
3. Relevant anatomy: The acetabulum, labrum, and femoral head and neck are visualized.1 The capsuloligamentous structure follows the bony contour of the head and neck of the femur.²
   
4. Points to remember: The joint is evaluated for excess fluid, capsular thickening, synovial hypertrophy, labral pathology (limited view), loose bodies, or bony irregularity or erosion, or to study the soft tissue structures overlying the joint like the iliopsoas bursa and iliopsoas muscle-tendon complex. Femoroacetabular impingement is suspected with the following changes in the anterior hip joint: presence of nonspherical head neck junction (cam deformity), focal bony protuberance at the femoral neck, or waist deficiency or convexity at the femoral head-neck junction (Figure 7-4).³
   
   
   

   

   
   

   Figure 7-4. The femoral head is normally spherical. Femoroacetabular impingement is suspected with the following changes in the anterior hip joint: presence of nonspherical head-neck junction (cam deformity), focal bony protuberance at the femoral neck, or waist deficiency or convexity at the femoral head-neck junction.

Iliopsoas Tendon

1. Patient position: Supine using the flexion, abduction, and external rotation (FABER) maneuver, where the patient is asked to place the lateral aspect of the foot on the side to be studied on the contralateral knee at the suprapatellar region⁴
   
2. Probe/transducer position: The probe is initially placed along the LX of the femoral head to identify the iliopsoas tendon overlying the joint, then the iliopsoas tendon is followed to its insertion site at the lesser trochanter (Figures 7-5 and 7-6).
   
   
   

   

   
   

   Figure 7-5. LX view of the iliopsoas tendon. (A) Probe placement with the patient supine using the FABER maneuver. The probe is initially placed along the LX of the femoral head to identify the iliopsoas tendon overlying the joint, then the iliopsoas tendon is followed to its insertion site at the lesser trochanter. (B) LX view of the hyperechoic iliopsoas tendon (white arrows). (FH = femoral head; LT = lesser trochanter.)

   
   

   
   

   
   

   

   
   

   Figure 7-6. (A) Relevant anatomy of the iliopsoas muscle-tendon complex. (B) Corresponding LX view of the iliopsoas tendon (white arrows) inserting on the lesser trochanter (LT). (FH = femoral head.)

   
   
3. Relevant anatomy: The main tendon in the distal iliopsoas is the psoas tendon, including fibers from the medial portion of the iliacus. The lateral iliacus muscle runs parallel to the iliopsoas tendon and attaches directly onto the proximal femoral shaft (Figures 7-7 and 7-8).^5,6
   
   
   

   

   
   

   Figure 7-7. Relevant cross-sectional anatomy of the iliopsoas muscle-tendon complex at the level of the iliopectineal eminence.

   
   

   
   

   
   

   

   
   

   Figure 7-8. (A) SX view of the iliopsoas muscle-tendon complex at the level of the iliopectineal eminence showing the lateral iliacus muscle (LI), medial iliacus muscle (MI), tendon (T), psoas muscle (PM), and femoral artery (red A). (B) Relevant anatomy

   
   
4. Points to remember: The most medial fibers of the iliacus form an accessory tendon that merges with the psoas tendon to form the main tendon. There is a fatty fascial plane that separates the distal iliopsoas tendon from the intramuscular tendon within the lateral portion of the iliacus muscle, which should not be confused with a split tear of the iliopsoas muscle-tendon complex.5

Tendons Originating From the Anterior Superior Iliac Spine

Anatomy of the anterior superior iliac spine (ASIS) and surrounding iliac crest region is shown in Figures 7-9 and 7-10.

1. Patient position: Supine
   
2. Probe/transducer position: The probe is placed in the SX orientation at the ASIS to evaluate the sartorius and tensor fascia lata origin in SX view (Figure 7-11), and then rotated to LX orientation to evaluate the sartorius (Figure 7-12) followed by the tensor fascia lata, proximal iliotibial band, and gluteal aponeurotic fascia in LX view (Figure 7-13). To scan these structures as they attach to the pelvic bone, a good understanding of the anatomy is required.
   
   
   

   

   
   

   Figure 7-11. SX view of the sartorius and tensor fascia lata. (A) Probe placement. First the probe is placed on the ASIS and then moved slightly distal to visualize the sartorius medially and the tensor fascia lata laterally. (B) SX view at the ASIS. (C) SX view at the level just distal to the ASIS showing the sartorius (S) medially and the tensor fascia lata (TFL) laterally.

   
   

   
   

   
   

   

   
   

   Figure 7-12. (A) SX view of the sartorius (white arrow). (TFL = tensor fascia lata.) (B) LX view of the sartorius (white arrow).

   
   

   
   

   
   

   

   
   

   Figure 7-13. Panoramic view of the anterolateral thigh showing the tensor fascia lata (TFL), superficial layer of the iliotibial band (yellow arrow), deep layer of iliotibial band (blue arrow), and common iliotibial band distally (white arrow). (VL = vastus lateralis.)

   
   
3. Relevant anatomy: The sartorius originates from the ASIS and runs anteromedially along the thigh to attach to the proximal aspect of the medial tibial surface as the most proximal tendon of the pes anserine tendons. The sartorius is a biarticular muscle, and the medial border of the sartorius forms the lateral border of the femoral triangle. The iliotibial band has 3 layers: superficial, intermediate, and deep. The superficial layer originates from the ilium superficial to the origin of the tensor fascia lata muscle, the intermediate layer originates from the ilium distal to the tensor fascia lata muscle, and the deep layer originates from the supra-acetabular fossa between the hip joint capsule and the reflected head of the rectus femoris. Posteriorly, the iliotibial band also receives tendinous fibers from the gluteal aponeurotic fascia and gluteus maximus muscle. All the layers of iliotibial band merge together at the level of the greater trochanter to continue distally along the entire length of the thigh and attach distally at Gerdy’s tubercle of the tibia (see Figure 7-10).
   
4. Points to remember: The superficial layer of the iliotibial band is thicker posteriorly at the level of the iliac tubercle compared with the anterior portion, which runs superficial to the tensor fascia lata. The posterior contribution from the gluteal aponeurosis is much thinner. The tensor fascia lata muscle has a unique echotexture due to internal fat content.^7,8

Tendons Originating From the Anterior Inferior Iliac Spine

1. Patient position: Supine
   
2. Probe/transducer position: The probe is placed in the LX orientation to the rectus femoris direct head attachment at the anterior inferior iliac spine (AIIS; Figures 7-14 and 7-15). This view can be obtained by first visualizing the femoral head-neck and then moving the probe slightly proximal and lateral until the AIIS is visualized. To scan the indirect head of the rectus femoris, the probe is moved slightly distal and lateral from the direct head with more pressure on the proximal end of the probe to counter anisotropy because the indirect rectus femoris fibers do not run parallel to the superficial structures (Figure 7-16).
   
   
   

   

   
   

   Figure 7-14. LX view of the rector femoris. (A) Probe placement. (B) Hyperechoic rectus femoris direct head (white arrow) attaching to the AIIS. The indirect head (yellow arrow) appears hypoechoic due to anisotropy as the tendon attaches to the superolateral margin of the acetabulum.

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