79
HIP THIGH KNEE Ultrasound – Fundamental STAFFORDSHIRE MSK STUDY DAY BMUS Kirstie Godson Academic lecturer Leeds University

HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

  • Upload
    others

  • View
    5

  • Download
    0

Embed Size (px)

Citation preview

Page 1: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

HIP THIGH KNEE

Ultrasound ndash

Fundamental

STAFFORDSHIRE MSK STUDY DAY

BMUS

Kirstie Godson

Academic lecturer Leeds University

Why Ultrasound

Readily available

Shorter waiting times

Less expensive than other modalities

No radiation

No reactions

Increase interest within MSK ultrasound

Rapidly growing and will continue ndash future improvements with technology

Ultrasound structure

Equipment Overview

Good quality Ultrasound Machine

High resolution Multi Frequency Linear Ultrasound Probe (175Mhz 145 9 mhz)

Hockey stick probe Curvilinear probe

Colour flow Power Doppler

EFV (trapezoid function)Panoramic

Liberal use of ultrasound gel (hairy)

HIP

Whatrsquos the big quanundrum

Anatomy

Bone structures and Soft tissue structures

Abdominal wall musculature

Anterior hip

Hip joint

Ilio-psoas

Adductor origin

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 2: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Why Ultrasound

Readily available

Shorter waiting times

Less expensive than other modalities

No radiation

No reactions

Increase interest within MSK ultrasound

Rapidly growing and will continue ndash future improvements with technology

Ultrasound structure

Equipment Overview

Good quality Ultrasound Machine

High resolution Multi Frequency Linear Ultrasound Probe (175Mhz 145 9 mhz)

Hockey stick probe Curvilinear probe

Colour flow Power Doppler

EFV (trapezoid function)Panoramic

Liberal use of ultrasound gel (hairy)

HIP

Whatrsquos the big quanundrum

Anatomy

Bone structures and Soft tissue structures

Abdominal wall musculature

Anterior hip

Hip joint

Ilio-psoas

Adductor origin

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 3: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Ultrasound structure

Equipment Overview

Good quality Ultrasound Machine

High resolution Multi Frequency Linear Ultrasound Probe (175Mhz 145 9 mhz)

Hockey stick probe Curvilinear probe

Colour flow Power Doppler

EFV (trapezoid function)Panoramic

Liberal use of ultrasound gel (hairy)

HIP

Whatrsquos the big quanundrum

Anatomy

Bone structures and Soft tissue structures

Abdominal wall musculature

Anterior hip

Hip joint

Ilio-psoas

Adductor origin

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 4: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Equipment Overview

Good quality Ultrasound Machine

High resolution Multi Frequency Linear Ultrasound Probe (175Mhz 145 9 mhz)

Hockey stick probe Curvilinear probe

Colour flow Power Doppler

EFV (trapezoid function)Panoramic

Liberal use of ultrasound gel (hairy)

HIP

Whatrsquos the big quanundrum

Anatomy

Bone structures and Soft tissue structures

Abdominal wall musculature

Anterior hip

Hip joint

Ilio-psoas

Adductor origin

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 5: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

HIP

Whatrsquos the big quanundrum

Anatomy

Bone structures and Soft tissue structures

Abdominal wall musculature

Anterior hip

Hip joint

Ilio-psoas

Adductor origin

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 6: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Whatrsquos the big quanundrum

Anatomy

Bone structures and Soft tissue structures

Abdominal wall musculature

Anterior hip

Hip joint

Ilio-psoas

Adductor origin

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 7: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Anatomy

Bone structures and Soft tissue structures

Abdominal wall musculature

Anterior hip

Hip joint

Ilio-psoas

Adductor origin

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 8: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Diagnostic difficulty

Complex regional anatomy

Insertion of rectus abdominis

adductor tendons hip

jointbursae hip flexors (iliopsoas)

Inguinal and femoral canals

Complex Nerve distribution

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 9: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

History taking

How long pain present

Pain localised to a particular site

Sudden onset

What movements or actions precipitate the pain

Is there associated clicking or catching

Is there a palpable lump

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 10: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

GROINHIP

Causes of pain

Inflammation of the adductor muscle of the thigh

Rupture of the adductor muscle of the thigh

Inflammation of the pubic joint (osteitis pubis)

Bursitis on the front of the hip joint (bursitis iliopectinea)

Other bursitis

Fluid accumulation in the hip joint

Degenerative arthritis in the hip joint

Rupture of the superficial hip flexor (ruptura musculus rectus femoris)

Rupture of the deep hip flexor (ruptura musculus iliopsoas)

Outer snapping hip

Inner snapping hip

Inguinal femoral hernia

Stress fracture in the femoral neck

Nerve entrapment

Lumbago

Piriformis syndrome

Hernia

Lymphadenopathy

Undescended testicle

Varicocoele

Hydrocoele of the canal of Nuk

Urological problems

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 11: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Hip

Pathology

Joint effusion

Trochanteric Bursitis

Septic Arthritis- guided aspiration

HaematomasSoft tissue masses

Clinical Conditions

Pain

Swelling

Redness

Soreness

Blood test resultsspiking temp

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 12: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

HIP

ANTERIOR HIP

LATERAL HIP

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 13: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Rule out other causes

Plain film ndash X-ray

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 14: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

MRI

Normal Pelvis

Right Hip fracture and

oedema

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 15: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

CT

Limited but useful for determining femoroacetabular impingement

33 year-old male with cam type FAI (A) Preoperative computed tomography shows a bump on the head and neck junction (B) Postoperative computed tomography shows removed bump after femoroplasty (C) Arthroscopic findings

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 16: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Ultrasound Anterior Hip joint ndash Probe position ndash

Longitudinal along the line of the neck of femur

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 17: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Anterior hip joint ndash Pathology

Joint Effusion

Femur

FLUID

Hip joint

effusion

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 18: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Anterior Hip Joint

Iliopsoas bursitis Snapping

hip frog leg flexion

Paralabral cysttear

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 19: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Trochanteric Bursa

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 20: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Therapeutic treatment

Steroid Injection

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 21: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

GTPS Ultrasound

Most commonly caused by gluteus minimis and gluteus medius injurytear

or tendinopathy rather than bursitis

Distension of bursa often accompany tendon tear therefore careful

assessment of tendons

Calcific tendinopathy

Rare that bursae alone involved with the pain

Eur Radiol 2007 Jul17(7)1772-83

MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 22: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Anatomy GT

Gluteus minimus attaches to the

anterior facet GT

Gluteus medius inserts

superoposterior and lateral facets

GT

Three bursae common

trochanteric subgluteus medius

and subgluteus minimus

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 23: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

ULTRASOUND GTPS

CORONAL

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 24: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Greater Trochanteric region

Probe position - Transverse

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 25: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Calcific tendinopathy Small partial tear at the

insertion of Gluteus medius

Bursitis

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 26: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Tensor fascia latae iliotibial tract

Lateral hip pain

Runners proximal enthesopathy

ASIS

Snapping hip ndash standing flexion and

extension - TS

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 27: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

IT Band

Leg position extension hip internally rotated

Tip find Gerdyrsquos tubercle and follow proximally

MRI equivalent frontal plane

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 28: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

HAMSTRINGS

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 29: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Posterior thigh - Hamstrings

Arise from the ischial tuberosity

Biceps femoris muscle lies

laterallyTendon inserts into head of

Fibula

Semimembranosus muscle lies-

medially ndash tendon inserts medial

condyle

Semitendinosus muscle lies-

medially inserts via long tendon

(Pes Anserinus Tendon)- onto the

medial side of the popliteal fossa

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 30: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Muscle related Pathology

Haematomas ndash bruise

Morel Lavallee lesion-

Rupture of muscle ndash PartialComplete tears

Abscess ndash Infection

Muscle fibrosis ndash formation of excessive fibrous bands of scar tissue between muscle fibres

Seroma ndash A pocket of clear serous fluid

Myositis Ossificans- abnormal bone formation within deep muscle tissue usually associated with haematoma due to trauma

Muscle hernia -

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 31: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pathology- Haematoma

Vastus lateralis muscle Gastrocnemius muscle

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 32: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Muscle rupture

Biceps Femoris

stump seroma

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 33: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Muscle Fibrosis

Normal muscle

Muscle fibrosis

Defect

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 34: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Myositis ossificians

Calcification

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 35: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Quadriceps tendon

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 36: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Clinical Conditions

Pain

swelling

Inability to actively extend knee

Palpable defect

Causes

Trauma ndash falls direct blows lacerations

Associated Conditions Renal disease DM RA gout obesity osteomalcia

steroid use

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 37: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Anatomy - Quadriceps tendon

It attaches the 4 Quadriceps muscle to the patella function ndash knee flexion and

extension

1 Rectus Femoris -superficialndash mid thigh ndash tendinous 3-5 cm

proximal to the patella

2 Vastus Lateralis ndash Lateral side of femur- tendinous 3cm from

patella

3 Vastus medialis- Medial side of femur- tendinous 3 cm from

patella

4 Vastus intermedius ndash In between ndash deep layer to RF

Inserts onto the proximal section of the patella

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 38: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Technique Quadriceps tendon

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow

beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps

and patellar tendons assume in full extension

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 39: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Ultrasound Technique- Transverse section

Anterior thigh- Quad muscles

RF- Rectus Femoris VI Vastus intermedius

VL ndash Vastus Lateralis VM ndash Vastus Medialis

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 40: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Probe position - Longitudinal section

1

2

3

Supra-patellar fat

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 41: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pathology

Tendinopathy

Calcific tendinopathy

Avulsion fracture

Partial tear Complete tear tendon

Muscle tears

Abscess

Miscellanous - Cyst

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 42: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pathology

Tendinopathy ndash term that describes predominantly degenerative conditions

that cause pain swelling and stiffness ( NICE April 2010)

Repeated overuse- causes degeneration and disorganization of the Collagen

fibres

Imbalance between pathological changes that occur in response to injury

Complications ndash lead to tearsruptures (NICE April 2010)

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 43: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Tendinopathy

Focal thickening - tendon is against another structure which causes friction

Hypoechoic areas within the tendon

Disruption of the normal architecture of the tendon

Noticeable vascularity

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 44: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pathology -Tendinopathy

Patella Patella

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 45: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Calcific tendinopathy

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 46: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Partial complete tears

Partial tearcomplete tear ndash generally over 40rsquos Men

bull High grade partial tear of the quadriceps tendon

bull Red arrow Quads tendon as is the large hematoma Green arrow ndash

haematoma

bull Pink arrow ndash Patella is positioned more inferiorly than normal

bull White arrow - patellar tendon is lax suggesting that this is

functionally a complete tear

bull The deep layer of the quadriceps tendon composed of the vastus

intermedius (yellow arrow) remains intact

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 47: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Avulsion Fracture

RFM

Quads Tendon

Patella

Avulsion fracture

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 48: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Abscess

femur

abscess

Quads

muscle

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 49: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

KNEE

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 50: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Extensor Mechanism

Tendons -Patella tendon

Quadriceps tendon

Popliteal fossa

Bursa

Medial and lateral Collateral ligament

Pes Anserinus

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 51: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Patella Tendon

5 cm in length

Originates from Apex of Patella

Inserts tuberosity of the Tibia

Function attaches the patella to

Tibia to allow straightening of

the knee

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 52: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Patella tendon technique

The anterior aspect of the knee is examined with the patient supine

A knee flexion of approximately 20deg-30deg obtained by placing a small pillow beneath the popliteal space stretches the extensor mechanism

avoids possible anisotropy related to the concave profile that the quadriceps and patellar tendons assume in full extension

from its cranial origin down to its distal insertion using long- and short-axis

planes

Because the lower pole of the patella has a V-shaped appearance one should be aware that the tendon inserts not only on the apex but also along the inferolateral and inferomedial edges of the bone

Short-axis US images over the proximal patellar tendon should be also performed

because tendinopathy may occur out of the midline

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 53: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Probe position ndash Longitudinal section

P Tibia bursa

HFP

Patella Tendon

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 54: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Patella tendon - Transverse Positioning

HFP

Patella tendon

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 55: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Clinical indications

Pain

Jumperrsquos Knee

Injury- Fallsdirect impact

Chronic disease

Osgood Schlatter Disease

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 56: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pathology

Tendinopathy- usually at insertion in the mid tendon

Ruptures

Intrasubstance tear- small fluid filled pocket within the tendon

Partial ndash Some tendon fibres identified through the tear

Complete ndash Complete disruption of fibres No fibres attached at

either ends of the tear

Chronic diseases- Weakens the tendon

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 57: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pathology- Tendinopathy

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 58: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Tendinopathy continued

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 59: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Jumperrsquos Knee

Tendonopathy at apex insertion thickened patella tendon micro ruptures increased cortico- irregularity and increased vascularity

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 60: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Partial ndash TearsRuptures

Mid Tendon

Patella Tibia

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 61: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Complete Rupture

This x-ray taken from the side shows the normal location of the kneecap

(Right)

The kneecap has moved out of place due to a torn patellar tendon

To reattach the tendon small holes are drilled in the kneecap (left) and

sutures are threaded through the holes to pull the tendon back to the bone (right)

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 62: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Popliteal Fossa

Anatomy - posterior aspect of the knee joint

Medial and lateral heads of Gastronemius muscle

femoral condyle

Sartorius muscle

Junction of the semimembranosus tendon ( most medial of the 3 hamstrings)

and Gastrocnemius tendon - important landmark

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 63: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Knee ndash Bursa

Protective cushion for the knee

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 64: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pre patellar bursitis

Aaron DL 2011

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 65: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Probe position

Head of

Gastrocnemius

muscle

Medial

Femoral

Condyle

Sartorius

SMT GT

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 66: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Clinical Indications

Pathology

Clinical indications

Pain

Swelling

Aching

Pathology

Bakerrsquos cyst

DVT

Popliteal aneurysm

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 67: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Popliteal fossa ndash Common pathology

Bakerrsquos cyst

Tail

Bakerrsquos

cyst

GT SMT

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 68: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Neurovascular bundle

DVT ndash Popliteal vein

Popliteal aneurysm

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 69: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Ligaments of the knee-

Medial and lateral collateral ligaments

Acts as a holding mechanism to keep the meniscus (shock absorbers)in

place

Clinical indications

instability

Pathology

Rupture

Bowing of the meniscusligament

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 70: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Ultrasound technique for assessment

of medial aspect of knee

For examination of the medial knee the patient is asked to rotate the leg

externally with a 20deg-30deg of knee flexion

Place the transducer obliquely-oriented over the long-axis of the medial

collateral ligament

Care should be taken to examine the entire length of this ligament

Dynamic scanning during valgus stress can improve the assessment of its

integrity

Check the soft-tissues immediately superficial to the base of the medial

meniscus

httpsessrorgcontent-essruploads201610kneepdf 42017

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 71: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Medial Collateral ligament

Probe positioning

Femur MCL Tibia

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 72: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Partial rupture of Medial Collateral

ligament

Femur

Tibia

MM

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 73: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Lateral Collateral ligament

Probe positioning

femur Tibia

FH LM

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 74: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Meniscus

Bulging

LM

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 75: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pes Anserinus ndash Goose feet

The Pes Anserinus Tendon- formed by the conjoined joining of

3 muscles

Sartorius

Gracilis

Semitendinosus muscles

Arise from posteriorly lower thigh and go from medially to laterally Remember

Say Grace before Tea Clinical importance Chronic knee pain and weakness

Clinical conditions Pain swelling and tenderness

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 76: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Pes anserinus

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 77: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

References Aaron DL Patel A Kayiaros S Calfee R 2011 Four common types of bursitis diagnosis and

management J Am Acad Orthop Surg19(6)359-67

httpstheultrasoundsitecoukultrasound-guided-injection-of-the-hip-joint-tutorial Accessed 1242017

httpwwwphysiopediacomDiagnostic_Imaging_of_the_Hip_for_Physical_Therapists

Chan Kang MD Deuk-Soo Hwang MD 2012 Arthroscopic Treatment of Femoroacetabular Impingement of the Hip 5-7 Years Sep201224(3)237-244

Httpsradiopaediaorgarticleship-joint-1 Accessed 1242017

httpsessrorgcontent-essruploads201610hippdf Accessed 1242017

httpsradiopaediaorgarticlesknee-joint-1 Accessed 1242017

Eur Radiol 2007 Jul17(7)1772-83 MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome

httpmusculoskeletalmriblogspotcouk201107stairs-and-tendon-tearhtml Accessed 1242017

httpwwwultrasoundcasesinfo Accessed 1242017

httporthoinfoaaosorgtopiccfmtopic=a00512 Accessed 1242017

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017

Page 78: HIP THIGH KNEE - BMUS · of medial aspect of knee For examination of the medial knee, the patient is asked to rotate the leg externally with a 20°-30° of knee flexion. Place the

Christopher C Annunziata MD Orthopedic Surgeon Commonwealth Orthopedics and Rehabilitation Assistant

Clinical Professor Department of Orthopedic Surgery Georgetown University Medical Center Team Physician

Washington Redskins Orthopaedic Consultant The Washington Ballet 2017 Patella tendon rupture and treatment

httpemedicinemedscapecomarticle1249472-treatmentd18 accessed 1242017

httpswwwslidesharenetsaurabsharma1-biomechanics-of-the-knee-joint-basics accessed 1242017

httpscksniceorgukpre-patellar-bursitisscenario Accessed 1242017