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Soft Tissue Pathology: Gluteal, Hamstrings,
Sports Hernia &Ischiofemoral Impingement
Sandip Biswal, M.D.
Assistant Professor of RadiologyDivision of Musculoskeletal Imaging
Department of RadiologyStanford University School of Medicine
Talk Outline • Anatomy
• Tendons/Muscle
– Gluteus minimus– Gluteus medius– Iliopsoas– Hamstrings– Snapping Hip– Sports Hernia– Ischiofemoral
Impingement
• Nerve-Related Issues– Sciatic– Piriformis Syndrome
Tendon Pathology
Anatomy
Anterior(Gluteus minimus)
Lateral(Gluteus medius)
Posterior
Gluteal anatomy
Dwek et al. MRI Clinics North Am 2005
Pfirrmann et al. Radiology 2001
Gluteal anatomy
Dwek et al. MRI Clinics North Am 2005
Pfirrmann et al. Radiology 2001
Gluteal anatomy
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)
Tendon Pathology
Rotator Cuff Tear of the HipTendon Pathology
Rotator Cuff Tear of the Hip
Tendon Pathology Rotator cuff tear of the hip
Tendon Pathology Rotator cuff tear of the hip
Tendon Pathology Rotator cuff tear of the hip
Tendon Pathology Small full thickness cuff tear
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)
Tendon Pathology Small full thickness cuff tear
Tendon Pathology Full thickness cuff tear
Tendon Pathology Full thickness cuff tear
Tendon Pathology Snapping Hip Syndrome
• Sudden, painful audible snapping of the hip which can be reproduced during specific movements of the hip.
• Typically occurs during flexion-abduction-external rotation (frogleg position) to the neutral position.
• Typically observed in athletic individuals.
• DDx– Intra-articular
• Labral tear• Chondral defect• Intra-articular bodies
– Extra-articular• Iliopsoas tendon• Iliofemoral ligament• Iliotibial band !"#$%&'"#(")(%$*(")(%$(+,--./(!"#$
Tendon Pathology Iliopsoas Snapping Hip
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Tendon Pathology Iliopsoas Snapping Hip
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)
Tendon Pathology External Snapping Hip Syndrome
• Iliotibial band (tensor fascia lata anteriorly and gluteus maximus posteriorly)
• Iliotibial band can be thickened - lies posterior to greater trochanter with extension and snaps forward with flexion
• Thickening and fibrosis of anterior border of gluteus maximus can occur following repeated i.m. injections (vits, analgesics or antibiotics)
• Trochanteric bursitis between iliotibial tract and greater trochanter causes pain and snapping
Normal iliotibial tract
(T2 WI)
Tendon Pathology Bilateral Snapping Hip
Tendon Pathology External Snapping Hip
Tendon Pathology External Snapping Hip, GT bursitis
Tendon Pathology
Iliopsoas Peritendonitis
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)
Tendon Pathology
Hamstring Anatomy
Primal Pictures Ltd.
Primal Pictures Ltd.
Proximal
hamstrings
20 year oldcross country
runner
Tendon Pathology
Hamstring Tear and
Peritendonitis
Tendon Pathology
Hamstring Tear and
Peritendonitis
19 year old cross country runner
Tendon Pathology
Hamstring Peritendonitis
26 year old marathon runner
Tendon Pathology
Hamstring Peritendonitis and Partial Tear
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)
Tendon Pathology
Hamstring Tendon Tears/AvulsionTendon Pathology
Hamstring Tendon Tears/Avulsion
Muscle Pathology
Adductor Strain
Tendon Pathology Athletic Pubalgia (Sports Hernia)
• Other names: Sportsman’s hernia, hockey hernia, Gilmore’s groin, osteitis pubis, adductor syndromes.
• Defined as athletic groin pain with multiple etiologies.
• Patients present with pain in the inguinal region. Pain with palpation is present at the external inguinal ring without palpable hernia.
• Opposing interconnected tendinous attachments play a role in pubic symphysis stability (esp. the rectus abdominis and adductor longus). Injury to one tendon leads to injury of the opposing tendon resulting in chronic groin pain.
• Imaging: – Large FOV (28-32 cm to include both hips & ASIS using body coil)
coronal STIR and T1. Ax T2 FSE with FS.– Dedicated smaller 20 cm FOV with surface coil placed at midline for
Obl Ax PD FSE & T2 FSE with FS, Sag T2 FSE with FS.
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Tendon Pathology Athletic Pubalgia (Sports Hernia)
• Differential– Osteitis Pubis– Rectus abdominis strain– Adductor tendon syndromes– Rectus abdominis/adductor aponeurosis injury– Inguinal hernias– Stress fracture (inf pubic ramus)– Hip pathology– Sacroiliitis– etc
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Tendon Anatomy
Athletic Pubalgia
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)
Tendon Anatomy
Athletic PubalgiaMuscle Pathology
Ischiofemoral Impingement (IFI) Syndrome Abnormal T2 signal in the mid to distal portion of the quadratus femoris muscle with relatively small ischiofemoral space (1.4 cm, normal subjects 2.3 +/- 0.8 cm); these findings may be seen in ischiofemoral impingement syndrome / hip pain.
Muscle Pathology
Radiation-Induced MyositisMuscle-Nerve Pathology
Nerve Anatomy
Muscle-Nerve Pathology
Nerve Anatomy
Pokorny D, Jahoda D et al (2005) Surg Radiol Anat 28(1):88-91
Lee, E. Y. et al. Am. J. Roentgenol. 2004;183:63-64
--40-year-old man with piriformis syndrome
Nerve-Related Pathology
Piriformis Syndrome
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)
Lee, E. Y. et al. Am. J. Roentgenol. 2004;183:63-64
--40-year-old man with piriformis syndrome
Nerve-Related Pathology
Piriformis SyndromeNerve-Related Pathology
Sciatic Schwannoma
Summary
• Tendons/Muscle
– Gluteus minimus– Gluteus medius– Iliopsoas– Hamstrings– Snapping Hip– Sports Hernia– Ischiofemoral
Impingement
• Nerve-Related Issues– Sciatic– Piriformis Syndrome
I would like to extend a Special Thanks to…
• Kate Stevens, MD• Chris Beaulieu, MD, PhD• Garry Gold, MD• Brian Suh, MD• Samuel Fuller, MD.• Nepenthe Fong, MD
Happy Walking!
Thank you!
for an updated syllabus, please feel free to email [email protected]
Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)