thigh and knee ultrasound

Stephen Bird

Thigh and Knee Ultrasound

Quadriceps Insertion

3 Layers• Superficial: (Rectus Femoris)• Middle: (Vastus Medialis / Vastus Lateralis)• Deep: (Vastus Intermedius)

• Partial tears commonly involve superficial layer only • Axial scans required to independently assess VM

and VL involvement

Quadriceps Insertion

Quadriceps Tendon Layers

Rectus Femoris Anatomy

Rectus Femoris Anatomy

Rectus Femoris Central Tendon Rupture

Rectus Femoris Central Tendon Rupture

Rectus Femoris Central Tendon Rupture

Stephen Bird

Hamstring Ultrasound

Hamstring

Origin : Enthesis / Tendon

Belly : MTJ x 2 / Myo-fascial Boundary

Insertion : Enthesis / Tendon

Bursae : Ischial, Semimemb, Pes Anserine

Adjacent Structures : Sciatic Nerve ,

Sacrotuberous Lig

Hamstring Muscle and Tendon Units

LateralMedial

Ischial Tub

Knee

SM

ST

BFL/H

BFS/H

Hamstring Muscle and Tendon Units

LateralMedial

Ischial Tub

Knee

SM

BFL/H

BFS/H

SN

ST

Hamstring Navigation Rules

• In the standard Bakers cyst plane the Semitendinosus tendon lies stacked on top of the Semimembranosus tendon

• The distal Semimembranosus tendon is short while the proximal tendon is long

• The distal Semitendinosus tendon is long while the proximal tendon is short

• Semitendinosus has the “inscription”

Hamstring Navigation Rules

• Sciatic Nerve always sits deep to the long head of Biceps Femoris

• In the proximal hamstring the Semimembranoustendon (pseudo-sciatic nerve) always sits deep to the Semitendinous muscle belly

• In the distal hamstring the Long Head of Biceps Femoris tendon sits superficial to the short head muscle

• Adductor Magnus forms the floor

Hamstring Navigation Rules• The first muscle to form as you head distal from

the iscial tuberosity is semitendinosus• The biceps femoris long head and

semitendinosus unite proximally to form the conjoint tendon

• The conjoint tendon occupies the medial 2/3 of the ischial tuberosity

• The proximal semimembranosus tendon occupies the lateral 1/3 of the iscial tuberosity

• The common peroneal nerve sits against the medial edge of the short head of biceps femoris

Origins

What do we see Sonographically ?At the Ischial TuberosityNote : C.T. = Conjoint Tendon (Semitend and Biceps Fem Long Head)

LateralMedial

SN

S.M.

ST

BFC.T.

What do we see Sonographically ?

1cm Below the Ischial Tuberosity

LateralMedial

SN

C.T.

S.M.

What do we see Sonographically ?

2cm Below the Ischial Tuberosity

LateralMedial

SN

C.T.

S.M.

ST

What do we see Sonographically ?

3cm Below the Ischial Tuberosity

LateralMedialST

SM

BF(L/H)

SN

Common MTJ Injury Site

What do we see Sonographically ?

3cm Below the Ischial Tuberosity

LateralMedial ST

SM

BF

(L/H)

SN

Common MTJ Injury Site

What do we see Sonographically ?

• 1/3 of the way from Ischial Tuberosity to Knee

LateralMedial ST

SM

BF

(L/H)

SN

Adductor Magnus

What do we see Sonographically ?

• 2/3 of the way from Ischial Tuberosity to Knee

LateralMedial ST

SM

BF

(L/H)BF

(S/H)

SN

What do we see Sonographically ?

• Just above the Knee

LateralMedial

ST

SM

BF (L/H)

BF

(S/H)

What do we see Sonographically ?

• At the Knee

LateralMedialST

SMBF

Hamstring Origin Pathology• Tendinosis• Enthesopathy• Avulsion with preservation of the sacrotub ligament• Complete avulsion with rupture of sacroptub ligament• Proximal MTJ tear• Proximal central tendon rupture

• Piriformis / Lateral Rotators• Sciatic Nerve• Ischial Bursa• Sacrotuberous Ligament

Myofacial Vs MTJ Vs Central Tendon

The MTJ Hot Spot

Cohens Triangle

Insertions

Pes Anserine

Sartorius

Gracilis

Semitendinosus

SG T

Pes Anserine Navigation Rules

• Follow the MCL to its distal insertion (6-7cm below medial joint line)

• Observe the 3 small tendons passing superficial to the MCL in short axis

• Rotate almost 90 degrees with the posterior end of the transducer a little proximal relative to the distal end

• Locate one of the tendons in LAX

Pes Anserine Navigation Rules

• Scan inferiorly until the tendons disappear

• Slowly scan proximally identifying the 3 tendons individually

• The order from proximal to distal is ST, Gr, Sart

• The Pes Anserine bursa lies between the 3 tendons and the underlying MCL

Biceps Femoris InsertionIntimate with FCL

Semimembranosus Insertion

Semimembranosus Insertion

Knee

Stephen Bird : © 2014

Knee Pathology, Joint Effusion / Synovial Hypertrophy

80% of patients with effusions >10mm have internal derangement.

14% of patients with effusions <10mm had derangement.

Haemarthrosis

Stephen Bird : © 2014

Synovitis

Trochlear Cartilage

Patellar Tendon

Usual Tendinosis Distribution

Patellar Tendinosis

Patellar Tendon Vessel Ingrowth

Hoffa’s Fat Pad Inflammation

MCL3 Layers

•Superficial Layer

Deep Fascia

•Middle Layer

Tibial Collateral Lig

•Deep Layer

Capsular Lig

MCL Tear

Pellegrini Stieda

Meniscus

Stephen Bird : © 2014

FCL Anatomy

Bakers Cyst Anatomy

Stephen Bird : © 2014

Bakers Cyst Anatomy

Stephen Bird : © 2014

Bakers Cyst

Stephen Bird : © 2014

Bakers Cyst Haemarthrosis

Stephen Bird : © 2014

Ilio-Tibial Band

Iliotibial Band Friction Syndrome

Iliotibial Band Friction Syndrome

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Happy Scanning