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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
