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220 Chapter 7
Other Small Rotators of the Hip
1. Patient position: Prone
2. Probe/transducer position: The probe is placed along the piriformis muscle as described in the
previous section. The probe is then moved slightly distal to evaluate the attachment of the
obturator externus and then the attachment of the quadratus femoris (Figures 7-26 and 7-27).
A
Figure 7-26. Obturator externus. (A) Relevant anatomy and probe placement. From the piriformis view, the probe is
moved slightly distal and rotated posteriorly to visualize the obturator externus tendon. (B) Obturator externus (white
arrows) and sciatic nerve (yellow arrow).
B
A B
Figure 7-27. Quadratus femoris.
(A) Relevant anatomy and probe
placement. From the obturator
externus view, the probe is moved slightly distal, bridging the lateral aspect of the ischium and intertrochanteric
crest of the femur. (B) The quadratus femoris (white arrow) attaches medially on the lateral aspect of the ischium and
laterally on the intertrochanteric crest of the femur. It is a flat quadrilateral muscle. Also shown is the sciatic nerve
(yellow arrow).
Hip 221
3. Relevant anatomy: The conjoint tendon is closely associated with the piriformis attachment,
with fibroconnective interdigitations present. The superior gemellus, obturator internus, and
inferior gemellus form a single tendon at the level of the head-neck junction and pass obliquely
inferior and anterior to the piriformis to insert near the anterior tip of the greater trochanter.
The obturator externus courses anterior and superior to the quadratus femoris to insert on the
obturator fossa, which is present at the junction of the femoral neck and the medial face of the
greater trochanter. The quadratus femoris has a teardrop-shaped footprint on the posterior
femur, overlying the inferior margin of the intertrochanteric crest. The quadratus femoris
is a rectangular-shaped muscle that covers the posterior aspect of the obturator externus
(Figure 7-28).
14
Figure 7-28. Relevant anatomy of the footprints of the posterior hip muscles.
4. Points to remember: The small rotators of the hip are challenging structures to visualize with
ultrasound because they are deeper and smaller structures. Knowledge of their anatomy and
their relative position is vital to visualize the structures. In ischiofemoral impingement, the
quadratus femoris muscle may present with edema.
222 Chapter 7
Hamstring Tendon Origin at the Ischial Tuberosity
1. Patient position: Prone
2. Probe/transducer position: The probe is placed in the SX at the ischial tuberosity to scan the
hamstring tendons in the SX (Figure 7-29). The probe can be moved distally in the SX view
to visualize the hamstring muscle-tendon complex in the SX. The probe is then moved in the
LX orientation to visualize tendons in the LX in a proximal-to-distal direction (Figure 7-30).
A
Figure 7-29. Hamstring tendon origin.
(A) Probe placement. (B) SX view of
the hamstring tendon origin from the
ischial tuberosity (Isch T) showing the
conjoint tendon of the biceps femoris
and semitendinosus (white arrow),
semimembranosus tendon (blue
arrow), and sciatic nerve (yellow arrow).
A
B
B
Figure 7-30. LX view of the hamstring
tendon. (A) Probe placement. (B) LX
view of the hamstring tendon (white
arrow) origin at the ischial tuberosity
(Isch T).
Hip 223
3. Relevant anatomy: There is a conjoint insertion of the biceps femoris and semitendinosus at
the ischial tuberosity that is medial and superficial. The semimembranosus tendon is lateral
and deep and immediately medial to the sciatic nerve (Figures 7-31 and 7-32).2 There are 2
bursae in this region: the bursa of the ischial tuberosity that overlies the bony prominence and
the bursa of the proximal biceps femoris that can be present between the common attachment
of the biceps femoris (semitendinosus and semimembranosus attachment). The sciatic nerve
can be seen overlying the quadratus femoris muscle. Parallel to the sciatic nerve is the posterior femoral cutaneous nerve and its perineal branches. The perineal branches of the posterior
femoral cutaneous nerve supply the bursa of the ischial tuberosity.
15
Figure 7-31. Relevant anatomy of the hamstring tendon attachment at the ischial tuberosity. The conjoint insertion
of the biceps femoris and semitendinosus at the ischial tuberosity is medial and superficial. The semimembranosus
tendon is lateral and deep.
224 Chapter 7
AB
Figure 7-32. Relevant anatomy of the individual muscle-tendon units of the hamstring group. (A) Biceps femoris (long
and short heads) and semitendinosus. (B) Semimembranosus.
4. Points to remember: The biceps femoris short head originates from the middle third of the
femur from the lateral lip of the linea aspera and descends laterally for the common attachment of the long and short head at the fibular head.
15
Injury of the conjoint tendon of the biceps femoris and semitendinosus is the most common sports injury, and it is important to determine whether it is a free-tendon or myotendinous injury.
16
Ultrasound imaging and magnetic resonance imaging (MRI) are the imaging modalities of
choice for hamstring muscle complex pathology. Combined with a good understanding of the
anatomy, imaging of the hamstring muscle complex will help differentiate a wide spectrum of
injuries and pathology at this area.
17
Hip 225
INGUINAL AND MEDIAL HIP REGIONS
Inguinal Canal and Its Contents
Anatomy of the lateral femoral cutaneous nerve (LFCN), femoral nerve, vessels, and other soft
tissue structures is shown in Figure 7-33.
Figure 7-33. Relevant anatomy of the inguinal canal.
226 Chapter 7
1. Patient position: Supine
2. Probe/transducer position: The probe is placed along the inguinal ligament, with the ASIS as a
bony landmark. Structures passing under the inguinal ligaments are visualized (Figure 7-34).
Figure 7-34. Inguinal ligament (white arrows), femoral nerve (yellow arrow), femoral artery (red A), and femoral vein
(V).
3. Relevant anatomy: From lateral to medial, structures are arranged as follows: LFCN, iliacus
and psoas muscle and tendon complex, femoral nerve, femoral artery, femoral vein, femoral
ring, pectineus muscle.
4. Points to remember: The LFCN appears as a small, round, flattened, hypoechoic structure
between 2 fascial layers: the fascia lata and fascia iliaca (Figure 7-35). It is a pure sensory nerve
and may show anterior and posterior division over the sartorius muscle. Anatomical variations are common. It is difficult to evaluate on MRI; therefore, ultrasound is the preferred
choice for LFCN imaging.
Figure 7-35. A shallow depth and
higher frequency probe are needed
to visualize the LFCN (yellow arrow).
18
Hip 227
Adductor Group of Muscles
1. Patient position: Supine with the hip in external rotation or frog-leg position
2. Probe/transducer position: The probe is placed in the LX over the pubic symphysis to visualize
the common adductor tendon attachment (Figures 7-36 and 7-37).
A
B
Figure 7-36. LX view of the adductor tendon origin at the pubis. (A) Probe
placement. (B) LX view of the common adductor tendon (white arrow) origin at the
pubis. Distally, each muscle can be seen from superficial to deep: adductor longus
(Add L), adductor brevis (Add B), and adductor magnus (Add M).
Figure 7-37. The relevant anatomy of the adductor tendons.
228 Chapter 7
3. Relevant anatomy: The adductor longus has a tendinous attachment on the anterior pubic
body. It is contiguous with the rectus abdominis aponeurosis (Figure 7-38). Posterior to the
tendon, the adductor longus has a direct muscle attachment to the pubis. The adductor brevis
originates immediately posterior and lateral to the adductor longus and is also contiguous
with the rectus abdominis aponeurosis. The adductor magnus originates from the lower border of the inferior pubic ramus, ischial ramus, and ischial tuberosity. The gracilis originates
from the anterior aspect of the pubic body and inferior pubic ramus.
2
Figure 7-38. Relevant anatomy of the adductor group of muscles and the rectus abdominis aponeurosis.
4. Points to remember: The rectus abdominis aponeurosis and adductor longus can be seen
blending at the pubic symphysis. It is difficult to differentiate each of the adductor tendons
proximally. Distally, the adductor longus is the most superficial, and the adductor brevis and
adductor magnus are deep to it.
2
Hip 229
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