Retrotrochanteric pain Ultrasound approach Dra Beatriz Alvarez de

Retro-trochanteric pain: Ultrasound approach Dra. Beatriz Alvarez de Sierra Garcia

Retro-trochanteric pain OBJETIVES • ULTRASOUND IMAGE TECHNIQUE • ANATOMY • COMMON LESIONS 1. 2. 3. 4. 5. 6. Piriformis syndrome Gluteal or hamstrings muscle disorders Obturatorius internus syndrome (OIS) Blood vessel–containing fibrous band Persistent sciatic artery Femoro-acetabular impingement (FAI)

Retro-trochanteric pain ULTRASOUND IMAGE TECHNIQUE • ALL CASES US EXAMINATION IS PERFORMED FOLLOWING THE SAME PROTOCOL • Not required any special preparation • Patient in lateral supine position and prone position • High- frequency linear array probe ( 5. 0– 14 MHz frecquency range ) • Panoramic view

Retro-trochanteric pain • ANATOMY 1 5 1 GEMELLI-OBTURATOR COMPLEX 2 GLUTEUS MEDIUS 3 PIRIFORMIS MUSCLE 4 FEMUR 5 PROXIMAL TENDONS (HAMSTRINGS) 6 VASTUS FEMORIS 7 BICEPS FEMORIS 8 GREATER TROCHANTERIC BURSA

Piriformis syndrome • 25 y. o. Male refers posterior hip pain after hir crossfit competition • US: Left Piriformis hypertrophy • Ultrasound-guided corticoid Injection

HAMSTRING INJURIES PROXIMAL DISEASE (HIGH HAMSTRING INJURIES) • Tendon enthesopathy TENDON AVULSION. COMPLETE TEAR • Peritendinous inflammation • Partial tendon tears (sprains) • Tendon avulsions MUSCULOTENDINOUS JUNCTION • Fibrillar pattern disruption • Perilesional edema • Intrasubstance anechoic clefts MYOFASCIAL INJURIES 32 y. o. Male sudden buttock pain after his cycling competition

HAMSTRING INJURIES: Proximal injury PROXIMAL INJURY - TENDON ENTHESOPATHY GM QF GM IT QF LEFT RIGHT 34 Y. O. FEMALE RIGHT BUTTOCK PAIN – ISCHIOFEMORAL IMPIGEMENT

HAMSTRING INJURIES MUSCULOTENDINOUS JUNCTION INJURY BICEPS - Fibrillar pattern disruption – 33 Y. O. MALE SOCCER PLAYER

GREATER TRONCHANTERIC PAIN SYNDROME INJURIES GLUTEAL TENDINOPATHY • Hypertrophy of the tendons and a diffuse hypoechoic appearance • Foci of dystrophic calcification • Neoangiogenesis at color or power Doppler (uncommon) TEARS • Partial- or full-thickness anechoic defects GREATER TROCHANTERIC BURSITIS • Hypoechoic fluid collection • Bursal wall thickening or synovial fold proliferation, deep to the gluteus maximus muscle and ITB and superficial to the lateral insertion of the gluteus medius tendon GLUTEAL MEDIUS TENDINOPATHY

GREATER TRONCHANTERIC PAIN SYNDROME GREATER TROCHANTERIC BURSITIS 74 Y. O. FEMALE THA –ROCHANTERIC PAIN- GREATER TROCHANTER FRACTURE- Hypoechoic fluid collection with bursal wall thickening and synovial fold proliferation, deep to the gluteus maximus muscle and ITB and superficial to the lateral insertion of the gluteus medius tendon

OBTURATORIUS INTERNUS SYNDROME (OIS) • Gemelli-obturator complex in the deep gluteal space • US examination: Internal and external rotations of the hip were performed with the knee at 90° flexion • Evidence of muscle tension during internal rotation - Sciatic nerve curves when intersecting the tendon of the obturator internus • Connective anchorage at the level of the sciatic nerve OI

PERSISTENT SCIATIC ARTERY • Usually regresses in the first few weeks of life • Aneurismal degeneration or mural trombus formation • Predictive factor : Caliber of superficial femoral artery

Retro-trochanteric pain TAKE HOME POINTS • Appropiate Ultrasound Examination • Know your anatomy • Familiarize yourself with common lesions