THE COMPLETE HIP AND GROIN PROTOCOL

by Kathy Quenneville BS, RMSKS, RDMS, RT

Traditionally, the complete hip ultrasound examination (following AIUM Practice Standards https://onlinelibrary.wiley.com/doi/10.1002/jum.16228) has been sectioned into 4 quadrants. The anterior quadrant of the hip including the anterior hip synovial recess, the labrum, the iliofemoral ligament, the iliopsoas tendon and the rectus femoris. The medial quadrant encompasses the adductor longus, adductor brevis, pectineus, adductor magnus, obturator externus and gracilis. The lateral quadrant: Gluteus minimus and medius tendons, the gluteus maximus and the greater trochanteric bursa. The posterior quadrant: Hamstrings, semitendinosis, semimembranosus, biceps femoris, sciatic nerve, subgluteus and ischiofemoral spaces.

PowerPoint slides and video will demonstrate crucial landmarks in the anterior hip including iliofemoral ligament, labrum, psoas and rectus tendons and the iliopsoas bursa. The anterior-inferior iliac spine is the single most important osseous landmark of the anterior hip. An important distinction in the location of synovial spaces should allow the ultrasound examiner to distinguish iliopsoas bursitis versus joint synovitis.

In the medial hip, the osseous landmarks of the symphysis and pubic bones should let one distinguish the different layers of the adductors and the location of the obturator nerve branches. Navigating the lateral hip is more complex and requires lateral decubitus positioning and a good understanding of the individual facets of the greater trochanter. One important anatomic detail to remember is that the gluteus maximus is the only gluteus muscles/tendon unit which does not insert on the greater trochanter.

The posterior hip is examined in procubitus. If the patient is unable to roll over on the stomach, an approach from the lateral decubitus perspective can be attempted. Right-left comparison is of the utmost importance as the hamstrings have a complex hoove shaped tendon origin. Observation of internal and external rotation of the hip with alternating contraction and elongation of the external hip rotators including the quadratus femoris is important maneuvering to evaluate for ischiofemoral impingement. The sciatic nerve which travels in close proximity to the quadratus femoris can be observed during such maneuvering to assess a patient with subgluteus syndrome and/or a narrowed ischial femoral space.

Over and above AIUM guidelines, the Henry Ford Hospitals’ hip and groin imaging protocol also includes evaluation of core muscles. The complex interplay of core muscle injury, nerve entrapment in the abdominal wall and gender dependent anatomy differences make the differential diagnosis of hip and groin pain frequently too difficult to resolve by clinical examination only. Ultrasound in these circumstances is ideally suited in assessing hernias as the source of pain by using its dynamic imaging aspects and noninvasive imaging of neurovascular axes.

An extensive video collection used in this chapter will illustrate the maneuvers used and the necessary anatomical details that make the distinction of individual hernias possible. Recent literature has shown that ultrasound can diagnose hernias that are clinically not palpable and therefore deemed unimportant in areas of the body that are often affected by life-threatening hernias rarely diagnosed before they present too late in the emergency room (https://pubmed.ncbi.nlm.nih.gov/37253821/).

The Complete Hip and Groin Protocol for Ultrasound

Chapter 1 - The Complete Hip and Groin Protocol - Kathy Quenneville