- This webinar is on examining hip anatomy
and structure with point-of-care ultrasound the
posterior hip.
This is part four of a four-part series on the hip,
and you may view the recordings of the rest
of the series on this website listed up here.
Before we begin, please be advised all attendees are muted.
You may type your questions into the q
and a box in the toolbar located at the bottom
of your screen at any time.
We will conduct a q and a session at the end
of the presentation and demonstration.
This webinar will be recorded in Archive
for future reference as well.
Our presenters today are Daniel Shelton and Bill Medford.
Daniel Shelton is the director
of musculoskeletal market development
for Fujifilm Sona site.
Daniel spent 16 years
as a dedicated musculoskeletal sonographer
and 10 of those years have been here at SonoSite.
He now leads musculoskeletal market development
where he works to spread the word about the benefits
of point-of-care ultrasound.
Bill Medford is the lead musculoskeletal specialist
for Fujifilm SonoSite with 40 years of experience
as a sonographer, including 22 years specializing in
musculoskeletal sonography.
Bill is an expert in using point-of-care ultrasound across
the breadth of MUS musculoskeletal specialties.
Bill, I will turn it over to you to get started.
- Well, thank you Laura and welcome to everybody
to the final presentation in our posterior
hip webinar series.
And with that we'll move along.
Today what you're going to see are images produced off
of the Sono site PX newly launched
about six months ago.
The PX office PX offers unmatched image clarity
and a system design that will be found to be very adaptable
in examination rooms.
Transducers cover the full breadth of transducers
that you're used to seeing with socy products.
Transducers that you'll see utilized today include the
linear 15 to four megahertz transducer as well
as the curved five to one megahertz transducer.
Also, when we're doing looking at structures with
that have SU anatomy, that's very superficial.
We want to use a higher frequency probe
and our linear 19
to five megahertz transducer offers the highest frequency
ever developed with sono site products
and results in
exceptional image clarity.
We won't have any demonstrations of that today,
but for any superficial imaging,
certainly a transducer to consider.
The anatomy that we will be covering today include D SI
joint, the gluteus maximus, piriformis,
quadrat, ephemeris, the hamstring complex, as well
as the sciatic nerve
bony acoustic landmarks.
Always. Our starting point in identifying anatomy
include the posterior superior iliac spine,
- The sacro iliac joint,
the dorsal iliac wing,
the sacral foramina,
the greater sciatic foramen,
and the ischial tuberosity.
- Let's start with the SI joint.
The SI joint is a di arthrodial joint.
It's sacral surface is covered with hy lung cartilage
and the iliac surface is lined with fibrocartilage.
It is smooth in the young and becomes irregular with age.
It can become unstable due to ligamentous injury
or laxity, which can result in instability and discomfort.
Ultrasound can be the procedure of choice
for therapeutic injection.
We begin our examination at the posterior
superior iliac spine
with the transducer placed in a transverse body plane.
At the level of the PSIS either identify a
viable on the image or by palpation.
Once we've identified the PSIS, we're going
to move the transducer distally
until we get this wider portion of the SI joint,
which we see on this sonographic image.
And then we'll want to move the transducer even a little bit
more distal to recognize this narrower point of
the SI joint.
Note that when we're more proximal, that the iliac side
has a steeper contour down to this wider joint
as opposed to when we're more distally.
The iliac side is more flattened
and we see that the joint is narrower.
Injections can be delivered at any location.
Some feel that the injection,
therapeutic injection is more effectively delivered at this
narrower place where up
above in the wider portion
of the SI joint there are more ligamentous constraints
and it's felt that the delivery of injections may not be
as effective in in sliding down into this narrower
portion of the joint space.
A needle is guided from medial to lateral
in plain when we're doing injection guidance procedures
under ultrasound of the sacroiliac joint,
the gluteus maximus we covered in our lateral hip,
but it is a posterior structure,
but it becomes a lateral insertion,
so we're covering it both places.
The gluteus maximus is the primary extensor
muscle of the hip.
It also assists with external rotation and abduction.
It is the largest
and most superficial of the gluteal complex
and is innervated by the inferior gluteal nerve.
Its origin is along the posterior aspect
of the dorsal ileum
and along the lateral aspect
and postal lateral aspect of the sacrum.
It will also blend with the lumbar fascia
and the sacral tubus ligament along
with the tensor fascia lata.
Its connection to the
IT band stabilizes the femur along the surface
of the tibia while standing during relaxation
of the extension extensors ultimately
to insert on on gertie's tubercle of the tibia.
A more proximal point
of insertion is along the gluteal tuberosity of the femur.
Daniel, I'll turn it over to you to demonstrate the SI joint
and gluteus maximus.
- All right, thank you Bill. I am gonna wait on
that to go full screen.
There we are. Thanks for joining us again today.
In front of me, I've got a sono site PX
and our live model here.
Just to orient everybody,
because you're gonna see a few different camera angles.
We've got proximal this way,
which may be I'll be doing the right hip.
They're laying down on their belly, so
proximal distal is this way.
And then from our upper camera angle,
I've labeled in the corners up here, proximal and distal.
And then you can see the same camera on the bottom.
So I know when we're, when we're zoomed in here,
it can be a little bit disorienting,
but I do want to kind of point that out ahead of time so
that everybody's familiar with what we're viewing here.
So we've got proximal this way, we distal this way.
And then just like we do in all the other hip
and pelvis courses,
I do wanna talk a little bit about patient modesty here.
This is the posterior hip. This is no exception.
So what I've got is two blankets here
that I'll be scanning kind of through a window
that I open up.
I've already tucked the blanket into the upper part of the
pants because we're gonna be right up here on the SI joint
and working our way inferiorly.
So for this first part of the presentation,
I'm coming from the top side down
and I've got the shorts pulled down here,
and they are tucked in here.
I've got this second blanket here just
to expose the upper part of the hip there.
So our, our ileum being
here and sacrum being here, I can, I can palpate that PSIS,
which will be the beginning of our examination.
Gonna have a little bit of gel here.
Again, this is the 15 to four L 15 four transducer.
I'm gonna spin the transducer around.
I had the orientation marker facing medial
or to the midline, and I just went ahead
and maybe by luck plop down right on the PSIS.
That may not always happen.
So if it doesn't, let's talk about going
and finding that that more superficial bony landmark.
So if you just set the transducer down and, and,
and you're kind of wondering where you might be, we need
to find a bony prominence, okay?
And if it's this with the slope on it,
this is the ileum here.
And what we're gonna do is just follow that ileum up high,
high, high, high until it's meets its most peak.
And then I'm gonna go proximal to distal to find the,
the absolute apex of that thing right there.
Now, if you start more midline,
you may catch this flat plate of the sacrum
and the spine of the sacrum.
So here's one of the spinous processes of the sacrum here,
and we're just gonna follow that down laterally.
Now, don't stumble on the first thing
that looks like a joint.
Those are just sacral foramen.
This could be S two or S one depending on how proximal I am.
But I need to go even more lateral until we see
that high riding bony peak of the PSIS.
So what I'm doing there is I'm, I'm planting the medial side
of the transducer with a finger like I did in a lot
of other body parts like the elbow
where we pivot and windshield wiper.
And I'm just gonna be moving my thumb across this way
until I see that PSIS really nice.
And what that does is it, it really nicely opens the joint
for the upper SI joint or the superior SI joint.
And you can even see the anti tropic
artifact of these ligaments here.
So that that lets you know that we're in the ballpark.
And as Bill mentioned, if we're coming in for an injection,
it's gonna be from midline to lateral this way.
Now let's follow that joint, the PSIS being easier
to follow inferiorly.
We're gonna follow that inferiorly, inferiorly inferiorly
until it completely disappears into the superior sciatic
framing, which would be here in the piriformis is
down here, which we'll get to.
But that tells me that I've gone
beneath the inferior SI joint, which is right here.
You can see that joint really nicely right there.
Not this space right here.
So this is the most inferior margin of the ileum.
And if I drop my thumb inferiorly,
you'll see it disappear completely and the sacrum remains.
So right here is that scro iliac joint,
and you can see the joint really nicely on the cyte px.
Superficial to that, these are the fibers of the glute max.
They're oblique, they dive this way.
So they're crossing my transducer obliquely
and you can see them jumping up
and over to dive onto the sacrum here.
So what I'm gonna do, I know that they slant this way
to wrap over the tr so I'm just gonna pivot
the transducer this way
until we elongate the muscle fibers of the glute max.
And it's a very broad muscle.
I can follow it right across the ileum.
And it's not necessarily a part of a examination protocol
on the posterior hip, even though
the more applications we find to do ultrasound on the hip,
especially the posterior hip,
the more it may become somebody's protocol.
But if clinically indicated, you would want to chase these,
the, the, the origin of these fibers,
you can actually see the glute max jump up
and over the sacrum here to that lumbar fascia
that bill mentioned right there, that little feathery edge.
So that's pretty neat. I'm gonna go even more inferior.
More inferior, more inferior until we see the glute max
really tapered up onto what looks like
the spine of the sacrum.
And we're actually down here at the coddle epidural anatomy.
So that's actually the sacral cornew that we're seeing here.
Maybe for a different subject in pain management
or something, we'll go over the cocal epi epidural anatomy.
But following that glute max laterally, laterally,
laterally, you can see how nice and parallel the fibers are.
And I'm sure Bill will mention when we get to piriformis,
which is right here, just how nice
and parallel they are to each other.
Bill, did I miss anything so far
while Bill unmutes I'll, I'll keep scanning that glute max.
I'm gonna add a little bit of gel getting a little
dry. There
- We go.
Daniel, I'm back on the PowerPoint now.
- Alright. All right,
go ahead Bill.
- Okay, let's move to the piriformis.
Daniel mentioned
that piriformis fibers do parallel the fibers
of the overlying gluteus maximus
and the piriformis courses like the gmax diagonally
its origin is on the anterior sacrum,
specifically three bundle attachments between the first
and second, second and third and third
and fourth anterior sacral foramina.
It exits through the greater sciatic foramen
and inserts onto the superior aspect
of the greater trocanter.
Also to be aware of is a sciatic nerve
as it comes out from what is
behind the piriformis muscle to cross over in front
of the Jemele eye and raders.
And ultimately the quadratus femes us 17%
of sciatic nerves, however, run through the piriformis
and predisposes this subgroup to tingling, numbness
and pain along the sciatic nerve and deep into the buttocks.
So where do we begin when we look for the look
for the piriformis muscle, we're going
to begin at the PSIS
and our transducer is going to, as where we started
with the SI joint is going to be placed as the PSIS.
Our next transducer movement is going to slide laterally
with the lateral aspect of the transducer towed in.
We're going to employ the heel toe maneuver,
this being the heel, this being the toe.
We're gonna tow in to
to level out this iliac wing so that
we have a continuous appearance
of bone on the under surface of
what here is gluteus medias.
Once we have established that we're going
to slide the transducer distally
and oblique the transducer to correspond
with the diagonal course of the piriformis.
So directly transverse up here
to demonstrate the iliac wing slide down until we lose
that continuous iliac wing
and begin to see the sciatic foramen.
Once we lose that bit of bone up here
and we come to
the sciatic foramen, we begin to see,
once we oblique the transducer along the diagonal course,
we'll begin to see the piriformis
adjacent anatomy that might help us identify.
This is again, the sciatic nerve
and the superior gluteal nerve.
And the associated vessels in particular
might turn on color doppler
and recognize the inferior gluteal nerve,
gluteal artery here.
So the sonographic appearance is again,
fiber's very parallel to one another,
gmax piriformis.
And we can use a dynamic maneuver by flexing the knee
and rotating the femur to see translation
of the piriformis back and forth.
I'm sure Daniel will be demonstrating
that in our lives scanning.
Moving a little further south, we'll go from the piriformis.
We'll cross over the GLI
and the OB trait to the quadratus fems.
Quadratus femoris is an external rotator
and adductor of the thigh.
It also assists in stabilizing the hip joint.
Its origin is at the lateral margin of the
- Ator ring.
And
- And I, I'm sorry, its lateral margin is
that the ator ring just superior to the ischial tuberosity,
which is where we'll find the hamstrings inserts.
It's distal insertion is on the quadrat tubercle
and the inter tro enteric crest of the posterior
medial femur right along here
and here on the sonographic image.
So this is the quadratus femes. Where do we begin?
We place the transducer at
or near the gluteal fold
where we'll recognize the bony acoustic landmark
of the ischial tuberosity medially.
And laterally we'll recognize the femur
quadratus femoral bridges that gap.
This is the ischial femoral space
and is a zone of impingement
of the overlying sciatic nerve.
Dynamic maneuvers can help
us recognize snapping that may occur due to a lessening
of this distance
and snapping at the ichi femoral space.
Okay, Daniel, I'll turn it over to you.
- All right, thanks Bill. As Bill mentioned, we are going
to go inferiorly on the hip now,
and I've re draped the hip, we're still proximal this way,
but I've got the shorts now up
and I've, I've taken the time to tuck
and protect the the patient's undergarments.
And then what we're gonna do is just expose
down to the gluteal fold.
So what we're gonna be looking at now is the inferior SI
joint, and we're gonna walk our way to the ilium
and then we're gonna go south into
that superior sciatic foramen.
And that will help us find the piriformis.
So left side of the screen again is gonna be medial,
and we're looking for a bony landmark there.
So let's find out which part of the, the
inferior SI joint that is.
It looks like I fell right on it.
So what we're gonna do is follow this ileum.
Now let's follow the ileum laterally, laterally, laterally.
There we go. And all I'm gonna do is just fall into
that superior satic notch.
So it's just a little short movement
and I can already tell I'm in that ballpark
because I can see that superior gluteal artery just resting
right here.
And what we're gonna do is throw our color feature on,
and I wanna be able to see that little artery.
And what that's doing is just a clue to say, Hey, I'm about
to hit the superior satic foram.
And you're gonna see that that artery start
to shoot straight up and down, headed towards my transducer
as it wraps up and around the inferior margin of the ileum.
So the very, very next structure underneath that
is gonna be our piriformis here.
So diagnostically, L 15,
great transducer to look at all these little fibers.
And I can see this big pizza slice headed laterally over
the isum.
So here we have isum piriformis,
inferior gluteal artery, superior gluteal artery.
And I think the, I always relate things
to food for some reason.
So I do, I think the piriformis just
looks like a big pizza slice.
It's a triangular shape structure.
It's gonna go up and over the isum.
As Bill mentioned, we start
to see the superior jamella right here
as it rests right on top of there.
And then just before we get to the isum down here, we've got
that sciatic nerve,
or at this point could be the distal lumbar complex still,
but here it is as a nice tight group of nerve.
So it's probably already sciatic at this point,
but this is nerve.
And then up over the isum is the superior jamella.
And then just resting on top of that superior jamella,
if I keep going laterally, is the piriformis
muscle in this thin strand is starting
to make itself into the piriformis tendon procedurally
and dynamically.
I like to switch over to the curvilinear probe.
So I'm gonna take a second to do that.
And I'm gonna select the C five one transducer
with a musculoskeletal exam type
to get a broader field of view.
And if your general patient population is not
of the body habitus of our model today,
you're really gonna want to consider
getting a carline probe.
So I'm starting with the left side of the screen again
to the patient's medial side,
things are gonna look a little bit different.
So I wanna go find a familiar landmark.
So what I have to do is find my inferior SI joint
or any of the part of the sacrum is fine,
and then move the probe laterally to the ileum.
So here this big ski slope here is the ileum,
the inferior part of that slope.
I'm aiming the beam all the way
to the anterior pelvis actually.
So here's minimus medias maximus.
So just to give you an idea of the broad field of view
that we get with the C five one transducer.
It's really nice just to get you oriented.
So let's follow the ileum now south.
And I need to see the ileum split into two pieces there.
So left side of the screen, sacrum side of the screen,
I see this opening, but I still see two bony landmarks.
So sacrum here and the beginnings of the isum here.
Back to our pizza slice piriformis here.
If I wanted to check my work on the inferior part
of the ileum, you can see
that superior gluteal artery pulsating really nicely
activate the color feature.
Again, check your work,
make sure you're still familiarizing yourself,
but you can just see the more broad field of view
that you get outta the coline and more appreciation
for the whole structure as that
that superior gluteal artery is just hugging the border,
the piriformis there.
Get my arrow back out here. So this is the
piriformis. Yeah, bill, go ahead
- Real quick.
Show how the angle of the transducer is
because frequently the most, one
of the most common mistakes I see,
and I I'm sure you do too, is
that the transducer isn't oblique
to go along the diagonal course of the piriformis.
- That's true, bill, I just kind of instinctively did that
because I've just, I've just scanned so many of the hips.
But when you're first learning this,
and I stumbled through a lot of things on the posterior hip,
it's kind of the final frontier on in terms of the joints
that we typically cover for me.
And I did find it useful to go ahead
and elongate the glute max.
Remember that those are running parallel to each other.
And the glute max is such an oblique structure.
We need to pivot our transducer
and set ourselves up for the long axis of the piriformis.
So there you can see
and I can palpate the trope to find out.
So here's tr and I'm aiming right at the trope.
It's not a horizontal structure,
it's a very much a vertically oriented oblique structure.
So here we have GL glute, max, max,
long axis, piriformis, long axis,
and you can even see some of the central tendon
of the piriformis starting to show itself here.
As we get over to the is yum superior isum here,
right on the upper margin of the isum,
here's our superior Jamila.
With more penetration out of a lower frequency transducer,
you can very nicely see the inferior gluteal artery,
the sciatic nerve down a little deeper.
We get into some pudendal structures, maybe
for a pain management talk we could get into.
But for the general survey, we're gonna keep following
that piriformis out laterally.
And we start to see that that posterior
femoral acetabular joint here, neck
of the femur trope starting to make itself known here.
I do see a lot
of people struggle when they're looking for a piriformis.
They start at the trope and they call just any
of these rotating structures.
A, a piriformis.
When when I was first learning
to do posterior hip a while back, I made the miss
call when doing external rotations
and just looking for the trope here.
And we call, oh, there's our piriformis.
And we got really excited. I'm gonna bring the arrow
to the spot that we got excited about.
Saw a huge wavy flag tear right there.
I mean, what else could that be?
It's the big it it,
it's the big rotating muscle we see on the anatomy scan.
And we sent it out for an MRI
and it came back as an wouldn't, you know,
as a quadratus femoris tear.
And that's when we really got to learn, hey, we need
to take a little bit more time
and start with our bony landmarks from the pelvis,
from the ileum, work our way south
from the superiors static notch where, you know,
it originates on the anterior sacrum there.
And so the two bones we have in the, in the,
in the view here,
and I'm gonna try to bring the leg where
you can see me rotate.
Upper left is sacrum.
Mid screen right is the isum.
And all I'm gonna do is just rotate passively.
Don't let the patient do it for you
because it'll start activating all the,
the surrounding gluteal structures
and it'll move your transducer.
Also an angle consideration is not
to stay per just perpendicular to the skin
because these structures tend to dive away
when the patient is laying down
and you are looking, say at a skeletal model, the
the ileum is not flat this way the ileum is diving this way
like two plates obliquely oriented.
And what I need to do is aim into
that big ileum wing this way, not this way.
So I need to be 90 degrees to the ileum
before I get down into the piriformis.
So starting with our familiar bony landmarks, again,
we have our big ileum here.
We can see glute max and mead
and I'm just gonna fall into that superior satic notch.
You can see the bones opening up right there closing up.
So I'm scanning superior, inferior, superior, inferior.
And now I'm gonna oblique the probe and go long axis there.
And all I'm doing now is, is just confirming my location
of the piriformis with the internal
and external rotations passively.
Gotta do this passively or it'll be a very frustrating exam.
- Daniel, while you're there, we have a question
and we usually wait until we're finished.
But while you're there, we have a request
to see if you can show the sciatic nerve
pause just a little bit and point it out for people to see.
Please.
- You bet. Right here,
see this triangular wedge resting against the isum.
So this is sciatic nerve, it's lateral
to the arterial structures
of the inferior gluteal artery in the pudendal.
And you could follow it down
and watch it stay on the edge of the isum and then jump up
and over that neck of the isum here.
And we'll get into the remainder
of the sciatic nerve when we get into quadratus femoris.
But I'm still just following that sciatic nerve
where my arrow is using.
Well it gets lost in a little bit of anisotropy.
Let's start right back up here again.
There, there is where, lemme go right back to where I was.
So here's our piriformis.
Sciatic is sitting just right here
and it's not just a centimeter
or so of motion,
you're gonna see the sciatic nerve climb upwards
there
and it is still subject to anti atropy.
So I kind of, kind of let it get away from me there,
but here it is, it's a flat ribbon at this
point over the isum.
So let's follow that, that nerve right here.
I keep remembering to move my arrow
and more distally.
It's really nicely, reliably found right here on top
of the quadratus femoris as this little triangle.
So screen left, we've got our ischial tuberosity
and our hamstring origins.
And then right here is the sciatic nerve.
And then here's that quadratus femoris.
And we could try to trace that proximally to see
that little, see the, an isotropic transition it's trying
to make right there.
So this is inferior jamella here it is on top
of there, there's the sciatic.
What I'm having to do is rotate my probe
and head back up towards the sacrum.
And here's where it's still kind of a flat ribbon.
- I would say that I've found it helpful to go down
to the quadratus femes and the ischial tuberosity
and identify it at that label
and then follow it up to the piriformis.
- That's what I just, that's what I just did.
And it kind of highlighted that anti isotropy,
but here it is trying to, trying
to maintain that perpendicularity.
But I'm, what I'm finding myself having
to do is almost like a rainbow of the transducer
to stay 90 degrees to the nerve
as it curves up and over theum.
So here it is, nerve sciatic, sciatic, sciatic, sciatic.
Remain that 90 degree relationship as I climb up
and over and I'll find myself
down at the quadratus.
Oh, there it is.
- I think that's great. Daniel. One other, one other thing.
Sure. One more time.
Could you demonstrate the dynamic,
dynamic motion of the piriformis?
- Sure. So back to our familiar landmark,
I'm gonna lose the arrow for a minute
because I need two hands.
Come up here to the sacrum
and the big tip here is as you go laterally
to aim back into the ileum, okay,
so we're aiming into the ileum, not 90 degrees,
to the skin, into the ileum.
And we see that big ski slope of the ileum.
And what I'm gonna do is just fall down keeping the sacrum
in the upper left portion of the screen.
That would be one of my other scanning tips, pearls
that I'm observing while I'm, while I'm sitting here talking
to you guys, sacrum upper left
and I'm gonna watch this, this horizontal bony structure
split into two pieces here.
When I see those two pieces,
I know I'm in the superior sciatic foramen.
You're gonna tilt the probe or rotate it.
In this case I just went clockwise
and that opens up that big triangular
pizza slice shaped piriformis.
And I'm gonna confirm that just
by doing passive rotations internally and externally.
And I'm on the medial or yeah, more medial side of the isum.
And you can see this muscle,
the more external rotation I apply,
which would be internal rotation I guess.
I hope that answers your question.
- Very good, thank you.
We, I'll share my screen
and we'll move on to the hamstrings.
So the hamstrings originate from the ischial tuberosity.
They can, they contribute to assisting with hip extension
and knee flexion as each
of the hamstrings muscles traverse the both the hip joint
and the knee joint.
There are three muscle tendon structures
that comprise the the hamstrings,
the semimembranosus muscle tendon, as well
as the semi tendonosis and long head of the biceps.
The semimembranosus muscle tendon group originates off the
sup lateral issue, tuberosity
and inserts onto the medial epicon dial.
So the semimembranosus here comes underneath
the semit
and the biceps to insert right here
on the ischial tuberosity.
And then it comes down
and inserts on the medial tibial condyle.
The semi tendinosis
and long head of the biceps are conjoined
the postal and the insert on the postal lateral ischial
tuberosity as one point of origin.
There are two heads to the bicep tendon, a long head
and a short head proximally.
The short head originates from the line aspera of the femur.
The in the insertion
of the biceps femorals is on the fibular head.
And at this point the long head
and the short head have become a common tendon
to insert as
as a single tendon onto the fibular head.
The semi tendinosis, on the other hand,
inserts on the antrum medial tibia as one of the pez
and serene tendons.
All of the hamstrings are innervated by the tibial branch
of the sciatic nerve.
So where do we begin?
We begin again at the gluteal fold
or near it,
at which point we'll recognize the hyper coic bony
acoustic landmark
of the issue tuberosity shape much like a matter horn
with a bony prominent peak over the, over the top
of which we will see on the lateral aspect,
the conjoin tendon of the semit
and the biceps femoris also just lateral,
as Daniel just covered nicely in his live demo.
The sciatic nerve will be identified
if we turn the transducer 90 degrees now.
And we look at
these structures in the long axis,
we'll see the ischial tuberosity superficial,
we'll see the conjoint tendon
and deep to that as we fall off the bone,
we'll see the semimembranosus tendon.
This, these are the tendon only portions
of the hamstrings complex proximally.
If we follow them more distally, we'll we'll see.
And we'll want to interrogate the myotendinous junction.
The biceps is the most commonly torn,
the most common running tear is a
musculo tenderness tear that you'll only see
that you frequently will see just immediately adjacent
to the central tendon.
A little further distal from here,
the sciatic nerve.
We're going to begin where Daniel demonstrated
before, I like
to interrogate it beginning at the piriformis.
We're going to position our transducer along the piriformis
so that again, we see the,
the thicker portion of the piriformis.
By the way, piriformis, the Latin
for piriformis is pear shaped as opposed to the pizza slice
that you were talking about, Daniel.
I must agree though that it is shaped more like a pizza,
a slice of pizza than a pear.
But the piriformis than we'll see the sciatic
nerve and adjacent to it,
the inferior gluteal artery.
If we slide the transducer distally now
past the gli
and the ator to the isum, again this is
that same image where we see the ischial tuberosity,
the conjoin tendon and slightly lateral to it.
We'll see the sciatic nerve
always good when you're looking at the
sciatic nerve at this level.
See this is, we don't, the depth of this image isn't set
to image the quadratus femes.
But at this level, always wise
to just look at the quadratus femes,
there are dynamic maneuvers that can be done
to demonstrate ischial femoral impingement
and snapping that may occur due to that.
And recognize decrease in
space here that could contribute to irritation
of the sciatic nerve.
Once we move slightly more distal, we're going
to be in the upper portion of the posterior thigh
where we'll see the conjoining tendon
and its myo tendonous component
with the biceps femoris laterally,
the semi tendinosis medially.
We'll see the typical tadpole shape
of the semimembranosus tendon
and the underlying semimembranosus muscle.
So myo tendinous junction
and laterally we'll identify the
- Sciatic nerve.
That concludes
- The PowerPoint presentation.
Daniel, I'll let you finish it up
with a live model demonstration of structures please.
- Alright, thanks Bill. So I've switched back over
to the L 15, linear 15 megaherz transducer.
There we go. And I'm gonna re-expose the hip back here
and pick up where we left off.
This time my bony landmark is gonna be the ischial
tuberosity and lateral.
I should see that, that sciatic nerve really nicely.
And to check my work,
we'll look at the quadratus femoris again, left side
of the screen will be medial.
And if, if you joined late, you can see in the upper corner.
This is superior, this is inferior, this is lateral,
this is medial here.
So I'm gonna place the transducer down here
where I believe I should find initial tuberosity.
If I don't see one right off the bat, what I have
to do is just follow these shadowing structures
up more medially.
Here we go. So let's find out which kind of bone this is.
I'm gonna follow it down and see if it, it comes
to a nice point and that's gonna be our ischial tuberosity.
I've run outta gel, so I'm just gonna squeegee some gel
down more inferiorly.
There we are. So we've got this, this prominent
bony peak here, just lateral to
that prominent bony peak of the ischial tuberosity.
We can see that conjoin tendon structure
starting to show itself.
I'm gonna keep moving laterally just
to orient myself a bit more.
So here's quadratus femoris, here's that sciatic nerve.
So we can see all those structures really nice.
So we know we're in the ballpark, we
know where we need to be.
Do now to differentiate these fibers,
I'm gonna bring my depth up because I can,
we want a more shallow depth and a more high resolute image
and we're gonna use tropic artifact to our advantage
and kind of split apart these layers here. So Dan,
- I'm gonna interrupt just for a second.
I know the image from your PX doesn't translate
to the zoom presentation perfectly.
I'm gonna have you just decrease your
gain just a little bit.
- Oh good. Good call Bill Zoom definitely does.
- Thank you.
- Hopefully that's better. Very good.
So we could see these layers differentiate themselves here
on the, on the hamstrings kind of common origin.
Deep down here we've got the deeper semi menos,
semi tendinosis, overlaying that
and laterally at that conjoin structure.
We've got our biceps femoris and we could trace these down
and watch the biceps femoris tendon move its way laterally
and its extended muscle belly here.
And semi tendinosis would be our next landmark,
just slightly medial to that.
And underneath the semi tendon
or the biceps femoris, here's our s static nerve just
as a a reference.
So I'm down at the, the, the gluteal fold again,
here we've got tendinosis.
Let's use isotropy to our advantage here. This.
So even though there's a component here,
our more superior showing tendon right here medially is our
semimembranosus, this little cleft edge.
And let's watch it join up with the semi tendinosis
and then the, the biceps femoris laterally.
So you can almost get all three of 'em in a row,
even though there is a conjoin component to it.
Here is biceps femoris,
semi tendinosis, semi menos.
This this little isolated shadow here.
So I'm just barely rocking the transducer like we do the
biceps tendon in the groove to see
what subtleties we can get.
What you don't wanna do is get in the habit of calling
that a tendinosis, even though that's in the name of one
of the, one of the tendons.
That is not a, a pathology if you can get it to fill in.
So an isotropy back here is really helpful,
but it can also be very misleading
and we don't wanna call things degenerated if they're not.
So now I'm gonna take one of these tendons here in this case
we'll we'll focus on menos
and rotate the probe so that the pro, the left side
of the screen is facing proximal.
So we've got our isum here
laterally.
It's really nice to see biceps femoris go ahead
and shoot off and go do its own thing.
And I could follow that, that more laterally oriented
structure pretty easily.
I'm gonna bring my pro more medial now
and focus more on the semi menos
and tendinosis area here, which we
can see really, really nicely.
It looks like a lot of tendons always insert
like a big bird's beak.
And we see that same pattern back here on another tuberosity
on the body, on the ischial tuberosity.
So we've got our conjoin tendon here superficially
and then deep, deep, deep down here where
as Bill pointed out, I'm not sure if gains
coming through on zoom.
I'm gonna auto this,
- Try your TGC deep.
- Yeah, there we go.
Hopefully that helps.
- Yeah, notice that we're trying to go. There we go.
You're seeing a little bit there Daniel.
The semimembranosus deeper,
but this is with the, give you an idea of how
nice the penetration is with the linear 15
to four megahertz transducer.
- Very true. Most of these higher frequency transducers
don't have much of a range to them.
And this, you know, we're scanning 15 to four
so really depends on where we are in the screen,
how deep we're trying to shoot, whether I'm in res or gen.
And I've dropped my frequency down to the gen spectrum.
So I'm on the lower lower end of that bandwidth,
which is really helping me with penetration here.
I'm gonna move laterally to my sciatic
and I'm gonna go cross section again,
find our ischial tuberosity, check our gain
with zoom, which looks a little hot.
I'm gonna hit auto. There we go.
Auto's doing a really good job.
So ischial tuberosity again here we have our,
our sciatic nerve
and quadratus femoris just to check our work.
And I kind of already went through the sciatic so I'd,
I'd find that to be redundant
to trace the sciatic approximal
time on it just a short time ago.
- Let's just follow distally, Daniel to the upper thigh to
- You. Got it.
- Yeah. - So what I'm gonna do is add a little bit of gel
'cause I know, I know I'm about to follow a track here
and it might even be nice to see it split
if, if, if I've set the camera
to go down there.
- Oh, very - Good. Looks like I did.
Okay, so quadratus femoris
back up here at the isum.
Here we are and let's
follow this structure here.
Sciatic nerve distally distally,
distally cross-section is the way to go.
I know that these nerves look really,
really pretty and long axis.
- Let's just turn, let's just turn the game
down just a little.
Daniel. Thank you. Perfect.
- You bet it's blinding you.
Okay, so sciatic nerve distally, distally distally.
Keep following it distally.
And we should start seeing an offshoot here
of the common peroneal
or common fibular nerve depending on when you went
to med school or started learning this,
I figured we'd already see it start
to bifurcate, but we're not quite there.
So here's the popliteal fossa where my hand is
and maybe I missed the bifurcation.
It should have already. There it is.
Okay. So right where my arrow is, you can see the
bifurcation take place right there.
That's just not separated. Hang on.
Oh that's not right 'cause it's gonna follow the
biceps femoris just as a scanning pearl
because I sure would not think to see,
- I think the main thing is Daniel, let's just go down
as far as the Mercedes-Benz sign to show how
to identify the conjoin tend,
and you're right there, the conjoin tendon, more superficial
between the biceps femorals and the, and the semi tendinosis
and then the semiosis,
that tad pole shaped structure there to the left.
Yep. And then the sciatic nerve so
that folks can identify at that level
where the nerve is and the two tendons in question.
That's a very common location for hamstring,
my tendonous injury.
- Great point Bill. And I really like that Mercedes-Benz,
that's a thing to put in the slides.
- I also wanna leave a little time
for questions if there are any.
- Now's the time. - Yeah, go ahead.
If you have any questions, put 'em into the q and a box
and we will address those.
- Yeah, this has concluded the normal part of the exam
and we're happy to stick around for a few minutes and,
and just answer these questions on the fly
however you want them to, to be addressed.
If there's something that you'd like reviewed again
that we did cover.
And depending on the subject that we didn't cover,
there's also an opportunity
to cover a few of those things too.
But I think, you know, posteriorly bill
orienting to the superior
sciatic foramen is just, it's just the way to go.
I'm just following the sciatic of long axis,
which has seemed, seems
to be helping me out quite a bit compared
- To earlier.
Good question here, Daniel is issue bursa, right?
As it arcs over the top of the conjoint tendon.
- That's another one of those bursa
that we're really not gonna see it
unless there's some pathology there,
- Right?
- But if you want, if you wanted to see that interface, it,
it's not a bad idea to add a little dynamic component
to your exam and just kind of roll,
roll the glute max a little bit by getting the femur
to rotate so you could at least delineate, hey, where does,
where do all of these connective tissue layers
begin and end?
And, and the answer to that,
sometimes depending on the patient's body habitus,
which we don't have a problem with today,
but when you're out in the, out in the real clinical world,
sometimes these tissue interfaces are not so obvious.
So what I'm doing is just causing an external rotation
by moving the leg
and I'm isolating that glute max superficially
over the ischial tuberosity in a, in a, in the hamstrings.
And I'd be looking for a bursa right up in that spot that
- Was so similar to what we do with the,
with the trocanter bursa.
- Absolutely. You know, this is ultrasound, make it move.
You know, static images are not going
to help you answer a lot of questions.
So anytime you get a chance, you need
to make these structures move
and oppose each other as frequently as you can.
And then, and sometimes you're gonna expose some additional
pathology like adhesions that are not
so obvious on a static image.
- Daniel, one other question we had was to
revisit the where, where it's common
to see a myo tendonous tear of the hamstrings.
So maybe down, start
with the conjoin tendon at the Mercedes-Benz sign
level and Sure.
Just follow that central tendon.
And that's basically what we're doing as we're following
that central tendon there
and we're looking right adjacent to it for any change in
what is normal echo architecture where the my,
where the muscle comes into the tendon right
- There.
Yeah. This nice little interface right here.
And now I'm tenderness Yeah,
I've left the myo tendus portion and now
- I'm as, as you proximally.
- That's correct. - So it's just
that myotendinous location kind like what we see
with gastro tears right up against the tendon
and you're looking for fluid defect, you're looking
for a change in that normal penate pattern
or starry eye appearance.
If you're short axis to the course of muscle,
you're just looking for a change in that.
What otherwise is a typical
echo architectural appearance right there.
Beautiful. See how you follow, see
how he's following that down.
So anywhere along
and adjacent to that central tendon is where you're going
to see changes, appearance change there,
you see the semimembranosus tendon deep to it.
See that tadpole looking structure there.
Hope that answers the question.
Are there any other questions that we have?
I'm not seeing any, Laura.
I think with that we'll turn it back over to you.
- Great. Bill, by any chance, do you have
that last slide that you can show? Or do you
- Want Oh yes, I, I do.
Thank you.
- Just so everyone knows, we will be posting the recordings
of all these webinars at this website that you see here,
secure dot sona site.com/behind theskin webinar
and look forward to some new webinars posting in January.
We'll have a few on in the MSK market
on dorsal wrist and carpal tunnel.
So I just wanted to let everyone know
that those are coming soon.
- Great. And we wish you all a happy holidays.
- Absolutely. And thank you all for joining us today
and thank you Bill and Daniel again
for an exceptional presentation and demonstration.
Very well done.
- Thanks everybody.

https://www.youtube.com/watch?v=A666VIJhqQ0

Transcript

0:02 - This webinar is on examining hip anatomy

0:04 and structure with point-of-care ultrasound the

0:06 posterior hip.

0:07 This is part four of a four-part series on the hip,

0:10 and you may view the recordings of the rest

0:12 of the series on this website listed up here.

0:15 Before we begin, please be advised all attendees are muted.

0:18 You may type your questions into the q

0:19 and a box in the toolbar located at the bottom

0:22 of your screen at any time.

0:23 We will conduct a q and a session at the end

0:25 of the presentation and demonstration.

0:28 This webinar will be recorded in Archive

0:30 for future reference as well.

0:32 Our presenters today are Daniel Shelton and Bill Medford.

0:35 Daniel Shelton is the director

0:37 of musculoskeletal market development

0:38 for Fujifilm Sona site.

0:40 Daniel spent 16 years

0:42 as a dedicated musculoskeletal sonographer

0:44 and 10 of those years have been here at SonoSite.

0:47 He now leads musculoskeletal market development

0:49 where he works to spread the word about the benefits

0:51 of point-of-care ultrasound.

0:53 Bill Medford is the lead musculoskeletal specialist

0:56 for Fujifilm SonoSite with 40 years of experience

0:59 as a sonographer, including 22 years specializing in

1:02 musculoskeletal sonography.

1:04 Bill is an expert in using point-of-care ultrasound across

1:06 the breadth of MUS musculoskeletal specialties.

1:09 Bill, I will turn it over to you to get started.

1:12 - Well, thank you Laura and welcome to everybody

1:15 to the final presentation in our posterior

1:20 hip webinar series.

1:22 And with that we'll move along.

1:25 Today what you're going to see are images produced off

1:28 of the Sono site PX newly launched

1:32 about six months ago.

1:34 The PX office PX offers unmatched image clarity

1:39 and a system design that will be found to be very adaptable

1:44 in examination rooms.

1:46 Transducers cover the full breadth of transducers

1:50 that you're used to seeing with socy products.

1:53 Transducers that you'll see utilized today include the

1:58 linear 15 to four megahertz transducer as well

2:02 as the curved five to one megahertz transducer.

2:07 Also, when we're doing looking at structures with

2:12 that have SU anatomy, that's very superficial.

2:16 We want to use a higher frequency probe

2:19 and our linear 19

2:22 to five megahertz transducer offers the highest frequency

2:26 ever developed with sono site products

2:29 and results in

2:32 exceptional image clarity.

2:35 We won't have any demonstrations of that today,

2:38 but for any superficial imaging,

2:40 certainly a transducer to consider.

2:46 The anatomy that we will be covering today include D SI

2:50 joint, the gluteus maximus, piriformis,

2:56 quadrat, ephemeris, the hamstring complex, as well

3:01 as the sciatic nerve

3:05 bony acoustic landmarks.

3:07 Always. Our starting point in identifying anatomy

3:12 include the posterior superior iliac spine,

3:17 - The sacro iliac joint,

3:21 the dorsal iliac wing,

3:25 the sacral foramina,

3:29 the greater sciatic foramen,

3:33 and the ischial tuberosity.

3:40 - Let's start with the SI joint.

3:43 The SI joint is a di arthrodial joint.

3:46 It's sacral surface is covered with hy lung cartilage

3:50 and the iliac surface is lined with fibrocartilage.

3:55 It is smooth in the young and becomes irregular with age.

4:00 It can become unstable due to ligamentous injury

4:03 or laxity, which can result in instability and discomfort.

4:08 Ultrasound can be the procedure of choice

4:11 for therapeutic injection.

4:15 We begin our examination at the posterior

4:20 superior iliac spine

4:22 with the transducer placed in a transverse body plane.

4:26 At the level of the PSIS either identify a

4:30 viable on the image or by palpation.

4:37 Once we've identified the PSIS, we're going

4:42 to move the transducer distally

4:45 until we get this wider portion of the SI joint,

4:51 which we see on this sonographic image.

4:55 And then we'll want to move the transducer even a little bit

4:58 more distal to recognize this narrower point of

5:02 the SI joint.

5:04 Note that when we're more proximal, that the iliac side

5:09 has a steeper contour down to this wider joint

5:15 as opposed to when we're more distally.

5:18 The iliac side is more flattened

5:22 and we see that the joint is narrower.

5:25 Injections can be delivered at any location.

5:31 Some feel that the injection,

5:33 therapeutic injection is more effectively delivered at this

5:38 narrower place where up

5:41 above in the wider portion

5:43 of the SI joint there are more ligamentous constraints

5:47 and it's felt that the delivery of injections may not be

5:51 as effective in in sliding down into this narrower

5:56 portion of the joint space.

6:00 A needle is guided from medial to lateral

6:04 in plain when we're doing injection guidance procedures

6:07 under ultrasound of the sacroiliac joint,

6:13 the gluteus maximus we covered in our lateral hip,

6:16 but it is a posterior structure,

6:18 but it becomes a lateral insertion,

6:21 so we're covering it both places.

6:23 The gluteus maximus is the primary extensor

6:26 muscle of the hip.

6:27 It also assists with external rotation and abduction.

6:32 It is the largest

6:33 and most superficial of the gluteal complex

6:37 and is innervated by the inferior gluteal nerve.

6:44 Its origin is along the posterior aspect

6:47 of the dorsal ileum

6:50 and along the lateral aspect

6:55 and postal lateral aspect of the sacrum.

6:58 It will also blend with the lumbar fascia

7:01 and the sacral tubus ligament along

7:05 with the tensor fascia lata.

7:07 Its connection to the

7:10 IT band stabilizes the femur along the surface

7:13 of the tibia while standing during relaxation

7:17 of the extension extensors ultimately

7:19 to insert on on gertie's tubercle of the tibia.

7:23 A more proximal point

7:25 of insertion is along the gluteal tuberosity of the femur.

7:31 Daniel, I'll turn it over to you to demonstrate the SI joint

7:35 and gluteus maximus.

7:41 - All right, thank you Bill. I am gonna wait on

7:44 that to go full screen.

7:45 There we are. Thanks for joining us again today.

7:47 In front of me, I've got a sono site PX

7:49 and our live model here.

7:51 Just to orient everybody,

7:52 because you're gonna see a few different camera angles.

7:54 We've got proximal this way,

7:57 which may be I'll be doing the right hip.

7:59 They're laying down on their belly, so

8:02 proximal distal is this way.

8:05 And then from our upper camera angle,

8:09 I've labeled in the corners up here, proximal and distal.

8:12 And then you can see the same camera on the bottom.

8:15 So I know when we're, when we're zoomed in here,

8:18 it can be a little bit disorienting,

8:20 but I do want to kind of point that out ahead of time so

8:23 that everybody's familiar with what we're viewing here.

8:26 So we've got proximal this way, we distal this way.

8:29 And then just like we do in all the other hip

8:31 and pelvis courses,

8:35 I do wanna talk a little bit about patient modesty here.

8:37 This is the posterior hip. This is no exception.

8:40 So what I've got is two blankets here

8:42 that I'll be scanning kind of through a window

8:44 that I open up.

8:45 I've already tucked the blanket into the upper part of the

8:49 pants because we're gonna be right up here on the SI joint

8:52 and working our way inferiorly.

8:53 So for this first part of the presentation,

8:55 I'm coming from the top side down

8:57 and I've got the shorts pulled down here,

9:00 and they are tucked in here.

9:03 I've got this second blanket here just

9:05 to expose the upper part of the hip there.

9:07 So our, our ileum being

9:12 here and sacrum being here, I can, I can palpate that PSIS,

9:16 which will be the beginning of our examination.

9:20 Gonna have a little bit of gel here.

9:22 Again, this is the 15 to four L 15 four transducer.

9:27 I'm gonna spin the transducer around.

9:28 I had the orientation marker facing medial

9:31 or to the midline, and I just went ahead

9:34 and maybe by luck plop down right on the PSIS.

9:37 That may not always happen.

9:39 So if it doesn't, let's talk about going

9:41 and finding that that more superficial bony landmark.

9:47 So if you just set the transducer down and, and,

9:49 and you're kind of wondering where you might be, we need

9:52 to find a bony prominence, okay?

9:53 And if it's this with the slope on it,

9:55 this is the ileum here.

9:57 And what we're gonna do is just follow that ileum up high,

10:00 high, high, high until it's meets its most peak.

10:04 And then I'm gonna go proximal to distal to find the,

10:07 the absolute apex of that thing right there.

10:09 Now, if you start more midline,

10:11 you may catch this flat plate of the sacrum

10:13 and the spine of the sacrum.

10:15 So here's one of the spinous processes of the sacrum here,

10:18 and we're just gonna follow that down laterally.

10:21 Now, don't stumble on the first thing

10:24 that looks like a joint.

10:25 Those are just sacral foramen.

10:27 This could be S two or S one depending on how proximal I am.

10:31 But I need to go even more lateral until we see

10:34 that high riding bony peak of the PSIS.

10:37 So what I'm doing there is I'm, I'm planting the medial side

10:41 of the transducer with a finger like I did in a lot

10:43 of other body parts like the elbow

10:45 where we pivot and windshield wiper.

10:47 And I'm just gonna be moving my thumb across this way

10:50 until I see that PSIS really nice.

10:53 And what that does is it, it really nicely opens the joint

10:56 for the upper SI joint or the superior SI joint.

10:59 And you can even see the anti tropic

11:00 artifact of these ligaments here.

11:02 So that that lets you know that we're in the ballpark.

11:05 And as Bill mentioned, if we're coming in for an injection,

11:07 it's gonna be from midline to lateral this way.

11:12 Now let's follow that joint, the PSIS being easier

11:15 to follow inferiorly.

11:18 We're gonna follow that inferiorly, inferiorly inferiorly

11:21 until it completely disappears into the superior sciatic

11:24 framing, which would be here in the piriformis is

11:26 down here, which we'll get to.

11:28 But that tells me that I've gone

11:29 beneath the inferior SI joint, which is right here.

11:32 You can see that joint really nicely right there.

11:37 Not this space right here.

11:39 So this is the most inferior margin of the ileum.

11:43 And if I drop my thumb inferiorly,

11:45 you'll see it disappear completely and the sacrum remains.

11:49 So right here is that scro iliac joint,

11:53 and you can see the joint really nicely on the cyte px.

11:58 Superficial to that, these are the fibers of the glute max.

12:01 They're oblique, they dive this way.

12:03 So they're crossing my transducer obliquely

12:07 and you can see them jumping up

12:08 and over to dive onto the sacrum here.

12:11 So what I'm gonna do, I know that they slant this way

12:14 to wrap over the tr so I'm just gonna pivot

12:18 the transducer this way

12:19 until we elongate the muscle fibers of the glute max.

12:26 And it's a very broad muscle.

12:28 I can follow it right across the ileum.

12:30 And it's not necessarily a part of a examination protocol

12:34 on the posterior hip, even though

12:36 the more applications we find to do ultrasound on the hip,

12:39 especially the posterior hip,

12:40 the more it may become somebody's protocol.

12:42 But if clinically indicated, you would want to chase these,

12:45 the, the, the origin of these fibers,

12:49 you can actually see the glute max jump up

12:51 and over the sacrum here to that lumbar fascia

12:53 that bill mentioned right there, that little feathery edge.

12:56 So that's pretty neat. I'm gonna go even more inferior.

12:59 More inferior, more inferior until we see the glute max

13:04 really tapered up onto what looks like

13:09 the spine of the sacrum.

13:11 And we're actually down here at the coddle epidural anatomy.

13:14 So that's actually the sacral cornew that we're seeing here.

13:19 Maybe for a different subject in pain management

13:22 or something, we'll go over the cocal epi epidural anatomy.

13:24 But following that glute max laterally, laterally,

13:27 laterally, you can see how nice and parallel the fibers are.

13:32 And I'm sure Bill will mention when we get to piriformis,

13:35 which is right here, just how nice

13:38 and parallel they are to each other.

13:42 Bill, did I miss anything so far

13:50 while Bill unmutes I'll, I'll keep scanning that glute max.

13:56 I'm gonna add a little bit of gel getting a little

13:57 dry. There

13:59 - We go.

14:00 Daniel, I'm back on the PowerPoint now.

14:02 - Alright. All right,

14:07 go ahead Bill.

14:08 - Okay, let's move to the piriformis.

14:12 Daniel mentioned

14:13 that piriformis fibers do parallel the fibers

14:17 of the overlying gluteus maximus

14:21 and the piriformis courses like the gmax diagonally

14:26 its origin is on the anterior sacrum,

14:30 specifically three bundle attachments between the first

14:34 and second, second and third and third

14:37 and fourth anterior sacral foramina.

14:40 It exits through the greater sciatic foramen

14:48 and inserts onto the superior aspect

14:50 of the greater trocanter.

14:52 Also to be aware of is a sciatic nerve

14:56 as it comes out from what is

15:00 behind the piriformis muscle to cross over in front

15:05 of the Jemele eye and raders.

15:07 And ultimately the quadratus femes us 17%

15:11 of sciatic nerves, however, run through the piriformis

15:15 and predisposes this subgroup to tingling, numbness

15:20 and pain along the sciatic nerve and deep into the buttocks.

15:27 So where do we begin when we look for the look

15:32 for the piriformis muscle, we're going

15:36 to begin at the PSIS

15:41 and our transducer is going to, as where we started

15:45 with the SI joint is going to be placed as the PSIS.

15:50 Our next transducer movement is going to slide laterally

15:54 with the lateral aspect of the transducer towed in.

15:59 We're going to employ the heel toe maneuver,

16:01 this being the heel, this being the toe.

16:03 We're gonna tow in to

16:06 to level out this iliac wing so that

16:11 we have a continuous appearance

16:14 of bone on the under surface of

16:18 what here is gluteus medias.

16:21 Once we have established that we're going

16:24 to slide the transducer distally

16:28 and oblique the transducer to correspond

16:32 with the diagonal course of the piriformis.

16:38 So directly transverse up here

16:41 to demonstrate the iliac wing slide down until we lose

16:45 that continuous iliac wing

16:48 and begin to see the sciatic foramen.

16:52 Once we lose that bit of bone up here

16:55 and we come to

16:59 the sciatic foramen, we begin to see,

17:02 once we oblique the transducer along the diagonal course,

17:06 we'll begin to see the piriformis

17:12 adjacent anatomy that might help us identify.

17:15 This is again, the sciatic nerve

17:18 and the superior gluteal nerve.

17:20 And the associated vessels in particular

17:24 might turn on color doppler

17:25 and recognize the inferior gluteal nerve,

17:29 gluteal artery here.

17:33 So the sonographic appearance is again,

17:37 fiber's very parallel to one another,

17:40 gmax piriformis.

17:44 And we can use a dynamic maneuver by flexing the knee

17:48 and rotating the femur to see translation

17:53 of the piriformis back and forth.

17:57 I'm sure Daniel will be demonstrating

17:59 that in our lives scanning.

18:08 Moving a little further south, we'll go from the piriformis.

18:13 We'll cross over the GLI

18:15 and the OB trait to the quadratus fems.

18:20 Quadratus femoris is an external rotator

18:23 and adductor of the thigh.

18:25 It also assists in stabilizing the hip joint.

18:28 Its origin is at the lateral margin of the

18:31 - Ator ring.

18:37 And

18:42 - And I, I'm sorry, its lateral margin is

18:45 that the ator ring just superior to the ischial tuberosity,

18:49 which is where we'll find the hamstrings inserts.

18:53 It's distal insertion is on the quadrat tubercle

18:57 and the inter tro enteric crest of the posterior

19:01 medial femur right along here

19:06 and here on the sonographic image.

19:09 So this is the quadratus femes. Where do we begin?

19:13 We place the transducer at

19:15 or near the gluteal fold

19:17 where we'll recognize the bony acoustic landmark

19:20 of the ischial tuberosity medially.

19:24 And laterally we'll recognize the femur

19:28 quadratus femoral bridges that gap.

19:31 This is the ischial femoral space

19:34 and is a zone of impingement

19:36 of the overlying sciatic nerve.

19:40 Dynamic maneuvers can help

19:43 us recognize snapping that may occur due to a lessening

19:48 of this distance

19:49 and snapping at the ichi femoral space.

19:57 Okay, Daniel, I'll turn it over to you.

20:05 - All right, thanks Bill. As Bill mentioned, we are going

20:08 to go inferiorly on the hip now,

20:11 and I've re draped the hip, we're still proximal this way,

20:14 but I've got the shorts now up

20:18 and I've, I've taken the time to tuck

20:20 and protect the the patient's undergarments.

20:23 And then what we're gonna do is just expose

20:25 down to the gluteal fold.

20:26 So what we're gonna be looking at now is the inferior SI

20:29 joint, and we're gonna walk our way to the ilium

20:32 and then we're gonna go south into

20:33 that superior sciatic foramen.

20:35 And that will help us find the piriformis.

20:37 So left side of the screen again is gonna be medial,

20:40 and we're looking for a bony landmark there.

20:43 So let's find out which part of the, the

20:47 inferior SI joint that is.

20:48 It looks like I fell right on it.

20:51 So what we're gonna do is follow this ileum.

20:55 Now let's follow the ileum laterally, laterally, laterally.

20:59 There we go. And all I'm gonna do is just fall into

21:02 that superior satic notch.

21:03 So it's just a little short movement

21:05 and I can already tell I'm in that ballpark

21:07 because I can see that superior gluteal artery just resting

21:09 right here.

21:11 And what we're gonna do is throw our color feature on,

21:13 and I wanna be able to see that little artery.

21:15 And what that's doing is just a clue to say, Hey, I'm about

21:18 to hit the superior satic foram.

21:21 And you're gonna see that that artery start

21:23 to shoot straight up and down, headed towards my transducer

21:26 as it wraps up and around the inferior margin of the ileum.

21:29 So the very, very next structure underneath that

21:32 is gonna be our piriformis here.

21:36 So diagnostically, L 15,

21:40 great transducer to look at all these little fibers.

21:43 And I can see this big pizza slice headed laterally over

21:46 the isum.

21:49 So here we have isum piriformis,

21:55 inferior gluteal artery, superior gluteal artery.

21:59 And I think the, I always relate things

22:02 to food for some reason.

22:03 So I do, I think the piriformis just

22:05 looks like a big pizza slice.

22:06 It's a triangular shape structure.

22:08 It's gonna go up and over the isum.

22:10 As Bill mentioned, we start

22:12 to see the superior jamella right here

22:14 as it rests right on top of there.

22:16 And then just before we get to the isum down here, we've got

22:19 that sciatic nerve,

22:20 or at this point could be the distal lumbar complex still,

22:24 but here it is as a nice tight group of nerve.

22:27 So it's probably already sciatic at this point,

22:31 but this is nerve.

22:32 And then up over the isum is the superior jamella.

22:35 And then just resting on top of that superior jamella,

22:38 if I keep going laterally, is the piriformis

22:42 muscle in this thin strand is starting

22:44 to make itself into the piriformis tendon procedurally

22:48 and dynamically.

22:49 I like to switch over to the curvilinear probe.

22:51 So I'm gonna take a second to do that.

22:52 And I'm gonna select the C five one transducer

22:55 with a musculoskeletal exam type

22:57 to get a broader field of view.

23:00 And if your general patient population is not

23:02 of the body habitus of our model today,

23:04 you're really gonna want to consider

23:05 getting a carline probe.

23:07 So I'm starting with the left side of the screen again

23:09 to the patient's medial side,

23:14 things are gonna look a little bit different.

23:16 So I wanna go find a familiar landmark.

23:18 So what I have to do is find my inferior SI joint

23:21 or any of the part of the sacrum is fine,

23:24 and then move the probe laterally to the ileum.

23:26 So here this big ski slope here is the ileum,

23:29 the inferior part of that slope.

23:31 I'm aiming the beam all the way

23:32 to the anterior pelvis actually.

23:34 So here's minimus medias maximus.

23:38 So just to give you an idea of the broad field of view

23:40 that we get with the C five one transducer.

23:44 It's really nice just to get you oriented.

23:46 So let's follow the ileum now south.

23:48 And I need to see the ileum split into two pieces there.

23:53 So left side of the screen, sacrum side of the screen,

23:57 I see this opening, but I still see two bony landmarks.

24:00 So sacrum here and the beginnings of the isum here.

24:06 Back to our pizza slice piriformis here.

24:11 If I wanted to check my work on the inferior part

24:13 of the ileum, you can see

24:14 that superior gluteal artery pulsating really nicely

24:17 activate the color feature.

24:19 Again, check your work,

24:20 make sure you're still familiarizing yourself,

24:22 but you can just see the more broad field of view

24:25 that you get outta the coline and more appreciation

24:27 for the whole structure as that

24:30 that superior gluteal artery is just hugging the border,

24:33 the piriformis there.

24:36 Get my arrow back out here. So this is the

24:38 piriformis. Yeah, bill, go ahead

24:39 - Real quick.

24:41 Show how the angle of the transducer is

24:44 because frequently the most, one

24:47 of the most common mistakes I see,

24:49 and I I'm sure you do too, is

24:51 that the transducer isn't oblique

24:54 to go along the diagonal course of the piriformis.

24:57 - That's true, bill, I just kind of instinctively did that

25:01 because I've just, I've just scanned so many of the hips.

25:04 But when you're first learning this,

25:05 and I stumbled through a lot of things on the posterior hip,

25:08 it's kind of the final frontier on in terms of the joints

25:10 that we typically cover for me.

25:12 And I did find it useful to go ahead

25:14 and elongate the glute max.

25:15 Remember that those are running parallel to each other.

25:17 And the glute max is such an oblique structure.

25:20 We need to pivot our transducer

25:21 and set ourselves up for the long axis of the piriformis.

25:25 So there you can see

25:26 and I can palpate the trope to find out.

25:28 So here's tr and I'm aiming right at the trope.

25:31 It's not a horizontal structure,

25:32 it's a very much a vertically oriented oblique structure.

25:35 So here we have GL glute, max, max,

25:39 long axis, piriformis, long axis,

25:43 and you can even see some of the central tendon

25:45 of the piriformis starting to show itself here.

25:47 As we get over to the is yum superior isum here,

25:52 right on the upper margin of the isum,

25:53 here's our superior Jamila.

25:58 With more penetration out of a lower frequency transducer,

26:01 you can very nicely see the inferior gluteal artery,

26:03 the sciatic nerve down a little deeper.

26:06 We get into some pudendal structures, maybe

26:08 for a pain management talk we could get into.

26:10 But for the general survey, we're gonna keep following

26:13 that piriformis out laterally.

26:15 And we start to see that that posterior

26:19 femoral acetabular joint here, neck

26:22 of the femur trope starting to make itself known here.

26:27 I do see a lot

26:28 of people struggle when they're looking for a piriformis.

26:30 They start at the trope and they call just any

26:33 of these rotating structures.

26:35 A, a piriformis.

26:37 When when I was first learning

26:39 to do posterior hip a while back, I made the miss

26:43 call when doing external rotations

26:47 and just looking for the trope here.

26:51 And we call, oh, there's our piriformis.

26:53 And we got really excited. I'm gonna bring the arrow

26:55 to the spot that we got excited about.

26:57 Saw a huge wavy flag tear right there.

27:00 I mean, what else could that be?

27:01 It's the big it it,

27:03 it's the big rotating muscle we see on the anatomy scan.

27:06 And we sent it out for an MRI

27:08 and it came back as an wouldn't, you know,

27:10 as a quadratus femoris tear.

27:12 And that's when we really got to learn, hey, we need

27:14 to take a little bit more time

27:15 and start with our bony landmarks from the pelvis,

27:18 from the ileum, work our way south

27:21 from the superiors static notch where, you know,

27:22 it originates on the anterior sacrum there.

27:26 And so the two bones we have in the, in the,

27:28 in the view here,

27:29 and I'm gonna try to bring the leg where

27:30 you can see me rotate.

27:32 Upper left is sacrum.

27:35 Mid screen right is the isum.

27:37 And all I'm gonna do is just rotate passively.

27:40 Don't let the patient do it for you

27:41 because it'll start activating all the,

27:43 the surrounding gluteal structures

27:44 and it'll move your transducer.

27:47 Also an angle consideration is not

27:49 to stay per just perpendicular to the skin

27:52 because these structures tend to dive away

27:54 when the patient is laying down

27:57 and you are looking, say at a skeletal model, the

28:01 the ileum is not flat this way the ileum is diving this way

28:06 like two plates obliquely oriented.

28:09 And what I need to do is aim into

28:11 that big ileum wing this way, not this way.

28:15 So I need to be 90 degrees to the ileum

28:18 before I get down into the piriformis.

28:20 So starting with our familiar bony landmarks, again,

28:23 we have our big ileum here.

28:25 We can see glute max and mead

28:27 and I'm just gonna fall into that superior satic notch.

28:29 You can see the bones opening up right there closing up.

28:32 So I'm scanning superior, inferior, superior, inferior.

28:38 And now I'm gonna oblique the probe and go long axis there.

28:42 And all I'm doing now is, is just confirming my location

28:46 of the piriformis with the internal

28:48 and external rotations passively.

28:51 Gotta do this passively or it'll be a very frustrating exam.

28:56 - Daniel, while you're there, we have a question

28:59 and we usually wait until we're finished.

29:01 But while you're there, we have a request

29:05 to see if you can show the sciatic nerve

29:08 pause just a little bit and point it out for people to see.

29:13 Please.

29:14 - You bet. Right here,

29:16 see this triangular wedge resting against the isum.

29:19 So this is sciatic nerve, it's lateral

29:23 to the arterial structures

29:25 of the inferior gluteal artery in the pudendal.

29:27 And you could follow it down

29:29 and watch it stay on the edge of the isum and then jump up

29:33 and over that neck of the isum here.

29:36 And we'll get into the remainder

29:38 of the sciatic nerve when we get into quadratus femoris.

29:40 But I'm still just following that sciatic nerve

29:42 where my arrow is using.

29:45 Well it gets lost in a little bit of anisotropy.

29:47 Let's start right back up here again.

29:55 There, there is where, lemme go right back to where I was.

29:59 So here's our piriformis.

30:00 Sciatic is sitting just right here

30:02 and it's not just a centimeter

30:04 or so of motion,

30:05 you're gonna see the sciatic nerve climb upwards

30:10 there

30:24 and it is still subject to anti atropy.

30:26 So I kind of, kind of let it get away from me there,

30:28 but here it is, it's a flat ribbon at this

30:30 point over the isum.

30:32 So let's follow that, that nerve right here.

30:52 I keep remembering to move my arrow

31:07 and more distally.

31:08 It's really nicely, reliably found right here on top

31:10 of the quadratus femoris as this little triangle.

31:12 So screen left, we've got our ischial tuberosity

31:16 and our hamstring origins.

31:18 And then right here is the sciatic nerve.

31:21 And then here's that quadratus femoris.

31:23 And we could try to trace that proximally to see

31:25 that little, see the, an isotropic transition it's trying

31:28 to make right there.

31:29 So this is inferior jamella here it is on top

31:34 of there, there's the sciatic.

31:36 What I'm having to do is rotate my probe

31:38 and head back up towards the sacrum.

31:40 And here's where it's still kind of a flat ribbon.

31:46 - I would say that I've found it helpful to go down

31:49 to the quadratus femes and the ischial tuberosity

31:52 and identify it at that label

31:53 and then follow it up to the piriformis.

31:57 - That's what I just, that's what I just did.

31:59 And it kind of highlighted that anti isotropy,

32:03 but here it is trying to, trying

32:05 to maintain that perpendicularity.

32:07 But I'm, what I'm finding myself having

32:10 to do is almost like a rainbow of the transducer

32:13 to stay 90 degrees to the nerve

32:15 as it curves up and over theum.

32:18 So here it is, nerve sciatic, sciatic, sciatic, sciatic.

32:23 Remain that 90 degree relationship as I climb up

32:28 and over and I'll find myself

32:32 down at the quadratus.

32:38 Oh, there it is.

32:40 - I think that's great. Daniel. One other, one other thing.

32:44 Sure. One more time.

32:46 Could you demonstrate the dynamic,

32:50 dynamic motion of the piriformis?

32:54 - Sure. So back to our familiar landmark,

32:56 I'm gonna lose the arrow for a minute

32:57 because I need two hands.

33:00 Come up here to the sacrum

33:04 and the big tip here is as you go laterally

33:07 to aim back into the ileum, okay,

33:10 so we're aiming into the ileum, not 90 degrees,

33:13 to the skin, into the ileum.

33:17 And we see that big ski slope of the ileum.

33:20 And what I'm gonna do is just fall down keeping the sacrum

33:23 in the upper left portion of the screen.

33:25 That would be one of my other scanning tips, pearls

33:28 that I'm observing while I'm, while I'm sitting here talking

33:32 to you guys, sacrum upper left

33:34 and I'm gonna watch this, this horizontal bony structure

33:37 split into two pieces here.

33:39 When I see those two pieces,

33:41 I know I'm in the superior sciatic foramen.

33:44 You're gonna tilt the probe or rotate it.

33:47 In this case I just went clockwise

33:50 and that opens up that big triangular

33:53 pizza slice shaped piriformis.

33:55 And I'm gonna confirm that just

33:58 by doing passive rotations internally and externally.

34:02 And I'm on the medial or yeah, more medial side of the isum.

34:08 And you can see this muscle,

34:12 the more external rotation I apply,

34:17 which would be internal rotation I guess.

34:27 I hope that answers your question.

34:29 - Very good, thank you.

34:32 We, I'll share my screen

34:33 and we'll move on to the hamstrings.

34:44 So the hamstrings originate from the ischial tuberosity.

34:49 They can, they contribute to assisting with hip extension

34:53 and knee flexion as each

34:55 of the hamstrings muscles traverse the both the hip joint

34:59 and the knee joint.

35:01 There are three muscle tendon structures

35:06 that comprise the the hamstrings,

35:09 the semimembranosus muscle tendon, as well

35:12 as the semi tendonosis and long head of the biceps.

35:16 The semimembranosus muscle tendon group originates off the

35:21 sup lateral issue, tuberosity

35:24 and inserts onto the medial epicon dial.

35:32 So the semimembranosus here comes underneath

35:37 the semit

35:38 and the biceps to insert right here

35:45 on the ischial tuberosity.

35:47 And then it comes down

35:48 and inserts on the medial tibial condyle.

35:53 The semi tendinosis

35:55 and long head of the biceps are conjoined

35:59 the postal and the insert on the postal lateral ischial

36:03 tuberosity as one point of origin.

36:08 There are two heads to the bicep tendon, a long head

36:12 and a short head proximally.

36:15 The short head originates from the line aspera of the femur.

36:20 The in the insertion

36:22 of the biceps femorals is on the fibular head.

36:25 And at this point the long head

36:27 and the short head have become a common tendon

36:32 to insert as

36:36 as a single tendon onto the fibular head.

36:41 The semi tendinosis, on the other hand,

36:45 inserts on the antrum medial tibia as one of the pez

36:50 and serene tendons.

36:52 All of the hamstrings are innervated by the tibial branch

36:57 of the sciatic nerve.

36:58 So where do we begin?

37:01 We begin again at the gluteal fold

37:05 or near it,

37:06 at which point we'll recognize the hyper coic bony

37:11 acoustic landmark

37:12 of the issue tuberosity shape much like a matter horn

37:18 with a bony prominent peak over the, over the top

37:23 of which we will see on the lateral aspect,

37:27 the conjoin tendon of the semit

37:31 and the biceps femoris also just lateral,

37:35 as Daniel just covered nicely in his live demo.

37:38 The sciatic nerve will be identified

37:45 if we turn the transducer 90 degrees now.

37:49 And we look at

37:51 these structures in the long axis,

37:56 we'll see the ischial tuberosity superficial,

38:01 we'll see the conjoint tendon

38:04 and deep to that as we fall off the bone,

38:08 we'll see the semimembranosus tendon.

38:12 This, these are the tendon only portions

38:15 of the hamstrings complex proximally.

38:18 If we follow them more distally, we'll we'll see.

38:22 And we'll want to interrogate the myotendinous junction.

38:26 The biceps is the most commonly torn,

38:29 the most common running tear is a

38:34 musculo tenderness tear that you'll only see

38:39 that you frequently will see just immediately adjacent

38:42 to the central tendon.

38:44 A little further distal from here,

38:54 the sciatic nerve.

38:55 We're going to begin where Daniel demonstrated

39:00 before, I like

39:02 to interrogate it beginning at the piriformis.

39:07 We're going to position our transducer along the piriformis

39:11 so that again, we see the,

39:14 the thicker portion of the piriformis.

39:16 By the way, piriformis, the Latin

39:18 for piriformis is pear shaped as opposed to the pizza slice

39:23 that you were talking about, Daniel.

39:24 I must agree though that it is shaped more like a pizza,

39:27 a slice of pizza than a pear.

39:30 But the piriformis than we'll see the sciatic

39:34 nerve and adjacent to it,

39:37 the inferior gluteal artery.

39:43 If we slide the transducer distally now

39:48 past the gli

39:49 and the ator to the isum, again this is

39:53 that same image where we see the ischial tuberosity,

39:57 the conjoin tendon and slightly lateral to it.

40:01 We'll see the sciatic nerve

40:04 always good when you're looking at the

40:06 sciatic nerve at this level.

40:08 See this is, we don't, the depth of this image isn't set

40:12 to image the quadratus femes.

40:15 But at this level, always wise

40:18 to just look at the quadratus femes,

40:21 there are dynamic maneuvers that can be done

40:24 to demonstrate ischial femoral impingement

40:27 and snapping that may occur due to that.

40:32 And recognize decrease in

40:36 space here that could contribute to irritation

40:40 of the sciatic nerve.

40:42 Once we move slightly more distal, we're going

40:46 to be in the upper portion of the posterior thigh

40:50 where we'll see the conjoining tendon

40:52 and its myo tendonous component

40:57 with the biceps femoris laterally,

41:01 the semi tendinosis medially.

41:04 We'll see the typical tadpole shape

41:07 of the semimembranosus tendon

41:09 and the underlying semimembranosus muscle.

41:12 So myo tendinous junction

41:14 and laterally we'll identify the

41:18 - Sciatic nerve.

41:24 That concludes

41:25 - The PowerPoint presentation.

41:29 Daniel, I'll let you finish it up

41:31 with a live model demonstration of structures please.

41:36 - Alright, thanks Bill. So I've switched back over

41:39 to the L 15, linear 15 megaherz transducer.

41:45 There we go. And I'm gonna re-expose the hip back here

41:49 and pick up where we left off.

41:51 This time my bony landmark is gonna be the ischial

41:54 tuberosity and lateral.

41:55 I should see that, that sciatic nerve really nicely.

41:58 And to check my work,

41:59 we'll look at the quadratus femoris again, left side

42:04 of the screen will be medial.

42:05 And if, if you joined late, you can see in the upper corner.

42:09 This is superior, this is inferior, this is lateral,

42:13 this is medial here.

42:14 So I'm gonna place the transducer down here

42:17 where I believe I should find initial tuberosity.

42:20 If I don't see one right off the bat, what I have

42:23 to do is just follow these shadowing structures

42:25 up more medially.

42:27 Here we go. So let's find out which kind of bone this is.

42:32 I'm gonna follow it down and see if it, it comes

42:34 to a nice point and that's gonna be our ischial tuberosity.

42:36 I've run outta gel, so I'm just gonna squeegee some gel

42:38 down more inferiorly.

42:40 There we are. So we've got this, this prominent

42:44 bony peak here, just lateral to

42:48 that prominent bony peak of the ischial tuberosity.

42:51 We can see that conjoin tendon structure

42:53 starting to show itself.

42:55 I'm gonna keep moving laterally just

42:57 to orient myself a bit more.

42:59 So here's quadratus femoris, here's that sciatic nerve.

43:04 So we can see all those structures really nice.

43:05 So we know we're in the ballpark, we

43:06 know where we need to be.

43:08 Do now to differentiate these fibers,

43:10 I'm gonna bring my depth up because I can,

43:13 we want a more shallow depth and a more high resolute image

43:16 and we're gonna use tropic artifact to our advantage

43:21 and kind of split apart these layers here. So Dan,

43:25 - I'm gonna interrupt just for a second.

43:27 I know the image from your PX doesn't translate

43:29 to the zoom presentation perfectly.

43:32 I'm gonna have you just decrease your

43:34 gain just a little bit.

43:35 - Oh good. Good call Bill Zoom definitely does.

43:39 - Thank you.

43:45 - Hopefully that's better. Very good.

43:47 So we could see these layers differentiate themselves here

43:50 on the, on the hamstrings kind of common origin.

43:54 Deep down here we've got the deeper semi menos,

43:58 semi tendinosis, overlaying that

44:00 and laterally at that conjoin structure.

44:02 We've got our biceps femoris and we could trace these down

44:05 and watch the biceps femoris tendon move its way laterally

44:10 and its extended muscle belly here.

44:13 And semi tendinosis would be our next landmark,

44:16 just slightly medial to that.

44:17 And underneath the semi tendon

44:22 or the biceps femoris, here's our s static nerve just

44:25 as a a reference.

44:27 So I'm down at the, the, the gluteal fold again,

44:31 here we've got tendinosis.

44:34 Let's use isotropy to our advantage here. This.

44:38 So even though there's a component here,

44:47 our more superior showing tendon right here medially is our

44:51 semimembranosus, this little cleft edge.

44:55 And let's watch it join up with the semi tendinosis

44:58 and then the, the biceps femoris laterally.

45:00 So you can almost get all three of 'em in a row,

45:03 even though there is a conjoin component to it.

45:05 Here is biceps femoris,

45:09 semi tendinosis, semi menos.

45:13 This this little isolated shadow here.

45:15 So I'm just barely rocking the transducer like we do the

45:18 biceps tendon in the groove to see

45:21 what subtleties we can get.

45:22 What you don't wanna do is get in the habit of calling

45:24 that a tendinosis, even though that's in the name of one

45:26 of the, one of the tendons.

45:29 That is not a, a pathology if you can get it to fill in.

45:33 So an isotropy back here is really helpful,

45:37 but it can also be very misleading

45:38 and we don't wanna call things degenerated if they're not.

45:41 So now I'm gonna take one of these tendons here in this case

45:43 we'll we'll focus on menos

45:46 and rotate the probe so that the pro, the left side

45:49 of the screen is facing proximal.

45:53 So we've got our isum here

46:00 laterally.

46:01 It's really nice to see biceps femoris go ahead

46:03 and shoot off and go do its own thing.

46:06 And I could follow that, that more laterally oriented

46:09 structure pretty easily.

46:11 I'm gonna bring my pro more medial now

46:13 and focus more on the semi menos

46:17 and tendinosis area here, which we

46:19 can see really, really nicely.

46:20 It looks like a lot of tendons always insert

46:22 like a big bird's beak.

46:23 And we see that same pattern back here on another tuberosity

46:26 on the body, on the ischial tuberosity.

46:30 So we've got our conjoin tendon here superficially

46:33 and then deep, deep, deep down here where

46:36 as Bill pointed out, I'm not sure if gains

46:38 coming through on zoom.

46:41 I'm gonna auto this,

46:43 - Try your TGC deep.

46:45 - Yeah, there we go.

46:55 Hopefully that helps.

46:56 - Yeah, notice that we're trying to go. There we go.

47:00 You're seeing a little bit there Daniel.

47:02 The semimembranosus deeper,

47:03 but this is with the, give you an idea of how

47:07 nice the penetration is with the linear 15

47:11 to four megahertz transducer.

47:15 - Very true. Most of these higher frequency transducers

47:17 don't have much of a range to them.

47:19 And this, you know, we're scanning 15 to four

47:22 so really depends on where we are in the screen,

47:24 how deep we're trying to shoot, whether I'm in res or gen.

47:27 And I've dropped my frequency down to the gen spectrum.

47:29 So I'm on the lower lower end of that bandwidth,

47:31 which is really helping me with penetration here.

47:39 I'm gonna move laterally to my sciatic

47:41 and I'm gonna go cross section again,

47:44 find our ischial tuberosity, check our gain

47:46 with zoom, which looks a little hot.

47:48 I'm gonna hit auto. There we go.

47:51 Auto's doing a really good job.

47:53 So ischial tuberosity again here we have our,

47:56 our sciatic nerve

47:59 and quadratus femoris just to check our work.

48:01 And I kind of already went through the sciatic so I'd,

48:04 I'd find that to be redundant

48:06 to trace the sciatic approximal

48:10 time on it just a short time ago.

48:13 - Let's just follow distally, Daniel to the upper thigh to

48:17 - You. Got it.

48:18 - Yeah. - So what I'm gonna do is add a little bit of gel

48:20 'cause I know, I know I'm about to follow a track here

48:25 and it might even be nice to see it split

48:30 if, if, if I've set the camera

48:34 to go down there.

48:36 - Oh, very - Good. Looks like I did.

48:40 Okay, so quadratus femoris

48:43 back up here at the isum.

48:45 Here we are and let's

48:47 follow this structure here.

48:50 Sciatic nerve distally distally,

48:52 distally cross-section is the way to go.

48:55 I know that these nerves look really,

48:56 really pretty and long axis.

48:58 - Let's just turn, let's just turn the game

48:59 down just a little.

49:00 Daniel. Thank you. Perfect.

49:03 - You bet it's blinding you.

49:06 Okay, so sciatic nerve distally, distally distally.

49:10 Keep following it distally.

49:12 And we should start seeing an offshoot here

49:14 of the common peroneal

49:16 or common fibular nerve depending on when you went

49:19 to med school or started learning this,

49:27 I figured we'd already see it start

49:28 to bifurcate, but we're not quite there.

49:32 So here's the popliteal fossa where my hand is

49:36 and maybe I missed the bifurcation.

49:40 It should have already. There it is.

49:45 Okay. So right where my arrow is, you can see the

49:49 bifurcation take place right there.

49:53 That's just not separated. Hang on.

50:02 Oh that's not right 'cause it's gonna follow the

50:07 biceps femoris just as a scanning pearl

50:15 because I sure would not think to see,

50:19 - I think the main thing is Daniel, let's just go down

50:21 as far as the Mercedes-Benz sign to show how

50:24 to identify the conjoin tend,

50:26 and you're right there, the conjoin tendon, more superficial

50:30 between the biceps femorals and the, and the semi tendinosis

50:35 and then the semiosis,

50:36 that tad pole shaped structure there to the left.

50:40 Yep. And then the sciatic nerve so

50:42 that folks can identify at that level

50:46 where the nerve is and the two tendons in question.

50:50 That's a very common location for hamstring,

50:53 my tendonous injury.

50:57 - Great point Bill. And I really like that Mercedes-Benz,

51:01 that's a thing to put in the slides.

51:07 - I also wanna leave a little time

51:09 for questions if there are any.

51:14 - Now's the time. - Yeah, go ahead.

51:16 If you have any questions, put 'em into the q and a box

51:19 and we will address those.

51:20 - Yeah, this has concluded the normal part of the exam

51:23 and we're happy to stick around for a few minutes and,

51:26 and just answer these questions on the fly

51:28 however you want them to, to be addressed.

51:30 If there's something that you'd like reviewed again

51:33 that we did cover.

51:35 And depending on the subject that we didn't cover,

51:39 there's also an opportunity

51:40 to cover a few of those things too.

51:42 But I think, you know, posteriorly bill

51:46 orienting to the superior

51:51 sciatic foramen is just, it's just the way to go.

51:55 I'm just following the sciatic of long axis,

51:57 which has seemed, seems

51:58 to be helping me out quite a bit compared

52:00 - To earlier.

52:01 Good question here, Daniel is issue bursa, right?

52:05 As it arcs over the top of the conjoint tendon.

52:10 - That's another one of those bursa

52:11 that we're really not gonna see it

52:13 unless there's some pathology there,

52:14 - Right?

52:15 - But if you want, if you wanted to see that interface, it,

52:18 it's not a bad idea to add a little dynamic component

52:21 to your exam and just kind of roll,

52:24 roll the glute max a little bit by getting the femur

52:28 to rotate so you could at least delineate, hey, where does,

52:33 where do all of these connective tissue layers

52:36 begin and end?

52:38 And, and the answer to that,

52:39 sometimes depending on the patient's body habitus,

52:41 which we don't have a problem with today,

52:44 but when you're out in the, out in the real clinical world,

52:46 sometimes these tissue interfaces are not so obvious.

52:51 So what I'm doing is just causing an external rotation

52:54 by moving the leg

52:56 and I'm isolating that glute max superficially

53:02 over the ischial tuberosity in a, in a, in the hamstrings.

53:06 And I'd be looking for a bursa right up in that spot that

53:09 - Was so similar to what we do with the,

53:11 with the trocanter bursa.

53:13 - Absolutely. You know, this is ultrasound, make it move.

53:16 You know, static images are not going

53:18 to help you answer a lot of questions.

53:20 So anytime you get a chance, you need

53:22 to make these structures move

53:24 and oppose each other as frequently as you can.

53:27 And then, and sometimes you're gonna expose some additional

53:29 pathology like adhesions that are not

53:32 so obvious on a static image.

53:35 - Daniel, one other question we had was to

53:41 revisit the where, where it's common

53:45 to see a myo tendonous tear of the hamstrings.

53:49 So maybe down, start

53:50 with the conjoin tendon at the Mercedes-Benz sign

53:56 level and Sure.

53:57 Just follow that central tendon.

54:00 And that's basically what we're doing as we're following

54:03 that central tendon there

54:04 and we're looking right adjacent to it for any change in

54:09 what is normal echo architecture where the my,

54:13 where the muscle comes into the tendon right

54:18 - There.

54:19 Yeah. This nice little interface right here.

54:25 And now I'm tenderness Yeah,

54:27 I've left the myo tendus portion and now

54:30 - I'm as, as you proximally.

54:32 - That's correct. - So it's just

54:37 that myotendinous location kind like what we see

54:40 with gastro tears right up against the tendon

54:44 and you're looking for fluid defect, you're looking

54:47 for a change in that normal penate pattern

54:50 or starry eye appearance.

54:52 If you're short axis to the course of muscle,

54:56 you're just looking for a change in that.

55:00 What otherwise is a typical

55:03 echo architectural appearance right there.

55:07 Beautiful. See how you follow, see

55:09 how he's following that down.

55:11 So anywhere along

55:13 and adjacent to that central tendon is where you're going

55:17 to see changes, appearance change there,

55:21 you see the semimembranosus tendon deep to it.

55:27 See that tadpole looking structure there.

55:33 Hope that answers the question.

55:36 Are there any other questions that we have?

55:39 I'm not seeing any, Laura.

55:43 I think with that we'll turn it back over to you.

55:46 - Great. Bill, by any chance, do you have

55:48 that last slide that you can show? Or do you

55:50 - Want Oh yes, I, I do.

55:52 Thank you.

55:54 - Just so everyone knows, we will be posting the recordings

55:58 of all these webinars at this website that you see here,

56:00 secure dot sona site.com/behind theskin webinar

56:04 and look forward to some new webinars posting in January.

56:08 We'll have a few on in the MSK market

56:12 on dorsal wrist and carpal tunnel.

56:14 So I just wanted to let everyone know

56:15 that those are coming soon.

56:18 - Great. And we wish you all a happy holidays.

56:20 - Absolutely. And thank you all for joining us today

56:22 and thank you Bill and Daniel again

56:24 for an exceptional presentation and demonstration.

56:27 Very well done.

56:29 - Thanks everybody.

Examining Hip Anatomy and Structure with POCUS: Posterior Hip

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