Dr Rene Tayar - Parkside Hospital

RADIOLOGY OF HIP PAIN
René Tayar

THE IMAGING MODALITIES
PLAIN RADIOGRAPHY
NUCLEAR MEDICINE
SPECT CT
FLUOROSCOPY
ULTRASOUND
CT
MR
MR ARTHROGRAPHY

CAUSES OF HIP PAIN
INTRA-ARTICULAR
ARTHROPATHIES
THE CAPSULE AND ILIOFEMORAL LIGAMENT ATTENUATION
SYNOVIAL DISEASES
LABRAL TEARS AND ARTICULAR CARTILAGE DELAMINATION
LOOSE BODIES
CAM AND PINCER IMPINGEMENT
CONGENITAL MALFORMATIONS eg hip dysplasia
EXTRA-ARTICULAR
ILIOPSOAS IRRITATION,SNAPPING,BURSITIS
ABDUCTOR TENDINOPATHIES AND TEARS
EXTRA-ARTICULAR TRAUMA
IMPINGEMENT SYNDROMES
HERNIAS AND OTHER MISCELLANEOUS LESIONS

CONDITIONS TO BE CONSIDERED IN DAY
TO DAY PRACTICE
• ARTHROPATHIES
• BURSITIS
• TENDONITIS
• DAMAGE TO ACETABULAR LABRUM AND ARTICULAR
CARTILAGE
• CAM AND PINCER IMPINGEMENT
• MUSCLE AND TENDON IMPINGEMENT
• HIP DYSPLASIA
• REPLACEMENT PROBLEMS
• TRAUMA
• HERNIAS

ARTHROPATHIES

T1gd CORRELATES WELL WITH PAIN SCORE

TRANSIENT REGIONAL OSTEOPOROSIS

DEGENERATIVE DISEASE

DEGENERATIVE DISEASE
jsw narrowing, denuded chondral surface, subchondral cysts,
osteophytes and sclerosis. Intact labrum

ACETABULAR SYNOVIAL CYSTS

ACUTE R.A AND O.A.

ACUTE AND CHRONIC R.A.
AND SECONDARY O.A.

GOUT

CALCIUM PYROPHOSPHATE DIHYDRATE
DISEASE (CPPD) AND PSEUDOGOUT

CHAARCOT’S NEUROPATHY
Neurotrauma: Loss of peripheral sensation and proprioception
leads to repetitive microtrauma to the joint in question; this
damage goes unnoticed by the neuropathic patient, and the
resultant inflammatory resorption of traumatized bone renders
that region weak and susceptible to further trauma. Indeed, it
is a vicious cycle. In addition, poor fine motor control
generates unnatural pressure on certain joints, leading to
additional microtrauma.
Neurovascular: Neuropathic patients have
dysregulated autonomic nervous system reflexes, and desensitized
joints receive significantly greater blood flow. The
resulting hyperemia leads to increased osteoclastic resorption
of bone, and this, in concert with mechanical stress, leads to
bony destruction.
In reality, both of these mechanisms probably play a role.

EARLY AND LATE CHARCOT’S NEUROPATHY

BURSITIS
• TROCHANTERIC BURSITIS
• ILIOTIBIAL BAND SYNDROME
• PSOAS BURSITIS
• GLUTEUS MEDIUS BURSITIS

ILIOPSOAS BURSITIS

PSOAS BURSITIS

TROCHANTERIC BURSITIS

PSOAS AND TROCHANTERIC BURSITIS IN
PATIENT WITH TRO

ULTRASOUND GUIDED INJECTION OF
TROCHANTERIC BURSA

GLUTEUS MEDIUS BURSITIS(white)
TROCHANTERIC BURSITIS(blue)

GLUTEUS MEDIUS BURSITIS

GLUTEUS MINIMUS BURSITIS

TENDONITIS

THE ILIOPSOAS TENDON

RUPTURE OF RIGHT ILIOPSOAS AFTER THR
LEFT ILIOPSOAS ATROPHIED BUT INTACT

ILIOPSOAS SYNDROME
Iliopsoas bursitis and/or tendonitis occurs
primarily in gymnasts, dancers and track athletes
and is caused by repetitive hip flexion.
Other pathologies such as iliopsoas abscess, bone
and soft tissue tumours have to be considered.
Iliopsoas tendonitis or rupture can occur after a
THR and can manifest as a radiolucency in the
lesser trochanter from disuse.
Rupture of the ilio-psoas tendon after a total hip arthroplasty: an unusual cause of radio-lucency of
the lesser trochanter simulating a malignancy
Aditya V Maheshwari 1* , Rajesh Malhotra 2* , Deepak Kumar 3* and J David Pitcher Jr
Journal of Orthopaedic Surgery and Research 2010, 5:6

IMAGING THE ILIOPSOAS TENDON
POST THR
• Ultrasound can demonstrate bursitis, tendonitis or snapping
of the tendon over the overhanging acetabular margin.
• CT is also helpful to rule out component malpositiong.
• MRI is emerging as an effective tool for assessment of
periprosthetic soft tissues, osteolysis and particle disease.
MR will show proximal muscle swelling and oedema,
thickening and interruption of the tendon with an otherwise
empty fluid-filled distal tendon sheath. Chronic cases will
show muscle atrophy with fatty degeneration.

WELL FIXED HYBRID IMPLANT WITH
RADIOLUCENCY IN LESSER TROCHANTER
THAT COULD INDICATE ILIOPSOAS
RUPTURE

ARTHRO MR SHOWING FILLING OF BURSA BOTH
MEDIAL AND LATERAL TO TENDON IN PATIENT
WITH HIP PAIN

ILIOPSOAS TENDON LATERAL TO BURSA

BONY SPUR IMPINGING ILIOPSOAS
TENDON

SNAPPING HIP SYNDROME
Snapping hip syndrome is characterized by an audible
snap or click that occurs in or around the hip.
External causes include snapping of the iliotibial band
and bursitis or gluteus maximus over the greater
trochanter.
Internal causes include snapping of the iliopsoas
tendon over the iliopectineal eminence resulting in
iliopsoas tendinitis, iliopsoas tendinosis, iliopsoas
bursitis or a combination, acetabular labral tears and
intra-articular loose bodies.
The latter are relatively uncommon causes of internal
snapping hip syndrome

SNAPPING HIP

ILIOPSOAS SNAPPING OVER PARALABRAL
CYST As hip is brought back from frogleg position to
neutral extended position, tendon moves medially, suddenly
flipping over paralabral cyst for second time.

ILIOPSOAS BURSA
may cause snapping hip syndrome

SNAPPING HIP
OEDEMA LATERAL TO TENDON

SNAPPING ILIOPSOAS TENDON
At rest the
hyperechoic psoas
lies over the
superior pubic
ramus.
The hypoechoic
iliacus lies over the
psoas

SNAPPING ILIOPSOAS TENDON
With flexionabduction-external
rotation the muscle
rolls laterally
getting trapped
between the tendon
and superior pubic
ramus

ULTRASOUND OF SNAPPING ILIOPSOAS
As the hip is progressively
brought back to neutral
position, the tendon and
trapped component of
muscle follow the reverse
path

SNAPPING ILIOPSOAS TENDON
The muscle is suddenly
released laterally,
allowing abrupt return
of iliopsoas tendon
against superior pubic
ramus producing the
audible snap.

DAMAGE TO ACETABULAR LABRUM AND
ARTICULAR CARTILAGE

ACETABULAR LABRUM/ARTICULAR
CARTILAGE INTERFACE
a: labrum
b: articular cartilage
c: transition zone
d: bony acetabulum
e: tidemark
f: capsule
g: capsular recess
h: vessels
1: capsular recess
2:labral thickness
3:width of labrum

NORMAL; LABRAL TEAR; O.A.

ULTRASOUND OF NORMAL LABRUM
FEMORAL HEAD ARTICULAR CARTILAGE
AND JOINT EFFUSION

LARGE FIELD OF VIEW
ILIOPSOAS AND LABRUM ARE INDISTINGUISHABLE.
THIS PATIENT HAD A TORN LABRUM AT ARHTROSCOPY

PLAIN MR MAY NOT DEMONSTRATE A
LABRAL TEAR

MR ARTHROGRAPHY OFFERS BEST IMAGES
good definition of labrum and articular
cartilage

LARGE SUPERIOR PERILABRAL RECESS
LIGAMENTUM TERES-TRANSVERSE
LIGAMENT COMPLEX

MYXOID DEGENERATION OF THE LABRUM

LABRAL TEAR AND PARALABRAL RECESS

LABRAL/ARTICULAR CARTILAGE
JUNCTION TEAR AND ACETBULAR CYST

COMPLETE LABRAL TEAR ON CT ARTHRO

TEAR WITH PARALABRAL CYST AND
ARTICULAR CARTILAGE DEFECT

DETACHED ANTERIOR LABRUM

LARGE LABRAL TEAR AND O.A. CHANGES

LABRAL TEAR AND COMMUNICATION OF HIP
JOINT WITH PSOAS BURSA

HIP DYSPLASIA WITH SUBCHONDRAL
CYSTS

HIP DYSPLASIA WITH FOCAL LOSS OF
ARTICULAR CARTILAGE

LABRAL TEAR AND LOSS OF ARTICULAR
CARTILAGE

LABRAL TEAR, FOCAL ATTRITION OF
ARTICULAR CARTILAGE AND LOOSE BODY

LABRAL ALTERATIONS AND FIBROCYSTIC
CHANGE

CARTIGRAM
When collagen breaks down, there is increased
mobility of water in the cartilage and therefore a
prolongation in T2 relaxation times.
These values are represented by colour maps and
allow visualisation of cartilage composition before
changes in thickness can be seen on routine MR

T2 MAPPING WITH CARTIGRAM SHOWS
EARLY DEGENERATIVE DISEASE

HIP IMPINGEMENT SYNDROMES
• CAM IMPINGMENT
• PINCER IMPINGEMENT
• COMBINED CAM AND PINCER IMPINGEMENT
• PIRIFORMIS SYNDROME
• ISCHIOFEMORAL IMPINGEMENT

CAM AND PINCER IMPINGEMENT

A: NORMAL; B: CAM IMPINGEMENT
C:PINCER IMPINGEMENT; D: COMBINATION

THE ALPHA ANGLE
NORMAL IS 55 DEGREES

FAI
CAM AND TEAR

CAM IMPINGEMENT AND OSTEOARTHRITIS
anterosuperior osseous bump and decreased
anterior offset on an oblique axial view (normally
12 mm, less than 8 in cam impingement).

CAM LESION

ACETABULAR DEPTH
CAM
PINCER

PIRIFORMIS IMPINGEMENT

ACCESSORY PIRIFORMIS IMPINGING ON
SCIATIC NERVE

ISCHIOFEMORAL INTERVAL IMPINGEMENT

ISCHIOFEMORAL IMPINGEMENT ON
QUADRATUS FEMORIS

HIP DYSPLASIA

Hip dysplasia: a significant risk factor for the
development of hip osteoarthritis. A cross-sectional
survey
S. Jacobsen and S. Sonne-Holm
Rheumatology Vol. 44 No. 2 © British Society for Rheumatology 2004

HIP DYSPLASIA

HIP REPLACEMENT PROBLEMS

VR OF SURFACE REPLACEMENT
NORMAL BONE/CEMENT
DIE BACK
OSTEOLYSIS FROM PARTICLE DISEASE

SEVERE METALLOSIS WITH OSTEOLYSIS

PSOAS MASS FROM METALLOSIS

RETRIEVAL CONFIRMS SEVERE DIE BACK
AND METALLOSIS

TRAUMA

FEMORAL NECK FRACTURE

SUBTLE ACETABULAR FRACTURE

POSTERIOR COLUMN FRACTURE

CORONAL MPR AND VR ANGIOGRAM OF
DISLOCATED PROSTHESIS

STRETCH INJURY OF ILIOPSOAS AND
NORMAL

MR AND CT OF ATROPHIED AND
RETRACTED TORN ILIOPSOAS

THE FOUR FACETS OF THE GREATER
TROCHANTER
anterior (A), lateral (L),
posterior (P), and
superoposterior (SP). The
gluteus minimus tendon
(Gmn) inserts on the
anterior (A) facet and the
gluteus medius (Gme)
inserts on the
superoposterior (SP) and
lateral (L) facets. Three
commonly encountered
bursae are: trochanteric
(TB), subgluteus minimus
(SGmn), and subgluteus
medius (SGMe).

GLUTEUS MEDIUS TENDON
INSERTED ON SUPERIOR-POSTERIOR
FACET

GLUTEUS MEDIUS TEAR
lax and elongated

TORN AND ATTENUATED GLUTEUS MINIMUS
displaced from insertion at anterior facet (arrowhead)
with fluid in bursa

RECTUS FEMORIS AVULSION

DISRUPTION OF ILIOFEMORAL LIGAMENT
FOLLOWING TRAUMATIC POSTERIOR
DISLOCATION
left: iliofem lig; right: capsule

RUPTURE OF POSTERIOR FIBRES OF
ISCHIOFEMORAL LIGAMENT

THE COMMON ADDUCTOR-RECTUS ABDOMINIS
APONEUROSIS
The common adductor-rectus abdominis
aponeurosis (CA-RA) is of critical biomechanical
and pathophysiologic importance.
This aponeurosis is composed of the tendons of
the adductor longus and rectus abdominis
muscles, which blend and insert on the anterior
pubis

NORMAL AND TORN CONJOINED TENDON

SECONDARY CLEFT AT TEAR OF CONJOINED
TENDON

RECTUS AND CONJOINED TENDON
IN SAGITTAL PLANE

STRAIN AND TEAR OF RECTUS ABDOMINIS
INTACT CONJOINT TENDON

STRAIN OF OBTURATOR EXTERNUS

TEAR OF ADDUCTOR LONGUS

COMMON ADDUCTOR-RECTUS ABDOMINIS
CONJOINED TENDON (CA-RA) TEAR

HERNIAS AND OTHER
MISCELLANEOUS LESIONS

AVN

AVN
GEOGRAPHICAL SUBCHONDRAL LESION WIH DOUBLE LINE
THE HIGH SIGNAL LINE AND INCREASED UPTAKE
REPRESENT HYPERVASCULAR TISSUE

BILATERAL TRANSIENT REGIONAL
OSTEOPOROSIS
ON STIR AND T1

SEPTIC ARTHRITIS VS TRO
NOTE MARROW AND SOFT TISSUE OEDEMA IN TRO

PERTHE’S DISEASE
POST GADOLINIUM SEQUENCE SHOWS LIMITED
INVOLVEMENT OF THE EPIPHSIS

SYNOVIAL CHONDROMATOSIS

STRANGUALTED INGUINAL HERNIA

CT PSOAS ABSCESS
contrast and air from bowel fistula

PVNS

CHONDROSARCOMA

VARICOCOELE AND RENAL CELL
CARCINOMA

PLEASE REMEMBER
• Degenerative disease
• Trauma
• Bursitis
• Tendonitis
• Impingement syndromes
• Labral and cartilage damage
• TRO, AVN, Septic arthritis
• Miscellaneous extrinsic to the hip eg.lumbar spine
disease, hernias etc.