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69 year old male with chronic low back pain radiating into the right hip,

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right hip bursitis. So when you look at an right hip R exam,

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you should always have one or two big field of view images because hip pain, uh,

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only a in a small percentage or a percentage of cases,

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the the hip itself is the cause of hip pain. The,

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there's so many other things that can mimic, uh, or present as hip pain.

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It'll be your low, uh, back pain with radiculopathy,

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si joint problems, anything outside the hip, the muscles around the hip,

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the other joints close to the hip, pubic synthesis and,

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and several other things that can mimic as hip pain. So it's,

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it's always a good idea to have two or one at least big field of view image

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through the entire pelvis where we can get a idea of how the lumbar spine is

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looking like the lower lumbar spine. How are the SI joints,

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just in general idea of how the bone marrow signal is.

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Any joint degenerative changes like, uh, as I said, of the SI joint,

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any insufficiency fractures like sacral insufficiency fractures can present as

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hip pain, obviously. Then looking at hips, if they have any arthritis.

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Then pubic synthesis. How's the pubic synthesis are, the muscle symmetric?

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And, and also, uh, intra pelvic abnormalities, um,

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like in females ovarian cyst, copus luteal cyst,

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sometimes they can present as hip pain as well, or some bubble abnormalities.

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So just to make sure everything else is looking okay.

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And that's what we have in this case. Then we,

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when we move on to dedicated right hip images

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here, we have an axial T two. We can go from the top.

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So you should know all your anatomy. That's your per performance.

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That's the superior wall of the asum As you go more

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inferiorly, you are getting to the joint space as we see,

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uh, what is more remarkable is, um,

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atrophy of the gluteus minimus and medias.

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So here along the posterior aspect of the hip, we have three muscles.

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The innermost is the gluteus minimus. Then we have medias,

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and this is your Maximus. And, um,

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we see at least moderate, uh,

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atrophy of minimus and medias as we follow them

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long. Um, we see, uh, a gap here,

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which is filled with fluid and it extends, and it,

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it looks like there is str enteric per, so this is a non-fat side sequence,

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but, uh, fluid is bright, so it'll be Aon density sequence.

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And one thing to know is, uh, the glu the, uh,

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the attachment of the gluteal tendons.

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So it looks like there is a tear of the gluteal tendons as we can follow the

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tendons. Um, the gluteus minimus tendon, this is,

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you can see how the tendon has formed here as,

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as we just keep an eye on the tendon. We follow it inferiorly

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and see how it fans out,

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and it inserts onto the anterior aspect of the greater truant.

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So this is your minimalist tendon inserting and just distally. Um,

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this is where you, I think the insertion of the, uh,

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gluteus minimus and then distally. The vastus laterals muscle will start.

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I'm going back again now to show you gluteus medias.

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So now follow the gluteus medias.

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This is your gluteus medias myo tendons junction, the muscle and the tendon here

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going distally. So see how the tendon became on the posterior side,

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that's the tendon. And then over here it fails to attach.

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So there is a, uh, the tear of the anterior part, the,

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the posterior most fibers I see are there inserting along the posterior part of

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the greater roc canta,

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but the anterior tendon is ripped off from its attachment onto the greater roc

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canta. So, uh, we first need to know, uh,

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the anatomy, um, how these tendons insert onto the roc canta. So here we had,

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and in this case, the findings were right.

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Gluteus medias full thickness tear with detachment from its insertion onto the

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lateral facet proximal retraction, the gap of 1.5 centimeters.

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We'll go back to the images and see that.

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And associated with there was grade two plus fatty atrophy of the muscles.

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There was reactive toteric bursitis and an intra superior labral tear. So first,

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uh, understanding the insertion of these gluteal tendons on the tuberosity.

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So this is the anterior, uh, greater tru cantor has four facets.

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The anterior facet, the lateral facet, the posterior facet,

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and the superior facet. This is a coronal limit showing the anterior facet,

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lateral facet and the superior facet.

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And you can see how the tendons insert the minimus inserts on the anterior

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facet. The medias, as you can see here,

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it inserts on the lateral facet. And,

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and some fibers go on the,

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I think this is different. So this is where the posterior, uh, facet is.

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So it inserts onto the posterior facet and comes and inserts onto the lateral

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facet too. So this is the tendonous part. Gluteus medias also has, um,

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uh, like the anterior fibers have a direct muscular attachment,

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like how we have in triceps tendon. So the, the fibers,

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the muscle fibers come and insert onto the superior part of the lateral facet.

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So minimus will be here on the anterior facet.

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The anterior fibers of medias have,

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will have a direct muscular attachment on the lateral facet.

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And then the tendon of the medias, which is more posterior,

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will insert onto the posterior facet and the la and, and the lateral facet.

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So that's what we need to look on imaging. So this is how a normal,

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this is your minimal tendon inserting onto the anterior facet.

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This is your media tendon inserting onto the posterior facet and anteriorly will

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be the direct muscular attachment.

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These are the coronal images showing this is medias attaching more on the

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lateral aspect. And this is minimal inserting more along the anterior facet.

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This is a sagittal image I move.

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You can see the medias inserting onto the posterior aspect of the,

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uh, means this posterosuperior corner and then along the lateral facet.

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So, um, tendinopathy of the adductor tendons is becoming increasingly commonly

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recognized as a significant cause of lateral hip pain.

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And now it is believed that tro enteric bursitis rather being a pro primary

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abnormality is often a manifestation of underlying adductor tendon pathology.

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So anytime we see tro enteric bursitis,

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we should carefully look for these tendons and make sure these are not torn,

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because if you don't carefully follow their course and see how they're

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inserting, um, we can easily miss these stairs.

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And MRI allows accurate detection of tears in the adductor tendon and that will

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allow effective treatment planning.

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So Mr Appearance is similar to other tendons.

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You can get tendinosis where the tendon is thick and of intermediate signal

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intensity. You can get partial thickness tears, complete tears.

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Then if there is a large tear, which has been chronic,

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you often get muscle atrophy as in this case. And, um,

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large field of view, you can look at both hips, but it'll,

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it'll be difficult to look for, um,

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smaller tears and details of these gluteal tendons.

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So these are best evaluated when you have small field of view images and,

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uh,

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the most frequently encountered sign is greater than one centimeter and diameter

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localized area of high signal superior to the greater tru cantor. Again,

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this is what we had in our case and a thin layer of increased signal intensity

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that lops the lateral and the superior aspect of the greater tru cantor also

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correlates with presence of an abducted tendon.

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There you can also get tendon elongation,

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and this is predominantly because when the muscle is atrophic,

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and this is also seen in patients more than 50, um,

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in slightly greater than 50% of patients with. So, um,

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I know we didn't review the images completely because I wanted to show you the

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anatomy, how these tendons insert. Now we come to a fat sat,

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um, axial image.

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Yeah, and we'll try to follow them

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from the proximal end. So again,

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we have the IAC Crestor posterior to it. We have the minimus medias and Maximus.

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As we go down,

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you start seeing a big fluid gap.

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So we said right more than one centimeter gap above the Tru Canta,

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which is fluid filled. So we have a big fluid pocket here, and as you can,

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if you can just pick up one tendon and try to follow it.

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So this is your minimus. We'll see it,

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it goes and inserts anterior on the tru canta. So minimus is fine,

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but it's the, it's the media tendon. This is your media tendon.

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Keep an eye on it. Scrolling the images,

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you see that this is toned from its attachment onto the posterior and

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lateral part of the facet. And this is your reactive roc bursitis. So it's,

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that's the finding. I think there was another small finding.

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There was like a small labral tear of the hip. So again,

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these are axial images. Labrum looks like a black triangle here.

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It's a little blunted, but there is no abnormal signal of fluid at its base.

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So we can go to other images and look For it.

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On the next image that we have is a coronal T two fat set. Again, we have this

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minimus and then this is the medial tendon that is torn. And as we are

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looking at the hip, nothing acute, it's well aligned.

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There's a little small reactive joint fusion,

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and you can see that abnormal signal in the labrum.

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So this is more intra superiorly. So we have a small intra superior labral tear.

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The articular cartilage looks okay, no acute. Finally, there's always, uh,

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one of the important indications for Mr.

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Hip is to rule out avascular necrosis because that can be subtle and may not be

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seen well on radiograph. So here the marrow signal is okay,

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there's no vascular necrosis

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And everything else that we are seeing in this field of view looks okay.

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So we have gluteal tendon tear medias complete tear. Uh,

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yeah, this is where you can measure the retraction and tear. So

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I don't know if I can, I have the measuring tool here.

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So around 1.5 was in the report, like two centimeters.

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So this is how you can talk about the retraction,

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like till how far back the tendon is retracted.

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And obviously whenever there's a tendon there, same things that we talk about.

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What is the location, which tendon is involved?

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So gluteus medias it's a complete tear, partial tear. So it's,

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it's almost like a near complete tear of the medias tendon.

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There's a retraction of approximately two centimeters,

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the ton tendon and has moved approximately.

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And then there is associated fatty atrophy.

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So that would be a complete description of the gluteal, um, tendon tear.

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And then other findings, you'll,

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we'll just say there's a small insuperior lab tear.

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I think that was all for case two. Any questions on case two?

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How did you distinguish your change fluid from a tear? And

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So can you be a little louder? I didn't hear that. Well.

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How can you differentiate, um, how

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Differentiate between fluid from a tear and um, uh,

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fluid within the tr bur?

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Oh, okay. So, uh, tear is uh,

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just by following the tendon and if I see a portion of the tendon that is

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missing from its attachment, and then as there is fluid,

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I know there's a tear and then there is fluid in simple trochanteric bursitis,

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these tendons should look intact. And again, as we said,

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if there is truca bursitis,

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very less likely that the tendons are going to be perfectly normal.

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They can have, uh, if not torn,

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they will at least have a little bit of degeneration and fraying and abnormal

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signal. So you have to just look at the tendon if it's normal or not. Uh,

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and that we can follow it on your,

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I think I can show it to you on axial images.

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Sometimes axial fat set images are better because

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all the pathology gets outlined with that bright signal from surrounding fluids.

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So as in this case,

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so if you follow these tendons here, right,

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this one right media tendon and it's drawn from here so the

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tendon is missing so that we know all this is reactive to.

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So all here should be the attachment here should be the muscle fibers

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attaching and more posteriorly should be the tendonous attachment.

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You did mention there's some fluid within the Tric bus. The,

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along with the test, just initially.

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So when there is a tendon tear that hold space is now communicating with the

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bursa, right? So everything will be just seen as like a fluid filled pocket,

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the tear and the fluid in the bursa,

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like how we have full thickness rotator cuff tear. So, and if there is fluid,

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obviously if there's a full thickness tear,

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you automatically get fluid in the subacromial subdeltoid bura.

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Could you, uh, point out the anatomical space for the traumatic bura?

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Would you look at the

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Yeah, so tro bura, uh,

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so this is the atomic location. It extends like here it is going a posteriorly,

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but the classic description of your tte bura is like,

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from here it'll go and it'll follow that curvature of the greater

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trocanter. So that's your location of the trocanter bursa. Here,

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this bursal fluid is combined with the tear,

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so it goes more anterior and then just extending posteriorly.

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But if you had like the,

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if the question was if there is an isolated tru enteric bursitis,

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then you just should have lo fluid along the postal lateral aspect of the

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greater, like right here.