0:00

Okay, let's move to the second group,

0:01

which is the flexors.

0:03

So for the flexors,

0:04

the area we're gonna focus on is anterior to the hip.

0:08

We have our sous tendon located more medially,

0:11

and then the tendons of the rectus, uh,

0:14

femoral located more laterally.

0:17

The sartorius is also considered a hip flexor,

0:22

a thin strap like muscle.

0:24

The only time I really see sartorious injuries is

0:27

in younger patients.

0:28

Uh, this is a patient who's a teenager, not

0:31

yet skeletally mature.

0:33

We see that a portion of the, uh,

0:37

hypothesis has been a vols.

0:39

When we did an mr.

0:40

You can see that the injury is much more extensive than

0:43

appreciable on the x-ray.

0:46

In addition to the sartorius,

0:47

and this is the retracted tendon here,

0:50

the injury extended along the iliac, uh, uh,

0:55

wing, uh, to involve the attachments of tensor fascia

1:00

and gluteal musculature, not apparent, uh,

1:03

on the radiograph, but in adults I don't typically see

1:07

injuries involving the sartorius,

1:09

so I'm not gonna show you those.

1:10

We're gonna focus on the other flexor tendons.

1:14

Now, the rectus femoral has two insertions

1:17

that we should be aware of.

1:19

The direct insertion is onto the anterior inferior iliac

1:24

spine, but there is a reflected head which rotates

1:28

horizontally and extends posteriorly

1:31

to insert along the upper part of the acetabulum immediately

1:36

above the area of the capsule.

1:38

And, uh, this is why it can become very difficult

1:42

to interpret that structure when there is a lot of arthrosis

1:45

or paralabral cyst formation,

1:47

because that can dissect through the capsule

1:50

and thicken these tissues,

1:52

making the tendon difficult to interpret.

1:56

We can get avulsions in the immature skeleton.

1:59

This is a nice example

2:00

of an avulsion at the direct head insertion

2:04

of the rectus in, uh, in a, in an adolescent.

2:07

And you can see the displacement as well

2:09

as the bone edema on the mr uh, examination.

2:13

So failure in the immature patient tends to occur, uh,

2:17

at the bone in young adults.

2:20

Failure is usually at the myo tendonous junction.

2:24

Every once in a while we will see direct tendon injury,

2:28

even in younger patients.

2:30

And this is such an example of an injury with AULs

2:34

of the direct head of the rectus at the anterior, uh,

2:38

inferior, uh, iliac spine.

2:41

But don't, don't forget

2:42

that the injuries may be more distal.

2:45

And one thing to keep in mind with these tendon injuries is

2:48

that they can result in significant delayed ossification,

2:52

especially in adolescents with displaced

2:55

Fractures. And that

2:56

this ossification shown here in both the direct

3:00

head and the reflected head can result in subs,

3:03

spinous impingement, uh, of the of the hip.

3:07

This is a patient that looks like there's a tear,

3:09

but in actual, uh, in actuality, this was an example

3:14

of calcific tendonitis,

3:16

which can occur in any tendon in the body.

3:19

Here on ultrasound, we can see the, uh, hyper, uh,

3:23

dense, uh, echoing calcifications, uh, within the tendon,

3:28

which were subsequently, uh, aspirated, uh, for baritage.

3:32

But don't, uh, forget to look for hydroxy appetite.

3:37

There's intense marrow edema

3:39

and surrounding edema from peri arthritis, uh,

3:42

in this, uh, in this patient.

3:43

Not a common location, certainly compared to the,

3:47

uh, shoulder, for example.

3:48

But it does occur. Um, as I mentioned,

3:52

in most young adults, the injuries

3:54

of the rectus typically are going to be myo tendonous.

3:58

They may be muscle strains.

4:00

Their anatomy is highly variable, uh,

4:03

depending upon which head is involved.

4:05

And I, I'll discuss that a bit later.

4:07

Late in the course when we talk about muscle injuries,

4:10

this is a different patient showing a complete tear

4:13

at the myo tendonous, uh, junction with a large, uh,

4:16

fluid filled, uh, gap as compared

4:19

to this more moderate grade injury seen here on the right.

4:23

I find the rectus, uh, femoral reflected had very difficult

4:27

to interpret, especially in older patients.

4:31

Uh, in this patient there was an acute injury

4:34

during Pilates.

4:35

There's a lot of edema

4:37

and swelling within the reflected head and edema around it.

4:41

We diagnosed this as a partial tear, though I have no proof.

4:45

Uh, she didn't undergo any kind of surgical, uh, procedure

4:48

and I didn't get any follow up.

4:50

But as the patients get older

4:52

and they get arthrosis, just be cautious

4:55

because you can see quite a bit

4:57

of edema in the reflected head in those,

5:00

uh, kinds of patients.

5:02

The other flexor tendon we want

5:04

to talk about is the ileal sous.

5:06

Now the ileal sous has a C shaped

5:09

or boomerang shaped course coming from the pelvis

5:13

anteriorly over the pectineus eminence

5:15

before diving posteriorly again

5:18

to insert on the lesser tuberosity.

5:21

Here we can see the tendon

5:22

and how sharply it curves to extend posteriorly

5:26

because of this.

5:27

Following this on the coronals is, is impossible.

5:32

You can follow it on the axials

5:34

or piece it together on your coronals,

5:37

but I actually like to use the sagittal images,

5:39

which show you the tendon very well, at least the portion

5:42

once it reaches the pectineal eminence

5:45

and extends inferiorly.

5:47

This is an acute traumatic injury with a hematoma

5:51

in the pelvis, extensive, uh, muscle strain

5:55

and, uh, tendon tearing, not

5:56

Optimally, uh, shown on this particular slice.

5:59

But I show this just so you're familiar with

6:01

that CS shaped course of the ilio sous.

6:05

And as long as you follow it down

6:07

and make sure it's inserting at the lesser tuberosity,

6:10

you're not going to have any problems.

6:13

So this is, uh, ilio bursitis, something

6:16

that we see very commonly.

6:18

And, uh, this is a nice case

6:21

because it shows you that we actually have

6:25

two tendons coming down.

6:27

The iliac tendon

6:29

and the sous tendon are not always fused.

6:33

And so it can normally look like it's split,

6:36

and you don't want to confuse that

6:38

with the tear of the tendon.

6:40

So you have the medial iliacus tendon

6:43

and the i uh, sous tendon traveling together.

6:47

The lateral iliacus is further lateral

6:50

and inserts pretty much as muscular fibers, uh, onto the,

6:55

um, intertrochanteric ridge.

6:57

Here's what that bursa looks like. Looks like a heart.

7:01

This is not a tendon sheet that surrounds the tendon,

7:04

but it lies deep to the tendon.

7:06

So you get this heart shaped appearance.

7:08

Usually the medial limb is larger and fills first.

7:12

The lateral limb fills later

7:13

and actually extends into that

7:17

lateral iliacus muscle belly.

7:19

That's quite common, uh, to see that particular appearance.

7:23

This is a nice picture taken from the literature showing the

7:27

confluence of these different tendon slips as they come

7:31

and insert onto the femur.

7:33

Sometimes you may get snapping, which is thought

7:36

to be related to snapping

7:39

between these various tendon slips rather than

7:42

between the tendon and bone.

7:44

And that has very few Mr findings.

7:46

Uh, this was a patient that has snapping hip

7:49

and we see some subtle synovitis

7:51

and edema around the SS tendon.

7:54

But in most patients who are snapping,

7:57

the MR is typically normal

7:59

and the diagnosis is established clinically.

8:02

And occasionally, uh, these patients may be referred

8:05

for ultrasound, uh, for confirmation

8:08

or to see if there is associated bursitis for, uh,

8:13

uh, steroid, uh, injection.

8:15

Now, so is tendon tears.

8:17

They're easy if they're retracted,

8:19

but sometimes the tears occur near the lesser trocanter

8:23

and the tendon doesn't move very much.

8:26

So this is such an example.

8:28

You can see a lot of swelling around this area.

8:31

Here's the tendon. It's very tendon, otic

8:33

and irregular with tearing.

8:36

But the key finding here is that it does not reach

8:40

the lesser, uh, uh, trocanter.

8:43

So always follow it down, make sure that it's touching down

8:47

so that you don't miss this particular injury.

8:50

It's usually seen in elderly patients. They will have had

8:54

Very minor trauma.

8:56

Sometimes it's just getting up out of a chair

8:59

that will tear the tendon.

9:01

And there's a background of tendinosis

9:04

should be particularly, uh, cautious about this, uh,

9:07

tendon in patients who've undergone total hip arthroplasty.

9:11

And it can be challenging to evaluate

9:13

because of the metal artifact,

9:15

but patients that have had total hip arthroplasties can

9:18

impinge on their sous tendon, they're prone

9:21

to developing tearing

9:23

and they're prone to developing, uh, ileus bursitis.

9:27

So I know it's a struggle,

9:28

but you do want to try, uh,

9:30

to look at this tendon in the patients

9:33

that have had a surgical procedure.