Anterior Hip Iliofemoral ligament

[Diane]

Hello!

I recently scanned a 30 year old male that complained of right anterior hip pain, more so looking for a hernia.
He didn’t have a hernia however when I went to have a look at the anterior hip joint, I noticed that the iliofemoral ligament perhaps looked thickened? I checked on the contralateral side and saw similar findings. The measurements for both iliofemoral ligaments were roughly 8mm.
No fluid was seen.

I was wondering what were your thoughts on the following images? Is there a specific measurement you use to classify thickening of the iliofemoral ligament or do you judge it on the convex/concave shape of it?
I forgot to include colour pictures but when I put colour on, there wasn’t any hyperemia.
Does the iliofemoral ligament need to have that convex shape and also increased vascularity to consider synovitis or is just the convex shape of the ligament enough?

Thank you!

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[Stephen Bird]

Hi Diane,

Lovely images,

If you look at these hips the iliofemoral ligament is still concave, but a little thickened.
If it truly becomes convex I would have no hesitation to call it synovitis if the ligament and synovium are thick and an effusion if there is fluid beneath it.
What you have here is just a slightly thick iliofemoral ligament / synovium when compared to what you expect to see in a normal volunteer.
I would have mentioned it on my worksheet and then it can be reported as a slightly thickened iliofemoral ligament / synovium and clinical correlation can be the decider as to the significance.
As it was bilateral it may be an early rheumatoid presentation and if they are symptomatic they can do the bloods etc and it may lead to a useful diagnosis.

The absolute measurement as usual doesn’t really mean much to me but eyeballing it it looks prominent not just over the femoral neck but over the head as well.

Colour Doppler or other Doppler algorithms are rarely helpful with hip synovitis due to the depth and transducer pressure required so the absence of colour flow means nothing to me but presence of colour flow would indicate synovitis.

My personal feeling on your case it that there is some low grade synovitis in both hip joint capsules and I would be asking about other joint pain and looking at the PACS for any other evidence of a rheumatological condition.

Lovely work,

Steve.

[Diane]

Thanks for the reply Steve! I appreciate the detailed responses.

Just the day after, I scanned this guy who they were querying a hernia on but he had right hip anterior pain that was radiating laterally and also down his leg.
I didn’t see any hernias but I saw a thickened joint capsule with hypoechoic fluid deep to the iliofemoral ligament. I thought the iliofemoral ligament itself appeared normal, as it did on the asymptomatic left side).
When I looked into the right labral area, there was lots of irregularity and 2 cystic spaces. I thought the cystic spaces could have been labral cysts so possibly an underlying labral tear? Do you think the images are typical for labral cysts or are they track more superficially into the muscle bellies as was seen in your hip webinar?

Also when the labrum area is that irregular, is it correct to label images as “labrum area” or could we use “acetabular area”. Or what would you use?

I have provided pics of the right hip, comparison with the left side and a cineloop of the right labrum area.

Thanks!

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[Stephen Bird]

Hi Diane,

Nice images,

I think the iliofemoral ligament is unremarkable here and there is no significant effusion.
The cystic areas are absolutely typical of para-labral cysts and this indicates there is certainly a labral tear and this can be confirmed with an MRI.

The appearance you are seeing is very common and I refer to it as a “swiss cheese” looking labrum where the labrum is expanded in size and has a herterogeneous echo texture with multiple small cystic spaces. Labral tears are common and so you can expect to see this regularly.
I label my images “anterior labrum”

In the webinar the paralabral cyst example I used was a larger cyst and hence it extends through the iliofemoral ligament and sits adjacent to the iliopsoas apparatus. This is also a common finding.

Your example is just a smaller version of the same thing.

The only confounder would be the possibility of an iliopsoas bursal effusion but if it is a mutiloculated, non compressible cystic area adjacent to the anterior labrum I would go for a paralabral cyst until proven otherwise.

The iliopsoas bursal effusions tend to be monoloculated, somewhat compressible and often larger as they commonly communicate with the hip joint.

Also remember that you can make this positive diagnosis but if a labrum looks normal on ultrasound it doesn’t exclude pathology as our sensitivity is very poor for labral tears.

Steve

[Diane]

**Repost of the cineloop for the labrum irregularity**
(Thanks Steve)

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