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    • #29461
      David Smith
      Participant

      Hi Steve,

      I was wondering if you could post some case images of hamstring origin tendinosis pathology.

      I imaged a hamstring origin that was 2x thicker than the other side in LAX, but very difficult to get the fibrillar echotecture of most other tendons. Just looked very thick and dark. Other side had same echo texture, but 1/2 the thickness. Patient had symptoms c/w the imaging.

      I find it challenging to get the normal fibrillar echo texture even in normal hamstring origins. Maybe I am just not skilled yet in avoiding anisotropy?

      Looking forward to seeing some images from your pathologic library to compare to what I see.

      Thanks,
      Dave

    • #29477
      Stephen Bird
      Keymaster

      Hi Dave,

      I will find some cases for you, but I want you to go about this in a different way.

      Personally I don’t like long axis imaging of the hamstring origin with the exception of measuring the length of a conjoint tendon stump, retraction distance or gap.

      For assessment of tendinosis I find it very unreliable,

      You can make it look as thick or thin as you want to with a tiny wiggle of the transducer and it is difficult to get nce fibrillar texture.

      I prefer a short axis approach with the transducer placed a little lateral to the ischial tuberosity and angled back toward it. That gives you a better angle by flattening out the profile of the ischial tuberosity. Using this view you have 2 advantages.

      Firstly you can do REAL comparison my getting the bony architecture symmetrical on each side giving you a genuine comparison.

      Secondly you get a great look at the enthesis for enthesopathy at the same time as the tendon for tendinosis.

      It also allows you to do an internal / external rotation manoeuvre looking for ischiofemoral impingement as well as sciatic nerve mobility.

      Hence I have virtually given up long axis imaging in the hamstring complex except for measuring haematomas and retraction distances.

      Another advantage is that I find I can control anisotropy better and make genuine comparisons of echogenicity of the tendon origins.
      In the long axis the architecture of the collagen makes it really hard to control anisotropy,

      Steve

    • #29671
      David Smith
      Participant

      Hi Steve,

      Wow, fantastic perspective. I will definitely give all of this a try on some patients. Do you also find that the tendon often looks uniformly dark when looking in LAX?

      The FAI also intrigues me, so if you have any images or cine clips of that, please share! Looking forward to seeing what you’ve seen!

      Thanks for your time,
      David

    • #29672
      David Smith
      Participant

      Hi Steve,
      One other question. Do you think that the lack of pain with sonopalpation over the ischiotuberosity rules out a tendinopathy or enthesopathy? I’m still not sure what is the best physical exam maneuver to isolate the hamstring origin to see if local pain in the buttock can be elicited.
      Cheers,
      Dave

    • #29691
      Stephen Bird
      Keymaster

      Hi Dave,

      Yes, I agree the collagen looks hypo echoic in long axis and hence I don’t trust long axis imaging and depend heavily on short axis assessment.
      Short axis is reproducible and reliable.

      I also agree there is usually pain with sonopalpation of the ischial tuberosity if there is enthesopathy or tendinosis present. A lack of pain and a hypo echoic , swollen tendon would indicate old disease that is now asymptomatic.
      As far as a provocative manoeuvre goes, I would need to consult a sports and exercise physican to find out what clinical test is most reliable.

      FAI is a different topic.
      You can see early OA changes on ultrasound and paralabral cysts from the early labral degeneration / tears. These are clues to the presence of FAI.
      With Cam type FAI you may see that the femoral head / neck contour is not as you would expect and the femoral head continues to bulge down into the expected neck area. You lose the typical “slippery slide” contour from the head down to the neck. You especially see this just lateral to the midline of the femoral neck and you may see an associated bony defect in the lateral margin of the acetabular rim.
      I can not see pincer type FAI on ultrasound, just the OA and labral changes associated with it.
      In the end a plain radiograph series is always essential.

      Steve

    • #29693
      Stephen Bird
      Keymaster

      Dave, also look in the tips and tricks section of the website.

      I have recorded my hamstring navigation technique and I think this might help you,

      Steve

    • #29760
      David Smith
      Participant

      Hi Steve,
      Just reviewed the Tips and Tricks video. More exemplary material. Thanks.
      David

    • #29768
      Stephen Bird
      Keymaster

      Hi Dave,

      I think once you establish a solid short axis assessment technique you will find hamstring navigation and diagnosis easier,

      Cheers

      Steve

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