Ultrasonography of the Hip

Download (0)

Full text



2012, Vol. 14, no. 3, 217-224


A complete physical examination of the hip is often difficult due to its size and deep position. During the last two decades, ultrasonography (US) of the hip has been widely accepted as a useful diagnostic tool in patients with hip pain and /or limited range of motion. It is commonly used in both adults and children. This technique allows evaluation of different anatomical structures and their pathological changes, such as joint recess (joint effusion, synovial hypertrophy), changes within the bur- sae (bursitis), tendons and muscles (tendinopathy, ruptures, calcifications), as well as changes in the bony profile of the joint surfaces, ischial tuberosity, and greater trochanter (erosions, osteophytes, calcific deposits). US is very useful for guided pro- cedures in hip joint and periarticular soft tissues under direct visualization. The needle aspiration of synovial fluid and steroid injections are commonly-applied activities in daily rheumatology practice. The relatively limited acoustic windows available to the US beam are the principal limitations to hip US. Therefore, conducting a detailed examination of some important struc- tures together with the interpretation of Doppler signal (sometimes undetectable) is not easy, requiring good knowledge of the modality. The aim of this review is to analyze the current literature about US of the hip and to describe the most frequently- observed normal and pathological findings.

Keywords: ultrasonography, hip, synovitis, bursitis, tendinopathy

Ultrasonography of the Hip

Rodina Nestorova


, VioletaVlad


, Tzvetanka Petranova


, Francesco Porta


, Goran Radunovic


, Mihaela C. Micu


, Annamaria Iagnocco


1 Centre of Rheumatology “St. Irina”, Sofia, Bulgaria

2 Sf. Maria Clinical Hospital, Bucharest, Romania

3 Clinic of Rheumatology, Medical University, Sofia, Bulgaria

4 University of Florence, Department of Internal Medicine, Section of Rheumatology

5 Institute of Rheumatology, Medical School, University of Belgrade, Belgrade, Serbia

6 Rheumatology Division, Department of Rehabilitation II, Rehabilitation Clinical Hospital Cluj- Napoca, Romania

7 Dipartimento Medicina Interna e Specialità Mediche: Reumatologia, Sapienza Università di Roma, Rome, Italy

Received 09.04.2012 Accepted 30.04.2012 Med Ultrason

2012, Vol. 14, No 3, 217-224

Corresponding author: Prof. Annamaria Iagnocco,

Dipartimento Medicina Interna e Specialità Mediche: Reumatologia,

Sapienza Università di Roma,

V.le del Policlinico 155, Rome – 00161, Italy.

Tel: +39 06 49974634 Fax: +39 06 49974642

Email: [email protected]


High-resolution ultrasonography (US) of the hip is commonly used for the assessment of hip pathology in adults and children as well.Due to its size and deep loca- tion, the physical examination of the hip joint is difficult.

Only rarely effusions of the hip joint can be detected by clinical examination [1-6].

Over the last decade, US has proven to be a useful tool in the assessment of tendons, ligaments, muscles, nerves, synovial recesses, articular cartilage, bone sur- faces and joint capsule. The goals of US imaging are to detect and localize pathological processes, to differenti- ate between intraarticular and extraarticular pathology, to perform diagnostic and therapeutic interventional proce- dures and to monitor the efficacy of the therapy. In addi- tion, US has considerable advantages over CT and MRI:

absence of radiation, good visualisation of the joint cav- ity, quantification of soft tissue abnormalities, possibility for multiple joint scannings, non-invasiveness, speed of performance, rapid side-to-side anatomic comparison, better characterization of fluid, relative low cost, good compliance with the patient as well as a dynamic real- time study of multiple planes [1-26]. Moreover, the direct contact with the patient allows for maneuvers that elicit symptoms to be evaluated while performing the US study


local perfusion considering that Doppler signal is detect- ed with difficulties in deep areas [1].

The correct transducer position in relation to the un- derlying structure to be examined is the key element in achieving a good diagnostic image. Subtle changes in the angulation of the transducer can significantly influence the information obtained [10,11]. All findings should be documented in two perpendicular planes [6]. The exami- nation of the contralateral hip is advisable for compari- son. [1,8,12]. Table I shows the appropriate scans for the assessment of the hip joint and periarticular soft tissues.

Anterior examination

The patient lies supine with the hips and knees ex- tended / neutral position/ with a mild degree of exter- nal rotation of the hip /10–15°/ obtained when the heels are kept together [1,4,10,13,19]. In that position a wider acoustic window is obtained and a larger area of the joint is exposed to the US beam on anterior scans [1,8,10].

Anterior joint recess

In longitudinal view, the transducer is placed in a sag- ittal oblique plane parallel to the long axis of the femoral neck [1,3,6,10,13,19]. The latter lies lateral to the palpa- ble pulsations of the femoral artery. The probe is moved from proximal to distal and then from lateral to medial regions to scan the entire hip recess [10]. Four osseous structures are identified as highly reflective lines when moving from proximal to distal regions: the antero-infe- rior iliac spine, acetabular rim, femoral head and femoral neck [1,2,9,10,13,14].

[9]. Last but not least, another advantage of US over the above-mentioned techniques is the fact that direct US visualization offers the possibility of guided procedures in hip joint and periarticular soft tissues. [1-3,5,9,23-25]

The aim of this review is to analyze the current lit- erature regarding US of the hip and to describe the most frequently-observed normal and pathological findings.


The routine scanning technique for US examination should consider the anterior, medial, lateral and poste- rior aspects of the hip as separate quadrants.Ultrasound equipment with multi-frequency linear transducer (5.0- 12.5 MHz) can provide a general evaluation of mus- culoskeletal structures. Superficial structures are well visualized with linear multi-frequency 9-15-MHz trans- ducers. Higher frequency probes provide better spatial resolution but with a limitation because of less penetra- tion. The joint recess of the hip is well visualized with lower-frequency transducers (5.0-7.5 MHz) due to the deep location of the joint. Hip structures are more dif- ficultly visualized in obese patients; and in these cases a frequency of 3.5-5 MHz can help the examination [1,2,3,11]. On some occasions, curved array probes can be used (convex transducers 3.5–5 MHz, traditionally used for abdominal imaging).In daily practice a com- bination of probes could be required [11]. For children examination 10-14 MHz transducers are recommended due to the relatively superficial position of the hip joint [1]. When inflammatory pathology is suspected, Doppler techniques should be used for the evaluation of increased

Fig 1. Sagital oblique image of normal anterior hip joint: 1-sartorius muscle; 2-iliopsoas mus- cle, 3-rectus femoris muscle; 4-femoral head;

5-iliofemoral ligament.

Тable I. US scans of the Hip:

Anterior examination Anterior recess of the hip Bony profile

Anterior regional muscles Medial examination

Insertion of the iliopsoas tendon Pelvic insertion of the adductor muscles

Lateral examination Greater trochanter

Gluteus minimus and medius tendons

Fascia latae Posterior examination

Ischial tuberosity

Hamstrings and sciatic nerve


The synovial recess lies between the profound fascia of the iliopsoas and the femoral neck ( fig 1). Over the femoral head and neck the joint capsule can be seen as a concave thin linear hyperechoic structure extending from the acetabular rim to its distal insertion to the femoral neck [1,10]. The joint capsule bounds the joint cavity which appears as a hypo/anechoic area, containing a small physiological amount of synovial fluid [1,15,16,17]. In the absence of an intraarticular effusion, the two layers of the capsule are visualized together as a hyperechoic line [1,2]. The distance between the bony profile and the capsule should be at its greatest point less than 7- 8 mm in normal joints. However, the most important finding for effusion diagnosis is the symmetry between the two sides (right-left difference < 1 mm) [1,3,8,13]. The hy- perechoic rounded surface of the femoral head is covered by a thin hypoechoic layer of hyaline articular cartilage [10,11,19].

The anterior superior labrum can be visualized sono- graphically as a triangular, echo-bright structure extend- ing inferiorly from the acetabulum and draping over the femoral head. Under US, only the anterior superior la- brum is satisfactorily visualized [10,11].

In transverse view, the probe is placed transversely to the long axis of the femoral neck and then moved from proximal to distal and from lateral to medial regions to scan the entire hip recess [10]. When moving from proxi- mal to distal regions, the acetabular rim and the femo- ral head are identified. The joint capsule can be seen as a hyperechoic band covering the femoral head and the articular cartilage as a thin anechoic layer between the joint capsule and the femoral head [2,6,9-11] (fig 2). An- terior transverse scans are commonly used during US

Fig 2. Transverse oblique image of normal an- terior hip joint: 1-iliopsoas muscle; 2-rim of the acetabulum 3-femoral head.

guided procedures to identify vessels and structures of the inguinal area and to ensure the correct needle position within the joint [1].

Anterior regional muscles, iliopsoas tendon and bursa The probe is placed parallel to the long axis of the femoral neck and it is moved from proximal to distal and from lateral to medial /longitudinal view [10].

The pennate structure of several muscles can be identified in this region: superficially the sartorius mus- cle as a longitudinal band parallel to the subcutaneous tissue with an oblique course into the anterior thigh; on its lateral side, tensor fascia lata muscle. The deep layer at this level consists of the rectus femoris iliopsoas and pectineus muscles [10]. The muscles pennate structure is seen on the US screen as contiguous hypoechoic mus- cular bundles /fascicles/ separated from one another by hyperechoic lines/ perimysium [9,11].

In normal conditions, the iliopsoas bursa, located be- tween iliopsoas muscle and the hip joint, communicates with the joint cavity in 10-15 % of cases and cannot be visualized with US because its cavity contains only a thin film of synovial fluid. The bursa can be seen, when dis- tended, along the medial aspect of the hip joint as an anechoic/hypoechoic mass [1,2,11].

The iliopsoas tendon overlies the labrum medially.

This tendon is a hyperechoic band running on the poste- rior aspect of the iliopsoas muscle. The distal attachment of the iliopsoas tendon can be difficult to identify with US in this position [11].

Anterior regional muscles and iliopsoas tendon are also evaluated in transverse scanning. This view is per- formed with the probe placed transversely to the long axis of the femoral neck and moved from proximal to distal and from lateral to medial regions.The sartorius muscle is located superficially under the subcutaneous tissue, the rectus femoris muscle laterally to the femo- ral head, and the iliopsoas muscle medially covering the femoral head [2,10,11].

Medial examination

Femoral neurovascular bundle

The patient lies supine with the hips and knees ex- tended / neutral position [10].

In both views /longitudinal and transverse, the femo- ral vein, artery and nerve can be identified in that order from medial to lateral. In transverse scan, the femo- ral nerve appears as several small, hypoechoic spaces, each surrounded by a hyperechoic thin rim. The femoral vein and artery are easily identified with Power Doppler [2,10,11]. The femoral vein has a greater cross-sectional


area than the artery and it is easily compressible with the probe [2,11]. The femoral nerve is lateral and the vein is medial to the artery [9].

Pelvic insertion of the adductor muscles longus, brevis and magnus/adductor compartment

The patient keeps his/her thigh abducted and exter- nally rotated with knee flexion [2,9,11,14]. This is similar to the frog position for paediatric radiography [9].

The adductor compartment (fig 3) includes three ad- ductor muscles (from anterior longus, brevis and mag- nus) descending into the thigh capped by the more me- dially placed and perpendicularly lying gracilis muscle [9].The US scan of the myotendinous insertions of these muscles and their tendons up to the pubis - longitudinal and transversal approach - demonstrates a fibrillar inter- nal structure [2,6,9,11,14]. The adductor longus is the prominent and the most easily recognizable muscle. It has both muscular and tendinous components close to its origin. The most superficial muscles are the adductor longus and gracilis. Both of them arise from the body of symphysis itself and can be traced distally. The adduc- tor brevis and then the larger adductor magnus are found deep to this muscle pair [9].

Lateral examination

The patient lies in lateral decubitus with hip joint in full extension [10].

Greater trochanter and Gluteus minimus and me- dius tendons

The transducer is placed longitudinally, parallel to the femoral diaphysis. The probe should be moved from an- terior to posterior to scan the gluteus tendons insertions.

The profile of the greater trochanter can be seen as a hy- perechoic line (fig 4). The gluteus tendons insertion can be seen as a hyperechoic fibrillar triangle over the greater trochanter and deep to the subcutaneous tissue [10]. Cra- nially to the greater trochanter are the superficial gluteus medius and the deep gluteus minimus muscles. The glu- teus minimus tendon is detected anteriorly as a hyper- echoic structure that arises from the deep aspect of the muscle to insert into the anterior facet of the greater tro- chanter [2]. Gluteus maximus is not attached to the great- er trochanter, as it inserts proximally into the iliotibial band. Dynamic imaging with external rotation followed by extension may reveal a snapping gluteus maximus or iliotibial band over the greater trochanter [2,11].

For transverse scan of the greater trochanter the probe is placed transversely to the femoral diaphysis. The probe should also be moved from anterior to posterior The glu- teus tendons insertions can be seen as hyperechoic fibrillar structures over the hyperechoic line of the greater trochanter [10]. There is a number of bursae that surrounds the greater trochanter and including the gluteus minimus, the gluteus medius anteriorly, and the gluteus maximus bursa posteri- orly. All of them are a potential space for fluid collection or thickening [11]. The bursae around the greater trochanter are not visible with US in normal conditions. Lateral hip tendons are best imaged by tilting the probe parallel to their long axis in order to avoid anisotropic effects [1,2].

Fascia lata

The fascia lata arises from the iliac crest anteriorly and appears as a linear hyperechoic band joining the an- terior edge of the gluteus maximus and the posterior por- tion of the tensor fasciae latae muscle [1,9]. Distally this structure forms the fibrous iliotibial tract [9]. It can be seen with US as a hyperechoic fibrillar structure.

Posterior examination

The posterior hip quadrant is rarely examined with US, being less commonly affected by pathological changes than other quadrants [2].

The patient is placed prone with the legs and knees extended with his/her feet hanging over the edge of the examination bed [2,11].

Fig 3. Longitudinal view of adductor insertion on pubis: 1-adductor longus; 2-adductor brevis;

3-adductor magnus.

Fig 4. Transverse view over the greater tro- chanter, anterior facet: 1-greater trochanter;

2-insertion of gluteus minimus tendon.


Ischial tuberosity, hamstrings, ischiogluteal bursa, and sciatic nerve

Ischial tuberosity is the main landmark of this area, It is easily apparent on US screen, due to the posterior acoustic shadowing of the bone. Once located, it allows an accurate detection of the surrounding anatomic struc- tures. On its lateral aspect, US visualizes the conjoined insertion of harmstrings/extensor/ischiocrural tendons, consisting of semimembranosus, semitendinosus and bi- ceps femoris. The last two extensors share a same tendon at the insertion point [2].

The ischiogluteal bursa is located between the ischial tuberosity and the gluteus maximus. In normal condi- tions, the bursa is invisible under an US examination because of the small amount of fluid inside it. Since the bursa has close contact with the sciatic and the posterior femoral cutaneous nerves, ischiogluteal bursitis may ap- pear clinically as a radiculopathy. This proves once more the utility of US examination that is capable to differenti- ate between the two pathologies [2].

The sciatic nerve is always located on the lateral side of the ischiocrural tendons, posterior to gluteus maximus.

More distally, it can be detected deep to the biceps mus- cle [2,11].

US Pathology Joint Effusion

Ultrasound is the imaging modality of choice for detection of fluid collections inside the hip joint. The most common causes of hip effusions in adults are os- teoarthritis and osteonecrosis (avascular necrosis). The most common synovial disease involving the hip joint in adults is rheumatoid arthritis. Using an accurate probe, as little as 1 mL of intraarticular fluid can be reliably seen [19]. US detected synovitis is defined as synovi- al hypoechoic hypertrophy or effusion (or both) meas- ured as an increase of the distance neck-capsule (DNC)

>8mm and asymmetric distension larger than 2 mm of the recess compared with the opposite side with possi- ble positive power Doppler signal in the synovial tissue [1,13,15,16,23].

Effusion is depicted with US by convexity of the joint capsule on the abnormal compared to the normal side [1,9,22] Other US signs of synovitis are the thickening of the joint capsule and the absence of the “stripe sign”

[1]. Power Doppler is able to assess the increased vas- cularization involving synovial hyperplastic tissue and consequently to give information regarding the activity of the synovial pannus [1,14,18]. However, due to the deep position of the joint, the absence of Doppler signal does not necessarily mean lack of inflammatory process

inside the hip joint. Nonhomogeneous echogenicity of the synovial fluid and/or echogenic spots with or without acoustic shadowing can be generated by protein contain- ing materials, cartilage fragments, crystal aggregates and calcified loose bodies [14]. The variable echogenicity of the collection usually depends on the nature of the fluid content (serous, bloody, infectious). Fine particulate de- bris floating in the synovial fluid is generally observed after long-standing or recurrent joint effusions or after intra-articular corticosteroid administration [11,14].

In patients with hip osteoarthritis, US can demon- strate thickening of the joint capsule due to fibrotic change, anterior osteophytes as hyperechoic projections arising from the junction between the head and the neck of the femur.US shows osteophytes as irregularities of the joint margins for new bone formation. Qvistgaard et al. describe “Osteophyte score” for the femoral osteo- phytes with 4 degrees as follows: 0 /no occurrence/; 1 / slight degree-irregularity on the cartilage–bone transition is just visible/; 2 /medium degree - well-defined osteo- phytes, shelf formation or irregularities on the femoral neck/; and 3 /severe degree -involvement of the whole femoral neck including shelf formation [3]. Also for bet- ter standardization of hip US, the mentioned article also scores curvature of the visible part of the femoral head (round/flattened) and the intraarticular effusion (present/

absent), defining a global score for osteoarthritis of the hip. This score was proven correlated to the subjective pain of the patient, quantified by VAS.

US can reveal marginal erosions as cortical defects with an irregular floor located at the interface between bone and the articular cartilage which covers the femoral head and neck [1,2].

Periarticular US Pathology Tendon pathology

Snapping of the Iliopsoas tendon

This entity is also known in medical literature as snap- ping hip and it associates hip pain with an audible click on walking. Dynamic US scanning can reveal a snap- ping iliopsoas tendon. Normally, the iliopsoas tendon is gliding smoothly over the ilium during hip movements.

In cases of iliopsoas instability, abrupt sudden motions of the tendon are apparent [2]. Patients with groin pain and a clinically suspected snapping iliopsoas tendon can benefit from injection into the iliopsoas bursa even if the snapping tendon is not visualized sonographically [20].

Insertional tendinopathy of the Adductor muscles This disorder is commonly described as pubalgia and clinically consists of diffuse tenderness over the groin area. Insertions appear on US thickened, inhomogene-


ous and hypoechoic and may show intratendinous pre-in- sertional calcifications at a later stage [1,7].The adductor origin appears hypoechoic with irregularities in case of partial tears. If completely ruptured, the adductor longus tendon appears totally separated from symphysis pubis.

It may be difficult to differentiate with US between the three adductors lesions in case of trauma [2].

Snapping Iliotibial Band

This entity is also known as extra-articular snapping hip and it associates hip pain in the external area with an audible click on walking. US can detect with maximal accuracy the cause of the click [22], as being either ili- otibial band over greater trochanter or gluteus maximus muscle. Fascia lata may appear thickened and hypoecho- ic. Dynamic sonography shows sudden displacement of the iliotibial band or the gluteus maximus muscle over- lying the greater trochanter as a painful snap during hip motion, mostly during flexion of adducted extended hip.

Transverse US images obtained over the lateral aspect of the greater trochanter are the most useful to depict this condition [2,22].

Hamstrings tendinopathy

The proximal attachment of these muscles appears swollen and hypoechoic reflecting changes related to tendinopathy. Calcifications can be detected at the ten- don insertion as irregular hyperechoic foci near the is- chial tuberosity indicating a calcific enthesopathy. Ex- tensor tendons of the hip represent the main area where tears /partial and full/ and avulsion can be identified. US can demonstrate the discontinuity of the affected tendon, which appears retracted downward and surrounded by lo- cal hematoma, whereas the adjacent non-affected tendon can be seen inserting normally into the hyperechoic cor- tex [2]. In cases of entesopathy/entesitis, US can demon- strate thickening of the insertion, also hypoechogenicity and/or Doppler signal and/or calcification [1].

Bursal pathology Iliopsoas bursitis

On transverse US images, the iliopsoas bursa is lo- cated between the medial femoral vessels and the lateral iliopsoas muscle. Bursitis is seen as distension of the wall and presence of fluid collection within the bursa [1].

When the bursa is filled with synovial pannus, it appears as a para-articular mass with internal echogenic solid components [2]. By Doppler US, the activity of synovial proliferation /with or without local hyperemia can be dis- tinguished [1].

Ischiogluteal bursitis

This disorder is also known as “weaver’s bottom”.

Sometimes, it is encountered in neoplastic patients af- fected by cachexia and severe weight loss. It is assumed

that reduction in the thickness of subcutaneous fat in the buttock region may result in repetitive minor trauma on the bursa causing its inflammation and fluid distention.

Ischiogluteal bursitis is often observed in patients with polymyalgia rheumatica [2].

US demonstrates hypo/anechoic fluid distention of the ischiogluteal bursa.

Common /tendon and bursal/ pathology Greater Trochanteric Pain Syndrome

US appears to be clinically useful in the greater tro- chanteric pain syndrome. The pathologic changes of the gluteus medius and minimus tendons represent the most common cause of the painful hip. US signs of tendinopa- thy include the focal or diffuse swelling of the affected tendon portion and the heterogeneous hypoechogenic- ity of the tendon and thickening with or without Dop- pler signal [1,2] Hyperechoic spots related to calcifica- tions may occasionally be found at the tendon insertion [2]. Intratendinous calcification may also be identified and appear as one or more hyperechoic foci within the body of the tendon with a posterior acoustic shadow [1].

Fluid distension of the trochanteric bursa appears as a well-circumscribed round-shaped hypoechoic to ane- choic collection located superficially to the posterior insertion of the gluteus medius and the lateral aspect of the greater trochanter and deep to the gluteus maximus [2]. In a recently published study, a group of Australian orthopedists established correlations between US find- ings and surgical/ histological findings in 24 patients with great trochanteric pain in whom non-operative man- agement had failed. US had a sensitivity of 0.79 and a positive predictive value of 1 regarding diagnosis of a tear of either tendon. When histology and US findings were computed in 15 patients with hip bursal pathology US showed a sensitivity of 0.61, a specificity of 1.0, a positive predictive value of 1.0, and a negative predictive value of 1.0 [21].

US-guided procedures

US is an ideal method for guiding interventional musculoskeletal procedures [9]. The main advantages of US guided hip injection are its safety, with no serious complications, portability and lack of ionizing radiation.

[1,2,5,7,9,23-26]. In daily practice a hand-free US-guid- ed anterior longitudinal approach technique is applied for puncture and/or injection. With the patient in the supine position and after triple skin disinfection, a needle (gauge 18-21, 0.8X80 mm) is inserted interiorly 8–10 cm under the inguinal ligament towards the anterior or inferior cap-


sule below the femoral head. Guided by US, the needle is traced from 1 cm below the skin surface all the way to the joint. Joint fluid is aspirated, if present [3,23]. On this scan, when the needle is perpendicular to the US beam, it appears as a sharply-defined echoic band with strong posterior reverberations [14]. The best visualization of the shaft of the needle is reached at 90 degrees. With in- creasing obliquity, the needle becomes less evident [2].

The injection within the hip joint cavity with long-act- ing steroids using sometimes a local anesthetic added in a mixture, is widely used. Anesthetics are usually meant to obtain relief of the local pain during the procedure and to treat reactions to steroid crystals. Diffusion of the drug into the joint can be evaluated with US as a hyperechoic filling similar to the effect of US contrast agents. Immo- bilization after injection is not necessary [23], but the ex- aminer should recommend the patient to keep the joint relatively immobile for maximizing the therapeutic effect of the injected drugs and reducing their possible diffu- sion into the adjacent tissues. Several randomized, place- bo-controlled clinical trials have shown improvement of pain and hip disability after the intraarticular injection of corticosteroids in the last years [23,27,28].

US-guided intra-articular injections with hyaluronic acid/ viscosupplementation/ are widely used for the treat- ment of hip osteoarthritis [25-27]. After injection of 2 ml of hylan G-F 20 under ultrasound guidance, in an open label study, hip pain and disability measured by Lequesne algofunctional index [29] improved in 12 osteoarthritic patients [25]. In a prospective double blind study, using a randomized controlled trial with a three-armed parallel- group design, however, viscosupplementation did not show marked improvement of clinical indices, suggest- ing further studies are required in that area [27].


US accessing of the hip joint has one main limitation, namely the limited size and number of acoustic windows.

This makes a detailed examination of some important structures e.g. the femoral cartilage impossible and the interpretation of power Doppler signal unreliable. The deep location of the hip joint can confer further problems to US scanning in obese or particularly muscular sub- jects. US gives little information in cases of bone frac- tures and labral tears [1].


High frequency US is a bedside diagnostic tool in pa- tients with hip pain and limited range of motion. US of the hip provides high sensitivity in the detection of joint

effusion and synovitis. It can be very useful in the evalu- ation of periarticular pathologic findings, too. The stand- ard scanning protocol includes multiplanar, dynamic and bilateral assessment. This protocol should be followed in order to avoid missing certain parts of the assessment of one or more anatomic structures. US is a highly-recom- mended method for guiding interventional procedures in the hip area.


1. Iagnocco A, Filippucci E, Meenagh G, et al. Ultrasound imaging for the rheumatologist III. Ultrasonography of the hip. Clin Exp Rheumatol 2006; 24: 229–232.

2. Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. Springer-Verlag Berlin 2007: 551- 610.

3. Qvistgaard E, Torp-Pedersen S, Christensen R, Bliddal H.

Reproducibility and inter-reader agreement of a scoring system for ultrasound evaluation of hip osteoarthritis. Ann Rheum Dis 2006; 65: 1613–1619.

4. Bierma-Zeinstra SM, Bohnen AM, Verhaar JA, Prins A, Ginai-Karamat AZ, Laméris JS. Sonography for hip joint effusion in adults with hip pain. Ann Rheum Dis 2000; 59:


5. Atchia I, Birrell F, Kane D. A modular, flexible training strategy to achieve competence in diagnostic and interven- tional musculoskeletal ultrasound in patients with hip oste- oarthritis. Rheumatology (Oxford) 2007; 46: 1583–1586.

6. Backhaus M, Burmester GR, Gerber T, et al. Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 2001; 60: 641-649.

7. Grassi W, Cervini C. Ultrasonography in rheumatology: an evolving technique. Ann Rheum Dis 1998; 57: 268-271.

8. Koski JM, Anttila PJ, Isomäki HA. Ultrasonography of the adult hip joint. Scand J Rheumatol 1989; 18: 113–117.

9. McNally EG. Practical Musculoskeletal Ultrasound. Phila- delphia Elsevier 2005: 23-28, 136-141.

10. Naredo E. Joint Ultrasonography. Sonoanatomy and Ex- amination Technique. Euromedice 2007: 134-145.

11. O’ Neill J. Musculoskeletal Ultrasound, Anatomy and Technique. Springer Science Business Media, New York 2008: 167-178

12. Koski JM, Anttila P, Hämäläinen M, Isomäki H. Hip joint ultrasonography: correlation with intra-articular effusion and synovitis. Br J Rheumatol 1990; 29: 189–192.

13. Schmidt WA, Schmidt H, Schicke B, Gromnica-Ihle E.

Standard reference values for musculoskeletal ultrasonog- raphy. Ann Rheum Dis 2004;63:988–994.

14. Martino F, Silvestri E, Grassi W, Garlaschi G. Musculoskel- etal Sonography. Springer, Berlin 2006: 52-61,97-107.

15. Cho KH, Park BH, Yeon KM. Ultrasound of the adult hip.

Semin Ultrasound CT MR 2000; 21: 214-230.

16. Koski JM, Isomaki H. Ultrasonography may reveal synovitis in a clinically silent hip joint. Clin Rheumatol 1990; 9; 539-541.


17. Koski JM. Ultrasonographic evidence of hip synovitis in patients with rheumatoid arthritis. Scand J Rheumatol 1989; 18: 127-131.

18. Naredo E, Bonilla G, Gamero F, Uson J, Carmona L., Laf- fon A. Assessment of inflammatory activity in rheumatoid arthritis: a comparative study of clinical evaluation with grey scale and power Doppler ultrasonography Ann Rheum Dis 2005; 64: 375–381.

19. Valley VT, Stanhmer SA. Targeted musculoarticular sonog- raphy in the detection of joint effusions. Acad Emerg Med 2001;8:361–367.

20. Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip.

Skeletal Radiol 2006;35:565-571.

21. Fearon AM, Scarvell JM, Cook JL, Smith PN. Does ultra- sound correlate with surgical or histologic findings in great- er trochanteric pain syndrome? A pilot study. Clin Orthop Relat Res 2010; 468: 1838–1844.

22. Choi YS, Lee SM, Song BY, Paik SH, Yoon YK. Dynamic sonography of external snapping hip syndrome. J Ultra- sound Med 2002; 21: 753–758.

23. Micu MC, Bogdan GD, Fodor D. Steroid injection for hip osteoarthritis: efficacy under ultrasound guidance. Rheu- matology (Oxford) 2010; 49: 1490-1494.

24. Sofka CM, Saboeiro G, Adler RS. Ultrasound-guided adult hip injections. J Vasc Interv Radiol 2005;16: 1121–1123.

25. Migliore A, Tormenta S, Martin LS, et al. Open pilot study of ultrasound-guided intraarticular injection of hylan G-F 2(Synvisc) in the treatment of symptomatic hip osteoarthri- tis. Clin Rheumatol 2005; 24: 285-289.

26. Migliore A, Tormenta S, Massafra U, et al. 18-month obser- vational study on efficacy of intraarticular hyaluronic acid (Hylan G-F 20) injections under ultrasound guidance in hip osteoarthritis. Reumatismo 2006; 58: 39-49.

27. Qvistgaard E, Christensen R, Torp-Pedersen S, Bliddal H.

Intra-articular treatment of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid and isotonic saline.

Osthearthritis Cartilage 2006; 14: 163-170.

28. Lambert RG, Hutchings EJ, Grace MG, et al. Steroid injection for osteoarthritis of the hip; a randomized, double blind, pla- cebo-controlled trial. Arthritis Rheum 2007; 56: 2278-2287.

29. Lequesne MG. The algofunctional indices for hip and knee opsteoarthritis. J Rheumatol 1997; 24: 779-781.




Related subjects :