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Hip and thigh

Magnetic resonance imaging (MRI) is the highest standard in diagnostic imaging of muscle injuries(1). Diagnosing muscle injuries of the hip and thigh is a relevant issue in professional sports(2).

Radiologists must familiarize themselves with typical MRI findings to accurately detect and classify muscle injuries. Proper interpretation of the findings is crucial, especially among elite athletes.

At 35% of all soccer players’ injuries, hip and thigh muscle injuries are the most common reason for missing a game(3). Such injuries often occur during a match.

Meanwhile, around 96% of muscle injuries have an indirect mechanism of an accident, usually due to muscle tears(4). Direct trauma is about 2% of the reasons for a muscle injury.

Eccentric contraction usually induces indirect trauma(5). In MRI, indirect muscle injuries typically include hematoma (blood pooling outside the blood vessel), muscle edema (swelling), and fiber disruption.

In contrast to indirect injuries, muscle contusions usually occur after direct trauma(6). MRIs can almost clearly detect direct traumas that induce muscle bleeding(7). Generally, muscle contusions heal quickly, allowing athletes to return and play within a week.

Knowing the typical imaging findings and distinguishing between the different kinds of muscle injuries is essential from a radiological standpoint.

Radiologists with significant knowledge on the subject may better identify the widely varying prognoses among the different types and recommend the appropriate therapy options.

Imaging Techniques

Ultrasound and MRI are suitable methods of evaluating muscle injuries. There is a large variety in imaging patterns of hip and thigh muscle injuries. Such variations range from very subtle muscle strain changes to complete tears with muscle retraction and large hematoma(8-9).

Radiologists may use ultrasound as the first modality in assessing muscle injuries due to its wide availability. Fast, easy-to-use, and affordable ultrasound machines are usually available in the immediate area of several sports arenas(10).

However, ultrasound can be very user-dependent, making it difficult to determine the muscle tear’s length. Ultrasound cannot immediately identify small hematomas, which is imperative to find within the first 24 hours after the injury.

Meanwhile, MRI may excellently depict the most relevant findings in muscle injuries(11). 

MRI also has a high sensitivity in identifying acute and chronic soft tissue alteration(12). MRI is a more elaborate imaging technique that experts consider the reference standard for muscle injuries.

Radiologists assess muscle injuries on MRI by acquiring fluid-sensitive short-tau inversion recovery (STIR) or proton density (PD) fat-saturated sequences and T1-weighted sequences.

Fluid-sensitive sequences allow radiologists to visualize edema, muscle tears, hematoma, and bone bruises. STIR is less sensitive to patient movement and metal artifacts.

Meanwhile, PD fat-saturated sequences provide more anatomical information and have a higher signal to noise ratio (SNR). T1-weighted sequences can assess stress fractures, including hematoma and bony avulsions.

Assessing anatomical features on non-fat-suppressed images is a common practice. Dixon sequences or chemical-shift imaging can be useful for their ability to provide separate water-only and fat-only images. This technique provides more uniform fat suppression(13-14).

Complications of Muscle Injuries of the Hip and Thigh 

The following conditions are possible complications of muscle injuries(15):

Muscle Hernia

Muscle hernias manifest in herniation (abnormal protrusion) of the muscle tissue through a small fascial defect concerning a prior blunt or penetrating muscle trauma.

Muscle hernias may increase in size during activity and can sometimes be undetectable during rest periods. Thus, dynamic or standing ultrasound is a requirement(16-19).

Acute or Chronic Exertional Compartment Syndrome

Muscle anoxia causes compartment syndrome due to a pressure increase within the compartment(20).

A chronic exertional compartment syndrome is caused by an increased compartment pressure during exercise and resolves with rest.

Meanwhile, an acute compartment syndrome is a surgical emergency presented in pain, disproportionate to the injury.

Myositis Ossificans

Myositis ossificans or heterotopic ossification is a common sequela of muscle injuries. This condition is not an inflammatory process.

Initially, edema and hematoma are present. There is a high signal intensity on MRI on fluid-sensitive images and an increased enhancement after contrast administration.

After six weeks, radiologists may find typical imaging features with a peripheral rim of ossification that progresses towards the center(21).

Calcific Myonecrosis

Calcific myonecrosis is a rare benign condition that mainly affects a single leg compartment’s muscles. Experts believe that the condition follows a history of trauma with a latent period of years. Patients may present with a slowly growing mass(22).

Morel-Lavallée Lesions

Morel-Lavallée lesions result from a closed degloving injury due to shear forces associated with severe trauma. Such conditions result in the separation of the subcutaneous tissue from the fascia(23). 

Assessing this condition using MRI often comes with recurrent fluid accumulation while the fluid is of variable signal intensity.

  1. Thierfelder, K. M., Gerhardt, J. S., Gemescu, I. N., Notohamiprodjo, S., Rehnitz, C., & Weber, M. A. (2019). Imaging of hip and thigh muscle injury: a pictorial review. Insights into imaging, 10(1), 20. https://doi.org/10.1186/s13244-019-0702-1
  2. Imaging of Muscle Injuries in Sports Medicine: Sports Imaging Series. Guermazi A, Roemer FW, Robinson P, Tol JL, Regatte RR, Crema MD Radiology. 2017 Dec; 285(3):1063.
  3. Injury incidence and injury patterns in professional football: the UEFA injury study. Ekstrand J, Hägglund M, Waldén M Br J Sports Med. 2011 Jun; 45(7):553-8.
  4. Terminology and classification of muscle injuries in sport: the Munich consensus statement. Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, Ekstrand J, English B, McNally S, Orchard J, van Dijk CN, Kerkhoffs GM, Schamasch P, Blottner D, Swaerd L, Goedhart E, Ueblacker P Br J Sports Med. 2013 Apr; 47(6):342-50.
  5. MR imaging of myotendinous strain. Palmer WE, Kuong SJ, Elmadbouh HM AJR Am J Roentgenol. 1999 Sep; 173(3):703-9.
  6. Review: Muscle injuries: biology and treatment. Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M Am J Sports Med. 2005 May; 33(5):745-64.
  7. Terminology and classification of muscle injuries in sport: the Munich consensus statement. Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, Ekstrand J, English B, McNally S, Orchard J, van Dijk CN, Kerkhoffs GM, Schamasch P, Blottner D, Swaerd L, Goedhart E, Ueblacker P Br J Sports Med. 2013 Apr; 47(6):342-50.
  8. Imaging techniques for muscle injury in sports medicine and clinical relevance. Crema MD, Yamada AF, Guermazi A, Roemer FW, Skaf AY Curr Rev Musculoskelet Med. 2015 Jun; 8(2):154-61.
  9. Traumatic injuries of thigh and calf muscles in athletes: role and clinical relevance of MR imaging and ultrasound. Hayashi D, Hamilton B, Guermazi A, de Villiers R, Crema MD, Roemer FW Insights Imaging. 2012 Dec; 3(6):591-601.
  10. Thierfelder, K. M., Gerhardt, J. S., Gemescu, I. N., Notohamiprodjo, S., Rehnitz, C., & Weber, M. A. (2019). Imaging of hip and thigh muscle injury: a pictorial review. Insights into imaging, 10(1), 20. https://doi.org/10.1186/s13244-019-0702-1
  11. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Ekstrand J, Healy JC, Waldén M, Lee JC, English B, Hägglund M Br J Sports Med. 2012 Feb; 46(2):112-7.
  12. Review: Magnetic resonance imaging of sports-related muscle injuries. Rybak LD, Torriani M Top Magn Reson Imaging. 2003 Apr; 14(2):209-19.
  13. Predicting Retear after Repair of Full-Thickness Rotator Cuff Tear: Two-Point Dixon MR Imaging Quantification of Fatty Muscle Degeneration-Initial Experience with 1-year Follow-up. Nozaki T, Tasaki A, Horiuchi S, Ochi J, Starkey J, Hara T, Saida Y, Yoshioka H Radiology. 2016 Aug; 280(2):500-9.
  14. Quantification of Fatty Degeneration Within the Supraspinatus Muscle by Using a 2-Point Dixon Method on 3-T MRI. Nozaki T, Tasaki A, Horiuchi S, Osakabe C, Ohde S, Saida Y, Yoshioka H AJR Am J Roentgenol. 2015 Jul; 205(1):116-22.
  15. Muscle injuries of the lower leg. Counsel P, Breidahl W Semin Musculoskelet Radiol. 2010 Jun; 14(2):162-75.
  16. Ultrasound of skeletal muscle injury. Koh ES, McNally EG Semin Musculoskelet Radiol. 2007 Jun; 11(2):162-73.
  17. Bates DG. Dynamic ultrasound findings of bilateral anterior tibialis muscle herniation in a pediatric patient. Pediatr Radiol. 2001;31(10):753–755. doi: 10.1007/s002470100534.
  18. Nguyen JT, Nguyen JL, Wheatley MJ, Nguyen TA (2013) Muscle hernias of the leg: a case report and comprehensive review of the literature. Can J Plast Surg 21(4):243–247
  19. Sharma N, Kumar N, Verma R, Jhobta A (2017) Tibialis anterior muscle hernia: a case of chronic, dull pain and swelling in leg diagnosed by dynamic ultrasonography. Pol J Radiol 82:293–295
  20. Thierfelder, K. M., Gerhardt, J. S., Gemescu, I. N., Notohamiprodjo, S., Rehnitz, C., & Weber, M. A. (2019). Imaging of hip and thigh muscle injury: a pictorial review. Insights into imaging, 10(1), 20. https://doi.org/10.1186/s13244-019-0702-1
  21. Matar, H. E., Stritch, P., Connolly, S., & Emms, N. (2018). Calcific myonecrosis: diagnostic dilemma. Annals of the Royal College of Surgeons of England, 100(6), e158–e160. https://doi.org/10.1308/rcsann.2018.0077
  22. Ultrasound of skeletal muscle injury. Koh ES, McNally EG Semin Musculoskelet Radiol. 2007 Jun; 11(2):162-73.
  23. Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the national football league.  Tejwani SG, Cohen SB, Bradley JP Am J Sports Med. 2007 Jul; 35(7):1162-7.

Arthrogram

Hip and thigh, Knee and leg, Shoulder and arm / By

Johns Hopkins Medicine defines arthrography as an imaging method to assess joints, such as the shoulder, knee, and hip(1). This procedure may be performed if standard X-rays do not offer the necessary information about the joint’s anatomy and function. Arthrography may be indirect, in which contrast material is injected into the blood, or direct contrast …

Arthrogram Read More »

MRI of the Hip: Detailed Anatomy

This webpage presents the anatomical structures found on hip MRI. Magnetic resonance imaging (MRI) utilizes magnet and radio waves to produce diagnostic images that allow a doctor to visualize the hips. This medical imaging method can detect stress fractures or bone bruises that a regular X-ray usually misses. According to a study, MRI is the …

MRI of the Hip: Detailed Anatomy Read More »

Hip Radiography

This webpage presents the anatomical structures found on hip radiograph. Hip radiography, AP view. Hip radiography, “frog leg” lateral view. Hip radiography (or hip X-ray) uses a small amount of radiation to produce images of the hip joints, which attach the legs to the pelvis. A radiographic examination is the most basic and critical method …

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Pelvis Radiograph

Pelvis Radiograph

This webpage presents the anatomical structures found on pelvis radiograph. Radiographs or X-rays are one of the many diagnostic imaging modalities used to diagnose and evaluate pelvic disorders. In particular, X-rays are a basic tool for studying the hip and are always used in initial examinations of hip and pelvic issues(1). Anatomy of the Pelvis …

Pelvis Radiograph Read More »

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