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A Visualization of the Hamstring Muscle Tendon Complex
PM R 8 (2016) 85-88
www.pmrjournal.org
Images
A Visualization of the Hamstring Muscle Tendon Complex Jack Porrino, MD, Hyojeong Mulcahy, MD, Felix S. Chew, MD Introduction and Anatomic Considerations The hamstring muscle complex (HMC) comprises 3 musclesdthe biceps femoris, semitendinosus, and semimembranosus. All 3 muscles originate in part from the ischial tuberosity. Specifically, the semimembranosus tendon arises from the anterolateral facet of the ischial tuberosity, whereas the conjoint tendon of the semitendinosus and the long head of the biceps femoris originate from the posteromedial facet (Figure 1A) [1]. In the more distal portions of the thigh, all 3 muscles/tendons are distinguishable (Figure 1B-G). The short head of the biceps femoris originates along the posterolateral linea aspera of the femoral diaphysis and lateral intermuscular septum and is the only component of the HMC that does not cross 2 joints. The short head of the biceps femoris merges with the long head, and the two collectively insert onto the fibular head, along with small contributions to the fibular collateral ligament and the lateral tibial plateau (Figure 1D-G) [2]. The semitendinosus and semimembranosus insert onto the posteromedial portion of the proximal tibia [2], with the semitendinosus contributing to the pes anserine muscle group.
being shot in the posterior thigh. They have pain with weight bearing and difficulty sitting because of discomfort at the ischial tuberosity. They may ambulate with a stiff-legged gait in an effort to avoid hip and knee flexion [2]. Grading Scale A grade 1 strain is characterized by overstretching of the muscle with microscopic injury but without perceptible muscle fiber disruption. A grade 2 strain is a macroscopic partial/incomplete tear, and a grade 3 strain is complete disruption of the muscle or tendon. Grade 3 strains are relatively rare [5]. Avulsion injuries, by definition, occur at tendon attachment sites to bone [6]. In children and adolescents, apophyseal avulsion injuries result from the same mechanism of injury that results in a myotendinous injury in a person with a mature skeleton [5]. The ischial tuberosity is the most common site of apophyseal avulsion, which typically occurs between the onset of puberty and age 25 years [7]. Avulsion injuries in adults usually occur without an osseous fragment and are more common at the proximal origin than at the distal insertion [8].
Clinical Background Mechanism Hamstring injuries are typically the result of sudden hip flexion with associated knee extension. Injuries most often occur at the myotendinous junction (where force is concentrated) while an eccentric load is applied to the muscle [3]. Hamstring strains are commonly encountered during running, jumping, hurdling, and kicking sports. Complete avulsions are most often seen in sprinters, football players, ice skaters, and water skiers [4]. Presentation Patients with acute hamstring injuries usually present with a history of pulling or popping and a sensation of
Imaging MRI In persons with an acute hamstring injury, imaging typically is performed to exclude proximal hamstring avulsion/grade 3 injury, which is often managed with prompt surgical repair if 2 or more muscles are involved. Magnetic resonance imaging (MRI) is largely considered the most accurate imaging modality for diagnosis of hamstring injuries, independent of the timing of the injury. MRI can confirm the clinical diagnosis of injury and provide information about the location, cross-sectional area, and extent of a tear. In addition, the longitudinal length of the strain, as measured with MRI, may be used as a predictor for the
1934-1482/$ - see front matter ª 2016 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.08.005
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Hamstring Muscle Tendon Complex
Figure 1. Normal hamstring muscle complex anatomy. Axial T1-weighted magnetic resonance images from the level of the left ischial tuberosity through the left knee (A-G) demonstrate the anatomy of the normal hamstring muscle complex. At the level of the ischial tuberosity (A) the semimembranosus tendon is situated anterolateral to the conjoint tendon (semitendinosus and biceps femoris). All 3 muscles/tendons become apparent in the more distal thigh (B-G), with the biceps femoris composed of a short and long head (E). The gracilis and sartorius muscles are noted for anatomic reference (C-G). B ¼ biceps femoris long head; Bs ¼ biceps femoris short head; C ¼ conjoint tendon; G ¼ gracilis; M ¼ semimembranosus; S ¼ sartorius; T ¼ semitendinosus.
Figure 2. A grade 1 hamstring injury. Axial T2-weighted fat-saturated (A) and coronal short tau inversion recovery (B) images demonstrate edema (open arrow) around and involving the abnormally thickened proximal right semimembranosus and conjoint tendons without disrupted fibers. Edema is also present within the right ischial tuberosity (closed arrow). Findings are consistent with a grade 1 injury.
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Figure 3. A grade 2 hamstring injury. Axial (A) and coronal (B) T2-weighted fat-saturated magnetic resonance images demonstrate edematous signal within the right semimembranosus tendon with partial fiber disruption (M with closed arrow). The origin of the right conjoint tendon is intact (C with open arrow). Findings are consistent with a grade 2 injury. C ¼ conjoint tendon; F ¼ femur; I ¼ ischial tuberosity; M ¼ semimembranosus.
amount of time needed until an athlete can return to competition [9]. A grade 1 injury manifests as abnormal T2-weighted hyperintense signal or edema around a tendon or muscle without visible disruption of fibers (Figure 2). Grade 2 injuries demonstrate abnormal T2-weighted hyperintense signal or edema within a tendon or muscle with partial fiber disruption (Figure 3). A grade 3 injury exhibits complete disruption of tendon or muscle fibers [10] (Figure 4). Ultrasound Ultrasound (US) can be used to evaluate the HMC, with the advantage of lower cost relative to MRI, portability, and absence of radiation [11]. Although the hamstring origin may be difficult to appreciate on US (especially in muscular athletes) because of the depth of the tendon and relatively poor acoustic window afforded by a large gluteus maximus muscle [12], some investigators have demonstrated that US can be as clinically useful as MRI in the assessment of acute HMC
injury [9]. In persons with a history of HMC injury, US should be used with caution to assess a new injury, because residual scarring may lead to misdiagnosis [9]. US-guided aspiration of a large hematoma may be beneficial to hasten recovery [13]. With a grade 1 injury, edema or hemorrhage appears as an area of hyper- or hypoechogenicity within or around the normally echogenic tendon [9,13]. Grade 2 and 3 injuries show variable degrees of disrupted muscle or tendon fibers as an interruption of the normal monotonous muscle or tendon (Figure 5). A hematoma is usually hyperechoic when acute, and with time and evolution of blood products, it becomes hypoechoic [13]. Conclusion The HMC comprises a group of 3 muscles that occupy the posterior thigh, arise in part from the ischial tuberosity, and insert about the knee. The complex anatomy of this muscle group accounts for the variable degrees of injury severity, which can be evaluated with
Figure 4. A grade 3 hamstring injury. Axial T2-weighted fat-saturated (A) and coronal short tau inversion recovery (B) images demonstrate complete avulsion of the left proximal hamstring tendon with retraction. The gap is filled with a fluid collection consistent with hematoma (arrows). F ¼ femur; I ¼ ischial tuberosity.
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Hamstring Muscle Tendon Complex
Figure 5. A grade 3 hamstring injury. A longitudinal ultrasound image at the level of the left ischial tuberosity demonstrates a 3-cm interval (crosshairs) separating the ischial tuberosity and the avulsed proximal hamstring tendon (arrow). I ¼ ischial tuberosity.
either MRI or US in effort to establish an appropriate management strategy. References 1. Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. A cadaveric study. J Bone Joint Surg Am 2007;89:44-48. 2. Ali K, Leland JM. Hamstring strains and tears in the athlete. Clin Sports Med 2012;31:263-272. 3. Clanton TO, Coupe KJ. Hamstring strains in athletes: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-248. 4. Ropiak CR, Bosco JA. Hamstring injuries. Bull NYU Hosp Jt Dis 2012; 70:41-48. 5. Shelly MJ, Hodnett PA, MacMahon PJ, Moynagh MR, Kavanagh EC, Eustace SJ. MR imaging of muscle injury. Magn Reson Imaging Clin N Am 2009;17:757-773, vii. 6. Nelson EN, Kassarjian A, Palmer WE. MR imaging of sports-related groin pain. Magn Reson Imaging Clin N Am 2005;13:727-742.
7. Micheli LJ, Fehlandt AF Jr. Overuse injuries to tendons and apophyses in children and adolescents. Clin Sports Med 1992;11: 713-726. 8. Orava S, Kujala UM. Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705. 9. Mariani C, Caldera FE, Kim W. Ultrasound versus magnetic resonance imaging in the diagnosis of an acute hamstring tear. PM R 2012;4:154-155. 10. Linklater JM, Hamilton B, Carmichael J, Orchard J, Wood DG. Hamstring injuries: Anatomy, imaging, and intervention. Semin Musculoskelet Radiol 2010;14:131-161. 11. Koulouris G, Connell D. Imaging of hamstring injuries: Therapeutic implications. Eur Radiol 2006;16:1478-1487. 12. Cohen SB, Towers JD, Zoga A, et al. Hamstring injuries in professional football players: Magnetic resonance imaging correlation with return to play. Sports Health 2011;3:423-430. 13. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol 2004;183: 975-984.
Disclosure J.P. Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105. Address correspondence to: J.P.; e-mail: [email protected] Disclosure: nothing to disclose
F.S.C. Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105 Disclosure: nothing to disclose
H.M. Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105 Disclosure: nothing to disclose
Submitted for publication August 14, 2015; accepted August 15, 2015.
www.pmrjournal.org
Images
A Visualization of the Hamstring Muscle Tendon Complex Jack Porrino, MD, Hyojeong Mulcahy, MD, Felix S. Chew, MD Introduction and Anatomic Considerations The hamstring muscle complex (HMC) comprises 3 musclesdthe biceps femoris, semitendinosus, and semimembranosus. All 3 muscles originate in part from the ischial tuberosity. Specifically, the semimembranosus tendon arises from the anterolateral facet of the ischial tuberosity, whereas the conjoint tendon of the semitendinosus and the long head of the biceps femoris originate from the posteromedial facet (Figure 1A) [1]. In the more distal portions of the thigh, all 3 muscles/tendons are distinguishable (Figure 1B-G). The short head of the biceps femoris originates along the posterolateral linea aspera of the femoral diaphysis and lateral intermuscular septum and is the only component of the HMC that does not cross 2 joints. The short head of the biceps femoris merges with the long head, and the two collectively insert onto the fibular head, along with small contributions to the fibular collateral ligament and the lateral tibial plateau (Figure 1D-G) [2]. The semitendinosus and semimembranosus insert onto the posteromedial portion of the proximal tibia [2], with the semitendinosus contributing to the pes anserine muscle group.
being shot in the posterior thigh. They have pain with weight bearing and difficulty sitting because of discomfort at the ischial tuberosity. They may ambulate with a stiff-legged gait in an effort to avoid hip and knee flexion [2]. Grading Scale A grade 1 strain is characterized by overstretching of the muscle with microscopic injury but without perceptible muscle fiber disruption. A grade 2 strain is a macroscopic partial/incomplete tear, and a grade 3 strain is complete disruption of the muscle or tendon. Grade 3 strains are relatively rare [5]. Avulsion injuries, by definition, occur at tendon attachment sites to bone [6]. In children and adolescents, apophyseal avulsion injuries result from the same mechanism of injury that results in a myotendinous injury in a person with a mature skeleton [5]. The ischial tuberosity is the most common site of apophyseal avulsion, which typically occurs between the onset of puberty and age 25 years [7]. Avulsion injuries in adults usually occur without an osseous fragment and are more common at the proximal origin than at the distal insertion [8].
Clinical Background Mechanism Hamstring injuries are typically the result of sudden hip flexion with associated knee extension. Injuries most often occur at the myotendinous junction (where force is concentrated) while an eccentric load is applied to the muscle [3]. Hamstring strains are commonly encountered during running, jumping, hurdling, and kicking sports. Complete avulsions are most often seen in sprinters, football players, ice skaters, and water skiers [4]. Presentation Patients with acute hamstring injuries usually present with a history of pulling or popping and a sensation of
Imaging MRI In persons with an acute hamstring injury, imaging typically is performed to exclude proximal hamstring avulsion/grade 3 injury, which is often managed with prompt surgical repair if 2 or more muscles are involved. Magnetic resonance imaging (MRI) is largely considered the most accurate imaging modality for diagnosis of hamstring injuries, independent of the timing of the injury. MRI can confirm the clinical diagnosis of injury and provide information about the location, cross-sectional area, and extent of a tear. In addition, the longitudinal length of the strain, as measured with MRI, may be used as a predictor for the
1934-1482/$ - see front matter ª 2016 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.08.005
86
Hamstring Muscle Tendon Complex
Figure 1. Normal hamstring muscle complex anatomy. Axial T1-weighted magnetic resonance images from the level of the left ischial tuberosity through the left knee (A-G) demonstrate the anatomy of the normal hamstring muscle complex. At the level of the ischial tuberosity (A) the semimembranosus tendon is situated anterolateral to the conjoint tendon (semitendinosus and biceps femoris). All 3 muscles/tendons become apparent in the more distal thigh (B-G), with the biceps femoris composed of a short and long head (E). The gracilis and sartorius muscles are noted for anatomic reference (C-G). B ¼ biceps femoris long head; Bs ¼ biceps femoris short head; C ¼ conjoint tendon; G ¼ gracilis; M ¼ semimembranosus; S ¼ sartorius; T ¼ semitendinosus.
Figure 2. A grade 1 hamstring injury. Axial T2-weighted fat-saturated (A) and coronal short tau inversion recovery (B) images demonstrate edema (open arrow) around and involving the abnormally thickened proximal right semimembranosus and conjoint tendons without disrupted fibers. Edema is also present within the right ischial tuberosity (closed arrow). Findings are consistent with a grade 1 injury.
J. Porrino et al. / PM R 8 (2016) 85-88
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Figure 3. A grade 2 hamstring injury. Axial (A) and coronal (B) T2-weighted fat-saturated magnetic resonance images demonstrate edematous signal within the right semimembranosus tendon with partial fiber disruption (M with closed arrow). The origin of the right conjoint tendon is intact (C with open arrow). Findings are consistent with a grade 2 injury. C ¼ conjoint tendon; F ¼ femur; I ¼ ischial tuberosity; M ¼ semimembranosus.
amount of time needed until an athlete can return to competition [9]. A grade 1 injury manifests as abnormal T2-weighted hyperintense signal or edema around a tendon or muscle without visible disruption of fibers (Figure 2). Grade 2 injuries demonstrate abnormal T2-weighted hyperintense signal or edema within a tendon or muscle with partial fiber disruption (Figure 3). A grade 3 injury exhibits complete disruption of tendon or muscle fibers [10] (Figure 4). Ultrasound Ultrasound (US) can be used to evaluate the HMC, with the advantage of lower cost relative to MRI, portability, and absence of radiation [11]. Although the hamstring origin may be difficult to appreciate on US (especially in muscular athletes) because of the depth of the tendon and relatively poor acoustic window afforded by a large gluteus maximus muscle [12], some investigators have demonstrated that US can be as clinically useful as MRI in the assessment of acute HMC
injury [9]. In persons with a history of HMC injury, US should be used with caution to assess a new injury, because residual scarring may lead to misdiagnosis [9]. US-guided aspiration of a large hematoma may be beneficial to hasten recovery [13]. With a grade 1 injury, edema or hemorrhage appears as an area of hyper- or hypoechogenicity within or around the normally echogenic tendon [9,13]. Grade 2 and 3 injuries show variable degrees of disrupted muscle or tendon fibers as an interruption of the normal monotonous muscle or tendon (Figure 5). A hematoma is usually hyperechoic when acute, and with time and evolution of blood products, it becomes hypoechoic [13]. Conclusion The HMC comprises a group of 3 muscles that occupy the posterior thigh, arise in part from the ischial tuberosity, and insert about the knee. The complex anatomy of this muscle group accounts for the variable degrees of injury severity, which can be evaluated with
Figure 4. A grade 3 hamstring injury. Axial T2-weighted fat-saturated (A) and coronal short tau inversion recovery (B) images demonstrate complete avulsion of the left proximal hamstring tendon with retraction. The gap is filled with a fluid collection consistent with hematoma (arrows). F ¼ femur; I ¼ ischial tuberosity.
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Hamstring Muscle Tendon Complex
Figure 5. A grade 3 hamstring injury. A longitudinal ultrasound image at the level of the left ischial tuberosity demonstrates a 3-cm interval (crosshairs) separating the ischial tuberosity and the avulsed proximal hamstring tendon (arrow). I ¼ ischial tuberosity.
either MRI or US in effort to establish an appropriate management strategy. References 1. Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. A cadaveric study. J Bone Joint Surg Am 2007;89:44-48. 2. Ali K, Leland JM. Hamstring strains and tears in the athlete. Clin Sports Med 2012;31:263-272. 3. Clanton TO, Coupe KJ. Hamstring strains in athletes: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-248. 4. Ropiak CR, Bosco JA. Hamstring injuries. Bull NYU Hosp Jt Dis 2012; 70:41-48. 5. Shelly MJ, Hodnett PA, MacMahon PJ, Moynagh MR, Kavanagh EC, Eustace SJ. MR imaging of muscle injury. Magn Reson Imaging Clin N Am 2009;17:757-773, vii. 6. Nelson EN, Kassarjian A, Palmer WE. MR imaging of sports-related groin pain. Magn Reson Imaging Clin N Am 2005;13:727-742.
7. Micheli LJ, Fehlandt AF Jr. Overuse injuries to tendons and apophyses in children and adolescents. Clin Sports Med 1992;11: 713-726. 8. Orava S, Kujala UM. Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705. 9. Mariani C, Caldera FE, Kim W. Ultrasound versus magnetic resonance imaging in the diagnosis of an acute hamstring tear. PM R 2012;4:154-155. 10. Linklater JM, Hamilton B, Carmichael J, Orchard J, Wood DG. Hamstring injuries: Anatomy, imaging, and intervention. Semin Musculoskelet Radiol 2010;14:131-161. 11. Koulouris G, Connell D. Imaging of hamstring injuries: Therapeutic implications. Eur Radiol 2006;16:1478-1487. 12. Cohen SB, Towers JD, Zoga A, et al. Hamstring injuries in professional football players: Magnetic resonance imaging correlation with return to play. Sports Health 2011;3:423-430. 13. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol 2004;183: 975-984.
Disclosure J.P. Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105. Address correspondence to: J.P.; e-mail: [email protected] Disclosure: nothing to disclose
F.S.C. Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105 Disclosure: nothing to disclose
H.M. Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way NE, Seattle, WA 98105 Disclosure: nothing to disclose
Submitted for publication August 14, 2015; accepted August 15, 2015.