DOI: 10.1148/rg.253045711
Hamstring Muscle Complex: An Imaging Review1
George Koulouris, FRANZCR and
David Connell, FRANZCR
1 From the Department of Radiology, The Alfred Hospital, Melbourne, Australia (G.K.); and the Department of Radiology, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, England (D.C.). Received May 13, 2004; revision requested June 23 and received October 12; accepted October 14. All authors have no financial relationships to disclose.
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Figure 1. Drawings illustrate the three muscles in the posterior compartment of the thigh that together constitute the HMC. The short head of the biceps femoris muscle is deep to the long head. The tendinous nature of the semitendinosus muscle inferiorly is appreciated, as is its raphe. The origin of the semimembranosus muscle is noted to be superolateral to the conjoint tendon.
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Figure 2a. Normal anatomy of the proximal HMC. (a) Axial magnetic resonance (MR) image obtained at the level of the ischial tuberosity (*) shows the conjoint tendon of the biceps femoris and semitendinosus muscles posteromedially (curved arrow), with the semimembranosus muscle anterolaterally (straight arrow). (b) Axial MR image obtained inferior to a at the level of the proximal third of the femur shows the belly of the semitendinosus muscle (solid arrow) and the semimembranosus tendon (arrowhead). Note the laterally placed muscle fibers of the adductor brevis (*). The low-signal-intensity adductor magnus tendon (open arrow) lies anterior to the conjoint tendon.
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Figure 2b. Normal anatomy of the proximal HMC. (a) Axial magnetic resonance (MR) image obtained at the level of the ischial tuberosity (*) shows the conjoint tendon of the biceps femoris and semitendinosus muscles posteromedially (curved arrow), with the semimembranosus muscle anterolaterally (straight arrow). (b) Axial MR image obtained inferior to a at the level of the proximal third of the femur shows the belly of the semitendinosus muscle (solid arrow) and the semimembranosus tendon (arrowhead). Note the laterally placed muscle fibers of the adductor brevis (*). The low-signal-intensity adductor magnus tendon (open arrow) lies anterior to the conjoint tendon.
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Figure 3. Avulsion injury in a 29-year-old athlete with a hyperextension injury and persistent disability. Oblique coronal MR image demonstrates a large hematoma (*) with retracted fibers of the semitendinosus muscle and the long head of the biceps femoris tendon (straight arrow), findings that are consistent with an avulsion injury. The semimembranosus muscle (curved arrow) remains intact.
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Figure 4a. Distal avulsion in a 44-year-old physical therapist who presented with acute distal posterior knee pain during rehabilitation following ACL reconstruction. (a) Coronal MR image shows avulsion of the semitendinosus tendon (arrow), with retraction of the muscle. The long head of the biceps femoris muscle is located laterally (*), with the semimembranosus muscle on the medial side. (b) Axial MR image shows absence of the normal uniformly low signal intensity of the semitendinosus muscle between the biceps femoris and semimembranosus muscles (arrow), a finding that is consistent with retraction.
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Figure 4b. Distal avulsion in a 44-year-old physical therapist who presented with acute distal posterior knee pain during rehabilitation following ACL reconstruction. (a) Coronal MR image shows avulsion of the semitendinosus tendon (arrow), with retraction of the muscle. The long head of the biceps femoris muscle is located laterally (*), with the semimembranosus muscle on the medial side. (b) Axial MR image shows absence of the normal uniformly low signal intensity of the semitendinosus muscle between the biceps femoris and semimembranosus muscles (arrow), a finding that is consistent with retraction.
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Figure 5a. (a–c) Chronic tendinopathy in a 29-year-old Olympic marathon runner who presented with a recent injury following a history of chronic posterior thigh pain. (a) MR image through the pelvis demonstrates thickening of the HMC origin with loss of the normal hypointensity of the tendons (straight arrow), findings that are compatible with repetitive microtears. A band of free fluid is also visualized (curved arrow). These findings are typical of partial tear set against a background of enthesopathy. Compare the normal morphologic features of the ischial tuberosity as shown in Figure 2a. (b) Sagittal (longitudinal) US image shows loss of the normal bright fibrillar echotexture of the muscle origin, which instead appears heterogeneous and thickened (straight arrow), findings that are consistent with enthesopathy. The low-echogenicity band deep to the tendon (curved arrow) is consistent with fluid and corresponds to the partial tear seen at MR imaging. * = ischial tuberosity. (c) US image demonstrates the normal appearance of the HMC (straight arrow), which inserts at the ischial tuberosity (*) and demonstrates uniform fibrillar echotexture. Superior to the ischial tuberosity, the HMC tendon blends with and continues as the sacrotuberous ligament (curved arrow). (d) Chronic tendinopathy in a different athlete. MR image shows ill-defined thickening of the HMC origin (arrow) with no discernible tear. There is no evidence of edema in the ischial tuberosity (*).
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Figure 5b. (a–c) Chronic tendinopathy in a 29-year-old Olympic marathon runner who presented with a recent injury following a history of chronic posterior thigh pain. (a) MR image through the pelvis demonstrates thickening of the HMC origin with loss of the normal hypointensity of the tendons (straight arrow), findings that are compatible with repetitive microtears. A band of free fluid is also visualized (curved arrow). These findings are typical of partial tear set against a background of enthesopathy. Compare the normal morphologic features of the ischial tuberosity as shown in Figure 2a. (b) Sagittal (longitudinal) US image shows loss of the normal bright fibrillar echotexture of the muscle origin, which instead appears heterogeneous and thickened (straight arrow), findings that are consistent with enthesopathy. The low-echogenicity band deep to the tendon (curved arrow) is consistent with fluid and corresponds to the partial tear seen at MR imaging. * = ischial tuberosity. (c) US image demonstrates the normal appearance of the HMC (straight arrow), which inserts at the ischial tuberosity (*) and demonstrates uniform fibrillar echotexture. Superior to the ischial tuberosity, the HMC tendon blends with and continues as the sacrotuberous ligament (curved arrow). (d) Chronic tendinopathy in a different athlete. MR image shows ill-defined thickening of the HMC origin (arrow) with no discernible tear. There is no evidence of edema in the ischial tuberosity (*).
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Figure 5c. (a–c) Chronic tendinopathy in a 29-year-old Olympic marathon runner who presented with a recent injury following a history of chronic posterior thigh pain. (a) MR image through the pelvis demonstrates thickening of the HMC origin with loss of the normal hypointensity of the tendons (straight arrow), findings that are compatible with repetitive microtears. A band of free fluid is also visualized (curved arrow). These findings are typical of partial tear set against a background of enthesopathy. Compare the normal morphologic features of the ischial tuberosity as shown in Figure 2a. (b) Sagittal (longitudinal) US image shows loss of the normal bright fibrillar echotexture of the muscle origin, which instead appears heterogeneous and thickened (straight arrow), findings that are consistent with enthesopathy. The low-echogenicity band deep to the tendon (curved arrow) is consistent with fluid and corresponds to the partial tear seen at MR imaging. * = ischial tuberosity. (c) US image demonstrates the normal appearance of the HMC (straight arrow), which inserts at the ischial tuberosity (*) and demonstrates uniform fibrillar echotexture. Superior to the ischial tuberosity, the HMC tendon blends with and continues as the sacrotuberous ligament (curved arrow). (d) Chronic tendinopathy in a different athlete. MR image shows ill-defined thickening of the HMC origin (arrow) with no discernible tear. There is no evidence of edema in the ischial tuberosity (*).
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Figure 5d. (a–c) Chronic tendinopathy in a 29-year-old Olympic marathon runner who presented with a recent injury following a history of chronic posterior thigh pain. (a) MR image through the pelvis demonstrates thickening of the HMC origin with loss of the normal hypointensity of the tendons (straight arrow), findings that are compatible with repetitive microtears. A band of free fluid is also visualized (curved arrow). These findings are typical of partial tear set against a background of enthesopathy. Compare the normal morphologic features of the ischial tuberosity as shown in Figure 2a. (b) Sagittal (longitudinal) US image shows loss of the normal bright fibrillar echotexture of the muscle origin, which instead appears heterogeneous and thickened (straight arrow), findings that are consistent with enthesopathy. The low-echogenicity band deep to the tendon (curved arrow) is consistent with fluid and corresponds to the partial tear seen at MR imaging. * = ischial tuberosity. (c) US image demonstrates the normal appearance of the HMC (straight arrow), which inserts at the ischial tuberosity (*) and demonstrates uniform fibrillar echotexture. Superior to the ischial tuberosity, the HMC tendon blends with and continues as the sacrotuberous ligament (curved arrow). (d) Chronic tendinopathy in a different athlete. MR image shows ill-defined thickening of the HMC origin (arrow) with no discernible tear. There is no evidence of edema in the ischial tuberosity (*).
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Figure 6a. MTJ strain in a 26-year-old professional football player who presented with recurring hamstring strains and prolonged rehabilitation periods. (a, b) Axial (a) and oblique coronal (b) MR images demonstrate hyperintensity (curved arrow) in the region of the MTJ of the biceps femoris muscle (long head) in keeping with myofibrillar disruption and retraction from the central tendon slip (straight arrow). Note the hyperintensity around the fascial sleeve. (c) Sagittal US image demonstrates an abnormality with mixed echogenicity that corresponds to the MR imaging findings. * = boundaries of the area of disruption.
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Figure 6b. MTJ strain in a 26-year-old professional football player who presented with recurring hamstring strains and prolonged rehabilitation periods. (a, b) Axial (a) and oblique coronal (b) MR images demonstrate hyperintensity (curved arrow) in the region of the MTJ of the biceps femoris muscle (long head) in keeping with myofibrillar disruption and retraction from the central tendon slip (straight arrow). Note the hyperintensity around the fascial sleeve. (c) Sagittal US image demonstrates an abnormality with mixed echogenicity that corresponds to the MR imaging findings. * = boundaries of the area of disruption.
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Figure 6c. MTJ strain in a 26-year-old professional football player who presented with recurring hamstring strains and prolonged rehabilitation periods. (a, b) Axial (a) and oblique coronal (b) MR images demonstrate hyperintensity (curved arrow) in the region of the MTJ of the biceps femoris muscle (long head) in keeping with myofibrillar disruption and retraction from the central tendon slip (straight arrow). Note the hyperintensity around the fascial sleeve. (c) Sagittal US image demonstrates an abnormality with mixed echogenicity that corresponds to the MR imaging findings. * = boundaries of the area of disruption.
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Figure 7a. Proximal MTJ strain in an elite athlete. Differentiation between muscle soreness following training and a small hamstring tear was difficult at clinical examination. (a, b) Axial (a) and coronal oblique (b) MR images demonstrate a small region of hyperintensity in the biceps femoris (curved arrow), a finding that is consistent with edema as a result of a subtle MTJ tear (straight arrow). (c) Corresponding transverse US image demonstrates a hypoechogenic area of edema (curved arrow) around the MTJ (straight arrow).
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Figure 7b. Proximal MTJ strain in an elite athlete. Differentiation between muscle soreness following training and a small hamstring tear was difficult at clinical examination. (a, b) Axial (a) and coronal oblique (b) MR images demonstrate a small region of hyperintensity in the biceps femoris (curved arrow), a finding that is consistent with edema as a result of a subtle MTJ tear (straight arrow). (c) Corresponding transverse US image demonstrates a hypoechogenic area of edema (curved arrow) around the MTJ (straight arrow).
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Figure 7c. Proximal MTJ strain in an elite athlete. Differentiation between muscle soreness following training and a small hamstring tear was difficult at clinical examination. (a, b) Axial (a) and coronal oblique (b) MR images demonstrate a small region of hyperintensity in the biceps femoris (curved arrow), a finding that is consistent with edema as a result of a subtle MTJ tear (straight arrow). (c) Corresponding transverse US image demonstrates a hypoechogenic area of edema (curved arrow) around the MTJ (straight arrow).
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Figure 8a. Distal MTJ strain in an athlete with posterior thigh pain who had experienced pain during sprinting. Longitudinal (a) and transverse (b) US images demonstrate a focal area of retraction (*), a finding that is consistent with a macroscopic tear in the distal MTJ of the semitendinosus.
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Figure 8b. Distal MTJ strain in an athlete with posterior thigh pain who had experienced pain during sprinting. Longitudinal (a) and transverse (b) US images demonstrate a focal area of retraction (*), a finding that is consistent with a macroscopic tear in the distal MTJ of the semitendinosus.
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Figure 9. Epimysial fascial strain in an elite athlete with a hamstring strain and evidence of a visible ecchymosis. Axial MR image shows an area of abnormal hyperintensity in the biceps femoris muscle (curved arrow), with subtle fluid-fluid levels predominantly in a myofascial distribution. There is relatively little involvement near the tendon (straight arrow). Hematoma and tearing resulted in disruption of the most superficial aspect of the muscle at the fascial boundary, accounting for the clinical findings.
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Figure 10a. Muscle belly injury. Axial proton-density–weighted (a) and coronal (b) MR images show an intramuscular hematoma in the biceps femoris muscle (arrow). The central location of the hematoma is unusual.
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Figure 10b. Muscle belly injury. Axial proton-density–weighted (a) and coronal (b) MR images show an intramuscular hematoma in the biceps femoris muscle (arrow). The central location of the hematoma is unusual.
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Figure 11a. Hematoma in an aerial skier who presented with persistent posterior thigh pain and swelling with focal posterolateral thigh tenderness after suffering a fall during training. Axial proton-density–weighted MR images obtained without (a) and with (b) fat saturation demonstrate a large hematoma of varying intensity (straight arrow) within the fascia of the thigh (curved arrow). The hematoma is located deep to the gluteus maximus muscle, which also contains an area of high signal intensity (*), a finding that is consistent with a contusion. However, the collection is superficial to the proximal hamstring tendons (double arrow) and the sciatic nerve (arrowhead), both of which appear normal.
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Figure 11b. Hematoma in an aerial skier who presented with persistent posterior thigh pain and swelling with focal posterolateral thigh tenderness after suffering a fall during training. Axial proton-density–weighted MR images obtained without (a) and with (b) fat saturation demonstrate a large hematoma of varying intensity (straight arrow) within the fascia of the thigh (curved arrow). The hematoma is located deep to the gluteus maximus muscle, which also contains an area of high signal intensity (*), a finding that is consistent with a contusion. However, the collection is superficial to the proximal hamstring tendons (double arrow) and the sciatic nerve (arrowhead), both of which appear normal.
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Figure 12. Retorn HMC in a 32-year-old football player with recurrent hamstring strain and a limited range of hip motion. MR image shows an area of hyperintensity (curved arrow) near the biceps femoris tendon (straight arrow), a finding that is consistent with an MTJ tear. However, an irregular area of low signal intensity deep within the muscle (arrowhead) is characteristic of scar tissue following a prior myofascial tear, which may have contributed to the decrease in hamstring flexibility, ultimately leading to tear. Recurrent tears at the site of prior scar tissue are uncommon owing to the greater strength of the fibrous tissue compared with the surrounding musculature.
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Copyright © 2005 by the Radiological Society of North America.
