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The Snapping Iliopsoas Tendon: New Mechanisms Using Dynamic Sonography

¹ All sauthors: Département de Radiologie, Centre Hospitalier Universitaire de Montréal (CHUM)–Hôpital Saint-Luc, 1058, rue Saint-Denis, Montréal, QC H2X 3J4, Canada.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Left hip iliopsoas tendon snapping over iliac muscle in 29-year-old man. Video recording of this case (Fig. S1E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. At rest, hyperechoic oval-shaped iliopsoas tendon (arrow) is located anterior to superior pubic ramus (SPR) and posterior to hypoechoic iliac muscle (m and arrowhead).

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Left hip iliopsoas tendon snapping over iliac muscle in 29-year-old man. Video recording of this case (Fig. S1E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. With flexion–abduction–external rotation of hip, iliopsoas tendon (arrow) rolls laterally and anteriorly over muscle (arrowhead), trapping it between tendon and superior pubic ramus (SPR).

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —Left hip iliopsoas tendon snapping over iliac muscle in 29-year-old man. Video recording of this case (Fig. S1E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. As hip is progressively brought back to neutral position, iliopsoas tendon (arrow) and trapped component of muscle (arrowhead) follow progressively reverse path (medially and posteriorly for tendon and laterally for muscle).

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —Left hip iliopsoas tendon snapping over iliac muscle in 29-year-old man. Video recording of this case (Fig. S1E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. At one point, muscle (arrowhead) is suddenly released laterally, allowing abrupt return of iliopsoas tendon (arrow) against superior pubic ramus (SPR), producing audible snap.

View larger version (8K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Diagrams illustrate snapping iliopsoas tendon from transverse oblique view above level of hip joint. As hip is flexed, abducted, and externally rotated, iliopsoas tendon (T) rolls laterally over part of iliac muscle (m) that becomes interposed between tendon and superior pubic ramus (SPR).

View larger version (8K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Diagrams illustrate snapping iliopsoas tendon from transverse oblique view above level of hip joint. As hip is brought back to neutral position, tendon (T) follows reverse path (medially and posteriorly) and part of its muscle (m) is trapped between its tendon and superior pubic ramus.

View larger version (7K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Diagrams illustrate snapping iliopsoas tendon from transverse oblique view above level of hip joint. At one point, muscle (m) is suddenly released laterally, allowing abrupt return of tendon (T) against pubic bone, producing audible snap.

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Right hip bifid iliopsoas tendon with medial and lateral heads snapping over one another in 13-year-old girl. Video recording of this case (Fig. S3E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. At rest, two heads of bifid iliopsoas tendon are located anterior to superior pubic ramus (SPR) and posterior to muscle (m). Hyperechoic medial head of one iliopsoas tendon (arrow) neighbors lateral head of second iliopsoas tendon (arrowhead), which shows less hyperechoic pattern than medial head due to anisotropy.

View larger version (68K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Right hip bifid iliopsoas tendon with medial and lateral heads snapping over one another in 13-year-old girl. Video recording of this case (Fig. S3E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. With flexion–abduction–external rotation of hip, medial head (arrow) of bifid iliopsoas tendon is flipping laterally over lateral head (arrowhead), producing first audible snap. SPR = superior pubic ramus.

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Right hip bifid iliopsoas tendon with medial and lateral heads snapping over one another in 13-year-old girl. Video recording of this case (Fig. S3E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. As hip is progressively brought back to neutral position, medial head (arrow) of iliopsoas tendon (now located laterally) follows reverse path medially, overlying lateral head (arrowhead) that maintained more medial position. SPR = superior pubic ramus.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —Right hip bifid iliopsoas tendon with medial and lateral heads snapping over one another in 13-year-old girl. Video recording of this case (Fig. S3E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. At one point, close to neutral position of hip, true medial head (arrow) is suddenly released over lateral head (arrowhead) against superior pubic ramus (SPR), producing second audible snap.

View larger version (9K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Diagrams illustrate bifid iliopsoas tendon snapping from transverse oblique view above level of right hip joint. m = iliac muscle, lh = lateral head of bifid iliopsoas tendon, mh = medial head of bifid iliopsoas tendon. In neutral position, medial head and lateral head of double iliopsoas tendons are overlying superior pubic ramus (SPR).

View larger version (8K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Diagrams illustrate bifid iliopsoas tendon snapping from transverse oblique view above level of right hip joint. m = iliac muscle, lh = lateral head of bifid iliopsoas tendon, mh = medial head of bifid iliopsoas tendon. As hip is flexed, abducted, and externally rotated, medial head of double tendon moves anteriorly and laterally to stable lateral head with rotation motion.

View larger version (9K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —Diagrams illustrate bifid iliopsoas tendon snapping from transverse oblique view above level of right hip joint. m = iliac muscle, lh = lateral head of bifid iliopsoas tendon, mh = medial head of bifid iliopsoas tendon. Then medial head of double psoas tendon abruptly flips over lateral head during hip motion, provoking snapping.

View larger version (9K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —Diagrams illustrate bifid iliopsoas tendon snapping from transverse oblique view above level of right hip joint. m = iliac muscle, lh = lateral head of bifid iliopsoas tendon, mh = medial head of bifid iliopsoas tendon. As hip is brought back to neutral position, medial head of iliopsoas tendon (now located laterally) follows reverse path.

View larger version (9K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4E —Diagrams illustrate bifid iliopsoas tendon snapping from transverse oblique view above level of right hip joint. m = iliac muscle, lh = lateral head of bifid iliopsoas tendon, mh = medial head of bifid iliopsoas tendon. Medial head of iliopsoas tendon flips abruptly over its lateral head and produces second snapping against pubic bone.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Right hip iliopsoas tendon snapping over paralabral cyst in 50-year-old woman ballet teacher. Video recording of this case (Fig. S5E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. At rest, hyperechoic iliopsoas tendon (arrow) is located anterior to superior pubic ramus (SPR) and medial to hypoechoic and heterogeneous paralabral cyst (arrowhead).

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Right hip iliopsoas tendon snapping over paralabral cyst in 50-year-old woman ballet teacher. Video recording of this case (Fig. S5E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. With full flexion–abduction–external rotation of hip, iliopsoas tendon (arrow) rolls laterally and anteriorly over cyst (arrowhead), snapping first time as it flips over cyst and contacts abruptly superior pubic ramus (SPR).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —Right hip iliopsoas tendon snapping over paralabral cyst in 50-year-old woman ballet teacher. Video recording of this case (Fig. S5E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. As hip is progressively brought back to neutral position, iliopsoas tendon (arrows) follows reverse path medially (C) until it flips again over cyst (D) and produces another snap on superior pubic ramus (SPR). Arrowheads point to cyst.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —Right hip iliopsoas tendon snapping over paralabral cyst in 50-year-old woman ballet teacher. Video recording of this case (Fig. S5E) can be seen in the AJR electronic supplement to this article, available at www.ajronline.org, and presents more detail than the images printed here. As hip is progressively brought back to neutral position, iliopsoas tendon (arrows) follows reverse path medially (C) until it flips again over cyst (D) and produces another snap on superior pubic ramus (SPR). Arrowheads point to cyst.

View larger version (45K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Diagrams illustrate iliopsoas tendon snapping over paralabral cyst. As hip is moved from neutral position to frogleg position, tendon moves laterally and flips abruptly over paralabral cyst, snapping against pubic bone.

View larger version (49K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Diagrams illustrate iliopsoas tendon snapping over paralabral cyst. As hip is brought back from frogleg position to neutral extended position, tendon moves medially, suddenly flipping over paralabral cyst for second time.

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