PICTORIAL ESSAY

Ultrasound Features of the Proximal

Hamstring Muscle-Tendon-Bone Unit
Marco Becciolini, MD , Giovanni Bonacchi, MD, Stefano Bianchi, MD

The hamstring muscle complex is made by a group of posterior biarticular thigh

muscles, originating at the ischial tuberosity, which extend the hip and flex the
knee joint. Proximal hamstring injuries are frequent among athletes, commonly
involving their long myotendinous junction during an eccentric contraction. In
this pictorial essay, we describe the ultrasound technique to visualize the normal
anatomy of the proximal hamstring muscle-tendon-bone complex and present
ultrasound findings in patients with traumatic injuries and tendinopathies.
Key Words—athlete injury; biceps femoris; hamstring; musculoskeletal;
myotendinous injury; tendinopathy; thigh muscles; ultrasound

T he hamstring muscle complex comprises a group of posterior

biarticular thigh muscles, originating at the ischial tuberosity:
the long head of the biceps femoris, semimembranosus, and
semitendinosus. These muscles extend the hip and flex the knee joint.1
Proximal hamstring muscle complex injuries are the most frequent
among athletes, commonly involving the proximal myotendinous
junction during an eccentric contraction.2,3 So far, magnetic resonance
imaging (MRI) has been considered as the modality of choice to
evaluate tendinopathy and injuries.3–6 In this pictorial essay, our aims
are to describe the ultrasound (US) technique for visualizing the
proximal hamstring muscle complex and to illustrate US findings in
patients with traumatic injuries and tendinopathies.
This human study was performed in accordance with the Dec-
laration of Helsinki. The study was approved by the Cabinet Ima-
gerie Médicale. All parents, guardians, or next of kin provided
written informed consent for the minors to participate in the
study. All adult participants provided written informed consent to
participate in the study.
Received June 13, 2018, from the Misericordia
di Pistoia, Pistoia, Italy (M.B., G.B.); Cabinet
Imagerie Médicale, Geneva, Switzerland
(S.B.). Manuscript accepted for publication
Ultrasound Anatomy
July 13, 2018.
Technical Considerations
Address correspondence to Marco Becciolini, A linear transducer with frequencies between 5 and 14 MHz is
MD, Misericordia di Pistoia, Via Bonellina
required. For a larger body habitus, the use of a lower-frequency
1, 51100 Pistoia, Italy.
transducer might be helpful.7–9 The patient lies prone with the hip
E-mail: [email protected] and the knee in a neutral position; flexion of the hip using a pillow
may be used to avoid artifacts produced by the gluteal fold.8
Abbreviations
MRI, magnetic resonance imaging; US,
ultrasound Scanning Technique
The examination begins with axial US scans at the level of the
doi:10.1002/jum.14804 ischial tuberosity, which can be palpated, being a good anatomic

© 2018 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2018; 00:1–16 | 0278-4297 | www.aium.org
Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

landmark. The long head of the biceps femoris and which is present when a tendon is not scanned per-
the semitendinosus muscle originate from a conjoint pendicularly, for tendinopathy.12,13 This action is
tendon at the medial and posterior aspects of the needed because the conjoint and semimembranosus
ischial tuberosity, whereas the semimembranosus tendons have different courses so that in a US scan,
tendon has a more lateral and anterior origin one can appear hypoechoic to the other; in doubtful
(Figure 1A).1,9 To improve image quality, we sug- and subtle cases, a comparison with the opposite
gest using a slight lateral approach (Figure 1, A and side is advised. Lateral to the hamstring muscle com-
B), and the patient should be informed that the plex tendon, the sciatic nerve, a fascicular and flat-
transducer may have to be pressed hardly; this tened structure, can be easily shown: it descends
maneuver is also recommended in symptomatic between and deep to the long head of the biceps
patients to reproduce pain: so-called sonopalpa- femoris and the semimembranosus tendon, superfi-
tion.10,11 The examiner should remember to slowly cial to the adductor magnus muscle.14 A smaller
tilt the transducer to avoid mistaking anisotropy, nerve departing from the sciatic nerve, the posterior

Figure 1. Hamstring muscle complex origin anatomy. A–C, Proximal-to-distal axial US scans (left), as described in the US anatomy part of
the article, with MRI comparison (right); amt indicates adductor magnus tendon; ct, conjoint tendon; gm, gluteus maximus; it, ischial tuber-
osity; smt, semimembranosus tendon; sn, sciatic nerve; and st, semitendinosus muscle.

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Figure 2. Axial color Doppler US scan at the level of the ischial tuberosity (it) in a healthy 22-year-old man. In this slender volunteer, US is able
to show a small branch of the inferior gluteal artery (a), interposed between the sciatic nerve (sn) and a small honeycomb structure (arrows),
consistent with the posterior femoral cutaneous nerve. Note the close relationship of the nerve and the proximal tendons of the hamstring mus-
cle complex, which can explain its irritation in proximal hamstring tendinopathy. The semimembranosus tendon (smt) in this view appears
slightly hypoechoic because of anisotropy; ct indicates conjoint tendon; and gm, gluteus maximus.

Figure 3. Proximal anatomy of the hamstring muscle complex. A–C, Proximal-to-distal axial US scans (left), as described in the US anatomy
part of the article, with MRI comparison (right). Dashed lines in A indicate the Cohen triangle; am, adductor magnus muscle; arrowhead,
semimembranosus membrane; arrows, semitendinosus raphe; ct, conjoint tendon; lbf, long head of biceps muscle; sm, semimembranosus
muscle; smt, semimembranosus tendon; sn, sciatic nerve; and st, semitendinosus muscle.
Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

femoral cutaneous nerve, may be sometimes (Figure 2); it distally passes superficial to the long
depicted as well in healthy and slender patients, head of the biceps femoris and gradually surfaces up
accompanied by the inferior gluteal artery to the cutaneous layer.15,16

Figure 4. Images from a 10-year-old boy who had sudden posterior pain while playing soccer. A and B, Axial and sagittal US scans
obtained 4 days later. The cortical surface of the ischial tuberosity (it) of the affected side (left) appears irregular (arrows), and the hamstring
muscle complex proximal origin (asterisks) looks swollen compared with the healthy side (right). Ultrasound palpation was painful. Clinical
and US findings are compatible with a minimal apophyseal injury without tendon displacement. The patient was treated conservatively with
a good outcome; ct indicates conjoint tendon; gm, gluteus maximus; and smt, semimembranosus tendon.

Figure 5. Images from a 20-year-old man evaluated for chronic pain at the level of the left ischial tuberosity (it). Comparative longitudinal
US scans depict a large calcification casting an acoustic shadow (arrow). The finding is consistent with a previous avulsion, as referred by
the patient who recalled a hamstring muscle complex origin injury at the age of 12 years; ct indicates conjoint tendon; gm, gluteus maximus;
and smt, semimembranosus tendon.

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 Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

The examination continues with axial caudal US to descend between the semitendinosus muscle and
scans. At the distal medial tip of the ischial tuberosity, the adductor magnus muscle, giving a “membrane”
another tendon originates: the adductor magnus, medially from which the first muscular fascicle of the
which also has a wider pubofemoral insertion; because semimembranosus muscle originates. At this level, a
of this anatomy, it is also called the “mini-hamstring” sigmoid raphe inside the semitendinosus muscle, which
(Figure 1B).17 Below the ischial tuberosity, the semi- travels the muscle from proximal-medial to distal-lat-
tendinosus muscle is the first to appear, medially to the eral, is another key anatomic landmark for a US evalua-
conjoint tendon; at this level, the semimembranosus tion of the hamstring muscle complex (Figure 3B).8 At
tendon starts to travel medially (Figure 1C). Caudally, the middle third of the thigh, the semimembranosus
the second muscle to appear is the long head of the tendon reaches the muscle (Figure 3C); its total length
biceps femoris; here, a good anatomic landmark, the according to van der Made et al1 is 24.3 ± 3.9 cm with
Cohen triangle,8 is composed of the aponeurosis of the a myotendinous junction of 14.9 cm. Usually just
conjoint tendon, the sciatic nerve, and the semimem- below this level, the long head of the biceps femoris,
branosus tendon (Figure 3A). Considering the con- the semitendinosus muscle, and the semimembranosus
joint tendon, according to a dissection study on muscle belly have a similar size.8 Anatomic variations,
56 hamstring muscle complexes by van der Made such as the absence of the semimembranosus muscle,
et al,1 the total length of the semitendinosus tendon is or a separate origin of the long head of the biceps
12.3 ± 3.6 cm with a myotendinous junction of femoris and semitendinosus tendons, have been
12.2 cm, whereas the long head of the biceps femoris reported.2 We perform longitudinal-axis scans of the
tendon is 19.6 ± 4.1cm with a myotendinous junction hamstring muscle complex in cases of disorders to con-
of 14.6 cm. The semimembranosus tendon continues firm it and to show its craniocaudal involvement.

Figure 6. Posttraumatic tendinopathy related to a partial-thickness tear with remodeling of the hamstring muscle complex origin in a 35-year-
old soccer player, evaluated 2 months after an indirect trauma for persistent pain. A and C, Axial and sagittal US scans (left) of the left ischial
tuberosity (it) show a swollen and inhomogeneous (arrows) conjoint tendon (ct) and semimembranosus tendon (smt) compared with the
healthy contralateral side (right). B and D, Corresponding MRI (B, axial; D, coronal); gm indicates gluteus maximus; and sn, sciatic nerve.

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Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

Limitations of US Ultrasound Findings

Ultrasound has some limitations in evaluations of
the posterior thigh in older and obese patients Apophyseal Injuries
because of muscular fatty degeneration and The weakest part of the hamstring bone-tendon-
increased thickness of the subcutaneous fat,7,8 espe- muscle unit is linked to the patient’s age2: in children,
cially at the level of the ischial tuberosity region; in it is the apophyseal region of the ischial tuberosity;
these patients, it may be helpful to search for the therefore, injuries may lead to an avulsion of a bony
other described anatomic landmarks (eg, Cohen tri- fragment, which can be assessed by radiography.
angle and semitendinosus raphe) and then to move Ultrasound is able to confirm the injury, depicting the
the transducer cranially to the ischial tuberosity. avulsed fragment as well as the retracted tendon.18
The distal course of the hamstring muscle complex Ultrasound is particularly helpful in mild cases, in
goes beyond the purpose of this pictorial essay, as which the apophysis is nondisplaced, by showing
well as the anatomy of the short head of the biceps irregularities in the ischial tuberosity and cartilage
femoris. compared with the contralateral side (Figure 4).19

Figure 7. Partial tear of the semimembranosus tendon (smt) in a 28-year-old soccer player with tendinopathy. A, Long-axis view of the hamstring
muscle complex proximal tendon (right) compared with the healthy contralateral side (left) shows a tear in the right semimembranosus tendon (smt),
highlighted by a hypoechoic-to-anechoic area related to edema or blood products (asterisks); the conjoint tendon (ct) is also swollen and heteroge-
neous, reflecting tendinopathy. B, Axial view of the right hamstring muscle complex proximal tendon confirms the findings; gm indicates gluteus
maximus; and it, ischial tuberosity.

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 Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

Magnetic resonance imaging should be performed in Tendinopathies

doubtful cases and, as in the case of a complete ten- Tendinopathies may be found in young adults and
don rupture, when there is a retraction and surgery is are usually related to trauma with microtears
an option.2,5,8 Chronic avulsion injuries may result in (Figure 6), which may lead to partial or complete
posttraumatic heterotopic ossification (Figure 5).18 tears (Figure 7); however, tendon injuries are more

Figure 8. Subcomplete tear of the hamstring muscle complex proximal tendons in a 75-year-old patient with tendinosis. The patient was
referred for sudden pain 3 days previously after falling while gardening on uneven ground. A, Axial US scan at the level of the ischial tuber-
osity (it). The conjoint tendon (ct) and semimembranosus tendon (smt) show fiber disruption associated with a hypoechoic-to-anechoic
area of edema or blood products (asterisk) highlighting the tear. B, Corresponding long-axis view of the hamstring muscle complex origin;
am indicates adductor magnus; and gm, gluteus maximus.

Figure 9. Complete avulsion of the hamstring muscle complex origin tendons, which are retracted distally, in a 68-year-old patient who fell
while walking downstairs and was referred for a snap below the buttock. A US examination was done 5 days later. A and B, Longitudinal
and axial US scans at the level of the ischial tuberosity (it) show the retracted proximal tendons. The retraction is measured (between cali-
pers); am indicates adductor magnus muscle; asterisks, hematoma; ct, conjoint tendon; gm, gluteus maximus; lbf, long head of the biceps
muscle; and smt, semimembranosus tendon. C, Note clinically how the hematoma has spread distally.

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Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

frequent in older adults because of tendon degenera- tendinopathy, commonly seen in athletes. Hamstring
tion (Figure 8).2,3 When a complete avulsion is syndrome may be associated with sciatic involvement.
shown, the distance between the ischial tuberosity Pain with sitting may be also related to posterior fem-
and the retracted tendon should be reported oral cutaneous nerve entrapment because of its closer
(Figure 9); surgery may be considered if there is dis- proximity to the hamstring muscle complex proximal
placement of greater than 2 cm.3 In tendinosis, the tendons, as this sensory nerve provides the innerva-
tendon loses its normal fibrillar pattern, becoming tion for the inferolateral gluteal region and posterior
thickened and hypoechoic on a US evaluation. Ultra- aspect of the thigh, the superomedial perineal region,
sound findings are similar in patients with a chronic and the skin at the popliteal fossa.14,16,22
partial tear, as it may coexist (Figure 6).13,20 Ham- Painful snapping of the hip, also called coxa salt-
string syndrome is a clinical entity described by Pura- ans, might be subsequent to proximal hamstring mus-
nen and Orava21 as pain in the lower gluteal area with cle complex injury and tendinopathy, caused by
caudal irradiation to the posterior thigh, which is subluxation of the conjoint tendon over the ischial
related to hamstring muscle complex proximal tuberosity. Dynamic US has been shown to be capa-
ble of depicting this kind of snapping during hip
flexion.23
Figure 10. Images from a 25-year-old soccer player evaluated for The examiner should keep in mind that tendino-
mild chronic pain at the proximal posterior thigh distal to the ischial pathy may affect only a tract, possibly the intramuscu-
tuberosity. The patient did not recall a hamstring injury. A and B, lar distal part of the tendons, leading to nonspecific
Transverse and sagittal US scans (left) at the proximal posterior
thigh show slight thickening of the distal part of the conjoint ten-
posterior thigh pain, and therefore should check the
don (between calipers) at the level of the myotendinous junction, tendons in their whole course with axial US scans:
without fissurations, compared with the healthy contralateral side only a systematic and comparative evaluation allows
(right). The conjoint tendon at the ischial tuberosity appeared nor- the diagnosis necessary for the athlete to plan rehabil-
mal (not shown); am indicates adductor magnus muscle; lbf, long
head of the biceps muscle; sn, sciatic nerve; and st, semitendino-
itation and avoid injuries (Figures 10 and 11).
sus muscle. Calcifications related to tendinopathy and chronic
injuries may also involve the hamstring muscle com-
plex tendons (Figure 12).6 Calcific tendinopathy, due
to deposition of calcium hydroxyapatite crystals within
the tendons, which is common in the rotator cuff, has
also been described at the level of the proximal ham-
string muscle complex tendons (Figure 13) and may
be the cause of atraumatic acute ischial pain, likely dur-
ing the resorptive phase.9,24

Myotendinous Junction and Proximal Muscle

Injuries
In young athletes, the weakest point of the hamstring
muscle complex is represented by the myotendinous
junction; in these patients, a powerful eccentric con-
traction with the hip and the knee on extension may
cause a partial (Figures 14 and 15) or a complete
(Figure 16) tear. These injuries are frequent in water
skiers and football players.2–4,8 Clinically, the patients
recall sudden onset of pain after specific indirect
trauma. A US examination should be performed at
least 48 hours after the trauma; otherwise, the mas-
sive soft tissue edema/blood products may produce
architectural distortion, which makes a detailed

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 Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

evaluation difficult.25 Ultrasound findings include a diffuse or focal hyperechogenicity and an increased
poorly defined hyperechoic or heterogeneous area size of the involved muscle(s), likely correlated with
with or without muscular architectural alterations, the edema, which can be shown by MRI (Figure 17).2,8,26
presence of an anechoic hematoma, and a complete Color Doppler imaging is widely used to assess
tear with muscular retraction, which can be confirmed tendinopathy20; however, in our practice, we find it
by dynamic imaging during muscle contraction.8,25 not effective for evaluation of proximal hamstring
Myotendinous junction tear classification is not pre- muscle complex tendons because of their deep
sented in this pictorial essay. Delayed-onset muscle course: the needed transducer pressure will artificially
soreness refers to a benign condition in which symp- hide neovascularity present in tendinosis. Instead, we
toms (muscular tenderness, soreness, or stiffness) find that it has an important role in follow-up of myo-
develop approximately 24 to 48 hours after strenuous tendinous junction tears, in which the disappearance
exercise, with a peak at 2 or 3 days and resolution of hyperemia indicates a subacute-to-chronic phase of
usually within 7 to 10 days. Ultrasound may depict injury (Figure 18).8,25

Figure 11. Images from a 42-year-old amateur marathoner referred for chronic posterior discomfort at the middle third of the thigh, which
worsened during a sprint. A US examination performed at 1 week. A and B, Transverse and sagittal US scans (right) depict tendinopathy of
the distal part of the semimembranosus tendon (smt) and membrane (arrowheads), with fissurations (asterisks) related to partial tear, com-
pared with the healthy contralateral side (left). C, Panoramic view of the semimembranosus tendon shows that the tendon is involved dis-
tally, whereas proximally it shows a normal thickness; am indicates adductor magnus muscle; arrows, semitendinosus raphe; sm,
semimembranosus muscle; and st, semitendinosus muscle.

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Figure 12. Images from a 24-year-old athlete referred for indirect trauma at the posterior thigh during a sprint. A, Transverse US scan at
15 days depicts the tear, involving the myotendinous junction of the long head of the biceps femoris (lbf ) as well as the intramuscular part
of the conjoint tendon (ct). A small hematoma is shown (asterisk). B, Corresponding sagittal US scan confirms the injury. C and D, Trans-
verse and sagittal US scans obtained during follow-up at 2 months show the disappearance of the hematoma; the conjoint tendon is thick-
ened and hypoechoic; along its course, a calcification (arrowheads) with a faint acoustic shadow can be seen as an outcome of the
trauma; sn indicates, sciatic nerve; and st, semitendinosus muscle.

Figure 13. Calcific tendinopathy of the hamstring muscle complex origin tendons and the adductor magnus tendon (amt) in a 58-year-old
woman presenting for acute posterior hip pain in the absence of a trauma. A, axial US scan at the level of the ischial tuberosity (it) shows
calcific deposits (arrows) in part with a faint acoustic shadow and in part “slurry.” Symptoms were likely related to the colliquation of the cal-
cification with resultant local inflammatory changes. Dashed lines in A indicate the sagittal US planes in B and C; ct, conjoint tendon; gm,
gluteus maximus; and smt, semimembranosus tendon.
Figure 14. Images from a 26-year-old soccer player who sustained indirect trauma at the proximal third of the posterior thigh while kicking,
causing him to leave the game. A, Transverse US scan (left) shows the tear, located at the long head of the biceps femoris (lbf ) myotendi-
nous junction, compared with the healthy contralateral side (right). The Cohen triangle is easily depicted. B, Corresponding sagittal
extended view confirms the injury, also involving the middle third of the conjoint tendon (ct); am indicates adductor magnus muscle; aster-
isks, hematoma; gm, gluteus maximus; smt, semimembranosus tendon; and st, semitendinosus muscle.

Figure 15. Images from a 23-year-old athlete referred for indirect trauma of the posterior medial thigh while sprinting. A and B, Axial and lon-
gitudinal US views, obtained 3 days later at the middle third of the thigh, show the tear, involving the semimembranosus (sm) myotendinous
junction in the proximity of its membrane (arrowheads); am indicates adductor magnus muscle; arrows, semitendinosus raphe; asterisks,
hematoma; smt, semitendinosus tendon; and st, semitendinosus muscle.
Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

Figure 16. Images from a 37-year-old athlete who had severe posterior thigh pain while sprinting, involving the whole hamstring muscle
complex proximal unit. Axial US scans of the right posterior hip from cranial (A) to caudal (B), obtained 4 weeks after the injury. The ham-
string muscle complex proximal tendon is swollen and hypoechoic (A). There is a complete rupture of the long head of the biceps femoris
(lbf ) at the myotendinous junction (B). C and D, Corresponding longitudinal US scans confirm the described findings; note the retracted
long head of the biceps femoris in D; am indicates adductor magnus muscle; asterisks, hematoma; gm, gluteus maximus; it, ischial tuberos-
ity; smt, semitendinosus tendon; sn, sciatic nerve; and st, semitendinosus muscle.

Figure 17. Images from a 20-year-old man evaluated for posterior thigh pain with onset approximately 1 day after intense activity (cross-fit).
A US examination was performed at 4 days. A, Transverse US scan shows a focal area of increased echogenicity (arrowheads) within the
lateral part of the semitendinosus muscle (st) without tears. B, Sagittal view of the involved part of the semitendinosus muscle. Note the
adjacent normal long head of the biceps femoris muscle (lbf ). The patient had complete relief of the symptoms at 7 days. The US and clini-
cal findings were consistent with delayed-onset muscle soreness; sn indicates sciatic nerve.

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Figure 18. Images from a 33-year-old man with a history of an indirect soccer injury of the posterior thigh muscles. A US examination was
performed at 10 days. A, Transverse US image (left) depicts a tear of the conjoint tendon (ct) and myotendinous junction of the long head
of the biceps femoris (lbf ), associated with a small hypoechoic-to-anechoic area of edema or blood products (asterisk), compared with the
healthy contralateral side (right). B and C, Transverse and sagittal color Doppler images show local hyperemia consistent with the normal
reparative process in action; am indicates adductor magnus muscle; sn, sciatic nerve; and st, semitendinosus muscle.

Figure 19. Images from a 30-year-old man referred for chronic pain at the posterior thigh after an injury. A, Transverse US scan shows
fibrotic scarring of the long head of biceps femoris (lbf ) myotendinous junction near the sciatic nerve (sn). B, Sagittal US image depicts the
scarring at its craniocaudal involvement; am indicates adductor magnus muscle; and st, semitendinosus muscle.

Figure 20. Ischial bursitis in an 85-year-old woman presenting for persistent left gluteal pain 1 month after direct buttock trauma. A and B,
Axial and longitudinal US scans at the level of the left ischial tuberosity (it) depict anechoic fluid (asterisks) overlying the hamstring muscle
complex proximal tendons, affected by high-grade tendinopathy. C, Contralateral longitudinal US scan shows bilateral tendinosis without
bursitis. Due to muscle hypotrophy, a convex transducer was used; ct indicates conjoint tendon; gm, gluteus maximus; lbf, long head of the
biceps muscle; and smt, semimembranosus tendon.

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Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

A possible complication of a myotendinous junc- (Figure 20).9,27 Deep venous thrombosis simulating a
tion tear is muscle scarring. On a US scan, the fibrosis hamstring muscle complex injury and causing diffuse
is depicted as a poorly defined hyperechoic spiculated posterior thigh swelling has been described; US is
area. The sciatic nerve’s relationship with the fibrotic able to show deep venous thrombosis and exclude a
area should be evaluated to rule out adhesions tear.28
(Figure 19).8 Among uncommon causes of pain near the ham-
string muscle complex origin, tumors must not be
Hamstring Injury Mimics: Differential Diagnosis neglected (Figure 21). Ultrasound may show soft tis-
The ischial bursa is an inconstant adventitial bursa sue masses and may suggest their benign or malign
superficial to the hamstring muscle complex proximal nature, but its main role is to differentiate between
tendons at the ischial tuberosity. Ischial bursitis is cystic and solid masses and to guide biopsy.11 When
usually related to chronic irritation or trauma and evaluating deep masses, we recommend completing
often leads to buttock pain; it appears as a fluid struc- the examination with a convex transducer, as it is
ture that may have irregular walls and internal septa more informative in showing a possible relationship

Figure 21. Images from a 55-year-old patient with Ollier syndrome presenting for suspected “hamstring syndrome.” A and B, Ultrasound
scans show a hypoechoic mass (pound signs) with internal calcification and a hard pattern on strain elastography (C). D, A convex trans-
ducer was used to analyze its deep aspect; it can be seen arising from the femur (f ). An internal color signal was shown on Doppler imag-
ing; pulsed wave Doppler imaging revealed arterial flux with a high resistive index. E, Corresponding axial contrast-enhanced T1-weighted
turbo spin echo MRI shows the mass displacing the hamstring muscle complex origin tendons and sciatic nerve (sn) medially. Biopsy
revealed that the mass was a chondrosarcoma; am indicates adductor magnus muscle; ct; conjoint tendon; gm, gluteus maximus; smt;
semimembranosus tendon; and st, semitendinosus muscle.

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 Becciolini et al—Ultrasound Features of the Proximal Hamstring Muscle Complex

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