The morphological variability of the pelvic girdle muscles: a potential trap during ultrasound
Abstract
Background: The muscles present in the pelvic girdle compartment demonstrate clinically significant anatomical variation regarding both their site of attachment and additions, such as accessory heads, muscles or tendinous slips. Many of those variations might be considered potential traps during ultrasound examination that may result in misdiagnosis. The aim of this study was to raise awareness of such possibility. Materials and methods: A comprehensive search for morphological variations was performed in PubMed and NIH. Relevant papers were listed and citation tracking was accomplished. Results: Although several anatomical variations of pelvic girdle muscles have been presented, few studies have examined their relevance in ultrasound imaging. Conclusions: The morphological variability of the pelvic girdle muscles does not vary from such incidence in other regions of the human body; however further ultrasound studies are needed of the numerous morphological variants that can be found in this region.
Keywords: morphological variabilityaccessory musclesultrasoundpelvic girdleiliopsoas muscle complexiliacuspsoas majorpsoas minorgluteus maximusgluteus mediusgluteus minimuspiriformisobturator internusobturator externusgemellus superior
References
- Abdulhameed A, Ahmed IM, Bello SS. Bilateral absence: a rare anomaly of the gemelli muscles. Morphologie. 2022; 106(353): 132–135.
- Aleksandrova JN, Malinova L, Jelev L. Variations of the iliacus muscle: report of two cases and review of the literature. Int J Anat Var. 2013; 6: 149–152.
- Al-Zamil A, Christenson JT. Psoas muscle hematoma — an acute compartment syndrome. Report of a case. Vasa. 1988; 17(2): 141–143.
- Arifoglu Y, Sürücü HS, Sargon MF, et al. Double superior gemellus together with double piriformis and high division of the sciatic nerve. Surg Radiol Anat. 1997; 19(6): 407–408.
- Arora J, Mehta V, Kumar H, et al. A rare bimuscular conglomeration gluteopiriformis case report. Morphologie. 2010; 94(305): 40–43.
- Aung HH, Sakamoto H, Akita K, et al. Anatomical study of the obturator internus, gemelli and quadratus femoris muscles with special reference to their innervation. Anat Rec. 2001; 263(1): 41–52.
- Babst D, Steppacher SD, Ganz R, et al. The iliocapsularis muscle: an important stabilizer in the dysplastic hip. Clin Orthop Relat Res. 2011; 469(6): 1728–1734.
- Bajka M, Manestar M, Hug J, et al. Detailed anatomy of the abdomen and pelvis of the visible human female. Clin Anat. 2004; 17(3): 252–260.
- Balius R, Pedret C, Blasi M, et al. Sonographic evaluation of the distal iliopsoas tendon using a new approach. J Ultrasound Med. 2014; 33(11): 2021–2030.
- Beaton L, Anson B. The relation of the sciatic nerve and of its subdivisions to the piriformis muscle. Anat Rec. 1937; 70: 1–5.
- Clarkson RD, Rainy H. Unusual arrangement of the psoas muscle. J Anat Physiol. 1889; 23(Pt 3): 504–506.
- D'Costa S, Ramanathan LA, Madhyastha S, et al. An accessory iliacus muscle: a case report. Rom J Morphol Embryol. 2008; 49(3): 407–409.
- Deslandes M, Guillin R, Cardinal E, et al. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol. 2008; 190(3): 576–581.
- Le Double AF. Muscles de la fosse lombo-iliaque. In: Le Double AF. ed. Traité des variations du système musculaire de l’Homme. Schleicher Frères, Paris 1897: 325–332.
- Duda GN, Brand D, Freitag S, et al. Variability of femoral muscle attachments. J Biomech. 1996; 29(9): 1185–1190.
- Duparc F, Thomine JM, Dujardin F, et al. Anatomic basis of the transgluteal approach to the hip-joint by anterior hemimyotomy of the gluteus medius. Surg Radiol Anat. 1997; 19(2): 61–67.
- Emilia S, Sharif T, Alzallal O, et al. Ewing sarcoma presenting as a gluteal mass in adult woman: diagnostic approach and its challenges. Malaysian J Pathol. 2020; 42(1): 121–125.
- Fabrizio PA. Anatomic variation of the iliacus and psoas major muscles. Int J Anat Var. 2011; 4: 28–30.
- Flack NA, Nicholson HD, Woodley SJ. A review of the anatomy of the hip abductor muscles, gluteus medius, gluteus minimus, and tensor fascia lata. Clin Anat. 2012; 25(6): 697–708.
- Flack NAMS, Nicholson HD, Woodley SJ, et al. The anatomy of the hip abductor muscles. Clin Anat. 2014; 27(2): 241–253.
- Gandhi S, Gupta N, Thakur A, et al. Anatomical and clinical insight of variant morphologies of psoas muscle: a case report. Int J Curr Res Rev. 2013; 14(5).
- Gonera B, Kurtys K, Karauda P, et al. Possible effect of morphological variations of plantaris muscle tendon on harvesting at reconstruction surgery-case report. Surg Radiol Anat. 2020; 42(10): 1183–1188.
- Heimkes B, Posel P, Plitz W, et al. Forces acting on the juvenile hip joint in the one-legged stance. J Pediatr Orthop. 1993; 13(4): 431–436.
- Hernando MF, Cerezal L, Pérez-Carro L, et al. Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal Radiol. 2015; 44(7): 919–934.
- Hopayian K, Danielyan A. Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. Eur J Orthop Surg Traumatol. 2018; 28(2): 155–164.
- Jelev L, Shivarov V, Surchev L. Bilateral variations of the psoas major and the iliacus muscles and presence of an undescribed variant muscle — accessory iliopsoas muscle. Ann Anat. 2005; 187(3): 281–286.
- Joshi SD, Joshi SS, Dandekar UK, et al. Morphology of psoas minor and psoas accessorius. J Anat Soc India. 2010; 59(1): 31–34.
- Khalid S, Iwanaga J, Loukas M, et al. Split femoral nerve due to psoas tertius muscle: a review with other cases of variant muscles traversing the femoral nerve. Cureus. 2017; 9(8): e1555.
- Kim JB, Lee W, Chang MC. Ultrasonographic and magnetic resonance images of a gluteus maximus tear. Yeungnam Univ J Med. 2021; 38(2): 157–159.
- King AD, Hine AL, McDonald C, et al. The ultrasound appearance of the normal psoas muscle. Clin Radiol. 1993; 48(5): 316–318.
- Kirici Y, Ozan H. Double gluteus maximus muscle with associated variations in the gluteal region. Surg Radiol Anat. 1999; 21(6): 397–400.
- Kirici Y, Yazar F, Ozan H. The neurovascular and muscular anomalies of the gluteal region: an atypical pudendal nerve. Surg Radiol Anat. 1999; 21(6): 393–396.
- Klammer A. Faszienlogensyndrom der iliakus-psoas-loge. Zeitschrift für Orthopädie und ihre Grenzgebiete. 2008; 121(03): 298–304.
- Kopsch F. Rauber’s Lehrbuch der Anatomie des Menschen. Abt. 3: Muskeln, Gefäße, 10th ed. Verlag von Georg Thieme, Leipzig 1914: 153–154.
- Kurtys K, Gonera B, Olewnik Ł, et al. A highly complex variant of the plantaris tendon insertion and its potential clinical relevance. Anat Sci Int. 2020; 95(4): 553–558.
- Lento PH, Primack S. Advances and utility of diagnostic ultrasound in musculoskeletal medicine. Curr Rev Musculoskelet Med. 2008; 1(1): 24–31.
- Liu H, Fletcher J, Garrison MK, et al. Bilateral absence of quadratus femoris and semimembranosus. Int J Anat Var. 2011; 4: 40–42.
- Macalister A. Notes on muscular anomalies in human anatomy. P Roy Irish Acad. 1866; 9: 444–469.
- Macalister A. Additional observations on muscular anomalies in human anatomy (third series): With a catalogue of the principal muscular variations hitherto published. Trans R Ir Acad. 1875; 26: 126–200.
- Moore K, Dalley AF, Agur AMR. Clinically Oriented Anatomy (7th ed.). Wilkins, Lippincott Williams and Wilkins, Philadelphia 2014.
- Natsis K, Totlis T, Konstantinidis GA, et al. Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome. Surg Radiol Anat. 2014; 36(3): 273–280.
- Nicholson H, Woodley S, Flack N. Gluteal uscles and lateral rotators of the hip. In: Tubbs RS, Shoja MM, Loukas M. ed. Bergman’s comprehensive encyclopedia of human anatomic variation. Wiley-Blackwell, Chichester 2016.
- Olewnik Ł. A proposal for a new classification for the tendon of insertion of tibialis posterior. Clin Anat. 2019; 32(4): 557–565.
- Olewnik Ł, Podgórski M, Polguj M, et al. A cadaveric and sonographic study of the morphology of the tibialis anterior tendon – a proposal for a new classification. J Foot Ankle Res. 2019; 12(1).
- Olewnik Ł, Podgórski M, Polguj M, et al. Is ultrasound effective in determining variation of the insertion of the extensor hallucis longus tendon? Clin Anat. 2020; 33(8): 1235–1239.
- Olewnik Ł, Podgórski M, Polguj M, et al. The plantaris muscle — rare relations to the neurovascular bundle in the popliteal fossa. Folia Morphol. 2018; 77(4): 785–788.
- Orthaber S, Pritsch A, Zach JL, et al. Gluteus medius accessorius and gluteus quartus scansorius in one specimen: case report of two rare variations. Eur J Anat. 2020; 24(2): 161–163.
- Pecina HI, Boric I, Smoljanovic T, et al. Surgical evaluation of magnetic resonance imaging findings in piriformis muscle syndrome. Skeletal Radiol. 2008; 37(11): 1019–1023.
- Philippon MJ, Devitt BM, Campbell KJ, et al. Anatomic variance of the iliopsoas tendon. Am J Sports Med. 2014; 42(4): 807–811.
- Pine J, Binns M, Wright P, et al. Piriformis and obturator internus morphology: a cadaveric study. Clin Anat. 2011; 24(1): 70–76.
- Pirouzmand F, Midha R. Subacute femoral compressive neuropathy from iliacus compartment hematoma. Can J Neurol Sci. 2001; 28(2): 155–158.
- du Plessis M, Loukas M. Thigh Muscles. In: Tubbs RS, Shoja M, Loukas M. ed. Bergman’s comprehensive encyclopedia of human anatomic variation. Wiley-Blackwell, Chichester 2016: 410–420.
- Prasad AM, Nayak BS, Deepthinath R, et al. clinically important variations in the lower limb: a case report. Eur J Anat. 2005; 9: 167–169.
- Protas M, Voin V, Wang JMh, et al. A rare case of double-headed psoas minor muscle with review of its known variants. Cureus. 2017; 9(6): e1312.
- Ramirez OM, Hurwitz DJ, Futrell JW. The expansive gluteus maximus flap. Plast Reconstr Surg. 1984; 74(6): 757–770.
- Rao TR, Kanyan PS, Rao S. Bilateral variation of iliacus muscle and splitting of femoral nerve. Neuroanatomy. 2008; 7: 72–75.
- Ravindranath Y, Manjunath KY, Ravindranath R. Accessory origin of the piriformis muscle. Singapore Med J. 2008; 49(8): e217–e218.
- Ruzik K, Waśniewska A, Olewnik Ł, et al. Unusual case report of seven-headed quadriceps femoris muscle. Surg Radiol Anat. 2020; 42(10): 1225–1229.
- Sajko S, Stuber K. Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implications. J Can Chiropr Assoc. 2009; 53(4): 311–318.
- Sen S, Senol GB, Ormeci T, et al. Gluteoperinealis muscle: a surgically important variation. Surg Radiol Anat. 2021; 43(9): 1467–1470.
- Shinohara H. Gemelli and obturator internus muscles: different heads of one muscle? Anat Rec. 1995; 243(1): 145–150.
- Siahaan YM, Tiffani P, Tanasia A. Ultrasound-guided measurement of piriformis muscle thickness to diagnose piriformis syndrome. Front Neurol. 2021; 12: 721966.
- Solomon LB, Lee YC, Callary SA, et al. Anatomy of piriformis, obturator internus and obturator externus: implications for the posterior surgical approach to the hip. J Bone Joint Surg Br. 2010; 92(9): 1317–1324.
- Spratt JD, Logan BM, Abrahams PH. Variant slips of psoas and iliacus muscles, with splitting of the femoral nerve. Clin Anat. 1996; 9(6): 401–404, doi: 10.1002/(SICI)1098-2353(1996)9:6<401::AID-CA8>3.0.CO;2-D.
- Stern JT. Anatomical and functional specializations of the human gluteus maximus. Am J Phys Anthropol. 1972; 36(3): 315–339.
- Tabatabaiee A, Takamjani IE, Sarrafzadeh J, et al. Ultrasound-guided dry needling decreases pain in patients with piriformis syndrome. Muscle Nerve. 2019; 60(5): 558–565.
- Tanyeli E, Pestemalci T, Uzel M, et al. The double deep gluteal muscles. Saudi Med J. 2006; 27(3): 385–386.
- Tichý M, Grim M. Morphogenesis of the human gluteus maximus muscle arising from two muscle primordia. Anat Embryol (Berl). 1985; 173(2): 275–277.
- Tsuyoshi S, Nagahiro T. Abdominal wall uscles. In: Tubbs RS, Shoja MM, Loukas M. ed. Bergman’s Comprehensive Encyclopedia of Human Anatomic Variation. Wiley-Blackwell, Chichester 2016.
- Tubbs RS, Oakes WJ, Salter EG. The psoas quartus muscle. Clin Anat. 2006; 19(7): 678–680.
- Tubbs RS, Salter G, Oakes WJ. Femoral head of the rectus femoris muscle. Clin Anat. 2004; 17(3): 276–278.
- Ueshima H, Otake H, Lin JA. Ultrasound-guided quadratus lumborum block: an updated review of anatomy and techniques. Biomed Res Int. 2017; 2017: 2752876.
- Unat F, Sirinturk S, Cagimni P, et al. Macroscopic observations of muscular bundles of accessory iliopsoas muscle as the cause of femoral nerve compression. J Orthop. 2019; 16(1): 64–68.
- Vervaecke AJ, Declercq H, Wetzels K, et al. Localized tenosynovial giant cell tumor: a rare case of snapping hip. Skeletal Radiol. 2022; 51(11): 2205–2210.
- Vicente EDJ, Viotto MJS, Barbosa CAA, et al. Study on anatomical relationships and variations between the sciatic nerve and piriformis mscle. Rev Bras Fisioter. 2007; 11(3): 197–202.
- Ward WT, Fleisch ID, Ganz R. Anatomy of the iliocapsularis muscle. Relevance to surgery of the hip. Clin Orthop Relat Res. 2000(374): 278–285.
- Whittaker JL, Emery CA. Sonographic measures of the gluteus medius, gluteus minimus, and vastus medialis muscles. J Orthop Sports Phys Ther. 2014; 44(8): 627–632.
- Windisch G, Braun EM, Anderhuber F. Piriformis muscle: clinical anatomy and consideration of the piriformis syndrome. Surg Radiol Anat. 2007; 29(1): 37–45.
- Wong TL, Kikuta S, Iwanaga J, et al. A multiply split femoral nerve and psoas quartus muscle. Anat Cell Biol. 2019; 52(2): 208–210.
- Zielinska N, Tubbs RS, Ruzik K, et al. Classifications of the extensor hallucis longus tendon variations: Updated and comprehensive narrative review. Ann Anat. 2021; 238: 151762.