Musculoskeletal Anatomy - The Quest for Knowledge

The quest to understand anatomy
We continue to improve our anatomical knowledge in sports medicine.  Clinicians use this as a basis for better understanding of the cause and extent of injury and to develop new treatment strategies.  So, all of us should be encouraged to keep improving our knowledge.   That makes it exciting and challenging!

Imaging-driven anatomical knowledge
Imaging quality continues to improve.  The latest generation of MRI and ultrasound machines show fantastic structural detail.  What you see on imaging and how you interpret it may be limited by your anatomical knowledge, not the imaging!  And how you use that information into clinical decision making, remains the challenge for any clinician in sports medicine.

For example, muscle and tendon imaging.  We can visualise great structural detail (pennate angles, intramuscular tendon and enthesis, and nerve and vascular details).  This has contributed to better injury classification/differentiation.  To have ‘a hamstring injury’ is too general a term; we can differentiate this to where, what type of issue and to what degree it has been injured.  That has helped towards understanding why certain injuries have a longer recovery time, have a higher recurrence rate or may require different rehabilitation strategies.  Of course, it provides as many new questions as it answers, which makes it interesting. 

The journey to increase your knowledge - Resources
Years ago, in the last century, before internet, I set out on my journey to learn MSK ultrasound imaging.  This involved spending a lot of time studying MRI, ultrasound and cross-sectional and cadaveric anatomy, and surgical and guided procedures.  In those days before the internet, a regular visit to the actual Royal Society of Radiology Library was required to be able to read each publication in the Journal it was printed in.  It also meant buy the textbooks.

This greatly improved not only my anatomical knowledge and my ultrasound scanning, it also prompted me to query clinical assessment and treatment strategies. No injury was ever the same again!  It certainly made me more critical as a clinician and passionate about integrating imaging into clinical practice, combining imaging information with clinical assessment.

And the journey still continues.  Imaging quality keeps improving.  There is an overwhelming world of information directly available online for anyone to read.  An explosion of anatomical-related publications alone is enough to keep any clinician on their toes.  Any subject seems covered, some more accurate than others, some old, some new.  It can be a challenge to navigate through this.

Some tips to improve your anatomical knowledge.

1. Set a target to study - an anatomical structure or subject. 
2. Cross sectional anatomy – Cadaveric, MRI and ultrasound.  Online or books.
3. Video tutorials for imaging, anatomy, injury and guided procedures. Search for ESSR, AIUM, Radiology, nerve blocks, ultrasound imaging tutorials and presentations.  YouTube channels, Facebook, LinkedIn and Twitter groups. 
4. Search for publications, many are open access.  Google Scholar or PubMed.
5. E-Books and books.  From Grey’s Anatomy, reference books to instructional books.  For MSK ultrasound the most popular books are by Martinoli, Jon Jacobson and Marnix Van Holsbeeck.
6. For general digital anatomy: 3D4Medical and Primal Pictures are widely used.
7. Test your knowledge.   Apply your knowledge in your daily clinic and discuss topics with colleagues.  In sports medicine there are plenty of opinions and latest ‘evidence-based’ (but in reality only ‘research-based’) trends and ‘experts’.  Form your own strong basis for decision making and keep learning!

At SMUG we are constantly updating our extensive library of reference resources.  We use it for pre-reading and references in our SMUG training courses and share it with our online SMUG community.

I have compiled a short list of publications that hopefully trigger your interest.  They are all free access and they are all relevant to using ultrasound imaging and sports injuries.

So here is a small sample of publications.  Do not just copy, paste and download.  Read them!
1. Gluteus minimus indirect tendon: another tendon around the hip with a capsular component.   https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1469-7580.2001.19820239.x

2. Iliotibial Tract: 5 distal attachments.  https://www.researchgate.net/profile/Eduardo_Vieira4/publication/6458420_An_Anatomic_Study_of_the_Iliotibial_Tract/links/57600ab808ae244d03707f54/An-Anatomic-Study-of-the-Iliotibial-Tract.pdf

https://www.researchgate.net/profile/George_Matcuk/publication/314070022_The_iliotibial_tract_imaging_anatomy_injuries_and_other_pathology/links/5df8eda792851c8364852bb4/The-iliotibial-tract-imaging-anatomy-injuries-and-other-pathology.pdf

3. Greater trochanter pain: not likely to be bursitis.
https://www.ajronline.org/doi/pdfplus/10.2214/AJR.12.10038

4. Hamstrings:
Proximal hamstring: it gets a lot of attention but let’s not forget the anatomical and functional details.  https://www.researchgate.net/profile/Akimoto_Nimura/publication/225272857_Anatomical_study_of_the_proximal_origin_of_hamstring_muscles/links/555f106c08ae6f4dcc8e7c04/Anatomical-study-of-the-proximal-origin-of-hamstring-muscles.pdf

https://www.researchgate.net/profile/Fernando_Ferro2/publication/262611011_A_qualitative_and_quantitative_analysis_of_the_attachment_sites_of_the_proximal_hamstrings/links/5784fa2b08aec5c2e4e10d17.pdf

Sacro-tuberal ligament and proximal hamstrings: STL and biceps tendon have a close connection. https://pubs.rsna.org/doi/pdf/10.1148/radiol.13130702

Distal biceps femoris tendon attachment.  The detail sometimes explains the injury.
https://onlinelibrary.wiley.com/doi/full/10.7863/jum.2011.30.8.1162

https://journals.sagepub.com/doi/pdf/10.1177/2325967115602255

5. Distal biceps brachii tendon.  Another tendon that rotates.  http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.964.3877&rep=rep1&type=pdf

6. Lacertus fibrosus: don’t forget it’s there. https://www.researchgate.net/profile/Olivier_Snoeck/publication/259699971_The_lacertus_fibrosus_of_the_biceps_brachii_muscle_An_anatomical_study/links/0f31752e1458ed8ed9000000.pdf

7. Hoffa’s fat pad.  Some interesting details.
https://link.springer.com/article/10.1007/s13244-016-0483-8

8. Aponeurosis slip supraspinatus and proximal biceps brachii tendon.  It’s not a tendon tear. https://www.ncbi.nlm.nih.gov/pubmed/25179795

By Robert Laus
Head of Faculty