Ankle
Direct coronal CTA has been used to assess the integrity of osteochondral lesions of the ankle since the early days of CT. Both single- 40 and double- Fig. 9. A Coronal reformation from ankle CTarthrogram. Tendon anchor arrow from prior lateral ligament reconstruction does not interfere with visualization of joint surfaces. Talar dome is normal. B Sagittal reformation, same patient, anterior to image left. Tiny cyst of posterior distal tibial articular surface arrowhead noted on radiograph not...
Tendons
Although sonography and MRI are often complementary in diagnosing pathologic conditions, the spatial resolution of sonography is superior to that of MRI for defining the fine internal fibrillar structure of large tendons 34,35 . The typical sonographic appearance of a tendon is that of a parallel series of hyperechoic lines separated by less echogenic lines 32 . An exception to this is at a tendon insertion, where the tendon often has a hypoechoic appearance that should not be misinterpreted as...
Wrist
There is little literature assessing the effectiveness of CTA in diagnosing wrist joint disease. An early report assessed the value of double-contrast CTA in the evaluation of the triangular fibrocartilage complex TFCC 37 . This study used 2-mm-thick direct coronal wrist imaging to assess the TFCC following wrist arthrography. The study authors reported that the site of tear could be determined accurately from the CT examination, but that the CT study did not reveal any information not provided...
Patellofemoral Osteoarthritis
Patellofemoral osteoarthritis is an extremely common cause of anterior knee pain. This is encountered primarily in older individuals, but can be seen in younger patients with accelerated degenerative changes brought on by comor-bidities such as obesity. The classic radiographic features of PO include loss of articular cartilage with joint space narrowing, subchondral sclerosis and or cyst formation, and osteophyte formation along the posterior margin of the patella. The symptoms commonly seen...
Proximal Injury 1
Injury to the proximal myotendinous junction of gastrocnemius posterior to the knee can occur but is an unusual clinical entity and the imaging appearance is rarely reported 112 . The clinical significance of proximal injuries is also unclear aside from localization of pain to the knee instead of the mid calf, which can alter the differential diagnosis. If no abnormality exits on MRI, one should consider referred pain related to lower lumbar disc pathology ie, L5 level . In children and...
Chondromalacia Patellae
As indicated by its Greek and Latin roots, chondromalacia patellae CP is a condition characterized by abnormal softening of the cartilage along the Fig. 4. A Patellar tendon rupture. T2-weighted sequence shows patella alta with discontinuity of the patellar tendon and associated edema. B Quadriceps tendon rupture. T2-weighted fat-saturated sagittal image shows discontinuity of the quadriceps tendon with associated edema. Fig. 4. A Patellar tendon rupture. T2-weighted sequence shows patella alta...
V 1
Fig. 22. Synovial osteochondromatosis. Coronal T1, fat-suppressed MR arthrogram demonstrates multiple cartilaginous, intra-articular loose bodies consistent with synovial osteochon-dromatosis. Fig. 23. Pigmented villonodular synovitis PVNS . A Coronal T2-weighted image demonstrates low signal hyperplastic synovium filling the joint space laterally arrow . This mass has resulted in lateral femoral neck osseous erosion curved arrow . B Oblique sagittal T1, fat-suppressed MR arthrogram image. In...
Hematoma
Sonography can depict both muscle contusion and hematoma. Sonographi-cally, a contusion is seen as an ill-defined area of hyperechogenicity in the muscle, which may cross fascial planes. In contrast, a hematoma appears as a hypoechoic fluid collection, and may contain debris Fig. 15 39 . Sonogra-phy can also provide guidance for aspiration of a painful hematoma. Fig. 14. Partial tear of the rectus femoris. A, B Two longitudinal images of the rectus femoris show hypoechoic areas within the...
Summary Lmx
Muscle injury and strains are very common among athletes. MR is the preferred method of evaluation because of superior contrast resolution, reproduc-ibility, and excellent anatomic detail. Ultrasound is also useful and advocated by some as a front line diagnostic modality because of its lower costs and portability particularly in experienced hands. It is important to remember that injury usually occurs at the myotendinous junction, which may be intramuscular in the hamstring and quadriceps...
Timothy J Mosher MD
Department of Radiology, MC H066, Pennsylvania State University Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA he knee and ankle are the most frequently injured sites in athletes, either through direct trauma or repetitive microtrauma associated with training. Osteochondral and chondral injuries are particularly prevalent in this population, particularly in younger, skeletally immature athletes 1,2 . Increased awareness of osteochondral injuries of the knee and...
Myositis Ossficans
Myositis ossificans circumscripta is another well-known sequela of muscle injury often affecting larger muscles in the extremities 10,18,23,24,135 . Myositis ossificans presents diagnostic imaging difficulties because of variable imaging appearance, which can be aggressive and overlap with neoplastic processes. The cause is usually blunt trauma, although burns and paralysis have also been implicated, but often no traumatic history is present. Acute to subacute lesions are ill defined and...
MRI of Sports Injuries of the Ankle
US Air Force Wilford Hall Medical Center, 2200 Bergquist Drive Suite 1, Lackland AFB, TX 78236, USA Ankle injuries are estimated to constitute as many as 21 of sports-related injuries 1 . Both intra-articular and extra-articular injuries may be present, commonly with multiple concurrent injuries 2 . The clinical manifestations of many injuries may be subtle 1 or may overlap with other injuries 2 . Although plain film radiography has traditionally been the most common modality to image the...
Groin Pain
Groin pain can be disabling to the high-performance and recreational athlete. It is often associated with sports requiring kicking and rapid change in directions, such as soccer, rugby, hockey, and American football players 16 . Injury data from the National Hockey League reveals groin injury occurs at a rate of 13 to 20 injuries per 100 players per year 71 . The differential for chronic groin pain is broad and includes both musculoskeletal and genitourinary etiologies. Musculoskeletally, the...
Patellofemoral Pain Syndrome
Patellofemoral pain syndrome has been suggested as a diagnosis of exclusion reserved for patients with anterior knee pain without one of the conditions described above. Causes of this variety of anterior knee pain are somewhat controversial. Fulkerson points out that there are six main tissues to consider when looking for the etiology of patellofemoral pain. These include subchondral bone, synovium, retinaculum, skin, muscle, and nerve. He believes that the most common causes of pain from an...
Summary 1
A variety of entities may be responsible for AKP. A combination of patient history, physical examination, and appropriate use of imaging may, in most instances, result in a reliable diagnosis in most individuals affected by this disorder. 1 Devereaux MD, Lachmann SM. Patello-femoral arthralgia in athletes attending a sports injury clinic. Br J Sports Med 1984 18 1 18-21. 2 Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin N Am 2000 84 4 983-1007. 3 Hording G. Chondromalacia of the...
Extensor Tendons
The anterior tibial tendon ATT originates from the lateral tibia and the anterior aspect of the interosseous tibiofibular ligament, and inserts onto the medial cuneiform and base of the first metatarsal. The ATT Fig. 37 acts to dorsiflex and invert the foot. The extensor hallucis longus tendon originates from the medial fibula and interosseous ligament, and inserts onto the base of the great Fig. 42. Sinus tarsi with the intermediate root of the inferior extensor retinaculum arrow . Fig. 42....
Articular Cartilage
2006 Elsevier Inc. All rights reserved. Fig. 1. Sagittal A and coronal B fast spin echo FSE images of the ankle demonstrate an osteochondral lesion of the lateral talar dome with cartilage fibrillation, but no exposed bone grade 2 . Fig. 1. Sagittal A and coronal B fast spin echo FSE images of the ankle demonstrate an osteochondral lesion of the lateral talar dome with cartilage fibrillation, but no exposed bone grade 2 . cartilage repair procedures have been used with osteochondral talar dome...
Pelvis
Pelvic stress fractures are relatively uncommon, representing only 1 to 2 of all stress fractures 79,80 . Pelvic stress fractures in runners most often occur in the pubic rami. Pubic rami fractures are commonly near the symphysis pubis Fig. 14 . Symptoms most commonly include groin, hip, buttock, or thigh pain 7984 . These fractures most commonly occur in long distance female runners 81-85 . Severe groin pain may make running impossible. Standing on the leg of the affected side may elicit the...
Tarsal Bones
Up to 20 of stress fractures in runners may occur in the tarsal bones 8 . Stress fracture of the tarsal bones are too often a diagnostic challenge, because many providers do not consider tarsal stress fractures in the assessment of foot and ankle pain. A high clinical suspicion of stress fractures is required for an accurate and timely diagnosis. The majority of tarsal bone stress fractures occur in the navicular Fig. 5A, B 28 . Fig. 2. Second metatarsal stress fracture. Fifty-one-year-old...
Contusions
Because of the superficial location, contusion injury of the quadriceps may occur. Typical clinical history of pain and swelling exists along either MRI Fig. 12. Sagittal image of a normal quadriceps tendon with superficial black arrow rectus femoris , middle white arrow, vastus lateralis and medialis and deep fibers open arrow, vastus intermedius A . Different patient with partial tear of quadriceps tendon black arrow and residual intact fibers of vastus intermedius B . Fig. 12. Sagittal image...
Fibula
Stress fractures of the fibula may occur in runners, presenting as local pain and tenderness over the fibula. The incidence of stress fractures in the fibula in running has been quoted between 7 and 12 , and is most common in the distal fibula 6,8,66 . Proximal fibular stress fractures may also rarely occur, but are more common in jumpers. A high clinical suspicion is particularly important in making both of these diagnoses. Fractures may present as pain and tenderness over the lateral proximal...
Avulsions in Adults
Complete hamstring proximal avulsions can occur in adults but are unusual with small series reported often involving forceful flexion of hip when the knee is extended during athletic activity, particularly waterskiing 92-96 . They can be treated with surgical intervention with good outcomes in the acute and chronic setting although acute intervention may be preferred 94,97,98 . Fig. 21. Axial T1 MR showing thin cortical rim of dark signal slightly avulsed from the ischial tuberosity arrow...
Tarsal Tunnel Syndrome
Located between the FDL and FHL tendons at the posteromedial aspect of the ankle is the neurovascular bundle consisting of posterior tibial artery and vein, and tibial nerve Fig. 32 . Symptoms of pain or numbness in the distribution of the medial or lateral plantar nerves may be caused by compression of the tibial nerve or plantar nerves, and have been referred to as tarsal tunnel syndrome 73 . There are multiple possible etiologies for tarsal tunnel syndrome, including fracture 74 , flexor...
Elbow
For many years, complex motion tomography with or without arthrography was the gold standard nonoperative method to assess elbow joint surfaces and loose bodies. One of the first reports of elbow joint CTA was in 1986 33 , describing the effectiveness of the double-contrast technique in the investigation of joint pain, stiffness, locking, or snapping. A more recent report 34 found no difference between conventional MRI and CTA in the detection of elbow loose bodies, and, furthermore found that...
Summary Cbm
Postoperative MRI plays a vital role in the assessment of patients who have undergone reconstructive knee surgery. Knowledge of the spectrum of normal, acceptable postsurgical appearances is crucial to interpretation of MRIs in patients with previous surgery, as signal and morphological changes considered pathological in the preoperative knee may routinely be visualized following repair without indicating operative failure or complications. As a result, refined diagnostic criteria are relied on...
Hip Bursal Fluid Collections
Periarticular and extra-articular fluid collections around the hip can be a source of hip pain. The greater trochanteric bursa and the iliopsoas bursa are the major bursa of the hip, which can be evaluated with ultrasound. Both iliopsoas and trochanteric bursitis is demonstrated on ultrasound as an enlarged, anechoic or hypoechoic bursa when compared with the contralateral, asymptomatic hip Figs. 4, 5 6 . Fluid distension of the bursa may be asymptomatic that is, non-tender when pressure is...
Osteochondral Injury In The Athlete
Osteochondral injuries represent a spectrum of articular conditions ranging from acute cartilage injury to chronic osteochondral defects, including osteo-chondritis dissecans OCD . In approaching osteochondral injuries, it is useful to conceive of the cartilage and subchondral bone as a functional unit, which in addition to cartilage and bone consists of the bone cartilage interface or tidemark zone. Although there is ongoing debate regarding the pathogenesis of OCD, there is a general...
Acetabular Labrum
The labrum can be visualized at the anterior attachment onto the acetabulum with sonography. The anterior labrum appears as a triangular hyperechoic focus at the ventral margin of the acetabulum. An irregular hypoechoic cleft at the base of the labrum is highly suggestive of an anterior labral tear 24 however, MR arthrography remains the primary imaging modality of choice for evaluation of the acetabular labrum. MR arthrography has a reported sensitivity and accuracy for detection of labral...
Bones
Common fractures occurring after ankle sprain include avulsion fractures, lateral talar dome fractures, anterior calcaneal process fractures, or fractures Fig. 2. Sagittal A and coronal B images demonstrate an osteochondral lesion of the lateral talar dome with bone exposed grade 3 . Fig. 2. Sagittal A and coronal B images demonstrate an osteochondral lesion of the lateral talar dome with bone exposed grade 3 . at the base of the fifth metatarsal 1 . Many of these may be radiographically occult...
Soleus
Injury to the soleus is considered uncommon and is only rarely reported. It has been postulated, however, that injury to this muscle may occur more frequently than reported as soleus tears may be erroneously diagnosed as tears of the gastrocnemius 115 . The soleus muscle originates at the posterior aspect of the proximal tibia and fibula and runs deep to the gastrocnemius muscle. The soleus and gastrocnemius muscles gradually conjoin to form the Achilles tendon 8 to 10 cm above its insertion...
Distal Injury
Distally the quadriceps tendons merge together before inserting on the patella. MR appearance of the quadriceps tendon is that of a layered structure usually trilaminar 56 , although occasionally one 6 , two 30 , or four 8 layers are seen. The superficial layer represents the rectus femoris, the deep layer the vastus intermedius, and the middle layer consists of variable contributions of the vastus lateralis and medialis 37 Fig. 12 . Distal injury to the quadriceps is an unusual injury most...
Ultrasound Of Knee Friedman 2001
1 Kijowski R, DeSmetAA. The role of ultrasound in the evaluation of sports medicine injuries in the upper extremities. Clin Sports Med 2006 25 3 569-90. 2 Robben SG, Lequin MH, Diepstraten AF, et al. Anterior joint capsule of the normal hip and in children with transient synovitis US study with anatomic and histologic correlation. Radiology 1999 210 499-507. 3 Koski JM, Anttila PJ, Isomaki HA. Ultrasonography of the adult hip joint. Scand J Rheumatol 1989 18 113-7. 4 Zieger MM, Dorr U, Schulz...
Imaging Modalities
Because of the common nature of these injuries, many muscle strains are treated clinically. However the clinical scenario may be unclear and grading of injury may be difficult. Imaging may help delineate the presence and extent of muscle injury. The main modalities used for evaluation almost exclusively include MRI and ultrasound. Radiographs are useful for evaluating bony avulsion injuries in adolescents particularly of the pelvis that can be missed with MR and ultrasound. Subtle areas of soft...
Tennis Leg
The term ''tennis leg'' has been used to describe muscle injury and pain in the calf. The term is attributed to the tennis serving motion of fully extending the knee with sudden ankle dorsiflexion invoking maximal stretch on the calf. Fig. 22. Sports-related traumatic avulsion of the lesser trochanter in a 15-year-old track athlete A . Avulsion of lesser trochanter in an adult without significant history of injury B . MRI in the same adult shows focal metastatic disease C . Fig. 22....
Posterior Tibial Tendon
Sonography is effective in diagnosing tendinopathy, tenosynovitis, and partial and complete tears of the posterior tibialis tendon PTT 24,41,55 . When compared with MRI, the sensitivity and specificity of sonography for diagnosing tendinopathy were 80 and 90 respectively, and for diagnosing periten-dinopathy, were 90 and 80 56 . The study by Gerling and colleagues 55 , showed that sonography and MRI had a similar overall accuracy in evaluating surgically created longitudinal PTT tears, but that...
Imaging Sports Medicine Injuries of the Foot and Toes
Albert Einstein College of Medicine, Division of Musculoskeletal Radiology, Jacobi Medical Center, Bronx, New York 10461, USA The Lisfranc joint, aka the tarsal-metatarsal TMT joint, marks the transition between the more rigid midfoot and the relatively flexible forefoot. It provides critical stability in maintenance of both the transverse and longitudinal arch of the foot. That stability is derived from both its osseous geometry and complex capsuloligamentous architecture. The second...
Imaging of Anterior Knee Pain
Stephen R. Christian, MD, M. Bret Anderson, MD, Ronald Workman, MD, William F. Conway, MD, FACR, Thomas L. Pope, MD, FACR Department of Radiology, Medical University of South Carolina, PO Box 250322, 169 Ashley Avenue, Charleston, SC 29425, USA Anterior knee pain AKP is a common complaint in primary care and orthopedic clinics. In fact, in the sports medicine clinic, up to 25 of patients with knee complaints have symptoms of anterior knee pain 1 . Adolescent females and other young individuals...
Bakers Popliteal Cyst
One of the primary indications for imaging the posterior knee is to confirm the presence of a suspected Baker's cyst Fig. 12 . With sonography, a simple cyst appears anechoic and well-defined, with posterior acoustic enhancement. Complicated cysts may contain internal echoes and septations on ultrasound. Anechoic or hypoechoic fluid beyond the caudal margin of the Baker's cyst on Fig. 10. Patellar tendinopathy. Longitudinal A and transverse B sonographic images of the patellar tendon show a...
Bipartite Patella And Patellar Stress Fracture
The patella is normally one bone, but in approximately 1 to 2 of the population the patella develops as two unfused ossification centers. This condition, known as bipartite patella, is a variant of normal and affects men more than women. These two bones are not separate, but are connected by thick fibrous tissue. The patient with a bipartite patella is usually asymptomatic but can experience pain with standing or jumping. The classic bipartite patella appears as a small unfused fragment of the...
Proximal Adductor Injury
The imaging finding of myotendinous strain of the adductor muscle have characteristics similar to muscle injury elsewhere in the body Fig. 14B . Adductor strains have been listed as one of the most commonly injured groups of muscles 12,18 . In a nonconsecutive series of adductor muscle injuries 13 all involved the adductor longus 12 . The adductor longus seems to be the most commonly injured muscle but other adductors such as adductor brevis, pectineus, and gracilis may be injured 56-58 ....
Anatomy Aaq
The quadriceps muscle group is composed of the rectus femoris and vastus muscles intermedius, lateralis and medialis Fig. 8 . The primary mechanism of action is knee flexion. Only the rectus femoris is biarticular. Proximally the rectus femoris has a direct head insertion on the anterior inferior iliac spine and an indirect head extending slightly laterally blending with the lateral aspect of acetabulum and hip capsule 26 . The direct head forms the anterior fascia of the proximal third of the...
Summary Xjb
Sonography of the lower extremities has an important role in the evaluation of sports-related injuries. Some advantages of sonography over MRI include Fig. 33. Intermetatarsal bursitis. Anechoic compressible fluid collection arrow located within the second interspace measuring 1.5 cm x 0.5 cm. Fig. 33. Intermetatarsal bursitis. Anechoic compressible fluid collection arrow located within the second interspace measuring 1.5 cm x 0.5 cm. Fig. 34. Plantar plate injury. Longitudinal sonographic...
Popliteus
The popliteus muscle originates at the posteromedial aspect of the proximal tibial metaphysis and can have several attachments but primarily inserts on the lateral aspect of femoral condyle. The popliteus muscle functions as an internal rotator of the tibia on the femur and assists in flexion of the knee. It is an important stabilizer of the posterolateral corner of the knee and prevents forward translation of the femur on the tibia 117 . The overwhelming majority of injuries to the popliteus...
Patellar And Quadriceps Tendon Rupture
Patellar tendon rupture, an overall infrequent occurance, is the third most common injury to the extensor mechanism of the knee after patellar fracture and quadriceps rupture. Rupture usually occurs unilaterally as a result of athletic injury in a patient younger than 40 years of age. Typically, an abrupt eccentric contraction of the quadriceps as the athlete lands with the knee flexed and foot planted will tear the tendon at the osseotendinous junction. In the setting of longstanding systemic...
Hip Joint Effusion
Sonography has been proven to be an accurate method for diagnosing a hip effusion in children, and its use in the diagnosis of pediatric joint effusions and septic arthritis is now commonplace 2 . In contrast, sonography is not widely used to detect hip joint effusions in adults, with both sonography and fluoroscopically guided aspiration being used for this purpose. E-mail address dg.blankenbaker hosp.wisc.edu D.G. Blankenbaker . Several authors have reported successful use of sonography to...
Sindinglarsenjohansson Syndrome
Originally described by Norwegian physician Christian Magnus Falsen Sind-ing-Larsen and Swedish surgeon Sven Christian Johansson, Sinding-Larsen-Johansson syndrome SLJS is defined as ''apophysitis of the distal pole of the patella'' and is considered one of the osteochondroses 9 . This condition of the distal patella and proximal patellar tendon is quite similar to Osgood-Schlatter disease and primarily affects athletically active adolescents between 10 and 14 years of age with prevalence in...
Anatomy Kik
The adductors are composed primarily of superficial pectineus, gracilis, and adductor longus , middle adductor brevis , and deep adductor magnus muscle structures 26 Fig. 14A,C . The adductor magnus has anterior and Fig. 13. Curvilinear fluid collection along the crural fascia consistent with degloving injury arrow . Fig. 14. Axial T1-weighted images of proximal thighs in professional football player with acute groin pain on the left. The annotated right side A shows normal anatomy of the...
Grade IIIII Lesions PartialThickness Cartilage Injury
Grade II lesions represent fissures, erosion, ulceration, or fibrillation involving the superficial 50 of cartilage thickness. In the modified Outerbridge classification, lesions that extend to the deep 50 of cartilage are considered Grade III. These injuries can occur in the setting of acute trauma or secondary to remote injury. Acute injuries are suggested by the presence of adjacent soft-tissue edema, joint effusion, and bone marrow T2 hyperintensity. As discussed previously, chronic lesions...
Metatarsal Bones
Metatarsal stress fractures are a common overuse injury in runners 28,29 . Along with the tibia, the metatarsals are among the most common stress fractures seen in runners 28 . It is thought that the plantar flexion musculature of the toes help to dissipate stress on the metatarsals. It has been demonstrated that dorsal strains are significantly reduced by simulated contraction of the plantar flexion musculature. It is therefore possible that fatigue of these muscles during strenuous or...
Lateral Ligaments
The interosseous tibiofibular ligament and anterior and posterior inferior tibio-fibular ligaments comprise the distal syndesmosis 18 . On axial MR images, the medial margin of the distal fibula can be used as an anatomic reference. When the medial margin of the distal fibula appears flat, the ligaments in view are the anterior and posterior tibiofibular ligaments Fig. 6 . The tibiofib-ular ligaments demonstrate an oblique course and may be seen on multiple Fig. 6. Axial A image demonstrating...