Grade IV Lesions

Grading Stress Fracture

Full thickness lesions with exposure of the underlying subchondral bone are classified as Grade IV lesions. The margin of the lesion can suggest the mechanism of cartilage injury. Sharply marginated borders are characteristic of traumatic cartilage injuries, whereas shallow or irregular margins are features more characteristic of chronic degeneration. Abnormal signal from the underlying bone marrow and central osteophytes are frequently associated with Grade Fig. 6. Flap tear 40-year-old male...

Summary

Lumbar Spine Capsular Pattern

Knee injuries are common at all levels of sporting activities, and range from minor to severe. Studies indicate that MRI is a reliable and cost-effective diagnostic tool in evaluating the extent of acute knee injury. A systematic approach to the assessment of key structures, including bone, cartilage, menisci, and ligaments requires detailed knowledge of normal anatomy and anatomic variants, as well as the expected MRI appearance of injury. In addition, using mechanism-based injury patterns can...

Grade I Lesions

Grade Meniscus Tear

In the surgical form of the Outerbridge classification, Grade I lesions are identified by a subjective assessment of cartilage softening or cartilage discoloration with an intact articular surface. Because there is no direct MRI finding that corresponds to cartilage softening, this has been modified to reflect MRI signal changes without morphologic changes of the cartilage surface. Early studies found poor correlation between Grade I MRI lesions and arthroscopy 70,71 , as well a low sensitivity...

Types Of Muscle Injury

There are many different sizes and shapes of muscle. Some are long like the biceps femoris with tendon insertions on bone at both ends and cross two joints biarticular . Others are short with a single tendon insertion spanning a single Corresponding author. Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213. E-mail address sportsmed.imaging yahoo.com D.R. Armfield . joint like the popliteus. Some have long muscle bellies sartorius whereas...

Jumpers Knee

Although often referred to as patellar tendonitis, a more accurate description of ''Jumper's knee,'' based on histologic studies, is of overuse tendinopathy. This is the most common tendinopathy in skeletally mature athletes, occurring in up to 20 of jumping athletes. Jumper's knee primarily affects the proximal posterior fibers of the patellar tendon and is a cause of significant functional disability in professional and recreational athletes 12 . Biomechanically, to squat and land softly from...

Distribution of Injuries and Ultrasound versus MR

Images Mri Hamstring

A review of 179 cases of injury to the hamstring muscle complex HMC using ultrasound 102 cases and MR 97 cases showed there were 21 injuries involving the proximal insertion on the ischial tuberosity with 16 tendon avulsions 154 injuries of the muscle belly, and only 4 injuries of the distal tendon or bone insertion site 33 . Approximately 80 124 cases of injuries involved the biceps femoris 54 proximal, 48 mid, and 22 distal 61 involved the myotendinous junction and 35 were considered...

Location of Injury and Imaging Prognosis

Hamstring Tendon Partial Tear

Intrinsic and extrinsic factors associated with recurrent hamstring injuries include inadequate warm-up, muscle fatigue, inadequate preseason training, muscle strength imbalances, decreased flexibility, increasing age, and history of prior injury 28 . Some suggest that an injured muscle may heal with scarring resulting in suboptimal muscle length that predisposes recurrent injury 29 . Because of the high risk of recurrent injury and variable convalescence period, imaging may have a prognostic...

Ankle

Arthrography Osteochondral

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...

Tarsal Bones

Stress Fracture Fifth Metatarsal Bone

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

Vastus Lateralis Tendinitis Mri

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...

Distal Injury

Distal Quadriceps Contusion

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

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

Posterior Calf Muscles

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...

Imaging Sports Medicine Injuries of the Foot and Toes

Images Leg Stress Fracture

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

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...

Proximal Adductor Injury

Obturator Externus Tear Mri

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

Stress Fracture Greater Trochanter

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...

Anatomy Thigh Axial

Hamstrings Mri Anatomy Axial

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...

Dysplastic Bump

Arthrogram Stress Fracture Femoral Head

Synovial herniation pits fibrocystic changes . A Anteroposterior radiograph showing a lateral femoral neck bump dotted arrow , indicating a cam type FAI. There is also a rounded lucency located in the anterolateral femoral neck solid arrow , an appearance known as a synovial herniation pit. The coronal view on the MR arthrogram is located far anteriorly B and shows the herniation pit to be low in signal arrow . This suggests the fibrous tissue within the pit they may also contain high...

Hip Tendons Muscles

Longitudinal Echo Imaging Hip

The superficial muscles and tendons about the hip can be evaluated with so-nography. Normal tendons demonstrate a hyperechoic fibrillar echo texture this is believed to be secondary to a highly organized collagenous makeup 10 . Partial tears are characterized by hypoechoic or anechoic focal defects involving either the surface or substance of the tendon Fig. 2 however, partial tears can be difficult to differentiate from tendinopathy, because imaging findings may overlap. Complete tears...

Compartment Syndrome

Ganglion Proximal Tibiofibular Joint

Compartment syndrome often involves the calf following blunt trauma or fracture 21,22 . It may also result from muscle strain injury and associated swelling and hematoma Fig. 29 . Compartment syndrome without muscle injury has been described in the anterior compartment of the lower leg in soccer players 127 . Increased pressure within fascial compartments leads to capillary circulatory compromise with ischemia to the musculature and nerves, and progress to tissue necrosis if left untreated....

Lateral Radiographs Of The Knee

Maldague Knee

Recently, several studies have described the limitations of the axial view for patellar alignment evaluation. Walker and colleagues 44 questioned the value of the axial view and compared the axial view with CT of the patellofemoral joint. They found that these two modalities often give conflicting results and concluded the axial view to be of limited value due to lack of sensitivity, as ''even florid examples of maltracking must be missed.'' Many researchers now advocate using the lateral view...

Distal Adductor injury

Distal insertional injury of the adductor may also occur as it inserts on the femur, known as adductor insertion avulsion syndrome and represents a traction injury along the muscle insertion on the femur similar to tibial shinsplints as a result of overuse often affecting athletes and military recruits 65-68 . MRI findings vary from periosteal edema to intramedullary signal changes. Radiographs may show periosteal reaction 67 . Based on anatomy, proximal injuries are associated with the...

Posteromedial Impingement

Occasionally after a severe ankle sprain, a thick, confluent scar persists between the medial wall of the talus and the posterior margin of the medial malleolus, causing persistent pain and localized tenderness, particularly with plantar flexion and inversion 43 . Development of this symptomatic local scarring has been referred to as posteromedial impingement, and is thought to result from the deep posterior deltoid ligament being crushed between the talus and the medial malleolus at ankle...

Plantar Plate Tear

Plantar Capsule Tear

Imaging sports-related injuries of the mid and forefoot complements the physical examination and clinical history. Stress fractures may be radiographically occult, in which case CT may facilitate detection, or MRI may be necessary Fig. 17. Sagittal 2D-GRE image A demonstrates pathologic elongation of the high signal zone, indicative of degenerative tearing of the plantar plate note hyperextension of the digit at the MTP joint. B Complete bilateral plantar plate rupture arrow with dorsal...

Peroneal Tendons

Calcaneocuboid Subluxation Mri

The peroneus longus originates from the proximal lateral fibula and inserts on the plantar aspect of the medial cuneiform and the base of the first metatarsal. The peroneus brevis originates from the distal lateral fibula and inserts on the base of the fifth metatarsal. On axial images, the peroneus longus tendon is located posterolateral to the peroneus brevis tendon Fig. 19 . Both are innervated by the superficial peroneal nerve and act to evert the foot. The peroneus longus also inhibits...

Snapping Hip Syndrome

Sonography Gluteal Bursa

This is a symptom complex characterized by pain and an audible or perceived snapping of the hip during movement such as exercise. It has various causes, which have been categorized as external, internal, and intra-articular. Fig. 6. Avulsion of the anterior inferior iliac spine apophysis AIIS in an adolescent. A Longitudinal ultrasound showing anteriorly displaced apophysis. Arrow, avulsed, displaced apophysis notched arrow, AIIS open arrow, femoral head. B Longitudinal ultrasound of normal...

Muscle Herniation

Chronic Compartment Syndrome Mri

One of the more common injuries to occur in the lower leg is a muscle hernia. A muscle hernia is a focal protrusion of a muscle through a small defect in the Fig. 29. Axial T2 image showing large soleus hematoma and lower extremity enlargement with muscle edema consistent with clinical finding of compartment syndrome arrow . Fig. 29. Axial T2 image showing large soleus hematoma and lower extremity enlargement with muscle edema consistent with clinical finding of compartment syndrome arrow ....

Anterior Inferior Acetabular Hip Paralabral Cyst

Iliopsoas Bursa

Rectus femoris avulsion in an athlete. A Coronal inversion recovery, and B axial T2, fat-suppressed images demonstrate avulsion of the origin of the biceps femoris from the left anterior inferior iliac spine. Note prominence of avulsed tendon arrows with surrounding soft-tissue edema and hemorrhage. Fluid distending the iliopsoas bursa, resulting in symptoms, is a common clinical problem. There may be communication between hip joint and bursa, with bursal distension resulting from...

Malalignment Evaluationtraditional Indices

Patella Subluxation Sunrise View

Several measurements obtained from the axial, or sunrise, view have traditionally been used to evaluate for malalignment. There are three main radiographic patterns of malalignment described with CT . These include subluxation of the patella with and without tilt, and tilt without subluxation 37 . Conditions that lead to malalignment and influence patellofemoral stability, such as depth of the trochlea, can be measured with imaging. The most common indices described in the literature are the...

Pelvic Apophyseal Avulsions Injury

Calcification Aiis

Likely sites of pelvic avulsions in adolescents with incomplete skeletal maturation include ischial tuberosity hamstring insertion , anterior superior iliac spine sartorius , anterior inferior iliac spine rectus femoris , pubic symphysis adductors , and greater and lesser trochanter gluteus muscles and iliopsoas and rarely iliac crest apophysis abdominal wall insertion 85 . Chronic avul-sive injuries can also be confused for malignant lesions or chronic infections and often result from chronic...

The Postoperative Meniscus

Meniscus Tear Exercises

All rights reserved. of preserving as much meniscal tissue as possible. Persisting symptoms following meniscal surgery may be from a recurrent tear at the site of previous surgery, the presence of a new tear at a site remote from the previous intervention, or extrameniscal pathology. Accuracy of MRI in assessment of meniscal tears in nonoperated ''virgin'' menisci is well established 5-7 . The MRI criteria for diagnosing meniscal tears in such cases include regions of...

Fatigue Fractures Of The Mid And Forefoot

Styloid Process 5th Metatarsal

Stress fractures are characterized by bone pain and tenderness without a history of direct trauma. The fatigue type of stress fracture results from repetitive cyclical loading and prolonged muscular force on bone that has normal elastic resistance. Conventional radiographs are often unremarkable at the onset of symptoms. Fatigue fractures usually result from alteration of the duration, intensity, or manner in which a physical activity is performed. Stress fractures of the foot are relatively...

Stress Reaction Femur

Femoral Shaft Stress Reaction Images

Stress fractures of the femur in runners may occur in the femoral neck, trochan-teric and subtrochanteric region, and femoral shaft. These injuries are often not considered in the initial presentation, and a high index of suspicion must be maintained. Patients commonly present with hip, groin, gluteal, thigh, or knee pain, depending on the location of the injury 18,72,73 . In a study by Clement and colleagues 72 , 71 patients who had 74 stress fractures of the femur were studied. Nearly 95 were...

Shoulder

Infraspinatus Tendon Tear

CT arthrography of the shoulder is an old technique, first developed for the assessment of the glenoid labrum 2 . Following the introduction and eventual widespread use of MRI for shoulder imaging, CTA was for all intents and purposes an antiquated study. Although a noncontrast MRI is excellent for the evaluation of rotator cuff disease, intra-articular pathology such as labral and biceps tendon tears is best evaluated with MRA, which is an invasive examination. As with other joints, a failed...

Osteitis Pubis and Marrow Edema

Mri Image Inguinal Region

Osteitis pubis inflammation of the pubic symphysis is generally associated with mechanical shear stresses, although direct traumatic and infectious etiologies have been described. It affects many different types of athletes including Fig. 18. Axial fluid-sensitive image showing asymmetric edema on the left in the inguinal region compatible with history of athletic pubalgia A . Coronal IR image demonstrating edema of pubic bones bilaterally arrows , which came by an incidental finding but this...

Plantar Fascia

The plantar fascia is a fibrous aponeurosis attaching to the plantar anterior aspect of the calcaneus, coursing adjacent to the plantar margin of the flexor dig-itorum brevis muscle, and sending digital slips to each toe. Interconnecting transverse fasciculi are present between the digital slips. The superficial transverse metatarsal ligaments and the flexor digitorum brevis tendons also have attachments to the plantar fascia. A smaller lateral band of the plantar fascia is present, extending...

Great Toe And Sesamoids

Medial Sesamoid

Stress fractures of the great toe and sesamoids are seen less frequently than other sites of stress-related injury, but when they do occur the diagnosis may be more difficult, resulting in a delay in diagnosis if this injury is not considered 8 . Stress fractures of the great toe have been reported in runners, soccer players, and volleyball players. Athletes who have pain in the first metatarso-phalangeal joint and who are exposed to excessive running, jumping, and repeated forced dorsiflexion...

References

1 Jarvinen TA, Jarvinen TL, Kaariainen M, etal. Muscle injuries biology and treatment. Am J Sports Med 2005 33 745-64. 2 Volpi P, Melegati G, Tornese D, et al. Muscle strains in soccer a five-year survey of an Italian major league team. Knee Surg Sports Traumatol Arthrosc 2004 12 482-5. 3 Garrett WEJr, Nikolaou PK, RibbeckBM, etal. The effect of muscle architecture on the bio-mechanical failure properties of skeletal muscle under passive extension. Am J Sports Med 1988 16 7-12. 4 Garrett WEJr,...

Intramuscular Central Tendon Injury

The largest study of the imaging appearance of quadriceps muscle strains followed 40 professional Australian Rules football players for 3 years and compared the rehabilitation interval time to return to full-time training after having completed a predefined rehabilitation regimen 8 . Fifteen cases involved the rectus femoris, six vastus intermedius, one vastus lateralis, and three had normal MRI exam. This study found central injuries around the central tendon had a statistically significantly...

Grade 3 Tibial Stress Fracture

Medial Malleolus Stress Fracture

The tibia is the most common site of stress-related injury in runners 6,8 . Leg pain is common in runners, and may be caused by a number of etiologies, Fig. 5. Navicular stress fracture. A Twenty-seven-year-old female tennis pro with pain and tenderness along the medial aspect of the navicular. Axial T2 SE image shows increased signal intensity within the navicular consistent with bone marrow edema, with a low-signal vertical line interrupting the dorsal cortex, consistent with a stress...

Diseases Of Hoffas Fat

Patellar Plica

A variety of disease entities can affect this structure and cause AKP, including impingement syndromes, postarthroscopy changes, plica syndromes, and mass lesions 27-30 . Acute or repetitive trauma to Hoffa's fat pad can result in edema and hemorrhage. The resultant changes of enlargement put the fat pad at risk for impingement between the femur and tibia. Fibrosis and anterior knee pain can result 27 . This is called Hoffa's disease or syndrome. Acutely, there is high T2 signal and mass effect...

Spring And Bifurcate Ligaments

Talar Stress Fracture

The spring ligament is composed of the superomedial calcaneonavicular ligament and the inferior calcaneonavicular ligament, and functions as a ''sling'' for the head of the talus Fig. 16 37 . Some authors describe a third portion of the spring ligament, with fibers extending from the notch between the calcaneal facets to the navicular tuberosity 44 . The deltoid ligament and posterior tibial tendon have direct attachments to the spring ligament 35-37 . The super-omedial calcaneonavicular...