Subtle Lesions: MSK MRI

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Subtle Lesions MSK MRI

• Steve Eilenberg, MD
• Director of MRI
• North County Radiology

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Expectations

• Earliest days of MRI
• MSK MRI had no future because cortical bone was
  black
• Midlife of MSK MRI
• Find those Grade 3 Menisci and FTRCTs
• State of the art MSK MRI
• Redefining anatomy and pathology
• Way beyond the menisci and RC
• Fewer truly negative MRIs
• Justification of MSK Fellowship programs

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Subtle Cases

• Disclaimer
• Not all cases shown in this presentation are
  proven.
• Some opinions/conclusions have not been validated
  in peer reviewed journals

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Case 1

• 51 year old female with atraumatic shoulder pain
  increasing over the last few months. Pain is
  worse at night

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Adhesive Capsulitis

• How could something so profound clinically and
  arthroscopically be so subtle on MRI?
• Surgeons do not think we can make this dx
• Are looking for co-existent pathology
• RCT
• Not particularly prevalent in this population
• Other

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Adhesive Capsulitis

• Taken from presentation of Scott Rodeo, MD from
  HSS
• Can be confused with impingement early on
• Females gtgt Males
• Early Dx important
• 15 have history of previous contralateral AC
• Most are treated non operatively
• Early treatment alters disease course

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Adhesive Capsulitis

• Stages
• Early proliferative (pain)
• Up to around 3 months
• Treatment IA steroids
• Late proliferative (pain)
• 3-9 months
• PT, arthroscopy, IA steroids
• Remodeling (stiffness. no pain)
• 9-13 months
• IA steroids of no value
• Capsular release and manipulation

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Adhesive Capsulitis

• History
• Pain. Dull Ache. Night Pain
• Pain precedes loss of motion
• Post menopausal, diabetes, RT history (breast
  cancer), cx spine disease

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Adhesive Capsulitis

• PE
• Loss of external rotation
• Pain on palpation of anterior capsule

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Axial Images

• Blurry capsule margins
• Indistinct articular side of the subscapularis
  tendon
• Isolated distension of the subscapularis bursa

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Coronal Images

• Thickened and indistinct axillary recess
• What is too thick?
• 4 mm or greater
• Amount of joint fluid?
• Usually not a large effusion otherwise not very
  helpful
• Abnormal tissue at interface of long head and
  musculotendinous junction of the supraspinatus
  tendon

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Coronal Images

• Thickened and indistinct axillary recess
• What is too thick?
• 4 mm or greater
• Amount of joint fluid?
• Usually not a large effusion otherwise not very
  helpful
• Abn tissue at interface of long head and
  musculotendinous junction of the supraspinatus
  tendon

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Sagittal

• High signal ring around the the glenoid fossa,
  deep to the RC muscles
• Thickening of the RC interval
• Identify the CA ligament
• Identify the bursa
• Identify the interval

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14 year old female with recent soccer injury and
a several month history of knee pain
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Root Ligament Avulsion

• Loss of Hoop Stress
• Hard to find arthroscopically
• Repairable in this case
• Excellent prognosis if repaired

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Arthroscopic Findings and Treatment
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Root Ligament Tear

• Bony avulsion of the posterior medial meniscal
  tibial ligamentous attachment
• Absence of the normal comma shaped terminal
  extension of the posterior horn as it inserts on
  the tibia
• In this case, bone marrow edema related to bony
  avulsion

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The Root Ligament

• This is the normal orientation of the meniscal
  tibial root ligament
• There is not much normal variation here
• Good technique should identify it on most

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42 Year Old Male with Medial Pain, Increasing
Over the Past 6 Months
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Findings?
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So, You Found the Mensical Tear

• Orientation and extent?
• Stable or unstable?
• Type
• Extent
• Repairable?
• Likely symptomatic?

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Associated Marrow Edema

• Is there associated chondromalacia?
• If so, this helps prognosticate the patient
• Do you feel that the edema is directly related to
  trauma?
• Do you think that the marrow edema is related to
  the tear and not underlying chondromalacia
• In some way, reflecting chemical or mechanical
  irritation
• Probably more likely to be symptomatic
• Probably likely to progress, fall apart, and lead
  to OA

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Companion Case
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15 Year Old Active Female with Progressive
Shoulder Ache Over the Past Year
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Chronic Osteochondral Injury to the Glenoid Fossa
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What Constitutes Chronic

• Lack of acute history
• Does not exclude chronic as can exacerbate
  acute on chronic
• Lack of significant effusion
• Lack of marrow edema

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39 Year Old Active Male with Retropatellar Pain,
Increasing over the Past Several Months
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Findings?
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Hoffitis

• Can be a generalized process involving all of
  Hoffas fat pad
• Can be focal involving a tongue of fat
  superiorly, inferiorly and posteriorly
• Can see an enlarged pad
• Cause?
• Result?
• Impingement?
• Trauma?

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Companion Case
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Hoffas Disease
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MR Arthrogram .2 T E Scan
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