Sports Medicine Imaging

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Sports Medicine Imaging

• Timothy G. Sanders, MD
• Director of Education and ResearchNational
  Musculoskeletal Imaging Weston,
  FLandProfessor, Part-TimeDepartment of
  RadiologyUniversity of Kentucky

NMSI
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MR Imaging

• T1-weighted (short TE/TR)
• Anatomy Image
• Muscle intermediate
• Fluid intermediate
• Calcium dark
• Fibrous tissue dark
• Fat (marrow) bright

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MR Imaging

• T2-weighted (long TE/TR)
• Pathology Image
• Muscle intermediate
• Fluid bright
• Calcium dark
• Fibrous tissue dark
• Fat (marrow) bright
• Fat saturation technique

Look for bright signal in joint Bright Fluid T2
image
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Intravenous GadoliniumNephrogenic Systemic
Fibrosis (NFS)

• 1997 a new fibrosing skin disorder was identified
  in patients with renal disease
• Fibrosis of skin and connective tissue
• Skin thickening/ decreased ROM joints
• Progressive disease with reports of death
• 2006 first linked to contrast agents containing
  gadolinium

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Intravenous GadoliniumNephrogenic Systemic
Fibrosis (NSF)

• No known treatment for NSF
• Reported only in patients with severe renal
  disease
• Often on dialysis, but not all patients
• FDA warning to avoid gadolinium
• Acute or chronic severe renal disease (GFR lt30)
• Hepato-renal syndrome
• Perioperative liver transplant period
• Incidence 3-5 in patients with severe / endstage
  renal disease

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Intravenous GadoliniumNephrogenic Systemic
Fibrosis (NSF)

• Question all patients to receive gadolinium for
  history of
• Acute or chronic kidney disease
• History of dialysis
• Diabetes
• Liver disease
• Recent chemotherapy
• Avoid gadolinium if GFR lt 30
• Informed consent

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Computed Axial Tomography (CT scan)

• Improved soft tissue contrast
• Occult fractures
• Complex fractures
• Axial skeleton
• Intra-articular fractures
• Hardware complications

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Nuclear Medicine
Screening tool -High sensitivity -Entire
skeleton -Poor anatomic detail
Indications -Radiographically occult
lesions -Orthopedic infections -Incidental bone
lesions -Surveillance for additional/multiple
lesions
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Nuclear Medicine Bone Scan
-Overuse injuries -Bone scan sensitivity near
100 -Radiograph sensitivity 15
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Nuclear Medicine Bone Scan

• Orthopedic Infections
• Bone scan
• No surgery or trauma
• Labeled white blood cells
• Recent surgery or trauma
• Bone scan and Ga-67
• Spine

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Ultrasonography
-Widely used as an imaging tool since the 1970s
-Popularized for imaging of the musculoskeletal
system mid-1980s -Primary Indications -Muscles
and tendons -Soft tissue masses and foreign
bodies -Dynamic evaluation
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Ultrasonography
-Mechanical pressure waves rather than ionizing
radiation -No known adverse biological effects
-Highly operator dependent -Time consuming for
the physician
-The probe functions as a transducer/
receiver -Sound wave sent into body -As wave
encounters different interfaces -Portion of wave
reflected back -Computer generates image
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Ultrasound
-Muscles, tendons, dynamic evaluation -Operator
dependent
Normal Achilles Tendon
Chronic Tendinopathy
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Muscles
-Gastrocnemius with hematoma
-Torn Rectus Femoris muscle
-Dynamic evaluation of Rectus Femoris -Complete
disruption of fibers
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S.T. Masses
Bakers Cyst
Subdeltoid Bursitis
Cyst versus solid Complex S.T. mass (MFH)
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Shoulder Imaging
Radiographs
CT
MR
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Osteolysis of Distal Clavicle
Post-traumatic osteolysis -Acute trauma (occurs
within 2 months of injury, self
limiting) -Repetitive stress (wt.
lifters) -X-ray loss of normal cortical line-
distal clavicle -MR high signal in distal
clavicle -Acromion normal abnormality isolated
to distal clavicle
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Anterior Dislocation
Diagnosis?
-Hill-Sachs defect
-Osseous Bankart lesion
West Point View
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Normal Labrum
Anterior/ Posterior Labrum Axial Plane
LABRUM -Dark on all Pulse Sequences -Triangular
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Bankart Lesions
Osseous
Fibrous
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Hill-Sachs Lesion
-Impaction Humeral Head against Anterior-inferior
Glenoid -Associated with Bankart Lesion -Top 3
Images Round -Hill-Sachs Flattening or Concavity
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Normal Superior Labrum
Coronal Plane
Superior Labrum -Dark on all pulse
sequences -Triangular -Extends off of Superior
Glenoid
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SLAP Lesion
-Normal Superior Labrum -Black
-SLAP tear -Signal within superior labrum
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Middle Glenohumeral Ligament
-Prevents external rotation of humeral head when
arm is between 45º and 60º of abduction
-Originates at superior glenoid tubercle
-Courses obliquely superficial to the anterior
labrum -Blends with the deep fibers of
subscapularis
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Normal Anatomic Variant
-Buford Complex -1.5 of Patients -Can Mimic
Anterior Labral Tear
-Thick Cord-like MGHL
-Absent or Diminutive Anterior-Superior Labrum
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Inferior Glenohumeral Ligament
-Redundant when the Arm is in Neutral Position
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HAGL Lesion
Humeral avulsion of glenohumeral ligament
Disrupted IGHL at humeral attachment site
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Locked posterior dislocation

• Reverse Hill Sachs
• Widening of GH joint
• Locked in internal rotation

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MRI Performed 3 weeks following original injury
Locked posterior dislocation Reverse Hill Sachs
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Rotator Cuff Imaging

• Normal cuff
• Dark on T1 and T2

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Rotator Cuff Imaging

• Tendonopathy
• Intermediate signal on T1 and T2
• Thickened tendon

• Calcific Bursitis/ tendonitis
• Globular low signal
• Blooming artifact- Gradient echo

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Rotator Cuff Imaging

• Tear
• Bright (fluid) signal on T2

Fluid Tear
Fatty atrophy
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Subscapularis tendon tear with medial dislocation
of the LHBT
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Axillary Nerve Neuropraxy
Axillary Nerve can be stretched at time of
anterior dislocation resulting in denervation
atrophy Deltoid and Teres Minor muscles
Denervation atropy -Acute edema -Chronic fatty
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Paralabral Cysts
-Suprascapular nerve entrapment -Denervation
edema

• SLAP tear
• Paralabral cyst
• Suprascapular notch

• Supraspinatus
• Infraspinatus

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Case 1
What is the most likely diagnosis?
Rotator cuff tear
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Case 2
MRI of a patient with shoulder weakness. What is
the most likely diagnosis?

• Quadrilateral space syndrome
• Axillary nerve
• Deltoid
• Teres minor

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Imaging of the Elbow
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Biceps Tendon Tear with Retraction
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UCL ligament Injury
T sign Partial thickness UCL tear
20 y.o. pitcher
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OCD of the Capitellum
Gymnast
Professional Baseball player
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Olecranon Stress Fracture
18 y.o. pitcher with posterior elbow pain
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Posterior Elbow Dislocation
-FOOSH -Fractures Adult coronoid/ radial head
Child Avulsion of medial epicondyle
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Radiographically Occult Fractures of the Elbow
The Sail Sign
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Radiographically Occult Elbow Fracture

• Adult radial head/neck fracture-
• Fracture line dark on T1
• Dark or fluid signal on T2

-adult
-Supracondylar fracture child
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Radiographically Occult Elbow Fracture
Child supracondylar fracture
-Supracondylar fracture child
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Posterior Elbow Dislocation in Child
-Associated with medial epicondyle avulsion in
50 of cases -Up to 30 become entrapped in the
joint following reduction
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Imaging of the Hand and Wrist
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Tendonopathy
-Fluid in Tendon Sheath -Thickening/ High Signal
in Tendon -T2 Axial Images
-Flexor Carpi Radialis Longus
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De Quervains Syndrome
-Tenosynovitis -Extensor Pollicis
Brevis -Abductor Pollicis Longus
-Sporting activity requiring repetitive ulnar
deviation of wrist Mechanical -Canoeists
-Weightlifters
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Scapholunate Ligament
-Perforation -Visualize Fluid Extending Through
Ligament -Traumatic Tear Vs. Age Related
Perforations
Coronal T1 Arthrogram/ fatsat
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Ulnar Impaction Syndrome
-Positive ulnar variance -Perforation of
TFCC -Cartilage defects distal ulna and proximal
lunate -Subchondral cystic change
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14 y.o. gymnast with bilateral wrist pain
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Carpal Dislocations
Triangular appearance
Dislocations

• Lunate
• Lunate dislocates in volar direction

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Diagnosis?
Scaphoid fracture with Avascular Necrosis
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Scaphoid Fracture Complications
-AVN complication of scaphoid fracture -Recurrent
blood supply -Risk factors delayed diagnosis,
displacement, proximal fracture site
Scaphoid fracture complication rate is
high -AVN -Delayed/ nonunion -Osteoarthritis
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What soft tissue structure is injured?
Mallet Finger (Baseball Finger)
Avulsion of extensor digitorum tendon
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Volar Plate Avulsion
What soft tissue structure is injured?
--Hyperextension avulsion injury -MCP or PIP
joint dorsal dislocation
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What soft tissue structure is injured?
-Avulsion of flexor digitorum profundus -Forced
hyperextension -Osseous fragment displaced
proximally Jersey Finger
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Imaging of the Hip and Pelvis
Double Line Sign Avascular Necrosis
-T2 -AVN -Zone of healing interface -80 of AVN
cases
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Stress Fracture of Hip

• Plain film
• Sclerotic line
• Perpendicular to normal trabeculae

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Stress Fracture of Hip
-MRI dark line on all pulse sequences -Line
incomplete -Surrounding edema
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Avulsion Injuries of the Pelvis
Sartorius
Rectus Femoris
Gluteus Medius
Hamstring
Iliopsoas
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Anterior Superior Iliac Spine
Sartorius/ tensor fascia lata attachment site
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Anterior Inferior Iliac Spine
Rectus Femoris
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Old Rectus Femoris Avulsion
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Rectus Femoris Avulsion Injury

• MR
• If x-ray is normal or equivocal

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Ischial Tuberosity Hamstring/ Adductor Magnus
Attachment Site
-Large avulsion fragment -Mimic
neoplasm -Sprinters
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Beware Avulsion Fracture Lesser Tuberosity in
Aduts
-Pathologic fracture until proven otherwise in an
adult
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FAICam Type
-Results from prominence of femoral neck -Labral
tear -Subchondral cysts lateral aspect of femoral
neck
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FAIPincher Type
Pincher Impingement -Results from acetabular
abnormalities
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Sports Imaging of the Knee
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Imaging of the ACLThings you must know!

• Normal MR appearance (all 3 imaging planes)
• Primary signs of ACL disruption (all 3 imaging
  planes)
• Secondary signs of ACL disruption
• Commonly associated soft tissue injuries
  (meniscal tears, posterolateral corner injuries)

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The Anterior Cruciate Ligament Normal MR
Appearance
-High signal striations between strands of distal
ACL
-2 separate bundles distal ACL -Anteromedial/
Posterolateral
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The Empty Notch Sign
Normal proximal ACL attachment
Fluid signal at normal attachment site of ACL
proximal avulsion
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Primary signs of disruption
Abnormal morphology
Disrupted fibers
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Secondary signs of ACL disruption

• Deep sulcus sign
• Impaction lateral femoral condyle against
  posterior tibia
• Normal sulcus lt1.5mm

ACL Tear
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Secondary signs of ACL Tear

• Pivot shift edema pattern
• Posterolateral femoral condyle
• Posterior lateral tibia

ACL Tear
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Secondary signs of ACL tear

• Segond fracture
• Avulsion of the lateral capsule

ACL Tear
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Diagnosis?
Tibial Avulsion Fracture of ACL Most commonly
seen in the adolescent patient
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Meniscal Tears Associated with ACL Tears
-Most common acute meniscal injury associated
with ACL tear -Vertical tear of the PHLM -Most
commonly missed meniscal tear on MR imaging
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Meniscal Tears Associated with ACL Tears

• ODonahues Triad
• ACL tear
• MCL injury
• MM tear

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Normal PCL
-Curvilinear dark structure -Usually seen on 1-2
images
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PCL Disruption Dashboard Bone contusion pattern
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Iliotibial Band Friction Syndrome

• Long distance runners
• Friction injury

• MRI Findings
• Edema deep to iliotibial band
• Thickened band

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Posterolateral Corner Injuries

• Injury of the arcuate ligament and of the
  popliteofibular ligament associated with edema of
  medial fibular head
• Associated with ACL disruption resulting from
  hyperextension or pivot shift injury

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Medial Collateral Ligament Injury
Grading MCL Injuries Grade 1 Superficial
edema Grade 2 Partial tear Grade 3 Complete tear
Grade 1
Grade 2
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Grade III- Complete Disruption
Proximal disruption
Distal disruption
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Diagnosis?
Transient Lateral Patellar Dislocation
-Anterolateral aspect of lateral femoral
condyle -Inferomedial patella
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Associated Injuries
Osteochondral Injury of Patella
Osteochondral Injury of Lat Femoral Condyle
Disruption of medial patellofemoral ligament
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Patellar Tendon
Patellar tendonitis Thickening of tendon
Partial tear of tendon Fluid signal on T2 images
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Quadriceps Tendon
Complete disruption
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MRI Normal Meniscus
-Normal DARK Signal -T1 Sensitive -T2
Specific
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MRI Normal Meniscus
Peripheral
Central
1.5 2 bow ties
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Direct Signs of Meniscal Tear
-Grade 3 Signal -Extending to articular surface
Vertical tear
Horizontal
Complex tear
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Direct Signs of Meniscal Tear
Missing fragment
Displaced fragment
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Diagnosis?
Double PCL Sign Bucket Handle Tear Medial
Meniscus
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Diagnosis?
Bucket Handle Tear Lateral Meniscus
Posterior horn flips anteriorly
Double anterior horn sign lateral meniscus
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What is the arrow pointing to?
- Anterior transverse meniscal ligament -Attaches
to the anterior horn lateral meniscus -Mimic
meniscal tear
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Meniscofemoral Ligament
-Attaches to the PHLM

• Mimic meniscal tear
• Humphry/ Wrisberg

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Popliteus Tendon Sheath
-Fluid tracking in popliteal tendon sheath
-Mimic meniscal tear PHLM
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Discoid Meniscus
-More than 2 Bow Ties -Lateral
meniscus -Increased risk of meniscal tear
Coronal image meniscus extends beyond1/2 way
point of condyle
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Diagnosis?
-Meniscal Cyst and meniscal tear -Horizontal
cleavage tear -DDX cruciate ganglia, bursitis,
other ganglia
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Imaging of the Ankle
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Achilles Tendonitis/ Tear

• Gap in Achilles tendon with high signal

• Thickened
• Increased signal
• Convex anterior boarder

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Flexor Tendons
Tom, Dick, and Harry Tibialis Posterior Flexor
Digitorum Longus Neurovascular Bundle Flexor
Hallucis Longus
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Diagnosis?

• Posterior tibialis tendonosis
• Thickened tendon
• Fluid in tendon sheath

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Diagnosis?
Split Peroneal Brevis
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Diagnosis?
-Disruption of Superior Peroneal Retinaculum
Peroneal tendons subluxation
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Commonly Missed Fracture Following Ankle
Inversion Injury
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Osteochondral Lesions
Type I- marrow edema, cortex intact Type II-
partial disruption of overlying cortex Type III-
complete separation, fragment in situ Type IV-
displaced fragment
Type III
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Thank you!