Musculoskeletal Ultrasound: Disclosures: Dynamic Imaging • Consultant: BioClinica • Advisory Board: GE, Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier • Not relevant to this talk Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc.

Adhesive Capsulitis: Outline: • Frozen shoulder • Dynamic imaging • Gradual limitation in motion • Calf ultrasound • Incidence 2 – 5% • Plantar plate ultrasound • Diabetic (insulin dependent): 30% • Associations: female, trauma, >40 years old, diabetes, immobilization, thyroid disease, stroke, MI, autoimmune disease

Griesser, et al, JBJS 2011; 93:1727

Adhesive Capsulitis Adhesive Capsulitis: • Supraspinatus tendon does not slide beneath acromion with lateral elevation of arm • Sensitivity 91%, specificity 100%, accuracy 92%

Ryu et al. J Ultrasound Med 1993; 12:445

1 Impingement Syndrome Subacromial Impingement • Thickened tendon or bursa – Possible snapping of thickened bursa A A – “Gathering” of bursa: may be asymptomatic1 • Superior movement of humeral head – Possible contact between humerus and acromion2

1Daghir A et al. Skeletal Radiol 2012; 41:1047 2Bureau N et al. AJR 2006; 187:216

Subacromial Impingement: anterior Impingement: osseous

Joint Effusion: subscapularis recess Rotator Interval Tear

• Abnormal hypoechogenicity, SST non-visualization B • Abnormal supraspinatus,

superior glenohumeral , “Chondral Print Sign” subscapularis • Biceps instability – “Chondral Print Sign”* SST – Intracapsular instability B

Case #2: instability Case #3: remote tear Yellow Arrow = coracohumeral ligament

*Zappia M et al. Skel Radiol 2016: 45:35

2 Boxer Knuckle Boxer Knuckle: • Damage to the sagittal bands of extensor hood Short Axis –Transverse orientation • Extensor tendon subluxation or dislocation with finger flexion

Lopez-Ben et al. Radiology 2003; 228:642

Patellar Clunk Syndrome

Patellar Clunk Syndrome: • After total arthroplasty • 1% to 7.5% incidence • Fibrous nodule: intercondylar notch • Pain with flexion - extension

Okamoto T. et al. J Orthop Sci 2002; 7:590

Snapping: Snapping: sartorius over pes anerinus bursa semitendinosus over semimembranosus

Sartorius Semitendinosus

MG Bursa

Semimembranosus Tibia Tibia

3 Snapping: semitendinosus over semimembranosus

Semitendinosus Muscle Hernia • Cause: trauma, activities, weak fascia • Lower leg: especially anterior tibialis • Swelling with muscle contraction • US: muscle bulge, possible fascial defect Semimembranosus – Site of perforating vessel

Beggs, AJR 2003; 180:395

Muscle Hernia: anterior tibialis Muscle Hernia: anterior tibialis

Slipping Rib Syndrome Slipping Rib Syndrome • Abnormal mobility of cartilaginous rib • Slips over adjacent rib with muscle contraction or activity • Visible with dynamic ultrasound

J Ultrasound Med 2002; 21:339

4 Calf: pathology Outline: • Dynamic imaging • Tendon tear: • Calf ultrasound –Medial gastrocnemius: distal • Plantar plate ultrasound • Tennis leg –Plantaris: proximal, tubular –Lateral gastrocnemius and soleus: less common

Medial Head of Gastrocnemius Tear Medial Head of Gastrocnemius Tear

MG MG MG

Soleus Soleus Soleus Long Axis Short Axis

Long Axis

Medial Head of Gastrocnemius Tear Plantaris Tendon: tear

MG • Between medial gastrocnemius & MG soleus muscles • Hypoechoic fluid: tubular – *Mid-calf level Soleus – Between medial gastrocnemius & soleus Soleus • Tendon fiber disruption Long Axis Short Axis AJR 1999; 172:185

5 Plantaris Tear Plantaris Tear

MG MG MG

Soleus Soleus Soleus

Long Axis Short Axis

Short Axis Axial T2w

Plantaris Tear Soleus Hematoma

MG

Soleus

Long Axis Short Axis Long Axis Sagittal T1w

Tumor

Outline: • Dynamic imaging • Calf ultrasound • Plantar plate ultrasound

Metastasis: Renal Cell Sarcoma: high grade Carcinoma

6 FHL and Plantar Plate: Long and Short Axis Plantar Plate FHL • • Central stabilizing structure Proximal Phalanx Metatarsal Head Long Sagittal PDFS • Plantar to metatarsal head axis • Does not attach to metatarsal Yellow arrows = FHL • Firmly attached to proximal plantar plate * = Sesamoid * * phalanx phalangeal in short Metatarsal * * Head Short axis (hypoechoic axis Coronal From: Gregg JM et al. AJR 2006; 186:984 from anisotropy) PD

FHL and Plantar Plate: Long Axis Plantar Plate Injury

• US: hypoechoic defect • At proximal phalanx • Partial tear: articular surface * • Full-thickness tear: complete Proximal detachment Metatarsal Phalanx Head • May be asymptomatic finding in 47% (MTP 2 – 4)

Note: plantar plate (*), and adjacent sesamoid at end of video clip From: Gregg JM et al. AJR 2006; 186:984 Gregg JM et al. Eur Radiol 2006; 16:2661

Plantar Plate Injury and Pericapsular Fibrosis Pericapsular Fibrosis • From plantar plate tear • Simulate Morton neuroma nd • 2 MTP MT PP • Hypoechoic, eccentric Courtesy of H. Umans, New York • No nerve continuity Umans et al. Skeletal Radiol 2014; 43:1361

Plate Plate Injury Contralateral Normal

7 Syllabus on line and other educational material: www.jacobsonmskus.com Twitter handle: @jjacobsn

8