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 ligament, “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 knee 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 • Fibrocartilage • 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 ligaments 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 joint 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
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