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Layered Approach to the Anterior Knee

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Layered Approach to the Anterior Knee 2069 I MUSCULOSKELETAL Layered Approach to the Anterior Knee: Normal Anatomy and Dis- orders Associated with Anterior Knee Pain M AG I Dyan V. Flores, MD NG Catalina Mejía Gómez, MD Anterior knee pain is a common complaint that can be caused by Mini N. Pathria, MD a wide spectrum of disorders affecting the many varied tissues at the anterior knee. The anatomy and pathologic conditions of the Abbreviations: ACL = anterior cruciate liga- anterior knee can be approached systematically by organizing the ment, FNS = focal nodular synovitis, MPFL = region into four layers: (a) superficial layer of fat, fascia, and bur- medial patellofemoral ligament, PD = proton sae; (b) functional layer composed of the extensor mechanism and density patellar stabilizers; (c) intracapsular extrasynovial layer contain- RadioGraphics 2018; 38:2069–2101 ing the fat pads; and (d) intra-articular layer. The superficial layer https://doi.org/10.1148/rg.2018180048 is composed of delicate tissues that are predisposed to blunt and Content Codes: penetrating trauma, irritation, and infection. The extensor mecha- From the Department of Radiology, Philippine nism forms the functional layer, is responsible for knee extension Orthopedic Center, Institute of Radiology, St and patellar stabilization, and is engaged in repetitive movements; Luke’s Medical Center Global City, Maria Clara overuse disorders dominate in this layer. The fat pads of the anteri- Street, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department or knee are discussed collectively as an extracapsular extrasynovial of Radiology, Hospital Pablo Tobón Uribe, layer, functioning to improve congruence and protect the articular Medellín, Colombia (C.M.G.); and Department of Radiology, UCSD Medical Center, San surfaces during motion. Diseases involving the fat pads can be pri- Diego, Calif (M.N.P.). Presented as an education mary or secondary to pathologic conditions in the rest of the joint. exhibit at the 2017 RSNA Annual Meeting. The synovial lining and cartilage surface are in the fourth and final Received March 2, 2018; revision requested April 16 and received April 25; accepted May 4. For intra-articular layer; pathologic conditions are centered around this journal-based SA-CME activity, the authors, arthritides and internal derangement. Symptoms in the anterior editor, and reviewers have disclosed no relevant relationships. Address correspondence to knee may be due to conditions affecting one or more of these in- D.V.F. (e-mail: [email protected]). terrelated layers. ©RSNA, 2018 ©RSNA, 2018 • radiographics.rsna.org SA-CME LEARNING OBJECTIVES After completing this journal-based SA-CME activity, participants will be able to: Introduction ■ Describe the anatomy of the anterior Anterior knee pain is a common clinical syndrome, accounting for knee and organize the many bone and 11%–17% of physician visits for knee symptoms and most commonly soft-tissue structures in this region into sequential layers to evaluate them sys- affecting activities in patients below the age of 40 years, but also affect- tematically. ing adolescents and older adults (1). Anterior knee pain can manifest ■ List the osseous, myotendinous, and as insidious onset of symptoms during activities associated with patel- ligamentous components of the extensor lar loading—such as squatting, climbing stairs, and running—or after mechanism involved in knee extension an acute injury; overuse and acute injury can affect any of the ana- and patellofemoral stabilization and tomic structures at the anterior knee (1,2). In addition to mechanical recognize the most common pathologic conditions associated with each of them. causes, there are a host of degenerative, inflammatory, and neoplastic ■ Discuss why intracapsular pathologic causes of anterior knee symptoms. The condition is variably referred conditions affecting the fat pads and to clinically as patellofemoral pain syndrome, jumper’s knee, runner’s knee articular cavity result in alterations knee, and chondromalacia (1,3). These terms are used interchange- that preferentially affect the anterior knee ably to describe clinical symptoms and chondral abnormalities at the joint and manifest as anterior knee pain. anterior knee of varying cause and severity. See rsna.org/learning-center-rg. 2070 November-December 2018 radiographics.rsna.org altered movement or metabolic activity play an im- TEACHING POINTS portant role in anterior knee pain (2,4). ■ The superficial layer at the anterior knee includes the skin, In this article, common pathologic conditions subcutaneous fat, superficial prepatellar bursae, superficial at the anterior knee are reviewed using a layered infrapatellar bursa, and fascia. Owing to their exposed posi- tion, these extracapsular soft tissues are predisposed to acute approach from superficial to deep (Table 1). injury, repetitive overuse, penetrating trauma, and infection. ■ There is inconsistent terminology applied to overuse-related Imaging Techniques patellar tendon disease, with the terms tendinitis, tendinosis, An array of imaging techniques are used for as- partial insertional tear, and jumper’s knee all applied to a spec- sessment of anterior knee disease (5). Anteropos- trum of abnormalities commonly affecting the tendon, par- terior and lateral radiographs allow detection of ticularly near its patellar attachment. Histologically, the most common finding related to overuse is tendinosis, a noninflam- effusion, arthrosis, alignment, and most fractures. matory disorder caused by repetitive tensile overloading re- Axial views profiling the patellofemoral joint allow sulting in collagen damage. better evaluation of patellofemoral alignment, ■ Normal patellofemoral tracking requires a complex interac- osteoarthrosis, and patellar fractures. CT allows tion between the osseous geometry of the articulation and evaluation of subtle or complex fractures, soft- mechanical balance between the static and dynamic extensor tissue mineralization, and bone lesions that are mechanism soft-tissue stabilizers that converge on the patella. poorly delineated on radiographs. CT, either static Chronic patellar maltracking is often multifactorial, related to both osseous morphology and soft-tissue imbalance, lead- or with incremental flexion, is useful for assess- ing to malalignment, instability, and accelerated arthrosis. ment of osseous morphology and patellofemoral Maltracking is a common cause of anterior knee symptoms, alignment in patients with suspected maltrack- particularly in young females. Despite extensive literature on ing (6,7). US is widely used for assessment of this disorder, there is little consensus on optimal imaging cri- soft-tissue disease and for guiding interventional teria or management. procedures (8,9). ■ The fat pads of the knee are deformable structures composed of a highly innervated and vascularized scaffold of adipose MRI plays a vital role in evaluation of anterior and fibrous tissue. They improve articular congruity and func- knee disorders. Spin-echo, fast spin-echo, and tion as both lubricants and protective cushions for the articu- short τ inversion-recovery (STIR) sequences are lar surfaces. There are three fat pads in the knee joint that will most commonly employed, highlighting anatomic be considered; all are extrasynovial structures located at the abnormalities and changes in fluid distribution in anterior knee and potential sources of knee pain. bone, cartilage, and soft tissue (10,11). Gradient- ■ Common intra-articular disorders related to anterior knee pain echo (GRE) sequences are useful in select cases include plica-related disorders, abnormalities of the patello- femoral cartilage, crystal-induced arthritides that favor the an- for assessment of physeal and hyaline cartilage terior knee, as well as inflammatory arthritides and synovium- and detecting hemosiderin (12). Intra-articular based neoplasms. pathologic conditions are better evaluated when there is an effusion or after injection of intra- articular contrast material. Enhancement with intravenous contrast material aids in assessment The anterior knee is a composite of a number of synovitis, infection, and neoplasms. Quanti- of tissues that need to interact in a cohesive man- tative MRI techniques are promising research ner during physical activity, and imaging plays an tools for detecting cartilage abnormalities before important role in evaluating the myriad abnor- structural damage (13). malities that can affect this region. It is challenging for the radiologist to evaluate the many anatomic Layer 1: Superficial Soft Tissues lesions that might be responsible for a patient’s The superficial layer at the anterior knee includes symptoms without a systematic approach (3). the skin, subcutaneous fat, superficial prepatellar Approaching the anterior knee as a series of tissue bursae, superficial infrapatellar bursa, and fascia. layers helps the radiologist systematically evaluate Owing to their exposed position, these extracapsu- all the structures at the anterior knee that may be lar soft tissues are predisposed to acute injury, re- contributing to clinical symptoms. petitive overuse, penetrating trauma, and infection. The anterior knee can be conceptualized as The most common pathologic condition affecting four layers of tissues: (a) a superficial layer, (b) a the superficial layer is symptomatic bursitis of the functional layer containing the extensor mecha- superficial prepatellar and infrapatellar bursae. The nism and patellar stabilizers, (c)
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