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Lower Extremity Ultrasound with MRI Correlation Lower Extremity Ultrasound with Disclosures: MRI Correlation • Consultant: Bioclinica • Advisory Board: Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier 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. Outline Hip: anterior recess •Hip – Effusion • Anterior and posterior layers – Trochanteric pain syndrome – Fibrous tissue + minute layer of synovium – Iliopsoas snapping – Hyperechoic Radiology 1999; 210:499 • Knee – Each 2 - 4 mm thick – Joint effusion and extensor mechanism – Baker cyst • Ankle and Foot – Achilles and peroneal tendons – Ligaments Hip: anterior recess Hip Effusion: 1 • Anterior +posterior layers • Separation of anterior and posterior layers – Fibrous tissue + • Capsule distention at femoral neck > 7 mm or minute layer of Anterior difference of 1 mm from opposite side2 synovium Posterior Femur • Extension & abduction improves – Hyperechoic visualization3 – Each 2 - 4 mm thick • Do not internally rotate hip: capsule thickens 1 Radiology Radiology 1999; 210:449 1999; 210:499 2Scand J Rheumatology 1989; 18:113 3Acta Radiologica 1997; 38:867 1 Hip Joint: septic effusion Hip Labrum • Normal: Labral Tear – Hyperechoic, triangular • Degeneration: hypoechoic • Tear: * – Anechoic cleft – Most common anterior Acetab * FH – Possible paralabral cyst Femoral Neck * – Sensitivity 82%, Head * specificity 60%* Long Axis Sagittal-oblique *Jin W et al. J Ultrasound Med 2012; 31:439 Labral Tear and Paralabral Cyst Outline •Hip – Effusion – Trochanteric pain syndrome – Iliopsoas snapping • Knee – Joint effusion and extensor mechanism – Baker cyst • Ankle and Foot Courtesy of D. Fessell, Ann Arbor, MI – Achilles and peroneal tendons – Ligaments Greater Trochanter Trochanteric Pain Syndrome: • Most commonly caused by gluteus minimus and medius tendon abnormalities1 • Trochanteric bursitis: uncommon – 20% of symptomatic patients2 – Not actually inflamed3 – Not associated with pain4 1Eur Rad 2007; 17:1772 2Long SS et al. AJR 2013; 201:1083 3Clin Rheumatol 2008; 14:82 4Skeletal Radiol 2008; 37:903 Pfirrmann et al. Radiology 2001; 221:469 2 Greater Trochanter Trochanteric Bursitis Subgluteus Medius Gluteus Medius Gluteus Bursa Minimus TFL Trochanteric Bursa Glut Subgluteus Max Minimus Bursa LF AF PF PF AF: anterior facet LF: lateral facet PF: posterior facet Transverse Coronal Gluteus Medius Gluteal Tendon Pathology: • Tendinosis: hypoechoic, no defects • Partial tear: anechoic clefts • Complete tear: discontinuous tendon LF • >2 mm cortical irregularity is associated with Short Axis Long Axis tendon tear – Positive predictive value = 90% (xray)* *Steinert et al. Radiology 2010; 257:754 Tear: Gluteus Medius Calcific Tendinosis: Gluteus Medius LF LF AF AF LF LF >2 mm cortical irregularity (x-ray) = 90% positive predictive value for gluteus tendon tear Steinert et al. Radiology 2010; 257:754 3 Outline •Hip – Effusion Snapping Hip Syndrome – Trochanteric pain syndrome • Painful snap with hip motion – Iliopsoas snapping • Intraarticular • Knee • Extraarticular: – Joint effusion and extensor mechanism – Anterior: iliopsoas tendon – Baker cyst – Lateral: iliotibial tract or gluteus maximus • Ankle and Foot – Achilles and peroneal tendons – Ligaments Iliopsoas Complex Snapping Hip Syndrome: iliopsoas • Image long axis to inguinal ligament superior to femoral head AIIS • Extension of flexed abducted and externally rotated hip Ilium • Abrupt movement of iliopsoas as iliacus muscle interposed between tendon and bone moves Red: psoas major Deslandes et al. AJR 2008; 190:576 Orange: medial iliacus fibers Purple: lateral iliacus fibers From: Guillin R. et al. Eur Rad 2009; 19:995 Snapping Hip Syndrome: iliopsoas Iliopsoas Bursa: • Hip joint communication in 10% – Increased with hip joint pathology • May extend cephalad into abdomen • May be mistaken for abscess: – Look for hip joint communication Radiology 1995; 197:853 4 Iliopsoas Bursal Fluid Outline • Hip – Effusion – Trochanteric pain syndrome – Iliopsoas snapping • Knee – Joint effusion and extensor mechanism IP – Baker cyst Femoral • Ankle and Foot Head – Achilles and peroneal tendons Axial T1w post-gadolinium – Ligaments Suprapatellar Recess and Gutters Joint Effusion • Suprapatellar recess – Superior • Prefemoral & quadriceps fat pad separation • Distends with partial knee flexion – Medial and lateral to patella • Distends with knee extension • Transducer pressure displaces joint effusion From: Miller PJ et al. Am J Sports Med 2001;29:822. Joint Effusion: transverse plane Joint Effusion: sagittal plane Patella Patella Quadriceps Femur Patella Femur * * Femur Sagittal T2w Transverse 5 Quadriceps Tendon: tendinosis Joint Effusion: Patella knee extension Quad Patella Patella Patella Femur Femur Long Axis Femur Quadriceps Tendon: Partial Tears Quadriceps Tendon: full-thickness tear RF RF Vasti P V P Patella Rectus Femoris Tear (1 layer) Vasti Tear (2 layers) Long Axis Sagittal PDw Patellar Tendon: tendinosis Patellar Tendinosis: • Jumper’s knee • Hypoechoic swelling • Mucoid degeneration, possible Patella interstitial tearing • Hyperemia: neovascularity • No inflammatory cells Long Axis Radiology 1996; 200:821 6 Patellar Tendon: tendinosis Patellar Tendon: full-thickness tear Patella Long Axis Sagittal PDw color Doppler power Doppler Gout: patellar tendon Outline • Hip – Effusion P – Trochanteric pain syndrome T – Iliopsoas snapping • Knee – Joint effusion and extensor mechanism – Baker cyst • Ankle and Foot – Achilles and peroneal tendons – Ligaments Anatomy: posterior Baker Cyst: • Semimembranosus-medial gastrocnemius bursa • 50% over age of 50 have communication with knee joint • Cyst communication to posterior knee between SM-MG tendons required AJR 2001; 176:373 From: Netter’s Atlas of Human Anatomy 7 Baker Cyst Baker Cyst MG SM MG Medial Gastrocnemius SM Transverse Longitudinal Axial Axial T2w Baker Cyst: intraarticular body Baker Cyst: rupture Longitudinal Coronal T2w Transverse Sagittal PDw Outline • Hip Achilles Tendon: – Effusion – Trochanteric pain syndrome • 2 – 6 cm proximal to insertion – Iliopsoas snapping – Tendinosis • Knee – Full-thickness tear – Joint effusion and extensor mechanism • Calcaneal attachment – Baker cyst – Tendinosis, tear • Ankle and Foot – Haglund Syndrome – Achilles and peroneal tendons – Ligaments 8 Achilles Tendon: partial-thickness tear Tendinosis: Achilles Long Axis Longitudinal power Doppler Courtesy of Jon Halperin, San Diego Achilles Tendon: full-thickness tear Achilles FTT + Intact Plantaris Plantaris Transverse Longitudinal Sagittal T2w Achilles Tendon: dynamic imaging Achilles Tendon: healing tear Prox Distal Long Axis Longitudinal 9 Longitudinal split: peroneus brevis Longitudinal split: peroneus brevis PL PL Fibula CFL Calcaneus Transverse: proximal Transverse: distal Transverse Peroneal Retinaculum Peroneal Tendon Subluxation: • Abnormal movement may only occur dynamically • Predisposes to peroneal tendon tears – Longitudinal split of peroneus brevis • US: examine with dorsiflexion / eversion – 100% accurate diagnosis with US Neustadter et al. AJR 2004; 183:985 Rosenberg et al. AJR 2003; 181:1551 Peroneal Subluxation: dynamic imaging Dislocation: peroneus brevis & longus Posterior Anterior Anterior Posterior Transverse Short axis 10 Intrasheath Subluxation Intrasheath Subluxation • Abnormal snapping of peroneal tendons • No lateral displacement, intact retinaculum • Associations: – Convex posterior fibula in 92% – Tendon tear in 86% – Low lying peroneus brevis muscle in 71% J Bone Joint Surg Am 2008; 90:992 J Foot Ankle Surg 2009; 48:323 Transverse Outline • Hip Technique: lateral – Effusion – Trochanteric pain syndrome • Anterior talofibular • Calcaneofibular – Iliopsoas snapping • Posterior talofibular • Knee • Anterior tibiofibular – Joint effusion and extensor mechanism • Posterior tibiofibular – Baker cyst • Ankle and Foot – Achilles and peroneal tendons – Ligaments From: Netter’s Atlas of Human Anatomy Anterior Talofibular Ligament Calcaneofibular Ligament PB PL Fibula Fibula Fibula Talus Talus Talus Calcaneus Long Axis Long Axis 11 Anterior Inferior Tibiofibular Ligament Anterior Talofibular Ligament Tear Fibula Fib Tibia Tib Tib Fibula F Talus Long Axis Axial T1w + gado Normal Anterior Talofibular Ligament Tear Calcaneofibular Ligament Tear PL/B PL/B Fib Calcaneus Fibula Talus Patient #2 Patient #1 Patient #2 Patient #3 Patient #1 Normal Short Axis Anterior Inferior Tibiofibular Ligament Tear Ligament Tear: • Anterior inferior tibiofibular ligament: Fibula – Look for interosseous membrane tear if Tibia absent lower fibular fracture – Maisonneuve fracture Long Axis Axial T2w 12 Maisonneuve Fracture Deltoid Ligament Tear MM T T F F Talus Transverse Normal Fibular Fracture Durkee, J Ultrasound Med 2003; 22:1369 Normal Take Home Points • Hip: bursitis is very uncommon • Knee effusion: – Suprapatellar and medial/lateral recesses • Extensor mechanism: dynamic evaluation • Baker cyst: must see neck to diagnose • Achilles: dynamic imaging • Peroneal: dynamic, subluxation See www.jacobsonmskus.com for syllabus and other educational material Twitter handle: @jjacobsn 13.
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