10/17/17
Lower Extremity Lower ExtremityImaging Imaging Considerations
Adam C. Zoga, MD Thomas Jefferson University Sydney Kimmel Medical College Philadelphia, PA, USA Professor of Radiology Vice Chair for Clinical Practice Musculoskeletal Fellowship Program Director Director of Musculoskeletal MRI OMED Philadelphia, October 09, 2017
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Athletic Pubalgia / Core Injury
• Clinical spectrum of disease associated with lower abdominal and groin injuries [1].
• Commonly referred to in the media as “sports hernia”
• Affects both high performance and recreational athletes.
1. Zoga AC et al. Athletic Pubalgia and the “Sports hernia”: MR Imaging Findings. Radiology 2008 Jun:247(3): 797-807.
Adam C. Zoga, MD www..jefferson.edu/msk
1 10/17/17
Lower Extremity Imaging
American footballer chronic bilateral groin pain and a more acute right sided adductor strain
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Incipient Breech
Adam C. Zoga, MD www..jefferson.edu/msk
2 10/17/17
Lower Extremity Imaging
Treated conservatively, continued to play with pain: MRI 12 months later
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Core stabilization discussed: opted for conservative treatment
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
3 weeks later, debilitating pain post game
Adam C. Zoga, MD www..jefferson.edu/msk
3 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD Aponeurosis rupture! www.. jefferson.edu/msk
Lower Extremity Imaging
Much larger teammate with “abdominal strain” in same game
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Midline aponeurotic plate rupture!
SurgicalAdam C. Zoga, MD Core Repair: playing again in www..6 weeksjefferson.edu /msk
4 10/17/17
Lower Extremity Imaging
Objectives:
•Be comfortable with an imaging algorithm for the adolescent and young adult with hip and/ or groin pain.
•Develop expectations for the value of imaging in creating treatment plans.
•Understand the anatomy and pathophysiology of core muscle injury.
•Be comfortable ordering and reviewing a dedicated athletic pubalgia imaging protocol.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging What is “The CORE”
www.bodyworlds.com
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Professional football (NFL) linebacker with acute, debilitating right sided groin pain after extending and twisting at waist
Adam C. Zoga, MD www..jefferson.edu/msk
5 10/17/17
Lower Extremity Imaging
PD FSE T2 FSE
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
LeftRight
T2 FSE Fatsat (TE = 55)
Adam C. Zoga, MD www..jefferson.edu/msk
Rectus abdominis Lower/ adductorExtremity Imaging aponeurosis tear
Rectus abdominis torn at attachment
Adductor longus torn and retracted
Entire rectus / adductor aponeurosis disrupted from pubic periosteum
Adam C. Zoga, MD www..jefferson.edu/msk
6 10/17/17
Lower Extremity Imaging
The rectus abdominis / adductor aponeurosis
Rectus Abdominis Lat/Sag AP
Pubic Symphysis
Common Adductor origin
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
The rectus abdominis / adductor aponeurosis
Rectus Abdominus
Common Adductor
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Robinson P, Salehi F, Grainger A, Clemence M, Schilders E, O'Connor P, Agur A. Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis. AJR Am J Roentgenol. 2007 May;188(5)
Adam C. Zoga, MD www..jefferson.edu/msk
7 10/17/17
Lower Extremity Imaging Fibrocartilage Plate The fibrocartilage extends the symphysis and forms a “disc” or plate, covering the bone
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Fibrocartilage Plate
FIBROCARTILAGE
FIBROCARTILAGE FIBROCARTILAGE
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
The rectus abdominis / adductor aponeurosis
Adam C. Zoga, MD www..jefferson.edu/msk
8 10/17/17
Lower Extremity Imaging
The rectus abdominis / adductor aponeurosis
Anterior
‘ ’ AsymetricT2Anteroinferior hyperintense BME soft secondary tissue edema cleft RectusAponeurotic defect injury Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
The rectus abdominis / adductor aponeurosis
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
The rectus abdominis / adductor aponeurosis
Right LeftSymphLeft
RightSymphLeft
Aponeurosis Tear Normal Aponeurosis
Adam C. Zoga, MD www..jefferson.edu/msk
9 10/17/17
Lower Extremity Imaging Rectus Abdominis / Adductor Aponeurosis Tear:
Pathoetiology:
.Disruption of the rectus abdominis insertion and common adductor origin on the anterior / inferior pubis adjacent to symphysis
.Likely reflects the injury commonly referred to as “Sports Hernia”
.Most commonly an acute injury on chronic, degenerative tendinosis
.RA tendinopathy may predispose to acute aponeurosis disruption. As the adductor longus opposes the rectus abdominis, a RA tear may lead to unopposed contraction of the AL, leading to a painful compartment syndrome and ultimately an AL tear.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Groin pain from the pubic symphysis:
•The importance of the secondary cleft
•Associated with osteitis pubis symptoms in ‘footballers’ ―Brennan et al. AJR, 2005 •Associated with adductor tendon origin injury Adam C. Zoga, MD ―Cunningham et al. AJR , 2007 www.. jefferson.edu/msk
Lower Extremity Imaging
MR arthrographic secondary cleft
Adam C. Zoga, MD www..jefferson.edu/msk
10 10/17/17
Lower Extremity Imaging The rectus abdominis / adductor aponeurosis
Rectus Abdominis
Pubic Symphysis
Adductor Longus
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
William C. Meyers has dedicated 25 years to pioneering the diagnosis, treatment, rehabilitation and prevention of core muscle injuries (also known as athletic pubalgia or sports hernia).
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
11 10/17/17
Lower Extremity Imaging Force Studies
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Core Muscle/Hip Interaction
Dividing portions of the rectus abdominis caused severe pressure changes in the adductor compartments and in the hip joints.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
AnatomyOsseous and Anatomy: Function:
Adam C. Zoga, MD www..jefferson.edu/msk
12 10/17/17
Lower Extremity Imaging Superior Pubic Ramus:
Lateral Border Medial Border
PubicPubicAngle Tubercle Crest
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Interpubic Disk:
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Arcuate Ligament:
Adam C. Zoga, MD www..jefferson.edu/msk
13 10/17/17
Lower Extremity Imaging Muscle Attachments: Rectus Abdominis
• Origin- Pubic symphysis/crest
• Insertion- Xiphoid process/lower costal cartilages
• Action- Flexes trunk
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Muscle Attachments: Pectineus
• Origin- Broad attachment at superior pubic ramus
• Insertion- Pectineal line of femur
• Action- Primary thigh adductor and secondary hip flexor
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Muscle Attachments: Adductor Longus
• Origin- Anterior superior pubic ramus at level of pubic angle, most superficial of the three thigh adductor muscles
• Insertion- Linea aspera of femur
• Action- Primary adductor of thigh and secondary external rotator and hip flexor
Adam C. Zoga, MD www..jefferson.edu/msk
14 10/17/17
Lower Extremity Imaging Muscle Attachments: Adductor Brevis
• Origin- Anterior pubis at the junction of the superior and inferior pubic rami, deep to adductor longus
• Insertion- Upper linea aspera and between the linea aspera and lesser trochanter
• Action- Primary thigh adductor, secondary hip flexor and external rotator
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Muscle Attachments: Adductor Magnus
• Origin- Broad origin from the inferior pubic and ischial rami, as well as the ischial tuberosity
• Insertion- Broad insertion on femoral linea aspera as well as adductor tubercle of the medial femoral condyle
• Action- Primary thigh adductor and thigh flexor/ extensor
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Muscle Attachments: Gracilis
• Origin- Lower half of anterior symphysis pubis and upper half of pubic arch
• Insertion- Upper, medial tibial body
• Action- Thigh adductor, hip flexor and internal rotator
Adam C. Zoga, MD www..jefferson.edu/msk
15 10/17/17
Lower Extremity Imaging Muscle Attachments: Obturator Externus
• Origin- Outer aspect of the pubic rami, inferior ischial ramus and obturator membrane
• Insertion- Trochanteric fossa of femur
• Action- Hip external rotator
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Accessory Muscles: Hip Flexors
• Iliopsoas and Sartorius muscles
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Biomechanics:
RA
AL Adam C. Zoga, MD www..jefferson.edu/msk
16 10/17/17
Lower Extremity Imaging Pathology :
Collegiate soccer player noncompliant with prescribed therapy
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Pathology :
Osteitis pubis is functionally an arthritis
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Pathology :
Professional hockey goalie with acute on chronic, recurrent groin pain preferential to one side and exacerbated with hip abduction
Adam C. Zoga, MD www..jefferson.edu/msk
17 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Rodeo Cowboy with acute on chronic injury
Adam C. Zoga, MD www..jefferson.edu/msk
18 10/17/17
Lower Extremity Imaging
Anterior Adductor Avulsion Lesion
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Anterior Adductor Avulsion Lesion: Traumatic aponeurosis tear where the pectineus and adductorlongus tendons deglove in a plate like fashion and can be reattached easily with early intervention Zoga AC, Meyers WC. Magnetic resonance imaging for pain after surgical treatment for athletic pubalgia and the "sports hernia". Semin Musculoskelet Radiol. 2011 Sep;15(4):372-82. Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging TJUH Athletic Pubalgia MR Protocol
• Athletic Pubalgia Exam Selection: – Indications: • Suspected rectus abdominis / adductor strain, osteitis pubis, “sportsman’s hernia” – Pointers: • Center on Symphysis Pubis • Coil: Phased Array Pelvic Coil (same coil used for gyn pathology) • Have patient empty bladder prior to scan
Omar IM, Zoga AC, et al. Radiographics. 2008 Sep- Khan W, Zoga AC, Meyers WC. Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice. Magn Reson Imaging Oct;28(5):1415-38. Clin N Am. 2013 Access at: http://www.bone.tju.edu/protocols.htm
Adam C. Zoga, MD www..jefferson.edu/msk
19 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging TJUH Athletic Pubalgia MR Protocol
Seq. FOV Matrix/NEX Slice TR TE TI ETL BW
Coronal 28 256x192 4/1 >2000 20-40 150 8 16 (cover B 2-3 STIR hips)
Coronal 28 256x256 4/1 400-800 minimum 16 (cover B 1-2 T1 SE hips) Axial T2 FSE 28 256x256 4/1 >2000 50-60 8 16 (cover B 2-3 Fat Sat hips)
Axial Obl PD FSE 20 384x384 3/1 3000 25-30 4 16 1-2 (max) Nonfatsat Sag T2 FSE 20-24 256x256 3/1 >2000 50-60 8 16 2-3 Fat Sat Axial Obl T2 FSE 20 256x192 3/1 >2000 50-60 8 16 2-3 Fat Sat
Access at: http://www.bone.tju.edu/protocols.htm
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging TJUH Athletic Pubalgia MR Protocol
Seq. FOV Matrix/NEX Slice TR TE TI ETL BW
Coronal 28 256x192 4/1 >2000 20-40 150 8 16 (cover B 2-3 STIR hips)
Coronal 28 256x256 4/1 400-800 minimum 16 (cover B 1-2 T1 SE hips) Axial T2 FSE 28 256x256 4/1 >2000 50-60 8 16 (cover B 2-3 Fat Sat hips)
Axial Obl PD FSE 20 384x384 3/1 3000 25-30 4 16 1-2 (max) Nonfatsat Sag T2 FSE 20-24 256x256 3/1 >2000 50-60 8 16 2-3 Fat Sat Axial Obl T2 FSE 20 256x192 3/1 >2000 50-60 8 16 2-3 Fat Sat
Access at: http://www.bone.tju.edu/protocols.htm
Adam C. Zoga, MD www..jefferson.edu/msk
20 10/17/17
Lower Extremity Imaging
M.L.B. catcher with chronic osteitis pubis, now with acute groin injury while fielding a bunt
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
21 10/17/17
Lower Extremity Imaging
R Symphysis L Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
A subset of patients had confluent, bilateral injuries at MRI
Professional soccer goalkeeper with chronic bilateral groin pain
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
22 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Adam C. Zoga, MD MRI of Athletic Pubalgia and the ‘Sports Hernia’
28 year old professional hockey goalie with acute on chronic groin pain
www.bone.tju.edu [email protected]
Adam C. Zoga, MD MRI of Athletic Pubalgia and the ‘Sports Hernia’
www.bone.tju.edu [email protected]
23 10/17/17
Adam C. Zoga, MD MRI of Athletic Pubalgia and the ‘Sports Hernia’
BLADDER BLADDER
Diastasis pubis Pelvic hematoma Pubic plate disruption
www.bone.tju.edu [email protected]
Adam C. Zoga, MD MRI of Athletic Pubalgia and the ‘Sports Hernia’
www.bone.tju.edu [email protected]
Adam C. Zoga, MD MRI of Athletic Pubalgia and the ‘Sports Hernia’
Flamingo views show instability at the symphysis
www.bone.tju.edu [email protected]
24 10/17/17
Lower Extremity Imaging
Professional football tight end with acute on chronic bilateral groin pain, exacerbated by ‘bravado’
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga,Classic MD “sports hernia” in a high level www..athletejefferson.edu /msk
Lower Extremity Imaging
In contrast, a professional football coach, who thinks he has a sports hernia
Adam C. Zoga, MD www..jefferson.edu/msk
25 10/17/17
Lower Extremity Imaging
“not a sports hernia hint #1”: did not fit in the pubalgia coil
“not a sports hernia hint #2”: rects abdomis has not been used in years
In old, out of shape “athletes”, groin pain is generally from the hip Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Why the term ‘sports hernia’?
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Lateral edge aponeurosis defect leaves patulous superficial ring
Adam C. Zoga, MD www..jefferson.edu/msk
26 10/17/17
Lower Extremity Imaging ‘Sports Hernia’
.Came from surgical literature: “non palpable, non visible inguinal hernia”
.Initial success treating with surgical mesh likely reflects proximity of lesion to superficial inguinal ring.
.Aponeurosis defect may leave patulous inguinal ring.
.No true hernia.
.Less than optimal term for this spectrum of musculoskeletal injury: Core Muscle Injury is a more accurate term.
Shortt CP, Zoga AC, et al. Semin Musculoskelet Radiol. 2008 Mar;12(1): 54-61.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Professional baseball player with refractory groin pain after herniorrhaphy
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Classic Core Muscle Injury treated as a hernia … unsuccesfully!
Adam C. Zoga, MD www..jefferson.edu/msk
27 10/17/17
Lower Extremity Imaging Can we predict injury patterns ?
From PaymonForootanshad’s channel, Youtube.com
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
• Retrospective study of a prospectively maintained database of 70 male football players (average age 22.3 years) with clinical athletic pubalgia.
1. All patients completed a questionnaire indicating level of play, side of injury, and past surgical history. 2. All patients underwent MRI utilizing a dedicated athletic pubalgia protocol [3].
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Patterns of Athletic pubalgia in American Football Players Injury Percentage Pattern of Patients
Unilateral 44.3%
Bilateral 8.6%
Midline Plate 41.4%
Other* 5.7%
*Isolated osteitis pubis and/or hip pathology -Unilateral lesions more common in defensive players, and situs contralateral to side of field played when applicable in > 90%
Kheterpal A, Zoga AC. Patterns of Athletic pubalgia in American Football Players. RSNA 2012
Adam C. Zoga, MD www..jefferson.edu/msk
28 10/17/17
Lower Extremity Imaging
Patterns of Athletic pubalgia in American Football Players Associated Injury Percentage of Patients Osteitis Pubis 82.9% Mild 32.8% Moderate 55.2% Severe 12.1% Hip Pathology 38.6%
Kheterpal A, Zoga AC. Patterns of Athletic pubalgia in American Football Players. RSNA 2012
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Improving Core Training Regimens
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
29 10/17/17
Lower Extremity Imaging
Ultrasound probe orientation
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adductor tenotmomy, 22G spinal needle:
- nerve block of anterior branch of obturator nerve between add longus and brevis (orange arrow) -dry needling of adductor origins and pubic plate (white arrows) -advancing needle into distal rectus abdominis and steroid injection (blue arrow)
Adam C. Zoga, MD www..jefferson.edu/msk
30 10/17/17
Lower Extremity Imaging
Recent Core Injuries
22 year old professional tennis player with abdominal pain ipsilateral to her serving arm
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Treated with steroid injection, imaged 4 days later
Rectus abdominis hyperextension strain
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
20 year old NBA power forward with subacute hip flexor strain and lower abdominal pain
Adam C. Zoga, MD www..jefferson.edu/msk
31 10/17/17
Lower Extremity Imaging
Rectus femoris avulsion
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
ACC quarterback with “acute lower abdominal strain”
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
32 10/17/17
Lower Extremity Imaging
External oblique avulsion from iliac crest
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Big 10 place kicker with kicking foot sided groin pain
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
AIIS apophysitis
Adam C. Zoga, MD www..jefferson.edu/msk
33 10/17/17
Lower Extremity Imaging
NFL QB injured in practice two days prior to worst performance of career
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Distal Adductor Magnus strain
Threw for NFL record 7 TDs two weeks later
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Olympic gymnast with acute, debilitating right lateral groin / abdominal pain
Adam C. Zoga, MD www..jefferson.edu/msk
34 10/17/17
Lower Extremity Imaging
Pennate pattern of soft tissue edema
Distribution of edema defines iliacus
Normal symphysis and aponeuroses
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging How should I image the hip ?? • Clinical scenerio ?? – Elderly hip fracture should be bony pelvis • Patient age – Legg calve perthes requires bilateral study • Likelihood of intra vs. extraarticular pathology • Likelihood of subspecialty referral – Athlete with labral tear warrants direct/indirect MR arthro • Imaging resources – Fluoro and contrast availability for arthrography?
Adam C. Zoga, MD www..jefferson.edu/msk
35 10/17/17
Lower Extremity Imaging AVN of femoral head- Chronic
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
27 year old professional hockey goalie with nagging right sided adductor pain
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging AVN on MRI
Bony Pelvis STIR
Higher res PD FSE -Treated conservatively for 5 months -15 months later played in finals -Rewarded with new 2 year contract
Adam C. Zoga, MD www..jefferson.edu/msk
36 10/17/17
Lower Extremity Imaging
33 year old MLB infielder with chronic athletic pubalgia lesion and lumbar HNP
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging AVN on MRI Early collapse
7 months prior
Bony Pelvis STIR Bony Pelvis T1 -Received 1 year contract with another team -Placed on D.L. in July … with concussion
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
7 y.o. female refusing to bear weight and complaining of left hip pain
Clinical suspicion for LCP, but radiographs normal
Adam C. Zoga, MD www..jefferson.edu/msk
37 10/17/17
Lower Extremity Imaging
T2 FatSat
T1
Adam C. Zoga, MD T1 SE www..jefferson.edu/msk
Lower Extremity Imaging
T1 FatSat Post Gad
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Legg-Calve-Perthes Disease
• DX: Consider Dynamic Enhanced MR • TX: Most often conservative • Develop Early OA if incongruent joint
Adam C. Zoga, MD www..jefferson.edu/msk
38 10/17/17
Lower Extremity Imaging Osseous Hip Pathologies
-femoral neck stress fracture
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Bursitis
•Iliopsoas •Obturator externus •Trochanteric •Can occur about any tendinous attachment
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Greater Trochanteric Bursitis
Adam C. Zoga, MD www..jefferson.edu/msk
39 10/17/17
Lower Extremity Imaging
Iliopsoas Bursitis
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Iliopsoas Bursitis
Non-enhancing
Tense
Mass-like
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Coxa Saltans - Tendinous
-snapping iliopsoas tendon
Adam C. Zoga, MD www..jefferson.edu/msk
40 10/17/17
Lower Extremity Imaging
Ischiofemoral Impingement
Bredella et. al.
Torriani M, Souto SC, Thomas BJ, Ouellette H, Bredella MA. Ischiofemoral impingement syndrome: an entity with hip pain and abnormalities of the quadratus femoris muscle. AJR Am J Roentgenol. 2009 Jul;193(1):186-90.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Apophysitis:
•15 year old hurdler acute onset pain with thigh flexion
•Avulsion of the anterior inferior iliac spine
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Apophysitis:
•Anterior superior iliac spine
•Iliacus strain •Sartorius strain Adam C. Zoga, MD www..jefferson.edu/msk
41 10/17/17
Lower Extremity Imaging Apophysitis:
•Ischial tuberosity apophysitis
14 year old Irish soccer player with decreased foot speed
•American variant
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Acetabular Labrum:
• Fibrocartilage; blends with articular cartilage • Triangle shaped • Deepens socket • attached to bone 270-300 degrees • inferior transverse ligament Axial Coronal Sagittal
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Recess between capsule and lateral labrum
Fluid around transverse ligament
Size: anterior = posterior Adam C. Zoga, MD www..jefferson.edu/msk
42 10/17/17
Lower Extremity Imaging
Labrum: Normal MR Appearance
Iliopsoas Tendon
Superior Labrocapsular Recess
Labroligamentous Recess
MR Arthrogram Axial T2 FSE NFS MR Arthrogram Axial T2 FSE FS
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Noncontrast MR for labral tear – the olden times
Paralabral Cyst Paralabral Cyst
Sagittal and Axial T2 FSE FS
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Anesthetic Arthrogram • Fluoroscopy guided hip arthrogram, with intraarticular anesthetic mixed with the contrast •2 3cc cc of0.25% 1% Ropivacaine Bupivacaine • 22cc cc 1%1% plainLidocaine Lidocaine
.Bupivicaine action lasts 3-4 hours, but onset may not occur in fluoro suite (30min)
.Lidocaine onset of action near immediate, but duration only approximately 45min
.Reports of potential bupivicaine related chondrolysisAdam C. haveZoga, MD surfaced www..jefferson.edu/msk
43 10/17/17
Lower Extremity Imaging
Anaesthetic arthrogram test accuracy for diagnosing labral tears using direct MR arthrography as gold standard
Sensitivity 57% Specificity 83% PPV 89% NPV 44%
Accuracy 64%
N=137
Chi-Square Test
(p= <0.001)
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging MR Arthrography of the Hip
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Classification of labral tears
Blankenbaker DG, De Smet AA, Keene JS, Fine JP. Classification and localization of acetabular labral tears. Skeletal Radiol. 2007 ay;36(5):391-7.Epub 2007 Jan 17.
Ilizaliturri VM Jr, Byrd JW, Sampson TG, Guanche CA, Philippon MJ, Kelly BT,Dienst M, Mardones R, Shonnard P, Larson CM. A geographic zone method to describe intra-articular pathology in hip arthroscopy: cadaveric study and preliminary report. Arthroscopy. 2008 May;24(5):534-9.
Adam C. Zoga, MD www..jefferson.edu/msk
44 10/17/17
Lower Extremity Imaging
Labral Tear Treatment Options
Debridement Repair
Adam C. Zoga, MD www..jefferson.edu/msk
Acetabular Lower Extremity Labrum Imaging Tears
25 year old female with pain on passive hip flexion:
Initial MR Arthrogram
Adam C. Zoga, MD www..jefferson.edu/msk
Acetabular Lower Extremity Labrum Imaging Tears
25 year old female with pain on passive hip flexion:
Persistent pain post arthroscopic debridement
Adam C. Zoga, MD www..jefferson.edu/msk
45 10/17/17
Acetabular Lower Extremity Labrum Imaging Tears Most pre-osteoarthritic acetabular labrum tears can be placed into one of two dominant categories:
Anterosuperior Anterior
Adam C. Zoga, MD www..jefferson.edu/msk
Acetabular Lower Extremity Labrum Imaging Tears 25 year old male:
Adam C. Zoga, MD www..jefferson.edu/msk
Acetabular Lower Extremity Labrum Imaging Tears 25 year old male:
60o
AdamAnterosuperior C. Zoga, MD (zones 1 and 2) with cam www.. morphologyjefferson.edu/msk
46 10/17/17
Anterosuperior Lower Extremity Imaging Tears
•M>>F •cam morphology common •anterosuperior cartilage lesions common •Detachment rare •Can identify lesion on both coronal and sagittal images
Adam C. Zoga, MD www..jefferson.edu/msk
Acetabular Lower Extremity Labrum Imaging Tears 22 year old female:
Adam C. Zoga, MD www..jefferson.edu/msk
Acetabular Lower Extremity Labrum Imaging Tears 22 year old female:
44o
AdamAnterior C. Zoga, MD (zone 1) tear with detachment at www.. labraljefferson.edu base/msk
47 10/17/17
Isolated Lower Anterior Extremity Imaging Tears
•F>=M •Alpha angle often normal •visible cartilage lesions less common •most localized to labral base •most detached •Often seen only on sagittal images •May be associated with posterosuperior acetabular insufficiency (crossover sign)
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Posterosuperior acetabular insufficiency (retroversion)
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Acetabular Retroversion: CT
Adam C. Zoga, MD www..jefferson.edu/msk
48 10/17/17
Lower Extremity Imaging Acetabular Retroversion: CT
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Acetabular Retroversion: CT
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Retroversion and anterior labrum tears: Flexion of Leg theoretical
AnteversionAdam C. Zoga, MD Retroversion www..jefferson.edu /msk
49 10/17/17
Results: Lower Extremity 261 Imaging hips
•Mean age 33.4 years – M:F = 208:53
•Pilot study: 10 labral tears in 10 hips .6 Anterosuperior, 4 Isolated Anterior .100% Concordance with Arthroscopic Examination
•231 Labral tears by MRI .137 Anterosuperior .71 Isolated Anterior .11 Isolated Superior .6 Posterior
Adam C. Zoga, MD www..jefferson.edu/msk
Results: 137 Lower Anterosuperior Extremity Imaging Tears
•M:F=116:21, 85% M •62/137 (45%) cam morphology (alpha angle > 60) •58/137 (42%) visible cartilage lesions •60/137 (44%) localized to labral base •44/137 (32%) detached •70/137 (51%) reported relief with intra-articular anesthetic .Most frequently abduction and external rotation
Adam C. Zoga, MD www..jefferson.edu/msk
Results: 71 IsolatedLower Extremity Imaging Anterior Tears
•M:F = 47:24, 66% M •18/71 (25%) cam morphology (alpha angle > 60) •8/71 (11%) visible cartilage lesions •49/71 (69%) localized to labral base •43/71 (61%) detached •30/71 (42%) reported relief with intra-articular anesthetic .Most frequently flexion, adduction and internal rotation
Adam C. Zoga, MD www..jefferson.edu/msk
50 10/17/17
Lower Extremity Imaging Radiographic Assessment
Standing AP Pelvis
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Radiographic Assessment
Dunn (elongated FN) Frog lateral False profile
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Professional hockey goalie after 20 year career
Adam C. Zoga, MD www..jefferson.edu/msk
51 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Labral Tear
Trauma
Dysplasia Impingement
Pincer-type Cam-type
Aspherical Protrusio Coxa Retroversion Gun Femoral Acetabulae Profunda Head Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging What Does Dysplasia Do?
• Causes instability • Increased stress on acetabular rim – Labral hypertrophy – Labral tear – OA
Adam C. Zoga, MD www..jefferson.edu/msk
52 10/17/17
Lower Extremity Imaging DDH •Leads to abnormal stresses on the“ Obviouslabrum and articular” cartilageDysplasia •BUT …. frequently subtle radiographic findings prevent early detection
Signs -Steep acetabular angle -upturn of lateral acetabular rim -widening of medial joint -uncovering of lateral femoral head
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Femoral Head Extrusion Index • Percentage of Femoral Head B uncovered by acetabulum A • Normal is less than 25 percent • Abnormal is greater than 25 percent
B-A/B x 100% Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Pincer-Type Impingement
MR Signs • Impaction injury to femur at anterosuperior head/neck junction • Small, focal cartilage defect • Acetabular overgrowth • Os Acetabuli • Normal alpha angle and femoral head morphology
Coronal T1 NFS
Adam C. Zoga, MD www..jefferson.edu/msk
53 10/17/17
Lower Extremity Imaging Labral Hypertrophy in Dysplastic Hip
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Labral Hypertrophy in Dysplastic Hip
Uncovering Lateral Head
Labral Hypertrophy
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Labral Hypertrophy in Dysplastic Hip
Adam C. Zoga, MD www..jefferson.edu/msk
54 10/17/17
Lower Extremity Imaging Labral Hypertrophy in Dysplastic Hip
Labral Hypertrophy
Labral Tear
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Labral Tear
Trauma
Dysplasia Impingement
Pincer-type Cam-type
Aspherical Protrusio Coxa Retroversion Gun Femoral Acetabulae Profunda Head Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Pincer Effect Acetabulum too big, deep or with overhanging edges -Impinges on femoral head/neck junction with ROM
Adam C. Zoga, MD www..jefferson.edu/msk
55 10/17/17
Lower Extremity Imaging Labral Tear
Trauma
Dysplasia Impingement
Pincer-type Cam-type
Aspherical Protrusio Coxa Retroversion Gun Femoral Acetabulae Profunda Head Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Cam-Type Impingement
Mechanism • Abnormal Morphology of femoral head causes altered mechanical stress across labrum and cartilage during flexion Courtesy Javad Parvizi, M.D.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Cam Impingement As the hip is flexed the non- Anterior labrum / spherical portion of the cartilage impinged femoral impinges on the acetabulum
Adam C. Zoga, MD www..jefferson.edu/msk
56 10/17/17
Lower Extremity Imaging Cam-Type Impingement Radiographic Signs • Abnormal femoral head morphology • Pistol-grip deformity • Osseous spur at junction of femoral head and neck • Synovial Herniation Pits • Early OA
“Pistol-grip” deformity Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Cam-Type Impingement Radiographic Signs • Abnormal femoral head Flattening of superolateral morphology Femoral margin • Pistol-grip deformity • Osseous spur at junction of femoral head and neck • Synovial Herniation Pits • Early OA
“Pistol-grip” deformity Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Labral Tear
Trauma
Dysplasia Impingement
Pincer-type Cam-type
Aspherical Protrusio Coxa Retroversion Gun Femoral Acetabulae Profunda Head Adam C. Zoga, MD www..jefferson.edu/msk
57 10/17/17
Lower Extremity Imaging Cam-Type Impingement
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Cam-Type Impingement
Osseous Spur
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Cam-Type Impingement MR Signs • Superior/ anterosuperior labral tear • Cartilage defects • Synovial herniation pits • Spur/Abnormal alpha angle
MR Arthrogram T1 FS (KassarjianAdam et C.al. Zoga, Radiology MD 2005; 236(2):588-92) www..jefferson.edu/msk
58 10/17/17
Lower Extremity Imaging Cam-Type Impingement MR Signs • Superior/ anterosuperior labral tear Spur • Cartilage defects • Synovial herniation pits • Spur/Abnormal alpha angle
MR Arthrogram T1 FS (KassarjianAdam et C.al. Zoga, Radiology MD 2005; 236(2):588-92) www..jefferson.edu/msk
Lower Extremity Imaging Cam-Type Impingement
MR Arthrogram T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Cam-Type Impingement
Anterior Labral Tear
MR Arthrogram T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
59 10/17/17
Lower Extremity Imaging Cam-Type Impingement
Cartilage loss and OA
MR Arthrogram T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Alpha Angle
MR Arthrogram Coronal T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Alpha Angle
• Measured from sagittal oblique sequence • Draw circle matching femoral head cortex • Draw line along long axis of the femoral neck and bisecting the femoral head • Draw second line from center of the femoral head to the anterior point where the femoral neck diverges from the circle
MR Arthrogram Coronal T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
60 10/17/17
Lower Extremity Imaging Alpha Angle
• Normal is less than or equal to 55 degrees
MR Arthrogram Coronal T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Alpha Angle
MR Arthrogram Sag Obl T1 FS
MR Arthrogram Coronal T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Alpha Angle
.
MR Arthrogram Sag Obl T1 FS
MR Arthrogram Coronal T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
61 10/17/17
Lower Extremity Imaging Alpha Angle
.
MR Arthrogram Sag Obl T1 FS
MR Arthrogram Coronal T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Alpha Angle
o . 60
MR Arthrogram Sag Obl T1 FS
MR Arthrogram Coronal T1 FS Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
40 Oblique Axial Images
NORMAL AND ABNORMAL VALUES 80
Control group (no FAI) avg 42 +/- 2.2 degrees FAI group avg 74 +/- 5.4 degrees
Noetzli HP et al. JBJS Br 2002 Adam C. Zoga, MD www..jefferson.edu/msk
62 10/17/17
Lower Extremity Imaging Femoral-acetabular Impingement Comparison: Cam and Pincer
CAM PINCER • M:F = 13:1 • M:F = 1:3 • Avg age = 32 • Avg age 40 • Large ant-sup lesion • Small ant-sup lesion • No contra-coup • Contra-coup lesion posteriorly posteriorly
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Summary: Dysplasia versus FAI
Dysplasia FAI • Shallow acetabulum • Flattening of lateral • Steep sourcil femoral head/neck • Excessive femoral junction undercoverage • Osseous spur • Lateralization • Synovial herniation pit • “Figure of 8” sign- • Acetabular overcoverage- retroversion pincer type
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Ligamentum Teres
• Ligament between the transverse ligament of the acetabulum and the ischial and pubic sides of the acetabular notch and the fovea of the femoral head.
• It is pyramidal in shape at its insertion on to the transverse ligament.
• Gradually tapers into a round or oval shape as it inserts on to the femoral head.
• May contain artery feeding a portion of the femoral head.
• Absent in some patients.
Adam C. Zoga, MD www..jefferson.edu/msk
63 10/17/17
Lower Extremity Imaging
Ligamentum Teres
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Coxa Saltans - Ligamentum Teres Tear
•Direct MR arthrogram •Surgically proven
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
31 year old professional hockey goalie with nagging right sided adductor pain
Adam C. Zoga, MD www..jefferson.edu/msk
64 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
NFL lineman post hamstring “tweak”
Adam C. Zoga, MD www..jefferson.edu/msk
65 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Return to Play Trifecta
• Return quickly • Maximal performance • Low risk of re injury
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Return to Play (RTP)
• Social stresses
• Statistics – 4.8 years – mean career length for professional baseball pitchers
– 3.5 years – mean career length for player in the NFL
Adam C. Zoga, MD www..jefferson.edu/msk
66 10/17/17
Lower Extremity Imaging
% Muscle Avg # Involved! Games Missed!
< 50 %! 1.8!
>75%! 3.2!
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Sciatic n
Adam C. Zoga, MD www..jefferson.edu/msk
67 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
>3 wk Retraction 1-2 wk >75% MTJ Cysts Multiple Muscle <1wk Dist MTJ Biceps Perimusc Edema Prox, Mid Biceps <25%
Cohen SB, Towers JD, Zoga A, Tejwani S, Makda J, Deluca P, Bradley JP. Hamstring Injuries in Professional Football Adam C. Zoga, MD Players: MRI Correlation with Return to Play. www..jefferson.edu/msk
Lower Extremity Imaging Former college football defensive back with instability 2 years post ACL reconstruction
Adam C. Zoga, MD www..jefferson.edu/msk
68 10/17/17
Lower Extremity Imaging Posterolateral Corner: Anatomy
Arcuate ligament
LCL
Popliteofibular lig.
Popliteus
Popliteus and its Tripartite stability
Seebacher JR et al: J Bone Joint Surg, 64-A:536, 1982.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Popliteus strain:
Pop is the “Window to the Posterolateral Corner” on MR
Arcuate and pop-fib injuries
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Non contact injury in quarterback
Popliteus muscle belly strain Intact popliteal-fubular ligament
Adam C. Zoga, MD www..jefferson.edu/msk
69 10/17/17
Lower Extremity Imaging College football player with twisting injury
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Similar popliteus strain, but …. Torn pop-fib and arcuate ligamnts Posterolaterally Unstable!! Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging NFL fullback with subacute ACL tear
Pop-fib tear, posterolaterally unstable
Adam C. Zoga, MD www..jefferson.edu/msk
70 10/17/17
Lower Extremity Imaging Severe hyperextension / dislocation
Knee dislocation Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging World’s Greatest Rodeo Injury
Thanks to Richard Walker, MD Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Posterolateral Corner MRI
Adam C. Zoga, MD www..jefferson.edu/msk
71 10/17/17
Lower Extremity Imaging
Tibial-peroneal Trunk Transection
Thanks to Richard Walker, MD Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
•Extremity coil •Fat suppressed and non-fat suppressed sagittal •High resolution axial sequence •Long TE fatsat axial sequence •Cartilage sequence in coronal plane (prescribed through malleoli) •At least one IR sequence (artifact discrimination) •Contrast for mass, infection
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Myotendinous / tendon dysfunction: • Tenosynovitis – Increased fluid in tendon sheath • Stenosing Tenosynovitis – Usually at a constriction or turn – Loculated tenosynovitis – IV Gd helpful • Tendinosis – Hypoxic: enlarged with normal signal – Mucoid: intrasubstance degeneration • Peritendinitis – Thickened tendon sheath – Infiltrated, edematous surrounding tissues • Tear – Interstitial: early degenerative tear – Complete: degenerative or traumatic Adam C. Zoga, MD www..jefferson.edu/msk
72 10/17/17
Lower Extremity Imaging Anterior (extensor) tendons:
Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging 70 year old with anterior ankle “mass”:
Traumatic ATT tear
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Lateral tendons:
Peroneus Longus
Peroneus Brevis
Adam C. Zoga, MD www..jefferson.edu/msk
73 10/17/17
Lower Extremity Imaging Peroneal tenosynovitis:
•More fluid than tendon volume •Synechiae may indicate stenosing tenosynovitis
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Peroneus Brevis Split:
Longus migrates into brevis just distal to fibula, first flattening, then creating “boomerang” and finally splitting
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Superior peroneal retinaculum failure:
Traumatic peroneus longus dislocation in NFL lineman
Adam C. Zoga, MD www..jefferson.edu/msk
74 10/17/17
Lower Extremity Imaging Proximal Peroneal Pathology:
Peroneus longus tendinosis with subtendinous marrow edema
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Peroneal Subluxation
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Acute lateral foot pain playing basketball:
Traumatic peroneus longus tear
Adam C. Zoga, MD www..jefferson.edu/msk
75 10/17/17
Lower Extremity Imaging Painful Os Peroneum Syndrome:
•Chronic pain, tenderness over cuboid •Distal peroneal tenosynovitis or tear •Marrow edema, in cuboid and ossicle •Necrosis, fragmentation of os •Surrounding soft tissue edema •Treatment is resection of os
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Distal Peroneal Pathology:
r/o occult base of 5th fracture
Peroneus Brevis insertional tear
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Distal Peroneal Pathology:
Peroneus longus tear in pro football player Adam C. Zoga, MD www..jefferson.edu/msk
76 10/17/17
Lower Extremity Imaging Posterior (Flexor) Tendons:
Posterior Tibialis Flexor Digitorum Longus Flexor HallucisLongus
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Radiologic Clinics of North America, 2016
• Even without weight-bearing, MRI can provide important information about hindfoot alignment
• A flat arch could reflect developmental or flexible flatfoot, or posterior tibial tendon dysfunction
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Posterior Tibial Tendon Dysfunction - MRI:
Uncovering Hindfoot of medial valgus talar head (spring lig failure)
Fibulocalcaneal abutment
Also: pes planus, arch collapse
Adam C. Zoga, MD www..jefferson.edu/msk
77 10/17/17
Lower Extremity Imaging Posterior Tibial Tenosynovitis:
Flexor tenosynovitis thresholds: •PTT: tendon>fluid •FDL: equal •FHL: variable, look for evidence of stenosing
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Posterior Tibial Tendinosis:
Atrophic tendinosis Hypertrophic tendinosis (more common)
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Posterior Tibial Tendinosis:
Tendinotic, failing and tearing PTT
Edematous, tearing spring ligament
Adam C. Zoga, MD www..jefferson.edu/msk
78 10/17/17
The Lower spring Extremity Imaging ligament (calcaneal-navinular ligament, CNL):
Traumatic spring ligament disruption with talar head declination and talar-cuboid impaction Kavanagh EC, Zoga AC, Gopez AG L, Omar I, Morrison WB, Traumatic spring ligament disruption Adam C. Zoga, MDwith talocuboid impaction. Radiology Case Reports. 2006,2: (1-3)www.. .jefferson.edu /msk
Lower Extremity Imaging PTT Dysfunction in young patient??
Bone marrow edema across the synchondrosis
Accessory navicular with stress response Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
15 year old female soccer player with refractory medial midfoot pain after playing/running for 15 minutes
Adam C. Zoga, MD www..jefferson.edu/msk
79 10/17/17
Lower Extremity Imaging
The Painful Bipartite Patella
Acromial Apophyseolysis
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging The Os Navicularis
Dwight Accessory NavicularRadiopedia Classification System (Thomas Dwight 1907)
Type 1: Type 2: Type 3: • 2-3 mm sized sesamoid • 8-12 mm, triangular • enlarged, solid navicular • within the substance of the • PTT inserts on the ossicle • 20 - 30% of all accessory posterior tibial tendon • 50 - 60% of accessory naviculars • 30% of all accessory navicular navicular bones • asymptomatic bones • synchondrosis with navicular • may be result of fusion of • generally asymptomatic tuberosity type 2 navicular os • ‘os tibiale externum’ • may become symptomatic in • ‘cornuate navicular’ ‘‘prehallux’ or ‘bifurcated hallux’,
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
80 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Posterior Tibial Tendon: Dynamic Stabilizer
• Function – Support medial arch of the foot – Invert foot – Plantarflex ankle
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Posterior Tibial Tendon: Dynamic Stabilizer
• If torn or stretched: arch collapses
Adam C. Zoga, MD www..jefferson.edu/msk
81 10/17/17
Lower Extremity Imaging • Results: Grade 1: 16 Grade 2: 13 Grade 3: 11
• M/F: 3/13 • M/F: 6/7 • M/F: 2/9 • mean age 26 yrs• mean age 28.4 • mean age 15 yrs • mean wt 153 lbs yrs • mean wt 135 lbs • mean pain 7.4 • mean wt 190 lbs • mean pain 8.4 mos mos • mean pain 11 Grade 1 mos Grade 2 Grade 3
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging • Results:
• Overall incidence of type II os navicularis was 3.1% • 40/40 reported medial foot pain on MRI questionnaire • 20/40 (50%) had no other findings at MRI (excluding PTT) • Most common activities were running (14), soccer (9) and dancing (8).
Grade 1 Grade 2 Grade 3
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging • Outcomes:
• 29 had either follow-up imaging or referring clinician visit • 0 had surgical resection • 25/29 (86%) had orthotics prescribed • 10/29 (34%) had taping prescribed • 10/29 (34%) were prescribed focused P.T.
Adam C. Zoga, MD www..jefferson.edu/msk
82 10/17/17
Lower Extremity Imaging Traumatic flexor tendon injury:
Traumatic FHL tear with dorsiflexion / eversion injury
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Achilles Tendon Pathology:
•Peritendonitis •Kagers fat edema •Hypoxic tendinosis •Mucoid degeneration •Interstitial tearing •Acute rupture •Critical zone vs. insertional •Haglund ’s syndrome •Xanthomatosis
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Achilles Tendon Pathology:
Peritendinitis (paratenon)
Adam C. Zoga, MD www..jefferson.edu/msk
83 10/17/17
Lower Extremity Imaging Achilles Tendon Pathology:
Hypoxic tendinosis: •Critical zone Mucoid degeneration •Normal signal •T1 hyperintensity •Impending tear •Bowed Adam C.conxex Zoga, MD anteriorly www..jefferson.edu/msk
Lower Extremity Imaging Achilles Tendon Pathology:
Insertional tear Interstitial tear Complete tear critical zone Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Professional baseball slugger with heel pain
Adam C. Zoga, MD www..jefferson.edu/msk
84 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
40 days post injection- struck with bat after swing
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging 32 year old NFLd Linebacker
Adam C. Zoga, MD www..jefferson.edu/msk
85 10/17/17
Lower Extremity Imaging Achilles Tendon Pathology:
Haglund’s Synrome •Upturned posterior calcaneus •Retrocalcaneal bursitis •Retro Achilles bursitis •Achilles tendinosis Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Compartmental Processes: The Tarsal Tunnel
•Closest tendon is FHL •Mass effect impinges posterior tibial nerve •Impingement can mimic plantar fasciitis •Flexor retinaculum (similar to carpal tunnel) •Neuroma •Varicies •FHL tenosyn •Ganglion •GCTTS •Accessory FHL
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging The Tarsal Tunnel:
Ganglion Rheumatoid Adam C. Zoga, MD www..jefferson.edu/msk
86 10/17/17
Lower Extremity Imaging The Sinus Tarsi:
•Fat signal is normal •contains 5 ligaments, fat, arterial anastomosis and Baxter’s nerve • space between posterior and middle facets of subtalar joint
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Sinus Tarsi Syndrome:
• lateral pain, tenderness, hindfoot instability • association with ankle sprains / lateral ligament injury or ganglion cyst • Acute = edema signal on T2 • Chronic = low signal (fibrosis) T1, T2 with replacement of fat signal
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging NFL cornerback with a gruesome noncontact injury
Adam C. Zoga, MD www..jefferson.edu/msk
87 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Tibiofibular Syndesmosis:
Anterior Inferior Tibiofibular Ligament: inversion or eversion
Posterior Inferior Tibiofibular
Adam C. Zoga, MD Ligament: eversion www..jefferson.edu/msk
Lower Extremity Imaging (INFERIOR) TIBIOFIBULAR LIGAMENTS AITF PITF
Adam C. Zoga, MD www..jefferson.edu/msk
88 10/17/17
Lower Extremity Imaging Tibiofibular Syndesmosis:
“High ankle sprain” dorsiflexion /
Adameversion C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Tibiofibular Syndesmosis:
Acute traumatic syndesmotic disruption
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
89 10/17/17
Lower Extremity Imaging Tibiofibular Syndesmosis:
Subacute syndesmotic injury Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
P T # 1
P T # 2
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Acute Sprain Grading: Anterior talofib. Ligament inversion injury Grade 3 injury: Grade 2 sprain: Grade 1 sprain: Complete tear Partial tear Edema
Adam C. Zoga, MD www..jefferson.edu/msk
90 10/17/17
Lower Extremity Imaging Patterns of chronic anterior talofibular ligament injury
Thickened
Absent
•Generally treated conservatively •Rarely leads to long term instability Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Calcaneal-fibular (calcaneofibular) Ligament
-CFL -Second Ligament to Disrupt During Inversion Injury -Axial: Thin Linear Structure Deep to Peroneal Tendons
Coronal: Tents over Peroneal Tendons
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Lateral Ligaments: Calcaneal-fibular lig. tear
•Can lead to long term lateral instability •Surgical reconstruction often considered •Can destabilize peroneal tendons
Adam C. Zoga, MD www..jefferson.edu/msk
91 10/17/17
Lower Extremity Imaging Lateral Ligaments:
Calcaneal-fibular ligament tear – extreme inversion
•Look for fluid extending from joint into common peroneal tendon sheath
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Medial Ligaments (Deltoid ligament):
Tibia
Post Navic Ant Talus TN TS TC Spring
Calcaneus
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Deltoid ligament:
Normal - intact •Very thick, heavy Edematous from •5 dominant fascicles impaction of •Rareley tears inversion Adam C. Zoga, MD www..jefferson.edu/msk
92 10/17/17
Lower Extremity Imaging Deltoid ligament:
Professional football player s/p acute eversion on artificial turf – complete deltoid disruption
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Acute Eversion Injury:
Professional football player with syndesmosis disruption, deltoid sprain and …
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Acute Eversion Injury:
Maisoneuve
Adam C. Zoga, MD www..jefferson.edu/msk
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Lower Extremity Imaging Impingement Syndromes
• Anterolateral impingement • Anterior impingement • Posterior impingement (os trigonum syndrome)
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Anterolateral Impingement Syndrome
-Scar tissue in anterolateral gutter following inversion injury and ligamentous injury; Post-traumatic inversion -Anterolateral pain, swelling, limited dorsiflexion; Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Anterior Impingement Syndrome
-Large anterior spur with limited dorsiflexion of foot/ anterior pain -Degenerative process- results from chronic ankle instability
Adam C. Zoga, MD www..jefferson.edu/msk
94 10/17/17
Lower Extremity Imaging Impingement Syndromes
Anterior impingement with intraarticular body
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Impingement Syndromes
Os trigonum syndrome
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Impingement Syndromes
neutral
Posterior impingement in ballet dancer Plantar flexion
Adam C. Zoga, MD www..jefferson.edu/msk
95 10/17/17
Lower Extremity Imaging Ballerina with “shin splints”
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Stress fracture related to altered biomechanics
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Turf Toe
• Radiographs – Proximal retraction of sesamoids
• MRI – Individual structures – Grade severity of injury – Determines treatment and RTP
Adam C. Zoga, MD www..jefferson.edu/msk
96 10/17/17
Lower Extremity Imaging Turf Toe - Radiograph
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Turf Toe - MRI
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Turf Toe
Low grade injury High grade injury
Adam C. Zoga, MD www..jefferson.edu/msk
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Lower Extremity Imaging Turf Toe - RTP
• Grade 1 – Attenuation or edema of structures – Treat symptoms – RTP as tolerated • Grade 2 – Partial tear with restricted range of motion secondary to pain – Walking boot or Morton’s extension orthotic as needed – RTP in 2 week with taping
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Turf Toe - RTP
• Grade 3 – Complete disruption and frank instability – Long term immobilization or surgery – RTP 6-10 weeks with taping; depends upon player position – Surgery seldom necessary – List of criteria leading to surgery includes loose body and chondral injury
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
NFL running back with inability to bear weight after injury “pushing off”
Adam C. Zoga, MD www..jefferson.edu/msk
98 10/17/17
Lower Extremity Imaging
Radiographs normal
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Surgery (exam under anesthesia): Both bundles of Lisfrank ligament (C1-M2M3) visibly intact at MRI stable Lisfranc joint, intact C1- M2M3
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Retrospectively, 1.5T MRIs were reviewed by two MSK radiologist in consensus (blinded to clinical data). Integrity of the following structures on long (axial) and short axis (coronal) were evaluated: . pC1-M2M3 (Lisfranc plantar)
. pC1-M1 (1st tarsometatarsal)
. pC2-M2 (2nd tarsometatarsal)
. dC1-M2 (Lisfranc dorsal)
. Fluid along M1
. Fractures Adam C. Zoga, MD www..jefferson.edu/msk
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Lower Extremity Imaging
Short axis anatomy
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging RESULTS III Logistic Regression Model determined: the strongest MRI predictor for instability of the Lisfranc Joint complex was disruption or attenuation of the plantar Lisfranc ligament bundle (pC1-M2M3)
Sensitivity = 94% Classification Table Specificity = 75% Predicted by use of pC1-M2M3 PPV = 94% Percentage Stable/Unstable Correct stable unstable
Observed Stable 3 1 75% in OR Unstable 1 16 94%
Overall: 19/21 were correctly classified 90.5%
Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC.Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings.J Bone Joint Surg Am. 2009. Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Another professional football player, point tenderness, difficulty bearing weight
Surgery: (C1=M2M3) disrupted, reconstructed
Adam C. Zoga, MD www..jefferson.edu/msk
100 10/17/17
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Case 2: MRI
Adam C. Zoga, MD www..jefferson.edu/msk
Blake Bowden MSIV Lower Extremity Bone Imaging Bruise vs. Fracture at MRI www.Jefferson.edu/msk Bone Bruise vs. Non-Displaced Fracture
• Classic Definition: – Fracture = cortical disruption – Bone Bruise = BME 2/2 subcortical trabecular disruption • Impaction mechanism may result in varying degrees of both • Which is clinically valuable?
Adam C. Zoga, MD www..jefferson.edu/msk
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Blake Bowden MSIV Lower Extremity Bone Imaging Bruise vs. Fracture at MRI www.Jefferson.edu/msk Bone Marrow EdemaWolff’s Law • Non-specific response to stress or injury • Pathophysiology is dynamic – Important consideration for MR early after injury
Wetzel, John. #Elas cModulusStress-Strain. Digital image. Wikipremed. Wikipremed Publica ons, n.d. – Process is adaptive/ Web. 9 Nov. 2015.
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Methods
• Retrospective analysis of catalogued MRI’s • 20 MR exams of LE in 15 professional hockey players from last 5 seasons • 2 blinded MSK radiologists evaluated – T1 cortical linear hypointensity • Small • Large • Spanning 2 cortices – Enthesial location – Weight bearing location – Trabecular disruption – T1 marrow replacement – T2 bone marrow edema – Soft tissue edema – Hematoma
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Methods- Bone Marrow Edema Grading
1 = patchy/ill defined
Axial Coronal Sag T2FS T2FS STIR
Adam C. Zoga, MD www..jefferson.edu/msk
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Lower Extremity Imaging Methods- Bone Marrow Edema Grading 2 = focal & mild
Axial Coronal T2FS T2FS
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Methods- Bone Marrow Edema Grading 3 = focal & intense
Short Axis Long Axis T2FS T2FS Sag STIR
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Methods- Bone Marrow Edema Grading 4 = intense throughout bone
Axial Sag T2FS STIR
Adam C. Zoga, MD www..jefferson.edu/msk
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Lower Extremity Imaging
Results: MRI Findings
RTP With RTP Without α Weight Bearing Loca on 11.5 5.2 0.077 Enthesial 10.4 8.9 0.385 Hematoma 8 9.9 0.341 So Tissue Edema 9.9 3 * Linear Hypointensity 10.8 7.5 0.267 Linear Hypointensity 2 cor ces 12 5.4 0.204 Trabecular Disrup on 11 6.8 0.170 GR3 BME 11.9 4.5 0.046 T1 Replacement 13.5 4.8 0.047 GR3 BME + T1 Replacement 13.5 4.2 0.040
* N=1 for RTP Without
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging Bone bruise vs. fracture results
• Mean RTP for constellation of GR3 BME with T1 replacement was 13.5 days vs. 4.2 days for those without (a = .040)
• Mean RTP for athletes with any linear hypointensity 10.8 days vs. 7.5 days for those without insignificant (a = .267) • Soft tissue edema and hematoma did not correlate with RTP
• Enthesial lesions correlated with increased RTP but not significant
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Case #1: MRI
Grade 2 BME RTP = 4 Days
Sag STIR Short Axis Long Axis T2FS T2FS
Adam C. Zoga, MD www..jefferson.edu/msk
104 10/17/17
Lower Extremity Imaging
Case #1: CT
No Findings!
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Case 2: MRI Grade 3 BME
T1 Marrow ReplacementT2 Bone Marrow Edema
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Case #2: MRI continued
RTP > 4 Weeks
Sag STIR Long Axis T2FS
Adam C. Zoga, MD www..jefferson.edu/msk
105 10/17/17
Lower Extremity Imaging
Case #2: CT
No Findings!
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Case #2: 2 Week f/u MRI
Fracture Line
Axial T2FS Coronal T2FS
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Case #3 Visible Fracture Line Grade 3 BME
Short Axis Long Axis Short Axis T1 T2FS T2FS
Adam C. Zoga, MD www..jefferson.edu/msk
106 10/17/17
Lower Extremity Imaging Discussion
• The MRI constellation of T1 marrow replacement with grade 3 BME correlates with a longer return to play than other MRI findings
• MR is a critically important modality with clinical application early after trauma in athletes
• CT plays little or no role in delineating clinical fracture from non-fracture in radiographically occult osseous injury
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
Adam C. Zoga, MD www..jefferson.edu/msk
Lower Extremity Imaging
[email protected] www.jefferson.edu/mskAdam C. Zoga, MD www..jefferson.edu/msk
107 10/17/17
Lower Extremity Imaging
THANK YOU
Adam C. Zoga, MD www.jefferson.edu/msk www.. jefferson.edu/msk
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