Musculoskeletal Diagnostic Imaging

Home , Calcaneal spur, Meniscus tear, Rotator cuff tear

Vivek Kalia, MD MPH October 02, 2019 Course: Sports Medicine for the Primary Care Physician

Department of Radiology University of Michigan

@VivekKaliaMD [email protected] Objectives

• To review anatomy of joints which commonly present for evaluation in the primary care setting

• To review basic clinical features of particular musculoskeletal conditions affecting these joints

• To review key imaging features of particular musculoskeletal conditions affecting these joints Outline • Joints – Shoulder – Hip • Rotator Cuff Tendinosis / • Osteoarthritis Tendinitis • (Greater) Trochanteric bursitis • Rotator Cuff Tears • Hip Abductor (Gluteal Tendon) • Adhesive Capsulitis (Frozen Tears Shoulder) • Hamstrings Tendinosis / Tears – Elbow – Knee • Lateral Epicondylitis • Osteoarthritis • Medical Epicondylitis • Popliteal / Baker’s cyst – Hand/Wrist • Meniscus Tear • Rheumatoid Arthritis • Ligament Tear • Osteoarthritis • Cartilage Wear Outline • Joints – Ankle/Foot • Osteoarthritis • Plantar Fasciitis

• Spine – Degenerative Disc Disease – Wedge Compression Deformity / Fracture Shoulder Shoulder Rotator Cuff Tendinosis / Tendinitis

• Rotator cuff comprised of 4 muscles/tendons: – Supraspinatus – Infraspinatus – Teres minor – Subscapularis • Theory of rotator cuff degeneration / tearing with time: – Degenerative partial-thickness tears  allow superior migration of the humeral head  in turn causes abrasion of the rotator cuff tendons against the undersurface of the acromion  full-thickness tears  may progress to complete (i.e. full- thickness and full-width) tears • When tendinosis / tear suspected, ultrasound and MRI are both viable options to consider – Ultrasound often can be scheduled quicker – MRI provides more “complete” picture of shoulder area

Morag Y, Jacobson JA, Miller B, De Maeseneer M, Girish G, Jamadar D. MR imaging of rotator cuff injury: what the clinician needs to know. Radiographics. 2006 Jul-Aug;26(4):1045-65. Shoulder Normal Anatomy

SST SST

IST

SSc TMin

Case courtesy of Brendan Cullinane, Radiopaedia.org, rID: 12939 Sagittal T1-weighted MR image shows the Coronal T1-weighted MR image shows the four rotator cuff muscles: supraspinatus tendon traversing the SST = supraspinatus subacromial space and inserting on the IST = infraspinatus greater tuberosity of the humerus Tmin = teres minor SSc = subscapularis

Radiology Masterclass, Department of Radiology, New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. Available online at: https://www.radiologymasterclass.co.uk/ Shoulder Normal Radiographic Anatomy

Radiology Masterclass, Department of Radiology, New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. Available online at: https://www.radiologymasterclass.co.uk/ Shoulder Rotator Cuff Tendinosis / Tear

Coronal T2 fat-saturated MR image shows intermediate Coronal T2 fat-saturated MR image shows fluid-signal hyperintensity (red signal intensity (white arrow) at the supraspinatus tendon arrow) just proximal to the supraspinatus tendon insertion on the greater insertion on the greater tuberosity, consistent with tuberosity, consistent with a high-grade, nearly-full-thickness bursal-sided tendinosis. No fluid defect to suggest an acute tear. tear.

Awh, Mark H. RadSource MRI Web Clinic — February 2013. Rotator Cuff Pitfalls. Available at: http://radsource.us/rotator-cuff-pitfalls/ Shoulder Ultrasound vs. MRI for rotator cuff tears?

• Both have their advantages and disadvantages • Both sensitive for rotator cuff pathology • One study – 114 patients who underwent arthroscopic repair of a full-thickness rotator cuff tear over a 1-year period – Of these patients, 61 had both preoperative MRI and ultrasound for review – Independent observers agree on findings on MRI more than on ultrasound – More variability on U/S – As tear size increases, the 2 image modalities show greater differences in measurement of tear size and retraction status. – Compared with MRI, ultrasound shows consistently lower reliability in detecting subtle, but clinically important, degeneration of the soft tissue envelope. • Ultrasound may be best used to identify a tear • MRI is superior for use in surgical planning for larger tears

Okoroha KR, Mehran N, Duncan J, Washington T, Spiering T, Bey MJ, Van Holsbeeck M, Moutzouros V. Characterization of Rotator Cuff Tears: Ultrasound Versus Magnetic Resonance Imaging. Orthopedics. 2017 Jan 1;40(1):e124-e130. Shoulder Adhesive Capsulitis

• AKA Frozen Shoulder • Thickening and contraction of shoulder joint capsule and surrounding synovium • 3 stages: – Freezing (Painful) • Often pts try OTC pain medications at this stage • Pain worsens with time with loss of active and passive ROM • Lasts 3 – 9 months

• Associated with acute GH joint synovitis Lateral Medial – Frozen (Transitional) • Most patients progress to this stage • Main feature is loss of ROM, which may cause muscular disuse • Lasts 4 – 12 months – Thawing • Lasts from 12 – 42 months • Gradual return of shoulder mobility Coronal T1-weighted shoulder MR image shows marked thickening and signal hyperintensity of the IGHL (inferior glenohumeral ligament) as well as tendinosis of the supraspinatus tendon. Shoulder Rotator Interval Adhesive Capsulitis • Imaging Diagnosis – Typically done by MRI – IV contrast not required, but does increase specificity – Thickening of the inferior glenohumeral ligament [IGHL] (synonymous with the inferior joint capsule at the axillary Anterior recess) Posterior – Signal alteration in the rotator interval (an anatomic space between the supraspinatus and subscapularis tendons) which the long head biceps tendon traverses through

– Thickening of the coracohumeral Sagittal T1-weighted shoulder MR image shows infiltration / replacement of ligament (CHL) the normal expected fat in the rotator interval with intermediate signal tissue Elbow Elbow Lateral Epicondylitis • AKA Tennis Elbow • An overuse syndrome involving the lateral (extensor) tendons of the forearm (i.e. the common extensor tendon, CET) • Predominantly affects the extensor carpi radialis brevis (ECRB) tendon • Imaging Findings: – XR: Up to 25% pts have calcification within soft tissues adjacent to lateral epicondyle – US: Thickening and hypoechogenicity of the CET, possible intra-tendinous calcification, bony irregularity at insertion – MRI: Medial (Ulnar) Side (Ulnar) Medial

• Thickening of CET and signal hyperintensity at the CET Side Lateral(Radial) origin from the lateral epicondyle • Abnormal thickening and separation of the CET from the radial collateral ligament (RCL) • Partial-thickness or full-thickness tearing of the ECRB tendon • Peritendinous edema and focal bone marrow edema at tendon attachment site Coronal STIR elbow MR image shows marked signal hyperintensity and thickening of the common extensor tendon along the radial (lateral) side of the elbow. Elbow Medial Epicondylitis • AKA Golfer’s Elbow • An overuse syndrome involving the medial (flexor) tendons of the elbow, also known as the common flexor- pronator mass • Less common than lateral epicondylitis • Imaging Findings: – XR: not well defined on XR normally – US: Outward bowing, heterogeneous Medial (Ulnar) Side (Ulnar) Medial echogenicity, and thickening of the CFT Side Lateral(Radial) – MRI: • Thickening and signal hyperintensity in the CFT • Soft tissue edema around the CFT

Coronal STIR elbow MR image shows marrow edema at the common flexor-pronator mass attachment on the medial epicondyle as well as edema deep to the ulnar collateral ligament Wrist / Hand Wrist Normal Radiographic Anatomy

Radiology Masterclass, Department of Radiology, New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. Available online at: https://www.radiologymasterclass.co.uk/ Wrist Normal Radiographic Anatomy

Radiology Masterclass, Department of Radiology, New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. Available online at: https://www.radiologymasterclass.co.uk/ Hand Normal Radiographic Anatomy

Radiology Masterclass, Department of Radiology, New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. Available online at: https://www.radiologymasterclass.co.uk/ Hand / Wrist Arthritis • Arthritis is complicated… • Some general guidelines: – CMC = carpometacarpal – CCMC = common CMC – ST = scaphotrapezial – MC = midcarpal – RC = radiocarpal – DRUJ = distal radioulnar joint

University of Washington Department of Radiology – “Appendicular Arthritis.” Available at https://rad.washington.edu/about-us/academic-sections/musculoskeletal-radiology/teaching-materials/online-musculoskeletal-radiology-book/appendicular-arthritis/ While we’re at it with arthritis…

Knee

Hip

• Chronic, autoimmune, systemic inflammatory disorder

• If untreated, can result in progressive joint destruction, deformity, and irreversible long-term disability

• MRI has greater sensitivity than radiographs for detection of early findings of RA in the hands and wrists

• As a general rule, findings are bilateral and symmetrical

• In hands, predilection for PIP and MCP joints, as well as ulnar styloid and triquetrum – Especially 2nd and 3rd MCP’s

• Late changes in hands & wrists: – Subchondral cyst formation due to destruction of cartilage and exposure of bone surface to synovial fluid – Joint subluxations  ulnar deviation at MCP joints, boutonniere and swan neck deformities – Carpal instability (scapholunate dissociation) – Ankylosis Hand / Wrist Rheumatoid Arthritis

Taouli B, Zaim S, Peterfy CG, Lynch JA, Stork A, Guermazi A, Fan B, Fye KH, Genant HK. Rheumatoid arthritis of the hand and wrist: comparison of three imaging techniques. AJR Am J Roentgenol. 2004 Apr;182(4):937-43. Hand / Wrist Osteoarthritis

4 key radiographic features of osteoarthritis anywhere in the body: – Joint space narrowing – Subchondral sclerosis – Osteophytosis – Subchondral cyst / geode formation

Subchondral cyst formation around joints can also occur with: – RA – CPPD – Avascular Necrosis / Osteonecrosis Hip Hip Greater Trochanteric Bursitis

• Anatomy is complex (see right) – GT bursa covers the posterior facet of the greater trochanter • Commonly caused by: – Acute or chronic trauma – Tendon or muscle tear – Hematoma – Arthritis • Imaging Findings: – US: Distension of the GT bursa by anechoic or hypoechoic fluid – MRI: • T1: low signal in region of GT bursa • T2: enlargement and distension of bursa with high signal fluid • Peripheral rim enhancement of GT bursa Hip Greater Trochanteric Bursitis

Coronal STIR MR images of the lower pelvis show significant fluid distention of the left greater trochanteric bursa both anteriorly (left image) and posteriorly (right image). Hip Abductor (Gluteal Tendon) Tear

• Gluteus minimus and gluteus medius • Tears of these are purported to be one of the leading causes of trochanteric pain syndrome (rather than greater trochanteric bursitis) • Increase with advancing age • Progression of tendinosis  low- grade tendon tears  high-grade tendon tears in a predictable sequence • Often associated with hip abductor muscle atrophy  important in fall-related hip fractures

No Tear Low-grade Glut Min Tear High-grade Glut Min Tear

• An underappreciated cause of morbidity in patients as they age, especially > 50 years

• The gluteus medius and minimus are critical to preserve with age as they play an important role in normal gait

• Dysfunction may play a significant role in increased risk of falls and subsequent fractures.

• These tendons tend to tear differently than the rotator cuff, for instance, in that they tend to undergo a gradual process of degeneration with repetitive injury and subsequent repair leading to dysfunction and atrophy rather than complete rupture (e.g. contrast with a full-thickness rotator cuff tear)

• Atrophy of the gluteus medius may have more clinical significance in symptomatic patients

Chi AS, Long SS, Zoga AC, Read PJ, Deely DM, Parker L, Morrison WB. Prevalence and pattern of gluteus medius and minimus tendon pathology and muscle atrophy in older individuals using MRI. Skeletal Radiol. 2015 Dec;44(12):1727-33. Hip Hamstrings Tendon Tear • Most commonly seen in athletes • Tend to heal slowly and to recur • Unique in that the hamstrings span two joints – Flex the knee – Extend the hip • Tears can occur at multiple levels – Often accompanied by an audible pop – In more severe injuries, ecchymosis and swelling visible • Because of proximity to sciatic nerve, temporary sciatica possible • Imaging Findings: – MRI: Fluid-filled defects in the tendon at the site of disruption, often with adjacent hemorrhage and edema – Avulsions at bone-tendon interface may occur with or without fracture avulsion fragment from the ischial tuberosity Axial T1-weighted MR image at the level of the ischial tuberosity shows – Myotendinous injuries can occur at any level along the muscle normal anatomy of the hamstrings tendon origin. Blue Arrow = semimembranosus tendon interface Red Arrowhead = conjoined tendon (semitendinosus and biceps femoris) – Biceps femoris muscle is most commonly injured Yellow Circle = Sciatic Nerve Hip Hamstrings Tendon Tear

Complete avulsion of both the semimembranosus and the conjoined tendon attachments of the right hamstrings origin, with early hematoma formation and intramuscular edema Knee Knee Normal Radiographic Anatomy

Radiology Masterclass, Department of Radiology, New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. Available online at: https://www.radiologymasterclass.co.uk/ Knee Osteoarthritis

• Typical imaging features include: – Medial femorotibial compartment preferentially affected – Joint space narrowing (usually asymmetric in 1 knee) – Subchondral sclerosis – Marginal osteophytes – Subchondral cysts – Articular surface irregularity / altered shape of the femoral condyles and tibial plateau • Can lead to angulation deformities, most commonly genu varum • Most common joint disease in the elderly Knee Popliteal / Baker’s Cyst

• Are distended cystic collections of fluid in the popliteal fossa between the medial head of the gastrocnemius and semimembranosus tendons • Communicate with the knee joint • Usually at or below the joint line • Symptomatic when rupture occurs, in which case the chief DDx includes a DVT (but will see strand edema going down into calf in case of ruptured cyst) • Imaging Findings: – Often elongated, may contain debris – Search for a “neck” between the two tendons that connects the fluid collection to the knee joint space (at the posterior capsule) – U/S: Usually anechoic/hypoechoic – MRI: High T2 signal fluid-filled collection in the appropriate location

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 66675 Knee Meniscus Tear

• The critical feature to diagnose a meniscus tear on imaging is fluid signal intensity within the meniscus which extends to an articular surface

• Menisci are normally black and have a predictable bowtie shape – Medial Meniscus: posterior horn is larger than anterior horn – Lateral Meniscus: anterior and posterior horns are the same size

David Rubin and Robin Smithuis. “Knee - Meniscus basics.” The Radiology Assistant website. Available at: http://www.radiologyassistant.nl/en/p42daafe92b280/knee-meniscus-basics.html Knee Meniscus Tear

Vertical longitudinal tear in the periphery of the medial Radial tear along the inner free edge of the medial meniscus meniscus

• Medial ligaments are the most commonly injured in the knee • Most medial knee injuries are isolated and occur in young active patients in sporting activities • Anteriorly, the medial supporting structures of the knee include: – Per anserinus tendons – attach to anteromedial tibia • Sartorius • Gracilis • Semitendinosus – Medial patellofemoral ligament (MPFL) • The medial collateral ligament is divided into superficial and deep layers: • Superficial MCL = MCL proper • Deep MCL = Deep medial meniscofemoral and deep medial meniscotibial ligaments • MCL is primary restraint to valgus force and external rotation of the knee Proton density-weighted fat-saturated coronal MR Tadros AS, Nguyen TB, Curtis BR, Huang BK, and Resnick DL. RadSource MRI Web Clinic — June 2018. Medial Supporting Structures of image shows a grade 3 injury of the MCL, with the Knee with Emphasis on the Medial Collateral Ligament. Available at: http://radsource.us/medial-supporting-structures-knee- emphasis-medial-collateral-ligament/ complete loss of continuity of ligamentous fibers. Knee Cartilage Wear

• Pathophysiology of cartilage loss is complex • Probability of cartilage loss increases with age, but it is not simply a process of “wear and tear,” as has been traditionally thought • Most common in weightbearing joints, e.g. knees, hips, ankles, and vertebral joints • Pain increases with motion and joint use (unlike the usual remission that is seen with chronic inflammatory joint diseases) Cartilage Anatomy • Hyaline articular cartilage mainly consists of collagen and proteoglycans • This collagen network is normally highly organized to help resist shear forces and pressures and to help distribute load evenly throughout the joint • Healthy articular cartilage is largely acellular, composed mainly of water (65-85% of its weight) and extracellular matrix (ECM) • The natural healing capacity of cartilage is very limited Cartilage Anatomy • The ECM of cartilage consists of: – Glycosaminoglycans (GAGs) – Type II collagen • At the osteocartilaginous junction, also referred to as the tidemark, collagen fibrils attach the cartilage to the subchondral bone • In the deep cartilaginous layer, also referred to as the radial zone, collagen fibers are oriented perpendicular to the articular surface • In the more superficial transitional zone, collagen orientation is anisotropic • In the most superficial or tangential zone, collagen fibrils are oriented parallel to the articular surface Cartilage Anatomy

Ariyachaipanich A, Bae WC, Statum S, Chung CB. Update on MRI Pulse Sequences for the Knee: Imaging of Cartilage, Meniscus, Tendon, and Hardware. Semin Musculoskelet Radiol. 2017 Apr;21(2):45-62. Full-Thickness Chondral Defect Full-Thickness Chondral Defect

Displaced Chondral Fragment Shindle MK, Foo LF, Kelly BT, Khanna AJ, Domb BG, Farber A, Wanich T, Potter HG. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:27-46. Shindle MK, Foo LF, Kelly BT, Khanna AJ, Domb BG, Farber A, Wanich T, Potter HG. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:27-46. Shindle MK, Foo LF, Kelly BT, Khanna AJ, Domb BG, Farber A, Wanich T, Potter HG. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:27-46. Ankle / Foot Ankle / Foot Plantar Fasciitis • Most common cause of heel pain • Most commonly due to repetitive microtrauma (i.e. mechanical) • Can be associated with ankylosing spondylitis and psoriatic arthritis • Imaging Findings: T1-weighted sagittal MR image shows normal – XR: plantar calcaneal spur (which can also be seen in appearance of the plantar fascia asymptomatic patients) – U/S: often initial modality of choice. Thickening of the plantar fascia > 4.5 mm in longitudinal view and hypoechoic appearance – MRI: • Intermediate T1 signal, high T2 and STIR signal in the plantar fascia at its calcaneal attachment • High STIR signal in perifascial soft tissues, e.g. heel pad • Thickening of plantar fascia • Limited marrow edema in the calcaneal tuberosity STIR sagittal MR image shows advanced plantar fasciitis, with Burdett Pamela H. RadSource MRI Web Clinic — April 2009. Plantar Fasciitis. heel pad edema, and bone marrow edema in the calcaneus Available at: http://radsource.us/plantar-fasciitis/ Spine Spine Degenerative Disc Disease

• Exceedingly common process in the spine

• Most consider these changes as expected with age to a varying degree depending on an individual

• Types of Degenerative Disc Disease described: – Loss of disc height – Endplate osteophyte formation – Disc bulge – Disc protrusion – Disc extrusion – Disc sequestration – Annular tear – Schmorl’s node

Robin Smithuis. “Lumbar Disc Nomenclature 2.0.” The Radiology Assistant website. Available at: http://www.radiologyassistant.nl/en/p586e67dab68a4/spine-lumbar-disc-nomenclature-20.html Spine Degenerative Disc Disease • “Modic” Changes – describe degenerative and inflammatory changes involving the vertebral endplates as seen on MRI 1 • Modic Type 1 – Dark on T1, Bright on T2 – Reflects fibrovascular tissue, inflammatory changes, endplate edema • Modic Type 2 2 – Bright on T1, Bright on T2 – Reflects bone marrow replacement by fat • Modic Type 3 – Dark on T1, Dark on T2 3 – Reflects reactive sclerosis

• Result from axial loading of the spine • Considered single-column (stable) fractures • Are typically insufficiency fractures secondary to osteoporosis, although some are pathological related to a focal bone lesion Spine Wedge Compression Deformity / Fracture

Sagittal T1 and STIR MR images of the spine demonstrate a compression deformity / fracture of the superior endplate of L3, with associated marrow edema. Always Remember… In Radiology, 1 View is No View - Donna Magid, MD Thank You • Please e-mail / message with any questions or concerns.

@VivekKaliaMD [email protected] [email protected]