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Musculoskeletal Diagnostic Imaging Musculoskeletal Diagnostic Imaging 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 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. IMAIOS eAnatomy. 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 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 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 Medial (Ulnar) Side • Thickening of CET and signal hyperintensity at the CET (Radial) Lateral Side 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 Medial (Ulnar) Side echogenicity, and thickening of the CFT (Radial) Lateral Side – 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/ 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 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/
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