Chronic sport injuries of the knee

5th Musculoskeletal MRI meeting 2018: Knee MRI

Saturday, May 5th, 2018; 14:00-16:00Gustav Andreisek, MD, MBA

Professor of Radiology, University of Zurich andHead of Radiology Spital Thurgau,Cantonal Hospital Münsterlingen,Switzerland

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Declaration of Financial Interests or Relationships

� Gustav Andreisek was co-worker of a study which resulted in US patent (USPTO Number 12/947,256); received grants from Swiss National Science Foundation (SNCF), Holcim, and Siemens; is currently Co-PI or Sub-PI in several third party funded clinical trials at the University of Zurich (Sponsors include: Millennium Pharmaceuticals, Eli Lilly, GlaxoSmithKline, Cytheris SA, Roche, BioChemics, Novartis, Bristol-Meyers Squibb, TopoTarget, and Merck Sharp & Dohme) and where money is paid to the department Gustav Andreisek works for. The department also receives grants from Bayer and Guerbet and has ongoing research collaborations with Siemens.

� Gustav Andreisek has given workshops and talks at a congress which was sponsored by Mepha Pharma AG, Switzerland, and received a speaker fee. He also gives talks at Lunch symposia and CME courses, which are organized and sponsored by Guerbet, and receives speakers fees. Gustav Andreisek served as a consultant for Otsuka Pharmaceutical Europe Ltd at a one-day meeting in London, and received a consultant fee and reimbursement of travel costs. Gustav Andreisek was invited by GE, Philips and Siemens for official company receptions at international radiological congresses (RSNA).

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Learning Objectives

After this talk you will be able

� To know common chronic sport injuries

� To recognize and report them

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Learning Material

Review Article, Book, and Online Video

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Content

� Tendinopathies & Avulsion fractures

� Morbus Osgood-Schlatter

� Morbus Sinding-Larsen-Johansson

� Jumpers Knee

� Hamstrings

� Pes anserinus

� Entrapment-, Friction-, and Impingement Syndroms

� Iliotibial band

� Patella

� Plica

� Fat pads

� Infrapatellar (Hoffa)

� Suprapatellar

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Our Knee MR Imaging Protocol

� Standard Protocol (Skyra 3T, transmit-receive coil)

� Sagittal T2 weighted fat sat, 4238 / 78 ms, 384x384, 3mm

� Sagittal intermediate weighted, 3000 / 29 ms, 448x403, 3mm

� Coronal intermediate weighted, 2270 / 25 ms, 384x346, 3mm

� Axial T2 weighted fat sat, 5200 / 41 ms, 448x358, 2.5 mm

� Additional Sequences

� Gadolinum enhanced T1 fat sat

� Direct MR arthrography

� After meniscus repair

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Causes for Knee MRI – mostly acute injuries

� > 40% sport injuries*

� 15% Soccer

� 12% Ski

� 7% Running

Bild: Getty

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… a typical week in Münsterlingen…

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Content

� Tendinopathies & Avulsion fractures

� Morbus Osgood-Schlatter

� Morbus Sinding-Larsen-Johansson

� Jumpers Knee

� Hamstrings

� Pes anserinus

� Entrapment-, Friction-, and Impingement Syndroms

� Iliotibial band

� Patella

� Plica

� Fat pads

� Infrapatellar (Hoffa)

� Suprapatellar

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Morbus Osgood-Schlatter

Facts

� Overuse / traction

� Microavulsion, Osteonecrosis

� 10-15 ys old, m > f

� Basketball, Volleyball

MRI Findings

� Bone marrow edema

� Bursitis, soft tissue reaction

� Fragmentation of apophysis

Bild: betterbraces.com

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12 ys old boy (acute)

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Morbus Sinding-Larsen-Johansson

Facts

� Overuse / traction

� Microavulsion, Osteonecrosis

� Teenager, m > f

� Running, Basketball, Volleyball

MRI Findings

� Bone marrow edema

� Tendinitis, calcifications

� Edema of Hoffa

� DD sleeve avulsion

Bild: wiki

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15ys old boy

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Jumpers Knee

Bild: knieweh.at

Facts

� Overuse / extension

� Tendon degeneration

� Jumping, Basketball

MRI Findings

� Tendon abnormalities

� Increased T1 and T2

� >7mm patellar tendon

� Soft tissue edema (Hoffa)

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23ys old femal medical student

Mit freundl. Genehmigung von PD Dr. Claudia Schueller-Weidekamm,Wien)

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Hamstrings

Facts

� Acute trauma

� Acute-on-chronic

� Soccer, Water-ski

MRI Findings

� Partial or complete rupture from the origin

� Increased T2 muscle signal may maintain

� Peetron classification (normal, T2 signal, fiber disruptionof less than 50% of the muscle, >50%)

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How one can train them …

Quelle: Google

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… and so it would look like

Quelle: Google

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Why does he show this in a knee talk?

Most cranial slide of a knee MRI

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Various degree of severity

Quelle: own images&radsource.us

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Pes anserinus

Quelle: physioworks.com

Facts

� Mostly M. sartorius

� Chronic stress

� Repetitive strains

� Jogging / MCL tear

MRI Findings

� Tendinitis /Tendinopathy

� Inflammation, degeneration, partial rupture

� Bursitis

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30ys old male

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Content

� Tendinopathies & Avulsion fractures

� Morbus Osgood-Schlatter

� Morbus Sinding-Larsen-Johansson

� Jumpers Knee

� Hamstrings

� Pes anserinus

� Entrapment-, Friction-, and Impingement Syndroms

� Iliotibial band

� Patella

� Plica

� Fat pads

� Infrapatellar (Hoffa)

� Suprapatellar

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Iliotibial Band Friction Syndrom («Runners Knee»)

Quelle: med-info.nl

Facts

� Runners, cyclists, soccer and hockeyplayers

� Most common lateral-side chronic injury

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Insertion

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23ys old female skier

MRI Findings

� Soft tissue edema (fat)

� May involve M. biceps femoris

� ITB thickening in chronic stages +/- fuid collection

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Patellar Pain Syndrome (PFPS)

Facts

� Syn: patellar overload syndrome

� Runners, cyclists, basketball players and other sports participants

� Often caused by a change in training regime that includes dramatic increases in training time, distance or intensity, it can be compounded by worn or the wrong type of footwear

� Discomfort while sitting with bent knees or descending stairs and generalised knee pain

Quelle: braceability.com

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MRI Findings

To differentate possible other causes

� Excessive lateral pressure syndrome (ELPS) due to abnormal lateral tilt of the patella

� Chondromalacia patellae which refers to softening and degeneration of the articular hyaline cartilage of the patella

� Patellofemoral maltracking

� …

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Patellofemoral chondromalacia

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Plica

Facts

� Repetitive trauma of plica

� Chronic inflammation / synovits, joint effusion

� Cartilage damage «kissing lesions»

� Plica mediopatellaris > infrapatellaris > suprapatellaris

MRI Findings

� Normal low signal on T1 and T2

� Increased T1 and T2, thickening of plica

� Chronic inflammation / synovits, joint effusion

� Synovial perfusion maps (4D Angio)

Magnetic resonance spin-labelingperfusion imaging of synovitis in inflammatory arthritis at 3.0 T.Boss A, Martirosian P, Fritz J, Kötter I, Henes JC, Claussen CD, Schick F, Horger M.MAGMA. 2009 Jun;22(3):175-80. doi: 10.1007/s10334-008-0162-y.

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Plica mediopatellaris

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Content

� Tendinopathies & Avulsion fractures

� Morbus Osgood-Schlatter

� Morbus Sinding-Larsen-Johansson

� Jumpers Knee

� Hamstrings

� Pes anserinus

� Entrapment-, Friction-, and Impingement Syndroms

� Iliotibial band

� Patella

� Plica

� Fat pads

� Infrapatellar (Hoffa)

� Suprapatellar

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Infrapatellar (Hoffitis)

Facts

� Syn: infrapatellar impingement syndrome

� Mechanic impingement

� Inflammation, fibrosis, calcification

MRI Findings

� Acute: Increased signal on T2 fat sat, contrast enhancement and hypertrophy

� Chronic: Fibrosis, hemorrage and calcifications

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Hoffa - infrapatellar impingement syndrome

Quelle: ultimate-radiology.blogspot.ch

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43ys old male and 25 ys old female

„patellar tendon lateral femoral condyle friction syndrome PT-LFCFS “«patellofemoral friction syndrome“,»

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Sagittal View

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Learning Objectives

After this talk you are now able

� To know common chronic sport injuries

� To recognize and report them

� Tendinopathies & Avulsion fractures

� Morbus Osgood-Schlatter

� Morbus Sinding-Larsen-Johansson

� Jumpers Knee

� Hamstrings

� Pes anserinus

� Entrapment-, Friction-, and Impingement Syndroms

� Iliotibial band

� Patella

� Plica

� Fat pads

� Infrapatellar (Hoffa)

� Suprapatellar

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See you in 5 days in Lausanne

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