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May 2003 (Vol. 11, Issue 2)
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CLINIC INFORMATION
Preface
• Consulting Editor
MR imaging of sports-related injuries
• Author Information
by Steinbach LS
• Abstracting/Indexing pages xi-xii
• Contact Information Full Text | PDF (41 KB)
• Media Information Review article
• Permissions Joint MR imaging: Normal variants and pitfalls related to sports injury
• Buy Back Issues by Pfirrmann CWA, Zanetti M, Hodler J
RELATED SITES pages 193-205
Full Text | PDF (539 KB)
More periodicals: Review article
FIND A PERIODICAL
MR imaging of sports injuries to the rotator cuff
FIND A PORTAL by Tuite MJ
GO TO PRODUCT CATALOG
pages 207-219
Full Text | PDF (724 KB)
Review article
MR imaging of shoulder instability injuries in the athlete
by Beltran J, Kim DHM
pages 221-238
Full Text | PDF (649 KB)
Review article
Sports injuries of the elbow
by Chung CB, Kim HJ
pages 239-253
Full Text | PDF (605 KB)
Review article
MR imaging of sports-related hip disorders
by Boutin RD, Newman JS
pages 255-281
Full Text | PDF (629 KB)
Review article
MR imaging of meniscal and cruciate ligament injuries
by Fritz RC
pages 283-293
Full Text | PDF (861 KB)
Review article
Imaging sports injuries of the foot and ankle
by Zoga AC, Schweitzer ME
pages 295-310
Full Text | PDF (756 KB)

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Magnetic Resonance Imaging Clinics of North America

Review article
Winter sports injuries: The 2002 Winter Olympics experience and a review of the
literature
by Crim JR
pages 311-321
Full Text | PDF (659 KB)
Review article
Imaging of stress fractures in the athlete
by Spitz DJ, Newberg AH
pages 323-339
Full Text | PDF (791 KB)
Review article
Imaging of sports-related muscle injuries
by Boutin RD, Fritz RC, Steinbach LS
pages 341-371
Full Text | PDF (999 KB)
Index
pages 373-378
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 Magn Reson Imaging Clin N Am
11 (2003) xi–xii

Preface
MR imaging of sports-related injuries

Lynne S. Steinbach, MD
Guest Editor

I have been fortunate enough to have edited that relate to sports imaging. This article is being
two issues of the Clinics that focus on sports- republished from the March 2002 issue of the
related injuries. This topic is very popular, and Radiologic Clinics of North America on sports
with good reason. Our society is more fitness-con- imaging because it provides a good baseline for
scious than ever. Children and adolescents, espe- decision-making. Athletic injuries to the shoulder
cially females, are more involved in sports than are discussed in two separate articles by three
they were in my generation. Elite athletes expect well-regarded authors who have published exten-
imaging to be interpreted instantly with the cor- sively on this material: Dr. Tuite, Dr. Beltran,
rect diagnosis and to be provided with a prognosis and Dr. Kim. Drs. Chung and Kim bring new
that determines the appropriate therapy and ex- concepts in elbow anatomy and MR imaging elo-
pected recovery period. Baby boomers are work- quently to light. Drs. Boutin and Newman present
ing out for their own health in record numbers a cutting edge report on sports imaging of the hip,
but, because of their age, are also more prone to discussing areas such as impingement and snap-
injury. On top of this, new knowledge and devel- ping hip. Dr. Fritz elucidates some important
opments in MR imaging technology are difficult new concepts regarding meniscal and cruciate
to find in books, which take years to write and ligament injuries, including the flap tear of the
publish. Clinicians are demanding that radiolo- posterior lateral meniscus and injuries to the dif-
gists know the material so that they may provide ferent bands of the cruciate ligaments. Drs. Zoga
helpful and accurate MR imaging interpretations. and Schweitzer use their extensive experience to
This compendium of articles focuses on the use of enrich our knowledge of sports injuries to the foot
MR imaging in sports injury. and ankle. Dr. Crim, who was in charge of radiol-
To play a useful role in diagnosis and therapy ogy in the polyclinic at the Salt Lake City Olym-
of sports injuries, it is important for the imager to pics, shares a unique, well-researched background
be familiar with normal musculoskeletal anatomy, and interesting cases from that event. Drs. Spitz
in addition to the potential pitfalls. Drs. Pfirr- and Newberg have done an admirable job of
mann and colleagues have put together a review reviewing the different types of stress fractures in
of normal variants and pitfalls in MR imaging the athlete and how they are viewed by different

1064-9689=03=$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016=S1064-9689(03)00030-8
xii L.S. Steinbach / Magn Reson Imaging Clin N Am 11 (2003) xi–xii

imaging techniques, which was originally pub- in a presentation of fresh concepts in another out-
lished in the Radiologic Clinics of North America. standing overview of sports imaging.
In an encore from the most recent issue of the
Radiologic Clinics of North America, Dr. Boutin
Lynne S. Steinbach, MD
comprehensively reviews imaging of sports-related
Department of Radiology
muscle injuries, with special attention given to
University of California–San Francisco
specific common musculotendinous injuries.
505 Parnassus, San Francisco
I want to thank this group of highly regarded
CA 94143-0628, USA
authors who contributed articles to this issue in
such an accomplished and timely manner. The E-mail address:
efforts of these leaders in the field have resulted [email protected]
 Magn Reson Imaging Clin N Am
11 (2003) 193–205

Joint MR imaging
Normal variants and pitfalls
related to sports injury
Christian W.A. Pfirrmann, MD*, Marco Zanetti, MD,
Juerg Hodler, MD
Department of Radiology, Orthopedic University Hospital, Balgrist, Forchstrasse 340, CH-8008 Zürich, Switzerland

Knowledge of normal anatomic variants and and are more pronounced in images acquired with
other diagnostic pitfalls is the first but crucial step narrow bandwidth. Motion artifacts arise from
for accurate analysis of MR images of the joint. several sources, including respiration, flow in
Such variants and pitfalls are commonly found blood vessels, and motion caused by pain or
as coincidental findings on MR images performed reduced levels of patient cooperation. Artifacts
after sport injuries and may easily be misdiag- caused by a nonuniform magnetic field may be
nosed as relevant abnormality. The consequences the cause of inhomogeneous fat saturation. Such
may be overtreatment, such as unnecessary reduc- problems are more pronounced in frequency-
tion of sports activities, plaster casts, or even selective T2-weighted spin echo images than on
arthroscopy or surgery. This article starts with STIR images [16]. They are commonly found in
a short discussion of artifacts as far as relevant for the presence of metallic implants and in peripheral
musculoskeletal imaging, followed by a descrip- regions, such as the forefoot. Shimming of the
tion of commonly found anatomic variants and magnet is another important aspect. Magnetic
pitfalls for all major joints. susceptibility artifacts are more severe in images
acquired with gradient echo sequences or fat-
suppressed sequences, when compared with stan-
Artifacts dard or turbo (fast) spin echo images.

Artifacts may simulate pathologic conditions

on MR images. Aliasing occurs when the field of Truncation artifacts
view does not include all of the anatomic struc-
tures present in the imaged section. Aliasing Truncation artifacts result from the use of
artifacts can be eliminated by increasing the field Fourier transform methods to reconstruct MR
of view, by oversampling, by applying saturation images. Ringing artifacts (Gibbs phenomenon)
pulses outside the region of interest, or by using occurring near highly contrasting interfaces rep-
surface coils. Chemical shift artifacts can be found resent one manifestation of truncation artifacts
at the interface between fat and other structures. [1]. Truncation artifacts appear as a series of high
Chemical shift artifacts increase with field strength and low signal intensity lines, adjacent and
parallel to these boundaries. Such a line of high
signal intensity within the low signal intensity of
the meniscus may simulate the appearance of
Reprinted with permission from Radiologic Clinics a meniscal tear (Fig. 1) [35]. When superimposed
of North America 2002;40(2):167–180. on the meniscus, truncation artifacts tend to be
* Corresponding author. subtle, uniform in thickness, and parallel to the
E-mail address: christian@pfirrmann.ch surfaces of the menisci. They may extend beyond
1064-9689=03=$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016=S1064-9689(03)00020-5
194 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205

Fig. 1. Truncation artifact: sagittal proton-density turbo

spin-echo image (TR 3610 milliseconds [ms], TE 14 ms)
at the level of the lateral condyle. Note the line of high
signal intensity (white arrowhead) within the low-signal
intensity of the meniscus, which may simulate the
appearance of a meniscal tear. This is an example of
a truncation artifact, which usually is subtle, uniform in
thickness, and parallel to the surface of the meniscus or
the femoral condyle. The line extends beyond the bound-
aries of the meniscus (black arrowheads).
Fig. 2. Magic angle phenomenon: sagittal T1-weighted
spin-echo image (TR 473 ms, TE 11 ms) through the
medial malleolus. The flexor digitorum longus tendon
the boundaries of the meniscus. Truncation
(white arrowheads) demonstrates hypointense signal. The
artifacts can be reduced with data extrapolation posterior tibialis tendon (black arrowheads) is slightly
algorithms, image filtering, or equal in-plane hyperintense because of the magic angle phenomenon,
resolutions [8]. which may simulate the appearance of tendinopathy or
even a tear.
Magic angle
The presence of magic angle effect contributes variability of the arthroscopically normal glenoid
to the difficulty of interpretation of MR images labrum. One hundred twenty-one (50%) of 241 ar-
of the joints. This effect is commonly found in throscopically normal labral parts demonstrated
ligaments and other ordered structures when they normal (low) signal intensity and normal form on
are oriented approximately 55
to the main mag- MR arthrograms. Increased linear or globular
netic field (B0). This orientation leads to shorten- signal was seen in 31% of normal labral parts. De-
ing of the apparent T1 time, resulting in an formed or fragmented labra were found in 12%.
increase in signal intensity of the tendon, which Complete separation of the labrum from the
may simulate the appearance of a tear or tendi- glenoid was found in 2%, a cleft in 2%, and
nosis [13]. This phenomenon is most pronounced complete absence in 2%. Because the MR imag-
when a short echo time is used [24]. Increased ing appearance of the arthroscopically normal
signal intensity within the distal portion of the glenoid labrum varies considerably with regard
supraspinatus tendon or within the long tendons to signal intensity, form, and size, other signs for
of the ankle (submalleolar and retromalleolar glenohumeral instability, such as capsular abnor-
region) is frequently observed and are probably malities, lesions of the glenohumeral ligaments,
caused by the magic angle effect (Fig. 2). Hill-Sachs impression fractures, or osseous abnor-
malities of the glenoid rim, should be considered
in the evaluation of the labrum. Several specific
Shoulder situations are discussed in the following sections.
Labral variability
Sublabral hole versus labral tear
The normal glenoid labrum is highly variable.
Most of the anatomic variants are found at the The sublabral hole is an anatomic variant
anterosuperior aspect of the shoulder joint, be- located anterosuperiorly at the 2-o’clock position,
tween the 11- to 3-o’clock position [18]. Zanetti anterior to the biceps insertion. A sublabral hole
et al [38] investigated the MR arthrographic is seen in 12% of individuals [37]. A sublabral hole
 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205 195

Fig. 3. Sublabral hole: axial T1-weighted spin-echo MR

arthrogram (TR 600 ms, TE 12 ms) demonstrating
Fig. 4. Buford complex: axial T1-weighted spin-echo
a sublabral hole (arrow). This anatomic variant is
MR arthrogram (TR 600 ms, TE 12 ms) in a shoulder
located antero-superiorly at the 2 o’clock position, and
with a Buford complex. The Buford complex is an ana-
anteriorly to the biceps insertion. A sublabral hole may
tomic capsulolabral variant that can be misdiagnosed as
be misinterpreted as a labral tear.
a lesion of the anterior labrum. The Buford complex
consists of a ‘‘cord-like’’ middle glenohumeral ligament
may be misinterpreted as a labral tear (Fig. 3) [9]. (arrow) and absent anterosuperior labrum (arrowhead).
The craniocaudal diameter of a sublabral hole
should probably not exceed 15 mm, is located at have to be differentiated from superior labrum
the labral base, and is not associated with anteroposterior (SLAP) lesions. There commonly
traumatic abnormalities of the joint capsule and is a physiologic sublabral recess, which is located
the glenohumeral ligaments. in the anterior part of the bicipitolabral complex.
There is an overlapping appearance between the
Buford complex versus labral tear physiologic sublabral recess and a type 2 superior
labrum anteroposterior lesion. A sublabral recess
The Buford complex is an anatomic capsulola- is found in approximately 70% of patients [17].
bral variant that can be misdiagnosed as a lesion The sublabral recess is a smooth line that follows
of the anterior labrum. The Buford complex con- the surface of the glenoid. This line is not usually
sists of a cord-like middle glenohumeral ligament oriented laterally toward the substance of the
and absent anterosuperior labrum. In a series of labrum (Fig. 5). Lesions of the superior labral
200 shoulder arthroscopies this unusual variant complex commonly can be differentiated from
was noted in 3 (1.5%) shoulders. In the presence the normal sublabral recess because they extend
of a Buford complex the thickened middle gleno- posterior to the biceps tendon insertion. More-
humeral ligament originates from the superior over, tears often have a frayed appearance, they
labrum at the biceps tendon origin, crosses under- can have a branching pattern, and they tend to
neath the subscapularis tendon, and inserts on the involve the labral substance.
lesser tuberosity the humerus. The anterosuperior
labrum is missing (Fig. 4). This anatomic varia- Os acromiale versus acromial fracture
tion has to be differentiated from a sublabral hole
and from true labral detachment. In the presence The os acromiale is an acromial apophysis
of a Buford complex the labral tissue of the re- that has not united with the main part of the
maining three glenoid quadrants is normal, and acromion. The os acromiale is bilateral in approxi-
no abnormalities, such as a Hill-Sachs lesion or mately 60% of patients. The connection between
capsular insertion abnormality, are found [37]. the os acromiale and the main bone is commonly
sagittal but may also have an oblique course. The
os acromiale may contribute to shoulder im-
Sublabral recess versus superior labrum
pingement syndrome. It can easily be detected on
anteroposterior lesion
routine MR images of the shoulder. The diagnosis
The attachment of the superior glenoid labrum is best made on axial images. Angled coronal and
deserves special attention because normal variants sagittal images may also be adequate, depending
196 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205

The postoperative shoulder

Imaging the postoperative shoulder is challeng-
ing. Zanetti et al [40] found residual defects or
retears in the rotator cuff in 21% and bursitis-like
abnormalities in 100% of asymptomatic patients
after rotator cuff repair (Fig. 6). The size of the
residual defects or retears was significantly smaller
in the asymptomatic group (mean, 8 mm; range, 6
to 11 mm) than in the symptomatic group (mean,
32 mm; range, 7 to 50 mm) (t-test, P ¼ 0.001).
Subacromial bursitis-like MR abnormalities are
almost always seen after rotator cuff repair. They
may persist for several years after rotator cuff
repair and seem to be clinically irrelevant. Small
Fig. 5. Sublabral recess: sagittal o-blique protonden-
density turbo spin-echo MR arthrogram with fat satu- residual defects or retears (<1 cm) of the rotator
ration (TR 3300 ms, TE 14 ms) of a right shoulder. Note cuff are not necessarily associated with clinical
the sublabral recess, which is located in the anterior part symptoms and are probably also unimportant [40].
of the bicipitolabral complex. This normal recess should
be differentiated from a superior labrum anteroposterior
(SLAP) lesion. The sublabral recess (arrowhead) is a Elbow
smooth line that follows the surface of the glenoid. SLAP
The pseudodefect of the capitellum
lesions can commonly be differentiated from the normal
sublabral recess because they extend laterally, have a The pseudodefect of the capitellum is one of
complex form, or extend posterior to the biceps tendon the most commonly encountered diagnostic pit-
insertion. falls in MR imaging of the elbow. The pseudode-
fect is found at the junction of the capitellum and
on the orientation of the attachment. The os lateral (radial) epicondyle of the distal humerus. It
acromiale can simulate an acromial fracture [11], is seen on cross-sectional images partially cutting
although such diagnosis is rare. It has been through the irregular surface of these bony
described in patients with shoulder prosthesis structures. The pseudodefect of the capitellum
where altered biomechanics may lead to a fatigue may simulate an osteochondral lesion on sagittal
fracture. (Fig. 7) and coronal MR images [26].

Fig. 6. Postoperative pseudobursitis: (A) coronal oblique T2-weighted turbo spin-echo (TR 3500 ms, TE 98 ms), and (B)
corresponding short–tau inversion recovery (STIR) (TR 4800 ms, TE 30 ms, TI 180 ms) images of a 53-year-old man 2
years after rotator cuff repair (supraspinatus tendon, arrows). The patient is completely asymptomatic and has regained
complete shoulder function. Note the bursitis-like high signal at the site of the subacromial bursa (arrowheads).
 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205 197

capitellum during repeated elbow flexion and

extension, particularly with the forearm in pro-
nation [7].

Wrist and hand

Pseudo dorsal intercalated segment instability
(DISI) seen on sagittal MR images
Lunar tilt is an important diagnostic sign of
a static carpal instability. It is usually diagnosed
on standardized lateral radiographs of the wrist.
Theoretically, such diagnosis can also be made on
sagittal MR images. Zanetti et al [39] have shown,
however, that on sagittal images the lunate ap-
parently is more dorsally tilted than on standard
lateral radiographs. A DISI configuration can be
mimicked (Fig. 8). In neutrally positioned wrists,
the authors found that the mean capitolunate,
scapholunate, and radiolunate MR imaging
Fig. 7. Pseudodefect of the capitellum: sagittal T2- angles were 13.6
–14.5
, 4
–9.9
, and 18
–20.3

weighted fat-saturated turbo spin-echo image (TR 3600 larger, respectively, than those measured on lateral
ms, TE 96 ms) at the level of capitellum of the humerus. radiographs. In 15
radially deviated wrists, the
Note the pseudodefect (arrowheads) at the posterior
mean MR imaging angles were similar to those on
aspect of the capitellum. The pseudodefect of the
lateral radiographs. In 15
ulnarly deviated wrists,
capitellum may simulate an osteochondral lesion.
the mean MR imaging angles were 32.3
, 16.6
,
and 37.1
larger than those on lateral radiographs.
At MR imaging, a DISI configuration would have
Variations of the trochlear groove
been diagnosed in 4 of 10 subjects with neutrally
The proximal portion of the ulna is formed by positioned wrists and in 8 of 10 subjects with
the olecranon and the coronoid process. They ulnarly deviated wrists. It may be difficult to
form the trochlear groove, which articulates with obtain a perfectly neutral position of the wrist
the distal humerus. The groove is constricted at during MR imaging. When the patient is exam-
the junction of the olecranon and the coronoid ined with the hand above the head, ulnar tilting
process. A thin, transverse, nonarticular ridge in- is very common. Analysis of a DISI or volar in-
tersects the groove at this junction. Both the tercalated segment instability (VISI) configuration
constriction at the periphery of the groove and the should only be performed on standard lateral
nonarticular ridge may simulate disease on MR radiographs to avoid this pitfall.
imaging of the elbow. The nonarticular ridge is
often not covered by articular cartilage [27]. Asymptomatic triangular fibrocartilage and
interosseous ligament lesions
Synovial plicae
With increasing age, defects and communi-
Synovial plicae are frequently found during cation within the triangular fibrocartilage and
MR imaging of the elbow. They are most often the interosseous ligaments increase in frequency.
located at the posterior part of the joint. Synovial Many of these defects have no clinical signifi-
plicae may be misdiagnosed as intra-articular cance. Zanetti et al [41] have shown that radial-
bodies on cross-sectional images. Plicae are usually sided communicating triangular fibrocartilage
asymptomatic. Rarely, they present with locking defects described in the literature as post-trau-
sensations or pain [7]. The lateral synovial fringe matic (Palmer classification type IA and ID)
is a particular synovial plica located between the are commonly seen bilaterally and in asymp-
radial head and the capitellum of the humerus. tomatic wrists. In a population of 56 patients (age,
Rarely, the lateral synovial fringe leads to an 16 to 52 years; mean, 32 years) with isolated
impingement between the radial head and the triangular fibrocartilage lesions communicating
198 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205

Fig. 8. Pseudo DISI configuration: sagittal T1-weighted spin-echo image (TR 435 ms, TE 21 ms) at the level of the
lunate- (A) and corresponding lateral radiograph of the wrist (B) in an asymptomatic subject without history of trauma.
The lunate usually appears to be tilted more dorsally on sagittal MR images than on standard lateral radiographs. On
sagittal MR images, a DISI configuration can easily be misdiagnosed.

defects were noted in 36 (64%) of 56 symptomatic were bilateral. Noncommunicating and commu-
and in 26 (46%) of 56 asymptomatic wrists. nicating defects of the triangular fibrocartilage
Twenty-five (69%) of 36 communicating defects near its ulnar attachment have a more reliable
were bilateral (Fig. 9). Almost all communicating association with symptomatic wrists than the
defects were noted radially. Noncommunicating radial communicating defects.
defects were noted in 28 (50%) of 56 symptomatic
wrists and in 15 (27%) of 56 asymptomatic wrists.
Eleven (39%) of 28 noncommunicating defects Hip
Labrum
In MR imaging of asymptomatic hips, abnor-
mal shape and signal intensity of the labrum are
frequent. Abe et al [43] investigated 73 asymp-
tomatic hips. They found a triangular shape in
80% of labral segments. The labrum was round in
13% and irregular in shape in the remaining 7%.
The labrum was not identified in 1% of labral
segments. Homogeneous low signal intensity was
observed in 56% of labral segments. Signal
changes were a frequent finding (Fig. 10). The
frequencies of labral irregularity or its absence
and of high signal intensity increased both with
subject age and with a more anterior anatomic
Fig. 9. Communicating defect of the triangular fibro-
labral location. The fact that the findings vary
cartilage (TFC): coronal T1-weighted image (TR 500
ms, TE 15 ms) of the wrist, demonstrating a communi- according to age and labral portion should be
cating defect (arrowheads) of the TFC near its radial considered in interpreting MR images in patients
attachment. Communicating defects are a frequent suspected of having a labral lesion. MR arthrog-
finding (46%) in asymptomatic writsts and are often raphy may be required to differentiate zones of
(69%) bilateral. degenerated tissue from detachments.
 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205 199

appearance and simulate a tear of the posterior

horn of the lateral meniscus [15].

Meniscofemoral ligaments
The meniscofemoral ligaments are accessory
ligaments of the knee that extend from the pos-
terior horn of the lateral meniscus to the lateral
aspect of the medial femoral condyle. As they
extend across the knee, they are intimate with
portions of the posterior cruciate ligament. The
anterior meniscofemoral ligament, or ligament of
Humphry, passes in front of the posterior cruci-
ate ligament, and the posterior meniscofemoral
ligament, or ligament of Wrisberg, passes behind
Fig. 10. Acetabular labrum variability: coronal T1-
the posterior cruciate ligament. The meniscofem-
weighted spin-echo MR arthrogram (TR 512 ms, TE oral ligaments are highly variable in size and
14 ms) demonstrating a slightly rounded labrum (arrow) may even be absent (both or one of them). Both
and signal changes in the substance. Signal changes and ligaments are visualized in about one third of MR
form variations are a frequent finding in asymptomatic imaging examinations. The meniscofemoral liga-
patients. ments are seen both on coronal and sagittal MR
images. They may simulate a tear of either the pos-
terior cruciate ligament or the posterior horn of
Knee the lateral meniscus (Fig. 11). On sagittal images,
the meniscofemoral ligaments can be mistaken for
Asymptomatic meniscal tear osteochondral or meniscal fragments [6,36].
Not all meniscal tears are symptomatic. In an
investigation by Boden et al [3] in asymptomatic The transverse ligament
volunteers meniscal tears were found in 16% of The transverse ligament connects the convex
knees. The prevalence of MR imaging findings of portions of the anterior horns of the medial and
a meniscal tear increased from 13% in individuals lateral menisci. Its diameter is variable, and it may
below the age of 45 years to 36% in those older be absent in some persons. This ligament is iden-
than 45. An additional 30% of the volunteers had tified on sagittal MR images of the knee as a
meniscal abnormalities consisting of a linear area hypointense structure close to the anterior horns
of increased MR imaging signal not communicat- of the menisci. On coronal and axial images it may
ing with a meniscal surface. The authors con- not be visible or appears as a linear structure. As it
cluded that the high prevalence of abnormal MR separates from the menisci, particularly the medial
imaging findings in asymptomatic subjects under- meniscus, the space filled by fat between the
scores the danger of relying on a diagnostic test ligament and the meniscus may be misinterpreted
without careful correlation with clinical signs and as a meniscal tear (Fig. 12) [15]. The transverse
symptoms. These findings also emphasize the im- ligament has a reported prevalence of about 58%
portance of access to relevant clinical data when on sagittal MR images [33].
interpreting MR imaging scans of the knee [3].
Chondrocalcinosis versus meniscal tear
Crystal deposition diseases, particularly those
Pitfalls mimicking meniscal tears
related to calcium pyrophosphate dihydrate and
Many anatomic structures and variations may calcium hydroxyapatite crystal accumulation, af-
simulate a meniscal tear. Increased signal intensity fect the menisci. Both of these disorders lead to
at the anterior horn of the lateral meniscus near cartilage calcification. Both the calcium deposits
its central attachment site is frequent and usually and the usually present surrounding zones of men-
does not represent a meniscal tear [32]. The syno- iscal degeneration lead to signal changes in the
vial recess of the popliteus tendon is located meniscal substance, which may simulate meniscal
between the posterior horn of the lateral meniscus tears [4]. Correlation of MR images with plain
and the popliteus tendon at the posterolateral radiographs may help to diagnose this condition.
aspect of the knee. This recess may have a linear Occasionally, calcification of articular cartilage
200 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205

Fig. 12. Transverse ligament: sagittal proton-density

turbo spin-echo image (TR 3610 ms, TE 14 ms) through
the medial condyle of a knee in a 34-year-old man.
Transverse ligament (straight arrow) is shown in close
relationship to the anterior horn (curved arrow) of the
medial meniscus simulating a meniscal tear (arrowhead).

medial collateral ligament is present in more than

90% of cadaveric knees. This bursa separates the
peripheral region of the midportion of the medial
meniscus and the medial collateral ligament.
Bursitis may lead to increased signal intensity in
Fig. 11. Meniscofemoral ligament (ligament of Wris- this junctional region that simulates the appear-
berg): (A) sagittal proton-density trubo spin-echo image ance of meniscocapsular separation [36].
(TR 3610 ms, TE 14 ms), and (B) coronal T1-weighted
spin-echo image (TR 450 ms, TE 14 ms) demonstrating Postoperative meniscus
a meniscofemoral ligament (ligament of Wrisberg, arrow-
heads) extending from the posterior horn of the lateral Imaging the postoperative meniscus is chal-
meniscus (arrow). A tear of the posterior horn of the lenging. Frequently, signal changes in the menis-
lateral meniscus (arrow) may be simulated. cal substance are seen, which may simulate tears.
It seems that grade 3 signal from both conserva-
tively treated and repaired menisci may persist
can be identified as small foci of low signal on MR long after the tear has become asymptomatic and
images [2]. has presumably healed. Moreover, signal associ-
ated with degeneration of the meniscal substance
Meniscocapsular separation may reach the meniscal surface after partial men-
iscectomy but does not represent a tear. Increased
The diagnostic performance of MR imaging
signal of the meniscus, which is interpreted as a
in meniscocapsular separation is low (positive
tear in nonoperated knees, should be interpreted
predictive value 9% medially and 13% laterally);
with caution after surgery [10]. MR arthrography
the reported MR imaging signs correlate poorly
may help to distinguish between healed or scarred
with arthroscopic findings [28]. The junctional re-
menisci and retears.
gion between the posterior portion of the medial
meniscus and the joint capsule contains peripheral
Meniscal ossifications
vessels whose signal intensity can mimic the ap-
pearance of a meniscocapsular detachment [14]. Meniscal ossicles are rare. Radiographically,
The differential diagnosis of a meniscocapsular sep- these ossicles often are mistaken for intra-articu-
aration includes normal recesses that may appear lar bodies. Meniscal ossicles have a character-
above or below the peripheral portion of the pos- istic MR imaging appearance that may help to
terior horn of the medial meniscus. A bursa of the distinguish them from loose bodies. They appear
 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205 201

as a circumscribed ossification with fatty bone nificant difference in the anteroposterior diameter
marrow in the center. They are usually located of the proximal patellar tendon (symptomatic, 7.1
within the posterior horn of the medial meniscus mm; asymptomatic, 5.5 mm [P ¼ 0.005]). Cutoff
[30]. values are unreliable, however, because of a signif-
icant overlap between symptomatic and asymp-
High signal in the patellar tendon tomatic subjects.
versus jumper’s knee
Thickening of the patellar tendon and foci of Joint effusion versus iliotibial band
increased tendon signal intensity have been de- friction syndrome
scribed as characteristic features of jumper’s knee The iliotibial band friction syndrome is clini-
(chronic patellar tendinitis). The presence of in- cally characterized by poorly defined pain in the
creased signal in asymptomatic subjects, however, lateral and distal aspects of the thigh or lateral
has been described by Reiff et al [25]. They found knee pain just proximal to the joint line. This
such signal on T2*-weighted gradient echo images syndrome is most commonly seen in long-distance
in 45 (75%) of 60 patients without anterior knee runners, cyclists, football players, and weight
pain (Fig. 13). They stated that the asymptomatic lifters. It is believed that the pain is caused by
patellar tendon usually shows uniform thickness friction of the iliotibial tract over the lateral
throughout most of its length, but some thicken- femoral epicondyle and a resultant inflammatory
ing is present at both the proximal and distal response. There is a close anatomic relationship
insertions. The patellar tendon usually demon- between the iliotibial tract and the lateral recesses
strates low signal intensity on MR images, but of the knee joint and the lateral femoral epicon-
may contain foci of increased signal intensity at dyle. On MR images, increased signal intensity on
either or both ends. Such signal is most pro- T2-weighted images, representing bursal fluid or
nounced on gradient echo sequences. With regard synovial hypertrophy, is identified deep to the
to the diameter, Schmid et al [29] found a sig- iliotibial band adjacent to the lateral femoral
epicondyle. This fluid must be distinguished from
fluid located intra-articularly in the lateral para-
patellar recess (Fig. 14). There is no normally
detectable bursa between the lateral femoral epi-
condyle and the iliotibial tract [22].

Ankle and foot

Normal fluid collections
Tenosynovial fluid collections are frequently
found about the foot and ankle. The presence of
small or even moderate amounts of fluid within
a tendon sheath by itself is not diagnostic of an
abnormality because such fluid is seen in asymp-
tomatic persons [31]. Tenosynovial fluid is more
frequent in flexor tendons (as compared with
extensor tendons) and may be particularly prom-
inent about the flexor hallucis longus tendon [19].
The extensor tendons are usually not surrounded
by fluid. Schweitzer et al [31] have shown that
Fig. 13. Psuedo jumper knee: sagittal proton-density fast
fluid in the articulations and tendon sheaths of the
spin-echo (TR 3610 ms, TE 14 ms) image of the patellar
ankle is common in asymptomatic patients, and
tendon. Hyperintensity (white arrowheads) occurs at the
proximal insertion of the patellar tendon (black arrow- the amounts of fluid are not significantly different
heads). This is a frequent finding and is present in up to from the amounts in patients with symptoms.
75% of asymptomatic patients without anterior knee There also seem to be complex interrelationships
pain. This finding should not be misinterpreted as a sign between fluid seen in the joint and in tendon
for a patellar tendinopathy or jumper’s knee. sheaths.
202 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205

Fig. 14. Iliotibial band friction syndrome and its pitfalls: (A) coronal STIR (TR 4980 ms, TE 35 ms, TI 160 ms) and (B)
axial T2*-weighted (TR 905 ms, TE 26 ms, flip angle 30
) images in a patient with a iliotibial band friction syndrome.
There is a close anatomical relationship between the iliotibial (curved arrow) and the lateral recesses of the knee joint
(straight arrow). Note increased signal intensity (arrowheads) deep to the iliotibial band (curved arrow) adjacent to the
lateral femoral epicondyle. This fluid must be distinguished from fluid located intraarticularly within the lateral
parapatellar recess (arrow).

Asymptomatic findings about ligaments can be seen on routinely obtained MR images and
and tendons must not be mistaken as soft tissue masses. The
peroneus quartus muscle, also called the peroneus
Noto et al [23] analyzed 30 asymptomatic
accessorius, peroneus externus, or peroneus cal-
ankles with MR imaging. They found several
caneus externus muscle, has been associated with
asymptomatic conditions. The posterior talofibu-
lar ligament frequently demonstrated an irregular
and frayed superior edge, which could simulate
a tear. The navicular insertion of the posterior
tibial tendon showed heterogeneous signal in-
tensity (47% of cases). The deltoid ligament was
also frequently (70%) inhomogeneous [23].

Imaging findings after physical activity

Recreational sports may lead to a number of
positive MR imaging findings without correlation
with clinical findings. Small amounts of fluid in
the retrocalcaneal bursa are common (prevalence
is 53% to 68% [Fig. 15]). Peritendinous joint fluid
is found in 22% of ankle tendons, most often
involving the tendon sheath of the flexor hallucis
longus tendon. An increased amount of joint fluid
is noted in 18% to 34% of the joints. Even bone
marrow edema may be found as an occasional
finding after physical activity [20].

Accessory muscles Fig. 15. Retrocalcaneal bursa: sagittal T2-weighted fat-

saturated turbo spin-echo image (TR 4000 ms, TE 64 ms)
Anomalous muscles occur in the ankle, in- demonstrating small fluid colletion in the retrocalcaneal
cluding accessory soleus, peroneus quartus, and bursa (arrow). This is a common finding (prevalence: 53%–
flexor digitorum longus accessorius muscles. These 68%) in asymptomatic physically active individuals.
 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205 203

chronic pain and swelling about the ankle. Its The groove contains the posterior talofibular
reported frequency, based on results of cadaveric ligament. This defect should not be misinter-
dissections, has varied from approximately 12% preted as an articular erosion or osteochondral
to 22% [34]. The peroneus quartus originates at defect [21].
the distal lateral portion of the fibula and the
peroneus brevis or longus muscle. The insertion is Accessory ossicles and sesamoid bones
located at the phalanges or metatarsal bone of the Accessory ossicles and sesamoid bones are
fifth toe, the calcaneus, the cuboid bone, and the frequently encountered about the ankle and foot.
lateral retinaculum of the ankle. Accurate di- They rarely cause diagnostic difficulties. Their ap-
agnosis is provided by MR imaging [5]. The pearance is rather typical, with rounded shape,
accessory soleus muscle is an unusual anatomic intact cortical bone, and typical location. It is
variant that may present as a mass in the distal important, however, to recognize these ossicles as
calf or medial ankle region. The accessory soleus normal variant to prevent their misdiagnoses as
muscle arises from the anterior surface of the fractures and loose bodies [19].
soleus or from the fibula and tibia. It inserts either
onto the Achilles tendon or the calcaneus poster- MR imaging of the forefoot: asymptomatic findings
omedially. The diagnosis is not difficult based on
the typical location and the MR imaging signal Fluid collections in the first three intermeta-
pattern corresponding to that of normal striated tarsal bursae are a frequent finding (prevalence
muscle [12]. 20% to 49%) in asymptomatic subjects (Fig. 17).
In addition, Zanetti et al [42] found Morton’s
neuromas in 30% of asymptomatic volunteers.
The pseudodefect of the talar dome Symptomatic Morton’s neuromas tend to be
The pseudodefect of the talar dome is a normal larger (range, 4 to 8 mm; mean, 5.6 mm) compared
groove at the posterior aspect of the talus (Fig. 16). with asymptomatic ones (range, 3 to 7 mm; mean,
4.5 mm). Morton’s neuroma may be relevant only
when the transverse diameter is 5 mm or more.
The diagnosis should be correlated to clinical
findings [42].

Fig. 16. Pseudodefect of the talar dome: sagittal T1- Fig. 17. Inermetatarsal bursae: coronal T2-weighted
weighted spin-echo MR arthrogram (TR 473 ms, TE 11 turbo spin-echo image (TR 4500 ms, TE 91 ms) of the
ms) of the hindfoot. Pseudodefect (arrow) at the pos- distal forefoot. Note fluid in the intermetatarsal bursae
terior aspect of the talar dome. This defect should not be (arrowheads). Fluid collections in the first three inter-
misinterpreted as an articular erosion or osteochondral metatarsal bursae are a frequent finding with a preva-
defect. lence of 20%–49% in asymptomatic subjects.
204 C.W.A. Pfirrmann et al / Magn Reson Imaging Clin N Am 11 (2003) 193–205

Summary tears: MR findings after conservative treatment or

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 Magn Reson Imaging Clin N Am
11 (2003) 207–219

MR imaging of sports injuries to the rotator cuff

Michael J. Tuite, MD
Department of Radiology, University of Wisconsin Hospital and Clinics, Clinical Science Center-E3/311,
600 Highland Avenue, Madison, WI 53792-3252, USA

Shoulder pain is a common complaint of diagnosing cuff tears in athletes involves looking
people active in sports, and can be due to a variety carefully for these small tears and knowing when
of causes, including glenohumeral joint instability to recommend an MR arthrogram with abduction
or injury to the acromioclavicular joint. Impinge- and external rotation (ABER), particularly for
ment and rotator cuff injury are also common throwers.
causes of shoulder pain in athletes, particularly in MR can be beneficial to orthopedic surgeons
overhand throwers and swimmers. treating athletes with impingement pain because it
Athletes with rotator cuff symptoms can have can reveal unsuspected cuff tears and alter the
several findings on MR, including a normal cuff, treatment plan [2]. Although the treatment of
tendonitis (more properly termed tendonosis), or impingement pain begins with physical therapy
a rotator cuff tear. Although it is helpful to and strengthening exercises, athletes who have
diagnose tendonosis on MR, the primary role of even a partial thickness tear may require arthro-
MR in imaging athletes with impingement pain is scopic debridement of the tear to become pain free
to identify or exclude a rotator cuff tear. In this [3,4]. In addition, MR provides information on
article, we will review the mechanisms that can the status of the labrum and glenohumeral
lead to rotator cuff pathology in sports enthusi- ligaments that can also be injured in athletes with
asts. We will then focus on the MR appearance shoulder pain.
of cuff injuries in athletes, various tear locations To understand why cuff tears occur in different
in younger and older individuals, and how to locations in athletes, it is necessary to review the
improve your accuracy for detecting cuff tears on mechanisms of shoulder injuries that occur during
MR images in athletes. athletics. Sports trauma to the rotator cuff can be
Correctly identifying a rotator cuff tear on divided into six main categories:
conventional MR images in young, athletic
1. Primary impingement
individuals can be difficult for two reasons. The
2. Secondary impingement from instability
first is that these tears are usually small and
3. Posterosuperior (internal) impingement in
shallow and therefore do not appear like the large
throwers
fluid-filled defects commonly seen in older pa-
4. Tensile overload (overuse)
tients. The second is that these tears often occur in
5. Macrotrauma from contact sports
atypical locations. When evaluating the rotator
6. The older athlete
cuff on MR images in older individuals with
chronic impingement pain, it is important to
concentrate on the anterior half of the supra- Primary impingement
spinatus tendon in the ‘‘critical zone’’ 1 cm medial
to the insertion where 89% of cuff tears occur Primary impingement refers to pain caused by
in people over the age of 35 [1]. Accurately contact between the rotator cuff and the coracoa-
cromial arch. The pain is believed to be caused
primarily by compression of the well-innervated
subacromial bursa between the cuff and the
E-mail address: mjtuite@facstaff.wisc.edu coracoacromial arch. Although it is an important
1064-9689/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1064-9689(03)00025-4
208 M.J. Tuite = Magn Reson Imaging Clin N Am 11 (2003) 207–219

cause of cuff pain in older patients, primary athletes [8]. This is considered a secondary im-
impingement is fairly uncommon in young indi- pingement because the root cause is instability of
viduals. When seen, it is often the result of a the humeral head within the glenoid fossa, and the
congenital or posttraumatic abnormality of the abnormal motion of the humeral head leads to
coracoacromial arch, such as a down sloping of rotator cuff tendonosis or tearing, which then
the anterior acromion (Fig. 1) or a mobile os becomes the main complaint of the athlete. The
acromiale [5]. Because the acromial apophysis cuff pain results from either contact between the
may not completely fuse until individuals are in cuff and the coracoacromial arch or from
their early twenties, a careful physical examina- microscopic or macroscopic tearing of the cuff
tion may be necessary in some young individuals from secondary tensile forces [8].
to distinguish a normal physis from a painful Although the primary problem is instability,
fibrocartilaginous union [6]. As in older patients this type of impingement rarely presents after
with primary impingement, the cuff pathology will a glenohumeral joint dislocation. The instability is
usually be in the anterior portion of the supra- usually minor and by itself asymptomatic, and
spinatus tendon adjacent to the inciting osseous results from a lax capsule or stretched glenohu-
structure. meral ligaments that develop over time. This is
Primary impingement can also result from particularly common in swimmers and in athletes
a congenitally thickened coracoacromial ligament who use an overhead motion, such as throwers or
[4], a ligament that is particularly well seen on tennis players. In swimmers, the pull-through
MR images. In addition, coracoid impingement phase against resistance leads to disproportion-
can occur in throwing athletes where there is ably strong internal rotators and adductors. This
decreased distance between the tip of the coracoid muscle imbalance, combined with the extreme
process and the humerus, although the rotator ranges of motion during the swimming stroke, is
cuff itself is usually not torn in this condition [7]. felt to be the cause of the instability in swimmers
[8]. In the cocking phase of throwing, the arm is
repeatedly placed in 90 degrees of abduction and
Secondary impingement from instability
maximal external rotation, which can gradually
Secondary impingement from instability is the stretch the anterior capsuloligamentous complex.
most common cause of impingement pain in As the anterior capsule and ligaments become
more lax, the cuff is increasingly overworked and
more likely to contact the coracoacromial arch. In
athletes who have a SLAP tear or weak long head

Fig. 1. A 51-year-old man with impingement pain. Fig. 2. A 15-year-old with impingement pain and
Oblique sagittal FSE proton density weighted image multidirectional instability. MR arthrogram axial T1-
shows a severely down-sloped acromion process (arrow) weighted image with fat suppression demonstrates a lax
indenting and causing increased signal in the supra- anterior capsule (arrow). No rotator cuff abnormality
spinatus tendon. was seen.
 M.J. Tuite / Magn Reson Imaging Clin N Am 11 (2003) 207–219 209

of the biceps tendon, the humeral head can posterosuperior, or internal, impingement. Walch
migrate superiorly and lead to cuff impingement. and colleagues [9] and Jobe [10] were some of the
Cuff tendonosis or tears can occur anywhere first to notice that the cuff tears in overhead
in the supraspinatus or infraspinatus tendon in athletes were often at the posterior aspect of the
athletes with secondary impingement, depending supraspinatus tendon or top of the infraspinatus
on the arm motion that is used during their sport. tendon. They also noted that the cuff tears were
Instability is the most important condition for the often associated with fraying or tears of the
orthopedist to diagnose because these patients are adjacent posterosuperior labrum. In a cadaver
treated by addressing the capsuloligamentous study, Jobe found that during the cocking phase
laxity and not by performing a decompression of of throwing there can be contact between the cuff
the coracoacromial arch. MR arthrography can in the region of the supraspinatus and infra-
be particularly useful in showing a capacious spinatus tendon interval and the posterosuperior
capsule and lax ligaments (Fig. 2). labrum [10]. They postulated that this repetitive
contact might lead to injuries to these two
structures, and termed this condition ‘‘internal
impingement’’ to distinguish it from the extrinsic
Posterosuperior (internal) impingement
impingement caused by the coracoacromial arch.
One of the major developments in treating Some authors consider posterosuperior im-
impingement pain in athletes over the past 10 pingement a subset of secondary impingement
years has been recognizing the entity called from instability. In normal throwers there is no

Fig. 3. A 31-year-old woman with a greater tuberosity fracture after a fall while snow skiing. (A) AP internal rotation.
(B) Neer AP external rotation radiographs were interpreted as no fracture. (C ) T1-weighted and (D) T2-weighted with
fat suppression oblique coronal MR images demonstrate the greater tuberosity fracture (arrows).
210 M.J. Tuite = Magn Reson Imaging Clin N Am 11 (2003) 207–219

significant contact between the posterior cuff and contact between the cuff and the glenoid rim. One
the adjacent glenoid, but in many athletes with group has reported that the cuff tear may result
posterosuperior impingement there is mild in- from the shearing forces from differences in the
stability that allows repetitive impaction to occur direction of pull between the supraspinatus and
[10–12]. Some of these throwers have a combina- infraspinatus tendons near their insertions [13].
tion of a tight posterior capsule and anterior These authors also found in their population of
capsuloligamentous laxity. The instability may be throwing athletes that the posterior cuff tears were
difficult to demonstrate, however, even at exam- not as often associated with any adjacent labral
ination under anesthesia [10]. Most researchers pathology, and that at arthroscopy in these patients
believe that the posterosuperior cuff tears in they could not simulate contact between the cuff
throwers belong in a separate category because and the adjacent glenoid rim. Regardless of the
they can occur in athletes without any evidence of etiology, posterosuperior impingement is an im-
instability, and because of the unique pattern of portant injury to recognize because it is common in
injuries [9,13]. throwers and because MR arthrography in the
In addition, there is some debate as to whether ABER position is crucial in helping make the
the posterosuperior cuff tear is caused by repetitive diagnosis before arthroscopy.

Fig. 4. A 22-year-old man with an articular surface partial thickness cuff tear at surgery. (A) Oblique coronal
T2-weighted image with fat suppression shows faint increased signal along the articular surface of the cuff (arrow).
(B) Oblique sagittal T2-weighted image with fat suppression also shows the subtle area of increased signal (arrow).
(C ) Angled oblique sagittal sections localized on an oblique coronal image. (D) Angled oblique sagittal T2-weighted
image with fat suppression demonstrates clearly the obliquely oriented cuff tear (arrow).
 M.J. Tuite / Magn Reson Imaging Clin N Am 11 (2003) 207–219 211

Tensile overload (overuse)

Tensile overload, a primary overuse injury,
refers to repetitive traction forces on the rotator
cuff leading to collagen fiber failure. This is seen
mainly in overhead throwing athletes who sud-
denly increase their intensity or duration of
throwing [11]. If the soreness or muscle fatigue
leads to altered throwing mechanics, mild in-
stability can exacerbate the situation further by
causing secondary tensile overload.
There is still some controversy regarding this
mechanism as a cause of tendonosis or cuff tears
in athletes. Jobe showed that the supraspina-
tus muscle never exceeds 60% of its maximum
activity during the throwing cycle, and therefore
that primary tensile overload should be rare [14]. Fig. 5. A 17-year-old man with a SLAP tear (arrowhead)
Others have also noted that in young healthy but no impingement symptoms and a normal cuff at
individuals the tensile strength of the supra- surgery. Note the low signal bursal (white arrow) and
spinatus tendon is greater than bone [4], and articular (black arrow) surfaces of the cuff on either side
therefore a fracture might be more likely to occur of intermediate signal within the tendon.
than a cuff tear. Other authors have reported,
however, that during the deceleration phase of
ation, the rotator cuff in older patients is vul-
throwing, which occurs immediately after the ball
nerable to tearing while playing sports. Chronic
is released, the eccentric traction force on the
cuff tendonosis can be aggravated by activities
rotator cuff is massive as it keeps the humeral
such as golf or tennis, and gradual-onset cuff tears
head properly situated within the glenoid fossa
can result [11]. As in occupational overuse or
[11,13,15]. They propose that the forces are great
non–sports-related trauma, the cuff tears tend to
enough, especially with the additional shear forces
occur in the anterior supraspinatus tendon in the
as the humeral head rotates during the throwing
so-called ‘‘critical zone.’’ Another location for
motion, to lead to tensile overload and cuff tears.
tears seen in middle-aged individuals is the rim
Most authors now include overuse injury as
rent-type tear, an articular surface partial thick-
a potential etiology of tendonosis and cuff tears
ness tear just at the insertion onto the greater
in throwing athletes.
tuberosity [1]. The already somewhat weakened
cuff is also more likely to tear after acute athletic
Macrotrauma from contact sports
trauma, such as a glenohumeral joint dislocation.
The rotator cuff can be injured by an acute Fortunately, current rehabilitation and surgical
traumatic event during athletics, although this is techniques can often help older individuals return
uncommon [11]. The cuff can be contused or torn to their previous level of athletic ability [17].
by an impaction injury where the tendon is caught
between the humeral head and the coracoacromial Conventional MR technique
arch. Acute traction injuries to the cuff in young Although conventional MR is accurate for
athletes are rare, again because the tensile strength detecting rotator cuff tears in older patients, its
of the normal cuff is greater than bone. Zanetti accuracy is less in young athletic patients [1,18].
and colleagues reported that greater tuberosity We therefore usually recommend MR arthrogra-
fractures following acute shoulder trauma are more phy for these patients, particularly for throwing
common in young patients, and may be occult athletes. If a conventional MR is obtained, for
on radiographs and thus first detected at MR im- example in older individuals with a sports-related
aging (Fig. 3) [16]. injury or an athlete after acute macrotrauma, we
typically perform the following pulse sequences:
The older athlete
1. Oblique coronal fast spin-echo (FSE) T2 with
Because the supraspinatus tendon is weakened fat suppression.
by age-related myxoid and eosinophilic degener- 2. Oblique sagittal FSE T2.
212 M.J. Tuite = Magn Reson Imaging Clin N Am 11 (2003) 207–219

3. Axial FSE mid-echo time (TE[eff]=30) with 4. Oblique coronal FSE T2 with fat suppression.
fat suppression. 5. ABER position coronal localizer.
4. Angled oblique sagittal FSE T2 with fat 6. ABER position oblique axial T1 with fat
suppression. suppression.
We prefer fat-suppressed FSE T2-weighted If the patient cannot abduct the arm into the
images for evaluating the rotator cuff with ABER position, we obtain instead an additional
conventional MR because most authors have axial T1-weighted set of images with the arm in
found that these are the most accurate for de- maximum external rotation. Full external rotation
tecting cuff tears [19–24]. They report a sensi- tightens the anterior capsuloligamentous structures
tivity of 84% to 100% and a specificity of 77% and may demonstrate better some anterior labral
to 97% for full-thickness tears, although the tears that can be associated with secondary
accuracy is lower for the partial thickness tears impingement.
that are more common in athletes. We also
obtain angled sagittal images perpendicular to
the lateral aspect of the supraspinatus tendon, Normal MR appearance of the rotator cuff
which are sometimes better at showing small in athletes
partial tears (Fig. 4) [25].
To recognize cuff pathology on MR images, it
is helpful to be familiar with the appearance of
MR arthrography the normal rotator cuff in young individuals.
Histologically, there are five layers that make up
MR arthrography is more accurate for detecting
the rotator cuff [30]. The two layers forming the
articular surface partial thickness tears, particularly
bursal one-third of the tendon contain closely
the posterior cuff tears seen in throwers [18,26–29].
packed, well-organized tendon fibers, as does the
MR arthrography is also better at showing the
layer forming the articular surface of the cuff. In
posterosuperior labral fraying seen in internal
the center of the cuff are two layers that contain
impingement, as well as SLAP tears or a lax inferior
less-organized fibers mixed with loose connective
glenohumeral ligament that may be contributing
tissue. On fat-suppressed T2-weighted MR im-
to the patient’s shoulder pain. Our standard
ages, this central third of the tendon can have
MR arthrography protocol follows:
intermediate signal even in young healthy indi-
1. Oblique coronal T1 with fat suppression. viduals. The articular and bursal portions of
2. Oblique sagittal T1 with fat suppression. the cuff should be low signal in a normal cuff
3. Axial T1 with fat suppression. (Fig. 5).

Fig. 6. A 15-year-old male gymnast with shoulder pain and a normal-appearing cuff at surgery. (A) Oblique coronal and
(B) oblique sagittal T2-weighted images with fat suppression show high signal within the posterior cuff (arrow) but with
intact articular and bursal tendon surfaces. The patient was believed to have tendonosis and did well with physical
therapy.
 M.J. Tuite / Magn Reson Imaging Clin N Am 11 (2003) 207–219 213

Fig. 7. An 18-year-old male baseball pitcher with mild instability and impingement pain, and an articular surface
partial-thickness tear in the anterior supraspinatus tendon at surgery. (A) Oblique coronal and (B) oblique sagittal T1-
weighted with fat-suppression images show contrast extending into the cuff (arrows) at the site of the tear.

Several authors have found that intermediate long-TE FSE T2-weighted images used in conven-
signal may involve the cuff surfaces in asymptom- tional MR imaging of the cuff.
atic athletic individuals, and that this may be
difficult to distinguish from subtle partial tears
[31,32]. Because of this, we do not interpret a tear MR imaging of impingement and rotator cuff
unless the signal intensity is greater than hyaline injuries
articular cartilage on fat-suppressed FSE T2- There is a continuum of injuries that occur to
weighted images. Although high signal on FSE the rotator cuff of athletes, from mild tendonosis
T2-weighted images disrupting the surface of the to full-thickness tears. In this section, we review
cuff is the most accurate MR sign of a cuff tear, this the variety of MR appearances of cuff pathology
finding has been reported in asymptomatic pro-
fessional baseball pitchers [31]. Some have specu-
lated that this may represent an asymptomatic (or
unacknowledged) partial tear in these athletes.
Finally, the signal intensity of the rotator cuff
tendon does not change after exercise, although the
supraspinatus muscle itself may have increased
signal intensity immediately after exercise [33].
One of the pitfalls in interpreting MR images of
the cuff is the magic angle effect seen laterally where
the tendon is oriented at 55 degrees to the main
magnetic field B0. The well-organized collagen
fibers in the outer portions of the cuff are organized
longitudinally, and therefore these normally low-
signal fibers have increased signal on short-TE
images as they curve and become oriented at the
‘‘magic angle’’ [34]. This is usually not a problem on
the fat-suppressed T1-weighted images obtained Fig. 8. A 48-year-old man with a rim-rent tear. Oblique
during MR arthrography because of the high coronal T2-weighted image with fat suppression shows
contrast resolution between the gadolinium solu- high signal at the enthesis disrupting the insertion of the
tion and the soft tissues of the shoulder, or on the articular surface cuff fibers (arrow).
214 M.J. Tuite = Magn Reson Imaging Clin N Am 11 (2003) 207–219

contusion [37]. A cuff contusion resulting from

a direct blow to the shoulder is often associated
with an edematous high signal subacromial bursa,
which over time can become thickened and low
signal from fibrosis [11].
Rotator cuff tears
Most cuff tears in athletes are small, articular
surface partial-thickness tears [3,8,11,13]. The
tears tend to be small because the high tensile
strength of the tendon in young people makes the
cuff resistant to extensive tearing at the time of
injury. Because the cuff in a young person does
not have preexisting myxoid degeneration, the
tears tend to stay small instead of enlarging by
extending through weakened portions of the cuff
as often occurs in older individuals. There are
Fig. 9. A 22-year-old man with multidirectional in- three main reasons why the partial thickness tears
stability and a normal cuff at surgery. Oblique coronal
also typically involve the articular surface: (1) the
T2-weighted image with fat suppression shows an
eccentric forces on the cuff that occur in athletes
intrasubstance fissure near the enthesis (arrow) but
intact articular (arrowhead) surface cuff fibers down to are greater on the articular side [15], (2) the
the insertion on the greater tuberosity. articular side fibers are weaker than the bursal
side, and (3) when injured, the articular surface is
less well vascularized and therefore does not heal
and the unique locations where tears can occur in as well [13].
athletes. There are three main locations where rotator
cuff tears occur in athletes: standard (critical
Tendonosis, cuff strain, and cuff contusion zone), rim-rent tears, and posterosuperior tears.

The most common MR finding in the athlete Standard (critical zone)

with mild impingement pain is a normal cuff. Some Cuff tears in the anterior half of the supra-
of these patients may have mild subacromial- spinatus tendon 0.5 to 1 cm from the insertion are
subdeltoid bursitis at arthroscopy even though common in athletes. In one study, 79% of the cuff
they do not have significantly increased bursal tears in patients under 36 years old were centered
fluid or thickened high-signal synovium on MR in the anterior half of the supraspinatus tendon
images. [1]. These tears can occur either from acute
With increasing severity, the cuff develops in- trauma or impingement by the coracoacromial
trasubstance fissures, edema, and myxoid change arch. Partial thickness tears even in this standard
that is often termed ‘‘cuff tendonitis’’ [35]. Bi- area can be difficult to diagnose, so the articular
opsies of the cuff in patients with this condition surface should be carefully inspected for disrup-
reveal no inflammatory cells and therefore tion by high signal in the athlete with impinge-
most authors now prefer a term such as ‘‘ten- ment pain (Fig. 7) [22,25,38].
donosis.’’ There are three main MR findings
that we like to see before we will interpret cuff ten- Rim-rent tears
donosis: fluid-signal fissures; high and not just The rim-rent tear is an articular surface partial-
intermediate signal within the cuff; or a swollen thickness tear that occurs right at the insertion of
cuff with increased signal (Fig. 6) [36]. the tendon onto the humerus (Fig. 8). Although
The cuff may also have a focal area of not specific for athletes, several authors have
increased signal after an acute traumatic event shown this tear to be more common in younger
without a tear involving the cuff surface, which individuals and may be the tear site in a middle-
depending on the mechanism represents either aged person with pain while playing sports
a hyper stretch injury or contusion. The signal [1,39,40]. The cuff is vulnerable to tearing in this
abnormality of a rotator cuff strain is often in the region because the collagen fibers make an abrupt
posterior cuff and may be associated with a bone 90-degree turn as they approach the greater
 M.J. Tuite / Magn Reson Imaging Clin N Am 11 (2003) 207–219 215

tuberosity, and this may be one of the weaker simply tendonosis (Fig. 9), or if there is high
points in an otherwise young healthy cuff. signal between the articular surface of the cuff
The main issue with rim-rent tears is distin- and the humerus consistent with a tear. Like all
guishing them from intrasubstance fissures at the partial-thickness tears, rim-rent tears are typically
enthesis. Fissures within the cuff that do not debrided at arthroscopy.
extend to the cuff surface are part of the spectrum
of findings seen in tendonosis, and fissures com- Posterosuperior (internal) impingement cuff
monly occur adjacent to the greater tuberosity. tears
The important feature is to determine if the arti- These cuff tears are seen in overhead athletes,
cular surface cuff fibers are intact down to their such as throwers and tennis players, and involve
attachment on the greater tuberosity, indicating the posterosuperior cuff about 0.5 to 1 cm from

Fig. 10. A 23-year-old man with a posterior supraspinatus tendon articular surface partial thickness tear at surgery. (A,
B) Two consecutive oblique coronal T2-weighted images with fat suppression show unusually extensive subcortical cysts
in the posterior greater tuberosity, and increased signal disrupting the articular surface of the cuff (arrow). (C) Oblique
sagittal T2-weighted image with fat suppression shows faint disruption of the low signal articular surface at the tear
(arrow). A, anterior; P, posterior.
216 M.J. Tuite = Magn Reson Imaging Clin N Am 11 (2003) 207–219

Fig. 11. ABER imaging. (A) Coronal localizer image with the right arm in the ABER position and showing the
orientation of the oblique axial images. (B) Orientation of the oblique axial images relative to the glenohumeral joint
during ABER imaging, as seen en face. A, anterior; P, posterior.

the insertion on the greater tuberosity. Internal overlooked [22,25,38]. Second, the orientation of
impingement tears are difficult to see on conven- the posterosuperior cuff in this region is oblique
tional MR images for two reasons. First, like all relative to the standard imaging planes. Partial
tears in athletes they are usually small, articular averaging can obscure tears as the high signal of
surface partial-thickness tears that can be easily a small rotator cuff tear is averaged with the

Fig. 12. A 29-year-old man with posterosuperior impingement. (A) Oblique coronal MR arthrogram T1-weighted with
fat suppression shows intraarticular contrast extending into a humeral head notch (arrow). No definite labral or cuff
abnormality was seen. (B) ABER position oblique axial T1-weighted image with fat suppression shows a small articular
surface partial thickness tear of the infraspinatus tendon (arrow) and fraying of a blunted posterosuperior labrum
(arrowhead).
 M.J. Tuite / Magn Reson Imaging Clin N Am 11 (2003) 207–219 217

adjacent low signal intact cuff within the same ABER position have two main advantages. First,
voxel. When these tears are seen on conventional the ABER position simultaneously relaxes the
MR images, they appear as increased signal posterosuperior cuff as the anterior labroligamen-
disrupting the articular surface of the cuff near tous complex is placed under tension. The de-
the supraspinatus–infraspinatus tendon junction creased tension on the posterosuperior cuff may
(Fig. 10). mean that small, shallow, partial-thickness tears
The most accurate way to diagnose postero- with smooth gradual margins are not as stretched
superior impingement tears is with MR arthrog- and therefore the edges of the tear are more
raphy, including images obtained with the arm conspicuous. Second, because of the arm position,
in abduction and external rotation (ABER) [18]. the oblique axial images are oriented from ante-
The images obtained by localizing oblique axial roinferior to posterosuperior and are therefore
images off a coronal localizer with the arm in the orthogonal to the posterosuperior cuff and labrum

Fig. 13. An 18-year-old man with posterosuperior impingement and a focal notch in the posterior greater tuberosity. (A)
Oblique coronal T2-weighted image with fat suppression shows a focal indentation in the cortex (arrow) and adjacent
high signal in the bone marrow (arrowhead). (B) Axial T1-weighted and (C ) fat-suppressed mid-TE images show the
notch (black arrow) and adjacent marrow edema (white arrow).
218 M.J. Tuite = Magn Reson Imaging Clin N Am 11 (2003) 207–219

(Fig. 11). There is less partial averaging of the high repetitive contact [18]. This marrow edema is not
signal from tears in the posterosuperior cuff, and well seen on fat-suppressed T1-weighted images
therefore the tears are more conspicuous. and is one of several reasons why T2-weighted or
When evaluating the ABER images, it is inversion recovery images should be obtained
important to inspect the front and the back of during an MR arthrogram study. Finally, al-
the joint. The anteroinferior side displays the though spinoglenoid or suprascapular notch
anteroinferior labrum and anterior band of the ganglion cysts are often associated with postero-
inferior glenohumeral ligament, and subtle inju- superior labral tears in patients with a prior
ries to these structures are common in patients history of trauma, paralabral cysts are uncommon
with posterosuperior impingement [26]. On the in athletes with chronic posterosuperior impinge-
posterosuperior side, the articular surface of the ment labral tears [13,29].
cuff should be inspected for contrast extending
into an articular surface partial thickness tear
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 Magn Reson Imaging Clin N Am
11 (2003) 221–238

MR imaging of shoulder instability

injuries in the athlete
Javier Beltran, MD*, David Hyun-Min Kim, MD
Department of Radiology, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA

During the past few decades, the use of sophis- This article will discuss the basic normal
ticated technology, such as arthroscopy and MR anatomy, biomechanics, and pathophysiology of
imaging, combined with a better knowledge of the shoulder instability in the athlete, with special
shoulder anatomy, biomechanics, and clinical emphasis on the overhead-throwing athlete, and
evaluation, has provided an improved understand- will review the MR imaging findings in some of
ing of the pathology of the shoulder in the the instability patterns seen in these patients.
athlete.
Because of its remarkable degree of mobility, MR imaging strategies
the glenohumeral joint is inherently prone to in-
stability. Functional stability of the glenohu- In the past, nonenhanced MR imaging of the
meral joint can be defined as the maintenance of shoulder for the detection of capsulolabral lesions
alignment of the center of the humeral head within has been reported to have variable results by dif-
the glenoid fossa during shoulder motion and is ferent researchers [1–3]. Different types of surface
achieved through precise synchronization of static coils, field strength, and imaging parameters
(or passive) mechanisms and dynamic (or active) may all have contributed to the differences.
mechanisms. The static mechanisms include neg- More recently, better knowledge of the anatomy
ative intraarticular pressure; adhesion and co- and normal variants, as well as improved imaging
hesion of the articular surfaces; size; and shape and techniques has led to improved accuracy [4]. The
orientation of the glenoid fossa and the capsulo- presence of a joint effusion provides capsular
labral complex. Dynamic mechanisms include the distension and aids in defining the anatomy of the
rotator cuff and the long bicipital tendon. intracapsular structures [4,5]. Although nonen-
The throwing action places high stress loads on hanced MR imaging has been demonstrated to
the capsulolabral complex and rotator cuff, and have high accuracy rates for the demonstration of
even minor degrees of injury to these structures labral tears [6], MR arthrography with intrar-
can become symptomatic and produce significant ticular injection of gadolinium has gained pop-
functional impairment. Joint laxity may develop ularity during the past few years because of its
as a consequence of the injury to the tissues, lead- ability to depict not only the labrum but also the
ing to even more damage and further instability. glenohumeral ligaments and the undersurface of
It is now understood that in the throwing athlete the rotator cuff when the joint capsule is distended
these injuries are not the consequence of a single [2,7–13]. The main disadvantage of direct MR
event of dislocation but are the result of multiple arthrography is the need to schedule the patient
episodes of microtrauma, producing gradual in- for fluoroscopy for needle positioning, although
crease of shoulder pain at some point in the some authors have used ultrasound-guided in-
throwing position. jection [14] and open MR needle positioning [15].
Indirect MR arthrography has also been pro-
posed as an alternative to direct intraarticular
* Corresponding author. injection of gadolinium [16,17]. Contrast material
E-mail address: [email protected] (J. Beltran). is injected intravenously, and images of the
1064-9689/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1064-9689(03)00023-0
222 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238

shoulder are obtained following a short period of dislocations, subluxations, and lesions related to
gentle exercise of the joint. Pathology is visualized chronic stress in the surrounding soft tissues.
by way of enhancement of hyperemic soft tissues The superior, middle, and inferior glenohu-
and small amount of contrast material accumu- meral ligaments reinforce the joint capsule anteri-
lated in the joint. This technique does not require orly (Fig. 1). The labrum is a fibrous structure
fluoroscopy or intraarticular needle placement, surrounding the edge of the osseous glenoid and
thereby making it less invasive and ensuring increases the depth of the glenoid fossa by about
greater patient acceptance. Additionally, it has 50% in all directions and hence the stability of the
the advantage of being faster and less expensive glenohumeral joint [22]. On MR imaging the la-
than direct arthrography. The main disadvantage brum is seen as a low signal intensity structure ad-
is that joint distension is not achieved unless a jacent to the glenoid margin. The labrum is most
preexisting joint effusion is present. In two differ- often triangular in shape on axial and oblique
ent series, Sommer et al [16] and Maurer et al [17], coronal images (Fig. 2). Articular cartilage is
comparing nonenhanced MR imaging with in-
direct MR arthrography in patients with suspected
labral tears, achieved significant improvement in
sensitivity and specificity with the latter technique.
Additional imaging strategies to improve de-
tection of lesions in patients with microinstabil-
ity have been described recently. These include
imaging in the abduction and external rotation
position (ABER) following intrarticular injection
of gadolinium [18,19] for improved visualization
of the anterior capsuloligamentous structures,
posterosuperior labrum, and undersurface of the
rotator cuff and imaging in the oblique coronal
plane with arm traction to better visualize lesions
of the superior labrum (SLAP lesions) [20].
Hodge et al [21] described recently dynamic
MR imaging and stress testing in patients with
glenohumeral instability using an open configura-
tion 0.5 Tesla magnet. These authors evaluated
the position of the humeral head on the glenoid in
11 subjects, comparing the symptomatic shoulder
with the asymptomatic one. They performed
imaging in abduction=adduction and in internal
and external positions. They also performed stress
testing during imaging. They found that dynamic
evaluation without stress testing underestimated
the abnormalities in symptomatic shoulders, and Fig. 1. Schematic rendering of the glenoid fossa,
when imaging during stress testing was per- capsuloligamentous structures, rotator cuff, and scapula.
formed, there was a strong correlation with clin- SSP, supraspinatus muscle and tendon; SSC, subscapu-
ical grading of instability. laris muscle and tendon; IS, infraspinatus muscle and
tendon; TM, teres minor muscle and tendon; BT,
intracapsular long bicipital tendon and tendon anchor;
Normal MR imaging anatomy and biomechanics SGHL, superior glenohumeral ligament; MGHL, mid-
The glenohumeral joint is the joint of the dle glenohumeral ligament; IGHL, inferior glenohu-
meral ligament; A, anterior band of the IGHL; P,
human body with the greatest range of motion
posterior band of the IGHL; AR, axillary recess; CCL,
(over 180 degrees in several planes). The relatively
coracoclavicular ligament; CAL, coracoacromial liga-
large articular surface of the humeral head ment; CHL, coracohumeral ligament. The space be-
compared with the small articular surface of the tween the anterior margin of the SSP and the superior
glenoid cavity explains the extended mobility of margin of the SSC is the rotator cuff interval (between
the joint. Because of its wide range of motion, the the two arrowheads). The joint capsule, BT, SGHL, and
glenohumeral joint is also more susceptible to CHL, occupies this space.
 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238 223

Fig. 2. (A, B) Normal glenoid labrum. Axial (A) and oblique coronal (B) T1-weighted fat-suppressed images obtained
following intrarticular injection of gadolinium. The most frequent appearance of the glenoid labrum is a triangular, low
signal intensity structure attached to the glenoid margin (long arrows in A and B). Frequently there is intermediate signal
intensity articular cartilage interposed between the labrum and the cortical bone. The distension of the capsule allows
visualization of the undersurface of the rotator cuff (short arrow in B). Note the flat appearance of the MGHL
(arrowhead in A) and the axillary recess (arrowhead in B). (Fig. A from Beltran J, Bencardino J, Padron M, et al. The
middle glenohumeral ligament: normal anatomy, variants and pathology. Skeletal Radiol 2002;5:253–62; with
permission.)

often seen between the fibrous, low signal inten- The superior glenohumeral ligament (SGHL) is
sity labrum and the subchondral cortex of the gle- a fairly constant structure that arises in the shoulder
noid margin. capsule just anterior to the insertion of the long
The glenoid labrum also helps in preventing head of the bicep tendon (LHBT) and it inserts
translational forces, especially in the lower half of into the fovea capitis line just superior to the lesser
the joint were the labrum is more firmly attached tuberosity. It varies in thickness and it is present
to the bony glenoid margin. However, the more 90% to 97% of the time in cadaver dissections.
important function of the labrum is to serve as the The coracohumeral ligament (CL) is an extracap-
anchoring structure for the glenohumeral liga- sular structure located superior to the LHBT.
ments and the long head of the biceps tendon, The middle glenohumeral ligament (MGHL)
superiorly. The normal labrum is attached to the has been described arthroscopically as being
glenoid margin of the scapula and the scapular attached to the anterior surface of the scapula,
periosteum. However, the anterior superior la- medial to the articular margin. It then lies
brum may be partially detached, creating a space obliquely, posterior to the superior margin of the
between the glenoid and the labrum called the subscapularis muscle and blends with the anterior
sublabral foramen or sublabral hole, not to be capsule. Distally, it is attached to the anterior
confused with an anterior superior labral tear aspect of the proximal humerus, below the attach-
when performing arthroscopy or MR imaging ment of the superior glenohumeral ligament
(Fig. 3) [4]. A second potential space or recess may [23,24]. Using MR arthrography, the scapular in-
exist between the superior labrum and the glenoid sertion of the MGHL is seen more often at the level
and it is termed the sublabral recess, often con- of the superior anterior labrum than at the level
fused with a superior labral tear (Fig. 4) [4]. of the scapula as was suggested arthroscopically
The glenohumeral ligaments are infoldings of [23,24].
the capsule and each one contributes to a different The MGHL presents the largest multiplicity
degree to the stability of the glenohumeral joint, of normal variants. In one anatomic study, the
depending on the position of the arm. ligament was absent in 30% of the specimens [25].
224 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238

absence of the anterior superior portion of the

labrum (Buford complex), and split or duplicate
ligament [26–30].
The IGHL is composed of an anterior band,
a posterior band and the axillary recess of the
capsule located in between the two bands. It
inserts in a collar-like fashion in the inferior
aspect of the anatomical neck of the humerus. The
IGHL is considered the most important stabilizer
of the glenohumeral joint, especially with the arm
in abduction and external rotation (the throwing
position). In this position the anterior band is
under tension. If the arm is placed in abduction
and internal rotation, the posterior band is in
Fig. 3. Foramen sublabrum. Axial T1-weighted image
more tension than the anterior band.
obtained fsollowing intraarticular injection of gadoli-
The relative contribution of each individual
nium through the superior aspect of the glenohumeral
joint. The anterior superior labrum (arrowhead ) is glenohumeral ligament to joint stability has been
separated from the glenoid margin (short single arrow) the subject of debate. Matsen et al [31] and Caspari
and the space is filled with gadolinium, representing the et al [23] indicated that the SGHL and MGHL are
foramen sublabrum (long arrow). The normal MGHL is absent in a high percentage of individuals and
anteriorly located (double short arrows). (From Shank- therefore must not be important structures in
man S, Bencardino J, Beltran J. Glenohumeral in- maintaining joint stability. Turkel et al [32] studied
stability: evaluation using MR arthrography of the the contribution of each one of the glenohumeral
shoulder. Skeletal Radiol 1999;7:365–82; with permis- ligaments by means of selectively cutting these
sion.)
structures in cadavers and then assessing the
stability of the joint at different degrees of ab-
Using MR arthrography, Chandnani et al [24] duction and external rotation. They concluded
identified the MGHL in 85% of their cases. Other that the IGHL is the most important structure in
frequent variants include common origin of the the prevention of dislocation with the arm at 90
MGHL with the SGHL, common origin with the degrees of abduction and external rotation.
SGHL and long biceps tendon, common origin In another classic experiment, O’Connell et al
with the inferior glenohumeral ligament (IGHL), [33] measured the tension of the glenohumeral
cordlike thickening, with or without associated ligaments in cadavers after application of a con-
trolled external torque. They concluded that at
90 degrees of arm abduction, the IGHL and the
MGHL developed the most strain, whereas with
the arm at 45 degrees of abduction, the most strain
was also developed by the IGHL and MGHL,
though some strain also occurred at the SGHL.
The different ligaments contribute to the
stability of the glenohumeral joint in a diverse
fashion, depending on the position of the arm.
The SGHL and the CL in concert limit inferior
translation of the adducted shoulder and posterior
Fig. 4. Sublabral recess. Oblique coronal T1-weighted translation of the flexed, adducted, and internally
image obtained following intraarticular injection of rotated shoulder. The MGHL limits anterior
gadolinium. The sublabral recess (long arrow) extends translation of the humeral head when the arm is
about halfway into the base of the labrum (arrowhead ). abducted between 60 degrees and 90 degrees. The
The labrum is continuous with the long bicipital tendon
IGHL complex prevents increased translation of
(short arrow). Note that the direction of the sublabral
recess is toward the head of the patient. This feature
the humeral head on the glenoid. With the arm in
distinguishes the sublabral recess from a superior labral abduction, the entire complex moves beneath the
tear (SLAP lesion). Superior labral tears tend to be humeral head and becomes taut. With internal
oriented in the opposite direction, toward the shoulder rotation the complex moves posteriorly and limits
(see Fig. 14A). posterior translation. With external rotation the
 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238 225

complex moves anteriorly and limits anterior

translation.
The long head of the biceps tendon and the
coracohumeral and coracoacromial ligaments are
also important structures contributing in different
ways to the normal biomechanics of the joint. The
coracohumeral ligament helps maintain the sta-
bility of the long head of the biceps tendon, and
the coracoacrial ligament is an important part of
the acromial arch. The long head of the biceps
tendon has an intracapsular portion and an ex-
tracapsular portion. The intracapsular portion
extends from its insertion into the superior labrum
to the bicipital groove. The insertion of the tendon
may be in a broad base or in a thin area.
The capsular mechanism provides the most
important contribution to the stabilization of the
glenohumeral joint. The anterior capsular mech-
anism includes the fibrous capsule, the glenohu- Fig. 5. Normal rotator cuff interval. Oblique sagittal
meral ligaments, the synovial membrane and its T1-weighted fat-saturated image following intraarticular
recesses, the fibrous glenoid labrum, the subsca- injection of gadolinium. The rotator cuff interval is
pularis muscle and tendon, and the scapular located between the asterisks, from the anterior margin
periosteum. The anterior capsular insertion can of the supraspinatus tendon to the superior margin of
be divided into three types, depending on the the subscapularis tendon (compare with schematic
proximity of the capsular insertion to the glenoid representation in Fig. 1). The long bicipital tendon
margin [30]. In general, the further the anterior (single arrowhead) and the striated CHL and SGHL
capsular insertion from the glenoid margin (type (short arrow) are seen within the rotator cuff interval.
Note the capsule containing the fluid within the joint
III), the more unstable will be the glenohumeral
(long arrow). The CAL is seen superficial to the rotator
joint. cuff interval (double arrowhead). (From Beltran J,
The posterior capsular mechanism [34] is Bencardino J, Padron M, et al. The middle glenohumeral
formed by the posterior capsule, the synovial ligament: normal anatomy, variants and pathology.
membrane, the glenoid labrum and periosteum, Skeletal Radiol 2002;5:253–62; with permission.)
and the posterosuperior tendinous cuff and
associated muscles (supraspinatus, infraspinatus,
and teres minor). The long head of the biceps tion of the rotator cuff interval is to limit inferior
tendon inserting in the superior aspect of the translation of the glenohumeral joint in the ad-
labrum and the triceps tendon inserting in the ducted shoulder and to provide stability against
infraglenoid tubercle inferiorly constitute addi- posterior dislocation in flexion or abduction and
tional supportive structures of the glenohumeral external rotation. In addition, this structure limits
joint. the range of flexion, extension, adduction, and
The rotator cuff is composed of the supra- external rotation.
spinatus, infraspinatus, subscapularis, and teres The muscles around the shoulder are impor-
minor muscles and their corresponding tendons. tant contributors to the stability of the shoulder
The space between the anterior margin of the joint. The rotator cuff muscles and perhaps to
supraspinatus muscle and the superior margin of a lesser degree the long bicipital tendon provide
the subscapularis muscle is called the rotator cuff dynamic compression of the humeral head into
interval (Fig. 5). The joint capsule covers this the glenoid fossa, centering the humeral head and
space and it contains the long head of the biceps countering the oblique translational forces gener-
tendon, the coracohumeral ligament, and the ated during the act of throwing [36–39]. Warner
superior glenohumeral ligament. Haryman et al et al [40] demonstrated that this concavity-com-
[35] have shown that sectioning the rotator cuff pression mechanism provides greater stability to
interval in cadaver shoulders significantly in- the glenohumeral joint in the inferior direction
creases anterior, posterior, and inferior humeral than negative intraarticular pressure or ligament
head translation. They concluded that the func- tension in all degrees of abduction and rotation.
226 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238

Another significant factor contributing to the early activation of the deltoid muscle and late
stability of the glenohumeral joint is the scap- activation of the rotator cuff muscles, with the
ulothoracic coordination during throwing. This is exception of the subscapularis muscle. During the
achieved mainly through synchronization with the third phase of late cocking the shoulder ends in
latissimus dorsi, pectoralis major, and serratus maximum external rotation of 170 degrees to 180
anterior muscles [41,42]. In a classic study, Inman degrees, maintaining 90 degrees to 100 degrees
et al [43] demonstrated that there is 2:1 ratio of of abduction. The 15 degrees of horizontal ab-
glenohumeral to scapulothoracic motion during duction changes to 15 degrees of horizontal
abduction. More recent studies indicate that this adduction (position 4, see Fig. 6). The scapula
ratio is even higher and it is more significant retracts to facilitate this position and provide
during the early degrees of abduction [44]. Failure a stable base for the humeral head. The combi-
of the scapulothoracic coordination may place nation of abduction and external rotation forces
additional stress on the capsulolabral complex, posterior translation of the humeral head on the
hence increasing the risk for soft tissue damage. It glenoid. The activity of the deltoid muscle de-
has been shown that patients with shoulder creases, while the rotator cuff muscles reach their
instability have increased scapulothoracic asym- peak. During the terminal portion of the late
metry [45]. cocking phase, the subscapularis, latissimus dorsi,
To understand the pathophysiology of the pectoralis major, and serratus anterior muscles
glenohumeral instability in the throwing athlete it increase their activity. During the fourth phase of
is important to know the normal joint motion acceleration, abduction is maintained while the
during the act of throwing. With minor differ- shoulder rotates to the ball release (position 5, see
ences, overhead throwing, the volleyball spike, the Fig. 6). The scapula protracts as the body moves
golf swing, and the tennis serve all have similar forward and the humeral head recenters in the
throwing mechanics [42–45]. There are six phases glenoid fossa, decreasing the stress on the anterior
in the overhead throwing motion: wind-up, early capsule. During the early acceleration phase the
cocking, late cocking, acceleration, deceleration, triceps muscle shows marked activity, while the
and follow-through (Fig. 6) [42]. During the wind- latissimus dorsi, pectoralis major, and serratus
up phase there is minimal stress loading and anterior muscles increase their activity during the
muscular activity of the shoulder. At the end of late acceleration phase. During the fifth phase of
this phase the shoulder is in minimal internal deceleration the energy not imparted to the ball is
rotation and slight abduction (positions 1 and 2, dissipated. It begins at the moment of ball release
see Fig. 6). During the second phase of early and it ends with cessation of humeral rotation to
cocking the shoulder reaches 90 degrees of 0 degrees. Abduction is maintained at 100 degrees,
abduction and 15 degrees of horizontal abduction and horizontal adduction increases to 35 degrees.
(elbow posterior to the coronal plane of the torso) All muscle groups contract violently, with eccen-
(position 3, see Fig. 6). During this phase there is tric contraction, allowing the arm to slow down.

Fig. 6. The six basic positions of a baseball pitch. Positions 1 and 2 are the wind-up phase. Note that the shoulder is in
internal rotation and mild abduction at the end of the wind-up phase, in position 2. Position 3: Early cocking phase. The
shoulder is in 90 degrees of abduction and 15 degrees of horizontal abduction. Position 4: Late cocking phase. Shoulder
in maximum external rotation at 90 degrees of abduction and 15 degrees of horizontal adduction. Position 5:
Acceleration phase. Shoulder in 90 degrees of abduction, rotating from external rotation to internal rotation. The ball is
released. Position 6: Deceleration and follow-through phases. Shoulder in internal rotation, horizontal adduction, and
moving from abduction to adduction.
 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238 227

During this phase, joint loads and compressive

forces are high posteriorly and inferiorly through
strong contraction of the biceps muscle. During
the sixth phase of follow-though the body moves
forward with the arm until the motion ceases.
Shoulder rotation decreases to 30 degrees, hori-
zontal adduction increases to 60 degrees and ab-
duction is maintained at 100 degrees while joint
loads decrease, ending in adduction (position 6,
see Fig. 6).

Pathophysiology and MR imaging manifestations

Fig. 7. Classic Bankart lesion. Axial T1-weighted image
Glenohumeral instability can be classified ac- following intrarticular injection of gadolinium. The
cording to the etiology or according to the direction labrum is completely separated from the glenoid margin
of the instability. Based on the etiology, three main (long arrow), still attached to the capsule and MGHL
types of shoulder instability are recognized: trau- (short arrow). The capsule is separated from the scapular
matic, atraumatic, and microtraumatic [45,46]. neck. Note the partially stripped periosteum (arrow-
Traumatic and atraumatic instability are not fre- head).
quently seen in the overhead-throwing athletes.
These athletes usually complain of gradually in- described by Perthes [52] and latter redefined by
creasing shoulder pain at some position during the Warren [53] in his circle concept of capsuloliga-
throwing motion, and the symptoms are the mentous instability of the shoulder. This concept
consequence of multiple episodes of microtrauma indicates that a significant lesion anywhere in the
rather than a single episode of injury (traumatic capsule affects motion of the humeral head on the
instability) or generalized joint laxity (atraumatic side of the lesion and also in other directions,
instability) [47]. The acronyms TUBS (traumatic, resulting in MDI.
unilateral, Bankart lesion, surgery) and AMBRI Variants of the Bankart lesion have been de-
(atraumatic, multidirectional, dilateral, rehabilita- scribed and include the Perthes lesion [54] (Fig. 8;
tion, inferior capsular shift) have been used as a see also Fig. 11), the anterior labral periosteal
simple guide to classification and treatment of sleeve avulsion (ALPSA lesion) (Fig. 9) [55], the
shoulder instability [46]. The acronym AIOS (ac- humeral avulsion of the glenohumeral ligaments
quired, instability, overstress, surgery) may be (HAGL lesion) (Fig. 10) [56,57], the bony avulsion
added to include the microtraumatic instability of the inferior glenohumeral ligament (BAGHL
developing in the throwing athlete. lesion) [58], the combined Bankart and HAGL
According to the direction of laxity testing, lesion (Floating AIGHL lesion) [59–61], and some
shoulder instability can be classified in anterior, types of lesions involving the superior labrum
posterior, and multidirectional instability (MDI). (SLAP lesions) [62–65]. Any of these lesions can
also be seen associated with a lesion of the articular
cartilage at the edge of the glenoid, resulting in the
Traumatic instability
glenolabral articular cartilage disruption (GLAD
Traumatic instability evolves following an lesion) (Fig. 11) [66]. A summary description of
acute episode of shoulder dislocation, more often these lesions is provided in Table 1.
anterior inferior dislocation resulting from an Anterior inferior glenohumeral dislocation
abrupt abduction and external rotation force. may also produce damage to the axillary nerve
Recurrence rates of dislocation and subluxations or its branches, leading to atrophy of selected
following the first episode are high [48]. The muscle groups. In a series of 77 cases, Visser et al
resulting injury to the anterior inferior capsulola- [67] found 43% incidence of axillary nerve damage
bral complex is the most frequently encountered in patients with history of glenohumeral joint
lesion, the so-called ‘‘classic Bankart lesion’’ dislocation.
(Fig. 7) [49], often accompanied by an impac- Injuries to the posterior capsulolabral complex
tion fracture of the posterior superior aspect of occur following acute traumatic posterior dislo-
the humeral head, the Hill-Sachs lesion [50,51]. cations, particularly in patients with seizures or
This circumferential pattern of injuries was first during electroshock therapy. The injury frequently
228 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238

Fig. 9. ALPSA lesion. Axial T1-weighted image through

the lower margin of the glenoid (arrowheads), following
intraarticular injection of gadolinium. The anterior
inferior aspect of the labrum (long arrow) is detached
from the glenoid and displaced medially. Note the large
gap between the labrum and the glenoid. In a chronic
ALPSA lesion this gap fills with ‘‘synovialized’’ tissue.
Note also that the labrum remains attached to the
capsuloperiosteal complex medially (short arrow). The
Fig. 8. Perthes lesion and posterior superior impinge-
medial displacement of the labrum in relationship with
ment. T1 fat-suppressed image in the ABER position,
the glenoid defines the characteristics of ALPSA lesion
following intraarticular injection of gadolinium. The
on MR imaging. (From Beltran J, Rosenberg ZS,
anterior inferior labrum is detached from the glenoid
Chandanani VP, et al. Glenohumeral instability: evalu-
(black arrow), without associated capsuloperiosteal
ation with MR arthrography. Radiographics 1997;
stripping. Normally the labrum is well attached to the
3:657–73; with permission.)
glenoid at this level. This feature distinguishes the
Perthes lesion from the Bankart lesion on MR imaging.
The separation of the labrum in the Perthes lesion is
interval has to occur, as described by Harryman
better seen on MR imaging using the ABER position,
placing tension in the anterior capsule. The failure of the et al [35].
anterior labrum and capsule allows anterior subluxation
of the humeral head, producing impingement of the Atraumatic instability
rotator cuff between the humeral head and the posterior
superior aspect of the glenoid (white arrow). Note the Atraumatic instability of the shoulder is seen in
fragmentation of the labrum at this level (arrowhead). patients associated with generalized joint laxity
See text for description of the posterior superior im- often presenting with classical stigmata such as
pingement syndrome. (From Shankman S, Bencardino J, genu recurvatum, hyperextensibility of the elbows
Beltran J. Glenohumeral instability: evaluation using and metacarpophalangeal joints, and ability to
MR arthrography of the shoulder. Skeletal Radiol passively abduct the thumb to the forearm [45].
1999;7:365–82; with permission.) Atraumatic instability includes MDI [68]. These
patients often have a patulous inferior pouch,
attenuation of the capsuloligamentous structures,
includes a posterior labral tear (Fig. 12), a disrup- and redundancy of the rotator cuff interval [69]. It
tion of the posterior capsule and periosteum and is possible that atraumatic instability is secondary
an anterior impacted fracture of the humeral head to repetitive microtrauma because bilateral laxity
(McLaughlin lesion or reverse Hill-Sachs lesion). is often present [45].
In the throwing athlete, posterior traumatic in-
stability resulting from an injury to the posterior
Microinstability
capsulolabral complex in isolation has been
questioned [45]. For a posterior dislocation to Microtraumatic instability or microinstability
take place with the arm in flexion, adduction and is seen typically in the overhead athletes involved
internal rotation, in addition to injury to the in events such as throwing, swimming, and ten-
posterior capsule, an injury to the rotator cuff nis. Injuries to any number of dynamic or static
 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238 229

Fig. 11. GLAD lesion and Perthes lesion. Axial T1-

Fig. 10. HAGL lesion. Axial gradient echo sequence weighted fat-suppressed image obtained following intra-
obtained at the level of the surgical neck of the humerus. articular injection of gadolinium. There is a tear of the
The patient had a joint effusion. The MGHL is anterior inferior labrum without capsuloperiosteal strip-
thickened (arrow) and detached from its humeral ping (Perthes lesion) (arrow). The intermediate signal
insertion (arrowhead). intensity articular cartilage is partially detached from the
glenoid fossa (arrowhead). This is the characteristic MR
imaging finding in GLAD lesion.
shoulder stabilizers can occur [69]. Kvitne and
Jobe [70] developed a classification system based
on various signs and symptoms seen in these increased ligamentous laxity and signs and symp-
patients. Group I includes patients generally over toms of instability, and Group IV includes pa-
the age of 35 years, with impingement syndrome, tients with classic anterior instability.
without instability. Group II includes patients More recently, Meister [42] modified this
with primary instability and secondary internal classification to include additional factors contrib-
impingement. Group III includes patients with uting to the pathomechanics of injury.

Table 1
Bankart lesion and variants
Lesion Definition References
Classic Bankart Tear of the anterior inferior labrum with capsuloperiosteal stripping 49–51
Perthes Tear of the anterior inferior labrum without capsuloperiosteal stripping 54
ALPSA Anterior labrum periosteal sleeve avulsion: anterior labral tear with posterior 55
medial displacement and capsuloperiosteal stripping
HAGL Humeral avulsion glenohumeral ligaments: avulsion of the humeral insertion 56,57
of the anterior band of the IGHL
BAGHL Bony avulsion glenohumeral ligament: same as HAGL with humeral body 58
avulsion
Floating AIGHL Floating anterior inferior glenohumeral ligament: combined Bankart and 59–61
HAGL
SLAP Superior labrum anterior posterior: tear of the superior labrum extending in 19,62–65,83–99
different directions (10 types described)
POLPSA Posterior labrocapsular periosteal sleeve avulsion: same as ALPSA but 101,102
located in the posterior labrum
SLAC Superior labrum anterior cuff: superior labral tear associated with partial tear 100
of the articular surface of the supraspinatus tendon
GLAD Glenoid labrum articular cartilage disruption: labral tear with associated 66
avulsion of articular cartilage
230 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238

subacromial impingement, coracohumeral im-

pingement), biceps tendon (tendinosis), posterior
capsule (Bennett lesion), and superior labrum
(some SLAP lesions). In this group, lesions of
the superior labral complex are mostly related to
pulling forces by the biceps tendon [42]. Another
cause for superior labral tears in this group is
related to the ‘‘grinding factor’’ described by
Andrews et al [71]. Displacement of the humeral
head combined with compression and internal rota-
tion during deceleration can cause the humeral
head to grind on the base of the biceps tendon
and anterosuperior labrum. Injuries to the rotator
cuff, latissimus dorsi, and subscapularis muscle
have also been well documented in overhead
throwers [41].
Coracoid impingement syndrome is a well-de-
scribed cause of anterior shoulder pain in the
throwing athlete [72]. The syndrome is produced
Fig. 12. Posterior labral tear. Axial T1-weighted fat- by impingement of the anterior rotator cuff be-
suppressed image obtained following intraarticular in- tween the lesser tuberosity of the humeral head and
jection of gadolinium. There is a tear of the posterior
the lateral aspect of the coracoid process. The
labrum (arrow) associated with posterior periosteal
normal distance between these two structures was
stripping (arrowhead ).
determined to be 8.6 mm by Gerber et al [73], based
on computed tomography studies. The distance
Primary disease decreases to 6.7 mm in patients with coracoid im-
Primary disease includes the lesions taking pingement. The causes for the decreased cora-
place in the throwing shoulder, related to normal cohumeral distance include idiopathic long or
overuse. In this group, minimal or no laxity is laterally based coracoid, posttraumatic deformity,
found and no significant instability is present. The or postsurgical deformity [72].
injuries may involve any or several of the following Bennett described a lesion related to repetitive
structures: the rotator cuff (primary tendinosis, traction posterior shoulder in the throwing athlete

Fig. 13. (A, B) Bennett lesion. Axial CT (A) and axial gradient echo MR imaging (B) in two different patients
demonstrate the characteristic ‘‘spur’’ adjacent to the posterior glenoid (arrows in A and B). The patient in (A) has also
developed osteoarthritis of the glenohumeral joint, with osteophyte formation. The Bennett lesion is difficult to
distinguish form a posterior labral tear on MR imaging due to the low signal intensity of both, the labrum and the
calcified lesion. (Courtesy of Lynne Steinbach, MD, San Francisco, CA.)
 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238 231

[74–76]. The lesion consists of an extraarticular Tears of the rotator cuff interval can lead to
deposit of calcium or bone along the posterior shoulder instability, as described by Harryman
inferior aspect of the glenoid rim in a subperi- et al [35]. As many as 50% of patients undergoing
osteal location, well seen on CT and MR imaging shoulder surgery for rotator cuff interval tears in
(Fig. 13). This traction ‘‘exostosis’’ is located at one series had instability [79]. Lesions associated
the insertion of the posterior capsule and the long with rotator cuff interval tears include injuries of
head of the triceps muscle. The Bennett lesion has the biceps tendon (tendinosis, tears, dislocation),
been attributed to an excessive pull on the pos- SLAP lesions, glenohumeral ligament lesions, and
terior capsule and is often associated with tears of coracohumeral ligament lesions (Fig. 14) [80,81].
the infraspinatus and teres minor tendons [75,76], Chung et al [81] evaluated the normal anatomy of
posterior labral tears, and instability [75,77]. the rotator cuff interval using MR imaging
Other investigators believe that the Bennett lesion arthrography in 20 cadaver specimens and con-
occurs from traction of the posterior band of the cluded that MR arthrography is useful in evalu-
inferior glenohumeral ligament during decelera- ating the rotator cuff interval, crossing structures,
tion [78]. and the rotator cuff interval capsule.
Superior labral anterior and superior lesions
Primary instability (SLAP lesions) are rare (3.9% of patients un-
Repeated microtrauma leads to instability as dergoing arthroscopy), although more frequent
a result of laxity and failure of the anterior use of MR arthrography has led to higher rates of
capsular complex, producing lesions in the rotator diagnosis of this lesion. These lesions involve the
cuff (secondary impingement, tendinosis, partial superior part of the labrum with varying degrees
tears, and rotator cuff interval tears), anterior of biceps tendon involvement. Pain, clicking,
labral tears, and SLAP lesions. Athletes with and occasional instability in a young patient are
generalized joint laxity (see discussion of atrau- the typical clinical manifestations. Four types of
matic instability) and secondary capsulolabral SLAP lesions were originally described based on
injuries are also included in this group. arthroscopic findings [82–85]. Type I is a partial

Fig. 14. (A, B) Rotator cuff interval tear with associated SLAP lesion. Oblique sagittal (A) and oblique coronal (B) T1-
weighted fat-suppressed images obtained following intravenous injection of gadolinium (indirect MR arthrogram).
There is extravasation of contrast material at the level of the rotator cuff interval (white arrow in A). Compare with the
normal, well-demarcated rotator cuff interval shown in Fig. 5. The CHL (arrowhead ) and the SGHL (short arrow) are
thickened, irregular, and partially torn. Compare with the MR imaging appearance of the normal fine striation of the
CHL and SGHL shown in Fig. 5. The oblique coronal image (B) of the same patient demonstrates a tear of the superior
labrum (SLAP lesion) (black arrow). (From Beltran J, Bencardino J, Padron M, et al. The middle glenohumeral ligament:
normal anatomy, variants and pathology. Skeletal Radiol 2002;5:253–62; with permission.)
232 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238

Fig. 15. (A–C) SLAP lesions in three different patients. (A) Oblique coronal T1-weighted fat-suppressed image obtained
following intraarticular injection of gadolinium. Note the ‘‘arrowhead’’ configuration of the superior labrum, pointing
toward the shoulder of the patient (arrow). This is the hallmark of SLAP lesions on MR imaging. In this case, the tear of
the superior labrum is partial and represents a type II lesion. (B) Oblique coronal T1-weighted fat-suppressed image
obtained following intraarticular injection of gadolinium. In this case, the SLAP lesion is like a bucket-handle tear of the
knee meniscus, with a displaced fragment (arrow) located between the articular surfaces of the humeral head and the
superior glenoid. This case represents a type III lesion. (C ) Oblique sagittal T1-weighted fat-suppressed image obtained
following intraarticular injection of gadolinium. SLAP lesion (type VII) extending from the superior labrum (arrow) to
the MGHL (arrowheads). (Fig. A from Shankman S, Bencardino J, Beltran J. Glenohumeral instability: evaluation using
MR arthrography of the shoulder. Skeletal Radiol 1999;28:265–382; Fig. C from Beltran J, Bencardino J, Padron M,
et al. The middle glenohumeral ligament: normal anatomy, variants and pathology. Skeletal Radiol 2002;5:253–62;
with permission.)
 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238 233

Fig. 16. (A, B) SLAC lesion. (A) Oblique coronal T2-weighted fat-suppressed image demonstrate a tear of the superior
labrum (SLAP lesion) (white arrow). There is an incidental large cyst in the greater tuberosity. (B) Oblique coronal
section of the same series obtained in a more ante0rior plane, at the level of the supraspinatus tendon, demonstrating
a tear (black arrow).

tear of the superior part of the labrum with utes to the stability of the glenohumeral joint.
fibrillation of the LHBT. Type II is an avulsion of Other reports [94–96] indicate that SLAP lesions
the LHBT with tear of the anterior and posterior also occur without associated instability.
labrum. Type III is a bucket-handle tear of the Patients with SLAP lesions and other types of
labrum, and type IV is a bucket-handle tear of labral tears often develop ganglion cysts adjacent
the labrum with longitudinal tear to the LHBT. to the labrum or at some distance form the labrum,
Maffet et al [86] expanded the classification to especially at the spinoglenoid notch and supra-
seven types. More recently, up to 10 types have scapular notch, causing compressive neuropathy
been described, representing a combination of and resulting in atrophy of the supraspinatus
superior labral tears with extension into different muscle, infraspinatus muscle, or a combination of
areas of the labrum and glenohumeral ligaments both, depending on the location of the cyst [97,98].
[19] (Fig. 15). Savoie et al [99] recently described a specific
Causative mechanisms for the development of combination of anterior superior labral tear
SLAP lesions include repetitive overhead activity (SLAP lesion) and partial tear of the undersurface
[87], internal impingement [88,89], ‘‘peel-back’’ of the supraspinatus tendon in a group of patients
[90], falling on an outstretched arm with the with anterosuperior instability. Other lesions
shoulder in abduction, and slight forward flexion found in this group included the anterior part of
(see ref. 7 in Musgrave and Rodosky [65]) and the biceps anchor and the superior glenohumeral
forced eccentric contraction of the biceps [91]. ligament. They coined the term ‘‘superior labrum
In the ‘‘peel-back’’ mechanism, described by anterior cuff’’ or SLAC lesion. MR imaging and
Burkhart and Morgan [90], the labrum is peeled MR arthrography was used in their series for
back from the superior glenoid by the posterior preoperative diagnosis of the lesions (Fig. 16).
dominant biceps attachment which undergoes tor- A variant of the posterior labral injury has
sional force generated by extreme abduction and been described by Simons et al [100] in a patient
external rotation (the cocking phase). Different sustaining posterior dislocation of the shoulder
mechanisms of injury are likely to be operational that was locked in position by an impacted
in different patients. fracture of the humerus. They coined the term
Some types of SLAP lesions are associated ‘‘posterior labrocapsular periosteal sleeve avul-
with Bankart lesions and shoulder instability sion’’ (POLPSA), owing to the similarity with
[86,91,92]. Cordasco et al [93] reported 70% the ALPSA lesion described by Neviaser et al
prevalence of instability in patients with SLAP [55]. Yu et al [101] described the findings in six
lesions regardless of the presence of a Bankart athletes with POLPSA lesions (four football
lesion, suggesting that the biceps anchor contrib- players, one wrestler, and one weightlifter), with
234 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238

but unusual in the overhead-throwing athlete [42].

Pathology and MR imaging manifestations are
described in the section of traumatic instability.

Posterosuperior glenohumeral instability

In the overhead-throwing sports, repeated
movements of abduction and external rotation of
the shoulder during the late cocking phase result in
contact of the posterosuperior glenoid margin,
labrum, and the greater tuberosity, producing
impingement of the supraspinatus and infraspina-
tus tendons, especially in patients with anterior
capsuloligamentous laxity and subsequent in-
creased anterior translation of the humeral head.
The syndrome was described originally by Walsh
et al [102] and subsequently confirmed by other
researchers [103,104]. The injuries resulting from
this mechanism include cyst formation in the
greater tuberosity, tear of the posterior superior
labrum, and undersurface tearing of the rotator
cuff.
MR imaging of the shoulder in the ABER
position has contributed greatly in identifying the
lesions occurring in patients with posterosupe-
rior impingement syndrome (Figs. 8, 17) [18,105,
106]. A recent study by Halbrecht et al [107] in
asymptomatic throwing and nonthrowing athletes,
Fig. 17. Posterior superior impingement syndrome. T1- using indirect MR arthrography in the ABER
weighted image in the ABER position, obtained
position, demonstrated that contact between the
following intraarticular injection of gadolinium. There
is abnormally high signal intensity of the anterior
undersurface of the rotator cuff and the poster-
inferior labrum (short arrow), an impacted fracture at osuperior glenoid occurred in all shoulders. No
the level of the grater tuberosity (arrowhead), and a tear clinical or MR imaging abnormalities were seen
of the superior posterior labrum (long arrow). in the nonthrowing athletes. The images of the
throwing athletes demonstrated superior labral
tears, paralabral cysts, and signal changes in the
clinical posterior shoulder instability, without rotator cuff tendons. Contact between the un-
history of posterior shoulder dislocation. They dersurface of the rotator cuff and the poster-
described the POLPSA lesion as an avulsion of osuperior labrum was seen normally in the
the attachment of the capsule and the periosteum, ABER position.
without capsular tear, creating a patulous recess
posteriorly. Although Yu et al [101] found lesions
to the infraspinatus tendon in all of their six cases, Summary
lesions of the rotator cuff interval were not Lesions leading to glenohumeral instability
described in their series, as one would expect may result from acute trauma, atraumatic laxity,
according to the theory of Harryman et al [35]. or repetitive microtrauma. Athletic activities,
The SLAC and POLPSA lesions can be in- especially overhead throwing, may lead to a series
cluded in the group of primary instability, because of lesions involving the stabilizing structures of
overhead activity, instability, and absence of acute the shoulder. The resultant injuries and pathome-
trauma are the common denominators in these chanics leading to shoulder symptoms can be
patients. classified as primary disease, primary instability,
acute traumatic instability, and posterosuperior
Acute traumatic instability impingement syndrome. MR imaging with or
As indicated above, shoulder instability sec- without intrarticular or intravenous injection of
ondary to an acute injury is frequent in athletes contrast material, along with clinical examination
 J. Beltran, D. Hyun-Min Kim / Magn Reson Imaging Clin N Am 11 (2003) 221–238 235

and stress testing, provides valuable preoperative [17] Maurer J, Rudolph J, Lorenz M, et al. A
assessment. prospective study on the detection of lesion of the
labrum glenoidale by indirect MR arthrography of
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 Magn Reson Imaging Clin N Am
11 (2003) 239–253

Sports injuries of the elbow

Christine B. Chung, MD*, Hyun-Jin Kim, MD
Department of Radiology, University of California San Diego and Veterans Affairs Healthcare System,
3350 La Jolla Village Drive, La Jolla, CA 92161, USA

The elbow is a complex joint comprised of and the ulnar collateral ligament complex. The
three components: the humeroradial, humeroul- lateral epicondyle is the osseous projection that
nar, and proximal radioulnar articulations. As is serves as the attachment site for the superficial
often the case in the architecture of the body, extensor muscles of the forearm and parts of the
structural complexity parallels functional com- radial collateral ligament complex. The medial
plexity. In the elbow, though the primary motion third of the humeral articular surface is referred
of flexion and extension explains its designation as to as the trochlea, is intimate with the ulna, and
a hinge joint, it also is capable of axial rotation. forms the humeroulnar articulation. The lateral
Perhaps most importantly, the elbow serves as the articulating surface of the humerus is formed by
functional link between the glenohumeral joint the capitellum, a smooth, rounded prominence
and the hand, facilitating remarkable accessibility that arises from its anterior and inferior surfaces.
of the fine motor and sensory abilities of the hand From its anterior margin with the distal hu-
and fingers for the performance of the activities of meral shaft, the capitellum curves downward and
daily living so commonly take for granted. posteriorly. As it does so, its width decreases
Elbow injuries in the athlete are common and from anterior to posterior. This morphology of
can be classified into acute or chronic injuries. the capitellum (smooth surface), in conjunction
The following discussion of sports injuries of the with the knowledge that the adjacent lateral epi-
elbow will address the complex anatomy of the condyle (rough surface) is a posteriorly oriented
elbow, variations in normal anatomy that represent osseous projection of the distal humerus, explains
pitfalls in imaging diagnosis, and commonly en- the pseudodefect of the capitellum (Fig. 1) [1].
countered osseous and soft tissue pathology. The pseudodefect is encountered in coronal MR
images, when an apparent interruption in the
capitellar surface occurs at the posterior aspect
Osseous anatomy and pathology
of the joint. This appearance can be mistaken
The elbow articulation is comprised of three for an osteochondral lesion of the capitellum
osseous (distal humerus, proximal ulna, and when it is simply the junction between the ante-
radius) structures that fit together like the pieces rolateral capitellum and posterolateral lateral
of a three-dimensional jigsaw puzzle to form three epicondyle.
articulations. At the distal aspect of the humerus, The articular surface of the proximal ulna is
the bone widens into a fanlike configuration. The formed by the combination of the posterior
medial most extent, the medial epicondyle, is an olecranon and the anterior coranoid processes
osseous projection that serves as the attachment with the articular surfaces taking the configura-
site for the superficial flexor group of the forearm tion of a figure of eight. At the waist of the eight,
or junction between anterior and posterior aspects
of the ulna, the articular surface is traversed by
a cartilage-free bony ridge (Fig. 2). This trochlear
* Corresponding author. ridge is 2 to 3 mm wide and is at the same height
E-mail address: [email protected] (C. Chung). as the adjacent cartilaginous surface, resulting in
1064-9689/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1064-9689(03)00024-2
240 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253

Fig. 1. (A) Coronal T1-weighted MR image of the elbow demonstrated irregular contour (arrow) in the region of the
capitellum. (B) Corresponding sagittal T1-weighted MR image verifies the coronal image was obtained at the junction of
the anterior capitellum and the posterior lateral epicondyle (arrow), the pseudodefect of the capitellum.

no impediment to smooth motion of the joint [2].

Osteochondral lesions
Knowledge of this anatomic detail avoids the
mistaken diagnosis of central osteophyte forma- In the case of acute medial elbow injury, the
tion, or articular surface irregularity on sagittal involvement of a valgus force is usually described
MR images of the elbow. as one of the most common mechanisms of injury
The figure-of-eight morphology of the ulnar [3]. Subchondral bone and cartilage injuries that
articular surface results in an additional imaging occur in this setting result from impaction and
pitfall in diagnosis that of the trochlear groove shearing forces applied to the articular surfaces
(Fig 3). The waist of the figure of eight is formed (Fig. 4). The overall configuration of the humero-
by the tapered central surfaces of the coronoid radial articulation, in this case, can be likened to
and olecranon processes medially and laterally, a mortar and pestle with the capitellar articular
forming small cortical notches devoid of cartilage. surface impacting that of the radius to result in
On sagittal MR images, these focal regions devoid a chondral or osteochondral lesion of the cap-
of cartilage could be mistaken for a focal chondral itellar surface. These acute posttraumatic lesions
lesion [2]. are manifested on MR images as irregularity of
The proximal end of the radius consists of the chondral surface, disruption or irregularity of
head, neck, and tuberosity. The radial head is the subchondral bone plate, or the presence
shaped like a mortar with a cupped articular of a fracture line (Fig. 5). The acuity of the lesion
surface. The neck is the constricted portion of the and posttraumatic etiology are implied by the
bone distal to the articular surface. The tuberosity presence of marrow edema and joint effusion.
is beneath the medial aspect of the neck and serves Close inspection of the location of the lesion on
as the attachment site for the biceps tendon. coronal and sagittal MR images is of the utmost
 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253 241

Fig. 2. A gross anatomic section in the sagittal plane

obtained through the midportion of the ulnar articular
surface demonstrates a focal area (arrow) between the
coronoid articular surface (Co) and the olecranon
articular surface (Ol) devoid of cartilage. This region is
called the trochlear ridge and should not be mistaken for
a central osteophyte.

importance to distinguish a true osteochondral

lesion from the pseudodefect of the capitellum.
Correlation with presenting clinical history is also
helpful in determining the etiology of imaging
findings.
The entity of osteochondritis dissecans remains
controversial, primarily because of debate over its Fig. 3. This sagittal MR arthrogram image in a cadaveric
etiology. The precise relationship of osteochon- specimen at the margin of the ulnar articular surface
demonstrates a focal area (arrow) between the coronoid
dritis dissecans and an osteochondral fracture is
articular surface (Co) and the olecranon articular surface
unclear, but many investigators regard the former (Ol) devoid of cartilage that is referred to as the trochlear
as a posttraumatic abnormality that may lead groove. This normal anatomic appearance can be easily
to osteonecrosis. Osteochondritis dissecans is confused with an osteochondral lesion.
believed to occur in immature athletes between
11 and 15 years of age, rarely in adults [4]. Os-
teochondritis dissecans of the elbow involves sensitive MR images, generally indicates an un-
primarily the capitellum, but reports have de- stable lesion. The introduction of contrast into
scribed this process in the radius and trochlea [5]. the articulation in conjunction with MR imaging
Regardless of the etiology of the osteochondral can be helpful in two ways: (1) to facilitate the
injury, the role of imaging is to provide infor- identification of intraarticular bodies (Fig. 6) and
mation regarding the integrity of the overlying (2) to establish communication of the bone-
articular cartilage, the viability of the separated fragment interface with the articulation by fol-
fragment, and the presence of associated intra- lowing the route of contrast, providing even
articular bodies. CT and MR imaging with and stronger evidence for an unstable fragment [6,7].
without arthrography can provide this informa-
tion to varying degrees, although no scientific in-
vestigation has been performed to date that
Capsule anatomy and pathology
establishes specific indications for each study.
MR imaging, with its excellent soft tissue con- The osseous structures of the elbow are in-
trast, can directly visualize the articular cartilage vested in a two-layer capsule. The synovial capsule
and the character of the interface of the osteo- or membrane comprises the deep layer and lines
chondral lesion with native bone. The presence of the more superficial fibrous capsule and the
joint fluid or granulation tissue at this interface, annular ligament. The fat pads of the elbow are
manifested as increased signal intensity on fluid- located between the synovial and fibrous capsules.
242 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253

In addition, if viewed en face in the sagittal

imaging plane, it could be misdiagnosed as an
intraarticular body.
The second variation in elbow anatomy that
occurs in the elbow articulation is that of the
plica. As previously mentioned, plica are believed
to be the remnants of embryonic septae. These
structures can become inflamed and thickened,
resulting in impingement, snapping, and the sen-
sation of intraarticular bodies. The diagnosis of
a painful snapping plica can be confirmed if the
plica snaps back and forward over the radial head
in flexion and extension. This entity is often as-
sociated with focal areas of synovitis and cartilage
lesions in the radial head [9]. The most common
location for an abnormal plica is in the postero-
lateral joint space (Fig. 8) [10].

Ligament anatomy and pathology

Classic descriptions of the ligamentous anat-
omy of the elbow emphasized radial and ulnar
collateral ligaments, characterized as regions of
focal thickening of the fibrous capsule that served
to reinforce and stabilize the joint. Though the
characterization and function of the ligaments has
Fig. 4. This diagram demonstrates the shearing and remained constant in the literature, the concept of
compressive forces associated with a valgus stress at their exact structural designation has become
the elbow. The compression at the humeroradial artic- more complex [11].
ulation can result in osteochondral injury to the
capitellar articular surface and radial head or neck Ulnar collateral ligament complex
fractures. Compression at the lateral elbow results in
opening of the medial joint space and potential in- The medial collateral ligament of the elbow is
sufficiency of the medial supporting structures (capsule, comprised of three components, an anterior,
ulnar collateral ligament complex, and common flexor posterior, and transverse bundle. The ligament
tendon). originates from the central 65% of the antero-
inferior surface of the medial epicondyle. The
anterior band is taut from full extension to 60
As there are normal variations in osseous degrees of flexion, whereas the posterior compo-
anatomy that can simulate pathology for the in- nent is taut from 60 to 120 degrees of flexion. The
experienced reader, so there are similar variations anterior band is the strongest and stiffest compo-
in capsular anatomy. One such variation is a tongue nent of the medial or ulnar collateral ligament
of synovial tissue that projects into the joint complex. Its distal attachment is to the most
between the radius and ulna, partially dividing medial portion of the coronoid process, also called
the articulation into humeroulnar and humero- the sublime tubercle, in close proximity to the
radial portions (Fig. 7). This has been referred to as attachment of the anterior capsule and brachialis
the synovial fold [8]. Embryologically, the elbow tendon. The posterior bundle of the medial col-
joint space is formed by mesenchymal cavitations lateral ligament is a less discrete structure or
in three regions (humeroradial, humeroulnar, and thickening of the posterior elbow capsule and
proximal radioulnar) that ultimately become attaches in a broad fashion along the periphery
confluent. The synovial fringe is believed to be of the medial ulna. The transverse bundle, also
a septal remnant, or incomplete plica [8]. It can known as Cooper’s ligament, is comprised of
become compressed between the radial head and fibers that bridge the base of the anterior and
the humerus, resulting in pain and inflammation. posterior bundles of the ligament complex.
 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253 243

Fig. 5. (A) Coronal fat-suppressed T2-weighted fast spin echo MR image of the elbow demonstrates irregularity of the
capitellar articular surface with bone marrow edema in the capitellum (arrow) and in the radial head (curved arrow). (B)
Corresponding fat-suppressed T2-weighted fast spin echo MR image verifies the anterior articular location of the
findings. The location, in conjunction with the bone marrow edema in the radius, suggests a posttraumatic etiology to
this abnormality.

significant attenuation or frank tearing within its

Valgus instability
substance. Though MR imaging allows direct
The principle function of the ulnar collateral visualization of the ligament complex, in chronic
ligament complex is to maintain medial joint cases, the development of heterotopic calcification
stability to valgus stress. The anterior bundle is along the course of the ligament has been
the most important component of the ligamentous described [13].
complex to this end, as it serves as the primary Valgus instability is examined with the patient
medial stabilizer of the elbow from 30 to 120 seated and his or her hand and forearm secured
degrees of flexion. The most common mecha- between the examiner’s torso and arm. The pa-
nisms of ulnar collateral ligament insufficiency tient’s elbow is flexed to 25 degrees to unlock the
are chronic attenuation, as seen in overhead or olecranon process from its fossa, and the medial
throwing athletes, and posttraumatic, usually after collateral ligament is palpated while a valgus
a fall on the outstretched arm. In the case of the stress is applied. Studies have shown that acquired
latter, an acute tear of the ulnar collateral (Fig. 9) valgus laxity does not exist in asymptomatic
may be encountered. athletes, and that furthermore, there is no
With throwing sports, high valgus stresses are threshold value of measurement indicated for the
placed on the medial aspect of the elbow. The diagnosis of acquired valgus laxity [14].
maximum stress on the ulnar collateral ligament Treatment for ulnar collateral ligament injury
occurs during the late cocking and acceleration in the throwing athlete includes rest with cessation
phases of throwing [12]. Repetitive insults to the of throwing, physical therapy with muscle strength-
ligament allow microscopic tears that progress to ening, and nonsteroidal antiinflammatories.
244 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253

Fig. 6. Sagittal MR arthrogram image in a 34-year-old

patient with a history of locking elbow shows a large Fig. 7. Gross anatomic specimen oriented in the coronal
intraarticular body (arrow) in the coronoid fossa out- plane in the region of the humeroradial articulation
lined by contrast material. demonstrates a tongue of synovial tissue (arrow), the
synovial fold, extending between the radial and the
capitellar articular surfaces.
Operative repair is typically reserved for compet-
itive athletes or those involved in heavy manual The annular ligament is circular in shape and
labor because valgus laxity has been shown to cause extends around the radial head neck junction to
minimal functional impairment in normal activities attach at the anterior and posterior margins of the
of daily living [11]. radial notch of the ulna. It serves as a restraining
ligament, maintaining the radial head in contact

Radial collateral ligament complex

Similar to the medial side of the elbow, on the
lateral side, a radial collateral ligament complex is
present. The radial, or lateral, collateral ligament
complex consists of four components: radial col-
lateral ligament, annular ligament, lateral ulnar
collateral ligament, and accessory lateral collat-
eral ligament. The radial collateral ligament is less
distinct and more variable than its counterpart on
the medial side. It is a thick, rough, triangular
band of fibrous tissue that attaches superiorly to
the lateral epicondyle of the humerus, beneath the
origin of the common extensor tendon and in- Fig. 8. Gross anatomic specimen oriented in the axial
feriorly to the annular ligament. This ligament plane shows a fold of synovial tissue (arrow), the
remains taut through the normal range of flexion posterior plica, extending into the posterolateral joint
and extension of the elbow. space.
 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253 245

Fig. 10. Coronal MR arthrogram image in a 40-year-old

patient demonstrates the normal appearance and course
of the lateral ulnar collateral ligament (arrows). It
extends from the undersurface of the lateral epicondyle
and around the posterior head neck junction of the
radius as it courses distally to its insertion on the
supinator crest of the ulna.

mechanism would be a stress or force applied to

the medial side of the articulation, resulting in
compression on that side, with opening of the
lateral articulation and subsequent insufficiency of
Fig. 9. Coronal inversion recovery MR image in a 27- the radial collateral ligament (Figs. 11, 12). As the
year-old patient shows abnormal signal intensity and radial collateral ligament attaches on and is
morphology of the ulnar collateral ligament. There is intimately associated with the annular ligament,
focal discontinuity of the ligament just distal to the an abnormality discovered in one of the structures
humeral attachment consistent with a full thickness tear. requires careful inspection of the other.
Varus stress applied to the elbow may occur as
an acute injury, but rarely as a repetitive stress as
with the ulna and preventing inferior displace- encountered on the medial side. Though lateral
ment of the radius. collateral ligament injuries rarely occur as the
The lateral ulnar collateral ligament originates result of an isolated varus stress, other causes can
from the lateral epicondyle and blends with commonly result in this injury, including disloca-
the fibers of the annular ligament proximally. tion, subluxation and overly aggressive surgery
It extends posteriorly to cradle the head–neck (release of the common extensor tendon or radial
junction of the radius as it moves to its distal head resection).
attachment at the supinator crest of the ulna (Fig. Varus instability is also tested with the elbow
10). This structure is one of the primary stabilizers in full extension and 30 degrees of flexion to
of the elbow and is taut in flexion and extension. unlock the olecranon. A varus stress is applied to
The accessory lateral collateral ligament is not the elbow while palpating the lateral joint line.
uniformly present but represents discrete fibers
that extend from the annular ligament to the Posterolateral rotary instability and elbow
supinator crest. When present, it may serve to dislocation
stabilize the annular ligament during varus stress.
The subject of elbow instability is complex and
has been a challenge because of the difficulty es-
Varus instability
tablishing a mechanism of injury and reliable
Lateral elbow instability related to isolated clinical tests for diagnosis. With the realization
abnormalities of the lateral collateral ligament that elbow instability is more common than
complex is not as well described as that on the previously thought, marked advances in the un-
medial side of the elbow. If it were to occur, the derstanding of this entity are occurring.
246 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253

perched under the trochlea. In this stage, the radial

collateral ligament, and anterior and posterior
portions of the capsule, are disrupted in addition to
the lateral ulnar collateral ligament. In stage 3, the
elbow dislocates anteriorly so that the coronoid
rests behind the humerus. Stage 3 is subclassified
into three categories. In stage 3A, the anterior band
of the medial collateral ligament is intact and the
elbow is stable to valgus stress after reduction. In
stage 3B, the anterior band of the medial collateral
ligament is disrupted so that the elbow is unstable
with valgus stress. In stage 3, the entire distal
humerus is stripped of soft tissues, rendering the
elbow grossly unstable even when a splint or cast is
applied with the elbow in a semiflexed posi-
tion. This classification system is helpful because
each stage has specific clinical, radiographic, and
pathologic features that are predictable and have
implications for treatment [15].
Traditional teaching dictated that the mecha-
nism of injury for elbow dislocation included hy-
perextension. More recently, it is believed that this
mechanism is the result of a fall on the out-
stretched hand. The elbow experiences an axial
compressive force during flexion as the body
approaches the ground. As the body rotates in-
ternally on the elbow (forearm rotates externally
Fig. 11. This diagram demonstrates the shearing and
on the humerus), a supination moment occurs
compressive forces associated with a varus stress at the
elbow. The compression at the medial elbow results in
at the elbow. This combination of valgus and
opening of the lateral joint space, and potential in- supination with axial compression during flexion
sufficiency of the lateral supporting structures (capsule, results in the posterolateral rotary subluxation
radial collateral ligament complex, and common exten- or dislocation of the elbow. The correspond-
sor tendon). ing pathoanatomy previously described can be
thought of simply as the disruption of a soft tissue
ring that progresses from posterolateral to medial
A simple classification for elbow instability in three stages [15].
does not exist. The literature points to five criteria Subluxation or dislocation of the elbow can be
that should be considered to produce a useful associated with fractures. Fracture dislocations
classification system for treatment: (1) timing most commonly involve the coronoid and radial
(acute, chronic, recurrent), (2) articulation in- head, a constellation of findings referred to as the
volved (elbow versus radial head), (3) direction of ‘‘terrible triad’’ of the elbow because the injury
displacement (valgus, varus, anterior, posterolat- complex is difficult to treat and prone to un-
eral rotary), (4) degree of displacement (sub- satisfactory results [15]. Radial head fractures do
luxation or dislocation), and (5) presence or not cause clinically significant instability unless
absence of associated fractures [15]. the medial collateral ligament is disrupted. An
For recurrent instability, posterolateral rotary important feature of elbow injuries to recognize is
instability is the most common pattern. This type that the small flake fracture of the coronoid,
of instability represents a spectrum of pathology commonly seen in elbow dislocations, is not an
consisting of three stages according to the degree of avulsion fracture. Nothing attaches to the tip of
soft tissue disruption. In stage 1, there is postero- the coronoid, rather the capsule attaches on the
lateral subluxation of the ulna on the humerus that downward slope of the coronoid, the brachialis
results in insufficiency of the lateral ulnar collateral even more distal. This fracture is a shear frac-
ligament (Fig. 13) [15–17]. In stage 2, the elbow ture and is likely pathognomonic of an episode
dislocates incompletely so that the coronoid is of elbow subluxation or dislocation (Fig. 14).
 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253 247

Fig. 12. (A) Coronal T1-weighted MR image of the elbow in a 47-year-old man shows discontinuity of the radial
collateral ligament (arrow) at the humeral attachment. The ligament also demonstrates somewhat abnormal morphology
with thickening. The overlying common extensor tendon is normal. (B) Corresponding axial fat-suppressed proton
density weighted MR image shows abnormal morphology and signal intensity (arrow) of the posterior attachment of the
annular ligament, consistent with a high-grade partial tear.

A second consideration with respect to elbow pathology commonly encountered in the elbow
dislocation is that as the ring of soft tissues will be addressed.
is disrupted from posterolateral to medial, the The classification of tendon injuries about the
capsule is torn and insufficient. In the absence of elbow can be organized by location, acuity, and
an intact capsule, joint fluid dissects through the degree of injury. Tendon injury related to a single
soft tissue planes of the forearm, negating an isolated event is uncommon, although exceptions
indirect radiographic sign of trauma in the elbow, to this rule do occur. More commonly, tendinous
that of the joint effusion. injuries in this location relate to chronic repetitive
microtrauma. MR imaging, with its excellent soft
tissue contrast, is particularly well suited to
Tendon anatomy and pathology
diagnose tendon pathology. This is done primarily
The many muscles about the elbow can be by close inspection of signal intensity and mor-
divided into four groups: posterior, anterior, phology of the tendons. As elsewhere in the body,
medial, and lateral. The muscles of the posterior the tendons about the elbow should be smooth,
group are the triceps and anconeus. The muscles linear structures of low signal intensity. Abnormal
of the anterior group are the biceps brachii and morphology (attenuation or thickening) can
brachialis. The muscles in the medial group are be seen in tendinosis or tear. If signal intensity
the pronator teres, the palmaris longus, and the becomes bright or increased on fluid sensitive
flexors of the hand and wrist. The muscles in the sequences within the substance of a tendon, a tear
lateral group include the supinator, brachioradia- is present. Tears can be further characterized as
lis, and extensor muscles of the hand and wrist. partial or complete. A complete tear is diagnosed
Specific anatomic considerations and tendon by a focal area of discontinuity.
248 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253

Fig. 13. Inversion recovery coronal MR image of the

elbow in a 52-year-old man shows abnormal high signal Fig. 14. Sagittal fat-suppressed proton density weighted
intensity (arrows) in the expected position of the lateral MR image demonstrates several findings of acute dis-
ulnar collateral ligament, with no visualization of a location: (1) anterior subluxation of the humerus, (2)
normal ligament. coronoid process fracture (arrow), (3) irregularity of the
articular surface of the olecranon (curved arrow), and (4)
disruption of the anterior and posterior capsule (double
Common flexor tendon and medial muscles arrow). The corresponding coronal image (not shown
here) further demonstrated complete disruption of the
The muscular anatomy about the medial elbow radial and ulnar collateral ligament complexes.
is complex and includes three separate layers. The
most superficial layer includes the pronator teres, the extensor carpi radialis longus does not take
flexor carpi radialis, palmaris longus, and flexor a part of its origin from the common extensor
carpi ulnaris. The middle layer is comprised of the tendon. As with the medial muscles, the vast
flexor digitorum superficialis, and the deep layer is majority of pathology encountered in this region
made up of the flexor digitorum profundus. Only is associated with the common extensor tendon
the flexor digitorum profundus does not take rather than specific muscles.
a part of its origin from the common flexor
tendon. In rare cases, it may be necessary to lo- Epicondylitis and overuse syndromes
calize pathology to a specific muscle group;
however, the majority of pathology will occur in Chronic stress applied to the elbow is the most
the common flexor tendon near its distal humeral frequent injury in athletes, and a spectrum of
attachment. pathology can exist with varying degrees of
severity. The frequency of involvement of the com-
mon flexor and extensor tendons to the medial and
Common extensor tendon and lateral muscles
lateral epicondyles, respectively, has led to the
The lateral extensor muscles include the designation of ‘‘epicondylitis’’ as a general term
extensor carpi radialis longus, extensor carpi applied to these overuse syndromes. Anatomically,
radialis brevis, extensor digitorum, extensor digiti these overuse syndromes are classified by location
minimi, and extensor carpi ulnaris muscles. Only and are further associated with sports that incite
 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253 249

the pathology. The injury is believed to result from includes repetitive valgus strain with pain result-
extrinsic tensile overload of the tendon, which, over ing from resisting pronation of the forearm
time, produces microscopic tears that do not heal or flexion of the wrist [18]. The imaging findings
appropriately. encountered can include tendinosis or tendi-
Although these overuse entities about the nosis with superimposed partial or full thickness
elbow have been termed ‘‘epicondylitis’’ for the tear (Fig. 15). When assessing the tendon, it
purpose of clinical diagnosis, inflammatory osse- is necessary to closely scrutinize the underly-
ous changes rarely occur. The imaging findings ing ulnar collateral ligament complex to ensure
are those reflecting chronic change in the tendon integrity.
as evidenced by tendinosis alone or in conjunction Lateral epicondylitis is the most common prob-
with partial or complete tear. The distinction be- lem in the elbow in athletes and has been termed
tween types of pathology is made by consideration ‘‘tennis elbow.’’ This term may be somewhat in-
of morphology and signal intensity changes. appropriate as 95% of cases of the clinical entity of
Medial epicondylitis involves pathology of the lateral epicondylitis occur in non–tennis players
common flexor tendon and is associated primarily [18]. Moreover, it has been estimated that 50% of
with the sport of golfing. It also has been reported people partaking in any sport with overhead arm
with javelin throwers, racquetball and squash motion will develop this process [19].
players, swimmers, and bowlers. The pronator Lateral epicondylitis is associated with repeti-
teres and flexor carpi radialis tendons are involved tive and excessive use of the wrist extensors. The
most frequently resulting in pain and tenderness pathology most commonly affects the extensor
to palpation over the anterior aspect of the medial carpi radialis brevis at the common extensor ten-
epicondyle of the humerus and origin of the don (Fig. 16). A number of investigators have
common flexor tendon. The mechanism of injury described the pathology encountered in the

Fig. 15. (A) Frontal view of the elbow shows subtle irregularity (arrow) of the medial aspect of the distal humerus. (B)
Coronal fat-suppressed T2-weighted fast spin echo image shows a focal full-thickness tear (arrow) of the attachment of
the common flexor tendon to the medial epicondyle.
250 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253

Biceps tendon
The biceps brachii muscle consists of two
heads, the short head and long head. The short
head arises from the tip of the coracoid process, in
common with the coracobrachialis. The long head
arises from the supraglenoid tubercle of the
scapula. The two muscles join to form a common
tendon 6 to 7 cm above the elbow joint line. This
common tendon traverses the antecubital fossa to
dive to its attachment at the radial tuberosity. An
aponeurosis, the bicipital aponeurosis or lacertus
fibrosus, arises from the musculotendinous junc-
tion, passes across the brachial artery, and merges
with the fascia that covers the pronator teres and
superficial flexors of the forearm. The distal biceps
tendon does not have a tendon sheath, rather there
is a bursa (cubital bursa) intimately associated
with its attachment to the radial tuberosity [24].

Distal biceps tendon rupture

Rupture of the tendon of the biceps brachii
muscle at the elbow is rare, and constitutes less than
5% of all biceps tendon injuries [25]. It usually
occurs in the dominant arm of males. Injuries to the
Fig. 16. Coronal fat-suppressed T2-weighted fast spin musculotendinous junction have been reported,
echo image of the elbow in a 50-year-old tennis player but the most common injury is complete avulsion of
demonstrates abnormal morphology of the common the tendon from the radial tuberosity. Although the
extensor tendon with superimposed intrasubstance high injury often occurs acutely after a single traumatic
signal intensity (arrow) consistent with a partial tear of event, the failure is thought to be the result of
the tendon. These imaging findings support the clinical preexisting changes in the distal biceps tendon
diagnosis of tennis elbow. caused by intrinsic tendon degeneration, enthesop-
athy at the radial tuberosity, or cubital bursal
degenerated tendon of this disease process. Histo- changes. The typical mechanism of injury relates to
logically, necrosis, round cell infiltration, focal forceful hyperextension applied to a flexed and
calcification, and scar formation have been shown supinated forearm. Athletes involved in strength
[20]. In addition, invasion of blood vessels, sports, such as competitive weightlifting, football,
fibroblastic proliferation, and lymphatic infiltra- and rugby, often sustain this injury.
tion, the combination of which are referred to Clinically the patient gives a history of feeling
as angiofibroblastic hyperplasia, occur and ulti- a ‘‘pop’’ or sudden sharp pain in the antecubital
mately lead to mucoid degeneration as the pro- fossa. The classic presentation of a complete distal
cess continues [21,22]. The absence of a significant biceps rupture is that of a mass in the antecubital
inflammatory response has been emphasized re- fossa caused by proximal migration of the biceps
peatedly and may explain the inadequacy of the muscle belly. Accurate diagnosis is more difficult
healing process. in cases of the rare partial tear of the tendon,
The imaging findings in this process are exactly or more common complete tear of the tendon
those encountered in the clinical entity of medial without retraction. The latter case can occur with
epicondylitis. As on the medial side, when pa- an intact bicipital aponeurosis, which serves to
thology is encountered in the tendon, close tether the ruptured tendon to the pronator flexor
scrutiny of the underlying ligamentous complex muscle group (Fig. 17).
is necessary to exclude concomitant injury. In MR imaging diagnosis of biceps tendon pathol-
particular, thickening and tears of the lateral ogy becomes important in patients who do not
ulnar collateral ligament have been encountered present with the classic history or mass in the
with lateral epicondylitis [23]. antecubital fossa, or for evaluation of the integrity
 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253 251

Fig. 17. (A) Axial T1-weighted MR image shows abnormal morphology of the distal biceps tendon (arrow). The
thickened lacertus fibrosus is intact (curved arrow). (B) Oblique coronal fat-suppressed T2-weighted MR image
demonstrates a small stump of residual tendon (arrow) coursing toward the radial tuberosity. The high signal intensity
around the tendon remnant is fluid within the cubital bursa.

of the lacertus fibrosus. MR imaging diagnosis of tendon from the infraglenoid tubercle of the
tendon pathology, as previously mentioned, is scapula near the inferior margin of the glenoid
largely dependent on morphology, signal intensity, cavity. It descends into the arm between the teres
and the identification of areas of tendon dis- major and teres minor muscles. The lateral head
continuity. In the case of the biceps tendon, an originates from the posterior and lateral surfaces
important indirect sign of tendon pathology is the of the humerus and from the lateral intermuscular
presence of cubital bursitis (Fig. 17). septum. The medial head arises from the posterior
With delayed diagnosis, chronic pain can surface of the humerus, medial and below the
ensue, as well as weakness in flexion, supination, radial groove, and from the medial and lower part
and with grip strength. Treatment options fa- of the lateral intermuscular septum. The tendon of
vor surgical reattachment because nonoperatively the triceps descends to attach to the upper surface
treated ruptures have been reported to result in of the olecranon process of the ulna and to the
loss of 20% of elbow flexion strength and 40% of antebrachial fascia near the laterally located
supination strength. If operative treatment is anconeus muscle and tendon.
chosen, early repair is desirable, particularly when Rupture of the triceps tendon is rare. The
the lacertus fibrosus is ruptured and there is mechanism of injury has been reported to result
muscle retraction. If the lacertus fibrosus is intact, from a direct blow to the triceps insertion or
delayed primary repair is feasible [25]. a deceleration force applied to the extended arm
with contraction of the triceps as in a fall. Similar
Triceps tendon
to pathology encountered in the distal biceps
The triceps consists of three muscle bellies: the tendon, most ruptures occur at the insertion site,
long head, the lateral head, and the medial head. although musculotendinous junction and muscle
The long head of the triceps arises by a strong belly injuries have been reported. Complete
252 C.B. Chung, H.-J. Kim / Magn Reson Imaging Clin N Am 11 (2003) 239–253

ruptures are more common than partial tears. [6] Steinbach LS, Palmer WE, Schweitzer ME. Special
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 Magn Reson Imaging Clin N Am
11 (2003) 255–281

MR imaging of sports-related hip disorders

Robert D. Boutin, MDa,*, Joel S. Newman, MDb
a
Med-Tel International, 3713 Lillard Drive, Davis, CA 95616, USA
b
Department of Radiology, New England Baptist Bone and Joint Institute,
New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120, USA

Physical activity is associated with better mon hip injuries in athletes are reviewed, in-
physical and mental health [1,2]. Indeed, physical cluding labral tears, ligament injuries, osteo-
activity reduces the risk of dying prematurely in chondral injuries, fractures, bursitis, and selected
general, and of coronary heart disease, hyperten- musculotendinous injuries.
sion, colon cancer, diabetes mellitus, and, in
particular, feelings of depression and anxiety in
Hip arthroscopy
particular [2]. The potential national medical cost
savings if all inactive American adults became Hip arthroscopy is an increasingly used alter-
physically active has been estimated at $76.6 native to arthrotomy for the treatment of internal
billion annually [3]. Consequently, it comes as derangements in athletes [7,8]. For example, in
no surprise that major public health campaigns a recent study of 42 athletes undergoing arthros-
have been aimed at promoting better health copy (with an average follow-up of over 2 years),
through physical activity and sport [4]. For there was a general postoperative improvement in
example, the United States Surgeon General calls hip pain and function, most prominently for
for incorporating at least 30 minutes of physical athletes with ligamentum teres tears, loose bodies,
activity into most, if not all, days of the week [2]. and avulsed bone fragments [7]. Labral tears
The benefits of exercise, however, come with the and chondral lesions also were addressed arthros-
potential for orthopedic injury, including injuries copically.
in and about the hip.
Injuries to the hip and pelvis generally account Indications and contraindications
for 5% to 6% of athletic injuries in adults and
10% to 24% of such injuries in children [5]. Some Proper patient selection is a fundamental
athletes are particularly prone to such injuries, dictum for ensuring successful outcomes after
including soccer players (13%), runners (11%), arthroscopic surgery [9]. Although there is debate
and ballet dancers [5]. Among disabled and blind over the indications and contraindications for
athletes, the prevalence of hip and thigh injuries is routine therapeutic arthroscopy [9–11], potential
reportedly as high as 14% to 21% [6]. indications in athletes include labral tears, liga-
This article focuses primarily on MR imaging mentum teres tears, joint instability, focal chon-
as the radiological test of choice for evaluating dral injuries, loose bodies, septic arthritis, and
sports-related hip injuries. From our perspective, synovial disease [9]. Potential contraindications
MR imaging is the most versatile and robust identified with imaging may include advanced
imaging method for examining injured athletes osteonecrosis, advanced arthritis, ankylosis, and
after radiography. After briefly discussing hip ipsilateral lower extremity fracture or osseous
arthroscopy and MR techniques, the most com- neoplasm. It is our belief that hip arthroscopy and
MR imaging often are complementary techniques,
each compelling the other to a more accurate
understanding of hip disorders that previously
* Corresponding author. went unrecognized and untreated.
1064-9689/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1064-9689(03)00029-1
256 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

Technique and complications guided injection of diluted gadolinium. (With MR

arthrography, the peak contrast-to-noise ratio
Arthroscopy is performed commonly with
and joint distention occurs at 30 minutes in the
three portals (anterior, anterolateral, and postero-
hip; the contrast-to-noise ratio decreases by more
lateral) that are established with the aid of
than 50% by 2 hours [16].) T1-weighted spin-echo
fluoroscopy [9,12]. Between 25 and 75 lbs of
or three-dimensional gradient-echo images (with
traction typically are applied to distract the hip
or without fat suppression) then are performed in
joint approximately 1 cm to permit the introduc-
the coronal, sagittal, and axial planes that may be
tion of arthroscopic instrumentation [9,13,14].
obliqued. (The oblique-sagittal plane is prescribed
Iatrogenic complications are infrequent (prev-
perpendicular to a line drawn between the
alence: 1.3% [13] to 5% [15]) but not insignificant
superior labrum and the transverse ligament
[9]. Most complications result from hip traction
[generally parallel to the femoral neck] on a mid-
(eg, transient sciatic, pudendal, or peroneal nerve
coronal localizer hip image.) Finally, coronal fast
neuropraxis) and fluid extravasation [15]. Un-
spin-echo (FSE) T2 and axial fat-suppressed
commonly, iatrogenic injury to the labrum,
proton density images help to evaluate for extra-
articular cartilage, or periarticular neurovascular
articular abnormalities that are inconspicuous on
structures may occur from insufficient traction or
T1-weighted spin-echo and gradient-echo images,
unintended portal placement.
such as soft tissue edema or bone marrow
pathology. (If saline is used as the intra-articular
MR imaging—technical considerations contrast agent [eg, because the injection is not
image guided], the MR imaging protocol usually
Hip MR imaging protocols vary from institu- includes fat-suppressed proton density or T2-
tion to institution, depending on the patient popu- weighted images in three planes.)
lation, the physicians’ experiences with various An additional benefit of the arthrography
pulse sequences, and the MR imaging equipment. procedure is that local anesthetic (eg, 1–5 mL of
Two different types of MR imaging protocols often lidocaine or bupivacaine) or cortocosteroid (eg,
are employed in athletes, depending on whether 1 mL [80] mg of depomedrol) may be injected
the primary clinical concern relates to (1) an in- concurrently with the contrast material under fluo-
ternal derangement (eg, labral tear, ligamentum roscopic control [17]. A positive response to the
teres tear, osteochondral injury, loose body) or (2) presence of intra-articular anesthetic confirms
nonspecific pain or an extra-articular abnormal- that the patient’s ‘‘pain generator’’ is in the hip
ity (eg, osseous injury, bursitis, musculotendinous (eg, labral tear). Conversely, if no pain relief is
injury). achieved, the examiner must consider that the hip
pain may be referred from another site (eg, the
Internal derangement protocol
lumbar spine). Local anesthetic can be injected
Detailed assessment for internal derange- before introducing contrast material into the joint
ments in the adult hip requires unilateral imaging or, alternatively, a mixture of contrast material and
(with a commensurate field of view), analogous to anesthetic from the same syringe can be injected
that used routinely for MR imaging of other together. (Such an injectate may be prepared by
appendicular articulations. Relatively high spatial mixing gadolinium contrast material (0.8 mL) and
resolution can be achieved by imaging the symp- normal saline (100 mL), and then combining 10
tomatic hip using a surface coil (eg, flexible shoul- mL of this mixture with 5 mL of 60% iodinated
der phased array coil), a 14 to 18 cm field of view, contrast material and 5 mL of 1% lidocaine [18].)
and a 3 to 4 mm section thickness. Image quality MR arthrography is a widely used, well-
is optimized further by the presence of joint fluid tolerated, safe procedure [19–21]. In a report of
from an effusion or arthrography, since fluid 13,300 such procedures [19], there were no severe
under pressure tends to outline pathologic areas reactions to intra-articular gadolinium injections,
(eg, labral tears, chondral defects, loose bodies). and the rate of minor reactions was significantly
To perform MR arthrography, a 20-gauge lower than that associated with intravenous gado-
spinal needle is commonly used to inject 8 to 12 linium injection. Still, MR arthrography is min-
mL of fluid intra-articularly (eg, sterile saline or imally invasive, and gadolinium contrast agents
diluted gadolinium [0.1 mL in 15–25 mL of sterile have not been approved for intra-articular use by
saline solution]). In our practices, MR imaging is the United States Food and Drug Administration.
commenced within 30 minutes of fluoroscopically An alternative to MR arthrography for evaluating
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 257

internal derangements uses intravenous gadolin- rior labral lesions typically occur as a result of
ium administration or leg traction during MR axial loading of the hip in a flexed position
imaging [22–24]. Traction is believed to be useful [8,17]. Athletes also may sustain tears in the set-
because distraction of the relatively tight hip joint ting of femoroacetabular impingement (see later
allows synovial fluid to outline abnormalities in discussion).
the labrum and articular cartilage. Recent reports Patients with labral tears typically complain of
also have described the prescription of ‘‘radial’’ hip or groin pain, often associated with painful
images (centered at the mid-point of the acetab- clicking, transient locking, or ‘‘giving way’’ of the
ulum) that diminish volume-averaging artifacts by hip [36,37]. Although the onset of symptoms may
displaying the acetabular rim in tangent [25–29]. be acute (eg, after a modest twisting injury), clin-
ical manifestations often are insidious and may in-
Extra-articular derangement protocol tensify over time [8].
When the primary clinical concern is an extra- On physical examination, several signs are
articular abnormality or if the patient complains considered typical of a torn acetabular labrum
of nonspecific hip pain, a relatively large field of [36,38,39], including pain elicited by the anterior
view is appropriate for at least part of the exam. impingement position (ie, flexion, adduction, and
An example of a screening hip MR examination internal rotation) or the posterior impingement
begins with coronal T1 and coronal FSE inversion position (ie, hyperextension, abduction, and ex-
recovery images of the pelvis that include both ternal rotation) [37,40,41]. However, in a recent
hips. Then sagittal T1, axial FSE T2, and coronal study of 60 arthroscopically-proven labral tears
fat-suppressed proton density–weighted images of [42], the maximum flexion-internal rotation ma-
the affected hip are obtained using a 16- to 22-cm neuver was positive in only 39% of patients. In
field of view. Other protocols also are commonly particular, this maneuver predicted incomplete
used [30]. (but not complete) detaching tears in the postero-
superior labrum in this report.
Labrum and labral tears
Association with hip osteoarthritis and dysplasia
Anatomy and function Labral derangements are associated with ar-
ticular cartilage lesions and may be a cause of
The acetabular labrum is a rim of fibrocarti- osteoarthritis [43–46]. The hypothesis that labral
lage that deepens the acetabular fossa for the tears contribute to early hip joint degeneration is
femoral head, thus promoting hip joint congru- supported by the observation that lesions of the
ency and stability [31]. Recent studies also suggest labrum and articular cartilage often are contigu-
that the labrum helps seal a layer of pressurized ous. In a study of 170 hips with mild or moderate
synovial fluid between the articulating surfaces of dysplasia evaluated arthroscopically [44], 113
the femur and acetabulum during weight-bearing, patients with anterior labral tears commonly had
thus distributing loads, decreasing contact pres- adjacent articular cartilage lesions in the anterior
sures, and protecting articular cartilage [31,32]. It acetabulum (69%) and anterior femoral head
is noteworthy that the labrum is innervated by (39%). In another study of 436 hip arthroscopies
nerves that play a role in proprioception and pain [45], 73% of patients with fraying or a tear in the
production [33,34]. Unfortunately, blood vessels labrum also had articular cartilage degenerative
reportedly only penetrate the labrum to a depth of changes. Labral tears may predispose the hip to
0.5 mm, leaving most of the labrum avascular and adjacent chondral lesions, because weight-bearing
limiting the potential for an injured labrum to loads are no longer distributed appropriately and
heal [8,35]. subsequent (repetitive or episodic) impaction
forces tend to overload adjacent articular carti-
Clinical features
lage.
The cause of a labral tear may be trauma- Individuals with even mild degrees of hip
tic, degenerative, dysplastic, or idiopathic. In ath- dysplasia are at increased risk for labral tears,
letes sustaining a labral tear, the mechanism of because decentering of the femoral head generates
injury may include hyperrotation, hyperextension, high loads at the acetabular rim. Certain types of
hyperflexion, or hyperabduction [8]. For example, athletic activities, such as gymnastics and dance,
anterior labral tears may occur with a hyperex- may self-select for athletes with greater arcs of hip
tension-external rotation injury, whereas poste- motion [8]. Although diminished femoral head
258 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

Fig. 1. A 59-year-old female with left hip pain and Fig. 2. A 30-year-old athletic female with superior labral
anterior labral tear. Sagittal fat-suppressed T1-weighted tear. Coronal fat-suppressed T1-weighted MR arthro-
MR arthrogram demonstrates gadolinium extending gram shows gadolinium extending into a defect at the
across the base of the labrum (arrow), indicating a tear. undersurface of the superior labrum (arrow), adjacent to
the labrum-articular cartilage junction.

containment due to mild hip dysplasia theoreti- when they appear enlarged, have indistinct mar-
cally might enhance performance of certain activ- gins, or demonstrate substantial intrasubstance
ities, increased forces on the labrum can result in intermediate signal intensity.
biomechanical overload and injury.
MR imaging
Tear classification
Diagnostic criteria Labral tears may be categorized according to
The clearly normal labrum is a triangular location and morphology. With respect to loca-
structure of homogeneous low signal intensity on tion, a tear may be in one or more of the quad-
all pulse sequences. The principal criterion for rants of the horseshoe-shaped labrum – anterior,
a labral tear is linear hyperintense signal contact- anterosuperior, posterosuperior, and posterior
ing the labral surface (on the articular side [45]), [49]. Most tears occur in the anterior or ante-
either at the labral-acetabular junction or the rosuperior portion of the labrum [36,37,50–53].
labrum itself (Figs. 1–3) [37]. Blunting or absence Sports-related tears typically target the antero-
of the labrum also can suggest a tear, but these superior quadrant [54]. In hips with mild to
two criteria may be insufficient for definitively moderate dysplasia undergoing arthroscopy,
differentiating a labral lesion from normal varia- labral tears can be found at the articular surface
tion, particularly in the anterosuperior quadrant free margin in 72% (specifically affecting the
[47,48]. Labra are considered to be degenerated anterior labrum in 66%) [45].

Fig. 3. A 37-year-old female marathon runner with hip pain and anterior labral tear. Oblique-sagittal (A) and sagittal
(B) fat-suppressed T1-weighted MR arthrogram images show a complex tear of the anterior labrum (arrow). There is
a transverse component cleaving the base of the labrum and a longitudinal tear within the substance of the labrum.
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 259

Regarding morphology, two basic types of In the adjacent soft tissue, paralabral cysts are
labral lesions are recognized: (1) a ‘‘tear’’ or not uncommon and are considered highly specific
cleavage plane in the substance of the fibrocarti- secondary signs of labral tears (Fig. 4) [58]. In one
lage, and (2) a ‘‘detachment’’ or avulsion of the recent study of 87 hips using conventional MR
fibrocartilaginous labrum from its attachment imaging [58], paralabral cysts were present in 13
to the adjacent articular cartilage [46]. Labral patients (15%). All 10 patients who went on to
detachments (sometimes referred to as ‘‘detaching surgery had a labral tear adjacent to the
tears’’ [42]) are more common than tears isolated paralabral cyst, but the labral tear itself could be
to the labral substance [37,47]. Some investigators seen only on three nonarthrographic MR exams.
differentiate between labral tears that are ‘‘par- At pathologic inspection, a paralabral cyst may be
tial’’ and ‘‘full-thickness’’ and suggest that these either a ganglion cyst (defined by a connective-
two types of tears have distinctive symptoms and tissue lining, thick mucinous fluid contents, and
treatment outcomes [55]. Four types of tear rarely a patent communication with the joint) or
morphology have been described at arthroscopy a synovial cyst (defined by a synovial cell lining,
[49,56]: radial flap (57%); radial fibrillated (22%); fluid contents, and often a patent communication
longitudinal peripheral (16%); and unstable (5%). with the joint).
An anterior paralabral cyst should not be
Secondary findings mistaken for fluid in the adjacent iliopsoas bursa
Labral lesions may be associated with several (which may arise through the hiatus between the
abnormalities in the adjacent bone and soft tissue pubofemoral and iliofemoral ligaments). A pos-
[57,58]. In the adjacent bone, common associated terior paralabral cyst rarely may impinge upon the
findings are subchondral bone marrow edema, sciatic nerve, thus causing sciatica [59]. Effective
subchondral cystic changes, and osseous fragmen- treatment of a paralabral cyst usually involves
tation, especially at the superior acetabulum. therapy for the underlying joint derangement,

Fig. 4. A 30-year-old female with painful right hip, extensive labral tearing, and large paralabral cyst demonstrated by
MR arthrography. Axial proton-density fat-suppressed (A) and coronal FSE T2-weighted (B) images show a high signal
intensity mass along the lateral articular margin (arrows). Oblique-sagittal fat-suppressed T1-weighted image (C) shows
degeneration and a tear of the anterior labrum (arrow). Coronal T1-weighted fat-suppressed image (D) shows the
superior labrum (arrow) completely replaced by abnormal signal, indicating the presence of severe degeneration and
a tear.
260 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

because these cysts commonly recur if the only Treatment and prognosis
treatment is cyst aspiration.
The rationales for excision of the torn labrum
are to alleviate pain and mechanical symptoms,
Imaging accuracy
prevent propagation of tearing to the adjacent
MR arthrography generally is considered more
labrum, and—some surgeons believe—slow any
accurate than conventional MR imaging for the
subsequent degenerative process [67]. After
diagnosis of labral tears. In one recent study
arthroscopic partial labrectomy in hips without
comparing the two techniques for the diagnosis of
arthritis, results are good to excellent in approx-
labral lesions [60], sensitivity and accuracy were
imately 70% of patients after a mean follow-up of
80% and 65% for conventional MR imaging, re-
3 years [70,71]. However, in hips with arthritis,
spectively, versus 95% and 88% for MR arthrog-
only 21% of patients have good to excellent
raphy. Reported results for both MR techniques
results [71].
vary considerably (with sensitivity reported as
high as 95% for conventional MR imaging [61]
and sensitivity/specificity reported as low as 49%/ Ligaments and ligament injuries
28% for MR arthrography [62]). The size of
a labral lesion affects the likelihood it will be Although the contribution of ligaments to the
detected, and small detachments are diagnosed stability of other joints has been studied sedu-
less reliably than large detachments [63]. lously, relatively little attention has been paid to
imaging of the ligaments that support the adult
Anatomic variations hip. Recently, the imaging of intrinsic and
Diagnostic accuracy may be limited by various extrinsic hip ligaments in adults has been studied
factors, including the variability in labral signal [72] and is summarized in this section.
intensity, shape, and size in asymptomatic persons
[48,64,65]. Intermediate signal intensity in the Ligamentum teres
labrum may result from magic angle artifact (on Anatomy and function
short echo-time images) or early myxoid degen- The two intrinsic ligaments of the hip are the
eration. Alterations in both labral signal and ligamentum teres and the transverse acetabular
shape have been correlated with age in asymptom- ligament. The ligamentum teres (also referred to
atic volunteers [66]. as the ligament of the femoral head) passes from
It is not uncommon for the shape of the labrum the acetabular notch to the fovea of the femoral
to be altered by a cleft, or sulcus [9,17,47,50,52,67]. head. Although the ligamentum teres generally is
The sublabral sulcus in the hip characteristically not thought to contribute to hip joint stability in
occurs at the junction of the articular cartilage with adults [73,74], it does carry the artery of the liga-
the superior or anterosuperior labrum. This mentum teres that supplies blood to the femoral
normal variant may be recognized by its location, head in children. The ligamentum teres also
smooth edges, and the absence of adjacent de- contains free nerve endings that are thought to
generative or traumatic changes. transmit signals to the spine and brain, enabling
The size of the labrum also can vary. Al- normal reflexive muscle actions that help protect
though some authorities have found that the the hip joint from excessive motion [75].
labrum is thinner anteriorly and thickest poste-
riorly [8,47], others have concluded that the Clinical
labrum is wider anteriorly and superiorly than it The presence of free nerve endings could
is posteriorly (average width, 5.3 mm; standard explain both altered proprioception and hip pain
deviation, 2.6 mm) [68]. An elongated appear- in patients with ligamentum teres derangements.
ance has been described in degenerated and Recent investigations [7,76,77] have emphasized
nondegenerated labra of adult dysplastic hips that derangements in the ligamentum teres can
anteriorly and superiorly [69]. Absence of the cause pain (that may be referred to the thigh) and
labrum should be considered abnormal, other mechanical symptoms (eg, clicking, catching). In
than in the anterosuperior quadrant [47]. Given particular, a ligamentum teres injury with hemor-
the many variations in the acetabular labrum, rhage can be confused clinically with a labral tear
MR findings are appropriately correlated with [53]. However, only approximately 5% of hips
clinical presentation and the response to intra- with ligamentum teres tears are diagnosed clinic-
articular anesthetic injection. ally (preoperatively).
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 261

MR imaging blend with the extrinsic ligaments superficially and

With MR imaging and MR arthrography, the do not attach directly to bone.
spectrum of ligamentum teres derangements is not
well publicized [78]. It has been suggested that the Clinical
ligament is best visualized on axial MR images, Patients with hip instability may present with
while coronal images mistakenly may suggest substantial hip pain, mechanical symptoms, and
ligament discontinuity and sagittal images are an antalgic gait. Hip instability is well recognized
the least helpful [78]. Thin-section, three-dimen- in patients with generalized ligamentous laxity
sional gradient-echo images along the course of (eg, Ehler-Danlos syndrome), with hip dysplasia,
the ligamentum teres also may be helpful in as- and after major trauma (eg, hip dislocation,
sessing fiber continuity [72]. subluxation). More recently, hip instability also
has been recognized in high-level athletes who
Arthroscopy subject their hips to episodes of trauma or
With hip arthroscopy, ligamentum teres de- repetitive microtrauma [90]. Ligamentous insuffi-
rangements are classified generally into three ciency possibly may predispose patients to sub-
groups: (1) complete ligament tear; (2) partial sequent hip dislocation and may result in
ligament tear; and (3) ligament degeneration [77]. subclinical joint instability that hastens the onset
The ligamentum teres also may become avulsed at of osteoarthritis. Hip instability reportedly may
either the acetabular or femoral attachments be treated effectively with promising surgical
[76,79–81], become ossified [82], or act as a pref- techniques, such as arthroscopic thermal capsu-
erential route for transarticular spread of tumor lorrhaphy [90]. However, accurate preoperative
[83,84]. Ligamentum teres derangements are diag- diagnosis of ligament insufficiency patterns re-
nosed in approximately 8% [76] to 25% [7] of hips mains challenging clinically.
examined arthroscopically, and the postoperative MR imaging
outcome for isolated derangements is regarded as With MR imaging, injuries to the extrinsic
good or excellent [7,76]. ligaments may be diagnosed using the criteria
commonly used for ligaments elsewhere in the
Transverse acetabular ligament body. For example, injury to the iliofemoral liga-
The transverse acetabular ligament traverses ment is common (89%) after traumatic disloca-
the acetabular notch at the inferior aspect of the tion of the femoral head and is diagnosed readily
acetabulum. The function of this ligament is with MR imaging [91]. After hip dislocation,
debated, particularly with respect to its possible a displaced iliofemoral ligament can play a role
role as a tension band that stabilizes the labrum in inhibiting reduction of the dislocated fem-
and resists the anteroposterior widening of the oral head [92]. The small foci of intra-articular gas
acetabular notch during loading [85,86]. Clinically, commonly seen immediately after a hip dis-
hypertrophy of the transverse acetabular ligament location may be less conspicuous by MR imaging
and the ligamentum teres may interfere with than CT. With an effusion or arthrography, there
concentric reduction of dysplastic hips in pediatric is improved delineation of the ligament under-
patients [87]. On MR images, the cleft formed by surfaces that might be useful in displaying a partial
the confluence of the transverse acetabular liga- undersurface tear or fiber laxity [72].
ment and the labrum should not be mistaken for
a labral tear [88]. Joint effusion, osteochondral injury,
and osteoarthritis
Extrinsic ligaments
Joint effusion
Anatomy and function
The three principal extrinsic ligaments are A joint effusion is considered an early—albeit
external to the hip joint capsule and pass from nonspecific—sign of an internal derangement.
the pelvis to the femur. These ligaments—the ilio- MR imaging is more sensitive than other imaging
femoral, pubofemoral, and ischiofemoral liga- techniques—including ultrasound—in detecting
ments—are named according to the bones to small joint effusions in adults [93]. In a study
which they are attached [85,89]. The circular fibers of hip joint fluid [94], the average fluid volume
of the zona orbicularis, seen as a collar surround- in asymptomatic hips was 2.7 mL (range, 0.7–
ing the femoral neck with arthrography, partially 5.6 mL) versus 6.1 mL (range, 1.7–11.6 mL) in
262 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

symptomatic hips [94]. These investigators also femoral head and are characterized by chondral
found that, when at least 5 to 10 mL of intra- irregularity and subchondral bone marrow edema
articular fluid is present, the joint capsule is dis- signal [95]. More extensive osteochondral injuries
tended by at least 5 mm along the length of the also can occur in athletes and may be accompa-
femoral neck. They concluded that this finding nied by joint effusion, joint capsule injury, ace-
can be used to define a hip joint effusion with MR tabular rim fracture, or loose bodies (Fig. 5).
imaging [94].
Osteoarthritis
Osteochondral injury
Clinical
Just as in other joints, osteochondral injuries Osteoarthritis is a well-known source of pain
may occur in the hip. Such osteochondral lesions and disability. The prevalence of hip osteoarthritis
characteristically are seen in young adults who are is approximately 3% to 6% in white populations
avid athletes and present with groin pain [95]. [97]. Interestingly, hip osteoarthritis is much less
Osteochondral injuries may be caused by a spec- prevalent in Asian and black populations in their
trum of injury, ranging from overt hip dislocation native countries [97]. For example, hip osteoar-
[91,96] to subclinical shearing or impaction injury thritis in China is 80% to 90% less frequent than
[95]. Although osteochondral lesions are thought in white persons in the United States, presumably
to be due to trauma, these patients may not recall due to genetic or environmental factors [98].
a distinct traumatic event. The relationship between exercise and sub-
On MR images of the hip, osteochondral sequent osteoarthritis has been the subject of long-
lesions in athletes often target the superomedial standing debate. Although the debate continues,

Fig. 5. A 21-year-old National Collegiate Athletic Association Division I football linebacker, injured during a tackle,
with consequent osseous and chondral injury. Axial fat-suppressed T2-weighted (A) and coronal FSE inversion recovery
(B) images of the pelvis show posterosuperior acetabular rim fracture (arrows) with marked surrounding edema and
hemorrhage in the soft tissues accompanying a capsular injury. Sagittal FSE T2-weighted image (C) shows a chondral
defect (arrows) in the superior femoral head. The patient experienced continued pain following the injury and a MR
arthrogram was performed. Axial FSE fat-suppressed proton density (D) and coronal T1-weighted (E) images show two
discrete intracapsular chondral fragments (arrows) near the fovea. This case illustrates the value of MR arthrography in
the detection of loose bodies.
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 263

recent studies offer some compelling insights [97]. Because reduced femoroacetabular offset can
Several studies [99–107] have concluded that one or only cause anterior impingement with flexion (es-
more of the following factors contribute to hip pecially with internal rotation), some authorities
osteoarthritis: obesity; joint injury; occupational suggest that a patient’s level of activity can play
activities involving heavy lifting; and prolonged, a role in this process becoming clinically signif-
intense activity in certain sports. While moderate icant [40,112]. Early treatment may potentially
activity has not been shown convincingly to be alleviate impingement microtrauma and preserve
a cause of osteoarthritis, certain activities may the hip joint. Indeed, for young to middle-aged
exacerbate the disease once degenerative changes adults with anterior femoroacetabular impinge-
are present. A specific biomechanical cause of hip ment and mild to moderate cartilage lesions,
pain, labral tears, and osteoarthritis propounded surgeons may debulk the anterior femoral head–
in athletes is femoroacetabular impingement. neck region and perform a periacetabular osteot-
omy [112] or perform cartilage debridement [111].
Femoroacetabular impingement
Femoroacetabular impingement occurs with Imaging
hip flexion, adduction, and internal rotation (the With radiography, the presence of osteoarthri-
‘‘anterior impingement position’’) in individuals tis is inferred by several ‘‘secondary’’ signs, in-
who have subtle predisposing anatomic features cluding the presence of joint space narrowing,
[40,108–112]. These anatomic features result in subchondral eburnation, subchondral cyst forma-
decreased clearance between the anterior acetab- tion, and osteophytosis [113]. These secondary
ular rim and the anterior femur at the head–neck signs also should be sought when interpreting MR
junction. In the anterior impingement position, examinations of the hip, although MR imaging
these two anatomic sites ‘‘impinge’’ upon each potentially allows direct inspection of articular
other, potentially resulting in injury to the labrum cartilage (Fig. 6).
and adjacent articular cartilage. This impingement Compared with the knee, MR imaging assess-
can be seen intraoperatively and can be demon- ment of articular cartilage in the hip is challenging
strated with open MR imaging of the hip [112]. owing to several factors, including: (1) articular
The proposed anatomic features predisposing hips cartilage in the hip is relatively thin, measuring
to this femoroacetabular impingement include: no more than about 3 mm in thickness [114];
reduced concavity (‘‘shallow tapering’’) at the (2) the thickness of the acetabular and femoral
femoral head-neck junction; reduced femoral head cartilage varies normally, depending on the
head-neck offset; reduced femoral anteversion; location in the joint [114]; (3) miscalculation of
acetabular retroversion; a wide femoral neck; and cartilage thickness may occur owing to use of
acetabular protrusion. A decreased anterior fem- two-dimensional image display for evaluating
oral head–neck offset can be demonstrated by cartilage on curving surfaces [115,116]; and (4)
specific orientation of the MR imaging plane the hip is relatively deeply located, resulting in
coaxial to the femoral neck [112]. a relatively diminished signal to noise ratio.

Fig. 6. A 30-year-old athletic female with right hip pain and premature osteoarthritis demonstrated on MR
arthrography. Sagittal fat-suppressed T1-weighted image (A) demonstrates superior femoral cartilage loss with a small
cortical rent and a large acetabular geode (arrow). Coronal FSE T2-weighted image (B) again shows the large acetabular
geode.
264 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

In a recent study on the detection of cartilage Septic arthritis

lesions in the hip, the sensitivity, specificity, and Septic arthritis is less common in adults than in
accuracy of MR arthrography were 50% to 79%, younger individuals. Risk factors for septic arthri-
77% to 84%, and 69% to 78%, respectively [111]. tis include septicemia, prior injection into the joint,
The accuracy of MR imaging tends to be more and an immunocompromised state. Patients typi-
favorable for high-grade or large cartilage de- cally present with considerable hip pain, often
fects; however, chondral softening, fibrillation, or accompanied by fever. Radiographs may be nor-
partial-thickness defects less than 1 cm in diam- mal or demonstrate soft tissue swelling, periartic-
eter are detected inconsistently by MR imaging. ular osteopenia, osseous erosion, and eventually
Furthermore, small intra-articular osteochondral joint space narrowing. MR imaging findings of
fragments often are not demonstrated well by MR septic arthritis include joint effusion with internal
imaging [117]. debris, marginal erosions, cartilage destruction,
and periarticular contrast enhancement. Prompt
Treatment
diagnostic aspiration of joint fluid in patients with
Treatment of hip osteoarthritis is influenced
suspected septic arthritis, of course, is imperative.
most by the severity of the disease. Management
of mild osteoarthritis typically includes adminis- Idiopathic synovial (osteo)chondromatosis
tration of nonsteroidal anti-inflammatory medi- Idiopathic synovial (osteo)chondromatosis is
cations and activity modification, while profound an uncommon synovial metaplastic disorder that
disease usually is treated with total hip arth- may occur in joints, bursae, or tendon sheaths
roplasty [118,119]. Other treatments that have [122]. It is most likely to be discovered in the third
gained attention for their potential role include to fifth decades of life. Men are affected twice as
glucosamine sulfate, chondroitin sulfate, hyal- often as women [123]. Clinical symptoms include
uronic acid, microfracture, and osteochondral pain, swelling, and locking of the affected joint
allografting. [123]. The hip may be the second most commonly
affected joint, after the knee [124].
Differential diagnosis
Radiographs may be normal, because the
When signs of arthritis are recognized, the chondromata are not mineralized in one third of
differential diagnosis in athletes occasionally cases [123,125]. In the remaining cases, radio-
may include inflammatory arthropathies, septic graphs may show multiple calcified or ossified
arthritis, synovial (osteo)chondromatosis, and nodules within a joint, classically with erosion of
pigmented villonodular synovitis. Inflammatory adjacent bone. The MR imaging appearance of
arthropathies can exhibit a proclivity for synovial- synovial (osteo)chondromatosis reflects nodule
lined joints, tendon sheaths, and bursae about the composition (Fig. 7). Purely cartilaginous nodules
hip [120,121]. are isointense with articular cartilage on all pulse

Fig. 7. A 37-year-old male with a history of synovial chondromatosis and previous synovectomy presented with
recurrent hip pain and limited range of motion. Axial FSE proton density fat-suppressed (A) and coronal FSE T2-
weighted (B) MR arthrogram images show erosions of the margins of the femoral neck (arrows). Note the innumerable
filling defects within the joint capsule indicative of tiny chondral bodies.
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 265

sequences. Calcified nodules are seen as signal are at statistically increased risk for stress injury
void foci on all pulse sequences. Ossified nodules (eg, owing to amenorrhea, disordered eating, low
have a peripheral rim of low signal intensity on all calcium intake [139]).
pulse sequences and a central area of high T1 The initial symptom of an osseous stress injury
signal intensity (corresponding to medullary fat) is activity-related pain that is relieved with rest.
[125–127]. With continued activity, the pain is progressive,
and may become more constant or nocturnal.
Pigmented villonodular synovitis With femoral neck stress fractures in athletes,
Pigmented villonodular synovitis is an idio- physical examination occasionally reveals tender-
pathic proliferative disorder of the synovium [122, ness to palpation, but heel strike and other
128–130]. This uncommon entity (annual inci- percussive tests have poor predictive value [140].
dence: 1.8 cases per million) most often occurs in Stress fractures occur at several locations
young to middle-aged adults, and is more com- about the hip, including the femur, acetabulum,
mon in men. Clinically, patients experience me- and sacrum [141,142]. Of all stress fractures adja-
chanical pain and a limited range of motion [131]. cent to the hip, those located at the femoral neck
Radiographically, pigmented villonodular sy- are the most common and clinically important.
novitis may be detected as lobulated soft-tissue Exercise-induced stress injuries to the femur also
swelling without calcification. MR imaging allows may occur in the femoral head, intertrochanteric
the diagnosis of pigmented villonodular synovitis region, or shaft [143–146]. Acetabular stress
to be suggested because of hemosiderin, joint fractures may occur in the roof or in the anterior
effusion, and hyperplastic synovium, generally column (usually with fracture of the inferior pubic
without prominent joint destruction [132,133]. ramus) [147].
Hemosiderin has a characteristic appearance,
and is displayed as very low signal intensity on MR imaging
both T1- and T2-weighted images [134]. Although Fractures are characteristically hypointense on
hemosiderin typically is present, it is not in- T1-weighted images (owing to trabecular impac-
variably detected by MR imaging [133,135–138]. tion) [148], with surrounding T2 hyperintensity
(from variable amounts of edema and hemor-
rhage) (Fig. 8). The diagnostic value of fast
Osseous injuries spin-echo inversion recovery and fat-suppressed
T2-weighted images is generally superior to
MR imaging facilitates the diagnosis of frac-
T1-weighted images in detecting and staging stress
tures, stress reactions, and bone contusions, and
injury to bone [149].
helps rule out other uncommon osseous derange-
MR imaging is the most accurate and rapid
ments in athletes (eg, transient bone marrow
method of diagnosing stress fractures, while
edema, osteonecrosis). Although the majority of
radiographs may not show abnormalities (eg, sub-
fractures adjacent to the hip joint are diagnosed
tle callus formation, irregular or disrupted cortical
by radiography, the diagnosis of nondisplaced
margin) for 4 to 6 weeks [150]. For example, in
fractures may be difficult with radiography alone.
a study of 340 consecutive conscripts with hip,
Fractures adjacent to the hip in athletes usually
groin, or buttock pain, MR imaging effectively
are observed in characteristic clinical settings, most
displayed 174 bone stress injuries in 137 patients
commonly occurring in the setting of chronic
(40%) [145]. In this series, radiography was 37%
repetitive microtrauma (stress fracture), indirect
sensitive, 79% specific, and 60% accurate. In
trauma (avulsion fracture), and direct trauma.
addition to facilitating the diagnosis of stress
fracture, MR imaging also allows the diagnosis
Stress fracture
of prefracture bone remodeling, termed stress
Clinical reaction (before a macroscopic fracture develops).
Bone is a dynamic tissue that continually MR imaging is also more sensitive and specific
responds to the stresses placed on it. Stress than bone scintigraphy for assessing stress injuries
fractures result from insufficient degrees of bone to bone [151]. In a prospective study of 22 hips in
deposition and bone resorption in the setting of endurance athletes [152], MR imaging was 100%
repetitive loading. Fatigue-type stress fractures accurate in diagnosing femoral neck stress frac-
characteristically occur in serious endurance tures. By contrast, radionuclide bone scans had an
athletes, dancers, or military recruits. Women accuracy of 68% for stress fractures, with 32%
266 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

Fig. 8. A 14-year-old athletic male with right hip pain and stress fracture in the femoral neck. Coronal T1-weighted
image of the pelvis (A) shows abnormal low signal intensity in the bone marrow of the right femoral cortex (arrow) with
low signal intensity line perpendicular to medial femoral neck, an appearance and location typical for stress fracture. On
coronal STIR image (B) bone marrow edema (arrow) is conspicuous. A frontal radiograph of the right hip (C) shows
a linear, transversely-oriented radiodense focus (arrow), compatible with callus associated with fracture healing.

false-positive results. MR imaging also allowed Treatment

the specific diagnosis of other derangements, The treatment of stress fractures is influenced
including synovial herniation pits, iliopsoas in- by the cause and location. In the femoral neck,
jury, and osteonecrosis. for example, nondisplaced compression-type stress
Synovial herniation pits of the femoral neck fractures (affecting the medial cortex) may be
frequently are considered normal variants but managed nonoperatively with protected weight-
may be symptomatic in athletes [153]. Symptoms bearing and frequent radiographic follow-up.
may occur as these pits enlarge, and the overlying Conversely, tension-type stress fractures (affecting
cortex even may fracture. These pits reportedly the lateral cortex) are potentially unstable and
are caused by the changing relationship between often are stabilized internally to prevent the ad-
the joint capsule and the iliopsoas muscle. verse consequences of fracture displacement [155].
Although the natural history of these signal Fracture displacement is associated with a high
intensity abnormalities varies with the clinical rate of complication, including osteonecrosis and
setting, 90% of young patients with stress frac- nonunion [156]. For femoral neck fractures that
tures of the femoral neck show resolution of signal are treated operatively with cannulated screws,
intensity abnormalities on inversion recovery there is increasing use of nonferromagnetic tita-
sequences within 6 months [154]. Conversely, nium screws, facilitating subsequent MR imag-
when high signal intensity persists on inversion ing evaluation for hip derangements such as
recovery images 6 months after the initial di- osteonecrosis [157–159]. Treatment of pelvic stress
agnosis of fracture, this indicates the presence of fractures includes rest and gradual return to ac-
a residual or recurrent injury. tivity; healing may take 3 to 5 months [150].
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 267

Apophyseal avulsion injuries avulsion injury potentially may resemble a neo-

plastic or infectious process, especially when no
Clinical
history of trauma is provided [161]. Knowledge of
In children and adolescents, injuries involving
the major tendinous attachments to bone is
the physis and apophysis are common. The pelvis,
indispensable in arriving at a correct diagnosis.
with its many apophyses, is a common location of
avulsion injuries. In a recent study of 203 apo- Treatment
physeal avulsion fractures seen on radiographs of Nondisplaced apophyseal avulsive injuries usu-
adolescent athletes [160], the most commonly in- ally heal with conservative therapy. Surgery may
jured sites in the pelvis were (in order of be considered for a recent apophyseal avulsion
frequency): (1) the ischial tuberosity (the origin displaced more than 2 cm. With old avulsions,
of the hamstrings and adductor magnus); (2) surgical excision of a malunited or hypertrophic
the anterior inferior iliac spine (the origin of the fragment may provide relief of pain in some
straight head of the rectus femoris); (3) the ante- patients [162].
rior superior iliac spine (the origin of the sartorius
and the tensor fascia lata); and (4) the superior
corner of the pubic symphysis. The most com- Hip bursae and bursitis
monly implicated sports in this study were soccer
Bursae are sacs of synovial tissue that mitigate
and gymnastics. Football, baseball, and track
friction between bones and tendons or between
athletes also are prone to avulsion injury [161].
bones and skin. Although bursae normally facil-
Avulsion injuries may be due to sudden force-
itate the gliding of one musculoskeletal structure
ful (often eccentric) contraction of the mus-
on another, they can become dysfunctional and
culotendinous unit during running, jumping, or
painful when inflamed [163]. In athletes, bursal
kicking a ball. Alternatively, repetitive micro-
derangements are typically secondary to repetitive
trauma from intensive training can cause bio-
microtrauma or acute trauma, but rarely may be
mechanical failure at the physeal plate (at the base
related to other causes (eg, infection, inflam-
of the apophysis).
matory arthritides, metabolic disease).
Imaging The hip is surrounded by 15 to 20 bursae
A displaced avulsion fracture fragment gener- [164,165]. Although most cases of bursitis are
ally can be recognized with ease on radiographs diagnosed clinically and treated conservatively,
[161]. However, radiographs may be interpreted MR imaging can be helpful in definitively in-
as negative in children when an apophyseal cluding or excluding the diagnosis of bursitis. MR
avulsion essentially is nondisplaced. In such cases, imaging has proved sensitive for detecting and
cross-sectional imaging may prove helpful by localizing fluid collections in several bursae at
showing subtle asymmetry or edematous changes characteristic sites, including in the iliopsoas [166]
(Fig. 9). In the subacute or chronic setting, an and trochanteric [167] bursae.

Fig. 9. A 17-year-old male after a soccer injury that resulted in sartorius avulsion. Coronal (A) and axial (B) FSE T2-
weighted images of the pelvis using a 0.3-T open MR unit show absence of the proximal left sartorius (arrow), which has
been avulsed from the anterior superior iliac spine, as well as adjacent soft tissue edema.
268 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

Iliopsoas bursa and bursitis mented villonodular synovitis) [174]. In a recent

study on iliopsoas bursitis, communication be-
Anatomy
tween the bursa and the hip joint was observed in
The iliopsoas bursa (also termed the iliopecti-
all patients by MR imaging and at surgery [175].
neal bursa) is the largest bursa in the human body.
With MR imaging, iliopsoas bursitis is displayed
When distended, intrabursal fluid can extend from
as a well-defined, thin-walled cystic mass along
the region of the lesser trochanter (inferiorly)
the iliopsoas that enhances peripherally [175].
upward into the iliac fossa (superiorly). The
Cross-sectional imaging also can define the ex-
clinical differential diagnosis of a soft tissue mass
tent of the bursal derangement if surgery is indi-
in this anatomic region may include such diverse
cated (eg, iliopsoas bursectomy via an iliofemoral
derangements as bowel herniation, hematoma,
approach).
abscess, lymphadenopathy, and neoplasm.
Trochanteric bursae and lateral hip pain
Clinical
Iliopsoas bursitis is believed to be caused most Anatomy
commonly by irritation of the iliopsoas as it moves A complex of three bursae has been described
over the iliopectineal eminence or femoral head. over the four facets of the greater trochanter
Athletes commonly present with anterior hip or (Fig. 10) [165].
groin pain, although patients with rheumatoid
 The trochanteric bursa is located between the
arthritis and other conditions are known to present
gluteus medius muscle and the posterior facet
clinically with a nonpainful soft-tissue mass that
of the greater trochanter. No tendon fibers
may compress adjacent structures [168–172]. This
attach to the posterior facet, which is best seen
pain tends to be exacerbated during hip extension
on sagittal images when the lower extremity is
(which stretches the iliopsoas) and relieved during
mildly externally rotated. On axial T1-weight-
hip flexion with external rotation. Iliopsoas bursi-
ed images, the nondistended trochanteric
tis, iliopsoas peritendinitis, and iliopsoas tendon
bursa may be seen as a thin, inconspicuous
injury have been associated with running, resis-
band of intermediate signal intensity immedi-
tance training, soccer, gymnastics, and dance.
ately posterior to the greater trochanter.
MR imaging  The subgluteus medius bursa lies between the
In approximately 15% of normal individuals, gluteus medius tendon and the lateral facet of
there is a hiatus between the pubofemoral and the greater trochanter. The gluteus medius
iliofemoral ligaments that allows connection be- tendon inserts into the lateral and supero-
tween the iliopsoas bursa and the hip joint [173]. posterior facets, which generally are best dis-
In the presence of this connection, the iliopsoas played on coronal and sagittal images.
bursa may contain fluid that has decompressed  The subgluteus minimus bursa is located
from the hip joint of patients with a joint effusion between the gluteus minimus tendon and the
or synovitis (eg, owing to osteoarthritis). Alterna- anterior facet of the greater trochanter. The
tively, pathologic changes may arise from within main tendon of the gluteus minimus tendon
the iliopsoas bursa itself (eg, owing to iliopsoas inserts into the anterior facet, which is best
bursitis, synovial (osteo)chondromatosis, or pig- seen on transaxial images.

c
Fig. 10. Trochanteric bursa and adjacent anatomy. (A) Schematic of the anatomy on sectional images. Sagittal,
transverse, coronal images through the anterior part of the greater trochanter, and coronal image through the posterior
part of the greater trochanter (a, b, c, d, respectively). The dotted lines display the needle paths for bursography. AF,
anterior facet; G. Medius, gluteus medius; G. Minimus, gluteus minimus; LF, lateral facet; oe, obturator externus; oi,
obturator internus; p, piriformis muscle; PF, posterior facet; SPF, superoposterior facet. (B) Axial T1-weighted image
shows the trochanteric bursa (white arrowheads) and subgluteus minimus bursa (black arrowheads) as thin hypointense
lines, the gluteus minimus tendon (curved arrow), and the iliotibial tract (straight arrow). (C) Coronal T1-weighted image
through the posterior part of the greater trochanter displays the lateral facet (arrowheads), the lateral part of the gluteus
medius tendon (curved arrow), and the iliotibial tract (straight arrow). (D) Coronal T1-weighted image through the
anterior part of the greater trochanter shows the anterior facet (arrowheads) with the gluteus minimus tendon (curved
arrow) attached to it. (From Pfirrmann CW, Chung CB, Theumann NH, Trudell DJ, Resnick D. Greater trochanter of
the hip: attachment of the abductor mechanism and a complex of three bursae–MR imaging and MR bursography in
cadavers and MR imaging in asymptomatic volunteers. Radiology 2001;221:469–77; with permission.)
R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 269
270 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

Clinical Treatment
Pain at the lateral aspect of the hip commonly
Treatment of bursitis generally consists of
is attributed to trochanteric bursitis. However,
conservative measures, such as activity modifica-
clinical misdiagnosis may occur because the symp-
tion (including protective padding, as appropri-
toms of trochanteric bursitis can be nonspe-
ate), ice, nonsteroidal inflammatory medications,
cific, with pain potentially referred to the groin,
stretching, specific exercises, and therapeutic
thigh, or buttock. Furthermore, a spectrum of ab-
sonography [185]. Percutaneous injection of local
normalities may occur at the lateral aspect of the
anesthetic and corticosteroid medications are
hip besides trochanteric bursitis, including tendi-
second-line therapeutic alternatives that may help
nosis, tendon tear, tendon avulsion, and various
confirm the clinical diagnosis [186]. Complications
muscle derangements [176–179]. This spectrum
after percutaneous injections are uncommon, but
of abnormalities—and the MR imaging find-
even a single steroid injection of the trochanteric
ings—are similar to those observed in the shoulder,
bursa has been reported to cause necrotizing
and thus the hip’s abductor mechanism has been
fasciitis and death [187].
referred to as the ‘‘rotator cuff of the hip.’’ Just
Surgical procedures to address recalcitrant
as in the shoulder, accurate diagnosis is impor-
bursitis are well described [163]. For treatment
tant because the treatment for bursitis and
of recalcitrant trochanteric bursitis, surgical pro-
tendon tears can be quite different (see details
cedures include open bursectomy with surgical
in later discussion).
release of the iliotibial band over the greater tro-
Trochanteric bursitis is a well-described athletic
chanter [188] and arthroscopic trochanteric bur-
injury. In runners, it has been associated with
sectomy [189]. Endoscopic treatment also has
tightness of the iliotibial tract, leg length discrep-
been successful in the treatment of chronic lateral
ancy, pelvic obliquity, and running on banked
hip pain owing to trochanteric bursitis with cal-
surfaces. Trochanteric bursitis also may occur with
cific tendinitis involving the gluteus medius and
other activities as an overuse injury (eg, ballet
minimus tendons [190]. MR imaging may be help-
dancers) or secondary to blunt trauma (eg, football
ful in preoperative planning, because trochanteric
and hockey players). The colloquial term hip
bursitis clinically may mimic gluteus medius
pointer has been used in athletes to describe soft
tendon tears [178]. The surgical treatment for
tissue contusions over the greater trochanter and
such tears is accomplished by reattaching the
iliac crest. Hematoma, scarring, and heterotopic
gluteus medius tendon to the greater trochanter.
ossification may be observed after such injuries.

MR imaging Musculotendinous injuries

Accurate diagnosis may be accomplished with
MR imaging, particularly when the relevant anat- The myotendinous unit may be avulsed,
omy is understood and examined with sufficient strained, fatigued, contused, lacerated, or de-
spatial and contrast resolution. For example, in nervated [191]. Several sequelae may be observed
a recent study of 24 women (age range: 36–75 after musculotendinous injury, including hemor-
years) with ‘‘greater trochanteric pain syndrome’’ rhage, fibrosis, atrophy, heterotopic ossification,
for more than 1 year [180], MR imaging showed muscle herniation, and compartment syndrome.
a variety of abnormalities: gluteus medius tear The various athletic injuries to muscle are dis-
(46%); gluteus medius tendinosis without a tear cussed in detail in the article by Boutin et al
(38%); trochanteric bursal distension (8%); and elsewhere in this issue [192]. We have chosen to
femoral head osteonecrosis (4%). The best phys- focus on musculotendinous and adjacent hip
ical examination test in predicting a gluteus injuries emphasized in the recent medical litera-
medius tendon tear in this population (a positive ture, including the snapping hip, pubalgia, osteitis
Trendelenburg sign) was only 73% sensitive and pubis, and adductor insertion avulsion syndrome.
77% specific. Other authors have reported young
Snapping hip
or athletic patients who were misdiagnosed clini-
cally with ‘‘trochanteric bursitis,’’ but later were Coxa saltans, commonly referred to as ‘‘snap-
determined to have other conditions, including ping hip syndrome,’’ is characterized by audible
muscle strain, stress fracture, lumbar radiculop- snapping that usually occurs with hip flexion
athy, entrapment neuropathy, and neoplasm and extension [193–196]. Such snapping is seen
[181–184]. commonly in athletes, and may or may not be
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 271

symptomatic. For example, snapping hip syn- a bony prominence coincident with an audible
drome can represent 44% of hip problems in snap. Sonography also permits assessment for
ballet dancers, with about one third of cases pain elicited by transducer pressure, even when
associated with pain [197]. Three types of coxa the tendons have a normal sonographic appear-
saltans are recognized: external, internal, and ance [195]. Although sonography is the best
intra-articular. imaging technique to demonstrate extra-articular
snapping dynamically, sonography does not eval-
External type uate optimally intra-articular structures.
The external (or lateral) type of coxa saltans is MR imaging generally is performed without
by far the most common. It occurs when the dynamic maneuvers. Secondary findings associ-
typically thickened iliotibial tract or gluteus ated with coxa saltans may include synovitis, bursi-
maximus snaps forward over the greater trochan- tis (affecting the greater trochanteric or iliopsoas
ter with hip flexion. Because the greater tro- bursa), and tendinopathy or fibrosis (affecting the
chanteric bursa lies just superficial to the greater iliotibial tract, iliopsoas, rectus femoris, or gluteus
trochanter, it may become inflamed and cause pain maximus) [199]. For the internal type of snapping
in patients with the external type of snapping hip. hip, MR imaging or MR arthrography may be
the single best imaging test. In a recent study
Internal type
comparing various imaging techniques [200], MR
Compared with the external variety of snap-
imaging identified the cause of internal snapping in
ping hip, the internal type is less prevalent but may
all cases. By comparison, the causative pathology
be more difficult to diagnose clinically [195].
was identified less commonly by radiography
Consequently, patients with this condition may
(37%), sonography (46%), combined radiography
more commonly be referred to radiologists for
and CT (88%), and combined radiography and
diagnostic evaluation. The internal (or anterior)
sonography (94%).
type is usually caused during hip extension when
the iliopsoas tendon snaps medially over the Treatment
iliopectineal eminence or femoral head. Inflamma- Conservative management of the extra-articu-
tion of the iliopsoas bursa has been implicated as lar types of snapping hip commonly includes rest
a potential pain generator in these patients [198]. from aggravating activities, nonsteroidal anti-
inflammatory medications, physical therapy (eg,
Intra-articular type
iliotibial tract stretching), and, occasionally, per-
The intra-articular type of snapping is due to
cutaneous injection of corticosteroid. For rare
an internal derangement within the joint, such as
cases of persistently painful extra-articular snap-
a loose body, labral tear, or redundant synovial
ping hip, surgery may be indicated (eg, iliopsoas
fold. These patients may complain of a clicking
tendon lengthening [193], greater trochanteric
sensation (rather than audible snapping), and pain
bursa excision with Z-plasty of the iliotibial tract
is generally the chief complaint.
[201,202]). For the intra-articular type of snapping
Imaging hip, arthroscopy may be indicated to remove loose
For evaluating extra-articular causes of the bodies or resect labral tears.
snapping hip, advanced imaging options include
Athletic pubalgia
iliopsoas bursography, sonography, and MR
imaging. Iliopsoas bursography is performed by Clinical
percutaneous injection of iodinated contrast using Groin injuries are said to comprise 2% to 5%
fluoroscopic guidance. The iliopsoas tendon can of all sports injuries [203]. Acute groin pain in
then be seen as a cord-like filling defect adjacent to athletes is caused most commonly by musculo-
the opacified iliopsoas bursa. By reproducing the tendinous injuries involving the hip adductors
range of motion that elicits the snapping hip (Fig. 11). However, pain referable to the groin can
during fluoroscopy, sudden jerking of the iliop- become chronic, and accurate clinical diagnosis
soas tendon may be documented. Disadvantages may be difficult because of vague or referred
of this technique include that it is invasive, requires symptoms involving the groin, medial thigh, lower
contrast material, and exposes patients (who are abdominal, perineal, and hip regions. Conse-
often of childbearing age) to pelvic radiation. quently, pubalgia in athletes can have an extensive
Sonography facilitates noninvasive, dynamic clinical differential diagnosis that potentially in-
visualization of abrupt tendon displacement over cludes: osteitis pubis; adductor tendinopathy and
272 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

Fig. 11. A 32-year-old professional basketball player with acute right groin pain after a fall during a game. Axial FSE
fat-saturated proton density (A) and coronal FSE inversion recovery (B) MR images show high signal intensity indicating
edema within the right adductor muscles (arrows) compatible with a mild (grade 1) muscle strain.

enthesitis; lower abdominal musculofascial de- 223]. In a recent study of 30 athletes with pubalgia
rangements; hernias (eg, inguinal, femoral); geni- caused primarily by abdominal musculofascial
tourinary tract abnormalities (eg, ureteral calculi); abnormalities, the authors concluded that pubal-
fractures (eg, apophyseal avulsion, femoral neck gia is a complex process that is frequently multi-
stress fracture); entrapment of the obturator nerve factorial [208]. Common MR findings in this series
by soft tissue fibrosis; and, rarely, other conditions included:
such as infection and neoplasm [198,203–221].
 Attenuation or bulging of the lower abdom-
This section discusses athletic pubalgia in general,
inal wall musculofascial layers (93%)
as well as osteitis pubis in particular.
 High T2 signal in one or both pubic bones
MR imaging (70%)
In a large, blinded, prospective study, a history  High T2 signal in one or more groin muscles,
of groin pain in athletes was associated signifi- particularly the adductor muscles (60%)
cantly with pubic bone marrow edema [209]
Stress-related reactive marrow changes in the
(Fig. 12). However, chronic groin pain (which may
pubic bones often are not seen in isolation, and
be defined as lasting longer than 3 months) com-
therefore should prompt a search for associated
monly has two or more etiologies in athletes [222,
musculotendinous, musculofascial, or osteoartic-
ular abnormalities. For example, athletes with
stress injuries involving the pubic symphysis
often may have an associated stress injury in the
sacrum and degeneration in the sacroiliac joints
[224].
Treatment
Although treatment of most musculotendinous
injuries is conservative (eg, with rest, ice, and
nonsteroidal anti-inflammatory drugs), surgery
may be indicated for certain causes of pubalgia
if nonoperative measures fail after 6 to 8 weeks,
particularly in high-level athletes [198]. Several
surgical techniques are variations on a standard
hernia repair, sometimes with musculotendinous
Fig. 12. A 20-year-old college football linebacker with
reattachment (eg, rectus abdominis muscle) or
midline lower abdominal pain and pubalgia. The MR
imaging examination was ordered to exclude a rectus
release (eg, adductor muscle). Postoperative prog-
abdominus muscle tear. An axial FSE fat-saturated T2- nosis is generally good [198,215], with rates of
weighted image shows bone marrow edema within the return to full athletic activity reported to be
symphysis pubis (arrows) correlating with symptoms. No 87% [207,219], 93% [220], 97% [210], and 100%
muscle tear was appreciated. [218].
 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281 273

Osteitis pubis resume athletic activities 2 days after the pro-

cedure. At 2-month follow-up, 31% of the pa-
Clinical
tients were completely symptom-free. In cases
The pubic symphysis is a nonsynovial am-
refractory to conservative management, surgery
phiarthrodial joint containing hyaline cartilage
may be performed (eg, symphyseal curettage
and a central fibrocartilaginous disk. Inflamma-
[205], arthrodesis with bone grafting and com-
tion, degeneration, and posttraumatic changes at
pression plate [211], wedge resection of the pubic
the pubic symphysis have been termed osteitis
symphysis [227]).
pubis and may cause substantial pain [198,204,
205,211,225–228]. In athletes, the pubic symphysis Adductor insertion avulsion syndrome
only rarely is affected by septic arthritis and
osteomyelitis [206,217]. Clinical
Sports-related injuries at the femoral shaft
Imaging entheses have been well demonstrated by MR
Radiographs may show variable degrees of imaging in children [230] and adults [231].
osteophytosis, subchondral cysts, subchondral Adductor insertion avulsion syndrome, also re-
osteosclerosis, subchondral irregularity, and peri- ferred to as ‘‘thigh splints,’’ presents clinically as
articular demineralization. Symphyseal joint lax- pain and tenderness in the hip, groin, or proximal
ity or disruption also may be observed, which has to mid-thigh. Similar to ‘‘shin splints,’’ this con-
been defined as a joint space measuring more than dition is thought to be due to repetitive avulsion
7 mm in width or malalignment of the upper stresses at the tendinous insertions into bone,
margins of the superior pubic rami measuring resulting in traction periostitis. With thigh splints,
more than 2 mm on flamingo radiographic views the periosteal changes occur at the medial aspect
[204,211]. of the proximal to mid-femur because of the pull
Bone scintigraphy characteristically shows in- of the adductor longus and brevis tendon in-
creased accumulation of radiopharmaceutical in sertions. Adductor insertion avulsion syndrome is
the parasymphyseal subchondral bone. Uptake is thought to represent one end of a continuum that
typically bilateral, but may be unilateral [204,226]. ranges from accelerated tissue remodeling to overt
This technique is imperfect in differentiating para- stress fracture.
symphyseal stress reaction from stress fracture
and in diagnosing nonosseous causes of pubalgia. Imaging
MR imaging findings of osteitis pubis include Radiographs are expected to be normal when
osteophytosis, subchondral cysts, irregularity of symptoms begin. Later, radiographs typically show
the pubic symphysis, juxta-articular pubic bone subtle periosteal new bone or cortical thickening at
marrow edema, and intraarticular fluid signal. the medial aspect of the proximal to mid-femo-
Additional findings that may be seen with this ral shaft. Bone scintigraphy shows an elongated
technique are joint incongruity (either in the area of increased tracer accumulation in the same
anteroposterior or superoinferior plane) and region. MR imaging characteristically shows a
extrusion of the fibrocartilaginous disk (most segment of high T2 signal along the medial perios-
frequently posteriorly or superiorly) [204,229]. teum of the femoral shaft. The underlying cortex
and medullary canal also may display hyperin-
Treatment tense T2 signal, but no osseous destruction or mass.
Treatment initially involves conservative mea-
sures (eg, rest, nonsteroidal anti-inflammatory Treatment
medications, physical therapy). In some patients, Treatment consists of rest from inciting activ-
imaging-guided percutaneous injection of the ities. Short-term follow-up imaging may be useful
symphyseal cleft may be an effective minimally to document appropriate healing, but symptoms
invasive treatment. In a recent study of 16 athletes typically resolve within 1 to 2 months with con-
with debilitating groin pain and osteitis pubis, servative management.
symphyseal cleft injection was accomplished with
an aqueous suspension composed of 20 mg of
Summary
methyprednisolone acetate and 1 mL of 0.5%
bupivacaine hydrochloride local analgesic [204]. Hip arthroscopy is being used increasingly for
Eighty-eight percent of patients experienced im- the diagnosis and treatment of hip disorders. MR
mediate relief of some symptoms and were able to imaging performed with appropriate technical
274 R.D. Boutin, J.S. Newman / Magn Reson Imaging Clin N Am 11 (2003) 255–281

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 Magn Reson Imaging Clin N Am
11 (2003) 283–293

MR imaging of meniscal and cruciate

ligament injuries
Russell C. Fritz, MD
National Orthopedic Imaging Associates, 1260 South Eliseo Drive, Greenbrae, CA 94904, USA

Knee pain is a common sports-related clinical currently obtained on 1.0 and 1.5 Tesla machines.
complaint that may be caused by abnormalities of Experience is now accumulating with dedicated
the cruciate ligaments and menisci as well as 1.0 Tesla extremity scanners that provide im-
various other pathologic conditions. An accurate proved image quality when compared with the
diagnosis is an essential element of a successful first generation of low field strength extremity
treatment plan in patients that present with knee scanners. Experience also is currently accumulat-
pain. Diagnostic imaging is especially important ing with 3.0 Tesla systems; however, problems
when there is significant uncertainty regarding the with chemical shift artifact on the images that
cause of knee pain, and the outcome may be are not fat suppressed make evaluation of the
improved by timely implementation of various chondral surfaces problematic. Moreover, the
treatment options. increased cost of these systems and the need to
MR imaging provides clinically useful infor- develop compatible surface coils have limited the
mation by detecting and characterizing pathologic orthopedic applications of 3.0 Tesla systems to
conditions of the knee. MR imaging is currently date. A surface coil is essential for obtaining high-
the premier imaging technique for evaluating quality images regardless of the field strength of
the knee and may help establish the cause of the MR imaging system. Ongoing improvements
a patient’s signs and symptoms by accurately de- in surface coil design and newer pulse sequences
picting the presence and extent of bone and soft have resulted in higher-quality MR images of the
tissue pathology about the knee. The information knee that can be obtained more rapidly when
provided by MR imaging is a useful piece of the compared with older MR systems. Phased-array
puzzle in a diagnostic workup and can help and quadrature surface coils are examples of
establish an anatomic diagnosis. In this article, newer coil configurations that allow faster, higher-
we focus on evaluation of the menisci as well as quality images of the knee.
the anterior cruciate ligament (ACL) and poste- We typically image the knee in the axial, oblique
rior cruciate ligament (PCL) with MR imaging. coronal, and oblique sagittal planes. The axial
images typically extend from the quadriceps
tendon, proximal to the epicondyles, to the patellar
MR imaging techniques tendon insertion on the tibial tuberosity. The
oblique coronal images are prescribed from the
The knee is typically scanned with the patient
axial images and are oriented parallel to a line
in a supine position with the leg fully extended.
drawn though the epicondyles. The oblique coronal
The patient should be scanned in a comfortable
images extend from the patella anteriorly into the
position to avoid motion artifact. Excellent
musculature posteriorly. The oblique sagittal im-
images may be obtained with midfield and high-
ages are prescribed from the axial images and
field MR systems; however, the best images are
oriented perpendicular to the oblique coronal
images. The oblique sagittal images are obtained
from the medial to the lateral subcutaneous tissues,
E-mail address: [email protected] extending just beyond the collateral ligaments.
1064-9689/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1064-9689(03)00028-X
284 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293

Fig. 1. A 44-year-old skier with an acute ACL tear. There is increased signal delineating a midsubstance rupture of the
ACL on these proton density (A) and fat-suppressed T2-weighted (B) sagittal images. The distal fibers of the ligament are
balled up and have a lax appearance (arrows). An edematous stump of the ligament remains attached to the femur
further proximally.

We use various pulse sequences to evaluate the

knee depending on the available software and the
field strength of the particular MR imaging sys-
tem. In general, we rely on fast spin-echo pro-
ton density and fast spin-echo fat-suppressed
T2-weighted images in the oblique coronal, oblique
sagittal, and axial planes to diagnose internal
derangement of the knee [4]. The images with and
without fat suppression are obtained in the same
locations to facilitate analysis of the anatomy.
Anatomic structures such as the menisci and the
cruciate ligaments are identified on the proton
density images and evaluated for their relative
water content on the fat-supressed T2-weighted
images (Fig. 1). It is essential to have properly
displayed and photographed fat-suppressed
T2-weighted images that allow differentiation
between tissue and fluid. We have found that
having control of the greyscale used for im-
age display is useful when reading MR scans;
therefore, we typically interpret the images on Fig. 2. A 54-year-old tennis player with a lateral
meniscal tear and cyst. There is a horizontally oriented
computer workstations rather than using the
tear of the body segment of the lateral meniscus
hard-copy film for diagnosis.
communicating with the free edge (curved black arrow)
on this fat-suppressed T2-weighted coronal image. There
Meniscal tears is an intrameniscal cyst displacing the superior leaf of
the meniscus superiorly. This cyst extends into a septated
MR imaging can be used to accurately di- lobular parameniscal cyst (white arrow). A small surface
agnose meniscal tears and has been the standard tear was found at surgery, resulting in a one-way valve
imaging technique in clinical practice for approx- mechanism between the superior and inferior leaf tissue
imately 15 years. Degenerative meniscal tears are of the lateral meniscus.
 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293 285

Fig. 3. Small radial tear of the lateral meniscus in a 25-year-old basketball player with an acute ACL tear. A proton
density coronal image (A) reveals a small radial tear of the lateral meniscus at the junction of the anterior horn and body
segments (arrow). A fat-suppressed T2-weighted axial image (B) also shows this small tear (arrow) that is limited to the
free edge of the meniscus.

common in the general population and in athletes. necessary to recognize displaced meniscal tears
Although intrameniscal signal that extends to an and discoid menisci on MR imaging. Bucket
articular surface is the hallmark of a meniscal handle tears, flap tears, and displaced radial tears
tear, this finding has been overemphasized relative may be subtle and can be missed if the menisci
to the alteration of meniscal morphology. Careful are only evaluated for intrasubstance signal
attention to the size and shape of the menisci is alteration.

Fig. 4. A 72-year-old woman with meniscal dysfunction secondary to a displaced radial tear of the medial meniscus.
There was no acute injury in this case. Interruption of the circumferential hoop fibers of the medial meniscus has resulted
in load transfer to the medial femoral condyle, contributing to a stress fracture. There is bone marrow edema (large white
arrows) in the medial femoral condyle surrounding a subchondral insufficiency fracture (small black arrows) on these fat-
suppressed T2-weighted coronal images (A, B). A displaced radial tear in the posterior horn segment (small white arrows
in A) has interrupted the meniscal hoop. There is associated peripheral displacement of the body segment of the meniscus
when its position is compared with the medial margin of the medial tibial plateau.
286 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293

Fig. 6. A 23-year-old soccer player with an ACL-

deficient knee and a bucket-handle tear of the medial
meniscus. There is absence of the proximal ACL fibers in
Fig. 5. A 25-year-old man with an acute ACL tear and
the superior lateral aspect of the intercondylar notch
lateral meniscal tear. There are ACL-associated con-
(large arrow) on this proton density coronal image. A
tusions (white arrows) of the posterolateral aspect of the
displaced bucket-handle fragment of the medial menis-
proximal tibia and more anterior aspect of the lateral
cus is seen along the superior margin of the medial tibial
femoral condyle caused by rotatory subluxation of these
spine (curved arrow). There is also a vertical tear in the
bones at the time of ACL rupture. This fat-suppressed
nondisplaced peripheral remnant of the body segment
T2-weighted sagittal image also reveals a vertical pe-
(small arrow).
ripheral tear of the posterior horn of the lateral meniscus
(black arrow). This small tear did not communicate with
an articular surface on other adjacent images and was The information provided by MR imaging can
considered stable upon arthroscopic probing. help establish an anatomic diagnosis of a meniscal
tear and depict intrameniscal and parameniscal
cysts that may develop through the substance of
the meniscus (Fig. 2) [4]. The cross-sectional

Fig. 7. ACL tear and associated displaced flap tear of the posterior horn of the lateral meniscus in a 35-year-old skier.
Fat-suppressed T2-weighted coronal (A) and axial (B) images reveal a flap tear of the far medial aspect of the posterior
horn of the lateral meniscus that is displaced superiorly and medially into the lateral aspect of the intercondylar notch.
This meniscal fragment (curved arrow) remains connected to the tibia by way of the posterior root attachment and is
displaced into the substance of the torn ACL.
 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293 287

Fig. 8. Normal fibers bundles of the ACL. Proton density sagittal images (A, B) depict the anteromedial bundle (black
arrows) and the posterolateral bundle (white arrows) of the intact ACL. A fat-suppressed T2-weighted axial image (C)
through the mid to proximal aspect of the ACL reveals the femoral attachment of the posterolateral bundle (white
arrows) and the midsubstance fibers of the anteromedial bundle (black arrows) further anteriorly. These bundles
normally diverge and become more discrete on distal axial images (not shown). The fibers within the ACL reciprocally
tighten and loosen to stabilize the knee throughout the arc of flexion and extension. The anteromedial bundle is tight in
flexion, and the posterolateral bundle is tight in extension.

morphology of a meniscal tear is well seen with weight bearing, the remainder of the meniscus
MR imaging and may be horizontal, oblique, or extrudes out to the periphery and the meniscus
vertical on a sagittal or coronal MR scan through becomes more dysfunctional in transmitting
the meniscus. A radial tear is a vertically oriented compressive load across the knee. The articular
tear that may be limited to the free edge of the cartilage and underlying trabecular bone are
meniscus and may be subtle on MR imaging (Fig. subjected to increased load when the meniscus is
3). These radial tears may progress out to the dysfunctional and may fail in response to this
periphery of the meniscus and gradually tear stress. MR imaging can depict the meniscal tear
through the circumferential hoop fibers of the and reveal the underlying biomechanics and the
meniscus. As the radial tear widens in response to stress response that can result from meniscal
288 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293

Fig. 9. Selective sprain of the posterolateral bundle of the ACL in a 22-year-old skier. A fat-suppressed T2-weighted
sagittal image (A) reveals a normal anteromedial bundle of the ACL (black arrows). A fat-suppressed T2-
weighted sagittal image (B) reveals a mildly lax posterolateral bundle of the ACL (white arrows). A fat-suppressed
T2-weighted axial image in the superior aspect of the intercondylar notch (C) reveals a normal anteromedial bundle of
the ACL (black arrows). A fat-suppressed T2-weighted axial image further distally (D) reveals normal anteromedial
bundle fibers (black arrows); however, there is increased signal and mild laxity of the posterolateral bundle fibers (white
arrows) caused by a selective sprain of this portion of the ACL.

dysfunction. Chondral defects or stress fractures more compressive load relative to the lateral
of the subchondral bone may develop in the compartment (Fig. 4). The subchondral bone
setting of meniscal dysfunction unless there is within these stress fractures typically seen in the
reduced demand on the knee from patient weight medial femoral condyle with MR imaging are at
loss or activity modification to allow time for the risk to develop osteonecrosis with subsequent
restoration of tissue homeostasis. This phenome- collapse or fragmentation.
non of meniscal hoop dysfunction resulting in The information provided by MR imaging can
load transfer to the articular cartilage and un- also help to establish if a tear is unstable by
derlying bone is more commonly seen with MR determining the extent and complexity of the tear
imaging in the medial compartment where there is (Fig. 5). Vertical longitudinal tears become more
 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293 289

Fig. 10. ACL rupture in a 42-year-old skier. A fat-

suppressed T2-weighted axial image reveals fluid (arrow)
extending across the mid to proximal aspect of the ACL.
Fig. 12. Conservatively treated midsubstance ACL
rupture that was documented by physical exam and
unstable as they propagate along the circumfer- MR imaging after a ski injury in a 42-year-old physician.
ence of the meniscus and may ultimately result in MR imaging at the time of injury (not shown) revealed
a displaced bucket-handle tear. Vertical longitu- a typical ACL rupture without gross separation of the
torn fibers. This fat-suppressed T2-weighted axial image
dinal tears are well seen with MR imaging and
was performed 2 years after the ACL rupture and reveals
should be carefully looked for in the ACL-
mild fiber thickening and poor delineation of the fiber
deficient knee (Fig. 6). A specific type of flap tear bundles compatible with scarring (arrows).
of the posterior horn of the lateral meniscus is
highly associated with a torn or dysfunctional

Fig. 11. Three-week-old sprains of the ACL and medial collateral ligament (MCL) in a 25-year-old basketball player. A
proton density sagittal image (A) reveals increased signal within the ACL fibers; however, there is no evidence of laxity
(arrows). A fat-suppressed T2-weighted axial image (B) reveals increased signal, poor definition of the fiber bundles, and
irregular thickening of the ACL (solid arrows) and the MCL (open arrow). The appearance is compatible with a subacute
sprain with developing scar formation.
Fig. 13. ACL ganglion cyst in a 28-year-old golfer who suffered a twisting injury 10 months before this MR scan. Fat-
suppressed T2-weighted axial (A) and sagittal (B) images reveal a mildly lax-appearing ACL with expansion and
peripheral displacement of the ligament fibers by dissecting cyst fluid (small arrows). A septated, lobulated component of
the cyst is seen within the proximal ACL (curved arrow). There also is an intraosseous component of the ganglion cyst
within the tibia (large arrow) with mild surrounding marrow edema.

Fig. 15. Distal avulsion of the PCL in a 16-year-old

Fig. 14. Proximal avulsion of the PCL in a 23-year-old football player. There is increased signal at the site of an
football player. There is edema within the mid to avulsion fracture of the PCL from the tibia (open arrows)
proximal portion of the PCL (solid arrows) on this on this fat-suppressed T2-weighted sagittal image. The
proton density sagittal image. There is detachment of the growth plate is almost closed (solid arrows) and is well
entire PCL from the femur (open arrow). The ligament seen just distal to the avulsion fracture. The ligament has
has a lax appearance and there is posterior translation of a lax appearance and there is posterior translation of the
the tibia relative to the femur. tibia relative to the femur.
 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293 291

ACL tears
MR imaging can be used to accurately diagnose
ACL tears and has been the standard imaging
technique in clinical practice for the last 15 years [8].
The information provided by MR imaging can help
establish the anatomic diagnosis of a complete
ligament rupture or less severe degree of sprain
injury. MR imaging also can help distinguish an
acute ACL rupture from a chronic deficiency based
on the morphology of the ligament. Rupture of the
ACL is a common sports-related injury that is
usually a straightforward diagnosis with MR
imaging. The ACL is composed of anteromedial
and posterolateral bundles that reciprocally tighten
in flexion and extension. The anatomy of these
bundles may be seen with MR imaging (Fig. 8).
Although an acute complete tear is the most
commonly encountered situation in clinical prac-
tice, partial tears and lesser degrees of ACL sprain
injury may occur and may be limited to the an-
teromedial or posterolateral bundle (Fig. 9). The
Fig. 16. Conservatively treated midsubstance PCL
midproximal fibers of the ACL most commonly
rupture that was documented by physical exam and
MR imaging after a soccer injury in a 32-year-old rupture, leading to a proximal stump of the ACL on
woman. MR imaging at the time of injury (not shown) the femur, posterior sloping of the distal ACL on
revealed a typical PCL rupture without gross separation the sagittal MR images, and a fluid-filled gap at the
of the torn fibers. This proton density sagittal image was site of the tear on the axial images (Fig. 10).
performed 4 years after the PCL rupture and reveals Axial, sagittal, and coronal T2-weighted im-
moderate fiber thinning and a lax appearance of the ages are useful in evaluating the status of the ACL
ligament (arrows). There is also mild posterior trans- because of its oblique course through the inter-
lation of the tibia relative to the femur that suggests condylar notch [3]. The axial and coronal planes
partial insufficiency of the PCL.
are especially useful for differentiating femoral
avulsion of the ACL and lesser degrees of sprain
injury from the more typical midsubstance rup-
ACL and may be detected with MR imaging. ture. Coronal and sagittal images are useful for
This flap typically arises from the free edge of detecting avulsion of the tibial attachment of the
the posterior horn of the lateral meniscus and ACL, which is more common in skeletally
displaces into the posterior aspect of the inter- immature patients. Evaluation of the ACL on
condylar notch. The displaced flap of meniscal fat-suppressed T2-weighted images in all three
tissue typically rotates up just posterior to the planes also facilitates detection of scarring of the
ruptured ACL fibers (Fig. 7). ligament fibers from previous injury that may be
Horizontal tears that communicate with a ra- more subtle when looking at the ACL only on the
dial tear may also result in displaced flap tears sagittal images. Injury of the ACL, as in other
that are commonly seen with MR imaging. These ligament injuries, is followed by a healing re-
flaps tears are most commonly seen arising from sponse and eventual scarring of the ligament
the body segment of the medial meniscus and (Figs. 11, 12). This healing response is character-
displacing peripherally just inferior to the joint ized by a gradual resolution of ligament edema
line. Superiorly displaced flap tears that arise from with the development of ligament thickening and
the superior leaf tissue are less common but may poor definition of the fiber bundles that is vari-
also be seen with MR imaging. Medial meniscal able in extent. There also may be hypertrophy of
flaps also are commonly seen at the posterior the bony attachment sites adjacent to the site
margin of the medial tibial spine where they may of ligament injury and subsequent scarring.
also be difficult to detect arthroscopically through The ligament may scar to the PCL or to the
standard portals. intercondylar notch in an area inferior to the
292 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293

Fig. 17. Selective rupture of the posteromedial bundle of the PCL in a 28-year-old football player who suffered
a hyperextension injury during a game that was documented by review of the videotape. Proton density sagittal images
(A, B) and a fat-suppressed T2-weighted axial image (C) reveals a normal anterolateral bundle of the PCL (curved
arrows); however, there is increased signal and poor definition of the posteromedial bundle compatible with a selective
rupture of this portion of the PCL.

normal femoral attachment site resulting in Acute injuries of the ACL are often accompa-
dysfunction. nied by injury to the posterolateral capsule and
A ganglion cyst of the ACL may be confused adjacent muscles in the posterolateral corner of
with rupture of the ACL on MR imaging. A the knee as well as lateral compartment bone
ganglion cyst of the ACL may develop after injury contusions. These contusions are caused by im-
and is characterized on MR imaging by a septated, paction of the anterior weight-bearing portion of
lobulated fluid collection that displaces the liga- the lateral femoral condyle with the posterior
ment fibers, though the ligament fibers remain in aspect of the lateral tibial plateau that occurs
continuity and are intact (Fig. 13). Intraosseous when the ACL ruptures [7]. Anterior subluxation
cyst components and reactive marrow edema are of the lateral tibial condyle relative to the lateral
common at the ACL attachment sites in patients femoral condyle occurs at the time of injury and
with ganglion cysts of the ACL [2]. explains the location of these bone contusions.
 R.C. Fritz / Magn Reson Imaging Clin N Am 11 (2003) 283–293 293

Anterior tibial translation relative to the lateral Summary

femoral condyle can be observed on sagittal MR
MR imaging provides clinically useful infor-
images as a sign of ACL insufficiency [1]. Anterior
mation in detecting and characterizing sports-
tibial translation and other secondary signs may
related pathology of the menisci and cruciate
be helpful in prompting a more careful analysis of
ligaments in a noninvasive fashion. Meniscal tears
ACL morphology, especially when a chronically
can also be detected and characterized with regard
torn ACL has scarred to the PCL or the femur
to extent and tear stability with MR imaging.
and is not obviously disrupted or sloping poste-
Acute and chronic tears of the anterior and
riorly on the sagittal images.
posterior cruciate ligaments can be accurately
identified and evaluated with MR imaging.
PCL tears
PCL injuries are less common than ACL and References
meniscal injuries. Midsubstance rupture of the
PCL as well as proximal and distal avulsions of [1] Chan WP, Peterfy C, Fritz RC, et al. MR diagnosis
the ligament from the tibia and the femur may of complete tears of the anterior cruciate ligament of
occur and seen easily with MR imaging (Figs. 14, the knee: importance of anterior subluxation of the
tibia. AJR Am J Roentgenol 1994;162:355.
15) [5,6]. Scarring of the PCL is characterized by
[2] Do-Dai DD, Youngberg RA, Lanchbury FD, et al.
thickening of the ligament fibers and the absence Intraligamentous ganglion cysts of the anterior
of edema as well as a somewhat lax appearance cruciate ligament: MR findings with clinical and
(Fig. 16). The PCL is composed of anterolateral arthroscopic correlations. J Comput Assist Tomogr
and posteromedial bundles that reciprocally 1996;20:80.
tighten in flexion and extention. The postero- [3] Fitzgerald SW, Remer EM, Friedman H, et al. MR
medial bundle is tight in extension and the evaluation of the anterior cruciate ligament: value of
anterolateral bundle is tight in flexion. Isolated supplementing sagittal images with coronal and axial
posteromedial bundle tears have been occasion- images. AJR Am J Roentgenol 1993;160:1233.
ally seen with MR imaging in our experience. [4] Munk B, Madsen F, Lundorf E, et al. Clinical
magnetic resonance imaging and arthroscopic find-
We have read approximately 10 clinical cases with
ings in knees: a comparative prospective study of
hyperextension injuries of the knee that appear to meniscus anterior cruciate ligament and cartilage
selectively injure the physiologically taut fibers of lesions. Arthroscopy 1998;14:171.
the posteromedial bundle of the PCL before fully [5] Patten RM, Richardson ML, Zink-Brody G, et al.
tearing the entire PCL (Fig. 17). Complete vs partial-thickness tears of the posterior
When combined rupture of both cruciate cruciate ligament: MR findings. J Comput Assist
ligaments along with collateral ligament injury is Tomogr 1994;18:793.
identified with MR imaging, the possibility of knee [6] Sonin AH, Fitzgerald SW, Friedman H, et al.
dislocation and associated dissection of the pop- Posterior cruciate ligament injury: MR imaging
liteal artery should be considered. An intraluminal diagnosis and patterns of injury. Radiology 1994;
190:455.
flap or thrombus in the popliteal artery may be
[7] Speer KP, Spritzer CE, Bassett FH, et al. Osseous
seen on the routine MR images. MR angiography injury associated with acute tears of the anterior
can sometimes be performed after the standard cruciate ligament. Am J Sports Med 1992;20:382.
MR study of the knee without moving the patient [8] Tung GA, Davis LM, Wiggins ME, et al. Tears of the
and is more accurate than the routine MR images anterior cruciate ligament: primary and secondary
for detecting injuries of the popliteal artery. signs at MR imaging. Radiology 1993;188:661.
 Magn Reson Imaging Clin N Am
11 (2003) 295–310

Imaging sports injuries of the foot and ankle

Adam C. Zoga, MD*, Mark E. Schweitzer, MD
Department of Radiology, Musculoskeletal Division, Thomas Jefferson University,
111 South 11th Street, Philadelphia, PA 19147, USA

As health care evolves in the early twenty-first tendons themselves demonstrate a varying pro-
century, a combination of factors has increased pensity for injury based on their anatomic course
the demand for accurate diagnosis and efficient and stresses. Tendons that change direction at some
treatment of sports injuries in high-level athletes point along their course employ a synovial sheath,
and throughout the general populous. Patient which is protective but susceptible to inflammation.
populations are gradually aging while simulta- Others are subject to hypoxic degeneration and
neously becoming increasingly fitness conscious, tearing at predictable locations when exposed to
with older patients living a more athletic lifestyle repetitive abnormal stresses. These locations are
and younger generations participating in a more determined in large part by regional tendinous
diverse array of traditional and ‘‘extreme’’ sports. vascularity, with degeneration beginning in the
Patient education continues to improve with ever- relatively hypovascular portions of the tendon [3].
expanding media and internet resources. Growing Ligaments are injured with one-time high-velocity
patient demands compounded by a trend away traction or impaction stresses and can be sprained
from specialization by health care providers create or ruptured. Bony injury can occur with high
a greater role for the science of imaging in injury velocity one-time injuries or repetitive overuse
diagnosis and assessment of pathology evolution stresses with resulting contusion and or fracture
and therapeutic response. [4]. Symptomatology presenting a significant
Foot and ankle structures bear massive amounts time after a trauma is often a manifestation of
of force during athletic activities and are naturally previous injury, such as articular cartilage and
susceptible to a vast and ever-expanding array of osteochondral defects or instability syndromes
injuries. MR imaging continues to become more (Fig. 1) [5].
widely available with a growing number of systems When imaging the foot and ankle after an
and shorter scan times, while technologic improve- athletic injury, we employ pathology-sensitive and
ments allow for better anatomic detail and an anatomy-specific MR sequences in multiple imag-
increased sensitivity for pathology. Often the exact ing planes. In most cases, a pathology-sensitive
location and nature of an injury is governed by the sequence in the form of a T2-weighted sequence
principle of failure at the weakest point along with fat suppression or STIR is obtained in planes
a musculo-teno-osseous axis. This point of failure sagittal, axial and coronal to the long axis of the
then varies with patient age and physical condition. body and anatomic T1-weighted or proton density
Adolescents and young adults are most susceptible sequences are performed in a short axis plane
to bony growth plate or apophyseal injury, whereas (coronal for foot, axial for ankle) and a long axis
tendinous and musculotendinous injuries are more plane (axial for foot, and coronal for ankle). It is
prevalent in the middle aged [1,2]. Additionally, important for one bone marrow-specific sequence,
usually T1 weighted, to be obtained without fat
suppression. Intravenous gadolinium contrast in
the form of an indirect MR arthrogram can be
* Corresponding author. helpful in postoperative joints and in specific
E-mail address: [email protected] (A. Zoga). differential considerations, such as stenosing
1064-9689/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1064-9689(03)00026-6
296 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310

The Achilles tendon may be the most com-

monly injured tendon in athletic activities. Pa-
tients with chronic symptoms are often given
a diagnosis of Achilles tendonitis. This is a clinical
syndrome but not a histologic entity, and MR
imaging most often demonstrates paratendinitis.
With Achilles paratendinitis, the tendon main-
tains its normal size and shape with abnormal
semicircumferential T2 hyperintensity peripher-
ally at its paratenon. It is important to remember
that a synovial sheath is absent in the majority of
tendons that do not change direction along their
anatomic course. Conservative, symptom-guided
therapy is effective in alleviating pain associated
with Achilles paratendinitis (Fig. 3). In contrast,
hypoxic tendinosis, another cause of clinical Achil-
les tendonitis, usually occurs in a region from
2 cm to 7 cm proximal to its calcaneal insertion.
The Achilles is enlarged in a fusiform configura-
tion on sagittal images with an abnormal anterior
convexity but without focal signal abnormality on
both T1-weighted and T2-weighted sequences. On
histologic examination, this is a degenerative
process, as opposed to an inflammatory one and
symptoms can be long-standing (years) with
persistent activity. Mucoid degeneration is more
Fig. 1. This professional football player suffered an often asymptomatic. In this entity, the tendon is
extreme eversion stress on an artificial surface. The again at least mildly enlarged, but there is focal
coronal short tau inversion recovery image shows an intratendinous signal abnormality in the form of
unusual high-grade deltoid ligament tear (arrow).
relative hyperintensity on T2-weighted, and some-
tenosynovitis. In our institution, intraarticular times T1-weighted sequences. Mixed results have
contrast (direct MR arthrography) in the foot and been reported with aggressive and conservative
ankle is generally reserved for cases of suspected therapies, but failure of therapy can ultimately
occult ligament injury or articular cartilage and lead to complete tendon rupture. A final cause of
osteochondral defects (Table 1) (Fig. 2) [6]. clinical Achilles tendonitis symptomatology is

Table 1
Foot and ankle sports protocols (1.5T)
Sagittal Coronal Axial
Routine ankle T1 non–fat suppressed T2-TSE fat suppressed Proton density fat suppressed
STIR T2-TSE fat suppressed
Biphasic indirect Early T1 non–fat Early proton density fat
ankle arthrogram suppressed suppressed
T2-TSE fat suppressed T2-TSE fat suppressed T2-TSE fat suppressed
Delayed T1 fat Delayed T1 non–fat Delayed T1 fat suppressed
suppressed suppressed
Routine foot STIR T1-weighted non–fat T1-weighted non–fat
suppressed suppressed
T2-TSE fat suppressed T2-TSE fat suppressed
Routine sports imaging protocols employed at our institution when MR imaging is performed on a 1.5 Tesla system.
We obtain pathology-sensitive and anatomy-specific sequences of commonly injured structures. When performing
a biphasic indirect arthrogram, we obtain early sequences immediately after IV contrast administration followed by T2-
TSE sequences in three anatomic planes and then a set of delayed sequences to allow for accumulation of contrast within
the joint.
 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310 297

Fig. 2. A coronal (short axis) fat suppressed indirect

arthrographic image at the level of the fifth metatarsal
base demonstrates intense soft tissue enhancement at the
site of a peroneus brevis avulsion (large arrow) and the
enlarged, retracted tendon (small arrow).

localized edema in Kager’s fat pad, anterior to

the tendon. In this case, symptoms are generally Fig. 3. T2-weighted fat-suppressed image through the
self-limited, and specific therapy is rarely indicated ankle demonstrating abnormal fluid signal at the Achil-
(Fig. 4) [7–9]. les paratendon (arrows). Note the loss of the normal
In contradistinction to clinical Achilles ten- anterior concave border of the Achilles, in this case of
donitis, symptoms localized to the region of the paratendinitis.
calcaneal insertion of the Achilles are associated
with etiologies such as insertional Achilles ten-
donitis and Haglund’s syndrome. There is con- already enlarged tuberosity (Haglund’s deformity)
siderable overlap in the symptomatology and MR and a cycle of accelerated injury. The diagnosis of
characteristics of these two entities, as insertional Haglund’s syndrome can often be confirmed by
paratendonitis and retrocalcaneal bursitis occur in the presence T2-weighted hyperintensity indicat-
both. The retrocalcaneal bursa is a physiologic ing bone marrow edema in the enlarged calcaneal
one, and bursitis in this location is defined as tuberosity (Fig. 5). Insertional Achilles tendonitis,
a cranial-caudad span greater than 14 mm and on the other hand, is a classic runner injury often
measurements greater than 2 mm anterior-poste- with intratendinous T2-weighted hyperintensity
rior and 6 mm transverse [10]. The sine quo non of in a flame-shaped or comet tail configuration
Haglund’s syndrome is an enlarged calcaneal extending to the calcaneal periosteum (Fig. 6)
tuberosity. Employing parallel pitch lines, this [7,9,11–14].
Haglund’s deformity can be identified on lateral In the medial compartment of the ankle, the
radiographs and sagittal MR images. Congenital majority of tendon disorders are degenerative and
enlargement of the calcaneal tuberosity causes fall outside the scope of this article. However, a
repeated compression of the retrocalcaneal bursa subtype of posterior tibial tendon injury occur-
and impaction on the insertional aspect of the ring distally near its insertion is seen occasion-
Achilles. The result is bony proliferation at the ally in athletes. These partial or interstitial tears
298 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310

Fig. 4. An axial T1-weighted image of hypoxic Achilles tendinosis (A). Intratendinous signal is homogeneous, but the
tendon is enlarged and has lost its normal concave anterior margin (arrows). In contradistinction, the fat suppressed T2-
weighted image (B) demonstrates abnormal intratendinous high signal typical of mucoid Achilles degeneration.

are often subtle and best demonstrated on coronal

T2-weighted sequences with a small field of view.
Any fluid in or around the distal posterior tibial
tendon is suggestive of pathology, as there is no
anatomic bursa in this location. Fluid signal
around the tendon implies tenosynovitis and
proliferative metaplastic synovium, whereas ten-
dinous enlargement and fluid signal within the
tendon itself indicates tendinosis and interstitial
tendon tear. Other medial tendons are uncom-
monly involved in sports injuries [3,14,15].
The deltoid ligament, though commonly
sprained, is rarely torn completely. More com-
monly, one or two of the five fascicles is partially
or completely torn with an eversion injury. With
an inversion trauma, MR in the subacute setting
commonly demonstrates edema within the deltoid
ligament and in the medial malleolus at its
insertion. This pattern is likely due to impaction
trauma at the time of the inversion stress and Fig. 5. A T2-weighted fat-suppressed sagittal image of
subsequent medial contusion [16]. Haglund’s syndrome demonstrating the prominent
At the lateral ankle, the peroneal tendons calcaneal tuberosity (arrowhead ), an enlarged and
function as dynamic stabilizers working in con- fluid-filled retrocalcaneal bursa (large arrow) and ab-
junction with static ligamentous stabilization. normal fluid in the retroachilles bursa (small arrow).
 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310 299

Fig. 6. A sagittal T1-weighted image of the ankle (A) demonstrating fusiform Achilles enlargement approximately 4 cm
from its calcaneal insertion, typical of hypoxic Achilles degeneration. In contrast, this fat suppressed fluid-sensitive
T2-weighted image (B) calls attention to intratendinous edema at the calcaneal insertion diagnostic of an often pain-
ful condition, insertional Achilles tendonitis.

Understanding of this interrelationship is essential dome. With complete tears, the remnant proximal
for accurate assessment of sports-related pathol- tendon can retract significantly, and a large field
ogy. With an acute lateral injury, most often from of view sequence may be necessary for localization
an inversion stress but occasionally related to before operative repair (Fig. 8).
axial loading, there is a tendency for hemorrhage Lateral ankle ligamentous injury is common,
into the peroneal tendon sheath. With subsequent and the anterior talofibular ligament (ATFL) is
activity and repetitive stress, a complex synovitis most commonly involved. With ATFL disruption,
lends to the evolution of fibrous bands within the primary lateral ankle stabilizer is missing, and
the hemorrhagic synovium, ultimately leading to the calcaneofibular ligament is susceptible to
stenosing tenosynovitis. On MR imaging, both sprain or rupture. The posterior talofibular liga-
the excessive fluid and complex fibrous bands are ment is rarely torn. Edema anterior to one or
often visible within the tendon sheath. If the more of these structures on fluid-sensitive se-
clinical picture is unclear, intravenous gadolinium quences is indicative of ligamentous sprain. An
contrast (indirect arthrography) can be helpful in enlarged ligament without surrounding edema
making the diagnosis of stenosing tenosynovitis suggests a chronic injury or scarring. When there
because the fibrous bands and surrounding soft is ligamentous disruption, fluid signal violates the
tissues tend to enhance intensely (Fig. 7) [17]. normal anatomic course of the ligament, most
Tendinous injury is least common in the often at its talar insertion. Lateral ankle ligament
anterior compartment of the ankle, but partial tears evolve rapidly, and a subacute tear may
and complete tears of the tibialis anterior tendon appear identical to a ligament sprain on MR
occur infrequently with an acute plantar flex- imaging, so secondary signs of pathology are
ion force. High-level kicking athletes, usually in helpful. Fluid dissecting around the distal fibula
soccer or American football, are predisposed to on coronal T2-weighted or STIR sequences is
tibialis anterior tendon rupture, and the location a strong indicator of ligamentous disruption. If
of injury is invariably at the level of the talar the fluid tracks cephalad, the anterior talofibular
300 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310

Fig. 7. Axial T2-weighted fat-suppressed image (A) demonstrating fibrous bands (arrow) within the peroneal tendon
sheath. A sagittal indirect arthrographic image (B) confirms the diagnosis of stenosing tenosynovitis. Note the extensive
enhancement of the peritendinous soft tissues (arrows).

ligament is likely torn, whereas caudal extension tions predisposing the tendons to repeated sub-
suggests a calcaneofibular ligament disruption luxation. This diagnosis should be made only at
(Fig. 9) [1]. the distal-most aspect of the fibula, as the normal
The term ‘‘high ankle sprain’’ is often used to anatomic position of the tendons is lateral to the
communicate a tibiofibular syndesmotic injury. fibula at its distal metaphysis. Sequelae of re-
This entity can be difficult to identify on MR current peroneal subluxation include a syndrome
because of normal fenestrations within the liga- of disorders ranging from attritional wear of the
ments and the obliquity of their anatomic course. peroneus brevis tendon to peroneus brevis split-
Axial MR sequences with high anatomic resolu- ting, which manifests on MR as an enlarged,
tion (proton density or T1-weighted non–fat boomerang-shaped peroneus brevis at the level of
suppressed) are usually the most useful in eval- the distal fibula (Fig. 11).
uation of the syndesmotic ligaments. Helpful sec- Though posttraumatic bony contusion after
ondary signs of syndesmotic ligament disruption inversion stresses are more commonly seen in the
include an increased syndesmotic recess height medial ankle structures because of compressive
and strain of the adjacent flexor hallicus longus tensile forces, lateral bone marrow edema in the
muscle belly immediately posterior to the syndes- fibula, talus, and cuboid also occur, likely owing
mosis. Tears of one or both syndesmotic liga- to the rotational component of ankle sprains
ments can occur in isolation without other [4,18]. Acute lateral tendon tears are less common
ligamentous injury, but often the anterior syndes- than the above disorders in sports-related inju-
motic ligament is ruptured while the posterior ries but occasionally involve the peroneus longus
syndesmotic ligament remains intact (Fig. 10). tendon at the level of the calcaneal-cuboid ar-
Ossification at the syndesmosis suggests a chronic ticulation or the peroneus brevis tendon at its
or remote ligament injury. insertion.
With insufficient lateral ligamentous struc- Plantar fasciitis is a common overuse injury
tures, the peroneal tendons are prone to sub- frequently related to athletic activities. MR imag-
luxation. The morphology of the peroneal-fibular ing is generally not essential in establishing the
groove plays a role as well, with hypoplastic, diagnosis at initial presentation but plays a role in
convex, and externally rotated groove configura- the evaluation and management of prolonged
 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310 301

Fig. 8. T1-weighted fat-suppressed indirect arthrographic image through the anterior ankle (A) shows enlargement and
interstitial tearing of the tibialis anterior tendon with extensive synovial enhancement (arrow) in this soccer player.
Correlative sonographic image (B) of the same patient in the axial plane demonstrates the same pathology with tibialis
anterior tendon enlargement and interstitial hypoechogenicity indicative of tear.

symptoms, or those refractory to conservative thickened plantar fascia without intrinsic or

therapy. Acute plantar fasciitis is visible on perifascial edema may indicate chronic plantar
unenhanced MR of the foot or the ankle as fasciitis or scar from previous plantar fasciitis and
perifascial edema at the proximal aponeurosis can be asymptomatic (Fig. 12). A subgroup of
near or at its calcaneal insertion. An entheso- patients with clinical plantar fasciitis will have
phytic calcaneal spur may be present but does not a normal plantar fascia by MR imaging. Intrinsic
necessarily correlate with symptoms. Simple acute muscle tears, most often involving the flexor
plantar fasciitis with perifascial edema only is digitorum brevis, can mimic plantar fasciitis and
treated conservatively based upon symptomatol- are identifiable on MR imaging by contrasting
ogy. When intrinsic fluid signal is present within T2-weighted signal in adjacent muscle bellies.
the plantar fascia on T2-weighted or STIR Linear high signal within a muscle belly suggests
sequences, a partial plantar fascia tear should be an intrinsic muscle tear. For this reason, a field of
considered, and more aggressive treatment may be view should be chosen in clinical plantar fasciitis
warranted. With recalcitrant plantar fasciitis, adequate to visualize the regional flexor muscle
bone marrow edema and reactive bony changes insertions [19].
at the anteroinferior calcaneus are common and There is a clinical overlap between plantar
indicate microavulsive trauma at the insertional fasciitis and plantar nerve impingement disorders.
fibers. Often this marrow edema is apparent on The majority of nerve impingement disorders
T1-weighted and T2-weighted sequences, and of the foot are occult to conventional imaging
there will be correlative increased radiotracer examinations. However, a diagnosis of either me-
uptake on bone scintigraphy. In such cases, the dial or lateral plantar nerve impingement can be
microavulsive plantar fascial injury can be treated suggested by the presence of muscle edema
as a typical fracture with a long leg boot. A localized to a compartment. This is a diffuse
302 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310

Fig. 10. T2-weighted axial fat-suppressed image in

Fig. 9. On this coronal T1-weighted fat-suppressed
a basketball player with an acutely disrupted anterior
image from the delayed phase of a biphasic indirect
syndesmotic ligament (large arrow). As is often the case
arthrogram, a traumatic ankle effusion allows for
in syndesmotic injuries, the posterior syndesmotic liga-
excellent joint opacification by the intravenous gadoli-
ment remains intact (small arrow).
nium contrast aiding in visualization of the completely
disrupted calcaneofubular ligament (arrows).

pattern of edema, in contrast to the linear edema Other sports-related nerve impingement disor-
typical of intrinsic muscle tears. More frequently, ders of the foot and ankle include tarsal tunnel
these disorders manifest as fatty replacement of syndrome, deep peroneal nerve entrapment, and
a muscle compartment, indicating chronicity. This sinus tarsi syndrome. These three entities overlap
frequently subtle finding may be imperceptible clinically as a result of posterior tibial nerve
without conscious comparison of directly adjacent anatomy and its variable branching pattern. The
compartments (Fig. 13) [20,21]. tarsal tunnel (tibiotalocalcaneal tunnel or Richet’s
Another entity encountered with some fre- tunnel) is formed medially by the concave medial
quency in the setting of sports medicine MR is de- calcaneus, posteroinferiorly by the medial calca-
layed onset muscle soreness (DOMS). With a new neal tuberosity and anterosuperiorly by the
activity, or a dramatic increase in an activity, entire posteromedial segment of the talus and the
muscle groups respond in a typical pattern of sustentaculum tali. The posterior tibial tendon is
diffuse edema and hypertrophy. This syndrome particularly likely to cause posterior tibial nerve
may mimic focal musculotendinous injuries on impingement as it passes through the tarsal
physical examination, but the MR pattern of tunnel. In most cases of tarsal tunnel syndrome,
diffuse edema in one or multiple muscle groups MR imaging is normal. But if a lesion with the
without more focal fluid signal is seen in DOMS. potential to cause mass effect is seen within the
 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310 303

Fig. 13. Short axis T1-weighted image through the

forefoot demonstrating near complete fatty replacement
of a medial flexor muscle group, including the flexor
hallicus brevis. This pattern of fatty atrophy is typical of
long-standing impingement of the medial plantar nerve.

the flexor retinaculum. Focal enlargement of the

posterior tibial nerve at the level of the tarsal
tunnel may indicate edema within the nerve
sheath, also associated with tarsal tunnel syn-
Fig. 11. Peroneus brevis splits syndrome: note the
drome (Fig. 14) [17,21,22].
boomerang-like configuration of the peroneus brevis
(arrow) at the level of the distal fibula on this proton The sinus tarsi is at the lateral aspect of the
density axial image. talocalcaneal articulation, its floor being the
superior surface of the anterolateral calcaneus.
Fat within the sinus tarsi is a reassuring MR
tarsal tunnel, commonly a ganglion or a nerve finding, but normal variant anatomy includes
sheath tumor, then the diagnosis can be suggested a posterior subtalar joint extending into the sinus
and clinical correlation is warranted. Less com- tarsi and a small but normal quantity of fat within
monly, MR imaging of patients with tarsal tunnel the sinus tarsi, limiting its perceptability. If edema
syndrome demonstrates subtle edema between the is seen within the sinus tarsi, impingement of
medial tendons distal to the tunnel or adjacent to the interosseous nerve should be suspected, but,
again, MR imaging is often normal in these pa-
tients. Fluid or edema within the sinus tarsi may
also represent sequelae of cervical ligament in-
jury (Fig. 15). This structure, which can also be
termed the external talocalcaneal ligament,
courses from the cervical tubercle on the medial
talus to the inferior aspect of the talar neck and is
the chief stabilizer of the talocalcaneal joint [21].
The subtalar articulation is predominantly
ligamentous and allows for stability during foot
inversion and eversion. Normal inversion at this
joint is typically 30 degrees, with 15 degrees
characterized as normal for eversion. The plantar
Fig. 12. A sagittal T1-weighted fat-suppressed image calcaneonavicular ligament, or spring ligament,
from an indirect arthrogram in plantar fasciitis. Note the originates at the coronoid process of the calcaneus
proximal fascial enlargement and enhancement (large and inserts on the plantar aspect of the navicular.
arrows) and the insertional bone marrow edema at the Most spring ligament injuries are chronic and
calcaneus (small arrow). related to posterior tibial tendon dysfunction, and
304 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310

Fig. 14. Axial T1-weighted (A) and T2-TSE (B) images through the tarsal tunnel showing an enlarged, edematous
posterior tibial nerve (arrows) in this patient with clinical tarsal tunnel syndrome.

abnormal eversion forces. On MR, the spring Lisfranc ligament. One should try to visualize the
ligament can often be identified on coronal or ligament directly and verify its integrity on long
long axis images of the foot, but injury may be axis images. As with other intrinsic ligament
difficult to perceive without noting abnormal injuries, edema within the expected course of the
hyperintensity on fluid-sensitive sequences along ligament or at its insertions is indicative of
its course [21,23]. disruption (Fig. 16). Additionally, one can and
Injury at the tarsometatarsal articulation or should use bony alignment of the tarsometatarsal
Lisfranc’s joint can be a diagnostic and therapeu- joint as a secondary indicator of Lisfranc ligament
tic dilemma. Lisfranc ligament injury may be
a prototype for sports medicine, as it rarely occurs
outside the realm of athletic activity and it can
cause a prolonged course of recovery and re-
habilitation. Stabilization of Lisfranc’s joint in-
tricately involves the base of the second
metatarsal and its articulations with the first and
second cuneiforms as well as the third metatarsal
base. The second cuneiform is normally posi-
tioned in recess of the first cuneiform by
approximately 8 mm, allowing for a mortise
configuration of the elongated second metatarsal
base. The Lisfranc ligament courses from the
lateral aspect of the first cuneiform obliquely to
the plantar-medial aspect of the second metatarsal
base. Of note, there is no plantar ligament joining
the second cuneiform to the second metatarsal Fig. 15. This sagittal STIR image at the level of the
base, leaving the integrity of the Lisfranc ligament midfoot demonstrates extensive edema in the sinus tarsi
vital to alignment of the tarsometatasal joint. On (arrows) in a patient with posttraumatic sinus tarsi
MR, there are two mechanisms for evaluating the syndrome.
 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310 305

Fig. 16. Axial T2-TSE fat-suppressed image (A) at the level of the Lisfranc joint demonstrates marked edema in the
expected location of the ligament (small arrow). Note the bone marrow edema at the base of the second metatarsal (large
arrow). A coronal fat-suppressed image (B) shows an enlarged, abnormal Lisfranc ligament with surrounding edema
(arrows). Using radiographic criteria, an abnormal alignment of the proximal second metatarsal with the middle
cuneiform image confirmed a Lisfranc ligament rupture.

integrity in a manner similar to that used with hand, the integral role of the plantar plate in
radiographic evaluation. It has been suggested running and jumping create for a uniquely dis-
that a congenitally shallow Lisfranc mortise can abling, and consequently frustrating, group of
predispose athletes to Lisfranc ligament injury injuries. In the acute plantar plate injury, fluid-
[21,24,25]. sensitive MR sequences demonstrate intense
Springing forward off a plantar flexed foot, as edema in the soft tissues of the first metatarso-
in a runner accelerating from the starting blocks, phalangeal articulation and often flexor hallicus
generates tremendous dorsiflexion forces at the longus tenosynovitis. Occasionally, a plantar cap-
metatarsophalangeal joints, predominantly the sular rupture can be identified on T1-weighted
first. This joint is stabilized from dorsiflexion sagittal or short axis sequences. In the setting of
failure by the plantar plate or plantar accessory a lingering or chronic turf toe, a striking synovitis
ligament, which is formed by the deep transverse often accompanies these findings. This is a di-
ligament combining with fibers from the flexor agnosis that can be more readily made using an
hallicus longus, abductor hallicus, and adductor indirect MR arthrographic protocol when there is
hallicus tendons. The plantar plate is a thick doubt (Fig. 17) [6,20,21].
fibrocartilaginous structure contiguous with the Embedded in the plantar plate are the tibial
first metatarsophalangeal joint capsule at its and fibular sesamoids, which are also subject to
anterior or plantar aspect. This mechanism has acute and chronic injury in athletic activities. The
been shown to be more prone to failure in athletes medial sesamoid or tibial sesamoid is usually
performing on firm surfaces such as artificial turf, the larger of the two, but more insertions reside
giving rise to the popular term ‘‘turf toe.’’ Though on the lateral or fibular sesamoid. As a complex,
turf toe is analogous to a volar plate injury in the sesamoid and plantar plate insertions include the
306 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310

times grouped together as different stages of

sesamoiditis. On MR, therefore, it is important
not only to confirm a normal sesamoid configura-
tion, suggesting ligamentous integrity, but also to
evaluate bone marrow signal within the sesamoids
on a non–fat-suppressed sequence (Fig. 18) [2,21].
Evaluation of bony pathology and bone
marrow patterns in traumatic foot and ankle
injuries is a complex and challenging task, but
correlating the injury with its vector of traumatic
force can serve as a guidance mechanism in this
undertaking. In the foot, fractures can result from
repetitive forces that would not be great enough to
cause a fracture had they occurred only once, or
from normal forces along abnormal axes, as in
a result of abnormal weightbearing related to
another injury. Some typical stress fracture
locations are invariably linked with specific
athletic activities. In basketball players or other
jumping athletes, the tarsal navicular is particu-
larly susceptible to fracture (Fig. 19). Calcaneal
fractures can also occur in basketball players,
though they are more commonly encountered as
insufficiency fractures in an older population. A
multitude of stress fractures are seen in distance
runners, with locations likely related to running
form and individual anatomy. The third, fourth,
and fifth metatarsals as well as the cuboid and
Fig. 17. Sagittal STIR image at the first metatarsopha- cuneiforms are all commonly involved, whether
langeal joint after an acute dorsiflexion stress on a hard a primary injury or secondary to altered weight-
surface. The extensive edema in the thick fibrous plantar
bearing after a soft tissue injury (Fig. 20). And
plate is typical of a ‘‘turf toe’’ injury.
second metatarsal stress fractures occur with such
frequency in young military recruits that the term
two heads of the flexor hallicus brevis, the abductor ‘‘march fractures’’ has become popular. MR
hallicus, the flexor hallicus longus fibrous tunnel, concepts for diagnosing stress fractures hold true
the oblique and transverse portions of the adductor regardless of location. STIR and fat suppressed
hallicus, the metatarsosesamoid ligaments, the T2-weighted sequences are most sensitive to cir-
deep transverse metatarsal ligaments, an intersesa- cumferential, intense bone marrow edema typical
moid transverse ligament, and portions of the of stress fractures. But loss of fat and ultimately
plantar aponeurosis. The medial metatarsosesa- a hypointense fracture line as well as periosteal
moid ligament is larger and stronger than its lateral reaction on non–fat-suppressed T2-weighted or
counterpart, sending oblique fibers to both the sometimes T1-weighted sequences are more spe-
closer tibial sesamoid and the more distant fibular cific indicators. It is important to remember that
sesamoid. Depending on the vector of stress, either radiographs have a sensitivity reported as low
metatarsosesamoid ligament can rupture and thus as 15% in early stress fractures, so MR imaging
allow for a rotational malalignment of the hallux- is often the cornerstone in making an imaging
sesamoid complex away from the injured ligament. diagnosis [18,26,27].
Additionally, the thick, fibrous transverse interse- MR evaluation of bone marrow in the foot and
samoid ligament within the plantar plate can ankle also is useful outside the realm of fractures.
rupture, allowing for a divergent configuration of Stress reaction can manifest as bone marrow
the sesamoids. Once the hallux-sesamoid complex edema across articulations and can be an early
is displaced, abnormal weightbearing vectors of imaging indicator of eventual bony or soft tissue
stress can cause sesamoid contusion, fracture, and failure. It also has been noted that distance run-
even avascular necrosis. These entities are some- ners can demonstrate a pattern of bone marrow
 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310 307

Fig. 18. This short axis T2-TSE fat-suppressed image (A) demonstrates edema in the location of the transverse
intersesamoid ligament (arrow) and an abnormally large distance between the two sesamoids. A long axis T1-weighted
image (B) confirms the diagnosis of an intersesamoid ligament rupture.

edema in multiple tarsal bones, though the sig- Bone marrow edema patterns related to altered
nificance of this finding is not entirely clear. Sub- biomechanics are characteristically only seen on
tendinous bone marrow edema, notably with fluid-sensitive sequences without periosteal re-
regard to posterior tibial and Achilles tendon action. When this marrow pattern is present,
insertions, has been described as associated with attention should be paid to regional ligamentous
evolving tendinopathy. Finally, a pattern of dif- and tendinous insertions as the cause of the
fuse bone marrow edema is well described after altered biomechanics or abnormal stresses can
periods of immobilization [1,28,29]. often be identified on the same study. Serial MR
MR imaging evaluation of bone marrow imaging examinations frequently play a role in
edema also plays an integral role in guiding evaluation of high-level athletes to evaluate re-
therapy in the setting of bony contusion. The sponse to therapy and interval resolution of bony
most common traumatic contusion pattern is seen contusion and soft tissue injury [4,16,18].
in conjunction with inversion stresses and lateral Although more often a secondary injury,
ankle sprain. This pattern includes a large impac- a discussion of sports injuries of the ankle would
tion contusion with bone marrow edema in the not be complete without touching on the topic of
medial malleolus, the medial talus, and the medial osteochondral defects. Articular cartilage injury
calcaneus with a smaller microavulsive contusion at the talar dome is particularly common with re-
at the lateral talus and fibula. Often, the pattern of newed weightbearing at some point after ankle
bone marrow edema can lend insight into axes fracture or ligamentous injury. Non–fat-suppres-
of abnormal weightbearing or atypical stresses. sed T1-weighted sequences and gradient echo (or
308 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310

Fig. 21. This indirect arthrographic T1-weighted fat-

suppressed image in a patient with a talar dome
osteochondral defect shows enhancing fluid surrounding
the osteochondral fragment (arrows), suggesting its
instability.

Fig. 19. A T2-TSE axial image in this basketball player

with chronic midfoot pain is significant for hypointensity
in a navicular stress fracture indicative of sclerosis and
an unstable, loose fragment; peripheral edema
suggesting chronicity. suggests a partially loose fragment. It is impor-
tant to differentiate fluid signal from the slightly
spoiled gradient echo) sequences are most sensitive more hypointense signal typical of granulation
for osteochondral injuries, and the ankle mortise tissue in a healing defect. If an articular cartilage
should be evaluated in coronal and sagittal pro- defect alone is present, it is important to measure
jections. When evaluating an osteochondral defect, the defect so as to monitor potential progression.
fluid signal surrounding the fragment indicates Additionally, localized collapse of the articular

Fig. 20. A short axis fat-suppressed T2-TSE image (A) in this recreational runner draws attention to a metatarsal stress
fracture by virtue of the striking bone marrow edema (small arrows). But a non–fat-suppressed T1-weighted image (B) is
helpful in visualizing a discrete fracture line (large arrows).
 A.C. Zoga, M.E. Schweitzer / Magn Reson Imaging Clin N Am 11 (2003) 295–310 309

surface is an important finding and portends [5] Anderson IF, Crichton KJ, Grattan-Smith T, et al.
a poor prognosis. Indirect or direct arthrography Osteochondral fractures of the dome of the talus.
can be helpful in evaluation of osteochondral J Bone Joint Surg Am 1989;71:1143–9.
defects as contrast can imbibe into a defect and [6] Zoga A, Schweitzer ME. Indirect MR arthrography
in sports imaging. Topics in MRI, in press.
surround a free osseous or chondral fragment
[7] Haims A, Schweitzer ME, Patel R, et al. MR
(Fig. 21) [5,6,30,31]. imaging of achilles tendon: overlap of findings
in symptomatic and asymptomatic individuals.
Skeletal Radiol 2000;29(11):640–5.
Summary [8] Schweitzer ME, Karasick D. MR imaging of dis-
orders of the achilles tendon. AJR Am J Roent-
The complexity of foot and ankle anatomy and genol 2000;175:613–25.
function is unique in the musculoskeletal system. [9] Sona CA, Mandelbaum BR. Achilles tendon dis-
Understanding the complex anatomy alone is orders. Clin Sports Med 1994;13:811–23.
a daunting task, not to mention transferring that [10] Bottger Bradford A, Schweitzer ME, et al. MR
understanding to the two-dimensional planes imaging of the normal and abnormal retrocalca-
encountered on imaging studies. When evaluating neal bursa. AJR Am J Roentgenol 1998;170:
sports injuries in the foot and ankle, the interpret- 1239–41.
ing radiologist must take into account the type of [11] Chauveaux D, Liet P, LeHuec JC, Midy D. A new
radiologic measurement for the diagnosis of
activity, vector of stress, and inherent character-
Haglund’s deformity. Surg Radiol Anat 1991;13:
istics of the involved structures. A strong working
39–44.
relationship with the health care providers man- [12] Frey C, Rosenberg Z, Shereff M, et al. The
aging patient care, ideally orthopedists, is essen- retrocalcaneal bursa: anatomy and bursography.
tial. But in this age of decreasing specialization Foot Ankle 1982;13:203–7.
and increasing availability of imaging resources, [13] Schweitzer ME, Van Leersum M, Ehrlich SS,
the interpreting radiologist must use all available Wapner K. Fluid in normal and abnormal ankle
tools for clinical investigation. When interpreting joints: amount and distribution as seen on MR
an ankle or foot MR imaging, one finding should images. AJR Am J Roentgenol 1994;162:111–4.
trigger a search for the next finding along a logical [14] Jahss MH. Spontaneous rupture of the tibialis
posterior tendon: clinical findings, tenographic stud-
pathway of injury evolution. Bone marrow edema
ies and a new technique of repair. Foot Ankle Int
patterns are guides to tendon and ligament failure.
1982;3:158–66.
And a clinical syndrome without correlative [15] Rosenberg ZS, Cheung Y, Jahss MH. Rupture of the
imaging diagnosis should call attention to poten- posterior tibial tendon: CT and MR imaging with
tial alternative diagnoses. As the number of MR surgical correlation. Radiology 1988;169:229–35.
imaging studies performed continues to increase [16] Alanen V, Taimela S, Kinnunen J, et al. Incidence
and MR technology continues to improve, we and clinical significance of bone bruises after supina-
expect further advancements in MR evaluation of tion injury of the ankle: a double-blind, prospective
foot and ankle injury. We hope to continue to study. J Bone Joint Surg Br 1998;80:513–5.
work closely with our referring orthopedists in [17] Weishaupt D, Schweitzer ME, Alam F, et al. MR
imaging of inflammatory joint diseases of the foot
this arena to improve our diagnostic skills and our
and ankle. Skeletal Radiol 1989;28:663–9.
understanding of foot and ankle injury.
[18] Labovitz JM, Jonathan M, Schweitzer ME. Occult
osseous injuries after ankle sprains: incidence,
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19(10):661–7.
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[2] Eustace SJ. Magnetic resonance imaging of ortho- come. AJR Am J Roentgenol 1999;173:699–701.
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[3] Schweitzer ME, Karasick D. MR imaging of dis- tendon. AJR Am J Roentgenol 2001;176:1145–8.
orders of the posterior tibial tendon. AJR Am J [21] Sarrafian SK. Anatomy of the foot and ankle. 2nd
Roentgenol 2000;175:627–35. edition. Philadelphia: J.B. Lippincott; 1993.
[4] Schweitzer ME, Haims AH, Morrison WB. MR [22] Baille DS, Kelikian AS. Tarsal tunnel syndrome:
imaging of ankle marrow. Imaging of the foot and diagnosis, surgical technique and functional out-
ankle. Foot Ankle Clin 2000;5(1):63–82. come. Foot Ankle Int 1998;19:65–72.
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[23] Rule J, Yao L, Seeger LL. Spring ligament of the [28] Lazzarini KM, Troiano RN, Smith RC. Can
ankle: normal MR anatomy. AJR Am J Roentgenol running cause the appearance of marrow edema
1993;161:1241–4. on MR images of the foot and ankle? Radiology
[24] Lee JK, Yao L. Occult intraosseous fracture: 1997;202:540–2.
magnetic resonance appearance versus age of in- [29] Morrison WB, Carrino JA, Schweitzer ME, et al.
jury. Am J Sports Med 1989;17:620–3. Subtendinous bone marrow edema patterns on MR
[25] Peicha G, Labovitz J, Seibert FJ, et al. The anatomy images of the ankle: association with symptoms and
of the joint as a risk factor for Lisfranc dislocation tendinopathy. AJR Am J Roentgenol 2001;176:
and fracture dislocation. J Bone Joint Surg Br 1149–54.
2002;84B:981–5. [30] DiPaola JD, Nelson DW, Colville MR. Character-
[26] Umans H, Pavlov H. Insufficiency fractures of the izing osteochondral lesions by magnetic resonance
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 Magn Reson Imaging Clin N Am
11 (2003) 311–321

Winter sports injuries

The 2002 Winter Olympics experience
and a review of the literature
Julia R. Crim, MD
Department of Radiology, University Hospital and Clinics, University of Utah Health Sciences Center,
50 North Medical Drive, Salt Lake City, UT 84132, USA

The 2002 Winter Olympics in Salt Lake City, open. MR imaging was provided by General
Utah, brought together 2345 athletes from 80 Electric, and ultrasound was provided by Siemens.
countries. A wide variety of competitions took One of the difficulties in obtaining data about
place, which can be divided into broad categories injuries in recreational sports is that the injuries
of alpine (downhill) and nordic (cross-country) occur in a mobile population; vacationers often
skiing, snowboarding, ice skating (figure skating, wait until they return home before having injuries
speed skating, and ice hockey), and bobsledding evaluated. One study found that 38% of Seattle
(bobsleigh, luge, and skeleton). students suffering ski injuries returned home
Medical care for the Olympians was provided without reporting their injuries to the ski patrol
at several levels. Care was directed and coordi- or local physicians [1]. In contrast, at the 2002
nated by the Medical Commission of the Inter- Olympics, the availability of rapid, free, high-level
national Olympic Committee. On-site clinics at services led patients to be evaluated at the
the Olympic venues provided triage and acute Olympic clinic. Therefore, the Olympic clinic pro-
care. Intermountain Health Care provided in- vided an excellent window into the types of in-
hospital services. Provisions were made to airlift juries suffered by high-level athletes in winter
major trauma cases, but fortunately these did not sports.
occur. Instead, the hospitals treated ailments such
as heart problems, frostbite, and altitude sickness. Study population
Musculoskeletal injuries and ambulatory med-
ical problems were evaluated and treated at a The 2002 Olympic records were reviewed for
multispecialty clinic in the Olympic village, built sports-related injuries. Only competing athletes
and staffed by the University of Utah. Musculo- were included in the analysis of injuries. Only
skeletal radiologists from around the country vol- injuries for which positive imaging studies were
unteered their services. At the clinic, all services obtained are included. Injuries for skiing, snow-
were provided free of charge to the Olympians, boarding, bobsled, and luge are given per race
their coaches, and other members of the Olympic per person, because an accurate measurement of
teams. Kodak, as a major sponsor of the Olympics, number of practice hours could not be obtained.
contributed the Picture Archiving and Communi- The injury patterns of the Olympians were com-
cation System (PACs) and digital radiography to pared with injuries in recreational athletes.
the Olympic clinic. They provided organizational
support during the building of the clinic and tech- Alpine (downhill) skiing
nical support throughout the time the clinic was
A variety of events are grouped under alpine,
or downhill, skiing: downhill, super-G, slalom and
E-mail address: [email protected] (J. Crim). giant slalom, moguls, and aerials. Moguls and
1064-9689/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1064-9689(03)00027-8
312 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321

aerials are classified as freestyle skiing, where one of three ways: first, the skier catches an inside
jumps feature prominently. Aerial skiing takes edge of the ski and falls forward between the skis
off from a ramp to a 12-foot-high takeoff point, (valgus-external rotation.) Second, the skier falls
from which flips, twists, and somersaults are backward between the skies and catches the inside
accomplished. edge of the downhill ski (flexion-internal rotation).
The overall risk of injury from skiing is Third, the skier lands at the back of the ski, while
estimated at 0.25/1000 skier days [2]. The rate of the boot goes forward (transient anterior disloca-
injuries found on MR imagine at the Olympics, in tion) [2]. In high-level athletes, strong contraction
contrast, was 20/1000 person-races. (This figure of the quadriceps muscle in landing from a jump
includes any on-site practice for the races.) or in falling backward appears to be an impor-
The knee is the joint most commonly injured in tant contribution to transient anterior dislocation
alpine skiers, and the most common skiing-related of the knee [4]. Although there are numerous
knee injury is anterior cruciate ligament (ACL) mechanisms causing ACL tear, the ACL is more
tear. At the 2002 Olympics, four alpine skiers vulnerable to injury in certain positions: one
(three women, one man) suffered an acute ACL cadaveric study found that internal rotation of
tear (Fig. 1). In the general population, ACL tears the tibia was most likely to cause ACL tear when
are more common in women, but that does not the knee was either fully extended or fully flexed,
appear to be true in high-level skiers. A retrospec- and that internal rotation was more likely to cause
tive study of professional skiers found an injury a tear than external rotation [5].
rate of 0.004/1000 skier days in men, and 0.0044/ An ACL tear does not preclude a return to
1000 in women [3]. competitive skiing. One report of four competitive
A number of different mechanisms of injury can alpine skiers found that after surgical repair, all
lead to ACL tear. In skiers, tears usually occur in returned to racing [6]. One skier was disabled by

Fig. 1. Tears of the medial collateral ligament (MCL), anterior cruciate ligament (ACL), and lateral meniscus in an
alpine skier. (A) Coronal STIR through the midknee shows abnormal signal at the femoral attachment of the ACL
(arrow). There is a horizontal cleavage plane tear of the lateral meniscus and a sprain of the MCL (arrowhead ).
(B) Sagittal PD image through the intercondylar notch shows the discontinuity of the ACL.
 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321 313

arthrofibrosis, but the other racers returned to com- than this, it will not prevent anterior translation of
peting at the World Cup. Moreover, their mean the tibia. If the graft is farther anterior than the
World Cup rankings improved from 24 before recommended position, it also can cause impinge-
the injury to 14.6 after the injury. ment of the graft on the roof of the intercondylar
After an athlete has suffered an ACL tear, there notch. Of the eight downhill skiers with recurrent
is an increased risk of recurrent injury to the knee. injuries following ACL repair, four had sub-
Oates et al [7] found that compared with skiers optimal position of the graft (Fig. 3). Five had
with intact ACLs, skiers who were ACL-deficient a lax ACL graft, with secondary buckling of the
had a 6.2 times higher rate of injuries, and skiers posterior cruciate ligament (PCL).
who had undergone ACL repair had a 3.1 times Foot and ankle injuries due to skiing have de-
higher rate. clined in incidence since the 1970s because of im-
Five alpine skiers who suffered knee injuries in provements in ski bindings. At the 2002 Olympics,
the 2002 Olympics had preexisting, unrepaired six foot or ankle injuries were seen in five alpine
ACL tears. The new injuries in this group in- skiers. Three aerialists suffered foot fractures
cluded medial and lateral meniscal tears, medial ranging from microtrauma to midfoot fracture
and lateral collateral ligament injury, cartilage in- dislocation. One of these had bilateral calcaneal
jury, bone bruises, and popliteus injury (Fig. 2). microfractures. Two downhill skiers suffered syn-
Eight downhill skiers suffered recurrent inju- desmosis sprains; one of them also had a partial
ries while competing with a repaired ACL. For tear of the peroneus brevis tendon (Fig. 4).
a graft ACL to replicate the function of a native Shoulder injuries constitute approximately
ACL, the tibial tunnel should enter the joint in its 11% of alpine skiing injuries [8]. They are usually
middle third, and the femoral tunnel should be at caused by falls, and much less commonly the re-
the posterior margin of the intercondylar notch. If sult of collisions with other skiers or trees, or to
the graft is placed in a more vertical orientation pole planting. The most common shoulder injuries

Fig. 2. New injury in an alpine skier competing with a previously torn ACL. (A) Coronal STIR image through the
posterior aspect of the knee demonstrates an osteochondral injury with a free fragment in the medial femoral condyle
(arrow) and an impaction fracture of the lateral femoral condyle. The fibular collateral ligament is torn (arrowhead ).
There is extensive bone marrow edema in the proximal tibia. (B) Sagittal FSE T2-weighted image with fat saturation
through the medial femoral condyle. There is a condylar osteochondral injury (arrow) and a slightly displaced tear of the
posterior horn of the medial meniscus (arrowhead). Additional injuries in this patient included a lateral meniscal tear,
a posterior capsular tear, and a popliteus muscle strain.
314 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321

Fig. 3. Recurrent injury in an alpine skier with a poorly placed ACL graft. (A) Sagittal T1-weighted image with fat
saturation, intravenous gadolinium, at the intercondylar notch of the femur. The tibial tunnel is appropriately positioned
(arrowhead), but the femoral tunnel is too far anterior. No intact fibers are seen entering the femoral tunnel; only a mass
of amorphous, enhancing scar tissue (arrow) is present in this region. The graft was from autologous patellar tendon. (B)
Coronal T1-weighted image through the midzone of the medial meniscus. The patient complained of ‘‘locking’’ of the
knee, due to a bucket handle tear of the medial meniscus. Arrowhead points to the torn meniscal remnant; arrow points
to the fragment that is displaced into the intercondylar notch.

are rotator cuff injury, anterior glenohumeral dis- fracture (Fig. 5). Three athletes with acute back
location or subluxation, acromioclavicular sepa- pain had disc protrusions, one cervical and two
rations, and clavicle fractures. Only one alpine lumbar.
skier suffered a shoulder injury at the 2002
Olympics, a supraspinatus tendon tear. Nordic (cross-country) skiing
Ulnar collateral ligament tears are a common
injury in skiing, occurring when the skier falls and Nordic skiing has a lower rate of injuries than
the thumb is forcibly abducted and deviated ra- Alpine skiing. Incidence of injury has been esti-
dially by the ski pole when the thumb is held in mated to be between 0.2 and 0.5 per 1000 skier
the pole strap [2]. A single skier in our series suf- days [10]. Telemark (ski jumping) and nordic
fered a tear of the ulnar collateral ligament, which combined (ski jumping plus cross-country sprint-
was evaluated with ultrasound. ing) have a higher rate of injury, close to that of
Spine injuries are uncommon in alpine skiing, alpine skiers [11]. Only one nordic skier suffered
although they can occur during collisions with an injury at the 2002 Olympics, a semimembrano-
other skiers or with trees, or from crashes during sus strain.
jumps. One retrospective review of 10 years ex-
perience at a ski resort found 0.001 significant
Snowboarding
spinal injury for every 1000 skier days, of which
only 9% required surgery [9]. One alpine skier in Snowboarding has a higher reported injury
our series had an acute back injury caused by rate than skiing. A large study at Lillehammer
a collision. MR imaging showed an L5 pedicle attempted to estimate the number or injuries per
 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321 315

Fig. 4. Syndesmosis sprain and peroneal tendon partial tear in an alpine skier. (A) Axial FSE T2-weighted image with
fat saturation at the level of the tibiofibular ligaments. Anterior (arrow) and posterior (arrowhead) tibiofibular ligaments
are torn. (B) Coronal FSE T2-weighted image with fat saturation through the hindfoot. Splitting of the peroneus brevis
tendon is present (arrow). Bone marrow edema related to the syndesmosis sprain is seen, centered on the syndesmosis
and also in the medial malleolus. Other images also showed a partial tear of the deltoid ligament.

kilometer of skiing or snowboarding and de- Foot injuries are common in snowboarders.
termined a risk of 13.5 per 1000 km for snow- One Olympic snowboarder underwent bilateral
boarders, compared with 3.9 for alpine skiers and foot MR imaging for ongoing foot pain and was
3.0 for telemark skiers [11]. The injury rate at the shown to have bilateral plantar fasciitis. The
2002 Olympics was 28/1000/person per race. ‘‘snowboarder’s fracture’’ is a fracture of the lateral
Half of all snowboarding injuries in the general process of the talus, which is reported to represent
population are to the upper extremity [12]. Almost 15% of ankle snowboarding injuries [15]. No such
half of the upper extremity injuries are to the fractures occurred in the 2002 Olympic snow-
wrist. Wrist injuries are common in inexperienced boarding population. Although common in snow-
snowboarders, who tend to fall on an outstretched boarders, this underreported fracture occurs with
hand. As might be expected in our elite group, no a wide variety of other sports, and even from trip-
athletes suffered wrist fractures. Shoulder injuries ping going down stairs. At the 2002 Olympics,
include dislocations, fractures, and tendon tears. a potential luge athlete was sidelined because of
One 2002 Olympic snowboarder suffered a shoul- foot pain. MR imaging showed a nonunited lateral
der injury, a posterior dislocation (Fig. 6). process fracture and the severe secondary subtalar
Snowboarders are less likely than skiers to in- osteoarthritis that develops when this fracture is
jure the knee [13,14]. Three 2002 Olympic snow- untreated.
boarders injured the knee, all suffering ACL and Snowboarders have a higher rate of spinal
meniscal tears. injuries (0.004/1000 snowboarding days) than do
316 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321

Fig. 5. Left L5 pedicle fracture in an alpine skier, due to a collision. The study was read blinded to clinical history, and
subsequent review with the patient and his physicians confirmed that the subtle fracture identified on MR imaging
corresponded to his site of pain. (A) Sagittal FSE T2-weighted image with fat saturation through the left pedicles. Arrow
points to focal bone marrow edema, and a thin vertically oriented low signal-intensity black line represents the actual
fracture. (B) Axial FSE T2-weighted image through the L5 pedicles. Edema is seen in the left pedicle (arrow). It is less
prominent on this non–fat-saturated sequence than on the sagittal image, which was obtained with a fat saturation pulse.

skiers (0.001/1000 skiing days) [16]. Most injuries evaluation of back pain; one had a stress response
are related to jumping, and the higher rate in in the L5 pedicle, and one an annular tear and
snowboarders most likely is due to the greater premature osteoarthritis of the facet joints. One
number of jumps in recreational snowboarding. athlete suffered a shoulder injury (Fig. 8), a tear of
One snowboarder in our series, who had a preexist- the superior labrum involving the biceps anchor
ing L5 spondylolysis, developed a stress response (SLAP tear, so-called because it is a tear of the
of an L4 pedicle. superior labrum from anterior to posterior). In-
juries, calculated as positive imaging findings per
person per race, were 8/1000.
Bobsled
Bobsled competition is performed by either
Luge
a two-person or four-person team. The team
members push the sled from a stationary position Luge is a sledding sport where the athletes
and then jump aboard into a seated position. The (either solo or as part of a doubles team) lie supine
pilot steers while the remaining members keep and feet first in a narrow, curved sled. Rather than
their heads down. Injuries occur during the push- having a running start, as in bobsled, the athlete
ing phase and as a result of crashes. Athletes rocks back and forth to start downward motion at
commonly complain of back problems. speeds of up to 90 miles per hour.
Bobsledding injuries at the 2002 Olympics oc- There has been only one published epidemio-
curred primarily in the initial sled-pushing phase. logic study of luge injuries [17]. The study found
There were three patients with strains or tears of 407 injuries in 57,244 track runs (1043 athletes).
thigh musculature, and one acute injury of the This translates to 0.7 injuries per 1000 runs/person.
plantar fascia (Fig. 7). Two patients presented for Most injuries were contusions (51%) or muscle
 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321 317

Fig. 6. Posterior shoulder dislocation in a snowboarder. (A) Axial FSE T2-weighted image with fat saturation through
the midglenohumeral joint shows avulsion of the posterior labrum (arrow) and edema at the attachment of the posterior
capsule to the humeral head. Edema anteriorly in the humeral head is related to impaction of the humeral head against
the posterior glenoid. (B) Axial FSE T2-weighted image with fat saturation through the inferior portion of the joint
demonstrates a humeral avulsion of the posterior band of the inferior glenohumeral ligament (reverse HAGL). The free
edge of the torn ligament is shown by the arrow.

strains (27%). Only 3% of injuries were concus- one chronic ACL tear with a new MCL injury;
sions and 3% were fractures. Sixty-four percent one patellar fracture; and one ruptured Baker’s
of injuries were the result of crashes. cyst. There was one acute foot injury, a first distal
At the 2002 Olympics, nine athletes had phalanx fracture from dropping the sled on a toe.
imaging studies showing injuries related to luge. This patient and one other presented with chronic
This is a rate of 20 injuries per 1000 runs/person. peroneal tenosynovitis. Three patients presented
Four were knee injuries: one ACL and PCL tear; with acute back pain and disc protrusions or an-
nular tears, including one patient who also had
bilateral spondylolysis. In considering spondylol-
ysis as a risk of luge, comparison must be made to
a background risk of 6% in normal college-aged
controls [18].

Skeleton
Skeleton is a variant of luge, but the solo ath-
lete rides on the sled head first, reaching speeds of
up to 80 mph. Steering is done by shifting body
weight, primarily using the shoulders.
Because of the body position and high speed,
there is a high risk of injury. An Olympic hopeful
was killed in training when he ran headfirst into
the blade of another sled. Fortunately, there were
no serious injuries at the Olympics. No imaging
Fig. 7. Plantar fascia tear occurring during initial phase studies showed acute injuries, although negative
of a bobsled race. Sagittal STIR through the hindfoot. plain radiographs were obtained in several pa-
Arrow points to the focal tear in the plantar fascia. tients who had suffered contusions.
Fig. 8. Shoulder injury in a bobsledder, resulting in SLAP tear. (A) Coronal FSE T2-weighted image with fat saturation
through anterior edge of tendon anchor shows fluid between the biceps tendon and the superior labrum (arrow).
(B) Coronal FSE T2-weighted image with fat saturation posterior to the biceps anchor shows continuation of the
superior labral tear (arrow).

Fig. 9. Anterior dislocation of the shoulder in a speed skater. (A) Axial FSE T2-weighted image with fat saturation
above level of coracoid. Bone marrow edema is seen at the posterosuperior aspect of the humeral head (arrow), and there
is a displaced tear of the anterior glenoid labrum (arrowhead). (B) Axial FSE T2-weighted image with fat saturation
below level of coracoid. Arrow points to the complex tear of the anterior glenoid labrum.
 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321 319

Ice hockey Imaging studies found shoulder injuries in three

ice hockey players at the 2002 Olympics: one
Ice hockey, as a high-speed contact sport,
anterior glenohumeral dislocation, one acromio-
causes a wide range of injuries, most commonly
clavicular separation, and one fracture of the
contusions, strains, and sprains. Injuries are much
greater tuberosity of the humerus. Two muscle
more common during games than during practice.
hematomas were seen, and there was a single injury
One study of junior league athletes found an
to the ankle, a syndesmosis sprain.
injury rate of 96.1/1000 player-game hours, of
One patient presenting with back pain had
which 51% were due to collisions [19]. Pro-
advanced premature degenerative disc disease.
fessional ice hockey teams in Finland had an in-
game injury rate of 66/1000 player-game hours Speed skaters and figure skaters
[20].
Four ice hockey players presented with acute Two speed skaters suffered shoulder injuries,
knee injuries at the 2002 Olympics. Two of them one a rotator cuff contusion, and one an anterior
had preexisting ACL tears and now suffered acute dislocation (Fig. 9). MR imaging of the contra-
meniscal tears. Two had direct blows to the lateral lateral shoulder in the second patient showed
aspect of the knee. In one of these, MR imaging residua of a prior anterior dislocation on that side.
showed a lateral collateral ligament tear and lat- There was only one knee injury, an ACL tear in
eral bone bruise. The second had only a bone a speed skater. One speed skater had MR imaging
bruise of the lateral femoral condyle. evidence of tenosynovitis of the tibialis anterior

Fig. 10. Tibialis anterior tenosynovitis in a speed skater. (A) Axial FSE T2-weighted image with fat saturation above
level of tibiotalar joint. Arrow points to intact tibialis anterior tendon, surrounded by abnormal signal material. The
abnormalities extended from above the ankle to the insertion of the tibialis anterior tendon. (B) Axial FSE T2-weighted
image with fat saturation showing distal tibialis anterior tendon surrounded by fluid (long arrow). Patient also had
a thickened, lax anterior talofibular ligament (arrowhead), consistent with old injury. Fluid surrounding the FHL tendon
(short arrow) was believed to represent normal extension of intraarticular fluid into the FHL tendon sheath.
320 J.R. Crim / Magn Reson Imaging Clin N Am 11 (2003) 311–321

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 Magn Reson Imaging Clin N Am
11 (2003) 323–339

Imaging of stress fractures in the athlete

Damon J. Spitz, MD*, Arthur H. Newberg, MD
Department of Radiology, New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120, USA

Stress reactions and stress fractures represent theories to explain the mechanism of these
a spectrum of soft tissue and osseous injuries that fractures. According to Radin et al [28], one of
occur in response to a changing mechanical the major roles of muscle is to minimize the tensile
environment. Stress fractures occur when ab- stress on bone. Their experience demonstrates
normal repetitive stress is applied to normal bone. that soft tissue stabilizing structures, such as
They are caused by prolonged periods of unac- muscles and tendons, decrease bending or tensile
customed or strenuous activities, such as running forces in bone and increase compressive forces.
or marching [2,10,11,17]. Stress-related bone Because bone is more resistant to force in
injuries are common among members of active compression than tension, the supporting muscles
society and account for up to 10% of patients in help prevent fatigue fractures. When the support-
a typical sports medicine practice. In 17% of ing structures fatigue, the tensile forces increase,
cases, injuries are bilateral, and the incidence of rendering bone failure more likely. Accordingly,
sustaining a stress fracture approaches 16% in fatigue of muscles in the poorly conditioned
runners [5]. Stress fractures were originally de- athlete creates increased tensile stress on bone,
scribed in 1855 before the advent of radiographs. resulting in stress fracture (Fig. 1).
Since then, numerous publications, especially The physiologic response of bone to stress is
from the military ranks, have described these also important in the pathophysiology of stress
injuries [17]. Although stress fractures can occur injury. Bone is a dynamic tissue that requires
throughout the body, they are common in the stress for normal development, and it undergoes
lower extremities, especially the femoral neck, constant remodeling in response to changing
tibia, and metatarsals [8,9]. environmental forces [2]. Initially, osseous remod-
eling manifests as osteoclastic activity and re-
sorption of lamellar bone. This is subsequently
Mechanism of injury replaced by denser, stronger osteonal bone. In
Stress fractures occur when normal bone is repetitive stress overload, however, the acceler-
subjected to repetitive stress. Although no in- ated remodeling results in an imbalance between
dividual stress is capable of producing a fracture, bone resorption and bone replacement, leading to
over time bone fatigue and failure result. Stress is weakening of the bone. Continued stress results in
the force or absolute load applied to a bone that further imbalance, leading to bone fatigue, injury,
may arise from weight-bearing or muscular ac- and fracture. Osseous stress injury is not an all-
tion. The force may be applied as an axial, bend- or-none phenomenon, but a physiologic continuum
ing, or torsional load [2,10,11]. ranging from normal osseous remodeling, to
The precise pathogenesis of stress fracture is accelerated remodeling with fatigue and early
poorly understood; however, there are several injury, to frank stress fracture.
Another explanation of the pathogenesis of
Reprinted with permission from Radiologic Clinics stress fractures relates to increased muscle
of North America 2002;40(2):313–31. strength. Under normal conditions when a new
* Corresponding author. stress is applied, muscle tone is achieved more
E-mail address: [email protected] quickly than bone strengthening. This results in
1064-9689=03=$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016=S1064-9689(03)00021-7
324 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

Fig. 1. Mechanism of injury. Muscles play a significant role in reducing the tensile stress across bone. On the left the
telephone pole represents an unsupported bone showing equal tensile and compressive forces. On the right a guy wire
represents the supporting soft tissue structures such as the iliotibial band’s effect on the femur. The tensile or bending
forces are reduced and the compressive forces are increased. Bone is known to be stronger in compression than in
tension. (Adapted from Radin E, Blaha J, Rose R, Litsky A. Practical biomechanics for the orthopedic surgeon. 2nd
edition. New York: Churchill Livingstone; 1992; with permission.)

a mechanical imbalance, with muscle exerting by rest and then reoccurs when activity is
excess force on bone, resulting in bone fatigue. restarted. As the injury becomes more severe,
According to Wolff’s law, as the amount of the patient may have rest pain and this can be
stress on a bone is increased, progressive de- a source of clinical confusion for the treating
formity occurs throughout the bone’s elastic physician. A careful history is important in
range. As long as the deformity remains within establishing the clinical diagnosis. Findings on
the elastic range, when the deforming force stops, physical examination include localized pain,
the bone returns to normal. Beyond the elastic redness, swelling, and warmth. In areas of the
range, further stress results in plastic deformity skeleton where there is not a thick soft tissue
and microfractures. Continued stress results in covering, like the anterior tibia, periosteal new
progression of microfractures leading to further bone may be palpable and tender.
structural failure [11].
Imaging evaluation
Clinical features Radiography
In most circumstances the athlete sustaining In early osseous stress injury and fracture,
a stress injury is engaged in a vigorous activity to radiographs may initially be normal and more
which he or she is not accustomed. Alternatively, sensitive and specific tests, such as MR imaging
a conditioned athlete may sustain a stress injury and bone scintigraphy, may be necessary. The
when he or she changes a training regimen, sensitivity of early fracture detection by radiog-
performs a new repetitive activity, returns to raphy can be as low as 15%, and follow-up
activity too soon after an injury, changes foot- radiographs may demonstrate diagnostic findings
wear, uses worn-out footwear, changes training in only 50% of cases [3].
surfaces, or in general uses poor training tech- In bones that are predominantly cancellous,
niques. Women athletes with amenorrhea are such as the calcaneus or femoral neck, radio-
especially susceptible to stress injuries of bone [2]. graphs demonstrate a line of sclerosis perpendic-
Patients with stress fracture usually have pain ular to the trabeculae representing the fracture
related to their activity. The diagnosis of a stress (Fig. 2). In cortical bone, there is typically
fracture should be considered in patients present- periosteal reaction, a cortical fracture line, or
ing with pain after a change in activity, especially both. The radiographic findings depend on when
if the activity is strenuous and the pain is in the the images are obtained relative to the spectrum of
lower extremities. Classically, the pain is relieved osseous remodeling (Fig. 3).
 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339 325

Fig. 2. Calcaneus stress fracture. (A) Image from a radionuclide bone scan demonstrates marked increase tracer uptake
in the posterior right calcaneus. (B) Several weeks later the lateral radiograph demonstrates a sclerotic line perpendicular
to the trabeculae of the posterior calcaneus. (arrow) This sclerotic line is the characteristic appearance of a stress fracture
occurring in cancellous bone.

The differential diagnosis of stress fractures on a more aggressive lesion (Fig. 4). Patients with
radiographs includes osteoid osteoma; osteosar- osteoid osteoma usually present with a distinct
coma; round cell lesions, such as Ewing’s sar- pain pattern with symptoms often present at night
coma; and Langerhans’ cell histiocytosis. Usually relieved by analgesics. In osteosarcoma, the lesion
a careful clinical history and sequential radio- has a more aggressive appearance with bone
graphs help differentiate a stress fracture from destruction, aggressive periosteal reaction, and

Fig. 3. Second metatarsal stress fracture. Sequential radiographs from left to right in a patient with a stress fracture. The
initial radiograph is negative but radiographs at two weeks show faint periosteal reaction along the medial diaphysis of
the second metatarsal (arrow). At one month there is callous around the fracture (arrows). By three months the stress
fracture has healed.
326 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

osseous abnormalities [12,29]. MR imaging has

the additional advantage of demonstrating con-
comitant soft tissue injury. MR imaging is non-
invasive, has no ionizing radiation, and is more
rapidly performed than bone scintigraphy.
Both resorption and replacement of bone
characterize the early changes of stress injury to
bone. This is manifest by local hyperemia and
edema [12,42]. Because of its high sensitivity for
the detection of edema, MR imaging is an ex-
cellent modality for the detection of early osseous
stress injury [2,3,14]. Subsequently, MR imaging
clearly depicts the more advanced findings of
cortical bone breakdown and frank stress frac-
ture. It is this differentiation between the changes
of early stress injury to bone, and later stress
fracture, that has predictive value in estimating
the duration of disability, helping to guide therapy
[4,14]. In the symptomatic athlete, an early stress
injury may be treated with a short period of rest,
in contrast to the several months required for
healing of an overt stress fracture.
When evaluating for stress injury, MR imaging
parameters should include both a T1-weighted
Fig. 4. Proximal tibial stress fracture. Anteroposterior sequence and an edema-sensitive sequence, such as
radiograph of the left tibia in a 17-year-old female. short tau inversion recovery (STIR) or T2 with
There is sclerosis across the medullary cavity represent- frequency-selective fat suppression. The STIR or
ing the fracture line. There is exuberant periosteal new
fat-suppressed T2 sequences are important for
bone formation and this appearance could be mistaken
detection of the earliest changes of stress reaction,
for an aggressive bone lesion. The history and sequential
radiographs are helpful in making a diagnosis of stress such as periosteal, muscle, or bone marrow edema
fracture. [36]. The edema, or increased water content,
results in high signal intensity against the dark
background of the suppressed fat [2]. T1-weighted
the presence of tumor osteoid. Cross-sectional sequences depict anatomy and more advanced
imaging may show a soft tissue mass. stress-related findings. Imaging should be per-
Sequential radiographs are important in eval- formed in multiple orthogonal planes, with specific
uating the evolution of a stress fracture and often planes designated for particular locations (eg,
help or eliminate the need for a biopsy. It should coronal plane for femoral neck stress fracture).
be noted that biopsy of a stress fracture is Dedicated surface coils and use of a relatively
problematic because the pathologist can mistake small field of view improve image quality.
the new bone formation of fracture for a more Early MR imaging findings in osseous stress
aggressive osseous lesion. injury begin with periosteal, muscle, or bone
marrow edema that is only appreciated on the
MR imaging
STIR or fat-suppressed T2-weighted sequence. As
MR imaging is an effective diagnostic tech- injury becomes more severe, findings include
nique for the evaluation of patients in whom there marrow edema identified on both T2- and T1-
is clinical suspicion for stress fracture. Numerous weighted images and signal abnormalities in the
recent studies have demonstrated the efficacy of cortical bone. Frank stress fractures are diagnosed
MR imaging in the evaluation of stress injuries to when identifying band-like areas of low signal in
bone [4,14,41]. MR imaging allows depiction of the intramedullary space that may be continuous
abnormalities weeks before the development of with the cortex [23]. The most common pattern
radiographic abnormalities and has comparable of a fatigue-type fracture is a fracture line that is
sensitivity and superior specificity compared with low signal on all pulse sequences, surrounded by
radionuclide techniques for the detection of a larger, ill-defined zone of edema (Fig. 5). ‘‘The
 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339 327

Fig. 5. Distal fibular stress fracture. This long distance runner reported pain over the distal fibula, increasing over
several weeks. (A) Sagittal STIR image of the distal fibula demonstrates extensive bone marrow edema (curved arrow).
There is adjacent periosteal and soft tissue edema and a horizontal low signal fracture line. (B) T1-weighted sagittal
image demonstrates diffuse low signal representing edema within the marrow of the fibula with a low signal horizontal
fracture line (arrow). The findings are in keeping with a grade 4 stress fracture.

fracture line is continuous with the cortex and injuries were able to reach that level in 4 to 6
extends into the intramedullary space oriented weeks, and patients with grade 3 changes were
perpendicular to the cortex and the major weight- notably more symptomatic and were withheld
bearing trabeculae’’ [12]. from impact running for 6 to 9 weeks. Grade 4
Fredericson et al [14] have described a contin- injuries (stress fractures) were treated with a cast
uum of MR imaging findings and a MR imaging for 6 weeks followed by 6 weeks of nonimpact
classification of osseous stress injury [4]. Grade 1 activity. Notably, by the time the pain was present
injuries (mild) demonstrate periosteal edema, in the runners during training and persisting with
without focal bone marrow abnormality. Grade daily ambulation, there was an 81% incidence of
2 injuries demonstrate more severe periosteal grade 3 or 4 stress injury. They concluded that
edema with bone marrow edema detected on T2- MR imaging is more accurate than bone scan in
weighted images only. Grade 3 injuries demon- correlating the degree of bone involvement with
strate moderate to severe edema of both the clinical symptoms, allowing for more accurate
periosteum and marrow on both T1- and T2- recommendations for rehabilitation and return to
weighted images. Grade 4 injuries demonstrate activity [14].
a low signal fracture line on all sequences, with In a more heterogeneous group of patients,
changes of severe marrow edema on both T1- and Yao et al [41] examined the prognostic value of
T2-weighted sequences. Using this classification, MR imaging in stress injury to bone. Thirty-five
Fredericson et al [14] studied 14 runners with 18 patients with clinically suspected stress fractures
symptomatic legs (tibia) with radiographs, bone underwent MR imaging. The MR imaging find-
scintigraphy, and MR imaging. In 14 of 18 ings were classified according to the MR imaging
symptomatic legs, MR imaging findings corre- classification system proposed by Fredericson et al
lated with the technetium bone scan and more [14], and correlated with total duration of symp-
precisely defined the anatomic location and extent toms and time to return to sports activity.
of injury. In their study, patients with grade 1 Although they were unable to demonstrate the
stress injuries were able to return to running on prognostic value of the MR imaging classification
grass within 2 to 3 weeks. Patients with grade 2 system, they did find that the MR imaging finding
328 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

of a fracture or fatigue line or a cortical signal The term shin splints has been used to describe
abnormality was predictive of a longer symptom- the clinical entity of activity related lower leg pain,
atic period. They also found that muscle edema, by typically associated with diffuse tenderness along
itself, was predictive of a shorter clinical course. the posteromedial tibia. Bone scintigraphic studies
They concluded that the MR imaging finding of have concluded that shin splints represent a dis-
either a medullary line or a cortical abnormality tinct clinical entity from early osseous stress
seems to indicate a more severe stress injury to injuries [42]. Recent MR imaging studies have,
bone, and has prognostic value (Fig. 6) [40]. however, suggested that shin splints are a part of

Fig. 6. Tibial stress fracture. Thirty-four-year-old ultra-marathoner presented with chronic bilateral lower leg pain. (A)
Lateral radiograph of the lower leg demonstrates a horizontal lucent anterior cortical stress fracture (curved arrow) with
adjacent sclerosis. (B) Bone scan demonstrates foci of increased tracer activity uptake in both mid tibiae. (C ) Axial STIR
images of the lower legs in the same patient demonstrates bilateral anterior tibial cortical linear high signal (arrows)
compatible with bilateral stress fractures.
 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339 329

Fig. 7. Mild osseous stress injury (shin splints). Long distance runner training for the Boston marathon with pain in the
medial right tibia. Axial STIR image of both tibia demonstrates the findings of early osseous stress injury on the right.
There is both periosteal edema (curved arrow) and bone marrow edema (straight arrow). No fracture line or cortical
signal abnormality was identified and the patient was diagnosed with a mild osseous stress injury.

the continuum of fatigue damage in bone marrow edema was present in eight patients
[3,14,15]. Gibbon [15] reported MR imaging (Fig. 7). Increased cortical signal reflecting overt
findings in 10 professional athletes with clinical stress fracture was identified in two of the athletes.
features of shin splints. Medial tibial periosteal Fredericson et al [14] have also shown that in all
edema was present in all 10 patients and bone grades of tibial stress injuries in runners, there is
a consistent distribution of contiguous periosteal
edema at the origins of the tibialis posterior, flexor
digitorum longus, and soleus muscles.

Fig. 8. Multiple stress fractures. Twenty-three-year-old

female runner with amenorrhea presented with a right
proximal femoral stress fracture (curved arrow). Bone
scintigraphy demonstrates multiple foci of increased Fig. 9. Advanced tibial stress fracture (grade 4). Runner
uptake in the lower legs and feet (arrows). The patient with right tibia pain. Delayed, skeletal phase image of
had pain only in the right hip, and the other areas of the lower legs demonstrates an extensive focus of in-
abnormal uptake represent previous stress fractures. creased tracer uptake in the right mid tibia (arrow).
330 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

Fig. 10. Shin splints. Twenty-three-year-old soccer player with bilateral shin pain. Skeletal phase of a bone scan of the
lower legs demonstrates long, linear foci of increased tracer uptake along the tibial cortices bilaterally (arrows). The flow
and soft tissue phase images were normal.

The clinical significance of bone marrow

edema depends on the severity of the findings
and the clinical context. The finding of bone
marrow edema on STIR is a relatively sensitive
finding and may be seen very early in the stress
response. Lazzarini et al [22] imaged ankles and
feet of 20 runners and 12 nonrunners with a STIR
sequence at 1.5 Tesla (T). Sixteen of 20 of the
runners had bone marrow edema compared with 3
of 12 in the nonrunner group (P \ 0.002). The
average number of bones with edema was 3.6 in
the runner group and 0.3 in the nonrunner group
(P \ 0.001). All subjects with positive MR images
were asymptomatic. They concluded that in
runners, bone marrow edema seen on STIR
imaging may be caused by exercise alone.
Schweitzer and White [32] studied 12 volun-
teers with STIR images at 1.5 T before and 2
weeks after altered weight bearing achieved with
overpronation of one foot. Changes were seen on
Fig. 11. Sacral stress fracture. Coronal oblique CT scan
the STIR images in 11 of the 12 volunteers. Most in a 21-year-old college football wide receiver with low
changes were a diffuse increase in marrow edema, back pain. There is an oblique line of sclerosis in the
usually in the foot on the overpronated side. In upper left sacrum (arrow) representing a stress fracture.
two of the volunteers the changes resembled Corresponding bone scan (not shown) demonstrated
a stress fracture. increased tracer uptake.
 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339 331

Fig. 12. Tibial stress fracture. (A) Anteroposterior radiograph of the right tibia demonstrates cortical thickening of the
tibia medially. There is an oblique fracture line identified in the cortex (arrow). (B) Axial CT scan through both lower legs
demonstrates benign periosteal new bone formation along the medial aspect of the right tibia. (curved arrow) In this
patient with an atypical pain pattern for stress fracture, the CT scan was obtained to rule out an osteoid osteoma. There
is no radiolucent nidus identified.

The finding of bone marrow edema by itself is demonstrate findings suggesting the diagnosis of
not a finding specific to stress injury. Many an aggressive lesion in patients with stress
pathologic conditions may cause bone marrow fracture, so too can the MR imaging findings of
edema and reference should always be made to the extensive edema appear aggressive and misleading
clinical history. Differential considerations for the and correlation to the clinical setting helps to
bone marrow edema pattern, in addition to stress avoid this pitfall. Additionally, the detection of
injury, include acute bone bruise, fracture, oste- more advanced stress-related changes, such as the
omyelitis, avascular necrosis, transient osteopo- presence of a fracture line, ensures the diagnosis
rosis, and tumor. Just as radiographs may of fracture.
332 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

Fig. 13. Ulnar stress fracture. Nineteen-year-old college weightlifter with forearm pain. (A) Radiograph of the forearm
demonstrates lamellated periosteal reaction in the mid ulna (curved arrow). (B) Bone scan demonstrates extensive tracer
uptake in the mid ulnar diaphysis (arrow). Follow-up radiographs demonstrated healing of the fracture.

Bone scintigraphy
injury and osseous injury. In the first phase, the
Bone scintigraphy is an effective modality in blood flow phase, imaging is performed by
the evaluation of athletes with clinically suspected acquiring dynamic 2- to 5-second images over the
osseous stress injuries. Before the advent of MR area of clinical concern for 60 seconds after the
imaging it had been the gold standard for bolus intravenous injection. In the second phase,
evaluating stress fractures [2] and studies have the blood pool or soft tissue phase, imaging is
described its high sensitivity in detecting stress acquired immediately after for time (5 minutes) or
fractures [37]. Bone scintigraphy demonstrates counts (300 k) [37]. Imaging at multiple angles in
abnormal findings early in the continuum of the relation to the symptomatic region helps to
stress response in bone, by detecting the increased localize abnormalities on these soft tissue–phase
bone metabolism and osteoblastic activity associ- images. The final phase of imaging is the delayed
ated with osseous remodeling (Fig. 8). Scintigra- skeletal phase. These images should be acquired
phy is typically abnormal 1 to 2 weeks or more approximately 2 to 4 hours after injection to
before the radiographic changes of stress fracture. maximize clearance of the radiopharmaceutical
Bone scintigraphy should optimally be per- from the overlying soft tissues. Medial and
formed using a three-phase technique, because this posterior views are required for optimal assess-
technique can help differentiate between soft tissue ment of the tibia, whereas plantar views are
 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339 333

Fig. 14. Bilateral medial malleolar stress fractures. Twenty-three-year-old professional basketball player with bilateral
ankle pain (A) Radionuclide bone scan demonstrates increased tracer uptake in the left medial distal tibia. There also is
uptake in the right medial malleolus representing a known previously diagnosed stress fracture. (B) Coronal CT through
both ankles demonstrates a fracture line in the left medial malleolus (arrow). The sclerotic right medial malleolus
represents a healing fracture (curved arrow).

mandatory to evaluate fully the tarsal and meta- lesions in their patients were classified as mild and
tarsal bones. Medial and lateral views of the feet showed early and more complete resolution on
are important for evaluation of the tarsal bones follow-up studies after treatment as compared with
and differentiating between the first metatarsal the severe grades. Long-term observations of the
head and sesamoid bones [12]. Single photon scintigraphs in their patients revealed progression
emission CT may be helpful in the pelvis and is of lesions from mild to severe in those cases left
especially helpful in the lumbar spine for the untreated, and regression and healing from severe
diagnosis of spondylolysis. to mild in cases diagnosed and treated. They
In the early stages of osseous stress injury, concluded that early recognition of mild scinti-
scintigrams demonstrate ill-defined areas of graphic patterns representing the beginning of
slightly increased tracer uptake. As injury becomes pathologic bone response to stress enabled prompt
more severe, scans exhibit more intense and focal and effective treatment to prevent progression of
tracer localization [30]. Based on their experience lesions, protracted disability, and complications.
of the bone scintigraphic findings in 310 military Acute stress fractures typically demonstrate
recruits suspected of having stress fracture, Zwas abnormal tracer activity on all three phases of the
et al [42] described a scintigraphic classification bone scan. Soft tissue injuries are characterized by
of stress fractures ranging from grade 1 (mild) to increased uptake in the first two phases only. Shin
grade 4 (severe). Grade 1 lesions are small ill- splints are typically positive on only the delayed
defined foci of increased tracer with mildly in- images, demonstrating long, linear foci of in-
creased activity in the cortical region. Grade 2 creased tracer uptake along the posterior cortex of
lesions are larger lesions with well-defined elongat- the tibia (Fig. 10) [12].
ed areas of activity with moderately increased Although false-negative bone scans have been
activity. Grade 3 lesions are wide fusiform lesions reported in patients with tibial stress fracture [25],
with highly increased activity in the corticomedul- bone scintigraphy has very high sensitivity. De-
lary bone. Grade 4 injuries are wide extensive spite this high sensitivity, bone scintigraphy lacks
lesions with increased activity in the transcortico- specificity and such conditions as tumors, in-
medullary region (Fig. 9). Eighty-five percent of the fection, and infarction may mimic stress injury.
334 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

Additionally, although scintigraphy may be useful CT also may help problem solve when there
in the initial staging of bone injury, it is less useful are equivocal findings on radiographs, MR
for follow-up because abnormal uptake may imaging, or scintigraphy. The value of CT in this
persist for several months [2]. regard lies in the detection of a discrete lucent or
sclerotic fracture line or periosteal reaction (Fig.
12). CT is also extremely helpful in differentiat-
Computed tomography
ing between stress fracture and osteoid osteoma,
CT is limited in its ability to detect early because both entities may be hot on bone scan,
osseous stress injuries, and is less sensitive than show edema at MR imaging, and demonstrate
bone scintigraphy and MR imaging. It does, sclerosis on radiographs. CT, however, detects the
however, have a role in more advanced injuries radiolucent nidus of osteoid osteoma.
and injuries in specific locations where radiogra- CT has also proved valuable in the diagnosis of
phy is limited. CT is particularly well suited for pediatric stress fractures. Initial radiographs may
stress fractures of the tarsal navicular; longitudinal demonstrate marked periosteal proliferation,
stress fracture of the tibia; pars interarticularis which may mimic tumor. The CT demonstration
stress fractures (spondylolysis); and stress frac- of endosteal bone formation in these cases often
tures in the sacrum (Fig. 11). leads to the correct diagnosis [2,18].

Fig. 15. Tarsal navicular stress fracture. (A) Coronal CT scan through the right and left midfoot demonstrates a right
tarsal navicular stress fracture in this high school senior basketball player recruited to play division I basketball. The CT
demonstrates the sagittal orientation of this fracture. (B) Repeat coronal CT 10 months later shows almost complete
fracture healing (arrow). The patient was asymptomatic at this time.
 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339 335

ball players; and football players, typically line-

backers. In addition, this injury has been seen in
athletes that practice and play extensively on an
artificial turf surface, including football and
women’s field hockey. The correct diagnosis of
a navicular stress fracture is often delayed for
several months, partly because the clinical onset is
insidious with nonspecific signs and symptoms
and also because these stress injuries are not
evident on radiographs in most cases [16,21]. The
interval between the onset of symptoms and the
diagnosis may be from 7 weeks [39] to 4 months
[20], but may be much longer in some patients.
Clinically, patients report pain along the dorsal
medial aspect of the midfoot associated with run-
ning [6,38]. Patients complain of ill-defined foot
soreness or cramping that increases during ath-
letic activity, and there is often pain to palpation
along the medial longitudinal arch or on the
dorsum of the foot [27]. Many patients with an
incomplete fracture can continue to jog or even
run especially if the forefoot is not used in foot
strike [13]. Sprinting and jumping, however, are
typically followed by pain and limp.
Navicular stress fractures are treated with cast
immobilization [20]. This treatment results in
a successful outcome in 80% of patients and most
athletes have a return to sports in 5 to 6 months
Fig. 16. Tarsal navicular stress fracture. (A) Coronal CT
[20].
image at the level of the midfoot demonstrates an un-
Most navicular stress fractures occur in the
united stress fracture of the navicular (arrow). The
fracture extends the full length of the navicular. (B) middle third of the navicular. Microvascular
Corresponding coronal STIR image demonstrates high studies show that there is relative avascularity of
signal at the fracture site and surrounding bone marrow the middle third of this bone. These findings
edema. suggest that repetitive cyclic loading may result in
fatigue fracture through the relatively avascular
central portion of the navicular [39]. The consis-
tent site of the fracture seems to correspond with
Sites of injury
the plane of maximum shear stress especially
Although most common in the lower extrem- during plantar flexion combined with pronation.
ity, stress injury to bone and stress fractures have Navicular stress fractures may be incomplete
been reported in nearly every bone in the body or complete. Incomplete fractures usually involve
[10,34]. Stress fracture sites in the upper extremity the dorsal 5 mm of the navicular adjacent to the
include the ulna (Fig. 13), humerus, carpal bones, talonavicular joint, an area that is difficult to
and ribs. Lower-extremity stress fractures can also evaluate on radiographs [27].
occur anywhere and include the pubic symphysis; There may be associated foot anomalies in
lumbar spine (spondylolysis); femur; tibia; distal patients with navicular stress fractures. These
fibula; medial malleolus (Fig. 14) [31]; calcaneus; include a short first metatarsal, a relatively long
tarsal navicular; metatarsals; and sesamoids. second ray, metatarsal hyperostosis, or an asso-
Sacral fatigue fractures have also been recognized ciated stress fracture of the second through fourth
in runners [7,24]. digits [27]. A short first metatarsal or long second
metatarsal may tend to accentuate shear stress
Tarsal navicular stress fractures
because of the greater force being transmitted
Navicular stress fractures usually occur in through the second metatarsal and intermediate
elite athletes including runners; gymnasts; basket- cuneiform [13].
336 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

Fig. 17. Stress fracture of the right femoral neck. Twenty-one-year-old female athlete with right hip pain and normal
radiographs. (A) Coronal T1 weighted image demonstrates low signal intensity area along the medial aspect of the right
femoral neck. (B) Coronal STIR image demonstrates bright signal intensity in the femoral neck, and a fracture line in the
medial aspect of the femoral neck (arrow).

The imaging of suspected stress fracture of the allows an internal comparison and may also
tarsal navicular should begin with radiographs of detect an asymptomatic or unsuspected contralat-
the foot. Historically, bone scans and tomography eral fracture. Again, both axial and coronal
were recommended as the diagnostic imaging tests images are valuable for the assessment of fracture
of choice [27]. Currently, however, the authors healing [21].
believe that if suspicion is high, CT or MR The CT appearance of healing fractures does
imaging are better initial imaging modalities. not necessarily mirror clinical union. In general,
Because all of these fractures are linear, in the the imaging evidence of navicular fracture healing
sagittal plane, and are located in the central third lags behind the clinical picture [20].
of the navicular, CT imaging performed parallel
Stress fracture of the femoral neck
and perpendicular to the midfoot clearly demon-
strates the fracture line (Fig. 15). New multislice Stress fracture of the femoral neck in the
CT scanners allow image acquisition in one plane athlete is an injury with potentially severe con-
with subsequent multiplanar reformatting of the sequences and prompt diagnosis is necessary to
data set. prevent complications. An inadequately treated
MR imaging detects the bone marrow edema stress fracture can progress to a complete fracture
associated with osseous stress reaction that may and result in prolonged disability with further
be present before a fracture line is visualized and complications including nonunion and osteone-
MR imaging is a good imaging choice if there is crosis of the femoral head. The clinical diagnosis
suspicion of early injury. Coronal, sagittal, and of a hip stress fracture may be difficult. Often the
axial imaging sequences are recommended, and at pain pattern is atypical and pain may be referred
least one fat-suppressed sequence should be to the knee [5]. The team physician or coach must
performed. In the authors’ experience with MR have a high clinical index of suspicion for this
imaging of this fracture, the fracture line is best fracture and should pursue additional imaging
seen on the coronal images (Fig. 16). tests even if radiographs are normal [26].
Because radiographs are often not sensitive Femoral neck stress fracture may occur on the
enough to detect the original fracture, it is clear medial (compression) side of the femoral neck or
that this imaging modality does not provide the lateral (tensile) side of the neck. Most athletic-
a reliable indicator of fracture healing. Once induced stress fractures occur medially where,
a fracture is identified, CT should be used to fortunately, there is less danger of the fracture
assess fracture healing. Imaging both feet with CT displacing. Usually, these patients are managed
 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339 337

intensity on the T1-weighted sequence with

corresponding bright signal intensity on T2 or
STIR sequences, extending a variable distance
across the femoral neck from its medial margin
[35]. If a fracture line is present on MR imaging it
appears as a line of decreased signal intensity
perpendicular to the cortical margin and is seen
on all the coronal imaging sequences (Fig. 17).
In one study, 7 of 10 patients with non-
displaced medial (compressive side) femoral neck
stress fractures showed return of the normal bone
marrow signal intensity on STIR images at 3
months following the fracture diagnosis. In
another two patients, the MR image returned to
normal by 6 months [35]. Full clinical healing may
not be synonymous with MR imaging edema
signal resolution. Slocum et al [35] hypothesize
that in patients imaged 6 months following a hip
stress fracture, persistent diffuse increase in signal
is abnormal and may represent new or ongoing
injury.
Longitudinal tibial stress fracture
Tibial stress fractures may account for up to
73% of all stress fractures [40]. Most tibial stress
fractures are identified by the development of
a fracture line in the cortex of the proximal or
distal tibia. Often, a variable amount of cortical
thickening or periosteal reaction is present.
Fig. 18. Longitudinal stress fracture of the distal tibia. Alternatively, jumping athletes, such as basketball
(A) Bone scan demonstrates increased uptake of the players and ballet dancers, may develop single or
tracer diffusely in the distal tibia. (B) Axial T1 weighted multiple horizontal anterior tibial striations best
fat suppressed MR images after the administration of visualized on lateral radiographs.
Gadolinium demonstrate periosseous and bone marrow An unusual type of stress fracture is the
enhancement and an anterior longitudinal tibial cortex
longitudinal tibial stress fracture [33]. This fracture
fracture (arrows).
is oriented in the vertical plane and may involve
the anterior or posterior tibial cortex. Patients
conservatively and do not need cannulated screw usually have normal radiographs, and axial CT or
fixation. In a noncompliant patient, however, MR imaging demonstrate the fracture line (Fig.
operative intervention may be necessary. 18). Periosteal new bone formation can be detected
Whereas radiographs are usually normal at the and there may be some focal endosteal sclerosis
time of presentation, radionuclide bone scanning adjacent to the fracture [19]. MR imaging has the
is usually positive. After several weeks, the radio- advantage of demonstrating the presence of bone
graphs may show a linear area of ill-defined marrow or soft tissue edema if present. In most
sclerosis perpendicular to the primary trabeculae cases, the fracture defect extends through a single
of the medial aspect of the femoral neck of the cortex, with abnormal signal in the marrow cavity
symptomatic hip. This faint linear sclerosis can be and in the adjacent soft tissues [40].
difficult to visualize, and careful inspection of the Radionuclide imaging demonstrates a long
radiographs and comparison with the contralat- area of increased uptake in the distal tibia [33].
eral hip are helpful. This reflects the length of this longitudinal type of
MR imaging is the diagnostic test of choice in stress fracture. The bone scan can be misleading
detecting and following stress fractures of the especially in an older patient where a more
femoral neck. Stress fractures are diagnosed on aggressive lesion is often suggested by the bone
MR imaging as a rounded area of decreased signal scan appearance [1]. It should be noted that
338 D.J. Spitz, A.H. Newberg / Magn Reson Imaging Clin N Am 11 (2003) 323–339

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 Magn Reson Imaging Clin N Am
11 (2003) 341–371

Imaging of sports-related muscle injuries

Robert D. Boutin, MDa,*, Russell C. Fritz, MDb,
Lynne S. Steinbach, MDc
a
Med-Tel International, 3713 Lillard Drive, Davis, CA 95616, USA
b
National Orthopedic Imaging Associates, 1260 South Elisio Drive, Greenbrae, CA 94904, USA
c
Department of Radiology and Orthopedics, University of California at San Francisco,
505 Parnassus, San Francisco, CA 94143, USA

Physical activity is associated with good health designing an appropriate MR imaging protocol.
and long life. In particular, exercise is correlated As an absolute minimum, each MR imaging exam-
with a substantially reduced risk of fatality from ination generally includes at least two orthogonal
such major killers as heart disease [222] and stroke planes and pulse sequences. In addition to the
[72,114]. Investigators also have proposed that requisite axial plane, the second long-axis plane is
exercise has salutary effects in preventing diseases generally sagittal (when evaluating abnormalities
as diverse as cholelithiasis and cancers of the at the anterior or posterior aspect of an extremity)
colon, breast, uterus, and prostate [208]—all while or coronal (when evaluating abnormalities at the
tending to improve one’s sense of well-being [32]. medial or lateral aspect of an extremity). At least
Although exercise does have proved health one of these pulse sequences should use a fat-sup-
benefits, overzealous activity is a common cause pression technique (Fig. 1).
of injuries to muscle that may result in pain and For example, when evaluating a suspected
disability. rectus femoris strain in the anterior thigh on a 1.5-
This article focuses primarily on MR imaging T MR imaging unit, an abbreviated protocol using
as the imaging test of choice for evaluating sports- four pulse sequences might begin with sagittal T1-
related muscle injuries. Although the authors weighted and inversion recovery (IR) fast spin echo
recognize the usefulness of other imaging techni- (FSE) images to show the big picture, the longitu-
ques (eg, sonography), it is their experience that dinal extent of the abnormality. In addition, two
MR imaging is the most versatile and robust of all axial series are obtained: one with and one without
radiographic methods for examining injured ath- fat suppression. The images acquired with fat-
letes. After discussing practical MR imaging suppression can use a long TR (3000 to 4000
techniques used for imaging muscle, the most com- milliseconds) and intermediate TE (40 to 60 milli-
mon sports-related muscle injuries are reviewed. seconds). These fat-suppressed proton density
images are adequately T2-weighted to detect patho-
logic changes in muscles and other structures in a
Practical MR imaging techniques reasonable amount of time without compromising
the signal-to-noise ratio. These images, sensitive
Routine MR imaging protocol
for most pathologic changes, can be compared
Although recognizing that each patient is directly with corresponding axial images that are
unique, certain generalizations may be helpful in intended for high-resolution display of anatomic
structures. These ‘‘anatomic’’ axial images may
be either T1-weighted or FSE proton density im-
Reprinted with permission from Radiologic Clinics ages (with a relatively long TR of 2000 to 3000
of North America 2002;40(2):333–62. milliseconds and a short TE of 25 to 40 milli-
* Corresponding author. seconds) [85].
1064-9689=03=$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016=S1064-9689(03)00022-9
342 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Fig. 1. Calf hematoma. These MR sequences are routinely used in the axial and longitudinal planes. Coronal T1-
weighted (A), axial T1-weighted (B), and axial FSE fat-suppressed T2-weighted (C) MR images demonstrate a hematoma
in the region of the gastrocnemius. Note the elevated signal intensity within the hematoma on T1-weighting (A) and (B).
There is low signal intensity hemosiderin within the hematoma (arrows) and in the capsule on T1- and T2-weighted
studies.

Supplemental scans MR imaging has been described as a method of

diagnosing particular entrapment neuropathies,
Gradient echo imaging
such as tarsal tunnel syndrome that may be caused
Gradient echo sequences accentuate certain
by a hypertrophied accessory soleus muscle [195].
paramagnetic effects. This ‘‘blooming’’ effect may
indicate the presence of hemosiderin, metallic for- Gadolinium enhancement
eign bodies, or gas, and help in honing a differen- The administration of gadolinium-based con-
tial diagnosis. Indeed, these paramagnetic effects trast material generally is not necessary. Muscle
may be so conspicuous that low-resolution local- disorders caused by recent trauma, inflammation,
izer images may be sufficient to demonstrate these and neoplasm generally are displayed conspicu-
distinctive findings. ously with fat-suppressed T2-weighted or IR-FSE
Fast gradient echo images have been used for images. Occasionally, intravenous gadolinium ad-
high temporal resolution to study anatomic and ministration may be helpful in assessing injuries to
pathologic changes in muscle. For example, muscle the muscles of athletes [73,150,159]. In particular,
contraction during the MR imaging examination contrast-enhanced T1-weighted images have been
may demonstrate retraction of a torn muscle or advocated when a clinically suspected muscle in-
herniation of a muscle through a fascial defect. Cine jury is not visualized on T2-weighted and IR-FSE
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 343

sequences. Detection of torn muscle fibers may be (growth) plate. In young adults, biomechanical
more conspicuous after gadolinium administra- failure tends to target the interface between a muscle
tion, particularly when there is extensive hemor- and its tendon. In older adults with tendonosis,
rhage and edema [159]. Several cases have been overload of the myotendinous unit commonly
reported in which professional athletes had muscle results in fibers tearing at sites that are structurally
strains that were not diagnosed on T2-weighted and weakened by tendon degeneration. Interestingly,
IR-FSE images, but were visualized on contrast- conservative treatment of a purely tendinous injury
enhanced T1-weighted images [73]. generally has a worse prognosis than an incomplete
tear located at the myotendinous junction [200].
Exercise enhancement
Although exceptions to these generalizations do
After a muscle is exercised, acute elevation in T2
occur, imagers should be aware that the patient’s
signal intensity occurs [79], a phenomenon that has
age tends to influence where a strain-type injury
been termed exercise enhancement. This hyper-
occurs in the chain of bone, tendon, and muscle.
intensity on T2-weighted images seems to be caused
by increased water content in muscle after exercise Apophyseal avulsion injury
that is mostly extracellular in location [197,231].
Extracellular water in muscle has a long T2, In skeletally immature individuals, the weakest
whereas intracellular water in muscle has a short biomechanical link tends to be the apophyseal
T2 [54,141]. Signal intensity changes are only growth plate. A displaced avulsion fracture
slightly the result of increased osmolarity caused fragment generally can be recognized with ease
by lactate and may be independent of blood flow on radiographs. Radiographs may be interpreted
[19,81,198]. as negative in children, however, when an apoph-
MR imaging with exercise enhancement has yseal avulsion is essentially nondisplaced or when
been used experimentally in assessing muscle re- the apophysis is unossified. In such cases, an
cruitment during exercise to optimize sports train- advanced imaging technique, such as MR imag-
ing and physical therapy programs. For example, ing, may prove helpful (Fig. 2). In the subacute or
when comparing trained and untrained athletes, chronic setting, an avulsion injury potentially may
MR imaging can document differences in muscle resemble a neoplastic or infectious process, es-
recruitment by showing obvious disparities in the pecially when no history of trauma is provided
location, extent, and degree of T2 signal intensity [236].
changes induced by exercise [101]. Furthermore, Knowledge of the major tendinous attach-
after completion of a training program, MR im- ments to bone is imperative in achieving the
aging demonstrates that individuals performing correct diagnosis, and avoiding misdiagnosis of an
a given exercise use less muscle volume [196], and osteosarcoma or osteochondroma. The pelvis, for
that the exercise-induced T2 hyperintensity in mus- example, has many apophyses, and is a common
cle is reduced [51]. Of greatest practical importance location of avulsion fractures. The single most
to practicing radiologists, however, is awareness common site of avulsion is at the ischial apophysis
that spurious increased signal intensity on T2- (Fig. 3). In a small minority of cases, avulsion
weighted and IR-FSE MR images may occur if injuries are multiple at the time of presentation.
imaging is performed within 30 minutes after exer-
cise [238]. Treatment
Nondisplaced apophyseal avulsive injuries usu-
ally heal with conservative therapy. Surgery may be
Sports-related injuries considered with a recent apophyseal avulsion
displaced more than 2 cm. With old avulsions,
The myotendinous unit in athletes may be
surgical excision of a malunited or hypertrophic
avulsed, strained, fatigued, contused, lacerated,
fragment may provide relief of pain in some
herniated, devitalized, or denervated [57,71,235,
patients [134].
236]. When an excessive stretching force is applied,
the weak link in the chain formed by muscle,
Myotendinous strain injury
tendon, and bone tends to vary depending on the
age of the individual. In children, injury caused by Myotendinous strain or tear results from
excessive tension on the muscle-tendon-bone chain excessive stretch, especially while the muscle is
tends to result in apophyseal avulsion fractures being activated. Such strain injuries typically
because the weak link is located at the physeal occur when a powerful muscle contraction is
344 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Fig. 2. Minimally displaced avulsion of the medial elbow apophysis not seen on conventional radiographs. Coronal T1-
weighted (A) and fat-suppressed FSE T2-weighted (B) MR images reveal abnormal signal intensity within the
synchondrosis between the humerus and the medial epicondyle, most evident as high signal intensity on the T2-weighted
image (arrow).

combined simultaneously with forced lengthening not cross two joints also may result in strain injury
of the myotendinous unit. Strains tend to occur in (eg, the hip adductors, especially the adductor
muscles that cross two joints; have a high pro- longus muscle) (Fig. 5) [113,121,204,234,254].
portion of fast twitch fibers; and undergo eccen- The degree of strain may be graded along
tric contraction (ie, stretch during contraction). a spectrum of injury, from mild (first-degree),
As such, the most commonly strained muscles in to moderate (second-degree), to severe (third-
the extremities include the rectus femoris, ham- degree). This grading system is used to facilitate
strings, and gastrocnemius muscles (Fig. 4). communication and research. Low-grade injuries
Eccentric contraction of certain muscles that do are more common than high-grade injuries. For

Fig. 3. Displaced ischial apophyseal avulsion injury. Axial gradient-echo MR image shows the fragment separated from
the rest of the ischium with high signal intensity edema/hemorrhage between the two osseous structures (arrow).
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 345

Fig. 4. Second-degree strain of the rectus femoris muscle in a soccer player. Axial T1-weighted MR image (A) does not
reveal the strain. The axial FSE T2-weighted MR image (B) shows a high signal intensity lesion within the rectus femoris
muscle (arrow). This lesion rim enhances on the postintravenous gadolinium fat-suppressed T1-weighted MR images (C)
(arrow), consistent with internal seroma/hemorrhage.

example, in a retrospective study of 431 pro- addition, a rim of hyperintense perifascial fluid
fessional football players with hamstring injuries may track around a muscle belly or group of
[142], 324 (75%) of the injuries were first-degree muscles. Perifascial fluid or edema is common,
strains. Second- or third-degree injuries were occurring in up to 87% of athletes with acute
observed in 107 players (25%), with 58 players partial tears [58]. No architectural distortion of
(13%) sustaining severe injuries with a discrete, the muscle or tendon is present with first-degree
palpable defect in the hamstring muscle. strains. Pain and imaging abnormalities resolve
with appropriate rest from aggravating activities.
First-degree strain
Mild strains are characterized by microscopic Second-degree strain
injury to the muscle or tendon, typically with less Moderate strains may be defined as a partial-
than 5% fiber disruption. No significant loss in thickness (macroscopic) tear, with continuity of
strength or range of motion is observed clinically. some fibers at the site of injury. Partial tears may
With MR imaging in the acute setting, edema be subclassified as low-grade injuries if less than
and hemorrhage located at the myotendinous one-third of fibers are torn; moderate if one-third
junction creates high signal intensity focally or to two-thirds are torn; and high-grade if more
diffusely on T2-weighted or IR-FSE images (Fig. than two-thirds are torn [52]. Partial fiber dis-
6). This edema and hemorrhage may track along ruption may be associated with some loss of
muscle fascicles, creating a feathery margin. In strength.
346 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Fig. 5. Adductor muscle strain. Axial fat-suppressed FSE T2-weighted (A) and coronal fat-suppressed FSE T2-weighted
(B) MR images show a retracted, grade-three tear of the adductor longus muscle (arrows).

The MR imaging appearance varies with the modification, physical therapy, ice, massage,
acuity and severity of the partial tear. In the acute therapeutic ultrasound, electrical stimulation, and
setting, high signal intensity on T2-weighted or nonsteroidal anti-inflammatory medications. In-
IR-FSE images reflects the extent of edema and tramuscular injection of corticosteroid solution
hemorrhage (see Fig. 4). Hematoma at the myo- (eg, 1 mL [4 mg] dexamethasone with 3 mL of 1%
tendinous junction is highly characteristic of lidocaine) may be effective, but it is highly
second-degree strain injuries [183]. Perifascial fluid controversial [142].
also is common in this situation. In the setting of Most of these strains resolve clinically within
an old second-degree strain, the presence of hemo- approximately 2 weeks, although some of these
siderin or fibrosis may cause low signal intensity injuries are associated with persistent pain and
on T2-weighted images. Diminished caliber of the increased susceptibility to recurrent strain. Given
myotendinous unit at the site of injury also may be that a myotendinous unit is significantly more sus-
observed if healing has been incomplete. ceptible to injury after an initial strain injury
Treatment of second-degree strains is gener- [87,242], imaging may provide objective informa-
ally conservative. Management includes activity tion regarding the status of recovery. In particular,
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 347

Fig. 6. First-degree strain of the flexor carpi radialis muscle in the forearm. Axial FSE T2-weighted image shows the
feathery edema pattern without architectural distortion (arrow).

the presence of persistently altered signal intensity

Hematoma and pseudotumor appearance
in strained muscles may define a period of
Hematomas are common after a myotendinous
vulnerability to reinjury, despite clinical resolu-
injury, and may be predominantly intramuscular
tion of symptoms [82,100,242].
or intermuscular in location. Intramuscular he-
Third-degree strain matomas often resorb spontaneously over a period
Severe strains are characterized by complete of 6 to 8 weeks [71]. Most of the intramuscular
musculotendinous disruption, with or without re- hematomas that have been evaluated with MR
traction. Retraction of fibers may result in a pal- imaging between 2 days [65] and 5 months [59]
pable defect or a focal soft tissue mass. Physical after injury display characteristics of methemo-
examination usually reveals loss of strength in the globin, with increased signal intensity on both
affected muscle group. T1- and T2-weighted images (Figs. 1, 8) [57].
Accurate clinical diagnosis of injury severity can Occasionally, serous-appearing fluid from a hema-
be hampered in at least three ways. First, clinical toma may linger within a connective tissue sheath,
attempts to palpate an acute myotendinous rupture creating an intramuscular pseudocyst (Fig. 9)
may be frustrated by patient guarding, swelling, [107].
hematoma, or the presence of a deeply situated in- With an equivocal or remote history of
jury. Second, muscle weakness, which is most char- trauma, imaging may be indicated to assess a
acteristic of a complete rupture, may be masked by soft tissue mass that is suspected of being neoplas-
recruitment of synergistic muscles during clinical tic clinically [115,183,212,244,259]. Pseudotumors
strength testing. Third, pain and spasm in a patient occurring after a muscle strain have been reported
with a low-grade strain may result in the misleading most commonly to involve the rectus femoris, but
impression of a high-grade tear owing to weakness may be observed at other sites, such as the semi-
in the acute clinical setting. membranosus or semitendinosus (Fig. 10). MR
MR imaging demonstrates complete disconti- imaging may show a ruptured tendon with
nuity of fibers, commonly with fiber laxity. A retraction or an ill-defined signal intensity abnor-
hematoma often is seen in the gap created by an mality at the myotendinous junction that may be
acute tear (Fig. 7). Surgery may be indicated interpreted as a soft tissue neoplasm, such as a fib-
occasionally for loss of function after a complete rous tumor or sarcoma [212,244]. Histologically,
rupture in the acute setting, or for persistent pain such abnormal signal intensity often corresponds
and functional limitations that may be caused to the presence of fibrosis, muscle fiber degen-
by scarring and adhesions in the chronic setting eration, and chronic inflammatory cells [244].
[31,135,213]. Muscular atrophy begins to develop Differentiation between a simple hematoma
within 10 days after immobilization and may be and a hemorrhagic neoplasm may be difficult in
irreversible by 4 months [34]. some patients both clinically and with imaging.
348 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Fig. 7. Third-degree strain (complete tear) of the biceps tendon at the elbow with significant retraction and fluid-filled
gap consisent with a hematoma. Sagittal fat-suppressed FSE T2-weighted (A) and fat-suppressed T1-weighted image (B)
following intravenous gadolinium reveal the fluid-filled rim enhancing region distal to the biceps muscle (arrows).

Administration of contrast material aids in ex- probably benign hematoma is in doubt, clinical
cluding a neoplasm when the lesion in question correlation and a follow-up MR imaging exami-
shows no enhancement. Conversely, the presence nation may be indicated to establish appropriate
of an enhancing nodule in a muscle lesion may evolution of the abnormality.
suggest the diagnosis of a neoplasm rather than
a hematoma [147]. Three potential diagnostic pit-
Strain injury of specific muscles: pectoralis major,
falls must be recognized, however, when inter-
hamstring, and gastrocnemius muscles
preting the enhancement of a focal lesion after
intravenous administration of gadolinium con- Pectoralis major muscle
trast material. First, contrast enhancement is The pectoralis major is the largest, most
possible in the fibrovascular tissue of an evolv- superficial muscle in the anterior chest wall
ing hematoma, potentially making differentiation [15,45,52,139,175]. This fan-shaped muscle origi-
from neoplasm difficult [132]. Second, gadolinium nates primarily from the medial half of the clavicle,
may diffuse slowly into a fluid-filled space, such as the sternum, and the first six costal cartilages. The
a hematoma or abscess. Consequently, imaging clavicular and sternal heads converge as they pass
should be performed promptly after contrast ad- laterally, generally producing a bilaminar tendon
ministration to avoid spurious enhancement that inserts into the lateral lip of the humeral
within a mass that falsely might suggest it to be bicipital groove. The pectoralis major muscle
solid. Third, minimal or mild enhancement may functions to adduct, flex, and internally rotate the
be observed in a myxoid lesion (eg, intramuscular humerus. Pectoralis major tears most commonly
myxoma or myxoid liposarcoma), which then occur while the arm is abducted during eccentric
may be confused with a cyst or a lesion with a contraction (eg, in weight lifters) or during a direct
cystic component [131]. When the diagnosis of a blow (eg, in a motor vehicle accident).
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 349

Fig. 8. Adductor muscle hematoma. Axial T1-weighted (A) and FSE T2-weighted (B) images show a hematoma with
classic features (arrows). There is subtle high signal intensity methemoglobin within the hematoma on the T1-weighted
image. This region remains with high signal intensity on the T2-weighted image along with higher signal intensity serous
fluid.

Partial tears of the pectoralis major are gener- Hamstring muscles

ally more common than complete tears [52,185]. The hamstring muscles (biceps femoris, semite-
Partial tears tend to occur at the myotendinous ndinosus, and semimembranosus) principally
junction, and are usually managed nonoperatively. originate proximally from the posterolateral ischial
Complete tears usually occur more distally at the tuberosity and insert distally into the tibia. The
enthesis (Fig. 11). With avulsion of the tendon short head of the biceps femoris muscle originates
from its insertion site, high T2 signal intensity may from the midshaft of the femur posteriorly [58]. The
be seen superficial to the adjacent cortex because hamstrings function primarily to flex the knee and
of periosteal stripping [52]. Complete tears, par- extend the hip. While running or jumping, the
ticularly avulsion injuries from the humerus, hamstrings play a pivotal role in decelerating the
are treated optimally in active individuals with knee before foot strike and assisting with hip
prompt surgical repair to hasten rehabilitation extension after foot strike.
and improve functional outcome [26,133,185, The hamstrings are the most commonly injured
267,271]. muscles in sprinting and jumping athletes [4,135].
350 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Fig. 9. Residual hematoma within the gastrocnemius muscle. Axial FSE fat-suppressed T2-weighted (A) and fat-
suppressed T1-weighted images following intravenous gadolium administration (B) show a classic hematoma that has
created a rim-enhancing pseudocyst in the muscle (arrows).

For example, 10% of 180 soccer players suffered In the hamstrings, the zone of transition
hamstring injuries during a single season in one between the muscles and tendons is particularly
prospective study [135]. In young adults, most long. Indeed, each hamstring tendon extends
hamstring injuries are partial tears [4,135]; com- completely or almost completely down the length
plete hamstring tears or avulsions are relatively of each muscle [88]. Consequently, when strain
uncommon (Figs. 12, 13) [137,177,213]. Of the injuries occur at the myotendinous junction, these
three hamstring components, the biceps femoris injuries can be located at the ends of the mus-
is the most commonly injured [58,135,200,234]. cle belly or in the muscle belly itself. In one study
Injury to more than one component of the ham- of MR imaging in 15 college athletes [58],
strings is not uncommon, with a prevalence of acute hamstring injuries at the myotendinous
25% [88] to 33% [58]. junction occurred in diverse locations: the

Fig. 10. Pseudotumor after a muscle strain. Sagittal FSE fat-suppressed T2-weighted MR image shows a nonacute
midsubstance rupture of the semitendinosus muscle that retracted distally and balled up posterior to the knee (arrow),
resulting in a soft tissue mass that was clinically thought to represent a popliteal cyst.
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 351

Fig. 11. Complete tear of the sternal portion of the pectoralis major tendon distally at the enthesis on the humerus. Axial
fat-suppressed FSE T2-weighted MR image shows a completely avulsed tendon with muscle retraction and a high signal
intensity fluid-filled gap (solid arrow). Note the nearby biceps tendon (open arrow).

proximal myotendinous junction (33%); the in- After a hamstring strain, convalescence peri-
tramuscular myotendinous junction (53%); and the ods reportedly vary from less than 3 months to
distal myotendinous junction (13%). Hamstring 1.5 years before patients can return to vigorous
strain injuries also may occur at other sites, such activities [213]. Recurrent injuries are common,
as partial or complete avulsions at the tendinous occurring in one fourth of athletes [110]. Even
origin when underlying tendinosis is present minor hamstring injuries may double the risk of
[213]. a more severe injury within 2 months [70].

Fig. 12. Complete hamstring avulsion. Axial T2-wieghted MR image shows a full-thickness avulsion of the right
hamstring tendons which are separated from the ischial tuberosity by high signal intensity fluid/hemorrhage (arrow).
352 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Fig. 13. Complete tear of the hamstring associated with a large hematoma. Axial T2-weighted (A) and coronal fat-
suppressed FSE (B) MR images display a full thickness tear of the hamstring tendons (arrow) with a 2–3 cm gap between
the proximal and distal retracted musculotendinous unit (small arrow). There is a large hematoma associated with this
tear.

Gastrocnemius muscle syndrome, overuse tendinitis, ruptured popliteal

Several muscles and tendons at the posterior cyst, stress fracture, fascial herniation, venous
aspect of the knee and calf may be subjected to thrombosis, nerve entrapment, and popliteal
strain injuries, including the gastrocnemius [29, artery entrapment syndrome [144,232,251].
83,89,232,234], soleus [47,183], plantaris [9,111], MR imaging may be used to help determine an
and popliteus [40,262,266] muscles (Fig. 14). accurate diagnosis and determine its severity
The most common isolated muscular strain in [29,89]. In one recent MR imaging study of 23
the calf affects the medial head of the gastrocne- injuries to the distal gastrocnemius [261], the
mius muscle, and is referred to in common myotendinous junction was involved in 96% of
parlance as tennis leg [29,89]. Sudden onset of cases. The medial head was more frequently
sharp pain classically occurs in middle-aged involved than the lateral head (86% and 14%,
athletes participating in racquet sports, skiing, respectively), and low-grade or partial tears were
and running. Clinical differential diagnosis occa- more common than complete tears. In another
sionally includes chronic exertional compartment recent study of 65 patients with suspected tennis
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 353

Fig. 14. Rupture of the plantaris tendon with adjacent gastrocnemius strain. Axial T1-weighted (A) and fat-suppressed
FSE T2-weighted (B) MR images show a hematoma between the soleus and gastrocnemius muscles in the region of the
torn plantaris tendon (arrow).

leg [29], 51 partial and 14 complete tears were abnormal signal intensity reportedly may remain
diagnosed sonographically. Treatment is conser- for up to 80 days in patients with DOMS [221].
vative, typically with relief of pain within approx-
Muscle contusion
imately 2 weeks and return to sports after at least
3 weeks [89]. Contusion of muscle is produced by direct
trauma, usually by a blunt object. Interstitial
Delayed-onset muscle soreness
edema and hemorrhage result in varying degrees
Delayed-onset muscle soreness (DOMS) refers of pain, swelling, ecchymosis, and spasm. In ad-
to the muscular pain, soreness, and swelling that dition, a recognized complication of muscular
follows unaccustomed exertion. Activities that contusion is myositis ossificans. Uncommon or
require eccentric muscle contractions are common rare complications of muscle contusions include
culprits, such as hiking downhill or certain types compartment syndrome [168] and even pyomyo-
of manual labor. DOMS is thought to occur from sitis [5,149,186]. Blunt trauma presumably results
reversible structural damage at the cellular level; in muscle damage, hematoma formation, and
no permanent damage to muscle function ensues. hyperemia that may create a fertile ground for
Patients with DOMS do not recall any one subsequent infection.
particular moment of trauma or experience an With MR imaging, the girth of the muscle
acute onset of pain. Rather, symptoms tend to typically is increased, but no fiber discontinuity or
begin within 1 to 2 days after exercise. Soreness laxity is observed. Fat-suppressed T2-weighted
often crescendos until it peaks 2 to 3 days after the and IR-FSE images provide a conspicuous display
inciting exercise, and then generally subsides of high signal intensity that may have a diffuse or
within 1 week. Interestingly, this soreness often geographic appearance, often with feathery mar-
is associated with temporarily diminished muscle gins (Fig. 15). Although contusion injuries often
strength. appear larger in size than strain injuries, the
With MR imaging, high signal intensity in- recovery time for contusions tends to be signifi-
dicative of interstitial edema is observed on T2- cantly shorter (mean time: 19  9 days versus
weighted or IR-FSE images. Perifascial fluid-like 26  22 days) [247]. The duration of disability,
collections occasionally may be seen in the early ranging from 6 to 60 days, also may correlate with
phase. The MR imaging appearance of DOMS is the degree that range of motion is restricted
generally similar to a first-degree muscle strain. acutely after a contusion [118].
Clinical history allows for easy differentiation
Myositis ossificans
between these two entities in most instances.
The history of a provocative event may not The most common type of heterotopic ossifi-
be forthcoming in all cases, however, because cation occurs in muscle and commonly is referred
354 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Fig. 15. Muscle contusion after a car ran over this patient’s foot. Sagittal T1-weighted (A) and fat-suppressed FSE
T2-weighted (B) MR images of the foot show high signal intensity methemoglobin within the muscles of the
flexor compartment of the foot (curved arrows). There also is associated high signal intensity within the muscles on
T2 weighting (solid arrow).

to as myositis ossificans. The moniker ‘‘myositis’’ insults (eg, paraplegia [126], traumatic brain in-
generally is regarded as misleading because it is jury [109], and stroke [104]); or bleeding dyscra-
not a primary inflammatory process pathologi- sias (eg, hemophilia [50]). Myositis ossificans is
cally [3,20]. Clinically, myositis ossificans may be diagnosed, on average, 4 months after a phys-
confused with an inflammatory or neoplastic ical or neurologic insult [125].
process, with symptoms and signs that include In the clinical and radiologic arenas, three
pain, tenderness, swelling, and a palpable mass typical phases of evolution occur: (1) an acute or
[93,106,129,225]. Myositis ossificans affects the pseudoinflammatory phase; (2) a subacute or
large muscles in the extremities in approximately pseudotumoral phase; and (3) a chronic, self-
80% of cases [130]. limited phase that often undergoes spontaneous
Well-recognized precursors are observed in healing [36]. In the acute and subacute stages of
37% to 75% of patients with myositis ossificans myositis ossificans, imaging examinations have
[124,173,187,218]. Predisposing factors most com- a notoriously nonspecific appearance. In the final
monly include traumatic insults (eg, contusion stage, the essential imaging findings that permit
[116], surgery [43,207], and burns [76]); neurologic confident differentiation of myositis ossificans
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 355

from neoplasm-containing areas of mineralization of the lesion is suggested when the cortex of an
are threefold: (1) the ossific mass is well-defined, adjacent bone is intact and not in continuity with
sharply marginated, and appears more mature the area of soft tissue mineralization.
peripherally than centrally; (2) the lesion generally At this subacute stage, the imaging findings of
decreases in size with the passage of time, and (3) a soft tissue mass with ill-defined margins
the lesion is not in continuity with the underlying containing foci of mineralization are confused
bone. In contradistinction to calcification that has most commonly with a soft tissue sarcoma (eg,
an amorphous appearance, the sine qua non of osteosarcoma [257], chondrosarcoma, or synovial
mature myositis ossificans with all imaging sarcoma [152]). Periostitis also may be seen,
techniques is its recognizable architecture that although osseous destruction is absent. Given
approximates native bone: an area of cancellous that this early, immature mineralization is not
bone centrally surrounded by compact bone diagnostic, short-term follow-up radiography or
peripherally (Fig. 16). CT (repeated at an interval of 3 to 4 weeks) is
necessary to confirm suspected myositis ossificans.
Radiography and CT This allows postponement of a percutaneous bi-
During the first week, radiographs are gener- opsy or surgical procedure in the appropriate
ally negative, whereas CT scans may demonstrate clinical setting until diagnostic imaging features
vague muscle swelling. Within 2 to 6 weeks after have declared themselves [106]. By 1 to 2 months
the onset of symptoms, radiography and CT after the onset of symptoms, CT effectively shows
characteristically demonstrate vague, faint, floc- a peripheral rind of mineralization. Decreased
culent mineralization [3,203]. The benign nature radiodensity inside the lesion may correspond to

Fig. 16. Myositis ossificans in the medial thigh of an 18-year-old water polo player. Anteroposterior radiograph of the
thigh demonstrates a well-organized oval ossified mass with a rim of compact bone, consistent with myositis ossificans
(arrow).
356 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

developing cancellous bone, whereas decreased been performed after the mass matures in the
attenuation around the lesion may be secondary hopes of minimizing the risk of recurrence
to edema. The ossific mass matures over a period [84,167,190,248,250]. The surgical excision of
of 6 months to 1.5 years [125,143,248]. Resorption myositis ossificans occasionally may be indicated
of the osseous lesion may occur over a period of for purposes of a histopathologic diagnosis, un-
1 to 5.5 years [50,203]. remitting pain, a bulky area of ossification that
limits range of motion, or nerve entrapment
Bone scintigraphy [106,160,174]. Nerve impingement by heterotopic
Bone scintigraphy with technetium Tc-99m ossification most commonly involves the ulnar
medronate is more sensitive than radiography [49,63,169], median [169], radial [78], and sciatic
for the detection of myositis ossificans in the early nerves [120]. Given that the acute and subacute
stages. The three-phase bone scan typically stages of myositis ossificans potentially may be
demonstrates an area of nonspecific increased confused with a sarcoma [6,7,10,12,92,93,98,106],
tracer uptake in all three phases [237]. As the myositis ossificans has been designated a ‘‘do not
lesion matures, the intensity of radiopharmaceu- touch’’ lesion that should not undergo biopsy
tical accumulation lessens, approaching the ap- injudiciously.
pearance of normal adjacent bone [179].
Muscle laceration
MR imaging
MR imaging findings also evolve over time. In Muscle lacerations are uncommon athletic
the acute and subacute stages, MR imaging injuries produced by a penetrating insult. In the
findings are nonspecific. The involved muscle is acute setting, these types of injuries rarely are
enlarged and exhibits ill-defined, poorly-margin- evaluated with MR imaging. MR imaging soon
ated intermediate T1 and high T2 signal intensity after a muscle laceration shows focal, sharply
[225]. Enhancement occurs in the lesion after marginated discontinuity of fibers and high T2
contrast administration. In the adjacent muscle signal intensity caused by hemorrhage and edema
and bone marrow [106], areas of high T2 signal (Fig. 18). In the chronic setting, MR imaging of
intensity and contrast enhancement also may be the affected muscle characteristically demon-
observed. Although periostitis may be present in strates scarring as low T2 signal intensity and
the adjacent bone, myositis ossificans does not fatty infiltration associated with atrophy as high
arise from or destroy the adjacent bone. Intrale- T1 signal intensity. In addition, muscle occasion-
sional fluid-fluid levels can be observed in myositis ally may be seen herniating through a laceration
ossificans, a feature that also may be seen with in the surrounding fascia.
certain soft tissue neoplasms (eg, synovial sar-
coma) (Fig. 17) [253]. As the intermediate stage Muscle herniation
progresses, edematous changes in and around the
lesion diminish. High T1 and low T2 signal Muscle herniation refers to protrusion of
intensity areas begin to appear in the lesion, muscle tissue through a focal fascial defect [28].
corresponding to (fat-containing) medullary bone These fascial defects most commonly occur
and compact bone, respectively. In the mature secondary to muscle hypertrophy and increased
lesion, the margins become more well defined. intracompartmental pressure, with subsequent
The character of the signal intensity may herniation of muscle through relatively weak
remain inhomogeneous, although areas of high areas in the fascia, such as those traversed by
T1 signal intensity may be seen that represent fat blood vessels and nerves [158]. Less commonly,
interposed between bone trabeculae in the lesion a tear of the fascial sheath occurs with trauma,
[129,225]. such as that associated with fractures or penetrat-
ing trauma. Muscle herniation also has been re-
Treatment ported in a familial setting, suggesting congenital
Management of myositis ossificans may in- weakness in the fascia in some individuals [37].
clude nonsteroidal anti-inflammatory agents (eg,
indomethacin); diphosphonates; low-dose irradi- Location
ation therapy; physical therapy; and in uncom- Muscle hernias characteristically occur in the
mon cases, surgical resection [143]. Surgical middle to lower portions of the leg. The tibialis
resection of myositis ossificans traditionally has anterior is the most commonly involved muscle
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 357

Fig. 17. Myositis ossificans of the arm. Axial T1-weighted (A) and T2-weighted (B) MR images reveal an inhomogeneous
soft tissue mass that contains a fluid-fluid level (arrows). This nonspecific appearance might be confused with a hematoma
or a soft tissue neoplasm.

[228], although virtually any muscle in the leg can Although most muscle herniations are asymptom-
be affected, including the extensor digitorum lon- atic, they can cause substantial pain, cramping, and
gus [95], peroneus brevis [223], peroneus longus tenderness [28,41]. Fascial defects also may enlarge
[24], and gastrocnemius [8]. Herniation of muscle over time [41], resulting in cosmetic complaints.
in the thigh [41,206,224] and in the forearm Rarely, herniated muscle may become incarcerated
[97,176,210] is uncommon. Muscle hernias may [230] or result in nerve entrapment. For example,
be multiple [123,148] and bilateral [37,230]. herniation of the gastrocnemius muscle can com-
press the peroneal nerve and result in a clinical
Symptoms and signs presentation that resembles sciatica [8]. Muscle
Clinically, patients typically present with a herniation also may be observed in patients with
small, superficial, soft tissue bulge that becomes compartment syndrome owing to intracompart-
more prominent and firm with muscle contraction. mental hypertension.

Fig. 18. Laceration anterior to the elbow. Axial T1-weighted (A) and fat-suppressed FSE T2-weighted (B) MR images
reveal a linear defect that demonstrates elevated signal intensity on T2-weighting in the anterior musculature (solid
arrows). This is consistent with a muscle laceration from a stab wound. Some methemoglobin is seen in the wound on
T1-weighting (open arrows)
358 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

Imaging synthetic mesh also has been reported as a thera-

Imaging examinations characteristically dem- peutic option [148,228], although this technique
onstrate outward bulging of muscle, sometimes may be complicated by compartment syndrome in
with mild irregularity in contour peripherally some cases [13]. In patients with muscle hernias
(Fig. 19). MR imaging [37,158,270] may docu- owing to compartment syndrome, fasciotomy
ment herniation of muscle and discontinuity in the may be indicated.
overlying fascia. In uncomplicated cases, the
signal intensity of the herniated tissue matches Compartment syndrome
that of the adjacent muscle belly. MR imaging
Compartment syndrome refers to elevated
may be performed dynamically during muscle
pressure in a relatively noncompliant anatomic
contraction and relaxation, which may increase
space that is associated with ischemia and may
the conspicuity of a fascial tear or herniated
result in neuromuscular injury [119,166]. The term
muscle tissue. For example, fast gradient echo
Volkmann’s ischemic contracture applies to the
MR imaging of the leg during active dorsiflexion
sequelae of compartment syndrome, in which
of the ankle may show an increased volume of
fibrous tissue replaces necrotic muscle and nerve
herniated muscle compared with images obtained
tissue [119]. Potential complications of compart-
during active plantar flexion. Conversely, in other
ment syndrome not only include contractures, but
patients, active plantar flexion may depict a fascial
also myonecrosis, rhabdomyolysis, renal failure,
tear to better advantage in some patients [158].
and even death [27,77,112,136,214,252].
Treatment
Treatment of asymptomatic muscle hernias is Pathogenesis
usually conservative [24]. For symptoms that are The fundamental derangement in patients with
recalcitrant or severe, management may include compartment syndrome is elevated intracompart-
local injection of botulinum toxin [41] or fasciot- mental pressure. A vicious cycle can occur in
omy [24,162]. Fascial repair with suture or which muscle ischemia results in increased capil-

Fig. 19. Muscle herniation. Sagittal T1-weighted image of the distal thigh shows herniation of the semimembranosus
muscle and semitendinosus tendon posteriorly through a defect in the overlying fascia (arrow). A fascial release was
subsequently performed.
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 359

lary permeability, increased interstitial edema, and are associated with chronic exertional com-
increased intramuscular pressure that exceeds the partment syndrome targeting specific sites [2,11,
intravascular pressure of small vessels. The 25,30,48,96,102,105,108,128,163,172,178,188,193,
thin walls of these small vessels may collapse, 202,220,226,229,258,260]. In running athletes, for
thereby impeding blood flow [67]. Regardless example, the most common site of chronic com-
of the type of insult in any particular patient, the partment syndrome is the leg. The thigh, forearm,
final common pathway to compartment syndrome and foot are the next most common sites in athletes
involves a decreased arteriovenous gradient that [117]. Compartment syndromes affecting the para-
can result in ischemia and, ultimately, tissue nec- spinous musculature and other sites are considered
rosis. Factors that may predispose a compartment uncommon [44,61,127,140,180,214].
to this syndrome include a history of trauma;
external compression; systemic hypotension; in- Symptoms and signs
creased intracompartmental volume (eg, hemor- Patients initially complain of painful throbbing,
rhage, edema, poor venous return, and muscle aching, tightness, or pressure that worsens with
hypertrophy); and loss of compartment elasticity palpation and passive stretching of the affected
(eg, fibrotic or constricted fascia) [35,219]. muscles. With acute compartment syndrome, the
Compartment syndrome is classified most most important early symptom is pain out of
commonly according to its duration, cause, and proportion to that expected for the given injury
location. Knowledge of compartmental anatomy [264]. With chronic exertional compartment syn-
is fundamental to accurate diagnosis and treat- drome, symptoms typically begin during or imme-
ment of this potentially devastating condition [16]. diately after exercise, and tend to resolve at rest
after a variable period. With both acute and
Acute compartment syndrome chronic compartment syndrome, the arterial pulses
Numerous common and uncommon causes usually remain palpable, although venous and
of acute compartment syndrome have been lymphatic drainage are impaired [255]. Relatively
described [17,18,22,23,33,42,55,56,69,86,103,122, late findings of acute and chronic compartment
138,145,146,156,165,171,182,192,194,201,205,209, syndrome are deficits in motor and sensory nerve
217,233,239,243,246,256,268]. Although most cases function caused by muscle and nerve ischemia.
of acute compartment syndrome are associated
with fractures, the second most common cause is Diagnostic examinations
injury to soft tissues (eg, contusion) without Diagnostic tests used to evaluate for com-
fracture [157]. Compartment syndrome caused by partment syndrome include compartment pres-
athletics occasionally may present acutely in the sure measurements, near infrared spectroscopy
absence of direct trauma. Muscle rupture, for [39,91,164,181], and imaging examinations. Nor-
example, may cause compartment syndrome in mally, intracompartmental pressures should be
numerous locations, including the biceps brachii less than 15 mm Hg to 20 mm Hg at rest and
compartment of the arm, [156] the flexor compart- within 5 minutes after finishing exercise [117,189].
ment of the forearm [103], the superficial posterior Chronic exertional compartment syndrome is
compartment of the leg [245], and the peroneal diagnosed when intracompartmental hypertension
compartment of the leg [103]. Acute compartment is documented before exercise (15 mm Hg to 20
syndrome in the absence of muscle rupture also mm Hg or more) or immediately after completing
may occur (eg, in the triceps and deltoid muscles of an exercise session (30 mm Hg or more). Although
weight lifters [62] and in the anterior compartment direct pressure measurements are the gold stan-
of the legs of soccer players [265]). dard for objective diagnosis, potential problems
of blindly placed percutaneous catheters include
Chronic compartment syndrome catheter insertion into an unintended compart-
Chronic compartment syndrome may occur ment, inadvertent damage to neurovascular struc-
because of exertional causes (eg, exercise or tures, and inaccurate or inconsistent pressure
occupational overuse) or nonexertional causes measurements [64,154].
(eg, a mass lesion or infection). Exertional chronic
compartment syndrome occurs because muscle MR imaging
activity can increase muscle volume by up to 20%, Although cross-sectional imaging is not the
causing hypertension in noncompliant com- primary technique for diagnosing compart-
partments [68]. Consequently, particular activities ment syndrome, imaging may complement direct
360 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

pressure measurements by providing noninvasive 2. Increased signal intensity on T1-weighted

data on the compartment or compartments that images, caused by foci of hemorrhage (sub-
are involved, particularly in the nonacute setting. acute compartment syndrome) or fatty
Imaging also assists in evaluation for an un- infiltration (sequelae of established compart-
derlying lesion (eg, hematoma or neoplasm) that ment syndrome) [14,90,178].
may contribute to compartment hypertension and 3. Decreased signal intensity on T1-weighted
need to be addressed at surgery. Other potential images, caused by fibrosis or dystrophic
indications for MR imaging include the diagnostic calcification (sequelae of established compart-
evaluation of atypical cases (eg, uncommon ment syndrome) [90,178].
location or cause for compartment syndrome 4. Decreased muscle volume, relating to atro-
and borderline pressure measurements) and fol- phy, fibrosis, or both (sequelae of established
low-up evaluations. compartment syndrome).
Familiarity with the imaging appearance of 5. Fascial thickening (sequelae of established
compartment syndrome is important, given that compartment syndrome).
imaging may be performed for assessment of pain
Although controversial, gadolinium-enhanced
that initially is thought to be caused by other
MR imaging may be helpful in evaluating patients
causes (eg, stress fracture, myotendinous strain, or
with impending compartment syndrome by show-
soft tissue tumor). MR imaging can be used to
ing avid contrast enhancement in the affected
clarify the location and extent of ischemic damage
muscles. This enhancement can be useful in
to muscle [227,263]. In the setting of acute and
distinguishing muscles that are still perfused from
chronic compartment syndrome, increased muscle
those with devitalized areas.
volume commonly is caused by muscle hypertro-
In patients with suspected chronic exertional
phy, edema, or both (Fig. 20). This increased
compartment syndrome, MR imaging before
intracompartmental volume and pressure may
and after exercise may be helpful [75]. The change
result in herniation of muscle through a tear in
of signal intensity between pre-exercise and
the surrounding fascia [178]. Once established,
postexercise images is significantly greater in
compartment syndrome may demonstrate at least
compartments with postexercise hypertension.
five other features:
Furthermore, the magnitude of this change in
1. Hyperintense signal on fat-suppressed T2- signal intensity correlates significantly with the
weighted images caused by increased inter- change in pre-exercise and postexercise pressure
stitial water or edema (acute or chronic measurements, and with the absolute postexercise
compartment syndrome) [178]. pressure.

Fig. 20. Compartment syndrome of the vastus intermedius muscle. Axial T1-weighted (A) MR image shows enlargement
of the vastus intermedius muscle with splaying of the surrounding quadriceps musculature. The overlying fascia is
thickened (curved arrow). Fat-suppressed FSE T2-weighted (B) MR image shows abnormal high signal intensity within
the enlarged muscle (straight arrow). (Courtesy of Vincent McCormick, MD)
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 361

Other MR imaging techniques also have Treatment

shown promise in evaluating acute and chronic The critical threshold at which myoneural
compartment syndrome. Diffusion-weighted echo- necrosis occurs may vary according to the
planar MR imaging potentially can depict alter- location of the compartment syndrome; its acuity
ations in the circulating blood volume in muscle and duration; and individual patient factors (eg,
induced by exercise and changes in compartment hypotension and soft tissue trauma). For example,
pressure [269]. MR spectroscopy with phosphorus- in athletes with acute anterior compartment
31 has been used experimentally to determine the syndrome in the thigh caused by a contusion,
pressure threshold for metabolic deterioration of conservative treatment reportedly yields results
skeletal muscle. This technique also has been used superior to fasciotomy, despite sustained pressure
clinically to document the extent of muscle da- elevations above 50 mm Hg [211]. In general,
mage after ischemia and healing after fasciotomy surgical decompression is performed when acute
[263]. compartment pressures reach 30 mm Hg to 80 mm
Hg [74,170,216,240]. Findings favoring fascial
Although MR imaging may be sensitive in the
release include increasing compartment pressures
evaluation of compartment syndrome, it is not
over time, paresthesia, and paresis. For chronic
specific. Depending on the clinical context, the
compartment syndrome, fasciotomy generally is
imaging differential diagnosis may include other
recommended if symptoms persist more than
causes of painful, swollen extremities, such as
6 months despite conservative therapy.
DOMS, muscle strain, deep venous thrombosis,
cellulitis, and lymphedema. Like compartment
Muscle denervation
syndrome, deep venous thrombosis may result in
muscle edema, particularly in the deep posterior Athletes with hypertrophy of muscles, espe-
compartment of the calf. Unlike compartment cially anomalous muscles in anatomically vulner-
syndrome, however, deep venous thrombosis able sites, may result in entrapment neuropathy.
causes venous occlusion and commonly results Entrapment neuropathy and denervation can be
in subcutaneous edema and skin thickening, a cause of pain and weakness that simulates
which are all findings that can be displayed by a primary abnormality in skeletal muscle. MR
sonography and MR imaging. Cellulitis and imaging may be a useful adjunct to electromyog-
lymphedema show prominent subcutaneous raphy (EMG) in detecting muscle denervation and
edema and skin thickening on MR images, but its causes (Fig. 21) [38,46,85,99,155]. For example,
swelling and abnormal signal intensity centered in a study of 90 patients with clinical evidence of
in muscle often are absent. peripheral nerve injury or radiculopathy [155], the

Fig. 21. Varying stages of denervation of the anterior tibial muscle. Axial T1-weighted (A) MR image shows fatty
atrophy of the muscle consistent with chronic denervation (arrow). Fat-suppressed FSE T2-weighted (B) MR image
demonstrates high signal intensity in the muscle, consistent with extracellular water related to subacute denervation
(arrow). Note the lack of perifascial edema.
362 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371

sensitivity and specificity of IR-FSE MR imaging changes of acute muscle denervation are revers-
relative to EMG were 84% and 100%, respec- ible, profound atrophic changes seen late in the
tively. Although less sensitive than EMG, MR course of denervation may be irreversible [235].
imaging may display the site and cause of nerve The atrophic changes from denervation are not
entrapment in many cases (eg, intervertebral disk specific, and may be seen with conditions as
herniation, ganglion cyst, or hematoma). diverse as motor neuron diseases (eg, poliomyelitis
With denervation, the signal intensity and [249]) and demyelination (eg, hereditary motor
morphology of muscle undergo characteristic and sensory neuropathies [215]).
changes with MR imaging. Although these de- Although chronic denervation usually results
nervation changes have been reported as early as in atrophy, pseudohypertrophy and true hyper-
4 days after a nerve insult, hyperintense signal on trophy have been reported [53,60,66,151,161,
T2-weighted or IR-FSE MR images usually are 184,191]. Both conditions may present clinically
not detectable for 2 to 3 weeks in most cases as a palpable soft tissue mass that serves as an
[80,85,199]. Three imaging features may help indication for MR imaging. Pseudohypertrophy
distinguish the hyperintense T2 signal in dener- refers to prominent accumulation of fat and
vated muscles from that seen with strained mus- connective tissue that causes paradoxical enlarge-
cles. First, unlike strain injury, the hyperintense ment of the affected muscle. On T1-weighted MR
T2 signal in denervated muscles is not associ- images, the enlarged muscle contains hyperintense
ated with perifascial edema. Second, the pattern signal from adipose tissue. True hypertrophy of
of muscle involvement may suggest a specific synergistic muscle fibers that remain innervated
nerve territory responsible for the denervation also may occur. In this situation, the affected
changes. Third, abnormally hyperintense T2 muscle is enlarged, but is typically isointense with
signal in peripheral nerves is a hallmark of most normal muscle.
neuropathies. Normally, peripheral nerves are In addition to entrapment neuropathy, hyper-
isointense to the normal muscle on T2-weighted trophied muscles in athletic individuals occasion-
images and only mildly hyperintense to normal ally may result in other abnormalities, including
muscle on fat-suppressed T2-weighted or IR-FSE intermittent claudication, arterial stasis, aneu-
MR images [1,85]. rysm, and venous stasis. For example, a hypertro-
With chronic denervation, diminished bulk and phied anomalous muscle in the popliteal fossa may
fatty infiltration occur in muscle. These atrophic result in popliteal artery entrapment syndrome.
changes are best displayed on T1-weighted MR Specific anomalous muscles that may be respon-
images (see Fig. 21). Whereas the signal intensity sible for popliteal artery entrapment include

Fig. 22. Radiation therapy mimicking a muscle strain. Axial fat-suppressed FSE T2-weighted MR image shows high
signal intensity within the left obturator externus muscle (arrows) with some abnormal signal intensity in the medial
aspect of this muscle on the opposite side. This ‘‘feathery edema’’pattern was produced by radiation for prostate cancer.
 R.D. Boutin et al = Magn Reson Imaging Clin N Am 11 (2003) 341–371 363

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 Magn Reson Imaging Clin N Am
11 (2003) 373–378

Index
Note: Page numbers of article titles are in boldface type.

A B
Achilles tendon, injuries of, in athletic activities, Bankart lesions, 227, 229
296
Baseball pitch, basic positions of, 226–227
Achilles tendonitis, 296–297
Bennett lesion, 230–231
Adductor insertion avulsion syndrome, 273
Biceps tendon, 250
Adductor muscle, strain of, 344, 346 distal, rupture of, 250–251
Ankle, accessory muscles of, 202–203 Bobsledding, injuries associated with, 316, 317,
accessory ossicles and sesamoid bones of, 203 318
foot and, bony injury of, 295, 296
Bone scintigraphy, in myositis ossificans, 356
force on, during athletic activities, 295
in stress fractures, 332–334
sports injuries of, imaging of, 295–310
sports protocols, for direct
MR arthrography, 296
‘‘high sprain’’ of, 300, 302
imaging of, after physical activity, 202 C
injuries of, in alpine skiing, 313, 314 Calf, hematoma of, imaging of, 342
lateral, ligamentous injury of, 299
Capitellum, pseudodefect of, elbow and,
ligaments and tendons of, asymptomatic
196, 197
findings about, 202
normal fluid collections in, 201 Cervical ligament injury, 303, 304
Anterior cruciate ligament, ganglion cyst of, Compartment syndrome, 358–361
290, 292 acute, 359
in meniscal and cruciate ligament injuries, chronic, 359
283–293 diagnostic examinations of, 359–360
normal fibrous bundles of, 287, 291 MR imaging of, 360–361
rupture of, 289, 291 pathogenesis of, 359
sprains of, 289 symptoms and signs of, 359
tears of, 291–293 treatment of, 361
in alpine skiing, 312–313
Computed tomography, in sports-related muscle
MR imaging to diagnose, 291
injuries, 355–356
Apophyseal avulsion injuries, 343, 344 in stress fractures, 330, 331, 334
clinical features of, 267
Coracoid impingement syndrome, 230
MR imaging of, 267
treatment of, 267 Coxa saltans, 270–271
MR imaging in, 271
Arthritis, septic, of hip, 264
Cruciate ligament, anterior. See Anterior cruciate
Athletes, stress fractures in, imaging of,
ligament.
323–339
injuries of, and meniscal injuries, MR imaging
Athletic pubalgia, 271–272 of, 283–293
MR imaging in, 272 posterior, injuries of, 291, 292, 293

1064-9689=03=$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016=S1064-9689(03)00039-4
374 Index = Magn Reson Imaging Clin N Am 11 (2003) 373–378

D injuries of, associated with snowboarding, 315

Delayed onset muscle soreness, 302 in alpine skiing, 313, 314
normal fluid collections in, 201
Deltoid ligament, tears of, 298
Foramen sublabrum, 224
Dysplasia, of hip, osteoarthritis and, 257–258
Forefoot, asymptomatic findings in, 203
E
Elbow, capsule anatomy and pathology of, G
241–242 Gadolinium enhancement, of magnetic resonance
common extensor tendon, and lateral muscles, imaging, 342–343
248
Ganglion cyst, of anterior cruciate ligament, 290,
dislocation of, posterolateral rotary instability
292
and, 245–247
epicondylitis and overuse syndromes of, Gastrocnemius muscle, residual hematoma in,
248–250 347, 350
flexor tendon of, and medial muscles, 248 strain injury of, 352–353
fracture dislocations of, 246–247, 248 Glenohumeral instability, atraumatic, 228
imaging of, normal variants and pitfalls of, classification of, 227
196–197 traumatic, 227–228
instability at, 243–244
lateral muscles of, common extensor tendon Glenohumeral joint, microinstability of, 228
and, 248 posterosuperior instability of, 234–235
ligamentous anatomy and pathology of, Glenohumeral ligament(s), 222
242–247 humeral avulsion of, 227, 229
medial muscles of, flexor tendon and, 248 inferior, 224
osseous anatomy and pathology of, 239–241 middle, 223–224
osteochondral lesions of, 240–241 superior, 223
posterolateral rotary instability of, and
dislocation, 245–247 Gradient echo imaging, in magnetic resonance
pseudodefect of capitellum and, 196, 197 imaging, 342
sports injuries of, 239–253 Groin pain, acute, in athletes, 271–272
subluxation or dislocation of, 246–247, 248
tendons of, anatomy and pathology of,
247–252 H
valgus stress at, 240, 242 Haglund’s deformity, 297, 298
varus stress at, 245, 246
Hamstring muscles, strain injury of, 349–352
Epicondylitis, and overuse syndromes of elbow,
Hand, imaging of, normal variants and pitfalls of,
248–250
197–198
Exercise, for enhancement of MR imaging, 343
Hematoma, and pseudotumor appearance,
347–348, 349, 350
F of calf, imaging of, 342
Femoral neck, stress fractures of, 336–337 residual, in gastrocnemius muscle, 347, 350
Femoroacetabular impingement, in osteoarthritis Hip, arthroscopy of, indications for, and
of hip, 263 contraindications to, 255–256
technique of, and complications of, 256
Fibrocartilage, asymtomatic triangular, 197–198
bursae of, and bursitis of, 267–270
Foot, and ankle, bony injury of, 295, 296 disorders of, sports-related, MR imaging of,
force on, during athletic activities, 295 255–281
sports injuries of, imaging of, 295–310 dysplasia of, osteoarthritis and, 257–258
sports protocols, for direct extra-articular derangement of, protocol for,
MR arthrography, 296 257
 Index = Magn Reson Imaging Clin N Am 11 (2003) 373–378 375

extrinsic ligaments of, anatomy and function superior, lesions of, 231–234
of, 261 rotator cuff tears in, 231
MR imaging of, 261 tear(s) of, classification of, 258–259
instability of, clinical manifestations of, 261 clinical features of, 257
internal derangement of, imaging protocol for, diagnostic criteria for, 258
256–257 secondary findings in, 259–260
joint effusion of, 261–262 treatment of, and prognosis in, 260
ligaments of, and ligament injuries, 260–261
Ligamentum teres, anatomy and function of, 260
MR imaging of, 198
arthroscopy of, 261
technical considerations for, 256–257
derangements of, 260
musculotendinous injuries of, 270–273
MR imaging of, 261
osseous injuries of, 265–267
osteoarthritis of. See Osteoarthritis, of hip. Lisfranc ligament, anatomy of, 304
osteochondral injury of, 262 injury of, 304–305
septic arthritis of, 264 Luge, injuries associated with, 316–317
stress fracture of, 265–266

I M
Ice hockey, injuries associated with, 319 Magnetic resonance arthrography, direct, foot
Iliopsoas bursa, and bursitis, 268 and ankle sports protocols for, 296
of rotator cuff tears, 212
Iliotibial band friction syndrome, joint effusion in
knee versus, 201, 202 Magnetic resonance imaging, exercise
enhancement of, 343
Interosseous ligament, lesions of, 197–198 gadolinium enhancement of, 342–343
Intersesamoid ligament, rupture of, 306, 307 gradiant echo imaging in, 342
of instability injuries of shoulder, 221–238
of joint, artifacts in, 193–194
J magic angle phenomenon in, 194
Joints, injuries of, related to sports, MR imaging truncation artifacts in, 193–194
in. See specific joints. variants in, related to sports injury, 193–205
Jumper’s knee, high signal in patellar tendon of meniscal and cruciate ligament injuries,
versus, 201 283–293
of sports injuries to rotator cuff, 207–219
of sports-related hip disorders, 255–281
K of stress fractures, 326–331
Knee, chondrocalcinosis of, versus meniscal tear practical techniques for, 341–343
of, 199, 200 routine protocol for, 341–342
joint effusion in, versus iliotibial band friction supplemental scans, 342–343
syndrome, 201, 202 to classify osseous stress injury, 327
meniscal tear of, versus chondrocalcinosis of,
199, 200 Malleolus, medial, stress fractures of, 333
MR imaging of, normal variants and pitfalls Meniscocapsular separation, 200
in, 199–201
transverse ligament of, 199, 200 Meniscofemoral ligaments, 199, 200
Meniscus, injuries of, and cruciate ligament
L injuries, MR imaging of, 283–293
ossifications of, 200–201
Labrum, acetabular, variability of, 198, 199
postoperative, 200
anatomic variations in, 260
tear(s) of, 284–291
anatomy and function of, 257
asymptomatic, 199
glenoid, 222–223
mimics of, 199
MR imaging of, 260
posterior tear of, 227–228, 230 Metatarsal stress fracture, 306, 308
376 Index = Magn Reson Imaging Clin N Am 11 (2003) 373–378

Muscle(s), and tendons, of elbow, 248 Pectoralis major muscle, strain injury of, 348–349,
denervation of, 362–363 351
herniation of, 356–358
Peroneus brevis splits syndrome, 300, 303
imaging in, 358
location of, 357 Pigmented villonodular synovitis, 265
symptoms and signs of, 357–358 Plantar fasciitis, 300–301, 303
treatment of, 358
injuries of, sports-related, apophyseal avulsion, Plantar nerve, impingement of, 301–302, 303
343, 344 Plantaris tendon, rupture of, with muscle strain,
delayed-onset muscle soreness in, 353 352, 353
differential diagnosis of, 362, 363
first-degree strain, 344–345, 346 Posterior cruciate ligament, injuries of, 291, 292,
hematoma and pseudotumor 293
appearance, 347–348, 349, 350 Posterosuperior impingement syndrome, 234
injuries of, 341–371
muscle contusion in, 353–354 Pseudo dorsal intercalated segment instability,
myositis ossificans, 354–355 197, 198
myotendinous strain injury, 344–345,
346
radiography and computed tomography R
in, 355–356 Radial collateral ligament complex, 244–245,
second-degree strain, 345–347 247
specific, 348–353
Radiography, in sports-related muscle injuries,
third-degree strain, 347, 348
355–356
lacerations of, 356, 357
in stress fractures, 324–326
Musculotendinous injuries, of hip, 270–273
Radionuclide imaging, of tibial stress fracture,
Myositis ossificans, 354–356 337–338
bone scintigraphy in, 356
Rotator cuff, contusion of, 214
MR imaging in, 356, 357
injuries of, MR imaging of, 213–218
treatment of, 356
instability of, secondary impingement and,
Myotendinous strain injury, 344–345, 346 208–209
macrotrauma of, from contact sports, 209, 211
normal interval, 225
N normal MR imaging appearance of, 211,
Navicular stress fracture(s), 306, 308, 335 212–213
posterior impingement of, 209
O primary impingement of, 207–208
secondary impingement of, and instability,
Osteitis pubis, 273
208–209
Osteoarthritis, of hip, clinical features of, 262–263 sports injuries to, categories of, 207
differential diagnosis of, 264 MR imaging of, 207–219
dysplasia and, 257–258 strain of, 214
femoroacetabular impingement in, 263 tear(s) of, 214
MR imaging of, 263–264 conventional MR imaging technique in,
treatment of, 264 210, 211–212
Overuse syndromes, of elbow, epicondylitis and, in older athlete, 211
248–250 in SLAP lesion, 231
MR arthrography of, 212
posterosuperior impingement, 215–218
P rim-rent, 213, 214–215
Patellar tendon, high signal in, versus jumper’s standard, 214
knee, 201 tensile overload of, 211
 Index = Magn Reson Imaging Clin N Am 11 (2003) 373–378 377

S mechanism of injury in, 323–324

Septic arthritis, of hip, 264 MR imaging of, 326–331
navicular, 306, 308, 335
Shin splints, 328–329 of femoral neck, 336–337
Shoulder, acute traumatic instability of, 234 of hip, 265–266
Buford complex versus labral tear of, 195 of medial malleolus, 333
injuries of, in alpine skiing, 313–314 pathogenesis of, 323–324
instability injuries of, MR imaging of, 221–238 radiography in, 324–326
labral variability in, MR imaging of, 194 sites of, 335–338
MR imaging of, in normal anatomy and tibial, 328, 329, 330, 331, 337–338
biomechanics, 222–227 ulnar, 332
pathophysiology and, 227 Stress injury, osseous, MR imaging classification
strategies for, 221–222 of, 327
muscles around, 225
os acromiale versus acromial fracture, 195–196 Sublabral recess, 224
pain in, causes of, 207 Synovial (osteo)chondromatosis, idiopathic,
postopertive, imaging of, 196 264–265
primary disease of, 230–231
sublabral hole versus labral tear of, 194–195 Synovial plicae, 197
sublabral recess versus superior labrum Synovitis, pigmented villonodular, 265
anteroposterior lesion, 195, 196
Sinus tarsi syndrome, posttraumatic, 303, 304 T
Skiing, alpine (downhill), events grouped as, Talar dome, osteochondral defect of, 308, 309
311–312 pseudodefect of, 203
knee injuries associated with, 312–313
Tarsal tunnel syndrome, 302–303
mechanisms of injury in, 312
risk of injury from, 312 Tendonitis, Achilles, 296–297
nordic (cross-country), risk of injury in, 314
Tendonosis, 214
Snapping hip syndrome, 270–271
Tendons, of elbow, anatomy and pathology of,
MR imaging in, 271
247–252
Snowboarding, foot injuries associated with, 315
Tennis leg, 352
risk of injury in, 314–315
spinal injuries associated with, 315–316 Tibia, stress fractures of, 328, 329, 330, 331
upper extremity injuries in, 315, 317 longitudinal, 337–339
Speedskating, injuries associated with, 318, Tibiofibular syndesmotic injury, 300, 302
319–320 Transverse acetabular ligament, 261
Sports injuries, hip disorders related to, MR Triceps tendon, rupture of, 251–252
imaging of, 255–281
in winter sports, 2002 Winter Olympics Trochanteric bursae, and lateral hip pain,
experience, 311–321 268–270
of elbow, 239–253 Trochlear groove, variations of, 197
of foot and ankle, imaging of, 295–310
of muscle, imaging of, 341–371 Turf toe injury, 305, 306
related to joint, MR imaging of, variants in,
193–205 U
to rotator cuff, MR imaging of, 207–219
Ulna, stress fractures of, 332
Stress fracture(s), bone scintigraphy in, 332–334
Ulnar collateral ligament, tears of, in alpine
clinical features of, 324
skiing, 314
computed tomography in, 330, 331, 334
in athlete, imaging of, 323–339 Ulnar collateral ligament complex, 242
378 Index = Magn Reson Imaging Clin N Am 11 (2003) 373–378

V nordic (cross-country) skiing and, 314

Volkmann’s ischemic contracture, 358–359 skeletal, 317
snowboarding and, 311–314
W speedskating and, 318, 319–320
study population for, 311
Winter sports, injuries associated with, alpine
2002 Winter Olympics experience,
skiing and, 311–314
311–321
bobsledding and, 316
ice hockey and, 319 Wrist, imaging of, normal variants and pitfalls of,
luge and, 316–317 197–198