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MRI knee

This chapter discusses the imaging techniques for the knee, particularly focusing on MRI protocols that achieve high sensitivity and specificity for diagnosing meniscal and ligament injuries. It outlines the importance of patient positioning, coil selection, pulse sequences, and the interpretation of normal and abnormal meniscal signals. Additionally, it describes various types of meniscal tears and their implications for treatment and surgical planning.

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15

Knee

C HA P T E R OU T LI N E with sensitivity and specificity of 90% to 95% for the menisci

How to Image the Knee and close to 100% for the cruciate ligaments. This chapter
shows how that kind of accuracy can be obtained.
Normal and Abnormal
• Coils and patient position: There are many ways to image
Menisci
the knee adequately, with different centers having differ-
Normal
Abnormal
ing imaging protocols based solely on personal prefer-
Tears ences. We hope to not only provide which techniques
Cysts work but also, more importantly, stress what should
Discoid Meniscus not be used. As with all joint imaging, a dedicated surface
Pitfalls coil must be used. A small field of view should be used to
Ligaments maximize resolution. Generally, we use one of 14 to
Anterior Cruciate Ligament 16 cm, depending on the size of the patient. The slice
Posterior Cruciate Ligament thickness can be 3 to 4 mm, with 4 mm being the stan-
Medial Collateral Ligament dard at most centers. A small interslice gap (0.3 mm or
Lateral Collateral Ligament Complex 0.4 mm) is used to reduce cross talk, unless volume imag-
Patella ing is employed. Having a slice thickness less than 4 mm
Synovial Plicae does not seem to increase accuracy and leads to increased
Patellar Tendon image interpretation, or information overload. A matrix
Fat Pad Impingement of 256 256 or 512 512 is standard. The knee should
Bursae be in about 5 degrees of external rotation so that the ante-
Popliteal (Baker’s Cyst) rior cruciate ligament (ACL) is parallel to the sagittal
Prepatellar Bursa plane of imaging. This is typically the position of the knee
Pes Anserinus Bursa in the relaxed state, and no effort at externally rotating the
Semimembranosus–Tibial Collateral Ligament Bursa knee needs to be made in most patients.
Medial Collateral Ligament Bursa • Pulse sequences: When evaluating the menisci, it is neces-
Bones sary to have a short TE to see intrameniscal signal and
Soft Tissues therefore meniscal tears effectively. This can be in the
Cartilage form of T1-weighted (T1W), proton density, or gradient
Suggested Reading echo sequences (Fig. 15.1). A long TE (>30) image
causes loss of intramensical signal, which may result in
missing some meniscal tears. Fat suppression may be
applied with the short TE images to provide a more
How to Image the Knee aesthetic-looking image when evaluating the menisci
(Fig. 15.2). This technique increases the contrast range
See the protocols for knee MRI at the end of this chapter. in the menisci and makes tears more conspicuous than
Magnetic resonance imaging (MRI) of the knee is the most without fat suppression. A 4-mm-thick sagittal fast spin
frequently requested MRI joint study in musculoskeletal radi- echo–T2-weighted (FSE-T2W) image with fat suppres-
ology. The reasons for this are simple: it works, and so refer- sion, which is excellent for examining the cruciate liga-
ring physicians request it. MRI provides a comprehensive ments, cartilage, and bone detail, is also performed. A
examination of the knee, giving surgeons information they short tau inversion recovery (STIR) image also would suf-
could not otherwise obtain clinically or noninvasively. This fice. A gradient echo sagittal image (volume or single slice)
method also provides a road map for a surgeon performing would do nicely for the cartilage and menisci but is
arthroscopic or open surgery, and has proved very accurate, unacceptable for examining the bones because marrow

376
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CHAPTER 15 Knee 377

pathology is poorly demonstrated by this technique at

high field strengths. A marrow-sensitive sequence is also
necessary to identify foci of bone marrow signal abnormal-
ities. This is often performed as FSE-T2W with fat sup-
pression or STIR imaging. The coronal plane is used to
examine the collateral ligaments and serves as another
plane to examine the cruciate ligaments. The coronal plane
should be performed with a fluid-sensitive sequence. If
FSE sequences are employed, fat suppression is recom-
mended. It can be difficult to differentiate fat from fluid
on an FSE-T2W sequence without fat suppression.
• T1W images are useful for assessing the appearance of the
marrow. Normal red (hematopoietic) marrow should be
brighter than skeletal muscle on this sequence. If the mar-
row signal is darker than muscle, this is concerning for a
pathologic process such as tumor or infection.
• A fluid-sensitive sequence should be employed in the axial
plane. This is the best plane to examine the patellar car-
tilage. The trochlear cartilage is also seen in this plane but
is often better evaluated on sagittal images. A second (or
third) look at the cruciate ligaments should be made on
the axial images, and, similarly, the collateral ligaments
can be reinspected. The articular cartilage can be
inspected in all three planes of FSE-T2W imaging. The
selection of a TE in the range of 40 to 60 ef (effective
echo) is ideal for assessing the articular cartilage.
• Contrast: There is no place for intravenous gadolinium in
routine imaging of the knee, but it may be used to evaluate
synovial pathology or infection or to differentiate between
cystic and cystic-appearing solid masses. MR arthrogra-
phy has been advocated as useful in the postoperative knee
• Fig. 15.1 Meniscus tear: short TE sequences. A, Sagittal proton
to help differentiate between a repaired meniscus and a
density image (TR/TE 2410/27) shows an oblique tear of the posterior torn meniscus, as fluid would insinuate in a tear, whereas
horn of the medial meniscus (arrow) that is also well demonstrated in the increased signal intensity in a repaired meniscus would
B, a sagittal gradient echo image (TR/TE 510/14). not allow contrast to extend through it.

• Fig. 15.2 Use of fat suppression for the meniscus. A, Coronal proton density–weighted image of the
lateral meniscus without fat suppression shows most of the signal emanating from the marrow in the femur
and tibia. B, The same sequence with fat suppression shows the meniscus and minimal irregularity along its
free edge (arrow) to better advantage because of the suppression of signal from the marrow.

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378 C HA P T E R 15 Knee

Normal and Abnormal The normal meniscus is devoid of signal on all imaging
sequences, with the exception of children and young adults,
Menisci who typically have some intermediate to high signal in the
Normal posterior horns near the meniscal attachment to the capsule.
The menisci in the knee are C-shaped, fibrocartilaginous This signal likely represents normal vascularity and should not
structures that are thick peripherally and thin centrally. A be misinterpreted as meniscal degeneration. The vascularity of
sagittal slice through the body segment should show the the meniscus is greatest near the periphery and is almost non-
meniscus as an elongated rectangle, depending on how existent near the free edge. This allows for repair of peripheral
peripheral the sagittal slice is (Fig. 15.3). The medial and tears, whereas more central tears are often unrepairable.
the lateral menisci should have two or three contiguous
images of the body of the meniscus if 4- mm images are Abnormal
obtained. Three or four sagittal images should be seen Several grading schemes for abnormal meniscus signals have
through the anterior and posterior horns of the menisci been developed. They are not generally in widespread use
(Fig. 15.4), triangular in configuration, with the posterior because the only abnormal signal that has any real significance
horn of the medial meniscus being larger than the anterior is that which disrupts the articular surface of a meniscus, repre-
horn. The anterior and posterior horns of the lateral menis- senting a tear. Any signal that does not disrupt an articular sur-
cus are equal in size. The posterior horn of either meniscus face, with one exception, which is covered in detail
should never be smaller than the anterior horn. This would subsequently, is intrasubstance or myxoid degeneration
suggest a tear or prior partial meniscectomy. (Fig. 15.5). Presumably, myxoid degeneration is a result of

Bow tie

A
• Fig. 15.3 Normal body segment of meniscus. A, Schematic shows how a sagittal slice through the body
of the meniscus gives an image of the meniscus that resembles a bow tie. B, Sagittal proton density–
weighted image through the body of the lateral meniscus shows the normal bow tie appearance.

• Fig. 15.4 Normal anterior and posterior horns of the meniscus. A, Schematic shows the appearance of
a sagittal slice through the anterior and posterior horns of the meniscus. B, Sagittal proton density–weighted
image demonstrates the normal appearance of the medial meniscus with its larger posterior horn and smaller
anterior horn.

aging or wear and tear, but its cause is unknown. It is not a It has been shown that sensitivity for meniscal tears
source of symptoms, does not always lead to meniscus tears, decreases considerably if there is an associated ACL tear.
and is not treated clinically or surgically. When myxoid degen- One reason for this is that meniscal tears that often occur
eration is prominent, it can be mentioned so that others who when the ACL is torn are located in two places: the posterior
may review the study would know the signal abnormality horn of the lateral meniscus and in the periphery of either
was noted and judged not to be a tear, rather than thinking meniscus. Ramp lesions are longitudinally oriented tears at
it was simply overlooked. Also, if it is especially prominent, the posterior meniscocapsular interface that often occur in
there is a possibility that it might represent a meniscal cyst. the setting of ACL injuries. These can be quite subtle and
Meniscal cysts are discussed in more detail later. easily overlooked. Also, several imaging pitfalls occur in
the posterior horn of the lateral meniscus that can be con-
Tears fused with meniscal tears, all of which are mentioned later
If a high signal clearly disrupts an articular surface of the in this chapter. Suffice it to say that when the ACL is torn,
meniscus, it is a torn meniscus; however, if a high signal a close inspection should be done for a peripheral tear or for a
comes close to the articular surface but does not quite reach tear in the posterior horn of the lateral meniscus.
the articular surface, it is not a tear, but rather intrasubstance
degeneration—but it is not always that clear-cut. In some Oblique or Horizontal Tears
cases, it is too close to call. In these situations, do what radi- There are many types of meniscal tears (Box 15.1). The most
ologists can be known to do—hedge. You will be able to give common is an oblique or horizontal tear (these are synony-
a definitive diagnosis in about 90% of cases. In approxi- mous terms; some surgeons prefer one term over the other,
mately 10% of cases, it can be difficult to discern definitively and others use them interchangeably) that affects the under-
if the meniscus is torn or not. In those cases, describe the surface of the posterior horn of the medial meniscus
findings, and the clinical examination will be paramount. (Fig. 15.6). These commonly are degenerative in nature,
If the patient gets better with conservative care, it was prob- rather than a result of trauma.
ably not a torn meniscus. If the patient does not improve, the
surgeon may decide to perform an arthroscopic procedure, in
which case the description of the location of signal abnormal-
ity is helpful for identifying the potential meniscus tear. • BOX 15.1 Types of Meniscal Tears
• Oblique or horizontal
• Vertical
• Flap
• Bucket handle
• Peripheral
• Medially flipped flap tear
• Radial (parrot beak tear)
• Meniscocapsular separation

• Fig. 15.5 Myxoid or intrasubstance degeneration. Sagittal proton

density image with fat suppression through the lateral meniscus shows • Fig. 15.6 Meniscus tear. Sagittal gradient echo image through the
some high signal in the anterior and posterior horns that does not disrupt medial meniscus reveals an oblique tear extending to the undersurface
an articular margin of the meniscus. This is myxoid degeneration. of the posterior horn (arrow).

Bucket-Handle Tears Radial or Free Edge Tears

Vertical longitudinal tears (Fig. 15.7) may result in a bucket- A radial tear is oriented perpendicular to the long axis of the
handle tear that occurs in about 10% of meniscal tears. With meniscus. Small free edge radial tears (Fig 15.10) are com-
this type of tear, the inner portion of the meniscus becomes mon and often asymptomatic. Larger radial tears disrupt
displaced into the intercondylar notch. The resulting bucket- the longitudinal collagen fibers of the meniscus, resulting
handle tear may be diagnosed by noting a decrease in the in loss of the “hoop strength” of the meniscus, which is crit-
number of normal body segments present on the sagittal ical to its role in dispersing forces and protecting the articular
images (Fig. 15.8). A careful search for a displaced fragment cartilage.
should be made when only one body segment is seen on the Three basic appearances of radial tears have been described:
sagittal images and is usually well demonstrated on coronal (1) ghost, (2) cleft, and (3) truncated triangle. A ghost menis-
images (see Fig. 15.8E). The displaced meniscal fragment cus is seen when a radial tear has completely traversed the
often lies beneath the posterior cruciate ligament (PCL), meniscus (Fig. 15.11). The MRI slice is parallel to the
resulting in a double PCL sign (Fig. 15.9). tear, and partial volume averaging of the adjacent meniscal

Tear

• Fig. 15.7 Vertical longitudinal meniscus tear. A, Schematic shows a meniscus with a vertical longitu-
dinal tear. If the inner edge displaced, it would be called a bucket-handle tear. B, Sagittal STIR image dem-
onstrates a vertical tear in the posterior horn of the medial meniscus (arrow). C, Coronal T2W image with fat
suppression in the same patient shows the tear extending into the body of the meniscus (arrow). D, Axial T2W
image with fat suppression better demonstrates the longitudinal extent of the tear (arrows).

A B A B

Bow tie
A A

B B

A B

• Fig. 15.8 Use of bow tie appearance to detect a bucket-handle tear. A, Schematic shows how two
sagittal images through the body normally produce two images of the meniscus that have a bow tie appear-
ance. B, Schematic shows how, in a bucket-handle tear with the free edge of the meniscus displaced, only
one sagittal image has a bow tie appearance. C, The first sagittal proton density–weighted image through the
medial meniscus in a patient with a bucket-handle tear shows a bow tie appearance with some abnormal
intrasubstance signal intensity. D, The adjacent sagittal proton density–weighted image in the same patient
shows irregular anterior and posterior horns rather than another bow tie. This appearance is characteristic of a
bucket-handle tear of the meniscus. E, Coronal T2W image with fat suppression confirms the bucket-handle
tear by demonstrating the displaced meniscal tissue within the notch (arrow) and small remnant of the body
(arrowhead).

tissue creates an intermediate or gray signal. This is a severe protective effect of the meniscus with axial loading. Meniscus
type of meniscal tear and results in profound loss of the “hoop extrusion is noted particularly when there is a radial tear at the
strength,” or springlike resistance, of the meniscus. The root attachment of the meniscus. If extrusion of the meniscus
meniscus usually extrudes off of the tibia (Fig. 15.12), and is identified, careful inspection of the attachment of the pos-
osteoarthritis ensues because of the lack of cushioning or terior horn of the meniscus to the condyle at the notch is

• Fig. 15.9 Double posterior cruciate ligament sign. Sagittal proton

density–weighted image through the intercondylar notch in a patient with
a bucket-handle tear shows the displaced fragment (arrows) inferior to
the posterior cruciate ligament (P)—the double posterior cruciate
ligament sign.

recommended. A gap at the attachment is diagnostic of a

root tear.
A cleft is the most reliable sign for a radial tear and is seen
when the MRI slice is perpendicular to the tear (see
Fig. 15.10). When the MRI slice is parallel to the same tear
with a cleft, it results in a truncated triangle (Fig. 15.13). A
radial tear usually, but not always, will have two of the de-
scribed signs, depending on the orientation of the tear to
the imaging plane. At surgery, the free edge of a meniscus with
a radial tear is treated with debridement and smoothing.

Medial Flipped Meniscus

A meniscus tear that can be seen with MRI but can be over- • Fig. 15.10 Radial tear. A, Schematic of a free edge or radial tear
looked with arthroscopy is a flap tear of the medial meniscus, shows how the sagittal image has a small gap in the expected bow
with the flap of meniscus flipped into the medial gutter tie appearance. B, Sagittal STIR image shows a small vertical gap in
the bow tie segment of the lateral meniscus (arrow). C, Axial T2W image
underneath the meniscus. It can be missed during surgery
with fat saturation in the same patient shows the radial orientation of the
if the surgeon fails to probe the medial gutter and deliver tear at the junction of the anterior horn and body (arrow).
the flipped fragment. These are common tears and should
be considered when the body segments look thinner than
a normal rectangular slab. The infolding of the body segment
causes this appearance (Fig. 15.14). The medial flipped frag- findings, such as meniscal cyst, discoid meniscus, or displaced
ment can be seen on coronal images lying along the medial fragments or flaps.
joint line just below the medial meniscus deep to the medial
collateral ligament. Cysts
A cyst abutting the capsular surface of a meniscus may or may
Description of Meniscal Tears not be related to an underlying tear. These are often associ-
When a meniscal tear is identified and characterized as to ated with a horizontal tear, and it is thought that with weight
which type (see Box 15.1), additional descriptors should bearing, fluid extrudes through the tear in a “ball-valve”
include location (anterior horn, posterior horn, body); extent mechanism and becomes trapped at the meniscocapsular
of the tear (which meniscal surface and length); and associated junction, where it forms a parameniscal cyst (Fig 15.15).

• Fig. 15.12 Extruded meniscus resulting from a radial tear. A, Cor-

onal T2W image with fat suppression through the posterior horn of the
medial meniscus shows a large radial tear at its posterior root (arrow). B,
• Fig. 15.11 Radial tear with a ghost meniscus. A, Schematic shows
Coronal image from the same sequence at level of the mid joint displays
how an image parallel to a large radial tear that involves the entire width of
associated extrusion of the meniscus along the medial joint line (arrow).
the meniscus posterior horn gives a ghost meniscus. B, Axial T2W image
Note also the cartilage loss in the medial compartment, a subchondral
with fat suppression shows a large, full-thickness radial tear near the pos-
fracture (arrowheads), and extensive marrow edema in the femoral con-
terior root of the medial meniscus (arrowhead). C, Sagittal proton den-
dyle that resulted from the meniscal abnormalities.
sity–weighted image demonstrates the absence of meniscal tissue at
the level of the tear (arrowhead)—the “ghost meniscus” sign.

In this case, it is important to alert the surgeon to the pres- of the meniscus (Fig. 15.17). In some cases, an intrameniscal
ence of the underlying tear because the cyst may recur if the cyst may collapse, resulting in a horizontal meniscal stripe
tear is not addressed (Fig. 15.16). that may mimic a horizontal tear.
In the case of a cyst occurring without an underlying tear,
it is important to alert the surgeon to this because the cyst can Discoid Meniscus
be missed at arthroscopy and it will need to be decompressed If more than two body segments are present on the
using an extra-articular approach, rather than via arthros- sagittal images, a discoid meniscus should be considered
copy. Most intrameniscal cysts do not exhibit fluid signal (Fig. 15.18). A discoid meniscus is most likely a congenital
with T2W images, but the parameniscal component usually malformation of the meniscus in which the meniscus, in
does. When the cyst is confined to the meniscus, the signal the most extreme form, is disk-shaped rather than C-shaped.
resembles intrasubstance degeneration, but may be also sus- Most discoid menisci are not completely disk-shaped, but
pected when it demonstrates some mass effect with swelling have a wider-than-normal body of the meniscus. The lateral

A B

• Fig. 15.13 Radial tear with a truncated triangle sign. A, Schematic shows how an image parallel to a
radial tear gives a truncated triangle. B, Sagittal image through a radial tear of the posterior horn shows a
truncated triangle (arrow).

Tear

• Fig. 15.14 Medial flipped meniscus. A, The first sagittal image through the body of the medial meniscus
in a patient with a medially displaced flap tear shows a fragment of meniscus that is inferiorly displaced
(arrowheads). B, An adjacent sagittal image reveals a defect in the undersurface of the meniscus (arrow). This
defect is the donor site for the displaced flap of meniscus seen in A. C, Coronal image shows the medially
displaced flap of meniscus inferior to the body of the meniscus (arrow). D, An artist’s depiction of a medially
displaced flap tear.

• Fig. 15.15 Parameniscal cyst. A, Coronal fat-suppressed proton density–weighted image. A small para-
meniscal cyst is present (arrowheads) related to an underlying horizontal/oblique tear in the lateral meniscus
(arrow). B, Axial fat-suppressed T2W image. The true extent of the cyst (arrowheads) is demonstrated.

• Fig. 15.16 Enlarging parameniscal cyst. A, Coronal fat-suppressed T2W image. A small parameniscal
cyst is present along the lateral meniscus. B, Coronal fat-suppressed T2W image obtained 5 years later
reveals marked enlargement of the cyst as well as an underlying horizontal tear of the meniscus.

meniscus is most commonly affected, with an incidence A discoid meniscus that can cause symptoms without
reported of around 3%, whereas the medial meniscus being torn is a Wrisberg variant of a discoid lateral meniscus.
is uncommonly affected. Often, a discoid meniscus is enlarged This is a discoid meniscus that lacks attachments to the cap-
and affects the anterior or posterior horns of the meniscus sule via the normal struts or fascicles and lacks attachment to
asymmetrically. In such a case, the anterior or posterior horn the tibia via the coronary or meniscotibial ligaments at the
is much larger than its counterpart. Although often encoun- posterior horn of the meniscus (Fig. 15.19). This allows
tered incidentally, discoid menisci are more prone to undergo the posterior horn to sublux or fold into the joint with knee
cystic degeneration with subsequent tears than a normal flexion, akin to a rug sliding or folding up on a slippery floor
meniscus. Even without cystic changes or a tear, a discoid if it is not attached. In a Wrisberg variant of a discoid lateral
meniscus can cause symptoms and require surgery. meniscus, the only attachment to the posterior horn is the

children, and a meniscectomy at an early age leads to prema-

ture osteoarthritis.
It is extremely valuable to recognize the normal rectangular
slab appearance of the body segments in the medial and the
lateral menisci as seen on sagittal images on every examina-
tion. Many of the aforementioned abnormalities can be rec-
ognized easily by noting the absence of the two normal
body segments. These include the bucket-handle tear, radial
tear, medially flipped flap tear, and meniscal cyst (Box 15.2).
A discoid meniscus exhibits more than two body segments.
Our routine search pattern on sagittal images includes a
close inspection of the body segments to be certain of the
appropriate number and that they are not deformed in any
way. The ratio of body segments to anterior and posterior
• Fig. 15.17 Meniscal cyst. Coronal fat-suppressed T2W image. Lat- horns is a good way to determine if there is an abnormality
eral meniscal cyst is noted (arrow), which gives a slightly swollen appear- within the body of the meniscus. Too many anterior and pos-
ance to the meniscus. terior horns would indicate a small body (bucket-handle
tear, flipped meniscus, radial tear), whereas an increase in
Wrisberg ligament—hence the name. It is important to body segments would indicate a discoid meniscus. A reason-
inspect every discoid lateral meniscus closely for the normal able ratio of body segments to anterior and posterior horn
struts or fascicles that surround the popliteus tendon and would be 1:2 or 1:3. This ratio then can consider a small
attach the meniscus to the capsule. If recognized, the surgeon meniscus in a small patient or a large meniscus in a large person
can reattach the meniscus to the capsule and the tibia, rather (Lebron James would undoubtedly have three to four bow
than performing a meniscectomy. These are typically seen in ties) (Box 15.3).

• Fig. 15.18 Discoid lateral meniscus. A-D, Successive sagittal images through the lateral meniscus show
a bow tie appearance, indicating the body segment is present on more than two images. This appearance
should suggest a discoid meniscus. E, Coronal image reveals that the meniscus extends almost into the inter-
condylar notch (arrowheads), indicative of a discoid lateral meniscus.

• Fig. 15.19 Wrisberg variant of a discoid lateral meniscus. Sagittal

image in a 31-year-old man with a discoid lateral meniscus reveals no
significant attachment of the meniscus to the posterior capsule and
some anterior meniscal subluxation in that region. These findings are
indicative of a Wrisberg variant.

• BOX 15.2 Abnormalities With Absent Bow

Tie Sign
• Bucket-handle tear
• Radial tear
• Medially flipped flap tear
• Meniscal cyst

• BOX 15.3 Pitfalls in Absent Bow Tie Sign

• Children or small adults
• Postoperative
• Severe osteoarthritis
• Older patients (>65 years old)

In patients with severe osteoarthritis or in older patients

(>65 years old), a decrease in the number of body segments
may occur as the free edge of the meniscus is worn away, leav-
ing a very thin body segment that can be confused with a
bucket-handle tear.
• Fig. 15.20 Transverse ligament. A, Sagittal proton density–
weighted image shows the transverse ligament in cross section
Pitfalls (arrow). B, Sagittal proton density–weighted image at the level of the lat-
A few pitfalls involving the menisci warrant mention. eral meniscus demonstrates the ligament just before it inserts onto the
anterior horn creating a pseudotear (arrow). C, Axial T2W image with
fat suppression shows the ligament in its entirety (arrowheads) coursing
Transverse Ligament from one anterior horn to the other
An easy pitfall to recognize is the insertion of the transverse
ligament on the anterior horns of the menisci. The transverse on the anterior horn of either meniscus, it often has the
ligament runs across the anterior aspect of the knee in Hoffa’s appearance of a meniscus tear (Fig. 15.20). This is especially
fat pad from the anterior horn of the medial meniscus to the common laterally. It can reliably be differentiated from a tear
anterior horn of the lateral meniscus. Its function is by following it across the knee in Hoffa’s fat pad on sequen-
unknown, and it is not present in every knee. At its insertion tial sagittal images.

Speckled Anterior Horn Lateral Meniscus the intercondylar notch, anterior (ligament of Humphrey) or
The anterior horn of the lateral meniscus occasionally has a posterior (ligament of Wrisberg) to the PCL (Fig. 15.22),
speckled or striated appearance, which can resemble a mac- and inserts into the posterior horn of the lateral meniscus.
erated or torn anterior horn (Fig. 15.21). This appearance is In 2% to 3% of knees, both ligaments (Humphrey and Wris-
caused by fibers of the ACL inserting into the meniscus. It berg) are present. The function of the meniscofemoral liga-
has been reported in 60% of normal patients. ment has not been clearly established, and no injury to it has
been described.
Meniscofemoral Ligament Insertion Insertion of the meniscofemoral ligament of Humphrey or
The posterior horn of the lateral meniscus has several imag- Wrisberg can give the appearance of a meniscal tear
ing pitfalls that mimic tears. A meniscofemoral ligament is (Fig. 15.23). When considering a pseudotear from the inser-
present in about 75% of knees. It originates on the posterior tion of one of the meniscofemoral ligaments as the cause for
medial femoral condyle and runs obliquely across the knee in abnormal signal intensity resembling a peripheral tear, one
needs to follow the ligament through the intercondylar notch
to the PCL on sequential sagittal images.

Pulsation From Popliteal Artery

The popliteal artery is just posterior to the posterior horn of
the lateral meniscus, and pulsation artifact can extend
through the meniscus, making it difficult to examine or,
in some instances, giving the appearance of a torn meniscus
(Fig. 15.24). This appearance is rectified easily by swapping
the phase and frequency direction before scanning so that the
vessel pulsation extends superior to inferior rather than ante-
rior to posterior.

Magic Angle Phenomenon

Occasionally, the posterior horn of the lateral meniscus has
an ill-defined, hazy appearance with diffuse intermediate
signal seen on the short TE images (Fig. 15.25). This is
• Fig. 15.21 Speckled anterior horn lateral meniscus. Sagittal proton due to the magic angle phenomenon. The posterior horn
density–weighted image through the lateral meniscus near its anterior
root attachment shows the anterior horn with a speckled appearance
of the lateral meniscus slopes upward as it approaches its
(arrow). This is a normal variant in this region created in part by fibers posterior root attachment so that increased intrameniscal
of the anterior cruciate ligament inserting into the meniscus. signal intensity may be seen in this region. This may mimic

• Fig. 15.22 Meniscofemoral ligaments. A, Coronal proton density–weighted image shows the menisco-
femoral ligament of Wrisberg (arrowheads) extending obliquely across the posterior intercondylar notch.
B, Sagittal proton density–weighted image displays the ligament (arrow) coursing posterior to the posterior
cruciate ligament.

• Fig. 15.23 Pseudotear from meniscofemoral ligament. A, Sagittal fat-suppressed T1W image after
intravenous gadolinium administration through the lateral meniscus shows a pseudotear (arrow) of the pos-
terior horn caused by the insertion of one of the meniscofemoral ligaments of Wrisberg (arrowhead). B, Cor-
onal fat-suppressed T2W image in the same patient displays the large Wrisberg ligament (arrowheads).

The muscle is located posterior to the proximal tibia. The

appearance of a meniscal tear can result as the tendon passes
between the meniscus and the capsule (Fig. 15.26), but
this should not be confused with a tear. Conversely, a
vertical longitudinal tear of the posterior horn of the lateral
meniscus is commonly seen in conjunction with an ACL
tear and should not be confused with the popliteus tendon
(Fig. 15.27).
Because the sensitivity for diagnosing meniscal tears is
known to decrease when the ACL is torn, and many of
the missed tears occur in the posterior horn of the lateral
meniscus, close attention should be directed to this area
when an ACL tear is present. Knowing the imaging pitfalls
that involve the posterior horn of the lateral meniscus is
imperative to achieving a high accuracy rate (Box 15.4) in
diagnosing meniscal tears.

Ligaments
Anterior Cruciate Ligament
The normal ACL has straight, taut fibers that run parallel to
• Fig. 15.24 Popliteal artery pulsation artifact. Sagittal proton den- the roof of the intercondylar notch (Fig. 15.28). It typically
sity–weighted image through the lateral meniscus demonstrates oblique, has a striated appearance with some high signal within it,
linear pulsation artifacts arising from the popliteal artery (P). These create especially at its insertion on the tibia. T2W sagittal images
a pseudotear in the posterior horn (arrow).
are recommended for evaluating the ACL, but it should
be routinely evaluated in all three planes. The accuracy of
MRI for the ACL is extremely high, approaching 95% to
a complex tear on sagittal image but disappears on T2W 100% in almost all reported series.
sequences, so it is not typically a problem. A torn ACL is usually obvious, as no normal-appearing
fibers can be identified (Fig. 15.29). When it tears, it literally
Popliteus Tendon Pseudotear explodes within the midsubstance. A tendon graft (usually
The popliteus tendon originates on the lateral femoral from the patella tendon or the hamstrings) is used to recon-
condyle and extends inferiorly and obliquely between the struct the ACL. Occasionally, an ACL tear is seen in which
posterior horn of the lateral meniscus and the joint capsule. the fibers of the torn ACL are seemingly intact but the angle

• Fig. 15.25 Magic angle phenomenon. A, Sagittal gradient echo image shows the posterior horn of the
lateral meniscus (arrow) as ill defined and of intermediate signal. B, Coronal gradient echo image demon-
strates the normal upward slope of the posterior horn of the lateral meniscus that causes the magic angle
artifact commonly seen in this portion of the meniscus (arrow). C, Sagittal STIR image. Note the normal
appearance of the meniscus on this sequence.

• Fig. 15.27 Lateral meniscus tear vs. popliteus tendon pseudotear.

• Fig. 15.26 Popliteus tendon pseudotear. Sagittal image through the Sagittal proton density–weighted image through the lateral meniscus
lateral meniscus shows the popliteus tendon (P) passing close to the shows a peripheral vertical tear of the posterior horn (white arrow) with
posterior horn of the meniscus, creating a pseudotear (arrow) a small amount of meniscal tissue peripheral to the tear (arrowhead),
appearance. which could be mistaken for the pseudotear related to the popliteus ten-
don (small arrow) illustrated in Fig. 15.26

is flatter than normal (not parallel to the intercondylar notch)

• BOX 15.4 Pitfalls Involving the Posterior Horn
(Fig. 15.30). The origin of the ligament should be carefully of the Lateral Meniscus
inspected on axial and coronal images, where an oval, low
signal structure should be seen to be firmly attached to the • Meniscofemoral ligament insertion
lateral wall of the notch with an intact ACL. • Pulsation artifact from popliteal artery
A partial tear of the ACL is a difficult clinical diagnosis • Magic angle phenomenon
• Popliteus tendon
because the knee is found to be stable on clinical exam in
the majority of cases. As such, MRI plays an important role
in arriving at a correct diagnosis. A sprain or partial tear of the
ACL can be mentioned when some intact fibers are identi- an unknown etiology but distend the ligament with mucin-
fied but there is more high signal than usual elsewhere in ous fluid (Fig. 15.31). The normal ACL fibers are present
the ligament. but appear thinned due to the mass effect of the cyst. These
A pitfall that may mimic an ACL tear is that of an ACL patients are stable on exam and usually are asymptomatic. At
ganglion. These cysts, which lie within the ligament, are of most, they have a feeling of swelling or fullness in the knee

• Fig. 15.28 Normal anterior cruciate ligament. A, Sagittal proton density–weighted image through the
intercondylar notch shows a normal anterior cruciate ligament paralleling the roof of the notch. B, Coronal
fat-suppressed proton density–weighted image. The ligament is seen to fill the lateral notch (arrow). Note
the normal posterior cruciate ligament in the medial notch (P).

• Fig. 15.29 Torn anterior cruciate ligament. Sagittal gradient echo

image through the intercondylar notch shows the anterior cruciate liga-
ment to be completely disrupted, with no normal fibers identified.
• Fig. 15.30 Torn anterior cruciate ligament. Sagittal STIR image
through the intercondylar notch shows the anterior cruciate ligament
to be somewhat wavy and slightly more horizontal in orientation than nor-
and are unable to flex the knee fully because of the mass mal. Also, its origin at the femur could not be identified (arrow). This is a
effect. The ACL has a drumstick appearance on sagittal torn anterior cruciate ligament.
images and on coronal or axial images demonstrates fluid sig-
nal within the substance of the ACL. The most important
reasons to recognize this are to not identify this as an ACL 18 months after reconstruction. If the graft is disrupted or
tear or any type of tumor. absent, it has failed (Fig. 15.33). The tibial tunnel should
After surgery to reconstruct the ACL, we often are be parallel to and in line with the roof of the femoral inter-
asked to reimage a patient because of pain or instability. condylar notch because when too steep or too anterior, the
The ACL graft should be present as a taut structure, usually graft may become impinged by the femur as it courses
with some increased signal on T2W sagittal images through the notch. If the tunnel is too flat, it may be too
(Fig. 15.32), particularly if reimaging within the first lax and not provide the needed stability.

• Fig. 15.31 Anterior cruciate ligament

cyst. A, Sagittal proton density image
through the intercondylar notch shows
the anterior cruciate ligament as a cystic,
drumstick-shaped structure without
clearly identifiable fibers. B, Coronal fast
spin echo–T2W image shows the ante-
rior cruciate ligament to have a cystic
appearance (arrows). This is characteris-
tic of an anterior cruciate ligament cyst.

• Fig. 15.32 Intact anterior cruciate ligament graft. Sagittal proton • Fig. 15.33 Torn anterior cruciate ligament graft. Sagittal proton
density–weighted image through the intercondylar notch in a patient with density–weighted image in a patient with a prior anterior cruciate liga-
a prior anterior cruciate ligament reconstruction shows the anterior cru- ment reconstruction demonstrates a complete rupture of the graft
ciate ligament graft to be intact. (arrow).

One of the most common reasons for pain after knee Posterior Cruciate Ligament
arthroscopy is the presence of arthrofibrosis (scar) in Hoffa’s The PCL normally is seen as a low signal structure in the
fat pad and along the anterior margin of the graft. In symp- medial intercondylar notch, gently curving between the pos-
tomatic cases, the patient will typically present with progres- terior femur and tibia on sagittal images (Fig. 15.36). It is
sive loss of the ability to extend the knee. A round, often infrequently torn and even less frequently surgically recon-
lobular, mass of scar tissue is seen along the anterior margin structed. When it tears, it may not result in actual disruption
of the graft and/or in Hoffa’s fat pad. This is called a cyclops of the fibers, as is seen with other ligaments, but rather it
lesion and often needs to be resected (Fig. 15.34). A linear stretches and becomes structurally incompetent, much
band of scar tissue that extends to the inferior pole of the like overstretching the elastic in one’s socks. On MRI,
patella can also restrict patellar motion and cause pain this type of injury is recognized as an enlarged ligament with
(Fig. 15.35). gray intrasubstance signal intensity on short TE images

• Fig. 15.34 Cyclops lesion. A, Sagittal proton density–weighted image in a patient with a prior anterior
cruciate ligament reconstruction (A) shows scar tissue within the intercondylar notch anterior to the graft
(arrowheads). B, On a sagittal STIR image, the scar stays predominantly low in signal intensity This is arthro-
fibrosis secondary to the surgery and has been termed a cyclops lesion.

• Fig. 15.36 Normal posterior cruciate ligament. Sagittal proton den-

sity–weighted image through the intercondylar notch shows a normal
posterior cruciate ligament with uniform low signal intensity.

• Fig. 15.35 Arthrofibrosis. Sagittal proton density–weighted image in

a patient with a prior anterior cruciate ligament reconstruction shows
scar tissue in Hoffa’s fat pad (arrow), which extends to the inferior pole
of the patella. This form of arthrofibrosis can cause patellar pain and
patellar tracking abnormalities.
diagnosed, but this is much less common than a tear.
Orthopedic surgeons are performing more PCL reconstruc-
(Fig. 15.37), although a tear may also demonstrate the more tions than in the past, but in most cases a torn PCL is not
typical high signal on T2W images (Fig. 15.38). Chronic repaired. In many cases, it does not matter what we say about
tears are difficult to distinguish from acute tears without clin- the PCL—the surgeon may not even inspect it at
ical history or additional MRI evidence of recent injury. If arthroscopy—but we still should be able to report with a
the PCL avulses from its tibial attachment, it is easily high degree of accuracy if the PCL is torn or not.

coronal images. Grade I, a sprain, shows high signal in the

soft tissues along the MCL (Fig. 15.39). Grade II, a severe
sprain or partial tear, shows high signal in the adjacent soft
tissues along with high signal within the MCL and partial
disruption of its fibers (Fig. 15.40). Grade III, or complete
tear, shows disruption of the MCL (Fig. 15.41). The
MCL is seldom repaired even if it is completely disrupted,
unless multiple other ligaments are torn. Grade I and II
sprains usually are treated conservatively with bracing and
continuance of athletic activities as pain allows. Other
causes of high signal medial to the MCL may occur from
abnormalities unrelated to an MCL sprain, such as an
underlying meniscal tear or osteoarthritis of the medial joint
compartment.
A meniscocapsular separation is easily diagnosed on fluid-
sensitive coronal images by noting fluid between the MCL
• Fig. 15.37 Torn posterior cruciate ligament. A, Sagittal proton den- and the medial meniscus (Fig. 15.42). This separation can
sity image through the intercondylar notch shows a thickened posterior
cruciate ligament that demonstrates diffuse intermediate signal intensity
be overlooked on non–fluid-sensitive sequences. Because
in its mid portion at the site of tearing (arrowheads). these patients present clinically in an identical manner to a
patient with a sprained MCL, they often are allowed to con-
tinue their activities with a brace. This is unacceptable treat-
ment for a meniscocapsular separation. The vascular
interface between the MCL and the meniscus can become
avascular with continued activity, resulting in a meniscus
that does not heal to the capsule. Patients with this type
of injury need either immobilization or surgical repair.

• Fig. 15.38 Torn posterior cruciate ligament. Sagittal STIR image

through the intercondylar notch shows a torn posterior cruciate ligament
with increased signal intensity and high-grade disruption of its mid to dis-
tal fibers (arrow).

Medial Collateral Ligament

The MCL originates on the medial aspect of the distal femur
and inserts on the medial aspect of the proximal tibia several
centimeters below the joint line. Its deep fibers are intimately
interlaced with the joint capsule at the level of the joint, and
the medial meniscus is attached directly to it. It is not an
intrasynovial structure; it is not seen or repaired arthroscopi-
cally. It is generally agreed that MRI is highly accurate in • Fig. 15.39 Grade I medial collateral ligament sprain. Coronal fat-
suppressed proton density–weighted image in a patient with an injury
depicting the MCL. to the medial collateral ligament (MCL). There is edema tracking along
The three grades of injury described clinically correspond the ligament (arrowheads), which is otherwise intact. This is a grade I
to three appearances of the MCL seen with fluid-sensitive MCL sprain. Note also the torn anterior cruciate ligament (arrow).

• Fig. 15.42 Meniscocapsular separation. Sagittal fat-suppressed

T2W image through the medial meniscus shows fluid between the pos-
terior horn attachment and the capsule (arrow). This indicates a menis-
cocapsular separation.

posteriorly, involving the posterior oblique ligament (a thick-

ening of the capsule at the joint line posterior to the MCL),
• Fig. 15.40 Grade II medial collateral ligament sprain (partial tear). seems to be more significant in terms of stability than one
Coronal fat-suppressed T2W image shows increased signal in a thinned
but otherwise intact medial collateral ligament (arrowhead)—this is a par- that is solely medial or anterior.
tial tear (grade II sprain). Note also the disruption of the meniscofemoral
component of its deep fibers (arrow). Lateral Collateral Ligament Complex
The lateral collateral ligament (LCL) complex is composed
of many structures, but only three are easily evaluated
with MRI; posterior to anterior, they are the biceps femoris
tendon, the LCL (Fig. 15.43A), and the iliotibial band. The
biceps tendon and LCL insert onto the proximal fibula
via a conjoined attachment, whereas the iliotibial band
inserts onto Gerdy’s tubercle on the anterolateral tibia.
Tears of the LCL (Fig. 15.43B) are not nearly as common
as tears of the MCL. LCL tears, however, are often associa-
ted with injury to other ligaments as well as other
structures in the posterolateral corner of the knee, as this area
is called.
Additional important structures in the posterolateral cor-
ner that can be seen on most, but not all, MRI studies
include the arcuate ligament and the popliteofibular liga-
ment. The arcuate ligament is Y-shaped and runs from the
fibular styloid process to the lateral femoral condyle, with
one limb inserting into the lateral joint capsule. Disruption
of the lateral capsule at the joint line is a reliable indicator of a
tear of the arcuate ligament (Fig. 15.44).
The popliteofibular ligament is thought to be one of the
strongest lateral stabilizers in the knee. It can be identified on
• Fig. 15.41 Torn medial collateral ligament. Coronal fat-saturated most MRI studies by finding the lateral geniculate vessels on
T2W image reveals a complete tear of the medial collateral ligament coronal images and noting the ligament just beneath them
(arrow).
(Fig. 15.45A). On sagittal images, it can be seen just super-
If the meniscocapsular separation is isolated solely to the area ficial to the popliteus tendon and inserting onto the fibula
of the MCL, it can be considered a partial tear involving (see Fig. 15.45B).
the deep fibers of the MCL. If the separation is over only Injury to a component of the LCL in association with
a short portion of the meniscal attachment, it is unlikely tears of the popliteus tendon, arcuate ligament, popliteofib-
to be significant. A meniscocapsular separation that extends ular ligament, and either the ACL or the PCL is termed a

• Fig. 15.43 Normal and torn lateral collateral ligament. A, Coronal proton density–weighted image
shows a normal lateral collateral ligament (arrowheads). B, Coronal fat-suppressed T2W image shows a torn
and slightly retracted lateral collateral ligament (L) from its fibular attachment (arrow).

A B

• Fig. 15.44 Normal and torn arcuate ligament. A, Axial image at the joint line shows the normal posterior
capsule (arrows), which indicates the arcuate ligament is intact. B, Axial image through the joint line in another
patient shows a large gap in the posterior capsule (arrowheads), which indicates that the arcuate ligament
is torn.

posterolateral corner injury. Such injury results in pain and incidence of a poor outcome. After recognizing the complex
instability with knee hyperextension if not surgically cor- of structural abnormalities comprising a posterolateral corner
rected. It is one of the few knee injuries that many surgeons injury, the referring clinician should be notified promptly of
consider a near-emergency. Failure to treat a posterolateral the results to implement appropriate and timely surgical
corner injury surgically in 10 to 14 days is said to have a high intervention.

A B

• Fig. 15.45 Normal popliteofibular ligament. A, Coronal fat-suppressed T2W image shows a prominent,
intact popliteofibular ligament (arrow) extending from the popliteus tendon to the fibular styloid process. The
lateral geniculate artery is just beneath the tip of the arrow. B, Sagittal fat-suppressed T2W image depicts the
popliteofibular ligament (arrow) inserting on the fibular styloid process (arrowhead).

The popliteus tendon can tear as an isolated injury but patella alta. A patellar dislocation usually is easily diagnosed
usually tears in conjunction with other structures, as in pos- with MRI due to the commonly associated bone contusions.
terolateral corner injuries or complete knee dislocations. A One contusion characteristically involves the anterior lateral
popliteus tear usually occurs at the musculotendinous junc- femoral condyle (Fig. 15.49A). The contusion is from the
tion and results in a large amount of fluid in the popliteus impaction of the patella as it either dislocates or reduces.
tendon sheath, a lax popliteus tendon, and high signal in There may or may not be a kissing contusion on the medial
or around the popliteus muscle (Fig. 15.46).
Pain in the anterolateral knee often is found in runners
because of the iliotibial band rubbing on the lateral femoral
condyle. This entity is called iliotibial band friction syndrome
or iliotibial band syndrome. It is easily diagnosed on MRI by
noting fluid on both sides of the iliotibial band (Fig. 15.47).
In the earlier stages, there may be only fluid or edema deep
to the iliotibial band; this can be very difficult, if not impos-
sible, to distinguish from fluid in the joint that has extended
posterolaterally. If there is no joint fluid present, edema
between the iliotibial band and the femur is a reliable indi-
cator of iliotibial band syndrome (Fig. 15.48). It is seen
most easily on axial images. The iliotibial band may be
slightly thickened or demonstrate high signal within its
fibers, and it usually has high signal around it. Iliotibial
band syndrome can be confused clinically with a lateral
meniscus tear, and imaging can play a vital role in avoiding
unnecessary surgery.

Patella
Dislocation of the patella frequently is diagnosed with MRI,
to the surprise of the referring physician. Because the dislo-
cated patella often spontaneously reduces, only about half of
patients with patella dislocations are aware of what really
• Fig. 15.46 Torn popliteus tendon. Sagittal fast spin echo–T2W
occurred. They get referred for imaging with the nebulous image shows a marked amount of fluid around the popliteus tendon.
“rule out internal derangement” history. Predisposing factors The tendon is wavy and lax, rather than taut (arrow). These findings
to patellar dislocation include a shallow trochlear groove and are typical for a torn popliteus tendon.

• Fig. 15.47 Iliotibial band syndrome. A, Coronal fat-suppressed proton density–weighted image
shows edema (arrow) between the iliotibial band (arrowhead) and lateral femoral condyle. B, Axial fat-
suppressed T2W image again demonstrates the edema (arrow) characteristic for iliotibial band syndrome
(arrowhead ¼ iliotibial band).

A B
• Fig. 15.48 Iliotibial band syndrome. A, Axial image in a patient with lateral knee pain shows more subtle
edema between the iliotibial band and the lateral femoral condyle than in the previous figure (arrow). B, Cor-
onal image again shows the edema (arrow).

side of the patella. The medial retinaculum is always injured, Synovial Plicae
although a frank tear can be difficult to appreciate. It is
important to identify any associated patellar or lateral femo- During fetal development, the knee is divided into three
ral condyle cartilage injury. If a piece of cartilage is missing, it compartments by anatomic folds. If these fail to completely
usually means an arthroscopic procedure is necessary (see regress, they appear as synovial folds within the joint known
Fig. 15.49B), whereas if the cartilage is normal, the patient as plicae. The three common plicae include the superior,
usually is treated nonsurgically, so one of the main roles of inferior, and medial patella plicae. More than half of all nor-
the radiologist is to examine the articular cartilage carefully. mal knees show one or more of the plicae on MRI.

• Fig. 15.49 Patellar dislocation. A, Axial fat-suppressed T2W image shows contusions in the lateral fem-
oral condyle and medial patella (arrowheads) consistent with a patellar dislocation. B, Axial fat-suppressed
T2W image through the patella in a different patient shows similar contusions, as well as a large defect in the
patellar cartilage (arrow), which is often an indication for surgery.

The medial patellar plicae is seen as a thin, fibrous band uncommon diagnosis. These findings should be sought
frequently on axial and sagittal images that extends from the when patients present for medial joint line pathology and
medial joint capsule toward the medial facet of the patella no meniscal pathology is identified.
(Fig. 15.50). The medial patella plica can become thickened, The suprapatellar plica is best seen on sagittal images
stiff, and trapped between the patella and the femur, causing coursing through the suprapatellar recess (Fig. 15.51). It
pain, clicking, and locking, similar to the clinical presenta- may be imperforate and divide the suprapatellar pouch into
tion of a torn meniscus. No measurements are used to diag- a separate compartment, in which case, pigmented villonod-
nose a thickened medial patellar plica. With experience, ular synovitis, synovial chondromatosis, or even a loculated
it becomes obvious when the plica appears to be too thick effusion in this space can rarely manifest as a suprapatellar
(see Fig. 15.50). But even so, numerous studies have mass that is mistaken for a tumor.
shown that there is no correlation between the appearance The infrapatellar plica originates in the inferior pole of the
of the plica and clinical symptoms. An inflamed plica is patella and extends through Hoffa’s fat pad to the transverse
easily removed at arthroscopy, but plica syndrome is an ligament and anterior to the ACL as it inserts onto the roof of

• Fig. 15.50 Medial patellar plica. A, Axial fat-suppressed T2W image demonstrates a thin fibrous band
extending off the medial capsule (arrow), a medial patellar plica. B, An adjacent slice immediately inferior to (A)
in the same patient reveals thickening of the plica (arrowheads) as it extends over the medial femoral condyle.

Patellar Tendon
Pain in the infrapatellar region in athletes, so-called “jum-
per’s knee,” is often seen on MRI as thickening of the prox-
imal patellar tendon with high signal in and around it on
T2W images (Fig. 15.53). Jumper’s knee can be a debilitat-
ing condition for athletes and can require surgery to remove
the focus of myxoid degeneration in the tendon.

Fat Pad Impingement

A common source of patellofemoral pain is fat pad impinge-
ment. This is seen on MRI as increased T2 signal in Hoffa’s
fat pad just inferior to the patella (Fig. 15.54) or in the supra-
patellar fat pad (Fig. 15.55). It is secondary to impingement
of the fat pads on the femoral condyle by the patella tendon
or the quadriceps tendon during flexion and has been
reported to be present in 12% of cases.

• Fig. 15.51 Suprapatellar and infrapatellar plicae. Sagittal proton

density–weighted image through the knee shows a suprapatellar plica
(arrow) as well as a thin infrapatellar plica (arrowhead), which extends into
Hoffa’s fat pad just anterior to the anterior cruciate ligament.

the intercondylar notch (see Fig. 15.51). The infrapatellar

plica can become thickened and irritated due to chronic
stress in some athletes resulting in anterior knee pain. This
is commonly seen with MRI as abnormal increased T2 signal
along its course in Hoffa’s fat pad (Fig. 15.52). It is easily
resected arthroscopically with pain relief.

• Fig. 15.53 Jumper’s knee. A, Sagittal proton density–weighted

image through the patellar tendon shows a thickened proximal portion
• Fig. 15.52 Irritated infrapatellar plica. Sagittal image shows of the tendon with high intrasubstance signal (arrow). This is diagnostic
increased signal along the infrapatellar plica in Hoffa’s fat pad (arrow). of jumper’s knee. B, Sagittal STIR image demonstrates the tendon
This patient was an athlete with anterior knee pain; the plica was abnormalities (arrow), as well as adjacent edema within Hoffa’s fat pad
removed arthroscopically, with resolution of his symptoms. (arrowhead).

correctly report their occurrence so that the orthopedic sur-

geon can institute the appropriate treatment.

Popliteal (Baker’s Cyst)

The most common knee bursa is a popliteal bursa, or
Baker’s cyst, which is actually a joint recess that extends
from the knee joint posteriorly between the tendons of
the medial head of the gastrocnemius and the semimembra-
nosus (Fig. 15.56). It can contain a small amount of fluid in
normal individuals in proportion to joint fluid. When dis-
tended, this should be mentioned because it could be a
source of symptoms. These bursae can get quite large,
may be associated with hemorrhage, and can cause a com-
partment syndrome. They can extend quite distally in the
lower leg in some patients, and if ruptured can cause
inflammation in the surrounding tissues, which can mimic
a deep vein thrombosis clinically.

Prepatellar Bursa
Prepatellar bursitis is a common cause of anterior knee pain. It
is caused from repetitive trauma from kneeling—it has been
termed housemaid’s knee in the older, less politically correct lit-
• Fig. 15.54 Hoffa’s fat pad impingement. Edema is seen in the erature. Because it is an easy clinical diagnosis, we do not usu-
superolateral aspect of Hoffa’s fat pad just inferior to the patella in
this patient with anterior knee pain. This is due to fat pad impingement.
ally see prepatellar bursitis as an isolated finding, but often we
see it in addition to other abnormalities. On MRI it is seen as a
fluid collection superficial to the patella (Fig. 15.57).

Pes Anserinus Bursa

A bursa that occurs on the anteromedial tibia, just below the
joint line, is the pes anserinus bursa. Pes anserinus means
“goose’s foot” in Latin and refers to the configuration of the
insertion of the pes tendons (gracilis, sartorius, and semitendi-
nosus) onto the tibia—it has a webbed foot appearance (it takes
a little imagination). The pes bursa lies beneath the tendons and

• Fig. 15.55 Suprapatellar fat pad impingement. Edema is seen in

the suprapatellar fat pad in this patient with anterior knee pain secondary
to fat pad impingement.

Bursae
Several bursae are present around the knee that can become
inflamed and cause symptoms that, in some cases, can mimic • Fig. 15.56 Popliteal (Baker’s) cyst. Axial fat-suppressed T2W image
shows a classic popliteal (Baker’s) cyst (B) with its neck emanating from
intra-articular pathology and result in inappropriate therapy, between the semimembranosus (arrowhead) and medial gastrocnemius
including surgery. It is important to recognize these and (arrow) tendons.

appearance that makes it easily recognized with MRI.

It occurs along the posteromedial joint line and drapes
over the semimembranosus tendon like a horseshoe
(Fig. 15.59). On coronal and sagittal images, it appears to
arise at the meniscus and extend inferiorly and may mimic
a parameniscal cyst.

Medial Collateral Ligament Bursa

An uncommonly seen bursa is the MCL bursa. It lies just
deep to the MCL and extends vertically above and below
the joint line (Fig. 15.60). It can be confused for a menisco-
capsular separation, but in contrast to a traumatic separation,
the fluid is well contained within the ligament and cystlike,
rather than diffusely distributed.
The four bursae described here all occur medially and are
located in distinctly different locations (Fig. 15.61). Occa-
sionally, a bursa is so distended that it overlaps an area usually
reserved for another bursa, and it can be difficult to deter-
mine which bursa is present. Axial images usually allow for
easy differentiation of each bursa. The actual name of the
bursa is not as important as recognizing that there is a bursa
• Fig. 15.57 Prepatellar bursitis. Sagittal fast spin echo–T2W image and communicating that to the referring clinician.
through the knee shows a well-contained fluid collection anterior to
the patella. This is prepatellar bursitis. Bones
superficial to the medial collateral ligament (MCL). When Bone contusions, seen as amorphous, subarticular high sig-
inflamed, it extends proximally toward the joint (Fig. 15.58). nal on T2W images, are commonly encountered on knee
MRI (Fig. 15.62). They have significance, in that they
Semimembranosus–Tibial Collateral can be the sole source of pain, they can precede a focal area
Ligament Bursa of bone necrosis (osteochondritis dissecans), and they can
Another bursa that can mimic internal derangement in the indicate additional internal derangements when they have
knee is the semimembranosus–tibial collateral ligament a specific pattern. Bone contusions are basically microfrac-
bursa. This commonly inflamed bursa has a characteristic tures. They invariably heal with rest, as would any fracture.

• Fig. 15.58 Pes anserinus bursitis. A, Coronal fat-suppressed T2W image demonstrates a medial fluid
collection (arrow) that lies superficial to the medial collateral ligament (small arrows). B, Axial STIR image dem-
onstrates thin septations within the fluid collection (P) that lies in the expected region of the pes anserine ten-
dons. This is pes anserinus bursitis.

• Fig. 15.59 Semimembranosus bursitis. A, Sagittal STIR image shows a fluid collection (arrow) adjacent
to the distal semimembranosus tendon (S). B, Coronal fat-suppressed T2W image shows the fluid collection
(arrowheads) wrapping around the tendon (S) from the level of the joint distally, the characteristic location and
appearance of the semimembranosus bursa.

internally rotates on the femur, allowing the lateral femo-

ral condyle to impact on the posterolateral tibial plateau.
This has been termed the pivot-shift phenomenon. There
is often a kissing contusion on the central to anterior lat-
eral femoral condyle above the anterior horn of the lateral
meniscus. This contusion pattern is occasionally found in
the absence of an ACL tear in children who have stretched
the ACL, but their increased flexibility protects it from
tearing.
The contra-coup contusion pattern results from impac-
tion of the medial femoral condyle on the posterior medial
tibial plateau due to the resulting instability after an ACL
tear. This finding is often seen in conjunction with a periph-
eral meniscal tear or meniscocapsular injury/separation.
Bone contusion patterns in ACL and patella dislocations
are discussed in detail in Chapter 8.

Soft Tissues
Acute, activity-related pain in the calf has been termed ten-
• Fig. 15.60 Medial collateral ligament bursitis. Fast spin echo–T2W nis leg because of its frequent association with that activity.
image shows a fluid collection just deep to the medial collateral ligament, The patient presents with acute calf pain and occasionally
which is a medial collateral ligament bursitis. displays swelling with purplish skin discoloration caused
by the hemorrhage. Classically this has been attributed to
a tear of the plantaris tendon, but has been shown to more
If they are not protected, however, there is at least the commonly result from partial tearing of the medial head of
potential that they can progress to collapse or fragmenta- the gastrocnemius muscle. It can clinically resemble a deep
tion, particularly when the contusion is more geographic venous thrombosis. MRI through the calf shows an abnor-
in appearance as opposed to the reticular appearance of mal signal within the medial gastrocnemius and a focal fluid
most contusions. collection between it and the soleus muscle (Fig. 15.64). In
A contusion pattern that is fairly specific for an ACL the case of a true plantaris rupture a torn, retracted tendon
tear is one that involves the posterolateral aspect of the tib- sometimes may be seen in addition to the often tubular
ial plateau (Fig. 15.63). When the ACL tears, the tibia fluid collection.

• Fig. 15.61 Knee bursae. Schematic shows the location of

the common bursae on the medial side of the knee.
Semimembranosus-gastrocnemius bursa is also known as
Baker’s cyst.

Semimembranosus-
gastrocnemius bursa

Tibial collateral Semimembranosus

ligament tendon

Pes anserinus Semimembranosus–tibial

bursa collateral ligament bursa

• Fig. 15.63 Bone contusions: ACL tear. Sagittal STIR image shows
reticular high signal intensity contusions at the level of the terminal sulcus
of the femoral condyle (arrowhead) and posterolateral tibial plateau (large
arrow). This contusion pattern typically is seen with an anterior cruciate
• Fig. 15.62 Bone contusions. Sagittal STIR image through the lateral
ligament tear. Note also the fragment from the posterior horn of the lat-
side of the knee shows prominent reticular contusions in the anterior
eral meniscus that has torn and become displaced to lie adjacent to the
aspects of the lateral femoral condyle and tibial plateau, a pattern typi-
anterior horn—the “double anterior horn” sign. This type of tear most
cally seen with a hyperextension injury.
commonly involves the lateral meniscus.

mimic a distended prepatellar bursa, the fluid often extends

A fluid collection at the subcutaneous fat-fascia interface farther (medially, laterally, or proximally) than is typical for
along the anterior aspect of the knee may result from a shear- the bursa.
ing injury (Fig. 15.65), force that causes a degloving injury
known as a Morel-Lavallee lesion. The fat is sheared off of its Cartilage
attachment to the fascia, and fluid accumulates in the injured
tissue. This type of injury is most commonly seen in the Discussion of articular cartilage has been covered thoroughly
gluteal region, and these are often very difficult to treat in Chapter 6. Please refer to that chapter for a detailed dis-
due to a high rate of recurrence. Although this injury may cussion on cartilage imaging and interpretation.

• Fig. 15.64 Plantaris tendon/medial gastrocnemius tear. Axial proton density (A) and fat-suppressed
T2W (B) images through the calf in a patient with sudden calf pain while playing tennis shows a fluid collection
(arrow) between the soleus and the medial head of the gastrocnemius muscle, which also demonstrates
faint edema.

• Fig. 15.65 Morel-Lavallee injury. Fluid has collected at the subcutaneous fat–fascia interface (arrows) in
this patient who sustained a shearing injury to the knee when sliding into a base during a softball game. Note
the more pronounced medial extension than would be expected with a prepatellar bursitis.

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Skaf AY. Magnetic resonance imaging-based morphological and

KNEE PROTOCOLS
This is one set of suggested protocols; there are many variations that would work equally well.

Dedicated Knee MRI

Sequence no. 1 2 3 4 5
Sequence type FSE PD with fat FSE with fat FSE with fat FSE with T1 fat FSE with T1 fat
saturation saturation saturation saturation saturation
Orientation Sagittal Sagittal Coronal Axial Coronal
Field of view (cm) 14-16 14-16 14-16 14-16 14-16
Slice thickness 4 4 4 4 4
(mm)
Contrast No No No No No
Sample Standard Report
Clinical information
Protocol
The examination was done using the routine knee protocol.
Discussion
1. Joint effusion: None; no evidence of a popliteal cyst
2. Menisci: Medial and lateral—no evidence of a tear
3. Anterior and posterior cruciate ligaments: Intact
4. Medial and lateral collateral ligaments: Intact
5. Quadriceps and patellar tendons: Normal
6. Articular cartilage: Normal; no focal defects, osteoarthritis, or other abnormalities
7. Osseous structures: Normal; no contusions, fractures, or other lesions
8. Other abnormalities: None
Opinion
Normal MRI of the (right/left) knee.

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MRI knee

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MRI knee

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C HA P T E R OU T LI N E with sensitivity and specificity of 90% to 95% for the menisci

pathology is poorly demonstrated by this technique at

• Fig. 15.5 Myxoid or intrasubstance degeneration. Sagittal proton

Bucket-Handle Tears Radial or Free Edge Tears

• Fig. 15.9 Double posterior cruciate ligament sign. Sagittal proton

recommended. A gap at the attachment is diagnostic of a

Medial Flipped Meniscus

• Fig. 15.12 Extruded meniscus resulting from a radial tear. A, Cor-

children, and a meniscectomy at an early age leads to prema-

• Fig. 15.19 Wrisberg variant of a discoid lateral meniscus. Sagittal

• BOX 15.2 Abnormalities With Absent Bow

• BOX 15.3 Pitfalls in Absent Bow Tie Sign

In patients with severe osteoarthritis or in older patients

Pulsation From Popliteal Artery

Magic Angle Phenomenon

The muscle is located posterior to the proximal tibia. The

• Fig. 15.27 Lateral meniscus tear vs. popliteus tendon pseudotear.

is flatter than normal (not parallel to the intercondylar notch)

• Fig. 15.29 Torn anterior cruciate ligament. Sagittal gradient echo

• Fig. 15.31 Anterior cruciate ligament

• Fig. 15.36 Normal posterior cruciate ligament. Sagittal proton den-

• Fig. 15.35 Arthrofibrosis. Sagittal proton density–weighted image in

coronal images. Grade I, a sprain, shows high signal in the

• Fig. 15.38 Torn posterior cruciate ligament. Sagittal STIR image

Medial Collateral Ligament

• Fig. 15.42 Meniscocapsular separation. Sagittal fat-suppressed

posteriorly, involving the posterior oblique ligament (a thick-

Fat Pad Impingement

• Fig. 15.51 Suprapatellar and infrapatellar plicae. Sagittal proton

the intercondylar notch (see Fig. 15.51). The infrapatellar

• Fig. 15.53 Jumper’s knee. A, Sagittal proton density–weighted

correctly report their occurrence so that the orthopedic sur-

Popliteal (Baker’s Cyst)

Pes Anserinus Bursa

• Fig. 15.55 Suprapatellar fat pad impingement. Edema is seen in

appearance that makes it easily recognized with MRI.

Medial Collateral Ligament Bursa

internally rotates on the femur, allowing the lateral femo-

• Fig. 15.61 Knee bursae. Schematic shows the location of

Tibial collateral Semimembranosus

Pes anserinus Semimembranosus–tibial

mimic a distended prepatellar bursa, the fluid often extends

Dedicated Knee MRI

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