Illustrated review of anterior knee pain with Magnetic Resonance.

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1 Illustrated review of anterior knee pain with Magnetic Resonance. Poster No.: C-2389 Congress: ECR 2013 Type: Educational Exhibit Authors: M. C. Ruibal Villanueva, P. Sucasas-Hermida, M. Rodríguez Álvarez, C. Saborido Avila, A. Nieto Parga, D. Fernández Alonso; Vigo/ES Keywords: Education, MR, Musculoskeletal system, Pathology DOI: /ecr2013/C-2389 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 80

2 Learning objectives Study the different causes of anterior knee pain describing their MR imaging findings. Background Lesions of any components of the anatomic anterior compartment of the knee may contribute to anterior knee pain. These conditions include: lesions of the extensor mechanism and soft tissue lesions around it, cartilaginous lesions, patello-femoral joint lesions and intramedullary abnormalities of the knee. Table 1. Images for this section: Fig. 1: Table 1. Page 2 of 80

3 Imaging findings OR Procedure details 1. EXTENSOR MECHANISM: The primary structures of the extensor mechanism are shown in the below drawing. Fig. 2 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES PATELLAR AND QUADRICEPS TENDONS: The patellar tendon originates in the inferior pole of the patella and inserts distally onto the anterior tibial tubercle. On MR imaging has a low signal intensity in all pulse sequences although due to the "magic angle" phenomenon, the proximal patellar tendon may have Page 3 of 80

4 not low signal and exhibit localized hyperintensity, specially its posterior fibers, resulting in false positive findings. The quadriceps tendon is a multilayered tendon that consists of a superficial portion receiving the fibers of the rectus femoris muscle and a deep portion receiving fibers of the vastus intermedius muscle, which is joined by the tendinous fibers of the vastus medialis and vastus lateralis muscles. We find fibro-fatty connective tissue between these layers, so the appearance on MR imaging will not be homogenously black, as with most of the other tendons, but will have longitudinal streaks of intermediate signal on most sequences. Most of its fibers insert on the superior pole of the patella; however the most superficial ones (contributed by the rectus femoris) continue over the anterior surface of the patella, forming an aponeurosis that merges into the patellar tendon. Fig. 3 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES PATELLAR TENDINOPATHY: Page 4 of 80

5 The patellar tendon shows an intratendinous high signal on sequences T1, T2 and STIR. It is focally or fusiform thickened. Its posterior aspect is the location usually involved, next to the inferior pole of the patella and sometimes the distal patellar tendon next to the tibial tuberosity is the one affected (jumper s knee). Ocasionally, there is cystic degeneration or an intratendinous cystic ganglion. Fig. 4 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Page 5 of 80

6 Fig. 5 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES QUADRICIPITAL TENDINOPATHY: It is less frequent than patellar tendinopathy and imaging findings are similar. In teenagers, the proximal patelar pole avulsion or the apophysitis are more often seen. In older patients might be calcifications at the site of insertion. Page 6 of 80

7 Fig. 6 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES ACUTE TENDON RUPTURE: Tendinous ruptures are usually at the sites of insertion on the patella. MRI allows to distinguish between complete and partial ruptures. There is a gap between the tendon and the patella in the complete ruptures, with bleeding associated. Partial ruptures might be low or high grade ruptures depending on the number of intact hypointense fibers on all pulse sequences we see. Page 7 of 80

8 Fig. 7 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Page 8 of 80

9 Fig. 8 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES SINDING-LARSEN-JOHANSON DISEASE (OSD): DISEASE (SLJD) and OSGOOD-SCHLATTER SLJD is the equivalent of jumper s knee on immature skeletons. On MRI the proximal patellar tendon is thickened with peritendinous edema and sometimes we see ossified fragments which are secondary to the inferior patellar pole avulsion or dystrophic fragments that are developed in the tendon due to long overuse. OSD: consists in a apophysitis due to patellar tendon traction over the tibial tuberosity. The imaging findings are similar to the ones we find in SLJD. Page 9 of 80

10 Fig. 9 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES PATELLA: The patella is a a sesamoid bone in the quadriceps tendon making easier its tracking on the trochlear groove. BIPARTITE PATELLA: It is considered an anatomic variant. The most frequent location is the superolateral aspect of the patella. It is usually asymptomatic but it may be painful sometimes, on MRI we find bone marrow edema and high signal of the surrounding soft tissues on fatsupressed T2 SE or STIR sequences. Page 10 of 80

11 Fig. 10 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES FRACTURES: secondary to direct traumas. Page 11 of 80

12 Fig. 11 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES 2. LESIONS OF THE CARTILAGE/CARTILAGINOUS LESIONS: PATELLAR CHONDROMALACIA: It is classified in 4 grades: - Grade 1: scattered areas of edema identified by increased signal on T2-weighted images but with an intact cartilage surface. - Grade 2: chondral fissurations. - Grade 3: fibrillation and crabmeat appearance. - Grade 4: full thickness loss of hyaline cartilage with underlying reactive bony changes. Page 12 of 80

13 Fig. 12 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES CHONDRAL AND OSTEOCHONDRAL LESIONS: Chondral lesions included chondral thinning, fissurations or chondral defects without underlying bone marrow edema. Page 13 of 80

14 Fig. 13 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES In osteochondral lesions, the cartilaginous lesion is accompanied by an underlying osseous fracture, trabecular osseous lesions or reactive bony stress response. An example of this is the osteochondritis dissecans which tipically involves the medial femoral condyle with an estable or an instable osteochondral fragment. Page 14 of 80

15 Fig. 14 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Page 15 of 80

16 Fig. 15 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES 3. PATELLOFEMORAL JOINT LESIONS: TRANSIENT PATELLAR DISLOCATION: It occurs in lateral direction. There are conditions that this entity more likely such as patella alta and trochlear dysplasia (an abnormal trochlear morphology and a shallow groove). On MRI there is a lesion of the medial retinaculum and medial capsule and post-contusive bone marrow edema appears on the anterolateral femoral condyle and the medial aspect of the patella with or without concomitant chondral lesion. Page 16 of 80

17 Fig. 16 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES OSTEOARTHRITIS: It is a degenerative articular process with loss of articular cartilage, cortical irregularity, osteophytes, subchondral cysts, and subchondral sclerosis. Page 17 of 80

18 Fig. 17 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES PATELLAR MALALIGNMENT: It refers to any abnormality of the position or tracking of the patella and may potencially cause pain and/or instability. These conditions include: lateral tilting of the patella, lateral ridging or the combination of both. Page 18 of 80

19 Fig. 18 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Page 19 of 80

20 Fig. 19 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES 4. SURROUNDING SOFT-TISSUE LESIONS: We refer to superficial and deep soft tissue structures surround the extensor mechanism. Page 20 of 80

21 Fig. 20 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES ANTERIOR BURSITIS: There are three different anterior bursitis: - Prepatellar bursitis: anterior to the inferior pole of the patella and the proximal patellar tendon. Page 21 of 80

22 Fig. 21 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - Pretibial bursitis (superficial infrapatellar) anterior and superficial to the distal patellar tendon. Page 22 of 80

23 Fig. 22 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - The deep infrapatellar bursitis located between the patellar tendon and the anterior aspect of the proximal tibia. Page 23 of 80

24 Fig. 23 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES SUPRAPATELLAR RECESS: We show examples of inflammatory synovitis, "rice-bodies" synovitis, pigmented villonodular synovitis, synovial ostochondromatosis and arborescens lipoma. Page 24 of 80

25 Fig. 24 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Page 25 of 80

26 Fig. 25 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - "Rice-bodies" synovitis: it is usually secondary to reumathologic diseases (reumatoid arthritis, systemic lupus erythematosus ) or infectious diseases (e.g. tuberculous arthritis). Page 26 of 80

27 Fig. 26 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - Pigmented villonodular synovitis: it is a synovial proliferation with characteristic hemosiderin deposition. Page 27 of 80

28 Fig. 27 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - Synovial osteochondromatosis: it is characterized by the synovial proliferation and metaplasia with formation of cartilaginous loose bodies that may calcified and/or ossified. Page 28 of 80

29 Fig. 28 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES FAT PAD SYNDROMES: 1) HOFFA S FAT PAD: Hoffa s fat pad is an intraarticular and extrasinovial estructure located posterior to patella tendon and anterior to the intercondylar notch and the ACL. Hoffa s fat pad syndome: it is produce due to the impingement between the intercondylar fat pad and the tibial plateau during extension of the knee. On an acute onset, there is inflammation identified by high signal on T2 WI and small effusion; on chronic stages there is low signal on T1 and T2 WI secondary to fibrin and hemosiderine deposition. Page 29 of 80

30 Fig. 29 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Impingement of the superolateral aspect of the fat pad: it is caused by the impingement of the Hoffa s fat pad due to the altered biomechanic of the femoropatellar Joint. On MRI edema in the superior aspect of the Hoffa s fat pad is seen, between the patellar tendon and the lateral femoral condyle. Page 30 of 80

31 Fig. 30 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Ganglion in Hoffa s fat pad: a cystic benign lesion. Page 31 of 80

32 Fig. 31 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Vascular lesion: synovial hemangioma. It shows intermediate signal on T1, very high signal on T2 with lineal fibrous septa, phlebolytes and intense enhancement after gadolinium injection. Page 32 of 80

33 Fig. 32 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES Tumours: we show examples of: - Localized nodular synovitis: it is a benign neoplasm of the synovium. Typically appears as an ovoid mass which may be iso or hyperintense on T1 WI related to skeletal muscle and with variable signal on T2 WI and enhancement after contrast administration. The infrapatellar fat pad is the most frequent location. Page 33 of 80

34 Fig. 33 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - Tenosynovial giant cell tumour: also called nodular tenosynovitis or fibrous histiocitoma of the synovial membrane. It is a benign proliferative process affecting the synovial membranes histologically related to pigmented villonodular synovitis. It is considered the extraarticular form of pigmented villnodular synovitis. Page 34 of 80

35 Fig. 34 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - Hoffa s fat pad chondroma: it originates from the articular capsule or the connective tissue that surrounds the capsule. On MRI it shows intermediate signal on T1 WI, heterogeneous signal on T2 WI with areas with similar signal to that of bone marrow in all pulse sequences and predominantely peripheral enhancement. Page 35 of 80

36 Fig. 35 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES 2) QUADRICEPS S FAT PAD: This fat pad lies between the distal quadricipital tendon anteriorly, the patella distally, and the suprapatellar recess posteriorly. There is edema sometimes and convexity of its dorsal margin causing mass effect on the suprapatellar recess. Page 36 of 80

37 Fig. 36 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES PLICA SYNDROME: Plicae are folds of embryonic remnants of synovial membrane into the knee joint. There are three different types of synovial plicae: Mediopatellar plica: localized in the medial aspect of the knee joint descending oblicually and inserts on the synovial lining of the Hoffa s fat pad. Suprapatellar plica: its extents from the inferior portion of the quadriceps tendon to the medial aspect of the knee joint. Infrapatellar plica: also known as ligamentum mucosum. It arises from the intercondylar notch, widens as it descends through the infrapatellar fat pad, anterior to the ACL. On MRI the plicae appear as linear low signal intensity structures surrounded by articular fluid and they are usually asymptomatic. Some conditions such as direct trauma or Page 37 of 80

38 overuse may affect the pliability of the synovial folds and can become symptomatic. The mediopatellar plica is considered the most likely to cause problems. In these cases the plica becomes thickened, with high signal on T2 WI and chondral lesions in the medial aspecto of the patella may be associated. Fig. 37 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES ILIOTIBIAL BAND SYNDROME: It is the result of inflammation an irritation of the distal portion of the iliotibial band as it rubs against the lateral femoral condyle during exercise. It is seen in long distance runners, cyclists, and other activities with repetitive flexion and extension of the knee. On MRI the iliotibial band is thickened and the soft tissues interposed between this band and the femoral condyle show high signal on T2 WI and STIR sequences. Page 38 of 80

39 Fig. 38 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES 5. INTRAMEDULLARY ABNORMALITIES OF THE KNEE: - TUMOURS: are rare and cause focal destruction of bone. Page 39 of 80

40 Fig. 39 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - BONE INFARCTS: metaphysis is the most frequent location, they show irregular or serpinginous morphology with a typical "double line sign". Page 40 of 80

41 Fig. 40 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES - INFECTION: acute osteomyelitis, as in the following example. Page 41 of 80

42 Fig. 41 References: Magnetic Resonance, Galaria. Empresa Pública de Servicios Sanitarios, Complexo Hospitalario Universitario de Vigo - Vigo/ES 6. EXTRAARTICULAR ORIGIN: Hip must be always explored. Anterior knee pain may be an irradiation of pain perception due to a hip lesion or due to malalignment of the lower limb. Images for this section: Page 42 of 80

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80 Conclusion Many factors may cause anterior knee pain and MRI is the best non ionizing imaging technique for establishing an accurate diagnosis of the anterior knee pathology. It also allows to know the extent of the lesion and its severity, what will be necessary to decide appropiate treatment. References Christian SR, Anderson MB, Workman R, et al. Imaging of anterior knee pain. Clin Sports Med 2006; 25 (4): Llopis E, Padrón M. Anterior knee pain. Eur Journal Radiol 62 (2007) Jackson AM. Anterior knee pain. J Bone Joint Surg Br 2001; 83 (7): Saddik D, McNally EG, Richardson MRI of Hoffa s fat pad. Skeletal Radiol 2004; 33 (8): Roth C, Jacobson J, Jamadar D et al. Quadriceps fat pad signal intensity and enlargement on MRI: prevalence and associated findings. AJR 2004; 182: Garcia-Valtuille R, Abascal F, Cerezal L et al. Anatomy and MR imaging appearances of sinovial plicae of the knee. Radiographics 2002; 22 (4): Personal Information Page 80 of 80