MR Imaging in Athlete s Hip/Pelvis
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1 MR Imaging in Athlete s Hip/Pelvis Tara Lawrimore, MD FRCPC Department of Radiology Musculoskeletal Division Massachusetts General Hospital Harvard Medical School
2 No disclosures
3 MR and Hip Pain in the Athlete MRI protocol, anatomy Bones: fracture, marrow disorders Extra-articular: bursae, muscles, tendons Intra-articular: cartilage, labrum, lig. teres, joint and synovium, plicae
4 MR Protocols Routine Hip Protocol MR Arthrography Protocol Specialized: Athletic Pubalgia Protocol
5 MRI : Routine Hip protocol Local surface coil Bilateral hips, FOV 36 cm Coronal STIR (5000/34/150) Unilateral hip, FOV 16 cm Oblique axial, coronal, sagital FS PD FSE (2800/90) Coronal T1 (500/16), axial PD (2500/17) 3D imaging, SPACE
6 MRI : Routine Hip protocol Local surface coil Bilateral hips, FOV 36 cm Coronal STIR (5000/34/150) Unilateral hip, FOV 16 cm Oblique axial, coronal, sagittal FS PD FSE (2800/90) Coronal T1 (500/16), axial PD (2500/17)
7 Osseous stress injury failure of skeleton to w/stand submaximal forces acting over time
8 Osseous stress injury Fatigue fracture: normal bone, abnormal forces Insufficiency fracture: abnormal bone, normal forces
9 Fatigue fracture 33yo nearly 70% in runners among athletes new activity d mileage new shoes, surface
10 Fatigue fracture 33yo difficult XR diagnosis periosteal RXN, callus T2, STIR: fx line high-lighted by BME T1: fx line obscured
11 Unilateral fracture
12 Met v. fracture? no line... met
13 Transient osteoporosis weight-bearing bone subchondral edema dissipates distally joint effusion ddx: subchondral fx, early ON
14 Bursae Greater trochanteric (subgluteus maximus): between greater trochanter, glut. max., IT tract greater trochanteric pain syndrome acute, repetitive trauma, gluteal tendon tears
15 Bursae Iliopsoas largest bursa communicates in 10-15% with hip joint medial to iliopsoas, anterior to hip joint repetitive trauma inflammatory conditions (RA)
16 Iliopsoas bursitis
17 Muscles and tendons Gluteals Iliopsoas Hamstrings Rectus femoris Quadratus femoris: ischiofemoral impingement
18 Gluteal tendons Gluteus medius and minimus: hip abductors greater trochanteric pain syndrome rotator cuff of hip gluteus medius: sup.-post. facet, lateral facet gluteus minimus: anterior facet Pfirrmann CW et al, Radiology 2001;221:469-77
19 Iliopsoas Iliacus and psoas muscles form iliopsoas tendon Insertion: lesser trochanter Hip flexion, lateral rotation Tendinopathy, tear Avulsion, detachment of lesser trochanter elderly patients: spontaneous, osteoporosis, neoplasm Hematoma, myositis ossificans
20 Myositis ossificans
21 Snapping hip Coxa saltans Snapping, clicking with hip movement External and internal causes iliopsoas tendon snapping over iliopectineal line edema, bursitis
22 Snapping psoas
23 Hamstrings Biceps femoris, semitendinosus: conjoined tendon postero-medial ischial tuberosity Semimembranosus antero-lateral ischial tuberosity Adductor magnus hamstring head inferior to hamstring origin Sacrotuberous lig. Strains, tendinopathy, partial tear, avulsion
24 Hamstring strain, biceps fem.
25 Ischiofemoral impingement Narrowing of ischiofemoral space ischial tuberosity and lesser trochanter Quadratus femoris muscle edema, partial tear, fatty infiltration Hamstring tendons edema, partial tear Torriani et al. AJR 2009;193:186-90
26 Rectus femoris Quadriceps: rectus femoris, vastus lateralis, intermedius, medialis Straight (direct head): anterior-inferior iliac spine Reflected (indirect) head: more posterior, superior lip of acetabulum Hip flexor, leg extensor Strain, partial tear, tear, avulsion, hematoma
27 Rectus femoris, direct head
28 Rectus femoris, reflected head
29 MR Arthrography Protocol Unilateral hip, FOV 16 cm Oblique axial, coronal, sagittal FS T1 FSE ( /17) Axial PD FSE (1900/25) Coronal T1 FSE (650/17), FS T2 FSE (5000/50)
30 Cartilage Intermediate SI thick superior, thin posterior Sports-related, FAI: ant-sup. acetabulum delamination + labral tears Contrast outlines defects, articular margins Subchondral cysts
31 Labrum Fibrocartilage ( SI) thick posterior, thin anterior Acetab. labrum = glenoid labrum sublabral contrast, displacement Sports-related, FAI: antsup sagittal, oblique axial Paralabral cyst
32 Ant-sup labral tear
33 Lig. teres arises from acetabular fossa inserts into fovea capitis blends in with transverese lig. stability, proprioception 4-15% of sport related injuries partial, complete tears, avulsions
34 Joint capsule Proximal attachment: along osseous rim of acetabulum, near base of labrum perilabral recess Distal attachement: femoral neck, base of trochanters Thickening of capsule: iliofemoral lig. (strongest) ischiofemoral lig. pubofemoral lig. Deep circular layer: zona orbicularis Tears: leak of contrast, post. hip dislocation
35 Hip plicae Synovial plicae: reflections of synovial membrane interface of articular surfaces Synovial fluid production, stability Hip pain: synovitis, entrapment
36 Synovium Capsule lined with highly vascularized synovium Inflammation, neoplasms RA amyloidosis PVNS synovial chondromatosis
37 Specialized: Athletic Pubalgia Protocol Coronal STIR, T1 SE, Axial T2 FSE fat sat FOV 28-36cm Axial Obl PD, T2 FSE FOV 20cm Sag PD, T2 FSE FOV
38 Athletic pubalgia Adductor longus injury Common adductor-rectus abdominus dysfunction Osteitis pubis Sportsman s hernia
39 Checklist: BONE Fracture, marrow disorders EXTRA-ARTICULAR Muscles and tendons strains, tears, degeneration, friction syndromes, myositis ossificans, others INTRA-ARTICULAR Cartilage, labrum, ligamentus teres, plicae, synovial disorders PUBALGIA Specialized imaging
40 Thank you!
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