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What is the primary investigation ?
35ys old jogger with achillodynia,All previous tests were negative
Rupture of plantar fascia30ys female: after pilgrimage from Leon to Santiago de Compostella
Stress fracture resulting fromexcessive jogging
Associated with TOS 2: peroneal tendovaginitis
Low bone density
vascular malformationen
Foreign body22ys male jogger with lateral knee pain:DDx: Runner‘s knee (ITBF syndrome
fluid
Soccer players
M de Jonge, Radiologe, 2002
Fibromatosis
Soccer player: rigid mass in hamstrings:DDx: myositis ossificans
discriminate a hamstring tendon avulsion frommusculotendinous strain and helps identify whichpatients necessitate surgical management.
Koulouris G, ConnellD, Skel Radiol
Hyperpronation syndrome
Patella partita vs. Patellar fracture
L. Johanna, 13 J., female:
Superolateral patellar defect
Stressfracture C 2
21-ys female dancer with upper cervical syndrome
Traumatic contusion of myelon
57ys female, fall from horse, tretraplegic
Runner‘s knee
Christian DopplerChristian DopplerChristian Doppler
“The best research results are yieldedif not only the investigator is satisfiedabout his work but if also a significantbenefit for humanity is created."
Ch. Doppler
born 1803 in Salzburgprofessor of physics in Prague and Viennadied 1853 in Venice
......
EU-referral criteriahttp://europa.eu.int/comm/environment/radprot/118/118.htm
continuous discussion needed to keep them livingsports overuse and trauma should be mentioned
Indication
Investigation
Interpretation
IMAGING IN SPORTS MEDICINE – AN UPDATE
Diagnosis
Specified referral – specified diagnosis
Trends towards High resolution3D displaydocumentation of functioncomputer-assistedtreatment planningopen role of NIRF
Referral: (sports related) overuse syndromeFoot
Tibialis-anterior-Tendovaginitis
Tibialis posterior-Tendinosis
Dancer‘s heel
Peroneal-split-syndrome
Sesamoiditis
Achilles: Tendinosis
Haglund‘s heel
Plantar fasciitis
(Snowboarder‘s foot)
Bursitis
Plantaris tendon rupture
Morton-Neuroma
Jogger‘s foot
High resolution US vs. MRITendinosis:MRT > US in zwei Fällen
Ulreich N, Huber W et al., 2002
US Panoramic (extended view) imagingTissue harmonic imagingSofka CM, Adler RS. Sonographic evaluationof shoulder arthroplasty. AJR 03
US contrast media with small bubble size and low mechanicalindex
US-guided pain management
Musculoskeletal US
Power-Doppler US
Ruptured Achilles tendon
Ohberg L, Alfredson H. US guided sclerosing of neovessels in tendinosis.ESSR 03
5 – 12 MHz
Zanetti M et al. Achilles Tendons: Clinical Relevanceof Neovascularization Diagnosed withPower Doppler USRadiology 2003
Kinematic „motion“ MRI
21-ys beachvolleybal lplayer withfemoropatellar pain syndrome
To document malalignment
K. Friedrich, doctorial thesis 2002Wiener Med Wochenschr 2002, Suppl.
16-row MD-CTfrom 3D-Reformation to 3 D Volume rendering
Hill-Sachs-lesion
Image interpretation based on 3D
Indication
Investigation
Interpretation
IMAGING IN SPORTS MEDICINE – AN UPDATE
Diagnosis
Specified referral – specified diagnosis
The higher the resolution the better
Patterns of overuse and injury
Tendon overuse syndrome (TOS)
Rosenberg Z et al., Radiology 1988
1 - Painful functional impairment2 - Inflammation of peritendineal tissue:tendovaginitis, bursitis, peritendinitis3 - Degenerative tendon disease:3 forms: tendinosis (former „tendinitis“)
fibroostosis, juvenile apophysitiscompression syndrome (impingement)
4 – Rupture:direct force (rare) or indirect force on tendinosis (common)
Kainberger et al., Wien Med Wochenschr, 2001
TOS 3: Tendinosis (grade 3)
Achillodynia
NODULAR TENDINITIS
Originating frominternal peritendinea
Van Holsbeeck, 1992
TOS 3: Tendinosis, spur, hyperpronation
Achillodynia
Tension of tendon with elongation:< 4 % : fully reversibel4 – 8 % : disruption of cross-link structures
Repair phase with high vulnerabilityi. e. destruction and reparation dysbalanced
> 8 % : frank ruptureO’Brien M. Clin Sports Med 1992; 11:505–520, Towers et al, 2003
Tendon rupture: due to microtrauma and/or microinfarction
Tendon tissue of mice in a hamster mill:Sedentary behavior: normalContinuous activity: slight abnormalitiesDyscontinuous activity: focal necrosis Wernig, 1992
Tibialis posterior tendon and flatfoot deformity and heel valgus
Tpt is part of „coxa pedis“ functional unitAssociated findings: Malalignment of talus (plantar flexion)
Insufficiency of Spring-Ligament, Sinus tarsi syndrome
Collapse of longitudinal arch
Traction injury of posterior tibial nerve
Tarsal tunnel syndrome
The risk of tendon rupture
US Doppler seems to be promising in differentiating stages of dysbalance[Richards et al. Clin Radiol 2001, Ulreich and Kainberger, 2004 in press].
THE CRITICAL ZONEAnatomic site specifically prone to trauma, vascular necrosis,or both
THE VULNERABLE PHASEtime during high dysbalance between destructive and reparative forces: active form due to sports: apophysitis: adolescents
tendinosis: 40 ys males (athletes earlier)passive form due to muscle insufficiency: middle-aged women
TOS: the radiologist‘s role
modif. after Kannus et al., Radiologe 2002 Oct
Malalignment: Tendinosis (TOS)
femoral anteversion,varus, valgus.foot deformitieslocal variants: systemic diseasehypomochlia, rheumatism,steroidsaccessory muscles fluoroquinolonemuscular imbalance psychosomaticage, gender, reactionsweight, height
Intrinsic factorsVariants diseases
Extrinsic factors
Training errors, doping
clothingimproper shoes
environmenthard/soft soil
to asess severity of disease and potential risk of rupture
Golfer‘s arm
Radiological conceptsTendinosis: a pre-stage of ruptureNehrer S, Breitenseher M, Brodner W, Kainberger F, Fellinger EJ, Engel A, Imhof F. Arch Orthop Trauma Surg. 1997;116hyaline cartilage is part of osteochondral unitImhof H, Breitenseher M, Kainberger F, Trattnig S. Degenerative joint disease: cartilage or vascular disease? Skeletal Radiol. 1997Osteonecrosis: etiology multifactorialEngel, Scand J Orthop1992Menisceal rupture is often degenerativeMink, Deutsch et al., Radiology 1987
IMAGING IN SPORTS MEDICINE – AN UPDATE
Indication
Investigation
Diagnosis Olympic onsite service
Interpretation
Specified referral – specified diagnosis
The higher the resolution the better
Patterns of overuse and injury