ultrasound of post traumatic leg...

Ultrasound of Post Traumatic Leg Pain

Nicholas C Nacey, MD

Assistant Professor

University of Virginia

Department of Radiology and Medical Imaging

Musculoskeletal Radiology Division

Overview

• Knee

• Effusion/Baker’s cyst

• Bursae

• Extensor mechanism

• Collateral ligaments and MPFL

• Fracture

• Calf

• Hematoma and

variants/mimickers

• Medial gastrocnemius

strain/tear

• Plantaris tendon rupture

• Muscle herniation

• Interosseous membrane

• Ankle

• Achilles tendon tear

• Peroneal tendon

tear/subluxation

• Posterior tibialis tendon

• Ankle ligament injury

The Knee

Visible

Extensor mechanism

Collateral ligaments

MPFL

Baker’s cyst

Joint effusion

Cortical bone

Largely not visible

Menisci

Cartilage

Cruciate ligaments

Medullary bone

Joint effusion

• Typically seen in

suprapatellar

recess, as well as

medial and lateral

joint recesses

• Layering

hyperechoic fat

suggest

lipohemarthrosis

Baker’s cyst

• A Baker’s cyst is a

synovial recess

extending posteriorly

through the

semimembranosus

tendon and the medial

head of the

gastrocnemius

• US 100% accurate if

neck visualized

SM

MG

Baker’s cyst

• Hypoechoic fluid beyond

the inferior margin

suggestive of rupture

• Fluid extends superficial

to gastrocnemius muscle

• Can present with swelling

in popliteal fossa and

calf, similar to DVT

• May present acutely, with

or without preceding

trauma

SM

SM

MG

MG

Baker’s cyst mimics

• Vascular

• Thrombosed varicose

veins

• Popliteal aneurysm

• Neoplastic

• Myxoid liposarcoma

• Synovial sarcoma

Ward et al, AJR 2001

Knee bursae

• Bursitis is a confined

fluid collection in

anatomic location of

known bursa

• No internal Doppler

flow

• May have thick walls,

septations, debris

• Prepatellar bursa

anterior to patella

• Superficial infrapatellar

bursa anterior to distal

patellar tendonNetter, Frank. Atlas of Human Anatomy. 1997.

Extensor mechanism


consists of

quadriceps tendon

and patellar tendon

• Ideally suited for

ultrasound given

superficial location

• Particularly

beneficial in post

arthroplasty

patients

Quadriceps tendon

• Hyperechoic, fibrillar

appearance best seen in

long axis with extended

FOV

• Slight flexion may

improve visualization

• The distal tendon is the

convergence of three

layers

• Rectus femoris

• Vastus medialis and

lateralis

• Vastus intermedius

• Fiber interruption at the

distal quadriceps tendon

is consistent with tear

• Distinguish partial from

complete tear

• Complete tear is

typically managed

surgically

• May fill with

heterogeneous

hemorrhage or scar tissue

• Typically occurs in older

patients with diabetes,

renal failure, or gout

Quadriceps tendon

• Dynamic imaging helpful

for visualizing tendon

stump in the setting of

adjacent debris

• Gentle passive

flexion

• Squeezing anterior

thigh muscles

• Slightly inferiorly

displacing the patella

Quadriceps tendon

Patellar tendon

• Extends from patella

to tibial tuberosity

• Less heterogeneous

than quadriceps

tendon

• Hoffa’s fat pad

posterior to tendon

Patellar tendon

• Tendinosis may have

tendon enlargement,

hypoechogenicity, and

blurring of the fascicular

architecture

• Confirm not positional

anisotropy

• Particularly common at

proximal patellar tendon

• “Jumper’s knee”

• May have hyperechoic

foci from

calcification/bone

Patellar tendon

• Tear may occur at

either proximal or

distal ends of tendon

• Wavy tendon with

retraction if complete

• Dynamic maneuvers

with flexion or superior

displacement of the

patella to differentiate

from partial tear

• ACL and PCL are not well

seen by US

• Indirect signs of injury at

US have been reported

• MRI remains the study of

choice

• MCL and LCL can be

visualized with US

• US uncommonly

requested as there is

typically concern for

concurrent meniscal or

cruciate ligament injury

Knee ligaments

Netter, Frank. Atlas of Human Anatomy. 1997.

• Medial Collateral ligament

• MCL arises from the medial

femoral condyle and

extends distally

• Can extend up to 5 cm

beyond the level of the

joint line before inserting

on tibia

• Overlying pes anserine

tendons distally

demonstrate anisotropy

Knee ligaments

FEMUR

TIBIA

S G T

• MCL sprain

• Grade 1 = Fluid along

MCL

• Grade 2 = Thickening

and hypoechoic signal

in ligament, partial

tearing

• Grade 3 = Complete

tear with lax fibers

Knee ligaments

Razek, Journal of Ultrasound, 2009

• Easiest parts of posterolateral

corner to visualize by ultrasound

are the biceps femoris, LCL, and

popliteus

• LCL attaches proximally at

femoral condyle overlying

popliteus

• Distal LCL attachment blends

with biceps femoris to produce

conjoined tendon insertion on

the fibular head

• Similar injury grading as MCL

Knee ligaments

POPLITEUS

• Associated with patellar

dislocation/relocation

injury

• Extends from medial

patellar facet to

adductor tubercle

• Frequently disrupted at

ether patellar or femoral

attachment

• Reported accuracy of

90%

• May be difficult to

evaluate for

osteochondral injury

Medial Patellofemoral Ligament

Zhang et al, Injury, 2013

Pat

Add Tub

Fracture

• Most, but not all,

patients have

radiographs as part of

a trauma evaluation

• Sometimes ultrasound

is the first modality

utilized

• Bones should be

evaluated in all

patients following

trauma, particularly

if no prior

radiographs

Fracture

• Many fractures can be

detected on US by

cortical disruption

• US can be targeted to

area of focal

tenderness

• Greater accuracy for

fractures in the straight

diaphyseal region of

bone

Overview

• Knee


• Bursae



• Fracture

• Calf

• Hematoma and

variants/mimickers


strain/tear




• Ankle


• Peroneal tendon

tear/subluxation



Hematoma

• Palpable mass with

bruising after trauma

• In subcutaneous tissues

or muscle

• May be minimal or no

trauma in patients on

anticoagulation or

bleeding diathesis

• Initially hypoechoic but

more heterogeneous

over time

• No internal Doppler flow

Hematoma

• Typically resorb

over time

• May form

chronic

hematoma with

thick

hemosiderin rim

• May calcify over

time, forming

hyperechoic

shadowing foci

Myositis Ossificans

• Typically follows

traumatic hemorrhagic

muscle contusion

• Majority in thigh, can

occur in calf

• Early on appears as

hypoechoic mass with

potential Doppler flow

• Later may see mature

ossification

• Radiographs helpful for

identifying maturation of

bone Abate, Journal of Clinical Ultrasound, 2012.

Morel Lavallee lesion

• Shear injury at junction

of superficial fat and

underlying fascia

• Fluid collection with

hemorrhage, lymph, and

fat

• Common locations in the

leg include overlying

greater troch and

prepatellar region

• Tends to flatten and

become more

homogeneous with time

Soft tissue tumor

• Patients may first feel a

palpable abnormality following

trauma

• Tumor can overlap in grayscale

appearance with hematoma

• Utilize Doppler to look for flow

• Biopsy ultimately needed of

any area with

flow/enhancement on MRI

• Tumor can also have internal

hemorrhage following trauma

• Short interval imaging or

clinical follow up

Muscle strain

• Strain vs sprain

• Strain = muscle injury

• Sprain = ligament injury

• Myotendinous junction is the weak

point of the myotendinous unit

• Muscle traits associated with

strain

• Extend across two joints

• Fusiform

• Frequently have eccentric

contraction

• Medial gastrocnemius most

frequently strained in the calf

• “Tennis leg”Palmer et al, AJR 1999

Calf Muscle structure

• Skin and fat are superficial

• Epimysium are the two

brightest reflectors, one

superficial to

gastrocnemius and one

between soleus and

gastrocnemius

• Perimysium is thinner

linear reflectors within

muscle tissue surrounding

fascicles

• Background muscle is

hypoechoic

Short axis Long axis


• Proximal aspect of medal

gastrocnemius has a

superficial aponeurosis

• Distal aponeuroses of

medial gastroc (deep to

muscle) and soleus

(superficial to muscle)

abut each other

• Soleus and gastroc

aponeuroses continue

distally beyond gastroc

muscle for a variable

length before beginning

to fuse

Bianchi and Martinoli, Ultrasound of the Musculoskeletal System, 2007

c


• Typical linear

bright/dark/bright appearance

secondary to:

• Distal gastrocnemius

aponeurosis (deep to medial

gastroc muscle)

• Interaponeurotic space

• Distal soleal aponeurosis

(superficial to soleus muscle)

• Distal aspect of medial

gastrocnemius particularly

prone to injury

• Normal triangular

appearance

Medial gastrocnemius muscle strain

• Grade 1 strain

• Edema and infiltrating

hemorrhage within muscle

produce hyperechogenicity

near myotendinous junction

• Contrast with normal

muscle or contralateral side

• Centered on myotendinous

junction

• Similar appearance as

muscle contusion or

delayed onset muscle

soreness

• Grade 2 strain

• Hypoechoic areas of partial

muscle tissue disruption/tear

• Background muscle

hyperechogenicity from edema

and hemorrhage

• Perifascial edema

• Potential hematoma between

soleus and gastroc in

interaponeurotic space

• Muscle fibers at triangular

myotendinous junction are

partially disrupted, aponeurosis

usually intact


• Grade 3 strain

• Complete disruption of

myotendinous junction

• Confirm that the entire width

of the tendon is disrupted on

transverse images

• Frequently large hematoma

that extends cephalad

• Distal gastroc aponeurosis

typically disrupted with

complete or significant partial

muscle tears


Plantaris tendon

• Plantaris tendon arises from

lateral aspect of posterior

femur, next to lateral gastroc

• Moves from lateral to medial

as it extends distally

• Passes in interaponeurotic

space between medial

gastrocnemius and soleus

• Eventually inserts onto

calcaneus just medial to the

Achilles tendon

• Short muscle belly and long

tendon segment

• Present in 80%Delgado, Radiology, 2002.

Plantaris tendon

• Can be seen along the

medial aspect of the Achilles

tendon at its insertion

• In the lower calf, it lies

along the superficial aspect

of the medial soleus

• In between medial gastroc

and soleus more proximally

• Can be seen in

interaponeurotic space as a

third echogenic line

between the gastrocnemius

and soleus aponeuroses

Plantaris tendon

• Previously thought to be cause of

“tennis leg” as opposed to medial

gastroc tear

• Tubular hematoma between medial

gastroc and soleus aponeuroses

• Med gastroc tear hematoma

typically wider

• May be able to trace tendon stump,

but difficult

• Typically rupture at myotendinous

junction which is proximal to

typical medial gastroc tear

Jamar et al, AJR 2002

Muscle herniation

• Most common location in the

body is anterior shin along

the tibialis anterior muscle

• Muscle protrudes through a

fascial defect and presents as

a painful mass

• May be associated with a

point of fascial weakness

from a perforating vessel

• Traumatic disruption of the

fascia has also been

implicated

Muscle herniation

• Dynamic imaging is

critical, thus US is test of

choice

• Typically worse with

contraction of the muscle

or standing

• Apply light pressure with

transducer to allow the

hernia to be demonstrated

Interosseous membrane

• Interosseous membrane is a thin

sheet connecting the tibia and

fibula

• Echogenic line on ultrasound

• Potentially disrupted in “high

ankle” sprain along with anterior

and posterior tibiofibular

ligaments

• Disrupted in Maisonneuve

fracture

• Proximal fibular fracture with

medial malleolar fracture or

deep deltoid ligament

disruptionDurkee et al, Journal of Medicine in Ultrasound, 2003

TF

Overview

• Knee


• Bursae



• Fracture

• Calf

• Hematoma and

variants/mimickers


strain/tear




• Ankle


• Peroneal tendon

tear/subluxation



Achilles tendon

• Visualize from level of

gastrocnemius

musculotendinous

junction to the

calcaneal insertion

• Extended FOV image

helpful for global

overview

• Flat or concave anterior

margin in short axis

Achilles tendon

• Tendon thickening and

hypoechogenicity

consistent with tendinosis

• Hyperemia on Doppler

imaging

• Loss of anterior concavity

on short axis imaging

Achilles tendon

• Usually at the watershed zone

2-6 cm proximal to the insertion

• Insertional tears are typically

associated with Haglund’s

deformity/syndrome from ill-

fitting shoes

• Heterogeneous hemorrhage or

scar tissue may be seen at the

site of rupture

• Typically shadowing artifact is

seen at tendon stumps from

refraction

• 92% accuracy differentiating

complete from partial tears

Achilles tendon

• Important information for

surgeon includes:

• Partial or complete

• Size of tendon gap

• Change in tendon gap with

plantarflexion

• Distance of distal stump from

calcaneal insertion

• Degree and length of

tendinosis at margins of tear

Achilles tendon

• Plantaris tendon inserts

into the calcaneus along

the medial aspect of the

Achilles tendon

• The plantaris tendon is

stronger than the Achilles

tendon and is often intact

following Achilles rupture

• Don’t mistake plantaris for

intact Achilles fibers

Taljanovich et al, Radiographics 2015

PB PL

SPR

Peroneal Tendons and Superior Peroneal Retinaculum (SPR)

• Peroneal tendons lie

within common

tendon sheath along

retromalleolar groove

behind distal fibula

• Held in place by

superior peroneal

retinaculum (SPR)

• Peroneus brevis (PB)

anterior to peroneus

longus (PL)

Peroneal Tendons and Superior Peroneal Retinaculum (SPR)

• SPR injury often clinically

mistaken for lateral ankle sprain

• SPR typically stripped from

fibula with formation of pouch

along lateral fibula

• May alternatively have SPR tear

with or without osseous fragment

• Look for extension of peroneal

tendons along lateral aspect of

fibula

• Usually a dynamic phenomenon,

so may be better seen with US

than MRI Wang et al, Radiographics 2005

PB PL

SPR

SPRFX

Per

Peroneal tendon tear

• Peroneus brevis is particularly

prone to tear

• Tendency for PB to form partial

split tears that wrap around the

PL

• “Boomerang sign”

• Peroneal tendon tears associated

with:

• SPR injury/subluxation

• Peroneus quartus

• Low lying peroneal brevis

muscle belly

• Shallow retromalleolar groove

Medial tendons

• Order of tendons beyond the

medial malleolus remembered

by the mnemonic:

• Tom (Posterior Tibialis

Tendon)

• Dick (Flexor Digitorum

Longus)

• A Very Nervous (Posterior

tibial artery and vein, Tibial

Nerve)

• Harry (Flexor Hallucis

Longus)

• PTT is the primary stabilizer of

the medial arch

Posterior tibialis tendon

• PTT abnormalities more

typically chronic and

associated with flatfoot

deformity

• PTT should normally be

twice as big as FDL

• Tendon thickening,

hypoechogenicity in

tendinosis

• Surrounding fluid in

tenosynovitis

• Anechoic clefts or tendon

thinning in tearing

Ankle ligaments

• Anterior and Posterior

tibiofibular ligaments superiorly

• Injured in “high ankle

sprain”

• Anterior talofibular and

posterior talofibular ligaments

inferiorly

• Calcaneofibular ligament deep

to peroneals

• Typical tear sequence Anterior

talofibular > Calcaneofibular >

Posterior talofibular

PBPL

Ankle ligaments

• Superficial and deep

deltoid ligaments on

the medial side

• Image in coronal

plane

• Deep frequently

anisotropic

• Superficial easier to

delineate

Sup

DeepTib

Tal

Ankle ligaments

• Ankle ligament

injuries all appear

similar by US

• Ligamentous

disruption = tear

• Adjacent hypoechoic

edema if acute

• Swollen, hypoechoic

ligament if sprained

Conclusion

• US is well suited to evaluate

certain post traumatic lower

leg conditions

• Baker’s cyst


• Medial gastrocnemius tear


• Achilles tear

• Peroneal subluxation

• Other conditions may be

encountered unexpectedly

• Fracture

• Tumor

References1. Abate M, Salini V, Rimondi E, et al. Post traumatic myositis ossificans: Sonographic findings. J Clin Ultrasound 39(3):135–140.

2. Anderson M, Temple TH, Dussault RG, Kaplan PA. Comprtmental Anatomy: Relevance to Staging and Biopsy of Musculoskeletal Tumors. AJR Am J Roentgenol

1999;173(December):1663–1671.

3. Balius R, Alomar X, Rodas G, et al. The soleus muscle: MRI, anatomic and histologic findings in cadavers with clinical correlation of strain injury

distribution. Skeletal Radiol 2013;42(4):521–530.

4. Balius R, Rodas G, Pedret C, Capdevila L, Alomar X, Bong DA. Soleus muscle injury: sensitivity of ultrasound patterns. Skeletal Radiol 2014;43(6):805–812.

5. Bianchi S, Martinoli C, Abdelwahab IF, Derchi LE, Damiani S. Sonographic evaluation of tears of the gastrocnemius medial head (“tennis leg”). J Ultrasound

Med 1998;17(3):157–162.

6. Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. Berlin: Springer Berlin Heidelberg; 2007.

7. Bianchi S, Sailly M, Molini L. Isolated tear of the plantaris tendon: Ultrasound and MRI appearance. Skeletal Radiol 2011;40(7):891–895.

8. Blitz NM, Eliot DJ. Anatomical Aspects of the Gastrocnemius Aponeurosis and Its Insertion: A Cadaveric Study. J Foot Ankle Surg 2007;46(2):101–108.

9. Beggs I. Sonography of Muscle Hernias. AJR Am J Roentgenol 2003;180(February):395–399.

10. De Maeseneer M, Marcelis S, Boulet C, et al. Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures.

Skeletal Radiol 2014;43(8):1025–1039.

11. De Maeseneer M, Marcelis S, Jager T, et al. Sonography of the normal ankle: A target approach using skeletal reference points. Am J Roentgenol

2009;192(2):487–495.

12. De Maeseneer M, Vanderdood K, Marcelis S, Shabana W, Osteaux M. Sonography of the medial and lateral tendons and ligaments of the knee: The use of

bony landmarks as an easy method for identification. Am J Roentgenol 2002;178(6):1437–1444.

13. Delgado GJ, Chung CB, Lektrakul N, et al. Tennis leg: clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US.

Radiology 2002;224(1):112–119.

14. Dong Q, Fessell DP. Achilles tendon ultrasound technique. Am J Roentgenol 2009;193(3):2009.

15. Donovan A, Rosenberg ZS, Bencardino JT, et al. Plantar tendons of the foot: MR imaging and US. Radiographics 2013;33:2065–2085.

16. Flecca D, Tomei A, Ravazzolo N, Martinelli M, Giovagnorio F. US evaluation and diagnosis of rupture of the medial head of the gastrocnemius (tennis leg). J

Ultrasound 2007;10(4):194–198.

17. Guillodo Y, Riban P, Guennoc X, Dubrana F, Saraux A. Usefulness of ultrasonographic detection of talocrural effusion in ankle sprains. J Ultrasound Med

2007;26(6):831–836.

18. Hoffman DF, Adams E, Bianchi S. Ultrasonography of fractures in sports medicine. Br J Sport Med 2015;49:152–160.

19. Hung EHY, Griffith JF, Ng AWH, Lee RKL, Lau DTY, Leung JCS. Ultrasound of musculoskeletal soft-tissue tumors superficial to the investing fascia. Am J

Roentgenol 2014;202(6).

20. Jacobson JA. Fundamentals of Musculoskeletal Ultrasoud. Second Edi. Philadelphia, PA: Elsevier Inc; 2013.

21. Jamadar DA, Jacobson JA, Theisen SE, et al. Sonography of the painful calf: Differential considerations. Am J Roentgenol 2002;179(3):709–716.

22. Lacelli F, Serafini G. Dynamic High-Resolution US of Ankle and Midfoot Ligaments. Radiographics 2015;35(11):164–178.

References

23. Lee JC, Healy J. Sonography of lower limb muscle injury. AJR Am J Roentgenol 2004;182(2):341–351.

24. Lee SJ, Kim OH, Choo HJ, et al. Ultrasonographic findings of the various diseases presenting as calf pain. Clin Imaging Elsevier Inc.; 2015;40(1):1–12.

25. Lutterbach-Penna RA ugusto, Kalume-Brigido M, Morag Y, Boon T, Jacobson JA rthur, Fessell DP aul. Ultrasound of the thigh: focal, compartmental, or

comprehensive examination? AJR Am J Roentgenol 2014;203(5):1085–1092.

26. Netter FH. Atlas of Human Anatomy. Second Edi. Icon Learning Systems; 1997.

27. Ng JM, Rosenberg ZS, Bencardino JT, Restrepo-Velez Z, Ciavarra G a, Adler RS. US and MR Imaging of the Extensor Compartment of the Ankle. Radiographics

2013;33(7):2047–2064.

28. O'Dwyer HM, Al-Nakshabandi NA, Al-Muzahmi K, Ryan A, O'Connell JX, Munk PL. Calcific myonecrosis: Keys to recognition and management. Am

J Roentgenol 2006;187(1):227.

29. Peer S, Kovacs P, Harpf C, Bodner G. High-Resolution Sonography of Lower Extremity Peripheral Nerves. J Ultrasound Med 2002;21:315–322.

30. Razek AAKA, Fouda NS, Elmetwaley N, Elbogdady E. Sonography of the knee joint. J Ultrasound Elsevier Srl; 2009;12(2):53–60.

31. Ryu J, Jin W, Kim G. Sonographic appearances of small organizing hematomas and thrombi mimicking superficial soft tissue tumors. J Ultrasound Med

2011;30(10):1431–1436.

32. Durkee NJ, Jacobson JA, Jamadar DA, Femino JE, Karunakar MA, Hayes CW. Sonographic Evaluation of Lower Extremity Interosseous Membrane Injuries. J

Ultrasound Med 2003;22(May):1369–1375.

33. Neal C, Jacobson JA, Brandon C, Kalume-Brigido M, Morag Y, Girish G. Sonography of Morel-Lavallée Lesions. J Ultrasound Med 2008;27:1077–1081.

34. Taljanovic MS, Alcala JN, Gimber LH, Rieke JD, Chilvers MM, Latt LD. High-resolution US and MR imaging of peroneal tendon injuries. Radiographics

2015;35(1):179–199.

35. Walsh M, Jacobson JA, Kim SM, Lucas DR, Morag Y, Fessell DP. Sonography of fat necrosis involving the extremity and torso with magnetic resonance imaging

and histologic correlation. J Ultrasound Med 2008;27(12):1751–1757.

36. Wang X-T, Rosenberg ZS, Mechlin MB, Schweitzer ME. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging

features. Radiographics 2005;25(3):587–602.

37. Ward EE, Jacobson J a, Fessell DP, Hayes CW, van Holsbeeck M. Sonographic Detection of Baker ’ s Cysts : Comparison with MR Imaging. AJR Am J

Roentgenol 2001;176(February):373–380.

38. Yablon CM, Melville DM, Jacobson JA. Ultrasound of the Knee. Am J Roentgenol 2014;202(3):W284–W284.

39. Zbojniewicz AM. US for Diagnosis of Musculo- skeletal Conditions in the Young Athlete : Emphasis on Dynamic. Radiographics 2014;34(5):1145–1163.

40. Zhang GY, Zheng L, Shi H, Qu SH, Ding HY. Sonography on injury of the medial patellofemoral ligament after acute traumatic lateral patellar dislocation:

Injury patterns and correlation analysis with injury of articular cartilage of the inferomedial patella. Injury Elsevier Ltd; 2013;44(12):1892–1898.

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