Back Clinic Mobility & Flexibility: The human body retains a natural level to ensure all its structures are functioning properly. The bones, muscles, ligaments, tendons, and other tissues work together to allow a range of movement and maintaining proper fitness and balanced nutrition can help keep the body functioning properly. Great mobility means executing functional movements with no restrictions in the range of motion (ROM).
Remember that flexibility is a mobility component, but extreme flexibility really is not required to perform functional movements. A flexible person can have core strength, balance, or coordination but cannot perform the same functional movements as a person with great mobility. According to Dr. Alex Jimenez’s compilation of articles on mobility and flexibility, individuals who don’t stretch their body often can experience shortened or stiffened muscles, decreasing their ability to move effectively.
As people grow into adults, maintaining normal flexibility gets to be much more challenging and losing flexibility can result in a lot of pain to the musculoskeletal system.
Unfortunately, many of us do not retain flexibility throughout the day, even when attempting to be active. Many jobs are largely sedentary, and even leisure activities keep us stuck in one place. In order to remain functional, joints and muscles need to be used, which means they need to be properly stretched without being overworked. The balance is often very delicate, fortunately, chiropractic adjustments increase flexibility.
Chiropractic’s Role in Flexibility
Most adults are not concerned with being able to twist like a pretzel, however, they do want to be able to maneuver through daily life without a lot of pain. One of the main things accomplished in most chiropractic visits is that the chiropractor will look for misalignments in the spine and seek to correct them with a combination of chiropractic adjustments and exercises.
Adjustments
When the spine is misaligned it can affect many different areas of the body including flexibility. Someone who is not flexible will have a limited range of motion (ROM) and treatments are designed to improve this and restore natural posture.
But being flexible is about more than moving better. When the body is stiff, even simple movement results in pain because it is blocked by the misalignment. When this is adjusted/corrected, blood flow improves and the process of improving flexibility becomes less taxing.
Nutrition
There is more to a chiropractor’s day than correcting misalignments in the spine. Chiropractic is holistic in nature and in order to be truly successful, it relies on the patient to be a cooperative participant in treatment. Giving nutritional advice is a big part of this.
While advice can vary from patient to patient, generally, when a person struggling with flexibility adds protein and fatty acids into their diet it can help joints and muscles to be properly nourished. People should also monitor their intake of processed and pre-packaged foods as these can contribute to inflammation.
Training Exercises
Because of many factors in our lives, as well as the effects of aging, people’s range of motion inevitably decreases as time goes by, especially if nothing is purposefully done to maintain it. Flexibility exercises are commonly strongly suggested by chiropractors as they strive to help their patients with range of motion (ROM) and flexibility issues.
In many cases, such as those where someone is suffering from tendinitis or bursitis, the truly therapeutic exercises are resistive exercises. These, however, are limited, unless a higher level of flexibility is achieved.
Flexibility programs are implemented in order to make a given joint have a wider level of extensibility, which may be achieved by either traditional static stretching or Proprioceptive Neuromuscular Facilitation (PNF) techniques, which incorporates a slow reversal hold.
Working with a chiropractor on a regular basis for help in gaining flexibility can help assure that a patient moves forward at an appropriate pace that is in line with their age and fitness level. This will help them achieve a higher level of success in their chosen sport or similar activity, and/or become more productive in their daily lives while experiencing less pain.
*FIX BAD POSTURE* with Custom Orthotics | El Paso, TX (2019)
Proper Posture
Your spine does more than keep your body upright: it�s the brain that communicates to the rest of the body. Posture even affects your emotional well-being, including self-confidence!
Poor posture takes a serious toll on health. Here are a few of the negative results:
Muscle soreness
Subluxations
Blood vessel constriction
Nerve constriction
As the years go by the problems worsen, which results
Maintaining proper posture involves sitting, standing, and lying down properly. Here is an excerpt from the American Chiropractic Association website on how to:
Sit the right way
Keep your feet on the floor or on a footrest, if they can’t reach the floor
Don’t cross your legs. Your ankles should be in front of your knees
Keep a small gap between the back of your knees and the front of your seat.
Your knees should be at or below the level of your hips.
Bear your weight primarily on the balls of your feet.
Keep your knees slightly bent.
Keep your feet about shoulder-width apart.
Let your arms hang naturally down the sides of the body.
Lie down the right way
Find the mattress that is right for you. While a firm mattress is generally recommended, some people find that softer mattresses reduce their back pain. Go with your comfort
Sleep with a pillow. Special pillows can help with postural problems resulting from a poor sleeping position
Avoid sleeping on your stomach
Healthy Feet Equals A Healthy Spine
The feet are complex structures which function�to provide protection and support to the body in relation to the spine and head posture. The feet are essential towards balancing the body�s entire weight, allowing it to walk, run, stand, and, jump. Consequently, foot complications may cause severe issues throughout the spine, hips, knees, and ankles if left untreated.
Gait & Chronic Postural Pain
Chiropractic care can be effective for treating injuries or conditions such as plantar fasciitis, Achilles tendonitis, and ankle sprains, among others. Foot health is essential towards establishing the body�s proper support and balance, together with a proper spinal posture. In the presence of foot complications, chiropractic treatment can be used to achieve long-lasting health.
NCBI Resources
Flexibility is a critical component of keeping your body fit and healthy. Research shows that people who are more flexible are better able to reach their�optimum fitness level. It can also help to prevent injury and reduce your risk of conditions like arthritis and other�chronic diseases.�They also have a better range of motion and mobility as they age.
According to the American Chiropractic Association (ACA), approximately 31 million Americans deal with some form of low back pain. Fortunately, there are steps you can take to lessen the pain you are experiencing. Taking care of yourself � including maintaining a healthy weight and regular exercise � can help prevent back pain. And when you do experience back pain, chiropractic treatment and stretching can often ease your symptoms.
Prepare for Stretching
Before we get to the stretching, we recommend preparing for your stretching session so you can stretch comfortably and safely. Tips for stretching include:
Ease into it. Stretching should be done gently and smoothly, traveling from stationary to a position slowly and carefully. Avoid bouncing, which can tear muscles.
Stretching should not hurt. You should not feel significant pain when you stretch. As you move into your stretch, listen to your body and stop before you start to feel pain. Stretching should feel good, not painful.
Wear comfortable clothing. Wear loose clothing that will allow you the full range of motion.
Choose an area to stretch that is flat and clean. Choose an area that will be comfortable and well-suited for your activity.
Use padding when necessary. If you are going to be stretching on a hard surface, a little padding can make things much more comfortable.
Hold each stretch 15-30 seconds, and repeat at least 2 times. Holding a stretch lets the muscles elongate, and repeating the stretch improves your results. Repeat the stretch four times for maximum benefit.
Modify to fit your needs. Everyone must work within their limitations. When you try a stretch and you find it is not working for you, try to modify it to suit your needs. You can find modifications to most popular stretches online.
Three Stretches that Are Great For Back Pain
1. Children’s Pose
The name Child�s Pose comes from yoga, where this stretch is often used to begin each session of stretching. Child�s Pose is so popular because it is gentle and effective, and just about anyone can do it.
To do Child�s Pose, get down on your hands and knees. To begin with, place your knees slightly wider than hip-width. Flatten the tops of your feet to the floor, toes pointing behind you. Slowly move your hips back over your feet. Once you have rested your buttocks on your ankles, stretch your arms out in front of you. Feel your lower back stretch out as you hold the pose.
2. Knees/Chest
Lying on your back, use your hands to pull your knees up to your chest, rounding out your back in the process. You can interlace your fingers to hold your knees in position. If you like, hug your knees more tightly to your chest and rock left to right. To enhance the stretch, slowly bring your chin towards your chest.
3. Spine Twist
Lying on your back, stick each hand out to the side of your body to create a T shape. Bring the right knee up to your chest while keeping the left leg straight on the floor. Use your left hand to gently pull your knee higher, then pull the knee across your body to the left. Try to keep your right shoulder on the floor. Repeat on the left side.
Contact For Customized Stretches
If you are suffering from back pain, please schedule an appointment to meet with our chiropractic team. We can help design a custom stretching plan to help you ease your back pain.
El Paso Back Clinic Chiropractor Personal Injury Attorney Recommended
Flexibility is something that many people would like more of, but few know how to achieve it. You might find that improving your flexibility is easier than you think.
This is because flexibility training is often seen as difficult, painful, and time-consuming. It is also significantly underestimated. Why bother getting flexible if you aren�t an athlete or dancer? Why do regular people need to improve their flexibility? The answers to these questions may surprise you.
Why is flexibility important?
Flexibility is a critical component of keeping your body fit and healthy. Research shows that people who are more flexible are better able to reach their optimum fitness level.
It can also help to prevent injury and reduce your risk of conditions like arthritis and other chronic diseases. They also have a better range of motion and mobility as they age.
Muscles that are flexible have the potential to become stronger. This can help increase metabolism and improve fitness level.
A more flexible body can also carry out day to day activities easier and have less chance of injury. Blood flow is increased and circulation is improved which also helps to prevent chronic conditions like kidney disease and diabetes as well as heart disease.
Stretch for upper body flexibility
This upper body stretch also helps improve your posture. It is also great if you are primarily sedentary throughout the day, such as sitting at a desk for extended periods.
Stand or sit in a chair, back straight, chin level, feel slightly apart and knees soft.
Put your hands behind your head, elbows out, chin tucked.
Gently press your head forward to feel the stretch through your neck, shoulders, and upper back; hold for five seconds.
Tilt your head back so that your chin is pointing toward the ceiling.
Place the heels of your hands on your forehead and gently press to get a stretch through the front of the neck and the arms; hold for five seconds.
Bring your head to the start position, chin parallel to the floor, neck straight.
Put your right hand on the top of your head and gently press as if you are trying to touch your right ear to your right shoulder and feel the stretch along the left side of the neck and shoulder; hold for five seconds.
Put your left hand on the top of your head and gently press as if you are trying to touch your left ear to your left shoulder and feel the stretch along the right side of the neck and shoulder; hold for five seconds.
Raise your hands over your head and clasp your hands.
Stretch and lift your body, lengthening your spine.
Release your hands and bend to the right, using your right hand to grasp your left elbow and gently pull it to the right. Hold for five seconds.
Raise your hands over your head and clasp your hands. Stretch and lift your body, lengthening your spine.
Release your hands and bend to the left, using your left hand to grasp your right elbow and gently pull it to the left. Hold for five seconds.
Stretch for lower body flexibility
This is a great stretch for women who wear high heels or for cyclists and people who walk, run, or use an elliptical machine.
Sit on the floor with your legs straight in front of you, feet together, knees soft, and back straight.
Slowly bend your right knee and lean back if necessary, using your right arm as support behind you. Place your left hand under your left knee and flex your toes toward the ceiling, feeling the stretch through your calf. Hold for five seconds.
Stretch both legs out straight in front of you.
Slowly bend your left knee and lean back if necessary, using your left arm as support behind you. Place your right hand under your right knee and flex your toes toward the ceiling, feeling the stretch through your calf. Hold for five seconds.
Roll onto your back with your knees bent toward the ceiling and feet flat on the floor.
Gently bring your right knee to your chest, holding it with your hands to get a nice stretch. Hold for five minutes.
Return to the start position, on your back with your knees bent and feet flat on the floor.
Gently bring your left knee to your chest, holding it with your hands to get a nice stretch. Hold for five minutes.
Return to the start position, on your back with your knees bent and feet flat on the floor.
Stretch for flexibility in the back
This stretch is very good for low back pain.
Lie on your stomach keeping your legs straight, knees soft, and feet shoulder-width apart.
Place your hands under your shoulders, palms down on the floor and push your upper body up so that your back is curved with your lower body still on the floor. Tilt your head back for more stretch. Hold for 10 seconds.
Lower your upper body back to the mat and slowly roll over to your hands and knees.
Keep your knees shoulder width apart and your back straight.
While on your hands and knees, tuck your chin and round out your back, pushing it towards the ceiling, feel the stretch through your entire back. Hold for 10 seconds.
Return to the start position with your knees shoulder width apart and your back straight.
While on your hands and knees, lift your chin, stretching it upwards and drop your back so that your spine curves toward the floor. Hold for 10 seconds.
Return to the start position with your knees shoulder width apart and your back straight.
You hear many people talk about the benefits of walking but may not know how it applies to you. Walking regularly can be exceptionally helpful if you have back pain by providing the spine with added support and increased blood flow. These three spinal health benefits of walking should be enough to convince you.
Walking Aids in Rehydrating Your Spinal Discs
Gravity is not your friend. Well, not when it comes to your back. From the time you get out of bed until you lay down again at the end of the day, the pressure of gravity compresses your spine. When your spine is compressed, that means your spinal discs are too. These fluid-filled discs provide a cushion for your vertebrae, but the constant compression that occurs throughout the day due to regular activity squeezes the fluid out of them.
Dehydrated discs can cause back pain and structural problems. That is why restful sleep and staying hydrated are essential for spinal health.
Walk because it increases circulation throughout your body, including your spine. This increased blood flow helps to rehydrate your discs that improve your spinal health. It also helps keep your spine younger, staving off the effects of the aging process.
Walking Relieves Back Pain and Reduces Stress to the Spine
Walking provides an excellent low impact aerobic workout, and it increases blood flow which helps improve mobility, flexibility, and range of motion. When you incorporate stretching, you can reap even more of the benefits of a healthy spine.
The human body is made to move. When you don’t move or are sedentary, your muscles become stiff and inflexible. Moving prevents that, but even if you are experiencing some stiffness, walking, stretching, and movement can help you regain that flexibility.
You will also find that walking regularly also helps with stress relief. Lower back pain is a prevalent stress symptom, but walking combats its effects by encouraging dopamine release.
When you are stressed, your pain sensitivity increases, you feel pain more acutely, and it is more challenging to manage. By reducing your stress level, you also make your pain more manageable but, at the same time, minimize lower back pain.
Walking Improves Posture
When you don’t use your muscles, they become weak and inflexible and cannot do their intended job. The back forces are designed to provide support to the spine, and when they are not used, they can atrophy and weaken, resulting in stooped or other improper posture.
Poor posture causes back pain by putting more pressure on the spine, leading to pain, soreness, tension, and headaches. Without the necessary support, it can also lead to misalignment of the spine, which can cause problems.
Walking strengthens the supporting muscle groups so that your back muscles get more robust, and your spine gets the structural support needed. As your back muscles get stronger, your body will naturally begin to adopt a correct posture. The benefits of good posture include improved organ function, reduced pain, less fatigue, and easier breathing.
Walking is good for your whole body as well as your mind. When you walk to reduce back pain, you are also doing great things for your body. If you have any questions about proper form or achieving a better, healthier posture, your chiropractor can help you. The spine is such an essential part of the body; it does so much. Please do your best to protect it and keep it in good health. In return, it will save you from moving for a long, long time.
If you are like most people, at some point in your life, you will experience back pain � if you haven�t already. The American Chiropractic Association estimates that around 80% of the population suffers from back pain, has suffered from back pain, or at some point in the future will suffer from back pain. That puts you in good company.
It also means that you have a better than average chance of falling into that 80%, so the smart thing to do is take steps not to prevent it. One powerful preventative measure against back pain is stretching. Try these four stretches to help your back pain.
Forward Bend
Stand with your feet shoulder width apart and your knees soft (not locked). Take a deep breath and as you exhale, bend forward at the waist, hands out as if you are reaching for the floor. When you feel a little stretching in your hamstrings (the backs of your legs), stop and hold that position for two or three breaths. If you can�t reach the floor, that is OK, don�t force it. If you need extra stability, you can use a chair to hold on to for balance. Repeat this movement seven to ten times.
Cat and Camel
This stretch is typically done on the floor, but if you don�t think you can safely get back up, you can stand and hold on to a chair. On the floor, get on your hands and knees with your back straight. If using a chair, stand with your feet shoulder width apart and your knees soft. Bend slowly and place your palms in the seat of the chair so that your back is parallel to the floor. Keep it straight.
Begin by arching your back up as high as you can. Hold for two or three breaths. Return to the starting position, then let it sway down toward the floor and hold for two or three breaths. Return to the starting position. Do this five to seven times.
Back Extension
Lie on your stomach on the floor or bed with your hand’s palm down near your face. Slowly push up with your arms, keeping your head level with your shoulders, until you are on your elbows. Hold for three or four breaths.
If you can push all the way up so that you are on your hands, that will give you a deeper stretch. You can also hold it for a little longer. Just remember to keep the movements slow and gentle to avoid injury.
If you are not able to safely get on the floor, you can stand with your feet several inches from a wall. Place both of your hands on the wall and bring your upper body toward them, letting your pelvis naturally follow. Gently push against the wall with your hands, pushing your upper body away from the wall. You can also do this with a chair if you need extra support. Repeat five to seven times.
Hip Flex and Stretch
Get on your hands and knees on the floor or bed. Slowly move your body back so that your bottom is over your heels. Keep your hips straight as you extend your arms in front of you. Drop your head between your arms and hold the stretch for three to five breaths.
If you can�t get on your hands and knees, sit in a chair with your feet flat on the floor in front of you, hip-width apart. Extend your arms in front of you and reach forward. Lean forward slightly until you feel the stretch.
You can also place your hands on your knees for support while you sit in a chair and bend at the waist, slowly rounding out your back over your thighs. Hold the stretch for three to five breaths then return to your upright position. Do this seven to ten times.
Before you begin any new exercise or stretching regimen, talk to your doctor or chiropractor to make sure you aren�t doing something that could exacerbate your problem. For the most part, stretching is very therapeutic and beneficial, but some injuries and conditions can be made worse.
It is well worth taking the extra time to talk with your doctor and perhaps even show him or her the movements. This will also allow them to correct any form problems you may have or recommend any modifications that will help you get the most out of your stretches.
Bone neoplasms and tumor-like conditions affecting the knee can be benign or malignant. Age at Dx is crucial for DDx
In patients <40: Benign bone neoplasms: Osteochondroma, Enchondroma are relatively frequent
Fibrous cortical defect (FCD) & Non-ossifying fibroma (NOF) are particularly frequent in children
Giant cell tumor (GCT) is the m/c benign neoplasm of the knee in patients between 20-40 years of age
Malignant bone neoplasms in <40: m/c Osteosarcoma and 2nd m/c Ewing sarcoma
In patients >40: malignant neoplasms: m/c are secondaries d/t bone metastasis. Primary bone malignancy:�the m/c
Multiple Myeloma (MM). Less frequently:�a 2nd�peak of Osteosarcoma (post-radiation or Paget�s), Fibrosarcoma or Malignant�Fibrous�Histiocytoma�(MFH) of bone.
Clinically: knee pain, pathological fracture
Some tumor-like conditions like FCD/Non-ossifying fibroma are asymptomatic and may regress spontaneously. Occasionally NOF may present with pathologic fracture. N.B. any knee/bone pain in a child/adolescents should be�treated with clinical suspicion and adequately investigated.
Imaging: 1st step: radiography
MRI with T1+C is crucial for lesion characterization/regional extent, staging and pre-operative planning. CT may�help with pathologic Fxs detection. If malignant bone neoplasms considered, CXR/CT, PET-CT to investigate�metastatic spread and staging are important
Imaging Approach Bone Neoplasms
Approach to imaging Dx of bone neoplasms includes age, bone location (epiphysis vs. metaphysis vs. diaphysis), zone of transition surrounding the lesion, periosteal response, type of matrix, permeating or moth-eaten destruction vs. sclerotic, ground-glass, osteoid, cartilaginous matrix, soft tissue invasion, etc.
Key x-radiography features to DDx benign vs. malignant bone neoplasm:
Zone of transition: lesion is geographic with a narrow zone of transition vs. ill-defined wide zone of transition suggesting aggressive bone resorption
What type of bone destruction occurred: soap-bubbly appearance vs. osteolytic vs. osteosclerotic changes
Is there a round-glass matrix? Is there a well-defined rim of the sclerotic border with septations potentially suggesting slow growth and encapsulation like most benign processes.
Periosteal proliferation: solid vs. aggressive spiculated/sunburst/hair-on-end with local soft tissue invasion and Codman triangle (study next slide)
FCD & NOF
FCD & NOF or more appropriately Fibroxanthoma of the bone are benign bone processes that m/c seen in children. DDx based on the size with FCD presenting as <3-cm and NOF >3cm lesion composed of a fibrous heterogeneous matrix. FCD are asymptomatic and may regress in many cases. Some may progress to NOF. Location: identified in the knee region as an eccentric cortical based lesion.
FCD must be DDx from an avulsive irregularity d/t repeated stress along Linea aspera by extensors muscles
Dx: radiography
Management: leave-me-alone lesion. Occasionally NOF may progress and lead to pathologic fracture requiring orthopedic consult
Osteochondroma
Osteochondroma: m/c benign bone neoplasm. Knee is the m/c location. Contains all bone elements with a cartilaginous cap. Presented as pedunculated or sessile bone exostosis pointing away from the joint.
1% malignant degeneration to chondrosarcoma if solitary lesion and 10-15% in cases of HME
Other complications: fracture (top left image) pseudoaneurysm of the Popliteal artery, adventitious bursa formation
Hereditary Multiple Exostosis (HME)– autosomal dominant process. Presents with multiple osteochondromas (sessile-type dominates). May lead to limb deformities (Madelung deformity, coxa valga) reactive ST pressure, malignant degeneration
Dx: radiography, MRI helps to Dx malignant degeneration to chondrosarcoma by changes in size and activity of cartilaginous cap (>2-cm in adults may manifest malignant degeneration). MRI will also help with Dx of regional complications
HME & Knee Pain
37-y.o male with HME and knee pain. Axial T1, T2 and STIR MRI slices at the popliteal region. Large cartilaginous cap and possible compression of the popliteal artery by osteochondroma. MRA was performed to evaluate popliteal A. pseudoaneurysm (large arrow). Pathology specimen obtained from the cartilaginous cap showed increased cellularity suggestive of malignant degeneration. Operative care was planned
Giant Cell Tumor (GCT) aka Osteoclastoma
GCT- is a relatively common primary benign bone neoplasm. Age 25-40. M>F slightly.
GCT is the M/C benign sacral tumor. In 50% of cases, GCT occurs about the knee.
GCT is histologically benign, but lung Mets may develop esp. if in distal radius and hands, often termed Malignant GCT
<1% unresponsive/recurring GCTs may undergo malignant transformation to high-grade bone sarcoma
Pathology: histologically composed of osteoclasts-multinucleated giant cells with stromal cells derived from precursors monocyte-macrophage type. Produces cytokines and osteolytic enzymes. GCT may contain blood and associated with secondary Aneurysmal Bone Cyst (ABC)
Clinically: knee pain unresponsive to conservative care. Pathologic Fx may occur
Imaging: always begins with radiography followed by MRI and surgical biopsy that are crucial to Dx.
Rx: operative with curettage and cementing, a surgical appliance may be used if pathological fx present and cortical breach. In more severe cases other options available
Radiologic-Pathologic Dx
Radiologic-pathologic Dx: osteolytic and soap-bubbly lesion typically involving metaphysis and into epiphysis (classic key feature) with subarticular extension. Zone of transition is generally narrow but occasionally in aggressive lesions wide zone of transition may be seen.
MRI: low T1, highT2/STIR, characteristic fluid-fluid levels noted that are present in GCT and ABC. Histology is crucial to Dx.
DDx: ABC, Brown cell tumor of HPT (osteoclastoma), Telangiectatic Osteosarcoma
Radiological rule: if the physeal growth plate is present Dx of GCT is taken off the list in favor of chondroblastoma and vice versa.
Primarily Soap-Bubbly Appearance of GCT
Coronal, Fat-Sat Sagittal & Axial MRI Slices of GCT
T1 coronal, T2 fat-sat sagittal and T2 axial MRI slices of GCT. Typically: low T1, highT2/STIR and fluid-fluid levels
Characteristic MRI Appearance of GCT
Fluid-fluid levels d/t different composition of blood degradation products
Important DDx: ABC
Malignant Neoplasms About the Knee
In children and very young adults, m/c primary malignant neoplasm is central aka intramedullary (osteogenic) osteosarcoma (OSA). Second peak of OS: >70 y.o d/t Paget�s (1%) and/or post radiation OSA.
The knee is the m/c location of OSA (distal femur, prox. Tibia)
A 2nd m/c malignant pediatric primary is Ewing sarcoma.
In adults >40 y.o. the m/c primary is Multiple Myeloma (MM) or Solitary Plasmacytoma
Overall m/c bone neoplasms in adults d/t bone Mets from lung, breast, prostate, renal cell, thyroid (discussed)
Dx: clinical and radiological with surgical biopsy
Imaging is crucial to Dx. 1st step x-radiography. MRI+ gad C is vital
CT scanning occasionally helps to evaluate pathological fracture
Central (Intramedullary) Osteosarcoma (OSA)
m/c age: 10-20. m/c location: knee, males>females. Increased risk in some
congenital syndromes and mutation of the retinoblastoma gene: Rothmund-Thompson AR syndrome.
Early Dx is important d/t 10-20% present with Lung Mets at Dx. Prognosis depends on stages. Early stages with local bone invasion and no
mets 76% of survival.
Rx: limb salvage procedures preferred with 8-12 weeks of chemo, amputation if encased neurovascular tissue, path Fx, etc.
Imaging: radiography and MRI.
Clinically: bone pain, Inc. Alkaline Phosphatase
Chest CT if lung Mets considered
Classic Rad Features of OSA
Osteoid forming a sclerotic mass with aggressive hair-on-end/speculated/sun-burst periosteal reaction, Codman’s triangle and soft tissue invasion. Order MRI for staging and extent. Chest CT is crucial for Lung Mets dx.
MRI is Crucial for Dx/Staging
Note sagittal T1 (left) and STIR (right) MR slices: large mass extending from distal femoral metaphysis to remaining shaft. A low signal on T1 and high on STIR d/t marrow invasion with edema, hemorrhaging and tumor invasion. Local ST invasion seen (white arrows). Periosteal lifting and Codman�s triangle (green arrow) are additional signs of aggressive neoplasm.
Note an interesting feature that the epiphysis is spared d/t physeal plate serving temporarily as an additional barrier to the tumor spread.
Ewing Sarcoma
Ewing sarcoma: age: 2-20, uncommon in black patients. 2nd m/c highly malignant bone neoplasm in children that typically arises from medullary cavity (Round cell tumors). Key symptom: bone pain that may mimic infection (ESR/CRP/WBC) Considered PNET Key Rad Dx: aggressive moth-eaten/permeative lucent lesions in the shaft of long bones with sizeable soft tissue invasion/typical onion skin periostitis. May produce saucerisation May affect flat bones. May appear as sclerotic in 33%. Early lung Mets (25-30%) bone-to-bone Mets Poor prognosis if delayed Dx. Imaging steps: 1st step x-rad, MRI is v. important followed by a biopsy. CXR/CT PET-CT Rx: combined rad-chemo, operative.
Note aggressive expansile osteolytic lesion in the distal femur metaphysis into epiphysis. No periosteal reaction present. Following further work up with abdominal and chest CT scanning, Dx of Renal cell carcinoma was established
Distal Mets into lower extremity are more common with lung, renal cell, thyroid and breast CA.
Renal cell and Thyroid will typically present with aggressive osteolytic expansile mass aka �blowout Mets.�
In general, imaging approach should consist of Radiographic knee series, followed by MRI if x-rays are unrewarding
Tc99 Bone scintigraphy is the modality of choice to evaluate metastatic bone disease
Soft Tissue Neoplasms About the Knee
Malignant fibrous histiocytoma (MFH) reclassified as Pleomorphic Undifferentiated Sarcoma (PUS) is the m/c S.T. sarcoma. MFH is aggressive biologically with poor prognosis M>F (1.2:1) 30-80 with a peak in a 6th decade. 25-40% of all adults sarcomas m/c extremities. Retroperitoneum next (worst prognosis d/t late Dx and large growth w/o symptoms) Clinically: painful, hard mass typically about the knee or thigh. Histology: poorly differentiated/undifferentiated malignant fibroblasts, myofibroblasts, and other mesenchymal cells Imaging: MRI is the modality of choice with T1, T2, T1+C. Typically appears as an aggressive heterogeneous mass intermediate to low signal on T1 and high signal on T2 with areas of necrosis and enhancement on T1+C. May appear misleadingly encapsulated w/o true capsule Management: operative with radiation and chemotherapy. Tumor depth is crucial for prognosis. 80% 5-year survival if <5cm deep in ST and 50% if >5-cm deep in ST.
Synovial Sarcoma
Synovial sarcoma: common malignant ST neoplasm esp. in younger patients or older children/adolescents. M/C found in knee area Clinically: can present slowly as a palpable mass in the extremity often ignored d/t slow growth Imaging is the key: radiography may reveal ST. density/mass. Some synovial sarcomas may show calcification and mistaken for Myositis Ossificanse or heterotopic bone formation MRI with T1, T2 and T1+C are Dx modality of choice. Other modalities: US, CT are non-specific DDx: MFH Management: operative, chemo-radiation Prognosis: variable depending on size, invasion, metastasis
Types, location, and stability of tears are v. important during MRI Dx
Vertical/longitudinal tears especially occur in acute ACL tears. Some longitudinal tears found at the periphery or “red zone” may heal
Bucket handle tear: longitudinal tear in the inner edge that is deep and vertical extending through the long axis and may displace into a notch
Oblique/flap/parrot-beak are complex tears
Radial tear at 90-degree to plateau
Axial T2
Axial T2 WI fat-sat and coronal STIR slices of the posterior horn of the medial meniscus.
Note a radial tear of the posterior horn of the medial meniscus near the meniscal root. This is potentially an unstable lesion requiring operative care
The meniscus, in this case, is unable to provide a “hoop-stress mechanism.”
MRI Slices Coronal & Sagittal
Fat-sat coronal and sagittal proton density MRI slices revealing horizontal (cleavage) tear that is more typical in the aged meniscus
In some cases, when this tear does not contain a radial component, it may partially heal obviating the need for operative care
T2 w GRE Sagittal MRI Slice
Complex tear with a horizontal oblique and radial component.
This type of tear is very unstable and in most cases may need operative care
Bucket Handle Tear
Bucket handle tear are m/c in the medial meniscus esp. with acute ACL and MCL tear
MRI signs; double PCL sign on sagittal slices
Absent “bow-tie” sign and others
Most cases require operative care
DDx From Meniscal Degeneration
Occasionally meniscal tears need to be DDx from meniscal degeneration which may also appear bright (high signal) on fluid-sensitive MRI
The simplest rule is that if there is a true meniscal tear aka Grade 3 lesion, it always reaches/extends to the tibial plateau surface
The Role of MSK Ultrasound (US) in Knee Examination
MSK US of the knee permits high resolution and dynamic imaging of primarily superficial anatomy (tendons, bursae, capsular ligaments)
MSK US cannot adequately evaluate cruciate ligaments and the menisci in their entirety
Thus MR imaging remains modality of choice
Potential Pathologies Successfully Evaluated by MSK US
Patellar tendionosis/patellar tendon rupture
Quadriceps tendon tear
Prepatellar bursitis
Infrapatellar bursitis
Pes Anserine bursitis
Popliteal cyst (Baker cyst)
Inflammation/joint effusion with synovial thickening and hyperemia can be imaged with US (e.g., RA) especially with the addition of color power Doppler
Patient Presented With Atraumatic Knee Pain & Swelling
Radiography revealed sizeable soft tissue density within the superficial pre-patella region along with mild-to-moderate OA
MSK US demonstrated large septated heterogeneous fluid collection with mild positive Doppler activity on the periphery indicating inflammation d/t Dx of Superficial pre-patella bursitis
Long Axis US Images
Note normal lateral meniscus and fibers of LCL (above bottom image) compared to
Horizontal degenerative cleavage tear along with protrusion of lateral meniscus and LCL bulging (above top image)
Major limitation: unable to visualize the entire meniscus and the ACL/PCL
MRI referral is suggested
Rupture of Distal Tendon of Quadriceps
Note rupture of distal tendon of the Quadriceps muscle presented as fiber separation and fluid (hypo to anechoic) fluid collection within the substance of the tendon
Advantages of MSK US over MRI to evaluate superficial structures:
Dynamic imaging
Availability
Cost-effective
Patient’s preparation
Disadvantages: limited depth of structures, inability to evaluated bone and cartilage, etc.
Osteochondral Knee Injuries (OI)
osteochondral knee injuries can occur in children 10-15 y.o presented as Osteochondritis Dissecance (OCD) and in mature skeleton m/c following hyperextension and rotation trauma, particularly in ACL tear.
OCD-typically develops from repeated forces in immature bone and affects m/c postero-lateral portion of the medial femoral condyle.
OI in mature bone occurs m/c during ACL tears mainly affecting so-called terminal sulcus of the lateral femoral condyle at the junction of the weight-bearing portion opposed to tibial plateau and the part articulating with the patella
Osteochondral injuries may potentially damage the articular cartilage causing secondary OA. Thus need to be evaluated surgically
Imaging plays an important role and should begin with radiography often followed by MR imaging and orthopedic referral.
OCD Knee
95% associated with some trauma. Other etiology: ischemic bone necrosis especially in adults
Other common location for osteochondral injuries: elbow (capitellum), talus
1st step: radiography may detect osteochondral fragment potentially attached or detached
Location: a posterior-lateral aspect of the medial femoral condyle. Tunnel (intercondylar notch) view is crucial
MRI: modality of choice >90% specificity and sensitivity. Crucial for further management. T1-low signal demarcating line with T2 high signal demarcating line that signifies detachment and unlikely healing. Refer to orthopedic surgeon
Management: stable lesion esp. in younger children>off weight-bearing-heals in 50-75%
Unstable lesion and older child or impending physeal closure>operative fixation.
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