Sports Spine Specialist Chiropractic Team: Athletes strive to achieve their body’s maximum performance by participating in numerous training regimens consisting of strenuous exercises and physical activity and ensuring they meet all of their body’s nutritional requirements. Through proper fitness and nutrition, many individuals can condition themselves to excel in their specific sport. Our training programs are designed for athletes that look to gain a competitive edge in their sport.
We provide sport-specific services to help increase an athlete’s performance through mobility, strength, and endurance. Occasionally, however, the excess workouts can lead many to suffer injuries or develop underlying conditions. Dr. Alex Jimenez’s chronicle of articles for athletes displays in detail the many forms of complications affecting these professionals while focusing on the possible solutions and treatments to follow to achieve overall well-being.
Every year an estimated 3.8 million people in the United States sustain mild traumatic brain injuries (MTBI) or concussions. Many of these injuries are due to sports-related activities, work related injuries, motor vehicle accidents, and military operations. It is also estimated that as many as 50% of MTBIs are never reported because the patient does not seek medical attention. This makes it difficult to get a substantial number on how many there are, but it is a prevalent condition.
The Brain and Skull
A patient does not have to hit their head to sustain an MTBI. It can be caused by whiplash even though the person never hit their head. The reason for this lies in the construction of the brain and skull.
The brain is very soft; some experts compare the texture to that of soft butter. The skull is designed to protect the brain, and it is tough. If you run your hand over your head, you may feel some lumps and bumps, it may not feel entirely even, but the surface will be smooth.
The same cannot be said for the inside of the skull. There are boney ridges on the inside that are quite sharp. The design is intended to keep the brain in place.
When the head is hit or is jolted hard enough it caused the brain to shift inside of the skull, coming into contact with those boney ridges � sometimes forcefully. This can cause damage and the result in a brain injury. The harder the jolt, the more serious the injury may be.
Symptoms of Mild Traumatic Brain Injury
Part of the problem with MTBI is that the symptoms may not show up immediately. They could emerge weeks or even months after the incident making it unlikely that the symptoms will be tracked back and connected to it.
Often, MTBI is called a �silent epidemic� because the symptoms that it causes are usually not visible and may not be immediately connected to the injury. Depression, anxiety, angry outbursts, and impaired memory are more likely to be considered a psychiatric issue instead of a neurological one. The symptoms can be debilitating just the same.
Evaluation and diagnosis of an MTBI
Chiropractors routinely treat patients with Mild Traumatic Brain Injuries. When they are presented with a patient that they know has sustained a head injury, or if they suspect a brain injury based on specific symptoms, they use the Sports Concussion Assessment Tool 2 (SCAT2) to determine the severity. The SCAT2 helps the chiropractor create evaluate the physical signs, symptoms, sideline assessment using Maddocks score, Glasgow Coma Scale, coordination, balance, and cognitive.
As they evaluate the patient, they look for specific markers that indicate the patient is experiencing worsening neurological symptoms. These include:
Loss of consciousness
Vomiting
Headaches get�worse
Increased confusion
Weakness on one side or in one leg or arm
Blurred vision
Dilated pupils
Balance or coordination problems
Chiropractic Treatment for MTBI
A head injury usually involves a neck injury as well. The chiropractor may use a variety of techniques to treat the patient, including spinal manipulation, massage, and bracing. The patient will also be advised to avoid anti-inflammatory medication, aspirin, alcohol, and sleep aids, using acetaminophen for pain as needed. If the patient needs to see another doctor or specialist, the chiropractor will refer them.
If you are one of the seven out of 10 Americans who have back pain, you are probably looking for relief. What you probably aren�t looking for are injections or pills with harmful side effects. Your doctor may have told you that exercise is a great way to relieve pain naturally, but you aren�t sure where to start or even what activity is best.
Running and walking are both good exercises, but they aren�t for everyone. Some back pain patients can run with no problem with others have significant trouble. So, which is better for back pain sufferers? The answer might surprise you.
Benefits of running
When it comes to health benefits, running and walking, don�t differ much. Both help to decrease your risk of developing heart disease, diabetes, and hypertension as well as lower your cholesterol.
Running also has the added benefit of increasing the bone that connects the femur head to the shaft, substantially strengthening the hips and helping to prevent hip fractures. Both running and walking burn calories, facilitate weight loss and can help to make you healthier. However, one activity is a lot harder on the back, so if you have chronic back pain, there are some things you should know.
How running affects the back
Running puts repetitive impact and stress on the back. If you have a problem with your lower back, running can exacerbate it or lead to additional issues like sciatica.
You can experience back muscle spasms, muscular strain, and other centralized lower back pain. If you have disc problems, the high impact nature of running can make put a lot of stress on your spine and make your disc problems worse.
How walking benefits back pain sufferers
Walking is a much lower impact activity than running. Although some back problems can be made worse by walking, that is relatively rare.
Most back pain is relieved with walking, and you can enjoy other great benefits as well. By adopting a regular walking routine, you will strengthen your hips, legs, ankles, and feet as well as your core.
This helps to provide better stability for your spine. It also helps to increase circulation in the spinal structures, draining toxins, and pumping nutrients into the surrounding soft tissues.
Pain often restricts mobility. Walking helps to improve range of motion and flexibility. You will find that your posture improves as well as your mood. A stronger body and increased flexibility help to prevent injury.
Walking at least three times a week for at least 15 minutes is great for overall wellness and a strong body. Combine it with a healthy diet and stress relief techniques, and you will look, feel, and move better � and your pain will be easier to manage.
Make walking work
When you start your walking program, don�t push too hard too fast. Go at your own pace and start slow. If you have a higher fitness level, you may want to try speed walking. After a five-minute warm-up, walk as fast as you can for about 8 minutes then slow to a moderate pace for two minutes to cool down.
You can also engage your core muscles by using several techniques. Walk on an incline or using walking poles are excellent for strengthening the core. Pulling your abdominals in toward your spine while you walk is also a great move.
Running is beneficial for your health, but it isn�t for everyone. Walking is a far better choice for most patients with lower back pain. You may even find that your pain is alleviated altogether so get out there and get moving.
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.
When the weather warms, melting the snow and ice as it ushers in the newness of spring, people are drawn outdoors, and increased activity soon follows. Runners top the list, training for upcoming marathons and races, or to get faster and increase endurance.
While some runners won�t let anything stop them, be it rain, sleet, or snow, most will not venture outside or engage in more rigorous training until the environment is more pleasant. This increased activity, though, can increase a person�s risk of injury, especially if they have been mostly inactive during the winter months. The most prevalent injury is runner�s knee, an umbrella term used to describe a variety of knee injuries including patellofemoral tracking syndrome.
What is Patellar Tracking Disorder?
When the patella, or kneecap, does not remain in place as the leg straightens or bends, it is called patellofemoral tracking syndrome. Many people believe that the kneecap only moves up and down, but that is not accurate. The kneecap is very mobile, rotating and tilting so that there are a variety of contact points between the femur and patella. The most common way that this disorder presents is the kneecap extends too far to the outside of the leg. Less frequent is when the kneecap shifts to the inside. The result is pain (sometimes severe) and limited mobility.
Understanding the syndrome means understanding the mechanics of the knee joint. The thighbone (femur) and lower leg (tibia and fibula) are joined by the knee, a large, complex hinge. A groove runs along the front of the joint, where the thighbone ends. The patella sits in the groove and is held in place by a network on the sides by ligaments and at the top and bottom by tendons. The underside of the kneecap is a layer of cartilage that allows it to move easily, or glide, along with the groove. When there is a problem with any of the parts that make up the knee it can lead to patellofemoral tracking syndrome.
Causes of Patellofemoral Tracking Syndrome
While overuse of the knee is the blanket term that describes the cause of patellofemoral tracking syndrome, it is the result of a combination of several problems. These can include:
Leg ligaments, tendons, or muscles that are too loose or too tight
Structural problems with the knee bones
Weak thigh muscles
The continuous stress put on the knee, such as activities that use a twisting motion to the knee
Repetitive, high-stress activities like running
Repeated movements like squatting, knee bending, or jumping
Improper alignment of the knee bones
Trauma to the knee that forces the kneecap off track, usually to the outside area of the leg
People who are most likely to develop the syndrome are those who experience any of these problems in addition to playing sports or running. Obesity or being overweight, when combined with the above problems can also put a person at risk for the syndrome.
Chiropractic for Patellofemoral Tracking Syndrome
Many people have experienced relief from the pain of patellofemoral tracking syndrome by using chiropractic care. Chiropractic for patellofemoral tracking syndrome is a medication free, non-invasive treatment that quickly and effectively treats the pain and helps to restore mobility. This is usually done by bringing the body back into alignment and performing specific manipulations depending on the unique needs of the patient. Treatment may involve the foot, ankle, spine, and hip in addition to the knee.
The patient may also be advised to make specific dietary adjustments, take special, targeted supplements, and do specific exercises in addition to the chiropractic treatments. Stretching is often recommended, and Kinesio taping is also a standard therapy to aid healing. Chiropractic will not only return the body to its natural balance and alignment, but it will get it to a state where it can begin healing itself.
More than 80% of children will experience at least one ear infection before they turn three-years-old. Ear infection is one of the top reasons that parents seek medical treatment for their children, causing fever, irritability, and ear pain. Also known as otitis media, an ear infection is caused by fluid buildup behind the eardrum that results in inflammation. It is typically caused by bacteria. According to the Centers for Disease Control (CDC), antibiotics are not a recommended treatment for most ear infections.
Types of Childhood Ear Infections
There are three types of childhood ear infections. Each type has its own distinct set of symptoms that can aid in diagnosis and treatment.
Otitis Media with Effusion (OME) � This results from a fluid buildup that occurs in the middle ear although there are no symptoms or signs of infection. While it can happen when the fluid remains after an ear infection has run its course, other causes may include allergies, previous respiratory infections (like cold or flu), elevation changes, environmental irritants, air travel, and drinking while lying down (usually on the back). Antibiotics are not sufficient for this type of ear infection.
Acute Otitis Media (AOM) � This type of ear infection is the most common, affecting the middle ear, and is marked by infection, swelling, and trapped fluid behind the eardrum. Symptoms may include an earache and fever. It may be seasonal (most earaches occur in the winter and fall months), environmental pollutants (second-hand smoke), age (children under two years of age are more prone to earaches), and attendance at daycare. AOM may also be caused when the fluid from OME becomes infected. Antibiotics are sometimes prescribed for more acute cases.
Chronic Otitis Media with Effusion (COME) � This can be a serious condition if left untreated. It occurs when fluid in the middle ear continuously returns or remains trapped for a long time. Often infection is not present, and there are no symptoms. Children with COME have a more difficult time fighting new infections, and they may suffer from hearing damage or loss.
Risk Factors for Ear Infections
Children are more prone to ear infections than adults. This is because the eustachian tubes (connecting the middle ear to the upper part of the throat) are smaller in children and more level. This means that the fluid does not drain as easily and if a respiratory illness like a cold causes the eustachian tubes to become blocked or swollen, the fluid may become trapped because it can�t drain. Other risk factors include:
Drinking while laying on their back
Respiratory illness such as a cold
Allergies
Air travel (changes in air pressure)
Cigarette smoke and other environmental pollutants
Changes in elevation
Childhood Ear Infection Symptoms and Signs
Most of the time children get ear infections before they are old enough to verbalize their discomfort so parents must rely on telltale sure signs and symptoms.
Crying and fussiness
Fever (most prevalent in younger children and infants)
Pulling or tugging at the ears
Difficulty hearing or failure to respond to quiet sounds
Fluid draining from the ear
Difficulty sleeping
Balance problems or clumsiness
Chiropractic for Ear Infections
Several studies have shown Chiropractic for ear infections to be an effective, natural, antibiotic-free treatment. While full spine adjustments are commonly used, other techniques include occipital subluxation, atlas subluxation, and axis subluxations.
Chiropractic care not only treats ear infections, but it also improves their overall health and ability to function. It has a strong focus on whole-body wellness so the chiropractor may recommend diet and lifestyle adjustments in addition to treatment. Parents need to realize that they have a choice when it comes to the type of care their children receive for ear infections and other kinds of illnesses.
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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