Imaging Hip Problems in Athletes - University of Wisconsin-Madison
Imaging Hip Problems in Athletes - University of Wisconsin-Madison
Imaging Hip Problems in Athletes - University of Wisconsin-Madison
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4/11/2011<br />
Part II: <strong>Imag<strong>in</strong>g</strong> <strong>Hip</strong><br />
<strong>Problems</strong> <strong>in</strong> <strong>Athletes</strong><br />
Donna G. Blankenbaker, MD<br />
<strong>University</strong> <strong>of</strong> Wiscons<strong>in</strong><br />
<strong>Madison</strong>, Wiscons<strong>in</strong><br />
Outl<strong>in</strong>e<br />
• <strong>Imag<strong>in</strong>g</strong> techniques<br />
• <strong>Hip</strong> pathology<br />
– Osseous<br />
– Intra-articular: articular: Labrum, LT, Chondral<br />
–FAI<br />
– Snapp<strong>in</strong>g hip<br />
– Bursitis<br />
– Muscle/tendon<br />
Zona orbicularis<br />
Anteroposterior (AP) pelvis<br />
•Comparison to<br />
contralateral hip<br />
•Coccyx must be centered<br />
over the pubic symphysis<br />
(not more than 2 cm)<br />
Sciatic n.<br />
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4/11/2011<br />
Frog-lateral<br />
X-table lateral<br />
Indications for Rout<strong>in</strong>e <strong>Hip</strong> MRI<br />
• Stress fracture (fatigue)<br />
• Nonspecific hip pa<strong>in</strong><br />
• Pubalgia (“osteitis pubis/sports hernia”)<br />
• Muscle/tendon <strong>in</strong>juries<br />
• Osteonecrosis<br />
• Tumor<br />
Indications for MR Arthrography<br />
• Assess the <strong>in</strong>tra-articular structures<br />
–Labrum<br />
–Cartilage<br />
–Intra-articular loose bodies<br />
–Ligaments<br />
–Capsule<br />
Indications for Sonography<br />
• Snapp<strong>in</strong>g hip<br />
–IPT<br />
– IT band<br />
• Guidance for <strong>in</strong>jection<br />
– Iliopsoas bursa<br />
– Greater trochanteric<br />
bursa<br />
– Synvisc <strong>in</strong>jection<br />
OSSEOUS<br />
ABNORMALITIES<br />
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4/11/2011<br />
Stress Fractures<br />
Femoral Neck: Fatigue<br />
Stress Fractures<br />
Femoral Neck: Fatigue<br />
<strong>Hip</strong> Dislocation<br />
Prior Posterior <strong>Hip</strong> Dislocation<br />
• Ass. with IA pathology<br />
– Labral<br />
– Chondral<br />
– Loose fragments<br />
– Tear LT<br />
• Complications: AVN<br />
– MRI <strong>in</strong>itially<br />
– If neg, repeat MRI <strong>in</strong><br />
6-12 weeks to exclude<br />
traumatic AVN (ok to return to play if -)<br />
Sh<strong>in</strong>dle Cl<strong>in</strong> Sports Med 2006<br />
Avulsion<br />
Avulsion <strong>of</strong> Sartorius from ASIS<br />
• 14 y/o boy with right sided hip pa<strong>in</strong><br />
follow<strong>in</strong>g hockey <strong>in</strong>jury<br />
Glut m<strong>in</strong><br />
<strong>in</strong>jury<br />
Hematoma<br />
3
4/11/2011<br />
Causes <strong>of</strong> Labral Tears<br />
LABRUM<br />
• Trauma (posterior dislocation,<br />
twist<strong>in</strong>g <strong>in</strong>jury)<br />
• Osteoarthritis<br />
• Acetabular dysplasia<br />
•FAI<br />
• Idiopathic<br />
www.sportsortho.co.uk/.../Labraltear.jpg<br />
MR Arthrography<br />
Anterior Superior Labral Tear<br />
• Labral tear detection: ↑distension <strong>of</strong> jo<strong>in</strong>t<br />
– Sensitivity: 90%<br />
– Accuracy: 91%<br />
– Specificity: 90-100%<br />
• Conventional MR imag<strong>in</strong>g:<br />
– Sensitivity: 30%<br />
– Accuracy: 36%<br />
Czerny C. Rad 1996;200:225-230<br />
H<strong>of</strong>mann S. Orthepade 1998;27:681-68<br />
Plotz GM. J Bone Jo<strong>in</strong>t Surg Br 2000;82:426-432<br />
T1 FS<br />
T1 FS<br />
Superior Labral Tear<br />
22 year-old runner with hip pa<strong>in</strong><br />
Anteriorsuperior Labral Tear &<br />
Paralabral cyst<br />
51 y/o athletic man with hip pa<strong>in</strong><br />
T1 FS<br />
4
4/11/2011<br />
Posterior Labral Tear &<br />
Paralabral cyst<br />
Labral surgical techniques<br />
28 y/o soccer and prior football player with hip pa<strong>in</strong> Debridement Repair<br />
Larson CM Arthroscopy 2009;4:369-376<br />
MR Arthrography<br />
Chondral Lesions<br />
• Cartilage abnormality detection:<br />
– Sensitivity: 79%<br />
– Specificity: 77%<br />
Schmid MR. Radiology 2003; 226: 382-386.<br />
Chondral Lesions<br />
34 y/o with hip pa<strong>in</strong><br />
IA loose bodies<br />
27 y/o athletic male with hip pa<strong>in</strong><br />
5
4/11/2011<br />
Capsule <strong>in</strong>jury<br />
22 year-old football player with hip pa<strong>in</strong><br />
Ligamentum Teres<br />
• LT connects the fovea to the PI acetabular fossa<br />
• Mechanical symptoms can occur with ruptured LT; click<strong>in</strong>g/<br />
“giv<strong>in</strong>g away”<br />
• ? Repair<br />
Posterior capsule<br />
T2 Fat Sat<br />
T2 Fat Sat<br />
<strong>Hip</strong> Plica<br />
FAI<br />
T1 FS<br />
http://www.edw<strong>in</strong>su.com/hip-arthroscopy.html<br />
Femoroacetabular Imp<strong>in</strong>gement (FAI)<br />
• FAI results from anatomic abnormalities<br />
<strong>of</strong> the proximal femur and/or<br />
acetabulum<br />
• FAI can cause:<br />
– Labral tears<br />
– Cartilage lesions<br />
– Premature OA<br />
Mechanisms <strong>of</strong> Imp<strong>in</strong>gement<br />
• Cam (“femoral”FAI)<br />
– Abnormal morphology anterior femoral headneck<br />
junction<br />
– Seen <strong>in</strong> younger <strong>in</strong>dividuals<br />
Beall Skeletal Radiol 2005; 34:691-701.<br />
Ganz Cl<strong>in</strong> Orthop 2003; 417:112-120.<br />
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4/11/2011<br />
Mechanisms <strong>of</strong> Imp<strong>in</strong>gement<br />
• Cam (“femoral”FAI)<br />
– Abnormal morphology anterior femoral headneck<br />
junction<br />
– Seen <strong>in</strong> younger <strong>in</strong>dividuals<br />
• P<strong>in</strong>cer (“acetabular” FAI)<br />
– Abnormal acetabulum contact<strong>in</strong>g a normal<br />
femur<br />
– More common <strong>in</strong> older women<br />
• Both types are common <strong>in</strong> athletes<br />
NORMAL<br />
CAM<br />
PINCER<br />
MIXED<br />
Philippon et al. Am J Sports Med 2007;35:1571<br />
Cl<strong>in</strong>ical Presentation<br />
Cam FAI<br />
• Slow onset <strong>of</strong> gro<strong>in</strong> pa<strong>in</strong> after m<strong>in</strong>or<br />
trauma<br />
– Intermittent<br />
– Exacerbated by athletic activities, walk<strong>in</strong>g<br />
• PE P.E.<br />
– Limitation <strong>of</strong> motion<br />
• Internal rotation and adduction <strong>in</strong> flexion<br />
– Positive imp<strong>in</strong>gement test<br />
29 y/o man with hip pa<strong>in</strong><br />
Radiographic f<strong>in</strong>d<strong>in</strong>gs can “predispose” to cam FAI<br />
Klaue K. J Bone Jo<strong>in</strong>t Surg 1991;73B:423-429.<br />
Cam FAI<br />
Sag T1FS<br />
Bilateral FAI changes<br />
20 year-old man with bilateral hip pa<strong>in</strong><br />
Cor T1FS<br />
Femoral<br />
bump<br />
Axial oblique T1FS<br />
Axial oblique T1FS<br />
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4/11/2011<br />
Bilateral FAI changes<br />
20 year-old man with bilateral hip pa<strong>in</strong><br />
P<strong>in</strong>cer FAI: Retroversion<br />
P<strong>in</strong>cer FAI: Coxa Pr<strong>of</strong>unda<br />
P<strong>in</strong>cer FAI: Protrusio Acetabuli<br />
Acetabular fossa is medial to ilioischial l<strong>in</strong>e<br />
Femoral head is medial to ilioischial l<strong>in</strong>e<br />
Snapp<strong>in</strong>g <strong>Hip</strong><br />
Pa<strong>in</strong>ful snapp<strong>in</strong>g hip<br />
External<br />
Internal<br />
Intra-articular<br />
http://zoom<strong>in</strong>local.com/wilm<strong>in</strong>gton-star-news/3rju66v17VkT8LB0/?article=389211<br />
ITB<br />
G. Max<br />
IPT<br />
Loose bodies<br />
Synovial folds<br />
Torn acetabular labra<br />
Femoral head subluxation<br />
Synovial chondromatosis<br />
Cartilage abnormalities<br />
8
4/11/2011<br />
Iliacus<br />
Psoas<br />
Snapp<strong>in</strong>g <strong>Hip</strong>: iliopsoas<br />
Most common <strong>in</strong>ternal cause:<br />
►Iliopsoas tendon roll<strong>in</strong>g over the medial part <strong>of</strong><br />
the iliacus muscle onto the superior pubic<br />
ramus<br />
Iliopsoas Tendon<br />
Deslandes et al. AJR 2008;190:576-581<br />
Copyright © 2008 by the American Roentgen Ray Society<br />
Normal iliopsoas tendon<br />
Snapp<strong>in</strong>g Iliopsoas tendon<br />
IPT<br />
Transverse<br />
IPT<br />
Acetabulum<br />
Femoral head<br />
Longitud<strong>in</strong>al<br />
• Pa<strong>in</strong> & audible or<br />
perceived snapp<strong>in</strong>g dur<strong>in</strong>g<br />
hip movement<br />
• Extension <strong>of</strong> flexed<br />
abducted and externally<br />
rotated hip<br />
– abrupt motion <strong>of</strong> iliopsoas<br />
tendon<br />
Iliopsoas bursa <strong>in</strong>jection<br />
Corticosteroid + anesthetic (8ml)<br />
Lateral<br />
needle<br />
Medial<br />
BURSITIS<br />
IP tendon<br />
Acetabular brim<br />
9
4/11/2011<br />
Bursitis: iliopsoas<br />
Sport-related: overzealous hip flexion & extension<br />
Row<strong>in</strong>g, runn<strong>in</strong>g uphill, competitive track/field, strength tra<strong>in</strong><strong>in</strong>g<br />
Bursitis: Trochanteric<br />
IPT<br />
Bursa medial<br />
to IPT<br />
IPT<br />
Trochanteric bursa <strong>in</strong>jection<br />
Gluteus m<strong>in</strong>imus partial<br />
tear<br />
needle<br />
Greater trochanter<br />
Sagittal PD fat-suppressed<br />
Coronal PD fat-suppressed<br />
MUSCLE/TENDON<br />
INJURY<br />
Muscle/Tendon Injury<br />
Partial Tear Hamstr<strong>in</strong>g Orig<strong>in</strong><br />
10
4/11/2011<br />
Muscle/Tendon Injury<br />
Complete Hamstr<strong>in</strong>g Avulsion<br />
Muscle/Tendon Injury:<br />
Partial Tear Iliopsoas<br />
10 y/o girl with left hip and gro<strong>in</strong> pa<strong>in</strong> after snowboard<strong>in</strong>g <strong>in</strong>jury<br />
Muscle/Tendon Injury<br />
Rectus femoris stra<strong>in</strong><br />
Ischi<strong>of</strong>emoral imp<strong>in</strong>gement<br />
•Imp<strong>in</strong>gement btwn ischium &<br />
lesser troch.<br />
–Described by Johnson <strong>in</strong> 1977<br />
–Seen <strong>in</strong> pts with prior hip<br />
surgery (THA)<br />
–Pa<strong>in</strong> relief after lesser troch.<br />
Excision<br />
•Consider <strong>in</strong> cases with MR<br />
signal abn. quadratus femoris<br />
Johnson KA. J Bone Jo<strong>in</strong>t Surg Am 1977;59:268<br />
Torriani M et al. AJR 2009;193:186<br />
Ischi<strong>of</strong>emoral imp<strong>in</strong>gement<br />
32 y/o woman with hip and thigh pa<strong>in</strong><br />
ATHLETIC<br />
PUBALGIA<br />
11
4/11/2011<br />
Athletic Pubalgia<br />
“<strong>Hip</strong>” Pathology<br />
In <strong>Athletes</strong><br />
• Adductor/gracilis<br />
syndrome<br />
• Osteitis pubis<br />
• Sportsman’s<br />
hernia<br />
“Athletic Pubalgia”<br />
Athletic Pubalgia<br />
•Osteitis pubis<br />
•Adductor <strong>in</strong>jury<br />
•Rectus abdom<strong>in</strong>is aponeurosis <strong>in</strong>jury<br />
Osteitis Pubis<br />
Omar IM et al. RadioGraphics 2008; 28:1415-1438<br />
Osteitis Pubis<br />
Osteitis Pubis<br />
• Pa<strong>in</strong>ful condition <strong>of</strong> the symphysis pubis<br />
• Self-limited, but very pa<strong>in</strong>ful<br />
• Etiology: overuse <strong>in</strong>jury with repeated stress,<br />
shear forces, microtrauma, ?AVN, <strong>in</strong>stability<br />
• Other assoc’s: spondyloarthrop, pregnancy,<br />
SI dysfunction<br />
12
4/11/2011<br />
Osteitis Pubis<br />
Adductor Injury<br />
Adductor Injury<br />
Rectus abdom<strong>in</strong>us<br />
common aponeurosis<br />
Adductors<br />
15 year-old male goalie on the school soccer team<br />
Conclusion<br />
T1<br />
F2FS<br />
T1FS POST<br />
• Many causes for hip pa<strong>in</strong> <strong>in</strong> athlete<br />
• MRI imag<strong>in</strong>g technique <strong>of</strong> choice<br />
<strong>in</strong>jured athlete<br />
j<br />
– Diagnosis<br />
– Guide rehab & treatment<br />
OSTEOMYELITIS WITH SEPTIC ARTHRITIS<br />
T2FS<br />
T1FS POST<br />
13
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