The Aches and Pains of Runners: Evaluation with Imaging

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The Aches and Pains of Runners Evaluation with
Imaging

• Timothy G. Sanders, M.D.
• National Musculoskeletal Imaging
• Weston, FL

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Running Injuries

• Osseous Injuries
• Repetitive stress on bones
• New/different type of training
• Abrupt Increase in level of training
• Soft Tissue Injuries
• Repetitive stress strain/sprain friction injury
• Inadequate warm up/ stretching

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Osseous Injuries in Runners
-Stress Fracture -Abnormal repetitive stress on
normal bone -Insufficiency Fracture -Normal
stress on abnormal bone -Rheumatoid arthritis
renal osteodystropy steroid use elderly patient
with osteoporosis -Miscellaneous Osseous
Abnormalities
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Imaging of Stress FracturesRadiographs

• Lucent or sclerotic line that runs perpendicular
  to normal primary trabeculae periosteal reaction
• May progress to complete fracture

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Imaging of Stress FracturesNuclear Medicine
-Abnormal increased uptake -Often linear in
distribution
-Very sensitive lacks specificity
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Imaging of Stress FracturesMRI
-Similar sensitivity to bone scan improved
specificity
Edema on T1/T2 Dark line on T1/T2 perpendicular
to trabeculae
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Principle Trabculae of the Hip
-Tensile Trabeculae Arc from lateral margin of
greater trochanter to lateral margin of femoral
neck and head
Compressive Trabeculae
-Compressive Trabeculae Vertically oriented from
medial neck into femoral head in a triangular
configuration
Tensile Trabeculae
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Stress Fracture Medial (compressive) Side of Neck
-Stress fracture through compressive
trabeculae -Most athletic induced stress
fractures occur medially -Less risk for fracture
completion than lateral stress fracture -Can
progress to complete fracture if untreated
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Stress Fracture Lateral (tensile) Side of Neck
-Stress fracture of tensile trabeculae -Less
common in runners -Leads to subcapital
fracture -High risk for progression to fracture
completion
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Stress Fracture of Hip
19 y.o. basic trainee presents with pain in left
hip while running -Plain film demonstrates
sclerotic line in femoral neck perpendicular to
normal trabeculae
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Stress Fracture of Hip
-MRI demonstrates black line on all pulse
sequences -Line does not traverse entire width
of femoral neck -Surrounding edema is present
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47 y.o. long distance runner with left hip pain
Lateral femoral neck stress fracture- progressed
to complete subcapital fracture
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Acetabular Stress Fractures
27 y.o. long distance runner
19 y.o. long distance runner
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Other Stress Fractures of the Pelvis
-Stress fracture of inferior pubic ramus occurs
in runners military recruits preganancy -Present
s with groin pain accentuated by walking or
running -Inferior ramus medially or superior
ramus laterally
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Pubic Symphysis Injuries in Runners
-Osteolysis -Sclerosis
-Overuse injury in sports -Change of direction/
runners -Ice hockey, soccer, tennis -Adductor
avulsion injuries
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Adductor Insertion Avulsion SyndromeThigh
Splints

• Female, long distance runners/military recruits
• Vague proximal thigh pain/difficulty localizing
• Activity/pain Rest/relief

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Adductor Insertion Avulsion SyndromeThigh
Splints
MRI of pelvis, abnormality often below normal FOV
Periosteal reaction along medial aspect of
proximal thigh
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Femoral Shaft Stress Fractures
-Most common site medial aspect femur, junction
of proximal and middle third -Insertion of
adductor brevis and origin of vastus medialis
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Long distance runner with knee pain
-Early stress changes- BME only no fracture
line -Microtrabecular injury with no
macrofracture
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19 y.o. airman basic with anterior tibial pain
14 Aug
7 Aug
3 Sept
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Tibial Shaft Stress Fractures
-Tibia most common location in runners (73)
-Transverse fracture proximal or distal
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Longitudinal stress fracture of tibia
-Unusual injury -Fracture located in vertical
plane -Usually involves single cortex anterior
or posterior
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Fibular Stress Fractures
-Most often distal starts laterally -Long
distance runners/ hard surfaces
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Insufficiency Fractures
-54 y.o. women with history of. breast
carcinoma -On Tamoxifen -Bilateral ankle pain
after trip to Hawaii
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Tarsal Navicular Stress Fracture
-Occurs in elite athletes runners, basketball,
gymnasts -Artificial turf- football
players -Delayed dx difficult to see on
x-rays -Dorsal foot pain associated with running
Middle 1/3 navicular
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Progression of stress fracture of the 3rd MT
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Metatarsal Stress Fracture
-Foot pain following increased level of training-
long distance runner
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Stress Fracture of the Tibial Sesamoid in a Runner
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Runners that Present with Pain Miscellaneous
Bone Lesions
Not every painful bone in a runner is a stress
fracture!
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Synovial Herniation Pit
-Small oval lucency on plain film -Well defined
sclerotic margins
T1- iso to muscle T2-bright (water)
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Synovial Herniation Pit
-Can present with pain- occasionally with
surrounding edema -Associated with femoral
acetabular impingement syndrome
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32 y.o. female long distance runner with
persistent right hip pain Suspected stress
fracture
-Chrons disease with remote history of high dose
steroids use
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59 y.o. active duty Air Force officer -Marathon
runner sudden onset right hip pain
T1
T2
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42 y.o. female with persistent left hip pain and
unable to complete fitness testing
-Left L5-S1 HNP with nerve root compression
presenting as chronic left hip and buttocks
pain -Atrophy of gluteus muscles
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18 y.o. male presents with worsening leg pain
exacerbated with running
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18 y.o. male collegiate athlete from the
University of Hawaii with thigh pain
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Osteoid Osteoma
-Benign bone forming tumor -Age range young
adults Same age range as stress
fx -Treatment Percutaneous radio- frequency
ablation
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21 y.o. runner with right hip pain, stress
fracture suspected clinically
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24 y.o. male with posterior knee pain exacerbated
while running
Long bone- osteoid production Bone scan- intense
uptake MRI- intense enhancement DDX Osteosarcoma
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Soft Tissue Injuries in Runners
Type of soft tissue injury Age related Weak
Link depends on age of athlete

1. Apophyseal injuries adolescents
2. Myotendinous injuries young adult athletes
3. Tendinous injuries older athletes

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Apophyseal Avulsions

• Result from violent muscular contraction
• Typically seen in adolescent athletes
• Equivalent to a muscle pull in a mature athlete
• Sprinters, long jumpers, cheerleaders, hurdlers,
  gymnasts
• Pelvis common location in adolescent runners

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Tendinous Attachment Sites
Sartorius
Rectus Femoris
Gluteus Medius
Hamstring
Iliopsoas
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Anterior Superior Iliac Spine
Sartorius/ tensor fascia lata attachment site
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Anterior Inferior Iliac Spine
Rectus Femoris
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Old Rectus Femoris Avulsion
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Rectus Femoris Avulsion Injury
MR can be helpful if x-ray is normal or equivocal
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Ischial Tuberosity Hamstring/ Adductor Magnus
Attachment Site
-Often large avulsion fragment -Can mimic
neoplasm -Sprinters
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• Complete avulsion with marked retraction of
  hamstring tendon
• Associated soft tissue hematoma

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Lesser Trochanteric Avulsion
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Old Lesser Trochanteric Avulsion Injury
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Beware Avulsion Fracture Lesser Tuberosity
-Pathologic fracture -Adult -Nontraumatic
avulsion
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Myotendinous InjuriesYoung Adult Runners

1. Occurs when powerful contraction of muscle occurs
   simultaneously with forced lengthening of the
   myotendinous unit
2. Occurs in muscles that cross two joints
3. Rectus femoris
4. Hamstring
5. Gastrocnemius
6. Eccentric contraction of muscles that do not
   cross two joints- especially the adductors
   (longus in particular)

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Hamstring Strain- 22 y.o. runner
First Degree Injury -Strain Microscopic
injury -MR edema myotendinous junction/
perifascial fluid no architectural distortion of
muscle or tendon -Clinical pain no significant
loss of ROM or strength resolves with rest
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Rectus Femoris Partial Thickness tear
Second Degree Injury -Partial thickness tear
Macroscopic injury -MR high signal at partial
tear- hematoma at myotendinous junction is highly
characterstic of partial tear old
tear -Clinical pain and some loss of strength
conservative Rx, increased risk for further tear
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Rectus Femoris Partial Thickness Tear
Often torn in running athletes Can present as a
mass in the mid thigh anteriorly
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Plantaris Rupture

• -Plantaris rupture
• -Charging net during game
• Sting in posterior calf
• Must R/O tear of gastrocnemius/ Achilles tendon

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Biceps Femoris Complete Tear
Third Degree Injury Complete Tear -Complete
myotendinous disruption, retraction of fibers,
palpable mass loss of strength of affected
muscle group -MR complete discontinuity of
myotendinous unit hematoma in the gap muscular
atrophy within 10 days surgery may be indicated
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Ultrasound Complete vs Incomplete Tear
-Torn Rectus Femoris muscle
-Dynamic evaluation
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Exercise-Induced Compartment Syndrome

• Muscle hypertrophy/ over exertion
• Increases with training
• Persists for several days
• Chronic fatty atrophy/fibrosis

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Tendon Injuries
-Middle age and older adult runners -Tendon
degeneration occurs -Spectrum of injury 1.
Tendinopathy 2. Partial thickness tear 3.
Complete tear -Repetitive trauma
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Achilles Tendonopathy
-Paratendonitis overuse syndrome -Complete
rupture 30-50 y.o. -Forceful dorsiflexion -Pain,
swelling, nodular mass -Thompson Test unable to
stand on tip-toes
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Achilles Tendon Partial Tear
-Fluid signal on T2 images
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Achilles Tendon Complete Rupture
-Fluid filled gap with retraction of fibers -Can
occur in any tendon -Most Commonly
Involves -Achilles Tendon -PT Tendon
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Tibialis Anterior
-Primary Dorsiflexor -Susceptible to ischemia
Ant Tibial Artery -Rupture Rare (gt45
y.o.) -Forced Plantar Flexion
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Quadriceps Tendon
-Middle aged males- weekend athletes -Urgent
orthopedic injury/ repair early
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Jumpers Knee Patellar Tendonitis
Partial tear of tendon Fluid signal on T2 images
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Snapping Hip SyndromeCoxa Saltans

• Audible snapping occurs with flexion and
  extension of the hip
• May or may not be symptomatic
• Three types
• External type
• Internal type
• Intra-articular type

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Snapping Hip Syndrome Coxa Saltans
Gluteus maximus edema
Trochanteric bursitis
External type -Most common type -Occurs when
thickened iliotibial track or gluteus maximus
snaps over greater trochanter -MR findings
thickened iliotibial track, gluteus maximus
edema, trochanteric bursitis -Running on banked
surfaces
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Snapping Hip Syndrome Internal Type
Internal Type -Iliopsoas tendon snaps over
iliopectineal eminence with flexion -MR normal
or cylindrical fluid collection anterior to hip
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Snapping Hip Syndrome Internal Type
-Inject iliopsoas bursa under fluoroscopic
guidance -Abduct and externally rotate
hip -Tendon pops over iliopectineal eminence/
sxs reproduced
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Snapping Hip Syndrome Intra-articular Type
Synovial Osteochondromatosis
-Internal derangement of hip -loose body, labral
tear -Clicking sensation/ pain is a dominate
feature
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Acetabular Labrum
-Black Triangular -Firmly attached to acetabulum
-Normal joint recess - Lateral to labrum -No
signal within or medial to labrum
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Acetabular Labral Tear
-Intra-articular pain, decreased ROM, clicking
sensation
Contrast extending between the medial aspect of
labrum and acetabulum
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Acetabular Labral Tear
-Subchondral cyst
-Normal labrum -Black triangle, no internal signal
-Labral tear -Signal within triangle
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Unilateral Hip OA
-Can result from chronic lateral
micro-instability of hip associated with lateral
acetabular labral tear
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Paralabral Cyst
-Labral cyst dissecting posteriorly into Sciatic
Notch
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Iliotibial Band Syndrome
-Friction injury iliotibial band rubs over
lateral femoral condyle -Long distance runners

• MRI Findings
• Edema deep to iliotibial band
• Possible edema in lateral femoral condyle

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Long distance runner with anterior knee pain

• -Hoffas Disease Inflammation/ arthrofibrosis of
  Hoffas fat pad
• Young athlete single vs repetitive injury
  entrapment of fat tibia/patella
• -Pain, swelling, tenderness
• -May require open or arthroscopic surgical
  debridment