0:01

Okay, so let's move on to case three.

0:08

So we're gonna stick with the perineal tendons

0:10

for just one more case.

0:12

Um, here we have odl, T two fat suppressed odl, T one

0:18

coronal oblique pd, fat suppressed,

0:20

and then our long axis PD fat suppressed images.

0:25

So this, uh, the history for this one,

0:28

this was a 67-year-old woman.

0:31

The history that the clinician gave us is not super helpful.

0:34

I think it was 30 days of pain radiating to the hip,

0:37

to the dorsum of the foot.

0:39

Um, what is probably more helpful here is the marker

0:43

that our technologist kindly placed for us on, uh,

0:48

the patient indicating the location

0:49

of the patient's symptoms.

0:52

Usually I find these to be the most helpful.

0:55

Um, a lot of times when I'm protocoling MRIs

0:58

and I, I know that the history is foot pain without

1:01

a specific location.

1:02

I'll actually add a little comment to ask our technologist

1:05

to put a marker where the patient hurts to at least try

1:08

and give us some clue where we can focus our attention.

1:12

So here in this case, you'll see that the marker is

1:15

right over a structure that, uh, Dr.

1:19

Resnick just talked about.

1:20

This is our OS peroneum within our peroneous long tendon,

1:25

and we can see quite a bit of edema within the os.

1:29

And there's also just a touch

1:31

of edema within the adjacent OID

1:33

and, um, some surrounding soft tissue edema around the os.

1:39

If we look at our T one weighted images,

1:41

I think perhaps the OS itself looks a little bit fragmented.

1:46

Um, if you wanted to confirm that,

1:47

you could ask for an x-ray.

1:50

One of the things that I learned from reading

1:51

tele cases with Dr.

1:53

Resnick is that if you think that an x-ray would be helpful,

1:57

even if they didn't give it to you,

1:59

it's perfectly reasonable to ask for it, um,

2:02

or ask them to do one and to correlate later.

2:06

So if we carefully inspect the perineal tendon itself,

2:11

looking at the longest, um, here, I think the,

2:16

uh, coronal oblique images are super helpful.

2:19

We can see some subtle increased signal within the substance

2:22

of the tendon proximal to the os,

2:25

and then a little bit distal to the os, um, just

2:28

before the tendon enters the cuboid tunnel.

2:33

So that's compatible with a split tear of the

2:37

perineal longus tendon.

2:39

We can see that also on our SAL images.

2:44

So this constellation of findings is compatible with a,

2:47

a diagnosis of painful eronium syndrome.

2:51

Dr. Raznick just showed you the slide on

2:53

that in his last lecture.

2:56

So, pops or painful oone syndrome is,

2:59

is not just one condition,

3:00

but it's gonna be a spectrum of different conditions

3:03

that contribute to plantar and lateral foot pain.

3:06

So you can have either acute

3:09

or chronic fractures on that oon, um,

3:13

or you can have diastasis of a multipart Peron.

3:17

Um, you can have problems with the tendon itself,

3:19

including either a partial

3:21

or complete tear of the peroneus longest tendon,

3:25

or, um, you might just have a very large perineal tubercle

3:28

that's gonna entrap the tendon

3:30

or the OS during tendon excursion.

3:34

So pops can be either conservatively managed

3:37

or you can treat it surgically.

3:39

Um, depending on what pathology is present, you just manage,

3:43

um, whatever issue is there.

3:45

So if the problem is the os, you can excise the os.

3:49

Um, if the problem is the tendon itself, you can either

3:52

repair the tendon or you can, um, perform a tenodesis.