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You can also sign up for a free trial of our premium membership to get access to

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hundreds of case based micro-learning courses across all key radiology

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subspecialties. Today we are honored to welcome Dr.

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Jenny Benardino for a lecture on overstretching injuries of the calf

0:45

musculature, tennis leg, and more. Dr.

0:48

Benardino is currently professor of radiology and chief from Musculoskeletal

0:52

Imaging at the hospital of the University of Pennsylvania.

0:55

She is also a faculty advisor member of the Radiology Inclusion Diversity Equity

0:59

Committee and one of diversity search advisors for Penn Radiology. Dr.

1:04

Benardino is an active member of several radiology associations and the

1:08

recipient of the 2014 R S N A Honored Educator Award,

1:12

2013 President's Medal of the International Skeletal Society,

1:16

and the 2023 Medal of the International Skeletal Society in the Public

1:21

Service Realm. Dr. Benardino is the founder of Free Spirit Tennis and Soccer,

1:26

a volunteer group that brings sports instruction to the Juvenile detention

1:29

center and respiratory New York. At the end of the lecture, please join Dr.

1:33

Benardino in a q and a session where she will address questions you may have on

1:37

today's topic.

1:38

Please remember to use the q and a feature to submit your questions so we can

1:42

get to as many before our time is up. With that,

1:44

we're ready to begin today's lecture. Dr. Benardino, please take it from here.

1:48

Hello everyone and welcome, uh, to this, uh, noon, uh,

1:52

conference of MRI online.

1:55

So the topic that we are going be discussing today is always stretching injuries

1:59

of the calf musculature with particular attention to tennis leg.

2:04

Um, I don't know if you, um, are watching the French happen. I love tennis.

2:09

Uh, so I've been busy after work catching up with the, uh,

2:13

with the matches that are taking place there. Um, uh,

2:17

guy Fields, uh, had a match, um,

2:20

about 10 days ago where he was completely cramped, um, in the,

2:25

uh, fifth set and managed to finish, uh,

2:28

the game and actually win. So I thought it was very opportunity to, uh,

2:33

put APIC picture of Moon Fields, uh, who I love, uh, as a tennis player,

2:38

uh, to start this lecture. So, as an introduction, uh,

2:42

we are going to be revealing over stretching, uh, muscle injuries. This, uh,

2:47

really the most common injuries that we see in athletes,

2:50

90% of them involved the lower extremities, um,

2:54

particularly the hamstrings, theo muscles, the quadriceps,

2:59

and the musculature of the calf. Um, and all these muscles have, um,

3:04

a common denominator. They, they all cross two joints,

3:09

and they are all superficially located while within the lower extremity,

3:13

making them more prone to over stretching or strain injuries.

3:19

Um,

3:20

oration mu muscle injuries are a common cause of removal from play in

3:25

high performance athletes and imaging has become really crucial element

3:31

in deciding when the patient is ready to return to play. So,

3:35

we are gonna be reviewing the imaging findings and how to inform, uh,

3:40

return to play. Now, uh, sl um,

3:45

is defined as an acute traumatic injury.

3:48

It's most commonly seen in, uh, active middle age individuals,

3:53

uh, who practice rackets sports, particularly tennis and a squash.

3:58

But it can also be seen in skiers and runners in athletics,

4:04

the muscles that involved in tennis leg. Um,

4:07

the most common one is the medial health gastro,

4:11

which has been reported torn in two thirds of the cases.

4:16

Uh,

4:16

a combination of me medial health of gastros and soleus injury with

4:21

fluid collections located in the space, uh,

4:25

inter muscle space between the medial health gastros and the soleus.

4:30

Um, that has been reported enough to 21% of patients.

4:35

And then, interestingly enough, the injury that, um,

4:39

everybody thinks about when the term tennis leg comes to, um,

4:43

to mine is plant tendon rupture.

4:46

And this is actually pretty rare.

4:49

Only 1.4% of patients who have tennis leg were

4:53

found to have an actual tear, uh, of the plantar tendon.

5:00

Now, in terms of anatomy,

5:01

it's very important to actually understand what is, uh,

5:06

what are the key components of the muscular tendus unit,

5:09

and we kind of split it into two groups.

5:13

We have muscle fibers and we have connective tissue. Um,

5:18

so in this drawing, we see the muscle fibers and then surrounding,

5:23

uh, the muscle fibers, we're gonna have a layer of connective tissue.

5:27

That layer of connective tissue is called endomysium.

5:32

When we have a group of, uh, muscle fibers, uh,

5:36

we call that a muscle fale.

5:39

And muscle fales are gonna be wrapped in permium. So,

5:44

um, permium is also connective tissue, uh,

5:48

that is surrounding a muscle fascicles.

5:51

So we go from endomysium to permium,

5:54

and then we have a collection of muscle fascicles making up a muscular

5:59

tendus unit, um, in this case the rectus femes.

6:03

And you can see that that muscle is surrounded by another layer of,

6:08

uh, connective tissue, uh, that would be the, um,

6:12

epi or asis or fashion.

6:16

So we have these, uh,

6:18

three layers of connective tissue that we see in

6:23

a given SCU tendinous unit,

6:25

and then we have the muscle fi fiber stem cells. So this is very important,

6:30

um, to, um, assess, um, the, uh, uh,

6:35

already stretching injuries because we want to look at all those, uh,

6:39

three places and, um, inform, uh, our, um,

6:44

preferring clinicians about which of those structures are, uh,

6:48

disrupted in terms of biomechanics. Uh,

6:52

we can have muscle injury, um, related to direct trauma. Uh,

6:56

and this is really blunt injury by, by contact, uh,

7:01

where there is a sudden compression of the muscle between

7:06

an external force and the bone. Uh, so we have a clash type,

7:11

um, injury to the, uh,

7:13

muscle unit that typically is going to disrupt muscle fibers,

7:17

and it's gonna give, um,

7:19

in some instances the instances intramuscular hematoma.

7:24

Um,

7:25

this has a better prognosis because it does not often affect the

7:30

connective tissue that we talk about.

7:32

So the connective tissue tends to be respected in, uh,

7:37

direct trauma as opposed to injuries that are, uh,

7:41

due to indirect trauma where there is over stretching of the muscular tendus

7:45

unit. And we see this, for example,

7:48

in the sprinting and also in tennis leg. Um, when,

7:54

um, there is a drop shot, the person is trying to,

7:56

the player is trying to get to that, uh, drop shot sprints towards it.

8:00

And then you have a, uh, overstretching of the castens,

8:06

um, and posterior, uh, superficial musculature in the calf, uh,

8:11

that results in an injury to the, um,

8:15

myat unit and the, uh, intramuscular tendon. So, uh,

8:19

those are, uh, areas that we're going to be, uh,

8:22

looking for alterations in the signal intensity on fluid

8:27

sensitive sequences, and also disruption of the connective tissue,

8:32

um, on anatomical sequences, the same mechanism of trauma.

8:37

Uh, these overstretching, um, may lead to avulsions, where,

8:41

which are traction related injuries at the size of insertions

8:47

of the muscular tend unit. So we could have a tendon evulsion,

8:52

uh, from the origin, um, in the pelvis or in the distal femur,

8:57

or we could have actually a fracture, uh,

9:01

evulsion fracture with a piece of bone detached at the end of the, uh,

9:06

muscular tendus unit.

9:06

But we're concentrating now on already stretching injuries of the, um,

9:11

muscle fibers and connective tissue, uh, for this presentation.

9:16

So, going into the specific, uh, muscles that, uh,

9:20

we are going to be addressing, we have the superficial, uh,

9:24

posterior compartment, um, and we have the gastro muscles. The, uh,

9:29

gastro muscle has a medial head and a ladder head. Um,

9:34

this is located in the most superficial aspect of the calf.

9:39

Um, both heads arise from the distal femur in the, uh,

9:44

posterior super region,

9:47

and the medial head on the media supr fo and the

9:51

laal head in the la laal la foa, along with the plantar,

9:56

um, muscle, as you can see, uh, in these drawings. So laal head,

10:01

plantars muscle, uh,

10:04

the main muscle part is located in the upper half of the calf. And then,

10:09

uh, the, um, muscle fibers are gonna taper into a rather flat,

10:15

uh, posterior, um, tendon, uh, that, uh,

10:19

strap like tendon that is gonna go all the way down to insert

10:24

into the calcaneus, along with the fibers of the sous, uh, to form,

10:29

um, the achilles tendon. Now, as I mentioned before,

10:33

the gastro are, uh,

10:36

the gastro muscle heads are, uh,

10:39

susceptible to a strain injury because they're crossing two joints.

10:43

They're crossing the knee joint as well as the ankle joint,

10:47

and they are superficially located in the posterior, uh,

10:51

compartment of the, of the calf. Uh,

10:54

the main function of the gastro, uh,

10:57

muscle is to planter flex the foot,

11:00

but it also flexes the knee. Um, so you can see due to the attachments, uh,

11:05

in the non-weight bearing, um, status. So in non-weight bearing,

11:10

uh, if you contract your gas trucks, uh, you can flex, uh, then,

11:14

then it can go into flexion as well. In, uh, a standing position, um,

11:19

uh, they are responsible for plantar, uh, flexion, um, of the foot.

11:25

Now these are, uh, consecutive, um,

11:29

these are images obtained in the axial plane, um, across,

11:34

uh, the proxima calf. So we start at the level of the, uh, femoral, uh,

11:38

condos here. Then we have, um, an axial image, uh,

11:43

through the arterial plateau, uh, arterial metsis.

11:46

And here we're going into, um, the, uh, tal shaft, uh,

11:50

the al shaft. Um, so if we look at the, uh, muscle components,

11:55

um, we are gonna identify the medial health gastro, uh,

11:59

muscle that I seen from the medial, uh, supr femur.

12:04

And then it's gonna be positioned the, uh, posterior,

12:09

uh, asis, uh, on the medial aspect of the,

12:14

uh, proximal calf. Uh, we can see that the, both the medial,

12:20

um, and the lateral heads, um, start to approach each other in the,

12:25

um, proximal calf region. And then, uh,

12:28

we are gonna see the convergence of the tendons, uh,

12:32

to form the ous tendon at the, uh,

12:35

proximal my tend junction of, uh, the Achilles. Um,

12:40

so here we have, um, that anatomy. Um,

12:43

I just wanted to highlight the point that the ladder and the medial

12:48

heads have a different tapering, um, when it comes,

12:53

um, in the, uh, region, uh,

12:56

with the medial head being more su more susceptible for

13:01

tears, uh, the, um, uh, myotendinous junction, uh,

13:05

due to the larger caliber of the muscle, uh,

13:10

with respect to the, uh, tendon that is being formed in that location.

13:14

So we often see, um,

13:17

fears of the media health gastro use, uh,

13:20

distal myotendinous junction due to this, um, uh,

13:24

sort of incongruency or discrepancy between the, um,

13:29

muscle bulk, um, and the tendon, uh, acid it tapers, um,

13:34

uh, as the muscle tapers down. So he will have an example of, uh,

13:39

a, an injury, uh, to the discal, uh,

13:43

intra muscle tendon of the immediate health gastro, uh,

13:47

with complete disruption. It's a transfer tear going across the tendon.

13:52

You can see the gap outlined by fluid.

13:55

And then we have a hema, uh, formation, uh,

14:00

proximal, uh, to the side of

14:04

moving on to the plantars. Uh,

14:06

so the plantars is also a component of the superficial posterior compartment

14:12

arises from the lateral supr line, uh,

14:15

in close proximity to the lateral hair gastro. Um, the,

14:20

um, muscle itself is about five to 10 centimeters long,

14:25

and then it, um, ends into a very,

14:28

very thin tendon that is going to close down between the medial

14:33

health algaes. You see, the orientation of the plantar is oblique,

14:38

uh, from the lateral supra canula

14:42

towards the media media calf. So, um, it's gonna come between the,

14:47

uh, media health asen and, uh, the sous,

14:51

which is just beneath the gastro.

14:53

So you can see a very thin tendon that can be tracked all the

14:58

way down into the calcaneus, attaching gas,

15:02

anti medial to Achilles in seven to 10% of, uh,

15:06

patients, um, uh, of, uh, the population.

15:09

There is no plantar muscle. So if you, you know,

15:13

are looking for the plantars and you don't find it, it could be that, um,

15:17

there is, uh, uh, developmental absence, uh, of the,

15:22

uh, muscle in that, in that person. So this, uh,

15:27

patient has a very nice depiction of the plantars muscle.

15:32

And so we can see it arising from the, um, um,

15:36

at the level of the, uh, lateral, uh, condi, uh,

15:40

femoral condi in very close proximity to the lateral health emia.

15:45

And then it shifts towards the midline here at the level of the TL

15:50

metastasis, and you can see it lodge between the al vessels

15:55

and the overlying, um, lateral health castes.

15:59

Then it's moving more towards the medial cycle. We have the medial,

16:04

uh, health gastros, um, muscle, and, um,

16:10

yes to cho the muscle anatomy there. So we have the media health of gastros,

16:15

and then it's located right here, um, between the,

16:20

in the inter muscle airplane between the sous and the, um,

16:25

gastros muscles. So this is why, um,

16:28

we often see fluid collections if the plant is, uh, torn.

16:33

You're gonna see the fluid collection, uh,

16:36

extending the hematoma in between the semiosis, um,

16:41

and the, um, the between the sous, I'm sorry, and the gastro.

16:50

Now also in the superficial posterior compartment, we have the sous, uh, we,

16:54

uh, we're talking about it, and here we have the sous, uh,

16:59

at the level of the meat, uh, leg. So we have the tibia,

17:03

the fibula, and, um,

17:11

the tibia, the ula, and the, um, um, um,

17:17

and the, the, the region of the midcalf.

17:21

And something that is really important about the soleus that, um,

17:25

pertains to overstretching injury is that there are four areas where

17:30

we can see, um, mild, uh, tendus, uh, injury,

17:36

uh, because the soleus has a medial intramuscular fascicle, uh,

17:40

that you can see in this drawing. Uh, learned from, um, Dr.

17:45

Ke and, uh, collaborators, uh, from a very nice, uh,

17:50

presentation at is n a 2019. Um,

17:54

and then you have the medial fascicle, the lateral fascicle,

17:58

and a central septum. So you could have a disruption,

18:03

the myo fascial disruption at the level of theosis.

18:07

This one, my tend is at the level of the central septum.

18:11

And then here, um, medial fascicle and lateral fascicle.

18:15

So there are four spots where we can see overstretching

18:20

injury to the connective tissue of the soleus given, uh,

18:24

this particular anatomy. Now,

18:28

in terms of MRI protocol, um,

18:30

we want to use the smallest field of view that we can, uh,

18:35

for the, um, region of anatomy that, uh, we are assessing. So,

18:40

typically, uh, for the calf, uh, we are imaging, um,

18:45

yes, the affected side, the, uh, unilateral, uh, um, uh,

18:50

lower leg, um, with the, with the, the side of injury. Um,

18:55

were using very thin slices, uh, so anywhere in the range between,

19:00

um, 2.5 to, uh, 4 cent, uh,

19:03

four millimeters in a slight thickness, uh,

19:07

and then adjusting the fill of view so that, uh,

19:11

we have a high re solution. Um, in terms of waiting,

19:15

we want to mix, um, structural, uh,

19:19

anatomic sequences, Corona, T one l, T one, uh, with,

19:24

uh, fluid, uh, sensitive sequences, uh, fat suppressed, uh,

19:29

coronal, t2, Axl, t2, oneal, t2, um,

19:34

in order to highlight the areas of, um, fluid like,

19:38

uh, abnormality at the level of the muscle fibers or,

19:44

uh, involving, uh, the connective tissue. So take home message.

19:48

From here on, uh, we have muscle fibers,

19:52

we have connective tissue,

19:54

we have connective tissue adjacent to the myat, um,

19:59

uh, intramuscular, uh, tendon or myin injunction.

20:03

And we also have, uh, connective, uh, tissue, uh,

20:07

muscle fibers attaching to the fascia. So that would be the peripheral,

20:12

uh, component of the muscular tendon central component,

20:16

the peripheral component, and then the muscle fibers in between,

20:20

in between those layers of connective tissue. In terms of,

20:25

um, um, helping ourselves with finding the abnormality,

20:31

uh, it is very important to, um,

20:33

educate our MR technologies to, uh,

20:37

use vitamin capsule markers so that we know, um,

20:42

the area where the patient is hurting, and we can quickly, you know, address,

20:47

um, uh, that region. So,

20:51

muscle anatomy and tears. Um, this is, um, adapted from,

20:56

um, Marcelo Martinez, uh, recent, uh,

20:59

article published in MRI clinics of North America. Um, and in this,

21:04

um, cross section of the thigh, uh,

21:07

we can see the different areas where we are going, um, assess, um,

21:12

injury in the setting of overstretching trauma.

21:16

So we have thick connective, uh, tissue injuries,

21:20

and by that we are talking about tendon, the,

21:24

the intramuscular tendon. So in the, in the thigh, uh,

21:28

the practice feor, we can see the intramuscular tendon.

21:32

And then we have, uh, signal intensity, uh, in this, uh,

21:37

drawing coming off directly from the tendon.

21:40

So that would be an intra injury. Um, they,

21:46

um, were looking for the presence of gaps, uh,

21:50

within the tendon, uh, and that those gaps could be, uh,

21:54

longitudinal split tears, transp or mixed stairs.

21:59

And we also want to assess for the presence of tendon retraction with

22:04

gaping between the fibers, uh, that give the, um,

22:08

intra tendon a wave, uh, like pattern, uh,

22:13

so intra tend thick connective tissue. Um,

22:17

so that will be, uh, thick connective, uh, tissue injury,

22:22

um, central or peripheral myo connective tissue injury. Um,

22:27

so that would be, uh,

22:28

the muscle fibers that are adjacent to the intramuscular

22:33

tendon and the muscle fibers that adjacent to the peripheral

22:38

fascia or osis. So we have my tend injury when it's,

22:44

uh, located, uh, adjacent to the central, um,

22:47

intramuscular tendon.

22:49

And then we have my fascia injuries that are located in the per

22:55

on periphery of the unit, adjacent to, uh,

22:58

the fascia or osis. And we wanna also, uh, we want to look for,

23:04

um, edema, light changes, um, gaps with fluid,

23:08

um, field, um, spaces. Uh,

23:12

so that would be disruption of the muscle fibers sinta location.

23:16

And we can also see, uh, loss of tension, uh,

23:20

of the fibers adjacent to both the central or the

23:25

peripheral myo connective tissue. Um, and,

23:28

and this is an adaptation to the drawing, I added, um, intra muscle.

23:33

So now we have muscle fiber injury. Uh,

23:36

we're looking for muscle edema. Um, so that would be the, um,

23:41

lowest grade where there is only, um,

23:44

a 30 pattern of edema interspersed between the muscle

23:49

fibers. Um, that can lend, uh, also to blurring, um, in,

23:54

in the, in the area of the, of the trauma of the injury. And then,

23:59

uh, we could also have full thickness disruption of the muscle

24:04

fibers with a measurable, um, uh, gap,

24:09

um,

24:09

between the muscle fibers that is outlined by fluid,

24:14

uh, fluid collection, which should be an intramuscular hematoma. So,

24:19

1, 2, 3. So one intra tenderness,

24:23

two my tends and mal fascial.

24:26

And three intrado would be the three regions that, uh,

24:30

we are assessing, uh, in the setting of over stretching.

24:36

And this, uh, drawing, uh,

24:38

summarizes the central myo connective tissues on the top

24:43

and the peripheral myo connective tissues on the bottom. So we have,

24:48

uh, injury to the intramuscular tendon,

24:51

so that'll be the thick connective tissue.

24:53

And we can see a foot thickness disruption of the intramuscular tendon,

24:58

um, in this patient. Uh,

25:00

muscle fibers adjacent to the, uh,

25:04

intramuscular tendon, but you can see that the, uh,

25:08

tendon itself is preserved. And then myo, connective, uh, tissue,

25:13

uh, abnormality, uh, with extension this, uh,

25:18

of the, uh,

25:19

edema from the intermuscular tendon into, uh, the adjacent,

25:24

uh, muscle fires. Now for the peripheral, uh, component,

25:28

so we have a peripheral, um, uh, uh, aosis here. And,

25:33

uh, we can also see a septum, for example,

25:37

the peripheral septum that we see posteriorly, um, and central, um,

25:42

in the soleus. Um, so we have these, uh, four, um,

25:46

possibilities, uh, injury directly to that thick connective tissue.

25:51

So we see the, uh, disruption of the, uh,

25:54

tendon in the peripheral portion here of the anterior peripheral portion of

25:59

the recor. Um,

26:01

this would be just confined to the muscle fibers, uh, and here,

26:06

uh, the myotic tissue and then myofascial, uh, tissue.

26:11

Uh, those would be, uh, the four options for, uh,

26:15

peripheral myo connective tissue disorder. Um,

26:20

very busy table, but just to bring to your attention, the,

26:25

um, um, Munich, uh, concept, uh, consensus,

26:28

muscle injury classification system, uh, pressure that, uh,

26:33

you are familiar with it. Uh, we have a, uh,

26:37

division of the, um, injuries into indirect muscle injury as,

26:42

uh, we stated on, um, biomechanics earlier, uh, during the, the,

26:47

the talk. And, uh,

26:49

that will be type A and then type B with direct, uh, muscle injury.

26:54

Those are confusions and lacerations,

26:56

which are not the topic of this presentation. Um,

26:59

then with muscle injury, will have functional, um,

27:03

and structural, um, abnormalities, uh, for, um,

27:09

functional abnormalities, uh, we have,

27:12

we split them into overextension fat fatigue use, or, uh, delay, uh,

27:17

onset muscle soreness. And there is also, um,

27:22

the second type would be neuro muscle spine related or muscle

27:27

related. So that would be the innovation change. And then we come into,

27:32

uh, the injuries that we are discussing today, which are structural injuries,

27:37

uh, with partial muscle tear. Um, that will be, uh,

27:41

type three, uh, which can be a minor or B moderate.

27:46

And four, when there is a, uh, total or ural tear, uh,

27:51

of the muscle, um, with, uh, or tending of Sion. Uh,

27:55

so that is really very broad. Um, um,

28:00

classification of muscle injuries using the Munich, uh,

28:04

consensus muscle injury, uh, classification system. Then we,

28:08

we have the British, um, uh, athletics muscle injury classification,

28:13

uh, which, uh, is here on the, uh, right side of this table.

28:18

Um, and, and basically it, what it does is that it uses, uh, what we discuss.

28:24

We have myofascial tear and muscu tendon,

28:28

tendon junction tiers, uh, for one A and one B. Um,

28:32

the main thing here is that we have less than 5% of the cranial,

28:37

uh, colon length of the muscle involved, and less of the less of, uh,

28:42

10% of the muscle belly involved. Um, for, um,

28:46

stage one injuries, grade one injuries,

28:53

grade two be more than 10%, but then 50%,

28:57

and then the extension in dimension be five to 15. And again,

29:02

we are assessing, um, here on, uh, eight, um, uh,

29:06

the myofascial B would be my attend there. And C,

29:10

here we come. Um, the intra stair, uh, comes into you.

29:14

So we have the three main categories, um,

29:18

my injunction,

29:21

myofascial and intra stairs.

29:24

And here we have a moderate, uh, um, injury, uh,

29:28

stage where we have more involvement of the, of the fibers,

29:33

uh, but yet less than 50%. And then when we move on to,

29:38

uh, grade three category, we have more than 50% involvement of the,

29:43

um, muscle, um, fibers. And we have greater than 50, uh, cent,

29:49

15 centimeter, uh, length,

29:52

length involvement in mentioned again, um,

29:57

uh, including here, uh, the, uh, intra tear,

30:02

uh, the myo, uh, junction tear, and the myofascial tear.

30:06

So those three areas. And, um, grade four would be a complete,

30:12

um, muscle, uh, uh,

30:13

rupture with complete discontinuity and retraction of the

30:18

proximal and distal stones. Now,

30:21

just a brush on ultrasound, and I'd like to thank Dr.

30:25

Catherine Gotman from Costa Rica, who let me, um,

30:30

some examples. Um, I do not do much ultrasound,

30:33

so I don't have my own cases.

30:35

I will show you some of my own cases on ultrasound and just see the difference.

30:39

So, um, so he will have a normal muscle, um,

30:43

composition where the muscle fascicles are the hypo coic,

30:48

um, structures, uh, running longitudinally, um, uh, in these,

30:53

um, ultra sonographic image.

30:57

And we have the connective tissue that we've been talking about, um, uh,

31:02

which, uh, is hyper. So we have, uh,

31:05

this pattern of hyper coic muscle fibers and hyper,

31:11

uh, connective tissue, um, in, uh, normal muscle. We,

31:15

when we lost that, uh, fbri pattern, uh,

31:19

we are in the real arm of, uh, grade one, um, muscle injury.

31:24

So that'll be what we see as a fairly pattern of, um, muscle,

31:29

uh, edema on mri. And, uh,

31:32

stating that is less than, uh, 5% of the, um, muscle,

31:37

5% involved. On grade two. We have data, uh,

31:42

fibrillate disruption. So we start seeing, uh, fluid collections, uh,

31:46

within the area of the injury. Um, here on this, um,

31:51

ultrasound, we see this, uh, antico, uh, area, um,

31:56

in between the fibers. Uh, you can notice also that there is loss of that, uh,

32:01

normal fbri pattern of, um, uh, immunogenicity.

32:06

Um, so we have a grade two, uh, clear, um,

32:09

between 10 to 50%, um, in this patient.

32:14

And then, uh, we come to a complete, um, muscle tear. We see,

32:19

uh, dangling here of the, uh, uh,

32:22

stump approximately and, uh, fluid collection, um,

32:27

interpose, uh, between the proximal and distal. Um, um,

32:32

so that's a complete rupture with a fluid field gap.

32:37

And that would be a grade three injury. Now, um,

32:41

this is a classification that is becoming more and more, uh,

32:46

known, uh, among, um, not only, uh,

32:50

musculoskeletal radiologist, but also as force, uh, medicine, uh,

32:55

specialist, and is, uh, the Barcelona Andar classification.

33:00

Um, it's kind of a coding mechanism so that,

33:05

um, we can have an agreement on, um, what we are,

33:10

uh, describing. Um, uh,

33:13

and the aim is really the goal is to increase that

33:18

understanding and correlation of findings. Uh,

33:23

so what the classification does is, uh, it goes over a mechanism of injury.

33:28

So that would be the first, uh, letter in the code, uh,

33:32

for a given injury is, um,

33:35

if the mechanism of trauma was indirect, indirect or direct.

33:39

So if it was indirect, which is, um, uh, the type of injuries that, uh,

33:43

we are addressing today, you'll have an eye at the beginning of, uh, that code.

33:49

Uh, then we have the location of the injury.

33:53

So by muscle belly reference, uh,

33:55

we could describe it in the proximal middle on distal area.

34:00

So in this example here, uh, is the distal area is involved,

34:05

so that would be d and then we have by tender origin reference,

34:10

so is, is it the proximal or the distal tendon that is involved?

34:14

So here is the distal tendon, um, the proximal, uh,

34:19

tendon that is involved.

34:20

So that will be p and then we go into the grading of severity.

34:25

Um, and zero is, uh, if there is no, uh, signal abnormality on,

34:30

on the mri one, if you have only edema, two,

34:35

if there is edema with minor muscle fiber, uh, architectural destruction,

34:39

or a minor intermuscular hemorrhage, but no, no,

34:44

no gap between the fibers.

34:46

And three is when you have a gap that is a fluid field area that you can

34:51

measure with, uh,

34:52

partial retraction plus or minus intramuscular hemorrhage.

34:57

So we see the difference, uh, here on the, um, um, tendon, uh,

35:02

in, in the intramuscular tendon injury where there is a gap, uh,

35:06

outlined by fluid. Uh, the next, uh,

35:10

letter in the code is R, uh, which, um, addresses three injuries.

35:14

So zero B for a first episode,

35:18

one for first re injury, and, uh, two for second reju injury.

35:23

And then, uh, we'll have this r uh, low lower case R,

35:28

uh, which, um, adds, uh,

35:30

the presence or not of disruption or retraction, uh,

35:34

or loss of tension, uh, in, in the gap. Uh, so we can put that,

35:39

um, adjacent to the, the grade of the injury. So this was grade three, uh,

35:44

with an eye, uh, lowercase R because there is retraction, um,

35:49

of the tender. All right,

35:53

so now these are, uh, cases, uh, from, um,

35:58

my teaching file, and I spent some time trying, uh, to code them.

36:03

I'm as confessed, I didn't run this by the Barcelona group, so, uh,

36:07

hopefully I'm doing this right. Uh, we have, uh,

36:10

here an injury to the media health gastro. Um,

36:15

the pattern is, um, of, um, muscle, uh,

36:19

of the muscle fibers adjacent, uh,

36:22

to the peripheral aosis. So, uh, it is a,

36:26

a myofascial type of injury. We don't see any, uh, fluid collection.

36:32

Um, so, uh, we are calling this an indirect injury.

36:36

It was over stretching. Um,

36:39

it's located in the middle portion of the muscle. So a,

36:44

uh, the tendon, uh, affected is the proximal tendon,

36:48

and grade one is just the presence of anema. Uh, so, um, and then,

36:53

uh, this was, um, this patient had actually a prior injury,

36:58

and that's something that we need to look for. Uh, you can see here, uh,

37:02

a thicken, uh, intramuscular tendon. Uh, this patient has had, uh,

37:07

a prior over stretching, uh, myat tend, uh, tear,

37:12

uh, that is completely healed, but it's, it's left behind, uh, the,

37:16

the thickening. And so, uh, this would be an R one, uh, due to,

37:21

uh, a first three injury, uh, in this patient.

37:26

This is another, uh, uh, patient, 35 year old tennis player. Uh,

37:31

she sustained the injury while on court, uh,

37:34

one week prior to the mri. And here we have, uh,

37:38

greater involvement, uh, of the, uh, connective tissue. Um,

37:43

and also there is, uh, muscle fiber edema.

37:46

So we see the muscle fiber edema pattern, but in addition to that,

37:50

we have fluid interpose between the sous and the

37:55

gastro ous muscle and the medial health of gastro use. Here, uh,

38:00

we see the central tendon, and there is a partial thickness trans transfer,

38:05

uh, here of the central tendon, uh, that is likely, you know,

38:09

giving the fluid, uh, collection, um, associated in this patient.

38:15

And then just to compare, we can see the lateral head of gastro, uh,

38:20

in this location. Uh, and this is the grade one, um,

38:23

type of injury with only, uh, edema of the muscle fibers.

38:28

We have some fluid that is going, um, along the, uh, upper neurosis,

38:33

so that is lamina collection of fluid, um, peripherally.

38:37

And we have also, uh, fluid collection, um,

38:41

between the soleus and the, um, media health emia.

38:46

Uh, because this injury was already one we call, were starting to see,

38:51

uh, the formation of a scar of the Carlos, early Carlos,

38:56

um, at the level of the torn, um, central tendon. Uh,

39:01

so I classified the injury as a grade three. Um,

39:05

it had retraction of the myat, um, um, uh,

39:10

of the central tendon. I'll show you that in the, um, Corona images,

39:15

um, in a sec. And then, uh, this was, um,

39:19

this patient also had a history of prior, um, my, um,

39:24

injuries. So, uh, it was also an aase, um, R one,

39:29

so he will have, uh,

39:31

that central tendon in the medial health gastro anemia. Uh,

39:36

we see the, uh, loss of tension and the tendon is looking,

39:41

uh, has this wave, uh, like, uh, deformity.

39:46

And then, um, interestingly enough, in this patient,

39:49

we had a tear of the plantar, which was, um, uh, you can see a plantar,

39:54

uh, muscle is retracted here. And I'd like to show you on the,

39:59

uh, consecutive axial images, you can see, uh,

40:03

the interposition that the plantar stand on there. Um,

40:08

I'm going to try to do this a little slower. Okay, there we go.

40:14

So we can see, um, that the plantar is right there, um,

40:19

is retracted to completely tore off the plantars.

40:22

And then lower down, uh, we can see, uh,

40:26

the findings that we were discussing before the, uh,

40:29

interposition of fluid between the soleus and the gastro anemia.

40:34

And as we come down to the, uh, health gastro, um,

40:38

central tendon, that is, uh, complete disruption of that tendon.

40:43

So that would be a grade three injury. Um, on the lateral, uh,

40:48

health gastro side, we see the, uh,

40:51

signal abnormality in the muscle adjacent to the aosis. Uh,

40:55

so we are calling that grade one in the, uh, lateral health gastro.

41:00

Um, so a combination of, of injuries here, grade four for the, uh,

41:05

plantar grade three for the health as,

41:09

and grade one for the LA health. As,

41:15

um, this is, um, our patients, um, uh, ultrasound. So we can see,

41:20

uh, the fluid interposition, uh,

41:23

between the media health astronomist and the soles. And I'd like to, uh,

41:27

also show you, uh, the, um, video clip. Um, the,

41:32

uh, scan is being done from, uh, lateral to medial. Uh,

41:37

so we can see, um, that, um,

41:39

fluid collection coming into view as we go into the, uh,

41:43

media health pastor use, um, with the interposition of fluid. Um, just,

41:49

um, and the, uh, the disrupted muscle fires.

41:54

Uh, this is a different patient, uh, 33, um, year old, uh, woman.

41:59

Uh, she also had an injury while playing tennis.

42:03

And here we have a, a nice, um, uh, depiction of, uh,

42:08

tier of the distal myo, uh,

42:12

junction of the media health emia, uh,

42:15

that we discuss how the, uh, larger, uh,

42:19

muscle bulk and the tapering of the, uh, muscle into a smaller, uh,

42:24

tendon makes, uh, this area very susceptible, uh,

42:28

to overstretching injury. Uh,

42:31

we see the retraction of the myat tend junction here it is the axial

42:35

plane going through that retracted, uh, tendon, um,

42:40

outlined by the fluid collection that is, uh, common, uh,

42:44

in between the, uh, solu sous and the media health emia. And,

42:48

and then in this location is completely surrounding the disrupted. Um,

42:53

this, uh, myo junction.

42:55

This patient also had a tear of the, uh,

42:59

myotendinous junction of the lateral health emia. So this is a step up, uh,

43:04

from what we saw, uh, in the prior patient. Um, we can see the,

43:09

uh, here, this is the Laal Health Paone, my tend obstruction, again,

43:13

loss of tension, um, and way form, um, uh,

43:18

configuration of the, uh, tendon of the Laal Health Paone.

43:22

So full thickness, uh, here, uh, we have also a,

43:27

a smaller, uh, fullness tier of these, um, um, uh,

43:32

lateral health gastro, um, mythe, uh, junction.

43:37

And this patient, um,

43:40

I mentioned that we should do unilateral images, but,

43:45

um, we did bilateral calves in this patient. Um,

43:49

and you can see I just, um, wanted to, um,

43:53

share it with you because, uh, you can see the normal, uh,

43:57

right calf against the abnormal left calf. Um, and again,

44:01

assess, uh,

44:02

those areas of the dys mys junction here of Famili Health ous

44:07

with the, uh, contra injur site, uh,

44:10

you see that very typical pattern of, uh, distribution of the fluid,

44:16

um, in that location. And then more proximally, um, in the,

44:21

um, lateral health astronomies, we can see also, uh,

44:25

a theater of the Central 10. So return to play.

44:30

Uh, this is, um, really, really important, uh, to discuss, uh,

44:35

any time that, um, we review a topic of, um, my attendings,

44:39

uh, tears, muscular attendings, uh, injuries, uh, so, um,

44:44

return to place this time lapse between the traumatic and, uh,

44:48

to the moment that the players successfully completes specific sports

44:53

activity without restriction or pain. Um,

44:56

and when it comes to, um, muscle injuries, uh,

45:00

we have, um, the grading here, uh,

45:04

as well as the MR findings and then the layoff time.

45:08

So as the grade increases, you can see the increased, um,

45:12

number of days, um, for return to play. Um, the, um,

45:17

longer return to play, um,

45:19

is always seen when there is injury to the proximal or central tendon

45:25

when there is injury to the connective tissue, um,

45:28

particularly the, um, um, uh, tendon, the central,

45:33

uh, connective tissue. And then, uh,

45:36

when tears are larger than 50%, which is grade three, and, uh,

45:41

when there are complete tears. So those are the, uh, four, um,

45:46

um, items, uh,

45:47

to keep in mind where we are assessing these patients is the proximal or central

45:52

tendon involved is the injury to the connective tissue. And, you know,

45:57

what is the grading of the, uh, connective tissue injury,

46:01

whether central or per. And then, uh,

46:05

if the tear is larger than 50% of the, of the unit, um,

46:10

muscle edema alone, um,

46:13

does correlate directly with return to prey and may persist for as up

46:18

to six months. So seeing muscle, uh, signal changes,

46:22

changes in the, uh, muscle fibers is not, uh,

46:26

directly related with return to play.

46:33

And then, um, just to briefly, uh, finish, uh, review the healing and, uh,

46:38

finish the presentation, uh, we have, we are looking for signal changes, um,

46:43

that should resolve over time. So we want to see recovery of muscle edema,

46:47

recovery of the peritus, um, signal, uh, um, uh, changes,

46:53

progression of the tendon hyper signal.

46:56

And then the morphological changes that we're looking for are gap filling,

47:01

uh, the formation of soft and heart call. And then, um,

47:06

see if there is any, uh, tendon tension loss.

47:09

We want to see that the tendon, um, gets reestablished and, uh,

47:14

recovers, um,

47:15

that loss of tension and recovery of the Norma morphology.

47:20

Um, so, um,

47:23

knowing that the tendon campus is taken or corrugated by a scar as, uh,

47:27

we show in, in one of our tennis players, uh,

47:30

who had sustained a prior injury to the media health gas, stroke,

47:33

and had residual, uh, thickening of the tendon. So here we have,

47:38

uh, a progression of, uh, findings in the patient who had, uh,

47:42

an injury to the sous. Uh, so, um,

47:45

we have here involvement of the, um, la septum,

47:50

and we can see the initial phase, uh, with, um,

47:53

anema of the muscle fibers, discontinuity of the tendon. Um,

47:58

then we have, this would be a soft callous formation.

48:01

You can see on T1 weighted images, uh,

48:04

there is intermediate signal intensity informing us that the scar,

48:08

the granulation tissue is stealing much more. And,

48:12

and there is T2 bright signal also within the callus.

48:16

And then when we get to eight weeks, we see, uh, more, um, uh,

48:21

homogeneously low signal intensity at the side of healing. Um,

48:25

so this is progressing well, unfortunately, a patient now, uh, develop,

48:31

uh, a muscle tear on the, uh, medial, uh, side of the,

48:35

of the gastro limbia. Um, and so we often see, um, this,

48:40

this type of pattern where while one side heals, you know,

48:44

the other starts to, um, have, uh, signal changes.

48:50

So if to conclude, con conclude a few pairs, uh,

48:53

muscle injuries can be inter tend myat tends or myofascial,

48:58

um, I think I hammered that, uh, really hard during the presentations.

49:03

So now we, uh, choose, uh, you know, use, uh,

49:07

that topographic classification, check the, uh,

49:11

central tendon check the my junction, and check the, uh,

49:16

junction of the muscle fibers with theosis. Um,

49:21

intra tears have a longer recovery time. So, uh,

49:25

that is for, to inform return, return to play,

49:28

and those are bad injuries to have. Uh,

49:31

ultrasound is less sensitive that MRI for low grade muscle injuries because,

49:36

um, I mean, it's operator dependent.

49:39

For a person like me who has very little ultrasound, you know,

49:43

it may be difficult to see, uh, the, uh, loss of the fibrillar pattern, uh,

49:48

in, um, um, lower grade injuries and then considered,

49:53

uh, using mri, uh,

49:55

in high performance athletes when there is potential for a, uh,

50:00

surgical indication, uh, particularly if, uh,

50:03

we are concerned that there is compartment syndrome, for instance, uh,

50:06

which is something that, um, has been reported in,

50:10

in tennis leg and differential diagnosis. Um,

50:14

and when we are assessing deep muscle groups, um, you know, ultrasound,

50:19

you know, may have, uh, um,

50:22

there may be more difficulty of assessing, uh,

50:25

muscle injury if the muscle is deeply located, um, in the,

50:30

um, in the area. So with that, I am done.

50:34

So we have a few, um,

50:37

minutes left for questions. Um,

50:42

all right, so the first question, um, uh,

50:45

is by an anonymous Satan. So it's, it, uh, the question says,

50:50

does sous muscle have a she fascia with the gastro

50:55

posteriorly? Uh,

50:57

so there is actually an inter fascia plane between the sous and the gastro.

51:02

Um, there is no she fascia. We have the central, uh,

51:07

septum in the sous, and then you can see the flaring of the osis.

51:12

Um, and that's distinct, uh, from the overlying gastro.

51:17

Um, next question is, uh, by Dr. Solomon. Um,

51:22

he says,

51:23

what advantage do you see using T2 fat over stair?

51:28

Are you concerned about incomplete fast saturation?

51:30

So are you be concerned about incomplete fast saturation depending on the

51:35

magnet that is being used, um,

51:38

to produce the images and also the, uh, the coils?

51:43

Uh, so if you have, uh, a state of the art coils, phase array coils,

51:49

um, you should be fine, uh, using, um, uh,

51:53

fat suppress two, I prefer, uh,

51:56

to use Fat suppress two because we have greater, um, spatial,

52:02

uh, uh, resolution that is better.

52:05

Sn r you can better distinct, uh, anatomical down there is,

52:09

and we've seen how, um, we're looking for, um, these, um,

52:14

subtle findings. Um, uh,

52:16

so I think that that's the advantage of fat suppression already stay.

52:21

Uh, of course, if in the middle of the study, um,

52:26

the technology tells you that, you know,

52:28

they're having issues with the fat suppress, uh, selective fat suppression,

52:33

definitely, you know, um, just convert the, the, uh,

52:37

the fluid sensitive sequences to, to a stair, um, because, um,

52:42

you'd prefer to have, uh, homogeneous fat starting, um, over, you know,

52:47

having to, uh, you know, a little bit, uh, less, um, uh,

52:51

anatomical resolution as, uh, with the stair. Next question is,

52:57

uh, is there any imagine showing difference helping identified

53:02

and or showing, uh,

53:04

difference in muscle injury and D V T in an MRI

53:08

image? So, thero thrombosis is, um,

53:13

something that, um, I'm glad that Dr.

53:16

Mustafa brought it up because, um,

53:20

it's been reported in tennis Slack, um, I believe, I don't remember,

53:24

but the paper, but, uh, uh, Dr. Resnick's group, um,

53:29

I'm trying to use my memory cells right now.

53:32

I think it was 17% in that cohort of 174

53:36

patients had, uh, D V T. Um,

53:41

so the pattern of, um,

53:44

edema that we see in D V T radiates from the vein that is

53:49

occluded or, uh, par, partially occluded or completely occluded.

53:54

So in those, uh, that's, that would be the way to distinguish the edema pattern.

53:59

Where is it radiating from? Is it emanating from,

54:02

from inside the muscle or, uh, is it maning from the intermuscular,

54:08

uh, planes in the calf, uh, adjacent to the, uh,

54:13

uh, neurovascular bundle? Uh,

54:17

next question is that should be per particular or parallel, uh,

54:21

in muscle to quality here. So the gap, um, the,

54:26

as we saw with the Barcelona, uh, classification,

54:31

um, the peers can be transfers or longitudinal,

54:36

so you can have, you know, different arrangement, uh, of,

54:41

in the disruption of the, of the tendon. So it can be,

54:44

it can go transfers, or it could, it could be, uh, a split here.

54:50

Um, I don't know if that answers the question. Um,

54:53

so it could be perpendicular or transfers, um, right.

54:58

Um, with severe exercise indu,

55:01

muscle cramping with pro muscle soreness over a few days be

55:05

considered an injury. So it is classified in the Munich, um,

55:10

uh, muscle injury classification.

55:13

We have a muscle soreness is classified as, uh,

55:17

grade one B if I don't remember that. Um, uh,

55:22

so it is, um, you know, uh, it, it is considered an injury.

55:29

Um, it's the one sensitive to muscle injury. So,

55:33

so the one, um, and I show the, the, um,

55:38

cases with T1 and fluid sensitive sequence just to, um,

55:43

show how you can, uh, uh, look for this, the,

55:48

um, connective tissue anatomy on t1. Uh,

55:53

if the person is very, um, and this happen in athletes,

55:57

if you have hypertrophic, um, hypertrophy of the,

56:02

of the muscle fibers, it can make very difficult to see, you know,

56:06

find connective, uh, tissue anatomy and morphology.

56:11

So, um,

56:12

that's why I wanted to show you the bilateral tasks on

56:17

fluid sensitive sequence,

56:18

because you still can see a lot of the connective tissue anatomy on,

56:23

uh, fluid sensitive on, uh, fat suppress situated images.

56:29

Okay. I just want to emphasize the importance of ultrasound in particularly,

56:34

uh, in particular case of hematoma fluid, uh, function.

56:38

That's really important for healing. That's, that's right. Yeah, that I,

56:42

that's absolutely correct.

56:44

So if there is a hematoma and you are doing ultrasound, uh,

56:49

it would be very easy to just drain the hematoma to promote healing.

56:57

Okay. Please explain again,

56:59

myo connective and take connective tissue in your take. Thick.

57:02

The thick connective tissue is the tendon. Um,

57:06

and then the myo connective, um,

57:09

central and peripheral, uh, tissue is the, uh, is what,

57:14

what is called the myos junction. So it is muscle fibers plus,

57:19

uh, the, uh, the, the, the inter the, the, the entertaining,

57:25

um, um, uh, tendon fiber.

57:29

So thick is just inside the tendon. Uh,

57:33

central myo connective is at the junction,

57:36

and then peripheral myo connective my,

57:42

all right. Okay. Um,

57:45

I'm gonna take two more questions and that's it. We running out of time.

57:49

So any role for CTS scan?

57:53

The role for CT cannot be, uh,

57:55

if there is concern for myositis significance

58:00

developing, you know, following, uh, one of these injuries, um,

58:05

that would be one. Um, I think that even if they, uh,

58:10

is concerned for associated, um, osteo, uh, injury, uh,

58:15

which looking for these cases, uh,

58:19

I did a search for calf mri, you know, over a period of time,

58:23

and I have to say there were 90 cases of t

58:28

medial stress syndrome and um, much fewer cases of,

58:33

uh, tennis leg. Uh, I believe it is because, um,

58:38

with, uh, a stress injury to bone, you are going to have,

58:43

um, you rely a lot on, on, on,

58:47

on MRI to highlight, uh, radiographically or cold,

58:51

uh, injuries. Uh, while with the muscle, uh, injuries,

58:56

you can just, you know, go ahead and do, um, you know,

58:59

conservative treatment if there is not too much chemosis or

59:04

swelling. And then, you know, if it is a high performance athlete,

59:08

of course you just want to, uh, do the mri. Um,

59:12

alright. Can injury happen in accessory muscles? Accessory muscles?

59:16

And this is the last question. Accessory muscles tend to be, um,

59:21

you know, smaller. Um, and so,

59:24

so they don't have the characteristic of crossing across, uh, two joints,

59:30

um, and be superficial, but, um, yeah, I mean, I mean,

59:34

injury can happen to any muscle, but it over stretching, um,

59:39

mild, um, myo, uh,

59:40

SCU tends injury will be very unlikely to happen in a smaller

59:45

se muscle. All right.

59:48

So I think we come to the end of the presentation.

59:52

I thank you all for your active participation. I love to, um,

59:57

uh, listen to you through the chat, um, uh, box.

60:01

And I hope that this, uh, was useful, uh, for all of you.

60:06

And thank you m i and life for the English station.

60:08

Thank you Dr. Ben Cardina.

60:10

Thank you so much for that awesome lecture and answering all those questions.

60:13

And for everybody else participating in the noom conference, we appreciate it.

60:18

You can access the recording of today's conference in all our previous new

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conferences by creating a free m r I online account.

60:25

Be sure to join us next week on Thursday, June 15th at 12:00 PM Eastern.

60:29

We're featuring Dr.

60:30

Aaron Gomez for a lecture on complex and high risk OB pathology,

60:35

a multimodal case review. You can register for this free lecture@mrionline.com.

60:40

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60:45

Thanks again, and have a great day.