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What is the primary investigation ?

35ys old jogger with achillodynia,All previous tests were negative

Rupture of plantar fascia30ys female: after pilgrimage from Leon to Santiago de Compostella

Stress fracture resulting fromexcessive jogging

Associated with TOS 2: peroneal tendovaginitis

Low bone density

vascular malformationen

Foreign body22ys male jogger with lateral knee pain:DDx: Runner‘s knee (ITBF syndrome

fluid

Soccer players

M de Jonge, Radiologe, 2002

Fibromatosis

Soccer player: rigid mass in hamstrings:DDx: myositis ossificans

discriminate a hamstring tendon avulsion frommusculotendinous strain and helps identify whichpatients necessitate surgical management.

Koulouris G, ConnellD, Skel Radiol

Hyperpronation syndrome

Patella partita vs. Patellar fracture

L. Johanna, 13 J., female:

Superolateral patellar defect

Stressfracture C 2

21-ys female dancer with upper cervical syndrome

Traumatic contusion of myelon

57ys female, fall from horse, tretraplegic

Runner‘s knee

Christian DopplerChristian DopplerChristian Doppler

“The best research results are yieldedif not only the investigator is satisfiedabout his work but if also a significantbenefit for humanity is created."

Ch. Doppler

born 1803 in Salzburgprofessor of physics in Prague and Viennadied 1853 in Venice

......

EU-referral criteriahttp://europa.eu.int/comm/environment/radprot/118/118.htm

continuous discussion needed to keep them livingsports overuse and trauma should be mentioned

Indication

Investigation

Interpretation

IMAGING IN SPORTS MEDICINE – AN UPDATE

Diagnosis

Specified referral – specified diagnosis

Trends towards High resolution3D displaydocumentation of functioncomputer-assistedtreatment planningopen role of NIRF

Referral: (sports related) overuse syndromeFoot

Tibialis-anterior-Tendovaginitis

Tibialis posterior-Tendinosis

Dancer‘s heel

Peroneal-split-syndrome

Sesamoiditis

Achilles: Tendinosis

Haglund‘s heel

Plantar fasciitis

(Snowboarder‘s foot)

Bursitis

Plantaris tendon rupture

Morton-Neuroma

Jogger‘s foot

High resolution US vs. MRITendinosis:MRT > US in zwei Fällen

Ulreich N, Huber W et al., 2002

US Panoramic (extended view) imagingTissue harmonic imagingSofka CM, Adler RS. Sonographic evaluationof shoulder arthroplasty. AJR 03

US contrast media with small bubble size and low mechanicalindex

US-guided pain management

Musculoskeletal US

Power-Doppler US

Ruptured Achilles tendon

Ohberg L, Alfredson H. US guided sclerosing of neovessels in tendinosis.ESSR 03

5 – 12 MHz

Zanetti M et al. Achilles Tendons: Clinical Relevanceof Neovascularization Diagnosed withPower Doppler USRadiology 2003

Kinematic „motion“ MRI

21-ys beachvolleybal lplayer withfemoropatellar pain syndrome

To document malalignment

K. Friedrich, doctorial thesis 2002Wiener Med Wochenschr 2002, Suppl.

16-row MD-CTfrom 3D-Reformation to 3 D Volume rendering

Hill-Sachs-lesion

Image interpretation based on 3D

Indication

Investigation

Interpretation

IMAGING IN SPORTS MEDICINE – AN UPDATE

Diagnosis

Specified referral – specified diagnosis

The higher the resolution the better

Patterns of overuse and injury

Tendon overuse syndrome (TOS)

Rosenberg Z et al., Radiology 1988

1 - Painful functional impairment2 - Inflammation of peritendineal tissue:tendovaginitis, bursitis, peritendinitis3 - Degenerative tendon disease:3 forms: tendinosis (former „tendinitis“)

fibroostosis, juvenile apophysitiscompression syndrome (impingement)

4 – Rupture:direct force (rare) or indirect force on tendinosis (common)

Kainberger et al., Wien Med Wochenschr, 2001

TOS 3: Tendinosis (grade 3)

Achillodynia

NODULAR TENDINITIS

Originating frominternal peritendinea

Van Holsbeeck, 1992

TOS 3: Tendinosis, spur, hyperpronation

Achillodynia

Tension of tendon with elongation:< 4 % : fully reversibel4 – 8 % : disruption of cross-link structures

Repair phase with high vulnerabilityi. e. destruction and reparation dysbalanced

> 8 % : frank ruptureO’Brien M. Clin Sports Med 1992; 11:505–520, Towers et al, 2003

Tendon rupture: due to microtrauma and/or microinfarction

Tendon tissue of mice in a hamster mill:Sedentary behavior: normalContinuous activity: slight abnormalitiesDyscontinuous activity: focal necrosis Wernig, 1992

Tibialis posterior tendon and flatfoot deformity and heel valgus

Tpt is part of „coxa pedis“ functional unitAssociated findings: Malalignment of talus (plantar flexion)

Insufficiency of Spring-Ligament, Sinus tarsi syndrome

Collapse of longitudinal arch

Traction injury of posterior tibial nerve

Tarsal tunnel syndrome

The risk of tendon rupture

US Doppler seems to be promising in differentiating stages of dysbalance[Richards et al. Clin Radiol 2001, Ulreich and Kainberger, 2004 in press].

THE CRITICAL ZONEAnatomic site specifically prone to trauma, vascular necrosis,or both

THE VULNERABLE PHASEtime during high dysbalance between destructive and reparative forces: active form due to sports: apophysitis: adolescents

tendinosis: 40 ys males (athletes earlier)passive form due to muscle insufficiency: middle-aged women

TOS: the radiologist‘s role

modif. after Kannus et al., Radiologe 2002 Oct

Malalignment: Tendinosis (TOS)

femoral anteversion,varus, valgus.foot deformitieslocal variants: systemic diseasehypomochlia, rheumatism,steroidsaccessory muscles fluoroquinolonemuscular imbalance psychosomaticage, gender, reactionsweight, height

Intrinsic factorsVariants diseases

Extrinsic factors

Training errors, doping

clothingimproper shoes

environmenthard/soft soil

to asess severity of disease and potential risk of rupture

Golfer‘s arm

Radiological conceptsTendinosis: a pre-stage of ruptureNehrer S, Breitenseher M, Brodner W, Kainberger F, Fellinger EJ, Engel A, Imhof F. Arch Orthop Trauma Surg. 1997;116hyaline cartilage is part of osteochondral unitImhof H, Breitenseher M, Kainberger F, Trattnig S. Degenerative joint disease: cartilage or vascular disease? Skeletal Radiol. 1997Osteonecrosis: etiology multifactorialEngel, Scand J Orthop1992Menisceal rupture is often degenerativeMink, Deutsch et al., Radiology 1987

IMAGING IN SPORTS MEDICINE – AN UPDATE

Indication

Investigation

Diagnosis Olympic onsite service

Interpretation

Specified referral – specified diagnosis

The higher the resolution the better

Patterns of overuse and injury