Think “pump bump” and you may come up with the correct answer in this adult male with heel pain

You are shown six images of a 58-year-old male athlete with persistent heel pain for two years. The case seems simple, but have a look at the images, and see how many conditions or abnormalities you can find.

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

 

With arrows now highlighting the key areas (images 7 to 12), see if you can answer the following questions.

Q1 – On images 7, 8 and 9, what does the pink arrow point to? If you think “pump bump”, you might come up with the right answer.

Q2 – The blue arrow on image 9 points to what?

Q3 – The green arrows on images 10, 11 and 12 point to what?

Q4 – The yellow arrow points to an abnormality in the calcaneus itself on images 10, 11 and 12. How would you describe this abnormality?

Q5 – A series of orange arrows are seen on image 12. How would you describe this abnormality?

 

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

Sagittal T1W TSE

Sagittal T2W TSE

Sagittal PD SPIR

 

A1 – A Haglund deformity, also known as a “pump-bump” in honor of high-heel wearers, is an exacerbating morphologic problem in this patient.

A2 – Delamination and/or separation of the footprint of the Achilles. These deeper fibers tend to have more of a soleal than a gastrocnemius contribution.

A3 – Supracalcaneal bursitis. But, there is more. A focal “spot” of hypointensity is seen on image 11. The findings represent a coalescent area of calcium pyrophosphate deposition disease (CPPD).

A4 – An erosion from traction enthesopathy. Erosions in the heel and plantar fascia may sometimes conjure up visions of seronegative spondyloarthropathies. However, in this case, the abnormality was mechanical due to exercise, overuse, and alteration in bone morphology. Erosion represents the inflammatory sequela of mechanical irritation and CPPD.

A5 – Any of the below would do:

  • Undersurface delamination as a partial thickness tear
  • 50% depth partial thickness undersurface tear (concealed from the superficial surface) associated with a hypertrophied tendon
  • Moderate depth fraying and delamination in a hypertrophic tendon

A cocktail of these adjectives would do just fine.

 

Diagnosis:

1 – Delamination partial thickness tear
2 – Hypertrophic tendinopathy
3 – Bursitis
4 – Calcium Pyrophosphate Deposition (CPPD)
5 – “Pump-bump” or Haglund deformity

 

For more case review, check out MRI Online.

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As a rule of thumb, just remember… the higher the slope, the further the fall

Chloe Kim, Red Gerard, and soon, Mikaela Shiffrin are representing the USA well in Pyeongchang, South Korea. So, let’s have a look at a winter sports case!

This 17-year-old female fell during a winter-related sporting accident, and now presents with right thumb pain. You are shown three finger coil images. Image 1 uses a coronal 3D data set.

Q1 – When falling, the patient attempted to brace herself using the sporting equipment in hand. What do you think the sport was?

Q2 – What is the name of the entity?

Q3 – What is the abnormality?

Q4 (BONUS QUESTION) – Why does a Stener lesion occur more frequently on the medial than the lateral side of the thumb?

Coronal T2 GE 3D

Coronal T1 FSE

Coronal STIR

 

A1 – Skiing.

A2 – Skier’s thumb.

A3 – Avulsion fracture to include the distal insertion of the ulnar collateral ligament (UCL) involving the base of the medial proximal phalanx.

A4 – While this is not a Stener lesion (folded entrapment of the proximal retracted UCL ensconced by the adductor aponeurosis), the reason is simple:

(a) The aponeurosis on the radial side of the thumb is more vertical, or oriented straight and parallel to the collateral ligament. This parallel course does not permit the deeper radial collateral ligament from transgressing the radial aponeurosis.

(b) On the other hand, the adductor aponeurosis has an oblique course allowing the UCL to retract underneath it, flap backwards, and then flip over the top.

The pink and blue arrows on images 4 and 5 highlight the avulsion fracture. On image 6, the oblique course of the adductor aponeurosis is indicated with a red line demarcated by a green arrow. The UCL will get caught in a small notch proximal to this (image 6, yellow arrow). The straighter course of the radial aponeurosis is highlighted with a purple line. You can see how much more oblique the adductor aponeurosis is by tracing the red line.

 

Coronal T2 GE 3D

Coronal T1 FSE

Coronal STIR

 

Check out MRI Online for more case review.

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What surgical emergency is afflicting this patient?

This 57-year-old female presents with hippocampal atrophy, sudden cognitive decline, and visual disturbances.

Q1 – Using images 1 and 2, what is the most likely diagnosis?

(a) Thrombosed aneurysm
(b) Pituitary apoplexy
(c) Craniopharyngioma
(d) Choristoma

Coronal T2 FSE

Coronal T1 SE

 

A1 – (b) Pituitary apoplexy

 

Q2 – Which statement is false about pituitary apoplexy?

(a) Often requires urgent surgical decompression
(b) Often requires steroid therapy
(c) Occurs with microadenoma
(d) May be present with ophthalmoplegia
(e) May be associated with subarachnoid hemorrhage

Q3 – Which statement is false about prolactin-secreting adenomas?

(a) May be invasive with skull base destruction
(b) May be diagnosed with greater than 95 percent accuracy by prolactin greater than 200 ng/ml
(c) Mild elevations of prolactin (<100 ng/ml) can be related to medications, hypothyroidsm, or “stalk effect”
(d) Microadenomas may demonstrate the “hook effect” on laboratory studies

 

Pituitary apoplexy may often present as ophthalmoplegia, visual loss, and confusion in a patient with known pituitary macroadenoma.

Pituitary apoplexy is a surgical emergency requiring acute decompression. Steroid administration is required for endocrine support as the patient may exhibit acute pituitary insufficiency. Sometimes, intravenous T3 is also required.

Pituitary apoplexy may be associated with subarachnoid hemorrhage as well as vasospasm.

Prolactinomas are known to be invasive and, when large, can produce skull base erosion.

Prolactin is the only pituitary hormone which is regulated by an inhibitory mechanism. Large nonsecreting lesions which compress the pituitary stalk can result in elevations of the prolactin described as “stalk effect.” Elevations on this basis are relatively small as are those secondary to medications or hypothyroidism. A rule of thumb in elevating prolactin elevations is that the percentage of chance of a lesion being a secreting prolactinoma is about half of the level, so a prolactin of greater than 200 has an essentially 100 percent chance of being a prolactinoma.

Falsely low prolactin in the face or a large or invasive prolactinoma may represent the “hook effect” where the binding sites of the RIA antibody become saturated and the antibody curve is no longer proportional to the amount of prolactin. This is resolved by performing serial dilutions. This effect never occurs in microadenomas, but rather in macroadenomas.

 

A2 – (c) Occurs with microadenoma

A3 – (d) Microadenomas may demonstrate the “hook effect” on laboratory studies

 

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For more case review, check out MRI Online.

References:

1. Diagnostic Imaging Brain Osborn et. al. Amirsys.

2. Greenberg MS Handbook of Neurosurgery. Thieme.

3. Liu JK, Couldwell WT Contemporary management of prolactinomas. Neurosurg. Focus 2004: 16 (4)

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When your hip has had enough of all that dancing and snapping

This 20-year-old female presents with hip pain. You are getting two clues for the price of one. First, look at images 1 and 2. Hip pain is quite an amorphous symptom. It can come from the joint, the groin, the sacrum, the pubis, or even the spine. We all have a tendency to gravitate towards the joint.

Q1 – Why are we getting two clues for the price of one?

Q2 – Why does the patient have hip pain?

Axial PDW SPAIR TSE

Coronal PDW SPAIR TSE

Axial PDW SPAIR TSE

 

A1 – Because there are two iliopsoas tendons. In other words, the iliopsoas tendon has a bifid morphology (image 4, pink arrows).

A2 – Swelling is more conspicuous around the lateral of the two heads (images 4 and 5, blue arrows). Such swelling is an indirect sign of irritation of the tendon and its surrounding tissues. The iliopsoas tendon is a primary hip flexor and passes over the iliopectineal eminence of the pelvis. This bony prominence is labeled on image 6 (yellow arrow). As the tendons ride over this area, a snap or a click occurs, otherwise known as coxa saltans. Hip flexion and extension, raising and lowering of the whole leg or rotation, namely twisting of the hip, may exacerbate or reproduce symptoms. The peritendinitis, demonstrated with the blue arrows, is a secondary manifestation of this catching phenomenon on the iliopectineal eminence. In this case, the eminence itself is indeed edematous (high signal deep to the yellow arrow on image 6).

 

Q3 – Names like coxa saltans, or iliopsoas tendonitis perhaps, are given to this condition. Can you think of another name?

 

Axial PDW SPAIR TSE

Coronal PDW SPAIR

Axial PDW SPAIR TSE

 

A3 – Dancer’s hip.

Some have actually broken down snapping hip tendon syndrome into extra- and intraarticular types.

Extraarticular Type:

  • Lateral extraarticular type occurs when the iliotibial band, tensor fascia lata, or gluteus medius slide back and forth across the greater trochanter. This can lead to tearing, especially of the gluteus medius and particularly in large women. Concomitant bursitis is frequently present.
  • The medial extraarticular type addresses the iliopsoas tendon catching on either the anteroinferior iliac spine, the lesser trochanter, or the iliopectineal eminence during hip extension especially. Peritendinitis and eventually bursitis results. Our patient has this type with peritendinitis.

Intraarticular Type:

  • With tight constriction and irregular tracking over the anterior labrum, some patients with snapping hip tendon syndrome may develop intraarticular abnormalities involving the labrum and even signs and symptoms of hip impingement with effusion. In this author’s experience, ligamentum teres rupture is another cause of intraarticular snapping hip syndrome.
  • The condition is more common in athletes and MR identifies the indirect, and sometimes direct, signs. However, the direct signs are best identified with dynamic ultrasound with hip motion.

 

Check out MRI Online for more case review.

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|MRI Online| Master the Shoulder – Rotator Cuff Review

Colleagues,

If you are looking for somewhere to start with our video series, MRI Online, the Shoulder series is a great choice. It’s short, it’s accessible and you’ll be able to put the learnings into practice right away. We will revisit the shoulder in additional series later this year, so stay tuned.

The Shoulder series starts with an adhesive capsulitis case, where I show you my approach to shoulder cases. My hope is that by the end of the series, you’ll have a confident framework for attacking shoulder studies in a way that is both thorough and fast.

Next, we review the Six Components of Rotator Cuff Anatomy leveraging medical illustrations from our early text book — MRI Total Body Atlas. We end with a thorough case review of an adult with impingement, which we will evaluate for a rotator cuff tear.

A detailed video curriculum is below. Note this course is only available to MRI Online Premium Members. If you’d like a 14-day trial, please fill out this form.

Enjoy,
Dr. Stephen J Pomeranz

Shoulder MRI: Rotator Cuff Review

Shoulder “Shark” Week — Review of Rotator Cuff Anatomy

The Six Components of the Rotator Cuff

Identifying The Six Components of Rotator Cuff Tears in Practice

How should you attack this hemifacial spasm case?

This 41-year-old female presents with left hemifacial droop and spasm. Try to give the following questions a shot.

Q1 – The differential diagnosis for causes of hemifacial spasm includes:

(a) Meningioma
(b) AICA vascular compression
(c) Multiple sclerosis
(d) PICA compression
(e) All of the above

Q2 – Other accepted neurovascular compression syndromes include all of the following, except:

(a) Trigeminal neuralgia
(b) Glossopharyngeal neuralgia
(c) Nervus intermedius syndrome
(d) Tongue fasciculation syndrome

Q3 – Hemifacial spasm related to vascular compression most often is generated from which vessel?

(a) Anterior inferior cerebellar artery or basilar artery
(b) Posterior inferior cerebellar artery or basilar artery
(c) Super cerebellar artery or basilar artery
(d) Posterior cerebral artery or basilar artery

Now, have a look at the first four images without arrows, and see what observations you can make. Then look at the duplicate images with arrows for key findings.

3DT MRA

3DT MRA

3DT MRA

MPR Auxiliary

3DT MRA

3DT MRA

3DT MRA

MPR Auxiliary

 

A1 – (e) all of the above

A2 – (d) tongue fasciculation syndrome

A3 – (a) anterior inferior cerebellar artery or basilar artery

The most common and well-defined neurovascular compression syndrome is trigeminal neuralgia which classically related to contiguity of a tortuous and low-drooping superior cerebellar artery in proximity to the trigeminal entry zone. The mechanism is presumed to be the creation of a zone of focal demyelination by the adjacent pulsatile vessel. This results in a syndrome of lancinating pain conforming to a trigeminal distribution or its divisions especially V2 followed by V3.

The best imaging method for assessing trigeminal neuralgia vascular loop compression is the raw data thin sections from an MRA.

Trigeminal neuralgia, also called “tic douloureux”, in its most classic form causes extreme, sporadic and sudden burning or shock-like pain that lasts from seconds to two minutes per episode. The attacks can occur in succession, in volleys lasting as long as two hours. This is known as type 1, or “TN 1.” In the atypical form or type 2, also known as “TN 2,” the pain is constant, aching, burning and stabbing.

The most classic imaging finding has already been described but the vascular compression may wear away the protective coating around the nerve, the so-called myelin sheath. Trigeminal neuralgia-type symptoms may also be seen due to “wearing away” or destruction of the myelin coat around the 5th nerve in multiple sclerosis (MS).

Trigeminal neuralgia most often occurs in people over age 50 but can occur at any age. In MS it is more frequent in young adults. It is more common in women than men with the incidence being 12 per 100,000.

ProScan Pearls: The differential diagnosis in a case like this includes post-herpetic neuralgia (often overlooked), cluster headaches, and TMJ disorder.

Besides looking for vascular compression, one of the most important aspects of MRI is excluding MS.

Isolated involvement in the third division of the trigeminal nerve is most uncommon.

Hemifacial spasm is the next most common vascular compression syndrome after tic douloureux and related to anterior inferior cerebellar artery or ectatic basilar compression of the seventh nerve complex at its entry zone.

Glossopharyngeal neuralgia features lancinating pain in the back of the throat and may be related to PICA or vertebral compression on cranial nerve IX.

Nervus intermedius syndrome (the sensory division of seven) results from seventh and eighth-nerve complex compression and presents as severe otalgias especially in the external auditory canal.

Tongue fasciculations are a diagnostic feature of ALS but have no vascular compression syndrome correlate involving nerve XII.

 

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For more case review, check out MRI Online.

Reference:

1. R. Tesh. Hemifacial spasm. AJNR, Vol 12, issues 839-842.

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What rare anomaly can be seen in this 28-year-old’s foot?  It’s often difficult to recognize something that’s not there!

This 28-year-old female presents with ankle and foot pain, with no recent injury and no history of surgery. Have a look at images 1 through 5, and see if you can come up with the rare diagnosis in this case.

Sagittal T1W aTSE

Sagittal T1W aTSE

Coronal PDW SPAIR

Coronal PDW SPAIR

Coronal PDW SPAIR

 

On the images provided, note apparent absence of the tarsal navicular bone, except for a small accessory ossicle dorsally (image 6, arrow). The talar neck appears elongated and the talar head enlarged in size (better seen on images 7 and 9).

Sagittal T1W aTSE

Sagittal T1W aTSE

Coronal PDW SPAIR

Coronal PDW SPAIR

Coronal PDW SPAIR

 

The rare diagnosis is congenital solid osseous talonavicular coalition. Note that the enlarged talar head directly articulates with the cuneiform bones. On images 7 and 10, the arrow indicates fusion of the middle cuneiform bone and base of the second metatarsal, as an additional anomaly. Note also multifocal, prominent bone marrow edema, seen as gray T1 marrow signal in the talus and calcaneus adjacent to the posterior subtalar joint on image 6 (arrows), and bright marrow signal on the PD fat sat coronal images 8 and 9 (arrows), consistent with osseous stress reaction involving body of talus and calcaneus and the lateral cuneiform and cuboid bones.

One of the rarest of tarsal coalitions, talonavicular coalition was first described by Anderson in 1879. Tarsal coalition represents a failure of embryologic mesenchymal segmentation, with calcaneonavicular and talocalcaneal coalition being more common types of tarsal coalition. The incidence of tarsal coalition in the general population has been thought to be at around 1 to 2%, but the incidence of the rare talonavicular coalition seen in this case is unknown.

Talonavicular coalition has shown a strong familial or genetic predisposition, and appears to be inherited in an autosomal dominant pattern with high penetrance and variable expression.  Like other coalitions, this anomaly is frequently bilateral, and is associated with other skeletal anomalies including symphalangism, clinodactyly, clubfoot and peroneal spastic flatfoot.  On exam, these patients typically demonstrate pes planus.  Often, these patients are relatively asymptomatic, compared to patients with the more common calcaneonavicular or talocalcaneal coalitions which affect hindfoot mobility.  When symptomatic, conservative treatment with orthotics and footwear modification is most common, although surgical treatment may be indicated for chronic painful flatfoot if conservative treatment fails.

Check out MRI Online for more case review.

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Dr. Stephen Pomeranz

Dr. Richard J. Rolfes

 

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What sign is a can’t-miss in this case?

Case: A 64-year-old male presents with a three-year history of progressive back pain, lower limb weakness and unstable gait. He experiences no bowel or bladder difficulty and there is no history of prior trauma or spinal surgery. Physical examination revealed lower limb weakness with spasticity.

Sagittal T1

Sagittal T2

Axial T2

Sagittal T1 post contrast

Sagittal CT myelogram

Axial CT myelogram

Axial CT myelogram

 

Findings: A focal dorsal indentation of the thoracic spinal cord is present at the T6 level, with associated compression and deformity of the cord which is displaced anteriorly (Images A-C).

Extensive abnormal cord signal abnormality is present below the level of the indentation extending to the T8 level (Image B).

No abnormal enhancement is present on the post contrast image (Image D).

The CT myelogram shows the “upside down scalpel sign” with the characteristic focal indentation of the dorsal thoracic spinal cord with widening of the dorsal cerebrospinal fluid space, and cord expansion below the level of the dorsal indentation (Image E, pink arrow).

Corresponding axial CT myelogram image at the level of the dorsal indentation (Image F, green arrow) demonstrates a remaining thin CSF space between the anterior cord and the ventral theca. This subtle but key finding helps exclude a diagnosis which is almost identical visual on MRI, namely spinal cord hernia through an anterior rent in the dura. Image G is an axial image below the level of the indentation.

Diagnosis: Dorsal thoracic arachnoid web with spinal cord compression.

Differential: Ventral cord herniation; Dorsal arachnoid cyst (simulates thoracic cord hernia).

Discussion: Spinal arachnoid webs represent intradural extramedullary bands of arachnoid tissue that extend to the pial surface of the spinal cord. They typically occur in the thoracic spine producing a focal indentation on the dorsal spinal cord.

The characteristic dorsal indentation of the cord has been described as the “scalpel sign,” due to the resemblance on sagittal imaging to a scalpel, with the blade pointing posteriorly.

The differential in this case is that of ventral spinal cord herniation, or a dorsal arachnoid cyst. In ventral spinal cord herniation, there is deformity on the ventral surface of the cord as it protrudes through a ventral dural defect, and there is NO space between the cord and the ventral theca. Arachnoid cysts can be identified on imaging by their marginated thin but low signal walls, and they produce a relatively smooth scalloping on the cord surface. On CT myelography an intraspinal filling defect or delayed filling of the arachnoid cyst is sometimes present.

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Editor’s note: This case was submitted by Dr. Tiffany So, who was selected for a scholarship for our upcoming Melbourne Case Review course. Congratulations to Dr. So!

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Can you classify this shoulder injury?

This 17-year-old presents with acromioclavicular (AC) separation. How do we classify shoulder injuries in young adults at ProScan?

Coronal PD FSE Fat Sat

 

Image 1 (green line) indicates a measured distance 11mm between the acromion and clavicle (normal in males is 7mm; females is 6mm). Note edema surrounds the clavicle. No microtrabecular fracture.

Sagittal T2 FSE Fat Sat

Coronal PD FSE Fat Sat

Coronal PD FSE Fat Sat

Sagittal T2 FSE Fat Sat

Coronal PD FSE Fat Sat

Coronal PD FSE Fat Sat

 

Injury is classified according to the system of Tossy, which simplifies the six shoulder descriptors by Rockwood and Green, and is helpful in MRI characterization. Tossy 1 represents contusion or strain, without offset of the inferior margin of the acromion at the clavicle. Tossy 2 has less than 50% offset or overlap with subtype 2A involving sprain of the trapezoid segment and 2B involved both conoid and trapezoid segments of the CC ligament. Tossy 3 has greater than 50% overlap. In this case, we see that the more lateral ligament (trapezoid) from the clavicle to the coronoid process demonstrates a high-grade tear (image 2, orange arrow). Further, there is a more swollen and perhaps minimally torn more medial conoid ligament (image 3, red arrow, and image 4, yellow arrows).

The cuff and labrum are normal, and no fracture is seen. Mixed hemorrhage and edema along the superior joint space margin with low-grade strain of a few deltoid fibers originate at the metaphysis and epiphysis of the distal clavicle separate from the AC joint (image 5, pink arrows).

Image 6 (purple arrow) highlights nominal strain, and contusion of the posterior most fibers of the lateral trapezius.

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Dr. Stephen Pomeranz

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Is there a bird in my head?

This 16-year-old male presents with a head injury. Denies neck pain, chest pain, abdominal pain or extremity pain. States that he did lose consciousness. Focus on the elongated right styloid process in image 1, and the elongated left styloid process of image 2. What do you think the diagnosis could be?

CT – MPR auxiliary image

CT – MPR auxiliary image

 

If you came up with Eagle syndrome (the bird in my head) as the diagnosis, then you hit the nail on the head. Image 3 highlights the elongated right styloid process measured at 4.6cm. Image 4 shows the elongated left styloid process measuring 3.4cm.

CT – MPR auxiliary image

CT – MPR auxiliary image

 

Clinical presentation of Eagle syndrome can be divided into two main subtypes:

1 – Due to compression of cranial nerves
2 – Due to compression of the carotid arteries

Cranial nerve impingement symptoms typically include facial pain when turning the head, dysphagia, foreign body sensation, pain on extending the tongue, change in voice, sensation of hypersalivization, and/or tinnitus/otalgia. On palpation of the styloid process tips, symptoms should ideally be exaggerated.

Arterial impingement symptoms include mechanical compression which would result in visual symptoms, syncope, carotid dissection, or sympathetic plexus irritation (carotodynia) such as eye pain or parietal pain.

Radiographic features of Eagle syndrome include styloid processes longer than 3cm which can be either unilateral or bilateral. Sometimes, styloid processes are elongated or the stylohyoid ligament is calcified.

Typical treatment includes transpharyngeal injection of steroids/local anesthetic agents. Severe cases would involve surgical excision either via transoral approach or a lateral approach. Transoral approach has the disadvantage of increased infection rates, but does not cause external scarring.

 

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Dr. Stephen Pomeranz

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