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September 2002 (Vol. 40, Issue 5)
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Abstracts
Preface
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Imaging of the lower extremity

by Disler DG, Recht MP
page xi
Full Text | PDF (44 KB)
Primary bone tumors of the lower extremities
by Nomikos GC, Murphey MD, Kransdorf MJ, Bancroft LW, Peterson JJ
pages 971-990
Soft tissue tumors of the lower extremities
by Bancroft LW, Peterson JJ, Kransdorf MJ, Nomikos GC, Murphey MD
pages 991-1011
MR imaging in nonneoplastic muscle disorders of the lower extremity
by Farber JM, Buckwalter KA
pages 1013-1031
A regional approach to osteomyelitis of the lower extremities in children
by Kleinman PK
pages 1033-1059
Pathologic conditions of the ligaments and tendons of the knee
by El-Dieb A, Yu JS, Huang GS, Farooki S
pages 1061-1079
MR imaging of the meniscus
by Anderson MW
pages 1081-1094
MR imaging of chondral and osteochondral injuries of the knee
by McCauley TR
pages 1095-1107
The knee: bone marrow abnormalities
by Barr MS, Anderson MW
pages 1109-1120
MR arthrography of the lower extremity
by Kramer J, Recht MP
pages 1121-1132
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Radiologic Clinics of North America
Postoperative evaluation of the knee

by Yoshida S, Recht MP
pages 1133-1146
MRI imaging of tendon, ligament, and osseous abnormalities of the ankle and
hindfoot
by Leffler S, Disler DG
pages 1147-1170
Work-up of the diabetic foot
by Morrison WB, Ledermann HP
pages 1171-1192
Index
pages 1193-1198
PDF (54 KB)
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Abstracts
2004 Elsevier, Inc. | Privacy Policy | Terms & Conditions | Feedback | About Us | Help | Contact Us
file:///C|/temporal/Radiologic%20Clinics%20of%20North%20America%20Septiembre%202002.html (2 de 2)07/03/2004 1:11:40
Radiol Clin N Am 40 (2002) xi
Preface
Imaging of the lower extremity
David G. Disler, MD
Michael P. Recht, MD
Guest Editors
This issue of the Radiologic Clinics of North

America is devoted to addressing current stateof-the-art applications of MR to musculoskeletal
imaging of the lower extremity. Our expert panel of
contributors has provided reviews of various topics
useful to the practicing radiologist. The articles are
designed to be reviews of specific topics that will
allow the reader to organize the information in a
meaningful fashion. We hope that the information
contained within this issue will help practicing radiologists provide clinically relevant interpretations to
referring clinicians and in so doing become relevant
to the care of the patient.
Musculoskeletal imaging has undergone rapid and
dramatic change with the advent of MR imaging. The
articles in this issue will highlight the unique advantages of MR imaging over other modalities. Topics
covered in this issue include assessment of neoplastic
disorders of the lower extremities, MR evaluation of
articular disorders, MR imaging of bone marrow

disorders and nonneoplastic muscle conditions, MR
of postoperative knee assessment, and MR assessment in the setting of osteomyelititis.
We would like to thank our colleagues for their
outstanding contributions to this issue as well as the
staff of W.B. Saunders, particularly Barton Dudlick,
for their help in its assembly.
David G. Disler, MD
Commonwealth Radiology, PC
5801 Bremo Road
Richmond, VA 23226, USA
Michael P. Recht, MD
Section of Muskuloskeletal Radiology/A21
The Cleveland Clinic Foundation
9500 Euclid Avenue
Cleveland, OH 44195, USA
0033-8389/02/$ see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 7 6 - 3
Radiol Clin N Am 40 (2002) 971 990
Primary bone tumors of the lower extremities

George C. Nomikos, MDa,*, Mark D. Murphey, MDb,c,d,
Mark J. Kransdorf, MDe, Laura W. Bancroft, MDe, Jeffrey J. Peterson, MDe
a
Department of Radiology, New York University Medical Center, 550 First Avenue, New York, NY 10016, USA
b
Department of Radiologic Pathology, Armed Forces Institute of Pathology, 6825 16th Street Northwest,
Washington, DC 20306, USA
c
Department of Radiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road,
Bethesda, MD 20814, USA
d
Department of Radiology, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
e
Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
The lower extremity is the most common location

for most osseous neoplasms. A thorough and organized approach is required when evaluating these
lesions to arrive at a reasonable differential diagnosis.
The radiologist, in consultation with the orthopedic
surgeon and pathologist, often plays a crucial role in
directing the work-up of bone tumors and may also be
asked to perform diagnostic or therapeutic interventions. Consequently, a careful pattern of analysis is
required when a suspected primary bone tumor is
discovered. Because a detailed discussion of all bone
tumors that occur in the lower extremity is beyond the
scope of this article, concentration is on the pretreatment evaluation and staging of primary osseous neoplasms occurring in the lower extremities.
Imaging techniques
Evaluation of bone tumors involves a multimodality approach, and whereas cross-sectional
The opinions and assertions contained herein are the

private views of the authors and are not to be construed as
official or as reflecting the views of the Departments of the
Army, Navy, Air Force, or Defense.
* Corresponding author. Department of Radiology,
Room 600, Hospital for Joint Diseases Orthopaedic
Institute, 301 East 17th Street, New York, NY 10003.
E-mail address: george.nomikos@med.nyu.edu
(G.C. Nomikos).
imaging has extraordinarily improved the ability to

characterize tumors, the differential diagnosis of
primary osseous neoplasms remains based on their
radiographic appearance. Radiographs provide critical information regarding lesion location, margin,
matrix mineralization, cortical involvement, and adjacent periosteal reaction. This information derived
from the radiographs permits formation of a reasonable differential diagnosis. Once this is constructed,
further evaluation of the internal characteristics
and extent of a lesion can be obtained better
with advanced radiologic techniques, particularly
MRI [1,2].
Cross-sectional imaging
In contradistinction to soft tissue tumors, CT and
MRI are often complimentary modalities in the
evaluation of primary bone tumors [3]. In a study
by Tehranzadeh et al [3], the information obtained
from CT and MRI was additive in 76% of malignant
primary bone neoplasms. CT is superior to MRI in
the detection and characterization (osteoid or chondroid) of matrix mineralization, cortical involvement,
and periosteal reaction [3,4]. Although some studies
suggest that CT and MRI are equivalent in the
evaluation of the local extent of tumor [5], most
studies and the authors experience indicate that
MRI is superior [1,3,4,6]. The Report of the Radiology Diagnostic Oncology Group, which reported
similar results for tumor evaluation with CT and MRI,
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 3 8 - 6
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G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990
suffered from several technical limitations, and most

subsequent studies have refuted its claims of equality
between CT and MRI [5,7]. The excellent contrast
resolution and multiplanar capabilities of MRI lead to
improved evaluation of both intracompartmental and
extracompartmental extent of bone tumors. This is
particularly true with regards to invasion of muscle,
neurovascular structures, and adjacent fat planes, and
degree of marrow involvement [1,3,4,7 16]. Radiologic-pathologic correlation conducted separately by
both Gillespy et al [11] and Bloem et al [8] demonstrated a high correlation between intramedullary
tumor extent on MRI and pathologic specimens. This
correlation was less reliable by CT [7].
MRI has also been shown to be superior in
assessing intra-articular extension and the presence
of intratumoral necrosis and hemorrhage [4,17].
Evaluation of joint involvement is important because
this constitutes extracompartmental disease in the
Enneking staging system (see later discussion) and
implies a higher-stage lesion. In the case of osteo-
genic sarcoma, intra-articular extension is evaluated

much more clearly by MRI than CT [17]. Using T1weighted images Schima et al [17] demonstrated a
sensitivity of 100% for intra-articular invasion; however, the overall specificity was only 63%. The most
common pattern of tumor involvement in the knee
was spread along the cruciate ligaments, whereas
direct spread across the articular cartilage seemed to
be uncommon [17]. In the authors experience, tumor
extensions into the suprapatellar recess anteriorly and
through the posterior capsule are also common sites of
intra-articular spread (Fig. 1). In the same study, MRI
demonstrated a sensitivity of 100% for transphyseal
spread [17]. Joint effusions related to adjacent tumors
may be sympathetic and reactive or related to tumor
involvement of the joint, leading to a low positive
predictive value. Conversely, the absence of a joint
effusion has a high negative predictive value for
intra-articular involvement by the tumor [17].
MRI should be performed in at least two orthogonal planes in the evaluation of bone tumors. Both
Fig. 1. Telangiectatic osteosarcoma of the distal femur in a 30-year-old man. (A) Sagittal proton density image demonstrating
joint invasion by the tumor (arrows) and an associated joint effusion (black * ). (B) The corresponding sagitally sectioned gross
specimen demonstrates the destruction of the distal femur by the tumor and the invasion into the joint (arrows), and the large
bloody effusion (white * ).
T1- and T2-weighted images should be performed in

the axial plane, supplemented by sagittal or coronal
images, depending on the location of the lesion. This
second plane of imaging should include both T1 and
a water-sensitive sequence, such as short tau inversion recovery sequence [18]. Gradient echo images
are useful in limited circumstances, such as in determining the presence of hemosiderin and in evaluation
of neurovascular involvement, because they improve
the conspicuity of fat-lesion interfaces [18]. For
lesions of the appendicular skeleton, it is crucial that
at least one long axis sequence be performed through
the entire involved bone to evaluate for the presence
of skip metastases. Skip metastases represent a second site of disease in the same bone as the primary
tumor separated by an area of normal marrow. The
presence of skip lesions is very important to determine because they may significantly worsen patient
prognosis and must be removed if limb salvage
surgery is to be successful (Fig. 2).
Because of the high-contrast resolution of MRI,
the field of view needs only to include the region of
973
the lesion. With CT, a larger field of view that

includes the contralateral extremity is often useful,
allowing comparison between the two sides. Such
comparison is rarely necessary with MRI.
MR angiography
Traditionally, catheter angiography has been used
in the preoperative evaluation of bone tumors to
delineate vascular anatomy surrounding the tumor
and to demonstrate tumor neovascularity and the
presence of vascular invasion by the tumor [19]. This
information is important in determining whether limb
salvage is possible and also in determining the need
for preoperative embolization in highly vascular
tumors [19]. Investigators have shown that MR
angiography adequately depicts the major vascular
anatomy in the tumor bed of musculoskeletal neoplasms and also demonstrates the relationship
between tumor and its blood supply [19,20].
Although small vascular branches, such as the sural
and genicular branches, are more difficult to see on
Fig. 2. Coronal T1-weighted (A) and coronal STIR (B) images demonstrate a large osteosarcoma with skip metastases of the
right distal femur in this 12-year-old girl. Note the large area of marrow replacement in the right distal femur. Above the primary
tumor are two skip metastases (arrows), separated from the primary tumor by normal intervening marrow (* ). (C) Sagitally
sectioned corresponding gross specimen. The skip metastases (arrows) are also nicely demonstrated on this specimen.
974
Fig. 2. (continued)
MR angiography, delineation of these small branches

is of only minimal clinical importance [19]. Delineation of feeding vessels from normal muscular
branches is more limited on MR angiography than
on conventional angiography because of the lack of
tumor blush. Improved techniques, however, including the use of gadopentetate dimeglumine enhanced
gradient echo images, may help alleviate these problems [19]. MR angiography has also been shown to
be useful before harvest of vascularized bone graft,
because the anatomy of the peroneal artery relative to
the fibula can be determined before surgery [20].
Contrast enhancement
Intravenous contrast administration is usually
required for optimal evaluation of bone tumors on
CT, particularly to assess the extent of soft tissue
involvement. Contrast is usually not necessary with
MRI, however, because of the improved contrast
resolution of the latter modality [18]. Although certain
lesions do show characteristic enhancement patterns,
unenhanced scans usually provide adequate information for lesion characterization. As an example,
whereas lesions containing a large amount of hyaline
cartilage often show a characteristic peripheral and
septal enhancement pattern, the pattern of mineralization on radiography and CT or the internal signal
characteristics on MRI often suggests the diagnosis of
a cartilaginous lesion without the use of contrast material. Contrast administration can also cause confusion
at times. Seeger et al [89] showed that in osteosarcoma both regions of tumor infiltration and regions of
peritumoral edema may enhance after intravenous
gadolinium administration. In some cases, contrast
administration made differentiation of normal from
abnormal marrow more difficult [6]. The necessity of
intravenous contrast administration to determine joint
involvement is controversial. Some studies contend
that intra-articular extension of tumor is evaluated
much better on enhanced images [17]. Other investigators believe that it is not necessary and they
maintain that joint involvement can be assessed adequately on T1-weighted MRIs by evaluation of the
synovial fat and presence of cortical destruction [4,6].
The authors believe that one important indication
for intravenous contrast is a lesion containing large
hemorrhagic, myxomatous, necrotic, or cystic areas.
Only the areas of solid tissue show significant
enhancement. This information may be quite useful
in directing biopsy to the solid enhancing portions of
the lesion that harbor the diagnostic tissue, as
opposed to the cystic, necrotic, or hemorrhagic nondiagnostic components (Fig. 3). This is one reason
why tumor studies require close monitoring to modify
technique as appropriate. Occasionally, the pattern of
enhancement may also provide clues to the diagnosis,
as in the characteristic peripheral and septal enhancement pattern seen with hyaline cartilage lesions.
Dynamic enhanced MRI
The response of high-grade osteosarcoma and
Ewings sarcoma to chemotherapy with dynamic
enhanced MRI has been studied by several investigators who proposed evaluation based on rather
complicated schemes relating to factor analysis of
dynamic MRI sequences [21] and regions of interest
[22 25]. Shapeero and Vanel [26] have proposed a
less cumbersome method for using dynamic contrast
enhancement to evaluate the degree of tumor necrosis
and tumor response to chemotherapy. For osteosarcoma, the absence of early enhancing nodules or
the presence of only one small early enhancing
nodule suggests greater than 90% tumor necrosis,
representing a good response to the chemotherapy.
975
Fig. 3. Twenty five-year-old man with an osteoblastoma of the talus. (A) Sagittal T1-weighted image before contrast
administration demonstrates the large expansile mass in the talus. The lesion is predominantly intermediate signal intensity;
however, note the numerous areas of high signal intensity that correspond to internal hemorrhage. (B) The corresponding sagittal
T1-weighted postcontrast image demonstrates diffuse enhancement of the solid portions of the lesion and peripheral and septal
enhancement of the cystic and hemorrhagic portions. Biopsy should be directed at the solid components, because these portions
harbor the diagnostic tissue, and not toward the cystic or hemorrhagic components.
Masses with early and persistent enhancement suggest a poor response to chemotherapy in both osteosarcoma and Ewings sarcoma [26]. A limitation of
this technique in the case of Ewings sarcoma is that
diffusely scattered neoplastic cells, which do not form
perceptible nodules, may remain after chemotherapy
[26]. This technique fails to demonstrate persistent
disease of this type. Such diffuse residual disease is
not usually a problem with osteosarcoma, which
tends to persist as nodular islands of viable tissue at
the margins of the tumor, in the soft tissues and
cortical bone, and along the endosteal surfaces [26].
This technique also is useful in distinguishing regions
of reactive edema around a tumor, which only
enhance on the delayed images, from the regions of
viable tumor, which demonstrate early dynamic
enhancement [7,26 28].
Bone scintigraphy
The role of bone scintigraphy in the preoperative
evaluation of bone tumors is limited. Tc 99m phos-
phate compounds are useful in evaluation for distant

sites of osseous metastatic involvement by the primary tumor. Although skip metastases may be identified with scintigraphy, their identification is less
sensitive with this technique than with CT or MRI
[29]. Because of their osteoblastic activity, pulmonary
metastases from osteogenic sarcoma often show
increased uptake of radionuclide at bone scintigraphy.
For evaluation of the primary tumor, triple-phase
imaging is recommended. The dynamic images demonstrate both tumor vascularity and its effects on
regional vascularity. In correlation with the pathology
this information may help further to define the
aggressiveness and prognosis of a lesion. Blood pool
images are quite useful in the postoperative period.
Although there is increased blood pool activity secondary to inflammation in the first several months
after surgery, persistent blood pool activity after this
period is suggestive of local recurrence or infection in
the operative field [29]. Delayed-phase images are
relatively nonspecific. Both benign and malignant
tumors typically demonstrate increased uptake on
976
delayed images [29]. Delayed images from Tc 99m

phosphate scans are less sensitive in detecting extracompartmental spread than CT or MRI and are also of
little use in detecting early recurrence [29]. Delayed
scintigraphy has been shown to be useful in differentiating chondrosarcoma from enchondroma. Chondrosarcoma typically demonstrates significant uptake
on scintigraphy that is equal to or greater in intensity
than the anterior superior iliac spine. Uptake that is
less intense than the anterior superior iliac spine
suggests the diagnosis of enchondroma [30,31].
Increased radiopharmaceutical uptake may be seen
across the joint from the primary tumor or around
adjacent joints. This phenomenon, referred to as
contiguous bone activity or the extended pattern of
uptake, is secondary to hyperemia in the adjacent
bone and disuse osteoporosis. It should not be confused with tumor spread (Fig. 4) [32 40].
Newer radiopharmaceuticals and scintigraphic
techniques hold promise in the evaluation of bone
tumors following preoperative chemotherapy. This
information holds significant implications regarding
patient survival. In the case of osteosarcoma and
Ewings sarcoma, patients with a poor response
(< 90% tumor necrosis) to neoadjuvant chemotherapy
have a significantly worse prognosis than those with
a good response (> 90% tumor necrosis) [41,42]. In
the case of osteosarcoma, this corresponds to 14.3%
local recurrence rate after surgery in those with a poor
response versus 4.8% in those with good tumor
necrosis [41,42]. Both thallium 201 chloride and Tc
99m methoxyisobutyl isonitrile (SestaMIBI) are use-
Fig. 4. Giant cell tumor of the distal femur in a 35-year-old man. The lateral radiograph (A) demonstrates a typical lesion
centered in the metaphysis with extension to the subchondral bone ( * ) of the distal femur. Note the narrow zone of transition
without a rim of sclerosis (arrows) and the lack of internal mineralization. The corresponding delayed lateral image from a bone
scan (B) demonstrates markedly increased activity in the region of the tumor, but also in the patella and proximal tibia (arrows).
The patellar and proximal tibial uptake represent contiguous bone activity caused by hyperemia and disuse osteopenia, and not
tumor spread.
ful in this regard. It has been shown that a negative

thallium or methoxyisobutyl isonitrile scan after preoperative chemotherapy also suggests >90% tumor
necrosis [29,43 48]. Comparison of prechemotherapy and postchemotherapy scans can also be useful in
surgical planning and in determination of the feasibility of limb salvage [29]. Both of these agents have
also been shown to be more useful than radiography,
CT, and standard MRI in patient follow-up, because
tumor recurrence is distinguished more easily from
fibrosis [29,49]. Relative to scintigraphy, however,
dynamic enhanced MRI offers improved spatial resolution and anatomic detail, and easier quantification
than scintigraphy [7,26]. It should also be noted that
lesions with a high myxoid component or significant
chondroid matrix may not show significantly
increased uptake of either thallium 201 or methoxyisobutyl isonitrile [29], likely reflecting the limited
vascularity of these tumors.
As it becomes more widely available, interest in
positron emission tomography (PET) scanning with
2-(18F) fluoro-2-deoxy-D-glucose (FDG) is increasing. A recent study of 27 cases of osteogenic sarcoma
suggested that FDG PET is useful in distinguishing
responders (>90% tumor necrosis) from nonresponders ( < 90% tumor necrosis) with a sensitivity of
100%, a specificity of 80%, and an accuracy of
92.6% [42]. Results from this study, however, imply
that FDG PET does not allow a precise quantitative
estimation of the amount of tumor necrosis based on
the uptake values [42]. This 92.6% accuracy rate is
similar to the 86% rate seen with dynamic enhanced
MRI in the study by Erlemann et al [23,42]. An
additional benefit of PET, however, is its ability to
evaluate for the presence of distant metastases simultaneously with evaluation of the primary tumor.
Because it is based on the presence of increased
glucose metabolism seen in viable cells, metastases
not only to bone, but also to the lungs and other
visceral organs, can be detected [42]. FDG PET may
hold promise in the evaluation of tumor recurrence
and in distinguishing this from postoperative necrosis; however, data in this regard remain preliminary.
Location
In the preoperative evaluation of bone tumors, the
site of origin of the lesion is often very helpful in
determining its etiology. Although the list of possible
bone tumors arising in the lower extremity is quite
extensive, some patterns in tumor origin can be
observed and may be helpful in refining a differential
diagnosis. The potential list of lesions arising in the
977
epiphysis is quite limited. Chondroblastoma usually

arises in the epiphysis or an epiphyseal equivalent
(apophysis, such as the greater trochanter of the
femur, or sesamoid, such as the patella). Chondroblastoma is an uncommon primary bone tumor,
accounting for less than 1% of all primary bone
neoplasms. The femur is the single most frequently
affected site and between 30% and 40% of all lesions
arise around the knee. Langerhans cell histiocytosis,
clear cell chondrosarcoma, and Brodies abscess may
also affect the epiphysis, with the former occurring
almost exclusively in children and adolescents.
Although giant cell tumor of bone almost always
involves the epiphysis, it is centered in the metaphysis and extends rapidly to the subchondral bone (see
Fig. 4A). Far more common than any of these lesions
is the subchondral cyst and intraosseous ganglion that
are commonly seen in the epiphysis. These lesions
may present as a solitary epiphyseal lytic lesion but
can usually be distinguished by their thin sclerotic
rim, lack of mineralization, lack of aggressive features, and sharply circumscribed lytic nature. They
are virtually always associated with some degree of
osteoarthrosis in the adjacent joint.
Diaphyseal origin of a lesion may also be helpful in
developing a differential diagnosis. In children and
adolescents Ewings sarcoma and primitive neuroectodermal tumor must always be kept in mind. These
lesions characteristically arise in the diaphysis of long
tubular bones or in flat bones, such as the pelvis. They
usually cause a moth-eaten pattern of destruction of the
involved bone. There is often permeation of the cortex
by the tumor cells to form a large soft tissue mass, and
matrix mineralization is absent (Fig. 5). Lymphoma,
usually seen in patients beyond the adolescent years,
often has a similar presentation. With lymphoma, as
with primitive neuroectodermal tumor and Ewings
sarcoma, a large soft tissue mass is often present at
the time of diagnosis. Periosteal osteosarcomas, an
uncommon variant of osteosarcoma, are an additional
tumor with a propensity for a diaphyseal origin.
Unlike conventional osteosarcomas, periosteal
lesions arise on the surface of the involved bone
and not in the intramedullary cavity. These tumors
demonstrate an aggressive radiographic appearance
and often cause cortical scalloping or saucerization at
their site of origin. Sunburst periosteal reaction and a
Codmans triangle are often identified. These lesions
arise on the surface of the bone and backgrowth into
the medullary canal is exceedingly rare. Periosteal
osteosarcoma must be distinguished from the less
aggressive, but also uncommon, parosteal subtype of
osteosarcoma that is also a surface lesion. Parosteal
osteosarcomas usually arise in a metaphyseal loca-
978
Fig. 5. Ewings sarcoma in a 17-year-old boy. The anteroposterior radiograph (A) demonstrates a large area of moth-eaten and
permeative destruction in the mid femoral cortex with associated multilayered, aggressive-appearing periosteal reaction (white
arrows), characteristic of Ewings sarcoma and other small round blue cell tumors. No internal mineralization is identified. The
coronal T1-weighted (B) and T2-weighted (C) images demonstrate a large area of marrow replacement ( * ) in the femur
corresponding to the area of permeative destruction seen on the radiograph. The periosteal reaction and periosteal elevation are
also nicely demonstrated on the MR images (black arrows). The corresponding sectioned gross specimen (D) demonstrates the
area of marrow replacement ( * ) and the cortical permeation by the tumor and associated periosteal elevation.
979
signal, similar to skeletal muscle, on T1-weighted

images, and may be low, intermediate, or high signal
on T2-weighted images [50]. MRI may also demonstrate areas of cystic change within the lesion.
Osteofibrous dysplasia and adamantinoma, which
are almost exclusively found in the tibial diaphysis,
may have an appearance similar to fibrous dysplasia.
These lesions are discussed more fully later.
Margin
Fig. 5. (continued)
tion, often on the posterior distal femoral cortex.

Reflecting their usually low-grade histology, parosteal osteosarcomas have a relatively nonaggressive
appearance with abundant mature-appearing osteoid
production. Parosteal osteosarcomas frequently show
medullary backgrowth (41 50% depending on histologic grade) [90].
Although it is certainly not limited to long bones,
when fibrous dysplasia occurs in long bones it most
commonly involves the diaphysis [50]. The femur
and tibia are commonly involved, and the classic
radiographic appearance of intramedullary ground
glass opacity with associated bubbly osseous expansion and surrounding sclerosis is well known. The
characteristic deformities of the lower extremities
(including the shepherds crook deformity of the
hip) caused by weakening of the involved bone by
abnormal packing of the marrow cavity with fibroosseous tissue, are also well known [50]. Evaluation
with CT is often useful to better define the extent of
the lesion and may demonstrate subtle areas of
internal mineralization [50]. Lesions are usually low
Proper evaluation of lesion margin is critical to

adequate assessment of bone tumors. It is especially
important in evaluating the degree of aggressiveness
of a lesion because lesion margin allows a relative
assessment of tumor activity and the ability of the
host bone to contain that growth. The presence of a
narrow zone of transition or sclerotic margin around a
lytic lesion suggests a less aggressive process that has
allowed the host bone time to remodel. More aggressive lesions typically demonstrate a wider zone of
transition or a moth-eaten and permeative pattern of
destruction. Evaluation of tumor margin is often
much more difficult on CT or MRI because both
benign and malignant sarcomas often demonstrate a
fibrous pseudocapsule. This pseudocapsule does not
aid in differentiation of aggressive from nonaggressive lesions, because malignant lesions are often
contained within a pseudocapsule and lack an
aggressive-appearing margin on cross-sectional
imaging. The radiograph may therefore provide more
valuable information regarding margin than more
advanced imaging techniques.
MRI, however, does allow evaluation of the
degree of soft tissue and marrow reaction around
the lesion. Benign lesions, such as Langerhans cell
histiocytosis, chondroblastoma, osteoid osteoma, and
Brodies abscess, may all cause an extensive surrounding inflammatory response including involvement of the adjacent joint that can lead to confusion
with a more aggressive process [28,51 53]. Differentiation of the reactive zone from tumor extension in
malignant lesions can be problematic; however,
dynamic enhanced MRI offers some promise in
distinguishing these two [26]. As mentioned previously, tumor enhances on the early dynamic images,
whereas peritumoral edema in the reactive zone does
not show early phase enhancement [7,26 28]. When
more widely available, this technique could be useful
to the orthopedic oncologist in surgical planning by
facilitating better distinction of the reactive zone from
the true neoplastic tissue.
980
Soft tissue mass

Although CT and MRI can both provide information regarding the presence of soft tissue extension,
most studies clearly indicate the superiority of MRI in
defining the precise extent of extraosseous disease
[1,4,6,23]. The presence of a soft tissue mass indicates involvement of a second compartment, which
increases the tumor stage (see later discussion) and
has significant implications not only regarding staging but also therapy. In addition, once a soft tissue
component is identified, the radiologist must be
careful to detect important soft tissue structures that
may be affected by the tumor. Involvement of major
neurovascular structures is critical information to the
orthopedic oncologist in surgical planning. In particular, involvement of the lumbosacral plexus, sciatic
nerve, and femoral neurovascular bundle and its
branches may prohibit limb-salvage surgery. Vascular
encasement may complicate the operative procedure
and require vascular reconstruction. A fat plane of
varying diameter surrounds virtually all major neurovascular bundles, aiding in radiologic determination
of tumor involvement. This is identified best on T1weighted images because of the high signal intensity
of the fat relative to the low tumor signal intensity.
Small amounts of peritumoral edema and the reduced
signal intensity of fat often make determination of
neurovascular involvement more difficult on fluidsensitive sequences (Fig. 6) [18]. Obliteration of large
segments of fat around a neurovascular bundle on T1weighted images is diagnostic of neurovascular
encasement (Fig. 7) [4]. MRI has been shown to be
both sensitive and specific in evaluation of neurovascular involvement (100% and 98%, respectively,
in one study) with a high accuracy (98%). In the same
study, the specificity (93%) and accuracy (82%) of
CT were relatively high; however, CT sensitivity
(33%) for neurovascular involvement was extremely
low [8]. Even when only small focal areas of fat
around a neurovascular structure are obscured, the
possibility of neurovascular involvement cannot be
excluded. In the authors experience, however, the
surgeon is usually able to delineate a plane between
the tumor and neurovascular bundle in these cases at
the time of resection.
Cortical involvement
Early cortical involvement or localization of a
lesion in the cortex is important to recognize. Subtle
cortical disruption suggests early extracompartmental
extension and a more aggressive lesion. For example,
the degree of cortical involvement may be especially
important in differentiating enchondroma from chondrosarcoma of long bones, where the degree of
cortical scalloping has been shown to be useful in
predicting diagnosis. Among hyaline cartilage lesions,
it has been shown that cortical scalloping of greater
than two thirds of the cortical thickness, among other
criteria, is highly suggestive of chondrosarcoma rather
than enchondroma [31]. Whereas studies suggest that
both CT and MRI are comparable in evaluation of
cortical involvement, in the authors experience CT is
preferable [18]. Regardless, this information may be
Fig. 6. Osteosarcoma of the distal femur in an 18-year-old girl. The tumor causes a large area of marrow replacement ( * ) and has
a large soft tissue component. The fat plane between the soft tissue mass (white arrows) and neurovascular bundle (black arrow)
is obviously preserved on the T1-weighted image (A), excluding neurovascular involvement. The peritumoral edema on the T2weighted image (B) obscures this fat plane (arrowheads), making evaluation of neurovascular involvement difficult.
981
Fig. 7. A 48-year-old man with osteosarcoma of the femur. The axial proton density image (A) demonstrates loss of the fat plane
surrounding the neurovascular bundle (arrows), compatible with tumor encasement. The corresponding axial gross specimen (B)
confirms the neurovascular encasement (arrows).
quite useful in cases of enchondroma versus chondrosarcoma in planning appropriate treatment (Fig. 8).
Lesions that are localized to cortical bone have a limited differential diagnosis, including osteoid osteoma,
Langerhans cell histiocytosis, and Brodies abscess.
Staging
Proper staging of osseous neoplasms is essential
for planning effective and appropriate therapy. There
are two widely used staging systems for primary
tumors of osseous origin: the system developed by
Enneking and the Musculoskeletal Tumor Society in
1985, and that developed by the American Joint
Committee on Cancer. These systems are very similar
and emphasize the same basic prognostic factors [54].
The Enneking system is emphasized in this discussion. The purpose of a staging system is threefold: (1)
to describe the risk of local recurrence and distant
metastases, (2) to stratify stages such that they may
have specific implications for surgical management,
and (3) to provide guidelines for adjuvant therapy
[55]. The Enneking staging system is applicable to
tumors of mesenchymal origin (eg, osteogenic sarcoma and chondrosarcoma) or connective tissue origin and not of tumors of round cell lineage (eg,
Ewings sarcoma or lymphoma) [55].
Tumor grade
The first component of the Enneking staging
system is tumor grade. In the Enneking system, grade
takes into account not only histologic appearance but
also radiologic assessment and clinical behavior. The
grade provides a prediction of the biologic behavior

of the tumor [55] and should be thought of as a
clinical or surgical grade and not purely as a histologic grade [56]. Grade 0 lesions have a benign
biologic behavior. They may have an indolent or
aggressive course. It is important to remember that,
for these lesions, the radiographic appearance may be
more useful for determining biologic activity than the
histologic grade [55]. Grade 2 lesions are high-grade
malignant neoplasms. Grade 1 tumors, classified as
low-grade malignant neoplasms, have a biologic
behavior in between these two extremes. Typically,
grade 1 malignant lesions demonstrate a relatively
indolent clinical course and local control can be
achieved with more conservative treatment [57]. In
contrast, grade 2 lesions require aggressive measures
to achieve local control. These grade 2 lesions are
characterized by a more aggressive clinical course,
have a more menacing histologic appearance, and
have resulting higher propensity for distant metastases [57]. For example, parosteal osteosarcomas
represent grade 1 lesions, whereas conventional
(intramedullary) osteosarcomas represent grade 2
lesions [55,57].
Site
The second component of the staging system is
site. T0 lesions remain within their capsule or pseudocapsule and involve only one compartment. Extension of the primary tumor or its reactive zone beyond
the pseudocapsule without extracompartmental
spread characterizes T1 lesions. These lesions are
limited by anatomic barriers, such as articular cartilage, cortical bone, joint capsule, or tendons and
982
Fig. 8. Chondrosarcoma of the proximal tibia in a 41-year-old man. Anteroposterior (A) and lateral (B) radiographs of the
proximal tibia demonstrate a large, mildly expansile lytic lesion in the proximal tibia. Note the deep, greater than two thirds of
the cortical thickness, cortical scalloping caused by this chondrosarcoma (arrows) and the lobular margin characteristic of
hyaline cartilage lesions. This cortical scalloping is seen to better advantage on the CT image (C). The mineralized chondroid
matrix is appreciated much more easily on the CT image than on the radiographs. The corresponding axial T2-weighted image
(D) demonstrates very high signal characteristic of hyaline cartilage lesions. No soft tissue mass is identified. (E) Sagittal gross
specimen. Note the numerous islands of hyaline cartilage and the deep cortical scalloping.
983
regional metastases, such as to regional lymph nodes,

and distant metastases, because they both carry the
same prognosis [55,57]. Skip metastases, as in the
case of osteogenic sarcoma, also require a designation
of M1 even without associated distant metastases
(see Fig. 2).
Together these criteria form the basis for overall
determination of surgical stage as shown in Table 1.
Note that for malignant lesions, the stage is further
divided by the presence (B) or absence (A) of
extracompartmental spread. Although a detailed
description of the implications of this staging system
is beyond the scope of this discussion, it is important
to recognize that staging plays a critical role in
determination of the proper treatment plan in the
hope of achieving both local control and preservation
of function [57]. The crucial role that the radiologist
plays in the staging process, in determination of both
the extent of tumor involvement and the presence of
metastases, is obvious. The tumor stage is usually not
stated in the radiology report, however, because
lesions should be imaged before obtaining biopsy
when the histologic grade of the tumor is not yet
determined by the pathologist.
Fig. 8. (continued)
ligaments [55,57]. Spread beyond the compartment of

origin characterizes T2 lesions. For example, a chondrosarcoma limited to the bone represents a T1 lesion
(see Fig. 8), whereas the same lesion with an associated soft tissue mass represents a T2 lesion (see
Fig. 6). Extension of the reactive zone beyond the
compartment of origin also obligates a T2 designation
because this area may often contain satellite nodules
or tumors projections [56]. Neurovascular involvement also defines a lesion as T2 (see Fig. 7) [55]. The
importance of determination of tumor site is that it
predicts the means by which adequate surgical resection can or cannot be performed [57]. T1 lesions may
be converted into T2 lesions due to extracompartmental contamination by fracture or an improperly
performed biopsy procedure [56]. It should be noted
that larger lesions are more likely to involve more
than one compartment, but size alone does not
obligate a T2 designation.
Metastases
The final component of the Enneking staging
system is the presence or absence of distant metastases (M0 or M1). No differentiation is made between
Percutaneous biopsy and treatment

The radiologists role in the evaluation of bone
tumors is not limited to imaging. The radiologist may
take a more active role in the management of these
lesions by performing percutaneous imaging-guided
biopsy procedures in conjunction with the orthopedic
oncologist. Properly performed, percutaneous biopsy
procedures may be of great use to the referring
physician. Improperly performed biopsy procedures,
whether open or closed, may have disastrous consequences. In a well-known study by Mankin et al
Table 1
Surgical staging of musculoskeletal sarcoma
Stage
Grade
Site
IA
IB
IIA
IIB
III
Low (G1)
Low (G1)
High (G2)
High (G2)
Any (G)
regional or
distant metastases
Intracompartmental (T1)
Extracompartmental (T2)
Intracompartmental (T1)
Extracompartmental (T2)
Any (T)
From Enneking WF, Spanier SS, Goodman MA. A system

for the surgical staging of musculoskeletal sarcoma. Clin
Orthop 1980;153:106 20; with permission.
984
[58] in 1982, the potential hazards of obtaining

biopsy of primary bone and soft tissue sarcomas were
reviewed in detail in a series of 329 patients. This
study demonstrated the numerous potential complications of an improperly performed biopsy procedure.
These included the following: major errors in diagnosis (18.2%); nonrepresentative or technically poor
biopsies specimens (10.3%); wound complications
(17.3%); alteration of treatment plan as a result of
biopsy procedure complications (18.2%); adverse
effect on prognosis and outcome (8.5%); and unnecessary amputation (4.5%) [58]. These complications
occurred three to five times more commonly when
the biopsy procedure was performed at a referring
center than when performed at a treating center [58].
Unfortunately, a similar study including 597 patients
showed virtually identical results 10 years later [59].
Both of these studies stressed the need to obtain
adequate representative tissue and placement of the
incision so as not to compromise the definitive
surgical procedure [58,59]. In particular, the biopsy
procedure should be performed so that the entire
biopsy tract can be excised at the time of the
definitive surgery [54]. This is usually performed
by a longitudinal incision; biopsy by a transverse
incision should be avoided [54,58]. In addition,
caution should be taken to avoid contamination of
additional compartments or neurovascular bundles
[54]. It should be noted that this contamination may
occur as the result of both the way in which the
biopsy is obtained and as a result of biopsy procedure
complications, such as hematoma [54].
Some authors suggest that accuracy is improved
by performing an open biopsy procedure rather than a
needle biopsy [59]. A recent study performed at a
major sarcoma referral center, however, demonstrated
high accuracy for needle biopsy when obtained by
experienced personnel [60]. In this study of 155 patients, major diagnostic errors were encountered in
only two cases and there were no cases of unnecessary amputation as a result of percutaneous biopsy
[60]. These results differ significantly from those
published in the study by Mankin et al [58] study
and reflect the importance of careful attention to
technique and adequate experience. Percutaneous
biopsy must be obtained so as not to compromise
the definitive surgical procedure. It is important to
avoid contamination of areas that may be used in the
surgical reconstruction. For instance, the biopsy tract
should not pass through the rectus femoris or gluteal
muscles because these muscles are often used for
reconstruction. Care also should be taken to avoid
any major neurovascular structures. The biopsy
approach should be chosen in consultation with the
referring surgeon to avoid potential compromise of

the treatment options. When properly performed, the
complication rate of percutaneous biopsy procedure
is known to be well below that of open biopsy
procedure [59 61]. Excision of the biopsy tract is
also easier after closed rather than open biopsy
procedure [61]. These data suggest that obtaining
percutaneous biopsy offers a relatively safe alternative to open biopsy when performed by experienced
personnel. Appropriately performed, percutaneous
biopsy has a lower complication rate and causes less
soft tissue damage (facilitating limb salvage surgery)
compared with open procedures [60,62].
Recently the potential for percutaneous imagingguided therapy for certain benign tumors has been
explored. A growing body of data suggest that
percutaneous radiofrequency ablation of osteoid
osteoma is a safe and effective alternative to surgery,
especially for extraspinal lesions [63 66]. Studies
have shown a success rate at least equal to surgery
and a very minimal complication rate and rapid
recovery [63 66]. In addition, these procedures can
be done on an outpatient basis and have a short
recovery time [65]. Similar treatment is now being
investigated for treatment of chondroblastoma [67].
Specific diagnoses
Fat-containing lesions
Certain tumors have a predilection for particular
anatomic sites in the lower extremities. The proximal
femur, especially the intertrochanteric region, is a
common location for fibrous dysplasia and lipomatous tumors, such as lipomas, ossifying lipomas, and
liposclerosing myxofibrous tumors [68,69]. These
lesions have a characteristically benign appearance,
usually with mild to moderate osseous expansion and
a rim of sclerosis. Definitive diagnosis of the lipomatous tumors can be made by identification of fat
within the lesion on CT or MRI. In the case of
liposclerosing myxofibrous tumors fat is characteristically not identifiable, but high water content is seen
on CT (low attenuation) or MRI (very high signal on
T2 weighting).
Adamantinoma and osteofibrous dysplasia
Adamantinoma and osteofibrous dysplasia almost
exclusively affect the tibia or fibula. These lesions
typically arise in the cortex of the anterior midshaft
and are often long lesions that cause mixed lysis and
sclerosis. Osteofibrous dysplasia, a benign condition,

must be differentiated from adamantinoma, which is a
malignant neoplasm of unknown histiogenesis usually treated with en bloc resection, wide margins, and
limb salvage [70]. Osteofibrous dysplasia is usually
distinguishable from fibrous dysplasia because of its
intracortical origin, as opposed to the intramedullary
origin of fibrous dysplasia. Signs suggestive of adamantinoma are an older patient (usually second
through fifth decade); multilayered periosteal reaction; moth-eaten destruction; and soft tissue extension
[71]. A younger patient age and the presence of an
intracortical mixed lytic and sclerotic lesion with
anterior tibial bowing argue against adamantinoma
and suggest the diagnosis of osteofibrous dysplasia.
The presence of infantile or congenital pseudoarthrosis eliminates the possibility of adamantinoma
[71,72].
Osteoid osteoma
Osteoid osteomas, which account for approximately 12% of all benign skeletal tumors, commonly
arise in the long bones of the lower extremities, with
the femur and tibia accounting for approximately
57% of all lesions [72,73]. Characteristically these
lesions are intracortical and diaphyseal in location,
although they occasionally involve the metaphysis
[72]. The characteristic radiographic appearance of a
small, less than 1.5 to 2 cm, cortically based radiolucency (nidus) with marked surrounding sclerosis
and cortical thickening, combined with the classic
clinical history of pain, worse at night, that is relieved
by aspirin, is usually highly suggestive of the diagnosis [28,72 74]. Although there is some disagreement, most authors believe that CT is more effective
than MRI in identifying the nidus of an osteoid
osteoma, and should be used primarily when this is
clinically suspected [75 77]. CT also demonstrates
the central calcification found within the nidus in
many cases to better advantage than other techniques. The MRI appearance of this lesion can be
confusing. Extensive bone marrow reaction and soft
tissue inflammatory changes surrounding the lesion
are commonly seen on MRI and may obscure the
nidus or suggest a more aggressive process, such as
infection, fracture, or malignant neoplasm [75]. This
bone marrow reaction has been shown to correlate
with replacement of the normal bone marrow by
fibrous tissue, inflammatory cells, and hypervascularity. The signal characteristics of the nidus are also
variable on T2-weighted images, depending on the
amount of fibrovascular tissue and mineralization that
are present.
985
Intra-articular and intramedullary osteoid osteomas present special problems. Joint effusion and
lymphoproliferative synovitis, similar to that seen in
rheumatoid arthritis, are often seen with intra-articular lesions and may suggest an arthritic condition, as
may the relatively nonspecific symptoms often seen
with these lesions [75,77]. This synovitis may be
quite extensive and has been reported as leading to
premature osteoarthrosis in up to 50% of patients
[74,77]. Intra-articular lesions are most commonly
reported in the hip, but they have been seen in
multiple other joints [73]. There is often no evidence of cortical thickening or periosteal reaction in
response to intra-articular lesions, likely because of
the lack of functional periosteum within the joint
capsule [74]. In addition, intramedullary lesions,
except those in the spine, do not demonstrate perilesional sclerosis, regardless of whether they are intraor extra-articular [74]. These characteristics often
lead to a confusing clinical picture and may delay
diagnosis.
Chondromyxoid fibroma
Although it accounts for less than 1% of all
primary bone tumors, chondromyxoid fibroma
deserves special mention in any discussion of bone
tumors of the lower extremities [78 81]. These
tumors have a slight male predominance and are
most commonly seen in the second and third decades
of life [79]. Although it is rare, a significant majority
of these tumors, approximately 68% to 71%, occur in
the lower extremity [78,80,81]. While most commonly seen about the knee (40%), chondromyxoid
fibroma has an unusual predilection for the small
bones of the foot. The foot accounted for 17% of all
lesions in one review of 356 cases [79]. Although not
characteristic, the radiologic appearance can be suggestive. The lesions are usually located eccentrically
or intracortically in the metaphysis or metadiaphysis
of a long bone; furthermore, they often demonstrate
lobulated margins, as do many tumors of cartilaginous origin [78 80]. Epiphyseal extension may
occur; however, extension to the subchondral bone
is uncommon in lesions of the long bones, aiding in
distinction from giant cell tumor [80]. The inner
margin of the lesion is often well defined and
sclerotic, whereas the bone along the outer margin
is often markedly expanded and either severely
thinned or absent [80,81]. This outer margin may
simulate the appearance of an aneurismal bone cyst or
more aggressive lesion, such as a telangiectatic
osteosarcoma [80,81]. Peripheral scalloping, creating
pseudotrabeculation, is common, as is expansile
986
remodeling [78,80,81]. Matrix mineralization is

reportedly seen in less than 10% of lesions. These
lesions may have a different appearance when they
involve the small tubular bones where they often fill
the medullary cavity and cause fusiform enlargement
and circumferential cortical thinning [81]. A more
aggressive appearance than that seen in the long
tubular bones has been reported as occurring in
lesions of the foot [79].
CT demonstrates the internal mineralization, if
present, superior to radiographs. In the cases in which
there is no discernable outer border on radiographs,
CT and MRI demonstrate an intact outer periosteum.
MRI reflects the high water content contained in the
chondroid and myxoid components of the tumor as
very high signal intensity on T2-weighted images and
low signal intensity on T1-weighted images [80].
Because of the diverse tissue constituents of these
lesions, their appearance on MRI is often heterogeneous [73].
Giant cell tumor
Giant cell tumors are most commonly seen in the
long tubular bones and approximately three times as
many lesions occur in the lower extremity than occur
in the upper extremity [35,72]. They affect women
somewhat more commonly than men and have peak
prevalence in the third and fourth decades of life
[35,72,82]. Only 1% to 3% occur in skeletally immature individuals [35]. Between 50% and 65% of cases
of giant cell tumor occur about the knee [35,72]. The
patella and apophyses, such as the greater trochanter
of the femur, are not uncommon sites of involvement,
and approximately 1% to 2% of lesions occur in the
foot. These lesions are thought to arise in the metaphysis and rapidly extend to the subchondral bone
(see Fig. 4) [35,82]. Approximately 84% to 99% of
lesions extend to within 1 cm of the subchondral bone
plate [35].
Radiologically, these lesions are expansile, eccentric, and demonstrate a geographic pattern of lysis,
usually with a narrow zone of transition (80% to
85%) [35]. Thinning of the overlying cortical bone is
characteristic [35,72]. Although a sclerotic rim is
uncommon, surrounding medullary sclerosis is often
seen on CT, as is pseudotrabeculation from osseous
ridges as a result of endosteal scalloping [35]. Mineralized matrix is absent [35,82]. These lesions often
have an aggressive radiologic appearance. Cortical
penetration, with or without an associated soft tissue
mass, is seen in 33% to 50% of cases; however,
periosteal reaction is uncommon and, when present, it
usually indicates the presence of a pathologic fracture
[35,82]. Soft tissue extension is more commonly seen

at the metaphyseal end of the lesion, because the
articular cartilage acts as a barrier to tumor growth
[35]. Cystic or secondary aneurysmal bone cyst
components are often demonstrated on CT or MRI,
and may suggest a more aggressive appearance
[35,82]. These areas are low attenuation on CT; low
or high (because of internal hemorrhage) signal on
T1-weighted MRIs; and high signal on T2- weighted
images [35,82]. Fluid levels in the aneurysmal bone
cyst component of the lesion may be seen on either
modality [35]. On T2-weighted MR images, the solid
portion of a giant cell tumor is usually low-tointermediate signal intensity, unlike most other bone
tumors [35,82,83]. This low-to-intermediate signal
intensity in the solid portion of the tumor has been
variously attributed to the presence of hemosiderin,
high collagen content, or high cellularity [35,82]. CT
or MRIs obtained after administration of intravenous
contrast may be quite useful to distinguish the cystic
from the solid portions of the lesion. It is important to
recognize these solid regions so that biopsy can be
obtained from this portion of the lesion and not from
the cystic and secondary aneurysmal bone cyst component, which does not harbor diagnostic tissue.
Osteoblastoma
The lower extremity is a common location for
appendicular osteoblastoma. In a collection of
reviews including 298 patients, 35% of these lesions
were located in the lower extremity [72]. In a review
of 329 patients from the Archives of the Armed
Forces Institute of Pathology (AFIP), the foot and
ankle was the third most common site of origin,
accounting for 12.5% of all lesions, after the spine
(19%) and femur (14.8%) [84]. Sixteen of the 41 foot
and ankle lesions in this series occurred in the talus,
the single most common location of hindfoot lesions
(see Fig. 3) [84]. These lesions are most common in
the second and third decades of life and are approximately two times more common in men than in
women [72,84]. Eight of the 16 lesions seen in the
talus in the AFIP series were subperiosteal in location
and were associated with a soft tissue mass; the other
eight talar lesions were intramedullary [84]. Mineralized matrix was seen in 56% of the foot and ankle
lesions in the AFIP series and was much more
common in subperiosteal lesions than in intramedullary or intracortical lesions [84]. Formation of a soft
tissue mass is also common (56% of the foot and
ankle tumors) [84]. A geographic pattern of lysis with
or without a rim of surrounding sclerosis is characteristic [84,85]. Extensive surrounding sclerosis is usu-
987
Fig. 9. Chondroblastoma of the greater trochanter of the femur in a 12-year-old girl. Note the characteristic low signal intensity
of the lesion on this T2-weighted image (arrow). Note the extensive surrounding marrow edema, also commonly seen with
these tumors.
ally absent; however, surrounding inflammatory

changes are often identified on MRI [72,84,85]. Like
giant cell tumor, osteoblastomas may demonstrate
secondary aneurysmal bone cyst formation; however,
unlike giant cell tumor, the solid portion of osteoblastoma is high signal on T2-weighted images.
Chondroblastoma
Chondroblastoma is an additional bone tumor
with a predilection for the lower extremity. In a series
of 332 cases from the AFIP, 76% of lesions were
located in the lower extremity, including the distal
femur (21%), proximal femur (17%), proximal tibia
(15%), and foot (13%). When they occur in the long
bones most lesions begin in the epiphysis. In the foot
most lesions occur in the talus or calcaneus. In the
AFIP series, the calcaneus accounted for 40% of foot
lesions and the talus accounted for 48% [86]. Lesions
in the foot tend to occur in patients slightly older than
patients with long bone lesions (mean age of 25.5
years versus 17.3 years for long bone lesions) and
often fail to demonstrate mineralized matrix or periosteal reaction on radiographs (unlike the long bone
lesions, which commonly demonstrate mineralization) [51,87,88]. Although secondary cystic or
aneurysmal bone cyst formation is common in chondroblastomas in general, such change is particularly
common in lesions of the foot and patella [86]. As
with giant cell tumor, the solid portions of chondroblastoma usually remain low-to-intermediate signal
intensity on T2-weighted images (92% of lesions in a
recent study) (Fig. 9) [87,88]. In the authors opinion,
this is caused by the very high cellularity of these

lesions. Again, as with giant cell tumor, CT or MRI
obtained after intravenous contrast may be very
useful in distinguishing the cystic from the solid
portions of the lesion and in guiding biopsy procedure to the solid portions of the lesion. Surrounding
inflammatory reaction, including extensive periosteal
reaction, is very commonly seen with chondroblastoma on MRI, and may lead to erroneous diagnosis of
a more aggressive lesion [51,53,87,88]. These inflammatory features may help in distinguishing chondroblastoma from giant cell tumor.
Summary
The key to adequate and accurate evaluation,
diagnosis, and treatment of bone tumors is an organized and integrated approach involving the surgeon,
radiologist, and pathologist. The radiologist plays not
only a valuable role in the diagnosis and preoperative
staging of bone tumors but may also play a role in
biopsy and treatment. Despite the wide variety of
imaging modalities available today, radiographs
remain the mainstay in the evaluation of osseous
neoplasms. Advanced imaging is, however, very useful for staging purposes and for characterization of the
internal characteristics of tumors and may aid significantly in limiting the differential diagnosis. Although a
detailed discussion of all of the various bone tumors of
the lower extremities is beyond the scope of this
article, an attempt is made to provide a framework
for a rational and comprehensive approach to these
988
complicated but relatively uncommon lesions. Certain

lesions with unique characteristics are discussed to
facilitate the diagnostic process.
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Radiol Clin N Am 40 (2002) 991 1011
Soft tissue tumors of the lower extremities

Laura W. Bancroft, MDa, Jeffrey J. Peterson, MDa,
Mark J. Kransdorf, MDa,b,*, George C. Nomikos, MDb,
Mark D. Murphey, MDb,c,d
a
Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 3899, USA
Department of Radiologic Pathology, Armed Forces Institute of Pathology, Walter Reed Army Medical Center,
Building #54, 6825 16th Street, NW, Washington, DC 20306 6000, USA
c
Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences,
4301 Jones Bridge Road, Bethesda, MD 20814 4799, USA
d
Department of Radiology, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201 1595, USA
b
MRI is the preferred modality for the evaluation

of a soft tissue mass following radiography. The
radiologic appearance of certain soft tissue tumors
or tumor-like processes may be sufficiently unique to
allow a strong presumptive radiologic diagnosis. It
must be emphasized that one cannot differentiate
reliably between benign and malignant lesions on
radiologic imaging alone. When a specific diagnosis
is not possible, knowledge of tumor prevalence by
location and age, with appropriate clinical history and
radiologic features, can be used to establish a suitably
ordered differential diagnosis.
Musculoskeletal tumors of the lower extremity are
not uncommon, and although there are a wide variety
of lesions that may occur in the lower extremity, there
are certain lesions that have a predilection for this
location. This article highlights the imaging of the
most common tumors of the lower extremity. It is not
intended as a comprehensive review, but as an
overview, emphasizing the use of MRI in the evaluation of these lesions and highlighting those diagnoses
that may be suggested by MRI.
The opinions and assertions contained herein are the
private views of the authors and are not to be construed as
official or as reflecting the views of the Department of the
Army or the Department of Defense.
* Department of Radiology, Mayo Clinic, 4500 San
Pablo Road, Jacksonville, FL 32224.
E-mail address: kransdorf.mark@mayo.edu
(M.J. Kransdorf).
It is difficult to determine the true prevalence of

soft tissue tumors of the lower extremity. Such data
are typically acquired from large referral populations,
and consequently incorporate a significant referral
bias. The situation is made more complex for the
practicing radiologist in that referral studies are
invariably based on surgical series. Such series include large numbers of superficial subcutaneous
masses that are only infrequently imaged. With these
caveats in mind the prevalence data from a large
retrospective analysis of over 7000 lower-extremity
soft tissue tumors seen in consultation by the Department of Soft Tissue Pathology, Armed Forces Institute of Pathology, is presented to determine the most
commonly encountered soft tissue tumors of the
lower extremity [1,2]. Because of the increased number of malignancies inherent in any referral population, benign and malignant lesions are considered
separately, to reflect more accurately their relative
prevalence. The foot and ankle are separated from the
remainder of the lower extremity in that these lesions
account for only one quarter of all lower-extremity
lesions and show a somewhat different tumor population (Table 1).
Initial evaluation
As with soft tissue lesions elsewhere, the imaging
evaluation of a suspected mass begins with conventional radiographs. Although radiographs are frequently
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 3 3 - 7
992
L.W. Bancroft et al / Radiol Clin N Am 40 (2002) 9911011
Table 1
Soft tissue tumors in a large referral population: prevalence and distribution of diagnoses by age and location
Location
Malignant diagnoses
No. (%)
Benign diagnoses
No. (%)
Age 0 25 years: common lesions by location

Foot and ankle
Synovial sarcoma
Total this location
596
DFSP
Malignant
154
Fibrosarcoma
Benign
442
Clear cell sarcoma
Rhabdomyosarcoma
Angiosarcoma
MFH
Other
Lower extremity
Synovial sarcoma
Total this location
1399
MPNST
Malignant
519
Fibrosarcoma
Benign
880
Liposarcoma
MFH
DFSP
Rhabdomyosarcoma
Other
38 (25)
18 (12)
16 (10)
14 (9)
11 (7)
8 (5)
8 (5)
41 (27)
104(20)
58 (11)
56 (11)
56 (11)
50 (10)
29 (6)
24 (5)
142(27)
Fibromatosis
Granuloma annulare
Hemangioma
GCTTS
Fibrous histiocytoma
Lipoma/lipoblastoma
PNST
Other
Hemangioma
Nodular fasciitis
PNST
Granuloma annulare
Fibromaotsis
Other
100(23)
69 (16)
42 (10)
42 (10)
38 (9)
27 (6)
24 (5)
100(23)
167(19)
128(15)
88 (10)
85 (10)
69 (8)
67 (8)
56 (7)
220(25)
lesions by location
Synovial sarcoma
890
MFH
254
Clear cell sarcoma
636
Liposarcoma
Hemangioendothelioma
DFSP
MPNST
Other
Liposarcoma
2444
MFH
1091
Synovial sarcoma
1353
MPNST
DFSP
Leiomyosarcoma
Chondrosarcoma
Other
64 (25)
44 (17)
29 (11)
19 (7)
16 (6)
15 (6)
13 (5)
54 (21)
299(27)
296(27)
105(10)
91 (8)
59 (5)
51 (5)
45 (4)
145(13)
Fibromatosis
PNST
GCTTS
Hemangioma
Chondroma
Lipoma
Other
Lipoma
Nodular fasciitis
PNST
Myxoma
Hemangioma
Fibromatosis
Other
134(21)
95 (15)
70 (11)
55 (9)
45 (7)
35 (6)
32 (6)
170(27)
304(22)
173(13)
171(13)
159(12)
101(7)
64 (5)
42 (3)
339(25)
lesions by location
Kaposi sarcoma
501
MFH
224
Leiomyosarcoma
277
Synovial sarcoma
Fibrosarcoma
Chondrosarcoma
MPNST
Other
MFH
1947
Liposarcoma
1363
Leiomyosarcoma
584
Fibrosarcoma
Chondrosarcoma
MPNST
Synovial sarcoma
Other
61 (27)
46 (21)
35 (16)
15 (7)
13 (6)
12 (5)
8 (4)
34 (15)
709(52)
307(23)
128(9)
37 (3)
33 (2)
32 (2)
24 (2)
93 (7)
Fibromatosis
PNST
Lipoma
Chondroma
GCTTS
Granuloma annulare
Other
Lipoma
Myxoma
PNST
Proliferative fasciitis
Nodular fasciitis
Hemangioma
Other
64 (23)
38 (14)
35 (13)
28 (10)
20 (7)
13 (5)
12 (4)
67 (24)
153(26)
105(18)
79 (14)
67 (14)
29 (5)
20 (4)
16 (3)
115(20)
Age 26 55 years: common

Foot and ankle
Total this location
Malignant
Benign
Lower extremity
Total this location
Malignant
Benign
Age 56 and older: common

Foot and ankle
Total this location
Malignant
Benign
Lower extremity
Total this location
Malignant
Benign
Abbreviations: DFSP, dermatofibrosarcoma protruberans; GCTTS, giant cell tumor of tendon sheath; MFH, malignant fibrous
histiocytoma; MPNST, malignant peripheral nerve sheath tumor; PNST, peripheral nerve sheath tumor.
unrewarding, they can provide invaluable information when positive. Radiographs may reveal soft
tissue calcifications, which can be suggestive, and
at times very characteristic, of a specific diagnosis.
For example, they may reveal the phleboliths within
a hemangioma, the juxta-articular osteocartilaginous
masses of synovial osteochondromatosis, or the peripherally more mature ossification of myositis ossificans. Radiographs may reveal an osseous excrescence
that may be masquerading as a clinically suspicious
mass and provide an excellent way to assess coexistent osseous involvement, such as remodeling, periosteal reaction, or overt destruction. A soft tissue mass
may also be the initial presentation of a primary bone
tumor and in such cases radiographs are useful in
identifying the osseous origin of the lesion.
Unlike intraosseous lesions, however, the biologic activity of a soft tissue mass cannot be assessed reliably by its growth rate. A slowly growing
soft tissue mass that may remodel adjacent bone
(causing a scalloped area with well-defined sclerotic margins) may still be highly malignant on
histologic examination.
MRI
MRI has emerged as the preferred modality for
evaluating soft tissue lesions, providing information
for both diagnosis and staging. Diagnosis is formulated on signal intensity, pattern of growth, and other
features that are discussed later [3]. Staging, which
uses the MRI anatomic information to provide a
standard manner in which readily to communicate
the local and distant tumor extent of a malignancy,
also is discussed briefly [4].
A detailed review of imaging techniques is beyond the scope of this article, but some fundamentals
are emphasized. Lesions should be imaged in at least
two orthogonal planes, using conventional T1- and
T2-weighted spin echo MRI pulse sequences in at
least one of these. Standard spin echo images are
most useful in establishing a specific diagnosis, when
possible. It is the most reproducible technique, and
the one most often referenced in the tumor imaging literature. The main disadvantage of spin echo
imaging remains the relatively long acquisition times
for double-echo T2-weighted sequences [5]. Typically, the authors obtain axial T1- and T2-weighted
spin echo images and choose an additional imaging
plane or planes depending on the size and location
of the mass.
Gradient echo imaging techniques may be a useful adjunct in demonstrating hemosiderin, because of
993
its greater magnetic susceptibility, and in general,

susceptibility artifacts related to metallic material,
hemorrhage, and air are accentuated on gradient
echo images [6]. Short tau inversion recovery (STIR)
imaging produces fat suppression and enhances the
identification of abnormal tissue with increased water
content, which is useful to confirm subtle areas of
soft tissue abnormality [7]. This technique increases
lesion conspicuity [7,8], which is usually not a significant limitation in tumor imaging. STIR imaging
typically has lower signal-to-noise than does spin
echo imaging, and is also more susceptible to degradation by motion [5,7]. Lesions are generally
well seen on standard imaging and in the authors
opinion, STIR imaging tends to reduce the variations
in signal intensities identified on conventional spin
echo MRI, which are most helpful in tissue characterization (Fig. 1).
Fat suppression on T2-weighted images is useful
to increase lesion-to-background signal intensity differences for high signal intensity lesions within
the marrow or fatty soft tissue [5]. Fat-suppression
imaging is also useful in decreasing or eliminating the
MRI signal from fat, allowing increased conspicuity
of lesions containing paramagnetic substances (eg,
methemoglobin) on T1-weighted images, and in
identifying contrast enhancement. As with STIR
techniques, fat-suppressed T2-weighted imaging
decreases variations in tumor signal intensities, and
the authors do not use this in place of conventional
T2-weighted images.
In general, a small field of view is preferred;
however, the field of view must be large enough to
evaluate the lesion and allow appropriate staging.
When an extremity is being evaluated, it is not
usually necessary to obtain the contralateral extremity
for comparison, unless no lesion is detected on initial
sequences. It is useful to place a marker over the
area of clinical concern, to ensure it is appropriately
imaged. This becomes important in evaluation of
lesions, such as a subcutaneous lipoma or lipomatosis, in which the lesion may not be appreciated as
distinct from the adjacent adipose tissue. When small
superficial lesions are being evaluated, care should be
taken to ensure the marker or patient position does
not compress the mass.
Contrast enhancement is often not required; however, the authors find it especially useful in the
detection of underlying tumors in the presence of
hematoma. In such cases, contrast-enhanced imaging
may reveal a small tumor nodule, which may not be
apparent within hemorrhage on conventional MRI
(Fig. 2) [9,10]. Gadolinium-enhanced imaging may
also be useful to differentiate solid from cystic (or
994
Fig. 1. Subcutaneous granuloma annulare in the lower leg of a 5-year-old girl. Corresponding axial T1-weighted (A) and
T2-weighted (B) spin echo MRIs show a relatively well-defined crescentic lesion (arrow) of intermediate signal intensity with
a superficial rind of high signal intensity (arrows in B), typical of granuloma annulare. Postcontrast imaging (C) shows
modest homogeneous enhancement (arrow). The characteristic signal intensities are obscured on short tau inversion recovery
(D) sequence.
necrotic) lesions, and to identify cystic or necrotic

areas within solid tumors, a distinction that may
be difficult or impossible to make on conventional
T2-weighted images.
MRI diagnosis
Despite the superiority of MRI in identifying, delineating, and staging soft tissue tumors, it remains
limited in its ability to characterize soft tissue masses
precisely, with most lesions demonstrating prolonged
T1 and T2 relaxation times [11,12]. There are instances, however, especially in the lower extremity, in
which a specific diagnosis may be made or strongly
suspected. These include benign vascular lesions,
lipomatous lesions, benign synovial proliferations, peripheral nerve sheath tumors, fibromatosis, and certain tumor-like lesions. Clearly, the percentage of
cases in which MRI may correctly suggest the diagnosis varies with the referral population. In general, a
correct histologic diagnosis can be reached on the
basis of imaging studies in approximately one quarter
to one third of cases [13]. Significantly higher levels
of accuracy may be achieved with common lesions
and by using a systematic approach to evaluation.
Hemangiomas
Hemangiomas are benign angiomatous lesions that
histologically resemble normal blood vessels. This
vascular lesion is one of the most common soft tissue
995
Fig. 2. Recurrent leiomyosarcoma in the proximal lower leg in a 66-year-old man, 3 months following surgical excision
complicated by postoperative hematoma. Corresponding axial T1-weighted (A) and T2-weighted (B) spin echo MRIs show a
subcutaneous mass with a superficial component (arrowhead) demonstrating increased signal intensity suggesting subacute
hemorrhage. The deeper area (arrow) shows a nonspecific signal intensity and definitive distinction between recurrent tumor and
evolving hemorrhage could not be made. Postgadolinium image (C) shows intense enhancement in the deep component (arrows)
confirming the diagnosis of recurrent leiomyosarcoma.
tumors and is the most common tumor of infancy and

childhood [14]. Hemangiomas are most common in
the first three decades and are more common in
females. Clinically, 98% of patients present with a
mass [15]. The mass may change in size and superficial lesions have a bluish skin discoloration. Approximately 60% of cases present with pain either at
rest or with activity. It has been postulated that pain
associated with intramuscular hemangiomas is caused
by a hypoxic effect of the adjacent musculature, and
may be accentuated by exercise [15].
Lesions may be divided into capillary, cavernous,
venous, and arteriovenous subtypes, depending on the
predominant type of vascular channel. Histologically,
hemangiomas can also include fat, smooth muscle,
fibrous tissue, bone, hemosiderin, and thrombus. Fat
is most commonly identified with cavernous heman-
giomas and this fatty overgrowth is believed to represent a reactive phenomenon, as opposed to a true
neoplastic component [15]. Hemangiomas may be
superficial or deep, with deep-seated lesions more
frequently being a diagnostic dilemma. This discussion is limited to intramuscular hemangioma, because
it is the lesion most likely to present clinically as a soft
tissue mass and the lesion most likely to be imaged.
Radiographs can be normal, demonstrate a soft
tissue mass, phleboliths (30% to 50% of all cases
and up to 90% of deep muscle hemangiomas), or
curvilinear or amorphous calcifications [8]. Hemangiomas may also involve the adjacent bone, evidenced by channel-like lucencies, or occasionally
cause bone overgrowth from hyperemia or rarely
periostitis. MRI is the imaging modality of choice
in the diagnosis and evaluation of extent of the
996
hemangioma. Lesions are poorly defined masses

that are hypointense or isointense to muscle on T1weighted images. Areas of high T1-weighted signal
have been attributed to reactive fatty overgrowth
or slow-flowing blood [16]. Hemangiomas are typically well-marginated, heterogeneous masses on
T2-weighted images with markedly hyperintense signal corresponding to vascular channels (Fig. 3) [15].
Cavernous hemangiomas tend to have larger vascular spaces, whereas arteriovenous hemangiomas have
serpentine vascular channels. Fatty components are
isointense to subcutaneous fat on all pulse sequences
and phleboliths are signal voids. Lesions that are
smaller than 2 cm have been reported to be more
homogeneous [15]. The combination of mass lobulation, septation, and central low-signal-intensity dots
are all more common in hemangiomas when compared with malignant soft tissue masses [15]. Hemangiomas typically demonstrate marked enhancement
after gadolinium administration.
Lipoma
The lipoma is the most common soft tissue tumor.
Tumors are composed of mature adipose tissue, and
believed to be true mesenchymal neoplasms. Lesions
are benign and usually solitary [17]. Although most
cases are spontaneous, there has been documentation
of genetic alterations in patients with single and
multiple lesions. Cytogenetic analysis of solitary lipomas has demonstrated a rearrangement of the mid
portion of chromosome 12 in some patients [18].
About one third of patients with multiple tumors have

familial multiple lipomas.
Lipomas are categorized by their location as either
superficial (subcutaneous) or deep. Superficial lipomas are much more common than deep lesions.
Patients typically present with a slowly growing mass
that usually stabilizes in size after an initial period of
growth. Tumors are usually asymptomatic, although
they can produce pain, tenderness, or compression of
peripheral nerves. Most lesions are small; 80% are
less than 5 cm [19]. In the lower extremity, superficial
lesions are found most commonly in the upper thigh
and are unusual in the foot [20]. Deep lipomas are
less well defined, more variable in shape, and larger
than superficial lipomas [20].
Radiographs may demonstrate a low-density
mass, which shows opacity similar to fat. Mineralization can be seen in associated cartilaginous or osseous
metaplasia, but this is rare, more typically seen in
large lipomas or lesions that have been present for
some time [20]. The lesion typically shows signal
intensity identical to that of subcutaneous adipose
tissue on all pulse sequences, although this may be
altered by fibrous tissue, metaplasia, or involutional
change. In the authors experience the distinction
between lipoma and liposarcoma is usually straightforward, but about 25% of lipomas have sufficient
nonadipose tissue to make this distinction difficult,
and sometimes impossible (Fig. 4). Superficial lipomas may blend imperceptibly with the surrounding
subcutaneous fat on MRI. Intramuscular lipomas may
appear infiltrative and dissect between muscle fibers,
giving the appearance of septations [21].
Fig. 3. Hemangioma in the distal thigh in a 23-year-old woman. Axial T1-weighted (A) spin echo image demonstrates areas of
high signal representing reactive fatty overgrowth (arrows) interdigitating with the vascular elements of the lesion. Axial
T2-weighted (B) spin echo image at the same level depicts markedly hyperintense signal corresponding to vascular channels
(arrowheads). Note intermediate signal fibrofatty tissue between the vascular channels.
997
Fig. 4. Lipoma in the thigh of a 30-year-old man. Anteroposterior radiograph (A) shows a large right thigh fatty mass (arrows),
with a focus of ossification inferiorly (arrowhead). Axial conventional T2-weighted (B) spin echo MRI though the inferior
aspect of the mass depicts the nonadipose component (arrow), corresponding to fat necrosis, and ossification demonstrated
on radiograph.
Benign proliferative lesions

Benign proliferative lesions of the joint, bursa,
and tendon sheath are common in clinical practice.
The most frequent of these is the localized giant cell
tumor of tendon sheath (nodular tenosynovitis), representing the localized form of a spectrum of benign
synovial proliferations, which when diffuse and intraarticular is termed pigmented villonodular synovitis
(PVNS) [22].
Giant cell tumor of tendon sheath
Giant cell tumor of tendon sheath is a benign
process in which there is proliferation of round
synovial-like cells, giant cells, inflammatory cells,
and xanthoma cells along tendon sheaths, occurring
in either a localized or diffuse form [23]. The localized form is often termed nodular tenosynovitis, and
as its name implies, this lesion clinically presents as a
nodular or polypoid mass, with a peak incidence in
the third to fifth decades and a slight female predominance (1.5 to 2.1:1) [24]. In its diffuse form,
the lesion is less well defined and grossly characterized by shaggy, beard-like projections (representing
hypertrophic synovial villi). Clearly, the distinction

between the localized and diffuse form is blurred on
occasion, and a function of its gross and microscopic
appearance. The term PVNS is usually reserved for
those cases in which there is diffuse involvement of a
large joint. The diffuse form of giant cell tumor of
tendon sheath usually occurs adjacent to large
weight-bearing joints, and in most cases represents
extra-articular extension of PVNS [23]. Ushijima et al
[24], in reporting a 20-year experience with 207
cases, found nodular tenosynovitis to be more than
seven times more common than PVNS. They also
noted 5% of lesions occurred in the foot and ankle,
with greatest involvement of the first and second
digits, and 4% occurred in the knee. Cases have also
been reported arising from the anterior knee adjacent
to Hoffas fat pad and from the posterior cruciate
ligament [25].
Patients may present with soft tissue swelling or a
slowly enlarging soft tissue mass usually less than 2 to
4 cm in size [24]. Lesions are usually painless,
although they can be associated with pain and aggravated by activity [24]. Lesions may progress slowly or
remain stable for years. Radiographs of giant cell
tumor of the tendon sheath most commonly dem-
998
onstrate a soft tissue mass [26]. Radiographs may be

normal or display various findings, however, such as
pressure erosions (15% of cases), cystic or degenerative change; periosteal reaction, calcifications, or intraosseous invasion in a small percentage of cases
[24]. Lesions in the feet and ankles are more likely to
cause pressure erosions because of the dense ligaments and tendency to prevent outward growth [24].
MRI typically demonstrates a nonspecific, welldefined mass adjacent to a tendon, isointense with
muscle on T1-weighted images and more heterogeneous and isointense or hypointense to fat on
T2-weighted MRI spin echo images [23]. Enhancement may be intense after gadolinium administration
(Fig. 5) [23].
Pigmented villonodular synovitis
Pigmented villonodular synovitis is a diffuse synovial-based process that has a similar pathologic
appearance as giant cell tumor of the tendon sheath.

Patients usually present in their third or fourth decade, and there is a female predominance. Patients
usually present with mechanical pain, swelling, or
decreased range of motion [27]. Patients typically
present with a serosanguinous or xanthochromic
effusion, more commonly in the knee than in tighter
joints. PVNS is usually a monoarticular process and
involves the large joints, approximately 80% of
which occur in the knee. The hip, ankle, shoulder,
and elbow are less commonly involved joints. Recurrence rates have been reported at about 50% in the
literature [28].
Radiographs may be normal, demonstrate a noncalcified soft tissue mass, effusion, or bone erosion.
Well-defined erosions with thin sclerotic borders can
be present in up to 50% of cases, being more common in joints with tight capsules, such as the hip [28].
Osseous erosions typically occur on both sides of
the joint and are multiple. Joint spaces and bone
Fig. 5. Giant cell tumor of tendon sheath in the flexor tendon of the third toe in a 15-year-old girl. MRIs show a wellcircumscribed ovoid soft issue mass (arrows) with an intermediate signal. Axial T1-weighted (A) spin echo MRI shows the
lesion to be isointense with muscle, and more heterogeneous and relatively isointense to fat on T2-weighted images (B). Sagittal
(C) images show the intense enhancement after gadolinium administration.
mineralization are commonly preserved. MRI is the

current imaging modality of choice for the diagnosis
of PVNS. Classically, this disease presents as a
heterogeneous process that involves the synovium
diffusely. Tumor nodules are typically isointense to
hypointense relative to skeletal muscle on T1- and
T2-weighted images. There may be scattered areas
of high T1-weighted signal and intermediate T2weighted signal, however, because of high lipid-laden
macrophage content (Fig. 6). Less likely, lesions may
be cystic on imaging and adjacent osseous edema
may be present. Gradient echo imaging may be
helpful in eliciting the blooming artifact because
of the paramagnetic effect of hemosiderin in the soft
tissues. Radiologic calcification within the mass has
been reported [29], but is extremely unusual and
should suggest an alternative diagnosis.
Benign peripheral nerve sheath tumors
Benign peripheral nerve sheath tumors are divided
into schwannomas (neurilemmomas) and neurofibromas. Schwannomas are well-encapsulated tumors that
arise from the Schwann cells of the nerve sheath.
They are slightly less common than neurofibromas
and comprise about 5% of all benign soft tissue
tumors [30]. Schwannomas occur most frequently
between the ages of 20 and 50 years and there is an
equal gender distribution. There is an association of
patients with schwannomas and type 2 neurofibromatosis. Tumors are usually solitary (except in the
presence of neurofibromatosis); slowly growing; and
less than 5 cm [30]. If large nerves are affected, the
tumor is eccentric with the nerve displaced to the
periphery of the mass. Because the nerve is displaced
999
rather than involved, the associated nerve can usually

be spared.
Neurofibromas are nonencapsulated, often infiltrative neoplasms comprised of a single cell line of
Schwann cells. Reactive fibroblasts, mast cells, perineural cells, and collagen are also present. They
represent more than 5% of all benign soft tissue
tumors [30]. Ninety percent are solitary and most
are not associated with type 1 neurofibromatosis
(NF1). There is an equal gender distribution. Patients
usually present in the third and fourth decades with
a slowly growing, painless mass, less than 5 cm in
size. Neurofibromas of large nerves more commonly
present with neurologic symptoms. Pathologically,
these tumors cannot be separated from the involved
nerve, and resection requires the involved nerve to
be sacrificed. Neurofibromatosis type 1 and type 2
genes are located on chromosomes 17 and 22,
respectively, and both of these genes encode tumorsuppresser proteins that normally control cell proliferation [18].
Schwannomas and neurofibromas have overlapping radiologic features, although differentiation between the two is sometimes possible. Radiographs
may be normal or demonstrate an oval or fusiform,
deep or superficial soft tissue mass. Mineralization
with the mass is uncommon, although more likely in
large tumors. Mineralization can be faint and amorphous, have mature areas of osteoid with cortex and
trabeculae, or chondroid areas with arcs and rings
[30]. Both schwannomas and neurofibromas typically
demonstrate a fusiform mass, often displacing the
associated neurovascular bundle. The nerve can often
be seen entering and exiting the mass as a tubular
structure on longitudinal images, especially when
Fig. 6. Pigmented villonodular synovitis (PVNS) in the knee in a 38-year-old woman. Axial T2-weighted (A) spin echo MRI
shows low-signal intra-articular nodules (arrows). The low signal intensity foci correspond to susceptibility artifact related to
hemosiderin deposition. Nodules are virtually imperceptible on corresponding axial T1-weighted (B); however, there is a small
focus of increased T1-weighted signal (arrowhead) within a lateral nodule, consistent with high lipid-laden macrophage content.
1000
larger nerves are involved [31,32]. Larger peripheral

nerves also demonstrate a split-fat sign [30]. This sign
reflects the nerve amid the rim of intact fat surrounding the growing tumor. In addition, the fascicular
sign is a term used to describe small ring-like areas
within the tumor when imaged in cross-section: this
reflects the fascicular bundles of tissue observed
pathologically in neurogenic tumors (Fig. 7) [30].
Differentiation between schwannomas and neurofibromas can sometimes be made based on the posi-
tion of the nerve relative to the tumor and the MRI

signal characteristics. Classically, the nerve is eccentric to the tumor in schwannoma, and is centrally
located or obliterated by the mass in neurofibroma
[30]. Schwannomas typically demonstrate intermediate to moderately high T1-weighted signal and heterogeneously high signal on T2-weighted sequences
[32]. Peripheral neurofibromas more commonly have
a more defined internal architecture, termed the target
sign. The target sign is evidenced by low central
Fig. 7. Schwannoma of the common peroneal nerve in a 49-year-old woman. Intraoperative photograph (A) of a schwannoma
displays the well-encapsulated tumor (arrow), with entering and exiting nerves (arrowheads). Preoperative coronal T1-weighted
(B) spin echo MRI shows the corresponding eccentric tumor (arrow), with peripheral displacement of the entering and exiting
nerves (arrowheads). Note the split-fat sign about the rather large peripheral nerve, indicative of a rim of intact fat surrounding
the growing tumor. Axial T2-weighted (C) spin echo MRI through the schwannoma demonstrates the subtle fascicular sign, a
term used to describe small ring-like areas within the tumor, corresponding to the fascicular bundles imaged in cross-section.
signal intensity and higher peripheral signal on conventional T2-weighted spin echo MRIs (Fig. 8).
Findings correspond histologically to central fibrosis
and dense collagen.
Granuloma annulare
Granuloma annulare is an uncommon benign inflammatory dermatosis characterized by the development of localized or generalized papules, often fused
into an annular arrangement [33]. Females are more
often affected than males (2.5 to 1) and two thirds
of patients present in the first three decades of life
[33]. Treatment is often not required, because most
lesions spontaneously resolve. There are several
forms of granuloma annulare: generalized, perforating, and subcutaneous. The subcutaneous form of
granuloma annulare presents as a nonspecific subcutaneous mass. In these cases, imaging evaluation is
frequently done to characterize and stage the lesion
further, and it is the subcutaneous form that is encountered by radiologists. The subcutaneous form
also differs from other types of granuloma annulare
in that it is seen almost exclusively in children [34].
This form has also been termed deep granuloma
annulare or subcutaneous palisading granuloma
[34]. The lesion is histologically indistinguishable
from the subcutaneous nodules seen in rheumatoid
arthritis and may also be referred to as pseudorheumatoid nodule or benign rheumatoid nodules [34,35].
Multiple lesions have been reported with varying
frequencies, and in one series were seen in as many
as 60% of patients [36].
1001
The radiologic appearance of subcutaneous granuloma annulare is characteristic, typically demonstrating a nodular soft tissue mass involving the
subcutaneous adipose tissue [77]. MRIs show a
mass with relatively decreased signal intensity on
all pulse sequences and variable, but generally welldefined margins. Poorly defined increased signal is
seen at the periphery of the lesion in about half of
cases. There is extensive diffuse enhancement following gadolinium administration (see Fig. 1). Radiographs show a soft tissue mass or soft tissue swelling
without evidence of bone involvement or mineralization [37].
Fibromatoses
The fibromatoses are a family of benign fibrous
tissue proliferation that has biologic behaviors between benign fibrous lesions and fibrosarcoma (L18).
Patients usually present in the first three decades of
life with a painless soft tissue mass. These lesions
have an infiltrative pattern of growth and, consequently, a high recurrence rate after resection. The
fibromatoses may be divided into two categories
based on their locations: superficial and deep. The
superficial form in the foot is termed plantar fibromatosis, taking origin from the plantar aponeurosis.
The deep (musculoaponeurotic) fibromatoses involve
the deep structures, especially the muscles of the
trunk and extremities. These lesions are usually larger
with a more aggressive biologic behavior. This latter
form is also called extra-abdominal desmoid tumor or
aggressive fibromatosis.
Fig. 8. Neurofibroma in a 74-year-old woman. Axial T2-weighted (A) spin echo MRI through a neurofibroma of the peroneal
nerve (arrows) elicits the target sign. The target sign has been described showing low central signal intensity and higher
peripheral signal on conventional T2-weighted MRIs, corresponding histologically to central fibrosis and dense collagen.
Corresponding enhanced axial T1-weighted (B) shows intense enhancement in the central cellular portion of the lesion with no
significant enhancement in the more peripheral myxoid portion of the lesion.
1002
Plantar fibromatosis is characterized by nodular

fibrous proliferation along the plantar aponeurosis
[38]. This typically occurs along the non weightbearing areas. The incidence of plantar fibromatosis
increases with age and there is a male predominance.
Lesions may be bilateral in 20% to 50% of cases, but
are usually metachronous [38]. Patients typically
present with a subcutaneous nodule in the mid or
medial sole of the foot, and may complain of pain
after prolonged standing or walking. MRI features of
plantar fibromatosis have been well documented with
lesions typically demonstrating a heterogeneous signal intensity that is isointense to minimally hyperintense to skeletal muscle on T1- and T2-weighted
images [2]. In the authors experience, lesions not
uncommonly demonstrate significant areas of signal
intensity similar to that of fat on T2-weighted images.
Lesions tend to be well defined against the adjacent
subcutaneous adipose tissue with poorly defined
margins against the adjacent muscle [2]. Enhancement is variable, but at times quite extensive (Fig. 9).
The deep or musculoaponeurotic fibromatosis

demonstrate a wider spectrum of signal characteristics [39]. Most tumors are isointense or slightly
hyperintense to muscle on T1-weighted images and
relatively isointense to fat on T2-weighted images.
Lesions are typically heterogeneous with corresponding areas of low signal on both T1- and T2-weighted
images, reflecting the densely collagenous portions
of the tumor. Less commonly lesions demonstrate
decreased signal intensity on T2-weighted images,
or signal intensity between that of muscle and fat.
T2-weighted signal intensity greater than that of fat
has been reported, but is rare [38,40]. Moderate to
marked enhancement has been demonstrated. Margins are variable but have been reported to be well
defined in as many as 78% of cases [38].
Nodular fasciitis
Nodular fasciitis is a benign, self-limiting reactive
process composed of proliferating fibroblasts. Pa-
Fig. 9. Plantar fibromatosis in a 59-year-old man. Coronal T1-weighted (A) and T2-weighted (B) spin echo MRIs show a
relatively well-defined lesion (asterisk) arising from the medial aspect of the plantar aponeurosis, with intermediate signal
intensity. Following contrast administration (C), the lesion (asterisk) enhances intensely.
tients most commonly present in the third and fourth

decades and there is an equal gender distribution.
Lesions are categorized by their location into subcutaneous (most common); intramuscular; and fascial
subtypes [41]. Lesions are uncommon in the foot and
ankle, and overall about 15% of cases occur in the
lower extremity. Patients present with a rapidly growing nodule, with half having pain or tenderness. Most
lesions are solitary, typically less than 2 cm in size.
Because the lesion is most frequently subcutaneous
(3 to 10:1), there is scant literature on its imaging
appearance [41].
Limited reports of the MRI features describe a
relatively well-defined nodule without associated
edema. Subcutaneous and fascial lesions may show
an irregular stellate appearance. Lesions typically are
mildly inhomogeneous and slightly hyperintense to
skeletal muscle on T1-weighted images and homogeneously hyperintense on T2-weighted images.
Considerable variation is seen and lesions may be
homogeneously hypointense on all pulse sequences.
Similar variations in enhancement may also be noted,
but intense enhancement has been most frequently
seen in the authors experience [41].
Malignant fibrous histiocytoma
Malignant fibrous histiocytoma (MFH) is the most
common soft tissue sarcoma in the adult, comprising
20% to 30% of all soft tissue sarcomas. There is a
male predilection (1.5 to 2:1), with a peak incidence
in the fifth and sixth decades, although the lesion
occurs in patients of all ages [1]. Sites of involvement vary greatly with the potential to be found in
any organ; however, 70% to 75% involve the extremities, with the lower extremity involved in 50%
[1,42,43]. Two thirds of lesions are deep intramuscular in location.
Patients typically present with a painless enlarging soft tissue mass. MFH may be radiation induced and is the most common postradiation
sarcoma. It may also be associated with prior shrapnel injury or can occur next to metallic orthopedic
hardware, such as joint replacements [44 46]. The
storiform-pleomorphic MFH is the most common
subtype and is the prototypical MFH, histologically characterized by spindle cells arranged in a
cartwheel-storiform growth pattern [47]. Myxoid
MFH, also referred to as myxofibrosarcoma, is the
second most common subtype and contains mucoid
material rich in extracellular mucopolysaccharide
and hyaluronic acid [47]. Giant cell MFH may be
referred to as malignant giant cell tumor of soft
parts and contains prominent osteoclast-like giant
1003
cells and frequently demonstrates areas of necrosis,

hemorrhage, and focal osteoid formation [47]. Inflammatory MFH may also be called xanthosarcoma
or malignant xanthogranuloma. As the name implies
it contains inflammatory and foam cells and may be
accompanied by fever and leukocytosis, simulating
infectious process [47]. The angiomatoid MFH has
been reclassified as angiomatoid fibrous histiocytoma by the World Health Organization Committee
for the Classification of Soft Tissue Tumors, reflecting the rarity of metastases and excellent overall
prognosis [48]. This relatively rare extremity lesion
is usually seen in the subcutaneous tissues of children and young adults and is not discussed.
Radiographs of patients with MFH typically reveal
an indeterminate soft tissue mass, with mineralization detected in 5% to 20% of cases [49]. Deep
intramuscular lesions may cause extrinsic erosion of
adjacent long bones, a feature not commonly seen in
other soft tissue sarcomas with the exception of
synovial sarcoma [46]. MRI typically demonstrates
a large, lobulated, well-circumscribed mass with
intermediate signal intensity on T1-weighted images and high signal intensity on conventional
T2-weighted images. Lesions are usually heterogenous on all pulse sequences, reflecting the variable
histologic patterns within the tumor [46]. Nonnecrotic areas of the tumor usually demonstrate marked
enhancement. Lesions are often large and lobulated,
frequently with a relatively well-defined margin
reflecting a surrounding pseudocapsule (of compressed normal tissue) [46]. Occasionally, lesions
may show intermediate signal intensity on T2-weighted images.
Liposarcoma
Liposarcoma is the second most common soft
tissue sarcoma after MFH, accounting for 16% to
18% of all malignant soft tissue tumors [1]. Most
patients present in the fifth or sixth decades of life,
with rare involvement in children [1]. Liposarcomas
are most commonly seen in the extremity, especially
the thigh, accounting for 50% of lower-extremity
cases. Most patients present with a painless soft
tissue mass; however, pain is reported in 10% to
15% of cases [50]. The imaging appearance of
liposarcoma and prognosis varies with histologic
subtype and degree of differentiation. There are five
histologic subtypes: (1) well differentiated, (2) myxoid, (3) round cell, (4) pleomorphic, and (5) dedifferentiated. It is most convenient to place them into
three distinct groups as described by Weiss and
Goldblum [51]: (1) well-differentiated and dediffer-
1004
entiated, (2) myxoid and round cell, and (3) pleomorphic. Well-differentiated liposarcoma is the most
common liposarcoma and is similar to lipoma both
grossly and histologically. It is a low-grade tumor
with a tendency to recur locally but no propensity to
metastasize. The terms well-differentiated liposarcoma and atypical lipoma are sometimes used
interchangeably. In accordance with the suggestion
of the World Health Organization, however, the
authors use the term atypical lipoma only for
subcutaneous extremity lesions, reserving the term
well-differentiated liposarcoma for lesions with similar histologies in all remaining sites [52]. The
dedifferentiated liposarcoma is an interesting variant
of the well-differentiated liposarcoma, being defined
as a bimorphic neoplasm in which a histologically
different high-grade sarcoma is juxtaposed to the
well-differentiated liposarcoma [53,54]. Dedifferentiated liposarcoma is unusual outside the retroperitoneum, but being reported with increasing
frequency [55 57].
Although the myxoid and round lesions are distinguished by the World Health Organization Classification of Soft Tissue Tumors, it is accepted that
they represent ends of a common spectrum [52]. To
emphasize this, some refer to round cell liposarcoma
as poorly differentiated myxoid liposarcoma [52].
The myxoid subtype is a low-to-intermediate grade
lesion, whereas the round cell subtype is a histologically similar, more cellular, high-grade lesion. These
lesions are more common in the extremities, especially the thigh. The pleomorphic liposarcoma is
the least common type, representing 10% to 15% of
all liposarcomas [51].
The imaging appearance of liposarcoma reflects
its gross morphology. Radiographs typically identify
a nonspecific soft tissue mass. Fatty components may
be seen, and calcification is infrequent, reported in
less than 10% of cases. MRI of well-differentiated
liposarcoma reveals a heterogeneous lipomatous
mass, resembling a lipoma, with nonadipose septal
and swirled or irregular nodular areas with nonspecific signal intensities [58 62]. Variable contrast
enhancement patterns have been described for the
nonadipose component (Fig. 10) [58,60]. Myxoid,
pleomorphic, and round cell liposarcomas usually
contain significantly less fat and only about half,
and some estimate three quarters, of these tumors
demonstrate fat radiologically [20]. About 20% of
myxoid liposarcomas may demonstrate signal characteristics simulating a cyst [63]. Dedifferentiated
liposarcoma is seen as a bimorphic neoplasm containing areas of well-differentiated liposarcoma with
a juxtaposed nonlipomatous mass [56].
Leiomyosarcoma
Leiomyosarcoma is a malignant tumor of smooth
muscle differentiation. It accounts for 9% of soft
tissue sarcomas and is the third most common lesion
following MFH and liposarcoma [1]. It is estimated
that between 12% and 41% of leiomyosarcomas
occur in the peripheral soft tissues, with the thigh
as the most common location [1]. Leimyosarcomas
tend to occur in middle age to older adults with a
median age in the fifth and sixth decades, and are rare
in children. Peripheral soft tissue lesions have a male
predilection, whereas retroperitoneal tumors are more
common in female patients. Overall, male and female
patients are equally affected [64]. The prognosis is
guarded with an overall median 5-year survival of
35% and a median survival of 43 months. Large
tumors and retroperitoneal tumors have a worse
prognosis [64].
Radiographs usually demonstrate a nonspecific
soft tissue mass. Calcification is uncommon, as is
invasion of the underlying osseous structures. MRI
demonstrates nonfatty mass frequently with areas of
necrosis [65]. Superficial lesions may be smaller and
more homogenous (see Fig. 2).
Malignant peripheral nerve sheath tumor
Malignant peripheral nerve sheath tumor (MPNST)
accounts for 5% to 10% of all malignant soft tissue
tumors [30]. Previous nomenclature for this tumor
has included neurogenic sarcoma, malignant schwannoma, and neurofibrosarcoma. Any peripheral nerve
may be affected, although major nerve trunks, such
as the sciatic nerves or sacral plexus, are most
commonly involved [66]. MPNST is associated with
NF1 in 25% to 70% of cases [30]. Lesions typically
occur in patients from 20 to 50 years of age, but
occur a decade earlier on average in patients affected with NF1 [30]. Patients often present with
pain or neurologic symptoms, and sudden enlargement of a pre-existing neurofibroma in patients with
NF1 is a worrisome sign for malignant transformation [67]. Up to 11% of cases may be radiation
induced with a latency period of 10 to 20 years
[30]. MPNSTs are high-grade sarcomas and despite
aggressive therapy, local recurrence and metastases
are common [66].
The MPNST are typically large ( > 5cm) with a
fusiform morphology intimately associated with a
major nerve [30]. Radiographs may be normal or
may demonstrate an oval or fusiform soft tissue mass.
Associated soft tissue overgrowth can be seen in
some cases associated with NF1 [30]. Mineralization
1005
Fig. 10. Well-differentiated liposarcoma in the medial distal thigh of a 74-year-old man. Coronal T1-weighted spin echo MRI (A)
shows a large fatty with a prominent focus of nonspecific nonadipose tissue (arrows). Corresponding short tau inversion recovery
images (B) show increased signal intensity that demonstrates heterogeneous enhancement on postgadolinium T1-weighted fatsuppressed image (C). Note background fat has poorly defined nonadipose signal, sometimes referred to as dirty fat.
is uncommon, as is involvement of adjacent bone.

MRI typically demonstrates a mass with low signal
intensity on T1-weighted sequences and high signal
intensity on conventional T2-weighted sequences,
with marked enhancement on postcontrast images
[30]. Homogeneous signal intensity may be seen on
T2-weighted images, with a reverse target sign on
postcontrast imaging, representing central necrosis
and internal hemorrhage [68]. Cross-sectional imaging demonstrates the lesions as fusiform in shape with
tapered ends that are contiguous with the parent
nerve. Many tumors may show a peripheral rim of
fat representing the fat surrounding the neurovascular

bundle. Similar to benign peripheral nerve sheath
tumors, MPNSTs may also demonstrate a split-fat
sign [30]. Muscle atrophy may be seen in the affected
nerve distribution.
Synovial sarcoma
Synovial sarcoma is a relatively common tumor
that accounts for 5% to 10% of all malignant soft
tissue tumors. It occurs mostly in young adults,
typically ages 15 to 35, although it can occur in a
1006
wide age range. The extremities are most commonly

affected, with the lower extremity affected in 60% to
70% of lesions [1]. True intra-articular lesions are
rare; however, intra-articular involvement is seen in
about 10% of cases.
Patients often present with a palpable soft tissue
mass. Metastases are present in 25% of patients at the
time of diagnosis, with lung metastases most common, followed by lymph node and bone lesions.
Local recurrence or metastases is seen in 80% of
patients [69]. The prognosis is guarded because the
median survival after diagnosis is 33 months with a
5-year survival rate of 27% to 55%. Young patients,
small tumors, and lesions with extensive calcification
have a better prognosis [70].
Radiographs may be normal in 50% of patients
with synovial sarcoma. A soft tissue mass is seen in
the remainder with calcification seen in up to one
third of all lesions. Adjacent osseous involvement has

been reported in 10% to 20% of cases. On MRI, the
lesion demonstrates heterogeneous signal intensity
with intensity approximately equal to muscle on
T1-weighted images and increased signal intensity
on T2-weighted sequences (Fig. 11). Evidence of
prior hemorrhage may be seen within the lesion in
up to 40% of cases with fluid-fluid levels seen in 10%
to 25% [71]. Heterogeneous enhancement may be
seen on postgadolinium images. It must be emphasized that although lesions are typically heterogeneous, small lesions may appear quite innocent.
Benign versus malignant

Although there is general agreement on the diagnostic value of MRI in many cases, the issue of
Fig. 11. Synovial sarcoma in the ankle of a 15-year-old boy. Resected gross specimen (A) shows a lobulated soft tissue mass
(arrows), with invasion of the talus. Coronal T1-weighted (B) and corresponding conventional T2-weighted (C) spin echo MRI
depicts the soft tissue mass and osseous invasion.
1007
Fig. 12. Compartments of the lower extremity. Cross-section of the foot (A) showing the medial, central, and lateral
compartments. Cross-section of the mid calf (B) showing the anterior, lateral, posterior, and deep posterior compartments. Crosssection of the mid thigh (C) showing the anterior, posterior, and medial compartments. The skin and subcutaneous tissues are
considered a single separate compartment.
1008
whether MRI reliably can differentiate benign from

malignant is much less clear. One study has suggested
that MRI can differentiate benign from malignant
masses in greater than 90% of cases based on the
morphology of the lesion [72]. Criteria used for
benign lesions included smooth, well-defined margins; small size; and homogeneous signal intensity,
especially on T2-weighted images. Other studies,
however, note that malignant lesions may appear as
smoothly marginated, homogeneous masses and MRI
cannot reliably distinguish benign from malignant
processes [3,13]. This discrepancy likely reflects
differences within the studied populations.
When MRI of a lesion is not sufficiently characteristic to suggest a specific diagnosis, a conservative approach is warranted. Malignancies, by virtue of
their very nature and potential for autonomous
growth, are generally larger and more likely to
outgrow their vascular supply with subsequent infarction and necrosis and heterogeneous signal intensity
on T2-weighted spin echo MRIs. Consequently, the
larger a mass is, the greater its heterogeneity, the
greater is the concern for malignancy. Only 5% of
benign soft tissue tumors exceed 5 cm in diameter
[73,74]. In addition, most malignancies are deep
lesions, whereas only about 1% of all benign soft
tissue tumors are deep [73,74]. Although these figures are based on surgical not imaging series, these
trends are likely still valid for radiologists.
When sarcomas are superficial, they generally
have a less aggressive biologic behavior than do deep
lesions [75]. As a rule, most malignancies grow as
deep space-occupying lesions, enlarging in a centripetal fashion [75], pushing rather than infiltrating
adjacent structures (although clearly there are exceptions to this general rule). As they enlarge, pseudocapsules of fibrous connective tissue are formed
around them by compression and layering of normal
tissue, associated inflammatory reaction, and vascularization [75]. Generally, sarcomas respect fascial
borders and remain within anatomic compartments
until late in their course [75]. It is this pattern of
growth that gives most sarcomas relatively welldefined margins, in distinction to the general concepts
of margins used in the evaluation of osseous tumors.
DeSchepper et al [76] performed a multivariate
statistical analysis of 10 imaging parameters, individually and in combination. These researchers found
that malignancy was predicted with the highest sensitivity when a lesion had high signal intensity on
T2-weighted images, was larger than 33 mm in
diameter, and had heterogeneous signal intensity on
T1-weighted images. The signs that had the greatest
specificity for malignancy included tumor necrosis,
bone or neurovascular involvement, and mean diameter of more than 66 mm.
Staging
The purpose of a staging system is to provide a
standard manner in which to communicate readily the
state of a malignancy; defining the local and distant
tumor extent. Local staging is best accomplished
using MRI, which can depict accurately the anatomic
compartments involved by tumor [4]. Although a
complete review of compartmental anatomy is
beyond the scope of this article, lower-extremity soft
tissue compartments for the thigh, lower leg, and foot
are as shown in Fig. 12. Readers are referred to an
excellent discussion of compartmental anatomy and
its relevance to biopsy and staging by Anderson et al
[4]. Accurate staging is critical for optimum patient
care and planning of percutaneous biopsy. It must be
emphasized that coordination with the orthopedic
surgeon who does the definitive surgery is essential
before biopsy.
Summary
MRI is the preferred modality for the evaluation
of a soft tissue mass following radiography. The
radiologic appearance of certain soft tissue tumors
or tumor-like processes may be sufficiently unique to
allow a strong presumptive radiologic diagnosis. It
must be emphasized that one cannot differentiate
reliably between benign and malignant lesions on
radiologic imaging alone. When a specific diagnosis
is not possible, knowledge of tumor prevalence by
location and age, with appropriate clinical history and
radiologic features, can be used to establish a suitably
ordered differential diagnosis.
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Radiol Clin N Am 40 (2002) 1013 1031
MR imaging in nonneoplastic muscle disorders of the

lower extremity
Joshua M. Farber, MD*, Kenneth A. Buckwalter, MD
Department of Radiology, Indiana University School of Medicine, University Hospital, 550 North University Boulevard,
Room 0615, Indianapolis, IN 46202 5253, USA
More athletes are carrying more muscle than their

frames can support, and therefore the trauma is
greater. You wouldnt believe the Achilles tendon
ruptures, the quadriceps ruptures, the hamstring tears,
the massive rotator cuff tears, the tearing of the biceps
muscles at the elbow joints. Theres just too much
mass for the body to handle.
James Andrews, MD [1]
The quote by Andrews refers to athletes and the

recent surge in anabolic steroid use to enhance athletic
performance. The stories of such drugs and other
performance enhancers increasingly find their way
into the popular press. Including the article previously
referenced, Sports Illustrated alone has had three
articles about athletic enhancement (the other two
articles concerned insulin hormone growth factor and
genetic engineering) in the past 12 months, and, as
Andrews points out, the use of these substances and the
concomitant injuries increasingly involves younger
athletes in high school and junior high school.
Radiologists are seeing more patients with these
types of injuries, typically for MRI. This imaging
needs to address the possibility of muscle or tendinous injuries, particularly in the appropriate patient
population. But not all myotendinous injuries occur
in overtuned athletes, and not all muscle imaging
involves diagnosing tears or strains. The approach to
all conventional MRI of muscle, however, is similar:
sequences that are fluid and blood sensitive should be
* Corresponding author.
E-mail address: jofarber@iupui.edu (J.M. Farber).
used; sequences with high spatial resolution should

be used; a large enough area must be covered to
include proximal and distal injuries or disease of a
muscle group; and multiple planes are helpful in
localizing abnormalities.
This article discusses the techniques for optimizing MRI of muscle in the lower extremity, and
reviews and demonstrates tears of these muscles and
other familial or acquired disorders of these structures, some of which may mimic muscle tears clinically. Finally, new MRI techniques that analyze
muscle at the molecular level are introduced.
MRI technique
MRI of the muscles of the lower extremities is
similar to imaging other regions of the body with
some exceptions. Because muscle injuries can present
with symptoms remote from the actual site of tear, it
is helpful to begin an examination for this indication
using a coronal short tau inversion recovery (STIR)
locator with the largest field of view available on the
scanner (nominally 45 to 50 cm). Using modern fast
spin echo pulse sequences, this can be accomplished
in less than 2 minutes. For large field-of-view applications, STIR is superior to fat-saturation imaging.
Both short-axis (transverse) and long-axis (sagittal or
coronal) views of the region of interest must be
obtained. Transverse imaging is critically important
because the individual muscle groups are best identified in this plane. The coronal plane is particularly
useful when performing a survey of the major muscle
groups, required when an inflammatory myopathy is
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 4 9 - 0
1014
J.M. Farber, K.A. Buckwalter / Radiol Clin N Am 40 (2002) 10131031
1015
Fig. 2. Right iliopsoas tear in a 35-year-old man. (A) Axial T2-weighted image (5700/117) demonstrates fluid around the distal
iliopsoas muscle belly. (B) Sagittal T2-weighted image (4590/117) demonstrates fluid about the iliopsoas myotendinous junction
and increased signal within the distal muscle fibers. The findings indicate a strain of the iliopsoas at the myotendinous junction,
which is a typical location for such an injury.
suspected. Imaging in the coronal plane covers a

wider region with thinner slices than imaging the
same region in the axial plane and enables simultaneous visualization of both sides. The sagittal plane is
useful when imaging muscle tears because the relevant anatomy of the myotendinous junction usually
is displayed best in this orientation.
A T1-weighted spin echo or T1-weighted spoiled
fast gradient echo sequence is important to visualize
the anatomy. Because fat is bright on T1-weighted
images, this sequence is useful to assess for fatty
atrophy that indicates an old injury or chronic muscle
denervation. Because muscle edema, inflammation,
or hemorrhage is best demonstrated with fluid-sensitive sequences, T2-weighted imaging with fat suppression or STIR imaging also is recommended.
For fluid-sensitive sequences the authors favor the
use of inversion recovery (IR) imaging because it is
generally more reliable than fat saturation. Fast spin
echo sequences are recommended to reduce imaging
times. For STIR imaging at 1.5 T, an echo time (TE)
of 40 to 50 milliseconds and a TI of 150 milliseconds
produces high-quality images with intense fat suppres-
sion. The use of a shorter TE time may obscure muscle

edema because the muscles are brighter than they are
with the longer TE technique. The use of a very long
TE (eg, 100 milliseconds) degrades image quality by
lowering the signal-to-noise ratio. If the intense black
fat of STIR is objectionable, one can use a modified
IR technique with a longer TE (100 milliseconds) and
shorter TI (110 milliseconds). Because the fat suppression is less intense, these parameters produce
images that preserve the interface between muscle
and fat. This technique also produces images that
demonstrate fluid and edema exquisitely. These
parameters need to be adjusted at lower field strengths
because of the dependence of T1 relaxation times on
magnetic field strength.
Conventional two-dimensional multislice gradient
echo imaging is helpful and can be performed to detect
hemosiderin when an old injury with a chronic hematoma is suspected. Gradient echo sequences also can
be helpful in illustrating tendons, particularly when
mixed imaging parameters are chosen because both
muscle and fat become isointense, sharply outlining
the tendons, which are low in relative signal intensity.
Fig. 1. Gastrocnemius tear in a 37-year-old woman referred with a suspected Achilles tendon tear. (A) Sagittal inversion recovery
image (2700/80/90) from a 0.3-T open unit demonstrates a tear of the proximal medial head of the right gastrocnemius. (B)
Sagittal T1-weighted image (500/20) demonstrates that the injury is proximal to the patients maximal area of pain indicated by a
vitamin E capsule. (C) Sagittal gradient recalled echo image (666/20/30) centered over the ankle demonstrates a normal Achilles
tendon. (D) Sagittal gradient recalled echo image (666/20/30) centered over the ankle demonstrates a large amount of fluid about
the ankle medially, which presumably explains the patients distal symptoms. This case illustrates the importance of imaging the
entire muscle in cases of suspected muscle injury.
1016
Fig. 3. Complete tear of a right rectus femoris muscle bundle with retraction in a 54-year-old man. (A, B) Sagittal modified
inversion recovery (IR) images (3050/45/110) demonstrate a complete tear of the anterior muscle bundle of the rectus femoris at
the myotendinous junction. Note the retraction of the distal muscle and the edema within the retracted fibers. Note also the
uniform and effective fat suppression with IR technique.
The use of intravenous gadolinium contrast agents

is valuable in a variety of situations. When an abscess
is suspected, intravenous contrast can help distinguish fluid from edema. The abscess cavity does
not enhance, but the surrounding hyperemic tissues
enhance. Gadolinium contrast agents may be helpful
in identifying active sites of inflammation in a patient
with an inflammatory myositis; gadolinium enhancement pinpoints the most useful sites for muscle
biopsy. Contrast agents also are useful in the evaluation of soft tissue tumors.
Postcontrast imaging usually is performed with a

fat-suppressed T1-weighted pulse sequence. Because
a survey scan of the thighs or the calves requires
extensive cranial- caudal coverage ( > 35 cm), the fat
suppression is likely to be nonuniform at the top
and the bottom of a stack of axial slices. If the
scanner automatically centers the imaging volume
by moving the scan table in or out, it is possible to
improve the image quality of the postcontrast fatsuppressed scans by dividing the region into an
upper and a lower half and prescribing each region
Fig. 4. High-grade incomplete tear involving the right quadriceps in a 49-year-old man. (A) Axial modified IR image (3033/48/
110) demonstrates increased signal consistent with edema in the vastus lateralis, vastus intermedius, and vastus medialis. (B, C)
Sagittal inversion recovery image (IR) (3700/30/150) and T1-weighted (500/9) images demonstrate a high-grade partial tear at
the myotendinous junction. Note the feathery appearance of the increased signal with IR technique of the distal muscle belly and
that the fluid has intermediate to low signal with T1-weighted imaging.
1017
1018
individually. Each half is done in a separate acquisition and the table movement between scans recenters the patient for optimal fat suppression. This
technique works as well for precontrast fat-suppressed T2-weighted imaging.
Using the approach outlined previously results in
scans diagnostic for muscle disorders. In addition,
this approach allows evaluation of a variety of
processes. As discussed, a scan approach that can

deal with the unexpected is crucial for patient care.
Muscle function
As muscle fibers fire, the muscle bundles that they
comprise may shorten, stay the same, or lengthen. If
Fig. 5. Intramuscular hematoma in the left rectus femoris in a 23-year-old man. (A C) Coronal T1-weighted (500/15),
T2-weighted (3500/117), and inversion recovery images demonstrate a fluid collection with increased signal in the quadriceps.
That this fluid is bright with T1 and T2 weighting suggests an acute hematoma. The fluid appears dark with inversion recovery
imaging because of the T1 shortening effect seen with this technique and blood; this confirms the acuteness of the hematoma.
Chronically, this hematoma may progress to myositis ossificans.
the force exerted against the muscle, the resisting load

[2], is less than the force exerted by the muscle then
the muscle shortens and contracts concentrically. If
the resisting load is equal to the force exerted by the
muscle, then the muscle length does not change and
the muscle contracts isometrically. If the resisting load
is greater than the muscle force, then the muscle
lengthens and contracts eccentrically. Generally,
eccentric muscle contractions exert high forces and
create high tension within the muscle [2 4], and it this
type of contraction that is responsible for muscle tears.
Muscle injuries
Muscle injuries may be direct, the result of a
direct blow, or indirect, the result of stretching.
Muscle tears or strains result from indirect injury
1019
and usually involve eccentric contraction. The contraction may be sudden and maximal or repetitive and
submaximal. Those muscles with a high percentage
of type II (high twitch) fibers and that cross two joints
are most susceptible to injury [4 6]. In the lower
extremity the quadriceps, hamstrings, and gastrocnemius muscles are most prone to injury and must be
imaged fully if injury to them is suspected (Fig. 1).
The sequelae of muscle injuries may be myositis
ossificans if the original injury causes hematoma
formation. As the hematoma resolves, bone is formed
with a characteristic dense rim. Early calcification
may begin 6 to 8 weeks after the initial injury, and
peripheral ossification begins after 4 to 6 months.
Identification of centripetal calcification ensures that
one is dealing with benign myositis ossificans and not
a tumor. The process is self-limiting and can be
followed if necessary with plain radiographs [7].
Fig. 6. Quadriceps myotendinous tear in a 22-year-old man. (A) Sagittal inversion recovery (IR) image (2967/53/150) through
the thigh demonstrates a high-grade partial tear of the quadriceps muscle proximal to the distal myotendinous junction, which is
an atypical site of injury. (B) Sagittal IR image (2700/53/150) through a more distal portion of the thigh demonstrates an intact
myotendinous junction. A small amount of fluid that has tracked down from the tear is seen superficially. Without large field-ofview images, the tear may have been missed.
1020
Sometimes a patient does not feel a muscle injury

at the time of insult. Rather, pain or soreness secondary to muscle strain leads to delayed-onset muscle
soreness. This is a result of eccentric contraction,
usually repetitive, and involves muscles not accustomed to eccentric exercise. On MRI, delayed-onset
muscle soreness produces findings of a low-grade
strain, with fluid seen in the injured muscle. As with
other muscle injuries, the myotendinous area is the
most common site of injury. The process is selflimiting, and with repeated exercise the involved
muscles become immune to the soreness [3,5,8 11].
When a muscle tears or strains, the myotendinous

junction is the most likely site of injury [4,12 14].
This attachment of muscle to ligament transfers force
during contraction and generally is the weakest link
in the muscle-tendon complex. Muscle tears are
ubiquitous, but strains or pulls tend to occur in
athletes during periods of acceleration and deceleration (Fig. 2) [12]. As noted previously, steroid use in
the athlete has made tears and strains more prevalent
[1]. Another risk factor for muscle injury is recent
prior muscle injury or incompletely recovered muscle
strength following a remote injury [4,15 20].
Fig. 7. High-grade partial tear of the left hamstring in a 23-year-old Olympic bobsledder. (A) Axial modified inversion recovery
(IR) image (3500/70/110) demonstrates increased signal in the biceps femoris muscle belly. (B) Coronal modified IR image
(3000/70/110) of both thighs again demonstrates this high signal in the biceps femoris. Note the feathery pattern to the edema
involving the distal fibers and extending to the myotendinous junction. The findings represent an injury to the hamstrings at a
typical location but involving a relatively uncommon muscle.
The role of MRI in muscle injuries is to evaluate

the extent of injury (eg, complete or partial tear) and
the location. Its use is well established [14,21 24].
The tear may appear as an abrupt separation of fibers
or as a feathery shredding; if the tear is complete,
retraction of the muscle belly may be seen [14,22,25].
In addition to the injury, MRI may demonstrate
edema and hemorrhage around the injury site (Figs.
3 5) . As noted in the technique section, one or two
large field-of-view sequences are needed in cases of
suspected muscle injury because the patients pain
may not be at the injury site (Fig. 6). In athletes eager
1021
to return to activity, MRI may serve to evaluate

muscle healing [14] and to predict the convalescence
period [23]. Depending on the muscle group, predictable patterns of injury may be seen. With hamstring
injuries, for example, the biceps femoris is injured
most commonly and the semitendinosus is injured
second most commonly (Fig. 7) [21]. If left untreated,
muscle tears or ruptures may lead to compartment
syndrome [26], which is caused by increased pressure
in an osseofascial compartment.
Compartment syndrome typically occurs in the
anterior and lateral compartments of the lower leg.
Fig. 8. Twenty one-year-old woman with acute onset of pain and suspected right quadriceps muscle tear. (A) Axial modified
inversion recovery (IR) image (3783/96/110) through the thigh demonstrates a large amount of venocentric edema about the
femoral vein, which has a flow void. (B) Coronal IR image (3700/45/110) demonstrates the full extent of the right thigh edema.
(C) Axial fat-saturated, opposed-phased fast multiplanar spoiled gradient recall image (100/2/90) through the right thigh
confirms the signal void in the femoral vein and the diagnosis of deep vein thrombosis. The quadriceps muscles, although
edematous from the deep vein thrombosis, are not injured.
1022
Although the exact pathogenesis of the disorder is

unknown, etiologies include crush injuries, drug
overdose, and any cause of prolonged ischemia
[25]. MRI of compartment syndrome demonstrates
increase signal in the involved compartment with
T2-weighting or IR sequences [26,27]. The findings
usually are unilateral, but may be multicompartmen-
tal [26,28,29]. In some cases, the syndrome is exercise induced and transient, and provocative activity is
needed immediately before MRI to demonstrate the
abnormality. In cases of exercise-induced compartment syndrome, exercise-induced muscle edema does
not return to baseline after 15 to 25 minutes; normal
muscle returns to baseline in this time frame [27].
Fig. 9. Eighty one-year-old man with acute onset of pain and swelling in the right thigh thought to be secondary to a quadriceps
muscle tear. (A, B) Axial spin echo T1- (650/9) and fast spin echo (FSE) T2-weighted (4000/112) images through the right thigh
demonstrate a large area of heterogeneous signal involving the quadriceps muscles. A fluid collection is seen that is bright with
both imaging techniques. (C) Axial multiplanar gradient recall image (750/15.7/30) through the same area also demonstrates the
fluid collection as an area of increased signal. Together, the images indicate the presence of a hemorrhagic liposarcoma; this
diagnosis was confirmed at surgery. (D) Coronal IR image (3500/45/150) demonstrates the extent of the mass and the extent of
the associated hemorrhage. The size of the fluid collection explains the acute onset of symptoms, although it is surprising that the
mass (also quite large) went undetected before the hemorrhage occurred.
1023
Muscle injury mimickers
Muscle atrophy
When a patient presents with a muscle injury, the

complaint usually is pain. As already noted, the area of
pain may not correspond exactly to the site of injury. In
addition, the cause of the pain may not be a muscle
injury. Other acute processes, such as deep vein
thrombosis (Fig. 8) or a ruptured Bakers cyst, may
clinically mimic a muscle injury. Chronic processes
may present acutely and also mimic a muscle injury if
an acute event, such as a hemorrhage, is superimposed
on the underlying process (Fig. 9). As noted in the
technique section, protocols for muscle disorders need
to be versatile enough to deal with the unexpected.
Such protocols benefit patients and, by obviating the
need for patient recalls for further imaging, help
maintain steady throughput on magnets.
Muscle atrophy in the lower extremity can result

from traumatic denervation or myopathies [30 38].
Regardless of the etiology, muscle atrophy has a
characteristic MRI appearance. Acutely, MRI may
demonstrate no abnormalities. In 2 to 3 weeks, a
denervated muscle appears edematous with increased
signal on T2-weighted or IR images. Chronically, the
involved muscles are small, and the muscle tissue is
replaced by fat [39 42]. Axial images through the
involved area are useful to delineate specific muscle
groups and T1- and T2-weighted or IR sequences can
characterize muscle size and demonstrate edema or
fatty proliferation; axial scans through both limbs
may be useful to evaluate asymmetric muscle atrophy
(Fig. 10). MRI also is valuable in guiding surgical
Fig. 10. Thirty seven-year-old woman with atrophy of the right rectus femoris muscle. (A) Axial T1-weighted image (450/9)
through both upper thighs demonstrates atrophy of the right rectus femoris muscle with fatty replacement. (B) Axial IR image
(3000/30/150) in the same location demonstrates complete suppression of the tissue replacing the muscle fibers, which confirms
the presence of fat. (C, D) Coronal T1-weighted (500/9) and IR (3300/30/150) images through the lower pelvis and both upper
thighs also illustrate the right rectus femoris atrophy and fatty replacement.
1024
planning for nerve graft and tendon transfer procedures [42].
Muscle infarction and inflammation

Muscle infarction is seen most frequently in
patients with end-stage or uncontrolled insulindependent diabetes [43 45]. In these patients, the
process typically involves the lower extremities and
is often bilateral and the cause is believed to be
thrombosis of end organ arterioles; patients experience acute pain during the infarction period [43,46
51]. MRI findings include enlargement of the
involved muscles; increased signal with T2 weighting

or IR technique in the involved muscles secondary to
edema; loss of intermuscular fatty septa; and fascial,
subfascial, and subcutaneous edema [52 55]. If necrosis occurs, peripheral enhancement of muscle
tissue with a dark center occurs after gadolinium administration and T1-weighted imaging with fat saturation (Fig. 11) [51,56].
Infarction need not occur only in diabetics, and
rarely may be spontaneous (Fig. 12). Regardless of
the cause, the imaging characteristics are similar and
the diagnosis should be considered when the MRI
findings present themselves. Unfortunately, the findings, although characteristic, are nonspecific and may
Fig. 11. Forty five-year-old woman with insulin-dependant diabetes and acute onset of bilateral leg pain. (A) Axial T1-weighted
fast multiplanar spoiled gradient recall image (100/4.2/90) through both thighs demonstrates loss of fatty intermuscular and
fascial planes. Subcutaneous edema is also seen, particularly on the left. (B) Axial T2-weighted fast spin echo image (3000/66) at
the same location demonstrates bilateral edema, particularly involving the vastus lateralis muscles; the left vastus lateralis is also
swollen. Extensive subcutaneous edema is seen bilaterally. (C) Coronal inversion recovery image (2600/53/150) through the
thighs demonstrates the extent of the edema. In diabetic patients with the proper clinical picture who present with lower
extremity pain, MRI findings like the ones presented here are characteristic of muscle infarction or diabetic myositis.
1025
Fig. 12. Fifty six-year-old man with acute pain in the left lower leg. (A) Axial T1-weigthed fast spin echo image (616/10)
through the left calf demonstrates a vitamin E capsule marking the area of the patients pain. An enlarged anterior tibialis is seen
beneath the capsule. Intramuscular fat planes are not visualized in this muscle, but are seen in the other muscles about the calf.
(B) T1-weigthed spin echo image (600/20) with fat saturation after gadolinium administration demonstrates vigorous
enhancement of the anterior tibialis. No areas of necrosis are seen. (C) Slide from a biopsy demonstrates muscle infarction with
micronecrosis and thrombosis. This patient had no known risk factors for muscle infarction.
overlap with muscle inflammation. A focal myositis,

for example, produces MRI findings similar to the
ones seen in the spontaneous infarct noted previously
[57,58]. More generally, a host of disorders cause
muscle inflammation and have the MRI appearance
of edematous, swollen muscles with loss of fat
planes. For example, inflammatory myopathies, such
as polymyositis, dermatomyositis, and infective myositis, have these MRI findings (Fig. 13) [57 59].
Even if nonspecific, MRI is useful in these cases to
direct biopsies; areas of increased signal with T2
weighting or IR technique that enhance after gadolinium administration generally represent areas of
active disease [60 63]. Similarly, as noted previously, MRI can detect areas of necrosis, and in cases
of infection MRI can delineate abscess formation
[64,65].
Muscle hernias
Muscle hernias in the lower extremities can cause
episodic, severe pain as the muscle involved herniates
and retracts through a fascial rent. Usually, however,
they are asymptomatic [66]. When the muscle is
1026
Fig. 13. Two-year-old girl with fever, rash, and dermatomyositis. (A) Axial modified inversion recovery image (IR) (3667/75/
110) through the thighs demonstrates areas of edema in the left quadriceps. (B) Coronal IR image (5100/45/10) through the
thighs confirms the presence of edematous, swollen muscles in the left quadriceps. (C) More anterior coronal IR image
demonstrates original lymph nodes.
herniated, a mass may be felt in the area of pain. MRI

is diagnostic in these cases when a muscle is seen to
protrude and retract through the connective tissue
defect. Demonstrating the protrusion and retraction
is accomplished by imaging the patient with the
muscle in question in the contracted and relaxed state
[66 68]. Reported herniated muscles include the
tibialis anterior, extensor digitorum longus, peroneus
longus and brevis, and gastrocnemius [66]. Some
hernia patterns may be hereditary [68]. Clinically,
the entity must be distinguished from hematomas,
lipomas, muscle ruptures, and varicose veins [68],
and MRI easily can differentiate these entities with

proper imaging technique.
Popliteal cysts
Popliteal cysts are the most common synovial
cysts about the knee, and they arise in the bursa
between the medial head of the gastrocnemius and
the semimembranosus [69]. They usually are asymptomatic, but may cause discomfort by virtue of their
size or severe, acute pain if they rupture. When
popliteal cysts rupture, the symptoms may mimic

deep vein thrombosis or muscle strain. MRI can
distinguish these entities, and also can demonstrate
the extent of the edema caused by the rupture (Fig. 14).
MRI also easily demonstrates intact popliteal cysts,
and the modality is useful to distinguish these benign
lesions from other abnormalities in the popliteal fossa
that may present as a mass.
1027
Functional imaging
Increasingly, new MRI techniques allow analysis
of muscle at the functional level. Relaxation time
measurement, echo planar imaging, and phosphorus
and sodium imaging give information about the
response of muscle to exercise and ischemia that is
not available with conventional MRI [70 74]. Nas-
Fig. 14. Sixty nine-year-old man with pain and a fatty mass in the right calf; imaging demonstrated a lipoma and ruptured
popliteal cyst. (A) Axial CT image with intravenous contrast through both calves demonstrates a fatty mass deep to the soleus.
No enhancement or internal architecture of the mass is seen. Loss of fat planes between the medial soleus and gastrocnemius is
seen. (B) Axial T1-weighted image (550/20) through the right calf again demonstrates the simple fatty mass. (C) Axial inversion
recovery image (2500/45/150) demonstrates complete fat suppression of the fatty mass. Also seen is fluid tracking between the
medial soleus and the medial head of the gastrocnemius. (D) Coronal fast spin echo T2-weighted image (3500/96) demonstrates
the full extent of the tracking fluid and that the fluid extends to the popliteal fossa and the knee joint. The MRI depicts a ruptured
popliteal cyst and a lipoma. (E) Lateral view of the right knee from an arthrogram confirms communication of this tracking fluid
with the knee joint and rupture of the cyst caudally. This case nicely demonstrates the ability of MRI to detect and characterize
various processes in the lower extremity.
1028
Fig. 14 (continued ).
cent techniques promise the analysis of ATP production in muscle; diffusion imaging can provide information about muscle fiber orientation and blood flow
[75,76]. Even in their early stages, these new imaging
methods have provided preliminary information
about the differences in skeletal muscles in active versus inactive individuals, and skeletal muscle in diseased states, such as diabetes [77 79]. As these
methods are refined, more basic knowledge about
how muscle functions will be obtained, and the approach to imaging injured but otherwise healthy
muscle and diseased muscle in the chronically ill will
evolve. Exercise and rehabilitation regimens may be
improved because of this information, and the anatomic focus of muscle MRI may shift to a more functional role. To a lesser extent, kinematic imaging is
already leading musculoskeletal MRI in this direction; these new techniques, coupled with the proliferation of wide-bore 3-T magnets, promise to
accelerate the pace of this change.
Summary
The exquisite tissue contrast and multiplanar capability of MRI make it the optimal imaging modal-
ity for diagnosing muscle injuries and other muscle

disorders. These examinations can be performed with
increasing speed because of improvements in gradient strength and software and coil design. Presently, some of the limitations of MRI of muscle relate
to the lack of specificity of the findings. The advent
of functional muscle MRI will increase the understanding of human muscle diseases, and increasingly
place MRI in a central role for diagnosis and followup analysis.
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Radiol Clin N Am 40 (2002) 1033 1059
A regional approach to osteomyelitis of the lower

extremities in children
Paul K. Kleinman, MD
Section of Musculoskeletal Imaging, Department of Radiology, Childrens Hospital Boston and Harvard Medical School,
300 Longwood Avenue, Boston, MA 02115, USA
Department of Radiology, University of Massachusetts Memorial Health Care, University of Massachusetts Medical School,
55 Lake Avenue North, Worcester, MA, USA
Osteomyelitis is a relatively common disease in

children. Historically, the diagnosis has been based
on clinical, laboratory, and plain radiographic findings. With the advent of modern imaging techniques,
diagnostic imaging achieves high sensitivity and
specificity for the diagnosis of osteomyelitis. These
technical advances have generated much interest in
the imaging of osteomyelitis; thorough discussions
can be found in most standard texts and several
recent reviews provide excellent discussions of the
subject [1 6].
A vast array of microorganisms can produce
osteomyelitis, but gram-positive cocci remain the
most frequent offenders. Infections tend to occur
near the sites of active endochondral bone formation
and the metaphyses and metaphyseal equivalent
regions of the lower extremities are the most frequent
sites for osteomyelitis. The tibias and femurs are
the most common bones involved, but the acetabula and the small bones of the hands and feet
are by no means rare [7]. Analysis of the imaging
findings of the lower extremities provides a broad
spectrum of the imaging patterns of osseous infection in childhood. The patterns are often similar to
those noted in other body regions, but in some
* Department of Radiology, Childrens Hospital Boston, 300 Longwood Avenue, Boston, MA 02115.
E-mail address: paul.kleinman@tch.harvard.edu
(P.K. Kleinman).
instances the imaging features are distinctive and

the clinical consequences may be profound because
of the specific anatomy and functions of the affected
sites. This article presents a regional analysis of the
typical imaging features of osteomyelitis involving
the lower extremities in children.
Pathophysiology
Although osteomyelitis may develop following a
direct inoculation, particularly with puncture wounds
in the feet, or by contiguous spread from soft tissue
infection, most infections occur with hematogenous
bacterial seeding. Early studies have shown that
blood-borne organisms tend to lodge in the highly
vascular regions of the primary spongiosa adjacent
to the physes. Turbulent flow within venous sinusoids, and a paucity of phagocytic activity in this
region, leads to bacterial proliferation [8]. More
recent studies suggest that organisms pass through
gaps in the metaphyseal capillaries to the extravascular space where inflammation develops [9]. In
the infant, infection may spread by transphyseal
vessels to the unossified secondary ossification
centers. This explains the relatively common occurrence of epiphyseal extension of metaphyseal osteomyelitis in infancy. Beyond 1 year of age, these
epiphyseal vascular connections gradually disappear
and epiphyseal extension is less common. The
physis presents only a relative barrier to the spread
of infection, and demonstration of transphyseal
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 3 7 - 4
1034
P.K. Kleinman / Radiol Clin N Am 40 (2002) 10331059
extension is by no means rare, particularly when

MRI is used.
General considerations
Although osteomyelitis can be divided into acute,
subacute, and chronic forms, strict classification with
respect to the age of the process is not always
possible on imaging grounds alone, and correlation
with clinical and laboratory findings is necessary.
High-quality plain films are mandatory. Subtle permeative bone destruction and subperiosteal new
bone formation easily may be overlooked on studies
that are inadequately collimated and performed on
general-purpose imaging systems. A high-detail
film-screen system is essential and when digital
imaging is used, studies should be performed with
maximal detail settings, with manipulation of window and level, and magnification of regions of
interest. Beyond plain films, ultrasound, CT, bone
scintigraphy, and MRI each have roles in the diagnosis and assessment of the extent of the inflammatory process. In general, MRI has been increasingly
substituted for scintigraphy, particularly for spinal
and pelvic disease, and when significant extraosseous involvement is suspected [3,10]. When MRI
is readily available and sedation is not required,
a good argument can be made to substitute it for
scintigraphy in cases where disease is localized.
Sonography has gained increasing popularity, particularly in the early diagnosis of subperiosteal
abscess [11 13].
Specific anatomic sites

Acetabulum
The pelvis has generally been considered to be an
uncommon site for osteomyelitis [14 17]. This is
caused in part by underrecognition because plain film

diagnosis of pelvic osteomyelitis is often difficult.
Because early spread to the surrounding soft tissues is
common, osteomyelitis may be misclassified as a
primary soft tissue infection when there is a failure
to identify the osseous origin of the disease. MRI has
had a dramatic impact on diagnosis and increasing
reports of the MRI features of pelvic osteomyelitis
have appeared [18 22]. Others have found sonography to be useful [13].
The process begins in the bony margins of the
triradiate cartilage. The histologic features of the
pubic, ischial, and iliac contributions to these synchondroses are identical to those at other growth
plates, and the rich vascularity in these regions provides the same conditions promoting osteomyelitis as
in the long bone metaphyses. Although patients generally present with symptoms referable to the hip and
initial diagnostic studies may be directed toward the
exclusion of septic arthritis, the tendency for the
infection to spread rapidly to the pelvic soft tissues
may result in symptoms corresponding to the obturator internus and externus, the iliacus, gluteus, and
thigh muscles. On occasion, features suggesting an
intra-abdominal process may result in a laparotomy
for suspected appendicitis. A history of trauma is
common and diagnosis is often delayed [19]. Sonography is often performed to exclude a septic hip and
may reveal a joint effusion. Although bone scintigraphy may show increased activity in the affected
bones, false-negative results occur and for this reason
MRI is recommended [3]. It is reasonable to perform
MRI immediately following plain films if acetabular
osteomyelitis is suspected.
On T2-weighted and short tau inversion recovery
(STIR) images, an increase in signal intensity may
be noted within the bony acetabulum adjacent to
the triradiate cartilage (Fig. 1). These findings are
often inconspicuous, and abnormalities may only
be evident following intravenous gadolinium. Contrast-enhanced images are essential to differentiate
Fig. 1. Acetabular osteomyelitis in a 9-year-old boy. (A) Gadolinium-enhanced coronal T1-weighted fat-saturated MRI
demonstrates abnormal enhancement in the ilium (short white arrow) and ischium (long white arrow). There is irregular signal
intensity within the adjoining triradiate cartilage (black arrow). (B) Coronal short tau inversion recovery (STIR) image through
the anterior pelvis demonstrates high signal intensity within the pubic bone and ilium. High signal is noted within the right side
of the pelvis within a discreet fluid collection (black arrows) abutting the triradiate cartilage (long white arrow). Note high signal
reflecting inflammatory changes within the adductor and pectineus muscles (short white arrow). (C) Gadolinium-enhanced
coronal T1-weighted fat-saturated image demonstrates a focal low signal intensity region corresponding to the abnormality in
(B), with surrounding enhancement consistent with abscess (arrow). (D) Gadolinium-enhanced axial T1-weighted image with fat
saturation shows inflammatory changes in and around the thigh muscles with enlargement of the obturator externus and adductor
muscles (arrows).
1035
1036
Fig. 2. Acetabular osteomyelitis. Eleven-year-old boy with prior pharyngitis and current Fusobacterium bacterial endocarditis.
(A) Anteroposterior (AP) radiograph of the left acetabulum demonstrates an area of lytic destruction at the margins of the
triradiate cartilage (arrows). (B) Coronal T2-weighted fat-saturated MRI demonstrates increased signal within the iliac and
ischial margins of the triradiate cartilage (large arrows). Note high signal intensity within the triradiate cartilage extending to the
adjacent bony margins consistent with abscess (small arrow). (C) Sagittal STIR image shows fluid collection (arrow) within the
ischium, extending across the triradiate cartilage to the ilium. Note surrounding edema above and below the acetabular margins.
(D) CT in prone position shows needle placed percutaneously within lesion. Aspirate grew Fusobacterium.
1037
Fig. 3. Subacute osteomyelitis and septic arthritis in a 10-month-old boy. (A) Sagittal sonogram of the right hip demonstrates a
hypoechoic joint effusion (arrows). (B) Anteroposterior radiograph of the hip demonstrates bone destruction within the proximal
femoral metaphysis (large arrow). A faint linear radiolucency is noted within the epiphysis reflecting transphyseal extension of
the metaphyseal infection (small arrow). (C) Follow-up study 2 weeks later shows sclerosis about the metaphyseal lucency and
destruction of the lateral half of the proximal femoral epiphysis (arrow).
1038
bone and soft tissue abscess from edema. Disease

within the adjacent muscle and fat planes may be
the most conspicuous finding on MRI. Inflammation
in the pubic bone and ischium usually extends to
the obturator internus and externus muscles, and may
produce signs and symptoms of a primary obturator
internus muscle abscess [20,22]. When these soft
tissue findings are encountered on MRI, careful
assessment of the acetabulum usually demonstrates
the bony origin of the process. Sonography may
demonstrate a joint effusion, but when the joint fluid
analysis does not support the diagnosis of a septic
arthritis, and the clinical findings are atypical, MRI
is advisable. Staphylococcus aureus is the most

common organism, but on occasion gram-negative
anaerobic organisms, such as Fusobacterium necrophorum, may be found (Fig. 2) [1,17,19]. This may
follow an episode of pharyngitis as a component of
Lemierre syndrome [1,23]. When the diagnosis is delayed, or if the process is an indolent one, the osseous
abnormalities may be more evident on presentation
and consist of a relatively geographic area of bone
destruction adjacent to the triradiate cartilage (see
Fig. 2A). This focal disease can be approached percutaneously with CT guidance (see Fig. 2D). Although
surgical management has been reported, the litera-
Fig. 4. Subacute osteomyelitis of the right femoral neck and head in a 9-year-old boy with a 10-day history of knee pain and
limp. Blood culture grew Staphylococcus aureus. (A) AP radiograph of the right hip shows subphyseal metaphyseal radiolucency
(arrows). (B) Coronal T1-weighted MRI shows heterogeneous signal in the femoral neck, loss of physeal definition, and
decrease in fat signal within femoral head (arrow). (C) Gadolinium-enhanced axial T1-weighted MRI with fat saturation shows
abnormal enhancement within the femoral neck and head (arrow) corresponding to the low signal intensity in (B).
ture suggests that intravenous antibiotics alone are

adequate [14,17].
Femur
The proximal femur
Osteomyelitis of the femoral neck is most common in infants and is often associated with a septic
arthritis of the hip (Fig. 3) [24]. When the child
presents acutely with an irritable hip, plain films are
often normal. Sonography may demonstrate a hip
joint effusion, but joint aspiration and culture are usually required (see Fig. 3A). With subacute disease, an
area of lucent bone destruction may be evident within
the femoral neck (see Fig. 3B). Because transphyseal
vessels are present in infants, the physis may be
widened and lytic change may be present within the
epiphysis. Physeal disruption may result in a septic
epiphyseal separation with lateral migration of the
femoral neck. When the epiphysis is not yet ossified,
this appearance simulates hip dislocation [25,26].
Involvement of the ossification center of the proximal
1039
femoral epiphysis may result in destruction of all or a

portion of the ossification center (see Fig. 3C). Some
older children present with pain referred to the knee. A
plain film may show subtle subphyseal metaphyseal
radiolucency (Fig. 4). This may simulate the appearance of acute leukemia. T1-weighted MRI shows
abnormal signal in the femoral neck, physeal disruption, and loss of T1 bright fat in the femoral head.
Postcontrast images confirm the transphyseal extension of the process. Long-term complications include
avascular necrosis of the femoral head and growth
disturbance related to physeal damage.
Additional sites of osteomyelitis in the proximal
femur include the metaphyseal equivalent regions of
the apophyses of the greater and lesser trochanters.
Although less common than the femoral neck, these
sites become more important beyond infancy when
the secondary ossification centers of these regions
develop [5,27]. With subacute disease involving the
region of the greater trochanter, the process may
extend across the physis into the greater trochanteric
apophysis (Figs. 5, 6). With external rotation, a
Fig. 5. Subacute osteomyelitis of the greater trochanter in a 6-year-old girl. On the frog lateral projection (A) a lytic lesion is
noted projecting within the medullary cavity of the femoral neck (arrows). In the frontal projection (B), the lytic lesion (arrow)
lies mainly within the medullary cavity, extending across the physis into the greater trochanteric apophysis. S aureus was
recovered at open biopsy.
1040
Fig. 6. Osteomyelitis of the greater trochanter in a 12-year-old girl. (A) Anteroposterior radiograph of the right hip demonstrates
a focal radiolucency within the physis of the greater trochanter (arrow) extending to the apophysis. (B) Gadolinium-enhanced
coronal T1-weighted image with fat saturation demonstrates high signal within the soft tissue surrounding the greater trochanter.
Two foci of low signal corresponding to plain film findings are consistent with abscess (black arrows). Note normal high signal
greater trochanteric physis on left (white arrow).
misleading image suggesting a central intramedullary

process may be present, raising concerns of a neoplastic lesion (see Fig. 5A), but the transphyseal
extension on the frontal projection points strongly
to infection (see Fig. 5B). With MRI, T2-weighted
and STIR images demonstrate high signal intensity
within the marrow. Following contrast, the area of
bone destruction may appear hypointense, suggesting
intraosseous abscess (see Fig. 6B).
Diaphysis
Primary diaphyseal osteomyelitis is uncommon in
otherwise normal children [28]. Plain film findings
include permeative bone destruction with increasing
sclerosis in subacute and chronic cases (Fig. 7).
Subperiosteal new bone formation is common,
which may produce a lamellated appearance. The
findings are nonspecific and may be seen with neo-
plasia, in particular Ewings sarcoma. Although MRI

is useful in assessing the extent of the intramedullary and extraosseous disease, tissue diagnosis is
usually necessary.
Distal femur
Osteomyelitis is common in this rapidly growing
region. Although the process begins within the metaphyseal spongiosa, rapid extension through Volkmanns canals and the haverisan system of the
relatively thin cortex to the subperiosteal space is common. Subtle permeative destruction of the bony trabeculi and loss of the overlying cortex are the earliest
findings and may precede the development of subperiosteal new bone (Fig. 8). In the infant, the features
may suggest a neoplastic process, such as leukemia,
metastatic neuroblastoma, or Langerhans cell histiocytosis. Because metaphyseal fragmentation may be
1041
vides a clue to the inflammatory nature of the process.

In such cases, there is a focal high signal intensity
zone within the metaphysis that extends to the
physis and also violates the overlying cortex (see
Figs. 9B, 10C.). These findings, in addition to synovial
enhancement, point strongly to the infectious nature
of the process.
Although epiphyseal extension of metaphyseal
osteomyelitis is common, primary epiphyseal osteomyelitis is quite unusual [31,32]; the distal femur is
the most commonly reported site (Fig. 11). Findings
are nonspecific and may suggest a primary bone
tumor, such as chondroblastoma. Although the route
of entry of the infection is most often hematogenous,
direct inoculation from a puncture wound may produce identical imaging features.
Tibia
Fig. 7. Diaphyseal osteomyelitis in a 21-year-old man. A
mixed sclerotic and lytic process is seen within the diaphysis
of the distal femur. Lamellated new bone formation is
present. Although the pattern is typical of osteomyelitis, a
neoplasm, such as Ewings sarcoma, cannot be excluded on
radiographic grounds
present, the features can suggest a fracture, raising the

possibility of child abuse (see Fig. 8A). Sonography
can be useful in this setting to demonstrate the extent
of the soft tissue disease. Longitudinal images show
subperiosteal inflammatory changes and cortical
destruction (see Fig. 8B) [29,30]. MRI elucidates the
soft tissue changes and also defines the extent of the
intramedullary edema (see Fig. 8C).
In other instances, plain films may be negative, and
MRI provides exquisite delineation of early inflammatory changes in the subphyseal metaphysis (Fig. 9).
Gadolinium-enhanced images also demonstrate the
subperiosteal extension of the process. When the
periosteum is violated, the process may rapidly progress within the soft tissues producing an impressive
soft tissue mass (Fig. 10). T2-weighted images may
demonstrate a relatively well-circumscribed high
signal intensity abnormality within the soft tissues,
in association with a joint effusion. Postcontrast
images may show an enhancing soft tissue mass with
a hypointense center. The soft tissue findings, in
conjunction with the diffuse high signal within the
metaphysis, can raise concerns of a neoplastic lesion.
Careful scrutiny of the juxtametaphyseal region pro-
Proximal tibia
Along with its counterpart in the distal femur,
the proximal tibial metaphysis is one of the most
common sites of osteomyelitis in children [7]. In the
early phase of the disease, plain films may show
subtle radiolucency of the subphyseal metaphysis
with loss of the zone of provisional calcification
(Fig. 12). Follow-up images demonstrate more
clear-cut bone destruction and transphyseal extension to the epiphysis becomes evident. The zone of
transition between the lucent lesion and the surrounding sclerosis is quite narrow and the sclerosis
gradually blends with the adjacent normal trabecula,
a feature pointing to the indolent nature of the
process. Although the process usually begins within
the metaphysis, the epiphyseal involvement may
appear to be greater than the metaphyseal extent
of the disease on plain radiographs. MRI provides
the best information regarding the extent of the
disease [33,34]. T1-weighted images show a sharply
circumscribed hypointensity, which may abut the
physis, or extend well into the epiphysis. Surrounding low signal intensity within the bone marrow
reflects edema. T2-weighted and STIR images
shows diffuse high signal intensity related to the
inflammatory changes within the process. The sclerotic bony margins evident on the plain films correspond to MRI hypointensity on all sequences (see
Fig.12D, E). MRI elegantly depicts the pathologic
changes and may provide a clue as to the chronicity
of the process, but it may be difficult to determine if
the findings reflect subacute or chronic osteomyelitis. Although marginal sclerosis is inevitably present beyond the acute stage, the extent of this
reactive change is variable and chronic osteomyelitis
1042
Fig. 8. Subacute S aureus osteomyelitis of the distal left femur in a 10-month-old boy refusing to bear weight. (A) Anteroposterior
radiograph shows lucency and fragmentation of the medial cortex of the distal femoral metaphysis (arrow). These findings raised
the possibilities of occult trauma. (B) Coronal sonogram through the distal femoral metaphysis demonstrates cortical disruption
(curved arrow), adjacent to the hyperechoic zone of provisional calcification. A small osseous fragment is displaced from the cortex
(open arrow). The periosteum is bowed by subperiosteal inflammatory changes (straight solid arrows). (C) Coronal gadoliniumenhanced T1-weighted MRI with fat saturation demonstrates edema within the medial soft tissues adjacent to the distal metaphysis. Open biopsy revealed S aureus. (From Nimkin K, Kleinman P. Skeletal injury in child abuse. Radiol Clin North Am
2001;39:843 64.)
1043
apy. Caution should be exercised when characterizing the chronicity of osteomyelitis based on
imaging grounds alone.
When osteomyelitis begins adjacent to the growth
plate cartilage of the tibial tubercle, the lytic disease
may extend to the diaphyseal region (Fig. 13). This
may produce a permeative or moth-eaten pattern with
cortical bone destruction. As mentioned, diaphyseal
osteomyelitis is uncommon in children and this
diaphyseal extension of disease may suggest a bone
tumor. Recognition of the relationship of the process
to the physis of the tibial tubercle may be a clue to an
infectious etiology.
Distal tibia
Osteomyelitis can involve any portion of distal
tibia, including the medial malleolus (Fig. 14). A
radiolucent lesion on plain films and a T1 hypointense lesion, which is hyperintense on T2-weighed or
STIR images, constitutes the typical findings of a
Brodies abscess (see Fig. 14B, C). Following gadolinium, T1-weighted images may show a distinctive
appearance of the abscess wall with an enhancing
inner margin and an outer hypointense rim, corresponding to the sclerosis on plain film (see Fig. 14D).
Although CT is usually not performed if osteomyelitis is suspected, it is usually done when an osteoid
osteoma is a consideration. Subacute osteomyelitis
may closely simulate an osteoid osteoma, with its
radiolucent nidus containing a central calcification
and surrounding zone of sclerosis (Fig. 15) [4]. When
transphyseal extension to the epiphysis is present,
osteoid osteoma is unlikely.
The fibula
Fig. 9. Acute osteomyelitis of the distal femur in a 17month-old boy. (A) Coronal proton density MRI with fat
saturation demonstrates a high signal focus within the distal femoral metaphysis extending to the physis (arrow).
(B) Axial proton density image with fat saturation demonstrates a high signal intensity focus destroying the posterior
cortex of the distal femur with extension to the subperiosteal
space (arrow).
Osteomyelitis within the slender fibula frequently

spreads to the subperiosteal space and clinical findings are often impressive. An initial evaluation with
sonography reveals the characteristic convex-shaped
hypoechoic fluid collection within the subperiosteal
space (Fig. 16). This is readily differentiated from a
deep extraosseous soft tissue collection by the characteristic morphology of the periosteal attachment at
the physis and epiphysis. MRI also delineates these
collections, and can demonstrate abnormal signal
intensity within the underlying bone and physis
(Fig. 17).
Foot and ankle
may be associated with relatively modest marginal

sclerosis. A variety of factors influence the pathologic features of osteomyelitis including organism
virulence, host defenses, and prior antibiotic ther-
The calcaneus is a relatively common site of

osteomyelitis in children. Up to 10% of all bone
infections involve the calcaneus and up to one third
1044
Fig. 10. Subacute osteomyelitis of the distal femur in a 12-year-old boy presenting with a soft tissue mass in the posterior thigh. (A)
Lateral radiograph demonstrates a subtle radiolucency with surrounding sclerosis within the posterior aspect of the distal femoral
metaphysis (small arrow). Subperiosteal new bone formation is noted along the posterior aspect of the femur (large arrows). (B)
Gadolinium-enhanced sagittal T1-weighted MRI with fat saturation demonstrates an enhancing process in the posterior thigh with
several sharply demarcated central areas of low signal intensity (black arrows). Findings in conjunction with the presence of
subperiosteal new bone suggest a necrotic neoplasm. Note synovial enhancement (white arrows). (C) Sagittal gradient echo image
demonstrates a high signal focus within the posterior metaphysis extending to the physis (arrow), correlating with the lytic area in
(A). Aspiration yielded S aureus.
1045
Fig. 11. Epiphyseal osteomyelitis of the distal femur secondary to puncture wound in a 5-year-old boy. Anteroposterior radiograph
demonstrates a lytic focus of osteomyelitis with surrounding sclerosis within the lateral femoral condyle (arrow).
of the infections of the small bones of the hands and

feet involve the calcaneus. Between 43% and 63% of
these cases are caused by hematogenous seeding,
usually with S aureus. Pseudomonas infection is
common when a history of a puncture wound is
present [35 37]. In most instances, the hematogenous infection occurs in the metaphyseal equivalent
of the posterior calcaneus or the adjacent apophysis.
The process may span the physis to involve both
regions. In general, symptoms tend to be less impressive as compared with osteomyelitis at other
sites, and diagnosis is often delayed. Although the
earlier literature describes plain film changes at
presentation in up to 100% of cases, the current
tendency for earlier diagnosis has resulted in radiographic changes in only 30% to 57% of cases [35
37]. An initial lateral plain film may be normal and
only a Harris view of the heel reveals an abnormality
(Fig. 18). This consists of an area of focal radiolucency within the posterior calcaneus. The indolent
nature of the process in association with minimal
systemic findings may raise the possibility of a

neoplasm. CT localizes the process to the metaphyseal equivalent region and the apophysis of the
calcaneus. MRI with gadolinium nicely depicts the
pathology (Fig. 19).
A less commonly involved tarsal bone is the
cuboid, and again the disease may be secondary to
hematogenous spread or a puncture wound (Fig. 20).
Plain films may be normal, demonstrate ill-defined
demineralization, or show a discreet lytic defect with
surrounding sclerosis (see Fig. 20A). As with calcaneal osteomyelitis, the lack of significant local inflammatory changes and systemic findings may raise the
possibility of traumatic or neoplastic etiologies. MRI is
useful in defining the extent of the osseous disease, and
is of particular value in excluding the presence of
associated soft tissue mass (see Fig. 20B, C).
Osteomyelitis involving the toes is quite uncommon. One of the more distinct patterns involves
the great toe and results from a stubbing injury
[38,39]. With forced hyperflexion of the toe, there
1046
1047
Fig. 12. Subacute osteomyelitis progressing to chronic disease in a 4-year-old girl. Initial anteroposterior (AP) (A) and lateral (B)
radiographs of the proximal tibia demonstrate a lytic process extending from the proximal tibial metaphysis to the epiphysis
(arrows). There is faint surrounding sclerosis. Intravenous antibiotics were administered. (C) One year later, AP radiograph
demonstrates persistence of the metaphyseal process with further sclerosis surrounding the lesion (arrow). Although the process
has been present for 1 year, differentiation of subacute from chronic osteomyelitis is not possible on imaging grounds. (D)
T1-weighted sagittal MRI demonstrates loss of normal high signal fat within the metaphysis and the anterior two thirds of the
epiphysis of the proximal tibia. A central area of intermediate signal intensity extends from the metaphysis to the epiphysis
(arrows). (E) T2-weighted fat-saturated sagittal image demonstrates corresponding diffuse increased signal within the marrow
of the proximal tibia and epiphysis. Surrounding zone of hypointensity (arrows) conforms to the sclerosis evident on the
plain films. Note the substantial residual signal abnormality within the epiphysis despite a relatively normal plain film appearance in (C).
1048
sclerotic changes (Fig. 22). Findings in conjunction

with a draining sinus are diagnostic. Again, Pseudomonas has a high association with phalangeal osteomyelitis secondary to puncture wounds.
Miscellaneous conditions
Fig. 13. Acute S aureus osteomyelitis involving the tibial

tubercle physis in a 10-year-old girl. Lateral view of the left
knee demonstrates a lytic process with a faintly sclerotic
margin involving the proximal tibial diametaphysis (arrows).
The process extends to the tibial tubercle physis.
is a distracting physeal injury, often associated with

an adjacent metaphyseal or epiphyseal fragment
(Fig. 21). With soft tissue disruption, the organisms
residing in the nail bed are inoculated into the fracture. The injury constitutes an open fracture and
prophylactic treatment with antibiotics is advocated
[38]. The diagnosis of osteomyelitis is often delayed
and a growth disturbance may result. Initial radiographs demonstrate a Salter-Harris type injury. Follow-up films demonstrate the fracture fragment and
focal demineralization within the adjacent metaphysis. Given the history, the inflammatory nature of the
process should be readily apparent, and no additional
imaging is needed.
Hematogenous osteomyelitis involving the toes is
uncommon; however, when there is a prior history of
a puncture injury, a chronic draining wound may
bring the patient to attention following considerable
delay. Plain film findings demonstrate lytic and
A wide array of fungal and bacterial organisms can

produce atypical imaging patterns. Several unusual,
but distinct processes deserve mention. Chronic multifocal osteomyelitis is a disorder of unknown cause
occurring mainly in children and adolescents. The
imaging features share many similarities with bacterial osteomyelitis, but the appearance may also suggest
Langerhans cell histiocytosis, leukemia, metastatic
neuroblastoma, or Ewings sarcoma. Most bones
can be involved, although there is a predilection for
the proximal tibial and distal femoral metaphyses
[2,4,5,40]. MRI is useful in assessing the extent and
activity of the disease [41].
Meningococcemia and disseminated intravascular
coagulation in infancy and early childhood can lead
to dramatic long-term sequelae [42]. Septic emboli to
the growth plates and epiphyses of the extremities
result in ischemia and osteomyelitis. The changes are
often most distinctive at the knees (Fig. 23). Findings
include diminished growth and angulation of the long
bones. Destruction of subchondral bone leads to
deformity and subluxation of the articular surfaces.
Involvement of the distal extremities may result in
infarction and autoamputation of the digits.
Summary
Modern cross-sectional imaging, particularly
MRI, has revolutionized the diagnosis and management of osteomyelitis in childhood. Diagnoses are
made sooner, with greater confidence, and with better
characterization of the extent of disease than possible
on plain film grounds. Because the infection begins
within the juxtaphyseal medullary bone, the MRI
features are distinctive and frequently diagnostic of
infection. Plain radiography continues to be an essential first step in the evaluation of suspected osteomyelitis and may on occasion be the only imaging
study required for diagnosis and treatment. An understanding of the fundamental pathophysiology of
osteomyelitis in the growing skeleton, in conjunction
with the application of newer diagnostic imaging
techniques, should continue to reduce the morbidity
from this common pediatric problem.
1049
Fig. 14. S aureus osteomyelitis with Brodies abscess involving the distal tibia in a 15-year old boy. (A) Anteroposterior
radiograph of the distal left tibia demonstrates a lytic defect with surrounding sclerosis centered over the remnants of the physis.
Note subperiosteal new bone formation (arrows). (B) Coronal T1-weighted MRI demonstrates a hypointense lesion
corresponding to the lytic defect in (A). The lesion margins show a slightly hyperintense inner zone (short arrow) corresponding
to the lining of the abscess, and a hypointense outer rim (large arrow) corresponding to the sclerotic margin in (A). Note
surrounding hypointensity within the adjacent marrow of the metaphysis and epiphysis. The fusing physis is evident as a
hypointense band (curved arrow). (C) Coronal short tau inversion recovery image demonstrates hyperintensity within the
abscess. The wall of the abscess remains hypointense (arrows). The surrounding marrow within the metaphysis and epiphysis,
and the medial soft tissues of the ankle, show increased signal intensity. (D) Gadolinium-enhanced axial T1-weighted MRI with
fat saturation demonstrates conspicuous enhancement within the wall of the abscess (arrows).
1050
Fig. 14 (continued).
1051
Fig. 15. S aureus osteomyelitis simulating osteoid osteoma in a 15-year-old boy. (A) Anteroposterior view of the ankle
demonstrates a focal lucency within the lateral aspect of the distal tibial metaphysis (black arrow). Note subperiosteal new bone
formation (white arrow). (B) Axial CT shows a corresponding lytic defect with surrounding sclerosis. Bony sequestrum (arrow)
simulates calcific nidus within an osteoid osteoma. (C) Sagittal reformatted CT image demonstrates that the metaphyseal lytic
lesion extends across the physis into the epiphysis. This finding in association with less well-defined surrounding areas of lytic
disease, points to the diagnosis of osteomyelitis.
1052
Fig. 16. S aureus subperiosteal abscess in an 11-year-old

boy. Longitudinal sonogram over the distal fibula shows a
large hypointense collection lying between the fibular cortex
(straight white arrows) and the periosteum (black arrows).
Note that the periosteum attaches distally to the zone of
provisional calcification of the physis (white arrowheads).
Fig. 17. Subperiosteal abscess of the fibula in an 8-year-old

boy with pain and swelling of right ankle. Coronal
T2-weighted fat-saturated MRI demonstrates hyperintense
subperiosteal fluid collection. Note that the periosteum
(black arrows) extends to insert at the physis and epiphysis.
There is T2 hyperintensity within the medullary space and
within the lateral aspect of the physis (white arrow).
1053
Fig. 18. Calcaneal osteomyelitis in a 9-year-old boy with heel pain. Harris view of the calcaneus demonstrates a lytic lucency in
the calcaneus, adjacent to the physis of the posterior apophysis (arrow).
1054
Fig. 19. Hematogenous osteomyelitis of the calcaneus in a 12-year-old boy. (A) Saggital reformatted CT scan of the calcaneus
reveals a lytic defect with surrounding sclerosis extending from the metaphyseal equivalent portion of the calcaneus, across the
physis to the apophysis (arrow). (B) Coronal reformatted CT image. Note sclerosis surrounding the lytic lesion (arrow). (C)
Sagittal gadolinium-enhanced T1-weighted MRI with fat saturation shows enhancement of the lesion, and the surrounding bone
marrow. Hypointense rim (arrow) corresponds to the sclerosis on the CT images.
1055
Fig. 20. Pseudomonas osteomyelitis of the cuboid in an 8-year-old boy with a history of prior puncture wound to the foot.
(A) Oblique view of the foot demonstrates diffuse demineralization of the foot most apparent in the cuboid. Faint sclerosis is
present centrally. (B) Sagittal T1-weighted MRI demonstrates loss of marrow signal within the cuboid (arrow). (C) Axial short
tau inversion recovery image shows hyperintensity within the marrow space of the cuboid (arrow).
1056
Fig. 21. Osteomyelitis of the great toe in a 13-year-old boy with a history of prior stubbing injury. (A) Salter-Harris type two
fracture with a metaphyseal fragment (large arrow) is present. There is loss of the adjacent dorsal cortex and zone of provisional
calcification (small arrows). Note overlying soft tissue swelling.
Fig. 22. Chronic osteomyelitis of the fifth toe in a 15-year-old boy with prior soft tissue injury. Anteroposterior view of the fifth
toe demonstrates mixed sclerotic and lytic process within the base of the proximal phalanx of the fifth digit.
1057
Fig. 23. Disseminated meningococcal osteomyelitis. Anteroposterior view of the left knee (A) and lateral view of the left knee
and lower leg (B) in a 6-year-old with a history of disseminated meningococcemia in infancy show extensive long-standing
changes within the metaphyses. The distal femoral epiphysis is deformed and there is lytic disease within the subchondral
articular cortex. There is loss of the knee joint space with subluxation. Lytic disease and a varus growth disturbance are evident in
the proximal tibia. The distal tibia and multiple other sites were involved, and amputation of several toes were noted.
1058
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Radiol Clin N Am 40 (2002) 1061 1079
Pathologic conditions of the ligaments and tendons

of the knee
Adam El-Dieb, MDa, Joseph S. Yu, MDa,*, Guo-Shu Huang, MDb,
Shella Farooki, MDa
a
Department of Radiology, The Ohio State University Medical Center, S-207 Rhodes Hall, 450 West 10th Avenue,
Columbus, OH 43210, USA
b
Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
Since its inception, MRI has been invaluable as a

safe noninvasive alternative to arthroscopy for diagnosis of internal derangement of joints. The knee
remains the most commonly studied articulation in
the skeleton and MRI has become the preferred
diagnostic imaging modality for assessment of the
soft tissue structures, replacing conventional radiography and diagnostic arthrography. This article discusses normal and pathologic appearances of the
ligaments and tendons of the knee using a regional
approach. Each section is summarized with the injury
mechanisms that lead to pathology. This article allows the reader to gain insight as to how different
injuries produce specific injury patterns in the knee.
distally to insert on the superior pole of the patella as

the trilaminar quadriceps tendon [2]. The most superficial layer arises from the rectus femoris muscle,
which originates from the anterior inferior iliac spine.
The deepest layer arises from the vastus intermedius
muscle, which originates from the femur. Between
these tendons are connective tissues that arise from the
vastus medialis and vastus lateralis muscles, which
also originate from the femur.
Fibers of the rectus femoris tendon course over the
patella and contribute to the patellar tendon, which
inserts on the tibial tubercle. The medial and lateral
patellar retinacula are extensions of the vastus medialis and lateralis tendons, respectively, and contribute
to passive stabilization of the patella [3].
Anterior structures
Mechanism of injury
Anatomy
It is difficult to rupture the extensor mechanism. A

tear usually occurs in the setting of a pre-existing
degenerative process, such as tendinosis and calcific
tendinitis, or a systemic disease, such as renal failure
and gout [1]. Injuries may be caused by direct or
indirect trauma. Direct trauma may produce an isolated
tear of the quadriceps or patellar tendon. Because the
patellar retinacula are not disrupted, some extensor
function persists.
Indirect trauma can produce complete transection
of the extensor mechanism, including the patellar
retinacula, resulting in inability to extend the lower
extremity at the knee joint or maintain passive extension against gravity [4]. The stress necessary to
produce a rupture is generated by forces created by
The main soft tissue structures in the anterior

aspect of the knee are components of the extensor
mechanism and include the quadriceps tendon, patellar tendon, and the medial and lateral patellar
retinacula [1]. These tissues act passively when the
quadriceps muscles contract during extension of the
knee. There are four muscle groups that converge
* Corresponding author. Department of Radiology, The

Ohio State University Medical Center, S-207 Rhodes Hall,
450 West 10th Avenue, Columbus, OH 43210.
E-mail address: JSYU@columbus.RR.com (J.S. Yu).
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 3 5 - 0
1062
A. El-Dieb et al / Radiol Clin N Am 40 (2002) 10611079
the contracting quadriceps muscles, applied to the

flexed knee, such as abrupt deceleration while running. A more common mechanism that affects elderly
people is sudden loss of balance, especially during
descent of a flight of stairs that results in a fall on a
fixed, flexed knee. An injury can affect a part of the
tendon or disrupt it entirely. A partial tear most
commonly involves the rectus femoris component
because it is the tendon that is under the greatest
tensile force. Most tears occur at the patellar enthesis
of the quadriceps and patellar tendons.
Valgus or varus angulation of the flexed knee joint
during quadriceps contraction can lead to isolated
disruption of the medial or lateral patellar retinaculum, particularly when there is complete dislocation
of the patella. Because a lateral dislocation is more
common than a medial dislocation, the medial retinaculum is more commonly injured than the lateral
retinaculum [5].
MRI
The layers of the quadriceps tendon can be
visualized best in the sagittal plane as uniform low
signal intensity bands with intervening higher signal
intensity fat separating each layer. The most common appearance is a smooth trilaminar tendon,
although a bilaminar and quadrilaminar appearance
is not unusual [6]. The average thickness of the
normal quadriceps tendon is 6 to 10 mm in an
anteroposterior dimension, and the average width is
28 to 42 mm [6].
Most tears occur at or near the insertion on the
superior pole of the patella. The layered configuration of the quadriceps tendon enables discrimination
between partial and full tears. Discontinuity of any
of the tendinous layers is consistent with a partial
tear, often involving the rectus femoris component
(Fig. 1). Transection of all layers is diagnostic of a
Fig. 1. Partial quadriceps tendon tear. Sagittal proton density (A) and T2-weighted (B) images show disruption of the superficial
and intermediate layers of the quadriceps tendon (arrowhead) and interstitial edema in the gap. Only the tendon of the vastus
intermedius muscle is intact (arrows).
complete rupture and may be associated with a mass

of edematous tissue and hemorrhage, which appears
increased in signal intensity on T2-weighted and
inversion recovery images (Fig. 2) [1]. In most cases
of complete tear, there is distraction of the ends of
the tendon because of muscle contraction. The position of the patella may be displaced inferiorly.
The patellar tendon also has a homogeneous low
signal intensity appearance except for small occasional triangular areas of intermediate signal intensity directly below the patella and adjacent to the
tibial tuberosity [7]. Both the superficial and deep
margins generally appear distinct and smooth. The
tendon generally thickens distally; however, the
normal thickness proximally does not exceed 7 mm
[8]. A large collection of adipose tissue, the infrapatellar fat pad of Hoffa, rests just posterior to the
patellar tendon. The medial and lateral patellar
retinacula are best visualized in the axial plane at
the level of the patellofemoral joint, connecting the
insertions of the vastus medialis and lateralis
1063
muscles to the medial and lateral margins of the

patella, respectively [3].
The patellar tendon ruptures less frequently than
the quadriceps tendon. Chronic patellar tendinosis,
which affects the proximal tendon, often precedes a
tear (Fig. 3) [9]. The tendon appears thickened and
the signal intensity in the medial fibers is increased
owing to degeneration. Complete tears are often
associated with bone marrow edema in the inferior
patella and fluid in the prepatellar bursa. Partial tears
are relatively uncommon (Fig. 4).
Retinacular tears are characterized by areas of
high signal on T2-weighted and short tau inversion
recovery (STIR) sequences secondary to edema and
hemorrhage. The avulsed free end of the retinaculum
is often frayed and thickened and fluid may dissect
around the vastus medialis obliquus, a muscular slip
of the vastus medialis muscle. Bone contusions in the
medial patellar facet and lateral aspect of the lateral
femoral condyle are typical of lateral patellar dislocations (Fig. 5).
Fig. 2. Complete quadriceps tendon tear. (A) Sagittal proton density weighted image shows characteristic location of a complete
tear of the quadriceps tendon, which is at or near the patellar insertion. (B) Sagittal inversion recovery image demonstrates the
accompanying hemorrhage and edema. Note that the frayed end of the tendon has retracted slightly.
1064
Fig. 3. Chronic patellar tendinosis. Sagittal proton density (A) and T2-weighted (B) images show thickening of the proximal
patellar tendon with a focal area of increased signal intensity (arrow). Note loss of the smooth posterior margin.
Fig. 4. Patellar tendon partial tear. Sagittal proton density (A) and T2-weighted (B) images show partial disruption of the distal
patellar tendon (arrow) with involvement of the deep fibers. There is indistinctness of the posterior margin and the tendon
appears thickened.
1065
Fig. 5. Lateral patellar dislocation. (A) Coronal inversion recovery image shows extensive edema in the vastus medialis
aponeurosis (e) and a bone contusion in the lateral femoral condyle (arrow). (B) T2* gradient echo transaxial image
demonstrates characteristic bone contusion pattern in the lateral femoral condyle and medial patellar facet (e). Note disruption of
the medial patellar retinaculum (curved arrow). e = edema.
Fig. 6. Complete anterior cruciate ligament (ACL) tear. Sagittal proton density (A) and T2-weighted (B) images show loss of the
fiber continuity in the proximal aspect of the ACL along with rupture of the sheath (arrow). An acute joint effusion is a
characteristic finding in this injury.
1066
Central structures
Anatomy of anterior cruciate ligament
The anterior cruciate ligament (ACL) provides
central support of the knee joint, contributing the most
significant stabilizing mechanism against excessive
anterior translation of the tibia. The ACL is a fanshaped structure, with a tightly bound femoral attachment that expands broadly at the tibial attachment.
The anteromedial bundle is the most important bio-
mechanical component of the ACL. It courses in an

anteromedial direction from the medial aspect of the
lateral femoral condyle posteriorly to the anterior tibia
about 1 cm posterior to the anterior tibial cortex and
anterior to the tibial spine [10].
ACL mechanism of injury
Several mechanisms of injury can cause disruption
of the ACL. The most common mechanism is external
rotation of the femur on a fixed tibia combined with
Fig. 7. Indirect signs of an anterior cruciate ligament (ACL) tear. (A) Anterior drawer sign. Note that displacement of the
posterior tibial cortex reference with respect to the posterior femoral cortex reference exceeds 6 mm ( < * > ). (B) Exposed lateral
meniscus sign. Note that the posterior horn of the lateral meniscus overhangs the posterior edge of the tibia by more than 2.5 mm
(arrow). (C) Buckled posterior cruciate ligament (PCL) sign. The angle formed by the PCL is less than 105. (D) Positive ACL
angle sign. The anteromedial bundle of the ACL usually parallels the roof of the intercondylar notch. Notice that ACL is too
horizontal forming an angle with the roof that points toward the tibia.
a valgus force (ie, a twisting injury). Most tears

occur within the ligament itself, whereas less than
20% involve the osseous attachments. When the
ligament ruptures, impaction of the condylopatellar
sulcus (lateral notch) of the lateral femoral condyle
against the posterolateral tibia creates a typical bone
1067
contusion pattern in the lateral compartment of the

knee [11 13]. Other less common injury mechanisms include hyperextension, internal rotation with
maximal extension, or anterior translation of the
tibia produced by a direct force against the back
of the calf.
Fig. 8. Indirect osseous signs of an anterior cruciate ligament tear. (A) Rotary bone contusion pattern. Note the edema in the
lateral femoral condyle near or at the condylopatellar sulcus and the posterolateral tibia (arrows). (B) Segond fracture. Note the
characteristic location of the tibial fracture in the lateral tibia slightly below the level of the joint (curved arrow). (C)
Posterolateral tibial fracture. Note a typical chip fracture in the posterolateral tibia (arrowhead).
1068
MRI
The ACL is best depicted on oblique sagittal
images oriented with the knee externally rotated about
15, although it is also well visualized on coronal and
axial images [14]. The large anteromedial bundle of
the ACL should parallel the roof of the intercondylar
notch and have a smooth anterior margin.
On MRI, there are both direct and indirect signs of
ACL disruption [15,16]. Direct signs include discontinuity of the fibers of the ACL, and an abnormal
contour of the ACL associated with edema (Fig. 6)
[13]. There are many indirect signs (Figs. 7, 8). Some
common indirect signs include angulation of the
posterior cruciate ligament (PCL) less than 105;
anterior tibial translation exceeding 6 mm; overhanging (uncovered) posterior horn of the lateral meniscus
by 2.5 mm; deep lateral femoral notch exceeding
2 mm in depth; Segond fracture of the lateral tibia;
chip fracture of the posterolateral tibia; in addition to
a rotary bone contusion pattern [16 20].
nism against excessive posterior translation of the

tibia. The PCL is a tubular structure that originates
from the lateral aspect of the medial femoral condyle,
courses directly posteriorly, and attaches at the posterior intercondylar fossa of the tibia. The PCL is
thickest at its midpoint and tapers slightly at its
proximal and distal attachments [21].
PCL mechanism of injury
Posterior cruciate ligament ruptures are much less
common than ACL tears. It takes a significant force to
injure the PCL. The most common mechanism of
injury is forced posterior translation of the tibia with
the knee flexed (ie, a dashboard injury). As with the
ACL, avulsion at either attachment is infrequent. The
most common location of a tear is at its midsubstance
[22]. Forced hyperextension can also disrupt the PCL.
When this occurs, kissing bone contusions are
produced in the anterior aspect of the femoral articular
surface and the anterior corner of the tibia.
Anatomy of PCL
MRI
The PCL provides central support of the knee joint,

contributing the most significant stabilizing mecha-
With the knee in extension, the PCL has a curved,

posteriorly convex tubular appearance with uniform
Fig. 9. Complete posterior cruciate ligament (PCL) tear. Sagittal proton density (A) and T2-weighted (B) images show linear
collection of fluid within the fibers of the PCL. The anterior surface of the sheath is disrupted in this image (arrow), whereas
disruption of the posterior surface was noted in another image (not shown).
low signal intensity and is usually visualized in its

entirety on one or two consecutive sagittal sections. In
the coronal and axial planes, the PCL has a characteristic rounded appearance when seen in cross-section.
On MRI, a complete PCL disruption appears as a
focus of high signal intensity between the fibers of the
ligament on the T2-weighted sequence (Fig. 9). When
there is significant edema in the cruciate sheath, the
1069
injured PCL may become difficult to visualize on all

pulse sequences. In some instances, the tear has an
oblique orientation and the primary finding may be
fraying of fibers with intermittent foci of edema within
the disrupted interstitium. Avulsion injuries are frequently associated with bone marrow edema at the
ligament attachment and the ligament may have a
redundant configuration (Fig. 10). Partial tears dem-
Fig. 10. Posterior cruciate ligament (PCL)-associated pathology. (A) Sagittal T1-weighted image shows avulsion of the distal
PCL attachment (arrow). (B) Coronal inversion recovery image shows the edematous marrow (e) where the bone is avulsed from
the posterior tibia. Sagittal proton density (C) and T2-weighted (D) images show partial disruption of the PCL. e = edema.
1070
onstrate more focal disruption of the ligament with

preservation of the normal orientation. The edema that
accumulates between the torn fibers can generally be
seen in the proper cross-sectional image as an area of
increased signal intensity.
Patients who sustain a dashboard injury may
present with a contusion of the anterior tibia. In
hyperextension injuries, however, the bone marrow
edema may involve the anterior region of both the
proximal tibia and distal femur [23].
Medial structures
Anatomy
Medially, the supporting structures of the knee are
arranged in three layers. The invested deep fascia of
the sartorius muscle, which overlies the gastrocnemius muscle, forms the most superficial layer [24,25].
The tibial collateral ligament, the superficial component of the medial collateral ligament (MCL),
forms the middle layer. The deepest layer is comprised of the meniscofemoral and meniscotibial ligaments, which constitute the deep components of the
MCL [26].
The MCL stabilizes the knee against excessive
valgus force and hyperextension. The tibial collateral
ligament, the primary support structure, extends from
the medial epicondylar region of the femur to the
medial surface of the proximal tibia and spans about
8 to 9 cm in length. Proximally, the anterior fibers
blend with the medial patellar retinaculum. The
posterior portion of the MCL blends with the medial
capsular ligament to form the posterior oblique liga-
ment, which provides stability to the posteromedial

corner of the knee [26]. The meniscofemoral and
meniscotibial ligaments anchor the medial meniscus
to the distal femur and proximal tibia.
Mechanism of injury
Twisting injuries cause a large number of MCL
injuries. Most tears occur in the proximal aspect of
the MCL. The rotational component and flexion
exposes the anterior fibers to injury much more
frequently than the posterior fibers. Pure valgus
injuries are uncommon and usually occur in the
setting of direct impaction against the lateral knee.
In this situation, kissing bone contusions may be
evident in the lateral compartment of the knee.
The severity of MCL tears is determined by the
amount of tissue traumatized. Most injuries that come
to clinical attention are partial tears, which disrupt
more than one half of the tibial collateral fibers.
Complete tears usually occur in high-velocity injuries, resulting in complete avulsions from either the
femoral or tibial attachments.
MRI
The MCL usually can be visualized in its entirety
in the coronal plane, appearing as a thin, uniformly
hypointense band. On transaxial images, it has a
comma appearance that is convex on its medial
surface and concave on its lateral surface. Occasionally, a bursa is present between the superficial and
deep layers of the MCL appearing as a small
collection of fluid at the level of the joint on T2weighted images.
Fig. 11. Partial medial collateral ligament (MCL) tear. (A) Coronal T1-weighted image shows marked thickening of the proximal
fibers of the MCL surrounded by edema (arrows). (B) T2* gradient echo transaxial image demonstrates a bulbous appearance to
the anterior fibers of the MCL (curved arrow).
A partial tear is characterized by the presence of

edema and hemorrhage surrounding the MCL and
interstitial edema within the ligament, manifesting
as areas of increased signal intensity on T2 and
STIR sequences (Fig. 11). The surface may be
indistinct and the ligament thickened proximally
and anteriorly. Distention of the MCL bursa occasionally coexists. Complete MCL disruption is demonstrated by marked soft tissue edema at the rupture
site and retraction of the free ends, producing a
ribbon-like appearance (Fig. 12). Adjacent bone
marrow edema in the medial femoral condyle and
medial tibia are common in the acute phase of the
injury [25].
Pure valgus injuries may produce bone contusions
in the lateral compartment of the knee (Fig. 13). It
differs from a rotary pattern seen in ACL tears in that
the contusions associated with a valgus injury are
visualized in the same coronal image.
Posteromedial structures
Anatomy
The tendon of the semimembranosus muscle and
the posterior oblique ligament are the main support
1071
structures in the posteromedial aspect of the knee

[26]. The posterior oblique ligament is formed by
the union of the posterior fibers of the MCL and the
medial capsular ligament. The semimembranosus
muscle originates from the posterolateral portion
of the ischial tuberosity, and inserts on the posteromedial surface of the medial tibial condyle. Some
fibers emerge from the main tendon and insert on
the medial tibial plateau deep to the MCL, the
posteromedial capsule, and oblique popliteal ligament [26].
The pes anserinus is composed of the sartorius,
gracilis, and semitendinosus muscles, originating
from the anterior superior iliac spine, inferior pubic
rami, and ischial tuberosity, respectively, and inserting on the posteromedial tibia.
Mechanism of injury
Posteromedial corner injuries usually result from a
valgus stress combined with rotational forces [27].
When the semimembranosus tendon is injured, the
ACL frequently is also injured [28]. Hyperextension
of the knee can strain the tendons of the pes anserinus. The sartorius tendon is most susceptible to
strain injury owing to its superficial location and
biarticular course [29].
Fig. 12. Complete medial collateral ligament (MCL) tears. (A) Coronal T1-weighted image shows complete avulsion of the
distal attachment of the MCL. Note the ribbon-like appearance of the ligament (arrowhead). (B) A coronal T1-weighted image
in another patient shows proximal avulsion (arrow).
1072
Fig. 13. Valgus contusion pattern. There is marrow edema in

the lateral femoral condyle, a small portion of the tibia, and
the head of the fibula, which in a true valgus injury often can
be seen in the same coronal image. Note the tear of the
medial collateral ligament medially (arrow).
of Gerdy located on the anterolateral tibia. It blends

with the anterior capsule of the joint and also sends
longitudinal fibers inferiorly to blend with the
fibrous expansion of the sartorius muscle [30].
The lateral patellar retinaculum is located just deep
to the iliotibial tract. The lateral capsular ligament
represents thickening of the lateral margin of the
joint capsule.
The biceps femoris muscle has long and short
heads. The long head arises from the ischial tuberosity
along with the semitendinosus, whereas the short head
arises from the lateral lip of the linea aspera on the
posterior distal femur and the lateral intermuscular
septum. The two heads unite in the lower third of the
thigh to form a single tendon that crosses the posterolateral aspect of the knee joint to insert primarily on
the styloid process of the fibular head and to a lesser
extent on the lateral tibial condyle.
The fibular collateral ligament or lateral collateral
ligament (LCL) is 5 to 7 cm long, arising from a
tubercle on the lateral femoral condyle directly above
the groove of the popliteus tendon origin. It inserts
on the lateral surface of the head of the fibula, joining
the biceps femoris tendon to form the conjoined
tendon. The main function of the LCL is to stabilize
the knee against varus forces. Additionally, the biceps
femoris tendon and iliotibial tract provide dynamic
lateral stabilization and prevent excessive external
rotation of the tibia [31].
MRI
Mechanisms of injury
The semimembranosus tendon is the largest tendon

in the popliteal fossa. It has a fusiform configuration
and appears uniformly hypointense on all imaging
sequences. A strain of the semimembranosus tendon
is manifested by loss of continuity at the enthesis and
high signal on T2-weighted and STIR sequences
owing to edema and hemorrhage (Fig. 14). Accompanying fluid within the tendon sheath is a common
finding. A focus of marrow edema may be present
when the posterior oblique ligament avulses.
Isolated tears of the biceps complex are important

in people with anterolateral-anteromedial instability
[29]. The LCL and iliotibial tract are most vulnerable when a varus force is applied to the knee when it
is in flexion or internal rotation. This is an unusual
position for the knee and the vector force required to
produce this mechanism is also uncommon, which
accounts for the relative rarity of this injury [27]. This
mechanism of injury may produce bone contusions
in the medial aspect of the medial femoral condyle
and proximal tibia.
The biceps tendon may rupture when there is a
direct force on the anteromedial aspect of the knee,
creating distraction in the posterolateral joint. When
this mechanism occurs, there may be an isolated bone
contusion in the anteromedial region of the medial
femoral condyle.
Lateral structures
Anatomy
The supporting structures in the lateral knee
include the iliotibial tract, biceps femoris muscle
and tendon, lateral retinaculum, lateral capsular
ligament, and fibular collateral ligament. The iliotibial tract originates from the tensor fascia lata
muscle superiorly and inserts on the lateral tubercle
MRI
The iliotibial tract is best visualized in its entirety
in the coronal planes. It is of low signal intensity on
1073
Fig. 14. Semimembranosus tendon tear. (A) Coronal T1-weighted image shows abnormal signal intensity at the insertion of the
semimembranosus tendon (arrow). It should appear as an oval low signal intensity structure at this level. (B) T2* gradient echo
transaxial image demonstrates high signal intensity in the expected insertion and an empty sheath from the avulsed tendon
(curved arrow). (C) Sagittal T2-weighted image shows a characteristic hyperextension valgus bone contusion pattern involving
the anterolateral tibia and femur (e). e = edema.
all pulse sequences and nearly uniform in thickness.

The transaxial images, however, are useful in confirming surrounding edema. The LCL is best visualized on the coronal images as an obliquely oriented
low signal intensity band between the femur and
fibula. On the axial plane, the LCL can be followed
from its femoral attachment to its junction with the
biceps femoris tendon.
Soft tissue edema characterizes the MRI findings
associated with acute iliotibial tract injuries. Contour
changes, such as thickening and irregularity, are more
typical of subacute or old injuries. Complete tears

with discontinuity and retraction of the iliotibial tract
fibers are uncommon but easy to diagnose and may
involve the midsubstance (Fig. 15). Avulsion of the
iliotibial tract may be associated with bone edema in
the anterolateral aspect of the tibia.
The appearance of LCL disruptions depends on
the extent of injury. Partial tears are characterized
by interstitial edema within the ligament and in the
surrounding soft tissues. Most complete ruptures
involve the conjoined tendon and may produce a
1074
Fig. 15. Iliotibial tract avulsion. (A) Coronal T1-weighted image shows marked thickening of the distal aspect of the iliotibial
tract and surrounding edema (arrowheads). (B) T2* gradient echo transaxial image demonstrates that the markedly enlarged
iliotibial tract is separated from its tibial insertion by a soft tissue gap (arrow).
small avulsion of the styloid process of the fibular

head (Fig. 16). When this occurs, marrow edema in
the proximal fibula is usually evident on T2weighted and STIR images. Retraction of the
tendon may produce a ribbon-like deformity of
the LCL.
Posterolateral structures
Anatomy
There are many structures that occupy the posterolateral aspect of the knee including the popliteus
Fig. 16. Avulsion of the conjoined tendon. (A) Coronal T1-weighted image shows increased signal intensity and fusiform
thickening in the distal aspect of the conjoined tendon (arrow). There is an avulsion of the fibular head at the site of the tendinous
attachment. (B) Coronal inversion recovery image shows the bone marrow edema surrounding the avulsion fracture of the
fibula (e). e = edema.
muscle and tendon, and fabellofibular and arcuate

ligaments [32]. The popliteal muscle arises as a
tendon from the lateral femoral condyle just anterior
and inferior to the origin of the LCL. The tendon
curves sharply from its site of origin, courses in a
posteromedial direction, and inserts at the medial
aspect of the tibia. It also attaches to the lateral
meniscus forming the popliteomeniscal ligament,
and it has a third attachment site on the styloid
process of the fibula, forming the popliteofibular
ligament. The popliteus is an important lateral stabilizer of the knee and serves as the primary internal
rotator of the tibia [32,33].
The fabellofibular ligament courses from the fibular styloid process to the fabella, a normal sesamoid
bone within the lateral gastrocnemius tendon. If the
fabella is absent, the fabellofibular ligament, also
known as the short lateral ligament, then inserts on
the lateral femoral condyle. In some people, the short
lateral ligament is diminutive or absent altogether [32].
The arcuate ligament is a Y-shaped structure that
represents thickening of the posterolateral joint capsule. It has two limbs, referred to as the medial and
lateral limbs. The medial limb emerges from the
posterior aspect of the joint capsule and courses superficially to the popliteal muscle, terminating at the
oblique popliteal ligament, a reflection of the semimembranosus tendon. The lateral limb of the arcuate
ligament emerges from the posterior joint capsule near
1075
the lateral head of the gastrocnemius and extends

superiorly to the popliteal tendon and inserts on the
posterior aspect of the fibular head [34].
Mechanism of injury
A direct varus force to the knee produces injuries
to the posterolateral corner when the knee is locked in
hyperextension. A dashboard injury, direct trauma to
the tibia with the knee in flexion, can also cause disruption of the posterolateral supporting structures.
Most injuries involving the popliteus muscle occur at
the myotendinous junction [35]. Arcuate complex injuries, however, tend to involve the fibular attachment.
MRI
The posterolateral structures are optimally depicted using a coronal oblique plane that is oriented
parallel to the popliteus tendon [32]. Acute injuries
of the popliteus muscle most commonly involve
the myotendinous junction, whereas avulsion injuries of fibular insertion are less common. When
the popliteal tendon tears, hemorrhage and edema in
the muscle and tendon produce focal enlargement
and high signal on T2-weighted sequences (Fig. 17).
Edema of the adjacent soft tissue structures can
also be observed. Complete tears of the popliteal
tendon cause enlargement of the muscle belly and
Fig. 17. Popliteus muscle partial tear. (A) Sagittal T2-weighted image shows a partial tear of the myotendinous junction of the
popliteus muscle. Note the enlargement of the muscle from interstitial edema and hemorrhage (e). (B) T2* gradient echo
transaxial image demonstrates intramuscular edema and perifascial fluid surrounding the muscle body. e = edema.
1076
the retracted tendon terminates abruptly [35]. Isolated popliteal injuries are rare, because most are
associated with concomitant injuries of the arcuate
ligament complex.
Visualization and characterization of the arcuate
ligament and fabellofibular ligament is not always
possible. The identification of injuries to these structures is challenging. The most common indication of
an injury is soft tissue edema in the posterolateral
region of the knee (Fig. 18). Occasionally, a small
piece of the fibular cortex may avulse, which serves
as a useful indirect sign [36].
Posterior structures
Anatomy
The gastrocnemius, soleus, and plantaris muscles
form the superficial muscles of the calf. The gastrocnemius muscle arises as two heads from the
posterior surface of the medial and lateral femoral
condyles. These two heads unite to form a prominent
muscle mass in the upper calf. The tendons of the
gastrocnemius muscles along with the soleus tendon
form the Achilles tendon, which inserts on the
posterior tubercle of the calcaneus. The primary
action of the gastrocnemius muscle is plantar flexion
of the foot but also serves as a passive supportive
structure of the posterior joint capsule.
Gastrocnemius injuries most commonly are caused
by hyperextension of the knee or when the tibia
posteriorly dislocates during knee flexion [27]. Isolated injuries of the medial gastrocnemius head can
also be seen in patients with posteromedial knee
instability. Isolated injuries of the lateral gastrocnemius head can be observed in patients with posterolateral complex injuries [29].
MRI
Acute injuries of the proximal gastrocnemius
include interstitial edema of the myotendinous junction and surrounding soft tissues [37]. Occasionally,
an intramuscular hematoma forms a space-occupying
mass in the muscle. MRI can assess the chronicity
of the hematoma by the general appearance of the
products of hemoglobin degradation. A complete rupture of the gastrocnemius head is associated with
retraction of the muscle belly.
Knee dislocations
A dislocation of the knee is a severe injury that is
caused by high-energy trauma, such as motor vehicle
and motorcycle accidents, falls, and industrial acci-
Fig. 18. Arcuate ligament tear. (A) Coronal inversion recovery image shows a typical hyperextension, varus bone contusion
pattern (arrows). (B) Sagittal T2-weighted image demonstrates a significant amount of edema in the posterolateral soft tissues
where the arcuate complex ordinarily should be located (e). (C) Coronal inversion recovery image also shows perifascicular
edema in the posterolateral aspect of the knee (e). e = edema.
dents. Knee dislocations are important because they

produce extensive disruption of the ligaments that
stabilize the knee and the surrounding soft tissue
structures, including the popliteal artery [38]. Most
dislocations are reduced before imaging. A patient
1077
with an acute knee dislocation may have extensive

ligamentous disruption without obvious evidence of
a dislocation. Instability of the joint and a popliteal hematoma may be the only indicators of this
significant injury.
Fig. 19. Complete knee dislocation. (A) The bone contusion pattern can identify the direction of injury. In this case it
was an anterior dislocation. (B) There are extensive ligament injuries with an avulsion of the anterior cruciate ligament,
midsubstance tear of the posterior cruciate ligament, and partial tears of the iliotibial tract and medial collateral ligament. (C) There
are also extensive soft tissue injuries involving the vastus medialis aponeurosis and posterior muscles.
1078
MRI
A knee dislocation is classified according to the
position of the tibia relative to the femur (Fig. 19).
There are five different types of dislocations: (1)
anterior, (2) posterior, (3) lateral, (4) medial, and (5)
posterolateral. Posterior and posterolateral dislocations have a high association with complete tears of
the popliteus and conjoined tendons, manifested by
retraction, hemorrhage, and muscle edema [38]. In
general, both cruciate ligaments are likely to be torn.
Complete disruption of one or both of the collateral
ligaments is expected with this severe injury. Concomitant meniscal injury is also common. Frequently,
the pattern of bone contusions allows definition of
the type of knee dislocation. This is an important
observation because posterior and posterolateral
dislocations have a high association with peroneal
nerve injury [38].
Summary
Excellent spatial resolution and unparalleled contrast resolution have allowed MRI to emerge as the
dominant imaging modality for diagnosis of ligament
and tendon pathology of the knee joint. This article
presents several important mechanisms of injury
associated with tendon and ligament disruptions.
When present, the pattern of bone contusions may
reveal the vector of force. When one is aware of
the mechanism of injury, it is possible to analyze
systematically the structures of the knee and maximize the detection of pathology. Recognition of a
knee dislocation pattern is important because the
diagnosis may be unsuspected, and the clinician
may have to be alerted to the possibility of vascular
and neural injury.
Acknowledgement
The authors acknowledge Jonathan Lee, BS, who
helped to identify from the teaching file many of the
figures used in this article.
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Radiol Clin N Am 40 (2002) 1081 1094
MR imaging of the meniscus

Mark W. Anderson, MD
Department of Radiology, University of Virginia Health Science Center, Box 170, Charlottesville, VA 22908, USA
MRI plays a central role in the work-up of a

patient with suspected knee pathology because of its
exquisite contrast resolution and ability simultaneously to display the osseous and soft tissue structures of
the knee in virtually any plane. Although meniscal
injuries are extremely common, the clinical history is
usually nonspecific. Locking, grinding, or joint line
tenderness and positive Lachmans or McMurrays
tests are suggestive, but not conclusive, of meniscal
pathology, and other types of intra- and extra-articular
pathology may confound the clinical picture [1].
MRI is the modality of choice for evaluating a
patient with suspected meniscal pathology. Its accuracy for detecting meniscal tears is greater than 90%
in most series [2 5]. By displaying the morphology
of the tear it provides valuable information for
determining the need for operative intervention and
predicting the feasibility of meniscal repair. If the
scan demonstrates only an extra-articular cause for
the patients symptoms (eg, an osseous contusion), it
may obviate an unnecessary arthroscopic procedure.
This article discusses meniscal anatomy and
pathology, the MRI appearance of each, and common
pitfalls encountered when evaluating MRIs of these
structures. Throughout, an attempt is made to discuss
these features in the context of what is most important
to the surgeon who is evaluating a patient presenting
with a potential meniscal tear.
Anatomy
The medial and lateral menisci are C-shaped
fibrocartilaginous structures situated within the knee
joint between the femoral condyles and tibial plateau
E-mail address: mwa3a@virginia.edu (M.W. Anderson).
(Fig. 1). The medial and lateral menisci cover roughly

60% to 80% of the tibial plateau in their respective
joint compartments and absorb approximately 50% of
an axial load placed on the knee joint [6]. This
increases to 85% of the load when the knee is in 90
degrees of flexion [7]. In addition to shock absorption, their structure and position give rise to at least
three more functions: (1) increased stabilization of the
knee by deepening the contact surface between the
femoral condyles and tibial plateau; (2) joint lubrication, probably by fluid exudation across their surfaces; and (3) proprioception related to nerve fibers in
their anterior and posterior horns [6,8].
Microanatomy
The menisci are predominantly made up of type I
collagen arranged into bundles. Most of the bundles
course circumferentially, parallel to the long axis of
the meniscus. A smaller number of fibers are oriented
in a radial fashion, functioning as stabilizing tie
fibers (Fig. 2). With axial loading of the joint, the
circumferential orientation of most of the collagen
bundles allows for meniscal deformation, the development of hoop stresses, and a relatively even
distribution of the load across the joint surfaces [6].
This serves to protect the articular cartilage. Loss of
meniscal integrity, either through complete disruption
of the circumferential fibers (eg, from a large radial
tear) or from meniscectomy, results in increased force
concentration on the articular cartilage. It has been
shown that removal of even 16% to 34% of a meniscus increases the contact forces on the articular cartilage by 350% [9]. This explains why there is a strong
correlation between the amount of meniscal tissue
resected after injury and the development of osteoarthritis, and why meniscal preservation is a primary
goal of the surgeon [10].
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 5 0 - 7
1082
M.W. Anderson / Radiol Clin N Am 40 (2002) 10811094
meniscus is vascularized [11]. This outer one third of

the meniscus is known as the red zone because of its
rich vascularity, whereas the inner, relatively avascular, two thirds are known as the white zone (see Fig. 2).
Macroanatomy and MRI appearance
Fig. 1. Diagram of the menisci. Note the transverse intermeniscal ligament anteriorly (small arrow), the meniscofemoral ligament attaching to the posterior horn of the lateral
meniscus (large arrow), an oblique meniscomeniscal ligament (open arrow), and the popliteus tendon (curved arrow).
Meniscal vascularity is derived from the medial

and lateral geniculate arteries that form a capillary
plexus along the periphery of each meniscus. In the
neonate, small vessels extend throughout each meniscus, but by approximately the age of 10, these have
regressed such that only the outer 20% to 30% of the
The menisci are C-shaped structures that are

conventionally described as having three segments:
(1) anterior horn, (2) body, and (3) posterior horn (see
Fig. 2). Each meniscus measures approximately 5 mm
in height along its periphery and tapers to a thin inner edge such that it demonstrates a triangular shape
when cut in cross-section (see Fig. 2). The upper
margin is designated the superior articular surface,
whereas the lower margin is called the inferior
articular surface. The superior articular surface is
visible to the arthroscopist, the inferior is less so, and
the outer, nonarticular capsular surface is not. The
anterior horns are connected by the transverse intermeniscal ligament (see Fig. 1).
The menisci demonstrate diffusely low signal
intensity on all MRI pulse sequences because of their
fibrocartilaginous nature. Meniscal pathology is best
demonstrated on sequences that use a short echo time
(TE) ( < 20 millisecond), such as T1, proton density,
Fig. 2. Meniscal anatomy. Each meniscus is arbitrarily divided into anterior horn, body, and posterior horn segments. A crosssection through the body illustrates the superior and inferior articular surfaces, and the more vascularized periphery of the
meniscus, designated as the red zone, and the relatively avascular inner two thirds of the meniscus, designated as the white zone.
Note that most collagen bundles course in a longitudinal (circumferential) direction (arrow) with fewer radially oriented tie fibers.
1083
Fig. 3. Medial meniscus. (A) Sagittal gradient echo image demonstrates the smaller anterior horn and larger posterior horn. Note
also the sharply defined free edge (arrow). (B) The body of the meniscus demonstrates a bow-tie configuration on this sagittal
gradient echo image more peripheral to that in (A).
and gradient echo. If a fast spin echo technique is

used, the echo train length should be kept below four
to five and the interecho spacing minimized to reduce
the blurring effect inherent to this technique that can
obscure a meniscal tear [12,13].
Medial meniscus
The anterior horn of the medial meniscus is the
smallest segment of either meniscus and is roughly
one third to one half as large as the posterior horn on
sagittal images (Fig. 3). The body of the meniscus is
seen as a bow tie shaped structure on the two most
peripheral sagittal slices through the meniscus when
3- or 4-mm-thick slices are obtained. On coronal
images, the anterior and posterior horns demonstrate
a band-like morphology, whereas the body is seen as
a roughly equilateral triangle (Fig. 4).
The anterior horn is attached to the medial tibial
spine just anterior to the insertion of the anterior
cruciate ligament, whereas the posterior horn is
attached immediately posterior to the insertion of
the posterior cruciate ligament (PCL). It is important
to ensure that the posterior horn of the medial
meniscus is seen on the sagittal slice adjacent to the
PCL not to miss a meniscal tear or avulsion at this
site. The medial meniscus is more tightly adherent to
the joint capsule than is the lateral meniscus and is
less mobile. It is attached to the medial femoral
condyle and tibial plateau by the coronary ligaments
(deep fibers of the medial collateral ligament) that are
usually well demonstrated on coronal images. Additionally, an oblique meniscomeniscal ligament may
course from the posterior horn of one meniscus to the

anterior horn of the other (Figs. 1, 5) [14].
Lateral meniscus
The lateral meniscus is configured in a tighter
C-shape than is the medial meniscus. It is also more
uniform in size such that its anterior and posterior
Fig. 4. Coronal anatomy. T1-weighted coronal image demonstrates the body segments of each meniscus as low signal
intensity, roughly equilateral triangles. Note the attachment
of the medial meniscus to the deep fibers of the medial
collateral ligament (arrow).
1084
popliteus tendon, to attach to the joint capsule (see

Fig. 6).
The meniscofemoral ligaments course from the
posterior horn of the lateral meniscus, along either
side of the PCL, to attach on the inner margin of the
medial femoral condyle. The ligament of Humphry
courses anterior to the PCL, whereas the ligament of
Wrisberg passes posterior to it. One of these two limbs
is present in approximately 70% of knees; both are
present in only 6% [6]. These ligaments are viewed en
face on coronal images, and in cross-section on
sagittal scans (Fig. 7).
Anatomic variants
Fig. 5. Oblique meniscomeniscal ligament. Axial short
tau inversion recovery image demonstrates the ligament
(small arrows) as it courses from the posterior horn of the
lateral meniscus, across the intercondylar notch between
the anterior (arrowhead) and posterior (large arrow) cruciate ligaments.
horns appear as equilateral triangles on sagittal

images (Fig. 6). Like the medial meniscus, the body
of the lateral meniscus appears as a bow tie on the
two most peripheral sagittal images through it, and
as an equilateral triangle on coronal scans. The
lateral meniscus is more loosely attached to the joint
capsule, especially along its posterolateral aspect
where the popliteus tendon courses through its
intra-articular tunnel. In this region, the superior
and inferior popliteal meniscal fascicles course from
the peripheral margin of the meniscus, around the
Discoid meniscus
A discoid meniscus is so-called because of its
abnormal, thickened, disk-like shape. Its exact origin
is uncertain. It more commonly occurs on the lateral
side, and is easily recognized on MR images. In the
coronal plane, the body of the meniscus is seen to
extend farther in toward the notch than normal
(Fig. 8). Because of this shape, three or more bow
ties are seen on sagittal images. Discoid menisci are
more prone to tear, and multiple tears within the same
meniscus are not uncommon [15].
Meniscus flounce (buckled meniscus)
Occasionally, the medial meniscus demonstrates
an undulating or buckled appearance on sagittal MR
images (Fig. 9). This redundancy is a normal variant
that is related, at least in part, to knee position. Close
inspection of the meniscus is needed, however,
Fig. 6. Lateral meniscus. (A) Sagittal gradient echo image demonstrates the equal size anterior and posterior horns of the lateral
meniscus. (B) Sagittal short tau inversion recovery image more peripheral to that in (A) demonstrates the superior popliteal
meniscal fascicle spanning from the posterior horn of the lateral meniscus to the capsule (arrow) around the fluid-filled sheath of
the popliteus tendon (arrowhead).
1085
Fig. 7. Meniscofemoral ligaments. (A) Sagittal short tau inversion recovery (STIR) image demonstrates the meniscofemoral
ligament of Wrisberg in cross-section posterior to the posterior cruciate ligament (arrow). (B) Coronal STIR image displays the
ligament (black arrow) as it courses from the posterior horn of the lateral meniscus (white arrow) to the medial femoral condyle.
because a meniscal tear may occasionally result in a

similar appearance [16].
Meniscal ossicle
A small focus of ossification within a meniscus,
usually the posterior horn of the medial meniscus, is
termed a meniscal ossicle [17]. This may represent an
embryologic variant or sequelae of prior trauma.
Although often clinically silent, an ossicle may cause
mechanical symptoms or pain, and easily can be
mistaken for a loose body on radiographs or MRI
(Fig. 10).
Fig. 8. Discoid meniscus. Coronal T1-weighted image demonstrates an enlarged, lateral discoid meniscus extending in
toward the intercondylar notch (arrow). Note the normal
size of the medial meniscus.
Pathology
Meniscal pathology is typically related to degeneration, acute trauma, or a combination of the two.
The collagen fibers of the menisci undergo mucoid
degeneration with advancing age. As the degree of
intrasubstance degeneration increases, interstitial
tears develop. These may propagate to an articular
surface with or without trauma. In addition to a
degenerative etiology, a meniscal tear may also result
from an acute traumatic event [18].
Fig. 9. Meniscus flounce. Sagittal gradient echo image

through the periphery of the medial meniscus demonstrates
the undulating, buckled appearance of the meniscus.
1086
Fig. 10. Meniscal ossicle. (A) Lateral radiograph of the knee reveals a triangular-shaped ossific density overlying the posterior
knee joint (arrow). Note the small fabella lying just above it. (B) Sagittal T1-weighted image reveals high signal intensity
marrow fat within ossicle in the posterior horn of the medial meniscus (arrow).
Meniscal tears
Meniscal tears are typically divided into two basic
types: vertical and horizontal. Vertical tears are often
of a traumatic origin, whereas horizontal tears are
usually secondary to meniscal degeneration [18].
Vertical tears are further subdivided into radial (perpendicular to the long axis of the meniscus) and longitudinal (parallel to the long axis) varieties (Fig. 11).
MRI findings
Abnormal signal intensity. A normal meniscus
demonstrates low signal intensity on all sequences.
In younger patients, however, mildly increased signal
may be observed within the substance of the menisci,
possibly related to the increased vascularity that is
present at these ages [19]. The mucoid intrasubstance
degeneration that occurs with advancing age is also
manifest as intermediate signal intensity on short TE
sequences that is confined to the meniscus. If inter-
mediate or high signal intensity is seen to extend

through either articular surface, this is compatible
with a tear as opposed to simple degeneration. It
should be remembered, however, that signal intensity
consistent with a tear may be found in asymptomatic
patients. Additionally, a healed tear is often indistinguishable from an acute tear based solely on signal
intensity. Unequivocal fluid extending into the tear on
a T2-weighted image is a helpful sign to confirm that
it is not a healed tear [20].
In some cases, it may be difficult to determine with
certainty whether or not the abnormal signal intensity
extends through an articular surface. In one series,
when this pattern was seen, only 35% were found to
be true tears at arthroscopy [21]. When linear signal
closely approximates, but does not convincingly violate an articular surface, it is best to be descriptive
rather than overcall a questionable finding.
In addition to the linear signal intensity typically
seen with a tear, more amorphous meniscal signal that
abuts an articular surface has been described with
Fig. 11. Meniscal tears (left to right): radial tear; longitudinal tear; horizontal tear (with superior flap retracted); and parrot beak
(oblique tear).
meniscal contusions that resolve over time [22].

Consequently, when this finding is encountered, it
is again better to be descriptive and alert the clinician
to the possible etiologies.
Abnormal morphology. In addition to abnormal
signal intensity, a tear may manifest as abnormal
meniscal morphology. Irregularity of the meniscal
margin, a focal defect in one of its articular surfaces,
or an abnormally small meniscal segment may be the
only sign of a tear. If a smaller than normal meniscal
segment is observed, a thorough search should be
performed to identify a displaced fragment.
1087
Radial tears
Radial tears extend perpendicular to the long axis
of the meniscus. These range from a small injury
along its free edge to a large tear extending through
its entire substance. A full-thickness radial tear
severely compromises meniscal function by disrupting the critical circumferential collagen bundles, such
that the meniscus can no longer develop the hoop
stresses necessary to disperse an axial load.
On MR images, a small, radial tear involving just
the free edge of the meniscus is seen as a focal defect
within its substance on the innermost bow tie segment of a sagittal or coronal scan. The MRI appear-
Fig. 12. Radial tear. (A) Diagram demonstrating a posterior horn radial tear. (B) Coronal short tau inversion recovery (STIR)
image obtained at the level of line B reveals fluid within the large tear (arrow). (C) Sagittal STIR image at the level of line C
reveals marked truncation of the posterior horn at that level (arrow).
1088
ance of a larger radial tear depends on the site of

injury and the imaging plane used. For example, a
radial tear in the posterior horn is seen as a focal
defect through an entire portion of the meniscus on
coronal scans. It can also be diagnosed on sequential
sagittal scans when the meniscus appears truncated
or absent between two normal-appearing images
(Fig. 12) [23]. Axial images can be used to confirm
the location and morphology of the tear.
Fig. 13. Longitudinal tear. Sagittal gradient echo image

showing a vertical, longitudinal tear in the posterior horn of
the medial meniscus (arrow).
Longitudinal tears
A longitudinal tear extends through the meniscus
parallel to its long axis (Fig. 13). It appears as a
vertically oriented, linear focus of abnormal signal
intensity within the substance of the meniscus along
Fig. 14. Bucket-handle tear. (A, B) Diagram demonstrating a bucket-handle tear with a large displaced fragment. (C) Coronal
STIR image at the level of line A demonstrates the truncated, irregular body of the meniscus (large arrow) and the displaced
fragment (small arrow) within the intercondylar notch beneath the posterior cruciate ligament. (D) Sagittal gradient echo image
at the level of line B displays the displaced fragment (white arrow) beneath the posterior cruciate ligament (black arrow),
designated as a double PCL sign.
its long axis. A purely longitudinal tear courses

through the meniscus at a constant distance from its
capsular margin on sequential scans.
If the tear extends over a long enough distance,
the inner fragment may become displaced into the
intercondylar notch, and it is then designated as a
bucket-handle tear (Fig. 14). The displaced fragment
may flip back and forth resulting in intermittent
locking and other mechanical symptoms. These types
of tears typically involve the medial meniscus and are
easily missed unless the displaced fragment is identified within the intercondylar notch.
Several MRI findings have been described for
bucket-handle tears. Findings on sagittal scans
include too few bow tie segments (less than two)
and a double PCL sign (see Fig. 14) [24]. On coronal
scans, findings include a truncated appearance of the
body of the meniscus and direct visualization of the
displaced fragment that is seen in cross section within
the notch.
Oblique (parrot beak) tear
This form of vertical tear demonstrates both radial
and longitudinal components as it courses obliquely
across the meniscus, and typically results in a flap of
unstable meniscal tissue (see Fig. 11).
Horizontal tears
A horizontal tear extends through the meniscus
along a plane parallel to the tibial plateau, separating
1089
the meniscus into superior and inferior fragments

(Fig. 15). Also called a horizontal cleavage tear, this
is the most common type of tear to be associated with
a meniscal cyst [25]. The cyst is thought to occur as a
result of fluid extruding through the tear by a ball
valve effect, and collecting either within the meniscus
(intrameniscal cyst) or at the meniscocapsular junction (parameniscal cyst) (see Fig. 15). If a cyst is seen
along the joint line at the meniscocapsular junction, it
is important to look carefully for an underlying tear,
because the cyst tends to recur after resection if the
underlying meniscal tear is not repaired.
Complex tear
A tear that demonstrates a combination of more
than one of the morphologies described previously is
considered complex.
Displaced tears
Bucket-handle tear.
previously.
This type of tear is discussed
Flipped fragment. If too much meniscal tissue is

identified in a certain region, this is most often related
to a displaced meniscal fragment. This occurs when a
portion of the meniscus is torn and then flips either
anteriorly or posteriorly on a pedicle to lie adjacent to
the intact anterior or posterior horn, resulting in a
flipped meniscus sign, also known as a double
anterior horn sign (Fig. 16) [26,27]. This type of
tear most commonly involves the lateral meniscus.
Inferior flap tear. With a horizontal tear, a portion
of the meniscus may flip into the adjacent synovial
gutter along the margin of the joint (Fig. 17). It is
important to identify this displaced fragment on MRI
because it may be missed easily at arthroscopy [28].
Free fragment. When a portion of a meniscus is not
seen, in addition to looking for the types of displaced
tears described previously, care must be taken to
examine all of the joint recesses, including the suprapatellar pouch, to identify any free fragments that have
become remotely displaced from their site of origin.
Fig. 15. Horizontal tear and associated meniscal cyst.

Coronal short tau inversion recovery image demonstrates a
horizontal tear in the body of the lateral meniscus (small
arrow) and an associated meniscal cyst (large arrow).
Peripheral tear
If a tear is confined to the outer one third of the
meniscus, it is important to describe it as a peripheral
tear because this may change the therapeutic plan for
the patient (Fig. 13). Because of the rich vascularity
in this portion of the meniscus, this type of tear is
more likely to heal with conservative therapy or
operative repair, whereas tears confined to the inner
1090
Fig. 16. Flipped fragment. (A) Diagram demonstrating a tear of the posterior horn resulting in a fragment that has flipped to lie
adjacent to the intact anterior horn. (B) Sagittal gradient echo image obtained at the level of the dashed line shows a double anterior
horn sign (arrows) related to the flipped fragment. Note also the abnormally small posterior horn.
white zone of the meniscus must often be debrided or

resected [29].
Meniscocapsular separation
A meniscocapsular separation refers to an injury in
which the meniscus separates from the adjacent capsule. This can lead to meniscal instability if unrecognized and is most commonly seen along the medial
meniscus, which is more tightly adherent to the joint

capsule. It can also occur along the posterolateral
corner of the joint where the lateral meniscus is
attached by the popliteal meniscal fascicles. This
injury is diagnosed when true fluid signal intensity
is seen interposed between the meniscus and adjacent
capsule or when the popliteal meniscal fascicles are
disrupted. One series, however, reported very low
Fig. 17. Inferior flap tear. (A) Coronal short tau inversion recovery image reveals a tear of the body of the medial meniscus with
displacement of the inferior meniscal flap into the medial gutter beneath the medial collateral ligament (arrow). (B) Correlative
diagram illustrates the tear and displaced fragment.
1091
positive predictive values for these MRI findings, so

this diagnosis should be made with caution [30].
Imaging challenges
Although MRI is extremely accurate in diagnosing meniscal pathology, there are numerous imaging
pitfalls and artifacts that may simulate a tear and lead
to an erroneous diagnosis. Several of these are
described next, and they are especially common in
the posterior horn of the lateral meniscus. A recent
study also described a tendency to overcall tears in
the anterior horns of the menisci on MRI studies. The
authors noted that tears involving the anterior horns
are relatively uncommon, because most of the forces
acting on a meniscus primarily affect its body and
posterior horn segments [31].
Potential pitfalls
Transverse intermeniscal ligament
On sagittal scans, the attachment of the transverse
ligament to the anterior horn of the medial or lateral
meniscus may be mistaken for a tear (Fig. 18) [32].
This pitfall is avoided by following the meniscal
fragment on successive sagittal scans, recognizing
that it is contiguous with the normal ligament coursing across the infrapatellar fat.
Meniscofemoral ligaments
Similarly, the attachment of the meniscofemoral
ligaments of Humphry or Wrisberg to the posterior
Fig. 19. Pitfall: meniscofemoral ligament. Sagittal short tau

inversion recovery image demonstrates linear intermediate
signal in the posterior horn of the lateral meniscus mimicking
a tear. This appearance is related to the attachment of the
meniscofemoral ligament (arrow) at this level.
horn of the lateral meniscus may be mistaken for a

tear on sagittal scans (Fig. 19) [33]. Again, examination of sequential sagittal or appropriate coronal scans
should allow for accurate diagnosis.
Oblique meniscomeniscal ligament
As it courses across the intercondylar notch from
the posterior horn of one meniscus to the anterior
horn of the other, this ligament may be mistaken for a
displaced meniscal fragment [14]. The key to diagnosis is recognizing its oblique course between the
anterior and posterior cruciate ligaments (PCLs), an
unusual site for a displaced meniscal fragment (see
Fig. 5).
Popliteus tendon
There is usually at least a small amount of fluid
within the popliteus tendon sheath that can be mistaken for a tear at the junction of the posterior horn
and body of the lateral meniscus on sagittal or
coronal scans.
Fig. 18. Pitfall: transverse ligament. Sagittal gradient echo

image demonstrates linear signal in the anterior horn of the
lateral meniscus simulating a tear. This appearance is related
to the attachment of the transverse intermeniscal ligament
(arrow) at this site.
Magic angle effect

The posterior horn of the lateral meniscus courses
slightly upward as it extends into the posterior
intercondylar notch. As a result, artifactually
increased signal may be seen within the meniscus
on short TE sequences because of the magic angle
artifact [34]. The signal, however, is often of a rather
diffuse nature and disappears on long TE images
( > 40 milliseconds).
Pulsation artifact from the popliteal artery
Phase artifacts propagating from the popliteal
artery may mimic a tear in the posterior horn of the
1092
lateral meniscus on sagittal scans. Misdiagnosis can

be avoided by recognizing the alternating lines of
increased and decreased signal propagating across the
entire image at that level.
Edge artifact
A horizontal band of intermediate signal intensity
may be seen in a meniscus on the most peripheral
sagittal image through its body (the last bow tie
segment), mimicking a horizontal tear. This artifact
is related to the concave margin of the meniscus at
that level.
Patient motion
Even a small amount of patient movement during
the scan can produce motion-related artifacts within
the meniscus, simulating a tear. On careful examination, however, the abnormal signal intensity can
usually be seen to extend beyond the meniscal tissue.
Also, like the pulsation artifact described previously,
abnormal bands of signal intensity also can usually be
observed elsewhere on the image.
Calcium pyrophosphate deposition
disease (pseudogout)
In patients with calcium pyrophosphate deposition
disease, susceptibility artifacts related to the paramagnetic effect of the calcium salts within the articular cartilage or menisci can simulate or in some cases
mask a meniscal tear [35].
Hemosiderin-vacuum phenomenon
Hemosiderin related to a prior hemarthrosis, or a
vacuum phenomenon within the joint, are of low
Fig. 20. Pitfall: hemosiderin. Sagittal gradient echo image

reveals an apparent tear of the free edge of the posterior horn
of the medial meniscus. The low signal focus (arrow) was
not seen on other sequences and is compatible with hemosiderin related to a subchondral fracture found in the distal
femur. Its conspicuity on this gradient echo image is related
to its paramagnetic effect.
signal intensity on all pulse sequences and may

simulate a small meniscal fragment. One key to the
correct diagnosis is that these foci appear more
prominent on gradient echo images (blooming effect)
than on other sequences (Fig. 20).
Surgical considerations
When faced with a meniscal tear, the surgeon has
three options: (1) leave the tear alone, (2) attempt a
primary meniscal repair, or (3) perform a partial or
complete meniscectomy. The paramount goal is to
preserve as much meniscal tissue as possible to lessen
the probability of developing osteoarthritis. There is a
direct correlation between the amount of meniscal
tissue resected and the onset and severity of articular
cartilage degeneration within the joint [10]. Although
a recent study found MRI to be only moderately
reliable for predicting meniscus reparability, several
features have been shown to be correlated with a
higher probability of a successful meniscal repair. It is
important for the radiologist to be aware of these
features to provide as much relevant information in
the MRI report as possible.
Tear location
The most important factor in predicting the success of a meniscal repair is where the tear is located
in the meniscus. A tear in the periphery of the
meniscus (within 3 mm of its capsular surface) has
the highest probability for healing because of the
excellent vascularity in that region. Tears in the
inner, avascular portion of the meniscus (greater than
5 mm from the capsule) heal poorly, whereas those
near the junction of the red and white zones (3 to
5 mm from the capsule) have a more variable rate of
healing [29].
Blind spots for the arthroscopist include the
anterior horn of each meniscus, the extreme inner
portion of the posterior horn of the medial meniscus,
and the undersurface of both menisci. It is important
to describe any tear in these areas clearly, and
especially those that extend to the inferior articular
surface of a meniscus. The bulk of the undersurface
of the meniscus is not visible to the arthroscopist,
and diagnosis of an undersurface tear at arthroscopy
is usually dependent on blind probing of that surface. An accurate description of the site of the tear
in the MRI report should assist the surgeon in its
identification. It is also important to describe any meniscal tissue that has become displaced into a paraarticular gutter so that the arthroscopist is able to
1093
probe for and resect the fragment, which might

otherwise be missed.
cing) to minimize the inherent blurring artifact that

can obscure tears.
Tear morphology and length
Tear morphology and location
Vertical longitudinal tears have the best prognosis

for healing because they do not disrupt the circumferential collagen bundles that are so important for
maintaining normal meniscal function. Those that are
in the periphery and that measure less than 1 cm in
length are often treated nonoperatively, whereas longer tears are repaired with sutures or other fixation
devices, again with a high rate of healing.
Small partial tears (involving less than half the
height of the meniscus) and radial tears measuring
less than 5 mm in length also have a higher rate of
healing than do larger tears [29]. A radial tear
extending through the meniscus to the capsule is
essentially unrepairable because of the complete
disruption of the circumferential collagen bundles.
Most horizontal tears are also not amenable to repair
and the surgeon typically resects either the superior or
inferior flap, leaving the other in situ. Complex tears
also demonstrate poor healing and often require
debridement or a partial meniscectomy.
When interpreting MRIs of the menisci, in addition to searching for abnormal signal intensity that
extends to an articular surface of a meniscus, assessment of meniscal morphology is also crucial. When a
portion of a meniscus is noted to be small, truncated,
or quite irregular, a careful search for a displaced
fragment should be performed. Areas to be scrutinized
include the intercondylar notch, the para-articular
gutters along the medial and lateral joint lines, and
the suprapatellar pouch. An accurate and complete
description of tear morphology and location helps the
surgeon to determine whether meniscal repair is
feasible, or if a meniscal resection is likely.
Tear stability
The stability of a meniscal tear is an important
factor because a stable tear is often treated nonoperatively. Stability is defined as a tear that does not
result in displacement of any portion of the meniscus
more than 3 mm during probing at arthroscopy.
Clearly, it is often impossible to determine with
certainty whether or not a tear is stable using MRI
(unless a displaced fragment is identified), but tears
that are considered stable include (1) a partial-thickness tear (less than half the height of the meniscus);
(2) a full-thickness oblique or vertical tear measuring
less than 7 to 10 mm in length; and (3) a radial tear
measuring less than 5 mm [36].
Conclusion
Technique
A meniscal-sensitive sequence using a short TE
(T1, proton density, gradient echo) should be a part
of any standard MRI knee examination. When using
a fast spin echo, proton density technique, care must
be taken to optimize the imaging parameters (eg,
shortening the echo train length and interecho spa-
Potential imaging pitfalls

It is important to be familiar with the most common anatomic variants and imaging artifacts that may
mimic meniscal pathology. These are especially common in the posterior horn of the lateral meniscus.
Summary
It should be the goal of any radiologist who
interprets MRI examinations of the knee to be able
not only to recognize normal meniscal anatomy and
accurately diagnose meniscal pathology, but also to
develop a better grasp of the surgical implications of
the imaging findings. By thinking more like an arthroscopist, one can provide a more clinically relevant
report, and by doing so, add value to the work-up of a
patient who presents with a potential meniscal tear.
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Lecas LK, Helms CA, Kosarek FJ, Garret WE. Inferiorly displaced flap tears of the medial meniscus: MR
appearance and clinical significance. AJR Am J Roentgenol 2000;174:161 4.
Belzer JP, Cannon Jr. WD. Meniscus tears: treatment in
the stable and unstable knee. J Am Acad Orthop Surg
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Rubin DA, Britton CA, Towers JD, Harner CD. Are
MR imaging signs of meniscocapsular separation valid? Radiology 1996;201:829 36.
Shepard MF, Hunter DM, Davies MR, Shapiro MS,
Seeger LL. The clinical significance of anterior horn
meniscal tears diagnosed on MR imaging. Am J Sports
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Herman LJ, Beltran J. Pitfalls in MR imaging of the
knee. Radiology 1988;167:775 81.
Vahey TN, Bennett HT, Arrington LE, Shelbourne KD,
Ng J. MR imaging of the knee: pseudotear of the lateral meniscus caused by the meniscofemoral ligament.
Peterfy CG, Janzen DL, Tirman PF, van Dijke CF,
Pollack M, Genant HK. Magic-angle phenomenon:
a cause of increased signal in the normal lateral meniscus on short-TE MR images of the knee. AJR Am J
Roentgenol 1994;163:149 54.
Kaushik S, Erickson JK, Palmer WE, Winalski CS,
Kilpatrick SJ, Weissman BN. Effect of chondrocalcinosis on the MR imaging of knee menisci. AJR Am J
Roentgenol 2001;177:905 9.
Matava MJ, Eck K, Totty W, Wright RW, Shively RA.
Magnetic resonance imaging as a tool to predict meniscal reparability. Am J Spots Med 1999;27:436 43.
Radiol Clin N Am 40 (2002) 1095 1107
MR imaging of chondral and osteochondral injuries of

the knee
Thomas R. McCauley, MD
Radiology Consultants, P.C., 40 Temple Street, New Haven, CT 06510, USA
Articular cartilage provides a nearly frictionless

joint surface that is strong and resilient, able to tolerate
both high-compressive loads and shearing stresses [1].
Joint replacements can improve symptoms caused by
articular cartilage damage; however, they cannot
completely reproduce the function of the native joint
and they have a limited life span. Maintaining articular cartilage function is a critical goal in the treatment
of joint disease. Damage to articular cartilage can
occur because of inflammatory arthritis or noninflammatory causes, most commonly osteoarthritis and
trauma. This article is limited to noninflammatory
causes of articular damage. Osteoarthritis is the most
common cause of articular cartilage damage, occurring in almost 75% of people over the age of 75 [2].
Damage to articular cartilage is also common in
younger patients, with articular cartilage damage
found in over 60% of patients undergoing arthroscopy
[3,4]. Interest in improved imaging techniques for
detecting articular cartilage damage has increased
with the development of new treatments including
osteochondral transplant and autologous chondrocyte
transplant. MRI can detect articular cartilage damage
along with determination of its site, depth, and extent,
which allows selection of patients for articular cartilage therapies.
Articular cartilage structure and damage

Articular cartilage is composed of an extracellular
matrix maintained by a relatively small population of
E-mail address: mccauley@biomed.med.yale.edu

(T.R. McCauley).
chondrocytes [5]. The framework of the matrix is

composed primarily of collagen, which is a highly
ordered structure with organization of fibers in a
pattern of arcades with densely packed fibers parallel
to the surface forming a covering layer and with deep
fibers oriented perpendicular to the bone cortex [5].
Proteoglycan molecules are the other major solid
constituent of the extracellular matrix of cartilage
and are located within the collagen framework and
covering, where they attract water into cartilage
because of their hydrophilic nature. Articular cartilage function is lost with damage to chondrocytes,
collagen, or proteoglycans. In early damage there is
loss of the collagen organization resulting in swelling
of the cartilage with increased water content and loss
of proteoglycans [6]. With more severe injury cracks,
fissures, and focal defects form in the cartilage.
Damage can occur from a suddenly applied load
because of acute injury as occurs with patellar dislocation [7] or anterior cruciate ligament tear [8] or
can occur because of repetitive stresses, as in osteoarthritis or osteochondritis dissecans [9]. When
defects form in the cartilage the cartilage repair
response generally results in fibrocartilage, which
incompletely fills the defect and which does not
reproduce the biomechanical properties of the highly
structured normal articular cartilage. This fibrocartilage generally degenerates within a year [10].
Articular cartilage injury causes pain, effusion,
and mechanical symptoms that mimic symptoms of
meniscal tear [4]. The cause of pain is not certain,
because cartilage is aneural [11]. Pain likely is the
result of abnormal stresses on adjacent bone, joint
capsule, or other adjacent structure [11]. Abnormal
stresses on subchondral bone seem to be a major
contributor to pain because full-thickness cartilage
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 3 4 - 9
1096
T.R. McCauley / Radiol Clin N Am 40 (2002) 10951107
defects and those with associated subchondral edema

are most likely to require treatment [12]. The association of pain and progression of osteoarthritis with
increased uptake on bone scintigraphy also suggests
that subchondral stress is a major contributor to
symptoms [13]. Although full-thickness defects are
commonly associated with symptoms, not all cartilage
defects cause symptoms or progress. In one study of
28 young athletes (mean age 25 years) who were
followed for 12 to 15 years for severe articular cartilage
damage found at arthroscopy, only 21% had symptoms
with routine daily activities and 43% developed radiographic findings of osteoarthritis [14]. Clinical symptoms and morphologic changes must be assessed
to identify patients who benefit from therapy.
MRI of articular cartilage

The demand for improved preoperative detection
and characterization of articular cartilage damage has
resulted in recent improvements in the accuracy of
MRI of articular cartilage with use of sequences
optimized for articular cartilage evaluation [15]. The
two most easily implemented techniques for clinical
MRI of articular cartilage are a fat-suppressed threedimensional spoiled gradient echo technique, which
produces T1-weighted images [4,16], and a fast spin
echo technique, which produces intermediate or
T2-weighted images [17,18]. Both techniques can
produce images for evaluation of articular cartilage
in less than 5 minutes using 1.5-T scanners. Suggested
parameters are listed in Table 1. All three imaging
planes are useful; however, the sagittal plane generally
is the best single plane for evaluation of articular
cartilage because it provides near orthogonal images
of most of the articular cartilage surfaces in the knee.
When using the three-dimensional spoiled gradient
echo images, high-quality axial reformatted images
can be created from the sagittal image set to evaluate
the patellofemoral joint. Intra-articular administration

of contrast has not been shown to improve accuracy for
detection of articular cartilage damage [19,20]. The
author reserves the use intra-articular contrast for
detection of loose bodies or for evaluation of osteochondral defects for assessment of integrity of overlying articular cartilage [21,22].
Normal MRI appearance of articular cartilage

Recognition of the normal MRI appearance of
articular cartilage is essential for accurate evaluation.
Articular cartilage varies in thickness within the knee
with the thickest cartilage seen at the patella and the
thinnest seen at the tibial plateaus. A band of thinning
is normally seen over the terminal sulcus at the lateral
femoral condyle (Fig. 1). Unfortunately, normal values for articular cartilage thickness have not been
determined and detection of diffuse thinning of cartilage can be difficult. Articular cartilage signal
intensity on fat-suppressed three-dimensional spoiled
gradient echo images is uniform and high with fluid
showing low signal intensity (see Fig. 1) [4]. An
artifactual low signal intensity lamina is often seen in
the center of the cartilage because of truncation
artifact (see Fig. 1) [23]. This artifact occurs when
imaging adjacent structures with marked difference in
signal intensity with a sharp transition. A single low
signal intensity lamina is seen in the center of
articular cartilage when three pixels correspond with
the cartilage thickness, and two low signal intensity
laminae that are symmetrically positioned are seen
when five pixels correspond with the cartilage thickness. Truncation artifact can be eliminated by increasing the in-plane resolution at the expense of increased
image acquisition time. Elimination of truncation
artifact is not necessary; it is easily recognized
because cartilage damage does not cause signal
abnormality in the center of cartilage parallel to the
Table 1
Suggested parameters for articular cartilage imaging at 1.5 T
Fat-suppressed three-dimensional spoiled gradient echo
Fast spin echo
TE = minimum full echo (5 ms), TR 23 40 ms

Flip angle 30 40 degrees (use lower flip with lower TR)
Fat suppression or water excitation
Field of view 14, matrix 256 160 256
1.5-mm slices, 60 locations
0.75 or 1 excitation
Image time 5 minutes with TR = 39 ms,
0.75 excitations, 256 160 matrix
TE = 30 70 ms, TR 3500 6000 ms

Echo train length 8 12
Fat suppression preferable
Field of view 14 cm, matrix 256 512 256 384
3 4-mm slices, 0 1-mm gap
two to three excitations
Image time 3 minutes with TR = 4000 ms,
ETL = 12, two excitations, 256 256 matrix
1097
Fig. 1. Full-thickness articular cartilage defect at lateral femoral in a 31-year-old man with lateral pain and with lateral meniscal
tear suspected clinically. (A) Fat-suppressed three-dimensional spoiled gradient echo image shows full-thickness articular
cartilage defect at lateral femoral condyle (solid arrow). Most defects with only a thin layer of high signal at the base of the
defect are found to be full thickness at arthroscopy, as in this case. Note articular cartilage elsewhere is relatively high signal.
Low signal laminae in patellar cartilage and trochlear groove are caused by truncation artifact (curved arrow). The normal area of
smooth thinning is seen over the terminal sulcus of the lateral femoral condyle (open arrow). (B) Fat-suppressed fast spin echo
T2-weighted image at same location as (A) shows high signal fluid in the defect (solid arrow). Note low signal in deep portion of
cartilage at weight-bearing surface (open arrow) with uniform intermediate signal in articular cartilage at trochlear groove
(curved arrow). This variation in the laminar appearance of the cartilage signal is in part caused by magic angle effect with the
deep lamina increasing in signal when it is oblique to the main magnetic field.
surface. Articular cartilage signal intensity on intermediate or T2-weighted fast spin echo sequences is
low or intermediate with high signal intensity seen for
intra-articular fluid [17,18]. The signal intensity of
articular cartilage may be uniform or may have a
laminar appearance depending on the location of the
cartilage and the selection of imaging parameters (see
Fig. 1). The most commonly seen low signal lamina
occurs in the deep cartilage adjacent to the cortical
interface, with a thin band at the surface rarely visible
(see Fig. 1) [24,25]. The laminar appearance varies
with orientation of the articular cartilage with the
main magnetic field because of magic angle effect
[24,25]. This variation of signal occurs because of
anisotropy of the collagen fibers within the different
layers of articular cartilage [24]. Typically, the lower
signal laminae in the deep cartilage is seen when the
cartilage surface is orthogonal to the main magnetic
field and is not seen when the cartilage is obliquely
oriented to the magnetic field. Variation in the laminar appearance is only partially explained by magic
angle effect, with other differences in cartilage structure and chemical content also likely contributing to
the signal variation [26].
MRI assessment of articular cartilage injury

Focal articular cartilage defects are seen containing low signal fluid on the T1-weighted three-dimensional spoiled gradient echo images and high signal
fluid on the fast spin echo images. Both techniques
diagnose articular cartilage defects with accuracies of
greater than 90% [4,17,18,27]. The author incorporates both techniques in routine imaging of the knee
because individual lesions may be seen with only one
technique (Figs. 2 4). In the authors experience the
three-dimensional spoiled gradient echo technique is
more sensitive for smaller defects and the fast spin
echo technique is more sensitive for internal cartilage
signal abnormalities. Focal areas of subchondral
edema are commonly associated with full-thickness
articular cartilage defects and are a marker of cartilage injury (see Fig. 2) [12]. Subchondral edema is
low signal compared with marrow fat on non fatsuppressed T1-weighted images and high signal on
short tau inversion recovery images and on fat-suppressed intermediate-weighted or T2-weighted
images. Marginal osteophytes are commonly associated with osteoarthritis, although not all patients with
1098
Fig. 2. Focal full-thickness cartilage defect seen more clearly on fast spin echo image than on gradient echo image in 23-year-old
woman with pain laterally with both meniscal tear (not shown) and articular cartilage defect. The presence of subchondral edema
(curved arrow) makes it likely this is a full-thickness defect, which was confirmed at arthroscopy. (A) Sagittal fat-suppressed
three-dimensional gradient echo image shows low signal at cartilage defect in lateral femoral condyle (straight arrow). (B) Fatsuppressed fast spin echo image at same location as (A) more clearly shows the defect containing high signal (straight arrow).
The associated articular cartilage defect worsens the prognosis for meniscal repair.
osteophytes demonstrate progression to clinical osteoarthritis [28,29]. Subarticular osteophytes and marginal osteophytes occur in association with osteoarthritis
(see Figs. 3, 4) [30,31]. Subarticular osteophytes were
seen in 15% of all MRI examinations of the knee in one
study [31]. Articular cartilage abnormality was associated with all of these subarticular osteophytes. When
subarticular osteophytes are seen with any imaging
technique, an associated articular cartilage defect
should be suspected (see Fig. 3).
The location, depth, size, and number of articular
cartilage defects along with the presence of findings of
osteoarthritis affect treatment decisions [32 34]. Isolated articular cartilage defects have a better prognosis
and are more amenable to treatment than are defects
associated with the other findings of osteoarthritis
[32,35]. Osteoarthritis is recognized at MRI by the
presence of osteophytes, subchondral cysts, and subchondral sclerosis [36,37]. The articular cartilage
defects in osteoarthritis often are multiple and have
an irregular surface and obtuse margins (see Fig. 4).
Numerous grading systems have been proposed for
assessment of depth of cartilage involvement, most of
which compare the thickness of cartilage at the defect
relative to adjacent noninvolved articular cartilage.
Using these grading systems MRI has been shown to
have moderate accuracy for grading depth [4,17,18,
27,38]. Full-thickness and near-full-thickness articular

cartilage defects are most likely to be symptomatic
and mostly likely to be treated [12,34], and thus,
detection of high-grade defects is more important than
detection of lower-grade defects. Assessment of the
size of defects is important because the larger the area
of the articular cartilage defect, the poorer the prognosis [33,39] and most treatment options are limited
to lesions below a certain size [34,39]. There are little
data on the accuracy of MRI for determining the area
of defects; however, a recent study using a specialized
magnetization transfer sequence showed moderate
accuracy [40]. In the authors experience MRI often
underestimates the size of the cartilage abnormality
found at arthroscopy because the cartilage beyond the
margins of the MRI-visible defect is often abnormal.
The location of articular cartilage lesions is also an
important determinate of prognosis and treatment
options [33], with femoral condylar lesions being
most easily treated. Patellar lesions have a worse
prognosis and require concurrent treatment of patellofemoral malalignment. Tibial plateau lesions are the
most difficult to treat and transplantation techniques
cannot be performed [33].
Meniscal and ligament tears often result in articular cartilage damage [41 45]. The long-term goal
for treatment of meniscal tears and anterior cruciate
1099
Fig. 3. Subarticular osteophyte at lateral femoral condyle in 56-year-old man seen on radiograph with subsequent MRI showing
overlying articular cartilage defect. (A) Notch-view radiograph shows subarticular osteophyte at the lateral condyle (arrow).
(B) Sagittal fat-suppressed three-dimensional spoiled gradient echo image shows the subarticular osteophyte (arrow) with
overlying articular cartilage defect at lateral femoral condyle. (C) Fat-suppressed fast spin echo image at same location as
(B) shows subarticular osteophyte (arrow) with overlying articular cartilage defect. Not shown are other articular cartilage
defects and a medial meniscal tear.
ligament tears is the prevention of osteoarthritis.

Treatment of meniscal tears has evolved from complete meniscectomy to either partial meniscectomy or
repair because of the improved long-term results with
decreased risk of osteoarthritis when the meniscus is
preserved [41,45,46]. The presence of articular cartilage damage decreases the likelihood of good outcome for repair of meniscal tears (see Figs. 2, 4)
[41,43,46]. Identification of articular cartilage abnormality is especially important in patients with pain at
the site of an articular cartilage defect rather than at
the site of meniscal tear. In these patients surgical
treatment of the meniscus is unlikely to result in
improvement in symptoms. Although meniscal and
ligament injuries can cause articular cartilage damage, articular cartilage defects without meniscal or
ligament tear are common, occurring in 25% of
patients who had MRI and subsequent arthroscopy
in one study [4]. These isolated articular cartilage
defects typically present with symptoms that mimic
meniscal tear, including effusion, pain, and mechanical symptoms (see Fig. 1). Patients with articular
cartilage defects without other injury may choose not
to have treatment of their articular cartilage injuries.
Identification of the cartilage injury with MRI and
exclusion of meniscal or ligament injury could avoid
the costs and morbidity of arthroscopy. Alternatively,
detection and characterization of these articular car-
1100
Fig. 4. Osteoarthritis with articular cartilage defect at both medial femoral condyle and tibial plateau adjacent to complex tear in
posterior horn of the medial meniscus in 43-year-old with chronic pain. The obtuse margins of the defects, irregular contours,
multiplicity, and presence of osteophytes are consistent with osteoarthritis. Articular cartilage defects are seen more clearly with
fat-suppressed spoiled gradient echo images than with fast spin echo images. (A) Fat-suppressed three-dimensional spoiled
gradient echo image shows articular cartilage defect at medial femoral condyle (arrowhead). Small osteophytes are present at the
joint margin (curved arrows). (B) Fat-suppressed three-dimensional spoiled gradient echo image adjacent to (A) shows fullthickness cartilage loss at tibial plateau (arrowhead). (C) Fast spin echo T2-weighted image at the same location as (A) less
clearly shows the femoral articular defect (arrowhead). (D) Arthroscopic view of the medial compartment from anterior shows
the articular cartilage defects at the femoral condyle (straight arrows) and tibial plateau (curved arrows). The complex tear in the
posterior horn of the meniscus is seen as indistinctness of the meniscal margin on this view (arrowhead).
tilage defects can lead to arthroscopy or surgery to

treat the defects.
Despite high accuracy for detection for most
articular cartilage defects, certain defects are poorly
visualized with MRI because of limited resolution.
These include delamination injuries (Fig. 5), flap
tears, fissures, and areas of fibrillation [47,48].
Delamination injuries are probably the most important of these injuries, which can be missed because
even large defects may not be visible and these
injuries typically require surgery. Cartilage softening
and loss of proteoglycan from cartilage are often not
1101
seen with routine MRI; however, because these are

not surgically treated, the low sensitivity of MRI does
not affect therapeutic decisions.
Therapeutic options and MRI for

preoperative planning
MRI can provide important information for therapeutic decision making in patients with articular
cartilage damage. Osteochondral injuries have a different prognosis and usually are treated differently
Fig. 5. Articular cartilage delamination injury in a 32-year-old man after a direct blow to the knee. (A) Sagittal fat-suppressed
three-dimensional spoiled gradient echo image shows low signal in articular cartilage with focal thinning (arrow) at the superior
aspect of the lateral trochlear groove. (B) Axial fat-suppressed intermediate-weighted fast spin echo image through superior
portion of trochlear groove shows heterogeneous signal in the delaminated cartilage with underlying marrow edema. Overlying
soft tissue edema indicates the injury likely was caused by the direct blow to this site. (C) Arthroscopic image looking up at
trochlear groove from below shows cracks at margins of delaminated cartilage (arrow). (D) Arthroscopic image from same view
as (C) shows defect after delaminated cartilage was removed. Cartilage was harvested and patient later returned for autologous
chondrocyte transplant.
1102
than osteoarthritis and isolated articular cartilage

defects, and their evaluation and treatment are considered separately later. Treatment of articular cartilage damage caused by osteoarthritis and isolated
articular cartilage defects are considered first. There
are numerous techniques available for treatment of
articular cartilage damage [32,33,39] and they have
different short- and long-term implications for the
patient. Therapeutic options include conservative
therapy including anti-inflammatory medications and
physical therapy without surgery; microfracture, abrasion, or drilling to stimulate cartilage repair; allografts; autografts; periosteal or perichondral grafts;
autologous chondrocyte transplantation; and osteotomy. Conservative therapy is directed at controlling
symptoms; however, it may not prevent development
or progression of osteoarthritis. The simplest techniques for surgical treatment are debridement and
stimulation of subchondral bone using such techniques as microfracture, abrasion, and drilling. These
can be performed with a single arthroscopic procedure
with little recovery time; however, the repair cartilage
that forms is fibrocartilage. It does not have normal
biomechanical properties and likely lasts for only
months to years [36,39]. Osteochondral shell grafts
and osteochondral transplants replace the articular
surface, but require open surgery and require limited
or no weight bearing during healing. Allografts have
the additional risk of transmission of infectious dis-
ease. Autografts do not have a risk of transmission of

infection from the donor, but have the risk of symptoms developing at the site of articular cartilage
harvest. All transplants can result in symptoms at
the site of transplantation because of movement of
the graft or failure of healing. Autologous chondrocyte transplantation requires two surgeries with chondrocytes harvested during an initial arthroscopy,
grown in culture for 2 to 5 weeks, and then placed
in the defect beneath a periosteal graft during a second
surgery. Patients undergoing transplant cannot fully
bear weight for weeks after surgery and pain relief
is generally not complete for greater than 1 year [39].
Osteotomies require open surgery and require limitations on weight bearing during recovery. The implications for patients for each of these therapeutic
options is quite different including time for non
weight bearing, open procedure versus arthroscopic
procedure, short-term risk, and long-term likelihood
of success. MRI can allow detection of articular
cartilage defects with determination of their location,
extent, depth, and associated meniscal or ligament
abnormalities so that orthopedic surgeons can discuss these different therapeutic options with patients
before surgery.
Osteochondral injuries are an important separate
group of injuries where both the cartilage and underlying bone are injured. These include osteochondral
fractures, impaction injuries, and osteochondritis dis-
Fig. 6. Osteochondral impaction fracture at posterior tibial plateau secondary to complete acute anterior cruciate ligament tear in
a 37-year-old injured planting foot to turn while running. The presence of cortical and articular cartilage fracture indicates this
injury is likely to result in a focal articular cartilage loss. (A) Sagittal fat-suppressed three-dimensional spoiled gradient echo
image shows osteochondral fracture at the posterior aspect of the medial tibial plateau (arrow). (B) Sagittal fat-suppressed
T2-weighted fast spin echo image at same location as (A) shows fluid in the osteochondral fracture line (straight arrow) with
extensive subchondral edema (curved arrow).
secans [7,9]. Osteochondral fractures and impaction

injuries typically result from acute trauma [7]. Osteochondritis dissecans is an osteochondral injury with an
associated avascular bone fragment that is believed to
be caused by repetitive trauma [9]. Osteochondral
impaction injuries are often associated with anterior
cruciate ligament tears, typically occurring near the
terminal sulcus at the lateral femoral condyle and at
the posterior aspect of the tibial plateaus (Fig. 6).
These injuries can result in articular cartilage fracture
with step-off at the cortical and articular surface. Even
with absence of acute articular cartilage fracture,
subcortical bone bruises can be associated with chondrocyte death and subsequent cartilage loss (Fig. 7)
[8,49]. Most osteochondral lesions with geographic
subchondral signal abnormality, with cortical impac-
1103
tion, or with osteochondral fracture subsequently

result in focal articular cartilage loss, whereas subarticular nonfocal bone bruises have a good prognosis
[7,50]. These injuries are usually treated conservatively or with limited weight bearing. Intra-articular
osteochondral fragments can arise secondary to acute
trauma, such as occurs with patellar dislocation [7]. In
the authors experience, cartilage-sensitive MRI
sequences usually can identify both the osteochondral
fragments and the donor sites for these lesions (Fig. 8).
Osteochondral fragments from patellar dislocation
typically arise from the patella medially or at the
median ridge with associated medial retinacular injury
and subcortical bone bruise in the lateral aspect of the
lateral femoral condyle [7]. The fragments are
removed or reattached to the donor site (see Fig. 8).
Fig. 7. Progression of osteochondral injury to full articular cartilage defect in 32-year-old who was hit by a truck 10 months
before first MRI examination. (A) Fat-suppressed three-dimensional spoiled gradient echo image through lateral femoral condyle
shows decreased signal in the articular cartilage with impaction injury at underlying cortex (arrow). (B) T1-weighted spin echo
image at same location as (A) shows linear subcortical signal abnormality with deformity of cortex, typical for impaction fracture
(arrow). (C) T2-weighted fast spin echo image at same location as (A) shows intermediate signal tissue at site of articular
cartilage injury (arrow). (D) Fat-suppressed T1-weighted spin echo image at same location as (A) obtained during MRI
arthrogram after intra-articular injection of dilute gadolinium, performed 2.5 years later, shows that the articular cartilage defect
has progressed to full-thickness articular cartilage loss (arrow).
1104
Fig. 8. Intra-articular osteochondral loose body arising from the medial facet of the patella and lateral femoral condyle impaction
injury caused by patellar dislocation in a 14-year-old gymnast injured on balance beam. (A) Axial intermediate-weighted fast
spin echo image shows tear of the medial retinaculum and patelloepicondylar ligament (arrowhead) with associated patellar
osteochondral defect (arrow). Loose body is seen in lateral recess (curved arrow). Marrow edema caused by impaction injury is
seen at the lateral femoral condyle. (B) Sagittal fat-suppressed three-dimensional spoiled gradient echo image shows
osteochondral loose body (arrow) composed of a high signal cartilage layer with underlying low signal osseous portion.
(C) Arthroscopic image of patella from anterior and below shows osteochondral fragment (arrow) being held with surgical probe
adjacent to patellar defect after the fragment was retrieved from the lateral recess of the joint.
Osteochondritis dissecans occurs in younger patients at convex surfaces of joints. The most common
sites of involvement are the femoral condyles, talus,
and capitellum [9]. Lesions with intact overlying
articular surface and with the bone fragment attached
to adjacent bone usually are treated with conservative
therapy, especially in younger patients with an open
adjacent epiphyseal plate. If the articular surface is

disrupted and the bone fragment is partially detached
or completely detached, surgical therapy is required.
Partially detached fragments usually are drilled to
induce healing. Completely detached fragments or
nearly completely detached fragments are pinned. If
the fragment is displaced into the joint space, it acts as
1105
Fig. 9. Chronic osteochondritis dissecans in a 21-year-old with pain. (A) Sagittal fat-suppressed T1-weighted spin echo image
through the osteochondral lesion in the medial femoral condyle after injection of dilute gadolinium shows signal abnormality in
the articular cartilage and subchondral bone (arrow); however, no gadolinium extends beneath the cartilage surface indicating the
surface is intact. (B) Coronal intermediate fast spin echo image also demonstrates a smooth contour of high signal gadolinium at
the articular surface (arrow).
a loose body and must be removed [9]. MRI arthrography is useful for determining the integrity of overlying articular cartilage and the extent of detachment
of the underlying bone fragment (Fig. 9) [22].
Future
There are many unresolved questions in the treatment of articular cartilage injury. Long-term studies
need to be performed to determine which patients
benefit from available treatments. The causes of osteoarthritis remain unclear and methods for prevention of osteoarthritis and prevention of progression
need to be developed. MRI has high accuracy for
detection of most high-grade cartilage defects; however, certain defects are missed because of limited
resolution. Improved resolution is necessary to detect
these defects. Early changes of osteoarthritis and
cartilage damage are currently not important for
clinical decision making, but studies of prevention
of osteoarthritis, and prevention of progression of
osteoarthritis, likely will benefit from detection of
early articular cartilage damage. Because lost articular cartilage cannot regenerate, optimal treatments
would stop or reverse damage to articular cartilage
before morphologic defects occur. Techniques, such
as the use of gadolinium for detection of proteoglycan loss [51,52] or mapping of relaxation times
[53], may allow detection and follow-up of treatments targeted to the early phases of articular cartilage damage.
Summary
MRI can detect accurately articular cartilage injuries and associated bone, meniscal, and ligament
injuries. Identification and characterization of articular cartilage abnormalities is important for determination of prognosis, therapeutic decision making,
and preoperative planning.
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Radiol Clin N Am 40 (2002) 1109 1120
The knee: bone marrow abnormalities

Michelle S. Barr, MD*, Mark W. Anderson, MD
Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
MRI is an invaluable tool for assessing the bone

marrow. It is the most sensitive imaging modality for
detecting marrow pathology and simultaneously provides a detailed depiction of the adjacent soft tissues.
This article describes the appearance of normal and
abnormal bone marrow in and around the knee as
depicted with MRI.
Normal bone marrow

Bone marrow is categorized into two types of
tissue based on differences in their color at gross
pathologic examination. The active, hematopoietic
component is comprised mostly of erythrocytes and
their precursors and is denoted as red marrow,
whereas yellow (inactive) marrow is comprised
primarily of fat.
Each type of marrow displays a distinctive appearance on MRI based on the relative amounts of fat and
water within it. Because fat tends toward very short T1
and moderately long T2 relaxation times, yellow
marrow exhibits high signal intensity on T1-weighted
and fast spin echo T2-weighted images, intermediate
signal intensity on conventional T2-weighted images,
and variable signal intensity on gradient echo images
depending on the amount of trabecular bone present.
On fat-saturated sequences, yellow marrow demonstrates relatively homogeneous signal intensity that is
lower than that of muscle. Contrast administration
results in only minimal alteration in the yellow marrow signal intensity [1].
The signal characteristics of red marrow stem from
its higher percentage of water (40% versus 15% in
E-mail address: msb9v@virginia.edu (M.S. Barr).
yellow marrow). On T1-weighted spin echo and fast

spin echo imaging, it exhibits lower signal intensity
than fat, whereas demonstrating higher signal intensity than that of muscle. Red marrow demonstrates
intermediate to high signal intensity on short tau
inversion recovery (STIR) or fat-suppressed T2weighted images and variable signal characteristics
on gradient echo images (Fig. 1). Enhancement of red
marrow is minimal in adults but can be quite marked
in children [1].
Normal marrow conversion

The normal distribution of red and yellow marrow
varies with age. In utero and through childhood,
hematopoietic marrow predominates. Shortly before
birth, marrow in the distal phalanges converts from
red to yellow. This process normally progresses with
age from distal to proximal within the appendicular skeleton.
Not only does bone marrow conversion progress
from the most distal to the most proximal portions of
the skeleton, but it also progresses in a predictable
fashion within each bone. Within a long bone, the
conversion from red to yellow marrow starts in the
diaphysis, in the region of the central diaphyseal
vessels, and extends both proximally and distally
toward each end. The epiphysis is different because
it converts to fatty marrow early in infancy when it
begins to ossify. Low signal intensity marrow within
an epiphysis on T1-weighted images is abnormal if it
is seen later than 6 months after the ossification center
first appeared [1].
Yellow marrow occupies most of the diaphysis in a
childs long bone during the first decade of life, and is
identified on T1-weighted images by its relatively
bright fat. Conversion from red to yellow marrow
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 5 1 - 9
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M.S. Barr, M.W. Anderson / Radiol Clin N Am 40 (2002) 11091120
Fig. 1. (A) Normal marrow. Coronal T1-weighted image shows a normal adult marrow pattern. Note the metadiaphyseal
hematopoietic marrow, which is slightly hyperintense to muscle and sharply marginated at the old physeal plate (arrow). (B)
Coronal short tau inversion recovery image highlights the hyperintense hematopoietic marrow adjacent to the dark, saturated fat
of the yellow marrow elsewhere in the bones.
continues to occur throughout the second decade,

although some residual red marrow is retained in the
proximal humeral and femoral metaphyses.
The adult marrow pattern is present by 25 years of
age. At this point, red marrow is found predominantly
in the axial skeleton, sternum, ribs, and proximal
metaphyses of the femora and humeri (Fig. 2). Marrow conversion slows at this point and becomes
dependent on variables, such as gender, nutritional

status, obesity, activity, medications, smoking, and
age [1 3].
Reconversion of yellow to red marrow occurs in
areas where sinusoidal networks and perivascular
reticular cells can appear rapidly: metaphyseal and
metaphyseal equivalent regions, subchondral epiphyseal areas, and diaphyseal endosteal spaces. This
Fig. 2. Adult marrow pattern. Coronal T1-weighted MRI of the pelvis demonstrates red marrow within the pelvis and proximal
femurs with fatty marrow in the femoral heads and greater trochanters.
pattern is the reverse of red to yellow conversion in

that reconversion to red marrow begins in the ends of
the bones and progresses toward the mid-diaphyses.
Difficulties may arise when attempting to distinguish normal red marrow from marrow pathology.
There are several imaging features that favor the
diagnosis of hematopoietic marrow. Most types of
marrow pathology result in signal intensity that is
lower than that of skeletal muscle or intervertebral
disk on T1-weighted images, whereas hematopoietic
marrow demonstrates signal intensity that is slightly
higher than that of skeletal muscle or disk on T1weighted images (owing to the relatively high amount
of fat present even in red marrow). Other features of
red marrow include signal intensity that parallels the
signal intensity of other areas of known hematopoietic
marrow, bilateral symmetry, scattered foci of fatty
signal within the region of concern, and an abrupt
margination at the level of a closed physis (see Fig. 1)
[1,2]. In some adults, however, red marrow also may
extend into the epiphyseal regions. Although normalappearing bone marrow on MRI does not definitively
exclude the possibility of disease, a thorough understanding of the MRI appearance of normal hematopoietic marrow allows for an improved ability to
distinguish the normal from the pathologic.
Marrow pathology
1111
pattern within the marrow that is most conspicuous on

fat-saturated T2 or STIR images (Fig. 3). Direct
trauma to the bone can produce a focal contusion,
but these most often result from one bone impacting
on another. The kissing contusions often seen with
anterior cruciate ligament tears are a classic example
of this type of injury (Fig. 4). Evaluation of a
contusion pattern often reveals the mechanism of
injury and predicts associated soft tissue pathology.
The marrow abnormalities may also prompt a careful
search for less easily detected avulsive injuries that
may result in joint instability necessitating surgical
intervention [5,6].
Acute avulsive injuries
Distraction injuries usually occur in response to
rotational, varus, or valgus stress on a joint and often
result in a small avulsion fracture related to a tendinous, ligamentous, or capsular attachment on the bone.
The associated marrow edema is much less extensive
than the edema seen with an impaction injury because
cortical rather than medullary bone is involved [4 7].
The avulsed fragment can be very difficult to detect
by MRI because there is usually a disproportionate
amount of edema and hemorrhage in the adjacent soft
tissue that may mask the small osseous fragment. A
small avulsion fragment is often demonstrated better
on conventional radiographs (Fig. 5).
Entities that affect the bone marrow are varied and

include trauma, osteonecrosis, infection, tumors,
arthritides, and metabolic disorders. Bone marrow
typically demonstrates a similar response, however,
regardless of the insult: increased fluid content in the
form of edema, hemorrhage, pus, or tumor [3,4]. With
this limited repertoire, it seems nearly hopeless that
MRI could provide any specificity when attempting to
differentiate between these varied etiologies, but a
systematic approach of analyzing the pattern of marrow pathology and associated abnormalities often
helps to limit the differential, or even arrive at a
specific diagnosis.
Trauma
Acute impaction injuries
An acute impaction force on a bone results in
marrow hemorrhage and edema, disruption of trabeculae, and interstitial fluid leakage within the marrow space. On MRI, these bone bruises (contusions)
are identified by the vague, geographic, edema-like
Fig. 3. Bone contusion. Coronal short tau inversion recovery

image demonstrates vague geographic edema in the lateral
tibial condyle compatible with a bone marrow contusion.
1112
that is exacerbated with activity and relieved with rest.

Palpation often reveals tenderness and soft tissue
swelling over the site of osseous damage [8,9].
MRIs reveal a spectrum of findings from periosteal
edema alone, to progressively severe marrow edema,
to a hypointense fracture line in cancellous or cortical
bone (Fig. 6). The fracture line is most often of a
transverse or oblique orientation within a long bone,
but longitudinal stress fractures also have been
described [10].
Chronic avulsive injuries
Fig. 4. Anterior cruciate ligament tear contusion pattern.

Sagittal T2-weighted fat-saturated MRI demonstrates the
kissing contusion pattern often seen with anterior cruciate ligament tears. Subchondral edema-like signal is present in the lateral femoral condyle and the posterolateral
tibial plateau.
Fatigue and insufficiency fractures

Fatigue and insufficiency fractures demonstrate
similar radiographic and MRI findings. Fatigue fractures develop when abnormal stress is applied to
normally mineralized bone, whereas insufficiency
fractures result from normal activities applied to
weakened bone. Clinically, these injuries induce pain
Shin splints refers to a syndrome of activityrelated lower leg pain that has long been thought to be
related to a traction periostitis of the calf muscle along
the posteromedial tibia. In addition to the expected
periosteal edema or fluid, MRI has also revealed
marrow edema and even cortical signal abnormalities
that indicate osseous stress injuries of varying degrees
[8,11].
Thigh splints (adductor insertion avulsion syndrome) is a similar condition and refers to activityrelated groin or thigh pain that is thought to be related
to the pull of the adductor tendons on the proximal to
mid femoral shaft. As with shin splints, MRI reveals a
spectrum of osseous injury from periosteal edema or
fluid to varying degrees of marrow edema (Fig. 7) [12].
The avulsive cortical irregularity syndrome (cortical desmoid) occurs along the posterior margin of the
distal femur and in some cases can be difficult to
distinguish from a paraosteal osteosarcoma. The MRI
appearance may also be confusing. Posch and Puckett
Fig. 5. (A) Avulsion fracture. Coronal short tau inversion recovery image of the knee reveals a small cortical avulsion fracture
(Segond fracture) along the lateral tibial plateau (black arrow). Compare the prominence of the soft tissue edema with the paucity
of marrow edema (white arrow). (B) Anteroposterior radiograph of the knee. The fracture fragment is seen more easily.
1113
Fig. 6. Stress fracture. Coronal short tau inversion recovery image of the proximal lower legs in a child with left lower leg pain
reveals a hypointense fracture line extending horizontally through an area of extensive marrow edema in the proximal left tibia.
Note also the marked periosteal thickening and soft tissue edema in that region.
[13] describe the features that favor a benign entity:

bilateral symmetry (even if the contralateral side is
asymptomatic); edema with enhancement at the base
of the irregularity, which remains outside of the
medullary canal and along the outer confines of the
cortex; clinical history of a physically active young
child; and minimal uptake on nuclear medicine bone
scan. The location of the lesion is characteristic, lying
at the medial ridge of the linea aspera just superior to
the adductor tubercle (Fig. 8). This site suggests a
relationship to the insertion of the adductor magnus
tendon or the origin of the medial head of the gastrocnemius muscle.

Spontaneous osteonecrosis
As its name implies, spontaneous osteonecrosis is
a condition that affects the knee and results in an area
of subchondral necrosis. Although long thought to
represent a form of primary osteonecrosis, recent
studies have concluded that this lesion is actually a
subchondral insufficiency fracture that results in a
Fig. 7. Thigh splints. Coronal short tau inversion recovery image of the proximal thighs in this young track runner demonstrates
foci of marrow edema along the medial endosteum of the proximal femoral shafts. The changes are slightly worse in the right
femur, which also displays mild periostitis (arrow).
1114
different location in the medial femoral condyle

(weight-bearing surface), and a unique MRI appearance. Radiographs are often normal, even though the
pain is severe, and the patient is unable to ambulate.
On MRI, extensive edema-like signal is seen in the
medial femoral condyle along with a linear subchondral focus of low signal intensity that represents the
insufficiency fracture (Fig. 9).
Osteonecrosis
Medullary infarction
Fig. 8. Cortical irregularity of the distal femur. Sagittal

gradient echo T2*-weighted image of the knee shows a welldefined, rounded, intracortical lesion along the posterior
metaphysis of the distal femur. Note the edema along the
surface of the bone and within the adjacent soft tissues.
devitalized segment of bone between the fracture line

and overlying articular cartilage [14].
This most likely explains why this entity can
usually be differentiated from osteochondritis dissecans (described later). Spontaneous osteonecrosis typically has an older age of onset (most commonly a
middle-aged woman), an abrupt onset of symptoms, a
Several factors are known to predispose to the

development of focal areas of medullary infarction.
These include the use of exogenous corticosteroids;
increased production of endogenous steroids (eg,
Cushings syndrome); alcohol abuse; pancreatitis;
vasculitis; trauma; radiation; hemodialysis; and hemoglobinopathies (sickle cell anemia, thalassemia, polycythemia). Some cases are idiopathic [4,14].
Medullary infarcts result in geographic areas of
ischemic and devitalized marrow that produce a characteristic MRI appearance: a geographic focus of typically heterogeneous signal within the marrow that
is surrounded by characteristic low signal intensity,
serpentine border on T1-weighted images. This border often demonstrates a classic double-line sign on
Fig. 9. (A) Spontaneous osteonecrosis. Coronal short tau inversion recovery (STIR) image of the knee demonstrates extensive
edema within the medial femoral condyle extending to the intercondylar notch. (B) Sagittal STIR image of the knee reveals a
linear subchondral fracture within the marrow edema (arrow).
1115
Fig. 10. (A) Medullary infarcts. Sagittal T1-weighted image of the knee demonstrates the classic undulating serpentine border of
medullary infarct in the proximal tibia that is pathognomonic for osteonecrosis. Note the central fat, characteristics for this lesion.
(B) Sagittal T1-weighted MRI of the knee reveals a second infarct in this same patient in a more subchondral location of the
medial femoral condyle.
T2-weighted images that manifests as an inner margin

of high signal intensity surrounded by an outer rim of
low signal intensity [15,16]. This is one of the few
medullary lesions that usually contain some central fat
(Fig. 10).
In the early stages of an acute medullary infarct,
only marrow edema may be present, making it difficult to differentiate this from other types of pathology. Similarly, ischemic foci may present as areas of
edema-like signal within the marrow, but unlike a true
medullary infarct, these tend to be transitory.
Osteochondritis dissecans
A special form of subchondral osteonecrosis is
termed osteochondritis dissecans. This entity is most
frequently seen in adolescents and young adults and
refers to fragmentation, and often separation, of a
portion of subchondral bone, typically along the lateral
aspect of the medial femoral condyle. The cause of this
lesion is uncertain but it is thought to result from
repetitive trauma that produces shear forces across the
cartilage. Radiographic findings include a geographic,
subchondral lucency along the non weight-bearing
surface of the medial femoral condyle [17].
MRI plays an important role in detecting the lesion

if plain films are normal. A crescentic or ovoid focus
of subchondral signal abnormality is evident (Fig. 11).
The primary concern when evaluating a focus of
osteochondritis dissecans is whether the fragment of
subchondral bone is unstable (ie, at risk of evolving
into a displaced loose body in the joint), in which case
it likely requires operative intervention.
Several MRI features have been shown to be
suggestive of an unstable fragment. These include
fluid tracking between the fragment and host bone,
cystic foci at that same interface, or a 5-mm or larger
defect in the overlying cartilage. MR arthrography can
be used in this setting to confirm that a fragment is
truly unstable by demonstrating intra-articular gadolinium tracking between the fragment and host bone
(Fig. 12).
Transient bone marrow edema syndrome
(transient osteoporosis)
Transient bone marrow edema syndrome (also
known as transient osteoporosis) was first described
in the hip. Originally reported in women during their
third trimester of pregnancy, this entity also has been
1116
Fig. 11. Osteochondritis dissecans. Coronal short tau

inversion recovery image of the knee. An osseous fragment
has partially detached from the lateral non weight-bearing
aspect of the medial femoral condyle (arrowhead ). Cystic
changes and some joint fluid are present between the
osseous fragment and femoral condyle.
shown to be common in men. Its exact cause is

uncertain but several authors have postulated that
local trauma, reflex sympathetic dystrophy, bone
marrow edema, and insufficiency fractures may actually represent successive stages of a process that could
ultimately culminate in osteonecrosis [18].
Affected patients present with an acute onset of

pain, usually not associated with trauma. Within 2 to
4 weeks of the initial symptoms, radiographs may
reveal femoral head and neck osteopenia with marked
indistinctness of the subchondral cortical bone [19].
MRI findings include diffuse, nonfocal, edema
(low signal on T1-weighted images and high signal
on T2-weighted or STIR sequences) [19,20]. In
the knee, the lateral femoral condyle is usually involved, although involvement of the medial femoral
condyle and tibial plateau has also been described
[15,21]. Resolution of pain and edema usually takes
place within 6 to 12 months. Long-term sequelae do
not occur.
The ability to distinguish transient bone marrow
edema syndrome from other entities is difficult and is
often a diagnosis of exclusion, with osteonecrosis,
reflex sympathetic dystrophy, insufficiency fractures,
or trauma constituting other differential possibilities.
Reflex sympathetic dystrophy
The exact cause of reflex sympathetic dystrophy
is unclear but it is believed to represent sequelae
from hyperactivity of the sympathetic nervous system. The most common of the varied entities producing this syndrome are trauma, hemiplegia, and
myocardial infarction.
Reflex sympathetic dystrophy most often affects
the upper extremities, and in many cases occurs after
Fig. 12. Osteochondral lesion. MR arthrogram. Coronal fat-saturated T1-weighted MR arthrogram reveals an unstable fragment
with gadolinium tracking between the fragment and host bone.
1117
Fig. 13. (A) Osteomyelitis. Radiograph of the left femur reveals a focal ill-defined lytic lesion in the lateral metaphysis of the
digital femur and an aggressive, interrupted periostitis. This proved to represent bacterial osteomyelitis on biopsy. (B) Coronal
T1-weighted MRI of the femur reveals disruption of the cortex in the lateral metaphysis of the distal left femur with effacement
of the normal fat signal adjacent to the bone (arrow). (C) Coronal short tau inversion recovery image of the femur better
demonstrates associated signal abnormality in the marrow and edema involving the soft tissues.
a recent episode of trauma. It results in circulatory

changes and may progress to muscle atrophy, contractures, pale skin, and loss of hair on the extremity
[18,21]. Rarely, it migrates to other joints. The ability
of MRI to distinguish reflex sympathetic dystrophy
from transient bone marrow edema is difficult, if not
impossible. Some authors have suggested that these
may represent stages of the same process. Clinically,
however, these are decidedly distinct entities.
MRI reveals diffuse, patchy bone marrow edema,
which does not progress to the subchondral collapse
seen in osteonecrosis. Epidermal and dermal edema
patterns may also be seen in various stages of its
evolution [22,23].
Infection
Osteomyelitis
Osteomyelitis exhibits increased signal intensity
within the marrow on T2-weighted, STIR, and contrast-enhanced T1-weighted sequences. Low signal
intensity predominates on T1-weighted sequences.
Involvement may be diffuse or focal. It is often
located adjacent to regions of skin ulceration, or
involves areas commonly affected by hematogenous
spread (ie, the metaphysis in a child) (Fig. 13).
Because other causes of marrow edema may mimic
Fig. 14. Osteoarthritis. Coronal short tau inversion recovery

image of an osteoarthritic knee shows degenerative changes
with severe loss of cartilage in the medial compartment,
meniscal subluxation, and bone marrow edema along both
sides of the joint.
1118
osteomyelitis, supportive findings of infection should

be sought, including overlying cortical destruction
and an abscess or fistula extending to the bone at
the site of the marrow abnormality.
nal intensity than muscle on T1-weighted sequences

and high signal intensity on T2-weighted, STIR, and
contrast-enhanced sequences [3,4]. The specific features of various bone and soft tissue tumors are discussed elsewhere in this issue.
Septic joint
A septic joint is another source of abnormal marrow signal intensity. Features that favor a septic joint,
although not pathognomonic, include a large joint
effusion, bone marrow edema on both sides of the
joint, and cartilage loss. These features unfortunately
also may be seen with an inflammatory arthritis or
neuropathic joint disease. Obtaining clinical history
and communicating with the clinician are essential and
if a septic joint is suspected, joint aspiration is indicated. Further discussion on marrow changes related
to infection can be found elsewhere in this issue [24].
Tumors
Most tumors involving the bone marrow are relatively vascular and contain a reasonably high fluid
content. As such, they tend to demonstrate lower sig-
Arthritis
Osteoarthritis
Classic findings in osteoarthritis include cartilage
thinning, osteophyte formation, subchondral cysts, or
sclerosis, and at times loose bodies within the joint.
The characteristic MRI features found in osteoarthritis
include thinned, fissured, or absent articular cartilage,
often with associated meniscal abnormalities; osseous
changes, such as subchondral edema, sclerosis, and
osteophyte formation; and a pattern of edema that is
most intense in the subchondral regions and fades as it
extends further from the joint (Fig. 14) [25]. The
edema-like subchondral marrow signal is especially
prominent in areas of deep cartilage fissuring or loss.
In one study, histologic evaluation of marrow demonstrating this edema-like signal on MRIs revealed
Fig. 15. (A) Rheumatoid arthritis. Sagittal fat-saturated T1-weighted image of the knee after intravenous administration of
Gd-DTPA reveals a moderate-sized low signal joint effusion that is surrounded by intensely enhancing, thickened synovial
tissue. The synovial tissue is particularly prominent in the posterior recess of the knee and the suprapatellar bursa. (B) Axial
gradient echo T2*-weighted image shows extensive high signal within the knee with synovial tissue isointense to joint effusion.
Note the erosion involving the posterior aspect of the lateral femoral condyle, in a typical bare area of the joint (arrow).
bone marrow necrosis, fibrosis, and trabecular abnormalities with a surprising paucity of actual bone
marrow edema [26]. Although these histologic findings are similar to those seen with subchondral osteonecrosis, the recognition of other classic imaging
abnormalities associated with osteoarthritis confirms
this as the etiology.
Inflammatory arthritides
In the acute stages of an inflammatory arthritis, the
patient presents with extensive synovitis and diffuse
sympathetic subchondral edema, secondary to the
increased metabolic activity and cartilage destruction
in the adjacent joint. During the quiescent phase, if
there are no osseous erosions, the bone may appear
normal or the appearance may resemble the findings
in osteoarthritis.
MRI is able to confirm the clinical suspicion of an
inflammatory arthropathy in most cases. Common
findings include joint effusions and variable degrees
of synovial thickening. Intravenous contrast is often
needed to distinguish synovial inflammation from
joint fluid, and is especially helpful in early cases
where there is minimal synovial inflammation. Occasionally, the synovitis and bone marrow edema are not
evident on fluid-weighted sequences and contrast
administration then becomes invaluable in detecting
the synovitis (Fig. 15) [27]. Additionally, MRI is more
sensitive than radiographs in detecting early osseous
erosions, in part because active bone erosions often
demonstrate underlying bone marrow edema.
In addition to these findings, the seronegative
spondyloarthropathies demonstrate fluid or edemalike signal adjacent to enthesis on T2-weighted
images. The seronegative arthropathies are more
likely to exhibit multifocal entheseal involvement
around a single joint than is rheumatoid arthritis.
McGonagle et al [27] identified numerous vulnerable
sites around the knee including the origin and insertion of the patellar tendon, medial and lateral collateral
ligaments, semimembranosus tendon, iliotibial band,
posterior cruciate ligament, and posterior capsule.
Summary
MRI is clearly the imaging modality of choice for
detecting and exploring joint, osseous, and soft tissue
injuries in the lower extremity and throughout the
musculoskeletal system. Its ability to detect and differentiate the various forms of marrow pathology is
unrivaled, and as such it should be obtained early in
the work-up of a patient with a suspected marrow
1119
abnormality. Additionally, the radiologist must be

familiar with the MRI appearances of normal marrow
and the most common types of marrow pathology if
its diagnostic power is to be fully realized.
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Radiol Clin N Am 40 (2002) 1121 1132
MR arthrography of the lower extremity

Josef Kramer, MD, PhDa,*, Michael P. Recht, MDb
b
a
Institut fur CT and MRI Diagnostik am Schillerpark, Rainerstrasse 6 8, 4020 Linz, Austria
Cleveland Clinic Foundation, Department of Radiology, A21, 9500 Euclid Avenue, Cleveland, OH 44195, USA
MRI has been shown to be very useful in the

diagnosis of several joint disorders. MR arthrography,
through its ability accurately to delineate intra-articular structures, further expands the clinical use of
MRI. There are, however, some features of MR
arthrography that have limited clinical use: the conversion of a noninvasive procedure into an invasive
procedure, and the increased cost and time required to
perform MR arthrography compared with conventional MRI. Despite these limitations, the use of MR
arthrography is increasing secondary to its improved
accuracy compared with conventional MRI for the
diagnosis of several intra-articular disorders.
MR arthrography is performed by injecting a
gadolinium diethylentriamine pentaacetic acid (GdDTPA) mixture into the joint. A Gd-DTPA mixture
consisting of 0.2 mL of a standard Gd-DTPA solution
(469.01 mg/mL, Magnevist, Schering AG, Germany)
mixed with 50 mL of saline (2 mmol/L Gd-DTPA
solution) has been observed to give an optimal contrast
between the contrast medium and the intra-articular
structures or abnormalities [1]. No side effects have
been reported to date that are attributable to intraarticular Gd-DTPA. Imaging should be performed
shortly after the intra-articular injection of contrast
medium, to prevent absorption of contrast solution
and guarantee the desired capsular distention, although imaging delays of up to 2 hours are tolerated
in the leg joints [2]. Gd-DTPA and iodinated contrast
material can be mixed before MRI without any release of free gadolinium and is safe for confirming
the intra-articular placement of contrast material [3].
E-mail address: roentgeninstitut@schillerpark.
telecom.at (J. Kramer).
Imaging should include T1-weighted spin echo sequences both with and without fat suppression. Fat
suppression is crucial in MR arthrography because fat
and contrast medium have similar signal intensities
on T1-weighted images. When looking at smaller
intra-articular structures, such as the hip labrum, or
when looking for subtle cartilage disorders, threedimensional gradient echo images are often helpful. It
has been shown that intravenous administration of
Gd-DTPA also leads to an enhancement effect of the
joint cavity (indirect MR arthrography). This technique has been proposed as an alternative to direct
MR arthrography [4 7,86,87]. Intra-articular enhancement in normal joints, however, is only mild
and often heterogeneous, although exercise improves
both the homogeneity and amount of enhancement in
the joint. This technique, however, has several drawbacks. The main limitation is the lack of joint distention compared with direct arthrography; joint
distention is of special help for the diagnosis of
capsular trauma or soft tissue injury. Another limitation of indirect MR arthrography is that juxtaarticular structures, such as vessels, and the synovial
membranes of bursae and tendon sheaths also demonstrate enhancement, which can lead to confusion
with extravasation of contrast medium or the presence of abnormal joint recesses. Studies have shown
that patients who have undergone MR arthrography
considered the discomfort less than expected [8]. Arthrography-related discomfort was well tolerated and
rated less severe than MRI-related discomfort. Although patients expressed fear of certain aspects of
MR arthrography, the reported average pain from the
arthrogram was low [3]. Despite its invasiveness,
clinicians should not hesitate to order MR arthrography when clinically indicated. This article describes
the role of MR arthrography in selected joints.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 5 7 - X
1122
J. Kramer, M.P. Recht / Radiol Clin N Am 40 (2002) 11211132
Hip
The hip is a ball-and-socket joint, which exhibits a
wide range of motion in all directions. The spherical
acetabular socket covers the femoral head nearly
completely except for its inferior medial aspect,
known as the acetabular notch, where the socket is
deficient. The transverse acetabular ligament spans
this deficient portion of the acetabulum. The fibrocartilaginous labrum rims the acetabulum and is
triangular in cross section. The labrum is thicker posterosuperiorly and thinner anteroinferiorly [9,10].
The acetabular labrum consists of fibrocartilaginous
tissue with fibrovascular bundles. This fibrocartilage
lacks the highly organized structure seen within the
fibrocartilaginous meniscus of the knee. The labrum
is attached directly to the osseous rim of the acetabulum. It blends with the transverse ligament at the
margins of the acetabular notch. Contrary to the
shoulder, the acetabular labrum increases the depth
of the joint rather than increasing its diameter [11].
Clinical and arthroscopic studies have documented
the importance of the acetabular capsular-labral complex as a biomechanical component of the hip joint
[12,13]. The joint capsule inserts onto the acetabular
rim. Along the anterior and posterior joint margins,
the capsule inserts directly at the base of the labrum; a
small perilabral recess is created between the labrum
and joint capsule. The iliopsoas bursa, directly anterior to the hip joint, communicates with the joint in
10% to 15% of normal anatomic specimens and may
be involved in patients with synovitis [14].
There are several possible causes for chronic hip
pain. The differential diagnosis in these patients
includes synovitis, labral tears, loose bodies, degenerative disease, and cartilage defects [15]. Acetabular labral lesions may be observed in patients with
developmental dysplasia of the hips, and in patients
with a history of hip trauma [16 20]. A click, or
snapping sound, or painful giving way often accompanies the hip pain in these patients. In patients
with acetabular dysplasia, the increased stress on the
superior labrum as it assumes more of the weightbearing function is believed to contribute to development of the tears [19]. Ganglion cyst association
with the labral tears has been described in this patient population [21]. Posttraumatic labral tears may
occur following minor trauma or as sequelae of
marked injury, especially dislocation. The torn labrum may block reduction of the dislocated hip [16].
Degenerative tears may also occur. Early recognition and resection can result in substantial pain
relief and may prevent development of degenerative
disease [22].
Conventional MRI is not accurate for the diagnosis

of labral tears [23 29]. There are most likely many
reasons for this inability, including inadequate joint
distention that prevents separation of the labrum and
capsule. The normal triangularly shaped labrum is of
homogeneous low signal intensity on all different
MRI sequences [24,25]. At the attachment site of the
labrum with the acetabular articular cartilage, however, is a focal area of higher signal intensity probably representing volume averaging with the hyaline
cartilage [30]. Although this site creates the potential
for overdiagnosis of a labral tear on conventional
MRIs, the lack of contrast material in this region on
MR arthrography images easily differentiates it from
a true labral tear. Ganglion cysts can be observed in
patients with detached labra in the anterior and
cranial portions of the labrum, where most of the
labral lesions are located [18,23]. One possible cause
for the formation of ganglion cysts is the presumed
existence of a labral lesion followed by fluid expressed through this defect to form a cyst [21].
MR arthrography of the hip, like MR arthrography
elsewhere, is a two-step procedure. Joint injection is
usually performed under fluoroscopy followed by
MRI. The patient is in supine position with the leg
extended and slightly internally rotated. The puncture
site is marked on the skin between the subcapital and
transcervical portions of the femoral neck. This point
is lateral to the femoral artery and below the inguinal
ligament. Under sterile conditions, a 20-gauge disposable needle is directed straight onto the femoral
neck. A few drops of iodinated contrast agent are
injected through an extension tube (to avoid radiation
exposure to the hands) to confirm intra-articular
location; following this 10 to 20 mL of the Gd-DTPA
solution is injected into the joint.
Fig. 1. Coronal T1-weighted fat-suppressed spin echo MR

arthrographic image. A normal labrum is visible outlined by
contrast material.
Because of the spherical nature of the hip, imaging in all three planes is necessary to evaluate the
entire labrum. T1-weighted imaging is used to visualize the high signal of the intra-articular contrast
solution (Fig. 1). Fat saturation increases contrast
between the intra-articular gadopentetate dimeglumine and the adjacent soft tissues. The combination
of MR arthrography and three-dimensional gradient
recalled echo-imaging shows an even higher sensitivity than MR arthrography with spin echo sequences
[31]. These sequences have the advantage of allowing use of very thin sections that eliminate partial
volume averaging artifacts and increase detection of
small tears. Additional imaging with a short inversion
time inversion recovery sequence or fat-suppressed
T2-weighted sequence, usually in the coronal plane,
enables the detection of unsuspected soft tissue or
bony abnormalities.
Czerny et al [23] created a classification system to
assess acetabular labral lesions (Fig. 2). In stage 0
(normal), the labra are of homogeneous low signal
intensity, triangular shaped, and a continuous attachment to the lateral margin of the acetabulum without
a notch or a sulcus is visible. A recess between the
joint capsule and the labrum, a so-called labral
recessus, is observed. Stage 1A lesions are characterized by an area of increased signal intensity within
the center of the labrum that does not extend to the
margin of the labrum, a triangular shape, and a continuous attachment to the lateral margin of the acetabulum and a labral recessus. Stage 1B (Fig. 3) is
Fig. 2. Schematic diagram of normal acetabular labrum and

the different stages of labral abnormalities.
1123
Fig. 3. Coronal T1-weighted spin echo MR arthrography

shows a normal hip with a minimal enlarged labrum
consistent with an IB labrum.
similar to stage 1A, but the labrum is thickened and

no labral recessus is present. These findings are
analogous to the mucoid degeneration seen in lowgrade meniscal lesions. Stage 2A lesions (Fig. 4) have
an extension of contrast material into the labrum
without detachment from the acetabulum, are triangular, and have a labral recessus. Stage 2B (Fig. 5) are
the same as stage 2A except the labrum is thickened
and a labral recessus is not outlined. Stage 2 findings
are consistent with partial labral tears. Stage 3A labra,
complete labral tears, are detached from the acetabulum but are of triangular shape, whereas stage 3B
labra (Fig. 6) are thickened and detached from
the acetabulum.
Contrast material enables the visualization of the
labral recessus and the clear delineation of the capsular-labral complex [30]. Labral lesions may be
staged incorrectly with MR arthrography if only a
small volume of contrast material is injected or there
is a scarred, shrunken joint capsule caused by previous surgical interventions. Controversy remains
Fig. 4. T1-weighted fat-suppressed spin echo MR arthrographic image demonstrating an IIA labral tear. There is
contrast material entering into the labrum.
1124
Fig. 5. Coronal T1-weighted spin echo image after intraarticular contrast material administration. A dysplastic hip
with relatively steep acetabular roof and deformed femoral
head can be observed. The labrum is enlarged and ruptured
consistent with an IIB lesion.
regarding the reality of a sublabral sulcus of the

anterosuperior aspect of the labrum. The presence
of a sublabral sulcus has been raised as the possibility
of a potential pitfall in the diagnosis of acetabular
labral abnormalities with MRI [32]. The presence of
such a sulcus, however, has not been documented in
arthroscopic studies and was not found in cadaveric
hip joint specimens [13]. Such a sulcus has been
described in histologic specimens of fetal hips, however, although the possibility that its existence is
artifactual because of fixation techniques has been
raised [33]. It is believed that any intralabral collection of contrast material should not be mistaken for a
normal sublabral sulcus but, rather, should be suspected to be a tear or detachment [24]. Another
potential pitfall with MR arthrography is a groove
separating the acetabular labrum from acetabular
articular cartilage in the region of the acetabular fossa
[9]. This groove should not be confused with a labral
tear because its location is different from that of labral
tears, which occur most frequently anterosuperiorly.
No instances of absent labra are reported [32]. The
sensitivity for detection and correct staging of labral
lesions with MR arthrography has been reported as
91%, the specificity as 71%, and the accuracy as
88%. Whereas the sensitivity of MR arthrography
was 90% and its accuracy was 91%, the sensitivity
of MRI was 30% and its accuracy was 36% compared with surgical findings [23,24]. Because labral
abnormalities are believed to be a precursor of osteoarthritis, orthopedists believe that surgical intervention is influenced substantially by the type, extension,
and location of labral abnormalities shown with MR

arthrography [30].
Loose bodies in the hip joint are rare but an
important cause of chronic, debilitating symptoms
(joint pain, locking, and limited range of motion)
and may occur with or without associated osteochondral defects. In patients with suspected intra-articular
loose bodies, the value of an imaging examination is
determined by its capabilities for excluding the presence of loose bodies and decreasing the need for
diagnostic arthroscopy [34,35]. Not infrequently,
intra-articular loose bodies cannot be differentiated
from surrounding tissues on conventional MRI. Conventional T2-weighted spin echo MRI may show
loose bodies with higher sensitivity in hips with joint
effusions. Specificity may be decreased, however,
because of the difficulty in differentiating true loose
bodies from osteophytes, synovial folds, and hypertrophic synovitis. On MR arthrography loose bodies
are surrounded by contrast material, which improves
their detection and enables an accurate determination
of their number and topography. Arthroscopic techniques offering the least traumatic method of removing loose bodies or foreign bodies from the hip joint
are preferred to open arthrotomy, although arthroscopy of the hip is still not widely practiced [36]. Only
the accurate detection of these lesions may allow
early therapeutic intervention, however, and relief of
pain, and prevent or delay the development of osteoarthritis [24]. In addition, the diagnostic sensitivity
and specificity of MR arthrography in detecting intraarticular bodies is improved because contrast solution
separates loose bodies from the capsule and com-
Fig. 6. Coronal T1-weighted fat-suppressed spin echo image

after intra-articular contrast injection. A severely dysplastic
hip is present. The labrum is torn and detached from the
acetabulum consistent with a stage IIIB labrum.
pletely surrounds them, whereas osteophytes and

synovial projections are only partially outlined.
MR arthrography is also helpful in detecting
traumatic or degenerative chondral lesions [37].
Localized cartilage defects or focal acetabular and
femoral head cartilage thinning can be seen. In
cases where the joint communicates with the iliopsoas bursa, the latter fills with contrast material
and the communication is visualized easily on axial
MR arthrograms.
Knee
Meniscal lesions
The knee joint is an extremely efficient structure
allowing remarkable motion limited primarily to a
single plane. A frequent indication for MRI is lesions
of the menisci, which are C-shaped fibrocartilaginous
structures and firmly attached to the tibia. The menisci distribute torsional and comprehensive forces
during mechanical loading, distribute synovial fluid
over the articular cartilages for proper nutrition and
lubrication, act as shock absorbers, facilitate complex
movements, prevent synovial impingement, and limit
abnormal motion.
Because of its superior soft tissue discrimination,
superb spatial resolution, and multiplanar capabilities, MRI is the main imaging technique currently
used for the evaluation of the knee. Tears of the
meniscus and secondary consequences of abnormal
meniscal function represent a major indication for
operative arthroscopy of the knee. Although arthroscopy has revolutionized the diagnosis and treatment
of knee disorders, most orthopedists acknowledge
the invasiveness of the procedure, its limitations in
evaluation of extra-articular pathology, and potential
complications associated with the procedure. Recognition of the biomechanical importance of the
meniscus has led to a shift to several meniscal-conserving techniques, including partial meniscectomy,
meniscal repair with suture, and meniscal repair with
bioabsorbable arrows [38 41]. Accurate noninvasive
assessment of menisci is necessary for proper preoperative planning.
Conventional MRI signs of a tear of a meniscus
without prior surgery include meniscal signal alterations extending to the meniscal surface and abnormal meniscal morphology [42 44]. Multiple large
studies have confirmed the reliability of MRI in
detecting meniscal abnormalities with sensitivities
of up to 97%. As the number of arthroscopic meniscal
resections and repairs increase, the percentage of
1125
postoperative knee evaluations increases. Conventional MRI of the postoperative meniscus has been
reported to have unreliable results, with accuracies
generally ranging between 38% and 82%. The conventional diagnostic criteria used to diagnose meniscal tears cannot be applied to the postoperative
meniscus. Once injured, the meniscus may never
return to normal, preinjury signal intensity. Furthermore, an area of meniscal healing may appear as an
abnormal signal that reaches the articular surface and
may be misinterpreted as a new tear unless the images
are compared with the original MRIs [45]. One of the
basic criteria for identifying a meniscal tear in a
nonoperative knee (increased intrameniscal signal intensity on a T1-weighted or proton density weighted
image extending to the meniscal surface) is an
unreliable predictor in the postoperative knee. In
addition, meniscal morphology following partial
meniscectomy is abnormal, and this distortion and
irregularity of shape may be interpreted as a meniscal
tear [46 49,85] if the history of previous partial
meniscectomy is not known. If less than 25% of the
meniscal is resected, standard MRI criteria for detecting meniscal tears can be used. In patients in whom
between 25% and 75% of the meniscal length had
been removed, neither the presence of internal signal
contacting the meniscal surface, nor abnormalities in
meniscal morphology, are as accurate in predicting a
recurrent meniscal tear as in a nonoperative knee.
Specific signs of a meniscal retear are fluid-like
signal within the meniscus on T2-weighted images
or a displaced meniscal fragment. If more than 75%
of the meniscal length has been removed, it is unlikely that a retear causes clinical symptoms.
MR arthrography has been shown to have greater
accuracy than conventional MRI for the detection of
meniscal retears [50]. There are several potential
advantages of MR arthrography compared with conventional MRI in diagnosing a meniscal retear. Because gadolinium-based contrast material has a lower
viscosity than synovial fluid, it is more likely to be
imbibed into a small cleft and thereby highlight the
presence of a tear (Fig. 7). The use of gadoliniumbased contrast material allows use of T1-weighted
pulse sequences with their inherently favorable signal-to-noise ratio. As in other arthrographic techniques, increased intra-articular pressure allows for
distention of normally apposed structures, such as
the edges of a nondisplaced meniscal tear. Studies
have shown increased accuracy for the detection of
meniscal tears following meniscectomy with MR
arthrography compared with conventional MRI
[48,50]. The MR arthrographic technique does not
differ from conventional arthrography. The knee is
1126
Fig. 7. Coronal T1-weighted spin echo MR arthrographic

image in a patient status post partial medial meniscectomy.
There is contrast material entering a cleft within the medial
meniscal remnant consistent with a meniscal retear.
placed in a slightly bent, recumbent position for the

usually used anterolateral access. The patella is pulled
laterally, and the puncture is made at the mid-patella
or above, with the needle entering the joint beneath
the surface of the patella. To be able to fill the knee
joint with a small volume of dissolved contrast
medium, compression is applied to the soft tissues
15 to 20 cm above the joint cavity with an elastic
bandage, to prevent entry of the contrast medium into
the suprapatellar recess. The injection is carried out
under sterile conditions. The total amount of the
contrast mixture injected should be 30 to 40 mL.
After the injection, active and passive movements of
the knee joint are carried out several times to achieve
uniform distribution in the joint.
Cartilage lesions
Chondral lesions of the knee are a common and
important orthopedic problem. Clinical symptoms of
chondral lesions are mostly nonspecific and exact
assessment is difficult to ascertain clinically. Articular
cartilage is a uniquely adapted, highly differentiated
tissue with a very limited repair capability. It acts as a
buffer to transmitted forces across the joint, protecting the underlying bone. Because of the excellent soft
tissue contrast, the ability to visualize directly hyaline
cartilage, and the multiplanar capabilities, MRI has
shown to be the best imaging technique for the
evaluation of articular cartilage [51 53]. A number
of different pulse sequences, including spin echo,
two-dimensional, three-dimensional gradient echo,
fat-suppressed, and magnetization transfer contrast
sequences, have been used to study articular cartilage.
The reported sensitivities and specificities of different
sequences vary from lows of up to 50%, respectively,
to highs of about 100% for both [53]. Administration
Fig. 8. Axial T1-weighted spin echo MR arthrographic

image. There are surface irregularities of the patellar cartilage
outlined by the intra-articular gadolinium-DTPA solution.
of an intra-articular contrast agent allows excellent

delineation of the cartilage surface, however, and
provides good discrimination of cartilaginous lesions
[54 56]. In most studies the following MRI criteria
are used:
Grade I: abnormal intrachondral signal with a
smooth chondral surface but without alterations of
the chondral thickness
Grade II: mild surface irregularity with or without
focal loss of less than 50% of the cartilage
thickness (Figs. 8, 9)
Grade III: severe surface irregularities with
thinning of the cartilage thickness of more than
50% (Fig. 10)
Grade IV: complete loss of articular cartilage with
denuded subchondral bone [57]
Despite the marked improvement in MR arthrography s ability to allow detection of higher grade (II
to IV, characterized by moderate to severe surface
Fig. 9. Axial T1-weighted spin echo MR arthrographic

image. At the medial aspect of the patella there is a small
cartilage blister.
1127
Intra-articular bodies
Fig. 10. Sagittal T1-weighted spin echo MR arthrographic

image demonstrating a grade E chondral lesion of the patella.
irregularities and defects) lesions, however, grade I

(intrachondral abnormality) lesions remain difficult to
detect by MR arthrography. This is not surprising,
because grade I chondral lesions have no surface
abnormality that is detected by the intra-articular
Gd-DTPA solution. On delayed sequences, however,
an enhancement effect in cartilaginous areas with
altered intrachondral structures can be observed. This
is caused by diffusion of contrast material into the
hyaline cartilage, although the thickness and surface
of the cartilage may still appear normal.
Intra-articular bodies are a common clinical finding and may provoke clinical complaints that necessitate surgical intervention [60]. Such bodies may
consist of bone, cartilage, or bone and cartilage.
Although intra-articular bodies may be encountered
in virtually any joint, the knee is affected most often
[61,62]. Imaging is usually necessary to confirm the
clinical diagnosis and to localize the intra-articular
bodies before surgery, because intra-articular bodies
may be missed during arthroscopy. Radiography and
conventional tomography are useful only when radiopaque intra-articular bodies are present. For the
evaluation of intra-articular bodies, MR arthrography
has been demonstrated to have the greatest sensitivity
(86%) and was significantly more sensitive than
conventional MRI [59].
Plica synovialis
The three plicae of the knee (suprapatellar plica,
medial patellar plica, and infrapatellar plica) are
remnants of the embryologic synovium that separate
the joint into different compartments during gestation. Partial plical remnants are often identified at
arthroscopy, but they usually are considered incidental findings without clinical significance. Some
plicae may persist into adult life and cause anterior
knee pain, clicking, catching, or locking of the knee
when it becomes inflamed and thickened by trauma
Osteochondrosis dissecans
Osteochondrosis dissecans (OCD) is a lesion that
characteristically affects the articular cartilage and
subchondral bone with the potential of fragmentation
and separation. The cause is believed to be a combination of focal stress, ischemia, or abnormal ossification within the epiphysis [58]. Early detection of
osteochondral lesion is desirable because the onset
of degenerative arthritis in patients with OCD is
estimated to occur 10 years earlier than in normal
individuals. Management and prognosis of these
osteochondral lesions depend on the stability of the
fragment within its bony crater and on the status of
the overlying articular cartilage. Accurate assessment
of these factors is necessary to decide if surgical
treatment is required [43,59]. In a study comparing
conventional MRI with MR arthrography in the
staging of OCD lesions of the knee, MR arthrography
(Fig. 11) demonstrated significantly greater accuracy
[31] in staging osteochondral lesion of the knee. MR
arthrography seems to be able to replace diagnostic
arthroscopy for staging of OCD lesions of the knee.
Fig. 11. Sagittal T1-weighted spin echo MR arthrographic

image. An osteochondral defect is present in the medial
femoral condyle. There is a small amount of contrast
material interposed between the fragment and the remainder
of the condyle.
1128
Fig. 12. Axial T1 spin echo MR arthrographic image

demonstrates a plica mediopatellaris and a cartilage lesion at
the medial facet of the patella.
or overuse [63]. Of all three folds that are ontogenetically possible in the knee joint, the plica mediopatellaris (Fig. 12), which extends from underneath
the quadriceps and slides over the medial femoral
condyle with knee movement, is of great pathologic
importance. The medial patellar plica is most closely
associated with symptoms. MRI is able to demonstrate thickened plica synovialis mediopatellaris
tissue as a low-signal intense band between the
medial patellar facet and the medial femoral condyle
on all pulse sequences [64]. In most cases, however,
the plica is usually attached closely to the femoral
condyle, and is not visualized when there is insufficient synovial fluid to outline. The role of a swollen
mediopatellar plica in anterior knee pain and locking
is controversial because meniscal tears and ligament
injuries may also cause these nonspecific clinical
symptoms. Differentiation between knee injuries
and inflammatory mediopatellar plica is important
to avoid unnecessary arthroscopy. MR arthrography
enables assessment of thickened plicae and should be
considered as an alternative to diagnostic arthroscopy
in patients with mediopatellar plica [1,65,66].
Ankle
Ankle and foot injuries are quite common, with
ankle sprains particularly of the lateral ligamentous
complex being the single most common injury in
sports [67 70]. Ankle sprains are treated by early
mobilization with or without limited immobilization,

immobilization alone, or surgical repair [71]. Regardless of the treatment, the prognosis of most low-grade
ankle sprains is excellent or quite good. Patients who
receive no treatment may have more serious consequences, including early osteoarthritis or chronic
ankle instability. Treatment is usually conservative at
first, with the exception of young athletes, for whom
surgery may be initially attempted to accelerate the
healing process and prevent sequelae, because the
likelihood of chronic instability is greatest in those
patients who are treated conservatively. In about
10% to 20% of patients with ankle ligament injuries
surgery is required for chronic instability [72].
The lateral ankle ligament complex consists of
anterior talofibular, the calcaneofibular, and the posterior talofibular ligament. The anterior talofibular
ligament originates from the anteroinferior segment
of the lateral malleolus and inserts on the talar body
just anterior to the lateral malleolar articular surface.
Because of a capacious anterior recess of the ankle
joint, fluid or contrast material can outline the
anterior border of this capsular ligament. The calcaneofibular ligament is a cord-like structure that originates at the lateral malleolus and usually inserts at
the posterolateral aspect of the calcaneus. The posterior talofibular ligament arises from the medial
aspect of the distal portion of the fibula close to the
origin of the calcaneofibular ligament and inserts in
the posterolateral talar tubercle [73].
Lateral collateral ligament complex injuries are
commonly caused by inversion stress, regardless of
the position of the ankle. The anterior talofibular
ligament is weakest and usually injured first; two
thirds of ankle sprains are isolated injuries to this
ligament. With increasing inversion stress the calcaneofibular ligament may be injured. Tears of the
calcaneofibular ligament are usually associated with
an anterior talofibular tear. Patients with complete
rupture of the calcaneofibular ligament are those
most at risk for potential chronic instability. Posterior
talofibular ligament ruptures are very uncommon,
and are almost always associated with injuries of
other ligamentous and bony structures. With still
increasing force, the deltoid ligament may be
injured. Injuries of the deltoid ligament are very
uncommon and are reported to occur only with
further increasing forces to the ankle joint [72].
The medial collateral ligaments are divided into two
layers, superficial and deep, each being formed by
multiple fascicles. Because MR arthrography does
not offer any advantage in evaluation of medial
collateral ligaments, these structures are not discussed
further in this article [73].
For sufficient treatment of ligament tears, a satisfactory clinical evaluation and accurate diagnosis is
recommended. Because of pain, clinical assessment
of the severity of ankle sprains may be limited
necessitating imaging evaluation [74]. For exclusion
of injuries of the bony structures plain radiography is
performed. Conventional arthrography with iodinated
contrast material has been reported as being 80%
sensitive in diagnosing acute ligamentous tears [71].
MRI, however, has replaced arthrography as the
modality of choice accurately to demonstrate normal
and acutely injured ligaments. MRI allows for identifying the location of the tear, determining the
proximity of the torn ligament ends, and evaluating
any concurrent injuries of other joint and periarticular
structures. In selected cases MR arthrography of the
ankle is indicated in the evaluation of chronic lateral
instability. With MR arthrography, the examined joint
is distended, permitting improved discrimination of
intra-articular structures. MR arthrography is helpful
in distinguishing among different disorders, such as
OCD, avulsion fractures, sinus tarsi syndrome,
anterior talo-fibular (ATF) ligament injury, and peroneal involvement, which may give symptoms of
instability similar to ankle instability.
Arthrography of the tibiotalar joint is a rapid and
simple procedure. The course of the dorsalis pedis
artery is palpated and marked. With fluoroscopic
guidance, a needle is inserted under sterile conditions into the ankle joint medially to the tendon of
the extensor hallucis longus muscle, to avoid contacting, puncturing, or injuring the artery. Initially,
less than 0.5 mL iodinated contrast material is
administered, to demonstrate the intra-articular position of the tip of the needle. Approximately 12 mL
of a Gd-DTPA solution is then injected, providing a
sufficient distention of the joint capsule. The patient
can help to reduce the discomfort of the procedure
by reporting a painful pressure feeling caused by
capsule distention. This should be the point of
finishing the contrast agent instillation even if less
than 10 mL is inserted.
After the injection of intra-articular contrast
material, contrast agent should be seen within the
tibiotalar joint. Contrast material may be seen within
the flexor hallucis longus and flexor digitorum longus
tendon sheaths and in the subtalar joint. These are
normal communications in 6% to 25% of individuals
[75]. Extravasation of contrast material anterior to the
anterior talofibular ligament may indicate an anterior
talofibular ligament tear. A capacious anterior recess
of the ankle joint, however, allows the contrast agent
to outline the anterior border of this capsular ligament. Accurate assessment of the thickness of the
1129
ligament and its integrity at the insertion site can be

made. Extravasation of contrast material lateral to the
calcaneofibular ligament or into the peroneal tendon
sheath indicates a calcaneofibular ligament tear, and
extravasation of contrast material into the soft tissues posterior to the posterior talofibular ligament
indicates a tear of this ligament. Direct signs of a
ligament tear also include nonvisualization of the
ligament; increased signal intensity within the ligament; discontinuity; abnormal course; or a wavy,
irregular contour of the ligament [76]. The efficacy
of stress radiography, conventional MRI, and MR
arthrography for detecting lateral collateral ligament
abnormalities in patients with chronic ankle instability has been compared [76]. It has been shown that
stress radiography was 57% sensitive for detecting a
ligament tear and had the drawback that torn ligaments could not be identified directly or individually.
Conventional MRI was 50% sensitive for diagnosing
anterior talofibular and calcaneofibular ligament
tears. MR arthrography was 100% and 90% sensitive
in diagnosing anterior talofibular and calcaneofibular ligament tears, respectively. Plain MRI and
MR arthrography further allowed direct visualization
of the status of the peroneal tendons.
MR arthrography has been demonstrated also to
be useful for the evaluation of anterolateral ankle
impingement syndrome. The anterolateral recess of
the ankle is bounded posteromedially by the tibia and
laterally by the fibula. Anteriorly, it is limited by
the capsule of the tibiotalar joint, and the anterior
tibiofibular, anterior talofibular, and calcaneofibular
ligaments [77]. Anterolateral impingement of the
ankle is thought to occur subsequent to relatively
minor trauma involving forced ankle plantar flexion
and supination [78]. Such trauma may result in
tearing of the anterolateral soft tissues and ligaments
without substantial associated mechanical instability.
Repeated microtrauma and soft tissue hemorrhage
can result in synovial scarring, inflammation, and
hypertrophy in the anterolateral recess of the tibiotalar joint, with subsequent soft tissue impingement
[79]. Other contributing factors are thought to include
hypertrophy of the inferior portion of the anterior
tibiofibular ligament and osseous spurs [80,81]. Previous studies on the value of conventional MRI
demonstrated sensitivities of 39% to 100% and specificities of 50% to 100% [79,81 83] for detecting
impingement. The MR arthrography appearance of
the anterolateral soft tissues agreed very well with
findings at arthroscopy [78].
Intra-articular bodies may also lead to impingement symptoms. In a cadaveric study conventional
MRI, MR arthrography, CT, and CT arthrography for
1130
diagnosing osseous and cartilaginous intra-articular

loose bodies have been compared [59]. MR arthrography, with a sensitivity of 86%, was found to be
the best imaging technique for detecting intra-articular bodies.
Complications of MR arthrography of the ankle
area are rare. Transient pain and swelling have been
described. Infection is a potential risk, but in a review
of conventional ankle arthrograms no cases of septic
arthritis were reported [84].
[7]
[8]
[9]
[10]
Summary
MR arthrography by virtue of its ability accurately
to demonstrate intra-articular structures and abnormalities of these structures has become an important
tool for the evaluation of a variety of articular disorders. Although not necessary in all patients, MR
arthrography may facilitate the evaluation of patients with suspected intra-articular pathology in
whom conventional MRI is not sufficient for an adequate therapy planning. MR arthrography combines
the advantages of arthrography, like joint distention
and delineation of intra-articular structures, with the
superior spatial resolution of MRI. This technique
improves diagnostic confidence, particularly in the
assessment of subtle lesions and of complex anatomic structures. MR arthrography is of high value
in the evaluation of osteochondral defects, loose
bodies, previously operated menisci, and acetabular
labral lesions.
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Radiol Clin N Am 40 (2002) 1133 1146
Postoperative evaluation of the knee

Sean Yoshida, MD, Michael P. Recht, MD*
Cleveland Clinic Foundation, Department of Radiology, A21, 9500 Euclid Avenue, Cleveland, OH 44195, USA
As lifestyles become more active, the incidence of

knee injuries has increased, as has surgery to repair
such injuries. It is important for the radiologist to be
able to recognize the normal appearance of the postoperative knee and complications that result from the
more common repair procedures. This article discusses the MRI appearance of the knee following
anterior cruciate ligament (ACL) repair, meniscal
surgery, and cartilage repair procedures.
The postoperative ACL

The most commonly injured ligament in the knee is
the ACL. ACL-deficient knees have a poor natural
history and can result in changes in mechanics causing
secondary meniscal and cartilage injury [1 3]. Reconstruction of ACLs is becoming more common.
Surgical factors
Multiple factors enter into the decision as to
whether to surgically reconstruct a torn ACL. These
variables include the degree of injury, associated
injuries, patients age, patients lifestyle, and compliance for rehabilitation. Partial tears are more likely to
be treated nonoperatively, whereas complete tears
more frequently undergo reconstruction. The presence of meniscal tears, collateral ligament injury, and
patellofemoral instability favors operative repair [4].
The most important factor, however, is the level of
patient activity. Sedentary patients with torn ACLs
are more likely to undergo conservative treatment,
E-mail address: rechtm@ccf.org (M.P. Recht).
whereas younger athletic individuals are usually

treated surgically.
Surgical treatment
Surgical treatment of torn ACL includes primary
repair and reconstructions. Primary repair is usually
reserved for avulsion injuries either at the femoral or
tibial insertions. The typical patients are young children who avulse a fragment of bone at the tibial
attachment of the ACL. Repair of midsubstance ACL
tears has not produced reliable success rates and is
not in common use [5,6]. Occasionally, primary
repair of the ligament is augmented with autografts
to allow earlier mobilization of the knee.
The most popular method of surgically treating
ACL tears is reconstruction [7,8]. Multiple reconstruction techniques have been used including extra-articular, intra-articular, and combination reconstructions.
Extra-articular reconstructions involve transferring
the pes anserinus and iliotibial tract to prevent anterior subluxation of the tibial plateau. This has only
produced limited success. Intra-articular reconstructions have met with favorable results and are the most
commonly performed reconstruction.
A variety of graft material has been used for
ACL reconstructions. These have included autografts, allografts, and synthetic grafts. Autografts are
popular because of their availability and lack of risk
of transmission of disease or immune reaction. Potential disadvantages include longer operative times for
harvesting the graft and donor site morbidity.
The most commonly used autografts are the bonepatellar tendon bone (BPTB) or hamstrings. When
the BPTB autograft is harvested, the patellar tendon
is divided longitudinally into thirds and the central
one third is removed with small bone plugs at either
end. The graft may be placed arthroscopically and the
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 5 3 - 2
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S. Yoshida, M.P. Recht / Radiol Clin N Am 40 (2002) 11331146
plugs fixed within the tunnels. Advantages of the

BPTB autograft include easy arthrographic access for
harvesting the graft, quicker healing, and better
fixation because of the bone-bone interface. The
patellar tendon graft itself is also stronger than the
native ACL. Although complications are rare, they
include patellar fracture and tendon rupture [9,10].
There has also been a statistically significant increase
in patellofemoral pain and quadriceps weakness when
compared with the hamstring technique [11].
Use of the hamstring as the donor site is also
frequently performed. Single gracilis and semitendinosus tendons individually do not have the same
strength as the patellar tendon. When the semitendinosus and gracilis are used, they are folded and
doubled, whereas when the semitendinosus is used, it
is quadrupled. Hamstring grafts have a larger crosssectional area than the BPTB grafts because of their
round cross section. For hamstring and patellar grafts
of the same diameter, the hamstring has more collagen fibers and subsequent strength. Donor site
complications with hamstring grafts are minimal
when compared with BPTB grafts [12], but there is
controversy as to whether they allow as early rehabilitation after reconstruction as does the BPTB graft.
Cadaveric allografts are used occasionally but are
far outnumbered by autografts. The most frequently
used allografts are the patellar tendon, Achilles tendon,
tensor fascia lata, semitendinosus tendon, gracilis
tendon, and combined semitendinosus and gracilis.
In the past synthetic grafts, such as knitted Dacron,
carbon fiber, braided polypropylene, and expanded
polytetrafluoroethylene (Gor-Tex), have been used.
Because of complications, however, these are not in
common use. The main complications included the
production of intra-articular particulate debris and
sterile effusions, which increases susceptibility to
infection and stretching and rupture of grafts.
There are multiple types of devices for securing
the grafts. These include endobuttons, interference
screws, suture posts, and screw-washer fixation. Endobuttons are 6-mm titanium buttons that attach the
graft to the outer cortex. Interference screws are
placed parallel to, but not within, the femoral or tibial
tunnels, to secure the graft. The suture post technique
involves using a suture to secure the graft into a screw
and washer drilled into the bone near the tunnel. The
screw washer mechanism directly fixes the graft to
the bone.
Imaging of the ACL graft
Although both conventional and fast spin echo
techniques can be used to evaluate the postoperative
ACL, fast spin echo is preferred because of the

decreased metallic artifact seen with fast spin echo
compared with conventional spin echo [13]. At the
authors institution a 14-cm field of view with a 256by-192 matrix is used. The slices are 3-mm thick with
a 1-mm interslice gap. Sagittal double echo with
proton and T2 weighting, coronal T1-weighted and
fat-saturated T2-weighted, and axial fast T2 are
obtained. In addition, using the coronal as a scout
image, an oblique sagittal scan is often performed in
the plane of the graft to allow better visualization of
the ACL graft on one slice.
Normal ACL graft
Evaluation of ACL reconstruction involves assessment of the femoral and tibial tunnel positions and the
morphology and signal characteristics of the ACL.
When planning the placement of the tibial and femoral
tunnels, it is imperative to achieve the principle of
isometry of the graft. Isometry is the maintenance of
the graft under constant tension throughout the full
range of motion of the knee from 0 to 90. The
femoral and tibial attachments of the ACL graft
should not vary by more than 2 to 3 mm throughout
the range of movement.
The position of the femoral tunnel is critical in
maintaining isometry. The tunnel should be at or very
close to the normal position of the insertion of the
native anterior cruciate ligament and courses from
just superior to the lateral femoral condyle to the
superolateral aspect of the intercondylar roof. Placing
the femoral tunnel a few millimeters anteriorly or
inferiorly results in loss of isometry. On a coronal
image, the tunnel originates at about the 11-oclock
position in the right knee and about the 1-oclock
position in the left. On a sagittal image, the tunnel
becomes intra-articular at the junction of the posterior
cortex and physeal scar of the distal femur. It is
important to note that the positions of the interference
screws, staples, or other fixation devices do not
correspond to the position of the tunnels.
The tibial tunnel is drilled at or directly adjacent
to the normal tibial insertion of the ACL. The tibial
tunnel must be parallel to the intercondylar roof. In
addition, the proximal entrance of the tunnel must
be positioned at or just posterior to the intersection
of a line drawn parallel to the roof with the tibial
plateau. Deviation of the alignment of the tibial tunnel may lead to impingement of the graft [14,15].
The tunnel enters the articular surface at the intercondylar eminence.
An intact graft is parallel to and just posterior to
the intercondylar roof. In the immediate postoperative
1135
Fig. 1. Twenty-five year old with intact anterior cruciate ligament graft. (A) Sagittal proton density and (B) sagittal T2-weighted
images show the graft is parallel to the intercondylar roof and is of homogenous low signal intensity on both the T1-and
T2-weighted images. The tibial tunnel is in the desired position, posterior and parallel to Blumensaats line
period and greater than 2 years after the surgery, ACL

grafts appear as a thick band of predominantly low
signal on T1-, proton density , and T2-weighted
images (Fig. 1) [16]. Even the graft within the tunnel
remains low signal during these sequences. During
the first 2 years, however, an intact ACL graft may

demonstrate variable signal intensity (Fig. 2) [16].
Initially, it was thought that the increased signal
within the ACL graft was secondary to neovascularity or graft impingement. Howell et al [17] used
Fig. 2. Thirty-two year old with a clinically stable knee and intact anterior cruciate ligament graft. (A) Sagittal proton density
image demonstrates some intermediate signal (arrows) within the midsubstance of the graft. (B) On the T2-weighted image,
however, the graft is of low signal without fluid-like signal to suggest a graft tear.
1136
gadolinium to study the vascularity of hamstring

autografts during the first 2 postoperative years. They
found that during this time no discernable blood
supply was evident and that the graft maintained a
similar hypovascular appearance as the posterior
cruciate ligament. The periligamentous soft tissues,
however, were richly vascularized and covered the
graft by 1 month.
A second study evaluated the signal intensity of
hamstring grafts in the first 3 postoperative years and
found that the signal intensity in unimpinged ACL
grafts remained low, whereas the impinged grafts
demonstrated increased signal intensity in the distal
two thirds of the grafts. This study supported the
suggestion that the increase in signal in the graft was
a result of impingement [18].
Several other studies have shown that increased
signal can be seen even in unimpinged grafts in the
first 2 years after surgery [13]. There should not,
however, be increased fluid-like signal intensity traversing the full thickness of the graft.
Graft rupture
Spontaneous graft rupture is rare and is frequently
secondary to trauma. The same criteria used to
diagnose a ruptured ACL graft are used to identify
a torn native ACL: discontinuity of normal fibers, and
abnormal signal intensity within the substance of the
graft (Fig. 3). There can be normal increased signal
within the graft immediately after ACL reconstruction, which may persist for up to 18 months as
previously mentioned. There should not, however,
be fluid signal intensity interrupting the graft. In
addition, with impingement, increased signal can be
seen within the graft on the proton density weighted
images, but this should not be fluid signal intensity
on the T2-weighted sequences.
Partial tears show disruption of some of the fibers
of the ACL with attenuation and thinning. There are
some intact dark fibers on all pulse sequences along
the course of the ACL.
Graft impingement
Graft impingement occurs when the graft abnormally contacts either the wall or the roof of the
intercondylar notch at the exit site of the bone tunnels
onto the articular surface. The presence of osteophytes, scar tissue, and the size of the intercondylar
notch are all factors contributing to impingement.
Impingement can lead to stretching, erosion, remodeling, and tearing of the graft.
Sidewall impingement occurs when the graft contacts the lateral aspects of the intercondylar notch.
Sidewall impingement is usually easily detected by
the arthroscopist and resolved with a notchplasty.
Roof impingement occurs when the tibial tunnel is at least partially anterior to a line drawn
along the intercondylar roof and extended to the
Fig. 3. Twenty-one year old with prior anterior cruciate ligament (ACL) repair who now presents with a clinically unstable knee.
On (A) proton density-weighted and (B) sagittal T2-weighted images, no intact ACL graft fibers are seen. Fluid-like signal
intensity (arrow) is seen in the expected course of the ACL graft on the T2 weighted images.
tibial plateau [19,20]. These patients present with

loss of terminal extension of the knee. Typically, a
prophylactic notchplasty is performed at the time of
the ACL repair to limit impingement of the graft.
Arthroscopists find this complication difficult to
detect, however, and MRI has proved helpful in
confirming its presence.
On MRI, the tibial tunnel projects anterior to a
line drawn along Blumensaats line. The graft contacts and is displaced posteriorly by the intercondylar
roof. The distal two thirds of the graft show increased
signal intensity (Fig. 4). Again, as with sidewall
impingement, roof impingement may be corrected
by notchplasty. By 12 weeks after notchplasty, the
abnormal signal in the graft decreases.
Arthrofibrosis
Following ACL reconstruction, loss of terminal
extension (extension lag) is one of the major causes
of morbidity. One of the major etiologies causing
extension lag is localized anterior arthrofibrosis. In
this condition, a focal fibrous nodule develops
anterior to the distal portion of the ACL graft within
1137
the intercondylar notch. The nodule physically

impairs terminal extension of the knee. The bluish
discoloration of this rounded lesion resembles an
eyeball on arthroscopy and was named the cyclops
lesion. Surgical removal of these lesions results in
immediate relief of symptoms where no other contributing factors are present.
The cause of these lesions is uncertain and several
theories have been proposed. Initially it was believed
that as the tibial tunnel was drilled superiorly and
posteriorly debris was raised, which stimulated the
formation of the nodule. Even when the drilling of
the tunnel was reversed, however, this did not prevent
the formation of the cyclops lesion. Graft impingement has also been proposed to stimulate the formation of these lesions; however, not all cases of
arthrofibrosis have associated impingement.
Cyclops lesions can be identified on MRI [21]. On
T1- and proton density weighted images, nodular
intermediate signal intensity mass is seen at the
anterior distal aspect of the graft in the intercondylar
notch. This mass is often homogenous in signal intensity and difficult to differentiate from fluid on these
sequences. The T2-weighted images allow easier differentiation of the heterogeneous but predominantly
low signal intensity of the arthrofibrosis from the
high signal of joint fluid (Fig. 5).
Donor site findings
Fig. 4. Twenty-year-old with an impinged graft. This patient

presented with loss of terminal extension of the knee
following anterior cruciate ligament repair with a bonepatellar tendon bone graft 17 months earlier. Sagittal proton
weighted image shows that the tibial tunnel is anterior to
Blumensaats line. The graft is bowed and contains
abnormal increased signal (arrow) in the distal two thirds,
which is consistent with an impinged graft.
Following the harvest of the BPTB autograft,

there is edema within the patellar and tibial donor
sites. There may be an increase in the thickness but
not in the width of the tendon. In addition, there can
be increased signal within the patellar tendon, which
is thought to be secondary to edema and granulation
tissue. These morphologic changes are most prominent at 6 months. The signal changes peak at 6 weeks
and by 18 months the signal intensity within the donor site returns back to normal [22]. The donor sites
for hamstring, iliotibial band, and Achilles tendons
also demonstrate similar changes with signal changes
also reverting to normal by 18 months.
Patellar fractures with use of the BPTB graft have
been documented but are rare. Persistent pain can
occur at the donor site of the BPTB graft and
correlates with abnormal increased signal within the
patellar tendon associated with patellar thickening,
which persists after 19 months.
Other complications
Occasionally, bone plugs can be pulled out. MRI
can also be used to identify infection of the graft and
1138
Fig. 5. Twenty-nine-year-old with a prior anterior cruciate ligament (ACL) repair and development of a cyclops lesion. Sagittal
(A) proton density and (B) T2-weighted images demonstrate a heterogenous mass (arrow) extending anterior to the distal aspect
of the ACL graft. The mass is approximately isointense to fluid signal intensity on the proton density weighted images but lower
than fluid signal on the T2-weighted images. The ACL graft was intact on the adjacent images.
donor site. Hardware failure including fracture of the

screws or staples can occur. Osteonecrosis of the
femoral condyles can also be assessed.
Postoperative cysts can develop in or around the
tibial tunnel. These are often associated with degenerative or partial tears. They are more common with
hamstring than with BPTB grafts. Occasionally, these
cysts can be symptomatic when they become large.
The postoperative meniscus

Before the advent of arthroscopy, total meniscectomy was performed for torn menisci. The result,
however, was accelerated damage to the articular
cartilage and secondary remodeling of the femoral
condyles and tibial plateau [23]. Preservation of
meniscal tissue is now the goal when treating a
meniscal tear.
The treatment of meniscal tears is divided into
conservative treatment or surgery. Conservative treatment is reserved for partial-thickness tears involving
less than half of the thickness of the meniscus and
full-thickness tears less than 10 mm in length. These
tears are usually either vertical or oblique and are
located in the peripheral vascular zone.
Surgical treatment involves primary repair, meniscectomy, or allografts. Primary repair is performed
on those menisci that are acute and traumatic in
nature. These tears involve the peripheral one third
of the menisci, which also is called the red zone
or vascular zone. These types of tears are usually

of the vertical longitudinal or meniscocapsular separation variety. Primary repair of horizontal tears
does not have favorable outcomes and is usually
not performed.
The most common surgery performed on menisci
is meniscectomy. This may be partial or complete.
Most of these menisci have chronic and complex
tears, often of the radial, parrot beak, or flap varieties
[24]. These tears are also usually located in the
avascular inner white zone.
In patients where the menisci cannot be repaired,
meniscal transplantation can be performed in some
patients to slow the progression of degenerative
change [25]. Usually this procedure is performed in
younger patients with total meniscectomy who are
susceptible to degenerative changes by midlife.
Allograft menisci are matched for size and age and
anchored with sutures.
Imaging of the postoperative meniscus
In nonoperative knees, MRI has an 85% to 90%
sensitivity, specificity, and accuracy for the evaluation of meniscal pathology [26]. Tears of native
menisci are based on increased signal within the
menisci extending to the articular surface on T1 and
proton density sequences, and morphologic changes
in the menisci.
The criteria for diagnosing meniscal tears in the
virgin meniscus do not apply to the postmeniscec-
Fig. 6. Forty-three year old status post partial meniscectomy

of the posterior horn of the lateral meniscus. Fat-suppressed
proton density image shows a truncated irregular posterior
horn (arrow) with fluid signal extending up to the margin
but not into the meniscal remnant consistent with an intact
meniscal remnant. .
tomy knee because there can be residual abnormal

signal intensity and morphology (Fig. 6) [16,27,28].
This is especially important when greater than 25% of
the meniscus is removed, in which case the remaining
meniscus can appear foreshortened with an irregular
margin. In addition, abnormal signal extending to an
articular surface can be seen in stable meniscal
1139
remnants [16,29]. The specificity of these findings

for meniscal retears is lower than that for tears in
nonoperative menisci. Several studies have reported
that these findings have an accuracy of 66% to 80%
in the postoperative meniscus [29,30].
Signal changes within the meniscus at a site
distant from the original tear, fluid signal intensity
in the meniscus remnant, and a displaced fragment
are specific signs of a meniscal retear but are not
very sensitive (Fig. 7). Direct MR arthrography has
been used at some institutions to increase the accuracy of diagnosing retears of the postoperative menisci. MR arthrography involves injecting 30 to 40 mm
of dilute gadolinium diethylentriamine pentaacetic
acid into the knee to distend the joint before MRI.
The dilute intra-articular gadolinium has a lower
viscosity than normal joint fluid and has better
penetration into the torn menisci (Fig. 8). T1weighted sequences can then be used to image the
menisci, which have the advantage over proton
density and T2 images of greater spatial resolution
and higher signal to noise. Applegate et al [29]
looked at meniscal tears that had either undergone
meniscal resection or repair, and had conventional
MRI and direct MR arthrography performed. They
showed increased sensitivity for diagnosing a retear
with intra-articular gadolinium when compared with
conventional imaging. However, recent studies by
White et al [30] evaluating the accuracy of conventional MRI, direct MR arthrography, and indirect MR
arthrography for the diagnosis of recurrent or residual
meniscal tears following meniscal surgery found that
Fig. 7. Nineteen-year-old status post prior meniscectomy with reinjury to the knee. Sagittal (A) proton density and (B) T2weighted images demonstrate linear fluid-like signal intensity (arrow) extending into the residual posterior horn of the lateral
meniscus consistent with a meniscal retear, which was confirmed at arthroscopy.
1140
Fig. 8. Twenty-nine year old status post prior meniscectomy of the peripheral aspect of the posterior horn of the medial
meniscus. (A) Sagittal and (B) coronal fat-saturated T1-weighted images following the intra-articular injection of gadolinium
demonstrates contrast extending into a cleft in the posterior horn of the medial meniscus (arrow) consistent with a retear
confirmed at arthroscopy.
there was no statistically significant difference in

diagnosing residual tears or retears between the
various modalities.
As with partial meniscectomy, when primary
repair of the torn meniscus has been performed,
residual abnormal signal extending to the articular
surface on short echo time (TE) sequences can be
seen as part of the normal healing process [27].
Retears following primary repair can be diagnosed
using the same findings associated with retears following partial meniscectomy: fluid signal intensity on
the T2-weighted images coursing through the repair
site, and displaced meniscal fragments. In addition,
abnormal signal on short TE sequences at a site
removed from the primary repair is also highly
suggestive of a new tear.
After partial meniscectomy, morbidity may be
caused by factors other than those related to the
meniscus. One cause of pain after arthroscopic meniscal recontouring or repair is osteonecrosis. Brahme
et al [31] looked at seven patients who had undergone
meniscal repair and articular cartilage shaving, and
returned with postsurgical knee pain. MRI in these
patients showed marrow abnormalities consistent
with osteonecrosis of the femoral condyle or tibial
plateau. The exact cause of the marrow abnormalities
is not clear. Both microtrauma from the procedure
and altered mechanics relating to the partial meniscectomy may be contributing factors [7].
Postoperative articular cartilage

Articular cartilage abnormalities are common,
difficult to recognize clinically, and may result in
significant disability and secondary degenerative
changes. The development of new cartilage repair
procedures that transplant or potentially reform hyaline-like articular cartilage has created a need for
accurate noninvasive evaluation of articular cartilage
lesions following repair procedures.
Surgical treatment
The surgical options of treating a full-thickness
cartilage defect include traditional procedures that
lead to the formation of fibrocartilage or several
new techniques that have the potential to reform
or transplant hyaline cartilage. The traditional
techniques that have been used to treat articular
cartilage lesions include debridement, drilling, microfracture, and abrasion arthroplasty. The main
disadvantage of these techniques is that the resultant biomechanics of the joint are changed because
1141
Fig. 9. Thirty-five year old 2 years status postmosaicplasty. (A) Coronal and (B) sagittal fat-suppressed three-dimensional
gradient echo images demonstrate a relatively smooth cartilage surface at the site of the mosaicplasty (arrows) at the medial
femoral condyle.
Fig. 10. Twenty-seven year old 3 years after an osteochondral autograft transplant. Sagittal fast spin echo (A) proton density and
(B) T2-weighted images demonstrate hypertrophic repair tissue (arrow) at the site of the mosaicplasty, which is of different
signal intensity than the native articular cartilage. There has been subsidence of the grafts (arrowheads).
1142
Fig. 11. Twenty-two year old status postosteochondral autograft transplant of the patella. (A) The coronal fat-saturated T2 images
depicts the osteochondral plug donor site laterally within the intercondylar notch (arrow). (B) Sagittal fat-suppressed threedimensional gradient echo and (C) T2-weighted images show the bone-bone interface (arrows) is offset with the osteochondral
plug subchondral bone plate more superficial than the native bone plate.
1143
Fig. 12. Thirty-four year old 1-year status postautologous chondrocyte implantation. (A) Sagittal proton density and (B) T2weighted images demonstrate the repair tissue at the site of the implantation involving the medial femoral condyle. The repair
tissue differs in signal intensity from the surrounding background articular cartilage and is slightly increased in signal intensity
on the T2-weighted images. (C) Sagittal fast spin echo proton density and (D) T2 fat-weighted fat-suppressed images show that
there has been hypertrophy of the repair tissue compared with the native articular cartilage. There is extensive signal abnormality
involving the underlying subchondral bone marrow, which is increased on the T2-weighted images. This amount of edema has
been associated with poor integration or abnormality of the repair tissue.
1144
Fig. 13. Twenty-eight year old with failure of an autologous chondrocyte implantation of the medial femoral condyle. The
coronal fat-saturated T2-weighted image demonstrates essentially no repair tissue at the site of the surgery (arrow).
of the replacement of hyaline articular cartilage

with fibrocartilage.
In contrast, several techniques have been used to
replace the hyaline cartilage. These techniques include autogenous osteochondral graft transplantation (osteochondral autograft [OAT], mosaicplasty)
(Fig. 9) and autogenous chondrocyte implantation.
Osteochondral autogenous graft transplantation
involves removing osteochondral plugs from the
relative non weight-bearing areas of the joint, such
as the lateral aspect of the femoral condyle at the
patellofemoral joint (Fig. 10). These plugs vary in
size from 2.7 to 15 mm in diameter and 10 to 15 mm
deep. These plugs are then inserted into holes drilled
within the region of cartilage deficiency while
attempting to cover the entire chondral defect (see
Fig. 10). The goal is to maintain the congruency of
the bone and cartilage between the transplant site and
the bone plugs. This technique is recommended for
lesions up to 2 cm2; however, larger defects up to
8 cm2 have been treated [32].
MRI has been used to assess incorporation of the
grafts, assess vascularity of the grafts, evaluate the
congruency between the graft and the native cartilage
and bone, and assess the donor site [33,34]. One
complication associated with this procedure is incongruence of the graft, which may be secondary to
incorrect initial placement of the plugs, subsidence,
or degeneration of the graft (Fig. 11). Other compli-
cations include loose bodies, and avascular necrosis

of the donor site, and condylar fracture.
Some centers have used autologous chondrocyte
implantation. This technique involves harvesting
chondrocytes from the relative non weight-bearing
surfaces, such as the intercondylar notch and femoral
trochlea. The chondrocytes are grown ex vivo and
replaced into the periosteal covered site of the cartilage
defect (Fig. 12). Chondrocytes progress through several stages. Initially, in the proliferative stage, there is
formation of a jelly-like substance. The second stage,
known as the transition stage, involves formation of a
type II collagen framework though which proteoglycans are interwoven. This occurs from approximately
7 to 12 weeks. Then from 13 weeks to about 3 years
the maturation stages involve remodeling of the
collagen framework, which results in firm hyalinelike tissue. MRI can assess the rate of growth and
characteristics of the cartilage and its incorporation
with the native cartilage (Fig. 13) [32,35]. Delamination and hypertrophy of the repair tissue can also
be evaluated. Furthermore, the state of the underlying
subchondral bone also may be assessed.
Summary
New developments and improvements in ligamentous and meniscal surgery and cartilage repair
procedures have led to an increased incidence of

these procedures being performed. Subsequently,
there has been a corresponding increase in postoperative imaging studies, and it is imperative for
radiologists to be comfortable with the normal
imaging appearance of these procedures and associated complications.
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Radiol Clin N Am 40 (2002) 1147 1170
MR imaging of tendon, ligament, and osseous abnormalities

of the ankle and hindfoot
Susan Leffler, MD*, David G. Disler, MD
Commonwealth Radiology, PC, 5801 Bremo Road, Richmond, VA 23226, USA
Musculoskeletal imaging requires a magnet and

coil system that allows for homogenous fat suppression and high-resolution imaging. The new standard
also requires the ability to obtain specialized cartilage
sequences and volumetric sequences.
The authors try to educate their technologists
about disease processes because pathology can
commonly occur at the myotendinous junction or
muscle belly that is at the edge or outside of the
field of view. In addition, subtle signal differences
on short tau inversion recovery (STIR) images in
muscle may prompt further investigation with contrast administration.
The authors try to maintain a constant dialogue
with referring orthopedists and sports medicine
physicians to optimize the history that is provided
and to establish a feedback loop to improve protocols
and understanding of findings.
The authors limit imaging to one extremity at a
time and scan with an extremity coil in the supine
position. The only exception is the supplemental use
of a body coil to compare the signal characteristics
of the calf muscles on coronal STIR images in cases
of suspected primary muscular systemic diseases.
They prefer to image the ankle in the plantar flexed
position when studying tendons because this position straightens the tendons; minimizes the wrap or
phase artifact; and eliminates the magic angle
artifact, which is seen when a short TE is used.
The trade-offs include a distortion of ligamentous
E-mail address: Susanleffler@attbi.com (S. Leffler).
anatomy and decreased visibility of the distal leg

including the Achilles tendon. The authors prefer
to image the ankle in the neutral position when
studying ligaments because they are better profiled
in that position.
The standard anatomy imaged includes the ankle,
hindfoot, and midfoot. It is desirable to include as
much of the Achilles tendon as possible without
compromising evaluation of the plantar fascia.
Standard sequences use no phase wrap (phase
oversampling) and flow comp (gradient moment
nulling to decrease pulse artifacts on long TE sequences). STIR images are obtained in at least one
plane because inhomogeneous fat suppression on fatsuppressed T2-weighted images can result in misleading images mimicking pathology.
The authors standard protocol begins with a
sagittal T1 (600/12) spin echo series and sagittal
STIR (3500/30/155) images. Axial spin echo T1
(600/12) images for anatomy are supplemented with
axial fat-suppressed T2-weighted fast spin echo
(3500/54) images for pathology. To decrease time, a
rectangular field of view is used rather than a square
matrix (Fig. 1).
The workhorse for evaluating cartilage is the
coronal fat-suppressed intermediate-weighted fast
spin echo (3000/12) sequence. Usually 3- to 4-mm
thick sections are used with a 1-mm gap and 2 NEX.
If there is a specific question regarding cartilage or
growth plate integrity, then a sagittal fat-suppressed
three-dimensional spoiled gradient echo sequence is
obtained 50 to 60/11 (40 degrees). The decreased
sensitivity of this sequence in cases of obese patients or edematous surrounding soft tissues that
is seen in the knee is not usually seen in the ankle
(Figs. 2, 3).
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 5 2 - 0
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S. Leffler, D.G. Disler / Radiol Clin N Am 40 (2002) 11471170
1149
1150
(Fig. 4). Gadolinium can be administered in cases of

possible tumor or infection.
Definitions
Berquist [1] describes the following tendon grading system:
Grade 1: minimal disruption
Grade 2: greater than 50% fibers disrupted
Grade 3: complete tear
For the purpose of this article, the following
definitions apply:
Tendinosis: thickened hypointense tendon
Acute (complete) tear (grade 3): morphologic discontinuity of tendon fibers
Acute (partial) tear: tendon thickening with increased signal on T2-weighted images
Tenosynovitis: fluid in the tendon sheath with a
normal to slightly thickened tendon
Peritendinitis: edema-like signal around a tendon
that is not invested by a tendon sheath (eg,
Achilles tendon)
Fig. 1. Normal ligament anatomy and posterior tibialis

longitudinal split are depicted in the following example. T2
coronal (5668/96): (A) posterior talofibular ligament and (B)
calcaneofibular ligament. T2 fat-suppressed axial (4522/85);
(C) anterior inferior tibiofibular ligament and posterior
inferior tibiofibular ligament; (D) anterior inferior tibiofibular ligament, transverse tibiofibular ligament, posterior
inferior tibiofibular ligament, and tibionavicular ligament;
(E) tibionavicular ligament, anterior tibiotalar ligament, and
tibiocalcaneal ligament; (F) anterior talofibular ligament and
posterior talofibular ligament; (G) anterior talofibular
ligament, calcaneofibular ligament, and posterior tibialis
longitudinal split; and (H) spring ligament.
If there is concern about the Achilles tendon, then

a T1 oblique sagittal series with an extended field of
view from knee to ankle is used and axial gradient
echo images are obtained perpendicular to the
Achilles tendon; the ankle must be imaged in the
neutral position to achieve true perpendicular images
Fig. 2. Normal cartilage in a 6-year-old boy. Sagittal

spoiled gradient volumetric (60/4/40 degrees) image
demonstrates a normal hypointense bone and hyperintense
cartilage contrast.
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Fig. 3. Normal and abnormal adult cartilage. (A) Sagittal spoiled gradient volumetric image (60/4/40 degrees) in a 24-year-old
man demonstrates normal discrimination between hindfoot structures. Note that the talonavicular and navicula-medial cuneiform
joints are developed fully and oriented parallel to each other. (B) Sagittal spoiled gradient volumetric image (60/5/40 degrees) in
a 41-year-old man demonstrates underdevelopment and malorientation of the talonavicular joint. The amount of cartilage is
decreased in the subtalar joint, consistent with a cartilaginous coalition (arrow).
In truth, the term tendinitis is not favored when

describing tendon pathology in the foot and ankle
because pathology typically is not inflammatory but
rather traumatic and reparative in nature.
Compartments
It is easiest to organize the approach to analyzing pathology at the ankle by considering compartmental anatomy. The compartments can simply
be divided into the anterior, posterior, lateral, and
medial soft tissue compartments. The signal characteristics of the marrow and contour detail of
the joints are also described. Last, the sinus tarsi,
plantar fascia, and subcutaneous soft tissues should
be surveyed.
Anterior compartment
The anterior compartment contains three tendons
and inconsistently a fourth. The pneumonic Tom,
Harry, Dick, and Paul describes the tendon order
from medial to lateral. The tibialis anterior originates from the lateral tibia and anterior surface of
the interosseous membrane and inserts onto the

doral surfaces of the medial cuneiform and first
metatarsal bones. The extensor hallucis longus originates from the anterior distal fibula and interosseous membrane and inserts onto the dorsal distal
phalanx of the great toe. The extensor digitorum
longus originates from the upper anterior tibia,
fibula, and interosseous membrane and inserts onto
the dorsal lateral four toes. The peroneus tertius,
when present, originates from the anterior distal
fibula and interosseous membrane and inserts onto
the dorsal base of the fifth metatarsal. All of these
tendons dorsiflex, the medial two invert, and the
lateral two evert the foot. All are innervated by the
deep peroneal nerve (L4-S1) and all are supplied by
the anterior tibial artery. Both of these structures lie
just deep to the extensor hallucis longus at the level
of the ankle.
The tendons are enclosed by the superior and
inferior extensor retinacula. The tibialis anterior is
separated by a thin septation [2].
Injury to these tendons is less frequent than that
seen in the other compartments. The most commonly
ruptured tendon in the anterior compartment is the
tibialis anterior, seen as a chronic tear in runners at
the level of the superior extensor retinaculum. The
1152
Fig. 4. Complete Achilles rupture. Axial images demonstrating a progressive increase in signal intensity of the abnormally
torn Achilles fibers. Gradient images give the best representation of the extent of the tear. (A) Proton density (2000/20). (B) T2
(2000/80). (C) Gradient echo (600/12/20 degrees).
patient presents with localized anterior soft tissue

pain and swelling secondary to proximal retraction
of the tendon. There may also be diminished dorsiflexion [3].
Lateral compartment
The lateral compartment contains two tendons: the
peroneus longus tendon lies just posterior to the
peroneus brevis. Both originate from the lateral fibula.
The peroneus longus inserts on the plantar base of the
first metatarsal and medial cuneiform. The peroneus
brevis inserts on the base of the fifth metatarsal. Both

tendons are evertors and weak plantar flexors. Both are
innervated by the superficial peroneal nerve (L4-S1)
and supplied by the peroneal artery. The peroneus
longus also gets innervation from the deep peroneal
nerve (L4-S1). The peroneal artery and vein lie just
medial to the peroneal tendon group, posterior to the
fibula [2].
Proximal to the fibular tip, the peroneus brevis
is broader and flatter than the peroneus longus. Distal
to the fibular tip (at the level where the common
sheath separates), the peroneus brevis and longus are
similar in size. The magic angle phenomenon can be

seen in these tendons, and occurs at a more cephalad
level for the peroneus brevis than longus because it
takes a sharper and more proximal turn [4].
Acute peroneal tendon ruptures are uncommon
and more likely to be associated with steroid use,
diabetes, or ankle arthropathies. Patients with an os
peroneum exterum may also present an acute rupture
of the peroneus longus at the os after a supination
inversion injury [5].
Chronic peroneus longus tendon injuries usually
occur at the level of the peroneal process of the
calcaneus and are longitudinal in nature. The peroneus brevis lies in groove in the distal fibula in 80%
of patients. If the groove is shallow or absent, there is
a higher incidence of subluxation or dislocation [1].
Peroneus brevis chronic longitudinal tears (split peroneus brevis syndrome) may be associated with a flat
or convex fibular groove and spur. Dynamic ultrasound is sensitive in identifying a longitudinal tear
and subluxation [6]. Stenosing tendonitis secondary
to a calcaneal fracture may require tenography for
diagnosis [7].
The peroneus quarteus is present in 10% to 13%
of individuals, more commonly in men. The importance of the tendon is its association with peroneal
brevis and longus tendon subluxation and tendinosis,
resulting in pain or instability. This peroneus quartreus is found posterior to the peroneus brevis and
longus and inserts onto the calcaneus, cuboid, or peroneal tendons [8].
The distal tibiofibular syndesmotic complex is
comprised of the anterior tibiofibular, posterior tibiofibular, inferior transverse, and interosseous ligaments. All have a striated appearance using standard
positioning. A separate distal fascicle of the anterior
tibiofibular ligament can result in a talar impingement
syndrome [1].
The lateral collateral ligament is comprised of the
anterior talofibular, posterior talofibular, and calcaneofibular ligaments. Both talofibular ligaments are
best seen in the axial plane with the ankle in a neutral
position. The anterior ligament is hypointense; the
posterior ligament is striated. The calcaneofibular
ligament lies deep to the peroneal tendons and is
obliquely oriented in the neutral position but can be
seen in the axial plane when the ankle is orientated in
a plantar flexed position (Figs. 5, 6) [9].
Medial compartment
The order of the medial tendons from medial to
lateral is remembered by the pneumonic Tom, Dick,
1153
and Harry. The flexor hallucis longus tendon originates from the posterior mid fibula; passes posterior
to the tibia into a groove on the posterior medial
talus; then into a groove on the plantar sustenaculum
tali, extending between the first metatarsophalangeal
joint sesamoids; and finally inserting on the plantar
aspect of the distal phalanx of the great toe. The
flexor digitorum longus originates from the posterior
tibia and inserts on the plantar aspect of the distal
phalanges of the second to fifth toes. The tibialis
posterior originates from the posterior tibia, fibula,
and interosseous membrane and inserts on the medial
navicular, and planton surfaces of the medial cuneiform, calcaneus, and second to fourth metatarsals.
The posterior tibialis tends to be twice as large in
diameter as the flexor digitorum longus and flexor
hallucis longus tendons on axial images. The tibialis
posterior has three functions that in combination
adducts the forefoot, inverts the hindfoot, and plantar
flexes the foot. The flexor digitorum longus flexes the
toes and foot and supinates the ankle. The flexor
hallucis longus flexes the great toe and ankle. All are
innervated by the tibial nerve (L5-S1) and supplied
by the posterior tibial artery. The artery and vein lie in
a bundle posterior to the space between the flexor
digitorum longus and flexor hallucis longus [1].
The posterior tibialis tendon is the most commonly injured tendon at the ankle and presents
clinically as a progressive flatfoot deformity that is
associated with weakness of inversion and inability to
extend the toes [10,11]. The tendon can be dislocated
medially if the flexor retinaculum is torn; a shallow
retromalleolar groove may be a contributing factor
[12]. Evaluation of the spring ligament is important
for surgical planning because it offers additional
stability to the arch (Figs. 7 9) [13].
The flexor hallucis longus can be injured in ballet
dancers and soccer players. Pain is localized to the
usual site of involvement at the sustenaculum tali [14].
There are both superficial and deep layers of the
deltoid ligament. The superficial layer is hypointense
on MRI and consists of the tibionavicular, tibiocalcaneal (spring ligament), and superficial talotibial ligaments, which insert respectively onto the navicula,
sustenaculum tali, and medial talar tubercle as their
names imply. The deep layer is striated on MRI and
consists of the anterior talotibial and posterior talotibial ligaments, which insert, respectively, on the neck
and medial talus [9].
The tarsal tunnel is defined as a space between the
flexor retinaculum (roof ) and talus and calcaneus
(floor). The tarsal tunnel syndrome is a clinical
diagnosis based on paresthesias, pain, and weakness
attributed to the posterior tibial nerve. MRI is used to
1154
Fig. 5. Anterior talofibular tear and calcaneofibular sprain. Axial T2 (3200/105) images demonstrate a small ankle effusion, (A)
detachment of the anterior talofibular ligament from the talus, and (B) increase in bulk and disorganization of fibers of the
hypointense calcaneofibular ligament.
Fig. 6. Anterior talofibular sprain. Axial T2 (4800/105) images demonstrate an intact anterior talofibular ligament outlined by
hyperintense fluid.
1155
Fig. 7. Posterior tibialis interstitial tear. Axial proton density (3200/15) images show (A) an abnormal macrolobulated
morphology of the posterior tibialis and (B) increased linear interstitial signal within the posterior tibialis. (C) Tendinopathy of
the tibialis posterior is commonly seen in those patients with an accessory os naviculare (arrow in A).
1156
Fig. 8. Posterior tibialis avulsion. Sequential axial fat-suppressed T2 (7752/85) images demonstrate progressive thickening of the
posterior tibialis with interposed fluid at its insertion into the navicula.
identify mass lesions including varicosities, ganglion

cysts, synovial hypertrophy, and edema. Developmentally distal flexor myotendinous junctions or
anomalous muscles can result in mass effect on the
posterior tibial nerve (Fig. 10). In addition, tarsal coalition, septae, or posttraumatic bony deformities can
decrease the volume of the tarsal tunnel [15].
Bones
Primary osseous pathology can be seen as an
isolated finding or in combination with other injuries
[17]. Congenital processes, such as a coalition, may
Posterior compartment
The gastrocnemius and soleus join to form the
Achilles tendon, which inserts on the posterior calcaneus. The gastrocnemius originates from the posterior aspect of the femoral condyles and the soleus
originates from the posterior aspect of the proximal
tibia and fibula. The plantaris originates from the
lateral femoral condyle and inserts onto the posterior medial calcaneus, just medial to the Achilles
tendon. All are innervated by the tibial nerve (S1-S2)
and supplied by the posterior tibial artery. The
plantaris receives additional innervation from tibial
nerve segments L4-5 along its long course. The
nerve and artery are interposed between the posterior
and medial tendon groups [1].
Achilles tendon pathology typically manifests as
cross-sectional enlargement of the tendon, peritendinous edema, and variable degrees of interstitial
tendon discontinuity (Fig. 11). Fluid in the retrocalcaneal bursa and induration of triangular fat anterior
to the Achilles tendon are usually signs of Achilles
tendinosis or calcaneal enthesopathy (Fig. 12). The
importance of recognizing an accessory soleus is
mainly to distinguish it from other medial ankle or
calf masses [16].
Fig. 9. Chronic posterior tibialis longitudinal tear. Axial

proton density (2000/20) image demonstrates a longitudinal
split of the tendon with atretic fibers. Fluid is commonly
seen within the sheath, even in chronic cases.
1157
Fig. 10. Low myotendinous junctions and Achilles tendinopathy. (A) Sagittal T1 (650/20) images incidentally demonstrate low
myotendinous junctions of the flexor tendons, which places this patient at increased risk for an entrapment neuropathy of the
tibial nerve. (B) Sagittal short tau inversion recovery (4300/30/150) image demonstrates fusiform enlargement of the Achilles
tendon with a longitudinal interstitial hyperintense tear. Edema is seen in the pre-Achilles fat pad.
Fig. 11. Partial Achilles insertional tear. (A) Sagittal T1 (800/15) image demonstrates a posterior fiber deficiency of the distal
4 cm of the Achilles. (B) Gradient axial images (600/12/20 degrees) better define the extent of the tear; although only one fifth of
the area of the tendon is torn, greater than one half of the radius is compromised centrally.
1158
Fig. 12. Haglunds disease (pump bump). (A) Short tau inversion recovery sagittal image (2500/43/140) demonstrates a large
amount of curvilinear hyperintensity superficial to the Achilles tendon. (B) Axial gradient echo (60/12/20 degree) image
demonstrates the superficial tendo-Achilles bursitis to greater advantage.
not manifest itself until adulthood (see Figs. 3, 13, 14).

Insufficiency or fatigue fractures may mimic primary
tendon or ligamentous injury (Figs. 13 18). Osteomyelitis and tumors are not discussed because they are
the focus of other articles in this issue.
Joints
Osteoarthritis is the most common arthropathy
in the ankle and may be associated with ligament,
tendon, and articular abnormalities (Figs. 18 20).
Rheumatoid arthritis tends to present with a midfoot
arthropathy and associated tenosynovitis (Fig. 21)
[18,19]. Reiters syndrome involves the lower extremity more commonly than the upper extremity. One
should recognize that psoriatic arthropathy can present before the skin manifestations of the disease
(Fig. 22).
Plantar fascia and subcutaneous tissues

The clinical diagnosis of plantar fasciitis is usually straightforward. The radiographic findings include
an enthesophyte in 50% of cases and blurring and a
downward convexity of the posterior plantar fascia

fat interface; MRI depicts these findings and the
associated marrow edema that can be seen in more
severe cases [20]. MRI is useful in distinguishing
these cases from other common clinical entities, such
as occult stress fractures or retained subcutaneous
foreign bodies. One should be cognizant of the fact
that the plantar fascia does not return to its original
configuration after fasciotomy. STIR images may be
useful to detect active edema (Fig. 23).
Sinus tarsi
The sinus tarsi is composed of fat, branches of the
posterior tibial and peroneal arteries and their associated nerves, and five ligaments. The sinus tarsi
ligaments include the lateral, intermediate, and medial roots of the inferior extensor retinaculum, the
interosseous talocalcaneal ligament, and the cervical
ligament. The sinus tarsi syndrome usually reflects
minor subtalar instability and is commonly seen in
combination with other findings (Figs. 24, 25). Typically, there is lateral pain and a history of prior inversion injury. The MRI manifestations can range
from edema to fibrosis to synovitis, with or without
associated cystic changes [21].
1159
Fig. 13. Calcaneonavicular coalition. (A) Sagittal T1 (650/20) image demonstrates the elongated processes of the calcaneus and
navicula and abnormal calcaneal cuboid osteoarthritis. (B) Sagittal short tau inversion recovery (4505/30/150) shows the
continuity between the structures and abnormal stress hyperintensity in the anterior calcaneus.
1160
Fig. 14. Fibrous versus cartilaginous talocalcaneal coalition. (A) Sagittal T1 (650/20) image demonstrates a serrated appearance to
the articulation. (B) Sagittal short tau inversion recovery (4300/30/150) images demonstrate a decrease in the amount of cartilage
with a serrated band of hypointensity at the articulation with a resultant mixed features of fibrous and cartilaginous coalition.
1161
Fig. 15. Calcaneal stress fracture. (A) Sagittal T1 (750/20) image demonstrates a 5-mm hypointense line along the inferior
aspect of the anterior calcaneus. (B) Sagittal short tau inversion recovery (7150/60/110) image shows marked hyperintensity in
the anterior calcaneus.
Fig. 16. Calcaneal stress fracture and Achilles tendinosis-peritendinitis. (A) Sagittal T1 (650/20) hypointense horizontal line in
the posterior calcaneus. (B) Sagittal short tau inversion recovery (4505/30/150) image shows the nonspecific edema in the
posterior calcaneus. Hyperintensity is also present in the Achilles tendon and surrounding fat.
1162
Fig. 17. Salter II fracture with subperiosteal blood. (A) T2 coronal (3500/115) image shows the fracture with hyperintense
physeal and subperiosteal blood. (B) T2 axial (4000/115) image depicts the circumferential subperiosteal hematoma. (C) Coronal
radiograph defines the resultant periosteal reaction
1163
Fig. 18. Osteochondritis dissecans. (A) Sagittal short tau inversion recovery (4300/30/150) image shows the crescentic fragment
at the talar dome. (B) Sagittal cartilage sequence (18/9/20 degree) better details the integrity of the overlying cartilage, the main
imaging feature which determines whether conservative therapy can be safely prescribed.
Fig. 19. Osteoarthritis of the subtalar joint. (A) Sagittal T1 (800/15) image highlights the sclerosis of the subtalar joint. (B)
Sagittal spoiled gradient (60/4/40 degree) image defines the degree of cartilage attrition.
1164
Fig. 20. Osteoarthritis with loose bodies. (A) Axial CT noncontrast image shows at least five 1- to 2-mm loose bodies in the
posterior joint recess. (B) The corresponding axial T2 (5000/105) image depicts the same structures as round bodies isointense to
marrow, but less conspicuously than by CT. (C) Sagittal short tau inversion recovery (4300/30/150) shows the large effusion but
is not as sensitive to cartilage attrition as a dedicated cartilage sequence.
1165
Fig. 21. Rheumatoid arthritis with midfoot arthropathy. Sagittal short tau inversion recovery (6292/60/110) images:
tibialis anterior (A) and peroneus longus (B) tenosynovitis manifest as fluid surrounding enlarged but hypointense tendons
(arrows). Edema is present in the midfoot and to a lesser degree distal talus. The appearance of erosions of the navicula is typical
for rheumatoid arthritis.
1166
Fig. 22. Psoriatic arthritis in a 50-year-old man that preceded the skin disease. (A) Short tau inversion recovery sagittal image
(3655/30/100) shows edema and erosions at the talonavicular joint (arrow). (B) T1 fat-suppressed sagittal images with
gadolinium (782/12) verify vivid enhancement of the synovium and adjacent bones. (C) Axial T1 fat-suppressed image with
gadolinium (520/12) demonstrates enhancing tenosynovitis (arrows) of the peroneus tendons, tibialis posterior, and flexor
digitorum longus.
1167
Fig. 23. Plantar fasciitis. (A) Lateral radiography shows blurring of the fat interface with the posterior plantar fascia. (B) T1
sagittal (500/13) image shows blurring of the posterior plantar fascia. (C) Short tau inversion recovery sagittal (1495/15/165)
image highlights the marked edema within the plantar fascia, subcutaneous tissues, and enthesophyte. (D) Delayed bone scan
image shows marked osteoblastic activity in the posterior calcaneus
1168
Fig. 24. Sinus tarsi edema related to an inversion injury. (A) Sagittal T1 (700/20) image depicts the loss of fat signal in the sinus
tarsi (arrow). A talar neck fracture is defined by the T1 hypointense line (open arrow). (B) Axial proton density (3200/15) image
demonstrates a tear by the loss of continuity of fibers of the anterior talofibular ligament (arrow) and sprain by the amorphous
increased signal in the calcaneofibular ligament (open arrow).
1169
Fig. 25. Sinus tarsi syndrome. (A) T1 sagittal (650/20) image shows loss of the fat signal in the sinus tarsi. The talus is
hypointense, consistent with a loss of the normal marrow fat in necrotic bone. (B) Short tau inversion recovery sagittal (4505/30/
150) image shows edema in the sinus tarsi and irregularity of the anterior talar dome. (C) Sagittal T1 fat-suppressed image after
gadolinium (969/20) demonstrates enhancement within the sinus tarsi and nonenhancement of the necrotic talus.
1170
Summary
This article serves as an overview of the pathologic processes that are seen in the foot and ankle.
MRI can play a pivotal role in making precise
diagnoses and then guiding treatment decisions.
MRI can be extremely helpful in determining response to therapy.
References
[1] Berquist TH. Radiology of the foot and ankle. 2nd
edition. Philadelphia: Lippincott Williams and Wilkins; 2000.
[2] Bowles JR, Berquist TH. Foot, ankle, and calf. In:
Berquist TH, editor. MRI of the musculoskeletal system. 4th edition. Philadelphia: Lippincott Williams and
Wilkins; 2001. p. 428 577.
[3] Khoury NJ, El-Khoury GY, Saltzman CL, et al. Rupture of the anterior tibial tendon: diagnosis by MR
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[4] Kirsch MD, Erickson SJ. Normal magnetic resonance
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[9] Mesgarzadeh M, Schneck CD, Tehranzadeh J, et al.

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[11] Alexander IJ, Johnson KA, Berquist TH. Magnetic
resonance imaging in the diagnosis of disruption of
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[13] Rule J, Yao L, Seeger LL. Spring ligament of the ankle: normal MR anatomy. AJR Am J Roentgenol 1993;
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Radiol Clin N Am 40 (2002) 1171 1192
Work-up of the diabetic foot

William B. Morrison, MDa,*, Hans Peter Ledermann, MDb
a
Department of Radiology, Thomas Jefferson University Hospital, 111 South 11th Street, 3390 Gibbon, Philadelphia,
PA 19107, USA
b
Department of Radiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
Diabetes is a systemic disease that may affect

numerous organ systems and anatomic sites. In the
foot and ankle vascular disease, tendinopathy, neuropathic disease, and infection are common sequellae.
These manifestations often prompt referral for imaging
evaluation. Over the past decade MRI has been used
with increasing frequency for evaluation of the diabetic foot and associated complications. It is important
for radiologists to be familiar with the MRI appearance
of these processes.
Background
Diabetic foot disease has a significant economic
impact [1,2]. Diabetes affects approximately 15 million people in the United States alone [3]. Of these, an
estimated 15% to 20% suffer a foot-related complication requiring hospitalization (predominantly for
ischemia or infection) at some point in their lives
[4]. These complications may necessitate amputation;
diabetes is the main reason for nontraumatic lower
extremity amputation, which is 15 to 40 times more
common than in nondiabetics [5,6].
Annually in the United States more than 50,000
lower-extremity amputations are performed on diabetic patients, each with a hospital stay averaging
14.7 days, resulting in over $1 billion dollars of
immediate health care expense [7]; rehabilitation,
prosthetics, or other mobility-assistance devices,
home nursing, and lost work productivity further
E-mail address: william.morrison@mail.tju.edu
(W.B. Morrison).
stress the health care system. In addition to decreased

quality of life [8], it has been shown that after pedal
amputation there is a 50% incidence of serious complication involving the contralateral foot within
2 years, resulting in a 50% to 66% [9,10] incidence
of amputation within 5 years. This reflects the systemic nature of the disease but seems to also be related
to shifting of weight bearing onto the intact extremity
following the initial surgery. As a result, over the past
decade there has been increasing emphasis on managing these patients earlier in their disease course [11];
these interventions include ulcer prevention [12,13]
and care and revascularization procedures. Once
infection is suspected, aggressive medical and surgical
management is instituted [14 17]. Surgical care
includes debridement of devascularized tissue and
partial, foot-sparing amputation intended to preserve
functionality. MRI facilitates this approach, used not
only to diagnose infection but also to determine
preoperatively the extent of osseous and soft tissue
infection [18 21].
Pathophysiology of the diabetic foot

Vascular disease is very common in diabetic
patients. It affects major vessels [22] and distal arterioles and capillaries [23,24], leading to chronic lowerextremity ischemia. Proximal arterial disease is seen
radiographically as calcification of the vessel walls
[25,26] and angiographically as stenosis; these proximal stenoses may be treatable with bypass grafts or
angioplasty and stenting. Distal vascular disease,
however, is more difficult to treat. Resultant baseline
ischemia creates a setting in which cuts or other minor
injuries heal slowly or not at all [27]. Calluses in
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 3 6 - 2
1172
W.B. Morrison, H.P. Ledermann / Radiol Clin N Am 40 (2002) 11711192
ischemic areas may also break down. This situation

promotes formation and progression of foot ulceration.
Immunopathy, also a feature of diabetes [27,28],
coupled with vascular disease and diminished sensation, leads to wound infection that is typically multiorganism [29]; progression of infected ulcers results in
soft tissue abscesses, sinus tracts, septic tenosynovitis,
and eventually septic arthritis and osteomyelitis. More
advanced ischemia may cause gangrene [30,31], particularly at the digits and forefoot, referred to as dry
gangrene if noninfected and wet gangrene if superinfected. With severe chronic ischemia, infarcts may
also be seen in the bone marrow.
Neuropathy is also a feature of diabetic disease.
Sensory neuropathy leads to diminished perception of
minor foot trauma [32 35], including cuts, ulcers,
blisters and friction-related skin breakdown, tendon
and ligament injury, joint injury, and fractures. Along
with ischemic disease, neuropathy contributes to
formation and progression of skin wounds and infection [35]. Articular injury with diminished sensation
and ischemia can result in an aggressive-appearing,
deforming arthropathy referred to as neuropathic
osteoarthropathy, or Charcots arthropathy [36,37].
Tendon injury and ischemia can also lead to tendinopathy and tear [38]. Foot deformity occurs because
of tendon dysfunction and articular deformity; in
particular, arch collapse can cause a rocker-bottom
deformity of the foot [39]. Diabetic neuropathy also
affects the peripheral motor nerves, causing atrophy
and muscle imbalance that contributes to deformity
[12,40]. Foot deformity alters weight bearing and
distribution of plantar pressures [41]; also, deformity
causes footwear to fit poorly. These factors lead to
abnormal friction with subsequent callus formation
and ulceration. Autonomic dysfunction also occurs;
this combined with vascular fragility, ischemia, and
reduced muscular activity results in deposition of fluid
in the soft tissues. This results in diffuse swelling of
the foot on physical examination; in fact, diffuse
subcutaneous and muscular edema on MRI is commonly seen in advanced diabetes [42,43]. Edema
within confined compartments of the foot increases
intracompartmental pressures [44] and can accentuate
the ischemic cascade.
Imaging of the diabetic foot

MRI protocol
The MRI protocols vary widely, but attention to
some general principles can help optimize the examination. If the primary site of infection is known, coil
selection and imaging planes should be tailored; for

example, an extremity coil designed for the knee is
generally excellent for imaging the ankle, but often
results in suboptimal examination of the toes. For toe
imaging, 3- or 5-in surface coils are preferred. If the
main concern is extent of proximal spread, however,
the small surface coils may not provide adequate
coverage. In this case, plantar flexion of the foot with
imaging in an extremity coil is useful. This is facilitated by partial flexion of the knee.
A minimum of two planes should be acquired to
depict best the area of concern; plane selection should
also be tailored to the situation. For the forefoot and
metatarsals, images coronal to the body should be
included because the narrow bones easily volume
average in sagittal and axial planes. For flexed or
deformed toes, however, sagittal images are very
useful. Axial images provide an excellent visualization
of the bones of the midfoot and depiction of anatomic
extent of infection. Sagittal images are optimal for
evaluation of deformities of the midfoot arch. Sagittal
and coronal images are most useful for evaluation of
infection associated with plantar ulceration.
For the ankle a field of view of 14 to 16 cm should
be used; for the toes and forefoot a field of view of 10
to 14 cm is recommended. In the ankle, sections can
be thick (4 to 5 skip 1 mm), but care must be taken in
the forefoot and toes to avoid volume averaging
effect, especially in the sagittal plane. Spin echo
T1-weighted images should be acquired to evaluate
anatomy and subcutaneous fat and marrow fat. Edema
and fluid signal are evaluated best using fat-suppressed fast spin echo T2-weighted images (when
using fat suppression, a lower echo time [TE] of 60
to 70 milliseconds is recommended to improve signalto-noise ratio). Use of fat suppression is important;
otherwise, edema in the bone marrow and soft tissues
blends with signal from fat. If fat suppression is not
available, or if fat suppression is heterogeneous, short
tau inversion recovery (STIR) images should be
acquired. Regarding use of gadolinium, some studies
recommend intravenous contrast [45,46], whereas
others believe it to be unnecessary [47 49]. It remains
controversial whether addition of a contrast-enhanced
sequence improves the accuracy of MRI for the
diagnosis of osteomyelitis. It is not disputed, however,
that contrast improves detection of soft tissue infection [45,46]. It differentiates cellulitis from diabetic
soft tissue edema and improves evaluation of soft
tissue disease extent [20,47]. It helps detect sinus
tracts and abscesses and is the only way to delineate
areas of devitalization or necrosis [50]. It is the
authors opinion that use of contrast is essential,
especially if the patient is being considered for sur-
gical management. Fat suppression is also important

when acquiring postcontrast T1-weighted images
[51]. Obtaining both precontrast and postcontrast
fat-suppressed images can be useful to differentiate
true enhancement from heterogeneous fat suppression. This can be facilitated by use of a T1-weighted
fast gradient echo sequence instead of a conventional
spin echo sequence to shorten scan time.
MRI findings
Vascular disease
Conventional angiography [52,53], CT angiography, or MR angiography [54 57] can be used for
diagnosis of diabetic vascular disease. Regardless of
the modality used, arterial stenosis is visualized as
focal narrowing of vessel caliber, abrupt cutoff of
flow, or nonvisualization of a branch (Fig. 1). Collateral vessels may form in the setting of a slowforming stenosis. In diabetic patients, it is common
for the lower extremity vessels to be diffusely diseased. Although these techniques are highly accurate
Fig. 1. Diabetic vasculopathy. MR angiogram of the foot

(anteroposterior projection) of a diabetic patient shows focal
stenosis of the dorsalis pedis artery (arrowhead ) and absence of detectable flow in the posterior tibial artery.
1173
for diagnosis of the large vessel disease and can assist

planning of revascularization procedures [58,59],
they are ineffective in diagnosing distal small vessel
pathology, which is a major component of diabetic
vascular disease.
Pedal ischemia resulting from a combination of
macrovascular and microvascular disease can be
evaluated on MRI by comparing precontrast and
postcontrast imaging sequences [50]. Imaging is
performed after administration of a standard intravenous dose of gadolinium (0.1 mmol/kg). Fat-suppressed T1-weighted images are acquired, using
spin echo or gradient echo technique. Imaging is
performed 1 to 2 minutes after injection, in the same
fashion as a typical postcontrast MRI study; dynamic
imaging in rapid fashion after injection may result in
a false-positive study related to premature imaging
before bolus arrival (because of macrovascular disease more proximally). It is essential to obtain precontrast and postcontrast images using identical
imaging parameters. Again, use of a fat-suppressed
fast gradient echo sequence for precontrast and postcontrast imaging can lead to significant time savings
over conventional spin echo imaging. Magnetic susceptibility artifact generally is not a problem because
it is equal on the precontrast and postcontrast images;
the only change is addition of contrast. Injection
quality can be assessed by comparing signal in the
blood vessels and proximal muscle tissue; blood
vessels should enhance brightly and normal muscle
tissue signal should increase by at least 10% [50].
Imaging parameters and display window-level should
be nearly identical to validate comparison. On a picture archiving and communications system (PACS)
workstation, region-of-interest values are simple to
obtain to gauge contrast uptake in different areas of
the foot.
Documentation of the presence and extent of
ischemic and devitalized areas can facilitate surgical
planning for debridement and limited, foot-sparing
amputations. If precontrast and postcontrast MRIs are
acquired, ischemia and devitalization of the foot can
be detected as focal or regional lack of soft tissue
contrast enhancement (Fig. 2). Devitalization, which
may be termed foot infarction, is seen as a focal area
of nonenhancement with a sharp cutoff [50]; the
surrounding soft tissues typically show increased
enhancement representing reactive, hypervascular tissue [50]. Only contrast-enhanced images allow reliable recognition of gangrenous tissue because T2- and
T1-weighted images reveal uncharacteristic signal
alterations [50]. Ischemic tissue that has not progressed to devitalization shows relatively subtle MRI
findings (see Fig. 2). These regions may merely
1174
Fig. 2. MRI of soft tissue ischemia and devitalization. (A) Axial contrast-enhanced fat-suppressed T1-weighted fast gradient echo
image shows diffuse enhancement of the soft tissues and bone marrow of the forefoot consistent with diffuse infection.
Relatively less enhancement of the great toe (arrows) is related to ischemia. (B) Axial contrast-enhanced fat-suppressed
T1-weighted fast gradient echo image of a different patient shows a region of decreased enhancement (arrows) within an area of
cellulitis consistent with devitalized tissue. Note small foci of signal void (arrowheads) representing soft tissue air.
enhance slightly less than surrounding tissue; if suspected, acquiring region-of-interest values of various
areas of muscle and subcutaneous tissue can be
obtained on a workstation to document and delineate
ischemic areas.
Noninfected gangrene is characterized by regional
soft tissue loss, particularly affecting the distal digits
(Fig. 3); T1 and T2 signal may be normal within these
areas, although subtle edema signal may be seen. Soft
tissue air, seen as small foci of signal void (see Fig. 2B),
may be seen within areas of devitalization, and is often
a sign of superimposed infection; however, this does
not generally imply presence of a gas-forming organism (gas gangrene), but is usually related to communication of devitalized soft tissue with overlying skin
ulceration, allowing air to enter.
Additional considerations regarding diabetic vascular disease should be noted when interpreting MRI
examinations. Addition of contrast-enhanced sequences provides a great deal of information, but it

should be recognized that intravenous contrast does
not enter regions of devitalization; underlying infection, including osteomyelitis, cellulitis, and abscess, is
not expected to enhance within necrotic areas [50].
In this setting, signal characteristics on T1- and
T2-weighted images (which are discussed in subsequent paragraphs) should be relied on primarily
for diagnosis of soft tissue and osseous infection. If
intravenous contrast is provided, the radiologist
should be familiar with the appearance of devitalized
tissue to reduce false-negative readings for infection.
Bone infarction (Fig. 4) may also be seen within
regions of chronic pedal ischemia. The MRI pattern is
similar to that of bone infarction in other areas of the
body; longitudinally oriented regions of signal abnormality are observed in the central medullary cavity,
1175
Fig. 3. Gangrene. Coronal T1-weighted image through the toes demonstrates loss of soft tissue (arrows) at the second toe
representing a chronically gangrenous digit.
generally longitudinally oriented with a serpentine

pattern and a sharp, well-defined margin [60,61].
Internal signal is variable, with fat signal; fibrous
signal (low T1 and T2); or edema-type signal.
Although high T2 signal is seen at the margins, the
classic rim of high and low T2 signal double line
sign [62] may not be evident in the small bones of
the foot. Surrounding marrow, if noninfected, is
generally normal. Also, it is common to see infarction
of multiple bones within a region of chronic ischemia.

The sharp margins, characteristic morphology, and
normal surrounding marrow help distinguish infarction from infection.
Diabetic edema or atrophy
Diffuse soft tissue edema is very common on MRI
of diabetic feet [42,43]. This edema, characterized by
high signal on T2-weighted or STIR images, is
Fig. 4. Bone infarction. Sagittal T2-weighted fat-suppressed image shows well-defined areas of high signal (arrowheads)
consistent with chronic bone infarction in this patient with severe chronic pedal ischemia but no infection.
1176
observed within muscles, subcutaneous fat, or both.

Subcutaneous fat signal is usually not replaced, as it is
with cellulitis. It is often difficult, however, to differentiate diabetic edema from infection on noncontrast
MRI. On gadolinium-enhanced images, diabetic
edema shows minimal enhancement, unlike cellulitis,
which enhances brightly. In advanced diabetes, the
muscles of the foot are typically atrophied; decreased
size and fatty infiltration of the muscle tissue are
observed, best seen on T1-weighted images [44].
The atrophied muscles often appear edematous on
T2-weighted images, similar to that reported in denervated muscles.
Tendon tear or dysfunction
Tenosynovitis and tendon degeneration, dysfunction, and tear are also commonly seen on MRI of
diabetic feet (Fig. 5). Tenosynovitis is seen as
increased fluid within the tendon sheath [48,63,64]
or tendon sheath fluid complexity representing syn-
ovial proliferation. Tendinopathy is seen as poorly

defined increased T1 and T2 signal usually associated
with tendon thickening or thinning [65]. Tendon tear
is diagnosed on MRI when there is focal fluid signal
within the tendon in question. Tendon injury is facilitated by diminished sensation, which is characteristic
of diabetes; baseline soft tissue ischemia leads to
inefficient healing. Tendon tear and dysfunction result
in foot deformity and altered gait, which places
additional stresses on the remaining tendons. Subsequent tendon injury continues the cascade, which
can result in severe foot deformity, and is a key factor
in formation and progression of neuropathic disease.
The posterior tibialis myotendinous unit is an
important active and passive stabilizer of the foot
and ankle, and is particularly susceptible to this
disease cascade; it functions to invert the ankle and
plantarflex the foot, but also supports the medial arch
and restricts pronation and forefoot abduction [38].
Dysfunction or tear of this tendon results in a char-
Fig. 5. Tendinopathy in diabetic patients: posterior tibialis tendon. (A) Axial T1-weighted image of a diabetic patient with
posterior tibial tendon dysfunction demonstrates thickening of and increased signal in the tendon (arrow). Note uncovering of the
medial talar head (arrowheads) related to overpronation and forefoot abduction. (B) Coronal T2-weighted fat-suppressed image
of a different patient reveals fluid within the posterior tibialis tendon sheath (arrow) consistent with tenosynovitis. Hindfoot
valgus is present, with lateral tilt of the calcaneus relative to the tibia and talus (angle demarcated by lines). Note cystic changes
(arrowheads) in the fibula and lateral calcaneus related to chronic fibulocalcaneal abutment caused by hindfoot valgus.
acteristic deformity pattern that includes pes planus,

overpronation and forefoot abduction, hindfoot valgus, and collapse of the medial arch [66]. In the early
stages of posterior tibialis tendon dysfunction the
deformity is seen only on stress or weight-bearing
studies. In the later stages of disease a fixed deformity
is readily observed on non weight-bearing studies,
including MRI (see Fig. 5). Posterior tibialis tendon
dysfunction is seen on axial MRI as uncovering of the
medial talar head [38]; on sagittal images, the talus
points toward the ground instead of along the first
metatarsal shaft; on coronal images the calcaneus tilts
laterally and may even abut the fibula, impinging the
peroneal tendons. Associated collapse of the arch may
be a sign of early neuropathic osteoarthropathy.
Neuropathic osteoarthropathy
Neuropathic osteoarthropathy is relatively common in the feet of diabetic patients. This aggressive,
deforming arthritis results from a combination of
repetitive microtrauma and macrotrauma to the articular surfaces and supporting ligaments [67,68], peripheral neuropathy with impaired perception of
injury [69], and ischemia with poor healing. A cascade of injury with inadequate healing leads to joint
instability, with dislocation or subluxation [70] and
resultant deformity. Underlying changes of osteoarthritis are usually evident, with surrounding bone
production (including subchondral sclerosis and
osteophytes), intra-articular bodies and debris, and
subchondral cysts [71,72]. These changes, however,
are typically more extreme than those seen in osteoarthritis. Unlike osteoarthritis, erosions may form
at the margins or central portions of the involved
joint, which may progress to frank bone destruction or
resorption [71,72]. In fact, neuropathic disease of the
foot tends to present with a mixed pattern of proliferation and erosion, as opposed to atrophic (primarily
erosive) and hypertrophic (mostly proliferative) manifestations seen elsewhere in the body.
Neuropathic osteoarthropathy in the foot and ankle
is most common at the Lisfrancs (tarsometatarsal)
[39,72 74] joint, but has been reported in many
different joints [39,73,74]. Multiple joints in a region
are often involved, reflecting the regional instability
that is characteristic of the disease. Acute and chronic
forms have been reported, and may be superimposed
on each other [73]. The acute form presents clinically
as a warm, swollen, erythematous foot that mimics
infection [68]. On MRI in the acute phase of disease
(Fig. 6) there is often diffuse soft tissue edema or
juxta-articular edema [48]. On postcontrast images,
the joint capsule and juxta-articular soft tissues
enhance (which may be related to acute injury or
1177
instability), but the subcutaneous tissues typically

show little enhancement. Although posterior tendon
dysfunction may initiate midfoot neuropathic osteoarthropathy, in the early stage of neuropathic disease
there may be no apparent malalignment or only minor
subluxation (this may be a function of the non
weight-bearing nature of the MRI examination). Joint
effusion is commonly seen; as discussed previously,
erosions may be present. Bone marrow edema and
enhancement are typically centered in the subchondral
bone reflecting the articular pattern of disease [75]. In
more severe cases, however, prominent edema and
enhancement can extend well into the periarticular
medullary bone. This marrow signal pattern and
associated periarticular soft tissue abnormality can
simulate infection [48]. In subsequent sections of this
article, factors that facilitate differentiation of acute
neuropathic disease from infection are discussed.
On MRI of the chronic form of neuropathic osteoarthropathy, edema and enhancement are less
prominent or may even be absent (Fig. 7) [48,63].
Subchondral cysts and bone proliferation are prominent, with debris or intra-articular bodies [68]. In
later stages of disease, adjacent bones can become
necrotic and collapse or resorb [72]. Joint deformity is
common, with subluxation or even dislocation
[68,74]. Neuropathic disease of the Lisfrancs joint
typically results in superolateral subluxation of the
metatarsals, leading to a rocker-bottom type deformity [39,76], in which the cuboid becomes a weightbearing structure. This deformity in the setting of
diminished sensation and healing response results in
callus formation and ulceration beneath the cuboid
[74]; ulcers may also form dorsally, because typical
footwear does not accommodate this deformity.
Acute neuropathic arthropathy may be superimposed on the chronic form of disease. In this situation, deformity characteristic of chronic disease is
often present, with periarticular soft tissue and bone
marrow edema and enhancement reflecting more
recent injury or possibly more acute instability.
Callus and ulceration
Deformity of the foot is common in diabetics [34].
Deformity is multifactorial and can occur related to
muscle atrophy or imbalance, joint disease, or tendon
and ligament tear or dysfunction [77 79]. This
deformity leads to altered weight bearing [41] and
stresses resulting in callus formation [80] and skin
erosion. Ulcers may form in these areas of skin erosion
or may originate from breakdown of calluses [81,82].
Minor trauma, often as minor as toenail cutting, may
also initiate ulceration. Traumatic episodes increase
with progression of diabetic retinopathy and lower-
1178
Fig. 6. Acute neuropathic osteoarthropathy. (A) Sagittal T1-weighted image shows marginal erosions (arrowheads) at the
Lisfrancs and intertarsal joints. Note that the surrounding subcutaneous fat is preserved, a finding that is unlikely in the setting of
infection. (B) Sagittal T2-weighted fat-suppressed image of the same patient shows bone marrow edema with extensive regional
distribution around the Lisfrancs and intertarsal joints, which contain small effusions. Note diffuse soft tissue edema, commonly
seen in diabetic feet.
extremity motor and sensory dysfunction. Ulcerated

callus and minor wounds heal poorly because of
ischemia and repeated friction or trauma and generally
progress without appropriate treatment [27].
On MRI, callus is seen as focal cutaneous and
subcutaneous soft tissue prominence (see Fig. 7); the
skin and subcutaneous signal often blend imperceptibly, although a rounded subcutaneous focus may be
observed. Calluses are low signal on T1-weighted
images, but show variable T2 signal based on the
degree of granulation tissue and vascularity. More
vascular calluses demonstrate higher T2 signal, and
enhance diffusely after gadolinium administration. In

the absence of infection, the margins of the callus are
fairly well defined. Common sites of involvement are
adjacent to the first or fifth metatarsal heads. With toe
deformity, callus often forms dorsally adjacent to the
proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP) joint [13,40,83]. Callus also is
common adjacent to the posterior calcaneal tubercle.
In the setting of deformity from neuropathic osteoarthropathy or posterior tibialis tendon dysfunction,
calluses can arise in atypical locations, most commonly beneath the cuboid and adjacent to the calca-
1179
Fig. 7. Chronic neuropathic osteoarthropathy. (A) Sagittal T1-weighted image demonstrates deformity of the midfoot and
hindfoot, with collapse, subluxation, and disorganization of the tarsal bones (arrows) and bone proliferation, characteristic of
chronic neuropathic disease. Diffuse muscle atrophy, commonly seen in diabetic feet, is also present. Note that neuropathic disease
has resulted in a rocker-bottom deformity; skin thickening and subcutaneous low signal (arrowhead) beneath the cuboid represents
callus formation. (B) Sagittal T2-weighted fat-suppressed image reveals numerous subchondral cysts (arrows) at the neuropathic
joints. Otherwise, little marrow edema is present. The vascular callus (arrowhead) shows relatively high T2 signal. (C) Sagittal
contrast-enhanced fat-suppressed T1-weighted image demonstrates enhancement limited to the synovium and subchondral cysts of
the arthritic joints (arrows); the surrounding soft tissues are normal except for enhancement of the callus (arrowhead).
neus [73]. The chronic friction that leads to callus

formation can also result in adventitial bursitis, seen
on MRI as a focus of fluid, usually thin and elongated
or ovoid, in the subcutaneous tissues adjacent to a
callus; if the focus is well defined without adjacent
soft tissue inflammation, it can be attributed confidently to friction-related bursitis rather than abscess.
Contrast-enhanced sequences can be useful to exclude
surrounding inflammation.
Detection of ulcerated callus is straightforward on
MRI (Fig. 8). Typically, a large skin defect is seen
with rounded or heaped up margins, surrounded by
vascular callus. The ulcer usually enhances at the
margin [84], unless the surrounding tissue is devitalized. If the ulcer forms from breakdown of a callus, it
is surrounded by a thick mound of soft tissue that
generally has low T1 signal and intermediate T2

signal. Minor skin disruption or superficial skin
erosion without underlying callus is more difficult
to detect, and may only be visualized as a focal
discontinuity of skin signal. Wound breakdown can
also occur in postoperative patients [85 87]. Any
form of skin interruption may serve as a route for soft
tissue infection, which in diabetic feet is usually
polymicrobial [88]. Deep ulceration is especially
important to identify because there is a high association with underlying osteomyelitis. In fact, the
distribution of ulceration corresponds closely to that
of osteomyelitis [87]. If a skin defect is seen on MRI
with a questionable marrow signal abnormality in the
adjacent bone, it should be considered highly suspicious for osteomyelitis.
1180
Fig. 8. Ulcerated callus, cellulitis, and osteomyelitis. (A) Coronal T1-weighted image shows ulceration (arrowheads) beneath the
fourth metatarsal head. Underlying replacement of the subcutaneous fat signal represents cellulitis, with low signal in the
adjacent bone marrow (arrow) consistent with osteomyelitis. (B) Coronal T2-weighted fat-suppressed image demonstrates fluid
signal at the ulcer (arrowhead) with edema in the surrounding soft tissues and adjacent metatarsal head and proximal phalanx
(arrows). (C) Coronal contrast-enhanced fat-suppressed T1-weighted image shows enhancement at the base of the ulcer (white
arrowheads). There is enhancement of the underlying inflamed soft tissues and the infected metatarsal head and phalanx
(arrows). Erosion at the metatarsophalangeal joint (black arrowheads) represents septic arthritis.
Cellulitis
Cellulitis most commonly arises adjacent to skin
breakdown, with contiguous spread of bacteria into the
subcutaneous fat. On MRI (Figs. 8, 9) cellulitis is seen
as replacement of the normal fat signal in subcutaneous tissues on T1-weighted images, with high signal
(although less than fluid) on T2-weighted or STIR
images, and diffuse enhancement after contrast administration [89,90]. The margins are generally poorly
defined. Identification and characterization of cellulitis can be difficult if contrast is not provided,
because diffuse pedal soft tissue edema is common
in diabetics with vascular disease [64,91]. This diabetic edema enhances only slightly or not at all
(see Fig. 9), and usually the normal subcutaneous fat
is relatively preserved. In contrast, areas of cellulitis
show intense enhancement. As noted previously, how-
ever, the reader should be aware that soft tissue

infection in an area of devitalization does not enhance;
nevertheless, the fat signal is replaced with tissue
isointense to muscle on T1-weighted images, indicative of the underlying pathology. Focally devitalized
areas have a characteristic pattern; the margin of nonenhancing tissue has a relatively sharp cutoff from the
background [50], which may show normal soft tissue
enhancement or brightly enhancing cellulitis. Gas also
can be seen within areas of cellulitis, and is particularly common in devitalized areas; presence of gas
within a region of nonenhancement seems to be a
reliable sign of underlying infection. This process does
not follow the same clinical course as necrotizing
fasciitis because of gas-forming organisms; it may be
caused by communication of air through deep ulcers
and sinus tracts into the soft tissues [92]. Soft tissue
1181
Fig. 9. Sinus tract. (A) Coronal T2-weighted fat-suppressed image shows diffuse soft tissue edema with focal signal near fluid
intensity in the fifth digit (arrow) extending to the skin margin (arrowhead). (B) Coronal contrast-enhanced fat-suppressed
T1-weighted image demonstrates soft tissue enhancement of the cellulitis of the fifth digit; thick rim enhancement of the central
fluid collection (arrow), represents an abscess surrounding the phalanx. Thin, linear rim enhancement (arrowheads) consistent
with sinus tracts extends from this collection to the skin.
gas can also be seen after wound irrigation or surgical

debridement. On MRI gas in the soft tissues is seen as
multiple small foci of signal void, often with slight
marginal susceptibility artifact best seen on gradient
echo images (see Fig. 2B); however, comparison
should be made with T1-weighted images, because
foci of preserved subcutaneous fat can mimic gas on
fat-suppressed images.
Sinus tracts
Sinus tracts are relatively common in cases of
osteomyelitis with adjacent skin ulceration [84]; on
MRI a sinus tract is characterized by a thin, discrete
line of fluid signal extending through the soft tissues
[51,93]. On noncontrast MRI, however, these tracts
can be difficult to detect, blending with adjacent soft
tissue edema. Also, if the tract is collapsed and not
actively draining, this fluid signal may not be
observed. Postcontrast fat-suppressed T1-weighted
images are very helpful in this regard; on this
sequence sinus tracts, like abscesses, stand out
because of enhancement of the hyperemic margins.
Sinus tracts are visualized as parallel lines of enhancement in a tram-track configuration (see Fig. 9) [84].
Osteomyelitis
Although hematogenous spread is the most common cause of osteomyelitis in other areas of the body,
such as the spine, contiguous spread and direct
implantation are more common in the foot and ankle.
Direct implantation can occur from puncture wounds
or deep lacerations, open fractures, and surgery or
injection procedures. Most osteomyelitis involving
the foot and ankle, however, occurs through contiguous spread from adjacent ulceration and subsequent
soft tissue infection [29,87]. This mode of spread is
particularly prevalent in feet of diabetic patients.
For patients with clinical suspicion of pedal infection, radiographs are typically the initial radiologic
examination obtained [93 95]. Early infection is seen
as soft tissue swelling; radiographic changes of osteomyelitis can be delayed as much as 2 weeks [95 97]
and sensitivity is poor [91,98 100]. When visible
radiographically, osteomyelitis results in focal rarefaction, or decreased density of bone, followed by
periostitis and frank bone erosion or destruction
(Fig. 10). Periostitis may not be seen, however, in
the tarsal bones or the phalanges. Despite low utility
for diagnosing osteomyelitis, radiographs nevertheless help define postoperative anatomy; identify soft
tissue calcification, gas, and foreign bodies; and
characterize the pattern and distribution of arthritis,
including neuropathic osteoarthropathy. Radiographs
obtained with weight bearing are useful to evaluate
foot deformities. Radiographs can be helpful in conjunction with MRI.
Nuclear medicine examinations are also performed commonly for evaluation of pedal infection.
Three-phase bone scintigraphy is highly sensitive for
detection of osteomyelitis [98,101], seen as regional
radiotracer uptake on the early phases and concentration in the underlying bone marrow on the delayed
phase (Fig. 11) [91,100,102 107]. When there is no
increased uptake the test is excellent for excluding
presence of osteomyelitis, except in the setting of
severe vascular disease [101,108]. Other processes
1182
Fig. 10. Radiographic findings associated with acute

osteomyelitis. Anteroposterior radiograph of the forefoot
shows bone rarefaction and destruction, predominantly at
the second and third metatarsal heads (arrows). Thick
periostitis (arrowheads) is seen more proximally.
resulting in hyperemia and bone turnover can also

result in a positive test, however, and consequently
specificity is low [51,91,105,109 111]. Labeled
white blood cell examination has higher specificity
and is generally interpreted in conjunction with the
three-phase bone scan [106], but together these
techniques are costly, time-consuming [94], and lack
the anatomic information provided by MRI [20,112,
113]. Because modern therapeutic regimens for infection of the foot and ankle depend on rapid diagnosis
and accurate anatomic depiction of extent of involvement, MRI is increasingly becoming the preferred
imaging test.
A multitude of articles in the radiologic and clinical
literature have documented the use of MRI for evaluation of osteomyelitis of the foot and ankle [18
21,47,63,91,99,100,113 119]. Sensitivity ranges
from 77% [116] to 100% [91], and specificity ranges
from 79% [87] to 100% [116] in the larger studies;
those that include at least 25 patients are summarized
in Table 1. Superimposed factors, such as prior surgery, neuropathic osteoarthropathy, or other inflammatory disease, such as rheumatoid arthritis may lower
the specificity of MRI [51,63,64, 94,113,120,121].
On MRI, osteomyelitis is characterized by altered
bone marrow signal, with low signal (loss of the
normal fat signal) on T1-weighted images, edema on
T2-weighted or STIR images, and enhancement on
postgadolinium T1-weighted images [51]. Other MRI
findings that may be seen in cases of osteomyelitis
include cortical disruption and periostitis. Periostitis is
seen as a thin, linear pattern of edema and enhancement surrounding the outer cortical margin, which
appears thickened if the periostitis is chronic.
Recognition of abnormal bone marrow signal in

the appropriate clinical setting results in high sensitivity for diagnosis of osteomyelitis; however, other
entities can mimic this alteration of the bone marrow
signal, including fracture, tumor, active inflammatory
arthritis or neuropathic disease, infarction, or recent
postoperative change [51,63,64,94,113,120,121].
These other processes usually have different morphology than osteomyelitis; recognition of these patterns
often enables differentiation. For example, identification of a fracture line, a discrete lesion, adjacent
arthritis or neuropathic disease, or postoperative metal
artifact improves specificity; correlation with radiographs and clinical history is also important. Another
consideration is that over 90% of the time osteomyelitis of the foot and ankle is a result of contiguous
spread through the skin [29,87,122]; most cases of
osteomyelitis also have some manifestation of adjacent soft tissue disease, such as skin ulceration,
cellulitis, soft tissue abscess, or a sinus tract [47].
These findings can be thought of as secondary signs of
osteomyelitis, recognition of which can also improve
specificity [84].
Secondary signs are of particular importance in
situations where findings on different MRI sequences
Fig. 11. Osteomyelitis on scintigraphy. Delayed phase of a

three-phase Tc99m-MDP bone scan in the lateral projection
shows uptake concentrating in the bones of the lateral
forefoot (arrow), representing osteomyelitis. Uptake in the
midfoot and hindfoot (arrowheads) is present because of
underlying neuropathic disease.
1183
Table 1
Utility of MRI for evaluation of osteomyelitis of the foot and ankle
Author
Year
Patients/
histology or
culture proved
% Sensitivity
% Specificity
%Accuracy
Comments
Ledermann et al [87]
2002
158/158
90
79
Croll et al [115]
1996
27/21
88
100
103 TP, 37 TN,

11FN, 10FP
95
Levine et al [116]
1994
27/18
77
100
90
Morrison et al [20]
1995
59/41
82 diabetic,
89 nondiabetic
80 diabetic,
94 nondiabetic
89 overall
Weinstein et al [100]
1993
47/32
100
81
95
Nigro et al [21]
1992
44/34
100
95
98
Wang et al [99]
1990
50/32
99
81
94
1.5 T
All gadolinium
1.5 T
No gadolinium
1.5 T
No gadolinium
1.5 T
Gadolinium and
fat sat N = 53
0.5 T N = 20
1.5 T N = 27
No gadolinium
1.5 T
No gadolinium
0.5 T N = 23
1.5 T N = 27
No gadolinium
Only studies that include at least 25 patients are listed.

Modified from Morrison WB, Ledermann HP, Schweitzer ME. MR imaging of inflammatory conditions of the ankle and foot.
Magn Reson Imaging Clin N Am 2001;9:615 37; with permission.
Table 2
MRI signal characteristics of conditions affecting the diabetic foot
T1
T2
T1 postcontrast
Comments
Low
Low
Sharp margins
High
High rim
Well defined
High
Marginal enhancement
Adjacent soft tissue infection
Low
High
High
To differentiate from
osteomyelitis, see Table 3
Normal to low
Normal to high
Subchondral enhancement
Soft tissue signal

Devitalization
Normal to low
High diffusely
Diabetic edema
High diffusely
Regional absence
of enhancement
Little enhancement
Osteomyelitis, abscesses,
cellulitis may not enhance
Associated with muscle atrophy
Enhancement regionally
Focal enhancement
Blends with skin signal
Marrow signal
Osteomyelitis
Infarction
Neuropathic
Acute
Chronic
Cellulitis
Callus
Normal to
slightly low
Low regionally
Focally low SQ
Ulcer
Sinus tract
Abscess
Low
Low
Low
High diffusely
Low
to intermediate
High
Linear high
Focal fluid
Marginal enhancement of crater

Tram-track linear enhancement
Rim enhancement
Focal discontinuity of skin signal

Connects to skin or abscess
From Morrison WB, Ledermann HP, Schweitzer ME. MR imaging of inflammatory conditions of the ankle and foot. Magn
Reson Imaging Clin N Am 2001;9:615 37; with permission.
1184
are discordant; for example, in a small proportion of

cases of osteomyelitis the marrow shows normal or
near-normal signal on T1-weighted images, but exhibits edema and enhancement on the other sequences
[84]. This pattern could represent an early manifestation of infection, because the fatty marrow is not
immediately destroyed after bacterial inoculation.
Another pattern can be seen if the vascular supply is
compromised in which infected marrow exhibits fat
replacement and edema, but little or no enhancement
[50]. In these situations, visualization of adjacent soft
tissue infection helps confirm the diagnosis of osteomyelitis. MRI signal characteristics of primary and
secondary signs of infection and vascular and neuro-
pathic conditions affecting the foot and ankle are

summarized in Table 2.
Abscesses
The reported incidence of soft tissue abscess on
MRI of patients with foot infection ranges from 10%
[28] to 50% [63,114] depending on patient selection.
In a recent study including patients with clinically
suspected pedal osteomyelitis, 18% of examinations
had evidence of an abscess [123]. Abscesses usually
arise in close proximity to the area of skin breakdown
or along adjacent fascial planes; however, as infection
spreads, abscesses can be seen at a distance from the
skin ulcer [123]. Abscesses often communicate with
Fig. 12. Abscess. (A) Sagittal T2-weighted fat-suppressed image shows focal fluid signal (arrow) representing an abscess in the
deep plantar soft tissues. (B) Sagittal contrast-enhanced fat-suppressed T1-weighted image demonstrates thick rim enhancement
of the abscess (arrow) with surrounding soft tissue enhancement consistent with cellulitis.
sinus tracts that extend to bones, joints, tendon sheaths,

or to skin ulceration. The latter can result in spontaneous drainage of the abscess and a flattened appearance of the fluid collection. Pedal abscesses are seen
significantly more frequent in MRI examinations of
postoperative feet and in feet with osteomyelitis [123].
Intraosseous abscess formation is uncommon [123],
possibly because patients undergo amputation rather
than MRI if they present with such severe disease.
Whether in soft tissue or bone marrow, abscesses
appear similar on MRI (Figs. 12, 13): a focal collection
of signal approximating fluid on T2-weighted or STIR
images, with thick rim-enhancement on postcontrast
T1-weighted images [45,89,124]. As discussed
previously, however, this rim-enhancement is not
observed if the contrast does not reach the tissue
because of severe vascular disease; in this situation,
fluid signal is often seen on T2-weighted images in a
broader region that shows lack of enhancement compared with the surrounding tissue [50]. This may
represent liquefied, necrotic tissue; identification of
this process and abscesses in general can be of great
help to surgeons who must decide how extensive a
debridement is required.
Septic arthritis
Septic arthritis in the foot and ankle may have a
hematogenous origin, but more commonly it is a
consequence of adjacent soft tissue infection [87,
125]. In the phalanges, this is often caused by ulcera-
1185
tion at the dorsal aspect of the toes [126]. At the

metatarsophalangeal joints, septic arthritis is common,
related to communication with adjacent ulcers. The
first and fifth metatarsophalangeal joints are particularly susceptible because of the high incidence of
ulceration in these areas [87]. Septic arthritis at the
midfoot is not as common, but may be seen in patients
with foot deformity related to neuropathic disease;
with collapse of the arch, ulcers can form directly
under the Lisfrancs or Choparts joints, or are dorsally
related to poorly fitting shoes, allowing spread of
bacteria to the adjacent joints. Ankle or subtalar joint
involvement is often related to infection arising over
the malleoli or over the posterior calcaneal tubercle.
Because the ankle and subtalar joints communicate in
approximately 20% of ankles, infection can involve
both joints simultaneously.
On MRI of a septic joint (see Fig. 13) an effusion
is usually seen. The fluid may drain through a sinus
tract or decompress into a tendon sheath before
imaging, however, leaving only a small amount in
the joint. Synovial thickening and enhancement are
seen on postcontrast images. Marginal erosions and
reactive subchondral edema are common [127]; if the
marginal erosions are small, and if edema is confined
to a thin rim beneath the cortex, it is not indicative
of secondary osteomyelitis. If the edema or enhancement related to septic arthritis extends deeper into
the medullary bone, however, osteomyelitis should
be considered.
Fig. 13. Septic arthritis. (A) Sagittal T1-weighted image reveals low signal in the calcaneus (arrow) representing osteomyelitis
with a central focus of lower signal (white arrowheads) proved to be an intraosseous abscess. There is septic arthritis of the
subtalar joint and ankle joint and the talonavicular joint, with an erosion evident at the anterior ankle joint margin (black
arrowhead). (B) Sagittal T2-weighted fat-suppressed image shows diffuse edema in the infected calcaneus (black arrow) with
effusions and thin subchondral edema (arrowheads) in the ankle, subtalar, and talonavicular joints representing hyperemia
related to septic arthritis. Edema extending deeper into the medullary bone (white arrows) is consistent with osteomyelitis.
1186
Septic tenosynovitis
Septic tenosynovitis of the foot and ankle is also
typically a result of contiguous spread [93]. Tendons
passing through areas of soft tissue infection are often
involved. Infection of the flexor hallucis longus
sheath, however, can also result from septic arthritis
of the ankle or subtalar joint with which it often
communicates. MRI reveals fluid within the tendon
sheath that is disproportionate to that in other sheaths.
On T2-weighted images the fluid may appear complex. Although mechanical tenosynovitis is common
in the foot and ankle, septic tenosynovitis should
be suspected if these changes are associated with
surrounding soft tissue infection. Contrast may also
help identify involved tendons. Postcontrast images
show a thick rim of enhancement around the tendon
representing the proliferative, inflamed synovium
(Fig. 14) [128].
can provide a surgical map of the infected and viable

tissue [18,19,21,47,64].
Extent of infection in soft tissue and bone is
usually fairly well delineated on postcontrast MRI.
Infection, however, does not tend to remain confined
by fascial planes [131]; it spreads centripetally from
the inoculation site and readily spreads into and across
joints, through tendons, and across fascial compartments [131]. Although tendon involvement seems to
be common in areas of soft tissue infection, this does
not seem to be a common mode of proximal spread
(Ledermann et al, unpublished data, 2001). Nevertheless, soft tissue involvement is often more extensive
than the osseous disease, so the radiologist should
carefully examine the soft tissues extending proximally from the source of infection; if this tissue is not
debrided, the patient may fail their foot-sparing procedure and require more extensive amputation.
Extent and spread of infection

Extent of soft tissue and osseous infection is very
important to evaluate on MRI, because this can alter
plans significantly for medical or surgical management [18,19,21]. Surgeons have recognized that
extensive amputation of the foot leads to more rapid
progression of disease in the contralateral foot because
of shifting of weight-bearing stresses [129]. In recent
years there has been increased emphasis on footpreserving therapy [11], in which optimally only the
infected tissue is removed [17,130]. This has in part
been facilitated by the development of MRI, which
Atypical manifestations of infection

Some manifestations of osteomyelitis may have
atypical signal characteristics; these include chronic
osteomyelitis and infection within devascularized
areas [94,50]. Chronic osteomyelitis is often indolent,
or quiescent with areas of bone necrosis and sclerosis;
as a result, MRI may show areas of low signal on
T1- and T2-weighted images [89,132]. Foci of granulation tissue are often seen, with intermediate to high
T2 signal and enhancement. Activity of infection can
be difficult to determine unless there are ill-defined
areas of marrow edema and enhancement and bone
Fig. 14. Septic tenosynovitis. (A) Coronal T2-weighted fat-suppressed image at the level of the metatarsals shows a large plantar
ulcer (arrowhead); diffuse soft tissue edema is present, with signal near fluid intensity around the flexor and extensor tendons
(arrows). (B) Coronal contrast-enhanced fat-suppressed T1-weighted image demonstrates rim enhancement surrounding the
flexor and extensor tendons (arrows) consistent with septic tenosynovitis.
erosion or destruction [45]. In the setting of active

infection, soft tissue abscess or sinus tract may form.
Unlike acute osteomyelitis, these soft tissue manifestations originate from the bone and penetrate through
the skin to drain. Persistent sinus tracts may also be
seen, which drain intermittently. To determine activity
of the infection, comparison with previous studies is
very useful. Metal artifact may be present because of
multiple prior surgeries, which can make interpretation difficult; if this is the case it is useful to alter the
protocol to include STIR sequences and non fatsuppressed T1-weighted sequences before and after
intravenous contrast. Biopsy should be directed to the
areas of enhancement or bone destruction, but is often
negative despite active infection [133]. In the authors
experience, however, chronic osteomyelitis of the foot
and ankle is relatively rare in diabetic feet; present
therapeutic regimens involve aggressive management
of infection before it reaches the chronic stage.
As noted previously, infection of devascularized
tissue may also result in an atypical MRI appearance.
Devascularization is common in diabetic feet [134,
135], and can be seen on postcontrast fat-suppressed
MRI as regional absence of enhancement (or minimal
enhancement) compared with more proximal tissue
[50]. Typically, this region is sharply marginated by a
narrow region of increased enhancement representing
ischemic tissue [50]. Because contrast does not diffuse
readily into devitalized tissues, infection does not
show enhancement expected on MRI. Similarly,
because there is decreased metabolic activity within
1187
the devitalized area, fat signal in infected soft tissue

and bone marrow may not be replaced. Without blood
flow, inflammatory response to infection may also be
diminished, and edema signal may not be as prominent
compared with typical foot and ankle infection.
Osteomyelitis versus neuropathic osteoarthropathy:
differentiation on MRI
Differentiation of osteomyelitis and neuropathic
osteoarthropathy can be difficult, because both can
demonstrate marrow edema and enhancement, joint
effusion, and surrounding soft tissue edema [48,75].
There are some rules of thumb, however, one may use
to help differentiate these entities on MRI (Table 3).
The first consideration is that most cases of osteomyelitis of the foot and ankle are caused by contiguous spread [87,88]. Infection spreads in centripetal
fashion from the soft tissue epicenter. A bone marrow
abnormality without adjacent skin ulceration, sinus
tract, or soft tissue inflammation is less likely to
represent infection. This is especially useful when
there are extensive bone marrow signal abnormalities;
in this setting infection is unlikely if the subcutaneous
tissues are uninvolved.
Another consideration is that neuropathic osteoarthropathy is a predominantly articular process;
because it is a manifestation of instability, often
multiple joints in a region are similarly affected
(eg, the entire Lisfrancs, Choparts, or multiple adjacent metatarsophalangeal joints). This finding and
other articular manifestations of neuropathic disease
Table 3
Differentiation of osteomyelitis from neuropathic osteoarthropathy
Osteomyelitis
Neuropathic
Comments
Typical location
Toes (tips, dorsum),

metatarsal heads
(esp. 1st, 5th),
calcaneus, malleoli
Lisfrancs joint
Choparts joint
In the setting of foot deformity

osteomyelitis can occur at
atypical locations
Distribution
Focal, local
centripetal spread
Predominant
involvement of
one bone
Uncommon
(unless there
is underlying
neuropathic disease)
Adjacent ulcer,
cellulitis, sinus tract
Multiple joints in
a region
Epicenter in joint and
subchondral bone
Choparts joint
Pattern of edema
and enhancement
Deformity
Soft tissues
Common
Enhancement limited to
juxta articular soft tissues;
skin, SQ tissues intact
Diffuse SQ edema is
typical in diabetic feet
From Morrison WB, Ledermann HP, Schweitzer ME. MR imaging of inflammatory conditions of the ankle and foot. Magn
1188
(subluxation, cysts, and necrotic debris) are not as

common in infection. Marrow changes associated with
neuropathic osteoarthropathy can be extensive (especially at the midfoot), but tend to be centered at a joint
and subarticular bone, and are present on both sides of
the joint fairly equally. Osteomyelitis shows more
diffuse marrow involvement and unless there is primary septic arthritis, the marrow changes are generally
greater on one side of the joint.
Location of disease is also important. Osteomyelitis occurs predominantly at the metatarsal heads, the
toes, the calcaneus, and the malleoli, a distribution
that mirrors that of friction, callus, and ulceration [71].
Neuropathic osteoarthropathy by far is most common
at the Lisfrancs and Choparts joints [39,72 74]. If
there is foot deformity, however, contiguous spread of
infection can occur at atypical sites (eg, the cuboid in
cases of rocker-bottom deformity).
In patients with underlying neuropathic osteoarthropathy, superimposed ulceration and soft tissue
infection can create a significant diagnostic dilemma.
In this setting to diagnose osteomyelitis one should
look for focal marrow signal abnormalities adjacent to
the site of soft tissue infection that are different than
the other areas of neuropathic involvement. Aspiration or biopsy of suspicious areas may be required. If
percutaneous biopsy is performed, the needle route
should be planned away from the area of soft tissue
infection: if there is no osteomyelitis, a sample
obtained by infected soft tissue could inoculate the
bone [122,136]. Culture results of percutaneous bone
biopsy specimens in pedal infection may be unreliable
because of contamination from underlying infected
soft tissue [29,122,136].
Summary
Diabetes is a common disease with potentially
devastating complications affecting the foot and
ankle. A combination of vascular disease, peripheral
neuropathy, and immunopathy results in a cascade of
conditions including ischemia and infarction, tendinopathy, atrophy, edema, deformity, neuropathic osteoarthropathy, callus, ulceration, and infection. MRI is
useful for evaluation of these complications, and
assists the clinician in medical or surgical planning.
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Radiol Clin N Am 40 (2002) 1193 1198
Index
Note: Page numbers of article titles are in boldface type.
A
Abscesses, in diabetic foot, MR imaging of,
1186 1187
Acetabular labral lesions, MR arthrography of,
1122 1124
Autogenous osteochondral grafts, for articular cartilage injuries, of knees, 1144

Autologous chondrocyte implants, for articular cartilage injuries, of knees, 1144
Acetabular osteomyelitis, in children, 1034, 1038

Adamantinoma, of lower extremities, 984 985
Ankles and feet
MR arthrography of, 1128 1130
for impingement syndrome, 1129 1130
for intra-articular lesions, 11129 1130
for ligament injuries, 1128 1129
for tibiotalar joint, 1129
MR imaging of, 1147 1172
compartment anatomy in, 1149, 1151 1153,
1155 1156
anterior, 1151 1152
medial, 1155 1156
posterior, 1156
for joint pathology, 1157
for osseous pathology, 1156 1157
for plantar fasciitis, 1158
for sinus tarsi, 1158
for subcutaneous tissues, 1158
tendon grading system in, 1149
osteomyelitis of, in children, 1053
Anterior cruciate ligament, MR imaging of,
1066 1068
postoperative. See Knees.
Arcuate ligament, MR imaging of, 1075 1076
Arthritis, of knees, bone marrow in, 1118 1119
Arthrofibrosis, anterior cruciate ligament repair
and, 1137
Articular cartilage, of knees, MR imaging of,
1095 1099, 1101
postoperative, 1140, 1144
B
Biceps femoris muscle, MR imaging of, 1072
Biopsy, of lower extremity bone tumors, 983 984
Bone infarction, in diabetic foot, MR imaging of,
1176 1177
Bone marrow abnormalities, of knees, MR imaging
of, 1109 1120
acute avulsive injuries, 1111
acute impaction injuries, 1111
chronic avulsive injuries, 1112 1113
fatigue and insufficiency fractures, 1112
marrow pathology, 1111
medullary infarction, 1114 1115
normal marrow conversion, 1109 1111
osteoarthritis, 1118 1119
osteochondritis dissecans, 1115
osteomyelitis, 1117 1118
reflex sympathetic dystrophy, 1116 1117
septic joint, 1118
spontaneous osteonecrosis, 1113 1114
transient osteoporosis, 1115 1116
tumors, 1118
versus normal bone marrow, 1109
Bone-patellar tendon bone graft, for anterior cruciate
ligament injuries, 1133 1134
Bone tumors, of lower extremities. See Lower
extremity bone tumors.
Bucket-handle tears, of knees, MR imaging of,
1088 1089
Buckled meniscus, MR imaging of, 1084 1085
PII: S 0 0 3 3 - 8 3 8 9 ( 0 0 ) 0 0 0 0 0 - 0
1194
Index / Radiol Clin N Am 40 (2002) 11931198
C
Calcaneus, osteomyelitis of, in children, 1053
Diaphyseal lesions, differential diagnosis of, 977
Calcium pyrophosphate deposition disease, of meniscus, MR imaging of, 1092
Discoid meniscus, MR imaging of, 1084
Callus, in diabetic foot, MR imaging of, 1179 1181
Diaphysis, osteomyelitis of, in children, 1048
Dynamic enhanced magnetic resonance imaging,

of lower extremity bone tumors, 974 975
Cellulitis, in diabetic foot, MR imaging of,

1182 1183
Chondral and osteochondral injuries, of knees,
MR imaging of, 1095 1107, 1126
articular cartilage, 1095 1099, 1101
for preoperative planning, 1101 1105
future directions in, 1105
osteochondritis ossificans, 1104 1105
E
Edema, in diabetic foot, MR imaging of, 1177 1178
Enneking classification, of osseous neoplasms,
981, 983
Chondroblastomas, of lower extremities, 987

Chondromyxoid fibromas, of lower extremities,
985 986
Computed tomography
of lower extremity bone tumors. See Lower
of lower extremity osteomyelitis. See Lower
extremity osteomyelitis.
Cortical irregularity, bone marrow in, 1112 1113
F
Fabellofibular ligament, MR imaging of, 1075 1076
Fat-containing lesions, of lower extremities, 984
Fatigue fractures, of knees, bone marrow in, 1112
Feet. See Ankles and feet.
Femur, osteomyelitis of, in children, 1038, 1048,
1050, 1945
Cuboid, osteomyelitis of, in children, 1053
Fibromatosis, of lower extremities, MR imaging of,

1001 1002
Cyclops lesions, anterior cruciate ligament repair

and, 1137
Fibrous dysplasia, of lower extremities, 979
Cysts, popliteal, MR imaging of, 1026 1027
Fibula, osteomyelitis of, in children, 1052 1053

Flexor digitorum longus tendon injuries, MR imaging
of, 1155 1156
D
Diabetic foot
for abscesses, 1186 1187
for atypical features of infection, 1188 1189
for callus and ulceration, 1179 1181
for cellulitis, 1182 1183
for edema or atrophy, 1177 1178
for extent and spread of infection, 1188
for neuropathic osteoarthopathy, 1179
for osteomyelitis, 1183 1184, 1186
versus neuropathic osteoarthropathy,
1189 1190
for septic arthritis, 1187
for septic tenosynovitis, 1188
for sinus tracts, 1183
for tendon tear or dysfunction, 1178 1179
for vascular disease, 1175 1177
protocol for, 1174 1175
pathophysiology of, 1173 1174
Flexor hallucis longus tendon injuries, MR imaging

of, 1155 1156
Fluorodeoxyglucose, in PET, of lower extremity bone
tumors, 977
G
Gadolinium
in MR arthrography, of lower extremities, 1121
in MR imaging, of postoperative meniscus, 1139
Gangrene, noninfected, in diabetic foot, MR imaging
of, 1176
Gastrocnemius muscle injuries, MR imaging of, 1076
Giant cell tumors, of lower extremities, MR imaging
of, 986, 997 998
Granuloma annulare, of lower extremities, MR
imaging of, 1001
H
Hamstring grafts, for anterior cruciate ligament injuries, 1134, 1136
Hemangiomas, of lower extremities, MR imaging of,
994 996
Hemosiderin-vacuum phenomenon, of meniscus,
MR imaging of, 1092
Hernias, muscle, MR imaging of, 1025 1026
Hips, MR arthrography of, 1122 1125
for acetabular labral lesions, 1122 1124
for loose bodies, 1124 1125
pitfalls in, 1124
I
Impingement, osseous, of ankles and feet, MR arthrography of, 1129
Infections, of knees, bone marrow in, 1117 1118
Inflammatory arthritides, of knees, bone marrow
in, 1119
Insufficiency fractures, of knees, bone marrow
in, 1112
Intra-articular lesions
of ankles and feet, MR arthrography of,
1129 1130
of knees, MR arthrography of, 1127
Intra-articular osteoid osteomas, of lower extremities,
985
Intramedullary osteoid osteomas, of lower extremities, 985
J
Joint pathology, of ankles and feet, MR imaging
of, 1157
K
Knees. See also Meniscus.
bone marrow abnormalities of. See Bone
marrow abnormalities.
chondral and osteochondral injuries of. See
Chondral and osteochondral injuries.
ligaments and tendons of, 1061 1079, 1091
anterior structures, 1061 1063
1195
anatomy of, 1061

mechanism of injury in, 1061 1062
central structures, 1066 1070
anatomy of, 1066, 1068
mechanism of injury of, 1066 1068
dislocations, 1076 1077
MR imaging of, 1078
lateral structures, 1072 1074
anatomy of, 1072
mechanism of injury of, 1072
medial structures, 1070 1071
anatomy of, 1070
posterior structures, 1076
posterolateral structures, 1074 1076
anatomy of, 1074 1075
posteromedial structures, 1071 1072
anatomy of, 1071
MR imaging of, 1072
MR arthrography of, 1125 1128
for cartilage lesions, 1126 1127
for intra-articular bodies, 1127
for meniscal lesions, 1125 1126
for osteochondritis dissecans, 1127
for plica synovialis, 1127 1128
postoperative evaluation of, 1133 1146
anterior cruciate ligament, 1133 1138
arthrofibrosis in, 1137
bone-patellar tendon bone graft in,
1133 1134
donor site findings in, 1137
graft impingement in, 1136 1137
graft rupture in, 1136
surgical factors in, 1133
tibial tunnel in, 1134 1136
articular cartilage, 1140, 1144
gadolinium in, 1139
meniscus, 1138 1140
L
Lateral collateral ligament, MR imaging of,
1072 1074
Leiomyosarcomas, of lower extremities, MR imaging
of, 1004
1196
Ligaments
of ankles and feet, MR arthrography of,
1128 1129
of knees. See Knees.
Lipomas, of lower extremities, MR imaging of, 996
Liposarcomas, of lower extremities, MR imaging of,
1003 1004
Loose bodies, in hips, MR arthrography of,
1124 1125
Lower extremity bone tumors, 971 990
adamantinoma and osteofibrous dysplasia,
984 985
chondroblastomas, 987
chondromyxoid fibromas, 985 986
cortical involvement by, 980 981
CT of, 971 973
dynamic enhanced MR imaging of, 974 975
fat-containing, 984
giant cell tumors, 986
location of, 977, 979
management of, 983 984
margins of, 979
metastatic, 983
MR angiography of, 973 974
nuclear medicine studies of, 975 977
osteoblastomas, 986 987
osteoid osteomas, 985
percutaneous biopsy of, 983 984
soft tissue extension by, 980
staging of, 981, 983
Lower extremity osteomyelitis, in children,
1033 1059
of acetabulum, 1034, 1038
of diaphysis, 1048
of feet and ankles, 1053
of femur, 1038, 1045, 1048, 1050
of fibula, 1052 1053
of tibia, 1050, 1052
pathophysiology of, 1033
Lower extremity soft tissue tumors, 980, 991 1011
benign versus malignant, 1008
initial evaluation of, 991, 993
MR imaging of
fibromatosis, 1001 1002
giant cell tumors, 997 998
granuloma annulare, 1001
hemangiomas, 994 996
leiomyosarcomas, 1004
lipomas, 996
liposarcomas, 1003 1004
malignant fibrous histiocytomas, 1003

malignant peripheral nerve sheath tumors,
1004 1005
neurofibromas, 999 1001
nodular fasciitis, 1002 1003
pigmented villonodular synovitis, 998 999
schwannomas, 999 1001
synovial sarcomas, 1005 1006
techniques for, 993 994
staging of, 1008
M
Magic angle effect, in MR imaging, of meniscus, 1091
Magnetic resonance angiography, of lower extremity
bone tumors, 973 974
Magnetic resonance arthrography
of ankles and feet. See Ankles and feet.
of hips. See Hips.
of knees. See Knees.
Magnetic resonance imaging
of ankles and feet. See Ankles and feet.
of diabetic foot. See Diabetic foot.
of knees
for bone marrow abnormalities. See Bone
marrow abnormalities.
for chondral and osteochondral injuries. See
Chondral and osteochondral injuries.
ligaments and tendons. See Knees.
of lower extremity bone tumors. See Lower
of lower extremity osteomyelitis. See Lower
of lower extremity soft tissue tumors. See Lower
extremity soft tissue tumors.
of meniscus. See Meniscus.
of nonneoplastic lower extremity muscle disorders. See Nonneoplastic lower extremity
muscle disorders.
Malignant fibrous histiocytosis, of lower extremities,
MR imaging of, 1003
Medial cruciate ligament, MR imaging of,
1070 1071
Medullary infarction, of knees, bone marrow in,
1114 1115
Meniscocapsular separation, MR imaging of,
1089 1091
Meniscus. See also Knees.

MR imaging of, 1081 1094, 1125 1126
and surgical options, 1092 1093
buckled meniscus, 1084 1085
challenges in, 1091 1092
discoid meniscus, 1084
for complete tears, 1089
for flipped fragments, 1089
for free fragments, 1089
for horizontal tears, 1089
for inferior flap tears, 1089
for longitudinal tears, 1088 1089
for meniscocapsular separation, 1089 1091
for oblique tears, 1089
for peripheral tears, 1089
for radial tears, 1086 1088
for tear morphology and location, 1093
for tears, 1085 1087
lateral meniscus, 1083 1084
macroanatomy in, 1082 1083
medial meniscus, 1083
microanatomy in, 1081 1082
postoperative, 1138 1140
technique for, 1093
1197
popliteal cysts, 1026 1027

techniques for, 1013, 1015 1016, 1018
Nuclear medicine studies
of diabetic foot, 1183 1184
of lower extremity bone tumors, 975 977
O
Oblique meniscal ligament, MR imaging of, 1091
Osseous pathology, of ankles and feet, MR imaging
of, 1156 1157
Osteoarthritis, of knees, bone marrow in, 1118 1119
Osteoblastomas, of lower extremities, 986 987
Osteochondral injuries, of knees. See Chondral and
osteochondral injuries.
Osteochondritis dissecans, of knees
bone marrow in, 1115
MR arthrography of, 1127
Osteochondritis ossificans, of knees, MR imaging of,
1104 1105
Meniscus flounce, MR imaging of, 1084 1085
Osteofibrous dysplasia, of lower extremities,

984 985
Metastatic disease, from osseous neoplasms, 983
Osteoid osteomas, of lower extremities, 985
Musculoaponeurotic fibromatosis, MR imaging

of, 1002
Osteomyelitis
in diabetic foot, MR imaging of, 1183 1184,
1186, 1189 1190
of knees, bone marrow in, 1117 1118
of lower extremities. See Lower
N
Neurofibromas, of lower extremities, MR imaging of,
999 1001
Neuropathic osteoarthropathy, in diabetic foot, MR
imaging of, 1179, 1189 1190
Neuropathy, in diabetic foot, MR imaging of, 1174
Osteonecrosis, of knees, bone marrow in, 1113 1117

Osteoporosis, transient, of knees, bone marrow in,
1115 1116
Osteosarcomas, periosteal, of lower extremities,
977, 979
Nodular fasciitis, of lower extremities, MR imaging

of, 1002 1003
Noninfected gangrene, in diabetic foot, MR imaging
of, 1176
Nonneoplastic lower extremity muscle disorders,
atrophy, 1023 1024
compartment syndrome, 1021 1022
gadolinium in, 1016
hernias, 1025 1026
infarction and inflammation, 1024 1025
muscle function, 1018 1019, 1027 1028
muscle injuries, 1019 1022
P
Patellar tendon, MR imaging of, 1063
Periosteal osteosarcomas, of lower extremities,
977, 979
Peripheral nerve sheath tumors, of lower extremities,
MR imaging of, 999 1001, 1004 1005
Peroneus brevis tendon injuries, MR imaging of,
1152 1153
Peroneus longus tendon injuries, MR imaging of,
1152 1153
1198
Peroneus quartreus tendon injuries, MR imaging

of, 1153
Pigmented villonodular synovitis, of lower extremities, MR imaging of, 998 999
Plain films
of diabetic foot, 1183
of lower extremities
for benign peripheral nerve sheath tumors,
999 1000
for giant cell tumors, 997 998
for lipomas, 996
for malignant fibrous histiocytomas, 1003
for malignant peripheral nerve sheath tumors,
1004 1005
for osteomyelitis, in children, 1053
for pigmented nodular synovitis, 998 999
for synovial sarcomas, 1006
fro hemangiomas, 995
Plantar fasciitis, MR imaging of, 1157
Plantar fibromatosis, MR imaging of, 1002
Plica synovialis, of knees, MR arthrography of,
1127 1128
Popliteal cysts, MR imaging of, 1026 1027
Popliteal muscle, MR imaging of, 1075 1076
Septic knee joint, bone marrow in, 1118

Septic tenosynovitis, in diabetic foot, MR imaging
of, 1188
Seronegative spondyloarthropathies, of knees, bone
marrow in, 1119
Sestamibi scans, of lower extremity bone tumors,
976 977
Shin splints, bone marrow in, 1112
Sinus tarsi, MR imaging of, 1157
Sinus tracts, in diabetic foot, MR imaging of, 1183
Synovial sarcomas, of lower extremities, MR
imaging of, 1005 1006
T
Tarsal tunnel syndrome, MR imaging of, 1156
Technetium scans, of lower extremity bone tumors,
975 976
Tendon disorders, in diabetic foot, MR imaging of,
1178 1179
Tendons, of knees. See Knees.
Popliteal tendon, MR imaging of, 1091
Thallium scans, of lower extremity bone tumors,

976 977
Positron emission tomography, of lower extremity

bone tumors, 977
Thigh splints, bone marrow in, 1112
Posterior cruciate ligament, MR imaging of,

1068 1069
Pseudogout, of meniscus, MR imaging of, 1092
Tibia, osteomyelitis of, in children, 1050, 1052

Tibialis posterior tendon injuries, MR imaging of,
1155 1156
Tibiotalar joint, MR arthrography of, 1129
Toes, osteomyelitis of, in children, 1053
R
Reflex sympathetic dystrophy, of knees, bone marrow
in, 1116 1117
Transverse intermeniscal ligament, MR imaging

of, 1091
Retinacular tears, MR imaging of, 1063
S
Schwannomas, of lower extremities, MR imaging of,
999 1001
Semimembranosus muscle, tendon of, MR imaging
of, 1071 1072
Septic arthritis, in diabetic foot, MR imaging of, 1187
U
Ulceration, in diabetic foot, MR imaging of,
1179 1181
V
Vascular disease, in diabetic foot, MR imaging of,
1175 1177

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Imaging of the lower extremity

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Radiologic Clinics of North America

Postoperative evaluation of the knee

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Radiol Clin N Am 40 (2002) xi

Imaging of the lower extremity

This issue of the Radiologic Clinics of North

articular disorders, MR imaging of bone marrow

Radiol Clin N Am 40 (2002) 971 990

Primary bone tumors of the lower extremities

The lower extremity is the most common location

The opinions and assertions contained herein are the

imaging has extraordinarily improved the ability to

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

suffered from several technical limitations, and most

genic sarcoma, intra-articular extension is evaluated

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

T1- and T2-weighted images should be performed in

the lesion. With CT, a larger field of view that

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

MR angiography, delineation of these small branches

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

phate compounds are useful in evaluation for distant

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

delayed images [29]. Delayed images from Tc 99m

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

ful in this regard. It has been shown that a negative

epiphysis is quite limited. Chondroblastoma usually

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

signal, similar to skeletal muscle, on T1-weighted

tion, often on the posterior distal femoral cortex.

Proper evaluation of lesion margin is critical to

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

Soft tissue mass

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

grade provides a prediction of the biologic behavior

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

regional metastases, such as to regional lymph nodes,

ligaments [55,57]. Spread beyond the compartment of

Percutaneous biopsy and treatment

From Enneking WF, Spanier SS, Goodman MA. A system

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

[58] in 1982, the potential hazards of obtaining

referring surgeon to avoid potential compromise of

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

sclerosis. Osteofibrous dysplasia, a benign condition,

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

remodeling [78,80,81]. Matrix mineralization is

[35,82]. Soft tissue extension is more commonly seen

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

ally absent; however, surrounding inflammatory

this is caused by the very high cellularity of these

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

complicated but relatively uncommon lesions. Certain

[14] Sundaram M, McLeod RA. MR imaging of tumor and

G.C. Nomikos et al / Radiol Clin N Am 40 (2002) 971990

primary bone and soft tissue tumors. Semin Nucl Med