MRI OF THE KNEE

MARIA THERESA M. NAVARRO, MD

Fourth Year Radiology Resident
Department of Medical Imaging
Quirino Memorial Medical Center
 MRI OF THE KNEE

• most frequently requested MRI joint study

• comprehensive examination of the knee
• road map for surgeons in arthroscopy or open sur
gery
• sensitivity & specificity of 90% to 95% for the meni
sci and close to 100% in cruciate ligaments
 MRI OF THE KNEE

• SAGITTAL IMAGES
• meniscus
• cruciate ligaments
• T1W images, proton density, gradient echo sequences
• T2W image with fat suppression (cruciate ligaments, c
artilage, and bones)
• CORONAL PLANE
• collateral ligament
• cruciate ligaments
• T2W images
 MRI OF THE KNEE

• AXIAL PLANE
• patellar cartilage
• trochlear cartilage
• medial patellar plica
• T2 sequences
ANATOMY OF THE KNEE
Anterior Supporting Structures: Central Supporting Structures:
• Quadriceps muscles • ACL
• Patellar tendon • PCL
• Medial Retinacular & Vastus Medialis
• Lateral Retinacular & Vastus Lateralis

Lateral Supporting Structures:

Medial Supporting Structures: • Illiotibial band
• Superficial MCL • Biceps femoris
• Deep MCL • Lateral retinaculum
• Joint capsule • LCL
• Medial Retinaculum • Joint capsule

Posteromedial Corner: Posterolateral Corner:

• Semimembranous Tendon
• Joint capsule
• Posterior Oblique Ligament
• Popliteus Muscle & Tendon
• Arcuate ligament
Posterior Supporting Structures: • Joint capsule
• Posterior Capsule
• Gastrocnemius Muscles
• PCL
By Hayes et al
MENISCAL TEARS
MENISCI

• Functions
• shock absorption
• stabilization
• lubrication
• proprioception
 Normal Menisci
• Medial meniscus • Lateral meniscus
Meniscal Tear
GRADE 1 GRADE 2 GRADE 3
Abnormal Menisci
• According to Kaplan, et al., the only abnormal sign
al that has any real signficance is that which disru
pts the articular surface of the meniscus  tear
• Any signal that does not disrupt an articular surfac
e  intrasubstance or myxoid degeneration
Meniscal Tear

• Abnormal morphology
• Irregular margin of meniscus
• Focal defect on articular surface
• Abnormally small meniscus
Meniscal Tear

• Vertical tear
• Longitudinal tear
• Radial tear

• Horizontal tear
• Complex tear
 HORIZONTAL TEAR
• horizontal tear, cleavage tear, fishmouth tear
• meniscal tear that occurs in horizontal plane, diss
ecting through the circumferential collagen fibers
• Best Diagnostic Clue: linear horizontally oriented, i
ncreased signal intensity on short TE sequences
• within meniscus from free edge inward

Stoller et al.2004. Diagnostic Imaging: Orthopaedics

 Horizontal Tear
• Most Common Location: posterior horn of the med
ial meniscus

Stoller et al.2004. Diagnostic Imaging: Orthopaedics

Horizontal Tear
 RADIAL TEAR
• Vertical tear oriented perpendicular to the free ed
ge of the meniscus
• Best Diagnostic Clue
• GHOST MENISCUS – when in plane of acquisition in
root tears
• includes root tear at meniscotibial attachement
• Location :
• junction of the anterior horn and body of the lateral me
niscus
• meniscotibial attachment posterior horn of the menisc
us (root tear), common in the medial meniscus
 Meniscal Radial Tear

Sagittal PD FSE MR shows a radial tear

Axial oblique graphic shows a radial tear
of posterior horn of the medial meniscus
involving the posterior horn of the lateral
at the root attachment giving a “ghost
mensicus at the meniscotibial attachment
meniscus” appearance.
Radial Tear
 MENISCAL CYST
• Cyst extending from meniscal tear
• horizontal tear most common
• Best Diagnostic Clue : cystic mass extending from
a meniscal tear
• Location :
• anterior horn of the lateral meniscus
• posterior horn of the medial meniscus
• Clinical Sign : Pisani’s sign (palpable mass that di
sappears with flexion)
• Sagittal FS PD FSE MR
shows a moderate size
d meniscal cyst projecti
ng anteriorly from an an
terior lateral meniscus t
ear

 Coronal PD FSE MR
shows a small meniscal
cyst (arrow) adjacent to a
lateral meniscal tear of
the body
Meniscal Cyst

• Fluid extrusion thru me

niscal tear
• MR evaluation
• Presence of cyst
• Presence or absence of
tear
Meniscal Tear

• Special types
• Bucket-handle tear
• Flipped meniscus
• Inferior flap tear
• Meniscocapsular separation
• Meniscal root tear
 BUCKET-HANDLE TEAR
• Vertical peripheral tear with displaced mesial porti
on to the notch of knee
• Best Diagnostic Clue:
• coronal images show small meniscus body and menis
cal fragments at the notch resulting in 2 meniscal frag
ments
• “double posterior cruciate ligament (PCL) sign” on sag
ittal images
• “double delta sign”
• Location : medial > lateral
Bucket Handle Tear
 MENISCAL FLAP TEAR
• Meniscus oblique tear
• Tear of the meniscus with both longitudinal and ra
dial components forming a flap of meniscal tissue
that may become displaced
• Best Diagnostic Clue: obliquely oriented tear of th
e meniscus containing
• longitudinal component
• radial component
• Location : posterior horn and posterior aspect of b
ody of medial meniscus
 Meniscal Flap Tear

Sagittal PD FSE MR shows a slightly

displaced flap tear of the medial
Vertical and horizontal component of
meniscus with characteristic vertical
a flap tear
signal intensity involving the inner 3rd of
the meniscus fibrocartilage
Flipped Meniscus

• Too much meniscal tissue

• Lateral meniscus
 Inferior flap tear

• Flap of meniscus
• flip into medial gutter
 Meniscal Root Tear
• Medial meniscus posterior root
• Disruption of posterior horn near PCL
 DISCOID MENISCUS

• Large congenitally dysplastic meniscus with loss o

f normal semilunar shape
• Result of failure of resorption of the central portion
• Best Diagnostic Clue : loss of normal semilunar sh
ape filling lateral or medial compartment
• Location : lateral discoid meniscus is more commo
n than the medial discoid meniscus
• MRI : continuous body segment appearance on >
3 consecutive sagittal 4-5 mm thick images
Stoller et al., 2004 Diagnostic Imaging: Orthopedics
Discoid Meniscus
 Pitfalls
• Meniscofemoral • Transverse ligament
ligament
Transverse Ligament
MRI OF KNEE LIGAMENT
S
Ligament injuries are usually graded in terms of
their severity:

Grade I sprain – some micro-tearing or slight

stretching occurs, however the overall
integrity of the ligament is preserved. The
ligament hurts if stressed but is stable.
Ligament injuries are usually graded in terms of
their severity:

Grade II sprain – partial disruption of the

ligament. Painful to stress, there is detectable
laxity but the ligament has an eventual
endpoint.
Ligament injuries are usually graded in terms of
their severity:

Grade III tear – complete ligament tear and

laxity with no endpoint or stability to testing.
As the nerves in the ligament are torn too,
there is often minimal pain with stressing the
joint
 Direction of Injury-Producing Forces Acting on th
e Knee
Hyperextension
Hyperextention, Hyperextension,
Varus Valgus

Pure Valgus
Pure Varus

Flexion, Varus, Flexion, Valgus,

Int. Rotation Flexion, Ext. Rotation
Anterior Tibial
Translation
By Hayes et al
Anterior Cruciate Ligament
 Anterior Cruciate Ligament Tear
• Best Diagnostic Clue : disruption of normal contin
uous low signal intensity ACL with irregularity and
increased signal on T2WI
• Location : ACL in the intercondylar notch of knee
• most commonly caused
• by forward translation of tibia,
• external rotation of the femur with respect to the tibia,
• valgus stress
• and axial loading
 Direct MR Signs of ACL Tear
• Discontinuity of fib
ers
• Abnormal slope of
ACL
• Nonvisualization of
the ACL fibers on b
oth sagital and cor
onal planes
• Avulsion of the ant
erior tibial spine
Indirect MR Signs of ACL Tear
• Bone contusion sign: Lateral femoral condyl
e and posterior tibial plateau (pivot-shift inj
ury)
• Deep sulcus sign: Lateral femoral condyle
• Segond fracture: Capsular avulsion fracture
of the lateral tibial plateau
• Kissing contusions: Anterior tibia and femu
r (hyperextension injury)
• Anterior drawer sign: Anterior translation o
f tibia relative to femur
Sagittal PD FSE MR shows
the typical appearance of a
proximal ACL tear

Coronal FS PD FSE MR
shows an “empty lateral
intercondylar notch wall”
representing a grade III ACL
tear
Associated bone contusions after
an internal rotation valgus
mechanism of injury involving the
lateral femoral condyle and the
posterolateral tibia

Sagittal FS PD FSE MR shows

lateral bone injuries associated
with an ACL tear including the
posterolateral tibia and sulcus
terminalis of the lateral femoral
condyle. Proximal fibula is also
injured.
Posterior Cruciate Ligament
 PCL Tear
• disruption of the PCL usually after forced posterior displac
ement of the tibia
• Best Diagnostic Clue: discontinuous and/or thickened PC
L fibers of increased signal intensity on all pulse sequenc
es
• Location: Posterior tibia insertion site avulsion fracture
• Clinical : positive posterior drawer sign (excessive mobilit
y of the tibia posteriorly)
• caused by direct trauma impacting the anterior knee in a
posterior direction (dashboard injury with the knee in flexi
on)
 PCL TEAR

Sagittal FS PD FSE MR
Sagittal FS PD FSE MR shows
shows a complete tear of the
a complete tear of the PCL
PCL mid portion
 PCL TEAR

Sagittal graphic shows the Sagittal STIR MR shows a partial PCL

typical anterior bone contusion tear and an anterior subchondral
pattern of hypertension often contusion of tibia in a patient who
seen with PCL tears suffered a dashboard injury
Contusion Patterns in PCL Tears
 Direct Sign of PCL Injury

• Complete tear
• Partial tear
• Peel-off injury: An avulsion injury of th
e femoral insertion of the ligament.
 Indirect Signs of PCL Injury

• Bone marrow edema involving the ant

erior proximal tibia
• Avulsion of the posterior tibia at the P
CL insertion site
 LCL TEAR
• fibular collateral ligament tear
• tear of the LCL after varus +/- external rotation str
ess
• Best Diagnostic Clue: Discontinuous LCL fibers +/
- thickening, hyperintense on FS PD FSE or T2WI
• Location: extends from lateral femoral condyle to i
nsertion with the biceps femoris on the fibular hea
d
• usually at the proximal region
 Lateral Collateral Ligament (LCL) Tear

Tear at distal aspect of the lateral

Sagittal FS PD FSE MR shows a tear
collateral ligament with mild
of the lateral collateral ligament
retraction of the ligament proximally
Sagittal PD FSE MR shows a normal Coronal PD FSE MR shows a
LCL normal LCL
 Lateral Collateral Ligament Tear

Coronal PD FSE MR shows a Sagittal FS PD FSE MR shows a

grade III sprain of the proximal mid and distal aspect LCL tear
aspect of the LCL
Medial Collateral Ligament Tear
• tibial collateral ligament tear
• secondary to valgus stress
• Best Diagnostic Clue: discontinuous MCL with thickening
and increased signal intensity on all sequences within the
ligament remnant
• Location : superficial and deep layers (medial capsular lig
ament)
• superficial component – medial (tibial) collateral ligament proper
• deep layer : meniscofemoral and meniscotibial attachments
 Medial Collateral Ligament Tear

Coronal oblique graphic shows a

grade III tear of the proximal Coronal FS PD FSE shows a grade
aspect of the medial collateral III MCL tear after valgus injury
ligament
Take Home Point

• MRI is a good imaging modality to detect t

he ligament injuries.
• Certain combination of forces cause specifi
c injury patterns.
• Understanding the mechanism of injury is i
mportant to improve the diagnosis.
• Direct signs and Indirect signs are importan
t for diagnosis of ligament injury.