Knee US - American Osteopathic Academy of Sports Medicine

Knee US - American Osteopathic Academy of Sports Medicine

11/4/14
MSK Ultrasound AOASM Knee
October 26, 2014
OMED
Patrick F. Leary DO FAOASM
FACSM FACOFP
Director LECOM Sports Medicine
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11/4/14
Osteopathic Medicine
1.  The body is a unit.
2.  The body possesses
self regulatory
mechanisms.
3.  Structure and function
are reciprocally
interrelated.
4.  Rational therapy is
based upon an
understanding of body
unity, self regulatory
mechanisms, and the
inter-relationship of
structure and function.
Objectives
•  Illustrate the anatomy of the knee in four
quadrants
•  Identify the major tendons and ligaments
of the knee
•  Demonstrate the pertinent structures via
MSK ultrasound using AIUM Technical
Guidelines
•  Feature and delineate common pathologic
findings
•  Demonstrate Intra-articular Injection
technique and potential extra-articular
injections
Nomenclature
• 
• 
• 
• 
• 
• 
• 
• 
Anechoic
Hyperechoic
Hypoechoic
Cortical Irregularities
Fibrillar Pattern
Enthesis
Linear slide
Long axis/
Longitudinal
•  Short axis/Transverse
•  50mm linear probe/
curvilinear probe/
hockey stick
•  Depth
•  Anisotropy
•  Shadowing
•  Artifact
•  Hyaline cartilage
stripe
•  Fin/Directional
indicator
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Organizations
•  AIUM
American
Institute of Ultrasound
Medicine
•  AOASM Fellowship
Curriculum
•  ESSR
European
Society of
Muskuloskeletal
Radiology
•  Certification
Requirements
•  Proficiency Exam
•  Reimbursements by
Third Party
MSK Ultrasound
Four Quadrants
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Anatomy
Knee Joint Anatomy: Quadriceps Tendon Complex
Quadriceps Tendon Complex:
1.  Vastus Intermedius
2.  Vastus Lateralus/Medialis
3.  Rectus Femoris
4.  Trochlear Hyaline Cartilage
5.  Distal Femur
6.  Proximal Patella
2
4
3
1
6
5
45 degree flexion flexion
Anatomy
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Anterior Long Axis
Anterior Short Axis
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Knee Joint Anatomy: Quadriceps Tendon Complex
Quadriceps Tendon Complex:
1.  Vastus Intermedius
2.  Vastus Lateralus/Medialis
3.  Rectus Femoris
4.  Trochlear Hyaline Cartilage
5.  Distal Femur
6.  Proximal Patella
2
4
3
1
5
6
45 degree flexion flexion
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Anatomy
Suprapatellar Recess/Bursa:"
1.  Quadriceps Fad Pad"
2.  Prefemoral Fat Pad"
3.  Simple Synovial Fluid"
4.  Trochlear Hyaline Cartilage"
5.  Distal Femur"
6.  Proximal Patella"
Cada
ve r w
ith K
n
ee str
aight
6
1
3
4
2
2
1
3
6
5
4
5
30 degree flexion
Suprapatellar Recess/Bursa Transverse Axis
Complex Effusion
Simple Effusion
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Knee Joint Anatomy: Anterior Trochlear Cartilage
45 degree flexion, Imaged axial to the Quadriceps Tendon view
Anterior Trochlea: Osteochondral Cortical Defect
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Knee Joint Anatomy: Infrapatellar Tendon
Infrapatellar Tendon:
1.  Distal Patella
2.  Tibial Tuberocity
3.  Infrapatellar Tendon
4.  Hoffa’s Fat Pad
1
3
2
4
3
2
4
Knee Joint Anatomy: Infrapatellar Pathology
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Patellar Tendon Short
Patellar Tendon Long Axis
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Medial Right Knee
Medial
Knee Joint Anatomy: Medial Collateral Ligament
Medial Collateral Ligament:
1.  Medial Epicondyle (MCL Origin)
2.  Medial Meniscus
3.  Medial Tibial Plateau
4.  Flair of medial tibia
5.  MCL Insertion
1
2
3
4
5
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Knee Joint Anatomy: Medial Collateral Ligament
Medial Collateral Ligament:
1.  Medial Epicondyle (MCL Origin)
2.  Medial Meniscus
3.  Medial Tibial Plateau
4.  Flair of medial tibia
5.  MCL Insertion
1
2
3
4
5
Medial
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Knee Joint Anatomy: Pes Anserinus Complex
Pes Anserinus Complex:
1.  MCL over Tibial Flair
2.  Shadow of oblique Pes Anserinus
3.  Sartorius
4.  Gracilis
5.  Semitendinosus
1
2
3
4
5
2
Transverse Pes Anserinus
Long Axis Pes Anserinus
Pes Anserine
Knee Joint Anatomy: Meniscus Visualization
•  Not the primary, definitive examination of choice
•  Negative examination does not exclude tear
•  Positive result should be confirmed
•  Medial and lateral menisci partially seen
Normal
Complex Meniscal Cyst
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Knee Joint Anatomy: Meniscus Visualization
Lateral Right Knee
Lateral Left Knee
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Lateral
Knee Joint Anatomy: Iliotibial Band/Tract
Iliotibial Band/Tract:
1.  Gerdy’s Tubercle
2.  Lateral Femur
3.  Lateral Joint Recess
4.  Iliotibial Bursa
5.  Lateral Meniscus
6.  Iliotibial Band/Tract
6
4
3
2
1
5
Lateral
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Knee Joint Anatomy: Lateral Colateral Ligament
Lateral Colateral Ligament:
1. 
2. 
3. 
4. 
5. 
6. 
7. 
Fibular Head
Lateral Tibia
Lateral Femoral Epicondyle
Lateral Meniscus
Lateral Collateral Ligament
Bicep Femoris Shadow
Popliteus Tendon Groove
5
6
3
7
3
1
2
4
Knee Joint Anatomy: Lateral Colateral Ligament
Lateral Colateral Ligament:
1. 
2. 
3. 
4. 
5. 
6. 
Fibular Head
Lateral Tibia
Lateral Femoral Epicondyle
Lateral Meniscus
Lateral Colateral Ligament
Bicep Femoris Shadow
5
6
3
1
2
4
Posterior Right Knee
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Areas of Interest
•  Criss Cross Sign Semimembranosis and
Medial Head Gastroc
•  Bakers Cyst
•  Posterior Femoral Condyle
•  Posterior Horn Medial Meniscus
•  Vessels
•  PCL
•  Medial/Lateral Gastroc Soleus
Posterior Lateral
Knee Joint Anatomy: Posterior Medial Exam
• Semimembranosus – Gastrocnemius Bursa “Baker’s Cyst”
Posterior Lateral Ganglion Cyst
Not a Bakers Cyst
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Post Horn
Knee Joint Anatomy: Posterior Medial Exam
Semimembranosus – Gastrocnemius Bursa “Baker’s Cyst”
1. 
2. 
3. 
4. 
Medial Femoral Condyle
Articular Cartilage
Semimembranosus
Medial Head of the Gastrocnemius
4
3
2
1
www.anatomy.tv
www.anatomy.tv
Knee Joint Anatomy: Posterior Neurovascular Structures
Posterior Midline Knee:
1.  Tibial Nerve
2.  Popliteal Vein and Artery
3.  Medial Femoral Condyle
4.  Medial and Lateral Gastrocnemius
4
4
1
3
2
4
1
2
2
Transverse Axis
Long Axis
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Knee Joint Anatomy: Posterior Medial Exam
• Semimembranosus – Gastrocnemius Bursa “Baker’s Cyst”
Medial Gastroc Tear
Knee Joint Anatomy: Posterior Medial Exam
• Semimembranosus – Gastrocnemius Bursa “Baker’s Cyst”
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Injection
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Anatomy
Anatomy
1
2
3
4
5
6
1. 
2. 
3. 
4. 
5. 
Subcutaneous Fat
Fascia Layer surround Distal Musculature
Quadriceps Tendon in Transverse (Axial) View
Synovial Capsule and fluid (Compressible)
Pre-Femoral Fat Pad
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Other Procedures: Platelet Rich Plasma Infrapatellar Tendon
References
•  Bouffard JA Ultrasonography of the knee
Semin Musculoskeletal Radiology 1998
2:245-270
Jacobson JA Fundamentals of
Musculoskeletal Ultrasound 224-238
2009
Moore RE Sonography of the Extremities
2007
AIUM Practical Guidelines MSK
Ultrasound
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Knee Joint Anatomy: Meniscus Visualization
Female ATC with palpable medial knee mass.
Knee Joint Anatomy: Posterior Neurovascular Structures
Posterior Midline Knee:
1.  Tibial Nerve
2.  Popliteal Vein and Artery
3.  Medial Femoral Condyle
4.  Medial and Lateral Gastrocnemius
4
4
1
3
2
4
1
2
2
Transverse Axis
Long Axis
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Needle Guidance: Suprapatellar Recess
Needle Guidance: Pes Anserine Bursa
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Michael Namey DO
1953-2014
26