Ara Kassarjian: MRI of the Rectus Femoris - PRP
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This document discusses MRI of injuries to the rectus femoris muscle. It begins with imaging technique recommendations, including using T1, T2, STIR and GRE sequences. It then reviews the anatomy of the rectus femoris. Common injuries in the skeletally immature include apophysitis and avulsion injuries. In skeletally mature patients, injuries often occur at the myotendinous junction or myofascial junction. Various injury patterns like direct tears, indirect tears and intra-muscular degloving injuries are depicted. Potential sequelae from injuries like scarring, heterotopic ossification and subspine impingement are also reviewed.
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Ara Kassarjian: MRI of the Rectus Femoris - PRP
- 1. © 2016 Ara Kassarjian, MD, FRCPC MRI of the Rectus Femoris Ara Kassarjian, M.D., FRCPC Consultant Radiologist Corades, LLC, Madrid, Spain and Brookline, MA, USA Medical Service Madrid Open Tennis Madrid, Spain
- 2. © 2016 Ara Kassarjian, MD, FRCPC Disclosures • Consultant: Arthrosurface
- 3. © 2016 Ara Kassarjian, MD, FRCPC Acknowledgements • Rosa Monica Rodrigo, Bilbao, España • Radiologist • Juan Maria Santisteban, Bilbao, España • Sports Medicine Physician • Óliver Marin-Peña, Madrid, España • Orthopaedic surgeon
- 4. © 2016 Ara Kassarjian, MD, FRCPC Objectives • MR Imaging technique • Anatomy • Common lesions • Skeletally immature • Skeletally mature (adults) • Sequelae of rectus femoris injuries
- 5. © 2016 Ara Kassarjian, MD, FRCPC MR Imaging Technique • Available hardware and software • coils • Location of lesion • Local preferences • More than one way to skin a cat….
- 6. © 2016 Ara Kassarjian, MD, FRCPC MR Imaging Technique • All cases • T1 for anatomy and atrophy • T2 fat sat, intermediate fat sat and/or STIR to detect edema/acute pathology • GRE to detect scars from prior injuries • At least one sequence to compare sides • usually axial for muscle bulk, other lesions
- 7. © 2016 Ara Kassarjian, MD, FRCPC MR Imaging Technique Cor PD FSAx PD Ax PD FS Ax STIR Ax GREAx T1 From: Kassarjian A, et. al. European Society of Skeletal Radiology, Sports Imaging Sub- committee. Guidelines for MR Imaging of Sports Injuries. 2016 http://www.essr.org/cms/website.php?id=/en/index/educational_material.htm
- 8. © 2016 Ara Kassarjian, MD, FRCPC MR Imaging Guidelines www.essr.org From: Kassarjian A, et. al. European Society of Skeletal Radiology, Sports Imaging Sub- committee. Guidelines for MR Imaging of Sports Injuries. 2016 www.essr.org
- 9. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy Rectus femoris Indirect Direct
- 10. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy Rectus femoris Indirect Direct *3rd head?? (recurrent head) Paturet G 1951 Tubbs RS 2006
- 11. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy
- 12. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Indirect Direct
- 13. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy Direct Indirect
- 14. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy
- 15. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy Indirect
- 16. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy
- 17. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy
- 18. © 2016 Ara Kassarjian, MD, FRCPC MR Anatomy
- 19. © 2016 Ara Kassarjian, MD, FRCPC Rectus Femoris Injuries • Skeletally immature • Skeletally mature
- 20. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis** • tendon • myofascial junction • myotendinous junction Rectus Femoris Injuries
- 21. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis** • tendon • myofascial junction • myotendinous junction AIIS Rectus Femoris Injuries
- 22. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • stress injury • “apophysitis” Rectus Femoris Injuries
- 23. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • stress injury • “apophysitis” Rectus Femoris Injuries
- 24. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • stress injury • “apophysitis” Direct Rectus Femoris Injuries
- 25. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • avulsion From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 26. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • avulsion From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Initial injury Rectus Femoris Injuries
- 27. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • avulsion From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 3 months later Rectus Femoris Injuries
- 28. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • avulsion • pseudotumor From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 29. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally immature • point of failure • apophysis • avulsion • pseudotumor From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 30. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Rectus Femoris Injuries
- 31. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Rectus Femoris Injuries
- 32. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Direct From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 33. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Indirect From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 34. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Direct From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 35. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Indirect From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 36. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Rectus Femoris Injuries
- 37. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Scar Rectus Femoris Injuries
- 38. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 39. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Direct From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 40. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • tendon • myofascial junction • myotendinous junction* Direct From: Kassarjian A, Rodrigo RM, Santisteban JM. Current concepts in MRI of rectus femoris musculotendinous (myotendinous) and myofascial injuries in elite athletes. Eur J Radiol. 2012 Rectus Femoris Injuries
- 41. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* Indirect Rectus Femoris Injuries
- 42. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* Indirect Rectus Femoris Injuries
- 43. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* Indirect Rectus Femoris Injuries
- 44. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* • myomyous junction (?) Rectus Femoris Injuries
- 45. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* • myomyous junction • intra-muscular degloving injury Rectus Femoris Injuries
- 46. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* • myomyous junction • intra-muscular degloving injury From: Kassarjian A, Rodrigo RM, Santisteban JM. Intra-muscular Degloving Injuries to the Rectus Femoris: Findings at MR Imaging. AJR 2014 Rectus Femoris Injuries
- 47. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* • myomyous junction • intra-muscular degloving injury From: Kassarjian A, Rodrigo RM, Santisteban JM. Intra-muscular Degloving Injuries to the Rectus Femoris: Findings at MR Imaging. AJR 2014 Rectus Femoris Injuries
- 48. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* • myomyous junction • intra-muscular degloving injury From: Kassarjian A, Rodrigo RM, Santisteban JM. Intra-muscular Degloving Injuries to the Rectus Femoris: Findings at MR Imaging. AJR 2014 calçot Rectus Femoris Injuries
- 49. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • point of failure • myotendinous junction* • myomyous junction • intra-muscular degloving injury From: Kassarjian A, Rodrigo RM, Santisteban JM. Intra-muscular Degloving Injuries to the Rectus Femoris: Findings at MR Imaging. AJR 2014 Rectus Femoris Injuries
- 50. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • other lesions Rectus Femoris Injuries
- 51. © 2016 Ara Kassarjian, MD, FRCPC • Skeletally mature • other lesions Rectus Femoris Injuries
- 52. © 2016 Ara Kassarjian, MD, FRCPC Sequelae of Rectus Femoris Injuries • Scarring • Heterotopic ossification • Pseudotumors • Cysts • Subspine impingement*
- 53. © 2016 Ara Kassarjian, MD, FRCPC • Scarring/atrophy • atrophy often missed on FS images Sequelae of Rectus Femoris Injuries
- 54. © 2016 Ara Kassarjian, MD, FRCPC • Scarring/atrophy • atrophy often missed on FS images Sequelae of Rectus Femoris Injuries
- 55. © 2016 Ara Kassarjian, MD, FRCPC • Scarring/atrophy • GRE for scar • “blooming” Sequelae of Rectus Femoris Injuries
- 56. © 2016 Ara Kassarjian, MD, FRCPC • Heterotopic ossification • easily missed on MR Sequelae of Rectus Femoris Injuries
- 57. © 2016 Ara Kassarjian, MD, FRCPC • Heterotopic ossification • easily missed on MR Sequelae of Rectus Femoris Injuries
- 58. © 2016 Ara Kassarjian, MD, FRCPC • Subspine impingement* Sequelae of Rectus Femoris Injuries
- 59. © 2016 Ara Kassarjian, MD, FRCPC • Subspine impingement* Images courtesy of Oliver Marin, MD, Madrid, ESP Sequelae of Rectus Femoris Injuries
- 60. © 2016 Ara Kassarjian, MD, FRCPC • Subspine impingement* 13 y.o. 14 y.o. 15 y.o. Images courtesy of Óliver Marin-Peña, MD, Madrid, ESP Sequelae of Rectus Femoris Injuries
- 61. © 2016 Ara Kassarjian, MD, FRCPC • Subspine impingement* Images courtesy of Óliver Marin-Peña, MD, Madrid, ESP Sequelae of Rectus Femoris Injuries
- 62. © 2016 Ara Kassarjian, MD, FRCPC Take Home Points • Appropriate MR protocol • www.essr.org (education) • Know your anatomy • direct, indirect • skeletal maturity • Lesions • apophyseal, tendinous, myotendinous, myofascial, degloving (myomyous) • Sequelae
- 63. © 2016 Ara Kassarjian, MD, FRCPC Thank you/Gracias/Gràcies Val d’Aran 2100m
Editor's Notes
- RF underneath the sartorius and TFL
- RF underneath the sartorius and TFL
- Thin arrow indirect tendon Thick arrow direct tendon
- Thin arrow indirect tendon Thick arrow direct tendon
- Thin arrow indirect tendon Thick arrow direct tendon
- partial tear direct head LM
- 3a direct and indirect head tears
- 3b direct and indirect head tears
- 3c partial of direct
- 3d total of indirect
- Fig. 8. (a) Axial fat suppressed T2-weighted image of a female professional European football (soccer) goalie shows myofascial disruption along the posterolateral margin of the middle third of the rectus femoris (thick white arrow). Fluid is seen tracking along the fascia and the belly of the muscle (open arrows). This injury was sustained while kicking the ball. There is also evidence of a small scar from prior myotendinous injury (long thin arrow). (b) Axial T1 weighted (b1) and T2 weighted (b2) images of another professional European football (soccer) player show a posterior myofascial injury (arrow) with fluid accumulating between the posterior muscle fibers and the fascia. This injury was sustained during a sprint.
- Fig. 8. (a) Axial fat suppressed T2-weighted image of a female professional European football (soccer) goalie shows myofascial disruption along the posterolateral margin of the middle third of the rectus femoris (thick white arrow). Fluid is seen tracking along the fascia and the belly of the muscle (open arrows). This injury was sustained while kicking the ball. There is also evidence of a small scar from prior myotendinous injury (long thin arrow). (b) Axial T1 weighted (b1) and T2 weighted (b2) images of another professional European football (soccer) player show a posterior myofascial injury (arrow) with fluid accumulating between the posterior muscle fibers and the fascia. This injury was sustained during a sprint.
- Fig. 6. (a and b) Axial fat suppressed T2-weighted images in two different young semi-professional European football (soccer) players demonstrate an injury to the direct tendon of the rectus femoris (wide arrow) with associated perifascial fluid (thin arrow) predominantly along the anterior aspect of the rectus femoris muscle.
- Fig. 6. (a and b) Axial fat suppressed T2-weighted images in two different young semi-professional European football (soccer) players demonstrate an injury to the direct tendon of the rectus femoris (wide arrow) with associated perifascial fluid (thin arrow) predominantly along the anterior aspect of the rectus femoris muscle.