·:{iC0Fp'16ACOFP 53rd Annual Convention & Scientific Seminars

Imaging of Common Orthopedic Pain

Bethany Casagranda, DO

3/18/2016

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Bethany Casagranda, D.O.

Associate Professor Adjunct Temple University

Director, Musculoskeletal Division

Program Director, Radiology Residency

Department of Radiology

Allegheny Health Network

IMAGING OF COMMON ORTHOPAEDIC PAIN

DISCLOSURES

• I have nothing to disclose.

COMMON ORTHOPAEDIC PAIN

• Back

• Shoulder

• Knee

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BACK PAIN

• Most common reasons to seek physician care (2nd only to upper

respiratory infections)

• Single leading cause of disability

• Most cases are musculoskeletal/mechanical

• Minority are caused by serious conditions such as inflammatory

arthritis, infection, fracture or neoplasm

• $50 billion/year

• Experts estimate 80% of population experiences a back problem

in our lifetime

BACK PAIN

ANATOMY PATHOLOGY

• BONES

BACK PAIN

ANATOMY PATHOLOGY

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• FRACTURE• BONES

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE• BONES

• JOINTS

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• BONES

• JOINTS

BACK PAIN

ANATOMY PATHOLOGY

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• FRACTURE

• ARTHRITIS

• BONES

• JOINTS

• LIGAMENTS

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• SPRAIN

• BONES

• JOINTS

• LIGAMENTS

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• SPRAIN

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

BACK PAIN

ANATOMY PATHOLOGY

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• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

• DISCS

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• TEAR/HERNIATION

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

• DISCS

BACK PAIN

ANATOMY PATHOLOGY

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• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• TEAR/HERNIATION

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

• DISCS

• MALALIGNMENT

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• TEAR/HERNIATION

• SCOLIOSIS, SPONDYLOLISTHESIS

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

• DISCS

• MALALIGNMENT

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• TEAR/HERNIATION

• SCOLIOSIS, SPONDYLOLISTHESIS

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

• DISCS

• MALALIGNMENT

NONSPINE

BACK PAIN

ANATOMY PATHOLOGY

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• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• TEAR/HERNIATION

• SCOLIOSIS, SPONDYLOLISTHESIS

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

• DISCS

• MALALIGNMENT

NONSPINE

• INTERNAL ORGANS

BACK PAIN

ANATOMY PATHOLOGY

• FRACTURE

• ARTHRITIS

• SPRAIN

• STRAIN

• TEAR/HERNIATION

• SCOLIOSIS, SPONDYLOLISTHESIS

• RENAL STONES, INFECTION,

VASCULAR (CLOTS,DISSECTIONS)

• BONES

• JOINTS

• LIGAMENTS

• MUSCLES

• DISCS

• MALALIGNMENT

NONSPINE

• INTERNAL ORGANS

BACK PAIN

ANATOMY PATHOLOGY

IMAGING BACK PAIN

• INITIAL ASSESSMENT

• RADIOGRAPHS

• VIEWS

• AP, LATERAL, OBLIQUE(S),

• FLEXION/EXTENSION (INSTABILITY)

• SECONDARY ASSESSMENT

• MRI

• OCCULT FRACTURE (NONDISPLACED, OSTEOPENIC PATIENT)

• DISC DISEASE (RADICULOPATHY)

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IMAGING BACK PAIN

• AP

IMAGING BACK PAIN

• lat

IMAGING BACK PAIN

• oblique

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PARS DEFECTS

IMAGING BACK PAIN

• Flex ex

INSTABILITY

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LUMBAR DISC NOMENCLATURE: VERSION 2.0

Recommendations of the combined task forces of the North

American Spine Society, the American Society of Spine Radiology

and the American Society of Neuroradiology

David F. Fardon, MDa , Alan L. Williams, MDb , Edward J. Dohring, MDc,d, *, F. Reed Murtagh, MDe

, Stephen L. Gabriel Rothman, MDf , Gordon K. Sze, MDg

• mri

NORMAL

• mri

BULGES

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• mri

FISSURES (TEARS)

• mri

HERNIATION ~PROTRUSION

• mri

HERNIATION ~EXTRUSION

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• mri

DISC SEQUESTRATION

• mri

SCHMORL NODE (INTRAVERTEBRAL HERNIATION)

SHOULDER

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SHOULDER PAIN

• DIRECT

• BONE, MUSCLE/TENDON, LIGAMENT, SYNOVIUM, CARTILAGE, LABRUM

• WORSENS WITH MOVEMENT

• REFERRED PAIN

• HEART DISEASE, GALLBLADDER DISEASE

• OFTEN UNAFFECTED BY MOVEMENT

SHOULDER PAIN

• OSTEOARTHRITIS

• ROTATOR CUFF

• BICEPS

• LABRUM

• BONE

OSTEOARTHRITIS

• JOINT SPACE LOSS

• OSTEOPHYTOSIS

• SUBCHONDRAL CYSTIC CHANGES

• PRIMARY IMAGING

• RADIOGRAPH

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OSTEOARTHRITIS - RADIOGRAPH

ROTATOR CUFF

• PARTIAL THICKNESS TEAR

• < 50% Low Grade - Conservative Management

• 50% Intermediate Grade

• >50% High Grade – Surgery

• FULL THICKNESS TEAR

• Specific Tendon, Retraction

• PRIMARY IMAGING

• MRI non-arthrogram

ROTATOR CUFF TEARS - MRI

PARTIAL TEAR COMPLETE TEAR

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LABRUM

• YOUNG ATHLETES

• Thrower Shoulder

• Contact Sports

• CONGENITAL INSTABILITY

• Capacious Capsule

• Abnormal Morphology To Glenoid

• TRAUMA

• DEGENERATIVE

• PRIMARY IMAGING

• MRI arthrogram

BONE

• FRACTURE

• AVN

• SALTER HARRIS 1 – LITTLE LEAGUER SHOULDER

FRACTURE

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AVN

LITTLE LEAGUER – SALTER HARRIS 1

KNEE

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KNEE PAIN

• TRAUMA

• FRACTURE, MENISCAL TEARS, LIGAMENT & TENDON INJURY,

VASCULAR INJURY

• ARTHRITIS

• OA, GOUT, RA

• INFECTION

• MALTRACKING

• POST OP

KNEE PAIN

• TRAUMA

• FRACTURE, MENISCAL TEARS, LIGAMENT & TENDON INJURY,

VASCULAR INJURY

• ARTHRITIS

• OA, GOUT, RA

• INFECTION

• MALTRACKING

• POST OP

• RHEUMATOID

• GOUT

• SERONEGATIVE

SPONDYLOARTHROPATHIES

• P.E.A.R. =

Psoriatic, Enteric, Ankylosing

Spondylitis, Reactive

• OSTEOARTHRITIS

• CALCIUM PYROPHOSPHATE

DEPOSITION (CPPD)

ARTHROPATHY

~pseudogout

ARTHRITIS

PRODUCTIVE EROSIVE

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• RHEUMATOID

• GOUT

• SERONEGATIVE

SPONDYLOARTHROPATHIES

• P.E.A.R. =

Psoriatic, Enteric, Ankylosing

Spondylitis, Reactive

• OSTEOARTHRITIS

• CALCIUM PYROPHOSPHATE

DEPOSITION (CPPD)

ARTHROPATHY

~pseudogout

ARTHRITIS

PRODUCTIVE = OSTEOPHYTES EROSIVE = EROSIONS

• OSTEOPHYTES

• JOINT SPACE LOSS

• SUBCHONDRAL CYSTIC

CHANGES

OSTEOARTHRITIS

OSTEOARTHRITIS

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• CHONDROCALCINOSIS

ASSOCIATION

• PATELLOFEMORAL

PROMINENCE

• ASSYMPTOMATIC VS. ACUTE

ONSET (PSEUDOGOUT)

CPPD ARTHROPATHY

CPPD ARTHROPATHY

RHEUMATOID ARTHRITIS

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GOUT

INFECTION

RED, SWOLLEN JOINT?

• Gout, Pseuodgout (CPPD), Infection?

• STICK A NEEDLE IN IT!

• Gout = urate crystals

• CPPD = calcium pyrophosphate crystals

• Infection = micro, gram stain & cell count

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CONCLUSIONS

• Knowledge of imaging modalities allows the clinician to select the best study

for their patient

• Radiographs remain important for initial assessment of MSK pain evaluating

primarily the bone

• MRI is most sensitive for assessment of the soft tissue structures

• Imaging findings help guide treatment

THANK YOU FOR YOUR

ATTENTION.

REFERENCES

• Cranial Treatment and Spinal Manipulation for a Patient With Low Back Pain: A Case Study Wayne Powell II, DCa, Simone F.C. Knaap, DC, MAppScb, , 22 January 2015

• What is back pain? National Institute of Arthritis and Musculoskeletal and Skin Diseases.

http://www.niams.nih.gov/health_info/back_pain/back_pain_ff/asp. Accessed May 29,

2015.

• Adult acute and subacute low back pain. Bloomington, Minn.: Institute for Clinical

Systems Improvement. http://www.icsi.org/low_back_pain/adult_low_back_pain__8.html.

Accessed June 4, 2015.

• Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the

Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116.

• Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism

and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.

3/18/2016

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REFERENCES

• Time to recognize value of chiropractic care? Science and patient satisfaction surveys cite usefulness of spinal manipulation. Orthopedics Today 2003 Feb; 23(2):14-15.

• Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No.14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December, 1994.

• Goodman D, Burke A, Livingston E. Low Back Pain. JAMA. 2013; 309(16):1738.Prevent back pain. U.S. Department of Health and Human Services. http://healthfinder.gov/HealthTopics/Category/everyday-healthy-living/safety/prevent-back-pain. Accessed May 29, 2015.

• Low back pain. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00311. Accessed May 29, 2015.

• Knight CL, et al. Treatment of acute low back pain. http://www.uptodate.com/home. Accessed May 29, 2015.

REFERENCES

• Firestein GS, et al. Kelley's Textbook of Rheumatology. 9th ed. Philadelphia, Pa.: Saunders Elsevier; 2013. http://www.mdconsult.com/das/book/body/208746819-6/0/1807/0.html. Accessed June 7, 2013.

• Seller RH. Differential Diagnosis of Common Complaints. 6th ed. Philadelphia, Pa.: Saunders Elsevier; 2012:301.

• Anderson BC, et al. Evaluation of the patient with shoulder complaints. http://www.uptodate.com/home. Accessed June 7, 2013.

• Zeiger Roni F. McGraw-Hill's Diagnosaurus 2.0. http://www.accessmedicine.com/diag.aspx. Accessed June 7, 2013.

• Wilkinson JM (expert opinion). Mayo Clinic, Rochester, Minn. June 12, 2013.

• Knee problems. National Institute of Arthritis and Musculoskeletal and Skin Diseases. http://www.niams.nih.gov/Health_Info/Knee_Problems/default.asp. Accessed Jan. 23, 2013.

REFERENCES

• Firestein GS, et al. Kelley's Textbook of Rheumatology. 9th ed. Philadelphia, Pa.: Saunders Elsevier; 2013. http://www.mdconsult.com/das/book/body/208746819-6/0/1807/0.html. Accessed Jan. 23, 2013.

• Anderson RJ, et al. Evaluation of the active adult patient with knee pain. http://www.uptodate.com/home. Accessed Jan. 23, 2013.

• Marx JA, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa.: Mosby Elsevier; 2010. http://www.mdconsult.com/books/about.do?about=true&eid=4-u1.0-B978-0-323-05472-0..X0001-1--TOP&isbn=978-0-323-05472-0&uniqId=230100505-57. Accessed Jan. 23, 2013.

• Common knee injuries. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=A00325. Accessed Jan. 23, 2013.

• Zeller JL, et al. JAMA patient page: Knee pain. Journal of the American Medical Association. 2007;297:1740.

• Laskowski EL (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 28, 2013.

• Calcium pyrophosphate deposition (CPPD). American College of Rheumatology. http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/pseudogout.asp. Accessed Jan. 24, 2013.