MR imaging of the finger tendons: Normal anatomy and commonly encountered pathology

MR imaging has emerged as a powerful tool in the evaluation of soft tissue structures such as the tendons of the hand and finger due to its excellent soft tissue contrast and multiplanar imaging capabilities. In the finger and hand, perhaps more than in any other location in the body, a detailed and intimate understanding of anatomy is crucial for lesion localization, directing clinical management and predicting long-term prognosis. These issues are of paramount importance to both the clinician and imager, both faced with the challenge of the complex anatomy and pathology associated with these delicate structures. The anatomy of the finger including intrinsic and extrinsic muscles, retinacular structures, and tendons will be discussed. The MR imaging features of common lesions of the tendons of the hand and finger will be reviewed.

Supraspinatus tendinosis associated with biceps brachii tendon displacement in a dog

A 4-year-old spayed female Australian Cattle Dog (Blue Heeler) was evaluated because of right forelimb lameness of 5 months' duration. Orthopedic evaluation revealed signs of pain localized to the cranial aspects of both shoulder joints. Via magnetic resonance imaging, the mass of the supraspinatus tendon insertion in both shoulder joints was increased, compared with findings in cadavers of clinically normal dogs; additional imaging procedures revealed that, compared with clinically normal tendons, the tendon had increased signal intensity that was consistent with increased fluid content. The increased supraspinatus tendon mass in each shoulder joint was associated with medial displacement of the biceps brachii tendon, which was more severe in the right limb. Arthroscopic evaluations of both shoulder joints revealed no abnormalities. The dog underwent surgery, and the abnormal parts of the tendons were resected. The most prominent finding on histologic examination of excised tissues was severe myxomatous degeneration. The lameness resolved, and at 22 months after surgery, the dog was reported to have had no recurrence of lameness. The clinical signs and histologic appearance of the tendons in this dog strongly resemble findings associated with tendinosis in humans. Decompression of the biceps brachii tendon may have contributed to the successful outcome after surgery in this dog. Supraspinatus tendinosis should be considered among the differential diagnoses in dogs with uni- or bilateral forelimb lameness.

Extracorporeal shock wave therapy in the treatment of calcific tendinitis of the rotator cuff

BACKGROUND

Low-energy extracorporeal shock wave therapy is an alternative treatment, with limited evidence for effectiveness, for calcific tendinitis of the rotator cuff.

HYPOTHESIS

Objective localization of the calcium deposit by 3-dimensional, computer-assisted navigation reveals superior clinical and radiographic outcomes compared to localization through patient-to-therapist feedback.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

A prospective, randomized, single-blind study was carried out on 50 patients. The population was divided into 2 groups of equal numbers (navigation group and feedback group). In all patients, treatment-resistant pain was evident for longer than 6 months. A total of 3 therapy sessions of constant low-energy focused shock wave therapy was administered in weekly intervals in both groups. Local anesthesia was not applied. Radiographs and clinical assessment, including the Constant and Murley shoulder scoring system and the visual analog scale for pain, were performed both before therapy and after 12 weeks. In the navigation group, the calcium deposit was localized using a radiographically guided, 3-dimensional, computer-assisted device. The feedback group was treated after locating the point of maximum tenderness through palpation by the therapist with feedback from the patient.

RESULTS

Both groups had significant improvements in the Constant and Murley score and the visual analog scale after 12 weeks. The results from the navigation group were statistically significantly superior to those of the feedback group. In the navigation group, 6 calcium deposits disappeared and 9 altered, compared to 1 disappearance and 12 alterations in the feedback group. No severe complications occurred.

CONCLUSION

Three-dimensional, computer-assisted navigation reveals significantly better results and is therefore recommended when extracorporeal shock wave therapy is used in the treatment of calcific tendinitis of the rotator cuff.

Are there age induced morphologic variations of the superior glenoid labrum? About 100 shoulder arthroscopies

Different anterosuperior aspects of the glenoid labrum have already been described and are thought to be normal anatomical variations. The goals of this study were first to characterize these anterosuperior labral morphologies and then to analyze their variations in function of the patients' age. One hundred shoulder arthroscopies were recorded to study the macroscopic characteristics of the anterosuperior labrum of the glenohumeral joint and its relationships with the proximal insertion of the tendon of the long head of the biceps. Then, patients were divided into two groups in function of their age (below and over 30 years old). Morphological modifications of the labrum were found in function of the age of the patient with an increase of the nonpathologic "mobile labrum" type after 30 years (P=0.0423). Therefore a mobile and loosely attached superior labrum should not always be considered as abnormal, especially in case of patient older than 30 years.

Reliability in the assessment of tendon volume and intratendinous signal of the Achilles tendon on MRI: a methodological description

The purpose is to introduce a method for accurately and objectively evaluating volume and mean intratendinous signal within the Achilles tendon using MRI. We prospectively studied MRI from 33 patients with chronic Achilles tendinosis (20 males and 13 females) with a median age of 52 years (range 29-70). In all patients, both Achilles tendons were investigated with T1-WI as well as PD-WI MRI. Thus, 66 Achilles tendons were evaluated in the study. Tendon volume and mean intratendinous signal were evaluated using a computerized 3-D seed-growing technique. In general, the computerized 3-D seed-growing technique resulted in an excellent overall observer reliability of the MRI-measurements. The reliability (R) for tendon volume measurements was highest for the T1-WI sequence (R=97.9%). For the mean intratendinous signal, the PD-WI sequence showed the highest reliability (R=88.1%). The same pattern was present when we studied the coefficient of variation (CV). For the CV, lower figures indicate more reliable estimates. CV was 4.9% for tendon volume and 8.9% for mean intratendinous signal. In conclusion, it could be said that a computerized 3-D seed-growing technique to monitor and evaluate the volume of the Achilles tendon and mean intratendinous signal, using MRI, shows an overall excellent reliability regarding inter- as well as intra-observer reliability.

Achilles tendinosis is associated with sprouting of substance P positive nerve fibres

OBJECTIVES

To identify and characterise nerve fibres and inflammatory alterations in painful Achilles tendinosis and thus gain evidence about the origin of pain in Achilles tendinosis.

METHODS

The composition of 10 tendon samples from patients with a prior history of painful Achilles tendinosis and 10 samples from patients with spontaneously ruptured tendons but no previous pain was compared by immunohistochemistry and conventional histology.

RESULTS

The presence of granulation tissue was shown in 8/10 cases of Achilles tendinosis. Nociceptive substance P (SP) positive nerve fibres were significantly increased, and an inflammatory infiltration comprising B and T lymphocytes was found. Additionally, small foci with iron positive haemosiderophages, indicating prior microtraumatic events, were found in 6/10 samples. None of the spontaneously ruptured tendons contained granulation tissue or haemosiderophages. Inflammatory infiltration in these patients consisted almost exclusively of granulocytes and SP positive nerve fibres were decreased. The density of sympathetic nerve fibres did not differ in the two conditions.

CONCLUSION

Achilles tendinosis is associated with the presence of granulation tissue, haemosiderophages, and SP positive nerve fibres, which may transmit the clinically pertinent pain. Achilles tendinosis may be caused by repeated microtraumata with ensuing organisation that is accompanied by sprouting of nociceptive SP positive nerve fibres.

Mechanism of cell death in inflamed superficial digital flexor tendon in the horse

The aim of the present study was to clarify the presence and determine the role of apoptosis in the degenerative process of the superficial digital flexor tendon (SDFT) in the horse. Samples were obtained from normal and inflamed SDFTs of horses. To detect apoptosis and to identify apoptotic cells, the samples were subjected to immunohistochemical labelling and Western blot analysis. Although a large number of cells in degenerate areas showed positive reactions with caspase-3 and single stranded DNA antibodies, cells in normal tendon samples showed very weak reactions. Excessive apoptosis was confirmed by the results of Western blot analysis, which showed a significant increase in activated caspase-3 protein in the inflamed SDFTs, suggesting that apoptosis occurred in the tendinocytes via a caspase-3-dependent pathway. This is the first report of excessive apoptosis in inflamed SDFT of the horse. The results indicate that apoptosis may play an important role in the process of degeneration of the tendon as well as other tissues.

[MR imaging of tendon diseases. Exemplified using the examples of rotator cuff, epicondylitis and achillodynia]

Diseases of tendons have recently increased in importance. This may be due to the increasing popularity of free time sport, but also to the increasing number of treatment possibilities. The origin of damage to the tendons can be explained by a series of mechanisms, of which reduced tissue perfusion and mechanical irritation with microtrauma, which lead to degeneration, can be considered as the most important. Imaging diagnostics plays a significant role in the diagnosis and planning of the therapy of such illnesses. In addition to the conventional x-ray to determine the position of the joint and bony structures, ultrasound can be used to examine the tendons, bursae and tissue.MRI is an excellent method for examining the pathology of tendons due to its exceptional qualities for imaging tissue and joints as well as its high specificity. Using MRI, it is possible to determine the degree of morphological change, make reproducible examinations, as well as determining comorbidity factors or the reasons for the changes early in the illness. It therefore influences surgical decisions and can play a key role in the planning of operations. MRI arthography can-depending on the question-increase the diagnostic power in cases of alterations in the rotator cuff.

Cervical spine and crystal-associated diseases: imaging findings

The cervical spine may be specifically involved in crystal-associated arthropathies. In this article, we focus on the three common crystals and diseases: hydroxyapatite crystal deposition disease, calcium pyrophosphate dihydrate (CPPD) deposition disease, and monosodium urate crystals (gout). The cervical involvement in crystal-associated diseases may provoke a misleading clinical presentation with acute neck pain, fever, or neurological symptoms. Imaging allows an accurate diagnosis in typical cases with calcific deposits and destructive lesions of the discs and joints. Most of the cases are related to CPPD or hydroxyapatite crystal deposition; gout is much less common.

The biceps tendon footprint

BACKGROUND

By arthroscopy, we observed a phenomenon that, according to our knowledge not previously described, we call the "biceps tendon footprint" (BTF)--an area of chondromalacia beside the bicipital groove.

PATIENTS AND METHODS

We studied 118 shoulder arthroscopies prospectively. We documented whether a BTF could be observed and what the main pathology associated with it was. We used 3 grades of cartilage wear to describe BTF, and we analyzed pathological changes in associated structures (subscapularis, biceps tendon and humeral head).

RESULTS

We found a BTF in 16% of the cases. Associated diagnoses were cuff tears and instabilities, most often multidirectional. We observed all 3 grades of cartilage wear, grade 3 being the commonest. Biceps synovitis occurred more often in the BTF group.

INTERPRETATION

BTF is not a rare phenomenon. Maltraction of the intraarticular biceps tendon in MDI and cuff tears in addition with biceps synovitis appear to cause BTF.

Chronic tendon pathology: molecular basis and therapeutic implications

Tendons are frequently affected by chronic pain or rupture. Many causative factors have been implicated in the pathology, which until relatively recently was under-researched and poorly understood. There is now a greater knowledge of the molecular basis of tendon disease. Most tendon pathology (tendinopathy) is associated with degeneration, which is thought to be an active, cell-mediated process involving increased turnover and remodelling of the tendon extracellular matrix. Degradation of the tendon matrix is mediated by a variety of metalloproteinase enzymes, including matrix metalloproteinases and ‘aggrecanases’. Neuropeptides and other factors released by stimulated cells or nerve endings in or around the tendon might influence matrix turnover, and could provide novel targets for therapeutic intervention.

Neovascularisation in chronic painful patellar tendinosis--promising results after sclerosing neovessels outside the tendon challenge the need for surgery

Sclerosing injections targeting neovascularisation have been demonstrated to give promising clinical results in patients with chronic painful Achilles tendinosis. In this study, fifteen elite or recreational athletes (12 men and three women) with the diagnosis patellar tendinosis/Jumper's knee in 15 patellar tendons were included. All the patients had a long duration of pain symptoms (mean = 23 months) from the patellar tendon, and ultra-sonography + colour doppler examination showed structural tendon changes with hypo-echoic areas and a neovascularisation, corresponding to the painful area. The patients were treated with ultrasound and colour doppler-guided injections of the sclerosing substance Polidocanol, targeting the area with neovascularisation. At follow-up (mean = 6 months) after a mean amount of three treatments, there was a good clinical result in 12/15 tendons. The patients were back to their previous (before injury) sport activity level, and the amount of pain recorded on a VAS-scale had decreased significantly (VAS from 81 to 10). Our findings indicate that treatment with sclerosing injections, targeting the area with neovessels in patellar tendinosis, has the potential to cure the pain in the tendons and also allow the patients to go back to full patellar-tendon loading activity.

Arthroscopic Biceps Tenodesis: Technique and Results in Six Dogs

Biceps tenodesis was performed using an arthroscopic-assisted technique on six dogs diagnosed with chronic bicipital tendon pathology. The technique was performed using two different fixation methods (i.e., cannulated interference screw, cannulated screw and tissue washer). All six dogs had successful outcomes in terms of return to full function at a mean follow-up time of 11.7 months after surgery. Arthroscopic biceps tenodesis is a feasible option for surgical management of biceps tendon pathology, and it may have advantages over open tenodesis and open or arthroscopic tenotomy. Further study is needed before definitive recommendations regarding indications, complications, and prognosis associated with arthroscopic biceps tenodesis can be made.

Correlation between ultrasonographic findings and the response to corticosteroid injection in pes anserinus tendinobursitis syndrome in knee osteoarthritis patients

The objectives of this study were to assess the ultrasonographic (US) findings in patients with knee osteoarthritis (OA) with pes anserinus tendinitis or bursitis (PATB) syndrome and to determine the correlation between the US findings and the response to local corticosteroid injection. We prospectively studied 26 patients with knee OA with clinically diagnosed PATB syndrome. A linear array 7 MHz transducer was used for US examination of the knee. Seventeen patients were injected locally with tramcinolone acetonide in the anserine bursa area. Response to local corticosteroid injection was evaluated by pain visual analog scale (VAS), Western Ontario and MacMaster (WOMAC) osteoarthritis index and Global patient/physician assessment using Likert scale. On US examination, only 2 patients (8.7%) showed evidence of PATB. Pain VAS, WOMAC pain index and WOMAC physical function index improved significantly after corticosteroid injection. Global patient assessment revealed that 2 patients showed best response, 6 good, 1 fair, 8 the same, and none worse. It is of note that the 2 patients who showed the best response were those who showed US evidence of PATB. This finding shows that US can serve as a useful diagnostic tool for guiding treatment in PATB syndrome of OA patients.

The causes of pain in benign solitary enchondromas of the proximal humerus

Patients with benign solitary enchondromas of the proximal humerus frequently present to the diagnosing physician with shoulder pain. Once the lesion is considered benign, emphasis can be placed on identifying the etiology for the pain. We reviewed our experience with these patients to identify the cause of the presenting pain. A retrospective review of clinical records and radiographic studies (radiographs, magnetic resonance images, and bone scans) was done for all patients presenting to an orthopaedic oncology unit with solitary enchondroma of the proximal humerus. Attention was focused on diagnostic evidence of additional disease in the shoulder. Fifty-seven patients (mean age, 53.6 years) met the criteria of the study and were included for evaluation. Of patients presenting with pain, 82% (47 of 57 patients) had findings seen on magnetic resonance imaging scans that correlated with the initial clinical diagnostic impression, suggesting that other disease was present that could explain the pain. Solitary enchondromas of the proximal humerus often are found incidentally during the initial evaluation of patients with shoulder pain. This study showed that additional treatable disease usually is present in patients with enchondromas of the proximal humerus.

Extracorporeal shock wave therapy for calcific and noncalcific tendonitis of the rotator cuff: a systematic review

The authors conducted a systematic review to assess the effectiveness of extracorporeal shock wave therapy (ESWT) for the treatment of calcific and noncalcific tendonitis of the rotator cuff. Conservative treatment for rotator cuff tendonitis includes physiotherapy, nonsteroidal antiinflammatory drugs, and corticosteroid injections. If symptoms persist with conservative treatment, surgery is often considered. Extracorporeal shock wave therapy has been suggested as a treatment alternative for chronic rotator cuff tendonitis, which may decrease the need for surgery. Articles for this review were identified by electronically searching Medline, EMBASE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), and Evidence Based Medicine (EBM) and hand-screening references. Two reviewers selected the trials that met the inclusion criteria, extracted the data, and assessed the methodological quality of the selected trials. Finally, the strength of scientific evidence was appraised. Evidence was classified as strong, moderate, limited, or conflicting. Sixteen trials met the inclusion criteria. There were only five randomized, controlled trials and all involved chronic (>/=3 months) conditions, three for calcific tendonitis and two for noncalcific tendonitis. For randomized, controlled trials, two (40%) were of high quality, one (33%) for calcific tendonitis and one (50%) for noncalcific tendonitis. The 11 nonrandomized trials included nine that involved calcific tendonitis and two that involved both calcific and noncalcific tendonitis. Common problem areas were sample size, randomization, blinding, treatment provider bias, and outcome measures. There is moderate evidence that high-energy ESWT is effective in treating chronic calcific rotator cuff tendonitis when the shock waves are focused at the calcified deposit. There is moderate evidence that low-energy ESWT is not effective for treating chronic noncalcific rotator cuff tendonitis, although this conclusion is based on only one high-quality study, which was underpowered. High-quality randomized, controlled trials are needed with larger sample sizes, better randomization and blinding, and better outcome measures.

Arthroscopic treatment of calcifying tendinitis of the shoulder: clinical and ultrasonographic follow-up findings at two to five years

From 1996 to 1999, 95 shoulders with calcifying tendinitis of the rotator cuff were treated arthroscopically by the same surgeon and assigned to the same rehabilitation program. The 63 patients matching the inclusion criteria were reviewed after a mean follow-up of 36 months. Preoperative and postoperative clinical functional assessment was performed separately by the same three surgeons using the Constant method. The Pearson correlation coefficient was used to verify interobserver variability and to correlate the presence of residual calcifications with follow-up Constant scores and preoperative ultrasound findings. At 24 months, improved Constant scores were inversely related to the number and size of residual calcifications in all patients. Ultrasound examination showed no cuff tears. As outcome seemed to relate strongly only to the presence of residual calcium deposits in the tendon, their complete removal is recommended.

Effect of hylan G-F 20 in achilles’ tendonitis: An experimental study in rats11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To investigate the local effects of hylan G-F 20 on locally administered corticosteroid-induced experimental Achilles' tendonitis.

DESIGN

Before-after trial.

SETTING

Institutional practice.

ANIMALS

Convenience sample of 18 male Wistar white rats (weight range, 322-375 g).

INTERVENTIONS

After performing Achilles' degeneration with local corticosteroid injections, the rats were divided into 4 groups. The right Achilles' tendon of the rats served as the hylan injection group and the left tendon as the control group, which was injected with saline at 5-day intervals. The tendons and paratenons were excised at the end of 60 or 75 days and evaluated histopathologically and statistically.

MAIN OUTCOME MEASURE

Histopathologic changes, including staining affinity, nuclear appearance, fibrillar appearance for tendon and thickness, occurrence of fibrosis and edema, capillary changes, and inflammation for paratenon, were assessed according to a semiquantitative scoring system. The Mann-Whitney U test was used for statistical analysis, with a P value of.05 or less considered statistically significant.

RESULTS

Semiquantitative scoring of histopathologic changes showed that histologic appearances differed between the hylan and saline groups and between 2 hylan groups. Hylan-injected tendons and paratenons demonstrated significantly lower scores, especially after 75 days.

CONCLUSIONS

Hylan G-F 20 has a promising curative effect on the tendon and paratenon and can be used in Achilles' tendonitis. This finding should be supported by biomechanical and biochemical studies.

Magnetic resonance imaging of the rotator cuff in destroyed rheumatoid shoulder: comparison with findings during shoulder replacement

PURPOSE

To evaluate the predictive value of preoperative magnetic resonance imaging (MRI) with respect to rotator cuff ruptures.

MATERIAL AND METHODS

Thirty-one patients with rheumatic disease underwent preoperative MRI before shoulder arthroplasty. The scans were reviewed independently by two experienced radiologists. Three surgeons performed all the replacements (hemiarthroplasties), and the condition of the rotator cuff was assessed. Complete and massive tears of the rotator cuff were recorded and compared at surgery and on MRI.

RESULTS

With MRI, 21 shoulders (68%) were classified as having complete or massive tears of the rotator cuff and at surgery 14 shoulders (45%). Cohen's kappa coefficient was 0.44 (95% CI: 0.16 to 0.72) and accuracy 0.71 (95% CI: 0.52 to 0.86).

CONCLUSION

In severely destroyed rheumatoid shoulder, the findings of soft tissues were incoherent both with MRI and at surgery. The integrity of tendons could not readily be elucidated with MRI because of an inflammatory process and scarred tissues; in surgery, too, changes were frequently difficult to categorize. Preoperative MRI of severely destroyed rheumatoid shoulder before arthroplasty turned out to be of only minor importance.

Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-beta1 and IGF-I expression

Extracorporeal shock waves (ESW) have recently been used in resolving tendinitis. However, mechanisms by which ESW promote tendon repair is not fully understood. In this study, we reported that an optimal ESW treatment promoted healing of Achilles tendintis by inducing TGF-beta1 and IGF-I. Rats with the collagenease-induced Achilles tendinitis were given a single ESW treatment (0.16 mJ/mm(2) energy flux density) with 0, 200, 500 and 1000 impulses. Achilles tendons were subjected to biomechanical (load to failure and stiffness), biochemical properties (DNA, glycosaminoglycan and hydroxyproline content) and histological assessment. ESW with 200 impulses restored biomechanical and biochemical characteristics of healing tendons 12 weeks after treatment. However, ESW treatments with 500 and 1000 impulses elicited inhibitory effects on tendinitis repair. Histological observation demonstrated that ESW treatment resolved edema, swelling, and inflammatory cell infiltration in injured tendons. Lesion site underwent intensive tenocyte proliferation, neovascularization and progressive tendon tissue regeneration. Tenocytes at the hypertrophied cellular tissue and newly developed tendon tissue expressed strong proliferating cell nuclear antigen (PCNA) after ESW treatment, suggesting that physical ESW could increase the mitogenic responses of tendons. Moreover, the proliferation of tenocytes adjunct to hypertrophied cell aggregate and newly formed tendon tissue coincided with intensive TGF-beta1 and IGF-I expression. Increasing TGF-beta1 expression was noted in the early stage of tendon repair, and elevated IGF-I expression was persisted throughout the healing period. Together, low-energy shock wave effectively promoted tendon healing. TGF-beta1 and IGF-I played important roles in mediating ESW-stimulated cell proliferation and tissue regeneration of tendon.

An underdiagnosed hip pathology: apropos of two cases with gluteus medius tendon tears

Until recently, gluteus medius tendon tears have been the sort of hip pathology that is relatively unknown in the realm of rheumatology. Their diagnosis can pose a serious challenge to physicians, despite diligence. In this report we summarize two relevant cases and put forward some hints for their evaluation. Magnetic resonance imaging is quite beneficial in demonstrating the pathology and ruling out other likely pathologies after a prompt physical examination. Physicians should exercise care and vigilance in order not to overlook these cases, in which prompt physical examination and radiological interventions remain a prerequisite in the diagnostic algorithm.