Through discussion of some of these cases,
we demonstrate various scenarios presenting to our institution and the patient's outcomes.
Case 1: Achilles rupture in a football player
[Fig. 1 Fig. 2 Fig. 3]: Plain radiographs at the time of injury demonstrating soft tissue swelling and interruption of the normal Achilles outline.
Fig. 2: Achilles tendon rupture: lateral radiograph of left ankle
References: Amanda Isaac
[Fig. 4 Fig. 5 Fig. 6]: MRI imaging at the time of presentation confirming the clinical and radiographic findings,
demonstrating the full extent of injury.
Fig. 4: Achilles rupture: Sagittal T1 TRIM MRI
References: Amanda Isaac
[Fig. 7 Fig. 8] : Post operative imaging 9 months later showing adequate healing and suture materials in situ,
on a background of tendonosis and soft tissue oedema.
Fig. 7: Post operative achilles tendon repair Sagittal TRIM MRI of left ankle
References: Amanda Isaac
Outcome: The patient made an uneventful recovery following repair.
Case 2: Acromioclavicular joint synovitis and subchondral marrow changes in a weightlifter
[Fig. 9 Fig. 10 Fig. 11] : MRI imaging of the right acromioclavicular joint.
Fig. 10: Coronal PDFS MRI demonstrating ACJ and distal clavicle osteolysis, oedema, bursitis, tendonosis and partial thickness tears.
References: Amanda Isaac
Outcome: The patient complained of clicking in his ACJ on specific weight lifting maneouvres (clean and jerk/pressing) and was forced to deload on his usual training weight for all his major lifts.
Symptoms settled conservatively over time.
Case 3: Talar impaction injury:
[Fig. 12 Fig. 13 Fig. 14 Fig. 15] : Anterior inferior talar impaction injury demonstrated on MRI but was radiographically occult.
Fig. 12: Anterior inferior talar fracture impaction injury: Lateral left ankle radiograph
References: Amanda Isaac
Fig. 15: Anterior inferior talar fracture impaction injury: Sagittal STIR MRI
References: Amanda Isaac
Talar impaction injuries either follow an inversion or eversion injury,
and are most common medially.
The talus has no muscle or tendinous attachments and is supported,
only by joint capsules,
ligaments,
and synovial tissues.
Treatment aims at ensuring stability,
removal of malunited bony fragments and strengthening exercises.
Case 4 : Little toe base apophysitis
[Fig. 16 Fig. 17] : Radiographic evidence of Islen’s disease.
Fig. 17: Fifth MT base apophysitis Lateral radiograph of the left foot
References: Amanda Isaac
Iselin disease is an overuse injury caused by repetitive pressure and/or tension on the growth/ossification centre at the base of the fifth metatarsal.
Running and jumping generates a large amount of pressure on the forefoot.
Tight calf muscles are a risk factor for Iselin disease because,
the restriction invariably increases the tension on the growth centre.
Flat feet or highly arched feet are also documented risk factors to developing this particular apophysitis.
Outcome: The patient made a full and uneventful recovery following rest,
anti inflammatory medications and ice packing.
Stretching exercises and foam rolling with myofascial release maneouvres were performed, aimed at releasing the tight calf muscles.
It is worth noting,
that in severe cases,
2-4 weeks of immobilization in a walking cast or boot is the treatment of choice.
Case 5: Bilateral distal tibial stress syndrome in a sprinter
[Fig. 18 Fig. 19 Fig. 20] : MRI imaging demonstrating marrow oedema and no fracture line.
CT is advised if there are any concern for fracture.
Fig. 18: Bilateral distal tibial stress reactions but no fracture: Coronal STIR MRI of the distal tibia and fibula
References: Amanda Isaac
Treatment: rest,
ice packs and periodic elevation.
Outcome: Uneventful recovery.
Case 6: Brachialis Syndrome in a personal trainer who is a keen weightlifter
[Fig. 21 Fig. 22 Fig. 23] : MRI imaging demonstrating isolated muscle belly oedema with no tears.
Fig. 21: Brachialis Syndrome: Axial STIR MRI demonstrating isolated muscle belly oedema and a normal tendon
References: Amanda Isaac
Outcome: Uneventful recovery following complete rest and then gradual return to sports.
Case 7: Chronic adductor avulsion injury and myositis ossificans in a professional footballer
[Fig. 24 Fig. 25 Fig. 26 Fig. 27] : Plain radiographs and MRI imaging demonstrating chronic avulsion of the adductors and calcification,
causing anterior impingement on extreme movements.
Fig. 24: Chronic adductor avulsion and myositis ossificans: AP pelvis radiograph
References: Amanda Isaac
Fig. 26: Chronic adductor avulsion and myositis ossificans: Axial CT
References: Amanda Isaac
Outcome: Following rehabilitation and physiotherapy,
the patient was able to return to a competitive level of sport.
Case 8: Exertional compartment syndrome
[Fig. 28 Fig. 29 Fig. 30 Fig. 31 Fig. 32] : The patient described specific symptoms of thigh and leg pain related to excessive sports and long distance walking or running.
MRI at rest and re-imaging following exercise confirmed the diagnosis.
Fig. 32: Exertional compartment syndrome: Coronal STIR of lower leg 60mins post exercise
References: Amanda Isaac
Outcome: Physical therapy and modalities geared toward decreasing inflammation seem to be of some value in those patients who have mild symptoms.
For those patients failing conservative care,
surgeons have used several approaches for fascial decompression.
Case 9: Anterior compartment syndrome in a rugby player following trauma and muscle tears,
with a large intramuscular haematoma
[Fig. 33 Fig. 34 Fig. 35 Fig. 36 Fig. 37 Fig. 38 Fig. 39 Fig. 40] : Radiographic and MRI imaging of the right thigh.
Intraoperative findings confirmed increased compartmental pressures.
Fig. 33: Compartment syndrome in a rugby player: AP radiograph of right femur
References: Amanda Isaac
Fig. 36: Compartment syndrome in a rugby player: Axial STIR MRI of distal femora
References: Amanda Isaac
Fig. 37: Compartment syndrome in a rugby player: Axial T1 MRI of femora
References: Amanda Isaac
Fig. 38: Compartment syndrome in a rugby player: Coronal T2 MRI of femora
References: Amanda Isaac
Fig. 40: Compartment syndrome in a rugby player: Intra-operative findings, demonstrating severely increased compartmental pressure
References: Amanda Isaac
Outcome: The patient is still in rehabilitation,
6 weeks following the original injury.
Case 10: Muscle contractures following repetitive exercise in a violinist:
[Fig. 41 Fig. 42 Fig. 43 Fig. 44 Fig. 45 Fig. 46 Fig. 47 Fig. 48 Fig. 49 Fig. 50 ]: US imaging demonstrating marked contractures which progressed on subsequent imaging,
as well as loss of normal architecture,
low echogenicity infiltration of the muscle bellies and limitation of movements on dynamic evaluation.
Fig. 41: A young violinist complaining of pain in his digits and hand: Ultrasound examination demonstrating progressive muscle contractures and fibrosis
References: Amanda Isaac
Fig. 46: A young violinist complaining of pain in his digits and hand: Ultrasound examination demonstrating progressive muscle contractures and fibrosis
References: Amanda Isaac
[Fig. 51 Fig. 52 Fig. 53 Fig. 54 Fig. 55] : MRI imaging demonstrating myositis and gradual fibrosis of the muscle bellies,
as well as nodular thickening of the myotendinous junctions.
Fig. 52: A young violinist complaining of pain in his digits and hand: Coronal STIR MRI examination at presentation demonstrating FDP and FDS muscle oedema RSI on a background of progressive muscle contractures and fibrosis
References: Amanda Isaac
Fig. 55: 6 months post presentation: axial T1 MRI demonstrates FDP and FDS muscle oedema RSI with established contractures and fibrosis
References: Amanda Isaac
Outcome: Muscle biopsies and EMGs confirmed the diagnosis and also suggested the presence of an underlying hereditary muscle dystrophy.
Case 11: Young sprinter - avulsion injury of the greater trochanter following a fall,
with direct impact
[Fig. 56 Fig. 57]: MRI imaging
Fig. 56: Greater trochanteric Avulsion fracture in a sprinter: coronal T1 MRI
References: Amanda Isaac
Fig. 57: Greater trochanteric Avulsion fracture in a sprinter: coronal STIR MRI
References: Amanda Isaac
Outcome: Non-weight bearing treatment measures as the patient declined surgery.
Case 12: Hallux toe MTPJ medial collateral ligament grade I/II sprain
[Fig. 58 Fig. 59] : radiographic and MRI imaging
Fig. 58: Hallux valgus MCL big toe sprain and grade II injury: weight bearing AP view of the left foot
References: Amanda Isaac
Fig. 59: Hallux valgus MCL big toe sprain and grade II injury: Coronal PDFS of the left foot
References: Amanda Isaac
Outcome: Following conservative management,
advice against high heeled shoes and custom made insoles,
the patient made an uneventful recovery.
Case 13: Isolated long head of triceps extensive exertional oedema in a keen weightlifter
[Fig. 60 Fig. 61 Fig. 62 Fig. 63 Fig. 64 Fig. 65] : MRI imaging
Fig. 60: Isolated long head triceps injury US
References: Amanda Isaac
Fig. 63: Isolated long head triceps injury US
References: Amanda Isaac
Fig. 65: Isolated long head right triceps injury: axial STIR MRI
References: Amanda Isaac
Outcome: Uneventful recovery following changes in exercises performed in the gym.
Case 14: Partial tear of the patellar tendon in a young athletics competitor
[Fig. 66 Fig. 67 Fig. 68 Fig. 69 Fig. 70]: Plain radiographs and MRI imaging
Fig. 67: Young athletics competitor: Jumper partial avulsion of the patellar tendon: lateral radiograph of the right knee
References: Amanda Isaac
Fig. 68: Young athletics competitor: Jumper partial avulsion of the patellar tendon: Axial PDFS MRI
References: Amanda Isaac
Fig. 69: Young athletics competitor: Jumper partial avulsion of the patellar tendon: Sagittal T1 MRI
References: Amanda Isaac
Outcome: Return to sport following 3 months of conservative management.
Case 15: Syndesmotic rupture in a rugby player
[Fig. 71 Fig. 72 Fig. 73 Fig. 74 Fig. 75 Fig. 76] : Plain radiographs and MRI imaging
Fig. 71: Syndesmotic rupture in a Rugby player: AP plain radiograph of the ankle
References: Amanda Isaac
Fig. 73: Syndesmotic rupture in a Rugby player: Axial T1 MRI of the ankle
References: Amanda Isaac
Fig. 74: Syndesmotic rupture in a Rugby player: Coronal STIR MRI of the ankle
References: Amanda Isaac
Outcome: Return to sport following surgery and 4 months of conservative management.
Case 16: Scapholunate disruption,
instability and synovitis in a retired gymnast
[Fig. 77] : MRI imaging
Fig. 77: Coronal PDFS MRI demonstrating SC disruption, synovitis, scaphoid and radial oedema with instability and TFCC tear
References: Amanda Isaac
Outcome: Surgery and hand therapy markedly improved the patient’s symptoms and improved the strength of the hand and wrist.
Case 17: Stress fracture in a marathon runner
[Fig. 78 Fig. 79 Fig. 80 Fig. 81 Fig. 82 Fig. 83 Fig. 84] : Plain radiographs pre and post operative
Fig. 78: Long distance marathon runner with a right femoral stress fracture: AP pelvis radiograph
References: Amanda Isaac
Fig. 79: Long distance marathon runner with a right femoral stress fracture: lateral femoral radiograph
References: Amanda Isaac
Fig. 80: Long distance marathon runner with a right femoral stress fracture: Intraoperative DHS insertion
References: Amanda Isaac
Fig. 82: Long distance marathon runner with a right femoral stress fracture: Post operative AP pelvis radiograph
References: Amanda Isaac
Outcome: Return to sport following 6 months of rehabilitation post surgery.
Case 18: Stress fractures in the hind foot in a runner following impact on the hurdles track
MRI imaging at presentation [Fig. 84 Fig. 85] and at 6 months follow up [Fig. 86 Fig. 87 Fig. 88 Fig. 89] demonstrating osteochodnraal changes in the talus and resolving oedema in the calcaneus.
Fig. 84: Stress response in the calcanuem and talus: Sagittal T1 MRI at presentation
References: Amanda Isaac
Fig. 85: Stress response in the calcanuem and talus: Sagittal STIR MRI at presentation. Note the extensive and striking marrow oedema
References: Amanda Isaac
At 6 months follow up:
Fig. 88: Stress response in the calcanuem and talus: Sagittal STIR MRI at 6 months follow up
References: Amanda Isaac
Fig. 89: Stress response in the calcanuem and talus: Sagittal T1 MRI at 6 months follow up
References: Amanda Isaac
Outcome: Return to sport following 12 months of conservative management.
Case 19: Ulnar abutment syndrome and TFCC tears in a weightlifter
[Fig. 90] : MRI imaging of the wrist
Fig. 90: Weightlifter, complaining of gradual onset of pain whilst lifting weights in the gym: Coronal PDFS demonstrates ulnar abutment and TFCC Tears
References: Amanda Isaac
Outcome: The patient remains in rehab and is on the waiting list for surgery.
Case 20: Tennis player with ulnar neuritis and triceps tendonosis
[Fig. 91 Fig. 92] : MRI imaging of the elbow
Fig. 91: Ulnar neuritis and triceps tendonosis: Axial PDFS MRI
References: Amanda Isaac
Fig. 92: Ulnar neuritis and triceps tendonosis: Coronal PDFS MRI
References: Amanda Isaac
Outcome: Return to sport following 9 months of conservative management and physiotherapy with improvement in the triceps tendonosis and residual ulnar neuritis.
No subluxation on dynamic evaluation.
Currently considering surgery.
Case 20: Stress fracture in a 12-year-old active child
[Fig. 93 Fig. 94] : Initial plain radiographs
Fig. 93: Stress fracture in the left femur: AP radiograph of the pelvis
References: Amanda Isaac
[Fig. 95 Fig. 96 Fig. 97] : intra-operative
Fig. 95: stress fracture in 12 year old intraoperative imaging
References: Amanda Isaac
[Fig. 98 Fig. 99] : post operative images.
Fig. 98: stress fracture in 12 year old postoperative, post-fixation appearances
References: Amanda Isaac
[Fig. 100 Fig. 101] : Bone scan & SPECT-CT demonstrating partial healing and metabolic activity at the fracture site.
Intact metalware.
No loosening.
Fig. 100: The patient presented with persistent pain 6 months post fracture fixation:
Tc99m HDP Nuclear medicine dynamic and blood pool phases, demonstrating activity in keeping with partial union.
References: Amanda Isaac
Fig. 101: The patient presented with persistent pain 6 months post fracture fixation: Tc99m HDP Nuclear medicine dynamic and blood pool phases, demonstrating activity in keeping with partial union.
References: Amanda Isaac
The DEXA scan and metabolic bone profile were normal.
[Fig. 104 Fig. 105] : The patient complained of pain in the contralateral hip.
MRI demonstrated contralateral psoas tendonosis.
No tears.
There was subtle bilateral sacroiliitis and transitional vertebrae.
Fig. 104: Axial STIR MRI:
-Contralateral iliopsoas tendonosis was also demonstrated 8 months following surgical fixation.
-The ipsilateral hip could not be assessed due to metal artifacts.
References: Amanda Isaac
[Fig. 106 Fig. 107 Fig. 107 Fig. 109] : The patient underwent left femoral osteotomy and fixation.
Subsequent imaging demonstrated gradual healing.
Fig. 106: Now 15 years of age, postoperative PAO
References: Amanda Isaac
Outcome: Gradual return to sport following surgery and conservative management.
Still under orthopaedic follow up.
Fig. 108: Now 15 years of age, postoperative PAO
References: Amanda Isaac
Case 21: Post traumatic myositis ossificans presenting with impingement in a young active student
Fig. 110: Post traumatic myositis ossificans presenting with impingement: AP pelvis radiograph
References: Amanda Isaac
Outocome: The patient had improved range of movement and was able to compete in various sports following surgical excision of the calcific foci.
Surgery was indicated in cases of full thickness or substantial partial thickness tendon tears affecting stability and function,
in unstable complete fractures.
All of our patients received a course of physiotherapy and rehabilitation,
with advice on the return to sports and intensity of training recommended during the rehabilitation period.