Tendon Sheath Fluid Research Articles

Physical activity increases synovial fluid in ankle tendon sheaths: an adjustment of MR Criteria is needed.

To compare the amount of fluid in synovial sheaths of the ankle before and after running. Our hypothesis was that this amount would increase and that the threshold for what is normally acceptable should be adjusted after physical activity. Twenty-one healthy volunteers (n = 42 ankles) ran for 40min on a treadmill. They underwent 3T MRI before and immediately after running using a dedicated ankle coil. The images were stored and subsequently measured in a standardized way and independently read by two readers for fluid in the tendon sheaths in the retro and inframalleolar area. Statistics were performed for each tendon (Wilcoxon signed rank test), and also for the pooled data. Intraclass correlation coefficients were calculated. For reader 1, for all tendons the values after running increased without reaching statistical significance. For reader 2 this was not the case for all tendons but for most. When all the data were pooled (n = 800 measurements), the statistical difference before and after running was significant (p < 0.001). Data pre and post-running show a trend of increasing synovial fluid, however, not significant for each individual tendon. The pooled data for all tendons, (n = 800) show a statistically significant increase after running (p < 0.001). The clinical implication is that the threshold for normally acceptable fluid should be adjusted if the patient undergoes an MR study after recent physical activity.

Do Not Judge an Ossicle by Its Size: Type 1 Ossicles Associated With Posterior Tibial Tendon Dysfunction.

Patients with type II navicular ossicles have traditionally been considered to be symptomatic, whereas patients with type I and III bones are considered asymptomatic without additional relevant imaging findings. The main objective of this study is to investigate the association of type I os naviculare with clinical symptomology and magnetic resonance imaging findings in comparison to types II and III ossicles. Three hundred nine subjects with accessory navicular bone types were identified, and their associations with focal navicular pain, pes planus alignment, ossicle or proximal navicular bone marrow edema pattern presence (BMEP), and posterior tibial tendon (PTT) sheath fluid distension were assessed. Fisher's exact test was used for categorical data and unpaired t tests for continuous data. Intraobserver and interobserver agreement was calculated. Overall, 28% (85/309) of type I, 57% (176/309) of type II, and 16% (48/309) of type III accessory bones had focal navicular pain (type I vs type II, P = 0.17; type III vs type II, P = 0.001). Thirty-two percent of type I, 38% type II, and 8% type III accessory bones had pes planus (type I vs II, P = 0.3; type III vs type II, P = 0.001). Nine percent of type I, 48% of type II, and 6% of type III accessory bones had BMEP (type I vs II, P < 0.0001; type III vs type II, P = 0.001). Thirty-three percent of type I, 42% of type II, and 6% of type III accessory bones had PTT intrasheath fluid (type I vs II, P = 0.16; type III vs type II, P = 0.001). Symptomatic type I navicular ossicle patients demonstrate an increased tendency to present with early findings of PTT dysfunction and morphologic pes planus to a greater degree than previously recognized. 3.

Tenosynovial fluid as an indication of early posterior tibial tendon dysfunction in patients with normal tendon appearance

Our primary aim was to quantify the posterior tibial tendon (PTT) sheath fluid volume in individuals with the clinical diagnosis of stage 1 posterior tibial tendon dysfunction (PTTD) and no MRI-detectable intra-substance tendon pathology and compare them with patients with other causes of medial ankle pain, also without MRI-detectable intra-substance PTT pathology and with normal controls. We also wanted to determine if there is a fluid measurement that correlates with the clinical diagnosis of PTTD. A total of 326 individuals with medial ankle pain and no intra-substance PTT pathology were studied. Group 1 included 48 patients with a clinical diagnosis of stage 1 PTT dysfunction, group 2 comprised 278 patients with other causes of medial ankle pain, and a third control group consisted of 56 patients without any medial ankle pain. MRI-based geometric measurements included PTT fluid volume, maximum cross-sectional fluid area, and fluid width. Fluid measurements were compared between groups and measurement reliability was tested. Group 1 showed greater PTT fluid volume, area, and width compared with groups 2 (other causes of medial ankle pain) and 3 (asymptomatic controls) (all p values < 0.001). A 9-mm threshold maximum fluid width was associated with PTTD (sensitivity 84%, specificity 85%). Measurements were reliable (all p values < 0.03) among three observers blinded to the gold standard. Patients with stage 1 PTT dysfunction displayed greater volumes of tendon-sheath fluid than those with other causes of medial ankle pain and compared with asymptomatic controls. A threshold maximum fluid width greater than or equal to 9mm distinguishes those with PTTD. An association between tendon sheath fluid distension and the clinical diagnosis of stage 1 posterior tibial tendon disease in the setting of no MRI-detectable intra-substance tendon pathology may allow for differentiation of medial ankle pain from other sources and may allow for early intervention aimed at preventing progressive PTTD. The level of evidence was prognostic (level III).

Frequency of inflammatory-like MR imaging findings in asymptomatic fingers of healthy volunteers.

To describe the frequency of inflammatory-like findings on MR imaging in asymptomatic volunteers and compare them with patients with known rheumatoid arthritis and psoriatic arthritis. MR images of fingers in 42 asymptomatic volunteers and 33 patients with rheumatoid/psoriatic arthritis were analyzed. The Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid/Psoriatic Arthritis MRI Scoring System (RAMRIS/PsAMRIS) and tenosynovitis scoring system were used to assess: bone marrow edema (BME), erosions, tendon sheath fluid/tenosynovitis, joint effusion, and soft-tissue edema. Findings and scores were compared between volunteers and patients. Inter-reader agreement was calculated (intraclass correlation coefficients, ICC). In volunteers, tendon sheath fluid was very common in at least one location (42/42 volunteers for reader 1, 34/42 volunteers for reader 2). BME, erosions, joint effusion, and soft-tissue edema were absent (except one BME in the 3rd proximal phalanx for reader 1). Tendon sheath fluid scores in volunteers and tenosynovitis scores in patients were high (reader 1, 7.17 and 5.39; reader 2, 2.31 and 5.45). Overall, inter-reader agreement was substantial (ICC=0.696-0.844), except for tendon sheath fluid (ICC=0.258). Fluid in the finger flexor tendon sheaths may be a normal finding and without gadolinium administration should not be interpreted as tenosynovitis. Bone marrow edema, erosions, joint effusion, and soft-tissue edema in the fingers most likely reflect pathology if present.

Pyogenic Flexor Tenosynovitis of the Finger due to Kingella Kingae

To the Editors: Pyogenic flexor tenosynovitis (PFT) is a closed-space infection of the sheath of the fingers’ tendons.1–3 Most of the time, the flexor sheath infection occurs after an injury to the finger, such as deep cut or penetrating trauma.1,3,4 When bacteria penetrate into the sheath, the body has only limited ability to fight off these infections because there is no blood supply to the lubricating synovial fluid within the tendon sheath, rendering the body’s immune system ineffective.1,3,5,6 Most infections are caused by native skin flora, and Staphylococcus aureus is the most common organism.3,4,6,7 Many other microorganisms may be responsible for PFT especially after cat bites, dog bites or even human bites.7 The purpose of this article is to report the first case, to our knowledge, of PFT caused by Kingella kingae in a young child. A 16-month-old Caucasian girl was brought to the emergency department of our hospital complaining of swelling and limited movement of the right ring finger. At the admission, the child was afebrile and the ring finger was slightly swollen, with a red area at the level of the proximal phalanx. The finger was held in extension and spontaneous movements were limited. Laboratory results showed a white blood cell count of 16,000 cells/mm3, an elevated C-reactive protein (28 mg/dL) and an abnormal erythrocyte sedimentation rate (25 mm/h). Magnetic resonance imaging demonstrated a collection in the flexor tendon sheath with moderate soft tissue reaction suggestive of tenosynovitis (Fig. 1). The child underwent surgery to clean out the flexor tendon sheath, accomplished by making 2 small incisions, 1 at the palm and the other near the tip of the finger. At the opening of the sheath, there was an abundant liquid and saline fluid was then washed through the sheath. K. kingae-specific real-time polymerase chain reaction was positive using synovial tendon sheath fluid. The patient was treated with intravenous antibiotics (cefuroxime) initially and switched to oral treatment after 3 days for 10 additional days. The child recovered full mobility of the affected finger.FIGURE 1: 3D SPACE inversion recovery T2 axial (A) and sagittal (B) reconstructions showing collection in the flexor tendon sheath with moderate soft tissue reaction (arrows) suggestive of tenosynovitis.Pyogenic flexor tenosynovitis is an aggressive closed-space infection of the digital flexor sheaths,2,3,7 which is uncommon in children.4 This condition necessitates urgent diagnosis and surgical care,2,8–10 as delay in diagnosis can result in a worse prognosis.8–10 Since the 1980s, the reported number of cases of K. kingae’s osteoarticular infections has markedly increased mainly owing to utilization of molecular methods.11–17 Many studies have demonstrated that K. kingae has become the major bacterial cause of osteoarticular infections in children between 6 and 48 months of age.12–15 However, its role in causing PFT has never been documented, and the present case is the first to be reported. Osteoarticular infections due to this microorganism are characterized by a mild-to-moderate clinical and biologic inflammatory response. Therefore, infected children may present few signs evocative of osteoarticular infections.12,18 Our patient had mild symptoms. PFT due to K. kingae seems to have a less aggressive presentation and course than PFT caused by Staphylococcus aureus or Streptococcus spp. Dimitri Ceroni, MD Pediatric Orthopedic Service Laura Merlini, MD Pediatric Radiology Service Davide Salvo, MD Pierre Lascombes, Professor Victor Dubois-Ferrière, MD Pediatric Orthopedic Service Children's Hospital Geneva Geneva, Switzerland

Abstract P5-11-18: Investigating Early Features of Aromatase Inhibitor-Induced Arthralgia

Abstract Background: Aromatase inhibitors (AI) are well known to be associated with troublesome musculoskeletal side effects but the underlying mechanisms are poorly understood and methods of objective assessment poorly defined. We have performed a prospective detailed evaluation of grip strength (primary endpoint), symptoms, imaging and biomarkers in patients receiving either an AI, tamoxifen or no endocrine therapy. Methods: 77 patients with early breast cancer from two specialist Breast Units were recruited prior to starting one of 4 treatment arms: upfront AI (A), switch from tamoxifen to AI (B), tamoxifen (C) and no treatment (D). Arthralgia was defined as worsening of joint pain score at 3 months and a positive Tinel's or Phalen's test was taken as evidence of carpal tunnel syndrome. Grip strength was measured (average of three readings from each hand) using a Jamar Dynamometer at baseline, 1, 2, 3, 6 and 12 months. In addition, biochemical (endocrine and collagen markers), rheumatological (inflammatory and cytokine markers) and radiological assessments of the hands (diagnostic ultrasound, bone density using DXA and plain radiograph) were performed at protocol-specified intervals. A subset of patients also underwent hand MRI at baseline, 3 and 12 months. Detailed rheumatological examination and questionnaire (DAS-28, SF-36, HAQ-DI and BPI-SF) assessment were performed at each visit. Grip strength was analysed using analysis of covariance with age, prior chemotherapy and baseline grip as covariates. The Kruskal-Wallis test was used for questionnaire data. The 3 month data on grip strength, questionnaire, clinical assessment and hand ultrasound are presented here. Results: 47 patients received an AI (34 upfront, 13 switch), 22 tamoxifen and 8 no endocrine treatment (controls). Median age (yearrs) for each group was: 62.1 (A), 51.0 (B), 65.2 (C) and 61.2 (D). The incidence of arthralgia at 3 months was 38% (A), 17% (B), 38% (C) and 14% (D). Mean baseline grip strength was similar in each arm: 22.5kg (A), 23.1kg (B), 20.2kg (C) and 23.2kg (D) (p=0.342 ANOVA). At 3 months, the mean percentage change in grip strength was +0.2% (A), +2.2% (B), +4.5% (C),+1.2% (D) (p=ns ANCOVA). In those on AI, the development of arthralgia was not shown to be associated with change in grip strength (p=0.82). Morning stiffness was also no different at 3 months. Clinical signs of carpal tunnel syndrome were evident in 10/45 (22%) of patients receiving AI therapy compared to 4/28 (14%) on tamoxifen/control. There were 4 cases of trigger thumb or finger, all in patients receiving AI treatment. Changes in HAQ-DI and pain (VAS) at 3 months were no different between groups (p=0.27, p=0.1 respectively). Ultrasound assessment of the flexor tendons at 3 month identified an increase in median score for tendon sheath fluid in those in the AI groups (3 (AI) v 1 (No AI) p=0.07, Mann-Whitney U test). There was no significant change in average median nerve cross-sectional area at 3 month. Conclusion: This study suggests that patient reported arthalgia does not correlate with early changes in and mean grip strength. However, there may be early signs of carpal tunnel syndrome, trigger finger and fluid in the flexor tendon sheaths detectable by ultrasound. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-11-18.

Cutaneous and Tendon Sheath Mastocytomas with Eosinophilic Joint and Tendon Sheath Effusions in a Horse

Cutaneous and Tendon Sheath Mastocytomas with Eosinophilic Joint and Tendon Sheath Effusions in a Horse

A prospective study of aromatase inhibitor‐associated musculoskeletal symptoms and abnormalities on serial high‐resolution wrist ultrasonography

Nearly half of women treated with aromatase inhibitors (AI) develop AI-associated musculoskeletal symptoms (AIMSS) such as arthralgias, but to the authors' knowledge the etiology is unclear. The upper extremities are frequently affected, especially the wrists, hands, and fingers. AI use may also increase the risk of developing carpal tunnel syndrome. Tendon sheath fluid and tenosynovial changes have been demonstrated by imaging symptomatic patients who were treated with AIs. The authors hypothesized that these abnormalities are correlated with AIMSS. Thirty consecutive patients in whom adjuvant therapy with letrozole or exemestane was initiated on a prospective clinical trial enrolled in a pilot study evaluating tendon and joint abnormalities at baseline and after 3 months of AI therapy. Patients underwent high-resolution ultrasonography of the wrists bilaterally and completed the Health Assessment Questionnaire (HAQ) and pain Visual Analog Scale (VAS). AIMSS were defined as an increase in the HAQ or VAS score during AI therapy that exceeded a predefined cutoff. Twenty-five patients completed both the baseline and 3-month assessments. During the first 12 months of AI therapy, 15 patients developed AIMSS, and 13 discontinued therapy because of musculoskeletal symptoms. There was a trend toward an association between the presence of tendon sheath abnormalities on wrist ultrasound at baseline and the development of AIMSS (P = .06). Clinically relevant musculoskeletal symptoms develop in women treated with AIs, leading to treatment discontinuation in a substantial percentage of these patients. However, in the current study, patient-reported symptoms were not found to be associated with changes visible on wrist ultrasonography.

Association of Aromatase Inhibitor-Associated Musculoskeletal Symptoms with Ultrasonographic Changes at the Wrist.

Abstract Background: About 40% of aromatase inhibitor (AI)-treated women develop AI-associated musculoskeletal symptoms (AIMSS) such as arthralgias, but the etiology is unclear. Tendon sheath fluid and tenosynovial changes have been demonstrated by imaging in symptomatic AI-treated patients. It is unclear if these changes correlate with development of AIMSS.Methods: Thirty consecutive patients (pts) initiating therapy with letrozole or exemestane on a prospective clinical trial were enrolled to this substudy. Pts with prior wrist trauma or who declined to provide informed consent were excluded. Pts underwent high resolution ultrasonography (US) of the wrists bilaterally and completed the Health Assessment Questionnaire (HAQ), pain Visual Analog Scale (VAS), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire at baseline (BL) and after 3 mo of AI. AIMSS was defined as increase in HAQ or pain VAS score during AI therapy that exceeded a predefined cutoff. Analysis of US images was performed in a blinded manner. Imaging abnormalities included the following: presence of fluid, synovitis, and/or hyperemia in the tendon sheath or joint recess. Statistical analysis was performed using univariate chi-square tests and logistic regression analyses.Results: Of the 30 enrolled subjects, 25 completed both BL and 3 mo assessments. Eight of 30 (27%) discontinued therapy because of AIMSS (2 before and 6 after the 3 mo timepoint), and 3 patients discontinued therapy for unrelated reasons. All patients have been followed for at least 6 mo. We observed a significant association between early treatment discontinuation and change in HAQ (Odds Ratio (OR) 1.525, p=0.0006) and VAS (OR 1.307, p=0.0096) but not DASH (OR 1.001, p=0.96) scores between BL and 3 mo. The proportion of pts with abnormalities on US at BL or that developed during therapy is given in tables 1 and 2, respectively. We did not observe a statistically significant correlation between objective abnormalities on US at BL or following initiation of AI therapy and the development of AIMSS or early treatment discontinuation because of AIMSS.Conclusions: Clinically relevant musculoskeletal symptoms develop in AI-treated women, leading to treatment discontinuation in a substantial percentage. However, patient-reported symptoms were not associated with inflammatory changes visible on wrist US in this pilot study.Proportion of pts with US abnormalities at BL # with abnl/total ptsof pts with AIMSS, # with US abnlof pts without AIMSS, # with US abnlof pts who d/c AI b/c AIMSS, # with US abnlof pts who continued AI, # with US abnlAny anatomic site27/30 (90%)9/10 (90%)18/20 (90%)7/8 (88%)20/22 (91%)--Tendon sheath14/30 (47%)7/10 (70%)7/20 (35%)5/8 (63%)9/22 (41%)--Joint recess24/30 (80%)6/10 (60%)18/20 (90%)6/8 (75%)18/22 (82%) Proportion of pts who developed new abnormalities on US during AI therapy # with abnl/total ptsof pts with AIMSS, # with US abnlof pts without AIMSS, # with US abnlof pts who d/c AI, # with US abnlof pts who continued AI, # with US abnlAny anatomic site13/25 (52%)5/9 (56%)7/16 (44%)4/6 (67%)7/19 (37%)--Tendon sheath5/25 (20%)2/9 (22%)3/16 (19%)0/6 (0%)5/19 (26%)--Joint recess12/25 (48%)5/9 (56%)6/16 (38%)4/6 (67%)6/19 (32%) Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 802.

Ultrasound of the ankle.

Ultrasound of the ankle.

MRI findings of juvenile psoriatic arthritis

The aim of this study was to describe the magnetic resonance imaging (MRI) features of juvenile psoriatic arthritis (JpsA) in children in order to facilitate early diagnosis and proper management. Two pediatric radiologists retrospectively reviewed in consensus a total of 37 abnormal MRI examinations from 31 pediatric patients (nine boys, 22 girls; age range 1-17 years; mean age 9.4 years) who had a definite diagnosis of JpsA and underwent MRI. Each MRI was evaluated for synovium abnormality (thickening and enhancement), joint effusion (small, moderate, and large), bone marrow abnormality (edema, enhancement, and location of abnormality), soft tissue abnormality (edema, enhancement, atrophy, and fatty infiltration), tendon abnormality (thickening, edema, tendon sheath fluid, and enhancement), and articular abnormality (joint space narrowing and erosion). The distribution of abnormal MRI findings among the six categories for the 37 MRI examinations was evaluated. The number of abnormal MRI findings for each MRI examination was assessed. Age at MRI examination and all six categories of abnormal MRI findings according to gender were evaluated. There were a total 96 abnormal MRI findings noted on 37 abnormal MRI examinations from 31 pediatric patients. The 37 abnormal MRI examinations included MRI of the hand (n = 8), knee (n = 8), ankle (n = 5), pelvis (n = 5), temporomandibular joint (n = 4), wrist (n = 3), foot (n = 2), elbow (n = 1), and shoulder (n = 1). Twenty-eight diffuse synovial thickening and/or enhancement were the most common MRI abnormality (29.2%). Joint effusion comprised 22 abnormal MRI findings (22.9%). There were 16 abnormal MRI bone marrow edema and/or enhancement findings (16.7%), and in seven (7.3%) the edema involved non-articular sites. Soft tissue abnormality manifested as edema and/or enhancement constituted 14 abnormal MRI findings (14.5%). There were ten MRI abnormalities (10.4%) involving tendons. Articular abnormality seen as joint space narrowing and/or bone erosion comprised six abnormal MRI findings (6.2%). Most MRI examinations had more than one abnormal finding (84%). Age at which MRI examinations were performed was not significantly different between boys and girls. All six categories of abnormal MRI findings were not significantly different between boys and girls. Children with JpsA typically present with more than one abnormal finding on their MRI studies. While synovial abnormality is the most common MR finding in children with JpsA, multi-focal bone marrow edema and enhancement at both articular and non-articular sites are also notable findings in children with JpsA. The rate of articular abnormality is much lower in children with JpsA in comparison to adults with psoriatic arthritis. Our findings suggest that MRI can play a useful role in the diagnosis and ongoing assessment of this uncommon, though important, pediatric rheumatologic disorder.

Biceps tendon tenosynovitis - a sonologic marker of shoulder joint derangement

Objectives: To study biceps tendon sheath fluid collection using musculoskeletal ultrasound and evaluate its cause. Materials and Methods: A total of 15 patients with biceps tendon sheath fluid collection were studied. All these patients presented with history of shoulder pain with inability of overhead abduction of arm and painful circumduction. Discussion: Ten had history of trauma, four had acute trauma and six had an old history of trauma. Five had degenerative shoulder joint disease, out of these two had osteoarthritis and three had rheumatoid arthritis with subacromiodeltoid bursitis. All cases were evaluated on B mode high frequency ultrasound. The gray scale findings were correlated with clinical and arthroscopic findings. These patients were treated conservatively and followed up sequentially. Results: Diagnosis of tendonitis prompted us for a detailed joint examination which revealed rotator cuff tear in eight patients, these tears varied from acute to chronic and partial to complete thickness tears. Five patients had arthritis, two had osteoarthritis with erosion and pitting of the bony groove and three had bursitis secondary to rheumatoid arthritis with tendonitis. Conclusion: The utility of high frequency ultrasound as an imaging technique for biceps tendon is a useful adjunct to clinical examination. The procedure is non invasive, safe without risk of exposure to harmful radiation, cost effective, dynamic and a useful aid in diagnosis. The diagnosis of biceps tendon sheath fluid must prompt a musculoskeletal sonologist for a detailed evaluation of the shoulder.

Surface-active phospholipid (surfactant) in equine tendon and tendon sheath fluid

AIM: To investigate the presence of surface-active phospholipid (SAPL, or surfactant) in equine tendon and tendon sheath fluid. METHODS: The left front flexor tendon and sheath were removed from five Thoroughbred horses. Phospholipid was extracted from tendon sheath fluid using Folch reagent and quantifi ed using spectroscopy. Transmission electron microscopy (TEM) was used to observe the tendon surfaces. RESULTS: The presence of phospholipid (90.6 (SD 4.3) μg/ml) in tendon sheath fluid, plus the appearance of oligolamellar layers and lamellar bodies on the tendon surface were indicative of SAPL. CONCLUSIONS: Evidence of SAPL was found in equine tendon, and may have a similar lubricating function as reported for synovial joints. CLINICAL RELEVANCE: These findings may have important implications for normal tendon function and possible therapeutic adjuncts for tendon and tendon sheath injuries.

MRI of sports-related injuries of the foot and ankle: part 2

La osteonecrosis del escafoides tarsiano (OET) puede acontecer tanto en la infancia (entidad denominada enfermedad de Köhler) como en la edad adulta. En los niños la enfermedad es infrecuente, se incluye dentro de las osteocondrosis de crecimiento y tiene un buen pronóstico, y en la mayoría de los casos evoluciona hacia la curación espontánea sin secuelas. En el adulto, la OET es también una lesión rara. Existen formas idiopáticas conocidas como enfermedad de Müller-Weiss y formas secundarias que se deben a fracturas del escafoides o aparecen en presencia de factores de riesgo que favorecen la aparición de la enfermedad. La OET idiopática suele presentarse en mujeres de edad media y ser bilateral, mientras que las formas secundarias suelen darse en pacientes jóvenes, sin ningún predominio de sexo y en estos casos la afección es unilateral. A diferencia de la infancia, en la OET del adulto nunca hay curación espontánea. Sin tratamiento la enfermedad presenta invariablemente una evolución crónica y progresa hacia el colapso de la zona necrótica, con deformidad, fisuración y migración del escafoides, y en último término se desarrolla un pie plano y una artrosis astragaloescafocuneana que es causa de dolor, a veces tan intenso que llega a impedir la deambulación del paciente. En estos casos, el diagnóstico y el tratamiento tempranos son cruciales para evitar el desarrollo de secuelas, por lo que la OET debe tenerse siempre en cuenta en pacientes con dolor en el mediopié.Osteonecrosis (ON) of the tarsal navicular bone has been described in children (Köhler's disease) and in adults. Köhler's disease belongs to the group of osteochondroses, is relatively rare, and usually has a self-limited and reversible clinical course. In adulthood, this is also an uncommon entity. There are two distinct forms of this condition: the idiopathic or spontaneous ON also known as Müller-Weiss disease, which appears in patients without risk factors for osteonecrosis, and secondary ON caused by well-recognized predisposing factors or by traumatic injuries. Spontaneous ON or Müller-Weiss disease is seen most frequently in middle- aged women and it's usually bilateral; in secondary ON, the age and sex distribution is dependent upon the primary disease, although it generally affects younger patients without gender differences, and the involvement is unilateral. ON of the adult navicular is usually more severe than Köhler's disease. In absence of treatment, it is characterized by a chronic clinical course, with collapse, deformity and osseous fragmentation, severe and sometimes devastating pain and disability, and progressive flatfoot deformity with secondary talonaviculocuneiform osteoarthritis. A high level of awareness of this condition is needed to prompt diagnosis and treatment before advanced collapse occurs. Although uncommon, it should be included in the differential diagnosis of adult patients with midfoot pain.

MR imaging of the tendons of the foot and ankle.

Hindfoot pain from tendon pathology is common and seen in a wide range of patients from young athletes to older sedentary individuals. Magnetic resonance (MR) is an excellent technique for imaging tendons and for identifying injuries that can be treated with surgery. MR also demonstrates the presence of bone marrow edema, which is a cause of pain and often a marker for adjacent tendon injury. Finally, MR can reveal other etiologies that cause similar hindfoot pain, such as osteochondral injuries and impingement. In this article, we review the normal MR appearance of the ankle tendons and tendon sheath fluid. MR protocols for imaging the various ankle tendon groups are presented. We discuss the MR appearance of tendon pathology, including tendonosis/ tendinopathy, tenosynovitis and peritendonosis, partial and complete tears, subluxation and dislocation, and entrapment. The Achilles, medial, lateral, and anterior tendon groups are discussed separately so as to focus on the MR appearance specific to each region of the ankle.

Tendon involvement in rheumatoid arthritis of the wrist: MRI findings.

To evaluate the distribution and extent of wrist tendon alterations in patients with active rheumatoid arthritis (RA) using magnetic resonance imaging (MRI). Forty-three clinically active RA patients with an illness duration of less than 4 years and no clinical evidence of tendons tears were enrolled in the study. There were 10 men and 33 women, with an average age of 52 years (range 33-63 years). MRI of both wrists, with one exception, was performed at 1.0 T using T1- and T2-weighted sequences (slice thickness 3 mm). Twelve healthy subjects (8 women, 4 men; mean age 31 years) were also evaluated as a control group. Two radiologists reviewed each of four schematic anatomical regions (volar, dorsal, ulnar, radial) for the degree of tendon and tendon sheath alterations using two progressive scales. In the control group all tendons had homogeneous low signal intensity on all sequences. A small amount of fluid was found in six subjects but the diameter was always less than 1 mm. In the patient group minimal fluid (< 2 mm) was found in 35 (41%) wrists, grade 2 fluid (< 2 > 5 mm) in 26 (31%) and grade 3 fluid (> 5 mm) in 24 (28%). Fifty-nine (69%) of the grade 1 changes were in the volar compartment but grade 2 involvement was evenly distributed. Grade 3 changes were most common in the dorsal compartment and combined grade 2 and 3 in the dorsal and ulnar compartments were 32 (38%) and 25 (30%) compared with 16 (18%) and 17 (20%) respectively in the volar and radial compartments. The tendons were normal (grade 0) in 47 (46%) wrists. A maximum tendon signal change (grade 1) was demonstrated in 28 wrists (32%). When associated with other individual tendons grades this grade was demonstrated in the dorsal compartment in 30 (35%) wrists, in the volar compartment in 12 (14%), in the radial compartment in 17 (20%) and in the ulnar compartment in 26 (30%). A partial tear (grade 2) was detected in 7 (8%) wrists, all involving the dorsal and ulnar compartments; five underwent surgical repair and one proved to have a complete rupture of extensor digitorum. Three (3%) had a grade 3 complete tendon tear: all of these were in extensor tendons. Surgical repair was successful in one case but two ruptured again within 3 months. Low grades of peritendinous effusion were more common in the volar compartment whereas moderate and high degrees of tendon sheath fluid collection and/or pannus and signs of tendonitis were more frequent in the dorsal and ulnar tendon sheaths.

Sonographically detected subacromial/subdeltoid bursal effusion and biceps tendon sheath fluid: reliable signs of rotator cuff tear?

Our purpose was to determine the association between sonographically detected subacromial/subdeltoid (SA/SD) bursal and biceps tendon sheath effusions and arthrographically proven rotator cuff tears. Shoulder sonography reports and sonograms of 105 shoulders in 102 patients who also underwent arthrography were retrospectively reviewed for the presence of fluid within the biceps tendon sheath and SA/SD bursa. Reports and sonograms for 151 asymptomatic shoulders were also reviewed. Biceps tendon sheath effusion and/or bursal fluid were detected in 50 (48%) of 105 shoulders. Fifty-one patients had rotator cuff tears; 28 of them had effusions at 1 or both sites. The sensitivity, specificity, and positive predictive value (PPV) of biceps tendon sheath effusions for diagnosing rotator cuff tear were 35%, 74%, and 56%, respectively. For SA/SD bursal effusions, the sensitivity, specificity, and PPV were 8%, 94%, and 57%, respectively. For combined biceps tendon sheath and bursal effusions, the sensitivity, specificity, and PPV were 12%, 91%, and 54%, respectively. There was no statistically significant association between rotator cuff tears and effusions in the biceps tendon sheath, SA/SD bursa, or both. Among the 151 asymptomatic shoulders, 12 (7.9%) had biceps tendon sheath fluid, 5 (3.3%) had SA/SD bursal effusion, and 2 (1.3%) had both biceps tendon sheath and bursal effusions. The sonographic detection of intraarticular fluid, SA/SD bursal fluid, or both has a low sensitivity and PPV in the diagnosis of rotator cuff tears. Isolated intra-articular and/or SA/SD bursal effusions are not reliable signs of rotator cuff tear.

Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US.

To determine the amount and distribution of synovial fluid detectable with ultrasonography (US) of the hindfoot and ankle in asymptomatic volunteers. US was performed with a 7.5- or 10-MHz linear transducer of 60 hindfeet and ankles in 30 volunteers. Presence and amount of fluid were assessed in the ankle joint recesses, adjacent bursae, and tendon sheaths. Symmetry of bilateral fluid was evaluated. Fluid was detected in the anterior recess in 20 ankles (bilaterally in eight volunteers), retrocalcaneal bursa in 30 ankles (bilaterally in 12 volunteers), posterior tibial tendon sheath in 46 ankles (bilaterally in 19 volunteers), and common peroneal tendon sheath in seven ankles (bilaterally in three volunteers). No fluid was seen in the posterior recess. On average, symmetry was present for only the retrocalcaneal bursal and peroneal tendon sheath fluid. US of the hindfoot and ankle commonly depicts articular, bursal, and tendon sheath fluid in asymptomatic volunteers. The presence of fluid in these locations, even when unilateral or asymmetric, does not necessarily imply underlying abnormality.

Fluid in normal and abnormal ankle joints: amount and distribution as seen on MR images.

The appearance of fluid in tendon sheaths of the ankle joint and in ankle articulations seems to vary. To determine the degree of this variability and to see if fluid occurs in normal ankles, we evaluated the presence, amount, and distribution of joint fluid as seen on MR images of normal and abnormal ankles. The study included 40 normal ankles of volunteers, 15 ankles of patients with disorders of the posterior tibial tendon, 73 ankles of patients with disorders not involving tendons studied (occult fractures, osteochondritis dissecans, and Achilles tendon disorders), and 46 asymptomatic ankles of patients with disorders of the opposite ankle. We analyzed the MR images of these ankles to determine the volume of fluid in the ankle and subtalar joints. We also analyzed the relative volumes of fluid in tendon sheaths. We then compared the results in patients who had symptoms with those in asymptomatic subjects and developed an algorithm of fluid interrelationships. Most patients had fluid in the ankle (77%) and subtalar joints (72%). Fluid was common around all tendons except the extensor tendons. Large amounts of fluid were particularly common around the flexor hallucis longus tendon (14%). No statistically significant difference in the prevalence or relative volumes of fluid in the subtalar or ankle joints or tendon sheaths was found between normal and abnormal ankles. A close relationship was found between volumes of fluid between tendons, usually those in close proximity to each other. We found no correlation between fluid in the subtalar and ankle joints. Our results show that fluid in the articulations and tendon sheaths of the ankle is common in asymptomatic patients, and the amounts of fluid are not significantly different from the amounts in patients with symptoms. There also appear to be complex interrelationships between fluid seen in the joint and in tendon sheaths.

The contents of macromolecule solutes in flexor tendon sheath fluid and their relation to synovial fluid: A quantitative analysis

The importance of synovial environment for minimal adhesion formation in flexor tendon healing has recently gained attention. Various techniques have been used to restore an injured synovial tendon sheath. Therefore a quantitative analysis of flexor tendon sheath fluid is of interest to increase our knowledge about the specific synovial milieu and to evaluate the success of different types of sheath reconstructions from a biochemical point of view. Samples of tendon sheath fluid from trigger digits and tendon sheaths containing ganglions have been assayed for contents of hyaluronic acid and proteins of different molecular weights. The results show concentrations of hyaluronate and several proteins similar to those in normal joint fluid. These results indicate that flexor tendon sheath fluid has a character similar to synovial fluid of joints and apparently has specific functions such as soft tissue lubrication and nutrition of avascular tendon tissue.