Regional pathologies and

evaluation:
Tendon – Muscle – Cartilage
and Nerve
Prof. Dr. İsmet TAMER
İstinye University, Faculty of Medicine
Dept.of Family Medicine
Liv Hospital Bahçeşehir
 Tendons
Terminology
- Tendinopathy: general umbrella term for pain and swelling of a tendon
- Tendinitis
previously popular term largely replaced by tendinopathy
now largely used to refer to an acute inflammatory process, e.g. calcific tendinitis, rheumatoid
arthritis
- Tendinosis
chronic tendon injury with cellular-level damage
some authors specifically define it as tendinopathy of the mid-tendon
- Tenosynovitis: pain and swelling affecting a fully-developed tendon sheath +/- tendinosis
- Tendon entrapment
- Tendon rupture
- Tendon instability (subluxation and dislocation)

Pathology
Tendon pathology can be “degenerative” or “traumatic”, e.g. acute ruptures, lacerations
 Calcific tendinitis
• Calcific tendinitis (or calcific tendonitis) is a self-limiting condition due to the
deposition of calcium hydroxyapatite within tendons, usually of the rotator cuff.
• Typically this condition affects middle-aged patients between the ages of 30 and
60, with a slight predilection for women.
• This condition most frequently affects the rotator cuff of the shoulder including
supraspinatus: 80%,
• infraspinatus: 15%,
• subscapularis: 5%,
• periarticular soft tissues in addition to tendons, ligaments, capsule and bursae.
However, the condition may occur anywhere in the body with the hip and knee
being the other most common locations.
 Supraspinatus tendinitis
(Plain X-ray)
(Calcific deposits are usually visualized as
homogeneous hyperdensity with variable
morphology.)
Calcific tendinitis
(Ultasound image)
(a curvilinear/ovoid calcification with acoustic
shadowing capsular soft tissue swelling)
Supraspinatus calcific tendinitis Supraspinatus calcific tendinitis
(CT) (MRI)

(Hypointense calcium deposits, hyperintense signal

may be present peripherally due to edema,
hyperintense subacromial-subdeltoid bursal fluid)
Tendon rupture
• Tendon tears and ruptures are common and sometimes disabling
injuries.
• In theory, any tendon can potentially rupture but more common
locations include:
• Achilles tendon rupture
• biceps brachii tendon rupture
• hamstring origin complex (ischial avulsion injury)
• peroneus brevis rupture
• quadriceps tendon rupture
 Achilles tendon tear Complete Achilles tendon tear
(MRI – sagittal view) (MRI – sagittal view)

(partial thickness or interstitial tears (a full-thickness tear often shows a tendinous

may show high signal, and tendon gap filled with edema or blood complete
swelling) rupture shows retraction of tendon ends)
Muscles
• Muscle disease is a disorder caused by derangement of the structure
or function of muscle fiber, blood supply and/or connective tissue
element of the muscle.
• The combination of clinical examination and MRI could improve the
accuracy of diagnosis and choice of treatment of patients
with muscular diseases.
• Anatomic muscle pathology variants, while common, do not
produce signal intensity alterations and therefore are easily
overlooked.
• Muscle edema is the most common pattern but is nonspecific, with a
broad differential diagnosis.
Muscle oedema pattern
• Acute or recent muscle injury is
characterised most commonly by
oedema, vascular engorgement and
inflammatory cellular infiltration.

• Figure shows: A 53-year-old female

with muscle oedema after radiation
therapy for lung cancer.
Coronal MR image shows
oedematous and enlarged
paraspinal muscles (arrowheads), in
the radiation field.
 Muscle strain

Α 10-year-old male who sustained a low-grade strain in the rectus femoris muscle, 4 days after an injury that occurred while
playing basketball.
(a) Axial MR image of the anterior thigh demonstrates faint increased signal (arrowhead) in the rectus femoris muscle adjacent
to the thickened myotendinous junction.
(b) Coronal MR image shows hyperintense signal (arrowheads) in the rectus femoris muscle surrounding the thickened
myotendinous junction and tracking along the muscle fascicles, in a feathery pattern (arrow).
Muscle tear
Figure shows: Adductor longus
tear in a 16-year-old male, 2 days
after a bowling injury.

Coronal MR image of the anterior

thigh demonstrates fluid signal
(arrow) collecting at the site of
complete fibre disruption, indicating
a high-grade (Grade 3) injury.
 Cartilage Injury
• The term cartilage injury summarizes a spectrum of different cartilage lesions which is
usually used in the context of hyaline cartilage damage within diarthrodial joints.
• In a narrower sense, the term cartilage injury describes types of articular injury with
sparing of bone and the subchondral bone plate. If the latter is affected this is referred to
as osteochondral injury.
• Cartilage injuries result from trauma or repetitive loading due to overuse and are
caused by different forms of stress and loading forces respectively as compression and
shear forces by direct blunt trauma, indirect impact loading and/or torsional loading.
Tension forces affecting diarthrodial joints mainly act on tendon and ligaments but can
cause secondary cartilage injury.
• Cartilage injuries are best evaluated on MRI, MR or CT arthrography. Features vary
with the type of injury.
• Chondral fractures are fractures that involve the
cartilage only unlike osteochondral fractures where
the articular cartilage, as well as the subchondral
Chondral fractures
bone plate, are involved.
• Pure chondral fragments are not easily detectable
neither on a plain radiograph nor on conventional
computed tomography.
• A focal chondral defect within the articular
cartilage, with chondral fragments is seen on MRI.

• Figure shows: Patellar chondral avulsion fracture

Evidence of full-thickness chondral disruption
(chondral delamination) of retropatellar cartilage of
the medial articular facet at the upper patellar pole
at the insertion of medial patellar retinaculum with
elevated (6 mm) chondral fragment, (4 mm) intra-
articular chondral loose body, and marrow edema of
the upper patellar pole.
• Moderate knee effusion is noted.
• Mild subcutaneous edema and prepatellar bursitis
noted. Painful left knee after direct trauma.
(Sagittal view of) Painful left knee after direct trauma.
 Nerve Injury
• The features of nerve injury on MRI depend on the
pathological events.
• Figure: MRI in a 58-y-old woman with sudden-
onset severe right upper extremity pain and
weakness. She reports history of two episodes of
respiratory viral infection in month preceding
onset of symptoms. Electrodiagnostic studies were
normal.

• MR neurography of brachial plexus was

performed.

• (a) Sagittal fat-saturated image demonstrates

diffuse signal hyperintensity of brachial plexus
nerve roots (arrows).
• Figure: MRI in a 58-y-old woman with
sudden-onset severe right upper
extremity pain and weakness. She
reports history of two episodes of
respiratory viral infection in month
preceding onset of symptoms.
Electrodiagnostic studies were
normal.

• MR neurography of brachial plexus

was performed.

• (b) Coronal MRI after contrast agent

administration for vascular
suppression demonstrates diffuse
signal hyperintensity and thickening of
right brachial plexus (arrows).
 Charcot-Marie-Tooth disease
• Charcot-Marie-Tooth disease is a group of inherited disorders that cause nerve damage. This damage is mostly in the arms and legs
(peripheral nerves). CMT is also called hereditary motor and sensory neuropathy. Figure shows: A 49-year-old man with progressive
left hand and arm weakness and numbness, which started approximately 5 years before the current imaging. Coronal MR images
show hyperintense and enlarged brachial plexus nerve roots and trunks with a preserved fascicular pattern (arrows). There is
asymmetric involvement of the brachial plexus in this case, with the left side more severely affected than the right side.
Thank you for your contribution!

ismet.tamer@istinye.edu.tr
: 0(532)332 09 29
@profdrismettamer