Dr. Alex Jimenez, El Paso's Chiropractor
I hope you have enjoyed our blog posts on various health, nutritional and injury related topics. Please don't hesitate in calling us or myself if you have questions when the need to seek care arises. Call the office or myself. Office 915-850-0900 - Cell 915-540-8444 Great Regards. Dr. J

Knee Pain & Acute Trauma Diagnosis Imaging Part II | El Paso, TX

Meniscal Tears

knee pain acute trauma el paso tx.
  • Acute or chronic. Imaged with MRI (95% sensitivity & 81% specificity)
  • Menisci are formed by a composition of radial and circumferential collagen fibers (97% type 1) mixed with cartilage, proteoglycans etc. 65-75% H2O
  • Aging can lead to meniscal attrition
  • Acute tears are d/t rotational and compressive forces, ACL deficient knees show greater chances of meniscal tears
  • Posterior horn of medial meniscus is m/c torn except in acute ACL tears when lateral meniscus is m/c torn
  • Meniscus is well vascularized in children. In adults 3-zones exist: inner, middle and outer (above bottom image)
  • Injury of the inner zone has no chance of healing
  • Injury of the outer zone (25% in total) has some healing/repair

Clinical Presentation

  • Pain, locking, swelling
  • Most sensitive physical sign: pain on palpation at the joint line
  • Tests: McMurry, Thessaly, Apply compression in prone
  • Management: conservative vs. operative depends on lacation, stability, patient’s age and DJD and the type of tear
  • Partial meniscectomy is performed. 80% good functions on follow up. Less favorable if >40-y.o and DJD
  • Total meniscectomy is not performed and only viewed historically. 70% OA 3-years after surgery 100% OA after 20 years post surgery.

Axial MR

knee pain acute trauma el paso tx.
  • Appearance the medial (blue) and the lateral meniscus (red)

Menisci Play Significant Role

knee pain acute trauma el paso tx.

Types Location & Stability

knee pain acute trauma el paso tx.
  • Types, location and stability of tears are v. important during MRI Dx
  • Vertical/longitudinal tears especially occur in acute ACL tears. Some longitudinal tears found at the periphery or “red zone” may heal
  • Bucket handle tear: longitudinal tear in the inner edge that is deep and vertical extending through long axis and may displace into notch
  • Oblique/flap/parrot-beak are complex tears
  • Radial tear at 90-degree to plateau

Axial T2

knee pain acute trauma el paso tx.
  • Axial T2 WI fat-sat and coronal STIR slices of the posterior horn of the medial meniscus.
  • Note a radial tear of the posterior horn of the medial meniscus near meniscal root. This is potentially an unstable lesion requiring operative care
  • The meniscus in this case is unable to provide a “hoop-stress mechanism”

MRI Slices Coronal & Sagittal

knee pain acute trauma el paso tx.
  • Fat-sat coronal and sagittal proton density MRI slices revealing horizontal (cleavage) tear that is more typical in the aged meniscus
  • In some cases, when this tear does not contain a radial component it may partially heal obviating the need for operative care

T2 w GRE Sagittal MRI Slice

knee pain acute trauma el paso tx.
  • Complex tear with a horizontal oblique and radial component.
  • This type of tear is very unstable and in most cases may need operative care

Bucket Handle Tear

knee pain acute trauma el paso tx.
  • Bucket handle tear are m/c in the medial meniscus esp. with acute ACL and MCL tear
  • MRI signs; double PCL sign on sagittal slices
  • Absent “bow-tie” sign and others
  • Most cases require operative care

DDx From Meniscal Degeneration

knee pain acute trauma el paso tx.
  • Occaisionally meniscal tears need to be DDx from meniscal degeneration which may also appear bright (high signal) on fluid sensitive MRI
  • The simplest rule is that if there is a true meniscal tear aka Grade 3 lesion it always reaches/extends to the tibial plateau surface

The Role of MSK Ultrasound (US) in Knee Examination

  • MSK US of the knee permits high resolution and dynamic imaging of primarily superficial anatomy (tendons, bursae, capsular ligaments)
  • MSK US cannot adequately evaluate cruciate ligaments and the menisci in their entirety
  • Thus MR imaging remains modality of choice

Potential Pathologies Successfully Evaluated by MSK US

  • Patellar tendionosis/patellar tendon rapture
  • Quadriceps tendon tear 
  • Prepatellar bursitis
  • Infrapatellar bursitis
  • Pes Anserine bursitis
  • Popliteal cyst (Baker cyst)
  • Inflammation/joint effusion with synovial thickening and hyperemia can be imaged with US (e.g. RA) especially with the addition of color power doppler

Patient Presented With Atraumatic Knee Pain & Swelling

knee pain acute trauma el paso tx.
  • Radiography revealed large soft tissue density within superficial pre-patella region along with mild-to-moderate OA
  • MSK US demonstraded large septated heterogeneous fluid collection with mild positive Doppler activity on the periphery indicating inflammation d/t Dx of Superficial pre-patella bursitis

Long Axis US Images

knee pain acute trauma el paso tx.
  • Note normal laterral meniscus and fibers of LCL (above bottom image) compared to
  • Horizontal degenerative cleavage tear along with protrusion of lateral meniscus and LCL bulging (above top image)
  • Major limitation: unable to visualize the entire meniscus and the ACL/PCL
  • MRI referral is suggested

Rupture of Distal Tendon of Quadriceps

knee pain acute trauma el paso tx.
  • Note rupture of distal tendon of the Quadriceps muscle presented as fiber separation and fluid (hypo to anechoic) fluid collection within the substance of the tendon
  • Advantages of MSK US over MRI to evaluate superficial structures:
  • Dynamic imaging
  • Availability
  • Cost-effective
  • Patient’s preparation
  • Disadvantages: limited depth of structures, inability to evaluated bone and cartilage etc.

Osteochondral Knee Injuries (OI)

  • osteochondral knee injuries can occur in children 10-15 y.o presented as Osteochondritis Dissecance (OCD) and in mature skeleton m/c following hyperextension and rotation trauma particularly in ACL tear.
  • OCD-typically develops from repeated forces in immature bone and affects m/c postero-lateral portion of the medial femoral condyle.
  • OI in mature bone occurs m/c during ACL tears particularly affecting so-called terminal sulcus of the lateral femoral condyle at the junction of the weight-bearing portion opposed to tibial plateau an the part articulating with the patella
  • Osteochondral injuries may potentially damage the articular cartilage causing secondary OA. Thus need to be evaluated surgically
  • Imaging plays an important role and should begin with radiography often followed by MR imaging and orthopedic referral.

OCD Knee

knee pain acute trauma el paso tx.
  • 95% associated with some trauma. Other etiology: ischemic bone necrosis especially in adults
  • Other common location for osteochondral injuries: elbow (capitellum), talus
  • 1st step: radiography may detect osteochondral fragment potentially attached or detached
  • Location: posterior-lateral aspect of medial femoral condyle. Tunnel (intercondylar notch) view is crucial
  • MRI: modality of choice >90% specificity and sensitivity. Crucial for further management. T1-low signal demarcating line with T2 high signal demarcating line that signifies detachment and unlikely healing. Refer to orthopedic surgeon
  • Management: stable lesion esp. in younger children>off weight-bearing-heals in 50-75%
  • Unstable lesion and older child or impending physeal closure>operative fixation.
knee pain acute trauma el paso tx.

Knee Trauma

Dr. Alexander Jimenez ♛
Advanced Chiropractic & Wellness Authority ⚕ Healthcare Educator • Injury, Sciatica Specialist • 915-850-0900 📞
We Welcome You 👊🏻. Purpose & Passions: I am a Doctor of Chiropractic specializing in progressive, cutting-edge therapies and functional rehabilitation procedures focused on clinical physiology, total health, practical strength training, and complete conditioning. We focus on restoring normal body functions after neck, back, spinal and soft tissue injuries. We use Specialized Chiropractic Protocols, Wellness Programs, Functional & Integrative Nutrition, Agility & Mobility Fitness Training and Cross-Fit Rehabilitation Systems for all ages. As an extension to effective rehabilitation, we too offer our patients, disabled veterans, athletes, young and elder a diverse portfolio of strength equipment, high-performance exercises and advanced agility treatment options. We have teamed up with the cities premier doctors, therapist and trainers to provide high-level competitive athletes the possibilities to push themselves to their highest abilities within our facilities. We’ve been blessed to use our methods with thousands of El Pasoans over the last three decades allowing us to restore our patients’ health and fitness while implementing researched non-surgical methods and functional wellness programs. Our programs are natural and use the body’s ability to achieve specific measured goals, rather than introducing harmful chemicals, controversial hormone replacement, un-wanted surgeries, or addictive drugs. We want you to live a functional life that is fulfilled with more energy, a positive attitude, better sleep, and less pain. Our goal is to ultimately empower our patients to maintain the healthiest way of living. With a bit of work, we can achieve optimal health together, no matter the age or disability. Join us in improving your health for you and your family. It’s all about: LIVING, LOVING & MATTERING! 🍎 Welcome & God Bless EL PASO LOCATIONS Central: 6440 Gateway East, Ste B Phone: 915-850-0900 East Side: 11860 Vista Del Sol, Ste 128 Phone: 915-412-6677