875

Semimembranosus-Tibial Collateral Ligament Bursitis:

MR Imaging Findings

Christopher

P. Rothstein1

Alan Laorr Clyde A. Helms

Phillip F. J. Tirman

PURPOSE. The purpose of this paper is to describe the MR imaging characteristics of semimembranosus-tiblal collateral ligament (SMTCL) bursitis. MATERIALS AND METHODS. Fifteen patients (37-68 years old) with medial joint pain and presumed internal derangements of the knee underwent MR imaging. Fluid collections around the SMTCL were found prospectively in five petients. Our retrospective evaluation of recent MR imaging cases that had been previously diagnosed as pes anserinus bursitis revealed 10 additional cases with similar findings. RESULTS. We believe that SMTCL bursitis clinically explained the patients medial pain In all cases diagnosed prospectively. We gave the additional cases the same diagnosis presumptively. CONCLUSIONS. SMTCL bursitis has a characteristic MR Imaging appearance of
fluid draped over the semimembranosus tendon in the shape of an inverted U. This

entity can clinically mimic more superior and posterior diagnosing SMTCL bursitis
AJR 1996;166:875-877

internal derangement of the knee, typically causing pain to that of pes anserinus bursitis. MR imaging Is useful in and avoiding unnecessary knee arthroscopy.

Several bursae have been described in the medial aspect of the knee which, when inflamed, cause symptoms that can be clinically confusing. Previous reports include the pes anserine bumsa [1] and the tibial collateral ligament bumsa [2]. The semimembranosus-tibial collateral ligament (SMTCL) bumsa has only recently been described [3], with two cases of inflammation of this bumsa identified by the authors. In this study we report 1 5 cases of semimembranosus-tibial collateral hgament bursitis that were depicted by MR imaging.

Materials

And Methods

Fifteen patients (10 women and five men, 37-68 years old) were studied. Five patients with medial joint pain and presumed internal derangement of the knee underwent MR imaging as part of their routine evaluation. All had fluid collections identified around the semimembranosus tendon, which were believed to explain clinically their medial joint symptoms. Additionally, after our review of patients who underwent knee MR imaging from

1993 to 1995 and who had been diagnosed

as having pes anserinus

bursitis,

we identified

Received September 8, 1 995; accepted after revision October 27, 1995. 1 All authors: Department of Radiology, School of Medicine, University of California San Francisco,

10 more patients with the same findings who had been misdiagnosed because we were unfamiliar with this bursa at the time. All images were obtained with a GE Signal .5 Tesla scanner (General Electric, Milwaukee, WI) using an extremity coil; field of view, 14-16 cm; slice thickness, 4 mm; interslice gap, 1 mm; two excitations; and matrix, 256 x 192.

505 Pamassus Ave., Am. M-392, San Francisco, CA 94143. Address correspondence to C. A. Helms. 0361 -803X196/1 664-875 American Roentgen Ray Society

Sequences included T2-weighted coronal and axial fast spin-echo imaging (TRITE, 28003400/42-54) with an echo train length of eight and fat suppression, and either T2weighted sagittal dual-echo spin-echo (TRITE, 2000-2233/20/80) images or Ti -weighted
sagittal
iOO-135)

(TRITE,
images,

600-833/i
also with

2-20)
an echo

and T2-weighted
train length

fast
of eight.

spin-echo
In one

(TRITE,
patient,

3700-4000/
gradi-

a coronal

ent-echo

sequence

(TRITE,

600/20;

flip angle, 20#{176}) performed. was

876

ROTHSTEIN

ET AL.

AJR:166,

April

1996

Results

Discussion

All 1 5 patients had fluid around the semimembranosus tendon in a shape similar to the inverted U that the bursa has on gross pathologic examination (Fig. 1 ). On coronal and sagittal images, the most proximal portion of the SMTCL bumsa was identified adjacent to the posterior horn of the medial meniscus in every case (Fig. 2). No other significant internal derangements were seen to explain the symptoms in the five patients studied prospectively. (One patient had a small, parrot-beak team of the medial meniscus [Fig. 1 B] that was believed to be clinically incidental.) The clinical diagnosis of SMTCL bursitis was made in these patients when the imaging findings and the physical examination findings were correlated. In the remaining 1 0 patients, we made the presumptive diagnosis because of similarly characteristic findings (although the MR imaging findings and physical examination findings could not be correlated because of the passage of time). Five patients had fluid in more than one medial bumsa, including the pes anseminus and the tibial cohlateral ligament bumsae.

SMTCL bursitis has recently been described in the orthopedic literature [3], but to our knowledge the MR imaging appearance of this bursa has not been reported in the madiology literature. The SMTCL bursa has the shape of an inverted U with a proximal deep pocket and a distal superficial pocket forming the two arms of the U. On both coronal and sagittal images, the proximal pole of the SMTCL bursa can be seen abutting the medial meniscus (Fig. 3). The proximal deep pocket lies between the semimembranosus tendon and the medial tibial condyle. The distal superficial pocket lies between the semimembranosus tendon and the tibial collateral ligament. The two pockets are joined superiorly (forming the base of the U) along the anterosupemiom margin of the semimembranosus tendon [3]. This bumsa is located between the more superior semimembmanosogastmocnemial bumsa and the more inferior bumsa of the pes anseminus (Fig. 4). The SMTCL bumsa does not communicate with either of these bursae or with the knee joint [3]. The proximal end of a normal SMTCL bumsa is

pain. spin-echo (2117/80) images reveal fluid collection draped over semimembranosus tendon with typical Inverted U configuration of semimembranosus-tibial collateral ligament bursa. Superficial (curved arrow) and deep (straight wide arrow) pockets are well visualized. Note parrot-beak medial meniscal tear (B, thin arrow).

Fig. 1 .-49-year-old man with medial knee A and B, Consecutive sagittal T2-weighted

Fig. 2.-5i-year-old dial knee pain when

man who complained of merunning who was believed to

have medial patellar plica syndrome. Coronal gradient-echo (600120/20) MR Image shows fluid collection abutting posterior horn of medial meniscus (arrow). Appearance Is characteristic of semimembranosus-tibial collateral ligament bursitis.

S.M.-GA5TROC. BURSA

Fig. 3.-Sagittal and coronal illustrations show relationship of semimembranosus-tibial collateral ligament bursa to posterior horn of medial meniscus and semimembranosus tendon.

coJ,

.,.SEMEMBRANOSUS

PES

ANSERINUS BURSA

Fig. 4.-Sagittal

illustration de-

SEMiMEMBRANOSUS.TcL

/f

BURSA

picts location of semlmembranosus-tibial collateral ligament (TCL) bursa In relation to pes anserinus and semimembranoso-

SAG1flAL

CORONAL

gastrocnemlal
bursae.

(S.M.-GASTROC.)

AJR:166,

April

1996

SEMIMEMBRANOSUS-TIBIAL

COLLATERAL

LIGAMENT

BURSITIS

877

Fig. 5-51-year-old male with medial knee pain. A, T2-weighted axial fast spin-echo (3200/ 54) image with fat saturation shows semimembranosus-tibial collateral ligament (SMTCL) bursal fluid (thickarrow), fluid in semimembranosogastrocnemial bursa that forms a popliteal cyst (curved arrow), and fluid in tibial collateral ligament bursa (thin arrow). B, T2-weighted coronal fast spin-echo (3200/54) image with fat suppression shows fluid superficial to semimembranosus tendon at level of medial meniscus (arrow), a charac-

....

.. ....

#{149}:

teristic

appearance

of SMTCL bursitis.

l,-..-

-;#{149}k

located where knee joint line extends

During

the semimembranosus posteromedially. The the joint line.

external rotation,

tendon distal end

and valgus

crosses the of the bumsa

stress of

existed
in the

and could fill with fluid. It is not unusual

pes ansennus, the tibial collateral bursae concomitantly

for fluid to gather

or the with semi-

ligament,

1-2 the

cm below

extension,

the

knee,

semimembranosus

tendon

is scissored tibial these

between condyle. cimcumto and often

the taut tibial The SMTCL

collateral ligament and the medial bursa protects the tendon under trauma is usually be acute treatment
is resumed.

stances. Repetitive or acute result in bursitis [3-5]. The can

return

of this

nature

is thought knee pain but

clinical

presentation which with

normal

medial and

tenderness, subside
when

can

or chronic.

The rest

symptoms

conservative
activity

mimic the more

other expected

internal the pain site

derangements and of the tenderness pes and

and anserinus closer

The symptoms can are clinically confusdo not occur bumsa, to the joint but line. rather Thus in

ing because superiorly,

usually

posteriorly,

a clinician who is unaware of this newly described entity be inclined to attribute the physical findings to a more
Ous cause, which may lead to unnecessary The findings on MR imaging consist around the semimembmanosus tendon, weighted images and homogeneously T2-weighted for other sequences. causes of medial A careful knee search pain such of

may semi-

arthmoscopy. a fluid collection

with low signal on Tihypenntense signal on should be performed meniscal patellam includes including as medial

team or cyst, medial collateral ligament injury, or medial plica thickening. The imaging differential diagnosis other meniscal popliteal Because
meniscus,

SMTCL bursitis (Fig. 5). The semimembmanosogastmocnemiaI bumsa (responsible for a pophiteal or Bakers cyst) normally ends 1 cm proximal to the joint space. The proximal end of the pes anserinus bumsa is 3-4 cm distal from the joint space. Still, diffementiation can occasionally be difficult because overlap often occurs. One of our cases was mistakenly diagnosed madiogmaphicaily and clinically as pes anserinus bursitis [1]. In this case, the orthopedic surgeon believed the location of the pain was too proximal for a pes ansennus bursitis. He diagnosed medial phica syndrome and recommended surgery. Review of the MR imaging findings convinced him and the radiologist that a probable pes anserinus bursitis was the source of the pain. In fact, it now appears thatthe pain was due to SMTCL bursitis. Patients may be referred to a radiologist for imaging before arthmoscopy. Awareness of the anatomy and the MR imaging appearance of this bumsa is important to establish the correct diagnosis and to avoid unnecessary arthmoscopic surgery. Once other internal derangements are excluded and the conrect diagnosis is made, appropriate conservative therapy can begin. Therapy consists of nonstemoidal anti-inflammatory drugs and cessation of the offending activity through either immobilization or rest. Refractory cases can be treated with intrabursal injections of corticostemoids.
membmanosogastrocnemial

isolated

fluid

collections

and

cystic

masses,

cyst with pamameniscal cyst, dissected joint fluid, the proximal a meniscal

component, ganglion cyst, and pes anserinus bursitis.

REFERENCES
1 . Forbes JR. Helms CA, Janzen DL. Acute pes anserinus bursitis: MR imaging. Radiology 1 995; 194:525-527 2. Lee JK, Yao L. Tibial collateral ligament bursa: MR imaging. Radiology 1991; 178:855-857 3. Hennigan SP. Schneck CD, Mesgarzadeh M, Clancy M. The semimembranosus-tibial collateral ligament bursa. J Bone Joint Surg Am 1994:76A: 1322-1327 4. Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med i988;16:344-346 5. Voshell AF, Brantigan OC. Bursitis in the region of the tibial collateral ligament. J Bone Joint Surg 1944:26:793-798

end ofthe SMTCL bumsa abuts the medial cyst with a pamameniscal component is of a meniscal team that extends into

differentiated

by the absence

the fluid collection. Synovial fluid from the joint can occasionally dissect into the region as well. Knowledge of the anatomy of this bursa should permit differentiation from a pophiteal cyst, tibial collateral ligament bursitis, and pes anseminus bumsitis.The lack of this knowledge led to the misdiagnoses in the 10 cases we diagnosed retrospectively. We simply did not know that this bumsa