ROLE OF MAGNETIC

RESONANCE IMAGING IN
THE DIAGNOSIS OF MUSCLE
INJURY AND STRAIN
By
Khaled AL Sayed Mohammed Shaaban
MBBCh, Alexandria University

Supervisors
Prof. Dr. Mohammed Emad El-Din Mohammed
Professor of Radiodiagnosis,
Faculty of Medicine,
University of Alexandria.

Prof. Dr. Hamdy Khamis Hassan Koryem
Professor of Physical Medicine, Rheumatology and Rehabilitation,
Faculty of Medicine,
University of Alexandria.

Dr. Mohammed Sami Ahmad Barakat
Assistant Professor in Radiodiagnosis,
Faculty of Medicine,
University of Alexandria.

Dr. Abdul-Aziz Mohammed AlNekaidy
Assistant Professor in Radiodiagnosis,
Faculty of Medicine,
University of Alexandria.

INTRODUCTION
Simply, skeletal muscle can be considered to be
composed of two main components: the myofibres
and the connective tissue.
(6)

The myofibres are responsible for the contractile
function of the muscle, whereas the connective
tissue provides the framework that binds the
individual muscle together during contraction.
(6)

Each myofibre is attached at both ends to the
connective tissue of a tendon or the tendon-like
fascia at the so-called myotendinous junctions
(MTJs).
(6)


Muscle Morphology and Anatomy

Structure of myofibre at microscopic level

The myofibre is mainly composed of contractile myofibrils and mitochondria.
These are supported by three levels of connective tissue sheaths:
-The endomysium surrounding individual myofibre.
-The perimysium which is bound myofibres together by into larger structures.
-The epimysium surrounds the entire muscle belly.
Skeletal Muscle Macrostructure

Muscle belly myotendinous junction tendon enthesis
bone/apophysis

Normal muscle has an intermediate-to-long T1 and
short T2 relative to other soft tissues, resulting in
intermediate signal intensity on T1- and T2-weighted
pulse sequences.
On T1-weighted images, the muscles demonstrate a
feathery or marbled appearance due to fat
interspersed between fibers and muscles. Muscle
groups also may be outlined by fat along the fascial
planes.
The tendons are easily identified as discrete linear
low-signal structures on all pulse sequences. The MT
junctions often are located peripherally
Normal Muscle on MRI
Normal muscle anatomy on MR. (a) T1-weighted (b) proton density
(c) T2 turbo spin echo with fat-suppression images of normal
muscles in posterior compartment of the thigh showing
intermediate signal intensity with typical feathery appearance due to
fat interspersed between muscles and fibers. The tendons are easily
identified as discrete linear low-signal structures (arrow) in all pulse
sequences. Arrowhead = MTJ
BASIC MECHANISMS OF MUSCLE
INJURY
Muscle Injuries
Indirect
Trauma
DOMS Muscle Strain
Grade I Grade II
Low Grade (<
1/3)
Moderate
Grade (1/3 - 2/3)
High Grade
(>2/3)
Grade III
Direct Trauma
Blunt
Muscle
Contusion
Penetrating
Muscle Tear
(laceration)
Grade I Grade II Grade III
The major purpose of muscle function is to produce
joint motion. Most muscles cross one joint, but many
muscles span two joints. The most commonly strained
muscles are those that cross two joints and perform
eccentric, rather than concentric contraction.
Eccentric contraction occurs when a muscle fiber is
forced to lengthen when the resisting force is greater
than the force generated by muscle.
Concentric contraction occurs if the resisting load is
less than the force generated by the muscle, thus, the
muscle shortens.
(9)


Mechanism of Muscle Injury

Common imaging techniques available to assess sports-
related muscle injuries include
Radiography
Computed tomography (CT)
Sonography
MRI
Although these techniques can have complementary
roles in achieving the correct diagnosis, each of these
imaging methods has particular indications, strengths,
and limitations
Imaging of Muscle Injury
Although MRI of sports-related muscle injuries is a
nascent field and has limitations (e.g., dynamic and
functional capabilities are not routinely evaluated),
the advantages of MRI include:
The lack of ionizing radiation.
Excellent soft tissue contrast resolution.
Multiplanar tomographic display.
Magnetic resonance imaging facilitates the diagnostic
process by detecting alterations in muscle size, shape,
and signal intensity.
MRI techniques of Muscles Imaging
The MRI protocols used at the same slice location are:
- T1W image
- Proton-density (PD) image
- Fat-suppressed (FS) T2W image.
- STIR

The T1W or PD images are used for anatomic detail and
the FS T2W images for delineation of edema and blood
fluid products

Biomechanical overload during muscle contraction
(e.g., strain).
Muscle contusion due to Blunt trauma.
Delayed-onset muscle soreness.
Muscle tear (laceration) due to penetrating trauma.
Muscle herniation.
Compartment syndrome.
Denervation.
Myositis ossificans.

Common Sports-Related Muscle
Disorders
AIM OF THE WORK
The aim of the work is to demonstrate
the magnetic resonance imaging
features as a non-invasive technique in
muscle injuries and strains.

AIM OF THE WORK
PATIENTS AND METHODS

Inclusion criteria included:
Suspected traumatic muscle injury.
Exclusion criteria included:
Contraindication to MRI.

All patients were subjected to:

1) HISTORY TAKING
2) CLINICAL EXAMINATION
3) Muscle testing:
Muscle testing in the joint involves four motions: flexion,
extension, supination and pronation.
4) RADIOLOGICAL SURVEY:
The plain X-ray conventional views for the affected limb or
body part.
MRI examination of the affected limb or body part.

PATIENTS AND METHODS
RESULTS
The study was conducted on a total of 20 patients with
clinical suspicion of muscle injury; that were referred
from Physical Medicine, Rheumatology and
Rehabilitation Department to Radiology Department,
Alexandria Main University Hospital for further
assessment in the period between 8-04-2012 and 3-05-
2013. All of the patients were included in the results of
this study.

RESULTS
Distribution of the studied group regarding age groups









Age ranged 21-30 and 31-40 had the most frequent number 6
(30%) for each followed by age ranged 11-20 with 4(20%).

Demographic data of the studied
sample
Distribution of the studied group regarding sex

Demographic data of the studied
sample
Distribution of the studied group regarding complain

Clinical History
Distribution of the studied group regarding mechanism
of injury

Clinical History
Distribution of the studied group regarding type of
muscle injury


Type of Muscle injury
Distribution of the studied group regarding complication.

Type of Muscle injury
Distribution of the studied group regarding muscle affected,
puborectalis and popliteus cases were the most frequent 4 (20%)
for each followed by vastus intermedius, vastus medialis,
gastrocnemius, gluteus minimus, rectus femoris and
semitendinosus with the same number 2(10%).

Muscles distribution

Imaging Findings and MRI Signs
Distribution of the studied group regarding muscle
edema.

Muscle edema
Distribution of the studied group regarding degree
of muscle disruption.


Grading of muscle injury:
Degree of muscle disruption
Distribution of the studied group regarding muscle
retraction.

Muscle retraction
Distribution of the studied group regarding T1
finding of hematoma or MO.


Signal intensity of a complicated
cases
In the two types of muscle injury, there was no
statistical significant different between age groups
and types of muscle injury.


Final Diagnosis
In the two types of muscle injury, there was no
statistical significant different between mechanism of
injury and types of muscle injury.

Relation between mechanism and
type of muscle injury
in the two types of muscle injury, there was statistical
significant different between degree of muscle
disruption and types of muscle injury.

Relation between degree and final
diagnosis of muscle injury
presentation Patients
18 years old male playing tycondo with pain in right
thigh since 7-8 weeks.
Case 1
AP radiograph show calcifications in
front of right femur not connected to it.
The deep fibers of the vastus intermedius muscles at the mid thigh
showed heterogeneous T1 iso and T2 hyper intense signal reflect
underlying intramuscular calcification with mild swelling limited to
the deep muscles fibers, the lesion average 8.5x3x2 cm in maximum
dimensions impressive of post traumatic myositis ossificans.

Axial T2WI and Coronal STIR
31 years old male with pain in left knee with history of
day life trauma to left knee.
Case 2
Sagittal T1 of left knee showing multiple soft tissue hematoma
predominately involving medial and lateral heads of gastrocnemius
muscle.
Sagittal T2 showing large amount of free fluid along facial
planes at posterior aspect of left knee.
43 years old male with pain in pelvic support structures
and history of day life trauma.

Case 3
MRI images shows T2
hyperintensity identified along
the 6 O'clock axis of the
puborectalis muscle measuring
around 6.5mm reflecting partial
tear.
22 years old female with pain in left thigh and knee
with history of road traffic accident.
Case 4
Sagittal T1 shows dense soft tissue calcifications
involving the surrounding soft tissues and deep fibers
of vastus medialis muscle reflecting myositis ossificans.

PD-WI shows deformed
appearance of the distal
left femoral metaphyseal
region showing ill-defined
medial cortex with
overlying solid periosteal
reaction and subperiosteal
ossification .
Considering patient's
history of trauma, picture
impressive of healed
incomplete distal femoral
fracture.

52 years old female with pain in pelvic floor with
history of day life trauma.

Case 5
T2WI revealed thinned out both puborectalis muscle
sling with T2 hyperintensity identified along the 7 and 11
o' clock axis with underlying partial tears.
29 years old female complaining of pain in right side of
the pelvis with history of day life trauma.

Case 6
Coronal T2 shows T2 hyper intensity at gluteus minimus
fibers indicating partial thickness tear (grade 2 tear).

Coronal T1 and axial T2 shows T2 hyper intensity at
gluteus minimus fibers indicating partial thickness tear
(grade 2 tear).


32 years old male with pain in the knee region with
history of sport injury.

Case 7
T2WI axial at knee showing T2 hyperintensity at
popliteus muscle with partial thickness tear indicating
grade 2 tear.

T2WI sagittal at knee showing T2 hyperintensity at
popliteus muscle with partial thickness tear indicating
grade 2 tear.


30 years old male with pain and sport knee injury
(Posterolateral corner injury).
Case 8
MRI T1 coronal, T2 Coronal showing T1 hypointense signal
and T2 hyperintense signal involving popliteus muscle fibers
with partial thickness tear (grade 2).


MRI T2 sagittal showing T2 hyperintense signal involving
popliteus muscle fibers with partial thickness tear (grade 2).



20 year old male with left thigh pain, with a history of
injury at football match, with a mass in anteromedial
aspect since 6 months.
Case 9
Axial T2 fat saturation show an area of intermuscular edema
hyperintense signal nearby rectus femoris tendon with
tendon tear.


Coronal T2 fat saturation the edematous area still
hyperintense signal. Another view at sagittal T2 fat
saturation.

40 years old male, had a history of right thigh pain since
7 days. With a history of day life trauma and indirect
muscle injury.
Case 10
Coronal T2 fat saturation, hyperintense signal at
semitendinosus muscle. Coronal T1 image shows
hyperintense signal also.

Sagittal T2 fat saturation shows hyperintense signal also.
Axial T2 image shows hyperintense signal in
semitendinosus muscle.
Axial T1 image shows mild hyperintense signal than the
muscle signal.

CONCLUSIONS
Muscle injury is directly related to activities that increase the
tension and thus the stress on the skeletal muscles.

Care must be taken in order to correct diagnose muscle tears
from other possible lesions or complications of the affected
muscle group.

MR imaging provide a muscle injury assessment and therefore
reveal associated complications or related pathology that may be
responsible for a lack of therapeutic response in patients with
complete muscle fibers tear.

Knowledge of the typical imaging features of muscle injury and
related complications, allows the radiologist to accurately
characterize and grade the injured muscle and guides the
referring clinician toward an appropriate treatment plan.


CONCLUSIONS
MR imaging allows immediate visualization of muscle
injuries not possible with other imaging modalities. To
maximize the effectiveness of MR imaging, the
practitioner must be familiar with the anatomy and
location of the muscle and its normal appearance and must
optimize imaging techniques to achieve the highest
possible spatial resolution, signal-to-noise ratio, and tissue
contrast.

Understanding the normal anatomy of the muscles,
pertinent clinical history and the overhead mechanism of
injury is necessary to interpret imaging appearances of
injury.

CONCLUSIONS
Role of MRI in sports-related muscle injury:
High accuracy rate for the diagnosis of specific muscle
injury.
Detection of sub-clinical injury and define a period of
continued vulnerability.
Distinction between non-operative and surgical conditions.
Accurate pre-operative planning.
Imaging and follow-up of complications like fatty atrophy,
scarring, etc.
Imaging of activity-specific muscle recruitment pattern to
tailor exercise and rehabilitation regimens.