a Closer Lo k
Inside Medical Imaging of Baltimore
Update on the PET/CT Registry
he NOPR (National Oncologic Pet Registry) was created in May 2006 to study the usefulness of PET scanning and to evaluate its impact on cancer treatment. This study ended in the Spring of 2008 and proposals for change have been sent to CMS. On January 6, 2009, CMS released a proposed National Coverage Determination (NCD), in response to an earlier request by the NOPR. The final NCD is expected in April 2009, just short of this newsletter. It is expected that the NOPR may close if the CMS allows for broader coverage in its new NCD. If this falls short, it is expected the NOPR will pursue a continuation to collect data for non-covered indications. Stay tuned for updates! ■
Spring is upon us and it’s a wonderful sight to see; the sun is shining, the weather is warmer and we are itching to move. We can finally break free of our winter cocoons and enjoy the outdoors. As we become more active, our bodies remind us just how dormant we have been. It’s important to get moving, but it’s most important to do it wisely. If you have any physical problems, it’s important to seek medical advice before starting a workout plan. This advice isn’t limited to weekend warriors, and can apply to anyone increasing their activity level. Injury and re-injury usually occurs when we do too much too soon. When starting a routine, never work out more than every other day. Adding flexibility Muscles need to get stronger slowly. Every workout should start with a Conditioning muscle groups should gentle warm-up. Warm-ups will be specific to the sport in which you increase blood flow to the musare participating. Your activity level cles, add flexibility and decrease should be increased gradually over injury. Athletes need to warm up a long period of time to increase their muscles prior to a workout muscle strength. For the first 4 to and probably just as importantly, 6 weeks, a 10% increase over a they need to cool-down after a week-to-week time frame will lessen work out. Stretching muscles a chance of injury. Consistency is after a workout, when the blood what gets you into shape. Choosing supply to the muscles is at its the right athletic shoes for your foot greatest, will increase flexibility. type and type of sport is essential This will also prevent cramping for your feet and will help your and muscle tears. Walking and workout. Cross training shoes are stretching for 10 minutes will be generally a good bet, but its’ best to very beneficial. choose a shoe designed for your sport. Most importantly, warm up and stretch muscles for approximately 15 minutes prior to any sports activity. If you’ve overdone it and feel an injury coming on, ice the area as soon as possible. ■
MOST COMMON SPORTS INJURIES
he most common sports injuries are sprains, strains, stress fractures and bone injuries. Many of the injuries are overuse injuries, as a result of inadequate conditioning or excessive training. Sprains are injuries to ligaments, the tough fibrous bands that connect bone to bone or cartilage. If you stretch a ligament past its limit, it becomes deformed or tears. A strain is an injury to muscle fiber or tendon, which connects muscle to bone. Another name for a strain is a pulled muscle, because over use and over stretching them will tear fibers near the muscle insertion and cause micro-bleeds.
ACL tears and strains, meniscal tears and patellofemoral syndrome are the most common injuries to the knee. Many of these injuries are a result of improper technique or overuse. The ACL (Anterior Cruciate Ligament) stabilizes the knee joint and is most often injured when the foot is planted and the knee twists to change direction. This is most common in tennis, skiing, basketball, soccer and lacrosse. The dreaded POP sound is heard followed by immediate swelling, loss of range of motion and instability. A partial tear should be stabilized to avoid re-injury, while a complete tear may require surgery. The meniscus is a crescent shaped cushion between the femur and tibia and has both anterior and posterior compartments; each knee has a medial and lateral meniscus. People are still able to walk on a torn meniscus, but when inflammation is present, walking becomes more difficult. Signs of inflammation are: stiffness and swelling, tenderness at the joint line, collection of fluid, catching or locking of the knee, and buckling. The meniscus is one of the most injured parts of the knee. Patellofemoral syndrome, sometimes called runners knee or chondromalacia patella, is characterized by fluid build up and swelling of the knee and pain behind the kneecap or in the back of the knee. Patellofemoral syndrome is
caused by misalignment of the patella in its groove. The patella normally moves up or down in its grove as the knee flexes and straightens. When misalignment happens, the patella pulls off to one side rubs on the grove. This causes wear and tear on the groove and causes the cartilage under the patella to wear out.
INDICATION: Patient presents with throbbing pain and a lump on the bottom of the foot after working out for 3 weeks. RESULT: A Sagittal FSEIR and B FSEIR shows focal thickening and edema within the plantar fascia at the level of the mid foot with overlying subcutaneous soft tissue edema. IB Well defined focus of edema surrounding the plantar surface of the 3rd and 4th metatarsal head most probably representing bursitis or a ganglion cyst.
FOOT AND ANKLE INJURIES
Overuse injuries are common in the foot and ankle in spring sports and include sprains, strains (plantar fasciitis), stress fractures and bone injuries. Most of these injuries are caused from inadequate conditioning or excessive training that puts too much stress on the foot and ankle. Running and tennis injuries include sprains, Achilles tendonitis and plantar fasciitis. Sprains are usually caused when the foot turns inward and stretches the ligaments on the outside of the ankle. Injuries to the Achilles tendon often occur when the tendon is overstretched, as in running up hill. The plantar fascia runs the length of the foot and supports the arch; when this becomes inflamed, it causes a dull ache in the arch of the foot, due to over-stretching or partially
tearing the fascia. Both soccer and football are contact sports, and fractures often occur from direct trauma to the ankle, especially if the injury is repetitive.
Repetitive overuse of the arm is the most common cause of Tennis elbow (lateral epicondylitis) and Golfers elbow (medial epicondylitis). Tennis elbow is caused when the muscles and tendons of the forearm become inflamed. During a swing, the wrist is flexed and the palm turns face up causing strain on the tendons. Golfers elbow is a similar type action, however, in a right-handed golfer, the left elbow is affected. While pulling the club through the swing, the left wrist is bent backwards with palm up.
Okay, so the workout may have been too strenuous and you’ve injured yourself. The first treatment for sprains is RICE (Rest, Ice, Compression, Elevation). The goal is to limit internal bleeding and decrease swelling. Resting the joint is important to avoid re-injury. Ice should be applied immediately, and for 20minute intervals, 4 times a day, for 3 or 4 days. The joint should be wrapped with an elastic bandage and elevated to decrease swelling. When you are ready to train again, it may be helpful to use an elastic bandage or brace to avoid further injury.
to contribute to shin splints. The condition commonly affects runners, aerobic dancers, and people in the military. Shin splints often develop after sudden changes in physical activity, such as running longer distances or on hills, or increasing the number of days you exercise each week. Flat feet are another factor that can contribute to increased stress on the lower leg muscles during exercising. To prevent shin splints, its best to start an exercise regime slowly and warm up the leg muscles. Athletic shoes with good support are a must. ■
INDICATION: Patient presents with lateral elbow pain RESULT: A Coronal FSEIR and B Axial T2 FSE of the elbow demonstrate tendonitis of the common extensor tendon and lateral epicondylitis. Arrow shows a moderate amount of fluid at the level of the extensor tendon.
AN OUNCE OF PREVENTION
The shoulder is a vulnerable joint in athletes who use their arms in overhead sports such as tennis, volleyball, swimming, baseball and tennis. The supraspinatus, infraspinatus, subscapularis and teres minor are muscles that come together to form the rotator cuff. These tendons cover the humeral head and work together to lift and rotate the shoulder. The acromion is the front INDICATION: Shoulder pain with edge of the shoulder blade. decreased range of motion and It sits over and in front of recent injury. RESULT: Obliquecoronal proton density with the humeral head. As the arm is lifted, the acromion fat saturation. Image shows tendinosis of the rotator cuff tenrubs, or “impinges” on, the dons, especially the supraspinatus. surface of the rotator cuff. Degenerative cystic changes This causes pain and limits within the greater tuberosity at the insertion of the rotator cuff. movement.
In addition to sports related injuries, many people injure themselves while spring-cleaning. As the weather starts getting warmer, we feel the need to open the windows and prepare our homes and yards for the season. Spring projects cause thousands of orthopedic injuries each year from ladder injuries, garden tool injuries and lawn mower injuries. Most of the injuries come from rushing to complete a task without taking the proper safety precautions. It’s more important to use the proper equipment and to take your time than to spend weeks or months recuperating from an injury. There are very easy techniques to follow for lifting, carrying and bending:
BENDING: Separate feet,
Shin splints affect the muscles in the front and inner parts of the shin. Overuse and running and jumping on hard surfaces are the common causes of pain and occur most often in people unaccustomed to training. Usually, the pain occurs on the medial aspect of the shin, where the muscle responsible for raising the arch of the foot is attached. Repetitive activity leads to inflammation of the muscles, tendons, and periosteum (thin layer of tissue covering a bone) of the tibia, causing pain. The bone tissue itself is also involved. Certain factors seem
INDICATION: Patient presents with anterior knee pain. RESULT: 3D sagittal image shows prominent abnormal signal and thickening of the mid to distal patellar tendon and cortical irregularity at the tibial tubercle with prominent bursitis. Findings are most consistent with Osgood-Schlatter disease.
shoulder width apart, keeping your back straight and bed at the knees while keeping the stomach muscles tight
LIFTING: Use leg muscles as you stand. Get help if an object is too heavy or an awkward shape STEP STOOLS: Always use
a step stool on a firm, flat surface and never stand on furniture when trying to reach high areas
REACHING: Never over-reach when standing on a ladder or step stool; you could lose your balance and fall. Your belly button should never go beyond the side of the ladder GARDENING: Avoid prolonged, repetitive motions while digging and planting. Take frequent breaks or change hands to rest muscles and joints. Wear gloves to protect your hands from blistering
LADDERS: Always use ladders for outside chores such as painting, washing windows, cleaning gutters and trimming trees. The surface should be even and never soft or wet
CHEMICALS AND PESTICIDES: Always wear protective clothing and follow label instructions regarding use and storing for chemicals.
BREAKS: Most importantly, take frequents breaks for rest and re-hydration.
Medical Imaging of Baltimore
(on the GBMC Campus)
6715 North Charles Street Baltimore, Maryland 21204-6822 410-296-5610 410-OPEN-MRI www.mibmri.com
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Come on spring! I hope you have found this newsletter informative. Doing research for this article has taught me to be more patient with my body and work out routine. Now let’s get moving!
I’m often asked “Which MRI scanner is best for my
Licensed, certified technologists Staff receives ongoing continuing education 24-hour report turnaround Extended hours of operation
patient”. In most cases, the answer is either. We have 2 high field scanners; a 1.5T “closed” scanner and a 0.7 High field open design scanner. We are able to image most exams in either scanner, comfortably. However, if your patient is of a larger build, the Open scanner may be more comfortable. We like to suggest the closed scanner for more complex neurological exams: Brains, IAC’s, Pituitary and Spinal Cord abnormalities. If in doubt, please feel free to call me at 410-296-5610.
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